Every finding on record at Yuba City Post Acute

Based on interview and record review, the facility failed to ensure adequate supervision and use of safety devises during transport for one of three sample residents (Resident 1), when Resident 1 was transported to a medical appointment without the use of a lap seat belt.This failure had the potential to result in falls or injuries during transport and caused Resident 1 to feel afraid and unsafe.Findings:During a review of the facility's policy and procedure titled, Abuse Prevention Program, undated, indicated residents have the right to be free from abuse and neglect. The policy further states that the facility will implement measures including staff training, prevention policies, and ongoing identification and assessment of potential abuse to ensure resident protection.During a review of Resident 1's medical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that include difficulty in walking, thrombocytopenia (a condition characterized by abnormally low platelet levels), myelodysplastic syndrome (a bone marrow disorder),and diabetes (high blood sugar).During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 2/27/26, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14 out of 15, indicating their cognition was not impaired.During an interview on 4/1/26 at 2:45 pm, Resident 1 stated that on 3/27/26, while being transported in the facility van in his wheelchair to a medical appointment, the driver secured the wheelchair with straps but did not apply a lap seat belt. Resident 1 stated he alerted staff that the lap belt was not in place but was told it was not needed. Resident 1 stated he does not use any type of securement device in his wheelchair and reported that during transport he held onto his wheelchair because he feared he might fall or be projected forward. Resident 1 stated he felt unsafe and afraid and would not want to be transported by that driver again.During an interview on 4/1/26 at 3:15 pm with the Facility Driver (FD), FD stated that wheelchair transport requires use of a four point securement system, application of wheelchair brakes, and placement of a lap belt across the resident. The driver stated that the lap belt is required to ensure safety, as without it only the wheelchair is secured and not the resident.During an interview on 4/1/26 at 4 pm with the Director of Staff Development (DSD), the DSD stated that Resident 1 was transported to an appointment without a lap belt. The DSD stated the wheelchair was secured but the lap belt was not used. The DSD reported the receiving facility notified them the resident was not properly secured. The DSD stated an alternate driver had been used that day and that this may have contributed to the oversight. The DSD stated the expectation is that the residents are safely secured prior to transport including the use of a lap belt to prevent falls and injury.

Based on observation, interview, and record review the facility failed to ensure the medication error rate was below 5% for 2 of 6 sampled residents (Resident 40 and Resident 4) when: 1. Registered Nurse (RN) B did not administer Resident 4's oral inhalation medication as ordered by prescriber.2. RN G administered Resident 44's medication not in accordance with the standards of practice.As a result, 2 errors were identified out of 26 opportunities for error during the observation of medication administration; the facility medication error was 7.69%.Findings:1. During an observation on 9/16/25 at 9:24 am, RN B was observed to prepare and administer Resident 4's morning medications which did not include a multidose inhaler, fluticasone furoate, umeclidinium, and vilanterol inhalation powder (combination of 3 medications used to treat shortness of breath), for oral inhalation use.During a reconciliation of the observation of medication administration with Resident 4's Physician Orders, indicated an order, dated 6/11/25, for fluticasone furoate, umeclidinium, and vilanterol inhalation powder for oral inhalation to be administered 1 puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Resident 4's Medication Administration Record (MAR) indicated a dose of Resident 4's oral inhalation medication was marked given on 9/16/25 at 9 am.During an interview on 9/16/25 at 11:25 am, with RN B, RN B stated, I forgot to give that inhaler. RN B acknowledged that she had not given the medication even though the MAR was marked given.During an interview on 9/18/25 at 11:30 am, with the Director of Nursing (DON), the DON stated, she expected the nurses to follow the Physician Orders. The nurse should have given resident's oral inhalation in the morning as prescribed.During a review of the policy and procedure (P&P) titled, Administering Medications, reviewed October 2024, the P&P indicated, medications are administered in accordance with prescriber orders, and are administered within one hour of their prescribed time, unless otherwise specified.2. During an observation on 9/16/25 at 11:59 am, RN G was observed to prepare and administer Resident 44's noon insulin, medication used to treat high blood sugar levels. RN G took out a vial of insulin from the medication cart, shook it vigorously for few seconds, withdrew two units of insulin lispro, and administered two units to Resident 44.During a reconciliation of the observation of medication administration with Resident 44's Physician Orders, indicated an order, dated 9/15/25, Inject as per sliding scale: if 0 - 150 = 0 units;151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 -400 = 10 units, subcutaneously before meals for Diabetes Mellitus II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels).A review of Resident 44's MAR indicated a dose of two units of lispro insulin was administered on 9/16/26 at 12:00 pm.During an interview on 9/16/25 at 3:20 pm, with RN G, RN G stated she shook the insulin vial when she was preparing resident 40's insulin. RN G acknowledged the insulin was already dissolved and she didn't know why she felt the need to shake the vial prior to drawing up insulin. According to an online publication by Mayo Clinic, Mayo foundation for medical information and research (a non-profit, American Academic center focused on integrated healthcare, education, and research), titled proper use of insulin lispro, last updated August 2025, indicated do not shake the vial.During an interview on 9/18/25 at 11:30 am, with the DON, the DON stated she expects the nurses to administer all medications according to the professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly as specified by the manufacturers when the temperature of a medication refrigerator was out of range below the freezing point.This failure resulted in liquid medications to crystalize and become ineffective.Findings:During a review of facility's policy and procedure (P&P) titled, Storage of Medications, reviewed October 2024, the P&P indicated, drugs and biologicals are stored in a safe, secure orderly manner including drugs being stored in locked compartments under proper temperature and light. The policy did not include the proper temperature range for the pharmaceutical items stored in the refrigerator.During a concurrent observation and interview with the Director of Nursing (DON) on 9/16/25 at 12:24 pm, the temperature of the medication refrigerator in the medication room was 29 F (degree Fahrenheit: unit of measurement). There were multiple medications in the refrigerator including insulin (medication used to treat high sugar level) vials. There was visible ice to the back wall of the refrigerator. The DON verified the refrigerator temperature was 29 F and one insulin vial presenting with crystalline almost frozen appearance present in the refrigerator. The DON stated the normal temperature range for the medication refrigerator was 36 F to 46 F. A review of insulin vial's product label, the label indicated, store refrigerated at 36 F to 46 F. Do not freeze.

Based on interview and record review, the facility failed to ensure the Medical Director (MD) and the resident was notified of a change in condition for one of three sampled residents (Resident 35) when Licensed Vocational Nurse (LN) J discovered exposed bone and a surgical screw in Resident 35's right lateral ankle wound . This failure had the potential to put Resident 35 at risk of infection and a decrease in quality of care.Findings:During a record review of facility policy titled Change in a Resident's Condition or Status dated October 2024, indicated The nurse will notify the attending physician when there has been a.significant change in the resident's condition.specific instruction to notify the physician of changes in the resident's condition. Facility policy further indicated A 'significant change' of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.impacts more than one area of the resident's health status. Facility policy also indicated A nurse or healthcare provider will inform the resident of any changes in his/her medical care.During a record review of LN J's job description titled Job Description: Licensed Professional Nurse/Licensed Vocational Nurse (LPN/LVN) dated 2/2024, indicated to Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition. LN J signed this document on 10/1/21.During a record review of facility job description titled Job Description: Treatment Nurse Registered Nurse (RN)/LVN/LPN dated 10/2016, indicated to Accurately observe wounds and pressure sores with prompt notification of physicians of lack of progress in healing or deterioration with the current treatment and or signs/symptoms of infection. Facility job description further indicated to Notify family and attending physician of significant treatments related issues regarding their residents including sudden and/or marked adverse changes in skin condition or wounds; report significant findings or changes in condition and potential concerns to RN Supervisor and/or Director of Nursing (DON).During a record review of Resident 35's admission record, she was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right lower leg (when there is a break in one or more bones of the right lower leg), disruption of wound (a condition where a previously closed wound reopens or separates), and dysphagia (a language disorder that affects a person's ability to understand, speak, read, or write).During a record review of facility document titled Wound Evaluation and Treatment dated 9/3/25 12:41 pm, indicated LN J evaluated Resident 35's wound and documented there was bone exposed on the right lateral ankle. Facility document indicated, Upon weekly skin assessment surgical incision on right lateral ankle is noted with 8-centimeter (cm) x 2 cm with opening in bottom of incision around 2.2 cm x 1.8 cm x 0.2 cm. Incision deteriorated and the bone is exposed on ankle. Continue treatment order to apply xeroform and wrap with kerlix wrap.During a record review of progress note titled eINTERACT Summary for Providers (SBAR - a tool used for communication between direct care staff and the resident's provider) dated 9/5/25 2:58 pm, indicated Nursing observations, evaluation, and recommendations are: .Resident noted with open wound on right lateral ankle.resident noted with exposed metal hardware on right lateral ankle about 2.5 cm x 2 cm x 0.3 cm. No drainage noted and metal hardware is exposed. Called orthopedic office and talked with a medical assistant. She stated Physicians' Assistant (PA) wrote down an order in chart that if metal hardware exposed to send resident out to emergency room for further evaluation. MD was in [facility] and made aware.During a concurrent observation and interview with Resident 35 on 9/18/25 at 10:47 am, Resident 35 stated LN J did not tell her that there was exposed bone on her right lateral ankle on 9/3/25. Resident 35 stated LN J told her she needed to go to a local acute care hospital on 9/5/25 for right lateral ankle wound evaluation and treatment because there was a screw sticking out.During an interview on 9/18/25 at 12:30 pm, with MD, MD stated she expected staff to notify her immediately of Resident 35's change in condition. MD stated she was not aware LN J documented the discovery of exposed bone and orthopedic screw during the wound evaluation and treatment on 9/3/25. MD stated she expected to be notified on 9/3/25. MD confirmed LN J did not notify her of Resident 35's wound changes of condition until two days later on 9/5/25.During an interview on 9/18/25 at 1:11 pm, with LN J, LN J confirmed she documented exposed bone on 9/3/25. LN J stated she called Resident 35's orthopedist's office on 9/3/25, but it was late in the day, and no one answered. LN J confirmed she should have contacted MD immediately. LN J confirmed she did not notify the DON and should have. LN J stated she will notify MD immediately for future reference.During an interview on 9/17/25 at 9:30 am, with DON, DON confirmed LN J documented exposed bone on Resident 35's right lateral ankle on 9/3/25. DON stated LN J should have notified herself and the MD immediately. DON confirmed LN J did not notify MD until two days later on 9/5/25. DON confirmed 9/5/25 was when Resident 35 was sent to a local acute care hospital for wound evaluation per MD order. DON confirmed LN J did not follow facility policy for notification of change in condition.

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans (a detailed, patient-centered document that summarizes a patient's medical, functional, and psychosocial needs and goals, outlining the interventions and resources needed to achieve them) for two of 18 residents (Resident 33 and 9) who's care plans were reviewed, when: 1. Resident 33 had a deep tissue injury (DTI, localized damage to the skin and tissue caused by pressure on an area for a long time) and there was no care plan developed.2. Resident 9 was noted to be missing teeth on admission and there was no oral/dental care plan developed. These failures had the potential to decrease the physical, psychosocial, and emotional well being of Residents 33 and 9.Findings: 1. A review of the facility's policy titled, Care Plans, Comprehensive, reviewed August 2024, indicated the policy statement is A comprehensive care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further indicated at paragraph number 5, subset-e, The comprehensive care plan will: Incorporate identified problem areas. A review of Resident 33's clinical record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included broken right ankle, and cirrhosis of the liver (a liver disease that destroys and scars liver tissue, which occurs over time and prevents the liver from functioning properly). Resident 33 was capable of making his own healthcare decisions. A review of the admission Minimum Data Set (MDS, a resident assessment tool), for Resident 33 dated 8/11/25, indicated that Resident 33 had no cognitive deficit, with a Brief Interview for Mental status (BIMS, assess a person's ability to think, reason and remember) score of 15 out of 15. During a concurrent interview and observation on 9/16/25 at 3:31 am, Resident 33 stated that he had fallen at home and broke his ankle. He stated that he had a cast and that the cast was recently replaced with a boot. It was observed that the resident had a Controlled Ankle Motion boot (CAM boot - a device designed to immobilize and support the ankle joint after an injury or surgery) on his right foot. During an interview on 9/17/25 at 1:11 pm, Resident 33 stated that he had a 'heel issue' on his right heel that was found the day his cast came off, which he thinks was on 9/9/25. During a concurrent interview with Licensed Nurse (LN) M and observation on 9/17/25 at 1:35 pm, LN M was observed doing wound care to Resident 33's right heel DTI. LN M confirmed that Resident 33 had a deep tissue injury on the right heel. During a record review of Resident 33's Care Plans initiated on 8/11/25, with a target date of 10/1/25 (a review of the individual care plans for a resident), the record indicated a Care Plan had not been initiated for Resident 33's DTI on the right heel. During a concurrent interview and record review on 9/18/25 at 12:42 pm, with the Director of Nursing (DON), Resident 33's care plan was reviewed. The DON confirmed that a Care Plan for Resident 33's DTI was not initiated. My expectations of the wound care nurse is to note changes in skin and to initiate Care Plans. The DON further stated that the wound care nurses did not follow policy and procedure for wound care, nor were professional standards demonstrated due to the failure to follow proper protocol for wound care, which included appropriate documentation. 2. A review of the facility's policy titled Care Plans, Comprehensive reviewed August 2024, indicated A comprehensive care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 6. Areas of concern that are identified during the resident assessment will be evaluated. 7. Identifying problem areas and their causes and developing interventions that meet resident needs. During an interview on 9/16/25 at 3:29 pm, Resident 9 stated that she only had a few bottom teeth and that she needed dentures. A review of Resident 9's admission record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a lung disease), depression, and stroke (when blood supply was blocked to an area of the brain causing cell death) which caused left sided weakness and paralysis. Resident 9 was able to make her own health care decisions. A review of Resident 9's MDS dated [DATE], Section C indicated BIMS assessment was performed. Resident 9's BIMS score was 14 (from a range 0-15), indicating she was able to reason, think and remember. Section L, Oral/Dental Status, indicated Resident 9 had no natural teeth in areas of her mouth. Section V (triggered care areas in which a care plan should be developed) indicated that the Oral/Dental care area was triggered. During a concurrent interview with the Social Service Director (SSD) and record review on 9/17/25 at 2:41 pm, Resident 9's admission Comprehensive Care Plan was reviewed. SSD stated that she had not developed an Oral/Dental Care Plan for Resident 9 and she should have due to the fact that Resident 9 only had bottom teeth and no other teeth. SSD stated We usually put in a care plan to watch for sores, and the goal is to be free from complications

Based on observation, interview, and record review, the facility failed to revise a comprehensive care plan (a detailed, patient-centered document that summarizes a patient's medical, functional, and psychosocial needs and goals, outlining the interventions and resources needed to achieve them) for one of seven residents (Resident 33) when Resident 33 had a medical equipment change from a cast to a Controlled Ankle Motion boot (CAM boot - a device designed to immobilize and support the ankle joint after an injury or surgery) on the right foot.This failure had the potential to decrease the physical, psychosocial, and emotional wellbeing of Resident 33.Findings:A review of the facility's policy titled, Care Plans, Comprehensive, reviewed August 2024, indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.A review of Resident 33's clinical record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included broken right ankle, and cirrhosis of the liver (a liver disease that destroys and scars liver tissue, which occurs over time and prevents the liver from functioning properly). Resident 33 was capable of making his own healthcare decisions.A review of the admission Minimum Data Set (MDS, a resident assessment tool), for Resident 33 dated 8/11/25, indicated that Resident 33 had no cognitive deficit, with a Brief Interview for Mental status (BIMS, assess a person's ability to think, reason and remember) score of 15 out of 15.During a concurrent observation and interview on 9/16/25 at 3:31 pm, Resident 33 stated that he had a cast and that the cast was recently replaced with a boot around 9/9/25. It was observed that Resident 33 had a CAM boot on his right foot.During a record review of Resident 33's Care Plans initiated on 8/11/25, indicated that the Care Plan was not revised to reflect the change from a cast to a CAM boot on Resident 33's right foot.During a concurrent interview and record review on 9/18/25 at 12:42 pm, with the Director of Nursing (DON), Resident 33's care plan was reviewed. The DON confirmed that Resident 33's Care Plan for the right foot cast was not revised to reflect the implementation of the CAM boot. My expectations of the wound care nurse were to update Care Plans.

