Every finding on record at Willows Post Acute

Based on interview, record and policy review, the facility violated Resident 1's right to manage her own financial affairs when the facility applied to have Resident 1's pension checks deposited into a resident fund management service (a bank account managed by a company who handles resident funds), without written authorization from Resident 1. This failure caused Resident 1 anger and frustration by not having control over how she chose to manage her finances.Findings:A review of the facility's policy and procedure titled, Resident Trust Account Policy dated 1/1/2023, indicated that no account may be opened until the Delegation of Responsibility for the Management of Personal Funds has been signed by the Resident or their Representative.Resident 1 was admitted on [DATE] with diagnoses that included, diabetes (high blood sugar), peripheral vascular disease (poor circulation), osteoporosis (weak bones), high blood pressure, delusional disorder (mental illness with persistent fixed false beliefs), and cognitive/communication deficits (memory, reasoning, attention and information processing problems). A review of Resident 1's Minimum Data Set (MDS, an assessment), dated 10/9/25, indicated that Resident 1 had no memory, recall, thinking or reasoning problems, and had no mood or behavior problems.A review of the facility's document titled, Business Office Activity Note, dated 12/6/23 at 1:49 pm, written by the Business Office Manager (BOM), indicated that Resident 1 was approached by the BOM and Social Service Assistant (SSA) who asked her to have her funds transferred into a resident fund management service bank account. Resident 1 declined and informed the BOM and SSA, that she wanted to continue managing her own bank account.A review of the facility's document titled, Authorization Agreement To Handle Resident Funds indicated, on 6/5/25 the facility's BOM signed the Authorization Agreement declaration to have Resident 1's funds transferred into a resident fund management service account. Resident 1 had not signed the Authorization Agreement. During an interview on 10/17/25 at 12:30 pm, Resident 1 stated, I owe a lot of money to this facility and I know they are right in what they think. I understand their position. They say I am not competent. I am competent. Resident 1 expressed that she wanted to manage her own bank account and had not agreed to the facility managing her funds. Resident 1 stated she was very angry and upset over no longer having control of her money.

Based on observation, interview and record review, the facility failed to provide services that promoted respect and dignity for four of four sampled residents (Resident 1, 2, 3, and 4) when direct care staff did not respond and help residents dependent on staff with their requests for assistance. These failures resulted in residents feeling afraid to ask for assistance, uncomfortable, and unwanted. Findings: 1. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/25 and medical record, indicated Resident 1 was cognitively intact with no memory issues. The MDS indicated Resident 1 required assistance with most activities of daily living (ADLs). During an interview on 7/10/25 at 1:50 pm, with Resident 1, when discussed going to the bathroom, Resident 1 stated that she was often afraid to ask for help. Resident 1 stated staff would ignore their call light, walk by or would answer the light and leave without assisting Resident 1. This resulted in episodes of incontinence of urine and feces, which Resident 1 stated was extremely embarrassing, humiliating, and caused burning pain to bottom and peri-area (the region between the anus and the genitals). When discussed how the night shift care was, Resident 1 began to cry stating I feel so alone and afraid. During an interview on 7/16/25 at 10:45 am, Resident 1 stated she was frustrated because there was always new staff and they don't know how to take care of Resident 1's needs, she must continue to tell the nurses what her plan of care is. 2. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact with minimal memory issues. The MDS indicated Resident 2 required assistance from staff for most ADLs. During an interview on 7/16/25 at 11 am, with Resident 2, when discussing call lights on the night shift Resident 2 stated staff just don't come when light is on. Resident 2 stated they see the light but ignore it because I see them walk by. Resident 2 stated the Certified Nurse Assistants (CNAs) will come in eventually, but they do not talk to her which makes Resident 2 feel uncomfortable. Resident 2 stated that she complained to management, but nothing ever changes. During an interview on 7/30/25 at 10:40 am, Resident 2 stated that one CNA was very rude and makes her feel very uncomfortable but cannot remember her name. 3. A review of Resident 3's MDS dated [DATE], indicated Resident 3 was cognitively intact with some memory issues. The MDS indicated Resident 3 required assistance with all ADLs. During an interview on 7/30/25 at 10:50 am, Resident 3 stated that the staff can be rude, and it makes her feel uncomfortable and unwanted. Resident 3 stated she is used to laying in her urine for long periods of time because she waits so long for help to come, especially at night. Resident 3 stated they don't come unless I am throwing up. 4. A review of Resident 4's MDS dated [DATE] indicated Resident 4 as being cognitively intact and required some assistance with ADLs. During an interview on 7/10/25 at 1 pm, Resident 4 stated he has had many issues with the care at this facility and has reported to management many times but feels nothing is being done. Resident 4 explained that his wife had cried and yelled in the night for help and no one came. Resident 4 tearfully stated he prays every night that he and his wife will get help. Resident 4 stated he hates when the staff gossip around him during care, stated he feels unwanted because of this. During a concurrent interview and record review on 7/10/25 at 11:30 am, with Director of Staff Services (DSD), Complain/Grievance report dated 6/16/25 was reviewed. The report indicated a resident filed a formal complaint with management for not receiving proper care one night in the facility. The report indicated one CNA was responsible for helping the residents and CNA received a corrective action notice (write up). During an interview with Licensed Vocational Nurse (LVN) A on 7/16/25 at 1 pm, stated she was aware of several residents complaining about one specific CNA. LVN A stated she now requests to not work with this CNA when they are scheduled together because she does not feel like she is a good team player and does not take good care of the residents. LVN A stated she has seen this CNA slam things on the desk when she gets upset and has witnessed her speak down to residents and other staff members. LVN A stated she has reported this behavior to management many times, but nothing seems to change. During an interview on 7/30/25 at 1:30 pm, with Director of Nursing (DON), he stated that he had not heard of any grievances from the residents about the CNA's or about staffing. DON stated he has heard of no issues with staffing to his knowledge. DON stated that he is aware of one CNA with behavior issues documented and they are following human resources policies for the process of termination of employment. DON stated residents should feel safe and comfortable while at this facility and not scared and afraid.

Based on interview, and record review, the facility failed to contact and consult with the Responsible Party (RP) and the family for Resident 1, a Native American individual with a diagnosis of unspecified dementia (where cognitive decline is present, but the specific type of dementia cannot be identified), regarding cultural practices related to hair. This failure resulted in Resident 1 given a haircut, which was against her family's cultural preferences. During a record review of facility policy titled Brushing and Combing Hair dated 2001 MED-PASS, indicated staff were to review resident's care plan to assess for any special needs of the resident prior to the haircut.During a record review of Resident 1's admission record, indicated that she was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, cerebral infarction (where a part of the brain is damaged or died due to a lack of blood supply), and encounter for palliative care (focuses on improving the quality of life for individuals facing serious illnesses by managing symptoms, relieving suffering, and providing emotional and spiritual support).During a record review of document titled Nursing Documentation Evaluation dated [DATE] 6:30 pm, indicated no documentation of cultural preferences. Document further indicated resident responds to name and understand simple commands.During a record review of document titled, Minimum Data Set (MDS - a resident assessment tool) Section C, dated [DATE] at 3:38 pm, indicated Resident 1 was assessed by facility MDS nurse to have a Brief Interview for Mental Status (BIMS) score of 5 (0 to 7 points suggests severe cognitive impairment).During an interview with RP on [DATE] at 8:15 am, RP expressed that cutting hair holds significant cultural importance in their heritage and that Resident 1 would have not have consented to this action. During an interview with Licensed Vocational Nurse (LN) A on [DATE] at 9:13 am, LN A stated Resident 1 could make wants and needs known such as I'm cold, I'm thirsty, but Resident 1 would answer 'yes' to almost anything. LN A stated Resident 1 was generally confused, and she did not believe Resident 1 would be able to make the decision for herself for a haircut.During an interview with MDS nurse on [DATE] at 9:26 am, MDS stated residents that wanted a haircut and had mental capacity (the ability to make their own decisions) received a haircut. MDS stated the facility's expectation was to call RPs for residents who did not have mental capacity and needed a haircut. MDS stated a BIMS score of 5 was not considered mental capacity, but it's on the line. MDS stated Resident 1 could answer simple yes or no questions. During an interview with Social Services (SS) on [DATE] at 9:56 am, SS stated she believed Resident 1 could make her wants and needs known. The SS stated she completed admission assessment with Resident 1 and determined Resident 1 did not have mental capacity. The SS stated Resident 1 could make her needs known for items like water or a blanket. SS stated a BIMS score of 5 is not considered mental capacity. SS stated Resident 1 would not be able to answer if she wanted a haircut. SS stated she found out Resident 1 was in the dining room on [DATE] when COS arrived. SS stated COS did not have any residents who wanted their haircut and asked the entire room Does anyone want a haircut? SS stated Activity Assistant (AA - helps plan, organize, and facilitate recreational and social activities) turned to Resident 1 and asked her, and this was when Resident 1 said yes. SS stated Activities Director (AD) completed an in-service with the AA staff.During an interview with facility cosmetologist (COS - a professional who is licensed to perform cosmetic treatments on hair, skin, and nails) on [DATE] at 10:39 am, COS stated she arrived at the facility on [DATE] and realized there were no residents who wanted a haircut. COS stated she asked everyone if anyone wanted a haircut. COS stated AA asked Resident 1 who said yes, and COS wheeled her into the facility salon. COS stated Resident 1's hair was one simple braid, not in her face or anything. COS stated she trimmed Resident 1's hair from her lower back to her mid back, approximately six inches.During an interview with AD on [DATE] at 10:54 am, AD stated AA staff expectation was to not get involved with asking residents if they wanted a haircut. AD stated AA staff did not have access to the residents' charts and should notify nursing staff if a resident requested a haircut. AD stated she completed an in-service on AA job description with AA staff after the incident. AD confirmed AA staff were not trained to understand medical diagnoses, mental capacity, etc. AD stated AA staff expectation was to involve nursing staff for anything other than activities.During an interview with Director of Nursing (DON) on [DATE] at 11:25 pm, DON stated AA staff were allowed to ask residents if they wanted a haircut, regardless of mental capacity. DON verified facility haircut policy stated to verify if residents did not have any special needs prior to a haircut. DON confirmed AA staff did not have access to residents' charts. DON confirmed AA staff were not medically trained and did not have access to care plans for residents. DON confirmed a BIMS score of 5 did not confirm mental capacity. DON confirmed that AA staff would refer residents to nursing staff if they wanted a haircut. DON confirmed family should have been contacted prior to Resident 1 given a haircut, especially with Resident's 1 diagnosis of dementia.

Based on observation, record review, interview, and facility policy review, the facility failed to provide nail care for 1 (Resident #119) of 2 residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, revealed, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy revealed, General Guidelines 1. Nail care includes daily cleaning and regular trimming. An Admission Record revealed that the facility admitted Resident #119 on 03/27/2025. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified cerebrovascular disease, weakness, and type 2 diabetes mellitus without complications. Resident #119's Care Plan Report, included a focus area initiated 03/28/2025, that indicated the resident had an ADL self-care performance deficit due to a cerebrovascular accident (CVA). Interventions (initiated 03/28/2025) directed staff to praise all efforts at self-care, promote dignity by ensuring privacy, and provide supportive care and assistance with mobility as needed. A Nursing Documentation Evaluation, dated 03/27/2025, revealed the section titled, Physical functional assessment/physical assist [assistance], indicated that the resident required extensive assistance of one person for bathing and person for hygiene. Resident #119's Documentation Survey Report, for March 2025, revealed staff had documented that personal hygiene was provided during the day shift on 03/28/2025, 03/29/2025, and 03/30/2025, and during the night shift on 03/27/2025 and 03/30/2025. The Documentation Survey Report revealed staff had documented that a bed bath was provided during the day shift on 03/28/2025, 03/29/2025, and 03/30/2025, and during the night shift on 03/30/3035. During an observation on 03/31/2025 at 10:55 AM, Resident #119's fingernails on the first three fingers of their right hand were soiled. During an observation on 04/01/2025 at 9:05 AM, Resident #119 was lying in bed. Resident #119's fingernails on the first three fingers of their right hand were heavily soiled. During a concurrent interview, Resident #119 stated that they did not know how long they had been in the facility and did not know if they had been given a shower or bath. During an interview on 04/01/2025 at 12:10 PM, Certified Nursing Assistant (CNA) #3 stated that residents were to get ADL care daily. CNA #3 stated that residents had assigned shower days and in between shower days, staff were to give bed baths. CNA #3 stated that when they provided showers to the residents, they cleaned the residents' nails. She stated that she checked the resident's nails daily, and if needed clipped their nails once a week, but cleaned the nails whenever it was needed. CNA #3 stated she had worked with Resident #119 for the past three days. She stated that she was to do nail care for Resident #119 if the resident's nails were long or if their nails were dirty. She stated that she had checked Resident #119's nails daily for the past three days. During an interview on 04/01/2025 at 12:32 PM, Licensed Vocational Nurse (LVN) #4 stated Resident #119 was a part of her assignment for the day. LVN #4 stated that all staff were to provide ADL care. She stated that each resident was to have assigned shower days, and in between the shower days each resident was to get peri-care or ADL care as needed. LVN #4 stated that the CNAs were to check the resident's nails once a week on shower days, and as a nurse she was to check the resident's nails once weekly. She stated that she was unsure as to where the CNAs documented nail care. LVN #4 stated that she was not aware of any reason why nail care would not be provided to Resident #119. During a concurrent observation of Resident #119's fingernails, LVN #4 confirmed that Resident #119 had dirty fingernails. She stated that her expectation was that staff clean the resident's nails when needed. During an interview on 04/03/2025 at 10:26 AM, the Interim Director of Nursing (DON) stated that the CNAs were to get a list of residents who needed nail care, and the expectation was that nails were to be cleaned during care, and if the resident was diabetic the nurses were to do the nailcare. During an interview on 04/03/2025 at 10:42 AM, the Interim Administrator stated that CNAs were responsible for ensuring ADLs were completed for residents as needed. She stated that nail care was to be performed while showering and bathing the resident and as needed. She stated that her definition of as needed meant that any time the resident's hands were soiled, they were to be cleaned. The Interim Administrator stated that his expectation was that Resident #119's nails should have been cleaned.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in accordance with professional standards for food service safety when: 1. A slimy, brown-pink substance was found inside the holding tray of the facility's icemaker. 2. Dirty dishwasher water from the dishwasher's air gap (directs dirty dishwater from a pipe in the dishwasher to a drain in the floor to prevent it from backing up onto clean dishes) was splashing onto floor tiles next to the drain. 3. A kick plate at the bottom of an oven/stove unit was missing, exposing wires and other internal parts. These failures created safety issues for staff and had the potential to cause avoidable food- or waterborne illness for all 68 facility residents. Findings: 1. During a review of Infection Prevention and Control Program (IPCP), revised 10/2018, the policy indicated an IPCP is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. The policy indicated an important facet of infection prevention includes following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). During a review of the facility's Sanitation policy, revised 11/2022, the policy indicated ice machines and ice storage containers are to be drained, cleaned, and sanitized per manufacturer's instructions. During a review of the Maintenance Department's Logbook Documentation, dated 3/27/24, the record indicated Director of Maintenance (DM) had sanitized the interior of the ice machine and cleaned and sanitized the ice bin. During a concurrent observation and interview with DM on 4/3/24 at 8:35 AM, DM stated he had recently (last week) sanitized the icemaker, which he does monthly. During observation, a white cloth was wiped over the interior of the ice machine where ice drops into a black container. A slimy, brown-pink substance was present on the white cloth after wiping the container. DM stated that the substance should not be there, and cleaning should be increased to more often than once a month. 2. During a review of Kitchen Observation, dated 10/25/23, the record indicated the kitchen was audited for practices that might indicate potential for foodborne illness with the following results: - Continued maintenance repair opportunities under dish machine. During a concurrent observation and interview with Registered Dietitian (RD A) at initial kitchen tour on 4/2/2024 at 8:57 AM, milky, gray-colored water splashed from the dishwasher air-gap pipe partially into the floor drain and partly onto the floor. The water was observed pooling on cracked floor tiles under a metal counter. RD A confirmed water should all flow into the drain and should not contact floor tiles. During an interview with DM on 4/2/24 at 11:24 AM, DM stated he was unaware the dishwasher's air gap was draining onto the floor. DM agreed water should only go into the drain and stated he had just (this morning) fixed the air gap by correcting the direction of all waterflow from the dishwasher pipe to the drain. 3. During an observation on initial kitchen tour on 4/2/24 at 08:57 AM, observed an oven/stove kick plate to be missing. Observed exposed internal wires, gas lines, and other parts which would be covered by the kick plate. During a concurrent interview and record review with RD A on 4/4/24 at 9:10 AM, RD A stated Maintenance was aware of the missing kick plate and had ordered the part. RD A produced an invoice dated 4/2/24, which indicated a kick plate had been ordered by DM.

Based on interview, and record review, the facility failed to consistently document the location of the pain, failed to administer a dental prescription order for a dental rinse, and failed to follow their pain assessment and management policy and procedure for one of seventeen sampled residents (Resident 416). These failures resulted in dental pain. Findings: During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated March 2020, the document indicated The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. Assessing residents pain including location of pain, and management interventions shall address the underlying causes of the resident's pain. A review of Resident 416's record indicated he was admitted on [DATE] with diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease (difficulty breathing), Diabetes (high blood sugar), and Dysphagia (difficulty swallowing). A review of Resident 416's Minimum Data Set (a resident assessment tool used to assess residents' functional capabilities and helps nursing home staff identify health problems), dated 1/6/24, Brief Interview for Mental Status screening (BIMS) (a cognitive assessment tool), recorded a score of 14 indicating no cognitive impairment. A review of Resident 614's Progress Notes for the months of December 2023 through March 2024 (4 months) indicated the facility missed 52 of 70 opportunities to document the locations of Resident 416's pain while administering pain medications. This prevented the facility from recognizing Resident 416's tooth pain and responding by getting dental care for Resident 416 in a timely manner. During a review of Resident 416's Hygiene Notes, dated 6/9/23, the record indicated an order for Chlorhexidine (Chlorhexidine is an antiseptic and disinfectant. It helps reduce the number of germs [bacteria] in your mouth or on your skin. It can help with mouth infections, mouth ulcers and gum disease). During a review of Resident 416's Order Summary Report dated 6/1/23 the record indicated Chlorhexidine was not ordered for Resident 416. During a review of Resident 416's Order Summary Report dated 7/1/23 the record indicated Chlorhexidine was not ordered for Resident 416. During a review of Resident 416's Care Plan dated 1/6/24 the record indicated that Resident 416 is at risk for oral health or dental care problems as evidenced by missing, broken, decaying teeth, Resident 416 will not have any discomfort or chewing problems related to broken, loose or carious teeth and nursing staff will Assess for oral lesions, inflammation and bleeding and signs and symptoms of pain during care and report to the Medical Doctor (MD) During an interview with Resident 416 on 4/2/24 at 9:30 am, Resident 416 stated, he had been at the facility for about a year and his teeth needed to be pulled, but no appointment had been made. During an interview with Resident 416 on 4/3/24 at 9:40 am Resident 416 stated he has tooth pain every day. Some days it is a 10, and some days it is a 3 (on the 0-10 pain scale, with 0 being no pain, and 10 being the worst pain). Resident 416 stated his dental issues make him feel like giving up on getting his bad teeth taken care of. During an interview with Licensed Vocational Nurse D (LVN D) on 4/3/24 at 3:09 pm LVN D stated Resident 416 never had an order for Chlorhexidine. During an interview with Resident 416 on 4/4/24 at 9:43 am Resident 416 stated, he has told a dentist, nurses, and others caring for him at the facility about his tooth pain since he was admitted to the facility in December of 2022, but he feels like they don't listen to him. During a concurrent interview and record review with the Director of Nursing (DON), on 4/4/24 at 11:39 am Resident 416's Progress Notes, dated 3/1/24 to 3/28/24, the records indicated facility staff have not documented the location of Resident 416's pain consistently. The DON confirmed the location of Resident 416's pain was not consistently documented and stated he expects the facility's nurses to document the location of pain when assessing pain and giving pain medication. Order Summary Reports for June and July of 2023 were reviewed and indicated Chlorhexidine was not ordered for Resident 416. The DON confirmed Chlorhexidine was never ordered for Resident 416.

Based on observation, interview and record review, the facility failed to ensure an infection prevention system was implemented when: 1. Medical supplies were found in dirty condition on the floor, and the sink, soap dispenser and towel dispenser were found in dirty condition, in the medication room. 2. Resident 316 was allowed to store and wash her soiled laundry in a shared bathroom that had the potential to spread infection to one of three Residents (Resident 44). 3. Certified Nursing Assistant (CNA) E failed to do hand hygiene with two of two Residents (Resident 15 and 50) when CNA E assisted Resident 15 to the toilet, wiped her, helped her put on clean pullups(disposable underwear) and then assisted with Resident 50 without doing hand hygiene. These failures had the potential for cross contamination (the transfer of bacteria from one source to another). Findings: 1. A review was made of a facility policy titled, Infection Prevention and Control Program, rev. October 2018, which indicated that the program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of diseases and infections. During an inspection of the medication room, a concurrent observation, and interview, was conducted with the Director of Nurses (DON) on 4/4/24 8:25 am. Packages of medical supplies were observed on the floor under a cart; upon removal they were found to be two packages of intravenous administration tubing and one package of suction tubing. The sink and soap dispenser were noted to have layers of dust and had dried drips of hardened material; the towel dispenser was also dusty. The DON confirmed that the both the equipment and the products were dirty and could cause cross contamination. 43755 2. A review was made of the facility's undated Policy titled Departmental Laundry and Linen which indicated to consider all soiled linen to be potentially infectious And, that all soiled linen must be placed directly into a covered laundry hamper The policy also indicated not to sort or pre-rinse soiled linens in resident-care areas. A review of Resident 315's face sheet indicated she was readmitted to this facility on 8/28/23 with diagnoses of Lung Disease, Stroke (a medical condition in which poor blood flow to the brain causes cell death) affecting the right non-dominant side (right side was weak) and depression. A review of Resident 315's Quarterly Material Data Set (MDS, A clinical assessment) dated 3/24/24, indicated Resident 315 scored a 13 on her Brief Interview for Mental Status (BIMS, a cognitive test 1-15) revealing she was cognitively intact. Section GG of the MDS indicated she was able to wheel herself around in her room with little assistance from staff. A review of Resident 44's face sheet indicated she was admitted to this facility on 6/14/22 with diagnoses of Lung disease, Dementia, Depression and Heart Disease. A review of Resident 44's Quarterly MDS dated [DATE] indicated Resident 44 scored a 10 on the BIM's indicating she was moderately cognitively impaired. Section GG of her MDS indicated she was able to wheel herself around her room independently. During an observation in Resident 316's, and Resident 44's shared bathroom on 4/2/24, at 10:01 am, a basin with black, white and tan clothes piled high above the rim of the basin and touching the plumbing was observed on the floor under the sink. Laundry detergent was also observed on the floor. During a concurrent observation and interview with Environmental Services (ES) C, on 4/2/24, at 10:07 am, Resident 316's and Resident 44's shared bathroom was observed. ES C confirmed that there was soiled laundry in an open basin on the floor of this bathroom. She stated I always see her (Resident 316) doing her laundry in the sink. I do not know why they let her do her laundry here. During an interview with Resident 44 on 4/2/24, at 11:01 am, Resident 44 stated she used the same bathroom as Resident 316 and that Resident 316 kept her soiled laundry in there and washed them in the sink. During an interview with Resident 316 on 4/2/24, at 11:20 am, Resident 316 confirmed that her soiled laundry was stored in an open basin on the floor under the sink in the bathroom. She stated she washed her under garments, nylons, shirts and blouses in the sink and hung them up to dry. During an interview with ES D on 4/2/24, at 11:30 am, ES D confirmed that she knew Resident 316 had done her own laundry in her bathroom. ES D was unsure of infection control policies concerning this practice. During an interview with the Infection Preventionist (IP) on 4/3/24, at 2:11 pm, the IP confirmed that Resident 316 did her laundry in a shared sink and that there was always a chance of cross contamination. The IP stated Resident 316 should be storing her soiled clothes in her own room and not in a shared bathroom. 3. A review was made of the facility's policy titled Handwashing/Hand Hygiene revised August 2019, which indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The policy interpretation indicated that the use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after direct contact with residents; Before moving from a contaminated body site to a clean body site during resident care; and after removing gloves. A review of Resident 15's face sheet indicated she was admitted to this facility on 7/31/23 with the diagnoses of Diabetes (disease with sustained high blood sugar in the blood), lung disease, repeated falls and schizophrenia (mental disorder). A review of Resident 15's MDS Quarterly MDS dated [DATE], indicated Resident 15 scored a 10 on the BIM's indicating she was moderately cognitively impaired. Section GG documented she required full assistance with toileting (cleaning and wiping herself after using the bathroom). A review of Resident 50's face sheet indicated she was admitted to this facility on 5/26/23 with diagnoses of Lung Disease, Heart Disease, Stroke, and Dementia. A review of Resident 50's Quarterly MDS dated [DATE], indicated she was severely cognitively impaired and was dependent with toileting. During an observation on 4/3/24, at 9:19 am, in Resident 15's room, CNA E was observed assisting Resident 15 to the toilet. With goves on CNA E: *Walked Resident 15 to the bathroom. *Took off Resident 15's soiled brief (a type of disposable underware that catches urine) and put it in a bag. *Wiped and cleaned Resident 15 after she urinated. *Took off her gloves. Without doing hand hygiene CNA E: *Helped Resident 15 walk back to the bed. *Obtained a clean pullup from Resident 15's closet. *Put the pullup on Resident 15. *Touched the bedside control and adjusted the bed and covers for the Resident 15. *Went over to the other resident in the room (Resident 50) and pulled back the covers to see if her brief was soiled. *Confirmed the brief was not soiled and pulled the covers up over the shoulders and around the face of Resident 50. CNA E left the room, walked down the hall to throw away the bag with the brief in it then did hand hygiene by using an alcohol-based hand rub. During an interview on 4/3/24, at 9:30 am, CNA E confirmed that she had not done hand hygiene after wiping and cleaning Resident 15, taking her gloves off or after she went from one resident to another, and she should have. During an interview on 4/4/24, at 9:46 am, the IP confirmed CNA E should have done hand hygiene after removing her gloves and before going from one resident to another to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable, and homelike environment when: 1. Varnish was worn off the wooden handrails in Unit 1 (hallway between Rooms 27-34 and hallway between Station 1 nurses' desk and patio). 2. Wall paint was scratched or in disrepair in Rooms 6, 10, 30, and 37, and curtains were missing in room [ROOM NUMBER]. These failures violated all (68) facility residents' rights to a clean, comfortable, homelike environment; diminished their quality of life; and increased the potential risk for infection from exposure to germs on uncleanable surfaces. FINDINGS: 1. During a review of Infection Prevention and Control Program (IPCP), revised 10/2018, the policy indicated an IPCP is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. The policy indicated an important facet of infection prevention includes following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). During a review of the CDC's website page, When and How to Clean and Disinfect a Facility, dated 11/2/22, indicated cleaning and disinfection of wood surfaces are not recommended. (https://www.cdc.gov/hygiene/cleaning/facility.html) During concurrent observation and interview with Environmental Services Director (ES D) on 4/2/24 at 12:13 PM, the reddish-brown varnish present on wooden handrails was worn off the handrails along the Unit 1 hallways. ES D stated handrails are wiped down a minimum of three times a day with Victory spray (a brand-name disinfectant cleaning solution); however, ES D stated the handrails were cleaned more frequently during the COVID pandemic, which she stated ruined the varnish on handrails. ES D acknowledged it is hard to maintain infection control on porous unvarnished wood surfaces. 2. During an observational facility tour on 4/2/24 at 10:25 AM, there were no curtains in room [ROOM NUMBER], and the wall paint was scratched off in several places. During an observation of room [ROOM NUMBER] on 4/3/24 at 10:02 AM, there was an approximately 7-inch by 7-inch circle of paint peeled off to reveal the drywall (a type of board made from plaster, wood pulp, or other material used to form interior walls of houses) over the left side of Resident 25's bed just above bed level. During concurrent observation and interview with Director of Maintenance (DM) on 4/3024 at 3:07 PM, DM stated the walls and curtains were fixed in Rooms 6, 10, 30, and 37, and handrails were in the process of being revarnished.

