Every finding on record at Woodcrest Post Acute & Rehabilitation

Based on interview and record review, the facility failed to ensure necessary discharge planning was provided according to the facility's policy and procedure, for one of three residents reviewed (Resident 1), when Resident 1's family member (FM) was not informed of the resident's current functional limitations, required level of care, and if the FM was capable of providing care to Resident 1, prior to discharging back to home.This failure resulted in Resident 1 being discharged home and the FM could not provide the required assistance in ADLs (Activities of Daily Living). This failure had the potential for Resident 1's overall health condition to be affected and further decline in ADLs.Findings:On April 1, 2026, at 9:18 a.m., an unannounced visit to the facility was conducted to investigate issues regarding discharge.On April 1, 2026, a review of Resident 1's admission Record, indicated he was initially admitted to the facility on [DATE], with diagnoses which included fracture (break in the bone) of the right lower leg and osteomyelitis (a serious bone infection) on left ankle and foot. Resident 1 was discharged home on March 25, 2026.A review of Resident 1's Care Plan Report, initiated on December 14, 2025, indicated the resident or family's discharge plan was to discharge back to the community with his wife and for the facility to discuss discharge plan with resident/family as appropriate.A review of Resident 1's PT (Physical Therapy) Evaluation & (and) Plan of Treatment, dated December 15, 2025, indicated Resident 1's prior level of function was mostly independent with ADLs (activities daily living) including ambulation and he used a rollator walker for longer distances.A review of Resident 1's Physical Therapy Treatment Encounter Note(s), indicated the following:-On December 15, 2025, to March 12, 2026, indicated Resident 1 had non-weight bearing status to his left lower extremity and had weakness to his right lower extremity;-On March 17 and 23, 2026, Resident 1 performed five feet side steps using a front wheeled walker with moderate assistance (resident performs 50% of the task and the therapist provides 50% of the effort).A review of Resident 1's Case Management Notes, documented by Case Manager (CM), indicated the following:- December 30, 2025, at 11:49 a.m., .resident lives with wife in a single-story home, where patient plans on returning, resident walking independently at home with no assistive device.;-On March 6, 2026, at 2:46 p.m., .Place call to (name of Family Member [FM]).informed (name of FM) resident will exhaust benefits on 3-24-2026 (March 24, 2026) and will discharge home, (name of FM) replied resident lives at home with wife and daughter and family will assist with care at home.; and-On March 24, 2026, at 1:23 p.m., .During (name of insurance) meeting with (name of physician, CM, & SW (Social Worker), and our Rehab (rehabilitation) Dir (director), MD (physician) is aware resident will benefit exhaust (sic) on 3-24-26 and will discharge home as planned on 03-25-26 (March 25, 2026, resident will have 24 hour care at home with family to assist with care. Place call to (name of FM) to inform of discharge date , (name of FM) replied she is aware resident exhaust benefits today 36-24-26 and will discharge home on [DATE].There was no documented evidence that the FM was notified of Resident 1's current level of ADL functioning before he was to be discharged , that a caregiver training was offered, and if the family would be able to provide the required care for Resident 1. On April 1, 2026, at 11 a.m., during a telephone interview, Resident 1 stated he was discharged from the facility due to exhaustion of his insurance benefits. Resident 1 stated that FM 1 and additional family members are currently providing care for both himself and his wife. Resident 1 further indicated that he and his wife are bedridden, and he is presently unable to ambulate, though he previously walked independently.On April 1, 2026, at 12:33 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 always liked to be in bed, he will only get up for physical therapy and shower. CNA 1 stated she never saw Resident 1 walk, but he can stand up on his own with a walker. CNA 1 stated she assisted FM 1 to get Resident 1 in the car when he was discharged .On April 1, 2026 at 1:29 p.m., during a concurrent record review of Resident 1's rehabilitation notes and interview with Occupational Therapist (OT) 1, OT 1 stated Resident 1 received physical and occupational therapy which started on December 15, 2025, and the resident was initially not ambulating due to a left foot wound infection with a wound vacuum (a medical device that uses gentle, controlled suction to help open or chronic wounds heal faster) and he had weakness from his hospital stay. OT 1 stated Resident 1 was also self-limiting as it was difficult to encourage the resident to participate with therapy even though he had capabilities. OT 1 stated Resident 1 was able to do five feet of side stepping along the edge of his bed on March 13, 2026. OT 1 stated Resident 1 was discharged home as planned and exhausted his benefits, and he required to have 24/7 (24 hours/7 days a week) care at home.On April 1, 2026, at 3:15 p.m., during a concurrent review of Resident 1's medical records and telephone interview with Case Manager (CM) 1, CM 1 stated discharge planning begins on admission, they talk to the resident or family members to find out what the plan is. CM 1 stated they do not discharge residents without a safe plan including having a place to go and family to support them. CM 1 Resident 1 was part of her case load. CM 1 stated the initial discharge plan for Resident 1 was to go home and she spoke with FM 1 on March 6, 2026, that the plan is for him to go home and that his benefits were exhausting on March 24, 2026. CM 1 stated Resident 1 was walking independently at home prior to hospitalization and was only doing side steps in the facility. CM 1 stated she talked to FM 1 about discharge plans to home but did not discuss regarding Resident 1's ambulation status of only able to do side steps while at facility. CM 1 stated caregiver training is offered prior to discharge. CM 1 stated she does not remember if caregiver training was offered to FM 1 as she thought FM 1 already knew what care was to be provided to Resident 1.On April 2, 2026, at 11:46 a.m., during a telephone interview, FM 1 stated Resident 1 used to be independent before hospitalization. FM 1 stated she only talked to CM 1 in the facility, and that CM 1 informed her that Resident 1 would need 24/7 care at home and when she asked what that meant, CM 1 just told her they would take it week by week because they meet weekly. FM 1 stated she did not know Resident 1 could not walk and CM 1 did not mention this to her. FM 1 stated she was not ready for the kind of care Resident 1 needed. FM 1 stated Resident 1's physician in the facility did not speak with her. FM 1 stated the facility did not offer caregiver training. FM 1 stated on the day of discharge, she picked up Resident 1 in the facility, a staff member assisted her to put Resident 1 in her car, and she noticed that he could not stand and when they reached home, she had to call another family member to help her get Resident 1 out of the car and they had to call the paramedics, twice on separate occasions, to help them put Resident 1 back to bed.On April 2, 2026, at 10:34 a.m., during an interview, Physical Therapist (PT) 1 stated they have (name of insurance company) meeting every Tuesday where they discuss when a resident is expected to be discharged , or if caregiver training is needed. PT 1 stated the CMs would let them know if the family would need caregiver training. PT 1 stated caregiver training depends on cognition of the resident. PT 1 stated if the resident could not demonstrate ADLs, they would involve the family members. PT 1 stated she did the evaluation for Resident 1, but she did not treat him every day. PT 1 stated she would recommend Resident 1 to have assistance at home because he was not independent with toileting, bed mobility, transfer, toileting and car transfer.On April 2, 2026, at 1:43 p.m., during an interview, the Administrator (AD) stated the Therapy, CM or Social Service Director explains to the family and give them a full picture of what the resident's functioning is, so the family knows what to expect and if they have the right accommodations for the resident at home; and if they did that then they have to document. A review of the facility's policy and procedure titled Discharge Summary and Plan, dated March 2025, indicated, .Every resident will be evaluated for his or her discharge needs and will have an individualized post discharge plan .The post discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include .the degree of caregiver/support person availability, capacity and capability to perform required care .

F814 Dispose Garbage and Refuse ProperlyBased on observation, interview, and record review the facility failed to ensure two of two dumpster bin lids were fully closed.This failure had the potential to cause insects and rodents infestation in the facility and potential for food borne illness.Findings:On January 5, 2026, at 10:03 a.m., during concurrent observation and interview with the Dietary Service Supervisor (DSS), the dumpster was overloaded with garbage bags and the cover was open about a foot and a half. The DSS stated the dumpster was not fully covered. The DSS further stated the dumpsters should be covered to prevent insects and rodents' infestation.On January 8, 2026, at 11:23 a.m., during concurrent observation of picture of the dumpster and interview with the Registered Dietician (RD), the RD stated there were a lot of bags, and the lids were open. The RD further stated that the dumpster lids should be covered, and the main objective is to keep the rodents out.A review of the facility policy titled, .Garbage and Trash, dated 2023, indicated .Garbage and trashcan must be inspected daily.lids are closed.

Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for two of 28 sample residents (Residents 83 and 100), when:1. Resident 83's refusal of medications was not addressed including identifying the reason for refusal, providing education and interventions, and evaluating the resident's response. There was no consistent documented evidence the physician was notified timely of Resident 83's refusal of medications.This failure had the potential to result in a delay in timely provision of care for Resident 83 and could contribute to complications related to medication not administered.2. Resident 100's abnormal laboratory (Hemoglobin A1C [HgbA1C - measures average blood sugar levels over the past 2-3 months]) result on October 16, 2025, was not addressed according to the facility's policy and procedure.This failure had the potential for Resident 100 to have uncorrected hyperglycemia (elevated blood sugar levels), and experience the side effects of hyperglycemia, such as neuropathy (disease nerves), retinopathy (disease retina [light sensitive tissue of the eye]), nephropathy (disease of the kidney) and coronary artery disease (heart disease). Findings: 1. On January 6, 2026, at 10:55 a.m., Resident 83 was observed lying in bed with head of bed slightly elevated. In a concurrent interview, Resident 83 stated she did not take any medications, since she did not need them and was not sick. A review of Resident 83's record indicated Resident 83 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia following cerebral infarction (muscle weakness or partial paralysis on one side of the body following a stroke), atrial fibrillation (irregular and very rapid heart rhythm which increases the risk for stroke), and hypertension (high blood pressure, which increases the risk for stroke). A review of Resident 83's History and Physical Examination, dated May 15, 2025, indicated Resident 83 had the capacity to understand and make decisions. A review of Resident 83's Minimum Data Set (MDS), dated [DATE], indicated Resident 83 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). A review of Resident 83's Order Summary Report, included the following physician's orders: - Amiodarone HCl (hydrochloride) oral tablet 400 MG (milligram- unit of measurement), give one tablet by mouth every 12 hours for Cardiac Arrhythmias (irregular heart rhythms), date ordered May 2, 2024; - amlodipine Besylate oral tablet 10 MG.Give one tablet by mouth one time a day for HTN (hypertension – high blood pressure), hold (do not give) for SBP (systolic blood pressure- upper number of blood pressure reading) less than 100 or heart rate (HR) less than 60 beats per minute, date ordered May 2, 2024; - Apixaban oral tablet 5 (five) MG, give one tablet by mouth every 12 hours for atrial fibrillation (an irregular and often very rapid heart rhythm), date ordered May 2, 2024; - Clonidine Transdermal (applied on the skin) Patch weekly 0.2 MG/24HR (hour), apply one patch transdermally (on the skin) one time a day every Friday for hypertension, hold for SBP less than 100 or HR less than 60, place overlay patch cover and rotate site, and remove per schedule, date ordered May 2, 2024; and - Hydralazine HCl oral tablet, give 75 MG by mouth every six hours for hypertension, hold for SBP less than 100, date ordered May 2, 2024. A review of Resident 83's Care Plan Report, dated June 2, 2025, indicated, .Focus. Refusing medication .Interventions .Administer medication as ordered by physician. Monitor for effectiveness and any side effects .Evaluate effectiveness of medication . A review of Resident 83's Medication Administration Record (MAR), for the months of October, November, December 2025,and January 2026, indicated Resident 83 refused all doses of Amiodarone, Amlodipine, Clonidine patch, Hydralazine, and Apixaban. A review of Resident 83's MAR for the months of October, November, December 2025, and January 2026, indicated Resident 83's blood pressure were taken on the following dates with readings above the normal blood pressure range (120 mmHg/80 mmHg [millimeters of mercury]): -October 1, 2025: 139/65 mmHg -October 6, 2025: 136/75 mmHg -October 12, 2025: 128/70 mmHg - October 13, 2025:133/65 mmHg -October 18, 2025: 158/76 mmHg (systolic high of 139 exceeded) -October 26, 2025: 132/71 mmHg - October 31, 2025: 139/72 mmHg -November 5, 2025: 132/65 mmHg -November 6, 2025: 142/73 mmHg (systolic high of 139 exceeded) - November 07, 2025: 142/66 mmHg (systolic high of 139 exceeded) - November 9, 2025: 124/80 mmHg - November 11, 2025: 135/74 mmHg - November 12, 2025: 131/65 mmHg - November 14, 2025: 122/62 mmHg - November 18, 2025: 135/60 mmHg - November 24, 2025: 141/74 mmHg (systolic high of 139 exceeded) - November 27, 2025: 134/81 mmHg -December 1, 2025: 143/59 mmHg, Amiodarone given, all other meds refused - December 17, 2025: 143/71 mmHg (systolic high of 139 exceeded) - December 18, 2025: 130/68 mmHg - December 23,2025: 141/60 mmHg - December 24,2025: 136/71 mmHg - December 25, 2025: 126/68 mmHg - December 28,2025:133/69 mmHg There were no blood pressure readings documented on other days in December 2025. There was no documented evidence blood pressure was monitored for January 2026. A review of Resident 83's licensed nurses' and physician's progress notes did not indicate consistent periodic evaluation addressing Resident 83's medication refusals, reasons for refusal, or interventions implemented to address elevated blood pressure readings when Resident 83 refused her blood pressure medications. A review of Resident 83's quarterly IDT (interdisciplinary team – a group of healthcare professionals) Care Conference notes, dated August 15, 2025, and November 11, 2025, did not indicate Resident 83's pattern of medication refusals was addressed. On January 8, 2025, at 2:19 p.m., an interview and record review for Resident 83 was conducted with the Assistant Director of Nursing (ADON). The ADON acknowledged that Resident 83 had been refusing medications and vital signs for at least a year. The ADON stated they would notify the physician, encourage compliance, and explain the risks and benefits to the resident. On January 8, 2025, at 2: 55 p.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated she was aware Resident 83 always refused her medications. LVN 3 stated that the facility's process for medication refusal involved contacting the physician for a care plan but could not specify the plan for Resident 83. On January 8, 2025, at 4:19 p.m., a concurrent interview and review of Resident 83's record was conducted with the Director of Nursing (DON). The DON stated she was aware Resident 83 has been refusing medications. The DON confirmed Resident 83's consistent refusal of medications from October 2025 to January 2026. The DON further stated the licensed nurses' progress notes, weekly summary and the IDT quarterly care conference notes should have included documentation regarding Resident 83's refusal of medications, physician notification of refusals, and the plans of care pertaining to the refusals. A review of the facility's policy and procedure titled, Refusal of Medication & Treatment and Notification of Physician Policy, revised September 2025, indicated, .To ensure resident rights ae respected while maintaining patient safety through timely assessment, documentation, and prompt notification of the attending physician when a resident refuses medications and treatments.When a refusal occurs, the facility shall assess the resident, provide education, document the refusal, notify the physician when required, and implement follow-up interventions as clinically indicated.Immediate Nursing Actions.Assess the resident and determine the reason for refusal.Educate the resident on risks and benefits.Attempt reasonable interventions.Documentation.Reason for refusal.Education provided.Interventions attempted.Resident response.Documentation must be entered in the eMAR/TAR (treatment administration record) and nursing notes.Physician Notification.The physician must be notified when.Medication is refused 3 consecutive times.After a pattern of refusal is identified. 2. A review of Resident 100's admission Record, indicated Resident 100 was admitted to the facility January 15, 2025, with diagnoses which included diabetes mellitus (high blood sugar). A review of Resident 100's blood sugar monitoring for August, September, and October 2025, indicated the resident's blood sugar level was within the range of 351- 400 mg/dl (milligram/deciliter - unit of measurement; the normal blood sugar range is 70-130 mg/dl) with the following number of episodes per month: - August 2025; 16 times; - September 2025, 26 times; and - October 2025, 31 times. A review of Resident 100's physician's order, dated October 15, 2025, indicated, .HGB A1C lab (laboratory) draw October 16, 2025. A review of Resident 100's lab report indicated, .Blood Chemistry: Procedure: HGBA1C Result: 9.1 % Reference Range (4.6- 7.4) . Further review of Resident 100's record indicated there was no documented evidence Resident 100's HgbA1C of 9.1% was addressed. On January 6, 2026, at 3:34 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 indicated that the elevated Hemoglobin A1c result from October 16, 2025, should have been promptly referred to the physician. LVN 1 further remarked that it should have been identified earlier. On January 6, 2026, at 3:50 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated the HgbA1c result was referred to the physician on October 31, 2025 (15 days from the date of laboratory results on October 16, 2025). RN 1 stated the elevated HgbA1C should have been referred to the physician promptly. RN 1 further stated the potential side effects of hyperglycemia included neuropathy (nerve damage, usually starting in the hands and feet) and retinopathy (complication of diabetes that affects the eye). On January 9, 2026, 3:56 p.m., during a concurrent interview with the Director of Nursing (DON), the DON stated all abnormal results should be reported to the physician timely. The DON further stated the physician should have been notified of the result, and the notification should have been documented. A review of the facility's policy and procedure titled, Diabetes – Clinical Protocol, dated November 2024, indicated, .the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results. A review of the facility's policy and procedure titled, Physician Orders and Physician Notification, dated November 2025, indicated, .The physician shall be notified of.abnormal findings.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents when:1. For Resident 76, a discontinued controlled substance (CS) was not removed from active medication storage, tablets continued to be removed from inventory after the physician order was discontinued. In addition, the documentation on the controlled drug record (CDR - medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances) did not reconcile with the Medication Administration Record (MAR) and the CS was administered after the CS was discontinued; and2. For Resident 120, documentation on the CDR did not reconcile with the MAR.These failures resulted in inaccurate accountability of controlled substances, which had the potential for diversion (medication taken by someone other than for whom it is prescribed) or misuse of controlled substances and had the potential to compromise residents' medication therapy and safety. Findings:1. On January 6, 2026, at 2:25 p.m., during an inspection of Medication Cart 1 at Nursing Station 1 with Licensed Vocational Nurse (LVN) 4, a blister card of hydrocodone-acetaminophen (generic for Norco, a controlled substance [CS] pain medication) 5-325 mg (milligram - unit of measurement), labeled for Resident 76 was observed stored in the medication cart with active medications. During a concurrent interview and record review with LVN 4, LVN 4 stated Resident 76 was admitted to the facility on [DATE], with diagnosis which included peripheral vascular disease (a slow, progressive circulation disorder involving narrowed, blocked, or spasmodic blood vessels outside the heart and brain, most commonly affecting the legs and feet). A review of the physician's order indicated Resident 76 had an order for hydrocodone-acetaminophen 5-325 mg, give 1 (one) tablet by mouth every 8 (eight) hours as needed for moderate to severe pain, dated December 22, 2025, which was discontinued on December 31, 2025, at 1:14 p.m. LVN 4 confirmed the medication had been discontinued on December 31, 2025, and the discontinued CS had not been removed from the medication cart. LVN 4 stated discontinued CS medications should have been removed from the medication cart and given to the Director of Nursing (DON) for destruction.On January 6, 2026, at 2:25 p.m., during a concurrent interview and record review with LVN 4, Resident 76's CDR indicated the nursing staff removed and signed out one tablet of hydrocodone-acetaminophen 5-325 mg on December 25, 2025, at 9 a.m. prior to discontinuation. However, there was no corresponding documentation of administration and pain assessment on December 2025 MAR for the tablet removed on December 25, 2025, at 9 a.m.Resident 76's CDR indicated the hydrocodone-acetaminophen was administered to Resident 76 after the CS was discontinued on December 31, 2025, on the following dates:- January 1, 2026, at 0521 (5:21 a.m.);-January 4, 2026, at 0340 (3:40 a.m.); and-January 5, 2026, at 0227 (2:27 a.m.).A review of January 2026 MAR showed no active physician's order for hydrocodone-acetaminophen 5-325 mg following the discontinuation of the medication on December 31, 2025. In a concurrent interview with LVN 4, she confirmed the discrepancy between the CDR and the MAR and stated the CS administrations are required to be documented on both the CDR and MAR and the medication including CS should not be administered without a current physician order.Review of Resident 76's progress notes dated December 31, 2025, at 1:14 p.m., indicated the physician order to discontinue Norco. On January 8, 2025, at 1:59 p.m., during a concurrent interview and record review with LVN 5, LVN 5 stated the nursing staff are notified of medication discontinuations verbally and through the PCC (PointClickCare, a cloud-based electronic health record (EHR) and care coordination platform designed for the long-term and post-acute care settings) communication tool and the discontinued medications no longer appear on the MAR. LVN 5 stated the nursing staff were required to verify active physician orders prior to administration and void tablet removal on the CDR if a medication is discontinued. LVN 5 stated if a discontinued medication is administered, nursing staff are required to notify the physician, follow the physician's instructions, and document the event in a progress note. LVN 5 confirmed there were no progress notes for Resident 76 on January 1, 4, or January 5, 2026, corresponding to the Norco tablet removals documented on the CDR.On January 8, 2026, at 2:15 p.m., during a concurrent interview and record review with Registered Nurse (RN) 2, RN 2 stated the nursing staff are notified verbally of discontinued medication orders so the assigned LVN could remove the medications from the medication cart. RN 2 confirmed he notified the LVN assigned to Resident 76 of the physician's discontinuation order for Norco and documented the discontinuation in a progress note on December 31, 2025, at 1:14 p.m.On January 8, 2026, at 2:30 p.m., during a concurrent interview with Resident 76 in the resident's room with assistance from LVN 5 for Spanish translation, Resident 76 stated he received pain medications whenever he reported pain to nursing staff. However, Resident 76 stated he could not recall which pain medication he received on December 25, 2025, January 1, January 4, and January 5, 2026. Resident 76 stated the nursing staff assessed his pain level before and after administering pain medication. Resident 76 stated he did not like Norco due to hallucinations and visual disturbances he had experienced, and stated Tylenol (acetaminophen - pain medication) helped his pain. On January 8, 2026, at 4:10 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON reviewed Resident 76's CDR and MARs and stated the following:-Confirmed one tablet of hydrocodone acetaminophen 5-325 mg were documented as removed from the blister card on the CDR on December 25, 2025, without corresponding documentation of administration on the MAR, and additional tablets were documented as removed on January 1, January 4, and January 5, 2026, after the physician's order had been discontinued on December 31, 2025;-Her expectation for the nursing staff was to remove the discontinued medications from active medication storage upon receipt of a discontinuation order and follow proper procedures for CS destruction;-The nursing staff were required to document medication administration on the MAR, document CS removal on the CDR, and report any discrepancies identified during CS reconciliation;-The nurse who documented the tablet removals was unavailable for interview during the survey period, and the facility was unable to verify whether the tablets documented as removed were administered to Resident 76 or otherwise accounted for;-After the discrepancy was identified on January 6, 2026, the facility interviewed Resident 76, who reported experiencing adverse effects with Norco and stated he did not like Norco or Tramadol (pain medication). The DON stated this was the first time the facility became aware of Resident 76's reported adverse effects;A review of the facility's policy and procedures (P&P) titled, Discontinued Medications, dated January 16, 2025, indicated, .Medications are removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.Discontinued medications not returned to the pharmacy are destroyed in accordance with the facility destruction policy and procedure.A review of the facility's P&P titled, Controlled Substances, dated November 2025, indicated, .Controlled substances remaining in the facility after the order has been discontinued.securely locked in an area with restricted access until destroyed.A review of the facility's P&P titled, Physician Orders and Physician Notification, dated November 2025, indicated, .The facility ensures that all resident care is provided in accordance with timely, complete, and authenticated physician orders.Orders shall be implemented promptly.Resident response shall be monitored.Physicians shall be notified of.incidents.unresolved pain.resident/family concerns.Licensed Nurses: Identify changes, notify physicians, document accurately, and implement orders.2. On January 6, 2026, at 2:25 p.m., during an inspection of Medication Cart 1 at Nursing Station 1 a blister card for oxycodone (CS pain medication) 5 mg labeled for Resident 120 was concurrently reviewed with LVN 4.A review of Resident 120's admission Record, indicated Resident 120 was admitted on [DATE], with diagnoses which included osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage-the protective, slippery tissue that cushions joints. It causes chronic joint pain, stiffness, reduced range of motion, and swelling, primarily affecting hands, knees, hips, and the spine).A review of Resident 120's physician order indicated an order for oxycodone 5 mg, give 1 (one) tablet by mouth every 6 (six) hours as needed for severe pain management 7-10 (pain scale), dated December 28, 2025.A review of Resident 120's CDR and December 2025 and January 2026 MARs indicated the nursing staff removed and signed out one tablet of oxycodone 5 mg on December 31, 2025, at 2342 (11:42 p.m.) and January 4, 2026, at 0015 (12:15 a.m.), but there was no corresponding documentation of administrations and pain assessments on the MAR. LVN 4 confirmed the discrepancy and stated the CS administrations were required to be documented on both the CDR and the MAR.On January 7, 2026, at 12:50 p.m., during a concurrent interview and record review with the DON, the DON confirmed discrepancies between the CDR and the MAR for Resident 120, including documented CS removals without corresponding MAR documentation of administration. The DON stated her expectation for nursing staff was to document CS removal on the CDR and document medication administration on the MAR.A review of the facility's P&P titled, Administering Medications, dated February 2025, indicated, .Medications administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label to verify.right medication.right time.before giving the medication.As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.A review of the facility's P&P titled, Controlled Substances, dated November 2025, indicated, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 20% was identified, with five medication errors out of 25 medication administration opportunities during medication pass observations for three of five residents observed (Residents 22, 61, and 110).These failures included administration of incorrect medication, incorrect dosage form, and incorrect dose, which had the potential to compromise residents' medication therapy and safety. Findings:1. On January 5, 2026, at 9:33 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed preparing and administering seven medications to Resident 22, including a red round multivitamin (MVI - supplement) tablet and an aspirin (used to prevent blood clots) 81 mg (milligram - unit of measurement) chewable tablet.A review of Resident 22's physician orders indicated the following: - Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals - supplement), Give 1 (one) tablet by mouth one time a day for Supplement, dated November 18, 2025; and- Aspirin Low Dose Oral Tablet Delayed Release (designed to release the drug later after ingestion rather than immediately) 81 mg (aspirin), give 1 (one) tablet by mouth one time a day for CVA (cardiovascular accident - stroke) PPX (prophylaxis - preventive medication given to prevent a disease), Give with Food, dated November 18, 2025.On January 5, 2026, at 12:52 p.m., during a concurrent interview and record review with LVN 2, LVN 2 confirmed one-daily multivitamin tablet and aspirin 81mg chewable tablet were administered to Resident 22 instead of the ordered multivitamin-mineral tablet and delayed-release aspirin. LVN 2 stated she should have verified the right medication and right dosage form prior to administration.On January 6, 2026, at 11:14 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON reviewed Resident 22's orders and stated the correct medication and correct dosage form of medication should have been administered as ordered by the physician. 2. On January 5, 2026, at 10:04 a.m., during a medication administration observation, LVN 3 was observed preparing and administering seven medications to Resident 61, including Vitamin D3-5 Cholecalciferol (supplement) 5,000-unit (unit of measurement) capsule and Vitamin B12 (supplement) 500 mcg (microgram - unit of measurement) tablet.A review of Resident 61's physician orders indicated the following:- Cholecalciferol (vitamin D3 - supplement) Tablet 1,000 UNIT, give 1 (one) tablet by mouth one time a day for SUPPLEMENT, dated November 6, 2025; and- Vitamin B12 Oral Tablet 1000 mcg (Cyanocobalamin -supplement), give 1 (one) tablet by mouth one time a day for SUPPLEMENT, dated November 7, 2025.On January 5, 2026, at 12:34 p.m., during a concurrent interview and record review with LVN 3, LVN 3 confirmed a 5,000-unit Vitamin D3 capsule was administered instead of the ordered 1,000 unit and Vitamin B12 500 mcg was administered instead of the ordered 1,000 mcg. LVN 3 stated she should have verified the right dose prior to administration.On January 6, 2026, at 11:14 a.m., during a concurrent interview and record review with the DON, the DON reviewed Resident 61's orders and stated the correct dose should have been administered as ordered by the physician.3. On January 5, 2026, at 10:22 a.m., during a medication administration observation LVN 3 was observed preparing and administering seven medications to Resident 110, including 20 mL (milliliter - unit of measurement) of lactulose (used to treat constipation) oral solution.A review of Resident 110's physician order indicated Lactulose Oral Solution 20 GM (gram - unit of measurement)/30 ML (Lactulose), Give 30 mL by mouth two times a day for constipation. Hold for loose stool, dated December 28, 2025. On January 5, 2026, at 12:45 p.m., during a concurrent interview and record review with LVN 3, LVN 3 confirmed 20 mL of lactulose was administered instead of ordered dose of 30 ml. LVN 3 stated she should have checked the right dose before administration.On January 6, 2026, at 11:14 a.m., during a concurrent interview and record review with the DON the DON reviewed Resident 110's lactulose order and stated correct dose should have been administered as ordered by the physician.A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated February 2025, indicated, .Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label to verify .right medication, right dosage.before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, for five out of nine residents reviewed for infection control practices when:1.For Resident 61, 110, and 111, nursing staff did not clean and disinfect shared medical equipment, wrist blood pressure (BP) monitor with an attached cuff, before and after each use, in accordance with the facility's infection control policy; 2.One housekeeper (HK) did not perform hand hygiene after removing PPE (personal protective equipment- like gowns, gloves, masks, worn to minimize exposure to hazards) used while cleaning an EBP (enhanced barrier precautions- infection control measures, primarily for nursing homes, that mandate gowns and gloves for healthcare workers during high-contact resident care to prevent the spread of multidrug-resistant organisms) room (room [ROOM NUMBER]); and3.The facility failed to follow the facility's standards of practice when a nasal cannula (a medical device used to deliver supplemental oxygen) was not changed weekly for one of three residents reviewed (Resident 14).These failures had the potential to expose residents to infection and compromise residents' health and safety in the facility.Findings: 1a. On January 5, 2026, at 9:52 a.m., during a medication administration observation Licensed Vocational Nurse (LVN) 3 was observed using a wrist BP monitor with an attached cuff to obtain Resident 111's blood pressure in the resident's room. After obtaining blood pressure reading, LVN 3 was observed placing the used wrist BP monitor with attached cuff on top of the medication cart without cleaning or disinfecting the equipment. 1b. On January 5, 2026, at 10:04 a.m., during a medication administration observation LVN 3 was observed using the same wrist BP monitor with attached cuff that had not been cleaned or disinfected after the prior use to obtain Resident 61's blood pressure in the resident's room. After obtaining blood pressure reading, LVN 3 was observed placing the used wrist BP monitor with attached cuff on top of the medication cart without cleaning or disinfecting the equipment. 1c. On January 5, 2026, at 10:25 a.m., during a medication administration observation LVN 3 was observed using the same wrist BP monitor with attached cuff that had not been cleaned or disinfected after the prior use to obtain Resident 110's blood pressure in the resident's room. After obtaining blood pressure reading, LVN 3 was observed placing the used wrist BP monitor with attached cuff on top of the medication cart without cleaning or disinfecting the equipment. On January 5, 2026, at 12:30 p.m., during an interview with LVN 3, LVN 3 acknowledged the wrist BP monitor with attached cuff was returned to the medication cart without being cleaned or disinfected after each use for Resident 111, 61, and 110. LVN 3 stated the wrist BP monitor with attached cuff is shared equipment and should have been cleaned and disinfected before and after each use with wipes in the purple cap container (Sani-Cloth germicidal [disinfectant that kills germs such as bacteria and viruses] disposable wipes) available in the medication cart for infection control. On January 5, 2026, at 4:03 p.m., during an interview with the Infection Preventionist (IP), the IP stated the wrist BP monitor with attached cuff is considered a shared medical equipment and is required to be cleaned and disinfected before and after each use for infection control prevention. The IP stated nursing staff may use either wipes in the purple cap container (Sani-Cloth germicidal disposable wipes) or bleach wipes in the blue cap containers (CaviWipes Bleach disposable wipes) to clean and disinfect the equipment. The IP confirmed these products are facility-approved disinfectants available in each medication cart and are required to be used in accordance with the facility's infection control policy. On January 6, 2026, at 11:14 a.m., during an interview with the Director of Nursing (DON), the DON stated any shared medical equipment, including the wrist BP monitor with attached cuff must be cleaned and disinfected with disinfectant wipes before and after each use to prevent the spread of infection, such as bacteria and viruses. A review of the facility's policies and procedures titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, dated September 2025, indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention - a nationally recognized disease control and prevention organization) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration – a government agency for workplace safety) Bloodborne Pathogens (disease-causing germs, like viruses or bacteria in human blood and other body fluids that can cause disease in people) Standard.Non-critical items are those that come in contact with intact skin. Non-critical resident-care items include.blood pressure cuffs.Reusable items are cleaned and disinfected.(e.g., stethoscopes, durable medical equipment).Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.Intermediate and low-level disinfectants for non-critical items include: a. ethyl or isopropyl alcohol; b. sodium hypochlorite (5.25-6.15% diluted 1:50 or per manufacturer's instructions); c. phenolic germicidal detergents; d. iodophor germicidal detergents; and e. quaternary ammonium germicidal detergents (low-level disinfection only). 2. On January 6, 2026, at 11:56 a.m., Housekeeper (HK) 1 was observed to enter an Enhanced Based Precaution room; after doffing her PPE (Personal Protective Equipment) she was not observed to follow hand hygiene. On January 6, 2026, at 12 p.m., during an interview with HK 1, she stated she should have done hand hygiene right after the PPE was doffed. HK 1 further stated it had the potential to cause cross-contamination. On January 8, 2026, at 10:06 a.m., the IP was interviewed. The IP stated hand hygiene is indicated in many instances, including hand hygiene should be performed prior to donning PPE and after doffing PPE. The IP stated hand hygiene is important to decrease instances of infection for all residents and staff. A review of facility's policy and procedure titled, Handwashing/hand Hygiene, dated November 2025, indicated .Use an alcohol- based hand rub Hand sanitizer after removing gloves; before and after entering isolation precaution room. 3. On January 6, 2026, at 9:26 a.m., a concurrent observation and interview was conducted with Resident 14 inside the resident's room. Resident 14 was observed using oxygen via nasal cannula at 2 L/min (liters per minute – a unit of measurement). Resident 14's nasal cannula tubing was observed with the date 12/29/25 (December 29, 2025) written in black permanent marker near the tubing connector point. Resident 14 stated she used oxygen continuously. A review of Resident 14's admission Record, dated January 8, 2026, indicated an admission date of November 8, 2024, with diagnoses which included shortness of breath. A review of Resident 14's History and Physical, dated November 13, 2025, indicated Resident 14 had fluctuating capacity to understand and make decisions. A review of Resident 14's Physician Orders, dated November 8, 2024, indicated, .CHANGE NASAL CANNULA QSUN (every Sunday) every night shift every Sun (Sunday). On January 6, 2026, at 9:56 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 2 in Resident 14's room. LVN 2 stated the nasal cannula tubing was observed with the date 12/29/25 (December 29, 2025) written in black permanent marker near the tubing connector point. LVN 2 stated the nasal cannula was dated a week past and should have been changed according to the facility's standards of practice. LVN 2 stated oxygen tubing should be changed weekly on Sundays. LVN 2 stated it was important to change the nasal cannula weekly to prevent cross contamination related to infection control issues. On January 8, 2026, at 9:49 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the oxygen tubing should be changed weekly on Sundays and as needed. The ADON stated the licensed nurse should have changed Resident 14's nasal cannula in accordance with facility practice. The ADON stated it was important to change the nasal cannula weekly to prevent infections to the residents. A review of the facility's policy and procedure titled, OXYGEN DELIVERY, NASAL CANNULA, dated July 21, 2025, indicated, .Change the nasal cannula once a week and PRN (as needed) and discard after use.

Based on observation, interview, and record review, the facility failed to provide fingernail care, for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 94), when her fingernails were observed to be long, yellowish, and with black residue underneath the fingernails.This failure had the potential to result in an increased risk of infection and injury due to unclean fingernails.Findings:On January 5, 2026, at 2:50 p.m., a concurrent observation and interview was conducted with Resident 94 in her room. Resident 94 was observed to have long, yellowish fingernails on both hands and with black residue observed under three fingernails on her left hand. Resident 94 stated fingernail care was not provided recently and wanted her fingernails to be cut and cleaned.A review of Resident 94's admission Record, dated January 8, 2026, indicated Resident 94 was admitted to the facility on [DATE], with diagnoses which included heart failure.A review of Resident 94's Care Plan, dated November 7, 2024, indicated, .Focus.at risk for skin breakdown.at risk for skin tears/skin injury R/T (related to) scratches self.age.fragile skin.Goal.Will remain free from tissue or skin injury.Interventions.keep fingernails clean and trimmed.A review of Resident 94's history and physical, dated November 28, 2025, indicated Resident 94 had the capacity to understand and make decisions.On January 7, 2026, at 12:42 p.m., a concurrent observation and interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated CNAs are responsible for providing fingernail care daily, which includes nail cutting, cleaning the surface and underneath the nails, and nail filing. CNA 1 stated fingernails should be cleaned and cut to prevent infections, especially when the residents use their hands to eat and grab items.On January 7, 2026, at 3:30 p.m., a concurrent observation and interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 94's fingernails were observed to be unkempt, yellowish, and with black residue underneath her fingernails. The DSD stated fingernail care should have been provided to Resident 94 and the fingernails should have been cleaned. The DSD stated this was important for infection control.On January 8, 2026, at 9:40 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 94's fingernails should have been cleaned and trimmed. The ADON stated it was important to perform fingernail care to reduce the risk for infection and self-injury.A review of the facility's policy and procedure titled, Fingernails/Toenail, Care of, dated February 2025, indicated, .Purpose.to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming.Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review the facility failed to follow the physician orders for oxygen administration, for two of two residents reviewed for oxygen (Residents 21 and 58), when:These failures had the potential to place Residents 21 and 58 at risk for adverse reactions from over-oxygenation.Findings:1.On January 5, 2026, at 3:06 p.m., an observation was conducted in Resident 21's room. Resident 21 was observed using oxygen at five (5) lpm (liters per minute - unit of measurement) via (through) a nasal cannula (NC).A review of Resident 21's admission Record, dated January 8, 2026, indicated the resident was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a lung condition making it difficult to breathe).A review of Resident 21's history and physical, dated March 17, 2025, indicated Resident 21 did not have the capacity to understand and make decisions.A review of Resident 21's Physician Orders, dated May 27, 2025, indicated, .OXYGEN VIA NC (nasal cannula) AT _3_LPM CONTINUOUSLY.A review of Resident 21's Care Plan, dated May 28, 2025, indicated, .Focus.The resident has asthma (a chronic inflammatory lung disease that causes recurring episodes of wheezing, coughing, shortness of breath, and chest tightness due to airway inflammation and narrowing) r/t (related to) COPD.Goal.remain free from complications.Interventions.Give.oxygen therapy as ordered.OXYGEN VIA NC as ordered.On January 5, 2026, at 3:25 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 21's oxygen flow rate was observed at five lpm. LVN 2 stated Resident 21's oxygen flow rate should have been at three lpm according to the physician's orders. LVN 2 stated it was important to follow the physician orders to prevent any adverse reactions from over-oxygenation.On January 8, 2026, at 9:52 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 21's oxygen flow rate should have been at three lpm according to physician's orders. The ADON stated it was important to follow physician orders to prevent respiratory issues related to increased oxygen rate, and to maintain the well-being of the resident.2. On January 5, 2026, at 2:55 p.m., an observation was conducted in Resident 58's room. Resident 58 was observed using oxygen at three lpm via nasal cannula.A review of Resident 58's admission Record, dated January 8, 2026, indicated the resident was admitted on [DATE], with diagnoses which included COPD.A review of Resident 58's history and physical, dated January 5, 2026, indicated the resident had the capacity to understand and make decisions.A review of Resident 58's Physician Orders, dated March 4, 2025, indicated, .OXYGEN VIA NC AT 2 LPM CONTINUOUSLY.A review of Resident 58's care plan, dated January 3, 2025, indicated, Focus.At risk for respiratory distress related to.COPD.Goal.no evident (sic) of respiratory distress.Interventions.Administer O2 (oxygen) as ordered.On January 5, 2026, at 3:27 p.m., a concurrent observation and interview was conducted with LVN 2. LVN 2 stated Resident 58's oxygen flow rate was observed at three lpm. LVN 2 stated Resident 58's oxygen flow rate should have been at two lpm according to the physician's orders. LVN 2 stated it was important to follow the physician's orders to prevent any adverse reactions from over-oxygenation.On January 8, 2026, at 9:54 a.m., an interview was conducted with the ADON. The ADON stated Resident 58's oxygen flow rate should have been at two lpm according to physician's orders. The ADON stated it was important to follow the physician's orders to prevent respiratory issues related to increased oxygen rate and to maintain the well-being of the residents.A review of the facility's policy and procedure titled, Physician Orders and Physician Notification, dated November 2025, indicated, .Orders shall be implemented.A review of the facility's document titled, Job Description, undated, indicated, .Charge Nurse.DUTIES AND RESPONSIBILITIES.Prepare and administer medications as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1.Cook (CK) 1 did not know how to fully test the minced and moist texture (Minced & Moist foods are soft and moist but with no liquid that can leak or drip from the food and no crumbs), based on the standards of practice. This failure had the potential for risk of choking for six residents who had dysphagia (difficulty swallowing) and received minced and moist diet from the kitchen during the lunch meal on January 7, 2026.2. [NAME] (CK) 2 could not articulate the proper cool down process for ambient food (food kept at room temperature 70 F).3.A Dietary Aide (DA) did not follow manufacturer's guideline for the length of time for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). These failures had the potential to cause foodborne illnesses for 111 residents who received food from the kitchen. Findings:1.According to standard of practice, the International Dysphagia Diet Standardization Initiative (IDDSI) Framework is a set of descriptors describing texture modified foods and thickened liquids for people with eating, drinking and swallowing problems across the lifespan. The Spoon Tilt Test is used predominantly for measures of food samples for Minced & Moist foods. Provides testing suggestions for exact sizes of food pieces consistent with a safe swallow based on research in children and adults. Added moisture is a must to make this level moist, cohesive, and not crumbly.On January 7, 2026, at 1: 23 p.m., during a concurrent interview and demonstration of how to test the right thickness and texture of minced and moist food, CK 1 could not show how the spoon tilt test was done. CK 1 further stated she did not know what spoon tilt test was. On January 9, 2026, at 11:07 a.m., an interview was conducted with the Registered Dietician (RD). The RD stated the cook should have known how to prepare and how to check the thickened liquids by using spoon tilt test if it is the right consistency for IDDSI diets. If not done correctly this could lead to difficulty chewing, difficulty swallowing and potential for choking. A review of the facility document titled, Minced And Moist, IDDSI (International Dysphagia Diet Standardization Initiative) . Tests.Critical: Spoon Tilt Test.Food slides off spoon with little food left on teaspoon. A review of the facility's undated Job Description titled, Cook, the Job Description indicated, Responsible for preparing food .in accordance with current applicable federal, state, and local standards .ESSENTIAL Functions: Ensure that all dietary procedures are followed in accordance with established policies.A review of the facility document titled, Minced And Moist, IDDSI (International Dysphagia Diet Standardization Initiative), . Tests.Critical: Spoon Tilt Test.Food slides off spoon with little food left on teaspoon. 2. On January 8, 2026, at 2:53 p.m. during an interview with CK 2, CK 2 stated cooling down is observed in the preparation of tuna salad. The tuna which is from a room temperature is cooled down to 40 F in two hours.On January 8, 2026, at 3:20 p.m. during an interview with the RD, the RD stated the cool down process from a temperature of 140 - 70 F for two hours, and then from 70 degrees F (Farenheit- unit of measurement for temperature) to 40 degrees F in the next four hours. The RD stated if the cooling down process was not followed, there was a potential for food to be in the food temperature danger zone and may result in food borne illness.A review of the facility document titled, Food Safety Inservice.Cooling Procedures., indicated, .Cooling procedures for Hot Foods.Improper cooling can lead to bacterial growth. The FDA Food Code requires that TCS (Time- Temperature Control for safety) foods to be cooled using a two-stage process.Stage one: cool from 135 F to 70 F within two hours. Stage two: Cool down from 70 F to 41 F or below within an additional four hours .3. On January 8, 2026, at 2:37 p.m., during a concurrent observation and interview, in kitchen with the DA, the DA tested the red bucket Quat sanitizer with a Quat sanitizer test strip. DA stated he needed to dip Quat sanitizer test strip into red bucket for 10 seconds. The DA only dipped Quat sanitizer test strip into red bucket for 6.9 seconds. The DA stated he should have followed what the instructions said, also saying, I should have waited for 10 seconds. The DA further stated if the instruction was not followed the right concentration of the sanitizer would not be accurate, leading to ineffective sanitization of work surfaces. On January 8, 2026, at 3:03 p.m., during an interview with the Dietary Services Supervisor (DSS), the DSS stated the dietary staff should have followed what was in the instructions for testing the red bucket Quat sanitizer. The DSS stated the Quat test strip was supposed to be dipped for 10 seconds. The DSS stated if Quat sanitizer test strip was dipped into the Quat sanitizer for a shorter length of time than the manufacturer's instructions, it could potentially lead to the dietary staff not getting the right concentration [NAME] sanitizer. The DSS stated if the [NAME] sanitizer was not in the right concentration, this could cause food contact surfaces to not be properly sanitized and lead to cross-contamination. A review of the Quat sanitizer test strip container's instructions, dated of July 30, 2026, indicated, Immerse for 10 seconds .