Based on interview and record review the facility failed to ensure one of two residents sampled (Resident 58) received services that met professional standards when Resident 58 did not have episodes of diarrhea documented in their medical record to provide a full description of a change of condition for Resident 58. This failure had the potential for Resident 58 to not receive proper care for her diarrhea which could cause decline in physical, mental and psychosocial health. Findings: A review of the facility's policy titled Change in a Resident's Condition or Status revised October 2024, indicated 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg, muscle weakness, diabetes (high sugar in the blood), depression, anxiety and heart failure. Resident 58 made her own health care decisions. During an interview with Resident 58 on 9/16/25 at 10:01 am, Resident 58 was lying in bed and complaining of a sore bottom and stated I am having trouble with my bowels and am having lots of diarrhea today. During a concurrent interview with Licensed Nurse (LN) M and record review on 9/17/25 at 9:31 am, Resident 58's nursing progress notes were reviewed. LN M said there was a progress note on 9/16/25 at 11:48 am, which noted NP (Family Nurse Practitioner, FNP) gave verbal order for cbc (complete blood count, a blood test), and for c-diff (a stool test for a highly transmissible infection in the stool that causes diarrhea) test. Order noted and carried out. LN M stated she did not know why the FNP had ordered these tests and there was no documentation that Resident 58 was having diarrhea. During an interview with Resident 58 on 9/17/25 at 9:33 am, Resident 58 indicated she was having bad diarrhea and it started yesterday. Resident 58 said she had 8 episodes of diarrhea yesterday and was still having some today. During an interview on 9/17/25 at 9:35 am, Certified Nursing Assistant (CNA) L confirmed Resident 58 had four episodes of bad smelling liquid diarrhea during her shift on 9/16/25 from 6:00 am, to 2:30 pm, and was still having some today. CNA L said she informed the nurse yesterday. A review of Resident 58's Nursing Progress Notes from 9/15/25 at 4:51 pm, to 9/17/25 9:39 am, indicated there was no documentation concerning Resident 58 having diarrhea. During a concurrent interview with the Infection Preventionist (IP) and record review on 9/17/25 at 10:00 am, Resident 58's 9/16/25 and 9/17/25 progress notes were reviewed. The IP confirmed that there was no documentation concerning Resident 58's diarrhea. IP stated that there should have been a change of condition done for Resident 58 and documentation on what the stool looked like and there was not. During an concurrent interview with the Director of Nursing (DON) and record review on 9/17/25 at 10:24 am, Resident 58's Point of Care (CNA's documentation of resident's bowel movements) dated 9/16/25, was reviewed. DON confirmed that there was only one episode of a documented bowel movement for the day of 9/16/25. DON stated that each episode of diarrhea should have been charted by the CNA and it had not been. During an interview on 9/18/25 at 8:42 am, Family Nurse Practitioner (FNP) stated she had trouble getting a full picture of what was going on with residents because of the incomplete charting from the nurses. FNP indicated there was no documentation concerning diarrhea for Resident 58.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided for two of three residents sampled for skin damage (Resident 49 and 58) when: 1. Resident 58 had developed redness to her bottom and it went unreported by staff and without appropriate treatments for healing. 2. Resident 49 developed a red rash around her mouth and it went unreported by staff and without appropriate treatments for healing. These failures had the potential for Resident 58 and 49's physical, mental, and psychosocial needs to go unmet. Findings:A review of the facility's policy titled Prevention of Pressure Ulcers/Injuries (pressure sores) reviewed October 2024, indicated Inspect the skin when performing or assisting with personal care or ADL's (activity of daily livings). Evaluate, report and document potential changes in the skin.A review of the facility's Certified Nursing Assistant (CNA) Job description, dated 2/2019, indicated essential duties included to report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical.1. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg, muscle weakness, diabetes (high sugar in the blood), depression, anxiety and heart failure. Resident 58 made her own health care decisions.A review of Resident 58's Braden Scale (a tool to assess a patient's risk for developing pressure sores, skin damage that develop when pressure is applied to the same spot) for Predicting Pressure Sore Risk dated 9/16/25, indicated Resident 58 was At Risk for pressure sores.During an interview on 9/16/25 at 10:01 am, Resident 58 stated that her bottom had been sore for a couple of days.During a concurrent interview with Licensed Nurse (LN) A and record review on 9/17/25 at 9:23 am, Resident 58's September 2025 Treatment record was reviewed. LN A stated that Resident 58 had no identified sore on her bottom in her record, and no current treatment for her bottom.During an interview with LN M (who is also the treatment nurse) on 9/17/25 at 9:25 am, LN M stated that she wasn't aware that Resident 58 had a sore on her bottom at this time.During a concurrent observation and interview with CNA L on 9/17/25 at 9:35 am, Resident 58's bottom was observed having a two inch by one inch dark red area on her tailbone area. Resident 58 confirmed her tail bone was where her pain was. CNA L stated she noticed the red area to her tailbone yesterday but had not reported it to the nurse.During a concurrent observation and interview with the Director of Nursing (DON) on 9/18/25 at 1:05 pm, Resident 58's bottom was observed. The DON confirmed that there was a red area to Resident 58's tailbone and that there should have been an assessment and treatment for this area but that there was not. DON stated that the CNA's should have reported skin changes to the nurse when the change was noticed.2. A review of Resident 49's admission record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses that included heart failure, abdominal pain, kidney failure, dehydration and dysphagia (difficulty swallowing). Resident 49 made her own health care decisions.During a concurrent observation and interview with Resident 49 on 9/16/25 at 12:40 pm, Resident 49 was observed in her bed and she had a red rash around her mouth. Resident 49 stated that she had a red rash around her mouth and she was not sure why.During a concurrent observation and interview with Registered Nurse (RN) B and Resident 49, on 9/17/25 at 1:49 pm (a day later from last observation), RN B confirmed that she had noticed Resident 49's red mouth this morning during medication pass. RN B stated that she had not assessed Resident 49's rash or documented concerning this because Resident 49 said she had no pain. RN B and this Surveyor went to Resident 49's room and observed Resident 49 in her bed with a large red rash around her entire mouth. Resident 49 stated that her lips were numb and that her rash hurt. Resident 49 stated I wish it wasn't this way.During a concurrent interview with RN B and record review on 9/17/25 at 1:56 pm, Resident 49's September 2025 Physician treatment orders were reviewed. RN B stated that Resident 49 had no treatments ordered for her red rash around her mouth and that there was no documentation concerning her red rash and numb lips.During an interview on 9/17/25 at 2:05 pm, CNA E stated I thought it (the rash) was something the nurses were aware of because it (the rash) was something that was there for a couple of days. I should have told the nurses about the rash when I noticed it. CNA E indicated skin assessments are done on shower days and new skin issues are relayed to the nurses.During a concurrent interview with the Medical Records Director (MRD) and record review on 9/17/25 at 2:14 pm, Resident 49's CNA Daily Body Check on Showers . assessment dated [DATE] for AM shift was reviewed. The assessment indicated no new or existing skin issues documented by CNA O. MRD confirmed that that there was no new or existing documented skin issues.During an interview on 9/17/25 at 2:18 pm, CNA O stated she had given Resident 49 a shower this day and she thought Resident 49 was wearing lipstick and had not mentioned it to the nurse but should have.

Based on interview and record review the facility failed to ensure annual performance evaluations for three out of four Certified Nursing Assistants (CNA C, E, and F) were completed every 12 months. This had the potential for direct care staff not to provide quality of care and meet the needs of the residents. Findings:During a record review of facility policy titled Performance Evaluations dated September 2024, indicated A performance evaluation may be completed on each employee at least annually based on the hire date. Facility policy further indicated The supervisor and the evaluated employee should sign and date the evaluation form.During a concurrent interview and employee file review on 9/17/25 at 11:19 am, Payroll Personnel (PP) confirmed there were no annuals performance reviews completed for:1. CNA C, Date of Hire (DOH) 11/22/23, missing a 2024 annual evaluation.2. CNA E, DOH 3/29/22, missing a 2023 annual evaluation.3. CNA F, DOH 4/1/23, missing a 2024 annual evaluation.During a concurrent interview with Director of Nursing (DON) on 9/18/25 at 12:12 pm, CNA employee files were reviewed. The DON confirmed annual staff evaluations had not been consistent. DON verified she had been at facility for about a year and was trying to get caught up on annual staff evaluations.

Based on observation, interview, and record review, the facility failed to maintain its infection prevention control program when: 1. One of one resident (Resident 58) sampled for Transmission Based Precautions (TBP) was suspected to have Clostridium Difficile (c-diff, a bacterium [germ], transmissible infection [easily spreads to another person], that causes an infection of the colon, the longest part of the large intestine. Symptoms can range from diarrhea to life-threatening damage to the colon) and no isolation precautions were initiated as per policy to prevent the spread of disease. This failure had the potential to spread c-diff to other residents and staff and cause severe illness and decline in health status. 2. One of two residents (Resident 10's) sampled for tube feedings, had a gastrostomy tube (G-tube, a feeding tube that delivers nutrition, fluids, and medications directly into the stomach thru a surgical created opening in the abdomen) Lopez valve (a three way stop cock that fits to the end of the G-tube to create a closed or open system) that was found to be filled with a dried, brown substance and had not been cleaned. This failure had the potential to allow bacteria to grow and cause an infection in Resident 10. 3. Blood pressure cuffs were shared between residents and were not cleaned and disinfected. This failure had the potential to allow the spread of infection between residents. Findings: A review of the facility's policy titled Clostridium Difficile revised October 2024, indicated, Measures are taken to prevent the occurrence of Clostridium difficile (CDI) infections among residents. Clostridium difficile infection is suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours). The primary reservoirs (places where they live) for c-diff are infected people and surfaces. Spores can persist on resident -care items and surfaces for several months and are resistant to common cleaning and disinfection methods. A review of the facility's policy titled Isolation-Categories of Transmission-Based Precautions revised October 2024, indicated Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection: .and is at risk of transmitting the infection to other residents. Contact Precautions (wearing a gown and gloves upon entering a patient's room to prevent the spread of infection through direct or indirect contact) may be implemented for resident's known or suspected to be infected with microorganism (germs) that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. A review of the Center for Disease Control's (CDC) site titled Transmission Based Precautions for health care providers, dated April 3, 2024, indicated Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. *Use Personal Protective Equipment (PPE, includes gowns, gloves, face masks) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patients room is done to contain pathogens [germs]. 1. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg, muscle weakness, diabetes (high sugar in the blood), depression, anxiety and heart failure. Resident 58 made her own health care decisions. A review of Resident 58's admission Minimum Data Set (MDS, a complete clinical assessment) dated 8/12/25, section H, Bladder and Bowel assessment, indicated that Resident 58 was always incontinent (unable to control) of her bowels. During a concurrent observation and interview with Resident 58 on 9/16/25 at 10:01 am, Resident 58 was lying in bed and stated I am having trouble with my bowels and am having lots of diarrhea today. Resident 58's room was observed and there was no isolation sign on the outside of the door, there was no PPE equipment outside the door, there was no garbage can near the door to discard potentially contaminated items. During a concurrent interview with Licensed Nurse (LN) M and record review on 9/17/25 at 9:31 am, Resident 58's nursing progress notes were reviewed. LN M said there was a progress note on 9/16/25 at 11:48 am, which noted NP (Family Nurse Practitioner, FNP) gave verbal order for cbc (complete blood count, a blood test), and for c-diff (a stool test for Clostridium Difficile, a highly transmissible infection in the stool that causes diarrhea) test. Order noted and carried out. LN M confirmed Resident 58 was being tested for c-diff. During an interview with Resident 58 on 9/17/25 at 9:33 am, Resident 58 indicated she was having bad diarrhea and it started yesterday. Resident 58 said she had 8 episodes of diarrhea yesterday and was still having some today. During a concurrent observation and interview on 9/17/25 at 9:35 am, Certified Nursing Assistant (CNA) L confirmed Resident 58 had four episodes of bad smelling liquid diarrhea during her shift on 9/16/25 from 6:00 am, to 2:30 pm, and was still having some today. CNA L said she informed the nurse yesterday. CNA L was observed going into Resident 58's room. CNA L put on gloves and then proceeded to take off Resident 58's brief (incontinent underwear that absorbs loose stool or urine) to exam her bottom. CNA L replaced Resident 58's brief, removed her gloves and did hand hygiene. CNA L confirmed that Resident 58 was not on contact isolation and that there was no isolation sign or Personal Protective Equipment (PPE) available to use except gloves, when giving cares to Resident 58. CNA L confirmed she had not been wearing a gown when providing care for Resident 58. During an interview with the Infection Preventionist (IP) on 9/17/25 at 10:00 am, 24 plus hours after the start of Resident 58's episodes of diarrhea, IP stated that if a resident was suspected to have c-diff and/or had loose stools we would put that resident on contact isolation right away. IP said that contact isolation consisted of putting on gowns, gloves, and a face shield outside of the room and putting large trash cans at the doorways before leaving the room to discard potentially contaminated items. IP stated that this should be done immediately when someone was suspected of having c-diff. IP indicated that she was unaware of Resident 58 having diarrhea yesterday and being tested for c-diff. The IP confirmed that Resident 58 should have been placed on contact isolation yesterday after having multiple loose stools and being tested for c-diff and she was not. During an interview with LN D on 9/17/25 at 10:33 am, LN D stated she was informed of Resident 58 having diarrhea on 9/16/25 around noon, and notified the Family Nurse Practitioner (FNP). LN D stated that when residents are suspected to have c-diff we are supposed to notify the IP right away and put the resident on contact isolation. LN D stated that she did not do that because it was a really busy day but she should have. During an interview with the FNP on 9/18/25 at 8:42 am, FNP stated that Resident 58 was found not to have had c-diff but when it was suspected, the facility should have put Resident 58 on contact isolation to prevent the spread of the disease if she would have had it and they did not. 2. A record review of Resident 10's admission record, indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included secondary parkinsonism (a progressive neurological disorder that affects movement, balance, and coordination that is caused by an underlying medical diagnosis), aphasia (inability (or impaired ability) to understand or produce speech, as a result of brain disease or damage), dysphasia (a language disorder that affects a person's ability to understand, speak, read, or write), and gastrostomy status (referring G-tube). During a record review of Resident 10's care plan dated 4/28/25, the care plan did not indicate any interventions for Resident 10's Lopez valve. During a record review of Resident 10's September 2025 Physician Orders, the orders did not indicate any orders or interventions for Resident 10's Lopez valve. During a concurrent interview with Resident 10 and observation on 9/16/25 at 9:31 am, Resident 10's Lopez valve was observed to have dried, brown substance in the main medication and food port as well as dried, brown substance on the three-way stopcock. Resident 10 stated the Lopez valve was not changed every day. Resident 10 stated staff changed it when they get around to it. During a concurrent interview with LN A and observation on 9/16/25 at 11:14 am, Residents 10's Lopez valve was observed. LN A confirmed Resident 10's Lopez valve had brown dried substance in the main medication and food port as well as dried brown matter on the three-way stopcock. LN A confirmed it needed to be changed due to the risk of infection to the resident. LN A stated Lopez valve was supposed to be changed by the cart nurse every day. LN A confirmed valve was probably not changed for days. LN A confirmed there was no documentation by staff that confirmed the Lopez valve had been changed in Resident 35's chart. LN A confirmed there was no physician order to change the Lopez valve every day or as needed. During a concurrent interview and observation on 9/16/25 at 3:26 pm, Registered Nurse (RN) B confirmed Resident 35's Lopez valve was not changed every day. RN B stated it was changed as needed. Residents 10's Lopez valve and observed and RN B confirmed that it had dried, brown substance in the main medication and food port as well as dried, brown substance on the three-way stopcock. RN B confirmed this was an infection risk for Resident 10. RN B stated this should have been monitored by staff and changed sooner. RN B stated he did not know if there was a facility policy or physician's order for Lopez valves. During an interview with Director of Nursing (DON) on 9/19/25 at 12:12 pm, DON confirmed Resident 10's Lopez valve should not be filled with a dried, brown substance. DON confirmed Resident 10 did not have a physician order to change the Lopez valve as needed. DON confirmed Resident 10 was at risk for infection with dried substance on the Lopez valve. 3. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items, Surfaces and Equipment, dated September 2024, the P&P indicated, reusable items, will be cleaned and/or disinfected between residents and when surfaces are visibly soiled. During a medication pass observation with RN B on 9/16/25 at approximately 9:30 am, RN B used a blood pressure monitor to measure a resident's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and parked outside in the hallway without being cleaned and disinfected. RN B moved on to the next resident on the list for morning medication pass. RN B used the blood pressure monitor on 3 different residents before disinfecting. During an interview with RN B on 9/16/25 at 9:30 am, RN B acknowledged that the blood pressure monitor and cuffs were not cleaned or disinfected between residents. RN B stated, the expectation is that they are cleaned after each resident. During an interview on 9/18/25 at 11:30 am, the DON confirmed blood pressure monitoring equipment should have been cleaned after each resident use.

Based on Interview and Record Review the facility failed to report a crime or abuse incident for 1 of 3 residents (Resident 1) when Resident 2 ' s Family Member (FM) exposed himself to Resident 1 while in Resident 1 and Resident 2 ' s shared room. This failure to report to proper authorities placed all residents at risk for allegations of abuse to go unreported. Findings: During a review of the facility ' s policy and procedure titled, Abuse Investigation and Reporting, revised December 2018, the Abuse Investigation and Reporting policy indicated, All reports of resident abuse .(and) mistreatment .shall be promptly reported to local state and federal agencies . A review of Resident 1 ' s medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included, Right Femur Fracture, R Femur Surgical Intervention, and History of Falls. The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 1/8/25, indicated Resident 1 rated 15/15, which equates to being cognitively intact. Resident 1 is their own representative (RP) and make their own medical decisions. During an interview on 1/21/25 at 08:30 am, with Resident 1 over the phone, Resident 1 stated Resident 2 ' s Family Member (FM) came out of the shared bathroom and stood at the foot of the bed, made sounds of clearing the throat for attention, and exposed his genitals. I did not feel abused, just very uncomfortable. During an interview with Social Services Director (SSD), in SSD office, on 1/21/25 at 11:00 am, SSD indicated, SSD was aware of the incident, and interviewed both Resident 1 and FM. Resident 1 informed SSD there were no feelings of abuse, just felt very uncomfortable and requested a discharge from the facility. The facility did not file a report based on Resident 1 ' s response. During an interview with Administrator (Admin) in Admin ' s office, on 1/21/25 at 2:10 pm, Admin confirmed he is aware of the incident ' s occurrence, and the investigation was complete. Resident 1 did not wish to pursue reporting or feel the incident was abuse, thus, the facility did not file a report. Based on Interview and Record Review the facility failed to report a crime or abuse incident for 1 of 3 residents (Resident 1) when Resident 2's Family Member (FM) exposed himself to Resident 1 while in Resident 1 and Resident 2's shared room. This failure to report to proper authorities placed all residents at risk for allegations of abuse to go unreported. During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting , revised December 2018, the Abuse Investigation and Reporting policy indicated, All reports of resident abuse .(and) mistreatment .shall be promptly reported to local state and federal agencies . A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] with diagnoses that included, Right Femur Fracture, R Femur Surgical Intervention, and History of Falls. The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 1/8/25, indicated Resident 1 rated 15/15, which equates to being cognitively intact. Resident 1 is their own representative (RP) and make their own medical decisions. During an interview on 1/21/25 at 08:30 am, with Resident 1 over the phone, Resident 1 stated Resident 2's Family Member (FM) came out of the shared bathroom and stood at the foot of the bed, made sounds of clearing the throat for attention, and exposed his genitals. I did not feel abused, just very uncomfortable. During an interview with Social Services Director (SSD), in SSD office, on 1/21/25 at 11:00 am, SSD indicated, SSD was aware of the incident, and interviewed both Resident 1 and FM. Resident 1 informed SSD there were no feelings of abuse, just felt very uncomfortable and requested a discharge from the facility. The facility did not file a report based on Resident 1's response. During an interview with Administrator (Admin) in Admin's office, on 1/21/25 at 2:10 pm, Admin confirmed he is aware of the incident's occurrence, and the investigation was complete. Resident 1 did not wish to pursue reporting or feel the incident was abuse, thus, the facility did not file a report.