Based on observation, interview and record review the facility failed to provide the necessary care to maintain good grooming and personal hygiene for 3 of 19 (Resident 6, 22, 56) sampled residents when: 1. Resident 6 had an unkept beard and mustache and his nails were long and dirty. 2. Resident 56 's and 22's hair was matted and sticking up. These failure had the potential to result in depression, poor self-esteem, denial of resident rights all of which could lead to negative clinical outcomes for these residents. Findings A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting revised 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. 1. A review of Resident 6's face sheet indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included limitation of activities due to disability, muscle weakness, other lack of coordination and dementia. A review of Resident 6's Minimum Data Set (MDS, resident assessment) dated 1/14/24, indicated he required maximal assistance (the helper does more than half the effort) with personal hygiene (combing hair, shaving, washing/drying face and hands). A review of Resident 6's ADL Care Plan dated 1/3/24, indicated Resident 6's ADL care needs will be anticipated and met. There were no interventions with respect to his beard preference. During a concurrent observation and interview in Resident 6's room on 4/2/24, at 10:49 am, Resident 6 was observed lying in bed in a red flannel shirt. He had a white beard and mustache about 1.5 centimeters(cm) long and all different lengths, and His nails were grown about a half a cm beyond the end of all 10 fingers. There was brown material under each nail. Resident 6 stated that he needed to have his nails cut and that he would like to be shaved. During a concurrent observation and interview in Resident 6's room on 4/2/24, at 2:49 pm, Resident 6 indicated He would like to get his beard shaved and nails cut. He stated, It makes me feel horrible. During a concurrent observation and interview in the dining room on 4/3/24, at 9:41 am, Resident 6 was sitting in the dining room drinking coffee. He had his same red shirt on with white and brown stains on it. His beard and nails were the same as the day before. Resident 6 stated again that he wanted a shave. Recreation Assistance (RA) was in the dining room giving coffee to residents. RA indicated to the surveyor that Resident 6 had asked her for a shave and haircut, and she confirmed that he needed it. RA indicated that the CNA (Certified Nursing Assistant), was responsible to shave him, and that Resident 6 did not like to have a beard and preferred to be clean shaven because he had been in the military and that was still important to him. The RA stated, The whiskers are driving him nuts. During an interview and record review of the undated shower schedule on 4/3/24, at 9:44 am, with Certified Nursing Assistant (CNA) E, CNA E commented beards and nails are done with their showers. The shower/bath schedule identified that Resident 6's shower days were on Tuesday and Saturdays. CNA E confirmed she gave Resident 6 a shower on Saturday but did not shave him. She stated I do not know if he prefers to grow a beard. I guess I could ask him, but I have never asked him. During an interview on 4/3/24 at 10:00 am, with the Director of Staff Development (DSD), the DSD indicated that Wednesdays were the days the staff would clean and cut the resident's nails. He was unable to provide documentation of this task for any resident. The DSD stated, since October, they were using a new program for task documentation and the nail task should be in there, but it was not. In an interview on 4/4/24 at 9:54 am, the DSD confirmed that there was no care plan for Resident 6 to indicated he wanted to be kept clean shaven and there should have been. He stated, the residents should be asked this question. In an interview on 4/4/24, at 12:10 pm, CNA A and the Infection Preventionist (IP) were unaware of a specific day that nails were supposed to be trimmed or cleaned. 2. A review of Resident 56's face sheet indicated she was admitted on [DATE] with diagnoses of Dementia, Anxiety, lack of coordination and Limitation of Activities due to Disability. Resident 56 was on comfort care (care that aims to keep the resident comfortable). A review of Resident 56's MDS dated [DATE], indicated she was severely impaired for daily decision making. Section GG indicated Resident 56 required full assistance from staff with personal hygiene. A review of Resident 56's ADL care plan dated 11/20/23, indicated her ADL care needs will be anticipated and met. During a concurrent observation and interview in Resident 56's room on 4/2/24, at 12:46 pm, Resident 56 was laying in bed with gown on, and her hair was matted together and sticking up. Licensed Vocational Nurse (LVN) B confirmed that Resident 56's hair needed attention. LVN B indicated she would ask the CNA to brush her hair. A concurrent interview and record review of Resident 56's personal hygiene care documented by the CNA on 4/2/24, indicated personal cares were done at 11:35 am, one hour before the above observation, and not again for the rest of the day. The DSD confirmed the documentation. A review of Resident 22's face sheet indicated she was admitted on [DATE], with the diagnoses of Polymyositis (inflammation of many muscles), heart disease, anxiety, depression, and stroke (poor blood flow to brain causing cell death). Resident 22 was on Hospice (end of life care). A review of Resident 22's change of condition MDS dated [DATE], indicated she was moderately impaired for daily decision making. Resident 22 required full assistance from staff with personal hygiene. A review of Resident 22's ADL care plan revised 2/12/24, indicated Resident 22's ADL care needs will be anticipated and met. During a concurrent observation and interview in Resident 22's room on 4/2/24 at 12:43 pm, Resident 22 was lying in bed and her hair was matted together and sticking up. LVN B confirmed that Resident 22's hair needed to be brushed.

Based on interview, and record review, the facility failed to ensure timely vision services for one of seventeen sampled residents (Resident 416). This failure resulted in continued vision issues and in Resident 416 feeling like giving up on getting his vision problems addressed. Findings: A record review of Resident 416's Minimum Data Set (MDS) (MDS, a resident assessment tool) indicated Resident 416 was admitted on [DATE], with diagnoses including Diabetes (high blood sugar), and Hypertension (high blood pressure). A review of Brief Interview for Mental Status screening (BIMS) (a cognitive assessment) dated 1/6/24, recorded a score of 14 indicating no cognitive impairment. During an interview on 4/2/24 at 9:30 am, Resident 416 stated he had been at the facility for about a year and has a cataract in his left eye (a condition in which the eye lens becomes opaque, resulting in blurred vision and the leading cause of blindness in adults) that needs treatment, but no appointment had been made for this issue. This made him feel like giving up on getting his vision problems addressed. During a review of Resident 416's Ophthalmology Consultation (ophthalmology, the branch of medicine dealing with the diagnosis and treatment of eye disorders) dated 8/25/23, the record indicated Resident 416 should be referred for cataract treatment for Quality of Life Enhancement. During a review of Resident 416's Physician's Transportation Order dated 2/27/24, the record indicated Resident 416 was not referred for cataract treatment until 2/27/24, 6 months after Resident 416's ophthalmology consultation on 8/25/23, more than 1 year after his facility admission. During an interview and concurrent record review with the Director of Nursing (DON) on 4/4/24 at 11:39 am the DON stated that Social Services usually make dental and vision appointments. The DON stated that the Administrator (ADMIN) delegated the social services work to the desk nurse and the MDS nurse about three months ago. The DON stated Social Services was inconsistent in the previous three months to when the ADMIN delegated the social services work to the desk nurse and MDS nurse. The Physician's Transportation Order, dated 2/27/24, and the Ophthalmology Consultation, dated 8/25/23, were reviewed. The DON stated that the wait between the vision exam on 8/25/23 and the date of referral of 2/27/24 is a long time and that Social Services should have followed up on it. During a review of the facility's job description titled, Social Worker, dated October 2020, under Duties and Responsibilities the job description states that the Social Worker will: 1.Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. 2.Coordinate social services activities with other members of the interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure accurate labeling of medications for two (of seven) residents, when: 1. The label for clonidine (a medication to control blood pressure, which is a measurement of the pressure of blood pushing against the arteries as it is pumped through the body) contained partial instructions, a failure with the potential for the medication being given inappropriately which may lead to a dangerously slow heart rate; and, 2. Eye drop solution Visine dry eye relief taken from general stock and used for Resident 38 was found to have been labeled with the resident's first and last initials, and not her name, a failure with the potential for confusion as to the intended recipients and the potential for cross contamination (the transfer of harmful bacteria from one source to another) which could lead to poor health outcomes. Findings: A facility policy titled, Medication Labeling and Storage, rev. February 2023, was reviewed which indicated that medication labels must include appropriate resident names, instructions and precautions, in addition to prescribed dose, strength, route, and expiration date where applicable. 1. Resident 44 was admitted to the facility with diagnoses which include essential primary hypertension (an abnormal increase in blood pressure [the force required to pump blood through the arteries], which is not caused by a medical condition) and a history of myocardial infarction (death of heart muscle tissue due to decreased blood flow, usually from an obstruction in a vessel). During a medication pass observation dated 4/3/24 at 8:45 am, Licensed Vocational Nurse (LVN) C took a blood pressure reading of 138/78 and a heart rate of 52 for Resident 44. She stated she was going to hold Resident 44's clonidine because the heart rate was less than 60. It was noted that the instructions on the label applied to the medication was incomplete; there was instruction to hold the medication for a systolic (a measurement of the blood pressure in the arteries during a heartbeat) blood pressure (SBP) under 100, but there was no instruction regarding the heart rate. A review was made of an order summary report for Resident 44 which contained an order for clonidine HCl 0.1 milligram (mg, a unit of measure), give one tablet by mouth two times a day related to essential primary hypertension, hold for SBP less than 100 and/or heartrate less than 60. A review was made of a medication administration record (MAR) for Resident 44 in which LVN C documented holding the clonidine. During a concurrent interview and record review on 4/4/24 at 8:15 am, the Director of Nurses (DON) stated, the MAR should always match the medication exactly and if a nurse read the instructions on the medication but not the instructions on the MAR, they could give the medication and cause a low heart rate. 2. Resident 38 was admitted to the facility with diagnoses which include diabetes mellitus (a chronic [long-lasting] disorder that affects how the body converts food into energy) and heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for nutrients and oxygen). A concurrent interview, and observation, was conducted on 4/3/24 at 9 am, during an inspection of medication cart number 4 with Licensed Vocational Nurse (LVN) C. An opened container of Visine dry eye drops was found with hand-written first and last initials of Resident 38. LVN C stated that the eye drops were over the counter medications that had been pulled from general stock. During a concurrent interview, and record review, on 4/4/24 at 1 pm, the DON stated, this will get fixed today, and that using only initials on medications could cause the medications to be given to the wrong residents with similar initials.

Based on interview, and record review, the facility failed to ensure timely dental services for one of seventeen sampled residents (Resident 416) when he complained of tooth pain. This failure resulted in continued dental pain and in Resident 416 feeling like giving up on getting his bad teeth treated. Findings: A review of Resident 416's record indicated he was admitted on [DATE], with diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease (difficulty breathing), Diabetes (high blood sugar), and Dysphagia (difficulty swallowing). A review of Brief Interview for Mental Status screening (BIMS) (a cognitive assessment) dated 1/6/24, recorded a score of 14 indicating no cognitive impairment. During an interview on 4/2/24 at 9:30 am, Resident 416 stated he had been at the facility for about a year and his teeth needed to be pulled, but no appointment had been made. During a review of Resident 416's Hygiene Notes dated 6/9/23, the document indicated Resident 416 could benefit from oral appliances due to multiple broken or rotting teeth and Resident 416 was interested in doing this. The record also indicated Resident 416 was prescribed a Chlorhexidine dental rinse (Chlorhexidine is an antiseptic and disinfectant. It helps reduce the number of germs [bacteria] in your mouth or on your skin. It can help with mouth infections, mouth ulcers and gum disease). During an interview on 4/3/24 at 9:40 am, Resident 416 stated he has tooth pain every day. Some days it is a 10 and some days it is a 3 (on the 0-10 pain scale, with 0 being no pain, and 10 being the worst pain). Resident 416 stated his dental issues make him feel like giving up on getting his bad teeth taken care of. During an interview on 4/3/24 at 9:50 am with Minimum Data Set/Social Services Nurse (MDS/SS B) (Minimum Data Set is a resident assessment tool used by MDS nurses to assess residents' functional capabilities and helps nursing home staff identify health problems), MDS/SS B stated that the dental service sends the results for authorization for further treatment after the dentist and x-ray specialist review the exam and x-rays, and it can take 6-8 weeks. It was 4 months (16 weeks) from the date of the last dental exam on 11/30/23 to the date of the interview with MDS/SS B on 4/3/24. During an interview on 4/3/24 at 10:00 am with the Director of Nursing (DON), the DON confirmed that Social Services (SS) usually coordinates dental care for residents and that the expectation for the time between an exam and follow up on dental issues depends on if there is pain or not. The DON stated they will make appointments right away if the resident is having pain. The DON confirmed Social Services should have followed up on Resident 416's dental consultation to ensure Resident 416 got dental treatment. During an interview on 4/4/24 at 9:43 am Resident 416 stated he has told a dentist, nurses, and others caring for him at the facility about his tooth pain since he was admitted to the facility in December of 2022, but he feels like they don't listen to him. During a review of Resident 416's Dental Notes dated 11/30/23, the document indicated x-rays (images taken of the bones) were completed of Resident 416's mouth to evaluate the degree of damage to his teeth. No further dental records were available after 11/30/23. During an interview with the DON on 4/4/24 at 11:39 am the DON stated that Social Services was responsible for making dental and vision appointments. The DON stated that the Administrator (ADMIN) delegated the social services work to the desk nurse and the MDS nurse about three months ago. The DON stated Social Services was inconsistent in the previous three months to when the ADMIN delegated the Social Services work to the desk nurse and MDS nurse. During a review of the facility's job description titled, Social Worker, dated October 2020, under Duties and Responsibilities the job description states that the Social Worker will: 1.Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. 2.Coordinate social services activities with other members of the interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). This deficient practice did not ensure there was effective oversight of day-to-day dietetic services operations and had the potential to put all residents at risk for unmet nutritional needs, weight gain/loss, and foodborne illness. Findings: During a review of Dietary Services Manager Coverage, dated 10/1/2023 to 3/31/2024, the record indicated a full-time (40 hours/week) RD started 3/24/2024, with Dietary Manager coverage less than 40 hours/week for 20 of 26 weeks: - Weeks of 10/1/2023 to 10/29/2023: 36 hours (4 days) - Weeks of 11/5/2023 to 11/19/2023: 30 hours (3 days) - Weeks of 12/31/2023 to 1/7/2024: 36 hours (4 days) - Weeks of 1/14/2024 to 2/18/2024: 30 hours (3 days) - Week of 2/25/2024: 16 hours (2 days) - Week of 3/3/2024: 32 hours (4 days) - Weeks of 3/10/2024 to 3/17/2024: 36 hours (5 days) During a review of Sanitation and Food Safety Checklist (a checklist tool for RD use to perform monthly Dietary Services audits), dated 10/17/23, the record indicated: - Healthcare Services Group Dietary Manager (CDSS) was present at the facility to cover the Dietary Manager position while the cook received Certified Dietary Manager credentialing. - The Dietary Manager was working on completing competencies of kitchen staff. - No Registered Dietitian approval signature was present on menu substitutions records from 9/10/23 to 10/17/23 . During a review of Kitchen Observation, dated 10/25/2023, the record indicated the kitchen was audited with observations focused on practices that might indicate potential for foodborne illness with the following results: - Issues were found with labeling/dates: Items not always labeled consistently with same number of days by staff. - Continued maintenance repair opportunities: under dish machine/sink. - The facility did not have a written policy that honors resident preferences safely. During a review of Facility Inspection Report, Discipline: Dietary, dated 3/29/2024, the record indicated: - No Quality Assurance (QA) was in place to see if residents were consuming physician-ordered nutritional supplements. - The facility did not have a Dining Committee that meets quarterly. - Menu was not followed as posted. Test Tray completed on 3/29/2024 had alternate vegetable. - Cool down log not used accurately. No entry since 3/2/2024. - Test Tray on 3/29/2024 was delivered at safe but not desirable temperatures. - Skill checks on file for all food service workers were not up to date. - Inadequate supply of food based on licensed bed capacity. During a concurrent observation and interview on initial kitchen tour with Registered Dietitian A (RD A) on 4/2/2024 at 08:57 AM, RD A stated she was hired three weeks ago and was here every day (full time). RD A stated the facility's Dietary Services Supervisor (DSS) position was in transition at the present time, and a Corporate DSS (CDSS) was the acting dietary manager while DSS A was on leave. During observation of the walk-in freezer, there was an open cardboard box of dough balls. The plastic bag inside the box containing the dough was open, and the dough was uncovered within the box. RD A acknowledged that the dough should not be exposed but rewrapped in a protective covering (e.g., freezer-safe bag) within the box. During an interview with the Administrator (ADMIN), RD A, and RD B on 4/3/2024 at 3:10 PM, ADMIN confirmed the facility did not hava a qualified DSS and and a full time RD.

Based on observation, interview, and record review, the facility failed to consistently incorporate resident preferences for 8 of 68 sampled residents (Residents 31, 28, 51, 41, 56, 416, and two confidential residents) in personal dietary choices. This failure had the potential for all facility residents to eat less food, leading to the potential for weight loss and unmet nutritional needs. Findings: During a review of Skilled Nursing Facility (SNF) Clinic, Resident Food Preferences, Dietary Services, revised 7/2017, the record indicated: - The dietitian or nursing staff will identify a resident's food preferences within 24 hours after his/her admission. - Staff will interview the resident directly, when possible, to determine current food preferences based on history and life patterns related to food and mealtimes. - The Food Services Department will offer a variety of foods at scheduled meals as well as access to nourishing snacks throughout the day and night. - The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. - Therapeutic diets will be ordered only after the resident or representative agrees with and consents to such a diet. - The resident has the right not to comply with therapeutic diets. - If the resident refuses or is unhappy with their diet, the staff will create a care plan that satisfies the resident. During a review of Facility Inspection Report, dated 3/29/24, the record indicated the facility did not have a Dining Committee. The record also indicated the facility had an inadequate supply of food based on licensed bed capacity. During a review of Resident Council Minutes, dated 3/22/24, the record indicated: - 2 of 13 residents (names not provided) in attendance stated they were receiving dislikes on their meal trays. - 2 of 13 residents (names not provided) in attendance stated they had not received butter on their meal trays for three weeks. During a review of Resident Council Concern Response Form, dated 3/22/24, the record indicated 'Investigation/Actions' included a staff in-service training on meal preferences and the difference between margarine and butter. During an interview on 4/2/24 at 9:15 AM, Resident 31 stated she likes Jell-O but that the facility buys pre-made Jell-O that's like rubber. During an interview on 4/2/24 at 10:15 AM, Resident 28 stated he wished his food had more spice in it. During an interview on 4/2/24 at 11:03 AM, Resident 51 stated hot chocolate is served lukewarm. Resident 51 stated, You want your hot chocolate to be hot, not cold. Resident 51 stated snacks are not always available on the weekends, adding, Someone did come and give me candy. That is not acceptable. During an interview on 4/2/24 at 11:24 AM, Resident 41 stated sometimes the facility runs out of snacks, noting, Sometimes they have them, sometimes they don't. Resident 41 stated snacks offered are Jell-O or a fruit cup, only canned sugary fruit and processed food, no fresh fruit. Resident 41 stated, I wish they offered string cheese or crackers. Resident 41 stated he cannot deal with the chicken the way it is cooked. Resident 41 stated residents were made aware a new dietitian had been hired at the facility and stated, Things have changed since she got here, adding, but they can do better. During a concurrent observation and interview with Licensed Vocational Nurse D (LVN D), observed the Nourishment Refrigerator (a mini refrigerator that contains snacks for residents) in the Unit 1 Medication Room which contained 4 blue Jell-O cups, 10 store-bought diced peach/pear cups, and four 6-ounce apple juice boxes. LVN D stated, That's not a lot of options. Sandwiches aren't stocked right now. LVN D stated prepackaged dried snacks (e.g., crackers, chips, cookies) were not readily available on Unit 1, and he would go to the kitchen and request snacks if they were not available in the Nourishment Refrigerator. During an interview with Resident 25 on 4/3/24 at 10:02 AM, Resident 25 stated fruit is typically canned or prepackaged and residents have to ask for fresh fruit if they want anything other than a banana. During a concurrent observation of ordered snack delivery tray and record review of Snack Summary - Week of 4/4/24 on 4/3/24 at 10:30 AM, the record indicated Resident 56 should get Chocolate Pudding, 0.5 cups for the 10:00 AM snack. However, chocolate was crossed out on the label of Resident 56's pudding cup, and vanilla pudding was substituted. During a concurrent observation and interview in the kitchen with COOK A, Registered Dietitian A (RD A), Corporate Dietary Services Supervisor (CDSS), and RD B on 4/3/24 at 10:35 AM: - Observed COOK A making 10 bologna sandwiches. COOK A stated she was making the sandwiches for snacks, noting, I do that when the Activities Director asks. - RD A stated the kitchen closes at 8:00 PM but the Nourishment Refrigerator has snacks for residents at all hours. - RD A stated, We address [food] issues if they're brought up in Resident Council. RD A stated if there are complaints, we'll fix it and change what we offer. - RD A stated chips and fresh fruit, other than bananas, are not offered but she is working on getting more fresh fruit. - Observed dietary ticket on Resident 416's tray indicating 2 Butter Packets.' Tray contained two 5-gram (unit of measure) packets of Gold-N-Sweet Whipped Spread. RD A stated the facility only ordered margarine for resident food trays. RD A stated the facility stocks large blocks of butter for cooking (observed in the kitchen refrigerator). RD A stated Resident 416's diet was a no-added-salt, diabetic diet. RD A stated, I don't see why they can't have butter. During a review of a Foods Product Specification Sheet for whipped spread dated 2024, ingredients are: - Water, - liquid and hydrogenated (charged with hydrogen, changes liquid into solid) soybean oil, - palm oil, - less than 2% of salt, - vegetable mono & diglycerides, - potassium sorbate (a preservative), - citric acid (increases shelf life), - natural & artificial flavor, - beta carotene (color), and - vitamin A (vitamin supplement) added. During a review of Snacks Available to Residents, (undated), the record indicated food items to include graham crackers, saltine crackers, applesauce, vanilla and chocolate ice cream, vanilla and chocolate pudding, Jell-O, cookies, cereal, chips, bananas, peaches, fruit cocktail, chilled peaches, deli sandwich, and egg salad sandwich. During an interview with ADMIN, RD A, and RD B on 4/3/24 at 3:10 PM, RD A stated, We stock [the Nourishment Refrigerator] based on what we hear from Resident Council. RD A stated she was in the process of interviewing residents now about preferences and added, We're checking preferences weekly.