Based on interview and record review, for one of five residents reviewed (Resident 50), the facility failed to ensure a change of condition was identified when Resident 5 had a decline in Activities of Daily Living (ADL) requiring total assistance in eating on July 18 and 19, 2025, and the meal intake was 50% or below on July 19, 2025.This failure had the potential to contribute to a delay in the care and treatment to address Resident 5's change of condition and affect the resident's overall health condition. Findings:On August 11, 2025, at 10:21 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care issue.On August 12, 2025, Resident 5's record was reviewed. Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease), diabetes mellitus (abnormal blood sugar) and heart failure.A review of Resident 5's Progress Notes, documented by the physician, on July 17, 2025, indicated Resident 5 had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool, dated July 19, 2025, indicated the following:-BIMS (Brief Interview of Mental Status) score of 12 (cognitively intact); and-Required supervision or touching assistance in eating.A review of Resident 5's care plan, dated July 16, 2025, indicated,- .Self care deficit related to inability to independently perform ADL's.Legend.S=Supervision.Eating.S.;- .Altered Nutrition.Goal: will eat greater than 75% .Interventions.Assist/feed resident.A review of Resident 5's Nutrition Amount Eaten Documentation Survey Report, indicated the following amount eaten:- .July 17, 2025.7 am.100% .;- .July 17, 2025.12 pm.100% .;- .July 17, 2025.5 pm.100% .;- .July 18, 2025.7 am.75% .;- .July 18, 2025.12 pm.75% .;- .July 18, 2025.5 pm.100% .;- .July 19, 2025,.7 am.50% .; and .July 19, 2025.12 pm.25% .A review of Resident 5's SBAR (Situation Background Assessment Record) Communication Form and Progress Note, dated July 19, 2025, at 10:52 p.m., indicated, .the change in condition.Resident unable to answer simple questions.unable to get words out.lethargic (a state of feeling tired, sluggish, and lacking energy).started on July 19, 2025 at 5:00 pm.Resident noted to have reduced movement, reduced alertness, cannot speak or get words out.resident unable to answer stroke (a medical emergency that occurs when blood flow to the brain is interrupted).MD (physician) notified, ordered to send out for eval (evaluation).A review of Resident 5's Order Summary Report, dated July 19, 2025, at 11:29 p.m., indicated, .Resident sent out (name of general acute hospital).rule out Stroke.A review of Resident 5's MDS section GG, indicated the following self-performance level in eating for the following dates:- July 17, 2025.8:21 am.independent.;- July 18, 2025.5:07 pm.set up assistance.;- July 19, 2025.12:20 pm.dependent.; and- July 19, 2025.2:41 pm.dependent.On August 12, 2025, at 4:15 p.m., during an interview conducted with Certified Nursing Assistant (CNA) 1, she stated she was assigned to Resident 5 on July 19, 2025, 3 p.m. to 11 p.m. CNA 1 stated resident 5 was quiet, and not talkative, and had family visiting that evening. CNA 1 stated she went on her lunch break and returned around 7:30 p.m., and the paramedics were there to transfer her to the hospital.On August 12, 2025, at 5:30 p.m., a concurrent interview and record review of Resident 5's record was conducted with the Director of Nursing (DON). The DON stated when they notice a change of condition, the CNA should report it to the charge nurse. The DON stated if there is a change of condition from day shift it should be endorsed to the following shift. The DON stated Resident 5 had a decrease in meal intake or meal percentage on July 19, 2025, starting at breakfast meal at 50% and 25%, respectively for breakfast and lunch.the DON stated Resident 5 was dependent in eating, started on July 18, 2025, which was a decline when she was initially admitted on [DATE]. The DON stated the decrease in Resident 5's food intake and decline in ADL need in eating would be considered a change of condition and the doctor should have been notified.On August 18, 2025, at 12:32 p.m., during a phone interview conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Licensed Nurse (LN) assigned to Resident 5 on July 19, 2025, from 3 p.m. to 11 p.m. LVN 1 stated there was no endorsement from the morning shift LN of any changes with Resident 5. LVN 1 stated when she was passing the medications and reached Resident 5's room, the resident was observed to be lethargic. LVN 1 stated the vital signs were stable, but Resident 5 was not able to answer questions. LVN 1 stated she verified with the family member present at bedside if that was normal for the resident, and the family member stated that was not normal for the resident. LVN 1 stated she was not sure of the time she was able to send out Resident 5 to the acute hospital. LVN 1 stated the physician should have been notified when Resident 5 had a decrease in meal intake as this was a change of condition. On August 18, 2025, at 4:55 p.m., during a phone interview with LVN 2, LVN 2 stated she was the LN assigned to the resident the morning shift of July 19, 2025. LVN 2 stated she did not recall the CAN notifying her of Resident 5's decrease in food intake. LVN 2 stated she did not recall Resident 5's family member reporting to her that Resident 5 was not her usual self. LVN 2 stated the physician should have been notified if the resident had a poor food intake or a decrease from previous meals. A review of the facility's policy and procedure titled, Acute Condition Changes- Clinical Protocol, revised date March 2023, indicated, .Direct care staff .including nursing assistants .recognizing subtle .significant changes .decrease in food intake .how to communicate .to the nurse . and, before contacting a physician .with an acute change of condition .nursing staff .collect pertinent details .to report to the physician .

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the facility's policy and procedures and physician's order, for four of four residents (Residents 1, 2, 3, and 4).This failure has the potential to result in reduced effectiveness of Residents 1, 2,3, and 4's medications.On July 16, 2025, at 5:06 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues.On July 16, 2025 at 5:23 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated she started the 6 a.m. and 6:30 a.m. medication pass (med pass - the process through which medication is administered to residents) at 4:20 a.m. LVN 1 stated she should start med pass at 5 a.m. but she started 40 minutes early because there were a lot of blood sugar checks, medications to be administered through G-tubes (gastrostomy tube - a tube inserted to the stomach used to give food and medications) and documentation to complete. LVN 1 stated she had just administered levothyroxine (medication to treat low thyroid hormone level) and omeprazole (medication to treat acid reflux) to Resident 1. LVN 1 stated she also administered insulin (medication to treat diabetes mellitus [abnormal blood sugar] to Resident 2 at 5:05 a.m.Resident 1's electronic Medication Administration Report (e-MAR), was concurrently reviewed with LVN 1. LVN 1 stated Resident 1's levothyroxine and omeprazole were scheduled at 6:30 a.m. LVN 1 further stated the facility's electronic health record system (PCC - Point Click Care) would not allow her to sign that she administered those medications earlier than 5:30 a.m. LVN 1 stated Resident 1 could have nausea or a little discomfort when her medications were given early.A review of Resident 2's e-MAR was conducted with LVN 1. LVN 1 stated Resident 2's long actin insulin was scheduled at 6:30 a.m. LVN 1 stated she administered Resident 2's insulin at 5:05 a.m LVN 1 stated Resident 2's blood sugar could drop when her insulin was administered early. LVN 1 stated they were not providing quality of care because medication administration was started early.On July 16, 2025, at 5:43 a.m., during a concurrent observation and interview with Resident 3 in her room, Resident 3 was alert lying in bed and watching TV. Resident 3 stated she received her thyroid medication at 4:30 a.m.A review of Resident 3's admission Record indicated the resident was re-admitted to the facility on [DATE], with diagnoses which included hypothyroidism (low thyroid hormone level). A review of Resident 3's Order Summary Report, included a physician's order, dated January 9, 2025, which indicated, .Levothyroxine sodium Tablet 125 MCG (microgram - unit of measurement) Give 1 (one) tablet by mouth in the morning .Administer on an empty stomach, 30 minutes before breakfast . A review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated May 12, 2025, indicated Resident 3 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact).On July 16, 2025, at 6:02 a.m., Resident 4 was observed awake and alert lying in bed. In a concurrent interview, Resident 4 stated she was supposed to receive her insulin before each meal. Resident 4 stated there was a time when she received her insulin between 5 a.m. to 5:15 a.m. and breakfast was being served between 8:15 a.m. to 8:30 a.m. Resident 4 stated her blood sugar could drop if insulin is being administered earlier than ordered by the physician. A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. A review of Resident 4's MDS, dated [DATE], indicated a BIMS score of 15. A review of Resident 4's Order Summary Report, included a physician's order, dated July 11, 2025, which indicated, .Novolog (short acting insulin) Injection solution 100 UNIT/ML .Inject 3 (three) unit .before meals .On July 16, 2025, at 6:30 a.m., during an interview with LVN 2, she stated she started 6:30 a.m. med pass at 4:30 a.m. because she would not be able to finish med pass on time before her shift ends. LVN 2 stated they used to have four (4) LVNs for med pass with 27 - 29 residents each but now they only have three (3) LVNs and had 36 - 38 patients each. LVN 2 stated when they had four LVNs, they were able to start and finish on time for medication pass.On July 16, 2025, at 6:47 a.m., during an interview with Registered Nurse Supervisor (RNS), he stated the LVNs would start their medication pass at around 4:30 a.m. so they could finish on time. On July 16, 2025, at 8:14 a.m., a follow up interview was conducted with LVN 1, she stated when medications were administered earlier than scheduled times, the physician should have been notified. On July 16, 2025, at 8:28 a.m., during a concurrent observation and interview, Resident 2 was in her room, lying in bed and awake. Resident 2 did not respond to interview questions. Resident 2's breakfast tray was observed on the overbed table. A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which indicated diabetes mellitus. A review of Resident 2's Order Summary Report, included a physician's order, dated July 2, 2025, indicated, .Insulin Glargine .Inject 25 unit .in the morning .On July 16, 2025, at 8:32 a.m., during a concurrent observation and interview with Resident 1 in her room, alert, awake and sitting in her wheelchair. Resident 1 stated she received medications at 4 a.m., but she did not know which medication it was, and she could not remember when it happened.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism and gastric ulcer (an open sore or raw area in the lining of the stomach). A review of Resident 1's Order Summary Report, included the following physician's order:-Omeprazole Capsule Delayed Release 20 MG (milligram - unit of measurement), Give 2 (two) capsule by mouth in the morning .Administer on an empty stomach, 30 minutes before breakfast ., date ordered December 28, 2024; and-Synthroid (thyroid medication) Oral Tablet 25 MCG .Give 1 (one) tablet by mouth in the morning ., date ordered December 31, 2024.A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 12 (cognitively intact).On July 16, 2025, at 9:30 a.m., during a concurrent interview with the Director of Staff Development (DSD) and record review of Resident 1, 2, and 4's physician's orders, the DSD stated if a medication was scheduled to be given at a certain time, it should be administered at the specified time. The DSD stated PCC would not allow the charge nurses to sign for med pass too early or too late. On July 16, 2025, at 10:01 a.m., during an interview with the Assistant Director of Nursing (ADON), she stated if a medication was scheduled to be administered at 6:30 a.m., the charge nurses should administer the medication one hour before or one hour after. The ADON stated if the charge nurse gave a medication earlier than what was allowed, the charge nurse needs to notify the physician. The ADON stated the charge nurses were not allowed to decide to give a medication early just because they have a lot to do.On July 16, 2025 at 12:42 p.m., during an interview with the Nurse Consultant (NC) and the Administrator (ADM), the NC stated the RN should be assessing if the LVNs were late with their med pass and step in to alleviate the pressure and the LVNs should administer the medications as ordered by the physician within the scheduled time, an hour before and an hour after.A review of the facility's policy and procedure titled Medication Administration Schedule, dated July 2024, indicated, .Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified .The exact time of medication administration is documented in the MAR. If medication is administered early .the reason is also documented .

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident A) received a post-discharge plan of care, which contained the necessary information for the continuation of care after discharge. This failure resulted in Resident A ' s family calling the facility for advice and sending Resident A to the emergency room, within 24 hours of his discharge from the facility. Findings: On March 28, 2025, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate quality of care concern and discharge rights. On March 28, 2025, at 1 p.m., an interview was conducted with the Social Service Assistant (SSA). The SSA stated the case managers and social service director are the ones who help the residents plan for discharge and follow up care. The SSA stated Resident A was discharged on March 18, 2025, and she called Resident A twice following his discharge, but she did not speak with Resident A. On March 28, 2025, at 1:10 p.m., an interview was conducted with the Case Manager (CM). The CM stated Resident A was discharged from the facility on March 18, 2025, she had ordered home health, a safety evaluation from physical therapy and occupational therapy, and wound care. The CM stated Resident A was receiving wound care when he was at the facility and the care should continue after he leaves. The CM stated a family member of Resident A ' s called about Resident A ' s leg being swollen and the CM told the family member if Resident A ' s leg was red and swollen, he may need to go to the hospital. The CM stated she called and spoke with the home health agency and asked when they would be out to evaluate Resident A. The CM stated she does provide discharge planning and speaks with the residents, and the nurse reviews all the information with the residents at the time of discharge and provides a handwritten discharge summary for their reference. On March 28, 2025, at 1:55 p.m., a review of Resident A ' s record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included a left above the knee amputation, COPD (chronic obstructive pulmonary disease- a group of lung conditions that damage the airways and lungs), and cirrhosis of the liver (chronic damage leading to scarring and failure) with ascites (a complication of cirrhosis causing a buildup of fluid in the abdominal cavity). Resident A ' s order summary indicated: -Follow up with [name] Cardiology (focuses on the heart and blood vessels) in one week, ordered March 4, 2025. -Abdominal x-ray due to abdominal distention (bloating and swelling of the belly), ordered March 11, 2025. -Follow up with [name] gastroenterology/Hepatology (medical specialty focusing on the digestive system and the liver) clinic one week, ordered March 4, 2025. A review of Resident A ' s Wound Evaluation and Treatment, dated March 10, 2025, indicated .+2 edema (a moderate level of swelling, where an indentation remains after pressing the skin for a few seconds) RLE (right lower extremity) .Rec (recommend) artena [sic] (arterial); and venous doppler (a non-invasive imaging test that uses sound waves to visualize blood flow in the arteries and veins) RLE. Elevate RLE .Site 003 .right dorsal (the part of the foot that faces upwards while standing) foot .venous ulcer (a wound on the leg or ankle caused by damaged or abnormal vein function) with fat layer exposed .measurement (LxWxD) (length x width x depth): 11.0 x 8.0 x 0.1cm (centimeter-a unit of measurement) .100% epithelial (packed cells lining a body surface) tissue .treatment Plan: cleanse with sterile normal saline (a fluid with 0.9% sodium) pat dry apply betadine (a topical antiseptic) cover with roll gauze dressing change dressing daily and PRN (as needed) for loss of integrity/soiling . A review of Resident A ' s Case Management Notes: -dated March 5, 2025, at 10:29 a.m., indicated .he lives alone .DME (Durable Medical Equipment-medical supplies) at home include W/C (wheelchair), walker, shower chair, power chair, prosthesis (artificial replacement for a body part) .patient states his discharge plan is to return home under [insurance name] ( name of program of all-inclusive care for the elderly) Program . -dated March 18, 2025, indicated .Spoke with .[insurance name] regarding transport not arriving as arranged for scheduled discharge on [DATE] (March 18, 2025) .will reschedule transport .attempted to reach [family member] .message left regarding change in discharge date s .[insurance name] aware of HH (home health), PT (physical therapy)/OT (occupational therapy) as well as needed visit for primary, hepatology, and cardiology . -dated March 19, 2025, indicated .family member has concerns of patients [sic] leg ' being swollen ' .advise patient to go to ER for evaluation .call placed to [care coordinator at insurance] in order to expedite home health visit, as well as scheduling F/U [follow up] with primary MD as soon as possible . A review of Resident A ' s Discharge Summary indicated, .diagnosis (identified cause of a disease or injury) during stay: COPD . There was no documentation found for discharge diagnosis or prognosis (predication of how a disease, injury, or illness will progress over time). A review of Resident A ' s Post DC (discharge) Plan of Care, indicated no documentation found for responsible party, relationship to patient, or phone number, Resident A ' s activity levels, equipment/supplies, home health agency or phone number, home health referrals for rehabilitation, what treatments/ supplies are needed for wounds, state ombudsman information and phone number, follow up appointments with dates and times, as well as pharmacy information on form. On March 28, 2025, at 3:00 p.m., and interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated she was the nurse who went over Resident A ' s discharge instructions. The LVN stated his discharge summary was reviewed, the resident had expressed an understanding, a copy was given to resident at discharge. On April 9, 2025, at 3:30 p.m., an interview was conducted with the CM. The CM stated Resident A had orders for follow up appointments with cardiology and GI/hepatology, Resident A has [insurance name] and their process is to contact them, they arrange the approval for follow up appointments and transportation. The CM stated she spoke with the Care Coordinator [name], on March 5, 2025, and gave them Resident A ' s follow up appointment orders, and called again, on March 7, 2025, to follow up. The CM stated she did not speak with Care Coordinator [name] again until March 18, 2025, when arranging Resident A ' s discharge from the facility, and again on March 19, 2025, when Resident A ' s family had called with a concern. The CM stated she did not make the follow up appointments for Resident A per the orders, nor discussed the possibility of applying for Medi Cal to receive additional services and resources, Resident A may not be receiving with only Medi Care services. On April 10, 2025, at 11:40 a.m., an interview was conducted with the CM. The CM stated she spoke with the Social Services Director (SSD), the SSD stated she did not speak with Resident A about applying for additional services and resources through Medi Cal. The CM stated she had spoke with Resident A ' s Care Coordinator at [name] multiple times, and no appointments had been made while Resident A was in the facility. On April 10, 2025, at 11:55 a.m., an interview was conducted with the Care Coordinator (CC) for Resident A ' s insurance. The CC stated Resident A was in the skilled nursing facility (SNF) from March 4th until March 18, 2025, Resident A has no follow up appointments pending at this time. The CC stated she had received orders for Resident A on March 7, 2025, from the SNF, the orders were sent to Resident A ' s primary doctor for approval. The CC stated she was notified by the SNF on March 12, 2025, that Resident A would need home health and wound care services upon discharge. The CC stated Resident A had wound care follow up appointments on March 24, and March 26, 2025, but Resident A was admitted to the hospital, and the appointments were cancelled. On April 10, 2025, at 12:10 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS) at [name]. The RNS stated Resident A was sent to the emergency room and admitted to the hospital on [DATE]. The RNS stated while Resident A was in the SNF receiving care, the SNF has control over the care, makes the decisions when assisting the resident, and is responsible for all follow up appointments, and additional care needs ordered. The RNS stated our program can assist by providing transportation if requested. The RNS stated the program will resume care once the resident is released from the SNF. On April 10, 2025, at 12:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was made aware Resident A had missing information on his discharge summary and Plan of Care, which should have been in the documents. A review of the facility ' s job descriptions for Case Manager indicated .is responsible for communicating care requirements to the facility care team and coordinating healthcare benefits for patients .ensures that the care needs of patients and residents within the facility are met in a competent, safe, and consistent manner and in accordance with current federal, state and local regulations .participates in patient/resident care plan meetings and follows-up as directed .educates patients/residents and their families of their benefits as needed .continuing communication with the interdisciplinary team and insurance providers .acts as a liaison/coordinator with insurance and other alternative .providers .participates in regular meetings for management of Medi Care/managed care patients and residents as needed . A review of the facility ' s policy titled Transfer or Discharge, Preparing a Resident for, dated December 2023, indicated .When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedure can be implemented .a post-discharge plan is developed for each resident prior to .transfer or discharge .Nursing services is responsible for .preparing the discharge summary and post-discharge plan .providing the resident or representative (sponsor) with required documents .