Based on observation, interview, and record review, the facility failed to provide adequate supervision based on individual resident needs, for three out of three sampled residents (Residents 34, 50, and 28) when: 1. Facility staff was aware Resident 34 wandered (roamed from place to place) in and out of other resident rooms. 2. Facility staff was aware Resident 50 wandered in and out of other resident rooms. 3. Facility staff was aware that Resident 28 demonstrated daily episodes of increased agitation and volatility exhibited by yelling, cursing, and throwing items. This failure had the potential to impact resident safety, privacy, dignity, and placed residents at an increased risk for resident-to-resident altercations. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 10/1/23, indicated, the facility staff would identify residents who were at risk for unsafe wandering and develop a plan to keep the residents safe. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, the residents of the facility had the right to respect, dignity, and privacy. A review of Resident 34's undated Admission Record, indicated, admission to the facility on [DATE] with the diagnoses of seizures (uncontrollable shaking of the body), down syndrome (a genetic condition that changed how the body and brain developed), and developmental disorder of speech and language (difficulty with language and understanding what was said to them, may not be able to speak verbally or communicate with hand gestures). Resident 34 was not his own responsible party (RP, person that made decisions about care). A review of Resident 34's Minimum Data Set (MDS, an assessment tool) dated 8/7/24, indicated, Resident 34 did not wander and had difficulty understanding and speaking. A review of Resident 34's care plan (a document that described health or behavioral concerns, what care was needed, and how staff would deliver care) dated 8/4/24, indicated, there was no care plan in place for Resident 34's wandering behavior. A review of Resident 46's MDS, dated [DATE], indicated Resident 46 was admitted to the facility on [DATE] with the diagnosis of a multidrug-resistant organism (in infection that many antibiotics would not cure). The MDS indicated, Resident 46 had good cognition (ability to remember and think). During an interview on 8/27/24 at 10:45 a.m., Resident 46 stated, Resident 34 often wandered into Resident 46's room. During an interview on 8/27/24 at 11:27 a.m., Resident 267 stated, sometimes Resident 267 was bothered by Resident 34 wandering into Resident 267's room and that facility staff would have to remove Resident 34. A review of Resident 35's MDS, dated [DATE], indicated, Resident 35 was admitted to the facility on [DATE] with the diagnoses of anxiety and depression. The MDS indicated, Resident 35 had good cognition. During an interview on 8/27/24 at 11:39 a.m., Resident 35 stated, Resident 34 would wander into Resident 35's room and Resident 35 had to tell Resident 34 to leave. A review of Resident 57's undated Admission Record, indicated, Resident 57 was admitted to the facility on [DATE] with the diagnoses of depression and a fracture to the shaft of the left tibia (the large bone in the lower leg, just below the knee joint). A review of Resident 57's MDS, dated [DATE], indicated, Resident 57 had good cognition. During an interview on 8/27/24 at 3:37 p.m., Resident 57 stated, Resident 34 would wander into Resident 57's room and Resident 34 did not know what he was doing. Resident 57 stated, tolerating the wandering behavior due to Resident 34's Down's Syndrome, and was not high functioning. 2. A review of Resident 50's undated Admission Record, indicated, admission to the facility on [DATE], with the diagnoses of Alzheimer's disease (inability to remember), anxiety (feelings of fear and dread), depression, and obsessive-compulsive disorder (uncontrolled and recurring thoughts, repetitive behaviors, or both), and was a hospice resident (six months or less left to live and received care focused on comfort). Resident 50 was not his own RP. A review of Resident 50's MDS, dated [DATE], indicated, Resident 50 had severe cognitive impairment, wandered, and Resident 50's wandering did not intrude on the privacy or activities of others. A review of Resident 50's care plan titled, Elopement, dated 7/10/24, indicated, Resident 50's safety would not be in danger related to wandering behaviors. There was no intervention that indicated what staff should do when Resident 50 wandered into other resident rooms. During an interview on 8/27/24 at 11:27 a.m., Resident 267 stated, sometimes Resident 267 was bothered by Resident 50 wandering into Resident 267's room and that facility staff would have to remove Resident 50. During an interview on 8/28/24 at 8:04 a.m., Resident 48 stated, Resident 50 was his roommate, Resident 50 would wander into Resident 48's side of the room, and touch Resident 48's arm. Resident 48 stated, reporting Resident 50's behavior to staff in the past and nothing had been done about it. Resident 48 stated, if staff did not do something about it, Resident 48 would hurt Resident 50. During an interview on 8/28/24 at 2:46 p.m., Certified Nursing Assistant (CNA) G confirmed, Residents 34 and 50 wandered the facility and stated, they usually wander on the evening shift. During an interview on 8/28/24 at 2:50 p.m., CNA E confirmed, Resident 34 and Resident 50 wandered into other resident rooms. CNA E stated, there were issues between Resident 48 and his roommate (Resident 50) and in the past, Resident 48 had made verbal threats to hurt Resident 50. CNA E was asked about the care plan and interventions in place regarding Residents 34 and 50's wandering. CNA E stated unawareness of care plans or interventions. A record review of Resident 37 indicated she was admitted on [DATE] with diagnoses of a fracture at the right humerus, chronic kidney disease and secondary parkinsonism (a condition that causes symptoms like Parkinson's Disease (a disorder that affects the nervous system and parts of the body controlled by nerves) but is caused by an underlying medical condition or other factor). Resident 37's Brief Interview for Mental Status (BIMS, evaluation of mental function), dated 08/12/2024, score was 15, which indicated no mental impairment. Resident 37 is her own responsible party; she makes her own decisions. During an interview on 08/27/24 at 10:51 am, Resident 37 stated that two male residents come into the room uninvited. Resident 34 will not knock and enters the room on a daily basis. Resident 50 comes in twice a week. One of them even grabbed her leg. A record review of Resident 30 indicated she was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and makes it difficult to breathe), diabetes (a disease that occurs when the body doesn't produce enough insulin (a hormone that regulates sugar in the blood) or can't use insulin properly), end stage renal disease, (a medical condition where the kidneys permanently stop working) and is dependent on dialysis (process of removing excess water, chemicals, and toxins from the blood by a machine), and has had both legs amputated (to cut off a limb by surgical operation) above the knee. Resident 30's Brief Interview for Mental Status (BIMS, evaluation of mental function), dated 08/05/2024, score was 10, which indicated a moderate mental impairment. Resident 30 is her own responsible party; she makes her own decisions. During an interview on 08/27/24 at 11:34 am, Resident 30 is, sick and tired of him (Resident 50) coming in here. Resident 50 has been in the room at least 5 times in the last few weeks and has been in the room twice today. He has drunk Resident 30's soda one week, another week while she was taking a nap, he got into her box of cereal and threw cereal at her while she was asleep, and recently drank her juice. Resident 34 also enters the room but he isn't a bother, he just roams. A review of Resident 43's medical record indicated that Resident 43 was admitted on [DATE] with diagnoses that included, Depression, muscle weakness, difficulty walking, and dementia. During an interview on 08/29/30, at 10:30 a.m., with Resident 43, Resident 43 stated, Resident 50 comes into my room and steals my cookies and drinks from my personnel water bottle and it is gross. During an interview with Activities Assistant 1 (AA 1) on 8/30/24 at 8:43 am, AA 1 stated Resident 50 mostly observed activities but did bother other residents by frequently tapping and touching others during activities. AA 1 stated Resident 50 had also spit chips in my face. During an interview on 8/28/24 at 2:57 p.m., CNA F confirmed, Resident 34 and Resident 50 wandered the facility. CNA F confirmed, Resident 34 wandered into other resident rooms and required redirection. During an interview on 8/27/24 at 3:04 p.m., Licensed Nurse (LN) A confirmed, Resident 34 wandered into other resident rooms. During a concurrent interview and record review on 8/29/24 at 10:20 a.m., with the Director or Nursing (DON), the care plans for Resident 34 were reviewed. DON confirmed, there was no care plan in place for Resident 34's wandering. DON stated, not being aware that Resident 34 wandered into other resident rooms. DON stated, not being aware that Resident 50 would wander into other resident rooms. DON reviewed Resident 50's care plan, titled Elopement, dated 7/10/24. DON confirmed, there were no interventions in place for Resident 50 regarding wandering into other resident rooms. DON stated, expectancy was for staff to notify DON of resident changes, DON would assess the resident, and revise the care plan to include appropriate interventions. 43031 3. During an observation on 8/27/24 at 12:30 pm, in the facility hallway outside and between rooms [ROOM NUMBERS], a plastic cup from room [ROOM NUMBER] flew into the hallway and broke when it hit the floor. Facility staff stated Resident 28 threw the cup. A review of Resident 16's medical record indicated that Resident 16 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy (a brain dysfunction that occurs when the body's metabolism is affected and leads to chemical imbalances), COPD, and Respiratory Failure (not enough oxygen passes from the lungs to the blood). The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 8/5/24 indicated Resident 16 rates 15/15, which equates to being cognitively intact. Resident 16 is their own representative (RP) and makes their own medical decisions. During an interview on 8/28/29 at 11:30 am, with Resident 16 in room [ROOM NUMBER] lying in bed A, Resident 16 stated, my neighbor in the other bed yells and throws things, cups, food items, whatever. I am afraid he will hit me with one of the plastic cups. I told him if he hits me with something I will come over there and blankity-blank. He said I'd like to see you do it. I can't get out of bed, however. Staff know what he does, and they shake it off. I don't feel safe with him. A review of Resident 28's medical record indicated that Resident 28 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy, Squamous Cell Carcinoma of left ear (cancer), and COPD. The MDS BIMS score dated 5/24/24 indicated Resident 28 rates 7/15, which equates to severe cognitive impairment. Resident 28 is not their own RP and does not make their own medical decisions. During a review of Resident 28's Care plan, dated 5/21/24, the Care Plan indicated, Resident 28 was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, and poor impulse control .related to failure to thrive (a syndrome of global decline). There was no intervention that indicated what staff should do when Resident 28 demonstrated increased emotional distress, ineffective coping skills, and poor impulse control related to yelling, cursing, and throwing items. During an interview on 8/28/24 at 4:00 pm with Resident 28 in room [ROOM NUMBER] lying in bed B, Resident 28 acknowledges he yells and throws things and that he does not know why he yells and throws things. During an interview on 8/28/24 at 4:20 pm with Certified Nursing Assistant (CNA) H in the hallway outside of room [ROOM NUMBER], CNA H stated all of us (floor staff) are aware of Resident 16's behaviors. It happens often, something occurs daily depending on Resident 28's agitation. I Believe it may be related to upset about not seeing their spouse often. Resident 28 has not hit Resident 16 with anything that I am aware of. During an interview on 8/28/24 at 4:35 pm, with Licensed Vocational Nurse (LN) B at the medication cart in the hall by a resident's room. LN B acknowledges Resident 28's behaviors are known to the staff. He has increased agitation and throws things and yells. This is a regular occurrence. Resident 16 has not been hit with anything. During an interview on 8/29/24 at 08:30 am with Director of Nursing (DON) by the Nurse's Station, DON denies having previous knowledge of Resident 28's agitated behaviors, including yelling, cursing, and throwing items. I understand the staff was aware. We will educate staff on documentation and communication for increased agitated states and change of condition. We are getting a tele psyche consult.

Based on observation, interview and record review the facility failed to assure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 11 of 30 residents (Resident 215, 28, 57, 45, 5, and 365), and Confidential Interview Residents), when call lights were observed and reported to go unanswered for extended periods of time resulting in: 1. Residents being left in soiled briefs with bowel movement and/ or urine. 2. Residents being left on the toilet for extended periods of time. 3. Residents left waiting for assistance in bed for a variety of reasons, including for generalized needs, or attempting to receive assistance to go to the to toilet. 4. Residents experiencing health concerns such as pain and shortness of breath (SOB). This failure had the potential to result in skin breakdown, increased overall pain, increase of resident accidents, and falls due to frustration and attempted self-help, decline in physical health status, and diminished mental and psychosocial well-being. Findings: During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, dated October 2023, Answering the Call Light indicated the purpose of the procedure is to respond to residents' requests and needs .Answer the residents' call light as soon as possible. During a review of the facility's Job Description for Certified Nursing Assistant (CNA), dated 2-2019, CNA Job Description indicated, The primary purpose of your job position is to provide each of your assigned residents routine daily nursing care and services .Ensure residents who are unable to call for help are checked frequently .answer residents call promptly. During a review of the facility's Job Description for Licensed Vocational Nurse (LVN), dated 11-2018, LVN Job Description indicated, The primary purpose of your job position is to provide direct nursing care to the residents, and supervise the day-to-day nursing activities performed by nursing assistants .Direct the day-to-day function of the nursing assistants in accordance to rules, regulations .Ensure all nursing service personnel are in compliance with the respective job description .Ensure that personnel providing direct care to residents are providing such care A review of Resident 28's medical record indicated that Resident 28 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy, Squamous Cell Carcinoma of left ear (cancer), and COPD. The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 5/24/24, indicated Resident 16 rates 7/15, which equates to severe cognitive impairment. Resident 28 is not their own RP and does not make their own medical decisions but can verbalize preferences and needs. During an interview on 8/28/24 at 4:00 pm with Resident 28 while lying in their bed in their room, Resident 28 stated, Staff sometimes answer my call light. It takes a long time a lot, 30 minutes, even when I am on the toilet. A review of Resident 215's medical record indicated that Resident 215 was admitted on [DATE] with diagnoses that included, displaced fracture of shaft of left clavicle, Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung diseases that block airflow and make it difficult to breathe), and Cerebrovascular event history (stroke, blood flow to the brain is lost damaging brain tissue). The MDS BIMS score dated 8/18/24, indicated Resident 215 rates 15/15, which equates to being cognitively intact. Resident 215 is their own representative (RP) and makes their own medical decisions. During an interview on 8/27/24 at with Resident 215 while sitting in their bed in their room, Resident 215 stated Staff are not consistent with answering the call lights. The call lights are not answered timely. I have watched the clock and waited for 30 minutes for my light to be answered, that is regularly. My son came in one day and my call light was on because I needed assistance, no one came in to answer it. We waited for a while, then he had to finally go to the nurse's station to see if they were going to help me. I had my light on before he even got here. I don't know how long that was, but it was a long time. During a confidential interview on 8/29/24 at 1:30 pm with Resident Council members, four of nine sampled residents stated that it takes a while for staff to answer the call lights especially when the Certified Nursing Assistant (CNA) assigned is on break or is busy. No one else will answer those lights. Sometimes on the night shift the entire staff goes on break together leaving only the medication cart nurse available for all issues including answering call lights. It takes a while to answer call lights then. We have seen it. We have been looking for staff for assistance and gone into the break room and found all the staff taking their dinner break together. Two of nine residents state they have to use the call light for their roommate because the roommate either cannot locate their call light, or staff is not answering the call light timely because the roommate calls too much. 45315 A review of the undated Admission Record, indicated, Resident 45 was admitted to the facility on [DATE] with the diagnoses of acute (happened quickly) respiratory failure (a serious condition that made it hard to breathe) unspecified whether with hypoxia (low oxygen levels that can cause confusion, rapid heart rate, and difficulty breathing) or hypercapnia (to much carbon dioxide in the body that could cause shortness of breath, tiredness, or confusion), difficulty in walking, and hypertension. A review of Resident 45's MDS, dated [DATE], indicated, Resident 45 had good cognition. During an interview on 8/27/24 at 3:47 p.m., Resident 45 stated, pressing the call light during the afternoon and waited for two hours before facility staff responded. Resident 45 stated, a few times she had urinated on herself while waiting for facility staff to respond to the call light and it happened mostly in the afternoon. A review of the undated Admission Record, indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses of chronic (ongoing) acute respiratory failure unspecified whether with hypoxia or hypercapnia, difficulty in walking, and chronic pain syndrome. Resident 5 was not her own RP. A review of Resident 5's MDS, dated [DATE], indicated, Resident 5 had good cognition. During an interview on 8/28/24 at 7:41 a.m., Resident 5 made statements of feeling ignored due to staff not answering the call light in a timely manner and stated it was difficult to find staff to assist when help was needed. A review of the undated Admission Record, indicated, Resident 57 was admitted to the facility on [DATE] with the diagnoses of fracture of shaft of left tibia (a fracture of the larger leg bone that occurred below the knee joint), pain, and had a history of falling. Resident 45 was her own RP and made her own decisions. A review of Resident 57's MDS, dated [DATE], indicated, Resident 57 had good cognition (ability to remember). During an interview on 08/27/24 at 3:37 p.m., Resident 57 stated, having pain and utilized the call light to request pain medication. Resident 57 stated, it took staff 45 minutes to respond to the call light. 49934 A record review of Resident 365 indicated he was admitted on [DATE] with diagnoses of surgical aftercare following surgical amputation (to cut off a limb by surgical operation), cellulitis (bacterial skin infection) of the right lower limb, diabetes (a disease that occurs when the body doesn't produce enough insulin (a hormone that regulates sugar in the blood) or can't use insulin properly), end stage renal disease, (a medical condition where the kidneys permanently stop working) and is dependent on dialysis (process of removing excess water, chemicals, and toxins from the blood by a machine). Resident 365's Brief Interview for Mental Status (BIMS, evaluation of mental function), dated 08/20/2024, score was 15, which indicated no mental impairment. Resident 365 is his own responsible party; he makes his own decisions. During an interview on 08/27/24 at 3:52 pm, Resident 365 stated he waited for 40 minutes to have his call light answered. He stated he was having breathing issues, and it took them 40 minutes! His roommate yelled and used his whistle to get someone to answer the call light. His oxygen flow was increased and Resident 365 states he is happy with his oxygen setting. Physician orders, dated 08/14/2024, note that the oxygen may be titrated as indicated, during an activity or therapy, and if greater than 5 liters is needed, notification of the doctor is required.