Based on interview, and record review, the facility failed to ensure social services arranged to provide dental and vision services for one of seventeen sampled residents (Resident 416). This failure resulted in Resident 416 feeling like giving up on getting his dental and vision problems addressed. Findings: Review of records indicated Resident 416 was admitted on [DATE] with diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease (difficulty breathing), Diabetes (high blood sugar), and Dysphagia (difficulty swallowing). A review of Brief Interview for Mental Status screening (BIMS) (a cognitive assessment) dated 1/6/24, recorded a score of 14 indicating no cognitive impairment. During an interview with Resident 416 on 4/2/24 at 9:30 am Resident 416 stated, he had been at the facility for about a year and has a cataract in his left eye (a condition in which the eye lens becomes opaque, resulting in blurred vision and the leading cause of blindness in adults) that needs treatment, and his teeth needed to be pulled, but no appointment had been made for either issue. This made Resident 416 feel like giving up on getting his dental and vision problems addressed. During an interview on 4/3/24 at 9:22 am with Minimum Data Set nurse/Social Services/Licensed Vocational Nurse (MDS/SS B) (Minimum Data Set is a resident assessment tool used by MDS nurses to assess residents' functional capabilities and helps nursing home staff identify health problems), MDS/SS B stated she and another nurse, Minimum Data Set nurse/Social Services/Registered Nurse (MDS/SS A) had been helping in Social Services since December 2023. MDS/SS B stated she and MDS/SS A are helping train a new person for social services. During an interview with MDS/SS B on 4/3/24 at 10:29 am, MDS/SS B stated the former social worker's final day was 2/22/24. During a review of Resident 416's Hygiene Notes dated 6/9/23, the record indicated Resident 416 could benefit from oral appliances due to multiple broken or rotting teeth and Resident 416 was interested in doing this. During a review of Resident 416's Dental Notes dated 11/30/23, the record indicated x-rays (images taken of the bones) were completed of Resident 416's mouth to evaluate the degree of damage to his teeth. During an interview with Director of Nursing (DON) on 4/4/24 at 11:39 am the DON stated Social Services usually make dental and vision appointments. The DON stated that the Administrator (ADMIN) delegated the social services work to the desk nurse and the MDS nurse about three months ago. The DON stated that Social Services was inconsistent in the previous three months to when the ADMIN delegated the social services work to the desk nurse and MDS nurse. Regarding Resident 416's vision services, the DON stated the wait between the vision exam on 8/25/23 and the date of referral of 2/27/24 is a long time and Social Services should have followed up on it. The DON confirmed the 11/30/23 dental services for Resident 416 were not followed up on by Social Services as their policy and procedure calls for. During a review of the facility's job description titled, Social Worker, dated October 2020, under Duties and Responsibilities the job description states that the Social Worker will: 1.Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. 2.Coordinate social services activities with other members of the interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure safe administration of medications for four (of seven residents) when: 1. Licensed Vocational Nurse (LVN) C failed to check expiration dates on medications administered to Resident 44, a failure that could have resulted in ineffective medication or adverse reactions to expired medications, and; 2. LVN D failed to confirm the identities of Residents 39 and 60 before administering medications, a failure that could have resulted in administration of medications to the wrong residents with the potential for harmful health outcomes, and; 3. Eye drops different from those ordered were found to have been pulled from over-the-counter stock for Resident 38, a failure that could have resulted in harmful health outcomes. Findings: A facility policy titled, Administering Medications, rev. April 2019, was reviewed which indicated that individuals administering medications verify the resident's identity, the medication, the dosage, the time, and the route before giving the resident his/her medications, and that the expiration date on the medication label is checked prior to administration. 1. Resident 44 was admitted to the facility with diagnoses which include essential primary hypertension (an abnormal increase in blood pressure [the force required to pump blood through the arteries], which is not caused by a medical condition) and a history of myocardial infarction (death of heart muscle tissue due to decreased blood flow, usually from an obstruction in a vessel). During a medication pass observation dated 4/3/24 at 8:45 am, LVN C was asked to point out on a medication label what she checks before administering medications. LVN C stated, and pointed to type on the label while stating, I check their name, the medication, the route, the dose, and look at the instruction. She then proceeded to provide the Resident 44 the following medications, and was not observed to check the expiration dates: PreserVision AREDS one capsule by mouth for macular degeneration (a condition that effects central vision and can lead to partial blindness); Cyanocobalamin (a synthetic form of vitamin B12) 1000 micrograms (mcg, a unit of measure) one tablet by mouth for supplement; Vitamin D 25 milligram (mg, a unit of measure) one tablet by mouth for supplement; Senna 8.6 mg, one tablet by mouth for constipation; Memantine HCl 5 mg, one tablet by mouth for dementia with behavioral disturbance (a form of dementia [a condition that affects brain functions such as memory, language, thinking, or behavior] that includes verbal and/or physical aggression and/or wandering); Zoloft 25 mg 1 tablet by mouth for major depressive disorder (a persistent depressive state) as evidenced by verbalization of sadness. In an interview on 4/3/24 at 9:30 am, LVN C confirmed she had not checked the expiration dates on the medications. A review was made of an order summary report for Resident 44 which contained an order dated 3/23/23 for PreserVision AREDS one capsule by mouth two times a day for macular degeneration; an order dated 12/1/23 for cyanocobalamin 1000 mcg one tablet by mouth one time a day for supplement; an order dated 3/11/24 for vitamin D 25 mg one tablet by mouth one time a day for supplement; an order dated 7/12/23 for senna 8.6 mg, one tablet by mouth one time a day for constipation; an order dated 6/15/22 for memantine HCl 5 mg, one tablet by mouth one time a day for dementia with behavioral disturbance; an order dated 1/10/24 for Zoloft 25 mg by mouth one time a day for major depressive disorder as evidenced by verbalization of sadness. A review was made of a medication administration record (MAR) for Resident 44 in which LVN C documented administering: PreserVision AREDS one capsule by mouth on 4/3/24 at 8:57 am; cyanocobalamin 1000 mcg one tablet by mouth on 4/3/24 at 8:57 am; vitamin D 25 mg one tablet by mouth 4/3/24 at 8:57 am; senna 8.6 mg, one tablet by mouth 4/3/24 at 8:58 am; memantine HCl 5 mg, one tablet by mouth 4/3/24 at 9 am; Zoloft 25 mg by mouth 4/3/24 at 9 am. During a concurrent interview and record review on 4/4/24 at 1 pm, the Director of Nurses (DON) acknowledged that LVN C had not checked the expiration dates when administering medications and confirmed that expiration dates need to be checked before giving them as expired medications can be ineffective or cause adverse effects. 2. Resident 39 was admitted to the facility with diagnoses which include paraplegia (inability to move the lower legs), adult failure to thrive (a state of decline due to poor nutrition, inactivity, depression and decreasing functional ability), and gastroesophageal reflux disease (GERD, a condition in which acidic stomach contents backflow from the stomach and into the throat). Resident 60 was admitted to the facility with diagnoses which include diabetes mellitus (a chronic [long-lasting] disorder that affects how the body converts food into energy) and fractures of the lumbosacral spine and pelvis (bones of the lower part of the back and pelvis that were broken, usually due to an accident). During two medication passes on 4/4/24, the following observations were made: At 11:14 am, LVN D administered the following three medications to Resident 39, and failed to confirm identity: - metoclopramide (commonly used for nausea/vomiting for patients with GERD) 10 milligram (mg, a unit of measure) I tablet by mouth. - simethicone (commonly used for gas/bloating) 80 mg by mouth. - nicotine (commonly used for nicotine addiction) lozenge 1 chewable tablet by mouth. At 11:22 am, LVN D administered the following medication to Resident 60, and failed to confirm identity: - gabapentin (commonly used to treat pain secondary to nerve damage) 100 mg, two capsules by mouth. In an interview immediately after administering medication to Resident 60, LVN D acknowledged he had not checked identity. A review was made of an order summary report for Resident 39 which contained orders dated 12/19/23 for metoclopramide 10 mg 1 tablet by mouth before meals for gastrointestinal (GI) support; simethicone 80 mg by mouth four times a day for GI support; nicotine polacrilex mini mouth/throat lozenge give 1 dose by mouth every 2 hours as needed for smoking cessation. A review was made of a medication administration record (MAR) for Resident 39 in which LVN D documented administering the metoclopramide, simethicone, and nicotine lozenge on 4/4/24 at 11:14 am. A review was made of an order summary report for Resident 60 which contained an order dated 2/26/24 for gabapentin 100 mg give 2 capsules by mouth three times a day for neuropathy (nerve pain). A review was made of a medication administration record (MAR) for Resident 60 in which LVN D documented administering the gabapentin on 4/4/24 at 11:22 am. During an interview dated 4/4/24 at 11:25 am, the DON confirmed nursing should identify resident names before administering medications and listed possible outcomes of failing to do so including that medications may not be given to the right patient. 3. Resident 38 was admitted to the facility with diagnoses which include diabetes mellitus, and heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for nutrients and oxygen). A concurrent observation, and interview, was made during the inspection of medication cart number 4 with Licensed Vocational Nurse (LVN) C on 4/3/24 at 9 am, when it was found that a bottle of Visine dry eye drops was found with the hand-written first and last initials of Resident 38. LVN C stated that the eye drops were over the counter medications that had been pulled from general stock. During a record review of an order summary report for Resident 38 it was found that there was no order for Visine dry eye drops; there was instead an order dated 11/21/23, for Refresh Tears Opthalmic solution (carboxymethylcellulose sodium), instill 2 drops in both eyes every 6 hours as needed for redness/itching, as needed. During a concurrent interview, and record review, dated 4/4/24 at 2:30 pm, the DON confirmed Resident 38 was given the wrong eye drop medication.

Based on interview, clinical record and policy review, the facility failed to ensure that; 1. Two of two sampled resident's (Resident 1 and 2) received a copy of their medical records within two-working days of the request, in accordance with federal regulations; and 2. The facility's medical records policy was in accordance with federal regulations. This failure violated Resident 1 and 2's right to allow them to have a copy of their medical records within 2 business days from their requests. Findings: 1. On 5/1/23 at 12:23 pm, an interview was conducted with Resident 1's family member (FM). The FM indicated that Resident 1 had signed a record release form on 2/21/23, and had not received Resident 1's records timely and in a manner that he could access. FM indicated that he received a flash drive (a memory device of data that plugs into a computer) in the mail on 4/18/23, two months after the records were requested. FM indicated he could not see the medical record information because the flash drive required a password that he was not given. The FM stated that on 4/18/23, he called the facility and notified the Health Information Manager (HIM) about this issue, but never heard back from the facility and the issue remains unresolved. On 5/1/23, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with the diagnoses of a lung disease, altered mental status and Post-Traumatic Stress Disorder. Resident 1 was capable of making his own healthcare decisions. He was discharged from the facility on 2/21/23. A review of the facility's form titled, Request and Authorization for Release Of Health Information reflected that Resident 1 had signed and requested a copy of his entire medical record on 2/21/23. On 5/1/23 at 2:20 pm, an interview and concurrent record review was conducted with the HIM concerning Resident 1's record requests. Resident 1's medical records request form was reviewed, and the HIM confirmed that the record was requested on 2/21/23. She stated that there was confusion with what format the Resident wanted his records in (paper or electronic). When it was confirmed to be electronic, she attempted to download the files on a flash drive but was unsuccessful. The HIM emailed their IT (Information Technology, the management of storing data using computers) Manager (ITM) on 3/31/23, for help. HIM indicated that she did not hear back from ITM until 4/5/23 (5 days later). The ITM proceeded to download the files himself and send the flash drive to Resident 1. HIM did not know exactly when this had happened and stated that she had not followed up on it. She was unaware that Resident 1 was still unable to access his medical records files. The HIM indicated she had not documented any information concerning this incident. She confirmed that Resident 1 had not received a copy of his medical record within 2 business days. On 5/1/23, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE] with the diagnoses of multiple fractures, lung disease, and an anxiety disorder. She was her own responsible party. A review of a record requests faxed to the facility on [DATE] at 9:28 am, from ChartSquad (a company that assists residents with requesting their medical records) revealed a record request signed on 3/1/23 by Resident 2. A Follow-up reminder for Patient Access Summary was reviewed and indicated, One of our members previously sent you a patient access request letter that is still pending. We wanted to send you a reminder to help promote Patient Access! Package sent on March 10th, 2023. On 5/1/23 at 3:07 pm, an interview was conducted with the Assistant Health Information Manager (AHIM). She indicated that she uploaded the documents onto a flash drive and sent it to ChartSquad on 3/24/23 at 11:00 am, four days after the request had been made. She indicated that she did not follow up to see if Resident 2 had received her medical records or if she was able to access the information on the flash drive. 2. On 5/1/23 at 3:07 pm, a concurrent interview and facility policy review was conducted with the HIM and AHIM. The facility's policy titled, Protected Health Information (PHI), Residents' Rights Relative to dated March 2014, indicated, Our facility will act upon a resident's request for access to his/her medical records or other information no later than thirty days after receipt of such request The HIM and AHIM indicated that they thought they had 30 days to get residents a copy of their medical records. The HIM and AHIM indicated that they were both not aware that the federal regulations specified that the facility had 2 days or 48 hours, to copy and provide a resident with their medical record, once requested. HIM and AHIM confirmed that Resident 1 and Resident 2 had not received a copy of their medical records within 2 days. On 5/1/23 at 3:37 pm, a concurrent interview and record review was conducted with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON). The Policy titled, Protected Health Information (PHI), Residents' Rights Relative to dated March 2014, was reviewed. The DON and ADON confirmed that the facility's policy incorrectly indicated that they had 30 days to provide a resident with a copy of their medical record, instead of 2 days.

Based on observation, interview, and record review, the facility failed to ensure that residents were safe from accidents when: 1) The facility did not have policies regarding resident care in hot weather, or resident patio use, and 2) One of six sampled residents (Resident 2) was allowed outside during peak temperatures, left unattended on an outdoor patio for an unknown length of time in hot weather and was found unresponsive on the patio. The patient expired. These failures had the potential to contribute to the death of Resident 2 and endanger all residents by providing patio access during high temperatures with no care plan in place to ensure safe use. Findings: A review of the clinical record indicated that Resident 2 was admitted on [DATE] and had diagnoses of lung disease, heart disease requiring a pacemaker, and kidney failure. He was unable to make his own healthcare decisions and was conserved by the Public Guardian. The Physician Orders for Life-sustaining Treatment, signed [DATE], indicated not to attempt cardiopulmonary resuscitation. A review of a physician order dated [DATE] at 1:51 pm, indicated that Resident 2 was to receive [MEDICATION(S)] 20 mg (a medication used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease) daily unless his systolic blood pressure was less than 110 mm Hg (millimeters of mercury- a unit of measurement). According to the manufacturer's instructions for [MEDICATION(S)], dated ,d+[DATE], excessive diuresis (increased production of urine) may cause dehydration and blood volume reduction with circulatory collapse (severe low blood pressure) and possibly vascular [CONDITION(S)] (occurs when blood clots block your blood vessels) and embolism (obstruction of an artery, typically by a clot of blood), particularly in elderly patients. A review of the Recreation Quarterly Progress Note dated [DATE] at 4:13 pm indicated that Resident 2 regularly enjoyed sitting out on the outdoor patio. A review of the Minimum Data Set (MDS, a resident assessment tool) dated [DATE] indicated that Resident 2 required extensive assistance (staff provide weight-bearing support) from one person for dressing and personal hygiene, limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from one person for moving about in his wheelchair, and supervision (oversight, encouragement, or cueing) by one person for eating. Walking with or without assistance did not occur during that reporting period. A review of the National Oceanic and Atmospheric Administration (NOAA) temperature readings for the facility location on [DATE] at 4:29 pm indicated that the temperature was 102 F (degrees Fahrenheit). A review of a progress note dated [DATE] at 6:39 pm indicated that staff had observed Resident 2 at 4:50 pm on the small patio unresponsive in his wheelchair. Staff assisted him to bed for assessment, where no pulse or respirations were found. During an interview on [DATE] at 4:10 pm, Staff A stated that Resident 2 was last seen between 3 pm and 4 pm on [DATE] sitting in the hallway in front of Nursing Station 1 near the small patio. During an interview on [DATE] at 11:10 am, Staff C stated that the last time Resident 2 was seen was between 3 pm and 4 pm on [DATE] sitting in the hallway in front of Nursing Station 1 near the small patio. During an interview on [DATE] at 11:25 am, Staff E stated that Resident 2 was found unresponsive on the small patio at about 4:50 pm on [DATE]. During an interview on [DATE] at 1:50 pm, the Medical Director (MD) stated that Resident 2 had been declining over the last six months and they were considering hospice services for him. MD did not think Resident 2 could open a door while manipulating his wheelchair, and that someone opened the patio door for him on [DATE]. A review of an IDT note dated [DATE] at 10:35 am indicated that Resident 2 had been assessed to have a temperature of 101.6 F, but that temperature had not been documented at the time. During an interview on [DATE] at 11:47 am, Staff F stated that she found Resident 2 on [DATE] on the small patio slumped over, unresponsive, and pulseless. They took him to his room to better assess him and were unable to obtain any life signs. Residents who are not independent are not allowed outside alone. Usually, staff turn Resident 2 around when they find him trying to get outside. During an interview on [DATE] at 2:51 pm, ADON stated that there were no facility policies regarding resident care during hot weather or resident patio use. During an interview on [DATE] at 1:25 pm, Staff F confirmed that she took Resident 2's temperature when he was found on [DATE] but did not record it. She stated his temperature was 101.6 F. During an interview on [DATE] at 2:20 pm, Staff G stated that the last time Resident 2 was seen on [DATE] was between 3 pm and 4 pm, sitting in the hallway across from nursing station 1 near the small patio. During an interview on [DATE] at 2:25 pm, Staff H stated that on [DATE] a nurse came to nursing station 2 where he was assigned and asked for help. They went to nursing station 1 where Resident 2 was cyanotic (a bluish discoloration due to lack of oxygen) and slumped in a wheelchair. Staff put him in bed and Staff H was unable to obtain a heart rate or respirations, and the oximeter (an instrument used to measure oxygen in the blood) did not register. During an interview on [DATE] at 11:30 am, the Conservator for Resident 2 (Cons) stated that he had been slowly declining over the last year, since having COVID-19 in [DATE]. Resident 2 had experienced difficulty swallowing and weight loss, with decreased food intake starting in [DATE]. He had also lost mobility and needed more assistance from facility staff. Cons stated that she was aware of his decline. During an observation and interview on [DATE] at 2:12 pm on the small patio, the Maintenance Director (Maint) confirmed that there was no thermometer in the small patio. This surveyor experienced the temperature to be uncomfortably hot, and there was no fan or other cooling device present. During an interview on [DATE] at 2:50 pm, the Activities Director (AD) stated that Resident 2 liked the small patio by nursing station 1 and would try to exit to it, but staff would redirect him. He would use the patio independently and with groups. There was no care plan addressing his use of the patio with supervision. He used to use the patio daily, but lately had used it less and less. During an interview on [DATE] at 3:45 pm, Staff F stated that Resident 2 would not go outside alone. The last time she saw him he was sitting across from nursing station 1 near the small patio between 3 pm and 3:30 pm. During an interview on [DATE] at 10:40 am, Staff L stated that Resident 2 had become less able the last four months and was unable to coordinate opening a door and propelling his wheelchair independently. A review of the NOAA temperature readings for the facility location on [DATE] at 1:29 pm indicated that the temperature was 105 F, and at 2:29 pm the temperature was 108 F. During an observation and interview on [DATE] at 2 pm on the small patio, the Maintenance Director (Maint) measured the temperature on the patio and confirmed that the reading was 158 F. Maint stated that the fan running in the corner had been installed on [DATE]. During an interview on [DATE] at 2:15 pm, the Social Services Director (SS) stated that Resident 2 could no longer walk independently, but he could get out a door in his wheelchair. During an interview on [DATE] at 3:23 pm, the Administrator (Admin) confirmed that the facility did not have policies for resident care during hot weather, or for resident use of the patios. Admin stated they followed the current All Facilities Letter (AFL) regarding hot weather from the California Department of Public Health. A review of AFL ,d+[DATE] dated [DATE] indicated that facilities must have plans in place to ensure residents are free of adverse conditions that may cause heat-related health complications. The AFL recommends facilities implement measures to keep residents indoors and out of the sun during the hottest parts of the day. A review of the Centers for Disease Control and Prevention (CDC) website on [DATE] indicated that people aged 65 or older are more prone to heat-related health concerns. During the warmer months, the CDC warns that people with Alzheimer's or related dementias may not always be aware of their surroundings and may be at risk of wandering. Older adults may have difficulty adjusting to sudden changes in temperature, and chronic medical conditions or prescription medicines may affect the body's natural responses to heat and hinder its ability to control temperature or sweat. The CDC recommends a care plan to ensure elderly people have ways to stay cool during extreme heat conditions. (https://www.cdc.gov/aging/emergency-preparedness/older-adults-extreme-heat/index.html.)

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors when medications were administered outside of physician ordered parameters for one of six sampled residents (Resident 2). This failure had the potential to lead to a decline in health status for Resident 2 as well as other residents with medication administration parameters. Findings: A review of the clinical record indicated that Resident 2 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was unable to make his own healthcare decisions, and was conserved by the Public Guardian of [NAME] County. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR for July 2022 indicated that Resident 2 received [MEDICATION(S)] on 7/18/22 at 8 pm, when his blood pressure was 96/56. A review of the MAR for August 2022 indicated that Resident 2 received [MEDICATION(S)] on 8/4/22 at 8 am, when his blood pressure was 101/58. A review of the MAR for August 2022 indicated that Resident 2 received [MEDICATION(S)] on 8/19/22 at 8 pm, when his blood pressure was 98/61. During an interview and record review on 9/7/22 at 12:05 pm, Staff M confirmed that [MEDICATION(S)] had been given to Resident 2 on 8/4/22 outside the prescribed parameters, and that there was no order changing those parameters in the clinical record. During an interview and record review on 9/8/22 at 5:25 pm, Staff N confirmed that [MEDICATION(S)] on 7/18/22 and 8/19/22, as well as [MEDICATION(S)] on 7/18/22, had been given when Resident 2 ' s blood pressure was too low. Staff N confirmed that administration parameters must be followed when administering medications, and that no order was in the clinical record changing the parameters for these medications. During an interview and record review on 9/12/22 at 10:45 am, Staff O confirmed that [MEDICATION(S)] had been administered to Resident 2 on 7/4/22 outside the prescribed parameters for that medication. During an interview on 9/12/22 at 3:13 pm, the Assistant Director of Nursing (ADON) confirmed that medications with parameters should be held if those parameters are not met. A review of the Lexicomp monograph on [MEDICATION(S)] indicated that this medication was used for heart failure, and had a heightened risk of causing significant patient harm when used in error. It may be used for patients if their systolic blood pressure was greater than 100 mm Hg. A review of the Lexicomp monograph on [MEDICATION(S)] indicated that it is a potent diuretic (causes fluid loss) that, if given in excessive amounts, can lead to a profound diuresis (water loss) with water and electrolyte (chemicals in the blood necessary for life) depletion. Therefore, careful medical supervision is required and the dose schedule must be adjusted to the individual patient's needs. [MEDICATION(S)] is used to reduce high blood pressure, and patients must have their blood pressure monitored when receiving [MEDICATION(S)] therapy. A review of the Lexicomp monograph on [MEDICATION(S)] indicated that it is used to treat heart failure, and has a heightened risk of causing significant patient harm when used in error. Heart rate and blood pressure must be monitored while receiving this medication.

Based on observation, interview, and record review, the facility failed to protect food and equipment from potential cross contamination when: 1. Staff did not consistently wear or change aprons when moving from dirty to clean tasks. 2. The ice machine was not clean. These failures had the potential to result in foodborne illness from cross contamination between staff clothing, food, and equipment during food preparation, meal service and dish washing processes, and between the ice machine and ice used in food production and served to residents. Findings: 1. A review of the FDA Food Code 2017, 2-304.11 indicated that food employees shall wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles. A review of the FDA Food Code 2017, Annex 3, 2-304.11 indicated that dirty clothing may harbor diseases that are transmissible through food. Food employees who inadvertently touch their dirty clothing may contaminate their hands. This could result in contamination of the food being prepared. Food may also be contaminated through direct contact with dirty clothing. During an observation, on 4/4/22 at 11:50 am, Dietary Aide B (DA B) wore a white cloth apron but Cook A, Dietary Aide C (DA C), and the Dietary Manager in Training (DMIT) did not wear aprons to protect food, equipment, and their clothing from potential cross-contamination while serving food and assembling resident meal trays during lunch tray line. During an observation, on 4/5/22 between 8:55 am and 9:45 am, Cook A poured a red sauce over the Chicken Enchilada Casserole and wore no apron to protect his clothing from contamination by food splatter. DA B wore a white cloth apron as she worked the clean side of the dish machine. The apron had a large black spot resembling felt pen ink below the pen pocket. DA C and DMIT did not wear aprons to protect their clothing from potential cross-contamination while putting away the truck delivery boxes. Dietary Aide D (DA D) wore a long sleeved, black, quilted coat with a plastic apron over the front as she worked the dirty side of the dish room area. Cook A wore no apron as he cleaned the food production counter. During an observation, on 4/5/22 between 10:45 am and 11:45 am, DA D wore her black coat and no apron as she pureed pineapple in the food production area. DA B continued to wear the apron with the black spot as she carried a tub of trash to a garbage can in the back hall, worked the dirty side of the dish machine, then put away clean dishes, cleaned the clean side of dish machine, and then went to help with cold food assembly for lunch tray line. At 11:25 am, DA B received soiled dishes from nursing at the door and carried them with her hands to the dirty side of the dish machine. She washed her hands and then received additional soiled dishes from nursing and carried them with her hands to the dirty side of the dish machine. She washed her hands, continued to wear the same apron, and proceeded to assist with assembly of cold foods on lunch tray line. DA B did not change into a clean apron to protect against cross contamination as she moved between these multiple clean and dirty tasks. During an observation, and concurrent interview, with DA B on 4/6/22 at 10:05 am, she wore a different white cloth apron with a large light brown stain resembling a coffee stain. DA B stated she wore two aprons each day, one from 5:00 am to 9:00 am, and then she changed it. She stated she wore an apron to protect her clothes (from being soiled by food and splash). She was not observed to change her apron at any time during her shift on 4/5/22, and she did not change her apron between dirty and clean tasks. During an interview, with the Dietary Manager in Training (DMIT) on 4/6/22 at 10:18 am, she stated they had plastic aprons that were mainly for staff working the dirty side of the dish area. She stated staff should change their apron when they go from a dirty task to other (clean) tasks, and they should wash their hands. The DMIT stated she believed apron use was a preference, and added if production staff wore aprons, they'd have to change them every time they went to the refrigerator. During an interview, with the DM on 4/6/22 at 3:15 pm, she stated staff wore coats/ outerwear in the kitchen because, Sometimes it's just cold and they wear a jacket. Since everyone didn't have a corporate-supplied jacket, they wore their own coats when it was cold. The DM confirmed the jackets that the staff wore in the kitchen were what staff also wore for everyday activities in their lives outside the facility. She stated it was not necessarily a cross contamination issue because it was the same as how staff wore their own clothes to work. If staff jackets were filthy, they couldn't wear them. The DM agreed most people didn't wash their jackets as often as they washed their clothes, so could potentially pose a higher risk for cross-contamination. The DM stated the department had plastic aprons and staff had a choice to wear them (or not). She stated staff should wear a plastic apron when working the dirty side of the dish area. They should take it off when they leave the dirty side. She further stated if staff clothes were clean, an apron was not an issue since their policy said clean attire and did not say staff had to wear aprons. Yet observations showed staff did not wear aprons to protect their clothing from potential cross contamination when performing dirty activities such as taking out the trash, putting away corrugated boxes of food from deliveries or carrying soiled dishes. Staff did not consistently change potentially soiled aprons before engaging in food preparation activities, or resident meal tray assembly. The facility's policy titled, Staff Attire, revised 9/17, was reviewed, and indicated that all employees should wear approved attire for the performance of their duties. All staff members will wear clean approved attire, including appropriate footwear for safety, daily. The policy did not suggest or require any use of aprons or changing out soiled aprons to decrease the risks of cross contamination in the dish room or any area in the kitchen. While both the DM and the DMIT stated aprons should be worn by staff working the dirty side of the dish area and that aprons should be changed before leaving the dish area, this potential source of preventable cross contamination was not included in the policy. 2. During an observation, and concurrent interview, and record review, with the Maintenance Director (MAINT) on 4/6/22 at 10:05 am, the ice machine was not clean. There was an accumulation of a black substance resembling mold in two interior locations. The MAINT stated he cleaned the ice machine monthly using the manufacturer's cleaning and descaling products. The Ice Machine Cleaning Log posted near the machine showed it was last cleaned 3/29/22. MAINT stated he cleaned and sanitized the bin using the descaler and sanitizer; he put in the Clear 1 Descaler and ran it for 45-minutes. Then he put in 7-ounces Scotsman Cleaner for 45-minutes. A review of the manufacturer's instructions titled, Scotsman Ice Systems, C0530D through C1030D Remote Condenser Models - User Manual: Cleaning, Sanitation and Maintenance, pages 19-20, dated December 2014, directed use of larger amounts of cleaner and descaler than was described by the MAINT. It directed use of 10 to 12 ounces of Scotsman Clear 1 ice machine scale remover to be poured into the reservoir. It directed mixing a cleaning solution of 1 ounce ice machine scale remover with 12 ounces of water to flush out the curtain in the ice machine and clean the removable parts. Step 14 directed creating a solution of sanitizer mixing 8 ounces NuCalgon IMS II, and 5 gallons of 105-115-degree Fahrenheit water to create a 200 ppm (parts per million) active quaternary solution (sanitizer) used to wash sensors, curtain, water distributor, freezing compartment and evaporator cover. Cleaning the ice storage bin included use of 7 ounces Scotsman Clear 1 ice machine scale remover to 84 ounces potable water to wash all interior surfaces of the bin, followed by thoroughly washing all interior surfaces of the ice storage bin.