Based on observation, interview, and record review, the facility failed to treat with respect and dignity, for two of five residents (Residents A and B), when the facility left a deceased resident (Resident C) in the same room with Residents A and B for approximately 12 hours, before removing the body. This failure resulted in Residents A and B ' s experiencing negative psychosocial (a person ' s well-being- mental, emotional, social, and spiritual health) outcomes. Findings: On [DATE], at 9:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint of resident rights. On [DATE], at 9:50 a.m., Resident C's bed was observed to be not made up and the sheets were dirty. Two wheelchair footrests were observed on top of the bed. On [DATE], at 10:00 a.m., an interview was conducted with Resident B. Resident B stated Resident C passed away early in the morning of [DATE], and the Resident C's body was left in the room until 7:30 p.m., that night. Resident B stated, it was a very traumatic day, things should have been handled differently, anyone who came in the room, did not acknowledge us (Resident A and B), the staff went to Resident C ' s bed, and then would walk out of the room. Resident B stated her family came in to visit her during dinner time and asked the staff if Residents A and B could eat our meals in another room, because Resident C's body was starting to smell. Resident B stated she did not eat very much as it was difficult to eat with a dead body next to her. Resident B stated the employees kept walking in and out of the room, not knocking on the door, it was disrespectful. Resident B stated all she could think about was she did not want to end up like Resident C, left dead in a room, no dignity. On [DATE], a review of Resident C ' s medical records was conducted. Resident C was admitted to the facility on [DATE], with diagnoses which included kidney disease and high blood pressure. A review of Resident C ' s Daily Nurses Note, dated [DATE], at 12 p.m., indicated, . At 7:28 a.m. CNA (certified Nursing Assistant) went into provide care for resident and she was unresponsive .CPR (cardiopulmonary resuscitation- an emergency procedure that involves chest compressions and rescue breathing) was started .fire department came in at 7:40 a.m. and took over . pronounce dead at 8:57 a.m. A review of Resident C ' s Social Service Note, dated [DATE], at 7:30 p.m., indicated, .residents remains (a dead body) picked up by (name of mortuary) . On [DATE], a review of Resident B ' s medical records was conducted. Resident B was admitted to the facility on [DATE], with diagnoses which included, fracture of the pubis (broken pelvis) and respiratory failure (difficulty with breathing). Resident B ' s history and physical, dated [DATE], indicated Resident B has the capacity to understand and make decisions. A review of Resident B ' s Trauma Evaluation, dated [DATE], at 9:53 a.m., indicated, .identify the worst event .witnessed roommate passing away and time it took for next steps after death .how much were you bothered by the event .quite a bit .feeling or acting as if the stressful experience was actually happening again .a little bit .fell ing very upset .quite a bit .having strong physical reactions .a little bit .avoiding external reminders .quite a bit .blaming yourself or someone else for the stressful experience .moderately .feeling jumpy or easily startled .a little bit .trouble falling or staying asleep .quite a bit . A review of Resident B ' s Social Service Notes, dated [DATE], at 12:12 p.m., indicated, .discussed recent passing of roommate and how resident is coping. Resident verbalized she is having a hard time. SSD (Social Service Director) offered to make a referral to psychology so that resident can discuss and process her feelings .resident agreeable. SSD offered room change, resident was interested . On [DATE], at 10:30 a.m., the Licensed Vocational Nurse (LVN) was interviewed. The LVN stated she was the nurse assigned to Resident C when she passed away on the morning of [DATE]. The LVN was observed to enter Resident C's room and stated the resident's bed was not cleaned since Resident C had passed away yesterday. The LVN stated Resident C's bed should have cleaned up after the resident was picked up by the mortuary. On [DATE], at 10:40 a.m., the Administrator (ADM) was interviewed. The ADM stated a resident's dead body would be removed from the room as soon as possible after the family arrives and given time to [NAME]. On [DATE], at 1:15 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated she followed up with Residents A and B, regarding the death of Resident C, and offered them both room changes. The SSD stated normally the facility would contact the family after a death, and if the family does not have a mortuary picked out, we can give them information, to make arrangements and to have the body be picked up as soon as possible. The SSD stated she understands there was a smell from the Resident C ' s body being left in the room for so long, the staff should have offered a room change to Residents A and B. On [DATE], at 1:40 p.m., an interview with the Staffing Coordinator (SC) was conducted. The SC stated he had been a Certified Nursing Assistant (CNA) and when a resident had died , and there are roommates, we may take the resident who had died out of the room, or we take the roommate(s) out. The SC stated once a resident had died , it would take about two or three hours until the mortuary picks up the body. The SC stated 12 hours was an unusual amount of time to have a resident who had died , remain in the facility, the roommates should not have to stay in the room with a dead resident. On [DATE], at 2:10 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated it was not discussed with her about moving Resident C out of the room, after she died or Resident A and B out of the room. The LVN stated before leaving at 3:30 p.m., she understood Resident C ' s family was making arrangements, and the Registered Nurse (RN) was going to call and have the mortuary pick up the body. The LVN stated the dead body was to be removed from the facility within two hours after a resident ' s death. Resident A or B did not say anything to her, about moving rooms, and the Registered Nurse said she will deal with it. On [DATE], at 2:25 p.m., an interview was conducted with the CNA. The CNA stated she felt bad for Residents A and B and thought it would be traumatic to have a dead body in your room. The CNA stated Resident C's body should have been removed from the room. On [DATE], at 3:45 p.m., a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE]. 2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- a group of lung problems that block airflow and make it difficult to breathe) and Fibromyalgia (a condition that involves widespread pain and tiredness). Resident A ' s history and physical, dated [DATE], indicated Resident A had the capacity to understand and make decisions. On [DATE], at 4:25 p.m., an interview was conducted with Resident A. Resident A stated the staff did not ask her if she wanted to move to another room after Resident C died . Resident A stated she was very angry about the way things were handled. Resident A ' s family stated he was upset Resident A had to stay in the room with a dead body for so many hours, it was very inappropriate. On [DATE], at 4:35 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the RN should have let her know Resident C had died , the body was in the facility too long. The DON stated the staff should have offered to move Residents A and B to another room. The DON stated the situation was not handled in an efficient way, the circumstances were not appropriate, and the expectations of the staff were not followed through well. A review of the facility ' s policy titled, Quality of Life-Dignity, dated February 2020, indicated, .each resident will be cared for in a manner that promotes and enhances his or her sense of well-being .Residents are treated with dignity and respect at all times .Staff are expected to knock and request permission before entering residents ' rooms .standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents . A review of the facility ' s undated policy titled, Resident Self Determination and Participation, indicated, .respects and promotes the right of each resident .what the resident considers to be important .facilitate resident choices .Residents are encouraged to make choices about aspects of their lives in the facility .

Based on observation, interview and record review, the facility failed to answer the call light within a reasonable time for three of three residents reviewed (Residents 5, 6, and 7). This failure had the potential to result in needs not to be met efficiently for Residents 5, 6, and 7. Findings: 1.On October 13, 2024, Resident 5 ' s electronic record was reviewed. Resident 5 was admitted on [DATE], with diagnoses which included osteoarthritis- right hip (type of arthritis when the cartilage that lines the joint is worn down), muscle wasting and atrophy (loss of muscle tissue and strength) and history of falling. On November 13, 2024, at 3:36 p.m., a telephone interview was conducted with Resident 5's family representative (FR 3). The FR stated Resident 5 called the family some weeks ago and stated she (Resident 5) pushed her call light button for assistance to the restroom and no one responded. 2. On November 13, 2024, Resident 6 ' s electronic record was reviewed. Resident 6 was admitted on [DATE], with diagnoses which included fracture (a break in a bone) of left lower leg, hypertension (high blood pressure), and difficulty walking. Resident 6 was awake, alert, and oriented and able to make decision for himself. On November 13, 2024, at 2:51 p.m., while in hallway of station 2, observe call lights activated in Resident 6's room and Resident 7's room. Observed several staff members walking up and down the hall, and no one checked with the residents for their needs. On November 13, 2024, at 3:10 p.m., a concurrent observation and interview with Resident 6 was conducted. Observed Resident 6's call light was on, with Resident 6 lying in bed, wearing a fall risk bracelet with a cast to his left lower leg. Resident 6 stated he pushed his call light over 10 minutes ago and no one has come in. Resident 6 stated this morning he waited over an hour for someone to empty his urinal; and the resident stated he found it upsetting to wait. 3. On November 13, 2024, Resident 8 ' s electronic record was reviewed. Resident 7 was admitted on [DATE], with diagnoses which included metabolic encephalopathy (chemical imbalance of the blood that affects the brain), osteoarthritis (type of arthritis when the cartilage that lines the joint is worn down) of both knees, and hypertension (high blood pressure). Resident 7 had a Brief Interview for Mental Status (BIMs) of 7 which indicated moderate cognitive impairment. On November 13, 2024, a concurrent observation and interview with Resident 7 was conducted. Observed Resident 7 ' s call light was on, and Resident 7 was awake, lying in his bed. The resident stated he needed to be changed, and he activated his call light over 15 minutes ago and no one has answered. Resident 7 stated did not complain to anyone, since nothing will be done. On November 13, 2024, at 3:26 p.m. during an interview, Certified Nursing Assistant (CNA) 1 stated she was not the nurse for Resident 7. CNA 1 stated the facility ' s policy is to answer the call lights right away. CNA 1 further stated everyone is responsible for answering the call lights, even if the residents were not assigned to them. On November 13, 2024, at 4:14 p.m. during an interview, CNA 2 stated the facility ' s process for answering call lights is to answer as soon as possible and it does not matter if you are not assigned to the resident. CNA 2 stated she had an in-service for call lights often this year, because of the complaints about the call lights. CNA 2 further stated the biggest complaint she gets from residents was, they feel no one is there for them. On November 13, 2024, at 4:41 p.m. during an interview with the Director of Nursing (DON), she stated her expectation is that call lights should be within reach of the residents and the staff should answer the call lights as soon as possible. The DON stated everyone is responsible for answering the call lights to ensure residents' needs are met. A review of the facility policy and procedure titled, Answering the Call Light, dated March 2021, indicated, The purpose of this procedure is to ensure timely response to the resident ' s requests and needs .

Based on record review, interview, and facility policy review, the facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for 2 (Resident #3 and Resident #59) of 2 sampled residents reviewed for PASARR requirements. Findings included: A facility policy titled, Admission Criteria, revised in 09/2023, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The policy revealed, a. The facility will ensure PASARR screen has been completed by hospitals or facility of origin for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. 1. An Admission Record revealed the facility admitted Resident #3 on 06/16/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dementia (onset 06/16/2024), schizophrenia (onset 06/16/2024), and major depressive disorder (onset 06/16/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2024, revealed Resident #3 had severe impairment in cognitive skills for daily decision making and short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). Resident #3's care plan revealed a focus area initiated 08/16/2024, that indicated the resident required antipsychotic medication for schizophrenia. Interventions directed staff to administer medications as prescribed by the physician (initiated 08/16/2024) and to monitor for behaviors every shift (initiated 08/16/2024). The care plan revealed a focus area initiated 06/17/2024, that indicated the resident needed antidepressant medication. Interventions directed staff to administer medications as ordered (initiated 06/17/2024) and to monitor for side effects (initiated 06/17/2024). Resident #3's Preadmission Screening and Resident Review Level I Screening, dated 06/14/2024, revealed the resident did not have serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disorder. During an interview on 10/02/2024 at 1:25 PM, Social Services #7 stated Resident #3's Level I screening was inaccurate. During an interview on 10/02/2024 at 2:06 PM, Registered Nurse #8 stated Resident #3's Level I screening was inaccurate because it did not indicate the resident's mental illness diagnoses. During an interview on 10/02/2024 at 2:20 PM, the Director of Nursing stated Resident #3's Level I screening was not accurate. During an interview on 10/02/2024 at 2:35 PM, the Administrator stated Resident #3's Level I screening was inaccurate. 47914 2. An Admission Record revealed the facility admitted Resident #59 on 12/15/2023. According to the Admission Record, the resident had a medical history that included diagnoses of psychosis (onset 12/15/2023), major depressive disorder (onset 12/15/2023). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2023, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include depression and psychotic disorder. Resident #59's care plan included a focus area initiated 12/25/2023, that indicated the resident had a mood problem related to admission to the facility, depression, psychosis, and a history of schizophrenia. Interventions directed staff to schedule behavioral health consultations as needed (initiated 12/25/2023), administer medications as ordered (initiated 12/25/2023), and report to the physician any signs or symptoms of depression, anxiety, or sad moods (initiated 12/25/2023). Resident #59's Preadmission Screening and Resident Review Level I Screening, dated 12/15/2023, revealed the resident did not have serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disorder. During an interview on 10/02/2024 at 1:25 PM, Social Services (SS) #7 stated a resident's Level I screening was usually completed at the hospital prior to admission, and once it was received, a resident could be admitted . SS #7 stated that a review of the screening was not completed for accuracy upon admission because the facility relied on the hospital to do their due diligence to make sure the documents were accurate. SS #7 stated that Resident #59's Level I screening was completed on the same day the resident discharged from the hospital, and the facility staff would have anticipated the information on the screening to be accurate. S #7 stated that the hospital staff should have placed the resident's psychosis diagnosis on the Level I screening that was completed on 12/15/2023. During an interview on 10/02/2024 at 2:06 PM, Registered Nurse (RN) #8 stated that the diagnosis of psychosis should have been on Resident #59's Level I screening completed on 12/15/2023. During an interview on 10/02/2024 at 2:20 PM, the Director of Nursing (DON) stated that Level I screenings were completed at the hospital and sent to the facility before a resident was accepted, and it was then uploaded into the resident's electronic health record. The DON stated that the importance of the Level I screening being completed was for residents that had a mental illness to get a second screening to ensure the resident got all the proper services they needed. The DON stated that PASARRs were not reviewed for accuracy, but if the Level I screening triggered a Level II evaluation, the facility would request that before the resident came. The DON stated that she did a review of Resident #59's Level I screening and it was inaccurate. During an interview on 10/02/2024 at 2:34 PM, the Administrator stated that the hospital completed the Level I screenings and the facility staff were not to accept any residents without one. The Administrator stated that the PASARR screening evaluated the mental capacity of a resident. The Administrator stated that during review of the Level I screenings, staff looked to make sure the resident did not require a Level II evaluation. The Administrator stated that he felt that when a Level I screening was inaccurate, it would mislead the facility about the resident.

Based on record review and interview, the facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness for 1 (Resident #59) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR) requirements. Findings included: An Admission Record revealed the facility admitted Resident #59 on 12/15/2023. According to the Admission Record, the resident had a medical history that included diagnoses of psychosis (onset 12/15/2023) and major depressive disorder (onset 12/15/2023). The Admission Record revealed the resident received a diagnosis of schizophrenia on 12/29/2023. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/22/2024, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include psychotic disorder and schizophrenia. Resident #59's care plan included a focus area initiated 12/25/2023, that indicated the resident had a mood problem related to admission to the facility, depression, psychosis, and a history of schizophrenia. Interventions directed staff to schedule behavioral health consultations as needed (initiated 12/25/2023), administer medications as ordered (initiated 12/25/2023), and report to the physician any signs or symptoms of depression, anxiety, or sad moods (initiated 12/25/2023). The care plan also indicated a focus area initiated 04/04/2024, that indicated the resident was at risk for increased confusion and disordered thought, secondary to schizophrenia. The care plan indicated the schizophrenia diagnosis was given by a psychiatrist on 12/29/2023. Interventions directed staff to provide psychiatry and psychology consultations as needed (initiated 04/04/2024). The care plan also revealed a focus area initiated 06/25/2024, that indicated the resident had psychosis behavior manifested by auditory hallucinations. Resident #59's medical record revealed no evidence that indicated a referral was made to the appropriate state-designated authority following the resident's new diagnosis of schizophrenia on 12/29/2023. During an interview on 10/02/2024 at 1:25 PM, Social Services (SS) #7 stated she was not necessarily responsible for PASARR screenings. She stated the Level I screenings were usually done at the hospital prior to the resident's admission, and once it was received, a resident could be admitted . SS #7 stated if a resident had a change in condition, whether physical or mental, the facility would do a review and if needed, a new Level I screening would be completed. SS #7 stated Resident #59's psychosis diagnosis was temporary, and when the psychiatrist saw Resident #59, the psychiatrist determined that the resident had schizophrenia. SS #7 stated the resident's mental status did not change, and the resident did not have a change in condition, so that information would not necessarily need to be on the Level I screening. SS #7 stated that if there was a change in a resident's condition, Registered Nurse (RN) #8 was responsible for completing another Level I screening, and if RN #8 was not able to, then she would complete it. During an interview on 10/02/2024 at 2:06 PM, RN #8 stated she worked together with an MDS coordinator and a social worker on the PASARR process. She stated that when a PASARR screening was received, a resident would come into the facility, and it was uploaded into the resident's electronic health record. RN #8 stated that she believed she would not do a new Level I screening for a new diagnosis, but would for a new order of psychotropic medication. RN #8 stated that she would complete the new Level I screening and if she did not, another member of the team would complete it.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. This was evidenced by two medication errors out of 33 opportunities, which resulted in a medication error rate of 6.06%, that affected 2 (Resident #10 and Resident #39) of 5 residents observed for medication administration. Findings included: A facility policy titled, Administering Oral Medications, revised in 09/2023, revealed, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy further revealed, Steps in the Procedure included 5. Select the drug from the unit dose drawer or stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR [medication administration record]. 1. An Admission Record revealed the facility admitted Resident #10 on 01/10/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified anemia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #10's care plan included an undated focus area that indicated the resident had an altered nutrition need related to diagnoses that included anemia. Interventions directed staff to administer ferrous fumarate (initiated 01/16/2024). Resident #10's Order Summary Report, which listed active orders as of 10/01/2024, revealed an order dated 01/31/2024, for ferrous fumarate oral tablet 324 milligrams (mg), one tablet by mouth three times a day for a supplement. During an observation of medication administration on 10/01/2024 at 8:16 AM, Licensed Vocation Nurse (LVN) #6 prepared and administered a ferrous sulfate 325 mg tablet to Resident #10. 2. An Admission Record revealed the facility admitted Resident #39 on 09/02/2024. According to the Admission Record, the resident had a medical history that included diagnoses of adult failure to thrive, unspecified dementia, and follicular lymphoma. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #39's care plan included a focus area initiated 09/04/2024, that indicated the resident was at risk for constipation due to a diagnosis of chronic constipation. Interventions directed staff to administer medication as ordered (initiated 09/04/2024). Resident #39's Order Summary Report, which listed active orders as of 10/01/2024, revealed an order dated 09/03/2024, for Senna-S (sennosides-docusate sodium, a combination of a laxative medication and a stool softener medication) oral tablet 8.6 milligram (mg) - 50 mg, give two tablets by mouth two times a day for constipation; hold for loose stools. During an observation of medication administration on 10/01/2024 at 8:55 AM, Licensed Vocational Nurse (LVN) #6 prepared and administered medications to Resident #39, including one Geri-kot (sennosides) 8.6 mg tablet and one docusate sodium 100 mg capsule. During an interview on 10/02/2024 at 2:28 PM, the Director of Nursing (DON) stated she expected nurses to administer medications per the physician's orders, and to give the right medications. The DON stated that if a medication was unavailable as ordered, she expected the nurse to either call the physician to get another order, or come to her so the facility could make the correct medications available. During an interview on 10/02/2024 at 2:40 PM, the Administrator stated that he expected the nurses to pay attention and know the medications. The Administrator stated that he expected staff to stay below a 5% medication error rate, ideally at 0%.