Based on observation, interview, and record review, the facility failed to ensure complete Medication Regimen Reviews (MRR) were performed for medication irregularities, appropriate indication (reason for use), and/or unnecessary psychotropic (affecting mental state) medications for two of four sampled residents (Residents 50 and 25) when: 1A. The indication for Seroquel (medication affecting mental processing and behaviors) use of mood disorder as evidenced by (AEB) striking during care was determined appropriate for Resident 50 on two MRRs by Consultant Pharmacist (CPH), though medication necessity and effectiveness had not been evaluated (50 days after admission) by the Psychotropic Interdisciplinary Team (IDT - group of professional healthcare providers including physician(s), nurses, pharmacists who meet to determine appropriateness of resident medication treatment plans). 1B. No medication irregularities were reported by CPH for Resident 50 despite Seroquel being administered in combination with donepezil (dementia medication that slows mental changes and improves behaviors), which is known to potentially reduce the effectiveness of donepezil and cause nervous system side effects of increased drowsiness, confusion, and mental impairment in dementia residents. These failures had the potential for Resident 50 to receive an unnecessary psychotropic medication without improvement goals and to suffer unnecessary adverse (harmful) effects that could negatively impact his physical, mental, and psychosocial well-being. 2. Resident 25 received oxybutynin (treats bladder control problems) 5 milligrams (mg - a unit of measure) extended-release (ER) tablets from 6/1/24 to 8/29/24 rather than the immediate-release (IR) formula that was ordered by the Medical Director (MD) - an error that went undetected and unreported for irregularity by CPH. This failure caused Resident 25 to receive a longer-lasting dose of oxybutynin with the potential to cause adverse effects from excessive build-up of the medication in his system that could negatively impact his physical, mental, and psychosocial well-being. FINDINGS: During a review of facility Policy and Procedure (P&P) titled Medication Regimen Review, dated 4/2024, the P&P indicated: A. When needed, a licensed nurse, Pharmacist, and/or Practitioner will review a resident's current medication regimen to identify whether (1) there is a clear indication for treating the resident with the medication, (2) the dosage is as prescribed by the physician, (3) the frequency of administration and duration of use are appropriate. B. Monthly, the Pharmacist and/or Physician will review the medication regimen for continued indications, dose and duration that is consistent with the order, and possible side effects. C. The Pharmacist and/or Physician will coordinate with the Director of Nursing (DON) or designee where medications should be tapered, discontinued, or changed to another medication. A review of P&P titled Antipsychotic Medication Use, dated 2023, indicated: A. The physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. B. Residents admitted from the community who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. C. Antipsychotic medications will be used only for the following conditions/diagnoses as documented in the record: schizophrenia, delusional disorder, mood disorders (bipolar disease, depression with psychotic features, and major depression not responding to treatment), psychosis in the absence of dementia, and behavioral and psychological symptoms of dementia (BPSD). A review of P&P titled Dementia Care, dated 11/2023, indicated: A. The staff and physician will evaluate individuals with new or worsening cognitive (mental function) impairment and behavior and differentiate dementia from other causes. B. The physician will help define potential benefits and risks of medical interventions based on individual risk factors, current conditions, history, and details of current symptoms. C. The Interdisciplinary Team (IDT - a team with members from different disciplines who work together to set goals and make care decisions) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. A review of record titled Medical Directorship Agreement signed by MD, dated 2/1/23, indicated MD duties included participating in effective resident care utilization review (UR - process to evaluate appropriateness and necessity of healthcare services) and participating in the development of medical care plans for each resident to include medications, nursing care, restorative services (interventions that help residents regain or maintain their ability to live independently and safely), diet, and other services. A review of record titled Physician Job Description signed by MD, dated 6/7/23, indicated primary accountabilities include prescribing medications, detecting, and responding to adverse drug reactions, and collaborating with healthcare professional staff to form a high-performing medical team. 1A. A review of Resident 50's medical records indicated he was admitted to the facility in early July 2024 with diagnoses of Alzheimer's dementia (causes progressive memory loss, inability to control thoughts and language), anxiety, depression, and obsessive-compulsive disorder (OCD - uncontrolled recurring thoughts, repetitive behaviors, or both), and was on hospice (had six or fewer months to live, receiving care focused on comfort). Family Member 1 (FM 1) was his Responsible Party (RP) because Resident 50 was not able to make his own healthcare decisions. A review of outside records titled Office/Clinic Notes, dated 3/11/24, indicated Resident 50 was taking quetiapine (Seroquel - a psychotropic medication; affects mental processes and behaviors) 25 mg, one tablet twice a day for sleep and disinhibition (inability to control behaviors). The record indicated recommendation to continue Seroquel 25 mg twice a day, titrate (adjust) as needed/tolerated. Adverse effects of Seroquel include sedation, orthostatic hypotension (drop in blood pressure within three minutes of standing), lightheadedness, dry mouth, blurred vision, constipation, urinary retention, increase psychotic symptoms, extrapyramidal effects (continuous spasms and muscle contractions), restlessness, dystonia (involuntary muscle contractions that cause repetitive or twisting movements), tremor, rigidity, akinesia (loss or impairment of the power of voluntary movement), tardive dyskinesia, (irregular, jerky movements). A review of outside records titled Hospice Nursing Clinical Note, dated 7/3/24, indicated Resident 50's Seroquel was increased to 100 mg in the morning, to continue 50 mg at bedtime, due to aggression. A review of outside records titled Hospice Nursing Clinical Note, dated 7/9/24, indicated the increased Seroquel had helped Resident 50's outbursts, but he was using his walker more often due to weakness, had become more clumsy, and almost fell on [DATE]. A review of letter from California Department of Health Care Services (DHCS) to facility on 7/10/24, indicated DHCS was unable to complete evaluation for serious mental illness for Resident 50. The letter indicated a Pre-Admission Screening and Resident Review (PASRR) Level II evaluation was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. The letter indicated the case was closed but could be reopened by submitting a new Level I Screening. A review of Care Plan, dated 7/10/24, indicated: A. Resident 50 was at risk for falls with or without injury related to altered mental status, antidepressant medication, antipsychotic medication, antihypertensive medication, with order to perform MRR as indicated. B. The record indicated Seroquel carried a black box warning (label used by the United States Food and Drug Administration to alert prescribers and patients to most serious safety risks) with potential adverse effects of sedation, falls, abnormal movements, negative cardiovascular (heart/vessels) effects, stroke, and increased mortality in older adult patients. Interventions dated 7/15/24: Attempt a gradual dose reduction as indicated/condition improves, as ordered; pharmacy review as indicated; attempt non-pharmacological approaches prior to medication administration; and observe/record effectiveness of drug treatment as indicated. A review of Minimum Data Set (MDS - a tool used to assess and manage care of residents in nursing homes) Brief Interview for Mental Status (BIMS - screens a resident's mental status using score 0 to 15: 0-7 severe impairment, 8-12 moderate impairment, 13-15 intact mental function), dated 7/16/24, indicated Resident 50 had a BIMS Score of 5, indicating severe impairment of mental function. The record indicated Resident 50 displayed no hallucinations or delusions (potential indicators of psychosis) and no physical (hitting, kicking, pushing), verbal (threatening others, screaming, cursing), or other behavioral symptoms (pacing, throwing food or bodily wastes, disrobing in public). The record indicated Resident 50 had wandering behavior one to three days. A review of Order Summary Report, dated 8/29/24, indicated orders as follows: A. A medication reconciliation (comparing resident's medication orders to current medications to ensure accuracy and avoid errors) was performed by MD with review of the prior care setting discharge medications on 7/10/24. B. Seroquel 100 mg, one tablet once a day (morning), Seroquel 50 mg, one tablet once a day (evening) for mood disorder as evidenced by striking during care, with start dates of 7/11/24 and 7/10/24, respectively. C. Every shift for Seroquel, observe resident closely for significant common side effects of drowsiness/sedation, dry mouth, constipation, blurred vision, urinary retention (unable to urinate), loss of appetite, with special attention for tardive dyskinesia (involuntary movements), seizure disorder, chronic constipation, diabetes. Start date 7/13/24. D. Admit to Hospice for diagnosis of senile degeneration of the brain. Start date 7/19/24. During an interview with DON on 8/29/24 at 11:38 am, the DON stated Resident 50's Seroquel was ordered because he was striking out during any Activities of Daily Living (ADLs - feeding, toileting, dressing) care. DON stated Resident 50 can get aggressive sometimes during care, and this prevented him from getting care. During an interview with Medical Director (MD) on 8/29/24 at 3:05 pm, MD stated she followed hospice admission orders when ordering Resident 50's medications for facility admission in July. MD stated the hospice record showed the indication for Seroquel was striking out, agitation. MD stated, My name will be on every order, even if following hospice orders. MD stated persons responsible for reviewing medications at admission include the physician (herself), the DON, MDS Nurse, and the Pharmacist. MD stated she takes part in monthly resident medications reviews at the facility but was on vacation in August and did not participate that month. MD stated Resident 50's medications had not yet been reviewed by the Psychotropic IDT. During an interview with Registered Nurse B (RN B) on 8/29/24 at 3:12 pm, RN B stated Resident 50 was living at home prior to admission to the facility, but Family Member 1 (FM 1) can't handle his increasingly aggressive behaviors of hitting, spitting, smearing, and eating his own feces, so he was admitted to the facility on hospice. RN B stated she evaluated Resident 50 twice weekly at the facility and he was more calm. RN B stated he used to hit and spit, but staff said he was not doing that as much. RN B stated family is happy that his behaviors are improving. During observation of Resident 50 in his room on 8/30/24 at 8:31 am, Resident 50 was lying on his right side, resting quietly, eyes closed, the overhead lights out but curtains open to provide a dimly lit room. During an interview with LN A on 08/30/24 at 08:40, LN A stated Resident 50 was usually calm but had one episode of wandering yesterday. LN A stated she did not believe Resident 50 was a danger to himself or others. A review of records titled Consultant Pharmacist's Medication Regimen Review: List of Patients Reviewed/Recommendations from July and August 2024 indicated Resident 50's medication regimen was reviewed with no recommendations for change or gradual dose reduction (GDR). A review of drug information for Seroquel on [NAME]-Drug (a drug reference platform that provides clinicians information to help make evidence-based drug decisions), updated 9/4/24, indicated elderly patients with dementia-related psychosis (mental condition that causes a person to lose touch with reality) who are treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis and is to be avoided for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If Seroquel is used, clinicians should consider deprescribing attempts to assess continued need and/or lowest effective dose. 1B. A review of Resident 50's Order Summary Report, dated 8/29/24, indicated an order for donepezil hydrochloride (dementia medication that slows mental changes and improves behaviors) 10 milligrams (mg - a unit of measure), one tablet once a day, start date 7/11/24. During an interview with Consultant Pharmacist (CPH) on 8/29/24 at 3:45 pm, CPH stated he checked medications and reviewed order input for appropriateness and accuracy of orders when residents were admitted , checked that allergies were entered correctly, that psychotropic medications had behavior and side effect monitoring ordered, and that no drug-drug interactions (reaction between drugs, often negative) were likely to occur. CPH stated the contraindications (reasons against doing something) of Seroquel use in elderly residents with dementia, particularly when used in combination with donepezil, were not clear and that there was positive data supporting the use of antipsychotics for dementia symptoms. CPH stated, A lot of doctors use it for these symptoms. CPH stated Resident 50's Hospice Admission Orders looked familiar and were probably what he used to verify medication orders. CPH verified that as of this interview, Resident 50's medications had not yet been reviewed by the Psychotropic IDT, 50 days after admission. A review of drug information for donepezil on [NAME]-Drug, updated 9/7/24, indicated donepezil may enhance the neurotoxic (damage to brain or nervous system caused by exposure to toxic substances) effects when used in combination with antipsychotic agents like Seroquel. 2. During a review of Resident 25's medical records, the record indicated Resident 25 was admitted in 10/2023 with diagnoses including unspecified symptoms of the genitourinary system (organs of the urinary and reproductive systems) and enlarged prostate. A review of facility document prepared by CPH titled Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated 7/2024, indicated Resident 25's medication regimen was reviewed and did not require any recommendations. During observation of medication administration on 8/28/24 at 8:42 am, Licensed Nurse D (LN D) prepared and administered Resident 25's medications, which included removing one tablet from a blister pack (medication packaging, packaged by the pharmacy) labeled oxybutynin extended-release (ER) 5 mg tab - take 1 tablet three times daily for overactive bladder. A review of Resident 25's Order Summary Report, dated 8/29/24, indicated an active order for oxybutynin chloride oral tablet 5 mg, to give one tablet by mouth three times a day for overactive bladder. The order was placed 6/1/24 with start date of 6/1/24. During concurrent observation of Resident 25's oxybutynin blister pack, review of Resident 25's active medication orders, and interview with LN D on 8/28/24 at 2:52 p.m., LN D acknowledged that the oxybutynin order did not indicate to use the ER formula of oxybutynin. During an interview with the Registered Pharmacist (RPH) on 8/28/24 at 12:36 p.m., RPH reviewed Resident 25's oxybutynin order. RPH stated the medication was first ordered 6/1/24 and had been filled three times. RPH verified the order indicated oxybutynin IR formula was to be given three times a day, not the ER formula. RPH stated, This is a medication error. RPH stated oxybutynin 5 mg ER should only be given once daily, not three times a day, noting it was done incorrectly. Review of Resident 25's Medication Administration Record, dated 8/1 to 8/31/24, indicated oxybutynin ER 5 mg was administered 83 times in 8/2024. During an interview with the Medical Director (MD) on 8/29/24 at 3:05 p.m., the MD stated, We all play a role in preventing medication errors and discrepancies: Pharmacy staff, MD and DON who review resident medications, MDS Nurse, and nursing staff who administer medications. During an interview with the Consulting Pharmacist (CPH) on 8/29/24 at 3:45 p.m., the CPH verified the pharmacy sent the longer acting ER formula in error. CPH stated it was interesting that oxybutynin got sent as ER. CPH stated in this case, the medication error should have been noticed by in-house pharmacists who reviewed the orders. CPH stated, If I were the pharmacist, I'd have questioned it. CPH stated the ER formula would take longer to metabolize (break down) and would stay in Resident 25's system longer than the IR formula. CPH stated he agreed with the MD's order to switch to oxybutynin IR and monitor Resident 25 for potential adverse effects of receiving the longer-acting ER formula three times a day for three months (6/1 to 8/29/24).

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent for two of six sampled residents (Residents 25 and 216) when: 1. For Resident 25, Licensed Nurse D (LN D) administered one oxybutynin extended-release (ER) 5 milligrams (mg - a unit of measure) tablet rather than the ordered oxybutynin chloride 5 mg, an immediate-release (IR) tablet, to treat overactive bladder. 2. For Resident 216, LN D did not administer scheduled or as-needed pain medications when Resident 216 stated his pain was 10 on a scale of 1 to 10 (1 being the lowest pain, 10 being the highest). These failures resulted in two medication errors identified out of 29 opportunities, resulting in a medication error rate of 6.9 percent, with the potential for adverse health consequences from medication toxicity effect and unaddressed pain. FINDINGS: 1. During a review of Resident 25's medical records, the record indicated Resident 25 was admitted in 10/2023 with diagnoses of unspecified symptoms of the genitourinary system (organs of the urinary and reproductive systems) and enlarged prostate. During observation of medication administration on 8/28/24 at 8:42 am, LN D prepared and administered Resident 25's medications, which included removing one tablet from a blister pack (medication packaging), packaged by the pharmacy, labeled oxybutynin ER 5 mg tab - take 1 tablet three times daily for overactive bladder. Reconciliation of the medication administration observation with Resident 25's Order Summary Report, dated 8/29/24, indicated an active order for oxybutynin chloride oral tablet 5 mg, to give one tablet by mouth three times a day for overactive bladder. The order was placed on 6/1/24 with a start date of 6/1/24. During an interview with the Registered Pharmacist (RPH) on 8/28/24 at 12:36 p.m., RPH reviewed Resident 25's oxybutynin order. RPH stated the medication was first ordered 6/1/24 had been filled three times. RPH acknowledged the order indicated oxybutynin IR formula was to be given three times a day, not the extended-release formula. RPH stated, This is a medication error. RPH stated oxybutynin 5 mg ER should only be given once daily, not three times a day, and noted it was done incorrectly. Review of Resident 25's Medication Administration Record, dated 8/1 to 8/31/24, indicated oxybutynin ER 5 mg was administered 83 times in 8/2024. During concurrent observation of Resident 25's oxybutynin blister pack, review of Resident 25's active medication orders, and interview with LN D on 8/28/24 at 2:52 p.m., LN D acknowledged that the oxybutynin ER administered was not the same as the oxybutynin IR order. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON stated she had written a medication error report and notified the Medical Director (MD) of the oxybutynin error. During an interview with the Medical Director (MD) on 8/29/24 at 3:05 p.m., the MD stated, We all play a role in preventing medication errors and discrepancies: MD and DON who review residents' medications, the Minimum Data Set (MDS - information gathered from assessing and monitoring residents in Medicare- or Medicaid-certified nursing homes) Nurse/Coordinator, pharmacy staff, and nursing staff who administer medications. During an interview with the Consultant Pharmacist (CPH) on 8/29/24 at 3:45 p.m., the CPH stated it was interesting that oxybutynin ER was sent from the pharmacy. CPH stated the medication error should have been noticed by in-house pharmacists. CPH stated the ER formula would take longer to metabolize (break down) and would stay in Resident 25's system longer than the IR formula. CPH stated he agreed with the MD's order switch to oxybutynin IR and monitor Resident 25 for potential adverse effects of receiving the longer-acting ER formula three times a day for three months (6/1 to 8/29/24). A review of facility document prepared by CPH titled Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated 7/2024, indicated Resident 25's medication regimen was reviewed and did not require any recommendations. A review of facility document titled Job Description: Licensed Practical Nurse (LPN) Licensed Vocational Nurse (LVN), undated, indicated licensed nurses are responsible for reviewing residents' charts for medication orders as necessary. A review of Policy and Procedure (P&P) titled Administering Medications, dated 10/2023, indicated: A. Medications are administered in accordance with prescriber orders, including any required timeframe. B. The person administering the medication verifies the resident's identity, then checks the label to verify the right resident, right medication, right dosage, right time, and right method of delivery (route) before giving the medication. C. If a dose is believed to be inappropriate or excessive, the person preparing and administering the medication will contact the resident's Attending Physician/Nurse Practitioner or the facility's MD to discuss concerns. 2. A review of Resident 216's medical record indicated Resident 216 was admitted in late 8/2024 with diagnoses of muscle weakness, repeated falls, fractured lumbar vertebrae (bones that protect the lower spinal cord) and multiple rib fractures, dementia (loss of brain function such as memory, language, problem solving and other thinking abilities), spondylosis (a degenerative spinal condition that causes pain and discomfort), and spinal stenosis (narrowing of the spinal canal that puts pressure on the cord and nerves causing pain, numbness, and weakness). The MDS Brief Interview for Mental Status (BIMS - Section C assessing cognitive function) had not yet been performed as Resident 216 was a new admit. A review of Nursing Note written by LN C, dated 8/28/24 at 9:04 am, indicated Resident 216 had his toes run over by a wheelchair this morning, but resident did not appear in pain. During observation of medication administration on 8/28/24 at 9:15 am, LN C stated Resident 216 bumped his foot and asked LN D if Resident 216 could have Tylenol. Resident 216 was wearing socks on his feet, seated in a wheelchair, and observed to rock back and forth, head in his hands, rubbing his left side, and making facial grimaces. LN C asked Resident 216 multiple times to rate his pain on a scale of 1 to 10; the pain scale was not explained to the resident, who appeared to be confused by the question. Resident 216 stated, I don't know, 10. LN D reviewed Resident 216's medication list and stated Resident 216 had received a dose of scheduled Tylenol that morning, and the only medication available was oxycodone (an opioid pain-relief medication for moderate to severe pain). LN D again asked Resident 216 to rate his pain on a scale of 1 to 10, and Resident 216 replied, I don't know. No medication was given, and Resident 216 was taken away by LN C. During an interview with LN C on 8/28/24 at 10:51 am, LN C stated she brought Resident 216 to LN D because he hit his toe on his wheelchair and was in pain. LN C stated he also fell recently and had pain from fractured ribs. LN C acknowledged Resident 216 did not receive any pain medication and stated he wasn't showing pain. Reconciliation of the medication administration observation with Resident 216's Order Summary Report, printed 8/29/24, indicated active orders placed 8/25/24 to include: A. No bending, lifting, twisting due to left-side rib fracture. B. Monitor for pain every shift using Scale 0 to 10 (0 no pain, 1 to 2 least pain, 3 to 4 mild pain, 5 to 6 moderate pain, 7 to 8 severe pain, 9 to 10 very severe/horrible/worst pain). C. Record non-pharmacological pain interventions every shift using 0 to 10 scale (0 no non-drug intervention needed, 1 repositioning/limb elevation, 2 reassurance/emotional support, 3 distraction/diversionary activities, 5 exercise/range of motion/ambulation/stretching, 6 deep breathing/relaxation, 7 guided imagery/meditation, 8 laughter/socialization, 9 aromatherapy). D. Resident does not have the capacity to make his decisions related to dementia. E. Tylenol 500 mg, two tablets by mouth every 8 hours for pain. F. Lidocaine patch (applied to skin in painful areas for pain relief) 4 percent applied to left side in the morning for rib pain; remove per schedule. G. Lidocaine patch 4 percent applied to low back in the morning for lower back pain; remove per schedule. H. Oxycodone oral tablet 5 mg, one tablet by mouth every four hours as needed for pain 6 to 10 for three days (8/28/24 at 9 pm). A review of Resident 216's Medication Administration Record (MAR), dated 8/1 to 8/31/24, printed 8/29/24 at 12:52 pm, indicated Resident 216 refused all ordered lidocaine patches to left side and low back since admission; received Tylenol 10 times since admission but refused scheduled doses at 1 pm on 8/25 and 8/28/24; denied having pain 10 times since admission, with one report of 1 out of 10 pain on morning shift 8/28/24; nonpharmacological pain interventions of repositioning/limb elevation seven times and rest period/quiet environment 11 times since admission; and oxycodone 5 mg was given three times for severe pain 7 out of 10 on 8/26/24 at 7:24 am, 8/26/24 at 9:55 pm, and 8/28/24 at 5:08 pm. During concurrent interview with LN D and review of Resident 216's active orders on 8/28/24 at 2:52 pm, LN D stated Resident 216 had complained of left rib pain but had been refusing pain medication. LN D stated he did not give Resident 216 oxycodone for pain at 9 am because the resident couldn't give him a pain scale and LN D didn't think [Resident 216] was in pain. LN D acknowledged an order for lidocaine patches (scheduled for placement at 9 am) was available for pain and was not offered. LN D acknowledged Resident 216 had received only one dose of Tylenol for pain relief on 8/28/24. During an interview with LN C and LN D on 8/28/24 at 3:08 pm, LN C stated the protocol when residents refuse ordered medications is to ask the resident three times to take the medication, explain the risks and benefits, and if the resident still refuses, the doctor will be informed. LN C and LN D acknowledged they had not notified anyone that Resident 216 had frequently refused pain medications since admission. During concurrent observation and interviews with Resident 216 and Activities Assistant 1 (AA 1) on 8/28/24 at 3:17 pm in the dining area, observed Resident 216 sitting in a wheelchair near other residents during Activities (Bingo). Resident 216 was not participating but was observed fidgeting with the drawstring of his sweatpants, a plastic bracelet on his wrist, and lifting his T-shirt to intermittently rub his left side. When questioned about pain, Resident 216 stated his side hurt and pointed to his left ribs. Informed Resident 216 he had pain patches that could be applied by nursing staff. Resident 216 stated he needed to remove the patch from his wrist and took off his bracelet. AA 1 stated she believed Resident 216 was in pain because he had been verbalizing ow and grimacing throughout the activity. During an interview with the DON on 8/29/24 at 11:38 am, discussed the observation of Resident 216, LN C, and LN D on 8/28/24 at 9:15 am, with the result being no pain medication given. The DON stated, That's so frustrating. The DON stated she would provide education to nursing staff regarding the Pain Assessment in Advanced Dementia Scale (PAINAD - an assessment tool that monitors dementia/nonverbal residents for labored breathing, moaning/groaning, facial expressions, tense body language, and consolability). During an interview with DON, Administrator (ADM), and Administrator in Training (AIT) on 8/29/24 at 4:34 pm, the DON stated the MD was here 8/28/24 and was made aware that not all pain medications were being administered to Resident 216 despite indications of pain. The DON again stated she was frustrated that nursing staff did not recognize Resident 216's nonverbal indications of pain and would re-educate staff to the PAINAD scale. A review of the facility's P&P titled, Pain Assessment and Management, dated 4/2024, indicated, The purpose of this procedure is to help the staff identify pain in the resident . Observe the resident for signs and symptoms of pain . Possible Behavioral Signs of Pain: (a) verbal expressions of pain, (b) facial expressions such as grimacing, frowning . Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive (mental) level . Implement the medication regimen as per physician's orders . The Interdisciplinary Team (IDT - a group of professionals who work in different disciplines and address common goals, issues, and/or concerns for each resident), including a physician, shall reconsider approaches and adjust if indicated to meet any further pain needs. A review of P&P titled Change in a Resident's Condition or Status, dated 4/2024, indicated the nurse will notify the resident's physician/nurse practitioner/physician assistant when there has been a(an) refusal of treatment or medications.