Based on observation, interview and record review the facility failed to ensure an environment free from abuse and neglect when: 1. A wandering resident (Resident 6) did not have care plan interventions in place to address his dementia (a group of symptoms that affects memory, thinking and interfers with daily life) and behavioral needs to prevent resident to resident altercations. 2. The facility did not provide sufficient staffing to ensure the protection and safety for all 58 residents including not providing staff for 24 hour, 7 day a week 1:1 care for Resident 6. The failure to protect and ensure the safety of all 58 residents resulted in two resident to resident altercations with injuries and resident fear and anxiety. An immediate jeopardy (IJ, deficient practice that caused or is likely to cause serious injury, serious harm, serious impairment or death where immediate corrective action is needed.) was declared on 4/14/21 at 2:28 pm with the facility Administrator, for the failure to provide supervision and care to prevent unsafe resident wandering into other resident rooms causing altercations with injuries, residents feeling unsafe and anxious, and put all 58 residents at risk for abuse and injury. An immediate corrective action plan to address the unsafe wandering was provided by the facility's Administrator and presented to the team. The IJ was abated onsite on 4/19/21 at 2:48 pm. Findings: 1. A review of a facility policy titled Abuse Prohibition revised 8/1/16, indicated the facility shall prohibit abuse and neglect by prevention of occurrences, identification of incidents/allegations, investigation, protection of residents, and respond to the results of their investigations. Neglect is defined as a threat to an adult's health or welfare by physical or mental injury or impairment, deprivation of essential needs or lack of protection from these threats. Staff shall identify events occurrences, patterns, and trends that constitute abuse, and determine the direction of the investigation. This includes resident to resident abuse. If the suspected abuse to a resident is from another resident, who has in any way been threatened or attacked shall be removed from the setting or situation and monitored by staff to assure safety. The facility shall seek alternative placement for the resident exhibiting the abusive behavior if warranted. The Center Executive Director or designee shall take all necessary corrective actions depending on the results of the investigation. A review of Resident 6's record indicated he was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 6 was unable to make his own health care decisions, he had a Resident Representative (RR) to make decisions. A review of Resident 6's Minimum Data Set (MDS, resident assessment tool) dated 1/29/21, indicated his Brief Interview for Mental Status scored a two (severe cognitive impairment). Resident 6 required extensive assistance with eating and toileting; was frequently incontinent of bladder, and was always incontinent of bowel. Resident 6's functional level indicated he was unsteady when walking, and was only able to stabilize with staff assistance. A review of nursing progress notes dated 1/25/21 at 12:13 pm, the weekly summary indicated Resident 6 required redirection to stay in bed, will self ambulate (shuffle) and was a high fall risk with a history of falls. Resident 6 required extensive assist with all activities of daily living. A review of a daily skilled nursing note dated 1/26/21 at 4:16 am, indicated Resident 6 will wander around hallways and needs constant supervision. A review of nursing progress notes dated 1/28/21 at 2:30 pm, indicated Resident 6 wanders around hallway, strips clothes off and needs constant supervision due to lack of safety awareness and confusion. Resident 6 slept a few hours last night, will keep attempting to get out of bed and has sleep cycle issues daily. A review of Resident 6's care plan dated 2/12/21, indicated Resident 6 was at risk for elopement related to dementia and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included visual checks, activities, allow time for expression, monitor for pain, provide calm well lit environment, maintain sleep/wake schedule, and social service support. A review of Physical Therapy notes from 1/25 to 2/21/21, indicated Resident 6 had minimal awareness of situation, had decreased communication skills, decreased orientation and attention to task requiring maximum verbal and cues to complete simple one step commands. A review of a nutrition progress not dated 2/15/21 at 2:55 pm. Registered Dietician (RD) A documented observed wandering around bumped head on glass twice, was trying to get out through the glass. A review of nursing progress notes dated 2/18/21 at 10:25 pm, indicated Resident 6 continued ambulating in hallways and going into other residents' rooms. A review of an Interdisciplinary Team (IDT, various disciplines review and develop resident plan of care) note dated 2/22/21 at 3:46 pm, indicated Resident 6's confusion was severe and he wanders aimlessly in hallway with tendency to push exit door. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include directions to check the Wandergard every shift for placement or functionality. 1. a. Resident to resident physical altercation #1 A review of a nursing progress note dated 2/25/21 at 7:23 pm, Registered Nurse (RN C) documented he heard yelling from a resident room, he entered the room and found Resident 11 yelling at Resident 6. The documentation included that the two residents were separated and then Resident 11 struck Resident 6 beneath the eye. A review of a Situation Background Assessment Recommendation (SBAR) communication form dated 2/25/21 at 7 am, indicated Resident 6 had a physical altercation with Resident 11. Nurses noted bruising to Resident 6's right eye. A review of an IDT note about the resident to resident altercation between Resident 6 and Resident 11, dated 2/26/21 at 1:30 pm, included interventions to immediately separate residents, perform skin check, continue medications, visual/check supervision as needed, redirected as needed, stop sign for Resident 11 at door, activities, and neuro psych evaluation (a series of tests designed to measure a person ' s cognitive abilities such as memory, attention, communication, and problem-solving, an assessment of psychological symptoms, and a review of the person ' s medical history). Resident 6 had a behavior of constantly pacing and wandering around facility. A review of Resident 6's care plan for a resident altercation dated 2/25/21, indicated interventions of visual check/supervision as needed, redirect as needed, continue Wanderguard, social service follow through, continue medications, skin check and anticipate daily needs. There were no new interventions noted. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/21, there were 23 hashmarks noted for pacing. No further monitoring for pacing was found in the record. A review of a nursing progress note dated 3/1/21 at 2:49 am, indicated Resident 6, needed constant redirection from other resident's rooms and beds. A review of an SBAR communication form dated 3/3/21, indicated Resident 6 had a change of condition due to an increase in agitation. A review of a care plan dated 3/3/21, indicated Resident 6 was reported exhibiting physical aggression and agitation. IDT recommendations included observe and monitor behavior, visual checks, redirect, provide rest periods, nutrition/fluids, activities, pharmacy review if determined, review with Medical Director (MD) for use of mood stabilizer (medication to treat mood fluctuations) at this time. In a review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no changes to plan of care noted. A review of an IDT note dated 3/5/21 at 10:03 am, late entry, reported with physical agitation and aggression. Review with MD A for use of mood stabilizer at this time - provide and observe rest periods daily. A review of an IDT behavior note dated 3/5/21 at 10:03 am, Director of Nursing (DON) 2 indicated Resident 6 had constant pacing and wandering around facility. The note indicated Resident 6 is redirectable at times and provided with escort upon staff availability. He remained pleasant until the incident that was reported signs and symptoms of aggression. There were no changes to the plan of care noted. A review of nursing progress note dated indicated: On 3/4/21 2:18 am, Pt (patient or resident) had S/S (signs and symptoms) of aggression, but was able to redirect after attempts. Complaints of moderate pain which was alleviated by as needed pain medication. On 3/8/21 at 3:06 am, Resident 6 required constant redirection out of other resident rooms and high risk for leaving facility, had signs and symptoms of pain, and at times aggressive. On 3/10/21 8:56 pm, behavior reviewed Resident 6 required constant redirection, elopement risk, tends to go into other resident rooms and at times aggressive. On 3/11/21 at 1:17 pm, Resident 6 struck out at caretakers. A review of the MAR for March 2021, indicated Resident 6 was to be monitored for episodes of uncontrollable irritability dated from 3/12 to 3/16/21. On 3/12 and 3/13/21 both dates had 18 hashmarks, on 3/15/21 10 hashmarks, and on 3/16/21 there were nine hashmarks. 1. b. Resident to resident physical altercation #2 A review of an IDT note dated 3/12/21 at 9:59 pm, DON 2 documented CNA (Certified Nursing Assistant) reported that demented resident (Resident 6) was in (a resident) Room and had a confrontation with Resident 31 at 6 pm. They were observed holding each others arms. They were pulled apart and Resident 6 was redirected back to his room. As a result of episode, Resident 31 had a skin tear to his right wrist. Resident 6 was redirected back to his room and required constant visual checks to ensure he does not end up near exit doors. Interventions, referral to MD A for review of event and medication, ongoing redirection, side by side assitance as needed/available, drinks snacks, and activities. A review of a progress note assessment dated [DATE] at 7:48 am, DON 2 noted since the last evaluation there have been no behavior symptoms present. DON 2 recommended behavioral health referral. A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 3/26/21. During a Drug Regimen Review dated 3/12/21, there was documentation that DON 2, Administrator, Social Services, and Activities Director discussed an assessment of Resident 6, and included that since the last evaluation there have been no behavior symptoms present. Refer to to anti anxiety monitor log. No medication changes last 30 days for the [CONDITION(S)] medications (medications that treat mood and thinking). A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff report increased agitation, wandering, and acting out, sleep pattern reversed. Started [MEDICATION(S)] (medication stabilize mood) 250 milligrams twice a day. A review of a weekly summary note dated 3/16/21 at 6:21 pm, indicated Resident 6 woke up angry yelling and had raised anxiety. A review of a physicians order dated 3/16/21 indicated the use of [MEDICATION(S)] (used for calming) aroma therapy. A review of a [CONDITION(S)] (medications that affect mental state) Evaluation Form dated 3/16/21, indicated Resident 6 experienced anxiety, shaked fists, striking, confused, and does not like redirection. Nursing staff reported wandering especially at night going into other resident rooms. Behaviors being tracked indicated hitting, signs and symptoms of anxiety, yelling, and wandering. [MEDICATION(S)] (antipyschotic used for mood/mental disorders) discontinued 2/23/21. Assessment indicated dementia with behaviors. Resident looked tired when walking. Medical Director (MD A) indicated [MEDICATION(S)] ([CONDITION(S)] for anxiety) at night for sleep. A review of a nursing progress note dated 3/18/21 at 10:39 pm, indicated Resident 6 wandering occurs daily and posed significant risk and he was intruding on others. Resident 6 experienced impulsive behavior, constant redirection and elopement risk, tends to go into other residents rooms and has sleep cycle issues. A review of an IDT review of a fall note dated 3/18/21 at 9:08 am, DON 2 documented Resident 6's root cause of fall was impaired cognitive skills, safety awareness and decision making. Use of new medication [MEDICATION(S)] (mood stabilizer). Resident 6's behavior of wandering and pacing in hallways with potential to enter other residents' room and opening facility exit doors which he may end up outside if not attended properly. No changes in interventions, continue visual check when wandering around and redirect. A review of a nursing note dated 3/21/21 at 2:25 pm, Licensed Nurse (LN) F documented Resident 6 exhibits behavior of shadowing staff and other patients; hovering near exits; frustration. A review of a weekly summary note dated 3/30/21 at 4:57 pm, indicated Resident 6 posed a significant risk and was intruding on others. Impulsive, agitation/restlessness, anxiety. Resident 6 had sleep-cycle issues daily, and shadows staff and other residents. A review of a weekly summary note dated 4/6/21 at 7:04 pm, indicated Resident 6 behaviors physical and verbal are directed toward others daily or almost daily, rejection of care, wandering, frustration and hovering near exits. A review of a weight change note dated 4/8/21 at 3:47 pm, indicated Resident 6 lost 6.8 pounds, about a 4.8 percent weight loss in one month, this was unavoidable as he walks continuously throughout building related to his dementia. He slept only a couple of hours at at time. Resident 6 was burning calories due to walking. A review of an IDT review of fall note dated 4/12/21 at 8:40 am, indicated Resident 6 had no falls since 3/17/21, he has a staff member while he was awake because he walks non stop related to dementia. Interventions in place are working so far. Continue current plan of care. There was no review or evaluation of behavior monitoring related to episodes of wandering in other resident rooms, inability to relax, striking out, sleep hours, and effectiveness of pharmacy interventions. A review of physicians orders dated 4/12/21, indicated [MEDICATION(S)] (a natural sleep supplement) 3 milligrams by mouth at bedtime was added for Resident 6. During an interview on 4/14/21 at 4:49 pm, MD A stated the day shift nurses stated Resident 6 was better and he had not spoken to any nursing staff on night shift. MD A stated Resident 6 had not hit anyone in the last week. MD A considered pain as a potential trigger, confirmed Resident 6 may not be able to verbally state pain level on pain scale. MD A stated he depended on facility staff and licensed nurses to provide information to make medical decisions about residents. MD A stated he did not want to overmedicate Resident 6. A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/13/21 9:15 am, Resident 6 ambulated in hallway, wearing gait belt (a cloth belt around waist for staff to grasp on to, to assist with holding resident steady) and was accompanied by a staff member. During an observation and concurrent interview on 4/13/21 at 12:30 pm, Activity Assistant (AA) 2 was seated at the bedside with Resident 6 while he was relaxing in a semi-sleep state. AA 2 stated she provided 1:1 supervision for Resident 6, and stated that other staff cover 1:1 during the 8-hour day shifts on her days off, so that during the day shift he has 1:1 care 7 days a week. She stated there was no 1:1 staff on the evening or night shifts, and there was not a specific CNA who cared for him, but that the CNAs took turns when he was awake on the evenings and night shifts. During an observation on 4/13/21 at 12:50 pm, Resident 6 attempted to exit through a doorway, was redirected by AA 2 and he continued ambulating down hallway. During an in interview on 4/14/21 4:15 pm, RN C stated he became aware of a resident to resident incident between Resident 6 and Resident 11 on 2/25/21, when he heard yelling from Resident 11's room. When he arrived, he found Resident 6 and Resident 11 face-to-face. RN C stated he reached out and turned Resident 6 to remove him from the room, and then Resident 11 reached out and hit Resident 6 in the eye. RN C escorted Resident 6 out of the room and noted faint redness to his eye. During an interview on 4/15/21 at 10 am, Activity Director (AD) stated staffing had been an issue, and showers were not being done. AD stated activity staff are mainly with Resident 6 during the day because they have three staff. AD stated Resident 6 sleeps about an hour in the afternoon and activity staff does not chart or communicate Resident 6 amount of sleep to anyone. During an interview on 4/15/21 at 11:45 am, LN S stated he'd observed that Resident 6 has limited awareness of safety for self and others. LN S stated during the day, Resident 6 was continually supervised. LN S recalled however observing Resident 6 wandering unsupervised into another resident's rooms. During a concurrent interview and record review on 4/15/21 at 2:40 pm, DON stated Resident 6 should have started on [MEDICATION(S)] (medication that treats sleeplessness related to depression) a couple week ago for sleep, but the medication was not started until yesterday (4/14/21). DON also stated that monitoring Resident 6's sleep was included in this order. DON stated there was no order, care plan or IDT that discussed the need for 1:1 staff or how they determined 1:1 staffing should be scheduled for only day shift. DON stated there was no official schedule, staff just did it when they could and 1:1 staffing was not consistent. DON stated monitoring Resident 6 usually fell to the activities staff due to having more activities staff available during the day. DON stated that not having enough nursing staff and monitoring Resident 6 could interfere with the CNAs ability to care for other residents. DON stated Resident 6 would strike out while receiving care and DON stated she was unaware this was not noted in the record. DON could not find a wandering elopement assessment in the record for Resident 6, which all residents should have received on admission. DON stated she was unaware of Resident 6's falls or Resident 6 entering other residents rooms. DON stated she started working at the facility about a month ago. DON stated there were no official staffing assignments for staff to monitor Resident 6 until yesterday (4/14/21). DON stated there were no consistent behavior or sleep monitoring documented for Resident 6 on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated staffing had been an issue and they were working on it. During an interview on 4/19/21 at 10:30 am, LN E, indicated Resident 6 would shake his hands when frustrated and he could strike out. LN E stated Residetn 6 required constant supervision and redirection. LN E stated she covered night shift at times, and confirmed no behavior or sleep monitoring was documented in the record. LN E stated there was no official 1:1 schedule for Resident 6. LN E stated the activities staff usually covered 1:1 stafffing for Resident 6 during the day, but no staff were assigned at night. LN E explained it was very difficult to provide 1:1 staffing to Resident 6 at night because at times other resident's needs became important. LN E stated Resident 6 wandered into a female resident room often. LN E stated yes, you can believe demented residents when they make allegations about abuse. LN E stated Resident 6 had pain, and would often hold his lower back area. LN E stated pain can be a trigger for behaviors and Resident 6 would grimace when he was in pain and due to confusion Resident 6 was unable to give a pain scale number or rating as he was non verbal only. LN E stated Resident 6 was much better since having a full time 1:1 staff. LN E stated this facility was not the right setting for him. LN E stated she had told administrative staff about needing more staff at night to supervise Resident 6. LN E stated she told DON 2, Staffing Coordinator, and Director of Staff Development, there was no extra staffing given to assist with Resident 6. During an interview on 4/19/21 at 10:45 am, LN F stated Resident 6 was exit seeking, mainly at the front door. LN F stated he could strike out while receiving care and he would hold his hands up and shake when aggressive, mainly with incontinence care and showers. LN F stated Resident 6 did not sleep much and was walking all the time. LN F stated Resident 6 was unable to state a pain level due to confusion and stated she was unsure where Resident 6's pain was. LN F stated Resident 6 did not like to be unclean from incontinence. LN F stated [MEDICATION(S)] (an antianxiety medication) may have contributed to Resident 6 sustaining a fall that resulted in a forehead abrasion. LN F stated [MEDICATION(S)] should not be given for sleep and did not improve Resident 6's sleep. LN F stated no there was no consistent behavior or sleep monitoring documented in the record. LN F stated the goal of the IDT was to try music and aromatherapy instead of drugs for sleep. LN F stated Resident 6's frequent wandering was communicated to the former DON 2, many times, but there were no changes made to night shift staffing. LN F stated Resident 6 did not have 1:1 staffing 24 hours a day, 7 days a week. LN F stated since starting [MEDICATION(S)] the night shift had reported Resident 6 was sleeping more and nursing staff were now tracking Resident 6's amount of sleep. During an concurrent interview and record review on 4/19/21 at 1:25 pm, Social Services Director (SSD) stated alternate placement was not sought for Resident 6 until 4/19/21. SSD stated eight dementia care facilities had been contacted for placement. A general note dated 4/19/21 indicated there was a discussion with the RR about a transfer to a dementia secure unit. SSD stated the IDT meeting notes did not discuss an alternative placement for Resident 6. SSD stated on occassion she had come into work on the night shift due to living close by the facility, to help night shift with staffing to supervise Resident 6 while he was sleeping. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to monitor for hours of sleep every shift daily, tallied by hashmarks. During an interview on 4/14/21 at 10:30 am, Resident 45 recalled times when Resident 6 wandered in and he would usually wander around their room. Resident 45 stated Resident 6 once sat on the end of her bed. Resident 45 stated, He's a nuisance. It feels eerie. There's something in this room he wants. 2. During an interview on 4/14/21 at 3 pm, AA 2 stated Resident 54 had told her that she woke a couple days ago to Resident 6 touching her hand and standing over her bed and told her it scared her. AA 2 stated Resident 35 told her Resident 6 had come into her room and moved her leg so that he could sit on her bed, which made her uncomfortable. AA 2 stated Resident 39 had reported Resident 6 had sat on her bed as well. During an interview on 4/14/21 at 4 pm, Resident 39 stated that Resident 6 had been in her room. Resident 39 stated Resident 6 usually stood in the room or looked at her things. Resident 39 stated that Resident 6 attempted to climb into bed with her twice, both times staff removed him when she called. She stated Resident 6 had not come into her room since staff placed a mesh stop guard across her entry to her room to keep him out. A review of Resident 60's record indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Admission Minimum Data Set (MDS, a standardized resident assessment), dated 3/29/21, indicated Resident 60 was cognitively intact (able to think and reason). During an interview on 4/13/21, at 4:30 am Resident 60 stated, Resident 6 came into my room early this morning. Around 3:30 am, I woke up to Resident 6 standing over me and it really scared me. This is not the first time Resident 6 has come into my room at night and it scares me to death every time. During a concurrent observation and interview on 4/13/21, at 4:00 am, with CNA R, at the facility in the lobby by the front entrance, CNA R was observed to be sitting on a bench by herself head down, next to Station 1's nursing station. CNA R stated, I am assigned to be Resident 6's 1:1 aide but he is in bed right now and someone will let me know when he gets up. CNA R stated, Once last night when I went to the bathroom Resident 6 wondered into Resident 60's room and another staff member had to get him out. During an interview on 4/13/21, at 5:30 am, CNA Q stated, there are only 2 of us on at night and when we are in rooms performing patient (resident) care we cannot keep an eye on Resident 6 and keep him out of other residents rooms. A review of the nursing staffing assignments and sign in sheets for night shift (6 pm to 6:30 am) indicated: From 3/1 to 3/14/21, there were no nursing staff assigned to Resident 6 for a one on one (1:1, staff to resident monitoring). On 4/5/21, there was were no nursing staff assigned to Resident 6 for 1:1 monitoring. During an interview on 4/19/21 at 1:18 pm, Staffing Coordinator (SC) stated the night shift staffing consisted of four CNAs and two nurses no matter what the census or acuity (need) level. SC stated she had not been informed from anyone in administration about any increased acuity or more staffing needs for one on one (1:1, monitoring) for Resident 6 from January 2021 to present. During confidential resident interviews on 4/13/21 at 10:31 am, two of six residents mentioned a male resident (Resident 6) that came into their rooms, one stated they felt unsafe and the other stated I don't trust him. During a concurrent observation and interview on 4/12/21 at 03:30 pm, Resident 31 had a stop sign that was attached to the room doorway, and stated they have resolved the problem of the guy (Resident 6) who came in his room. During an interview on 4/14/21 at 8:30 am Resident 18 stated, (Resident 6) came in to our room everyday. especially at night, two nights ago, he tried to get into my roommate's bed (Resident 8) and she told the staff. A review of Resident 35's Progress Notes dated 4/14/21 at 8:47 am, indicated, Social Services Director spoke with Resident 35 in the morning related to Resident 6 wandering. Resident 35 stated that this particular resident (Resident 6) has not wandered into their room recently. During an interview on 4/19/21 at 1:40 pm Resident 18 stated, (Resident 6) hasn't come into my room since last week, they are doing one and one now, and I feel safer. During a concurrent interview and record review on 4/20/21 at 8:04 am, DON stated the information from the risk management system (RMS, where incidents are tracked and recorded) was not integrated into the resident's electronic medical records. DON stated the RMS system only had recorded two falls for Resident 6 on 2/11 and 2/25/21, missing two other falls and only included one resident to resident altercation for Resident 6. DON stated the IDT notes about falls and resident to resident altercations, did not include detailed investigations and no evaluation of past interventions. DON stated during the time between herself and the previous DON 2, the SSD ran the IDT meetings. DON stated she had just started participating in IDT with SSD and the Activities Director. DON stated she did not know Resident 6 very well. DON stated she would include CNAs in IDT especially for Resident 6, to assist with care planning. DON stated Resident 6 required a secure dementia unit. The Clinical Consultant (CC) joined the conversation about the nursing documentation found in the record. CC stated the nursing documentation was not integrated with the progress notes. CC stated they had concerns about the documentation in the progress notes. CC stated the expectation for any reported concerns through their risk management system such as falls or resident to resident incidents, she would expect a root cause analysis with plan of action, and a pharmacy review. CC stated they had identified the issue with their electronic medical record with progress note integration issues and were looking at it in their Quality Assessment and Performance Improvement Committee.