Based on observation, interview, and record review, the facility failed to ensure medications were administered on time as prescribed by the physician and according to the facility ' s policy for three of three residents reviewed (Residents 1, 2, and 3). This failure had the potential to result in an increased risk of changes of condition to Residents 1, 2 and 3. Findings: On August 12, 2024, at 9:20 a.m., an unannounced visit was conducted at the facility to investigate a complaint. On August 12, 2024, at 9:49 a.m., during a concurrent observation and interview with Resident 1, Resident 1 was in his room, sitting on his wheelchair by the door, alert and conversant. Resident 1 stated he received his medications on time, but he looked for the nurse when it ' s time for his pain medication. On August 12, 2024, at 10:04 a.m., during a concurrent observation and interview with Resident 2, Resident 2 was lying on his bed, watching television, alert and conversant. Resident 2 stated he received his medications and that he took a lot of it. Resident 2 stated he did not even know what those medications were for. On August 12, 2024, at 10:50 a.m., Licensed Vocational Nurse (LVN 1) was observed passing medications. LVN 1 stated he was not done with med pass and still has three more rooms to go. On August 12, 2024, at 11:42 a.m., LVN 1 was observed passing medications. LVN 1 stated he was still passing medications that were due at 9:00 a.m. On August 12, 2024, at 12:03 p.m., during an interview with LVN 2, LVN 2 stated med pass (medication pass) should be completed in two hours from the scheduled time. LVN 2 stated for medications due at 9:00 a.m., med pass can be started at 8:00 a.m. up to 10:00 a.m. LVN 2 stated if medications were given outside that two-hour time frame, the effectiveness of the medications can be affected. On August 12, 2024, at 12:15 p.m., during a follow up interview with LVN 1, LVN 1 stated, for the 9:00 a.m. med pass, medications can be administered between 8:00 a.m. to 10:00 a.m. LVN 1 further stated if medications were given outside the two hour period, there can be medication interactions and a blood pressure given too early or too late may cause an uncontrolled low or high blood pressure to a resident. On August 12, 2024, at 12:55 p.m., during an interview with LVN 3, LVN 3 stated med pass can be started one hour before and one hour after the scheduled time. LVN 3 stated when medications were not given on time, she would notify the Medical Doctor and ask if the medications should still be given, LVN 3 stated licensed nurse should pour (prepare the medications), pass (administer the medications) and then sign (document after medications were administered) for each resident. A review of Resident 3 ' s AR indicated he was admitted to the facility on [DATE], with diagnoses which included status post amputation of the right foot trans metatarsal (bones between the ankle and toes), DM (diabetes mellitus) and HTN (hypertension). A review of Resident 3 ' s H&P dated July 24, 2024, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3 ' s Progress Notes dated August 1, 2024, indicated he was discharged to home per request. A record review of Resident 3 ' s July 2024 electronic Medication Administration Record (eMAR) - administration details on PointClickCare (PCC - an electronic health care record) was conducted with LVN 3. LVN 3 stated the following medications ordered by the physician were administered as follows: 1. Aspirin (lowers risk of heart attack) was due at 9:00 a.m. and it was administered on July 25, 2024, at 10:02 a.m., on July 26, 2024, at 11:33 a.m., July 28, 2024, at 1:39 p.m., on July 29, 2024, at 2:59 p.m. and on July 31, 2024, at 10:51 a.m. 2. Atenolol (treat high blood pressure) was due at 9:00 a.m. and it was administered on July 26, 2024, at 10:33 a.m., on July 28, 2024, at 1:37 p.m., on July 29, 2024, at 12:00 p.m. and on July 31, 2024, at 10:57 a.m. 3. Clopidogrel (prevents heart attack) was due at 9:00 a.m. and it was administered on July 26, 2024, at 11:33 a.m., on July 28, 2024, at 1:38 p.m., on July 29, 2024, at 2:59 p.m. and on July 31, 2024, at 10:57 a.m. 4. Fish Oil (lowers cholesterol level) was due at 9:00 a.m. and it was administered on July 26, 2024, at 11:33 a.m., on July 28, 2024, at 1:38 p.m., on July 29, 2024, at 2:59 p.m. and on July 31, 2024, at 10:51 a.m. 5. Lisinopril (treat high blood pressure) was due at 9:00 a.m. and it was administered on July 26, 2024, at 10:33 a.m., on July 28, 2024, at 1:39 p.m., on July 29, 2024, at 12:01 p.m. and on July 31, 2024, at 10:57 a.m. 6. Senna-Plus (treat constipation) was due at 9:00 a.m. and it was administered on July 26, 2024, at 10:33 a.m., on July 28, 2024, at 1:39 p.m., on July 29, 2024, at 12:01 p.m. and on July 31, 2024, at 10:57 a.m. 7. Atorvastatin (lowers cholesterol and fat levels) was due at 9 p.m. and was administered on July 31, 2024, at 11:27 p.m. There was no documentation of the reason Resident 3 ' s medications were administered late. On August 12, 2024, at 2:57 p.m., during an interview with the Director of Nursing (DON), the DON stated the licensed nurses have one hour before and one hour after the scheduled medications to give the residents ' medications. The DON stated it was hard to say if there will be any outcome on residents when medications were administered late and that it depends on what kind of medication and how frequent it was supposed to be given. A review of Resident 1 ' s ADMISSION RECORD (AR) indicated he was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - high blood pressure) and hyperlipidemia (HLD- high cholesterol level). A review of Resident 1 ' s History and Physical (H&P), dated June 26, 2024, indicated Resident 1 has the capacity to understand and make decisions. On August 12, 2024, at 4:35 p.m., record review of Residents 1 ' s July 2024 eMAR administration details on PCC were conducted with LVN 3. LVN 3 stated the following medications ordered by the physician were administered as follows: 1. Imatinib (treats different types of cancer) was due at 8:00 a.m. and was administered on July 25, 2024, at 11:53 a.m., on July 27, 2024, at 9:16 a.m., on July 30, 2024, at 9:55 a.m., and on July 31, 2024 at 9:06 a.m. 2. Acetaminophen was due at 9:00 a.m., 1:00 p.m. and 5:00 p.m. and the 9:00 a.m. doses were administered on July 25, 2024, at 11:53 a.m. and on July 31, 2024, at 10:24 a.m., the 1:00 p.m. doses were administered on July 29, 2024, at 2:12 p.m. and on July 30 at 2:53 p.m.; the 5:00 p.m. doses were administered on July 23, 2024 at 7:24 p.m., on July 25, 2024 at 7:27 p.m., on July 26, 2024 at 7:06 p.m., on July 29, 2024 at 6:28 p.m., and on July 30, 2024 at 7:07 p.m. 3. Aspirin was due at 9:00 a.m. and was administered on July 25, 2024, at 11:53 a.m. 4. Budesonide (treatment for asthma - lung disease) was due at 9:00 a.m., and at 5:00 p.m.; the 9:00 a.m. doses were administered on July 5, 2024, at 11:55 a.m. and on July 25, 2024, at 1:14 p.m. and the 5:00 p.m. doses were administered on July 23, 2024, at 8:24 p.m., on July 25, 2024, at 7:28 p.m., on July 26, 2024, at 7:06 p.m. and 5:28 p.m. 5. Clopidogrel was due at 9:00 a.m. and was administered on July 25, 2024, at 11:53 a.m. 6. Cetirizine (allergy medications) was due at 9:00 a.m. and was administered at 11:53 a.m. 7. Duloxetine (treats depression or nerve pain) was due at 9:00 a.m. and 5;00 p.m., the am doses were administered on July 25, 2024, at 11:53 a.m.; the 5:00 p.m. doses were administered on July 25 at 7:28 p.m., on July 26, 2024, at 7:11 p.m., on July 29, 2024, at 6:32 p.m. and on July 30, 2024, at 7:07 p.m. 8. Furosemide (treats hypertension) was due at 9:00 a.m. and was administered on July 25, 2024, at 11:54 a.m. and on July 31, 2024, at 12:56 p.m. 9. Lidoderm Patch (pain medication) was due at 9:00 a.m. and was administered on July 25, 2024, at 11:55 a.m., on July 27, 2024, at 10:42 a.m., on July 29, 2024, at 2:12 p.m. 10. Polyethylene Glycol (prevents constipation) was due at 9:00 a.m. and was administered on July 25, 2024, at 11:53 a.m. 11. Multiple Vitamins-Mineral (prevents vitamin and mineral deficiency) was due at 9:00 a.m. and was administered at 11:53 a.m. 12. Potassium (supplement for low potassium level) was due at 9:00 a.m. and was administered at 11:53 a.m. 13. Pregabalin (treats nerve pain) was due at 9:00 a.m. 1:00 p.m. and 5;00 p.m.; the 9:00 am dose on July 25, 2024, was administered at 11:53 a.m.; the 1:00 p.m. doses were administered on July 26, 2024, at 2:46 p.m., on July 29, 2024, at 2:12 p.m., on July 30, 2024, at 3:01 p.m.; the 5:00 p.m. doses were administered on July 25, 2024, at 7:28 p.m., on July 26, 2024, at 7:11 p.m., on July 29, 2024, at 6:34 p.m. and on July 30, 2024 at 7:07 p.m. 14. Spiriva (treatment for asthma) was due at 9:00 a.m. and was administered on July 25, 2024, at 11:53 a.m. and on July 26, 2024, at 1:14 p.m. 15. Vitamin D3 (supplement) was due at 9:00 a.m. and was administered on July 25, 2024, at 11:53 am. 16. Ascorbic Acid (supplement) was due at 8:00 a.m. and 5:00p.m.; the 8:00 a.m. dose was administered on July 25, 2024, at 11:53 a.m.; the 5:00 p.m. doses were administered on July 25, 2024, at 7:28 p.m., on July 29, 2024, at 6:29 p.m. and on July 30, 2024, at 7:07 p.m. There was no documentation of the reason Resident 1 ' s medications were administered late. A review of Resident 2 ' s AR indicated he was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM- high blood sugar level) and HLD. A review of Resident 2 ' s H&P dated December 14, 2023, indicated Resident 2 has the capacity to understand and make decisions. A record review of Residents 2 ' s July 2024 eMAR administration details on PCC were conducted with LVN 3. LVN 3 stated the following medications ordered by the physician were administered as follows: 1. Ascorbic Acid was due at 9:00 a.m. and was administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 1:59 p.m. 2. Folic Acid (supplement) was due at 9:00 a.m. and was administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 1:59 p.m., on July 29, 2024, at 11:14 a.m. and on July 31, 2024, at 1:36 p.m. 3. Metformin (treats high blood sugar level) was due at 9:00 a.m. and 5;00 p.m.; the 9:00 a.m. doses were administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 2:00 p.m., on July 29, 2024, at 11:15 a.m.; on July 31, 2024, at 1:36 p.m. 4. Multi-Vitamin was due at 9:00 a.m. and was administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 2:02 p.m., on July 30, 2024, at 11;15 a.m. and on July 31, 2024, at 1:36 p.m. 5. Ditropan (treats loss of bladder control) was due at 9:00 a.m. and 5:00 p.m.; the 9:00 a.m. doses were administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 2:01 p.m., on July 29, 2024, at 11:15 a.m., on July 31, 2024, at 1:36 p.m. and the 5:00 p.m. doses were administered on July 23, 2024, at 6:42 p.m., on July 25, 2024, at 10:29 p.m., on July 26, 2024, at 6:14 p.m., on July 28, 2024 at 6:49 p.m., on July 30, 2024 at 6:37 p.m., on July 31, 2024 at 7:23 p.m. 6. Pantoprazole (reduces the amount of acid in the stomach) was due at 9:00 a.m. and was administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 2:01 p.m., on July 31,2024 at 1:36 p.m. 7. Vitamin D3 was due at 9:00 a.m. and was administered on July 26, 2024, at 12:08 p.m., on July 28, 2024, at 2:02 p.m., on July 29, 2024, at 11:15 a.m. and on July 31, 2024, at 1:36 p.m. 8. Hydralazine (treats high blood pressure) was due at 6:00 a.m., 2:00 p.m. and 10 p.m.; the 6:00am dose was administered on July 25, 2024, at 7:23 a.m., the 2:00 p.m. doses were administered on July 29, 2024, at 3:58 p.m., on July 30, 2024, at 3:52 p.m., July 31, 2024 at 1:36 p.m.; the 10 p.m. doses were administered on July 24, 2024 at 11:22 p.m., on July 29, 2024 at 12:29 a.m. and on July 31, 2024 at 11:56 p.m. There was no documentation of the reason Resident 1 ' s medications were administered late. A review of the facility ' s policy and procedure titled, Medication Administration Schedule, dated November 2020 indicated .medications are administered according to the following routine schedule . qid (four times daily) 9 a.m. / 1 a.m. / 5 p.m. / 9p.m . tid (three times daily) 9 a.m./ 1 p.m./ 5 p.m . bid (two times daily) 9 a.m. / 5 p.m. Daily 9 a.m. Every morning 9 a.m. scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified . if medication is administered early, late (beyond the allowable interval), or is omitted, the reason is also documented .

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staffing to provide care and services for the residents of the facility. This failure had the potential to cause residents in the facility to experience delays and inadequate care. Findings: On July 23, 2024, at 5:06 a.m., an unannounced visit was conducted at the facility. On July 23, 2024, at 5:26 a.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated the facility needed more staffing so they can be able to do their work effectively for the residents. On July 23, 2024, at 5:58 a.m. during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there had been staffing issues at the facility. LVN 1 stated there was one night shift (11-7) when there was only four CNAs on the floor. LVN 1 stated they tried to get coverage, but nobody wanted to work. LVN 1 further stated that they are always short-staffed, weekday or weekend. On July 23, 2024, at 5:50 a.m. during an interview with CNA 2, CNA 2 stated she's had 26-27 residents, and that was unmanegable. CNA 2 stated, other CNAs were calling off and not having any CNAs. On July 23, 2024, at 6:30 a.m., during an interview with LVN 2, LVN 2 stated that there had been one night shift when there was only four CNAs and the licensed nurses helped on the floor. On July 23, 2024, at 8:50 a.m., during an interview with Resident 4, Resident 4 stated the facility did not have enough staff. Resident 4 stated the staff were always saying they were busy and were short-handed. Resident 4 stated staff do not answer his call button. Resident 4 stated there was one time when he asked to be changed at 3:30 p.m., and a CNA changed him at 9:00 p.m. Resident 4 further stated that he had not been showered since May 28, 2024. Resident 4 stated he received a bed bath, but he preferred showers. Resident 4 stated he did not bother to ask staff to give him a shower because he knew they were always short on staff. On July 23, 2024, at 10:19 a.m., during an interview with the Staffing Coordinator (SC), the SC stated the required Direct Care Service Hours per Patient Day (DHPPD- a tool to assess the value nursing staff provides around patient safety and care quality) was 3.5 and the CNA DHPPD was 2.4. The SC stated there should be 12 to 14 CNAs in the morning shift (7-3), 10 to 12 CNAs in the evening shift (3-11), and nine to 10 CNAs in the night shift and it depends on the census (number of residents in the facility). A review of the DHPPD and nursing assignment sheets conducted with the SC, indicated the following: 1. On July 13, 2024, the census (number of residents in the facility) was 104, the actual DHPPD was 3.8 and actual CNA DHPPD hours was 2.12; there were four CNAs for the night shift. The SC stated the four CNAs were assigned 26 residents each. 2. On July 14, 2024, the census was 105, the actual DHPPD hours was 2.88 and CNA DHPPD hours was 1.31. 3. On July 19, 2024, the census was 102, the actual DHPPD hours was 4.10 and CNA DHPPD hours was 2.31. 4. On July 20, 2024, the census was 104, the actual DHPPD hours was 3.47 and CNA DHPPD hours was 1.91. 5. On July 21, 2024, the census was 103, the actual DHPPD hours 2.29 and CNA DHPPD hours was 1.10. The SC stated proper care is not provided to the residents when the required DHPPD hours were not met and when CNAs had 26 resident each. The SC also stated the facility staff had more workload which interfered with providing quality care. Further review of the nursing assignment sheet dated July 13, 2024, indicated that LVN 1, and LVN 2 worked the night shift and there was only four CNAs. A review of Resident 4 ' s medical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a medical condition in which a person ' s kidneys stopped functioning on a permanent basis). Resident 4 ' s History and Physical dated June 12, 2024, indicated Resident 4 had the capacity to understand and make decisions. Resident 4 ' s care plan dated January 20, 2024, indicated Resident 4 had a self-care deficit related to inability perform activities of daily living (ADL) and he required total assist with bathing. There was no documented evidence that Resident 4 refused showers nor that he had a preference of a bed bath. On July 23, 2024, at 12:05 p.m., during an interview with Registered Nurse (RN) 1, RN 1 stated if a resident wanted to shower then staff should provide the shower. RN 1 stated there may be times when showers are offered but residents would decline. A concurrent review of Resident 4 ' s medical record was conducted with RN 1. RN 1 stated Resident 4 ' s care plan did not indicate any refusal of shower nor preference of bed bath. RN 1 stated Resident 4 ' s ADL Bathing Sheet indicated that he did not receive a shower between June 25, 2024, and July 22, 2024. On July 23, 2024, at 12:50 p.m., during an interview with the Director of Nursing (DON), the DON stated the required DHPPD hours was 3.5 and CNA DHPPD hours was 2.4. The DON stated the facility staffed beyond the requirement. The DON stated some staff are asked to work additional hours, partial or double shifts and they were actively recruiting more staff through job postings and referrals. The DON stated there could be resident dissatisfaction, delay in answering call lights, somethings may get missed when the facility is not adequately staffed and when four CNAs had 26 residents each. On July 23, 2024, at 2:19 p.m., during a follow up interview with the SC, the SC stated for a facility census of 104, there should be 12 CNAs in the morning shift, nine CNAs in the evening shift and seven to eight CNAs in the night shift. A review of the facility's policy and procedure, titled Staffing, dated September 2019, indicated .our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents . licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services .staffing numbers and the skill requirements of direct care staff are determined by the needs if the residents based on each resident's plan of care .

Based on observation, interview, and record review, the facility failed to ensure updated staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff was posted in a prominent place readily available to residents and visitors. This failure had the potential for the facility not to be able to provide and determine the actual nursing hours required for the provision of care and services for the residents in the facility. Findings: During an observation on July 15, 2024, at 9:34 a.m., the facility document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD - used to measure the duration of care residents receive in a day) was posted on the wall of the facility lobby next to the receptionist's desk. The DHPPD information was not updated. The DHPPD forms did not indicate the actual total direct care service hours, actual total CNA (certified Nursing Assistant) direct care service hours, the average patient census, the actual DHPPD and the actual CNA DHPPD on multiple dates. During a concurrent interview and record review on July 15, 2024, at 12 p.m., with the Staffing Coordinator (SC), he stated the Interim Director of Staff Development (IDSD) was responsible for calculating the actual DHPPD. He stated the IDSD should enter the information for the actual direct care services and the DHPPD on the form. During a concurrent interview and record review on July 15, 2024, at 2:20 p.m., with the IDSD, she stated she was responsible for calculating the actual direct care service hours and DHPPD and placing the information on the facility document for posting. The IDSD stated the actual direct care service hours and DHPPD calculations were done on a weekly basis when she received the data from payroll. She stated she did not have access to payroll and could not calculate the actual hours. She stated the facility documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), from July 1 to July 14, 2024, were not updated. The documents did not indicate the actual direct care service hours and DHPPD. During an interview on July 15, 2024, at 2:45 p.m., with the Administrator (ADM), the ADM stated the facility document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD) was posted but did not include the actual hours provided by the nursing staff. The facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers, dated July 2016, indicated, .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs [Registered Nurses], LPNs [Licensed Practical Nurses], and LVNs [Licensed Vocational Nurses] and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following .The actual time worked during tht shift for each category and type of nursing staff .Total number of licensed and non-licensed nursing staff working for the posted shift .