Based on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. A discontinued medication was not removed and discarded from an active medication drawer in Medication Cart A (MC A), 2. Six multi-dose tubes of noncontrolled medicated creams (prescription medications with less risk of addiction and abuse) were in a facility supply basket in Treatment Cart 1 (TC 1) without patient-specific labeling, 3. A used oral medication syringe was affixed with a rubber band to a bottle of liquid Keppra (anti-seizure medication) for reuse and was stored in a drawer of TC 1, 4. A bottle of glucose test strips was open and undated in MC A, 5. Eight loose pills were found in drawers and on the bottom of MC A, 6. A bottle of ketoconazole shampoo (antifungal) in TC 1 was being used on a resident despite an expiration date of 7/2023, and 7. An intravenous (IV) line filter (filters potential impurities to prevent infection) that expired 9/1/23 was in a medical supply drawer in Treatment Cart 2 (TC 2). 8. The Housekeeping Supervisor (HSK), an unlicensed staff member, maintained a key to the locked Medication Room. These failures had the potential for medication misuse, drug diversion, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from reused or expired supplies for all 58 residents. FINDINGS: 1. During concurrent observation of medication preparation and administration and interview with Registered Nurse A (RN A) on 8/27/24 at 11:10 am, RN A stated the facility had two large medication carts: Medication Cart A (MC A - North Wing near the nurses' station) and Medication Cart B (MC B - East Wing), and two Treatment Carts near the nurses' station: Treatment Cart 1 (TC 1) oral medications; medicated creams, ointments, liquids) and Treatment Cart 2 (TC 2 - IV medications and supplies). Observation revealed a pharmacy-labeled baggie containing multiple packets of potassium chloride (a noncontrolled mineral supplement) 20 milliequivalents (mEq - a unit of measure) in MC A. The label indicated the potassium order had been discontinued. RN A acknowledged discontinued medications should have been removed from active medication areas. During an interview with Licensed Nurse C (LN C) on 8/27/24 at 11:23 am, LN C reviewed the potassium order and stated the prescription was filled by the pharmacy on 6/5/24 but was discontinued by the physician on 6/7/24. LN C verified the medication should have been removed from MC A. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON acknowledged discontinued medications should not be mixed with active medications and verified the potassium packets should have been removed from MC A and properly discarded. A review of Policy and Procedure (P&P) titled Discarding and Destroying Medications, dated 10/2023, indicated medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances . Both controlled and non-controlled substances may be disposed of in a medication collection receptacle at the facility. A review of P&P titled Storage of Medications, dated 10/2023, indicated the facility stores all drugs and biologicals (D&Bs - a vaccine or drug created from biological sources) in a safe, secure, and orderly manner . Discontinued, outdated, or deteriorated D&Bs are placed in designated appropriate bins for destruction. 2. During concurrent observation of contents of locked TC 1 and TC 2 and interview with Licensed Nurse E (LN E) on 8/27/24 at 11:35 am, observed six tubes of prescription-strength medications in a basket without patient-specific labeling: A. Gentamicin sulfate ointment 0.1 percent (% - a unit of measure; an antibiotic that treats bacterial skin infections), B. Santyl ointment 250 units per gram (units/gm - a unit of measure; used to remove damaged tissue from wounds), C. Nystatin ointment 100,000 units/gm (treats fungal or yeast infections on the skin), D. Ketoconazole cream 2% (treats fungal or yeast infections on the skin), E. Triamcinolone acetonide cream 0.5% (reduces swelling and itching from eczema, allergies, rashes), and F. Mupirocin ointment 2% (an antibiotic that treats bacterial skin infections). Observation revealed the unlabeled medications were mixed with active, labeled medications. LN E stated the unlabeled tubes were facility supply that had once been prescribed to specific residents, but the labels had been removed and placed in TC 1. LN E acknowledged that medications should not be administered to residents without an order, and the unlabled tubes should have been removed from active medication areas. LN E acknowledged the risk to all residents from administering medications not ordered by a physician including potential adverse side effects, allergic reaction, and/or incorrect medication/dose. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON verified unlabeled medications should not be administered to residents or mixed with active medications, and the unlabeled medications should have been properly removed from TC 1 and discarded. A review of facility document titled Job Description: Licensed Practical Nurse (LPN) Licensed Vocational Nurse (LVN), undated, indicated licensed nurses are responsible for reviewing residents' charts for medication orders as necessary. A review of Policy and Procedure (P&P) titled Administering Medications, dated 10/2023, indicated: A. Medications are administered in accordance with prescriber orders, including any required timeframe. B. The person administering the medication verifies the resident's identity, then checks the label to verify the right resident, right medication, right dosage, right time, and right method of delivery (route) before giving the medication. C. Allergies to medications and vital signs, if necessary, are checked/verified for each resident prior to administering medications. 3. During concurrent observation of contents of TC 1 and TC 2 and interview with Licensed Nurse E (LN E) on 8/27/24 at 11:35 am, observed a bottle of prescribed liquid Keppra (anti-seizure medication) in the bottom drawer of TC 2. An uncovered, sticky medication syringe (small hollow tube used to inject or withdraw liquids) that appeared used was secured to the bottle by a rubber band. LN E acknowledged a syringe that was placed in a resident's mouth should not be reused or stored in a drawer used by multiple staff members to prevent potential spread of infection to residents and staff. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON acknowledged concern that a disposable medication syringe was saved for reuse and stored uncovered in a TC 2 drawer. The DON stated education would be provided to the nursing staff. A review of P&P titled Storage of Medications, dated 10/2023, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. A review of Policy and Procedure (P&P) titled Administering Medications, dated 10/2023, indicated staff follows established facility infection control procedures for the administration of medications as applicable. 4. During concurrent observation of medication preparation and administration and interview with Registered Nurse A (RN A) on 8/27/24 at 11:10 am, observed an opened, undated bottle of glucose test strips (strips inserted into a device that measures blood sugar levels). RN A acknowledged she opened the bottle the day prior and should have written an Opened on date for discard one month after opening. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON acknowledged opened test strip bottles required an Opened on date per professional standards and manufacturer instructions to prevent use of an ineffective or less effective product. 5. During concurrent observation of medication preparation and administration and interview with RN A on 8/27/24 at 11:10 am, observed four loose pills in medication drawers of MC A and four loose pills under the drawers of MC A. RN A acknowledged loose pills create a risk for medication diversion and should have been disposed of/removed from the cart. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON verified loose pills should not be present in medication carts and should have been disposed of/removed to prevent medication diversion and/or misuse. A review of P&P titled Storage of Medications, dated 10/2023, indicated D&Bs are stored in the packaging, containers, or other dispensing systems in which they are received. Nursing staff is responsible to maintain medication storage and preparation areas in a clean, safe, and sanitary manner. 6. During concurrent observation of contents of TC 1 and TC 2 and interview with LN E on 8/27/24 at 11:35 am, observed a bottle of ketoconazole shampoo 2% with expiration date of 7/2023. LN E stated the shampoo was being administered to a resident but acknowledged the expired shampoo should have been discarded and the medication refilled to assure full effectiveness. During an interview with the Director of Nursing (DON) on 8/29/24 at 11:38 am, the DON verified that expired medications should not be administered to residents, and the expired shampoo should have been discarded and a refill requested. A review of P&P titled Storage of Medications, dated 10/2023, indicated discontinued, outdated, or deteriorated drugs and biologicals are placed in designated appropriate bins for destruction. 7. During concurrent observation of contents of TC 2 and interview with RN A on 8/27/24 at 11:45 am, observed an expired IV extension set with filter, dated 9/1/23. RN A acknowledged the product was expired and should not be used to administer medications to a resident. RN A stated the RNs and the DON clean the carts together to assure there are no expired products in the carts. During an interview with the DON on 8/29/24 at 11:38 am, the DON verified expired medication supplies should be discarded and replaced. During an interview with DON, Administrator (ADM), and Administrator in Training (AIT) on 8/29/24 at 4:34 pm, DON and ADM acknowledged all concerns above and stated education would be provided to nursing staff. 8. During concurrent observation of locked Medication Room and interview with Housekeeping Supervisor (HSK) on 8/27/24 at 12:36 pm, HSK unlocked the Medication Room for state surveyors with a key in her possession. HSK stated she is not a licensed nurse. Observation of the Medication Room indicated three Emergency Medication Kits (E-kit - a small amount of potentially dangerous medications for emergency situations when pharmacy services are unavailable) on the counter. The E-kits were secured with easily breakable plastic locks. Three unlocked cupboards contained potentially hazardous medications and supplements. During an interview with the Director of Nursing (DON) on 8/27/24 at 12:59 pm, the DON verified HSK was issued a key to the locked Medication Room and was not a licensed nurse. DON stated HSK was responsible for Central Supply and had a key to clean and stock supplies in the Medication Room. During an interview with HSK on 8/28/24 at 9 am, HSK acknowledged that a nurse must be present with her when she enters the Medication Room. HSK stated she unlocks the door for nurses because they may not have immediate access to a key. During an interview with the DON on 8/29/24 at 11:38 am, DON acknowledged the potential for drug diversion by unlicensed staff having access to facility medications. DON stated she would discuss HSK having a key to the Medication Room with the team. During an interview with the DON, Administrator (ADM), and Administrator in Training (AIT) on 8/29/24 at 4:34 pm, ADM stated their policy indicated HSK can go in the Medication Room if a nurse is present. ADM stated he did not believe it was a violation of policy for HSK to have a key. During a review of Policy and Procedure (P&P) titled Storage of Medications, dated 10/2023, the P&P indicated the facility stores all drugs and biologics in a safe, secure, and orderly manner. The P&P indicated: A. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. B. Only persons authorized to prepare and administer medications have access to locked medications. C. Access to controlled medications is limited to authorized personnel. During a review of facility document titled Job Description: Registered Nurse (RN), undated, the record indicated nursing care and equipment/supply functions include: A. Ensuring nursing service work areas, including medication preparation rooms, are maintained in a clean and sanitary manner, B. Ensuring an adequate stock level of medications and medical supplies, and C. Ensuring that only trained and authorized personnel operate the nursing service department's equipment.

Based on observation, interview, and record review, the food and nutrition services department failed to provide food that was palatable (good temperature, tasted good) when residents from a confidential interview and 11 out of 22 sampled residents (Residents 5, 16, 28, 30, 37, 38, 43, 45, 57, 59, and 215) stated the food did not taste good and was cold. This failure had the potential for unintended weight loss. Findings: A review of the facility's undated policy and procedure titled, Meal Service, indicated, Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. A review of the undated Admission Record, indicated, Resident 57 was admitted to the facility on [DATE] with the diagnoses of type 1 diabetes and type 2 diabetes (body could not regulate the amount of sugar in the blood). Resident 57 was her own responsible party (RP, made own decisions). A review of Resident 57's Minimum Data Set (MDS, an assessment), dated 7/20/24, indicated, Resident 57 had good cognition (ability to remember). During an interview on 8/27/24 at 3:37 pm, Resident 57 stated, sometimes the hot food was served cold and this morning the eggs and toast were cold. A review of Resident 45's undated Admission Record, indicated, admission to the facility on [DATE] with the diagnoses of gastro-esophageal reflux disease (stomach acid backs up into the tube that connected the stomach to the throat) and anemia (a lack of iron that caused the body to produce less red blood cells). Resident 45 was her own RP. A review of the MDS, dated [DATE], indicated, Resident 45 was cognitively intact. During an interview on 8/27/24 at 3:47 p.m., Resident 45 stated, the food reminded her of hospital food, did not like it, and the hot food was often cold. A review of the undated Admission Record, indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses of dysphagia (trouble swallowing) and oral impaired glucose tolerance (higher than normal blood sugar levels but did not meet criteria to be diagnosed with diabetes). Resident 5 was not her own RP. A review of Resident 5's MDS, dated [DATE], indicated, Resident 5 had good cognition. During an interview on 8/28/24 at 7:41 a.m., Resident 5 stated, the food was terrible, cold, and looked like my cat or dog went to the bathroom out in the yard. During a concurrent observation and interview, during a taste test of the lunch that was served to residents on 8/29/24 at 1:05 p.m., Certified Dietary Manager (CDM) took the temperature of each food item on two test trays. The temperature of the regular textured French fries was observed to be 105 degrees ( ) Fahrenheit (F), was chewy, did not taste good, and was barely warm. The pureed (smooth and thick like pudding) textured French fries was observed to be 105 F and was barely warm, the pureed fish was observed to be 114 F and was barely warm. The pureed corn was observed to be 120 F and was barely warm. The facility's Food Service Support (FSS), CDM, and Registered Dietician (RD) were all present and participated with the taste test. FSS confirmed, the regular textured French fries were gummy. The CDM and RD both stated, there was not an issue with the temperature of the food during the taste test. RD stated the regular textured French fries tasted good and compared them to the quality of a well-known fast-food restaurant. Both RD and CDM stated, unawareness that the residents of the facility were unhappy with the taste and temperature of the food. 43031 A review of Resident 215's medical record indicated that Resident 215 was admitted on [DATE] with diagnoses that included, displaced fracture of shaft of left clavicle, Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung diseases that block airflow and make it difficult to breathe), Cerebrovascular event history (stoke, blood flow to the brain is lost damaging brain tissue). The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 8/18/24, indicated Resident 215 rates 15/15, which equates to being cognitively intact. During an interview on 8/27/24 at 1:00 pm, with Resident 215 in their bed in their room, Resident 215 stated Food is terrible. It is often cold. It tastes bad. They put on way too much salt. It is always the same. I don't want to always eat the same thing all the time. A review of Resident 16's medical record indicated that Resident 16 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy (a brain dysfunction that occurs when the body's metabolism is affected and leads to chemical imbalances), COPD, and Respiratory Failure (not enough oxygen passes from the lungs to the blood). The MDS BIMS score, Section C assessing cognitive function) dated 8/5/24, indicated Resident 16 rates 15/15, which equates to being cognitively intact. During an interview on 8/28/24 at 11:30 am ,with Resident 16 lying in their bed in their room, Resident 16 stated, The food is not good. Everyday I get something that doesn't taste good or is a problem with my stomach issues. A review of Resident 28's medical record indicated that Resident 28 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy, Squamous Cell Carcinoma of left ear (cancer), COPD. The MDS BIMS score dated 5/24/24, indicated Resident 28 rates 7/15, which equates to severe cognitive impairment. During an interview on 8/28/24 at 4:00 pm, with Resident 28 in their bed in their room, Resident 28 stated, Food is terrible, taste and texture. During a confidential interview on 8/29/24 at 1:30 pm, with Resident Council members, four of nine sampled residents stated that meals were often cold, especially for those eating in their rooms and last to receive trays, and meals are lacking in taste. One of nine sampled residents stated the food was visually displeasing, looks like a dog turd. Three of nine sampled residents concurred that slow eaters were not given enough time to eat, and their food would be removed. One of nine residents stated there was not enough food provided. 49934 A record review of Resident 30 indicated she was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and makes it difficult to breathe), diabetes (a disease that occurs when the body doesn't produce enough insulin (a hormone that regulates sugar in the blood) or can't use insulin properly), end stage renal disease, (a medical condition where the kidneys permanently stop working) and is dependent on dialysis (process of removing excess water, chemicals, and toxins from the blood by a machine). Resident 30's Brief Interview for Mental Status (BIMS, evaluation of mental function), dated 08/05/2024, score was 10, which indicated a moderate mental impairment. Resident 30 is her own responsible party; she makes her own decisions. During an interview on 08/27/24 at 11:34 am, Resident 30 stated that the Food is crap! The chicken tastes like rubber! A record review of Resident 37 indicated she was admitted on [DATE] with diagnoses of a fracture at the right humerus, chronic kidney disease, and secondary parkinsonism (a condition that causes symptoms similar to Parkinson's Disease (a disorder that affects the nervous system and parts of the body controlled by nerves) but is caused by an underlying medical condition or external factor). Resident 37's Brief Interview for Mental Status (BIMS, evaluation of mental function), dated 08/12/2024, score was 15, which indicated no mental impairment. Resident 37 is her own responsible party; she makes her own decisions. During an interview on 08/27/24 at 10:51 am, Resident 37 stated that the Food is awful. It is way over-cooked! The veggies are mushy, potatoes are instant, breakfast is blah and it's the same thing every day- eggs and toast. 40425 A review of Resident 59's medical record indicated that Resident 59 was admitted on [DATE] with diagnoses that included, muscle weakness, difficulty walking, infection, and inflammatory reaction due to other internal joint prosthesis. During an interview on 08/27/24, at 1:30 p.m., with Resident 59, Resident 59 stated, The food is terrible and doesn't taste good. It has no flavor. A review of Resident 38's medical record indicated that Resident 38 was admitted on [DATE] with diagnoses that included, diabetes, irregular heartbeat, muscle weakness, and difficulty walking. During an interview on 8/27/24, at 1:45 p.m., with Resident 38, Resident 38 stated, The food has no flavor, and it doesn't taste good. A review of Resident 43's medical record indicated that Resident 43 was admitted on [DATE] with diagnoses that included, Depression, muscle weakness, difficulty walking, and dementia. During an interview on 8/27/24, at 2:15 p.m., with Resident 43, Resident 43 stated, the food sucks.