Based on food production observations, dietary and contracted vendor interview and departmental document review the facility failed to ensure safe and effective food production systems when; 1) Three residents in a feeding census of 50 were served unpasteurized, undercooked shell eggs. The use of unpasteurized, undercooked eggs may result in the transmission of Salmonella Enteritidis resulting in foodborne illness and in severe instances may result in death. Salmonella Enteritidis (S. Enteritidis) is a bacteria associated with unpasteurized shell eggs and may cause foodborne illness. While the death rate is generally less than one percent in a healthy population S. Enteritidis has a 3.6% death rate in outbreaks in nursing homes and hospitals, with the elderly being particularly affected. The effective dose can be as low as one cell, depending on age and health of host. Symptoms include nausea, vomiting, abdominal cramps, diarrhea, fever and headache [MEDICATION NAME] ,[DATE] days. Complications include dehydration which can lead to death the elderly, and the immunocompromised, if not treated promptly. Additionally, S. Enteritidis may lead to [DIAGNOSES REDACTED] (i.e., arthritis from an immune reaction) which may follow 3 to 4 weeks after the onset of acute symptoms. S Enteritidis may also cause blood poisoning ([MEDICAL CONDITION]) or infect the blood, internal organs, and/or joints (Bad Bug Book - Food and Drug Administration). The standard of practice requires additional safeguards for highly susceptible populations, such as those residing in nursing homes. It requires pasteurized eggs shall be substituted for raw eggs in the preparation of partially cooked foods such as soft cooked or fried eggs (USDA Food Code, 2017). [STATE] Department of Agriculture requires that pasteurized shell eggs be labeled as such on the shipping box and/or the stamping of individual eggs with a P. As a result of the unsafe food handling practices an Immediate Jeopardy was declared on [DATE] at 9:25 AM in the presence of the facility Administrator. The extent, the lack of the contracted vendor to provide pasteurized shell eggs for residents, considered a highly susceptible population, who were served eggs with undercooked yolks and the lack of a qualified Director of Food Services providing oversight and guidance to dietetic services staff. An acceptable plan of action was provided by the facility Administrator on [DATE] at 4:00 PM. The actions to remove the immediate jeopardy situation included: removal of all unpasteurized eggs; removal of the unqualified Director of Food Services; purchase of pasteurized shell eggs; designation of an on-site Registered Dietitian as the Director of Food Services effective [DATE]; availability of the Director of Food Services to dietetic staff on weekends via phone consultation; and in-service training of all food production staff in relationship to the use of pasteurized shell eggs when offering undercooked eggs. The immediate jeopardy was abated (reduced in amount, degree or intensity and immediacy) on [DATE] at 10:30 AM when the facility was able to demonstrate the presence of pasteurized shell eggs; staff competency in relationship to the use of shell eggs; and the presence of a full time qualified Director of Food Services, who was a Registered Dietitian, for day to day management and guidance of foodservice operations. 2) lack of cool down monitoring of foods capable of supporting bacterial growth associated with food borne illness; 3) storing of food production equipment that was wet; 4) presence of flies in dietetic services; 5) the food production sink was plumbed directly into the waste water system; 6) dietary staff were not wearing aprons and did not practice good clothing hygiene; 7) multiple areas of the kitchen were not clean; 8) one dietary staff member (Dietary Staff D) was not wearing a beard restraint; 9) the Director of Food Services and Dietary Staff A engaged in food production practices that contributed to contamination of foodservice equipment and 10) there were stored food items that were unlabeled, undated and/or expired. These lapses in safe food handling practices may result in bacterial or physical contamination of resident food which may lead to food borne illness further compromising medical status of 50 residents receiving meals in a facility census of 64. Findings: 1. During initial tour on [DATE] beginning at 9:00 AM there was a case of shell eggs in the refrigerator adjacent to the dining room door. It was noted the eggs were not pasteurized. On [DATE] beginning at 7:00 AM the Director of Food Services (DFS) was preparing breakfast. During meal preparation he pulled a flat of unpasteurized shell eggs from the refrigerator. In a concurrent interview the DFS stated he had several residents that wanted fried eggs. The DFS proceeded to place eggs on the grill. In a concurrent interview the DFS stated the eggs were done when the white was fully congealed and the egg yolk remained jiggly. The surveyor asked the DFS how food safety was ensured with the use of shell eggs. The DFS replied he was using pasteurized eggs. The surveyor asked how he knew they were pasteurized. The DFS stated the box was labeled as such. In a concurrent observation Vendor Registered Dietitian B (VRD) pulled the box from the refrigerator. There was no labeling on the box or the individual eggs indicating they were pasteurized. Additionally, there was no indication the DFS or VRD B recognized the eggs were not pasteurized. The DFS continued to use the unpasteurized eggs for residents. Observation in the dining room on [DATE] at 7:35 AM, demonstrated there were 2 residents (Residents 37 and 214) who were consuming over easy eggs. The egg yolk was runny, not firm. Additional observation on [DATE] at 7:43 AM, the DFS prepared additional soft cooked eggs for Resident 38 as well as an additional 2 separate orders for Resident 37 who requested a total of 6 eggs during breakfast. In a follow up observation and concurrent interview on [DATE] at 8:05 AM with the DFS and VRD B the surveyor asked to again look at the labeling of the shell eggs. At that time the DFS stated he misspoke and the eggs were not pasteurized. The DFS stated he stopped ordering pasteurized shell eggs approximately 1 month ago because the unpasteurized eggs were less expensive. He stated he had a limited food budget and was trying to keep within designated parameters. He also stated his food budget was developed at the corporate level but had no knowledge of how the food budget was determined. In a concurrent interview VRD B stated part of her position duties was to complete kitchen reviews. Review of food invoices beginning [DATE] revealed that beginning on [DATE] the facility discontinued the purchase of pasteurized shell eggs. In an interview on [DATE] at 01:39 PM with VRD A stated she has been coming to the building 2 times/week for the past 3 months. VRD A stated she has been told by her supervisor not to participate in kitchen work however, has done monthly audits. VRD A acknowledged there were many issues in the kitchen and has spent a small amount of time working with staff. She also stated she was aware the DFS did not have the skill set to provide guidance and oversight to dietetic services. Based on recent guidance from her supervisor her position is clinical, not foodservice. In an interview on [DATE] at 2:53 PM, Vendor Staff (VS) C, the position responsible for oversight of the facility on the behalf of the contracted foodservice vendor, stated she has been with company for three months and has had one visit, [MEDICATION NAME] approximately three hours, intended as an introduction to the facility. She stated she did a brief kitchen walk though, but not an onsite in-depth review. She also stated the primary identified issue during that visit was staff not reporting for work. There was no documentation of the visit. In an interview on [DATE] at 11:37 AM, Vendor D confirmed an established Registered Dietitian contract for 16 hours per week. Vendor D also confirmed a recent call from VS E at which time there was a client request for VRD A to focus only on resident clinical nutrition as the hours were limited. In an interview on with the Administrator on [DATE] at 2:38 PM, he indicated that any foodservice internal audits were done at his request to determine the status of the department. He also stated he evaluated the effectiveness of dietetic services based on resident complaints. The administrator acknowledged this would focus on meal temperatures and flavor, however would not assess food safety. The Administrator also acknowledged a Registered Dietitian would be the expert in evaluating foodservice operations. Review of an undated recipe titled Fried Eggs number 2707 guided staff to utilize pasteurized shell eggs. Undated position description titled Dining Services Director/Account Manger indicated the DFS was responsible for ensuring established sanitation and safety standards were maintained. Review of food invoices revealed the DFS discontinued the use of pasteurized eggs beginning [DATE]. Review of four Food Service and Sanitation audits, dated ,[DATE], ,[DATE], ,[DATE] and [DATE] failed to comprehensively evaluate food production operations. The food safety component of these audits was limited to items such as use of hair restraints, refrigerator/freezer temperatures, labeling/dating, recording of dish machine temperatures, chemical storage and handwashing. The remaining audit categories consisted of sanitation and cleanliness reviews. An additional review completed by the DFS dated [DATE] was limited to general feedback from residents and families. There was no evaluation of issues related to food safety. Review of undated contract titled Exhibit A Description of Services, in relation to dietetic services, indicated it was the responsibility of Vendor F to perform services in accordance with all applicable federal, state and local laws. 2. Potentially Hazardous Foods (PHF's) are those capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as tuna are considered PHF's. The standard of practice for handling PHF's is to ensure time and temperature control for food safety. Specifically, PHF's that are prepared from room temperature ingredients must be monitored for cool down after preparation and reach a temperature of 41 degrees F (Fahrenheit) within no more than 4 hours (USDA Food Code, 2017). During food production observation on [DATE] at 11:30 AM, Dietary Staff (DS) B was preparing tuna salad by mixing a 5 pound can of tuna with mayonnaise. In a concurrent interview DS B stated both ingredients were obtained from the dry storage area. Upon completion of the salad, DS B covered the item, dated it and placed it in the refrigerator. There was no temperature monitoring prior to putting the item in the refrigerator. On [DATE] at 3:57 M, the surveyor took a temperature of the tuna salad which was 45 degrees F. In an interview on [DATE] at 10:30 AM, DS I stated she was trained to monitor temperatures during the cool down process and acknowledged the temperature was not taken on [DATE]. In a concurrent interview with Vendor Staff (VS) E she acknowledged undated facility document titled Cooldown Log did not include guidance for monitoring room temperature PHF's. Review of facility policy titled Food handling dated [DATE] revealed it was not in accordance with food safety standards, as cool down monitoring was limited to hot PHF's. It did not address PHF's from room temperature ingredients. Review of undated recipe titled Tuna Salad failed to provide additional guidance with respect to food safety monitoring. 3. The standard of practice is to ensure cleaned equipment and utensils are stored in a self-draining position that allows air drying. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. (Food Code, 2017). During warewashing observation on [DATE] at 11:00 AM, it was noted that DS C was inverting and stacking clear plastic food bins and patient meal trays on top of one another while they were still wet. This process is referred to as wet-nesting. Wet nesting occurs when clean pans are stacked together as they are coming out of the dish machine or pot sink without completely drying first. In a concurrent interview DS C indicated that while cups and bowls were individually stacked on trays for drying, items such as the plastic food bins and patient trays were dried for several minutes before storing them. DS C also stated that it was not feasible to leave larger items in the dish racks for longer because he needed the space along the drying area in order to continue the dishwashing process. DS C indicated there was inadequate space and/or racks to fully dry items prior to storage. In an interview on [DATE] at 10:00 AM, the DFS stated he had not identified lack of air drying space or wet-nesting as an issue. Review of undated departmental guidance titled Cleaning Procedures Warewashing Machine guided staff to allow dishes to dry on the drain board. 4. Flies can present a serious food safety concern. Research has shown that house flies can harbor more than 200 pathogens, including types of foodborne illness-causing bacteria, such as Salmonella, Shigella, Campylobacter, E. coli, and others. Their sticky feet and body hairs are ideal for collecting and holding bacteria. Because of this, even a single fly is a food safety risk. Large flies landing on solid food items will often regurgitate digestive enzymes onto the food surface to dissolve the food allowing the fly to suck it back up. Flies will also deposit fecal matter on resting surfaces, leaving risks of contamination wherever they go. Additionally, a fly that has been on filth such as garbage, decaying meat, feces, etc. can pick up bacteria and carry them onto a clean surface or ready-to-eat food product (Ecolab, 2018). During initial tour on [DATE] beginning at 8:30 AM, there were two flies in the kitchen landing on cleaned sanitized dishes. It was also noted that the back door of the kitchen leading to the outside did not have a tight seal, rather there was an area approximately 6 inches long and ¼ inch high which may allow pests to enter the kitchen. On [DATE] at 9:15 AM, it was noted there were decaying unidentifiable food stuffs in two floor sinks in the food production area. In an observation on [DATE] at 10:30 AM, there was a fly in kitchen landing on multiple uncovered baked cookies intended as dessert for the noon meal. It was also noted there was an uncovered trash can containing food remnants. In a concurrent interview the DFS acknowledged the presence of flies however, has not taken any actions. Facility nutrition and food services policy titled Pest Control dated [DATE] indicated that pest sightings should have been recorded in a log book as well as maintaining dietetic services in a clean and sanitary manner at all times. 5. The standard of practice related to food production equipment, including sinks, is to ensure the installation of an air gap. The purpose of the air gap is to prevent water discharging directly into the waste water system. The air gap also provides sufficient space to prevent unsanitary water from flowing back into the sink, thereby contaminating the sink and future contents (USDA Food Code, 2017). During initial tour on [DATE] 8:45 AM, it was noted the two compartment sink was used for production activities as evidenced by a colander with sliced beets. In a follow up observation on [DATE] at 9:40 AM, DS A was observed peeling eggs in the same sink. In a concurrent interview he stated the noon meal was marinated beet salad and egg salad sandwiches. In an interview on [DATE] at 11:00 AM, the DFS stated he had not identified the lack of an air gap as an issue. 6. The standard of practice is to ensure food employees wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles. In order to have active managerial control over personal hygiene and cross-contamination, certain control measures must be implemented in all phases of the operation. Control measures including but not limited to the use of aprons should be implemented regardless of the food preparation process used (Food Code, 2017). During general food production observations on [DATE] beginning at 9:40 AM, with the exception of the dishwasher remaining dietetic services staff were not wearing aprons. This included DS A as well as the DFS. It was noted the black T-shirt DS A was wearing was not clean. It was also noted there were 2 soiled aprons hanging on hooks on the side of the freezer, however they were not clean or utilized. In a concurrent observation the DFS acknowledged the presence of the aprons, however was unable to offer an explanation of why they were not used. The DFS stated there were not enough aprons for all staff and he placed a request for additional aprons through from Vendor F more than one month ago but hadn't heard back. The surveyor requested documentation of the request. In a follow up observation on [DATE] at 11:00 AM, DS B was observed in food production activities. She was not wearing an apron that covered the lower abdominal area and was also wearing a black T-shirt neither of which were not clean. On [DATE] at 10:38 AM, DS E was observed preparing the noon meal, she was not wearing an apron and her clothing was soiled. As of [DATE] the facility was unable to verify the request or placement of an order for [REDACTED]. 7. It is the standard of practice to ensure equipment, food contact surfaces and utensils shall be clean to sight and touch. Similarly, surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Additionally, non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, and other debris (Food Code, 2017). During the survey from ,[DATE]-,[DATE] there were multiple areas of the kitchen and/or equipment that was not clean. During initial tour on [DATE] beginning at 8:45 AM, the following was observed. The dry storage area was not clean. Plastic food storage containers containing items such as flour and sugar were not clean. There were unidentified food particles on multiple shelves as well as a white substance resembling flour on food storage container lids. There was an unopened supplement carton as well as food stuffs in the floor sink underneath the free standing refrigerator. There was a build-up of dried on food particles on the stove as well as oven doors. The toaster had a build-up of bread crumbs as well as the sheet pan underneath the toaster. There was a fuzzy gray material resembling dust on brackets holding up speaker over the spice rack as well as the knife holder. The top of microwave not clean; there was as well as a napkin and plastic spoon in the floor sink by steamer. Refrigerator doors were smeared with a clear grease-like substance as well as unidentified food particles. Steam pans and serving utensils were stored with dried on food particles. In an observation of the Resident refrigerator/freezer in the nursing unit on [DATE] at 12:30 PM the unit was placed directly onto the floor, it was not clean, and appeared to have hair on the bottom shelf of the unit. In a follow up observation of the kitchen on [DATE] 10:35 AM, the toaster was not clean, the buildup of crumbs on the toaster and sheet pan remained. The can opener also had unidentified food particles and gray particles resembling metal shavings on the blade In an interview on [DATE] at 3:57 PM, the DFS stated there was no standardized cleaning checklist. Cleaning duties were embedded into individual position duty statements. He also stated that floors were mopped and swept each evening by the dishwasher. The DFS acknowledged it appeared the floor has not been routinely mopped. The DFS also indicated it was unclear, whether it was dietary or nursing, who was responsible for cleaning of the nursing unit refrigerator. In an interview with Licensed Nurse C stated it was dietary that was responsible for cleaning the patient refrigerator. Review of facility documents titled Food Nutrition Services Food Safety and Sanitation Audit dated ,[DATE]; ,[DATE]; ,[DATE] and [DATE] revealed that in each of the reports there were multiple areas of the kitchen that were not clean. An additional document dated [DATE], completed by the DFS in behalf of Vendor F ranked the cleanliness of the kitchen as average to good. Facility policy titled Cleaning Schedule dated [DATE] indicated the purpose of the policy was to maintain a clean and sanitary department in all areas to prevent the growth of bacteria. The policy described a process whereby the DFS establishes a department cleaning schedule, including all areas of the department, frequency of cleaning and position assigned. The cleaning schedule was to have been posted in the department. 8. It is the standard of practice to ensure food employees wear hair restraints such as hats, hair coverings or nets, beard restraints, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment and utensils On [DATE] beginning at 2:35 PM, warewashing procedures were reviewed with DS D. During the interview it was noted DS D had facial hair, without the benefit of a beard restraint. In a concurrent interview DS D stated he was not requested to wear facial covering or was trained on the use of beard restraints. Facility policy titled Personal Hygiene dated [DATE] indicated facial hair coverings are used to cover all facial hair. 9. The standard of practice is to ensure non-food contact surfaces shall be cleaned and remain clean at a frequency necessary to preclude accumulation of soil residues (Food Code, 2017). During initial tour on [DATE] beginning at 8:45 AM, the handle from the oven door was covered with unidentified dried food particles. It was also noted the handle of the door was affixed to the door on the left side and was broken on the right side, resulting in a hole in the door, measuring approximately one-quarter inch, which also had an accumulation of food particles. During food production observation on [DATE] at 11:15 AM, DS A was removing a tray of rolls from the oven. He closed the oven door with his shoe. An identical practice was observed on [DATE] at 11:40 AM, when the DFS of food services was also removing items from the oven. Facility policy titled Cleaning Schedule dated [DATE] indicated the purpose of the policy was to maintain a clean and sanitary department. 10. The label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safe. Additionally, food products must be protected from physical contamination (Food Code, 2017). During initial tour observation on [DATE] beginning at 8:45 AM, there was a opened gallon of fat free milk with an expiration date of [DATE], greater than two weeks prior. There was also raw, thawed chicken breast with no thaw date; individual 4 ounce containers of pudding with no date; health shakes with individual resident names but no thaw date and other greater than 25 additional health shakes with no thaw date; a clear plastic container or tuna salad with no preparation date. Additionally, there was a plastic sandwich bag with cut peppers that dropped on the floor, the DFS picked up the bag from the floor and replaced it in the refrigerator. In the walk-in freezer there was a box of frozen sausage that was opened and not resealed, exposing the item to air. There were additional sausage links that were repackaged in freezer sandwich bags that were undated and opened chicken patties with no date. In concurrent interview the DFS stated all items should have a receive, pull and/or use by date. He also stated it was each employees' responsibility to check expiration dates. The surveyor asked how he monitored the labeling/dating process. He replied that he completed a daily walk through and acknowledged the identified items were not comprehensively reviewed. During review of patient food storage practices on [DATE] at 12:30 PM at the nursing station there was one convenience food item in the freezer with no name or date. In the refrigerator there were greater than 5 soda cans with no name. Facility labeling policy titled Food and Nutrition Services Use By Dating Guidelines dated [DATE] provided guidance for labeling use by dates for all refrigerator, freezer and dry storage items. As an example poultry should have been labeled with a use by date of ,[DATE] days after thawing. Similarly, tuna salad should have been labeled with a use by date of 7 days after preparation. Facility policy titled Refrigerated/Frozen Storage dated [DATE] guided staff that individual supplements are labeled with a use by date when removed from the original container. Facility policy titled Food Brought in for Patients/Residents dated [DATE] indicated food items must be labeled with resident name and date

Based on food production observations, Director of Food Services (DFS), Registered Dietitian (RD), Vendor staff interview and administrative document review, the facility failed to ensure Food and Nutrition services was directed by qualified personnel when three residents in a feeding census of 50 were served unpasteurized, undercooked shell eggs. The use of unpasteurized, undercooked eggs may result in the transmission of Salmonella Enteritidis resulting in foodborne illness and in severe instances may result in death (Cross Reference F812, Finding 1). The department was directed by an unqualified Director of Food Services. Also, there was lack of comprehensive oversight by a Registered Dietitian of dietetic servce. Salmonella Enteritidis (S. Enteritidis) is a bacteria associated with unpasteurized shell eggs and may cause foodborne illness. While the death rate is generally less than one percent in a healthy population S. Enteritidis has a 3.6% death rate in outbreaks in nursing homes and hospitals, with the elderly being particularly affected (Bad Bug Book, Food and Drug Administration). The standard of practice requires additional safeguards for highly susceptible populations, such as those residing in nursing homes. It requires pasteurized eggs shall be substituted for raw eggs in the preparation of partially cooked foods such as soft cooked or fried eggs (USDA Food Code, 2017). [STATE] Department of Agriculture requires that pasteurized shell eggs be labeled as such on the shipping box and/or the stamping of individual eggs with a P. As a result of the unsafe food handling practices, the absence of a full time qualified Director of Food and Nutrition Services and lack of guidance and oversight of the department by a Registered Dietitian, an Immediate Jeopardy was declared on November 6, 2019 at 9:25 AM, in the presence of the facility Administrator (Admin). The extent, the lack of the contracted vendor to hire a qualified Director of Food Services, lack of oversight of foodservice operations by a Registered Dietitian and lack of effective oversight, guidance and training to dietetic services staff. An acceptable plan of action was provided by the facility Admin on November 6, 2019 at 4 PM. The actions to remove the immediate jeopardy situation included: removal of the unqualified Director of Food Services; designation of a full time, on-site RD as the Director of Food Services effective 11/6/19; availability of the qualified Director of Food Services (Registered Dietitian) to dietetic staff on weekends via phone consultation; and in-service training of all food production staff in relationship to the use of pasteurized shell eggs when offering undercooked eggs. The immediate jeopardy situation was abated (reduced in amount, degree or intensity and immediacy) on 11/7/19 at 10:30 AM, after verification of the Director of Food Services (DFS) work schedule; DFS training and education qualifications; and verification of staff competency in relationship to the use of pasteurized shell eggs. Findings: [STATE] Health and Safety Code requires in the absence of a full time Registered Dietitian, responsible for food services, the facility employ a qualified Director of Food Services as the responsible person for managing day to day departmental functions. The dietetic services supervisor shall have completed at least one of the following educational requirements: (1)A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility; (2)A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration; (3)A graduate of a dietetic assistant training program approved by the American Dietetic Association; (4)Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific [STATE] dietary service requirements contained in Title 22 of the [STATE] Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility; (5)Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific [STATE] dietary service requirements contained in Title 22 of the [STATE] Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility; (6)A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision; or (7)Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). During initial tour and concurrent interview on 11/4/19 beginning at 8:35 AM, the DFS indicated dietetic services was operated through a contract with Vendor (V) F. The DFS stated he has been with the facility for 8 months and previously worked in two local hospitals as a patient care clerk and a stockroom supervisor. The DFS indicated his oversight responsibilities included day to day management of all aspects of Food and Nutrition Services. In an interview with the Admin on 11/4/19 at 9:35 AM, he confirmed dietetic services was a contract with V F. He also stated services of the RD was a subcontract arranged by V F for two days per week. The Admin also stated all dietetic employees were employed by V F. On 11/5/19 at 10:15 AM, the DFS presented a certified food handlers card. In a concurrent interview he acknowledged he possessed no other qualifications or certifications. In an observation on 11/6/19 beginning at 7 AM, the DFS was preparing breakfast. During meal preparation he removed a flat of unpasteurized shell eggs from the refrigerator. In a concurrent interview the DFS stated he had several residents that wanted fried eggs. The DFS proceeded to place eggs on the grill (Cross Reference F812, Finding 1). In a concurrent interview, the DFS stated the eggs were done when the white was fully congealed and the egg yolk remained jiggly. The DFS was asked how food safety was ensured with use of shell eggs. The DFS replied he was using pasteurized eggs. The surveyor asked how he knew they were pasteurized. The DFS stated the box was labeled as such. In a concurrent observation Vendor Registered Dietitian B (VRD) B pulled the box from the refrigerator. There was no labeling on the box or the individual eggs indicating they were pasteurized. There was no indication the DFS or VRD B recognized the eggs were not pasteurized. The DFS continued to use the unpasteurized eggs for residents. Observation in the dining room on 11/6/19 at 7:35 AM, demonstrated there were 2 residents (Residents 37 and 214) who were consuming over easy eggs. It was noted the yolk was runny. Additional food production observation on 11/6/19 at 7:43 AM, the DFS prepared additional soft cooked eggs for Resident 38. In an interview on 11/6/19 at 8:05 AM, the DFS stated in the presence of VRD B, he misspoke and the eggs were not pasteurized. The DFS stated he stopped ordering pasteurized shell eggs approximately 1 month ago because the unpasteurized eggs were less expensive. In a concurrent interview VRD B stated she had experience in food service operations as her position duties included completing kitchen reviews. In an interview on 11/5/19 at 1:39 PM, VRD A stated she has been coming to the building 2 times per week for the past 3 months. Her typical day included reviewing resident meal intake; review of Minimum Data Set (a resident assessment tool) notes. While she acknowledged she spent some time in the kitchen working with the DFS and staff, she was told by her supervisor not to participate in kitchen work. VRD A also stated there were multiple foodservice issues in the kitchen for which she provided limited guidance to the DFS and dietary staff. With respect to attendance at resident care planning meetings, weight committee, interdisciplinary team meeting or quality assurance meetings VRD A was told by the DFS that her attendance was not required, as he attended as the representative for Food and Nutrition Services. She acknowledged, based on guidance from her supervisor, she was not providing the amount of required oversight to dietetic services. In an interview on 11/6/19 at 2:53 PM, Vendor Staff (VS) C, the position responsible for oversight of the facility on the behalf of V F, stated she has been with company for three months and had one visit, [MEDICATION NAME] approximately three hours, intended as an introduction to the facility. She stated she did a brief kitchen walk though, but not an onsite in-depth review. She also stated the primary identified issue during that visit was staff not reporting for work, however there was no documentation of the visit. To her knowledge there was no comprehensive assessment of required operational resources or effectiveness of the contracted services. She also stated her oversight responsibilities would include monthly visits. VS C stated to her knowledge there were no documented site visits within the past 6 months. In an interview on 11/7/19 at 11:37 AM, V D confirmed a recent call from VS E at which time there was a request for VRD A to focus only on resident clinical nutrition as the contract hours were limited. In an interview on 11/7/19 at 2:38 PM, the Admin indicated evaluation of the effectiveness of dietetic services was based on resident food complaints. The Admin acknowledged this would focus on meal temperatures and flavor, however would not assess food safety of department effectiveness. The Admin was asked if there was any guidance from Administration that prevented VRD A attending functions such as resident care planning, interdisciplinary or quality assurance meetings. He stated no such guidance was given to the DFS or V F. The Admin also acknowledged the RD would be the expert in evaluating foodservice operations. In an interview on 11/7/19 at 3:15 PM with VS G, the position responsible for recruitment on behalf of V F acknowledged the DFS was not qualified in accordance with Federal or State regulatory requirements at the time of hire. VS G stated he interviewed the DFS twice. The decision was made by V F to hire the DFS despite lack of mandatory qualifications. Review of the undated position description for the DFS indicated job responsibilities included ensuring established sanitation and safety standards were maintained. Core responsibilities included, but not limited to, orienting and training dietary staff; forecasting and planning the purchase of food, supplies and equipment. It was also noted the position description listed the required certification in accordance with State and Federal regulations. It also listed that there was no replacement for Federal/State/County required certification(s)/training. Review of personnel records for the Director of Food Services revealed training was primarily limited to V F's mandatory administrative training such as abuse reporting, social media policy and workplace violence. There were three dietetic services trainings related to warewashing, plate presentation and texture modification. Additionally, it was noted that all 15 trainings were completed on 2/18/19, which was consistent with the DFS's date of hire. Review of V F's document titled Competency Evaluation-Manager, for the period of 3/1/19 to 4/9/19 indicated the DFS was fully competent in all areas of food service. Vendor F nor the facility was able to provide documentation the core functions required of the DFS position were carried out effectively despite documentation the DFS was fully competent in all position duties. Review of V F's undated position description for the Registered Dietitian included oversight and guidance to the DFS; participation in the interdisciplinary team; review of regular and therapeutic diet plans; reviews and recommends ongoing quality assurance programs. Additionally, the position description required participation in committee meetings such as care planning and quality assurance as well as participation in staff development by providing training and mentoring to dietary personnel. Review of V F's undated document titled, Exhibit A Description of Services, a vendor service level agreement indicated V F was responsible for providing services in accordance with all applicable federal, state and local laws. Additionally, the vendor agreed to implement a program whereby performance of the contract will be submitted, reviewed and signed off by the facility Administrator. The agreement also ensured that all requirements for food service licenses are maintained. As of 11/13/19 V F was unable to demonstrate the conditions of the agreement were fully implemented.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. tube (a tube going in to a surgically created hole in the neck) on [DATE]. After the nurse and respiratory therapist removed Resident 1's [MEDICAL CONDITION], they were unable to get the new tube into the [MEDICAL CONDITION] passage. Resident 1 died due to lack of oxygen. Findings: A visit was made to the facility on [DATE] to investigate the facility reported death of Resident 1 during a monthly [MEDICAL CONDITION] change. Resident 1's record was reviewed. Resident 1 was [AGE] years of age, admitted to the facility on [DATE], after a [MEDICATION NAME] and [MEDICAL CONDITION] (bleeding into the brain) left her unable to breathe on her own and was dependent on a ventilator attached to a [MEDICAL CONDITION] in her neck. Resident 1 had multiple diagnoses, which included, chronic [MEDICAL CONDITION], past opioid (narcotic pain medication) dependence, hypertension (high blood pressure), dysarthria (disruption of normal speech ability), gastrostomy (feeding tube into the stomach), [MEDICAL CONDITIONS] (low [MEDICAL CONDITION] activity), esophagitis (inflammation of the passage that carries food to the stomach), gastro-[MEDICAL CONDITION] reflux disease (stomach acid backs up into the [MEDICAL CONDITION] passage), and [MEDICAL CONDITION] (over 100 pounds overweight). Resident 1's record contained orders to change her [MEDICAL CONDITION] once a month on day shift or as necessary, due to malfunction. Resident 1 had her [MEDICAL CONDITION] changed by Registered Nurse 2 (RN 2) and Respiratory Therapist 3 (RT 3) at approximately 10:33 pm on [DATE]. The Medical Director, who was also Resident 1's attending physician, was interviewed on [DATE] at 8:45 am. When asked why his orders contained the direction to do the monthly [MEDICAL CONDITION] change on day shift, he responded that more resources are available on day shift in case of problems. He added that [MEDICAL CONDITION] are changed on other shifts due to other circumstances, such as accidental or purposeful removal of the [MEDICAL CONDITION], such as removal by the resident. Individual interviews with the RN 2 and RT 3 were completed on [DATE] at 9:30 am and 9:55 am. When each was asked why they did not follow physician's orders [REDACTED]. During their respective interviews on [DATE] at 9:30 am and 9:55 am, RN 2 and RT 3 both stated that they did not feel any pressure or repercussions to change Resident 1's [MEDICAL CONDITION] on [DATE], despite the last monthly change being on [DATE]. They agreed that doing the change on the 29th, 31st, or 32nd day would be acceptable. According to RN 2 and RT 3's interviews on [DATE] at 9:30 am and 9:55 am, Resident 1 was prepared for the [MEDICAL CONDITION] change on [DATE] at 10:33 pm. RN 2 and RT 3 met at the bedside. RN 2 stated that RT 3 was responsible to bring the necessary equipment to the bedside and set up for the procedure. RN 2 stated that she removed the [MEDICAL CONDITION] and RT 3 was standing by, ready to reinsert the new tube, with RN 2 at the bedside. During interview, RT 3 stated that he did not have a smaller sized [MEDICAL CONDITION] available at the bedside, which was standard practice according to the American Association for Respiratory Care and the facility's policy. A smaller size at the bedside was to ensure that if there was a problem placing the same size [MEDICAL CONDITION], a smaller sized tube would be on hand. RN 2 and RT 3 stated they did not have a smaller sized [MEDICAL CONDITION] at the bedside of Resident 1. The facility's [MEDICAL CONDITION] change policy, revision date [DATE] was reviewed. The policy read, gather supplies: two [MEDICAL CONDITION], one the size of the tube the patient has in place and the other one a size smaller. According to interview with RN 2 on [DATE] at 9:30 am, RT 3 was not able to replace the removed [MEDICAL CONDITION] after several attempts. According to interview with RN 2, she took over attempting to get the new tube in. RN 2 stated she thought she had inserted the [MEDICAL CONDITION] in the trachea. At one point, RN 2 and RT 3 stated they attached the oxygen supply but realized that the airway was not patent (open exchange of air through the respiratory passages) and Resident 1 was gasping for air. RN 2 stated she attempted repositioning Resident 1, placing the tube, then placing just the inner cannula, and then just the obturator, but could not establish a patent airway. The [MEDICAL CONDITION] consists of three parts: outer cannula with flange (neck plate), inner cannula (which can be used for daily cleaning and suctioning, and an obturator (has a smooth rounded tips to guide the tube's insertion). When none of these attempts succeeded in reestablishing Resident 1's airway, RN 2 and RT 3 stated they initiated a code. A code is a crisis where the resident may die, so outside emergency personnel are called. According to review of Resident 1's nursing notes, when Resident 1 health condition continued to decline and she became cyanotic (skin turning blue due to lack of oxygen), RN 2 and RT 3 initiated Cardiopulmonary Resuscitation (CPR) and continued it until the emergency personnel took over. According to RN 2 during interview on [DATE] at 9:30 am and concurrent review of the emergency personnel's log, the emergency personnel arrived on scene 4 minutes after receiving the emergency call, on [DATE] at 10:41 pm. According to the emergency personnel's report, dated [DATE], Resident 1's airway was completely obstructed (blocked). Resident 1 was cyanotic and did not have a detectable carotid pulse (large arteries in the neck). The emergency personnels' attempts to open the resident's airway failed. They contacted their affliated local hospital's physician and the physician ordered the cessation (stopping) of rescusitation efforts. Resident 1 died from a [MEDICAL CONDITIONS] after her airway could not be opened.