Based on observation, interview, and record review, the facility failed to ensure the safety of one of three sampled residents (Resident 3) reviewed for falls, when the facility failed to repair a loose toilet seat being used by Resident 3 after it was reported to staff as needing repair on April 2, 2024. This failure resulted in Resident 3 falling off the loose toilet seat and sustaining a broken hip that required surgical repair at the general acute care hospital (GACH). Findings: On April 23, 2024, at 12:37 p.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was in his room, lying in bed, alert and conversant. Resident 3 stated, he fell in the restroom on April 3, 2024, at approximately 2:30 p.m. Resident 3 stated he was going to use the toilet, and as he was sitting down, he placed one of his hands on the toilet seat and the toilet seat moved sideways which caused him to fall to the ground. Resident 3 stated he had spoken to the Social Service Assistant (SSA) about the loose toilet seat the day before he fell (April 2, 2024). Resident 3 stated he was assessed by a Registered Nurse, and two Licensed Vocational Nurses (LVNs) helped him from the ground to the bed, and then he was transferred to the hospital. Resident 3 stated he had just returned from the hospital after having surgery on his left hip. Resident 3 stated his goal was to be able to walk again at least with a walker. Resident 3 stated he was in pain, had lost his self-respect because he now had to use a commode (portable toilet) and he needed assistance with toileting. A review of Resident 3 ' s medical record was conducted. Resident 3 was initially admitted to the facility on [DATE]. A review of Resident 3 ' s Minimum Data Assessment (MDS- an assessment tool) dated February 10, 2024, indicated Resident 3 ' s cognition (the ability to make decision and produce appropriate response) was intact, and Resident 3 was independent with toilet transfer (the ability to get on and off a toilet or commode - a portable toilet) and independent with walking 150 feet. The MDS further indicated that Resident 3 had diagnoses which included hypertension (high blood pressure) end stage renal disease (a permanent kidney failure that requires a regular course of dialysis - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and stroke (loss of blood flow to a part of the brain). A review of Resident 3 ' s care plan dated June 21, 2023, indicated Resident 3 .was at risk for falls and interventions included .maintain safe environment . A review of Resident 3 ' s Daily Nurses Note dated April 3, 2024, indicated Resident 3 .was trying to use the toilet but the toiled (sic) lid (sic) was lose (sic) and when he sit (sic) the toilet the sit (sic) moved and he ended on the floor .pt complain (sic) of pain 10/10 (a score of 0 means no pain, and 10 means the worst pain) . 911 (emergency telephone number) was called .pt was taking (sic) to hospital at 3:25 p.m. A review of Resident 3's GACH notes titled, Trauma - History and Physical, dated April 3, 2024, indicated, [AGE] year-old male .presents from skilled nursing facility after ground level fall early this morning . trauma surgery consulted for left hip fracture .he notes that his toilet seat has been loose for several days and had not been fixed. He sat on the toilet seat, and it slipped, and he fell on to his left side .extremities . LLE (left lower extremity) shortened and externally rotated .ROM (range of motion) limited due to pain . Further review of Resident 3 ' s medical record indicated Resident 3 was readmitted to the facility on [DATE], with diagnoses which included fracture of the left femoral neck (a break in the left hip bone), status post left hemiarthroplasty (received a partial left hip replacement), and history of stroke with left hemiparesis (left sided weakness). A review of Resident 3 ' s IDT (interdisciplinary team - group of health care professionals with various areas of expertise who work together) - Incident Review dated April 10, 2024, indicated that Resident 3 had a fall incident on April 3, 2024, at 3:00 p.m. The IDT Incident Review indicated description of incident .denies hit his head. pt (patient) states was trying to use the toilet and the seat was lose (sic) which lid (sic) to fall . The IDT Incident Review further indicated .contributing factors/root cause analysis (the process of discovering the root cause of a problem) were diagnosis/comorbidities (two or more diseases present at once) and environmental . A review of Resident ' s 3 PT (Physical Therapy) Evaluation & (and) Plan of Treatment, dated April 11, 2024, indicated .Pt has significant deficits in functional mobility due to recent L (left) hip arthroplasty (surgical reconstruction or replacement of a joint) . Pt requires increased time to perform tasks due to pain and weakness .Pt is currently functioning below previous baseline and requires skilled PT intervention to restore safe functional mobility . On April 23, 2024, at 1:12 p.m., an interview was conducted with LVN 1. LVN 1 stated on April 3, 2024, during the change of shift between 7-3 (am) and 3-11 (pm), she was rounding (visiting the residents) with another LVN, when they found Resident 3 on the restroom floor inside his room. LVN 1 stated Resident 3 stated the toilet seat went sideways when he sat down and caused him to fall. LVN 1 stated she had not received any reports from Resident 3 or any other residents about a loose toilet seat. LVN 1 stated if Resident 3 had told her, she would have reported it to the maintenance department right away. On April 23, 2024, at 1:20 p.m., an interview with the Maintenance Assistant (MA) was conducted. The MA stated there were maintenance logs at each station where staff can record broken equipment. The MA stated he reviewed the maintenance logs every day, in the morning, to check what needed to be fixed. The MA stated he was informed about the loose toilet in Resident 3's restroom on April 4, 2024 (the day after Resident 3 ' s fall). A review of the facility ' s maintenance logs for April 2024, at Station 1, 2 and 3 was conducted. There was no information written on the maintenance logs for April 1, 2 and 3, 2024. On April 23, 2024, at 2:06 p.m., an interview was conducted with the SSA. The SSA stated if there was broken facility equipment, she would write it on the maintenance log. The SSA stated she was not initially aware that there were maintenance logs at each nurse ' s station. The SSA stated Resident 3 told her about the loose toilet seat the day before he was transferred to the hospital (April 2, 2024). The SSA stated she reported it to her supervisor, the Social Service Designee (SSD). The SSA stated the SSD told her that there were maintenance logs at each nurse ' s station. The SSA stated she was able to locate the maintenance logs, but she did not record the loose toilet seat in Resident 3 ' s restroom. On April 23, 2024, at 3:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there were maintenance logs in each nurse ' s station. The DON stated the staff can record on the logs what needs to be fixed. The DON stated the maintenance department checked the logs every day and the maintenance director attended the morning meeting. The DON stated Resident 3 fell on [DATE], and he mentioned that the toilet seat was loose in his restroom. The DON stated the maintenance department was notified right away and the loose toilet seat was fixed the same day. The DON stated she was not aware that the SSA knew about the loose toilet seat in Resident 3 ' s restroom before Resident 3 fell . The DON stated the SSA should have written it down on the maintenance log and alerted the maintenance staff verbally when she knew about it. The DON stated a loose toilet seat was an accident hazard. On April 23, 2024, at 4:43 p.m., an interview with the Administrator (ADM) was conducted. The ADM stated when staff noticed broken facility equipment or a loose toilet seat, they should record it on the maintenance log. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents dated November 2023 was reviewed. The policy indicated, .resident safety and supervision and assistance to prevent accidents are facility-wide priorities .employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents .

Based on observation, interview, and record review, the facility failed to provide supervision consistent with the resident's needs, goals, care plan, and current professional standards of practice, in order to eliminate the risk of an accidental fall, to one of three residents reviewed (Resident A), when Resident A was left unattended while in a wheelchair at Station 3 lobby. This failure resulted in the resident getting up unassisted from the wheelchair, and falling face down to the floor, for the second time in 38 days, sustaining a right frontal subdural hematoma (SDH-a pool of blood between the brain and its outermost covering). Resident A was transferred to the acute care hospital for evaluation. Findings: On [DATE], at 8:15 a.m., an unannounced visit was conducted at the facility to investigate a quality of care issue. On [DATE], a review of Resident A's record indicated the resident was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a brain disease that alters the brain function or structure), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (mood swings), and unsteady gait (abnormal or uncoordinated walking). A review of Resident A's history and physical dated [DATE], indicated Resident A did not have the capacity to understand and make decision. A review of Resident A's Minimum Data Set (an assessment tool) dated [DATE], indicated that Resident A had a BIMS (Brief Interview of Mental Status- a screening tool) Score of 02 (severe impairment in cognition [thinking process]). Resident A had exhibited physical and behavioral symptoms directed towards others, and rejection of care. Resident A's functional status required extensive assistance with one-person physical assist in most of his activities of daily living (ADLs) and used wheelchair for mobility device. The assessment further indicated Resident A's balance was not steady and only able to stabilize with staff assistance. A review of Resident A's Quarterly Fall Risk Assessment, dated [DATE], indicated a score of 17 (high risk for fall). A review of Resident A's care plan, initiated on [DATE], indicated, Focus: At risk for fall R/T (related to) Use of BP meds (blood pressure medications), Balance problem, ASE (adverse side effects) from medication, agitation, dementia, poor safety awareness, does not call for assistance prior to getting up from safe position, incontinence .Interventions: .Position resident closer to activity personnel when in activity room for closer supervision .Prompt resident to adjust his placement in his wheelchair when he appears too close to the edge to prevent him from sliding off. Assist as needed .Call light within reach and staff to answer promptly .Encourage resident to call for assistance if needed .Maintain safe environment, room free of clutter . A review of the SBAR (Situation, Background, Assessment, Recommendation- a communication tool between nurses and prescribers) Communication Form, dated [DATE], indicated an unwitnessed fall incident on [DATE], at 1:26 p.m. The Nursing Notes indicated, Resident sitting on patio in wheelchair. Resident tried to stand up and fell and hit his head. Resident A sustained abrasion on the right forehead and treatment was conducted at the facility. A review of the Care Plan, titled Unwitnessed fall, dated [DATE], indicated, Goal: Resident may have bilateral floor mats in place with bed in lowest position and call light and belongings within reach, to prevent falls X (for) 30 days .Interventions: Maintain safe environment, bed in lowest position, frequent checks on resident, call light and belongings all left within reach .Neuro checks X 72 hours . The care plan developed related to unwitnessed fall of Resident A dated [DATE], did not address the fall incident while the resident was out in the patio area. The Fall Risk Assessment, dated [DATE], was reviewed. The assessment indicated a score or 16 (high risk for fall). A review of the IDT (Interdisciplinary Team)-Incident Review, dated [DATE], indicated Resident A, has not had any prior incident of getting up unattended. It is noted that resident recently has been having changes in condition and there might be some increase in confusion associated with it. The IDT's Interventions/Recommendations indicated, Resident is currently on PT (physical therapy) for rehab (rehabilitation) and will continue to address safety and therapeutic exercises. Will also alert rehab staff not to allow resident to go to the patio unattended by staff outside . A review of the SBAR Communication Form, dated [DATE], indicated Resident A had another unwitnessed fall on [DATE], approximately 38 days after the first fall. The Nursing Notes documented, Resident was found on floor beside of wheelchair, with head on floor .Redness and swelling above right eyebrow, no other injuries noted .Resident sent out to (name of hospital) for evaluation due to falling and hitting head . A review of the IDT-Incident Review, dated [DATE], indicated Resident A had a fall on [DATE], at 12:10 p.m.The Description of the Incident documented, About 12:00pm, resident was up on his reclining wheelchair with the high back slightly tilted back, situated at the (sic) station 3 lobby with a couple of other residents .At 12:10pm, Staffer heard a thud as she was walking towards the nurse's station at station 3 .she found resident lying on the floor, face down, in front of his wheelchair . On [DATE], at 11:45 a.m., an observation was conducted in the areas where Resident A had the fall incidents. The patio area, where Resident A's first fall incident happened on [DATE], had cemented floor and located adjacent to the rehabilitation gym (formerly the activity room). The front lobby area, where Resident A's second fall incident happened on [DATE], had carpeted floor and located across Nurse Station. During a concurrent interview with the Director of Nursing (DON), the DON stated Resident A was taken out from his room on [DATE], at around 12:00 noon, to be brought to the Dining Room for the lunch feeding assistance program. He stated Resident A required feeding assistance from the staff, and the resident (Resident A) was sitting in his reclining wheelchair in front of Nurse Station 3 with two other residents, while waiting to be brought by the staff to the Dining Room. The DON stated he had a brief conversation with Resident A at the front lobby just before the fall incident happened. The DON stated there was a staff at Nurse Station 3, who had briefly left the nurse station to assist another resident in the hallway. The DON stated there was no staff in the nurse station to supervise the resident around the time of the fall. At around 12:10 p.m., as the staff was walking back to Nurse Station 3, the staff heard a noise, like a thud, and saw Resident A on the floor, face down, in front of his reclining wheelchair. Resident A was assessed by the licensed nurses and noted abrasion with redness and swelling above the resident's right eyebrow. A neuro check and vital signs were conducted, and it was within normal limits. Resident A was sent to the hospital for further evaluation and treatment. On [DATE], at 12:01 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was the charge nurse for Nurse Station 2 on [DATE], where Resident A's room was located. LVN 1 stated Resident A's functional status had declined rapidly in August to [DATE]. The resident's physician had indicated that Resident A's dementia was getting worse, and he became forgetful, combative, and noncompliant with his care and medications. LVN 1 stated Resident A was placed in front of Nurse Station 3 in the front lobby, around noontime on [DATE], while waiting to be brought to the Dining Room for the feeding assistance program. LVN 1 stated the staff in Nurse Station 3 would usually monitor residents that are placed in the front lobby, while waiting to be brought to the Dining Room. On [DATE], at 3:40 p.m., a telephone interview was conducted with the DON. The DON clarified the documented IDT's Intervention/Recommendation, dated [DATE], .not to allow resident to go to the patio unattended by staff . would include any areas within the facility building and not just the patio area. The DON stated Resident A was assessed as high risk for fall and a Falling Leaf flag was attached in his reclining wheelchair, so that the staff can frequently monitor the resident. The DON stated the staff at Nurse Station 3 had briefly left Resident A unattended, because she went to the hallway to assist another resident. As the staff was walking back to Nurse Station 3, it was at the same time when Resident A got up from his wheelchair without staff assistance, and fell to the floor. The staff heard a sound of a thud and found Resident A lying on the floor, face down, in front of his reclining wheelchair. The DON acknowledged there was a failure by the facility to implement the IDT's Intervention/Recommendation, not to allow the resident to be left unattended by the staff. A review of the history of present illness at the acute care hospital dated [DATE], indicated, .presents as fall from wheelchair. Patient does not participate in the interview as he in non verbal. There is no reported usage of blood thinners. He was able to move all four extremities. Pupils appear to be equal; however, the patient becomes combative when testing for pupil reactivity. CT (computed tomography-diagnostic imaging procedure) scan of the head shows 2mm (millimeter-unit of measurement) right frontal SDH with no midline shift or mass effect . A review of the acute care hospital record titled, deceased Discharge Summary, dated [DATE], indicated, .Preliminary cause of death: R (right) frontal SDH after fall . A review of Resident A's death certificate, indicated, .date of death ([DATE]) .Cause of Death. Subdural Hematoma .Blunt Force Head Trauma .Place of Injury .Rehabilitation Facility .Describe How injury Occurred .Unwitnessed Mechanical Fall . A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated [DATE], indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received necessary care and services to achieve his highest practicable physical, mental and psychosocial well-being when: 1. The facility failed to ensure licensed nursing staff promptly responded, assessed and provided immediate care to Resident 1 when it was reported Resident 1 was unresponsive. This failure resulted in a delay in medical treatment and a decline in physical and mental status, which required Resident 1 to be transferred to the acute hospital for medical treatment due to [CONDITION(S)] (low blood sugar). 2. The facility failed to obtain a physicians order for blood sugar monitoring for Resident 1 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 1's blood sugar not being managed and resulted in Resident 1 to experience an altered level of consciousness and [CONDITION(S)] (low blood sugar), which required Resident 1 to be transferred to the acute hospital for medical treatment. Findings: On August 26, 2020, at 9:55 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident involving Resident 1. During an interview with the Assistant Administrator (AA) on August 26, 2020, at 10:13 a.m., the AA stated Resident 1 was no longer in the facility. 1. On August 26, 2020, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NURSING CARE NOTES, dated August 2, 2020, at 10:45 a.m., indicated, .Noted resident to be unresponsive, cold, clammy. Performed sternal (area on mid chest) rub did not have any reaction from resident .BGL (blood glucose level) reading of 27 (normal range 70 -100) .call 911 to send to ED (Emergency Department) . On September 15, 2020, at 11:50 a.m., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 confirmed Resident 1 was assigned to her on August 2, 2020. CNA 1 stated at 7 a.m., she tried to wake up Resident 1 by calling (Resident 1's name) and shaking the resident. CNA 1 stated, He wouldn't wake up. CNA 1 stated another CNA came and tried to wake up Resident 1 but Resident 1 would not wake up. CNA 1 stated she reported to Licensed Vocational Nurse (LVN) 1 that Resident 1 would not wake up. CNA 1 stated at 9 a.m., on August 2, 2020, she went back to Resident 1 and tried to wake him up. CNA 1 stated, Resident 1 still would not wake up. CNA 1 stated she reported to LVN 1 that Resident 1 still would not wake up. CNA 1 stated the third time (no time stated), she asked LVN 1 if she had been in to see Resident 1 because he was still sleeping. CNA 1 stated a little while later she saw Resident 1 being sent out to the hospital. On September 17, 2020, at 1:42 p.m., a telephone interview was conducted with LVN 1. LVN 1 stated at 7 a.m., on August 2, 2020, she made her rounds and found Resident 1 sleeping and snoring a lot. LVN 1 stated CNA 1 reported to her that she tried to serve Resident 1 breakfast but Resident 1 would not wake up. LVN 1 stated she told CNA 1 to let Resident 1 rest because she assumed he got to sleep late. LVN 1 stated she did not go check or assess Resident 1 at that time. LVN 1 stated she went into Resident 1's room again at 9 a.m., on August 2, 2020, to give Resident 1 his routine medication. LVN 1 stated she tried to wake Resident 1 by calling his name and shaking Resident 1 but he did not wake up. LVN 1 stated she continued to give medications to other residents. LVN 1 stated she did not go back to Resident 1's room until 10:45 a.m. LVN 1 stated at 10:45 a.m., she went back to Resident 1 to give him his routine medication. LVN 1 stated Resident 1 was still very sleepy and would not wake up. LVN 1 stated she checked the MAR (Medication Administration Record) and noticed Resident 1 was on [MEDICATION(S)] (medication to lower blood sugar). LVN 1 stated she realized it might be a blood sugar problem and noticed there was no order for Resident 1 to have his blood sugar monitored. LVN 1 stated she reported Resident 1's condition to the Registered Nurse Supervisor (RN 1) at 10:45 a.m., on August 2, 2020, (three hours and 45 minutes after it was first reported to LVN 1 that Resident 1 would not wake up). LVN 1 stated when RN 1 checked Resident 1's blood sugar it was 21 (70-100 is the normal range level). LVN 1 stated she should have notified RN 1 when she could not wake Resident 1 at 9 a.m., so RN 1 could have checked Resident 1's blood sugar sooner. On September 17, 2020, at 2:25 p.m., a telephone interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the LVN's should notify the RN Supervisor immediately for any change in a resident's condition. On September 22, 2020, at 12:10 p.m., a telephone interview was conducted with RN 1. RN 1 stated on August 2, 2020, at 10:45 a.m., CNA 1 came to her and reported that Resident 1 was not waking up and did not eat breakfast. RN 1 stated CNA 1 told her she felt something was wrong. RN 1 stated she immediately went to assess Resident 1. RN 1 stated Resident 1's blood sugar was super low. RN 1 stated she called Resident 1's physician and Resident 1 was sent out to the hospital via emergency ambulance. A review of the acute hospital record dated August 2, 2020, indicated Resident 1 was admitted to the [NAME] (Direct Observation Unit - a unit that provides a second highest level of care) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy and procedure titled, Change in a Resident's Condition or Status, dated February 2014, was reviewed. The policy indicated: .Our facility shall promptly notify the .Attending Physician .of changes in the resident's medical/mental condition and or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician .when there has been .A significant change in the resident's physical/emotional/mental condition . 2. On August 26, 2020, at 10:20 a.m., A record review for Resident 1 and concurrent interview with the Director of Nursing (DON) was conducted. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NURSING CARE NOTES, dated August 2, 2020, at 10:45 a.m., indicated, .Noted resident to be unresponsive, cold, clammy. Performed sternal (area on mid chest) rub did not have any reaction from resident .BGL (blood glucose level) reading of 27 (normal range 70 -100) .call 911 to send to ED (Emergency Department) . The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] (medication to lower blood sugar) 10 mg (milligram) tab (tablet) po (by mouth) BID (twice a day) for DM (Diabetes Mellitus) . There was no documented evidence blood sugar monitoring was ordered for Resident 1 upon admission. The physician's History and Physical, dated August 1, 2020, indicated, .TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION .Monitor glucose (blood sugar) bid (twice a day) and PRN (as needed) . The PATIENT CARE PLAN: DIABETES MELLITUS, dated July 27, 2020, indicated, .Monitor BS (blood sugar) per MD (medical doctor) order. A review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence blood sugar monitoring was ordered or conducted for Resident 1 for the months of July 2020, and August 2020. The DON confirmed there was no blood sugar monitoring ordered for Resident 1. On August 26, 2020, at 11:55 a.m., an interview was conducted with the DON. The DON stated blood sugar monitoring should have been ordered for Resident 1 upon admission. The DON acknowledged the facility failed to monitor Resident 1's blood sugar level. The facility's policy and procedure titled, Diabetes - Clinical Protocol, dated October 2010, was reviewed. The policy indicated .For the resident on oral (by mouth) medication(s) who is well controlled: monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages) .For the resident receiving oral medication(s) who is poorly controlled: monitor blood glucose levels twice to four times daily as needed .The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management .The staff will incorporate such parameters into the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure the necessary equipment, care, and services to prevent accidents were provided for two residents reviewed (Residents 79 and 235) when: 1. One to one (1:1) supervision was not provided, for one of 10 residents reviewed for supervision (Resident 79), who required 1:1 supervision for all oral intake as ordered by the physician. This failure resulted in the potential for Resident 79 to aspirate (food entering the lungs) while eating, which could lead to choking, shortness of breath, difficulty breathing, and/or death. Due to this failure, the Administrator (AD) and Assistant Administrator (AA) 1 were verbally notified of an immediate jeopardy situation, on (MONTH) 11, 2019, at 3:25 p.m. The immediate jeopardy was removed in the presence of the AD and AA 1 at the facility on (MONTH) 14, 2019, at 5:10 p.m., after the facility's plan of action to remove the immediacy was reviewed and was confirmed to have been implemented; and, 2. For one of three sampled residents reviewed for falls (Resident 235), the facility failed to ensure interventions to prevent falls were identified and implemented to address Resident 235's repeated episodes of falls. In addition, the facility failed to provide a low bed and floor mats as recommended by the interdisciplinary team (IDT - a group of healthcare professionals who work together for the common goal of the resident). These failures contributed to Resident 235 sustaining four episodes of falls, with the last fall resulting in a laceration (cut) on Resident 235's face which required Resident 235 to be sent to the general acute care hospital. Findings: 1. On (MONTH) 11, 2019, at 12:45 p.m., Resident 79 was observed eating in his room by himself. Resident 79 was sitting up on his bed at approximately 70 degrees (semi-upright). Resident 79 was observed to be eating half of a sandwich. Resident 79 was observed to cough while he was eating the sandwich. A sheet of paper was observed posted on the wall by the top of Resident 79's bed. The paper was signed by the Speech Language Pathologist (SLP) on (MONTH) 7, 2019, with the following instructions: SWALLOWING PRECAUTIONS .1:1 supervision during oral intake .sit up with hips flexed at 90 degrees for all oral intake .sit up with hips flexed at 90 degrees for 30 minutes following meals .take small bites and sips .check for pocketing (holding food in the mouth without swallowing) .eat slowly . There was no staff observed supervising Resident 79 while he was eating. During a concurrent review of the diet card on Resident 79's meal tray, the diet card indicated, .Provide 1:1 supervision during all oral intake. During a concurrent interview, Resident 79 stated he choked on the food sometimes. On (MONTH) 11, 2019, at 1:15 p.m., Certified Nurse Assistant (CNA) 2 was observed to remove Resident 79's meal tray from the room. Resident 79 was observed eating his meal from 12:45 p.m. to 1:15 p.m. During that time, Resident 79 was observed eating and there was no staff present providing 1:1 supervision while he was eating. On (MONTH) 11, 2019, at 1:16 p.m., CNA 2 was interviewed. CNA 2 stated Resident 79 ate independently. On (MONTH) 11, 2019, at 1:25 p.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated Resident 79 was on swallowing precautions and required 1:1 supervision during meals due to Resident 79's episodes of choking. On (MONTH) 11, 2019, at 2:40 p.m., CNA 3 was interviewed. CNA 3 stated the licensed nurses discussed special instructions regarding residents with the CNAs during the start of shift huddle (meeting). CNA 3 stated he did not remember if Resident 79 was discussed during the huddle regarding requiring 1:1 supervision during meals. CNA 3 stated he was unable to recall if Resident 79 required 1:1 supervision during meals. CNA 3 stated residents with an order for [REDACTED]. On (MONTH) 11, 2019, at 3:02 p.m., LVN 4 was interviewed. LVN 4 stated he was not aware Resident 79 required 1:1 supervision during meals. LVN 4 stated the facility's process for residents with an order for [REDACTED]. During a concurrent review of Resident 79's MAR indicated [REDACTED]. On (MONTH) 11, 2019, at 5:46 p.m., Resident 79 was observed eating his dinner in his room. Resident 79 was observed coughing while eating the soup. In a concurrent interview, Resident 79 stated he coughed on the soup and did not want to eat the soup anymore. On (MONTH) 11, 2019, Resident 79's history and physical examination [REDACTED]. The document indicated Resident 79 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. The document indicated Resident 79 did not have the capacity to understand and make decisions. The facility document titled, Physician and Telephone Orders, dated (MONTH) 7, 2019, was reviewed. The document indicated, .safe swallow mgt (management), 1:1 supervision with all oral intake, sit 90 degrees from hip for all oral intake, sit 90 degrees from hip for 30 min (minutes) following meals, 1 tsp (teaspoon) per swallow, check for pocketing, eat slowly. The facility document titled, PATIENT CARE PLAN: NUTRITIONAL CARE PLAN, dated (MONTH) 4, (YEAR), was reviewed. There was no documented evidence the order for 1:1 supervision for all oral intake was included in Resident 79's care plan. The undated facility document titled, Dysphagia (difficulty swallowing) Evaluation, in Resident 79's record, completed by the SLP, was reviewed. The document indicated the following: .BARRIERS TO LEARNING .unable to follow multiple commands .not oriented to time . Recommended: 1:1 supervision by nursing .check mouth for pocketing .upright position (90 degrees) . head flexed slightly forward .remain upright for 30 min (minutes) after meal .small bites/sips . On (MONTH) 12, 2019, at 8:29 a.m., a concurrent interview and record review was conducted with the SLP. The SLP stated the undated Dysphagia Evaluation was completed on (MONTH) 7, 2019. The SLP stated Resident 79 had difficulty chewing and moving the food inside his mouth. The SLP stated Resident 79 required 1:1 supervision with all oral intake because Resident 79 would aspirate due to his short term memory loss. The SLP stated Resident 79 had a tendency to put too much food in his mouth at one time. The SLP stated Resident 79 needed to be on 1:1 supervision during meals to prompt him to eat slowly and take small bites of food and sips of liquid. The SLP stated the order for 1:1 supervision required a nursing staff member to be present at all times while Resident 79 was eating. The SLP further stated Resident 79 should have been provided 1:1 supervision during meals. On (MONTH) 13, 2019, at 11:05 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 79 had an order for [REDACTED]. The policy and procedure regarding 1:1 supervision during meals was requested from the DON. On (MONTH) 14, 2019, at 10:05 a.m., Resident 79's care plans were reviewed with the Minimum Data Set (MDS - an assessment tool) Nurse (MDSN). During a concurrent interview, the MDSN stated the care plan indicating the need for Resident 79 to have 1:1 supervision during meals should have been initiated on (MONTH) 7, 2019. On (MONTH) 14, 2019, at 1:05 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the facility did not have a policy and procedure for 1:1 supervision during meals. Due to the facility's failure to ensure 1:1 supervision was provided during the lunch meal on (MONTH) 11, 2019, for Resident 79, who was at risk for aspiration and was ordered by the physician to have 1:1 supervision during meals, the AD and AA 1 were verbally notified of an immediate jeopardy situation, on (MONTH) 11, 2019, at 3:25 p.m. The facility submitted a written plan of action to correct the immediate jeopardy situation on (MONTH) 11, 2019, at 8:17 p.m. The plan of action included the following: - A CNA or LVN would supervise Resident 79 during meals. The DON or designee ensured a staff member was present during dinner on (MONTH) 11, 2019; - The Dietary Supervisor and Nursing Department triple checked all dietary orders on (MONTH) 11, 2019, to ensure all orders in the dietary and medical records were current for residents with orders for 1:1 supervision; - Seven additional residents were identified with an order for [REDACTED]. - The CNA or LVN would provide 1:1 supervision during meals to the identified residents; and - The DON or designee in-serviced all nursing staff by (MONTH) 13, 2019, to include residents requiring 1:1 supervision, the requirement for the licensed nurse to sign off the order for 1:1 supervision on the MAR, and communicating new or existing orders during shift report between licensed nurses and CNAs. The immediate jeopardy was removed in the presence of the AD and AA 1 at the facility on (MONTH) 14, 2019, at 5:10 p.m., after the facility's plan of action to remove the immediacy was reviewed and verified to have been implemented. 2. On (MONTH) 11, 2019, at 10 a.m., Resident 235 was observed in a regular height bed, asleep. The right side of Resident 235's face, eye, eyebrow, head, and cheek were observed to have red, blue, and purple discoloration. Resident 235's right eye was partially closed and was observed to have swelling. There were no floor mats observed by his bed. On (MONTH) 11, 2019, at 12:12 p.m., an interview was conducted with Resident 235's Private Care Giver (PCG). The PCG stated the facility staff told her, Resident 235 fell last night after getting out of bed unassisted. The PCG stated Resident 235 was more groggy than usual today and not up to getting up to the dining room as he usually did. On (MONTH) 11, 2019, at 1:18 p.m., an interview was conducted with Resident 235's family member (FM). The FM stated Resident 235 had fallen four times in the past three weeks since coming to the facility. The FM stated all of the falls have been during the night. On (MONTH) 13, 2019, at 9:24 a.m., Resident 235 was observed lying on a regular height bed. On (MONTH) 13, 2019, Resident 235's record was reviewed. The record indicated Resident 235 had episodes of falls on the following dates: - (MONTH) 24, 2019. The document titled, Fall Scene Investigation Report, dated (MONTH) 24, 2019, was reviewed. The document indicated, .Patient (Resident 235) was found sitting on the bathroom floor by the toilet .IDT RECOMMENDATIONS .Re-educate patient to use call light, wait & (and) call for assistance, do frequent visual check, neurocheck (assessment for level of consciousness), & nsg (nursing) staff to anticipate patient's (Resident 235's) need . - (MONTH) 25, 2019. The document titled, NURSES' PROGRESS NOTES, dated (MONTH) 25, 2019, at 11:50 p.m., was reviewed. The document indicated, .Resident (Resident 235) yelled for help and CN (charge nurse) rushed towards resident (Resident 235) and found resident (Resident 235) on the floor in the hallway .he also complained about his back . The document titled, Fall Scene Investigation Report, dated (MONTH) 26, 2019, was reviewed. The document indicated, .IDT RECOMMENDATIONS .Re-educate patient (Resident 235) for use of call light. Frequent reminder not to get OOB (out of bed) without assistance. Reorient for use of call light . - (MONTH) 4, 2019. The document titled, Fall Scene Investigation Report, dated (MONTH) 4, 2019, was reviewed. The document indicated, .Patient (Resident 235) heard from hallway by CNA (certified nurse assistant) and charge nurse, pt (patient, Resident 235) was on floor mat by (bed number of roommate) Bed (sic) .IDT RECOMMENDATIONS .Floor mattress (mats) and low bed when available . - (MONTH) 10, 2019. The document titled, NURSES' PROGRESS NOTES, dated (MONTH) 10, 2019, at 11 p.m., was reviewed. The document indicated, .Resident (Resident 235) fall in the hallway at 9:50 p.m .bleeding from his forehead .Staff call 911 .Resident (Resident 235) was taken to (name of general acute care hospital) hospital by Paramedics by gurney . The general acute care hospital's document titled, Emergency Department Record, dated (MONTH) 10, 2019, at 10:29 p.m., was reviewed. The document indicated, .PHYSICIAN CHART .The location of the pain or injury involved (the) head and face. There are lacerations (cuts) located on the face .The laceration was 5 (five) centimeters in length .CT (computed tomography - a type of imaging) Head .Right frontal (the area of the forehead) soft tissue swelling and laceration .Repair of the laceration was completed . The document titled, Fall Scene Investigation Report, dated (MONTH) 11, 2019, was reviewed. The document indicated, .Resident (Resident 235) fall in the hallway at 9:50 p.m. Staff heard the thud and saw Resident (Resident 235) on the floor .Resident (Resident 235) was laying on his R (right) side and bleeding from his forehead .open area to R eyebrow about 2 1/2 (two and a half) inch (sic) and skin tear to R hand and 3rd (third) finger . On (MONTH) 13, (YEAR), Resident 235's record was reviewed. The document titled, FALL RISK ASSESSMENT, indicated, .Total score of 10 or above represents HIGH RISK . The document indicated Resident 235's fall risk scores were as follow: - (MONTH) 3, 2019 = 12; - (MONTH) 25, 2019 = 19; - (MONTH) 25, (YEAR) = 19; - (MONTH) 4, 2019 = 21; and - (MONTH) 10, 2019 = 21. There was no documented evidence interventions were identified and/or initiated to prevent Resident 235's falls on (MONTH) 24, 2019, and (MONTH) 25, 2019. On (MONTH) 13, 2019, at 10:23 a.m., an interview and concurrent review of Resident 235's record were conducted with the DON. The DON confirmed Resident 235 had four falls since his admission to the facility on (MONTH) 3, 2019 (four episodes of falls in a period of six weeks). The DON confirmed Resident 235 was assessed as being at high risk for falls on (MONTH) 3, 2019, (MONTH) 25, 2019, (MONTH) 4, 2019, and (MONTH) 10, 2019. The care plans titled, .Actual Fall, dated (MONTH) 24, 2019, and (MONTH) 25, 2019, were reviewed with the DON. The DON confirmed there were no new interventions or changes on Resident 235's care plans after the first fall on (MONTH) 24, 2019, and after the second fall on (MONTH) 25, 2019. The DON confirmed the only new intervention identified after the third fall, on (MONTH) 4, 2019, was to encourage Resident 235 to attend activities. The DON confirmed the care plans should have been updated with new interventions to minimize the risk of another fall and possible injury. The DON confirmed Resident 235 received floor mats on (MONTH) 12, 2019 (eight days after the IDT recommended them on (MONTH) 4, 2019). The DON confirmed Resident 235 did not have a low bed (nine days after the IDT recommended it on (MONTH) 4, 2019). When asked why the floor mats and the low bed were delayed, the DON stated, availability. The DON stated a low bed was not available for Resident 235. When asked when Resident 235 should have received the floor mats after the IDT recommended them, the DON stated, right away. When asked when Resident 235 should have received the low bed after the IDT recommended it, the DON stated it depended on the availability of the low bed. The facility policy and procedure titled, Falls - Clinical Protocol, revised (MONTH) 2013, was reviewed. The policy indicated, .Based on the .assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .

Based on observation, interview, and record review, the facility failed to ensure their infection control policy was implemented when: 1. Recommendations by the (County Public Health office) were not implemented to prevent the spread of the gastrointestinal illness (with symptoms including nausea, vomiting, and loose bowel movement); 2. One resident (Resident 19) was not placed on contact isolation after exhibiting symptoms of watery, loose bowel movement; 3. The facility continued to admit residents within one incubation period (48 - 72 hours is the time period between exposure to an illness and the appearance of symptoms) from the last case onset date; 4. Certified Nurse Assistant (CNA) 3 did not perform hand hygiene between handling dirty and clean diet trays; 5. Multiple staff were observed not donning the appropriate Personal Protective Equipment (PPE - gowns and gloves); and 6. Licensed Vocational Nurse (LVN) 1 was unable to state what a red isolation sign meant. These failures resulted in the delay in identification, treatment, and prevention of spread of infectious agents (virus and/or bacteria) in a vulnerable population of 106 residents. Findings: 1. On (MONTH) 11, (YEAR), at 10:09 a.m., an unannounced visit was made to the facility to investigate a facility reported incident regarding a gastrointestinal outbreak initially involving 11 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) and three staff members (Social Worker (SW), Certified Nurse Assistant (CNA) 1, and Licensed Vocational Nurse (LVN) 5) between (MONTH) 2 through (MONTH) 6, (YEAR). On (MONTH) 11, (YEAR), at 10:51 a.m., the Administrator (ADM) was interviewed. The ADM stated she reported the gastrointestinal outbreak to the (County Public Health office) and to the Department on (MONTH) 6, (YEAR). On (MONTH) 11, (YEAR), at 10:56 a.m., the Director of Staff Development/Infection Control Preventionist (DSD/ICP) was interviewed. The DSD/ICP stated the (County Public Health office) was notified on (MONTH) 6, (YEAR), of the gastrointestinal outbreak involving 11 residents and three staff members, which began on (MONTH) 2, (YEAR). On (MONTH) 11, (YEAR), beginning at 11:34 a.m., Residents 1 through 11 were interviewed. The residents stated they experienced symptoms of nausea, vomiting, and/or diarrhea, between (MONTH) 2 through (MONTH) 6, (YEAR). On (MONTH) 11, (YEAR), at 11:41 a.m., Resident 7 stated he had nausea and vomiting (MONTH) 3, (YEAR), which lasted about four days. Resident 7 stated he was on a rice diet, and looks forward to eating a regular diet again. On (MONTH) 14, (YEAR), at 12:17 p.m., the Administrator (ADM) was interviewed and stated she made contact with the (County Public Health office) on (MONTH) 6, (YEAR), and they directed her to: A. Begin contact precautions (used for organisms that can be spread by hand or contact) using the proper PPE; B. Begin inservicing all the staff members on infection precautions; C. Ensure medical consultation is done for symptomatic residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 17, and 18), and staff members; D. Restrict of new admissions; E. Report symptomatic residents and staff members as directed by the (County Public Health Nurse); F. Notify the 18 family members and responsible parties for symptomatic residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18); G. Begin education to residents and visitors of identifying signs and symptoms of nausea, vomiting, and diarrhea; and H. Assess all residents and employees by obtaining stool cultures for symptomatic bacteria and norovirus. On (MONTH) 14, (YEAR), at 12:38 p.m., the [MEDICATION NAME] Outbreak Log, was reviewed with the DSD/ICP. In a concurrent interview, the DSD/ICP stated the following residents and staff had gastrointestinal (GI - illnesses with symptoms including nausea, vomiting, and loose bowel movement) symptoms: - On (MONTH) 2, (YEAR), three residents (Residents 1, 2, and 3); - On (MONTH) 3, (YEAR), one resident (Resident 7); - On (MONTH) 4, (YEAR), two residents (Residents 4 and 5) and one staff (SW); - On (MONTH) 5, (YEAR), two residents (Residents 6 and 10) and two staff (CNA 1 and LVN 5); - On (MONTH) 6, (YEAR), three residents (Residents 8, 9, and 11); - On (MONTH) 7, (YEAR), four residents (Residents 12, 14, 15, and 17) and five staff (Medical Records (MED. REC), CNA 5, LVNs 6, 7, and 8); - On (MONTH) 8, (YEAR), one resident (Resident 18) and three staff (CNAs 6, 7, and 8); - (MONTH) 9, (YEAR), one resident (Resident 16) and two staff (CNAs 9 and 10); - (MONTH) 10, (YEAR), one resident (Resident 13) and two staff (CNAs 11 and 12); - (MONTH) 11, (YEAR), one staff (LVN 9); and - (MONTH) 12, (YEAR), one staff (CNA 13). Between (MONTH) 2 through (MONTH) 12, (YEAR), a total number of 35 cases consisting of 18 residents and 17 staff developed the symptoms of nausea, vomiting, and diarrhea. On (MONTH) 14, (YEAR), at 2:55 p.m., upon further observation and investigation of an increase in the total residents and staff involved the GI outbreak, and finding no evidence the facility implemented the (County Public Health office's) recommendations A to E, the Administrator was verbally informed an Immediate Jeopardy (IJ) was called for the facility. On (MONTH) 14, (YEAR), beginning at 4:44 p.m., interviews were conducted with the additional seven residents (Residents 12 through 18). Resident 12 indicated she had diarrhea, fever, and decreased appetite on (MONTH) 7, (YEAR). On (MONTH) 14, (YEAR), at 4:54 p.m., Resident 16 stated he had diarrhea on (MONTH) 9, (YEAR), which lasted until (MONTH) 10, (YEAR). On (MONTH) 14, (YEAR), at 4:59 p.m., Resident 15 stated he had nausea and vomiting along with diarrhea beginning (MONTH) 2, (YEAR), which subsided with medication, but came back on (MONTH) 10, (YEAR). The facility policy and procedure titled, Isolation - Initiating Transmission - Based Precautions, revised (MONTH) 2012, was reviewed. The policy indicated, .6. In an emergency, the Infection Preventionist, Administrator and/or Medical Director shall have the administrative authority, accountability, and responsibility to .a. Institute all actions necessary to control or prevent infections within the facility .b. Notify the health department of reportable diseases, as appropriate .c. Initiate isolation precautions .d. Obtain laboratory specimens .e. Restrict or ban admissions .f. Restrict or ban visitation .and g. Implement other measures as necessary to prevent and control infections within the facility . 2. On (MONTH) 15, (YEAR), Resident 19's record was reviewed. Resident 19 was admitted to the facility on (MONTH) 22, (YEAR). The Progress Record, dated (MONTH) 14, (YEAR), indicated, Resident 19 c/o (complained of) loose stool 4-5 times/ (per) day x (times) 2-3 days with VS (vital sign) of 96/56. The assessment included, Diarrhea R/O (rule out) [DIAGNOSES REDACTED] ([MEDICAL CONDITION] - type of bacteria that causes infectious diarrhea). Resident 19's Activities of Daily Living (ADL) tracking form for the month of (MONTH) (YEAR), indicated that Resident 19 had the following bowel movements on the following dates: - (MONTH) 9, (YEAR): six bowel movements; - (MONTH) 10, (YEAR): five bowel movements; - (MONTH) 11, (YEAR): four bowel movements; - (MONTH) 12, (YEAR): three bowel movements; and - (MONTH) 13, (YEAR): three bowel movements. On (MONTH) 15, (YEAR), at 12:54 p.m., Certified Nurse Assistant (CNA) 2 was interviewed. CNA 2 stated Resident 19 had one watery, loose bowel movement that day, (MONTH) 15, (YEAR). CNA 2 also stated Resident 19 was not on any type of isolation. On (MONTH) 15, (YEAR), at 1:04 p.m., the ADL tracking sheet form was reviewed with Licensed Vocational Nurse (LVN) 2. LVN 2 verified and stated Resident 19 had loose bowel movement on (MONTH) 9 to 13, (YEAR), based on the documentation on the ADL tracking form. On (MONTH) 15, (YEAR), at 4 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated Resident 19 was not on any kind of isolation that morning. RN 1 stated the facility only place a resident on isolation once they have a confirmed positive test result for [DIAGNOSES REDACTED]. On (MONTH) 15, (YEAR), at 4:15 p.m., LVN 3 was interviewed. LVN 3 stated she provided care for Resident 19 on (MONTH) 14, (YEAR). LVN 3 stated Resident 19 had loose bowel movement three times on (MONTH) 14, (YEAR), during her shift. LVN 3 stated Resident 19 was not placed on isolation (MONTH) 14, (YEAR). LVN 3 further stated they should have placed Resident 19 on contact isolation when Resident 19 had diarrhea and not wait for the results of lab tests. The facility policy and procedure titled, Isolation - Initiating Transmission - Based Precautions, revised (MONTH) 2012, was reviewed. The policy indicated, .In an emergency, the Infection Preventionist, Administrator and/or Medical Director shall have the administrative authority, accountability, and responsibility to .a. Institute all actions necessary to control or prevent infections within the facility .c. Initiate isolation precautions . 3. On (MONTH) 11, (YEAR), at 10:51 a.m., the Administrator (ADM) was interviewed. The ADM stated she reported the gastrointestinal outbreak to the (County Public Health office) and to the Department on (MONTH) 6, (YEAR). On (MONTH) 14, (YEAR), at 12:17 p.m., the Administrator (ADM) was interviewed and stated she made contact with the (County Public Health office) on (MONTH) 6, (YEAR), and they directed her to restrict new admissions. On (MONTH) 14, (YEAR), at 12:21 p.m., the Administrator (ADM) was interviewed. The ADM stated she began admitting residents to the facility on (MONTH) 12, (YEAR). On (MONTH) 14, (YEAR), at 2:30 p.m., a document was received from the ADM regarding the daily census from (MONTH) 6, (YEAR), to (MONTH) 13, (YEAR). - On (MONTH) 12, (YEAR), there were two admissions listed (Residents 22 and 25); and - On (MONTH) 13, (YEAR), there were three admissions listed (Residents 26, 27, and 28). The last case with gastrointestinal signs and symptoms was reported on (MONTH) 23, (YEAR), for one resident (Resident 28), and on (MONTH) 24, (YEAR), for one staff member. 4. On (MONTH) 15, (YEAR), at 12:32 p.m., Certified Nurse Assistant (CNA) 3 was observed removing a dietary tray from Resident 13's bedside table, and placing the tray on top of the resident's bedside commode. CNA 3 then took the dietary tray, walked out of the room, and placed the tray on the bottom rack of the dietary cart which was in the hallway. CNA 3 was observed to take a dietary tray from the dietary cart and brought it to Resident 21's room and placed the dietary tray onto Resident 21's bedside table. Resident 21 was on contact isolation. CNA 3 was not observed wearing gloves during the observation. CNA 3 did not perform hand hygiene throughout the observation. During a concurrent interview with CNA 3, she was asked if she wore gloves when entering the room, CNA 3 stated, No. CNA 3 stated she should have worn gloves when inside a resident's room who was on contact isolation while providing care. The facility policy and procedure titled, Handwashing/Hand Hygiene, revised (MONTH) 2012, was reviewed. The policy indicated, .All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors .Employees must wash their hands for at least fifteen (15) seconds .Before and after entering isolation precaution settings; .After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella and [DIAGNOSES REDACTED]icile (hand washing with soap and water) . 5a. On (MONTH) 15, (YEAR), Resident 19's record was reviewed. Resident 19 was admitted to the facility on (MONTH) 22, (YEAR). The Progress Record, dated (MONTH) 14, (YEAR), indicated, Resident 19 c/o (complained of) loose stool 4-5 times/ (per) day x (times) 2-3 days with VS (vital sign) of 96/56. The assessment included, Diarrhea R/O (rule out) [DIAGNOSES REDACTED] ([MEDICAL CONDITION] - type of bacteria that causes infectious diarrhea). Resident 19's Activities of Daily Living (ADL) tracking form for the month of (MONTH) (YEAR), indicated, Resident 19 had the following bowel movements on the following dates: - (MONTH) 9, (YEAR): six bowel movements - (MONTH) 10, (YEAR): five bowel movements - (MONTH) 11, (YEAR): four bowel movements - (MONTH) 12, (YEAR): three bowel movements - (MONTH) 13, (YEAR): three bowel movements On (MONTH) 15, (YEAR), at 12:54 p.m., CNA 2 was interviewed. CNA 2 stated Resident 19 had one watery, loose bowel movement that day. CNA 2 stated she was only wearing gloves when she cleaned Resident 19 after a bowel movement. CNA 2 stated she did not wear a gown when cleaning Resident 19 after a bowel movement. On (MONTH) 16, (YEAR), at 10:11 a.m., the DSD/ICP, ADM, and Director of Nurses (DON) were interviewed. The ADM stated the staff should be wearing gown and gloves when attending to residents who had GI symptoms. b. On (MONTH) 15, (YEAR), at 4:17 p.m., CNA 4 was observed inside Resident 23's room with a green isolation sign (a sign to visually remind staff to observe certain infection precautions when entering the room) located to the left of the doorway. CNA 4 was observed placing a blood pressure cuff (an instrument for measuring blood pressure) that wraps around Resident 23's arm. CNA 4 wore an isolation gown loosely, untied, and draped on her forearm. During a concurrent interview, CNA 4 stated she did not tie the gown. CNA 4 stated she should have tied the gown properly. c. On (MONTH) 16, (YEAR), at 9:42 a.m., two transportation staff (TS 1 and TS 2) were observed entering the room of Resident 24. TS 1 and TS 2 were not observed to don gown and gloves prior to entering the room. During a concurrent interview, TS 1 and TS 2 stated they did not wear gown and gloves. TS 1 and TS 2 stated they should have worn gown and gloves when entering Resident 24's room, who was on contact precautions (green sign) for [MEDICAL CONDITION]. d. On (MONTH) 17, (YEAR), at 4:04 p.m., an observation was made of two visitors in Resident 25's room. The visitors were wearing gowns only, and not wearing gloves. During a concurrent interview, the two visitors stated a Physical Therapy Aide (PTA) gave the two visitors gowns, but did not give them gloves. On (MONTH) 17, (YEAR), at 4:12 p.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated Resident 25 was positive for norovirus. On (MONTH) 17, (YEAR), at 4:26 p.m., the PTA was interviewed. The PTA stated he could not say if he told the two visitors to wear gloves. The PTA stated he should have told the visitors to wear gloves and gowns. The facility policy and procedure titled, Personal Protective Equipment - Using Gowns, revised (MONTH) 2010, was reviewed. The policy indicated, .To prevent soiling of clothing with infectious material .When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident . The facility policy and procedure titled, Personal Protective Equipment - Using Gloves, revised (MONTH) 2010, was reviewed. The policy indicated, .To prevent the spread of infection .Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces .Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . 6. On (MONTH) 15, (YEAR), at 12:30 p.m., Licensed Vocational Nurse (LVN) 1 was observed walking out of Residents 20 and Resident 21 room, where a green and red isolation signs (used to warn staff and visitors of the presence of an infection in the room) were on the wall. During a concurrent interview, LVN 1 stated both residents were on contact isolation for [MEDICAL CONDITION] (C. diff, is a specific kind of bacterial infection that causes mild to life-threatening forms of diarrhea). LVN 1 stated, Green is for [MEDICAL CONDITION], yellow is for urine, red .I'm unsure, . On (MONTH) 16, (YEAR), at 10:55 a.m., the copies of the contact isolation sign color codes were reviewed with the DSD/ICP. In a concurrent interview, the DSD/ICP stated red color sign indicated contact isolation for blood. The DSD/ICP stated the green color sign indicated contact isolation for GI and stool. On (MONTH) 17, (YEAR), at 4:26 p.m., the Assistant Administrator (ASST. ADM) was interviewed. The ASST. ADM stated she did not understand how the types of isolation corresponded with the colors on the cards. The facility policy and procedure titled, Isolation - Notices of Transmission-Based Precautions, revised (MONTH) 2010, was reviewed. The policy indicated, .When Transmission-Based Precautions are implemented, an appropriate sign (example: color coded) will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of Transmission-Based Precautions and to alert visitors to report to the nurse's station before entering the room .