Based on interview and record review, the facility failed to report an allegation of abuse to local, state, and federal agencies, including the California Department of Public Health (CDPH), when Certified Nurse Assistant (CNA) E stated, CNA E observed Resident 48 shaking a fist and making verbal threats to harm Resident 50. This failure placed all residents at risk for allegations of abuse to go unreported. Findings: A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised 7/1/17, indicated, reports of alleged abuse would be reported to local, state, and federal agencies. A review of the facility's P&P titled, Abuse Prevention Program, revised 2/1/24, indicated, residents had the right to be free from abuse. A review of the State Operation Manual, revised 8/8/24, defined abuse as a willful infliction that included verbal abuse or intimidation, which could affect a person's psychosocial well-being. A review of the undated Admission Record, indicated, Resident 48 was admitted to the facility on [DATE] with the diagnoses of muscle weakness, difficulty in walking, and major depressive disorder, single episode, with psychotic features (A distinct type of depression that could cause hallucinations or delusion while in a depressive episode). Resident 48 was not his own responsible party (RP) and had a public guardian that made decisions for him. A review of Resident 48's Minimum Data Set (MDS, an assessment tool), Section C-Cognitive Patterns, (a memory assessment), dated 7/31/24, indicated, Resident 48's cognition was moderately impaired (decline in memory, thinking, and judgement). A review of Resident 50's undated Admission Record, indicated, admission to the facility on [DATE] with the diagnoses of Alzheimer's disease (inability to remember), anxiety (feelings of fear and dread), depression, and obsessive-compulsive disorder (uncontrolled and recurring thoughts, repetitive behaviors, or both), and was on hospice (six months or less left to live and received care focused on comfort). Resident 50 was not his own RP and did not make his own decisions. A review of Resident 50's MDS, Section C-Cognitive Patterns, dated 7/16/24, indicated, Resident 50 had severe cognitive impairment. Section E-Behavior, dated 7/23/24, indicated, Resident 50 wandered (roamed from place to place), and Resident 50's wandering did not intrude on the privacy or activities of others. During an interview on 8/28/24 at 8:04 a.m., Resident 48 stated, Resident 50, who was Resident 48's roommate, would come over to Resident 48's side of the room and touch Resident 48's arm and has been doing so since Resident 50 was admitted to the facility. Resident 48 stated, telling facility staff about Resident 50's behaviors and facility staff had not done anything about it. Resident 48 stated, not liking Resident 50 touching him. Resident 48 stated, the facility better do something soon though, I'm going to hurt him. During an interview on 8/28/24 at 2:50 p.m., CNA E confirmed, Residents 48 and 50 were roommates. CNA E stated, Resident 48 and Resident 50 did not like each other. CNA E stated, on 8/27/24, Resident 48 tried to get into Resident 50's face, used a fist, and threatened to hit Resident 50. CNA E stated the incident was reported to Licensed Nurse (LN) A. During an interview on 8/28/24 at 2:57 p.m., CNA F stated, on 8/27/24 at approximately 2:45 p.m., CNA F was transferring Resident 48 into bed from the wheelchair. CNA F stated, during the transfer, Resident 50 had a smile on his face and was waving at Resident 48. CNA F stated, Resident 48 got mad and tried to walk over to Resident 50. CNA confirmed, Resident 48 made a verbal threat to Resident 50 that involved physical abuse. CNA F stated, she reported the incident to LN A. During an interview on 8/28/24 at 3:04 pm, LN A confirmed, there was an incident between Resident 48 and Resident 50 that occurred on 8/27/24. LN A stated, she was told Resident 48 had a fist pulled up as if he was going to hit Resident 50. LN A stated, reporting the incident the Director of Nursing (DON). During an interview on 8/29/24 at 10:20 a.m., DON stated, facility staff did not notify DON of the incident between Residents 48 and 50 that had occurred on 8/27/24. DON stated, not being notified until CDPH staff brought it to DON's attention. DON stated, staff expectancy for allegations of abuse included notifying the DON. DON stated, the DON would then report the allegation of abuse to the abuse coordinator who was the facility's Administrator. DON confirmed, the allegation of abuse was not reported to local, state, and federal agencies, including CDPH.

Based on interview and record review, the facility failed to revise care plans (a document that described health conditions, the level of care the resident required, and how that care would be provided) for two out of two sampled residents (Residents 34 and 50) when: 1. Resident 34's care plan was not revised to include wandering behaviors (roaming from place to place). 2. Resident 50's care plan was not revised to include a change in wandering behaviors. This failure had the potential to cause a decline in physical, mental, and psychosocial well-being and placed Residents 34 and 50 at risk for harm. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive, indicated, the care plan would Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated, the care plan would Incorporate identified problem areas and that care plans would be revised when resident information changed. A review of Resident 34's undated Admission Record, indicated, admission to the facility on [DATE] with the diagnoses of seizures (uncontrollable shaking of the body) and down syndrome (a genetic condition that changed how the body and brain developed). Resident 34 was not his own responsible party (RP, did not make own decisions about care). A review of Resident 34's Minimum Data Set (MDS, an assessment tool) dated 8/7/24, indicated, Resident 34 did not wander. A review of Resident 34's care plans, dated 8/3/24 through 8/23/24, indicated, there was no care plan in place for Resident 34's wandering behavior. A review of Resident 46's MDS, dated [DATE], indicated Resident 46 was admitted to the facility on [DATE] with the diagnosis of a multidrug-resistant organism (in infection that many antibiotics did not cure). The MDS indicated, Resident 46 had good cognition (ability to remember and think). During an interview on 8/27/24 at 10:45 a.m., Resident 46 stated, Resident 34 often wandered into Resident 46's room. During an interview on 8/27/24 at 11:27 a.m., Resident 267 stated, Resident 34 would wander into Resident 267's room. Resident 267 stated, facility staff would have to remove Resident 34 from the room, and sometimes, it bothered Resident 267. A review of Resident 35's MDS, dated [DATE], indicated, Resident 35 was admitted to the facility on [DATE] with the diagnoses of anxiety and depression. The MDS indicated, Resident 35 had good cognition. During an interview on 8/27/24 at 11:39 a.m., Resident 35 stated, Resident 34 wandered into Resident 35's room and Resident 35 would have to tell Resident 34 to leave. 2. A review of Resident 50's undated Admission Record, indicated, admission to the facility on [DATE], with the diagnoses of Alzheimer's disease (inability to remember), anxiety (feelings of fear and dread), depression, and obsessive-compulsive disorder (uncontrolled and recurring thoughts, repetitive behaviors, or both), and was a hospice resident (six months or less left to live and received care focused on comfort). Resident 50 was not his own RP and did not make his own decisions. A review of Resident 50's MDS, dated [DATE], indicated, Resident 50 had severe cognitive impairment, wandered, and wandering did not intrude on the privacy or activities of others. A review of Resident 50's care plan titled, Elopement, dated 7/10/24, did not indicate Resident 50 wandered into other resident rooms. During an interview on 8/27/24 at 11:27 a.m., Resident 267 stated, Resident 50 would wander into Resident 267's room. Resident 267 stated, facility staff would have to remove Resident 50 from the room, and sometimes, it bothered Resident 267. During an interview on 8/28/24 at 8:04 a.m., Resident 48 stated, Resident 50 was his roommate and Resident 50 would wander into Resident 48's side of the room and touch Resident 48's arm. Resident 48 stated, reporting Resident 50's wandering behavior to staff in the past and nothing had been done about it. Resident 48 stated, he did not like it when Resident 50 did that and if staff did not do something about it, Resident 48 would hurt Resident 50. During an interview on 8/28/24 at 2:50 p.m., CNA E confirmed, Residents 34 and 50 wandered into other resident rooms. CNA E stated, awareness that there were issues between Resident 48 and his roommate Resident 50 and in the past, Resident 48 had made verbal threats to hurt Resident 50. CNA E was asked about care plans and interventions that were in place regarding Residents 34 and 50 wandering into other resident rooms. CNA E stated, unawareness of care plans or interventions. During an interview on 8/28/24 at 2:57 p.m., CNA F confirmed, Residents 34 and 50 wandered the facility. CNA F confirmed, Resident 34 wandered into other resident rooms and required redirection. During an interview on 8/27/24 at 3:04 p.m., Licensed Nurse A confirmed, Resident 34 and Resident 50's wandering behaviors and stated the Director or Nursing (DON) had been notified. During a concurrent interview and record review on 8/29/24 at 10:20 a.m., with the facility's DON, the care plans for Resident 34 were reviewed. DON confirmed, there was no care plan in place for Resident 34's wandering behaviors. DON stated, having no awareness that Resident 34 wandered into other resident rooms and staff should have reported that information to her. DON stated, Resident 50 wandered the facility but had no awareness that Resident 50 wandered into other resident rooms. Resident 50's care plan titled, Elopement, dated 7/10/24 was reviewed. DON confirmed, there were no interventions in place for Resident 50 regarding wandering into other resident rooms. DON stated the expectancy was for staff to notify the DON when there were changes with residents so the DON could assess the resident and revise the care plan as needed.

Based on observation, interview, and record review the facility failed to ensure that residents' pain was managed for 1 of 30 residents (Resident 216) sampled for pain management when Resident 216 complained of having pain in their ribs and low back while making facial expressions and exhibiting body movements that demonstrate signs related to the experience of pain. Resident 216 was unable to verbalize a specific number to represent the level of pain being experienced per the Pain Scale (standardized numeric scale to identify an individual's pain level. Scale rates pain from 0-10; 0 = no pain to 10 = most severe pain). Thus, Resident 216 did not receive pain medication per the medical doctor's (MD) orders. This failure had the potential to result in an overall increase of pain, decline in mobility, increased health issue complications, and diminished mental, emotional, and psychosocial well-being. Findings: During a review of the facility's policy and procedure titled, Pain Assessment and Management, dated April 2024, the Pain Assessment and Management policy indicated, The purpose of this procedure are to help the staff identify pain in the resident .Observe the resident for signs and symptoms of pain .Possible Behavioral Signs of Pain: a. Verbal expressions of pain. b. Facial expressions such as grimacing, frowning .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Implement the medication regimen as per physician's orders . a physician, shall reconsider approaches and make adjustments if indicated to meet any further pain needs. A review of Resident 216's medical record indicated that Resident 216 was admitted on [DATE] with diagnoses that included, fractured lumbar vertebrae and multiple fractured ribs, Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung diseases that block airflow and make it difficult to breathe), and Dementia (loss of brain function such as memory, language, problem solving and other thinking abilities). The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 8/28/24, indicated Resident 216 rates 3/15, which equates to severe cognitive impairment. Resident 216 is not their own representative (RP) and does not make their own medical decisions but can verbalize needs and preferences. During a concurrent observation and interview on 8/28/24 at 09:00 am with Resident 216 in the hallway outside of the resident's room while in a wheelchair being pushed by Licensed Nurse (LN) C. Resident 216 was rocking backward and forward in the wheelchair holding their left side ribs, demonstrating facial grimacing, furrowed brow, and frowning while holding their forehead in their other hand. Resident 216 stated they were having quite a bit of pain in their ribs and back. During an interview on 8/28/24 at 09:10 am with LN C in the hallway outside the Resident 216's room while LN C was pushing Resident 216 in a wheelchair, LN C acknowledged Resident 216 was having pain, that they had fallen at home and broken ribs and their low back which is why Resident 216 was admitted to the facility. LN C stated they would wait for the Medication Cart Nurse, LN D, to have a moment and get pain medication if available to give to Resident 216. During an observation on 8/28/24 at 09:15 am, at the end of the hallway by the medication cart, LN C and Resident 216 in a wheelchair were observed waiting to address LN D, the medication cart nurse. LN D and, LN C asked Resident 216 repeatedly to give a numeric pain scale number from 0-10 to represent their pain. Resident 216 was having difficulties identifying and verbalizing a numeric value, but 10 was heard at one point by surveyor. LN D determined the routine Tylenol had already been administered and the only other pain medication ordered per LN D's review of the Medication Administration Record (MAR, record where medication administration is documented) was Oxycodone (strong pain medication). LN C and LN D continued to request Resident 216 verbalize a pain scale number from 0-10. LN C and LN D spoke privately and then LN C wheeled Resident 216 away from the medication cart without having any pain medication oral (by mouth) or transdermal (applied to skin) administered. During a record review of Resident 216's Order Summary, dated August 2024, the Order Summary indicated that Acetaminophen (APAP, Tylenol) capsule 500 milligrams (mg, unit of measurement) was ordered to be given routinely as follows: Give 2 tablets by mouth every 8 hours for pain not to exceed (NTE) 3 grams (gm, unit of measurement) APAP in 24 hours from all sources. During a record review of Resident 216's MAR, the MAR indicated that Acetaminophen was administered to Resident 216 on 8/28/24 at the following times: 08:00 am was administered, 13:00 (1:00) pm was refused by resident, and 2100 (9:00) pm was administered. Start date 8/25/24. During a record review of Resident 216's Order Summary, dated August 2024, the Order Summary indicated that Oxycodone Hydrochloride (Oxycodone HCl, strong pain medication) 5 mg tablet was ordered to be given as follows: 1 tablet by mouth every 4 hours as needed for pain 6-10 for 3 days hold for respiratory rate (RR) less than (<)12. Start date 08/25/24. During a record review of Resident 216's MAR, dated August 2024, the MAR indicated Resident 216 received Oxycodone on 8/28/24 at 17:08 (5:08) pm for a pain level of 7. During a record review of Resident 216's Order Summary, dated August 2024, the Order Summary indicate that Lidocaine patches (pain medication infused in a patch form that is applied to the skin) 4 percent (%, quantitative measurement) were ordered to be applied as follows: apply to left (L) lateral side for rib pain in the morning, and Lidocaine patch 4% apply to low back in the morning for low back pain. Start date 8/26/24. During a review of Resident 216's MAR, dated August 2024, the MAR indicated Resident 216 refused the Lidocaine patches for 8/28/24. During an interview on 8/28/24 at 4:35 pm with LN B at the medication cart in the hall by a resident's room. LN B stated Resident 216 is a new admission, has pain but is confused, alert, but not oriented. Because of his dementia he refuses some of his pain medication. Resident 216 is not always able to verbalize pain per the numeric pain scale with a 0-10 response, but I would use the face and body assessment based on the grimacing, frowning, rocking, holding their side and guarding while holding their forehead, along with the mumbling, moaning, or making statements about having quite a bit of pain to determine the pain level. I would think it would be a higher level of pain if most of these actions were observed, probably at least a 6 or 7. It is a pain assessment for advanced dementia (PainAD, Assessment tool that monitors dementia/nonverbal residents for labored breathing, moaning/groaning, facial expressions, tense body language, and consolability to determine resident pain) that I would use. During an interview on 8/29/24 at 11:30 am with DON in the conference room. DON confirmed the painAD should have been utilized if the resident could not verbalize a numeric figure to represent their pain. The assessment looks at facial expressions, grimacing, frowning, moaning, and behaviors such as rocking, clenching fists, holding, or guarding an area. DON concurs staff will receive more training on identifying or recognizing pain and managing it adequately especially for dementia residents. 49418 A review of Nursing Note written by LN C, dated 8/28/24 at 9:04 am, indicated Resident 216 had his toes run over by a wheelchair this morning, but resident did not appear in pain. During observation of medication administration on 8/28/24 at 9:15 am, LN C stated Resident 216 bumped his foot and asked LN D if Resident 216 could have Tylenol. Resident 216 was wearing socks on his feet, seated in a wheelchair and observed to rock back and forth, head in his hands, rubbing his left side, and making facial grimaces. LN C asked Resident 216 multiple times to rate his pain on a scale of 1 to 10; the pain scale was not explained to the resident, who appeared to be confused by the question. Resident 216 stated, I don't know, 10. LN D reviewed Resident 216's medication list and stated Resident 216 had received a dose of scheduled Tylenol that morning, and the only other medication available was oxycodone (an opioid pain-relief medication for moderate to severe pain). LN D again asked Resident 216 to rate his pain on a scale of 1 to 10, and Resident 216 replied, I don't have any. No medication was given, and Resident 216 was taken away by LN C. During an interview with LN C on 8/28/24 at 10:51 am, LN C stated she brought Resident 216 to LN D because he hit his toe on his wheelchair and was in pain. LN C stated he also fell recently and had pain from fractured ribs. LN C acknowledged Resident 216 did not receive any pain medication and stated he wasn't showing pain. A review of Resident 216's Medication Administration Record (MAR), dated 8/1 to 8/31/24, printed 8/29/24 at 12:52 pm, indicated Resident 216 refused all ordered lidocaine patches to left side and low back since admission; received Tylenol 10 times since admission but refused scheduled doses at 1 pm on 8/25 and 8/28/24; denied having pain 10 times since admission, with one report of 1 out of 10 pain on morning shift 8/28/24; nonpharmacological pain interventions of repositioning/limb elevation seven times and rest period/quiet environment 11 times since admission; and oxycodone 5 mg was given three times for severe pain 7 out of 10 on 8/26/24 at 7:24 am, 8/26/24 at 9:55 pm, and 8/28/24 at 5:08 pm. During concurrent interview with LN D and review of Resident 216's active orders on 8/28/24 at 2:52 pm, LN D stated Resident 216 had complained of left rib pain but had refused pain medications. LN D stated he did not give Resident 216 oxycodone for pain at 9 am because the resident couldn't give him a pain scale and LN D didn't think [Resident 216] was in pain. LN D acknowledged that the lidocaine patches scheduled at 9 a.m. were not offered because Resident 216 refuses those. LN D acknowledged Resident 216 had received only one dose of Tylenol for pain relief. During an interview with LN C and LN D on 8/28/24 at 3:08 pm, LN C stated the protocol when residents refuse ordered medications is to ask the resident three times to take the medication, explain the risks and benefits, and if the resident still refuses, the doctor will be informed. LN C and LN D acknowledged they had not notified anyone that Resident 216 had frequently refused pain medications since admission. A review of P&P titled Change in a Resident's Condition or Status, dated 4/2024, indicated the nurse will notify the resident's physician/nurse practitioner/physician assistant when there has been a(an) refusal of treatment or medications. During concurrent observation and interviews with Resident 216 and Activities Assistant 1 (AA 1) on 8/28/24 at 3:17 pm in the dining area, observed Resident 216 sitting in a wheelchair near other residents during Activities (Bingo). Resident 216 was not participating but was observed fidgeting with the drawstring of his sweatpants, a plastic bracelet on his wrist, and lifting his T-shirt to intermittently rub his left side. When questioned about pain, Resident 216 stated his side hurt and pointed to his left ribs. Informed Resident 216 he had pain patches that could be applied by nursing staff. Resident 216 stated he needed to remove the patch from his wrist and took off his bracelet. AA 1 stated she believed Resident 216 was in pain because he had been verbalizing ow and grimacing throughout the activity. During an interview with the DON on 8/29/24 at 11:38 am, discussed the observation of Resident 216, LN C, and LN D on 8/28/24 at 9:15 am, with the result being no pain medication given. The DON stated, That's so frustrating. The DON stated she would provide education to nursing staff regarding the Pain Assessment in Advanced Dementia Scale (PAINAD - an assessment tool that monitors dementia/nonverbal residents for labored breathing, moaning/groaning, facial expressions, tense body language, and consolability). During an interview with DON, Administrator (ADM), and Administrator in Training (AIT) on 8/29/24 at 4:34 pm, the DON stated the MD was here 8/28/24 and was made aware that not all pain medications were being administered to Resident 216 despite indications of pain. The DON again stated she was frustrated that nursing staff did not recognize Resident 216's nonverbal indications of pain and would re-educate staff to the PAINAD scale.