Based on observation, interview, and record review, the facility failed to ensure effective administration and implementation of its Abuse Prohibition and Grievance/Concern policies to ensure five of seven sampled residents' (Residents 1, 2, 3, 4, and 5) rights to be free from abuse, neglect and mistreatment by Certified Nursing Assistant (CNA) E, and during a power outage, the disaster protocol was not followed and an unusual occurrence was not properly reported to the State when: 1. Center Executive Directors (CED A, CED B, CED C, and CED D) permitted CNA E, hired on 6/29/16, to work at the facility although the facility had knowledge that CNA E had a poor employment history and criminal background, having been found guilty by a court of law three times of abusing, neglecting or mistreating others, was currently on probation, and without evidence of verification of a current CNA certificate. 2. Mandated reporters Center Executive Directors (CED A, CED B, CED C, and CED D) and their staff; the Medical Director (MD), the Center Nurse Executive (CNE), Nurse Practice Educator (NPE), Social Services (SS), and three Certified Nursing Assistants (CNAs F, G, and H) failed to recognize, thoroughly investigate, and/or report allegations of abuse, neglect, and mistreatment by CNA E towards Residents 1, 2, 3, 4 and 5 to the California Department of Public Health (CDPH) or the Long Term Care Ombudsman Program within one working day, and to remove CNA E from duty to protect residents from further abuse, neglect, and mistreatment for [REDACTED]. 3. CED A, CED B, CED C, and CED D failed to ensure staff were trained and competent in correctly recognizing activities that constituted abuse, neglect, and mistreatment, implementing the facility's Abuse Prohibition and policy, and adhering to mandated reporter law. These failures resulted in undignified, disrespectful mistreatment, abuse, and neglect toward Residents 1, 2, 3, 4, and 5 by CNA E, and placed all residents at risk for being abused, neglected, and mistreated. 4. Power outage on 12/16/16 due to faulty electrical wires caused smoke and a fire watch (disaster) protocol was not implemented and an unusual occurrence report was not sent to the State. Refer to F 518. This failure resulted in a lack of coordination and support for the Charge Nurse (CN) M and Director of Maintenance (DM) to assist in evaluating and planning for the effect of the power outage in the Center which put all residents at risk for accidents and hazards. Due to a systems failure and an immediate threat for continued abuse, neglect, and mistreatment of [REDACTED]. Findings: The facility policy titled, Abuse Prohibition, revised 8/1/16, indicated, the CED, or designee, is responsible for operationalizing policies and procedures that prohibit abuse and neglect. The policy indicated the facility will not employ individuals who have been found guilty by a court of law of abusing, neglecting or mistreating others. 1. A review of CNA E's employee file indicated she was employed from 6/29/16-1/16/17, at the facility. There were four CEDs (CED A, B, C and D) during that time period that failed to follow the Abuse Prohibition policy. CNA E was hired under CED A and the five allegations of abuse, neglect and mistreatment occurred during the months that CED A, B, C and D spent time as the active Center Executive Director. These grievances went without being identified, investigated or reported to the California Department of Public Health (CDPH). CNA E's employment history indicated that CNA E was fired from the two previous positions held due to customer service concerns. The file contained a background report that indicated CNA E had a criminal history, having been found guilty by a court of law of abusing, neglecting or mistreating others on 11/4/14, 5/8/14, and 8/18/15. The file did not contain evidence that the facility had verified that CNA E had a current CNA certification. During an interview and concurrent record review with CDE D on 1/6/17 at 2:10 pm, CED D reviewed CNA E's employee file and stated she (CNA E) shouldn't have been hired. CED D had stated that his plan was to either suspend CNA E or move her to the day shift to provide increased supervision. During an interview on 2/1/17 at 11:50 am, Center Nurse Executive (CNE), stated that CNA E's hiring went up to corporate level. CNE stated CNA E's license was still pending. CNE confirmed that she had the ability to decline hiring an individual but stated, We all came to the conclusion that she (CNA E) was behaving appropriate and everyone is entitled to make mistakes. 2. The facility policy titled, Abuse Prohibition, revised 8/1/16, indicated the actions to prevent abuse and neglect shall include, identifying, correcting, and intervening in situations that abuse is more likely to occur, and all cases of suspected abuse, neglect or exploitation require mandatory reporting within one working day to the Department of Health and Human Services as well as the Long Term Care Ombudsman's Program. The facility policy titled, Grievances/Concerns, revised 11/28/16, indicated the CED will serve as the grievance officer and will be responsible for providing oversight of the grievance process. The CED will be responsible for receiving and tracking grievances through to their conclusion and lead any necessary investigations by the facility, as well as, coordinate with state and federal agencies as necessary in light of specific allegations. The grievances and concerns will be discussed at the Quality Improvement Committee meetings to identify trends. During an interview with CED D on 1/25/17 at 9:33 am, CED D stated that following the CDPH visit on 1/6/17, CNA E was suspended and then terminated. CED D stated the process for grievances now is to include the Ombudsman in the process, notify the family, inform the residents of the outcome, and use a tracking tool. During an interview with CED D on 1/25/17 at 2:45 pm, after reviewing CNA E's employee file, it was determined that CNA E had not been suspended, moved to day shift, or terminated during the time frame that the facility had indicated, which allowed for the residents to go unprotected, and another incident on 1/8/17 involving CNA E to occur, while CED D was the acting CED. CED D stated, he had attempted to get a hold of CNA E following the CDPH visit on 1/6/17, but did not reach her. CED D stated CNA E showed up to work her scheduled shift on 1/8/17, and according to reports from staff, the incident occurred involving Resident 5. CED D stated he came in on the morning of 1/9/17 and suspended CNA E and she was terminated on 1/16/17. CED D confirmed the 1/8/17 allegation was not reported because he terminated CNA E. CED D stated the only investigation into the 1/8/17 allegation of abuse and mistreatment was the written statements from CNAs F, G and H. During an interview with CED D on 1/26/17 at 10:24 am, CED D stated a thorough investigation of grievances was not being done. CED D stated Social Services (SS) would get a statement from the resident and make a decision for the corrective action. CED D stated there was no engagement of the Ombudsman to any grievance filed before 1/2017, the residents were not notified of grievance resolutions with in 72 hours and the grievances were not being reported to the CDPH. CED D stated the facility had no way of keeping track of trends with grievances. During an interview on 2/1/17 at 1:45 pm, the CED D stated that he was advised by the Director-Regional Human Resources (DRHR) to do an Individual Performance Improvement Plan (IPIP, a plan between the employer and employee when performance or conduct fails to meet expectations) for CNA E. CED D stated they scanned grievances involving CNA E and sent them to DRHR for review and the DRHR instructed to do an IPIP regarding customer service for CNA E. CED D stated, I failed to convince them how serious this was. CED D stated that he was not aware when trying to contact CNA E to suspend her, that she was scheduled to work on the night of 1/8/17. CED D stated that CNE, HR, SS were aware of the plan to suspend CNA E, but nursing supervisors working on 1/8/17 were not aware of the intention to suspend CNA E. CED D stated, We failed and that's my fault. 3. Review of the facility policy titled, Abuse Prohibition revised 8/1/16, indicated ongoing training shall be provided to all employees; how staff should report their knowledge related to allegations, how to recognize signs of burnout, frustration and stress that may lead to abuse, and what constitutes abuse and neglect. A visit was made to the facility on [DATE] to interview staff members regarding their knowledge of the facilities Abuse Prohibition policy with regards to identifying and reporting abuse. LN I, LN J, LN K, and PT L were given scenarios that included abuse, neglect and dignity issues. Five out of eight employees interviewed were unable to correctly identify abuse, dignity and neglect and/or what constituted a need to be reported. 4. During a concurrent observation and interview on 12/16/16 at 10:25 am, the Nurse Practice Educator (NPE) stated they had a power outage that morning and some of the electricity had not returned to some parts of the building. During an interview on 12/16/16 at 10:30 am, the DM stated he was notified at around 6 am that the facility power went out for a short period, the generator came on, and the staff smelled smoke. The staff called the DM before calling 9-1-1 and the DM instructed staff to call the fire department. The DM stated upon arrival, he determined the main breaker had frayed wires which caused a power outage. The fire department evaluated the situation and found no further risk for fire. The DM stated the generator came on within 2 minutes, though there were some rooms that did not have overhead lights, Rooms 14-21. The DM called an electrical vendor to come out and evaluate the electrical system of the building. The DM stated the CED C was notified and he was not instructed to initiate a fire watch nor implement a disaster protocol. The DM stated he started three weeks ago and had no emergency preparedness training for this facility. During a concurrent observation and interview on 12/16/16 at 1:20 pm, the DM was unaware that the overhead and bathroom lights were out (would not illuminate) in Rooms 12-23, not as originally thought to be the subacute Rooms 14-21. The DM stated there was no coordination with the CN M about how the residents would be monitored and provided light until the electricity was returned to this area. The DM stated they had audited the entire building and missed checking the bathrooms. During a concurrent observation and interview on 12/16/16 at 1:30 pm, the CN M was in room [ROOM NUMBER]'s bathroom and stated she was unaware the lights were not working and it was dark, which could put the residents at risk for falls. The CN stated she was not notified by DM that bathroom lights were out and there was no discussion or plans of how to ensure residents needs were being met or to ensure their safety until the electricity was returned completely. The CN M stated the facility would buy lanterns to place in the rooms and bathrooms affected until the electricity was fixed. During a interview on 1/6/17 at 10:15 am, the CED D stated the staff should have initiated the disaster protocol and fire watch, once the smoke was identified in the facility on 12/16/16. The CED D stated a fire watch log should have been documented while the problem of the power outage was being monitored. The CED D stated this was an unusual occurrence and should have been reported timely to the State regulatory agency. During an interview on on 1/6/17 at 11:25 am, the CN M stated the CED C was notified of the power outage due to faulty conduits. CN M stated there was no discussion about implementing a fire watch, disaster plan nor reporting the unusual occurrence to the State agency. Due to a systems failure and an immediate threat for continued abuse, neglect, and mistreatment of [REDACTED]. On 2/1/17 at 4 pm, the facility presented a corrective action plan that indicated training would be provided to all staff including administrative and the content would be around the facility's abuse policy and procedures. A new post test was to be implemented after the abuse training to assist with determining competency. All alert residents would be interviewed by social services in regards to abuse. On 2/6/17, an onsite visit occurred to verify that the facilities corrective action plan was implemented and effective. The IJ was removed on 2/6/17 at 3 pm, in the presence of the CED D and CNE.

Based on interview and record review, the facility failed to implement its Abuse Prohibition policy to ensure five of seven sampled residents and potentially all residents right to be free from abuse, neglect, and mistreatment when: 1. The facility hired Certified Nursing Assistant (CNA) E on 6/29/16 knowing that CNA E had a poor employment history and criminal background, having been found guilty by a court of law three times of abusing, neglecting or mistreating others, was currently on probation, and without evidence of verification of a current CNA certificate. 2. Facility staff mandated reporters Center Executive Directors (CED A, CED B, CED C, and CED D), the Center Nurse Executive (CNE), Nurse Practice Educator (NPE), Social Services (SS), and three Certified Nursing Assistants (CNAs F, G, and H) failed to recognize and thoroughly investigate allegations of abuse, neglect, and mistreatment by CNA E toward Residents 1, 2, 3, 4, and 5, to report the allegations to the California Department of Public Health (CDPH) and the Long Term Care Ombudsman Program within one working day, and to remove CNA E from duty to protect residents from further abuse, neglect, and mistreatment, for a period of six months. These failures resulted in undignified, disrespectful maltreatment, abuse, and neglect toward Residents 1, 2, 3, 4, and 5 by CNA E, and placed all residents at risk for being abused, neglected, and mistreated by CNA E. Due to a systems failure to protect residents from actual and potential abuse, neglect and mistreatment where facility mandated reporters, Center Executive Directors (CED A, CED B, CED C, and CED D), the Center Nurse Executive (CNE), Nurse Practice Educator (NPE), and Social Services (SS), and CNAs F, G, and H failed to prohibit, prevent, recognize, thoroughly investigate, and report allegations of abuse, neglect, and mistreatment toward residents to the California Department of Public Health (CDPH) and/or the Long Term Care Ombudsman Program, for a period of six months, in accordance with the facility's Abuse Prohibition policy, and current facility staff were unable to verbalize key components of being mandated reporters and how to follow the abuse policy when identifying and reporting abuse. An immediate jeopardy (IJ) situation was declared on 2/1/17 at 3:02 pm in the presence of CED D. Refer to F 226, F 250, F 490, F 493, and F 501. Findings: 1. Review of the facility's policy titled, Abuse Prohibition, revised 8/1/16, indicated, The Facility shall not employ individuals who: Have been found guilty by a court of law of abusing, neglecting or mistreating others. The Facility Employee Handbook, dated 4/2016, indicated job offers for new employees or eligible former employees applying for rehire are contingent upon successful completion of a comprehensive criminal background check. This policy protects the patients and residents we serve, ensuring they are safe and secure in our care. On 1/6/17, CNA E's employee file was reviewed. CNA E was hired on 6/29/16. CNA E's employment history indicated that CNA E was terminated from two previous positions held due to customer service concerns. The file contained a background report that indicated CNA E had a criminal history, having been found guilty by a court of law of abusing, neglecting or mistreating others on 5/8/14, 11/4/14 and 8/18/15. The file did not contain evidence that the facility had verified that CNA E had a current CNA certification. A document titled, Attestation of Good Moral Character, dated 6/29/16, indicated that upon accepting a conditional offer of employment, CNA E disclosed to the facility that she had three misdemeanors; two in 2015 and one in 2014, and was on probation for these violations. A review of a facility email from Human Resources Compliance Coordinator (HRCC) to the facility's Human Resources (HR) and CED A, dated 7/6/16, referenced CNA E's criminal background and indicated, per the company hiring policy, the criminal background did not deem her ineligible for hire, but would require the record to be reviewed and Human Resources Management approval. A review of a facility Grievance/Concern form indicated, on 7/25/16, Resident 2 indicated that CNA E argued with her over providing a proper washcloth during a shower and then called a male nurse in to assist with the shower which left her (Resident 2) feeling embarrassed and mortified. A review of a facility Grievance/Concern form indicated, on 7/28/16, Resident 3 indicated that she requested assistance to her room to have a bowel movement and CNA E responded by telling her to have a bowel movement in her brief and she would be back later to help clean her up. A review of a facility Grievance/Concern form indicated, on 11/17/16, Resident 1 indicated that CNA E scared and bullied her when CNA E accused her of always wetting the bed. CNA E stated she was going to make Resident 1 get up every hour to go to the bathroom and she refused to give her ice chips. Later that night Resident 1 stated CNA E came by her room and flickered the lights on and off for no reason. On 11/17/16, Resident 4 indicated that CNA E was verbally rude to her when she requested ice chips. During an interview and concurrent record review with CED D on 1/6/17 at 2:10 pm, CED D reviewed CNA E's employee file that included a criminal history and four grievance reports involving CNA E that occurred from 7/2016 to 11/2016 of allegations of mistreatment, undignified treatment, and rude verbalizations. The CED D stated that he began employment at the facility on 12/20/16. The CED D stated CNA E was hired during CED A's employment and the grievances occurred during CED B's and CED C's employment. The CED D stated CNA E should not have been hired and should have had Individual Performance Improvement Plans (IPIP, a plan between the employer and employee when performance or conduct fails to meet expectations), and that he would have terminated her after the first two complaints in 7/2016. A review of written statements, dated 1/8/17 and 1/9/17, made by CNA F, CNA G, and CNA H indicated these CNAs witnessed inappropriate verbal exchanges between Resident 5 and CNA E in the dining room when CNA E approached Resident 5 two times in the dining room and Resident 5 indicated he did not want CNA E caring for him, to which CNA E responded with laughter. Resident 5 wanted CNA E to stop harassing him because he is very bothered by that. Resident 5 stated, she's mean to me and puts the blanket over my face and holds it there so I can't breathe. I can't use my hands good so I can't defend myself. She put me in the lift and dropped me and puts my things where I can't get to them. Resident 5 stated that CNA E drops him in bed using the emergency release on the Hoyer (a mechanical lifting device) and also covers his face with a blanket and places her hand over his face and he is unable to move or breathe. Resident 5 was described to as clearly upset, mad and shaking after verbal exchange. On 1/10/17 at 9:00 am, the CDPH contacted the CNA certification program review unit which indicated CNA E required proof of passing written and skills competencies for certification, and her criminal background was pending review and had not been cleared. A review of the facility's current schedule report, dated from 1/1/17 to 1/31/17, indicated that CNA E was assigned to the night shift where there was one Registered Nurse and two Licensed Nurses staffed to oversee the care for the whole facility. The facility allowed CNA E to work on the night shift, the shift with the least amount of direct supervision, and did not provide any oversight of care through performance evaluations. During an interview with the CNE on 2/1/17 at 11:50 am, the CNE stated, due to the facility's location and the pay scale, hiring CNAs was difficult. The CNE stated that CNA E's hiring was reviewed at the corporate level. The CNE stated, We all came to the conclusion that she was behaving appropriately and everyone is entitled to make mistakes. 2. Review of the facility's policy titled, Abuse Prohibition, revised 8/1/16, indicated, The employee alleged to have committed the act of abuse shall be immediately removed from duty, pending the investigation. All cases of suspected abuse, neglect, or exploitation require mandatory reporting within one working day to the Department of Health and Human Services. A review of a facility Grievance/Concern form indicated, on 7/25/16, Resident 2 indicated that CNA E argued with her over providing a proper washcloth during a shower and then called a male nurse in to assist with the shower which left her (Resident 2) feeling embarrassed and mortified. A review of a facility Grievance/Concern form indicated, on 7/28/16, Resident 3 indicated that she requested assistance to her room to have a bowel movement and CNA E responded by telling her to have a bowel movement in her brief and she would be back later to help clean her up. A review of a facility Grievance/Concern form indicated, on 11/17/16, Resident 1 indicated that CNA E scared and bullied her when CNA E accused her of always wetting the bed. CNA E stated she was going to make Resident 1 get up every hour to go to the bathroom and she refused to give her ice chips. Later that night Resident 1 stated CNA E came by her room and flickered the lights on and off for no reason. On 11/17/16, Resident 4 indicated that CNA E was verbally rude to her when she requested ice chips. A review of inservice sign in sheets, dated 11/29/16, indicated that CNA E received in-service training regarding customer service, 4 months after an initial grievance was filed and 3 more grievances occurred with CNA E. The customer service training and talking points did not include information regarding abuse, neglect, mistreatment or mandated reporting. During an interview and concurrent record review on 1/6/17 at 11:35 am, NPE stated based on information received from the grievance report involving Resident 1 and CNA E, she educated CNA E on customer service. NPE indicated that determining abuse or neglect should happen with the SS investigation of the grievance. NPE reviewed the handwritten note by Resident 1 that alleged abuse and mistreatment and stated, she felt it warranted further investigation. A review of CNA F's written statement, dated 1/8/17, identified one verbal exchange between CNA E and Resident 5 and indicated that one of the CNAs asked Resident 5 why don't you like her and he replied that CNA E would put the sheets over his head and that he couldn't breathe .he couldn't take the sheets down because he can't move his hands, and indicated that Resident 5 stated she (CNA E) needs to stop harassing him because he is very bothered by that. A review of CNA G's written statement, dated 1/9/17, indicated that CNA E approached Resident 5 two times in the dining room with verbal exchange from Resident 5 indicating he did not want CNA E caring for him to which CNA E responded with laughter. Resident 5 asked another aid to lay him down. Once CNA E left the dining room Resident 5 stated that CNA E drops him in bed using the emergency release on the Hoyer and also covers his face with a blanket and places her hand over his face and he is unable to move or breathe. A review of CNA H's written statement, dated 1/9/17, indicated that CNA E approached Resident 5 two times in the dining room with verbal exchange from Resident 5 indicating he did not want CNA E caring for him to which CNA E responded with laughter. CNA D described Resident 5 as clearly upset, mad and shaking after verbal exchange and indicated the staff asked Resident 5 why he didn't like CNA E and he stated she's mean to me and puts the blanket over my face and holds it there so I can't breathe. I can't use my hands good so I can't defend myself. She put me in the lift and dropped me and puts my things where I can't get to them. There was no evidence provided to indicate these allegations had been thoroughly investigated. The evidence indicated CNA E was not removed from duty during the investigation and facility staff deemed mandated reporters, (CED A, B, C and D, CNE, NPE, SS, and CNAs F, G, and H) were involved in the grievance process and did not report these allegations to the CDPH or the Long Term Care Ombudsman Program within one working day per their Abuse Prohibition policy. During an interview and concurrent record review with CED D on 1/6/17 at 2:10 pm, CED D reviewed the grievance reports filed by Residents 1, 2, 3, and 4. CED D was asked if the facility was keeping track of how many grievances involved one specific CNA and CED D stated the facility did not have processes in place and not all the staff had been involved or communicated with. CED D confirmed the investigations involving Residents 1, 2, 3 and 4 were not complete and stated, No nothing is here. CED D stated he was considering suspending employee (CNA E) or assigning her to the day shift to provide increased supervision. During an interview on 1/24/17 at 10:04 am, HR stated that CNA E was terminated on 1/8/17. An onsite visit to the facility was made on 1/25/17 to validate that CNA E had been terminated as stated by HR and was no longer posing a threat to residents as well as to ensure the abuse prohibition policy was being understood and implemented throughout the facility. During this visit, documentation was found indicating that CNA E had not been suspended and terminated within the time frame stated by facility, and another incident had transpired involving CNA E with Resident 5. During an interview with HR on 1/25/17 at 1:55 pm, HR stated that they were waiting until Monday to do the write up for CNA E and suspend her, but then the incident on 1/8/17 happened which led to her termination. During an interview with CED D on 1/25/17 at 2:45 pm, CED D stated that he had attempted to, but was unable to, get a hold of CNA E on 1/6, 1/7, and 1/8/17 to suspend her. CED D stated CNA E showed up to work on 1/8/17, and apparently from the reports from staff, the incident had occurred. CED D stated he came in early on the morning of 1/9/17 and suspended CNA E then terminated her on 1/16/17. CED D indicated the investigation into Resident 5's verbal grievance only consisted of the employee statements and this was not reported to the CDPH because he terminated CNA E. During a telephone interview with CED D on 1/26/17 at 10:24 am, CED D stated the course of action taken after all grievances were filed against CNA E was to not have her care for the specific residents that made the complaints. CED D stated in the past a thorough investigation was not being done. SS took statements from the residents and made the decision for what corrective action would be taken. CED D stated there was no engagement of the ombudsman to any grievance filed before 1/2017, residents were not being notified of resolution within 72 hours and the grievances were not being reported to the CDPH. During an interview with SS on 2/1/17 at 11:15 am, SS confirmed the facility had never discussed that CNA E had multiple grievances involving her, or identified that the alleged abuse involving CNA E needed to be reported. During an interview and concurrent record review with CNE on 2/1/17 at 11:50 am, the CNE reviewed Residents 1, 2, 3, 4, and 5's grievances involving CNA E. When asked why the grievance regarding Resident 1 was not reported she stated, I couldn't tell you. The CNE then reviewed Resident 2's grievance and stated, we should have never hired her (CNA E), then stated this should have resulted in suspension during investigation and followed up with an IPIP. The CNE reviewed Resident 3's grievance and stated this was a dignity issue that should have been reported, CNA E should have been suspended, and this should have been investigated. The CNE reviewed Resident 4's grievance and stated she remembered this grievance and stated it was not a complete investigation. The CNE reviewed the handwritten statements from CNAs F, G and H, regarding Resident 5 and stated that this incident resulted in CNA E's termination. The CNE stated that she was out of the building, but someone should have been manning the door when they couldn't get a hold of CNA E (to prevent her from working with residents). When asked if this incident was reported, the CNE stated, No, it should have been. The CNE stated that she couldn't answer why the incident on 1/8/17 was not investigated or reported. During an interview with CED D on 2/1/17 at 1:45 pm, CED stated, I'll be honest, it fell apart right here. They had a mistrust of reporting from the CNAs to the nurses. When the incident that occurred on 1/8/17 was referred to as not being reported, CED D stated, You're right I should have reported it. Due to an immediate threat for continued abuse, neglect, and mistreatment of [REDACTED]. On 2/1/17 at 4 pm, the facility presented a corrective action plan that indicated training would be provided to all staff including administrative and the content would be focused on the facility's abuse policy and procedures. A new post test was to be implemented after the abuse training to assist with determining competency. All alert residents would be interviewed by social services in regards to abuse. On 2/6/17, an onsite visit occurred to verify that the facilities corrective action plan was implemented and effective. The IJ was removed on 2/6/17 at 3 pm, in the presence of CED D and CNE.