Based on interview and record review, the facility failed to report an outbreak (two or more residents exhibiting symptoms of an illness) at the facility involving 11 of 106 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11), and three of 157 staff members (Social Worker (SW), Certified Nurse Assistant (CNA) 1, and Licensed Vocational Nurse (LVN) 5), to the California Department of Public Health (CDPH) within 24 hours as mandated by regulations. This failure resulted in the delay of the investigation by CDPH. The facility first learned about the infection on (MONTH) 2, (YEAR), and reported the infection to CDPH on (MONTH) 6, (YEAR), four days later. Findings: The California Code of Regulations (CCR), Title 22, Division 5, , specifies, Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. On (MONTH) 11, (YEAR), at 10:09 a.m., an unannounced visit was made to the facility to investigate a facility reported incident regarding a gastrointestinal (GI, illnesses with symptoms including nausea, vomiting, and loose bowel movement) outbreak involving 11 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11), and three staff members (SW, CNA 1, and LVN 5) between on (MONTH) 2 through (MONTH) 6, (YEAR). On (MONTH) 11, (YEAR), at 10:56 a.m., the [MEDICATION NAME] Outbreak Log, was reviewed with the Director of Staff Development/Infection Control Preventionist (DSD/ICP). In a concurrent interview, the DSD/ICP stated the following: - On (MONTH) 2, (YEAR), two residents (Residents 1 and 2) had vomiting and one resident (Resident 3) had diarrhea; - On (MONTH) 3, (YEAR), one resident (Resident 7) had diarrhea and vomiting; - On (MONTH) 4, (YEAR), one resident (Resident 4) had diarrhea, vomiting, and nausea, one resident (Resident 5) had vomiting and nausea, and one staff (SW) had diarrhea and vomiting; - On (MONTH) 5, (YEAR), one resident (Resident 6) had diarrhea and vomiting, one resident (Resident 10) had diarrhea, vomiting, and nausea, one staff (CNA 1) had diarrhea, vomiting, and nausea, and one staff (LVN 5) had vomiting and nausea; and - On (MONTH) 6, (YEAR), one resident (Resident 8) had vomiting, one resident (Resident 9) had diarrhea, and one (Resident 11) had diarrhea and vomiting. The DSD/ICP stated she was unaware of the need to notify CDPH of the outbreak. On (MONTH) 26, (YEAR), at 3:34 p.m., the Assistant Administrator (ASST. ADM) was interviewed. The ASST. ADM stated reporting of infection outbreaks should be completed within 24 hours of the identification of the outbreak. On (MONTH) 26, (YEAR), at 3:37 p.m., The Director of Nurses (DON) was interviewed. The DON stated reporting of infection outbreak to CDPH should be completed within 24 hours of when the outbreak was identified. The facility policy and procedure titled, Unusual Occurrence Reporting, revised (MONTH) 2007, was reviewed. The policy indicated, .Our facility will report the following events to appropriate agencies .An outbreak of any communicable disease .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest level practicable physical, mental, and psychosocial well-being for three of 21 sampled residents (Residents 69, 93, and 37). 1. For Resident 69, the facility failed to provide the necessary pain management, which included assessment and treatment during the wound care treatment on June 17, 2015. This failure resulted in the resident to yell-out in response to pain and/or discomfort, which included facial grimacing; 2. The facility failed to consistently communicate with the [MEDICAL TREATMENT] center and monitor for post [MEDICAL TREATMENT] complications for Resident 93. This failure had the potential to result in undetected complications from the [MEDICAL TREATMENT] treatment, subsequently resulting in the delay of necessary treatment; and 3. For Resident 37, the facility failed to maintain communications with the contracted hospice agency, concerning hospice care and hospice staff visits. This failure had the potential for Resident 37 not to receive coordinated care to meet her needs. Findings: 1. On June 17, 2015, at 3:20 p.m., Minimum Data Set Nurse (MDS Nurse (MDS 1); also a Licensed Vocational Nurse (LVN)) and LVN 3 (Wound/Treatment Nurse) were observed to provide wound care treatment on Resident 69's wound located on the sacral (tail bone) area, using a [DEVICE] ([DEVICE] is an equipment used to promote wound healing). Resident 69 was observed lying on her left side, with the sacral wound already exposed (old dressing had already been removed). LVN 3 explained to Resident 69 that she was going to change the resident's sacral wound dressing. Resident 69 responded, No .Tomorrow . In addition, Resident 69 was observed pushing MDS 1 away; pointing and making hand gestures at MDS 1 to go across the room. The resident stated, I want you far away . MDS 1 stated, Oh, okay .Maybe we should stop and do it later . LVN 3 then stated, .But it is open (referring to the wound) . LVN 3 then suggested to MDS 1 to get another LVN (LVN 1), because Resident 69 likes LVN 1. MDS 1 left the room to get LVN 1 to help MDS 1. (During all this time, the resident remained laying on her left side.) In a concurrent observation, LVN 1 came in the room to assist LVN 3 with the wound care treatment. LVN 1 proceeded to speak with Resident 69 and stated, It's not that bad . Then, LVN 3 and LVN 1 attempted to turn the resident to the right side (when the resident was already on her left side and the wound exposed).The resident then started pointing making hand gestures at LVN 1 to go across the room (the same gestures observed with MDS 1). The resident again stated, I want you far away . LVN 3 and LVN 1 proceeded to turn and reposition Resident 69 to her right side. The resident was then observed yelling-out, with facial grimacing and tears on her face. The resident yelled-out, I can't; Sorry; No. LVN 3 and LVN 1 did not pause and continued to turn the resident to her right side when the resident yelled-out. As soon as Resident 69 was turned to the right side, Resident 69 stopped yelling-out. LVN 3 proceeded with the wound care treatment. While applying the wound care treatment, LVN 3 asked Resident 69 if she was okay. Resident 69 nodded her head up and down. LVN 3 stated to Resident 69, You got it. On June 17, 2015, at 4:35 p.m., Certified Nursing Assistant (CNA) 1 (assigned to Resident 69) was interviewed concerning Resident 69. CNA 1 stated Resident 69 only yelled, grimaced, and, moaned, when she was uncomfortable. CNA 1 stated the resident complained of pain from her sacral wound. On June 17, 2015, at 4:42 p.m., Resident 69's record was reviewed with LVN 4. LVN 4 stated the Tylenol was ordered every 8 hours as a routine medication and [MEDICATION NAME] was ordered every 8 hours as needed for severe pain. The Medication Administration Record [REDACTED]. In a concurrent interview with LVN 4, he stated Resident 69 usually yelled out when the resident experienced severe pain and/or discomfort. During the discussion of Resident 69's wound care treatment observed on June 17, 2015, at 3:20 p.m., LVN 4 stated, when Resident 69 yelled out and moaned, the physician should have been called to try to obtain additional pain medication orders to manage the resident's pain and/or discomfort. He also stated the Tylenol given at 2 p.m. (one hour and 20 minutes prior to the wound care treatment) was not sufficient for Resident 69, if she was yelling and moaning when she was being treated and turned. On June 15, 2015, Resident 69's record was reviewed. Resident 69 was admitted on [DATE], with [DIAGNOSES REDACTED]. The latest Minimum Data Set (MDS - an assessment tool), dated May 20, 2015, was reviewed. The record indicated: *The resident did not have alteration in mood and/or behaviors, including refusing treatment, yelling, or screaming; *The resident was totally dependent on bed mobility and needed one person physical assist; *The resident manifested pain with non-verbal sounds, vocal complaints of pain, and facial expressions; and *One Stage 4 pressure ulcer (does not indicate the location; a Stage 4 pressure ulcer is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling .Category/Stage 4 ulcers can extend into muscle .Exposed bone/muscle is visible or directly palpable). The Long Term Care Plan (dated January 30, 2015), for Alteration in communication related to impaired ability to make self understood or to understand others . was reviewed. The record indicated, Approach/Plan .Ask simple 'yes' or 'no' questions when necessary .Allow resident sufficient time to answer questions .Speak slowly and clearly .Provide calm and unhurried manner/environment . The Long Term Care Plan (dated May 15, 2015), for Alteration in comfort r/t (related to) Pain, was reviewed. The record indicated, Approach/Plan .Report sign and symptoms of pain as evidence by flinching, moaning or or (sic) crying .Position for comfort and report for c/o (complain of) pain .Enc. (Encourage) res. (resident) to report any pain . On June 17, 2015, at 4:50 p.m., an interview with LVN 1 was conducted. LVN 1 stated Resident 69 was usually happy and exhibited no behavior problems such as refusing treatment and yelling. LVN 1 stated when Resident 69 had discomfort and/or pain, the resident would yell-out and would show facial grimacing. LVN 1 further stated they (LVNs) should have called the physician if the pain medication (Tylenol and [MEDICATION NAME]) were not effective. LVN 1 stated, when the resident said No, the wound care should have been stopped. On June 17, 2015, at 4:55 p.m., an interview with LVN 3 was conducted. LVN 3 stated Resident 69 was able to respond to simple questions by answering yes or no. LVN 3 stated she should have stopped the treatment after Resident 69 refused (when the resident said, No.) On June 18, 2015, at 9:35 a.m., an interview with MDS 1 was conducted. Discussed with MDS 1 the wound care treatment observed on June 17, 2015, at 3:20 p.m. MDS 1 stated Resident 69's refusal to the wound treatment was possibly due to pain. MDS 1 stated, I (would have) stopped and come back in 15 minutes . On June 18, 2015, at 10:35 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated during the wound care treatment for [REDACTED]. The DON stated, with Resident 69 yelling out, moaning, and refusing treatment during the wound care, the licensed nurses should have notified her (DON) or called the physician for additional pain medication orders before proceeding with the wound care treatment. On June 18, 2015, the facility policy and procedure titled, Pain Assessment and Management (revised 2010), was reviewed. The document indicated: Purpose: 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 goal and needs and that address the underlying causes of pain . Steps in the Procedure .Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain . Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc . 2. Ask the resident if he/she is experiencing pain . 3. Review the Medication Administration Record [REDACTED]. Monitoring and Modifying Approaches: 3. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools . 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated . 2. On June 17, 2015, at 10:25 a.m., a record review was conducted for Resident 93. Resident 93 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 93 had orders to receive [MEDICAL TREATMENT] (treatment to remove waste products from blood) three times a week. The [MEDICAL TREATMENT] Communication Form (form used to document and exchange information between the skilled nursing facility and the [MEDICAL TREATMENT] agency) was not found for May 9, May 19, June 6, or June 13, 2015. For Resident 93 there was no documentation post [MEDICAL TREATMENT] to indicate the site had been checked for bleeding or infection for ten of 17 dates, (May 15, May 16, May 19, May 21, May 26, May 28, May 30, June 6, June 13, and June 16, 2015). For Resident 93's entire admission of 40 days (May 6, 2015-June 16, 2015), there were 27 dates with no documentation that his right chest shunt (access site) for [MEDICAL TREATMENT] had been checked for bleeding, infection, or other signs of complication. On June 17, 2015, at 10:25 a.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated there should be charting every time Resident 93 left the building for [MEDICAL TREATMENT] and when he came back. LVN 1 stated there should always be a [MEDICAL TREATMENT] Communication Form for each time Resident 93 went to [MEDICAL TREATMENT] treatment. LVN 1 could not locate the [MEDICAL TREATMENT] Communication Form for May 9, May 19, June 6, or June 13, 2015. LVN 1 stated she would also expect to see a notation regarding the [MEDICAL TREATMENT] in the nurses notes after every [MEDICAL TREATMENT] treatment. On June 17, 2015, at 12 noon, an interview was conducted with the Director of Nurses (DON). The DON stated she would expect to see documentation after each [MEDICAL TREATMENT] treatment regarding vital signs and observation of the access site for [MEDICAL TREATMENT]. The DON stated there should be a [MEDICAL TREATMENT] Communication Form for each day a resident has [MEDICAL TREATMENT]. On June 17, 2015, at 3:15 p.m., an interview was conducted with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated he would check the vital signs and check the [MEDICAL TREATMENT] when a resident returned from [MEDICAL TREATMENT] and would document that information in the nurses notes. LVN 2 stated he hadn't received any specific training regarding [MEDICAL TREATMENT] patients. On June 17, 2015, the facility policy and procedure (P&P) dated October 2010, and titled [MEDICAL TREATMENT] Access Care was reviewed. The P&P indicated, The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of the catheter, 2. Condition of the dressing (interventions if needed), 3. If [MEDICAL TREATMENT] was done during the shift, 4. Any part of the report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given, and Observation post [MEDICAL TREATMENT]. 3. On June 17, 2015, Resident 37's record was reviewed. Resident 37's [DIAGNOSES REDACTED]. Resident 37 was under hospice care (end of life care). The hospice plan of care for hospice services included skilled nurse, home health aide, social worker and spiritual visits. Resident 37's record did not have a calendar that indicated when hospice personnel were to conduct visits and what services (skilled nurse, home health aide, social worker, etc.) would be provided during the visits. On June 17, 2015, Licensed Vocational Nurse 6 (LVN 6) was interviewed. LVN 6 stated he did not know when hospice staff was coming, because there was no calendar in the chart. LVN 6 further stated there should be a calendar in Resident 37's record, for the facility to be able to coordinate care for Resident 37. Review of the SKILLED NURSING FACILITY CONTRACT AGREEMENT effective September 1, 2013, indicated, .Hospice Agency and Facility will communicate pertinent information with each other .to ensure that the needs of each hospice patient are met .