Based on observation, interview and record review, the facility failed to have an effective Pressure Ulcer (PU- bedsore, injury to skin and underlying tissue resulting from prolonged pressure on the skin, usually over a bony prominence) prevention program to prevent the development of avoidable new or recurring PUs for eight of 18 sampled residents (Residents 1, 5, 9, 10, 11, 13, 16, and 17) by failing to ensure complete, accurate resident assessments and individualized, comprehensive planned care interventions to prevent PU development/progression and promote wound healing when: 1. Resident 1 developed two avoidable Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed. May also present as a blister) PUs on her tailbone and right buttock. The facility failed to ensure complete and accurate assessments, pressure relieving interventions, re-evaluate PU risk, and develop individualized planned care interventions, in the presence of weight loss, decreased mobility, and increased urinary incontinence which placed Resident 1 at greater risk for developing PUs. 2. Resident 11 had a Stage II PU on the coccyx (tailbone) that progressed to an Unstageable PU (Unstageable PU is defined as a full thickness tissue loss with the depth of the ulcer obscured by slough or eschar (yellow tissue or brown, black scab tissue) in the wound bed, that once removed will show a Stage III or IV PU) on the tailbone. The facility failed to ensure complete and accurate assessments for skin integrity, nutritional needs, mobility, and incontinence status and develop individualized planned care interventions to prevent the PU progression. 3. Resident 17 had a Stage II PU on the left buttocks that resolved, but re-developed. The facility failed to ensure complete and accurate assessments for skin integrity, nutritional needs, PU evaluation, PU risk re-evalutaion, and develop and implement individualized planned care interventions to prevent the PU recurrence. 4. Resident 13 developed two facility acquired Stage II PUs on the tailbone and left heel. The facility failed to ensure complete and accurate PU risk assessment and develop and implement individualized planned care interventions to prevent the PUs development. 5. Resident 9 developed two facility acquired Unstageable PUs on the right calf and heel. The facility failed to ensure PU risk assessment upon admission, complete and accurate skin integrity, mobility, and nutritional assessments, appropriate application and removal of a leg brace, and develop and implement individualized planned care interventions to prevent the PUs development. 6. Resident 16 developed a facility acquired Stage II PU on the left inner thigh. The facility failed to ensure complete and accurate PU risk assessments and re-assess PU risk after discovery of the new PU. 7. Resident 5 had a right buttock Stage I PU. The facility failed to ensure complete, accurate skin integrity and nutritional assessments. 8. Resident 10 developed a facility acquired Unstageable PU on the left ankle. The facility failed to ensure complete, accurate skin integrity and nutritional assessments. These failures resulted in actual harm to residents caused by the development of avoidable PUs, and had the potential for residents to develop further PUs, wound progression and infection, pain/discomfort, and other related adverse clinical outcomes, including death. Findings: Review of the facility's undated policy titled, The Skin Care Management System, indicated, Residents with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The Practice Guidelines section showed that residents were to be assessed for skin integrity upon admission with a head to toe physical assessment of the skin and Braden Scale (tool used to assess risk of PUs) and the Braden Scale was to be completed with each minimum data set (MDS, a standardized assessment); Preventative surfaces were to be implemented on residents with a high risk; Wounds were to be tracked on the Weekly Report of Pressure Ulcers that is reviewed and maintained by the Director of Nurses (DON); A nutritional assessment would be completed within 72 hours of admission and/or a change in the skin integrity; Skin impairments would be evaluated by the Registered Dietitian (RD) in a timely manner; Assessments would be reviewed by a Multidisciplinary Action Team weekly and treatment recommendations would be made; Skin assessments would be documented weekly on Treatment Records (TARs); and treatments and care plans would be checked for appropriateness. 1. Resident 1 was admitted to the facility on [DATE], from the acute care hospital, with [DIAGNOSES REDACTED]. The facility's admission MDS, dated [DATE], showed she was at risk for but did not have PUs. The acute care hospital's SNF (skilled nursing facility) Transfer form, dated 5/21/14, showed Resident 1 had pink, undamaged skin and no PUs at the time of transfer to the facility. The facility's Resident-Data Collection admission assessment, dated 5/21/14, confirmed Resident 1 did not have PUs upon admission to the facility. Resident 1's physician's admission orders [REDACTED] Resident 1's nurse note, dated 5/22/14 at 10:10 pm, showed she had fluid filled pustules (blisters) on her coccyx (tailbone and common area for PUs) and the left upper quadrant of her right buttock. A fluid filled blister is a Stage II PU. Resident 1's Skin Integrity, Impaired Pressure Ulcer care plan, dated 5/29/14, identified a Stage 1 (non-blanchable (skin loses redness when pressed on) area) PU on her right buttock. There were no updates or other dated entries to the care plan. Resident 1's TARs included the order for weekly skin assessments and were left blank on 5/28/14, 6/30/14, 9/22/14, 10/13 and 10/27/14. Resident 1's weekly skin assessment for 6/2/14 showed her skin was open (meaning not intact). Resident 1's Nursing Assistant Daily Flow Sheets for 5/14, 6/14, 7/14, and 8/14 were all left blank in the section marked Turning and Repositioning per care plan. Resident 1's nurses note, dated 6/2/14 at 11 pm, read, Area on buttocks healing well. A nurses note, dated 6/4/14, showed Resident 1 had lost 9.6 pounds the first week at the facility. Resident 1's Nursing Assistant Daily Flow Sheets for the AM (morning) and PM (afternoon) shifts for June/2014 showed she had incontinent episodes starting 6/5/14 and became consistently incontinent most of the time from 6/10/14 on. Resident 1's physician's orders [REDACTED]. On 11/4/14 at 12:40 pm, Administrative Nurse (AN) A stated that Resident 1 stopped walking and refused to get up on 6/16/14, so her therapies were discontinued. AN A confirmed that Resident 1 becoming immobile, incontinent (loss of bladder and/or bowel control) and having significant weight loss, increased her risk for developing PUs. A concurrent review of Resident 1's Braden Scale, completed on 5/21/14, showed it had never been updated, nor had her risk for PU been reevaluated. AN A stated that Resident 1's PU risk should have been reassessed when her mobility, continence, and weight changed, and upon the development of her new PU on 5/22/14. On 11/4/14 at 2:35 pm, the facility's Registered Dietitian (RD) stated that weight loss contributes to PUs and she should have been contacted with Resident's 7.1% initial weight loss during her first week at the facility. On 11/4/14 at 4:40 pm, AN K stated the facility had just now put Resident 1's pressure relieving mattress on for the first time and that it should have been on since her PU risk change. AN K stated that Resident 1 should have had a significant change MDS done when she first lost weight, became immobile, became incontinent and developed a PU. 2. Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], from the acute care hospital, with [DIAGNOSES REDACTED]. The acute care hospital's SNF (skilled nursing facility) Transfer form, dated 11/3/14, showed Resident 11 had two Stage II PUs; One on her coccyx and one on her right hip, at the time of transfer to the facility. The facility's Resident-Data Collection admission assessment, dated 11/3/14, included a section for the facility to indicate PUs. Resident 11's Stage II PUs were not identified or assessed on the form. The Functional Status (mobility and ability to do things for oneself) and Bowel and Bladder (continence) evaluation sections were not completed and left blank. The facility physician's History and Physical for Resident 11, dated 11/4/14, identified a few stage 2 and stage 1 decubitis (PU). On 11/7/14 at 2:30 pm, Resident 11 was observed, slumped down in the bed with the back up at a 45 degree angle (head of the bed was elevated), putting most of the pressure on her coccyx area (the location of the PU). On 11/7/14 at 2:45 pm, AN A stated Resident 11's Bowel and Bladder assessments were not done and should have been started on 11/4/14 and finished on 11/7/14 (today). AN A confirmed that Resident 11's continence status affected her risk for PU development and worsening. On 11/10/14 at 11 am, Resident 11's Nutrition Screening form, dated 11/12/14, was concurrently reviewed with Dietary Services Supervisor (DSS). The Wounds section was left blank. The Food Preferences and Mobility sections were left blank. DSS confirmed she had missed the Wounds section and that the RD should have been notified promptly of Resident 11's PUs, following her admission. On 11/11/14 at 9:20 am, the surveyor informed CNA D that Resident 11 was observed slumped down in her bed with the back at a 45 degree angle, putting the pressure on her coccyx. CNA D stated that Resident 11 should have been laid flat to take the pressure off her coccyx. Resident 11's Wound Care Specialist (WCMD) Initial Evaluation, dated 11/4/14, identified the wound on her coccyx as a Stage II PU. Resident 11's Wound Care Specialist Evaluation, dated 11/11/14, identified the coccyx wound as Unstageable. Unstageable PU is defined as a full thickness tissue loss with the depth of the ulcer obscured by slough or eschar (yellow tissue or brown, black scab tissue) in the wound bed, that once removed will show a Stage III or IV PU. Resident 11's Skin Integrity, Impaired Pressure Ulcer care plan, dated 11/4/14, indicated a Stage II PU on her coccyx. There were no updates to Resident 11's care plan, following WCMD's evaluation on 11/11/14, that identified a deterioration of his coccyx PU to Unstageable. On 11/13/14 at 3:50 pm, the facility's WCMD was interviewed about Resident 11's PU. He confirmed that Resident 11's PU had deteriorated from a Stage II to a Unstageable (either a Stage III or IV underneath when dead tissue removed). 3. Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], then readmitted on [DATE] from the acute care hospital, after having a feeding tube (tube through the skin to the stomach) placed for nourishment. His [DIAGNOSES REDACTED]. The facility's Resident Transfer Form, dated 9/28/14, showed the facility was transferring Resident 17 to the acute care and that his skin was in good condition (intact). The facility's Resident Data Collection form, dated 10/2/14, showed an open area to Resident 17's left buttock (Stage II PU) upon admission from the acute care hospital to the facility. Resident 17's TARs included the order for weekly skin assessments, dated 9/22/14. The 9/28, 10/4, 10/19, 10/26, 11/9/14 weekly skin assessments were all left blank. The TARs showed the open area to his right buttock was resolved on 10/12/14. Resident 17's Weekly Pressure Ulcer Record showed an open area to his left buttock (Stage II PU) was discovered on 11/8/14. The facility's undated Nutritional Screening /Assessments/ Resident Care Planning policy read, The Dietary Services Supervisor will also chart on any resident with changes in weight, eating habits or skin problems as these problems arise. On 11/12/14 at 3 pm, DSS stated she was not aware of Resident 17's PU wounds when she did his Nutritional Progress Notes on 10/7/14. Resident 17's Registered Dietitian Nutrition Assessment, dated 10/6/14, did not include any information about an open wound on his buttocks. There was no information about the wound on his Nutritional Progress Notes between 10/2 and 11/7/14. On 11/13/14 at 9 am, RD stated she had not charted and was not aware of Resident 17's Stage II PU following his readmission to the facility 10/2/14. RD stated that she not received the facility's Weekly Skin Report-Pressure Ulcers until 11/11/14 which was concurrently reviewed. RD stated the facility had not provided them weekly until this. A review of Resident 17's Skin Integrity, Impaired Pressure Ulcer care plan, dated 9/22/14, did not show updated interventions for the Stage II PU on his buttocks, discovered at the time of his readmission on 10/2/14. There was no evidence in Resident 17's record that he had been seen by WCMD, following discovery of the Stage II PU on 10/2/14. On 11/13/14 at 10:20 am, Resident 17's Stage II PU was observed on his upper left buttock. On 11/13/14 at 9:10 am, AN A stated that Resident 17's weekly skin assessments were not found and his Skin Integrity, Impaired Pressure Ulcer care plan was not updated when he was readmitted on [DATE] with a Stage II PU. AN A stated that Resident 17's Braden Score should have been re-evaluated after he had the feeding tube placed on 9/18/14 and following hospitalization and readmission on 10/2/14 with the Stage II PU on his buttock. 4. Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a skin assessment, dated 10/20/14, the day of admission, and an MDS dated [DATE], Resident 13 did not have any PUs. A Nurse's Note, dated 11/7/14, indicated that two open PUs were found; one on Resident 13's coccyx (tailbone) and one on her left heel. A Physical Therapy Evaluation, dated 10/21/14, noted the resident as non-ambulatory (unable to walk). Nursing Assistant Flow Sheets, dating 10/20 to 11/10/14 indicated she was dependent or required extensive assistance with mobility. There was no documentation of turning or repositioning the resident. According to a Braden Scale (a tool for determining the risk of developing PUs), dated 10/20/14, Resident 13 walks occasionally, and was determined to be at low risk for PUs. During an interview on 11/10/14 at 1:55 pm, AN A confirmed the above, stating that Resident 13's Braden Scale was inaccurate. 5. Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The nurses notes, dated 9/10/14, indicated an open area was discovered on the back of Resident 9's right leg, under the leg brace. A wound care specialist evaluation, dated 9/16/14, indicated Resident 9 had developed a PU on the right calf on 9/10/14, and a PU on the right heel on 9/16/14 while residing in the facility. The weekly PU records were reviewed. They indicated Resident 9 had developed two pressure areas while in the facility. A right calf PU was discovered on 9/10/14 and on 9/16/14 was classified as unable to determine (UTD). A second PU on the right heel was discovered on 9/16/14 and also classified as a UTD. A UTD PU is described by the National PU Advisory Panel as an unstageable PU in which the actual depth of the wound is completely obscured by slough (dead tissue). After the dead tissue is removed to expose the base of the wound.it will be either a stage 3 or 4. Stage 3 is a full thickness loss of skin and underlying tissue. Stage 4 is a full thickness loss of skin and underlying tissue with exposed bone, tendon or muscle. The MDS assessment, dated 9/7/14, indicated Resident 9 was unable to walk or stand and required extensive assistance of two staff members to move around in bed, and transfer from her bed to a shower chair for showers. Resident 9 had impaired mobility on one lower extremity (hip, knee,ankle, foot) on one side of her body. The MDS care area worksheet, dated 9/10/14, after Resident 9 had developed a pressure area, identified Resident 9 was at increased risk for impaired skin integrity in the form of a pressure area due to being dependent on staff assistance to move around in bed and utilizing devices, such as a leg splint, that can cause pressure. The facility's undated policy titled, Skin Care Management System, indicated all residents at risk for skin compromise would be identified, assessed and provided appropriate treatment to maintain skin integrity. It indicated the facilities risk assessment method (Braden scale) would be completed upon admission and a care plan would be developed upon admission identifying contributing risks for skin breakdown and the interventions implemented. It also indicated a nutritional assessment would be completed within 72 hours of admission on all residents assessed as being at risk or with compromised skin integrity. The policy also stated all residents identified with skin impairment will be evaluated by a Registered Dietitian for nutritional status in a timely manner. The resident assessment (Braden scale) used for identifying a resident at high risk for developing impaired skin integrity was not completed for Resident 9 upon admission and not completed until nine days after Resident 9 was identified as having developed first one and then a second PU while in the facility. Resident 9's care plans were reviewed, the facility failed to develop a resident specific care plan to address Resident 9's impaired skin integrity risk and impaired mobility status. A risk for PU care plan was initiated on 9/10/14, after Resident 9 was identified as having developed a PU on her right calf. The care plan titled, Self care deficit, initiated 9/10/14, did not indicate Resident 9 had impaired mobility on her right leg. The care plan titled, Fracture, dated 9/12/14, did not indicate Resident 9 had a leg brace in use, no interventions to address leg brace use or care were developed. During an interview with Resident 9 on 11/6/14 at 10:50 am, she stated that prior to the facility identifying a PU on her right calf, the leg brace Kept rubbing on my leg. During an interview with Licensed Nurse (LN) B on 11/6/14 at 10:45 am, she stated she was a full time nurse for Resident 9 and Resident 9 had the right leg brace left on her right leg at all times, prior to the development of the right leg PU. LN B stated the leg brace was even left on during showers and wrapped to prevent it's getting wet. LN B stated the leg brace was not removed at all. The nutritional progress note, dated 9/22/14, twelve days after the identification of a pressure area on Resident 9's right calf inaccurately indicated the residents Skin (was) clear (free of any pressure or other type open areas). During an interview with the facility's Registered Dietician (RD) on 11/7/14, at 1:30 pm, she stated the facility had no system in place to routinely notify her of new wounds. She stated she reviews the treatment records for the entire facility to attempt to identify new wounds. RD stated she was not aware Resident 9 had two PUs when she evaluated Resident 9's nutritional needs on 9/22/14. During an interview with AN K on 11/6/14 at 10 am, she stated she would expect facility nurses to remove Resident 9's leg brace when she was in bed and not being mobile. AN K stated the leg brace should only be placed on Resident 9's leg when she was being moved as the physician had indicated in the order. AN K reviewed the record and was unable to find any documentation which indicated the leg brace had been removed, prior to the PU on her calf or that her heels had been floated up off the mattress to prevent pressure on them. During an interview with AN A on 11/5/14 at 11 am, she stated the facility expectation is a Braden Skin risk assessment would be done on all residents within 24 hours of admission to the facility and when a new pressure area is identified. AN A stated a care plan should be developed within 24 hours of admission addressing Resident 9's leg brace use and potential for impaired skin integrity related to her leg brace and inability to move herself and those had not been done. AN A stated the nurses should have called the physician to clarify exactly when he wanted the leg brace on or off of Resident 9's leg. AN A stated the leg brace should have be fully removed daily to allow the skin to breathe. 6. Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The interdisciplinary progress note, dated 11/10/14, indicated Resident 16 had developed an open area on the left inner thigh. The impaired skin integrity care plan identified the open area as a PU (Stage II). A review of the document titled, Braden scale, indicated it was last updated 9/23/14. During an interview with Director of Staff Development (DSD) on 11/12/14 at 11:50 am, she confirmed the above stating, Resident 16's Braden scale had not been updated with in 24 hours of the facility identifying a new pressure area, as their policy indicated. 7. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS admission assessment, dated 5/8/14, described Resident 5 as being cognitively intact and in need of assistance with daily activities. Resident's 5 record contained a Resident-Data Collection form, dated 5/1/14, the day Resident 5 was admitted . The skin condition section had a hand written note that directed See Tx (treatment) sheet. The treatment sheet had a physician's orders [REDACTED]. Resident 5 had a care plan, dated 5/1/14, describing a Stage I (intact skin with non-blanchable redness of a localized area, usually over a boney prominence) PU to the right buttock. On 11/6/14 at 11:30 am, during an interview and record review, the DSD confirmed that Resident 5 was admitted with a Stage I PU. The DSD provided the facility's undated policy titled, Skin Care Management System which indicated that residents with skin impairment will have appropriate interventions implemented to promote healing, a physician order [REDACTED]. The policy indicated that a Nutritional assessment will be completed within 72 hours of admission on all residents at risk or with compromised skin integrity. The DSD confirmed that there was no record of the Weekly PU Record being completed or interventions in place to prevent the PU. On 11/7/14 at 3 pm, during an interview and record review, the RD confirmed that Resident 5 was admitted on [DATE] and she completed a Registered Dietician Nutritional Assessment on 5/9/14. The RD confirmed that she had documented skin was clear and no nutritional interventions were implemented to assist with the healing process. 8. Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS admission assessment, dated 10/25/14, described Resident 10 as requiring extensive assist with daily activities. Resident's 10 record contained a nurses note, dated 10/19/14, that indicated Resident 10 had an open area on the left ankle. Resident had a care plan, dated 10/19/14, that read, Undetermined PU to left ankle (Unstageable). On 11/10/14 at 11:30 am, during an interview and record review, AN A confirmed that Resident 10 had a PU identified two days after admit. AN A confirmed that the record contained only one note on Weekly PU Record documenting an evaluation of the PU with measurements on 11/4/14, 15 days after it was discovered. AN A confirmed that the RD Registered Dietician Nutritional Assessment, dated 10/20/14, inaccurately indicated that Resident 10's skin was clear.