Based on interview and record review, the facility failed to implement it's Abuse Prohibition policy to prohibit and prevent abuse, neglect, and mistreatment toward five of seven sampled residents (Residents 1, 2, 3, 4, and 5) and potentially all residents when: 1. Facility staff mandated reporters, Center Executive Directors (CED A, CED B, CED C, and CED D), the Medical Director (MD), the Center Nurse Executive (CNE), the Nurse Practice Educator (NPE), Social Services (SS), and three Certified Nursing Assistants (CNAs F, G, and H) failed to recognize and thoroughly investigate allegations of abuse, neglect, and mistreatment by CNA E toward Residents 1, 2, 3, 4, and 5, to report allegations of abuse to the California Department of Public Health (CDPH) or the Long Term Care Ombudsman Program within one working day, and to remove CNA E from duty to protect residents from further abuse, neglect, and mistreatment for [REDACTED]. 2. The facility failed to ensure CED A, CED B, CED C, and CED D, the MD, the CNE, the NPE, SS, and CNAs F, G, and H, licensed nurse (LN) I, LN J, LN K, and Physical Therapist (PT L) were trained and competent in correctly recognizing activities that constituted abuse, neglect, and mistreatment, implementing the facility's abuse policy. These failures resulted in undignified, disrespectful mistreatment, abuse, and neglect toward Residents 1, 2, 3, 4, and 5 by CNA E, and placed all residents at risk for being abused, neglected, and mistreated by CNA E. Due to a systems failure and an immediate threat for continued abuse, neglect, and mistreatment of [REDACTED]. Refer to F 250, F 490, F 493, and F 501. Findings: The facility policy titled, Abuse Prohibition, revised 8/1/16, directed the following: The facility shall not employ individuals who have been found guilty by a court of law of abusing, neglecting or mistreating others. Training shall be provided to all employees, through orientation and ongoing sessions, about: how staff should report their knowledge related to allegations without fear of reprisal. What constitutes abuse, neglect exploitation, and misappropriation of resident property. Actions to prevent abuse, neglect exploitation, involuntary seclusion, and misappropriation of property shall include: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. Staff shall identify events .occurrences, patterns and trends that may constitute abuse, and determine the direction of the investigation. The employee alleged to have committed the act of abuse shall be immediately removed from duty, pending the investigation. All cases of suspected abuse, neglect .require mandatory reporting within one working day to the Department of Health and Human services and one or more of the following: The Long term Care Ombudsman Program or Adult Protective Services. Upon receiving information concerning a report of abuse, the CED or designee shall: conduct an immediate and thorough investigation which shall focus on if abuse or neglect occurred and to what extent, causative factors and interventions to prevent further injury. The facility shall protect residents from further harm during an investigation. The CED or designee shall take all necessary corrective actions depending on the results of the investigation. A review of a facility Grievance/Concern form indicated, on 7/25/16, Resident 2 indicated that CNA E argued with her over providing a proper washcloth during a shower and then called a male nurse in to assist with the shower which left her (Resident 2) feeling embarrassed and mortified. A review of a facility Grievance/Concern form indicated,on 7/28/16, Resident 3 indicated that she requested assistance to her room to have a bowel movement and CNA E responded by telling her to have a bowel movement in her brief and she would be back later to help clean her up. A review of a facility Grievance/Concern form indicated, on 11/17/16, Resident 1 indicated that CNA E scared and bullied her when CNA E accused her of always wetting the bed. CNA E stated she was going to make Resident 1 get up every hour to go to the bathroom and she refused to give her ice chips. Later that night Resident 1 stated CNA E came by her room and flickered the lights on and off for no reason. On 11/17/16, Resident 4 indicated that CNA E was verbally rude to her when she requested ice chips. A review of written statements, dated 1/8/17 and 1/9/17, made by CNA F, CNA G, and CNA H indicated these CNAs witnessed inappropriate verbal exchanges between Resident 5 and CNA E in the dining room when CNA E approached Resident 5 two times in the dining room and Resident 5 indicated he did not want CNA E caring for him, to which CNA E responded with laughter. Resident 5 wanted CNA E to stop harassing him because he is very bothered by that. Resident 5 stated, she's mean to me and puts the blanket over my face and holds it there so I can't breathe. I can't use my hands good so I can't defend myself. She put me in the lift and dropped me and puts my things where I can't get to them. Resident 5 stated that CNA E drops him in bed using the emergency release on the Hoyer (a mechanical lifting device) and also covers his face with a blanket and places her hand over his face and he is unable to move or breathe. Resident 5 was described to as clearly upset, mad and shaking after verbal exchange. a. Employee Screening and Hiring: On 1/6/17, CNA E's employee file was reviewed. CNA E was hired on 6/29/16. CNA E's employment history indicated that CNA E was terminated from two previous positions held due to customer service concerns. The file contained a background report that indicated CNA E had a criminal history, having been found guilty by a court of law of abusing, neglecting or mistreating others on 5/8/14, 11/4/14 and 8/18/15. The file did not contain evidence that the facility had verified that CNA E had a current CNA certification. A document titled, Attestation of Good Moral Character, dated 6/29/16, indicated that upon accepting a conditional offer of employment CNA E disclosed to facility that she had 3 misdemeanors; two in 2015 and one in 2014, and was on probation for these violations. A review of a facility email from Human Resources Compliance Coordinator (HRCC) to the facility's Human Resources (HR) and CED A, dated 7/6/16, referenced CNA E's criminal background and indicated, per the company hiring policy, the criminal background did not deem her ineligible for hire, but would require the record to be reviewed and Human Resource Management approval. During an interview and concurrent record review with CED D on 1/6/17 at 2:10 pm, CED D reviewed CNA E's employee file that included a criminal history and the four grievance reports involving CNA E that occurred from 7/2016 to 11/2016 of allegations of mistreatment, undignified treatment, and rude verbalizations. CED D stated that he began employment at the facility on 12/20/16. CED D stated CNA E was hired during CED A's employment and the grievances occurred during CED B's and CED C's employment. CED D stated CNA E should not have been hired, should have Individual Performance Improvement Plans (IPIP, a plan between the employer and employee when performance or conduct fails to meet expectations), and that he would have terminated her after the first two complaints in 7/2016. On 1/10/17 at 9 am, the CDPH contacted the CNA certification program review unit which indicated CNA E required proof of passing written and skills competencies for certification, and her criminal background was pending review and had not been cleared. During an interview with the CNE on 2/1/17 at 11:50 am, the CNE stated due to the facility's location and the pay scale, hiring CNAs is difficult. The CNE stated that CNA E's hiring was reviewed at the corporate level. The CNE stated, We all came to the conclusion that she was behaving appropriately and everyone is entitled to make mistakes. b. Employee Training: On 2/1/17 at 10:15 am, a tour of the facility was conducted and employees LN I, LN J, LN K, PT L, SS, CED D, and MD were interviewed regarding abuse. These employees were provided scenarios of dignity concerns, abuse allegations and mistreatment and were unable to identify abuse or unable to describe their responsibility as mandated reporters. During an interview on 2/1/17 at 10:18 am, LN I was given an abuse scenario. When asked if this was reportable, LN I stated I would just step in and assist the CNA provide care and instruct them to come get me if they need help. LN I stated that she was trained on abuse and mandated reporting on a regular basis. During an interview on 2/1/17 at 10:20 am, LN J was given an abuse scenario. LN J was unable to verbalize that they were a mandated reporter. LN J did not know where the policy and procedure was located in the facility. LN J stated they would report the abuse to the SS and could not state who else should be contacted for the alleged abuse. During an interview on 2/1/17 at 10:25 am, LN K was given an abuse scenario. LN K stated they would report the abuse to the Administrator and Ombudsman. When LN K was given a harassment abuse scenario, they stated they would have a talk with the employee and did not state they would report to the individuals required through being a mandated report. During an interview on 2/1/17 at 10:55 am, a Physical Therapist (PT L) was given a reportable abuse scenario and stated they would notify the charge nurse. The PT was unable to find the policy and procedure manual that outlined the reporting process. The PT was unaware that they were the mandated reporter not the charge nurse. During an interview on 2/1/17 at 11:15 am, SS stated that she takes grievances to the CED because he is the abuse coordinator and the CED determines if it is a grievance or abuse. SS stated if the CED or CNE are not at the facility she would call them to report it immediately. SS stated she understands that she is a mandated reporter, but she was instructed to go to them (CED & CNE) when she was being oriented for her position by CED A. During an interview on 2/1/17 at 1:45 pm, CED D stated, I'll be honest it all fell apart right here. They had a mistrust of reporting from the CNAs to the nurses. CED D stated, Yes, things have been reported and they failed to act. During an interview on 2/2/17 at 2:15 pm, the Medical Director (MD) stated he usually hears of allegations during meetings and what the facility's plan is for correction. MD stated that he assumed that when the facility informed him, they had already reported the incident. MD confirmed that he has not reported an allegation and stated, No, that's a nursing job, usually they take care of those things. c. Prevention: During an interview and concurrent record review on 1/6/17 at 11:35 am, NPE stated based on information received from the grievance report involving Resident 1 and CNA E, she educated CNA E on customer service. NPE indicated that determining abuse or neglect should happen with the SS investigation of the grievance. NPE reviewed the handwritten note by Resident 1 that alleged abuse and mistreatment by CNA E and stated, she felt it warranted further investigation. A review of in-service sign in sheets, dated 11/29/16, indicated that CNA E received in-service training regarding customer service, four months after an initial grievance was filed and 3 more grievances occurred with CNA E. The customer service training and talking points did not include information regarding abuse, neglect, mistreatment, or mandated reporting. During an interview with CED D on 1/26/17 at 10:24 am, CED D stated the course of action taken after all grievances were filed against CNA E was to not have her care for the specific residents that made the complaints. (Permitting an alleged abuse perpetrator to continue to care for other residents, placing them at risk for abuse, neglect, and mistreatment). During an interview and concurrent record review on 2/1/17 at 11:15 am, SS stated that she notifies the CED, CNE and NPE of all grievances. SS reviewed the grievance that she had received and investigated regarding Resident 1 on 11/17/16 and the handwritten note from Resident 1 that was submitted with the grievance. SS stated that she did not feel this was abuse, it was a customer service issue. During an interview and concurrent record review on 2/1/17 at 11:50 am, CNE confirmed if a grievance is related to nursing she gets a copy of it from SS. CNE reviewed all five grievances that included allegations of abuse, neglect and mistreatment involving CNA E. CNE stated, Can I just say we should have never hired her. CNE confirmed that these grievances should have resulted in suspension of CNA E, a thorough investigation should have been done, and the incidents should have been reported. d. Identification and Reporting: During an interview and record review on 1/6/17 at 2:10 pm, CED D stated he was unaware of the incidents involving CNA E. CED D stated these (four) grievances happened before he was employed at this facility, during the months of 7/2016-12/2016, when there were three other CEDs employed during that time frame (CED A, CED B and CED C). CED D stated they were not tracking grievances because the facility did not have processes in place and not all of the staff had been involved or communicated with. During interviews on 1/25/17 from 2:10 to 2:20 pm, CNAs F, G and H were interviewed individually. All three CNAs indicated that an incident occurred in the dining room involving Resident 5 and CNA E. The CNAs reported that Resident 5 had made allegations that CNA E covered his face with blankets and he could not breathe and that Resident 5 had told them that CNA E uses the emergency release on the Hoyer lift (a mechanical lifting device), dropping him on the bed. CNA G stated this information was reported to Charge Nurse (CN M). During an interview on 1/25/17 at 3:06 pm, CN M stated that she does not work on Sundays and she was not present when the incident with Resident 5 occurred but she was made aware of it when the staff were called in to the DON's office to make their statements. During an interview on 2/1/17 at 1:45 pm, CED D confirmed that CN M was not working on the night of 1/8/17. During an interview on 1/26/17 at 10:24 am, CED D stated resident's were not being notified of the grievance resolution within 72 hours and the grievances were not being reported to the CDPH. During an interview on 2/1/17 at 11:15 am, SS confirmed that all grievances that involved CNA E were determined as not needing to be reported and the facility never identified the grievances as multiple allegations involving one CNA (CNA E). During an interview on 2/1/17 at 1:45 pm, CED D confirmed he had not reported any of the grievances and stated, I should have reported it. The CDPH did not receive any reports from the facility of alleged abuse or dignity concerns for any of the 5 known grievances involving CNA E during the time that CED A, B ,C or D were the active CED, abuse coordinator. During an interview on 2/2/17 at 2:15 pm, the Medical Director (MD) stated he usually hears of allegations during meetings and what the facility's plan is for correction. MD stated that he assumed that when the facility informed him, they had already reported the incident. MD confirmed that he has not reported an allegation and stated, No, that's a nursing job, usually they take care of those things. e. Investigation During an interview on 1/6/17 at 11:18 am, SS stated she goes in to investigate the grievance and then hands the investigation to the CNE and the NPE. In discussing the information contained in the grievance reports, for example CNA E making rude comments to residents, SS stated that she didn't get any interviews to discover what the actual comments included. SS stated she just takes the information and passes it on to the CNE and NPE. During an interview and record review on 1/6/17 at 2:10 pm, CED D confirmed that the resident grievances involving CNA E were not thoroughly investigated. CED D stated, No, nothing is here. During an interview on 1/26/17 at 10:24 am, CED D stated in the past a thorough investigation was not being done. CED D stated SS took the statement from the resident then made the decision for what corrective action would be taken. CED D stated there was no engagement of the ombudsman to any grievance filed before 1/2017. CED D stated residents were not being notified of the grievance resolution within 72 hours. During an interview and concurrent record review with CNE on 2/1/17 at 11:50 am, the CNE reviewed all grievances involving CNA E. When asked why the grievance regarding Resident 1 was not reported she stated, I couldn't tell you. The CNE then reviewed Resident 2's grievance and stated, We should have never hired her (CNA E), then stated this should have resulted in suspension during an investigation and followed up with an Individual Performance Improvement Plan (IPIP, a plan between the employer and employee when performance or conduct fails to meet expectations). The CNE reviewed Resident 3's grievance and stated this is a dignity issue that should have been reported, CNA E should have been suspended, and this should have been investigated. The CNE reviewed Resident 4's grievance and stated she remembered this grievance and stated it was not a complete investigation. The CNE reviewed the handwritten statements from CNA's F, G and H, regarding Resident 5. The CNE stated that this incident resulted in CNA E's termination. The CNE stated that she was out of the building, but someone should have been manning the door when they couldn't get a hold of CNA E (to prevent her from working with residents). When asked if this incident was reported, the CNE stated, No, it should have been. The CNE stated that she couldn't answer to why the incident on 1/8/17 was not investigated or reported. f. Protection: During an interview on 1/25/17 at 2:45 pm, CED D stated that he attempted to, but was unable to, get a hold of CNA E to suspend her. CED D stated CNA E showed up to work her scheduled shift on 1/8/17 and another incident occurred involving CNA E that resulted in Resident 5's reported allegations of abuse and mistreatment. CED D confirmed this allegation was not thoroughly investigated or reported because he terminated CNA E. During an interview with HR on 1/25/17 at 1:55 pm, HR stated they were waiting until Monday to do the write up for CNA E and suspend her, but then the incident on 1/8/17 occurred with Resident 5, which led to her termination. During an interview on 1/26/17 at 10:24 am, CED D stated the only intervention taken by the facility after the grievances were filed against CNA E was to not allow her to care for the specific residents that made the complaints against her. This allowed CNA E to continue to have access to the residents that had reported allegations against her and failed to protect other residents from possible abuse, mistreatment, and neglectful care. During an interview on 2/1/17 at 1:45 pm, after the CDPH visit on 1/6/17 where CED D had been made aware of CNA E's criminal background and four grievances filed against her, and at that time, CED D had stated that his plan was to either suspend CNA E or move her to the day shift to provide increased supervison, it was discovered that CNA E was not suspended and was not moved to the day shift which allowed CNA E to continue to have full access to all the residents and the residents to go unprotected. The incident on 1/8/17 occurred while CED D was the CED, abuse coordinator. CED D stated that he was not aware when trying to get a hold of CNA E to suspend her, that she was scheduled to work on the night of 1/8/17. CED D stated that CNE, HR, SS were aware of the plan to suspend CNA E, but nursing supervisors working on 1/8/17 did not know of plan to suspend CNA E. CED D stated, We failed and that's my fault. g. Corrective Actions: During an interview and concurrent record review on 1/6/17 at 2:10 pm, CED D reviewed four grievances filed against CNA E that included resident allegations of abuse, neglect, and mistreatment. CED D stated CNA E should have performance improvement plans. CED D called HR and requested information on CNA E's IPIPs. HR stated there was a pending IPIP that had not been given to CNA E yet. A review of the IPIP disciplinary scale indicated there are 3 groups of action: Group A, unsatisfactory performance/misconduct and Group B, unsatisfactory attendance record. Both Group A and B indicated the first, second and third offense are responded to with counseling and on the fourth offense, termination of employment; and Group C, grounds for immediate dismissal, indicated termination of employment on first offense included actions that fall under abuse, neglect, violence, and failure to immediately report abuse, neglect or misappropriation of property. During an interview and concurrent record review of CNA E's IPIPs on 1/25/17 at 1:45 pm, the CNE confirmed that the IPIPs were not done until 1/9/17. CNA E had two IPIPs in her employee file: The first IPIP was initiated on 1/9/17 for an event that occurred on 12/28/16 related to insubordination when CNA E failed to do vital signs (check a resident's heart rate, breathing rate, blood pressure, and temperature), as requested by the charge nurse. This was categorized as a Group A action and indicated written counseling. The second IPIP was initiated on 1/9/17 for the incident involving Resident 5 reporting that CNA E was mean and mistreats him. The IPIP indicated a concern that several residents have requested CNA E not be assigned to their room, due to rudeness and personality conflicts. This was categorized as a Group A action and indicated Final Written Counseling and the need for training on Customer Service, Residents Rights, Dignity and Code of Conduct. This IPIP did not pertain to abuse allegations reported in the four previous grievances and did not indicate the abuse that was reported by Resident 5. This incident was not categorized as Group C where abuse and neglect are indicated, which would have indicated grounds for immediate dismissal. During an interview on 2/1/17 at 1:45 pm, CED D confirmed that he did not need HR approval to suspend an employee, but did need to notify them. CED D stated that he was advised by the Director of Regional Human Resources (DRHR) to do an IPIP for CNA E. CED D stated they scanned all of the grievances involving CNA E and sent them to DRHR for his review, and DRHR instructed to do an IPIP regarding customer service for CNA E. CED D stated, I failed to convince them how serious this was. Due to a systems failure and an immediate threat for continued abuse, neglect, and mistreatment of [REDACTED]. On 2/1/17 at 4 pm, the facility presented a corrective action plan that indicated training would be provided to all staff including administrative and the content would be around the facility's abuse policy and procedures. A new post test was to be implemented after the abuse training to assist with determining competency. All alert residents would be interviewed by social services in regards to abuse. On 2/6/17, an onsite visit occurred to verify that the facilities corrective action plan was implemented and effective. The IJ was removed on 2/6/17 at 3 pm, in the presence of the CED D and CNE.

Based on observation, interview, and record review, the facility failed to prevent avoidable resident to resident altercations between Resident 11 and Resident 21 and other residents by failing to implement it's Abuse policy to take actions to prevent abuse including identifying, correcting, and intervening in situations in which abuse was likely to occur. The facility failed to identify the potential risks of Resident 11's aggressive behaviors and provide adequate monitoring and interventions to prevent occurrences of conflict for one of 15 sampled residents (Resident 11) and one resident outside the sample (Resident 21). These failures resulted in harm to Resident 21 from an altercation with Resident 11, requiring Resident 21 to be transferred to the hospital emergency room (ER) for further evaluation and treatment for [REDACTED]. Resident 11 sustained a scratched arm as a result of a resident to resident altercation, further resident to residents altercations between Resident 11 and other residents occurred and had the potential for Resident 11 to be abused or other residents to be abused by Resident 11. Refer to F 250 and F 323. Findings: The facility's policy titled, Abuse Prohibition State of California, revised 10/15/15, indicated the facility will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients preventing occurrences and identification of possible incidents or allegations which need investigation. Actions to prevent abuse included identifying, correcting, and intervening in situations in which abuse and neglect is more likely to occur. Staff will identify events such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse to include patient to patient abuse. A review of Resident 11's facility admission records, indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11 was unable to make health care decisions and [AGE] years of age. Resident 11's record was reviewed. A review of the Minimum Data Set (MDS, resident assessment), dated 10/7/15, indicated that Resident 11 had verbal behaviors directed toward others such as threatening, screaming and cursing that occurred four to six days per week. Resident 11 had behaviors one to three days per week of behaviors not directed towards others, physical symptoms such as hitting or scratching, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or screaming. It was identified that the overall impact of Resident 11's behaviors on himself and others was putting himself and others at risk for physical injury. A review of the admission history and physical examination [REDACTED]. The MD documented Resident 11 was on [MEDICATION NAME] (antipsychotic to treat mood and mental disorders) at home and no longer wanted to take diabetes or [MEDICAL CONDITION] medications. According to the Food and Drug Administration (FDA), [MEDICATION NAME] is an antipsychotic medication known to have increased mortality in elderly patients with dementia-related [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] Injection is not approved for the treatment of [REDACTED]. Side effects of [MEDICATION NAME] include: dizziness, [MEDICAL CONDITION], fast or pounding heartbeat, restless muscle movements in your eyes, tongue, jaw, or neck, tremor (uncontrolled shaking), [MEDICAL CONDITION] (convulsions), pale skin, easy bruising or bleeding, flu symptoms, very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out, stabbing chest pain, feeling short of breath, cough with yellow or green mucus, sudden mood changes, agitation, hallucinations, unusual thoughts or behavior, headache, dizziness, spinning sensation, drowsiness, sleep problems ([MEDICAL CONDITION]), feeling restless or anxious, mild skin rash or itching. The care plan for behaviors, dated 10/7/15, had identified the risk for Resident 11 to be involved in resident to resident altercations. The goal was to have not more than three episodes of combativeness for 90 days. An ID note, dated 10/7/15 indicated, Resident (Resident 11) has severe dementia with exit seeking behaviors. Resident is not easily redirected. Resident is at risk for self injury because of his poor safety awareness . Resident is very ambulatory and wanders into unsafe areas . An Interdisciplinary Progress (ID) note, dated 10/8/15, indicated Resident 11 struck another resident. Resident 11 was identified to be at risk for being a victim of abuse related to his wandering, confusion, and getting into other residents' rooms. A care plan for behaviors was updated on 10/24/15, to include interventions of listening to resident needs, to calm resident and adjust plan appropriately, maintain safe environment, and provide close observation. An ID note, dated 10/27/15, indicated Resident 11 was the aggressor in a resident to resident altercation with his roommate . (Resident 11) struck the roommate on the leg after a verbal shouting match. An ID note, dated 11/17/15, indicated Resident 11 was involved in a resident to resident altercation (victim) on 11/15/15 (Resident 11) trying to prevent another female resident from entering his room. He was scratched on the right arm . The care plan for behaviors was updated on 11/16/15, to include the injury incurred (scratch and skin tear) was to be monitored, and no other care plan updates were made. There was no ID meeting or care plan updates found in the record for the incident on 11/18/15. A Communication form sent to the physician on 11/28/15, indicated Resident 11 had been increasingly agitated lately and was the aggressor in a resident to resident altercation. An ID note, dated 11/30/15 at 10:50 am, indicated Resident 11 was aggressive towards another resident. (Resident 11) hit resident x 3 (three times) in face. An ID note, dated 12/1/15 at 12:30 PM, indicated Resident 11 was combative beating on staff and hit several female staff. [MEDICATION NAME] was given intramuscularly (IBM) 3 milligrams (mg). A Client At Risk (CAR) team meeting note, dated 12/2/15, indicated, ADDENDUM-Resident (Resident 11) aggressor in Resident to Resident incident . Victim unharmed. A new care plan for combative behavior, dated 12/2/15, indicated to provide constant monitoring of resident. Duplicated interventions from the previous care plan for behaviors, dated 10/5/15, of maintain safe environment, consistent routine/caregivers, and document interventions and resident's response. An ID note, dated 12/12/15 at 2:30 PM, indicated Resident 11 reports another resident threatening me. A new care plan for behaviors dated 12/12/15, indicated Resident 11 will not cause harm to self or others through behaviors for 14 days. The interventions listed were the same ones identified on the first care plan for behaviors on 10/5/15. An ID note, dated 12/14/15, indicated Resident 11 was upset and stated, Someone made a threat against me in the past and that he was not retractable while walking around the facility. An ID note, dated 12/16/15, indicated (Resident 11) verbal altercation with male resident in next room . The monthly physician assessment note, dated 1/15/16, indicated Resident 11 had mild behavioral problems. The monthly physician assessment note, dated 2/1/16, indicated Resident 11's behaviors had increased to mild/moderate behavioral problems. The record indicated, on 2/18/16, Resident 11 had an unwitnessed fall resulting in a skin tear to his arm. An ID note, dated 2/22/16 at 7:45 pm, Resident 11 exhibited verbal threats saying he would hit a Licensed Nurse (LN) with a big rock. Resident 11 repeatedly swung closed fists into counter of nurses station and verbalized he would punch them in the throat just like this. Two mg of [MEDICATION NAME] was given IM to Resident 11 who required monitoring for two hours until he calmed down. A transfer discharge note, dated 2/22/16 at 12 pm, indicated Resident 11 had become highly combative danger to self, staff, and other residents. Resident 11 kept walking out of the building and refusing to return. Resident 11 was transferred to the hospital ER. A review of a late entry IDT note, dated 2/24/16, for the events on 2/22/16, indicated Resident 11 had increased imaginary, paranoid thinking and frequent episodes of elopement requiring staff members to follow him outside for long walks (30 minutes) sometimes in the dark. Resident 11 became aggressive, highly anxious, and starts a fast pace with clenched fists. Resident 11 was sent to the ER for his behaviors and returned same day with no new treatments or orders. A review of transfer discharge note, dated 2/22/16 (no time), indicated Resident 11 had [MEDICAL CONDITION], unable to urinate for over 12 hours during the night shift. Resident 11 was aggressive & combative, refusing to allow staff to take his vital signs (temperature, heart and breathing rates, and blood pressure) and assess his abdomen. Staff indicated they could not get close enough to assess Resident 11 or catheterize him (insert a tube into his bladder to drain urine). An IDT note, dated 2/23/16 at 3 pm, indicated Resident 11 refused to participate in the Telepsychiatry (psychiatric evaluations via phone/television). An IDT note, dated 2/26/16 at 12:42 pm, indicated Resident 11 had not voided for 12 hours, refusing nursing assessments and was sent to the ER for evaluation and treatment. The ER gave 10 mg of [MEDICATION NAME] and identified a Urinary Tract Infection [MEDICAL CONDITION]. A review of hospital ER documentation indicated, on 2/26/16 at 11:22 am, indicated Resident 11 arrived at the ER with Irritability, Confusion, Alteration in Consciousness (level of alertness) . and does not follow commands . symptom onset 11:30. At 1:30 pm, in the ER, Resident 11 was administered intramuscular injections of [MEDICATION NAME] ([MEDICATION NAME] medication used alone or with other medications to treat shaking (tremor) and muscle stiffness caused by [MEDICAL CONDITION] or to teat side effects of certain psychiatric drugs or to treat allergic reactions) 50 mg and [MEDICATION NAME] 5 mg. The discharge [DIAGNOSES REDACTED]. Resident 11 was returned to the facility on [DATE] at 6:30 pm with orders for an antibiotic medication to be started for UTI. A care assessment meeting note, dated 3/2/16 at 2 pm, indicated to continue to monitor Resident 11 behaviors, his unwitnessed fall on 2/18/16 that resulted in a skin tear, unexpected discharge to hospital on [DATE], and that he was being treated for [REDACTED]. The care plan continued daily walks, redirection and emotional support. The monthly physician assessment note, dated 3/5/16, indicated Resident 11's behaviors had significantly increased to severe behavioral problems. An IDT note, dated 3/8/16 at 12:05 pm, indicated Resident 11 refused to participate in the Telepsychiatry appointment. An IDT note, dated 3/14/16 at 4:50 pm, indicated Resident 11's behaviors were escalating. A prescription for daily [MEDICATION NAME] was discussed between the Medical Director (MD) and psychiatrist. An IDT note, dated 3/12/16 5:53 pm, indicated the MD was contacted about Resident 11's resistance to redirecting and verbalizing wanting to leave loudly and intensively with clenched fists threatening to strike if stopped. A one time dose of [MEDICATION NAME] 2 mg by mouth was ordered. An IDT note, dated 3/15/16 at 1 pm, indicated Resident 11's behaviors were escalating and was given the as needed [MEDICATION NAME] 1 mg. An IDT note, dated 3/20/16 at 8 pm, indicated Resident 11 was heard yelling at another resident (Resident 21). Resident 11 was seen kicking with his left foot and hit Resident 21's left hand which resulted in an ER visit and a full thickness laceration measuring three centimeters of the left 5th finger down to the tendon, requiring stitches. An IDT note, dated 3/21/16 at 3:30 pm, Resident 11's behavior was escalating again, speech pressured and loud, and started to threaten staff. An IDT note, dated 3/21/16 at 11:34 pm, the Director of Nursing (DON) called the family and they agreed to have facility start looking for a higher level of care facility (secured dementia unit). The new care plan interventions for behaviors, dated 3/21/16, included provide one on one interactions, medications as ordered by physician ([MEDICATION NAME]), and included repeated interventions from previous care plans of maintain consistent routines and remove resident from environment. An IDT note, dated 3/22/16 at 2:32 pm, Resident 11 had increased agitation. An IDT note, dated 3/22/16 at 6:32 pm, Resident 11's behaviors were escalating and he was medicated with as needed [MEDICATION NAME]. A care assessment meeting note, dated 3/23/16 at 1:32 pm, three days after the altercation that resulted in injury to Resident 21, indicated Resident 11 barricaded his room with an empty bed. Social Services (SS) to work on referrals in a 100 mile radius. An IDT note, dated 3/23/16 at 2:04 pm, Resident 11 continues to have verbal outbursts mainly yelling and statements of elopement. An IDT note, dated 3/24/15 at 1:35 pm, Resident 11 continued to have sporadic outbursts. An IDT note, dated 3/25/16 and 3/26/16, indicated Resident 11 had increasing exit seeking behaviors and was taking extended walks. An IDT note, dated 3/27/16 at 12:55 pm, Resident 11 yelled at another resident he thought was entering his room. An IDT note, dated 3/28/16 at 11:45 am, indicated Resident 11 was given [MEDICATION NAME] at 10 am on 3/27/16 for agitation and kicking in the direction of another resident and pacing in the hallway. An IDT note, dated 3/28/16 at 11:46 am, indicated Resident 11 kicked the admission's room door. An IDT note, dated 3/29/16 at 2:35 pm, indicated Resident 11 became agitated and walked out the front door, then staff followed. An IDT note, dated 3/29/16 at 2:57 pm, Resident 11 was agitated and walking around the facility often. An IDT note, dated 3/31/16 at 7:41 pm, Resident 11 had increased exit seeking behavior, redirected with activities, effectiveness of redirects do not last long. The final walk outside building of that day, Resident 11 did not want to return to the facility. Resident 11 was exhibiting combative behavior, pressured speech, darting eyes, large gestures. [MEDICATION NAME] was administered. An IDT note, dated 4/3/16 at 6:35 pm, Resident 11 had increased behaviors and an altercation with another resident at 3:30 pm. Resident 11 was given four separate walks with staff redirected often and resident still continued with agitation and wanted to leave building without staff. [MEDICATION NAME] given. A Care Plan meeting note, dated 4/3/16 at 2:59 pm, indicated the SS, a Registered Nurse, and Activities Director (AD) were in attendance, family was invited and not present. Summary of meeting included that Resident 11 was an elopement risk, had a weight change, pain was managed, [MEDICATION NAME] was given for agitation and [MEDICATION NAME] (antipsychotic medication) for combative behaviors. An IDT note, dated 4/6/16 at 4:05 pm, Resident 11 had two walks and just had a walk that lasted 30 minutes, then redirected to courtyard and started to kick doors and having loud, angry outbursts with a mad angry scowl on face. [MEDICATION NAME] was given. The monthly physician assessment note, dated 4/11/16, indicated Resident 11 continued to have severe behavioral problems. An IDT note, dated 4/12/16 at 6:45 pm, Resident 11 was being very demanding for a walk and was told it was change of shift and would have to wait. Resident 11 went out to patio and started to push/throw furniture. [MEDICATION NAME] was given. During a resident group interview, on 4/13/16 at 3 pm, Resident 16 stated there was a resident to resident altercation which resulted in an injury to Resident 21. Resident 16 stated she was fearful of Resident 11. On 4/13/16 at 4:15 pm, Resident 11 was observed alone in the hallway near his room, there were no staff present to monitor him. During a follow up interview on 4/14/16 at 10:40 am, Resident 16 stated she had seen Resident 11 physically push nurses. Resident 16 stated she had in the past come close to Resident 11, and he threatened her to come no closer than this (he used his hands to indicate distance) or I will kick you. Resident 16 had told nurses about her anxiety about Resident 16 and their response had been He does not know what he is doing. A review of an update to the care plan for behaviors on 4/15/16, included a similar intervention of checking on the resident frequently. During an interview on 4/15/16 at 9:15 am, the MD stated Resident 11 had a intracranial AV fistula (brain bleed) that was ablated (surgically removed) a few years ago and had a history [MEDICAL CONDITION] and stroke (can cause neurological damage). The MD stated the behaviors started after this procedure and have been present since admission. The MD stated Resident 11 was on [MEDICATION NAME], prior to admission, and it seemed to work well. The MD stated the facility was resistant to prescribing [MEDICATION NAME]. The MD stated Resident 11 could be volatile (explosive), unpredictable and had exit seeking behaviors. During an interview on 4/15/16 at 9:45 am, Registered Nurse (RN) C stated Resident 11 had increased restlessness since admission. RN C stated Resident 11 had personal space issues and does not want anyone close to him. RN C explained Resident 11 had increased agitation with over stimulation and noise. During an interview on 4/15/16 at 10:10 am, Nurse Practice Educator (NPE) stated Resident 11 had increased agitation since admission and required more monitoring for aggression. NPE stated Resident 11 yelled at a confused resident who frequently passed by his room. NPE stated Resident 11 had exit seeking behaviors when he was amped and wanted to go for walks immediately. NPE stated Resident 11 needed more supervision when he was in lobby near the front door due to personal space issues and exit seeking behaviors. NPE stated Resident 11 had hit residents and staff in the past. NPE stated Resident 11 was unpredictable and issues with his personal space and impatience with waiting to be walked outside triggered his behaviors. NPE stated Resident 11 was not always in plain sight of staff and often staff have to catch up to him as he is exiting the front door. During an interview on 4/15/16 at 11:10 am and 2:15 pm, the Administrator (Admin) stated Resident 11 had unpredictable behaviors and was very territorial. The Admin confirmed there had been no new interventions implemented for Resident 11 since the incident involving Resident 21 and the facility continued to monitor his behaviors. The Admin stated there had never been a time that Resident 11 required one on one supervision, but could receive it, if needed. During an interview on 4/15/16 at 12:50 pm, the AD stated Resident 11 had been observed charging out of his room when other residents pass by. During an interview on 4/15/16 at 1 pm, SS stated Resident 11 needed a walk when his behaviors started to escalate. SS described Resident 11's behaviors as unpredictable. SS stated Resident 11 needed one on one supervision when he starts to pace and becomes agitated. SS had to follow Resident 11 out the front door this morning for a 30 minute walk. During an interview on 4/15/16 at 1:30 pm, the DON stated Resident 11 and his behaviors had been difficult to manage since admission. The DON stated no new interventions had been implemented other than medication changes since elopement and the altercation that resulted in an injury to Resident 21. The DON confirmed that Resident 11 had not been on any scheduled one on one observation or scheduled walks. The DON stated the facility could not provide one on one observation due to not having enough staff, further stating, Resident 11 can be fast and not always under supervision of staff. The DON stated the facility was looking to place Resident 11 in a facility with a higher level of care to meet his needs.