Based on interview and record review, the facility failed to maintain adequate nutrition for one of 18 sampled residents, when Resident 3 experienced a significant weight loss (a weight loss of more than 10 percent (%) in six months), and when six of 18 sampled residents', (Residents 1, 3, 5, 8, 9, 11, and 17) had incomplete, inaccurate nutritional assessments, and interventions. This had potential for the residents' nutritional needs to go unmet and for them to develop a significant weight loss and malnutrition. Findings: 1. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS) assessment, dated 9/10/14, described Resident 3 as cognitively intact, his own decision maker, and in need of assistance with meals and mobility. Resident 3's weight was recorded as follows: 4/1/14, 195 lb (pounds) 5/1/14, Resident 3 refused weighing and there was no documentation of follow-up. 6/1/14, 188 lb (7 lb weight loss, a 3.5 % in 2 months) 7/1/14, 184.6 lb (3.4 lb weight loss, a 1.8 % in 1 month) 7/7/14, 180.8 lb (3.8 lb weight loss, a 2.6% in 1 week) 7/15/14, 186 lb 7/21/14, 187.1 lb 8/1/14, 185.2 lb (1.9 lb weight loss, a 1.2% in 1 week) 9/1/14, 182.8 lb (2.6 lb weight loss, a 1.3% in 1 month) 9/23/14, 173 lb (9 lb weight loss, a 5.36% in 3 week, a total loss of 11.2% in 6 months) 9/30/14, 173 lb On 11/7/14 at 9:15 am, during an interview, the Dietary Services Supervisor (DSS) stated that recorded weights are given to her, and written in the resident's medical record. The DSS confirmed that during the 10/2014 Weight Committee Meeting, the committee did not look back at the 6 month weight loss record and the weight loss was not identified. The DSS stated that because the weight loss was not identified, it was not reported to the Registered Dietician (RD). On 11/7/14 at 9:30 am, during an interview, the Director of Staff Development (DSD) confirmed that she manages the Weight Committee. The DSD stated that she looks at 3 lb weight changes, the committee assesses meal intake and notes if residents are eating less then 50% of their meals. When asked how to calculate weight loss and gains by percentage, DSD stated she was unsure how to do the calculation. The DSD confirmed that Resident 3's weight loss was not identified during the last Weight Committee meeting. On 11/7/14 at 3:30 pm, during an interview the RD confirmed that she had not identified the significant weight loss. The RD stated that she gets a report that lists who has lost weight and that Resident 3's weight loss was not identified on the report. The RD confirmed that she does look at the weights in the medical record, and she had recognized that Resident 3 was having an unplanned weight loss. The RD confirmed that no interventions had been put into place because Resident 3 was OK with the weight loss. The facility's undated, policy and procedure titled Nutritional Management System, Evaluating Weight Changes, indicated that weight variance reports are printed weekly using standard criteria of 30 days, 5% weight change, 90 days, 7.5% weight change, and 180 days, 10% weight change. Copies of the report are to be given to the Director of Nurses and the Registered Dietician for review and initiating of interdisciplinary interventions. Any resident who experiences an unplanned weight loss, significant or insignificant, will be assessed and monitored by the clinical staff and the Action Team. The Resident Care Plan will reflect the current interventions, evaluations, revisions and progress notes will describe the change, plan of action and progress. 2. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS admission assessment, dated 5/8/14, described Resident 5 as being cognitively intact, and in need of assistance with daily activities. Resident's 5 was admitted to the facility with a Stage 1 pressure ulcer. Resident 5's record contained a physician order [REDACTED]. On 11/7/14 at 3 pm, during an interview and record review the RD confirmed that she had not identified a skin problem on the Register Dietician Nutritional Assessment and no dietary plan was developed and no nutritional interventions were implemented to maintain an acceptable nutritional status and protein levels to assist with the healing process. 3. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's admission minimum data set (MDS, an assessment tool), dated 5/28/14, showed she weighed 135 pounds. A nurse's note, dated 6/4/14, showed Resident 1 had lost 9.6 pounds the first week at the facility (7.1% of her admission weight and considered significant). On 11/4/14 at 2:30 pm, Director of Staff Development (DSD), was interviewed about what the facility did when a resident had weight loss. DSD did not identify that the RD should be notified upon discovery of a significant weight loss. On 11/4/14 at 2:35 pm, RD stated that she should have been contacted by the facility for Resident 1's initial significant weight loss. RD confirmed that Resident 1 was not on her Weight Log and that she never received the facility's Weight Variance Reports. RD stated that there was no weight recorded for Resident 1 on 5/23/14 and that on 6/6/14 there was no accurate weight for her. On 11/4/14 at 2:37 the DSD stated the facility's policy was to weigh newly admitted Residents weekly for 4 weeks, then if stable, monthly. 4. Resident 11 was admitted to the facility on [DATE] from the acute care hospital, with [DIAGNOSES REDACTED]. On 11/4/14, the acute care hospital's SNF (skilled nursing facility) Transfer form, dated 11/3/14, showed Resident 11 had two Stage II PUs; One on his coccyx (tailbone) and one on his right hip, at the time of transfer to the facility. The facility's policy titled, The Skin Care Management System read, A nutritional assessment will be completed within 72 hours of admission on all residents assessed at risk or with compromised skin integrity. Additionally, all residents identified with skin impairment will be evaluated by a RD for nutritional status in a timely manner. On 11/10/14 at 11 am, Resident 11's Nutrition Screening form, dated 11/12/14 was concurrently reviewed with Dietary Services Supervisor (DSS). The Wounds section was left blank. The Food Preferences and Mobility sections were left blank. DSS confirmed she had not completed Resident 11's Nutrition Screening form, Wounds section and that the RD should have been notified promptly to assess Resident 11's nutritional status and its impact on her PUs. 5. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Her medical record was reviewed. Three days a week she received [MEDICAL TREATMENT] (a procedure which filters the blood when the kidneys do not function adequately). Resident 8's Weight Flow Sheet showed: --9/24/14: 193.4 pounds (lbs) wet weight (prior to a [MEDICAL TREATMENT] treatment) --9/23/14: 184.5 dry weight (after a [MEDICAL TREATMENT] treatment, when fluid has been removed, resulting in decreased weight); a weight loss of 8.8 lbs --9/29/14: 163.9 lbs dry weight; a total weight loss of 29.5 lbs in 10 days --10/7/14: 163.9 lbs dry weight --10/14/14: 163.9 lbs dry weight In an interview on 11/6/14 at 9:40 am, the Director of Staff Development (DSD) stated that she had copied the weights from the [MEDICAL TREATMENT] Communication forms. However, she confirmed that she did not know the difference between the estimated dry weights (EDW) and the actual dry weights, and that she had been recording the EDWs from 9/21 to 10/14/14, instead of the actual dry weights. The DSD stated that the admission weight was apparently inaccurate, but that the facility did not re-weigh Resident 8 at any point. She also confirmed that there was no weight loss care plan, and no apparent follow-up. During an interview on 11/7/14 at 9:50 am, the Dietary Services Supervisor (DSS) stated that she had noted Resident 8's weight loss, but did not document any follow-up. According to the facility's policy and procedure titled, Weight Monitoring, undated, For weekly weights, re-weighs are required for any unplanned three pound variance from week to week.Any resident who experiences an unplanned weight loss.will be assessed and monitored by the clinical staff and the Action Team. The resident's Care Plan will reflect the current interventions/evaluations/revisions and progress notes will describe the change, plan of action and progress. 6. Resident 9's record was reviewed, it indicated Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A wound care specialist evaluation dated 9/16/14, indicated Resident 9 had developed a pressure sore on the right calf on 9/10/14, and a pressure sore on the right heel on 9/16/14 while residing in the facility. During an interview with the facility Registered Dietician (RD) on 11/7/14, at 1:30 pm, she stated the facility had no system in place to routinely notify her of new wounds. She stated she reviews the treatment records for the entire facility to attempt to identify new wounds. RD stated she was not aware Resident 9 had two pressure ulcers when she evaluated Resident 9's nutritional needs on 9/22/14 and documented Resident 9's skin was free from open areas.

Based on interview and record review, the facility's Quality Assurance and Assessment (QAA) committee failed to identify and develop plans of action to implement quality improvement activities that ensured quality of care to residents when: The QAA committee failed to identify that residents were not receiving the necessary assessment, treatment, and services to promote wound healing, and prevent avoidable new pressure ulcers (wounds caused by pressure or friction) from developing. The QAA committee failed to identify that residents had complete, accurate nutritional assessments and interventions, and to prevent unplanned weight loss. These failures resulted in an ineffective QAA program and substandard quality of care to the residents which had not been identified or addressed by the QAA committee, prior to survey, and had the potential for the residents' nutritional needs to go unmet and for them to develop significant weight loss, malnutrition, and the development of avoidable pressure ulcers. Findings: The QAA committee failed to identify systems failures in pressure ulcer prevention and nutrition and weight loss. Residents were not receiving the necessary care and services to promote wound healing, prevent the development of avoidable pressure ulcers (wounds caused by pressure or friction) and prevent unplanned weight loss. (Refer to F 314 and F 325). On 11/12/14 at 11 am, during an interview and concurrent review of the sign in sheet for the quarterly QAA meetings, the Administrator stated that the Director of Nurses was responsible for overseeing committee meetings and bringing concerns to the QAA committee. The Administrator stated that the above resident care concerns identified during survey had not been addressed in the facility's quality improvement process by the QAA committee.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and services to restore as much bladder function as possible for three of 18 sampled residents (Residents 1, 7, and 11) when: 1. Resident 7 was not provided the necessary services to address increased urinary incontinence (inability to hold urine) at the time of admission, and a subsequent further loss of urine continence, over a period of 6 months. 2. Resident 1 was not provided the necessary services to address increased urinary incontinence (inability to hold urine), over a period of 6 months, and the facility failed to reassess Resident 1 for a toileting program when she had a decline in urinary continence (ability to hold urine). 3. A Bowel and Bladder continence evaluation was not completed for Resident 11. This resulted in a loss of bladder function with increased incontinence for Residents 1 and 7, placed Resident 11 at risk for skin breakdown and bladder function loss, and had the potential for other residents' bladder function to decline and not be restored. Findings: 1. Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized assessment), dated 4/18/14, indicated Resident 7 was occasionally incontinent of urine. No trial toileting program had been attempted to assist Resident 7 to gain full bladder function, urinary continence. Resident 7 required extensive assistance of one staff for toileting and hygiene. Review of a document titled, 3-day bowel and bladder screening, dated 7/7/14 through 7/9/14, indicated that in the three day assessment period, Resident 7 was continent of urine 40 times and incontinent 7 times. The MDS, dated [DATE], indicated a decline in Resident 7's bladder function. Resident 7 was now frequently (more than occasional) incontinent of urine. No trial toileting program had been attempted to assist Resident 7 to maintain or gain full bladder function, urinary continence. Review of a document titled, Bowel and Bladder Retraining Assessment, dated 10/22/14, indicated no change in Resident 7's bladder function and the facility had not developed plans to provide Resident 7 with bladder retraining. The undated facility policy titled, Urinary management, indicated, The facility is committed to providing. programs to assist residents in retaining or regaining. their highest level of functioning. Based on the voiding pattern baseline established using the 3-day bowel and bladder screening, residents will be placed in a bladder retraining' prompted voiding or habit training program according to their. needs and the facility will Ensure that adequate interventions have been initiated to prevent, improve and or manage urinary incontinence. During an interview with Administrative Nurse (AN) A on 11/5/14 at 11 am, AN A stated she manages the resident bladder retraining programs at the facility. AN A stated there is no specific protocol the facility follows to assess the need for or place a resident on bladder retraining. AN A reviewed Resident 7's record and stated, because Resident 7's 3 day screening (conducted in July 2014, three months after admission) indicated she was continent much more than she was incontinent, AN A should have placed Resident 7 on a bladder retraining program, but the facility had not done so, and AN A did not know why. AN A confirmed the documentation on the MDS, dated [DATE], indicated Resident 7 had lost bladder function since the assessment of 4/18/14, and no attempt at bladder retraining had been discussed or attempted by the facility. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/4/14, Resident 1's MDS, dated [DATE], showed that she was continent of bladder and bowel. A nurses note, dated 6/9/14, showed Resident 1 had episodes of incontinence (loss of control) of bowel and bladder. Resident 1's Nursing Assistant Daily Flow Sheets for the AM (morning) and PM (afternoon) shifts for June/2014 showed she had incontinent episodes starting 6/5/14 and became consistently incontinent most of the time from 6/10/14 on. On 11/4/14 at 12:40 pm, Administrative Nurse (AN) A confirmed that when Resident 1's continence status changed, she should have been reassessed and been re-screened for bowel and bladder retraining (a toileting program) to restore continence. 3. Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE] from the acute care hospital, with [DIAGNOSES REDACTED]. The facility's Resident-Data Collection admission assessment for Resident 11, dated 11/3/14, included a section for Bowel and Bladder (continence) evaluation that was not completed and left blank. On 11/7/14 at 2:45 pm, AN A stated Resident 11's Bowel and Bladder assessments were not done and should have been started on 11/4/14 and finished on 11/7/14. AN A confirmed that Resident 11's continence status affected her risk for PU worsening and development. Resident 11's Wound Care Specialist Evaluation, dated 11/11/14, identified the coccyx wound as Unstageable. Unstageable PU is defined as a full thickness tissue loss with the depth of the ulcer obscured by slough or eschar (yellow tissue or brown, black scab tissue) in the wound bed, that once removed will show a Stage III or IV PU. On 11/13/14 at 3:50 pm, the facility's WCMD was interviewed about Resident 11's PU and confirmed that it had deteriorated from a Stage II to Unstageable.

Based on observation, interview, and record review, the facility failed to ensure a hazard free resident care environment for residents when: 1. The facility failed to develop and implement planned fall prevention interventions to prevent Resident 7 from eight falls, over a period of four months. 2. The facility failed to safeguard hazardous chemicals when two of two housekeeping carts with toxic chemicals were left unlocked and accessible to residents. These failures resulted in Resident 7 sustaining injuries from avoidable falls (head, right wrist and ear pain, and a fractured right wrist), and had the potential for Resident 7 to suffer further falls with injury and residents to be exposed to toxic chemicals. Findings: 1. Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized assessment), dated 4/18/14, indicated Resident 7 was unable to walk and required extensive assistance of one staff member to transfer from the bed to a commode for toileting and was occasionally incontinent (unable to hold) her urine. During an interview with Administrative Nurse (AN) K on 11/4/14 at 4 pm, AN K stated she had completed three full MDS with care plan evaluations and revisions, as necessary, for Resident 7, most recently two weeks ago, and was aware Resident 7 had a significant number (eight over a period of four months) of falls in the facility. AN K stated, I don't know what interventions are in place to attempt to either limit the number of Resident 7's falls or protect her from injury related to a fall. AN K stated an interdisciplinary (IDT) meeting is held after each fall to evaluate the need for new interventions to prevent falls. AN K further stated she does not attend the fall management committee meetings. Review of nine documents titled, Fall Management Committee Notes, were reviewed. AN K signed nine of the nine documents as having attended these fall management committee meetings that were to address the concern of Resident 7's falls. Review of a Fall Management Committee note regarding Resident 7's fall on 5/11/14, indicated Resident 7 was found on the floor after attempting to go to the bathroom. Resident 7 was sent to the hospital emergency room after she complained of pain on the right side of her head, right wrist and ear. The section of the note titled, corrective action, indicated Resident 7 would be encouraged to ask for assistance and a bed alarm in place. Review of a Fall Management Committee note, dated 5/21/14, indicated Resident 7 was diagnosed on [DATE], (the day after her first fall when she complained of right wrist pain) as having a fractured right wrist after Resident 7's son and former caregiver assisted her in repositioning in bed. The section of the note titled, corrective action did not indicate any new interventions would be initiated to prevent Resident 7 from falling, or to protect her from injury related to a fall. Review of a Fall Management Committee note regarding Resident 7's fall on 7/14/14, indicated Resident 7 unintentionally ended up on the floor, after having slid to the floor from a seated position on the edge of her bed while wearing socks. The section of the note titled, Corrective Action indicated Resident 7 would wear non-skid socks. A Fall Management Committee note regarding Resident 7's fall on 7/23/14, indicated Resident 7 was found on the floor after she attempted to get up out of bed. The section of the note titled, Corrective Action had no new interventions to keep Resident 7 safe from falls. A Fall Management Note regarding five more falls, suffered by Resident 7 on 7/26/14, 8/24/14, 8/30/14, 9/18/14 and 9/29/14, each indicated Resident 7 was found on the floor after attempting to get up out of bed to toilet herself. The section of the note titled, Corrective Action had no new interventions to keep Resident 7 safe from falls. These notes indicated Resident 7 had redness on her back and complaints of back pain after the fall on 8/30/14, was sent to the hospital emergency room for evaluation after the fall on 9/18/14, and was treated for [REDACTED]. During an interview with Resident 7's Licensed Vocational Nurse (LN) G on 11/6/14 at 8 am, she stated Resident 7 does not use any alarms and she does not know what interventions are in place to prevent Resident 7 from falls. During an interview with Resident 7's Certified Nursing Assistant (CNA) H on 11/6/14 at 10:45 am, she stated she does not know if Resident 7 uses any alarms, she would have to check the book at the nurses station, which she has not done since coming on shift about 3 hours ago. CNA H stated she does not know what interventions are in place to prevent Resident 7 from falls but she does know Resident 7 keeps a bunch of her personal stuff on her bed and on the floor around her feet between her bed and the bedside commode. CNA H suggested perhaps Resident 7 trips on some of the stuff on the floor around her bed. During an interview with Resident 7's CNA C on 11/7/14 at 9:20 am, she stated Resident 7 does not currently use any alarms because she wouldn't leave them alone and she kept taking them off. CNA C stated she does not know what interventions are currently in place to prevent Resident 7 from falls. The care plan titled, Fall risk, initiated 4/11/14 and reviewed on 7/2014 and 10/2014, did not indicate any revisions to Resident 7's long term fall risk care plan, since it's inception on 4/11/14. The care plan did not indicate Resident 7 presently used or in the past had used any type of alarms, non-skid socks or special instructions regarding calling staff for assistance. During an interview with AN A on 11/5/14 at 11 am, she stated Resident 7 used an alarm at some point to alert staff when she attempted to get up without assistance, but Resident 7 kept removing it. AN A stated she does not know when use of a fall alarm for Resident 7 was either initiated or stopped, and she is not aware of any current interventions in place to prevent or protect Resident 7 from falling. AN A stated Fall Management Committee meetings are not an actual meeting, rather one staff member fills out the Fall Management Committee notes. AN A stated she has in the past signed the note implying she attended a meeting, when directed to do so by her immediate supervisor. AN A stated the intention of an interdisciplinary meeting, such as the Fall Management Committee meeting with notes, is for various staff who have knowledge of the resident to come together to discuss the residents problem, attempt to determine why the problem occurs, and to come up with solutions for the residents problem (falls). AN A stated she would expect the facility to come up with a new intervention each time Resident 7 fell . 2. On 11/4/14 at 9:15 am, during the initial tour of the facility and interview with the Director of Staff Development (DSD), the housekeeping cart which contains chemicals used to clean the facility had a whole in the cabinet where the lock should have been. The DSD confirmed that the cabinet on the cart had no locking mechanism and contained chemicals. The DSD confirmed that the housekeeper was not on the hall supervising the cart. On 11/4/14 at 9:18 am, during an observation and interview on the north hall of the facility with the Housekeeper (HSK), she confirmed that the housekeeping cart was not locked. The HSK stated that the lock did not work and she never locks the cart. On 11/4/14 at 9:20 am, during an interview the Environmental Supervisor (ES), he confirmed that he was the supervisor for the housekeeping staff. ES confirmed that one housekeeping cart had no lock and the other housekeeping cart, lock did not work properly. ES stated that he was aware that cleaning chemicals were stored in the carts. ES confirmed that he was aware that the housekeeping carts were not being locked and that this allowed resident access to the chemicals.