Based on observation, interview and record review, the facility failed to ensure that one of fifteen sampled residents (Resident 2) did not develop a pressure ulcer (PU - bedsore, injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) when: Resident 2 was identified as a high risk to develop a pressure ulcer and the resident's need for necessary interventions consistent to standards of practice to prevent the development of new pressure ulcers were not developed or implemented after Resident 2 developed pressure ulcers on two separate occasions. The facility failed to accurately identify the resident's skin integrity status on the skin integrity reports (weekly monitoring and assessment) and obtain treatment orders from the physician appropriate to the PU. These failures resulted in an avoidable PU, potential delayed healing, had an adverse effect on the resident's well-being, had the potential to prolong her healing, and negatively impact her comfort. Findings: Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems), dated 6/19/15, indicated Resident 2 had no PUs and was totally dependent on staff for activities of daily living (ADL) including bed mobility (turning from side to side and positioning her body while in bed), dressing, bathing, personal hygiene, and transferring into a chair. The MDS indicated Resident 2 had a functional limitation of all her arms and legs and was always incontinent (unable to hold or control) her urine and stool. A record review of the formalized pressure ulcer risk assessment tool titled, Braden Scale for Predicting Pressure Score Risk, dated 12/14/15, 12/28/15, and 1/3/16, indicated Resident 2 scored as a high risk for development of a PU. A record review of Resident 2's care plan titled, at risk for pressure ulcer initiated 8/7/15, indicated she was at risk due to, limited mobility and very fragile skin. Interventions dated 8/7/15, indicated the facility would use Pressure redistribution surfaces to bed as per protocol, assist the resident in repositioning, and utilize positioning devices to prevent pressure over a bony prominence. The facility's policy titled, Skin Integrity Management, last updated 3/15/16, indicated that staff would implement revisions to the plan of care as needed, identify the resident's skin integrity status and implement pressure ulcer prevention for identified risk factors including determine the need for support surface for bed and chair and develop a comprehensive interdisciplinary plan of care including prevention and wound treatments as indicated. The facility's policy titled, Pressure Ulcer Prevention Guideline, (undated) indicated the facility would utilize pressure redistributing surfaces and for a resident with a history of PUs would provide protection from pressure to high risk areas. The policy tilted, Support surfaces: Utilization, dated 10/01/12, indicated support surfaces would be used as a standard of care to provide pressure redistribution and specialty mattress replacement surfaces such as low air loss (LAL, a specialized air flow mattress which achieves greater levels of pressure distribution) may be utilized. The National Pressure Ulcer Advisory Panel (NPUAP), a nationally recognized society which educates, researches and provides public polices for pressure ulcer prevention and treatment provided the following definitions for PU categorization: Stage I is intact skin with area of localized redness usually over a bony prominence. Stage II is partial thickness skin loss, appears as a shallow open ulcer with a red pink wound bed, without slough (dead tissue frequently of a brown, yellow or tan color) which obscures a significant part of the wound bed. Stage III is a full thickness skin loss, fatty tissue may be visible. Slough does not obscure the depth of tissue loss. Unstagable is a full thickness tissue loss of unknown depth due to the wound bed being obscured by slough. Suspected deep tissue injury (SDTI) is an purple localized area of intact skin over a bony area due to damage of unknown depth to underlying soft tissue caused when pressure on the skin is created from an external source (such as a mattress) and a bony prominence (such as a tailbone). The MDS dated [DATE], indicated that Resident 2 continued to be dependent on staff for ADL, was not able to walk or stand, weight was 93 pounds, within the previous 7 days had a pressure ulcer of her lower back and continued to be at risk of developing pressure ulcers. A physicians order dated 12/3/15, indicated to discontinue Resident 2's LAL and return her to a regular mattress. An interview was conducted on 4/14/16, at 3:30 pm, with the Director of Nurses (DON). The DON stated the facility had initiated an LAL on Resident 2's bed prior to 12/3/16 to protect her skin due to her low weight and high risk and history of impaired skin integrity. The DON stated due to the slickness of the LAL's nylon like surface Resident 2 had slid off the LAL. DON stated the LAL had been discontinued on 12/3/16, and no alternatives were explored to maintain a LAL for Resident 2 such as bolsters (a firm raised perimeter) used specifically on LAL mattresses to prevent a residents sliding. The DON stated no new care interventions had been developed in 12/2015 to compensate for the LAL removal, or later in 1/2016 when Resident 2 developed another PU on her hip area. The Skin Integrity Report, dated 2/1/16, indicated Resident 2 had a new area of impaired skin integrity on her left trochanter (hip bone area)identified as a Stage I PU. The records reviewed titled, communication to the physician and nurse progress note, dated 1/31/16, and risk for pressure ulcer care plan initiated 8/7/15, indicated and the DON confirmed that Resident 2 had developed a Stage I PU in the facility on 1/31/16, on her left side hip bone area despite the care planned interventions initiated 8/7/15, of staff assisting the resident to reposition and utilizing positioning devices such as pillows. The DON stated that other than providing a physician ordered foam dressing specific for the left hip area only, no other interventions were developed or changes to the care plan were made to address Resident 2's impaired mobility and prevent further pressure ulcer development. A nurse progress note dated, 3/13/16, at 4:25 pm, indicated Resident 2 was observed with Deep purple discolorations to coccyx (tailbone area) and left lateral (the side) foot, consistent with pressure related breakdown secondary to immobility and poor intake (meal eating) The Braden Scale for Predicting Pressure Sore Risk, dated 3/13/16, indicated Resident 2 scored higher than high risk and was at severe risk for pressure ulcer development. The Skin Integrity Report dated 3/15/16, categorized Resident 2's PU identified on 3/13/16, as an unstagable wound on her sacrum (area above the coccyx) partially having a deep purple appearance which overall measured 3.0 centimeters (cm) by 2.5 cm and a depth of 0.1 cm. A physicians order dated 3/16/16 included an order to treat the sacral PU with [MEDICATION NAME] and silicone products (designed for the maintenance of moisture and to assist with prevention of infection) to a wound bed. A physicians order dated 3/17/16, indicated to resume the LAL on Resident 2's bed to prevent skin breakdown. The Skin Integrity Report dated 3/21/16 and 3/28/16, for Resident 2's sacrum PU categorized it as an unstagable (full skin thickness loss) with 40-60 percent slough (patch of dead cells and fluid that cover a wound) and moderate drainage. A physicians order dated 3/21/16, indicated the sacral wound treatment be changed to include Santyl (An enzymatic cream intended to dissolve slough). Skin Integrity Report, dated 4/1/16 (3 days after the 3/28/16 assessment) and 4/11/16, for the sacrum PU categorized it as a Stage II (partial thickness loss), 100 percent healthy tissue without the presence of slough. The report of 4/1/16, indicated the wound had no drainage (weeping of fluid). A physicians order dated 4/8/16, indicated to change the treatment to the sacral PU, discontinue the Santyl and begin a treatment of [REDACTED]. An observation and concurrent interview was conducted on 4/15/16, at 8:30 am, with licensed nurse (LN) J. LN J stated he was a regular nurse who cares for Resident 2 and was familiar with her. Resident 2 was initially positioned in bed lying on her left side on the LAL mattress. Resident 2 appeared thin with an appearance of her skin being draped over her bones. LN J exposed Resident 2's sacral area and no dressing or wound was visualized, despite LN J's repositioning Resident 2 in a far left side lying position. LN J stated the PU was not able to be seen with the resident lying on her left side and obtained assistance from another staff who together repositioned Resident 2 onto her right side. LN J and surveyor were then able to readily visualize a dressing located on Resident 2's left upper buttocks over the top of the hip bone area which LN J removed. LN J stated he would categorize the wound to be a Stage III. LN J confirmed the presence of slough obscuring the wound base and an area of soft appearing whitish tissue surrounding the perimeter of the PU. LN J stated the PU had started as a deep purple discoloration and shortly after it opened and had always had slough. LN J stated the wound location was not in the sacral area but on Resident 2's left upper buttock. When asked why Resident 2 had not been utilizing an LAL prior to development of this third PU, LN J stated she should have, but to use an LAL was a corporate decision. An observation and concurrent interview was conducted on 4/15/16, at 9:30 am, with the facility's Minimum Data Set/Wound Registered Nurse (MDS/WDRN). MDS/WDRN stated that one of her facility titles and responsibilities was Wound Coordinator. MDS/WDRN and this surveyor observed Resident 2's PU with Resident 2 lying on her right side. MDS/WDRN stated she categorized the PU as unstagable due to the presence of slough obscuring the wound bed. No wound was present at the sacrum. MDS/WDRN confirmed the presence of soft whitish substance around the perimeter of the wound appeared to be maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture). An interview was conducted on 4/15/16, at 1:40 pm, with LN K. LN K stated her current job incorporated being a Unit Manager which included the desk nurse responsibilities to process various physician and pharmacy notifications and orders. LN K stated she had no previous first hand knowledge of Resident 2's wound when she had performed Resident 2's skin integrity report on 4/1/16. LN K stated on 4/1/16, she had examined Resident 2's sacrum (area above the tailbone) while Resident 2 was lying on her left side, and had seen a very small superficial pinpoint red open area. During an interview on 4/15/16, at 3 pm, MDS/WDRN confirmed that the pressure ulcer was initially a dark purple SDTI PU. MDS/WDRN stated she did not believe the skin integrity reports of 4/1/16 and 4/11/16 were accurate. MDS/WDRN stated the physician was contacted for treatment orders based on the skin integrity report of the wound as treatment wound products have various effects and were selected to address specific symptoms of a PU, including the condition of the wound base, presence or absence of slough, maceration and drainage. MDS/WDRN stated correct documentation of wound appearance and staging was important in determining the appropriate treatment for [REDACTED]. MDS/WDRN stated inaccurate documentation of the site location may have contributed to incorrect staging and inaccurate documentation of Resident 2's PU. Resident 2's care plan titled, at risk for pressure ulcer initiated 8/7/15, and included Pressure redistribution surfaces to bed as per protocol, assist the resident in repositioning and utilize positioning devices to prevent pressure over a bony prominence had no interventions added until 3/18/16, after the development of Resident 2's unstagable PU. During an interview on 4/14/16 at 3:30 pm, the DON confirmed that no new care interventions had been developed or implemented to address Resident 2's impaired mobility and prevent Resident 2's PU since 12/3/16.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest physical and mental well being for one of 15 sampled residents when the fluid restriction was not monitored per the physician order [REDACTED]. (Resident 12) These failures had the potential for causing physical complications related to fluid overload and harmful phosphorus/calcium imbalances which could lead to bone disease. Findings: Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 12 had a minimum data set (MDS, an assessment tool) which indicated that he was able to complete his own activities of daily living independently and was able to make decisions for himself. Resident 12 had a physician's orders [REDACTED]. Dietary to provide 480 ml in 24 hours, breakfast 240 ml, coffee, lunch tray 120 ml and dinner tray 120 ml. Record amount of fluids from each shift. Resident 12 had two physician's orders [REDACTED]. The second physician's orders [REDACTED]. On 3/11/15 at 2:30 pm, during an interview and review of Resident 12 Medication Administration Record [REDACTED]. LN B stated that Resident 12 leaves the facility between 8-8:30 am, and returns between 4 and 4:30 pm three days a week when he receives [MEDICAL TREATMENT]. LN B confirmed that there was a physician order [REDACTED]. LN B confirmed the fluid monitoring was not documented in the MAR. LN B confirmed that Resident 12 was scheduled to receive [MEDICATION NAME] a total of five times every day. LN B stated that when Resident 12 went to [MEDICAL TREATMENT], his medication was not sent with him and confirmed he did not take it as prescribed. On 3/11/15 at 3:15 pm, during an interview and record review the Director of Nurses (DON) confirmed that Resident 12 had physician order [REDACTED]. The DON confirmed that Resident 12 had a physician order [REDACTED].

Based on interview and record review, the facility failed to ensure that one of 15 sampled residents (Resident 11) received adequate caloric intake to maintain her weight when she experienced severe insidious (gradual, unintended, progressive) weight loss. This failure resulted in and/or contributed to severe weight loss and placed Resident 11 at risk for continued weight loss and malnutrition. (Refer to F 322) Findings: Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11's Minimum Data Set (a resident assessment tool), dated 2/11/15, indicated that Resident 11 received all of her nutrition through a feeding tube inserted into her stomach and was totally dependent on staff for these feedings. Resident 11's current physician's orders [REDACTED]. (calories) at 50 ml (milliliters) an hour for 20 hours, equaling 1200 cal. a day. The formula was to be delivered via pump, starting at 12 pm and finishing the next day at 8 am. A record of Resident 11's weight indicated on: 3/2/14, weight 107.8 lb. (pounds) 4/4/14, weight 105.8 lb. (2 lb. weight loss in one month) 5/2/14, weight 106.2 lb. 6/2/14, weight 105.2 lb. 7/2/14, weight 102.8 lb. (2.4 lb. weight loss in one month) 8/3/14, weight 103.4 lb. 9/2/14, weight 98.4 lb. (5 lb. weight loss at one month, a decrease of 4.8 percent in one month) 10/1/14, weight of 97.4 (1 lb. weight loss in one month and 6 pounds in two months, a decrease of 5.8 percent in two months) 11/4/14, weight of 93.4 (4 lb. weight loss in one month and 10 pounds in three months, a decrease of 9.6 percent in three months, considered severe weight loss) 12/4/15, weight of 97.8 12/14/14, weight of 93.2 1/3/15, weight of 95.8 Resident 11's record contained a Registered Dietitian (RD) dietary note, dated 9/10/14, that acknowledged the 9/2/14, 5 pound weight loss and requested re-weight. Resident 11 had a re-weight documented on 9/14/14 that indicated a gain of 1 lb. Resident 11 had a RD Tube Feeding Review, dated 9/24/14, that indicated Resident 11 had a 8.4 lb. weight loss in the last six month, equaling 7.8 percent and was on an undesired weight loss trend. The RD indicated Resident 11 weighed 99.4 lbs on 9/14. The RD indicated the resident was receiving [MEDICATION NAME] 1.2 at 45 ml per day times 20 hours and to provide 1080 cal (24 cal per kilogram (kg) current weight and 50 grams (g) of protein (1.1 g per kg current weight). The RD's interventions included; tube feeding and water flushes as ordered, monitor documentation on the MAR (Medication Administration Record), record weekly weights for three weeks or until stable, and RD available as needed. Resident 11 had a RD Tube Feeding Review, dated 10/22/14, that noted no significant weight loss, however weight loss noted. The RD had no new interventions documented. Resident 11 had a RD Quarterly/Tube Feeding review/Weight review note, dated 11/17/14, that indicated that there had been a significant weight loss of 12.8 lbs. or 12 percent in the last six months. The RD indicated Resident 11 weighed 93.4 lbs (42 kg) on 11/4/14. A new intervention recommended the increase of tube feeding amount by 5 ml per hour during the 20 hour feeding. This would provide 1200 cal (28.5 cal per kg) and 55 g of protein (1.3 g per kg). On 3/10/15 at 4:20 pm, during an interview and record review the Registered Dietitian (RD) confirmed that she was notified of and monitors residents with a loss or gain at 5 percent in one month, 7.5 percent at three months, and 10 percent at six months. The RD stated that she attends weekly weight meetings and completes quarterly and annual nutrition assessments. The RD confirmed the above mentioned weight changes in 9/2014 and stated that on re-weigh the weight losses were just under what was considered a significant change. The RD confirmed that she does monitor insidious weight changes as well significant weight changes. The RD agreed that Resident 11 was totally dependent on staff for all personal care and feedings and that there were no change in Resident 11's nutritional needs. The RD was asked about interventions documented in the dietary notes and confirmed that the nurses' initial the MAR as the task is complete but do not put specific information about the amount of tube feeding that was administered. The RD stated she was unsure what caused the weight loss and confirmed that she did not suggest any interventions other than the non-specific monitoring until 11/17/14 (by this time the resident had sustained severe weight loss). According to Practical [MEDICATION NAME], June 2003, the suggested caloric requirements per kg of estimated euvolemic (presence of proper amount of blood in body) weight for anabolism (building up) is 30-35 cal per kg. The tube feeding only provided 28.5 cal/kg for Resident 11, who for anabolism would need 30-35 cal/kg. On 3/10/15 at 5 pm during an interview and record review the Director of Nurses (DON) confirmed Resident 11 had been having a slow decline in weight. The DON confirmed the first Interdisciplinary Team (IDT) note identifying Resident 11's weight loss was written on 12/17/14 and no prior nursing review. The DON stated that they had recently moved Resident 11 because there was some thoughts that a stressful roommate situation may have been contributing to her weight loss. The DON stated that the feeding pump had been replaced with a new pump in 12/14. The DON confirmed that there had been no increased activity or change in Resident 11's medical condition that would account for Resident 11's weight loss. Review of the facility's policy and procedure titled Weights and Heights, dated 1/2/14, indicated the resident will be weighed on admission and re-admission and if a resident's weight is less than or greater than five pounds from the previous weight, the resident will be re-weighed. The weight will be verified by a licensed nurse to determine accuracy. Significant weight changes, defined as: 5 percent in one month, 10 percent in six months, will be reviewed by the licensed nurse for assessment. The licensed nurse will notify the physician and dietitian of significant weight changes and document notification of physician and dietitian in the computerized Weight Change Progress Note. The facility policy did not mention how the facility monitors insidious weight loss or what interventions are put in place.

Based on observation, interview, and record review, the facility failed to protect Resident 1 from verbal and physical abuse when Certified Nurse Aide (CNA) A forcefully pushed the resident to the floor, yelled obscenities at her, and threw a bed cover over her. Resident 1 was witnessed crying immediately after being abused by CNA A, as she was assisted into her bed. Findings: On 6/5/13 at 6:28 pm, the Department of Public Health was sent a faxed notification from the facility titled, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated that on 6/5/13, CNA A, allegedly pushed Resident 1 who fell to the floor. Another staff member, CNA B had witnessed the event. The facility records indicated that on 6/5/13, both the County local Police Departments were also notified. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Low bone density contributed to Resident 1's risk for easily broken bones. The Minimum Data Set (MDS-an assessment tool) for Resident 1, dated 3/17/13, indicated Resident 1 was a [AGE] year old, 100 pound female. Resident 1 required extensive assistance from CNA staff with dressing and was totally dependent on CNA staff for bathing and personal hygiene. The MDS identified Resident 1 as having felt down, depressed or hopeless nearly every day. The Care plan titled, "Psychosocial well being" for Resident 1 was reviewed and indicated that due to dementia, Resident 1 was prone to repetitive requests despite repeated assistance. Staff interventions to assist Resident 1 in coping were to provide supportive feedback and develop trust/rapport. During an observation on 6/19/13 at 1:45 pm, Resident 1 was interviewed while sitting up in her room, she was repeatedly mumbling to herself "somebody help me." During an interview with CNA B on 6/19/13 at 2:25 pm, she stated Resident 1 was usually very confused and says, 'Please help me,' constantly and it is very hard to listen to. She further stated that on 6/5/13, she witnessed Resident 1 standing by her bed and CNA A enter the resident's room. She watched CNA A grab Resident 1 by the right arm and forcefully push her down, causing Resident 1 to fall to the floor. CNA B then heard CNA A "snap" at Resident 1 saying, "I'm not putting up with your bullshit tonight!" On 6/19/13, the facility Administrator provided a copy of an interview statement by CNA B who witnessed the event. It stated after the Resident had been pushed, CNA's A and B picked her up off the floor, put her in her bed and CNA A "threw cover over her (Resident 1)" and left the room. Resident 1 "cried" when she was returned to bed. On 6/19/13, the facility provided an abuse policy. The policy dated, 1/2008, indicated, "Physical abuse may include pushing." The policy indicated verbal abuse is the use of language that willfully includes disparaging terms to residents, regardless of their ability to comprehend." During an interview with the Administrator on 6/19/13 at 9:30 am, she confirmed the abuse report filed on 6/5/13 had been substantiated. The Administrator stated it was,"willful and intentional" behavior by CNA A who had been subsequently discharged and reported to the CNA licensing board.