Every finding on record at Atherton Park Post-Acute

Based on interview and record review, the facility failed to maintain an effective infection prevention and control program when two of five sampled staff did not receive N95 respirator (a mask that filters airborne particles very effectively) fit testing (a process used to determine N95 respirator fits properly).This failure had the potential for spread of airborne infections (an illness that spreads through tiny germs in the air that people can breathe in) to the residents, staff, and visitors. During an interview on 4/16/26 at 10:45 AM, Licensed Vocational Nurse (LVN) 1 stated the facility uses N95 respirators when there is a COVID-19 (an illness caused by a virus that spreads easily through the air) outbreak. LVN 1 opened a plastic cabinet with drawers containing N95 respirators, and stated, We have them here. These are what we use. When asked if she has been fit-tested for the N95 respirators, LVN 1 stated, No. The last time I was fit-tested was when I was in nursing school, more than three years ago.During an interview on 4/16/26 at 10:58 AM, the Infection Preventionist (IP) confirmed LVN 1 has no respirator fit testing record. The IP was asked if she had been fit-tested for N95 respirator. The IP answered, Not here. I did it when I worked at (name of hospital). That was three years ago.During an interview on 4/16/26 at 1:24 PM, The IP stated staff must use an N95 respirator that has been fit-tested for them when caring for residents with COVID-19. The IP stated, We use enhanced respiratory precautions (ERP, extra safety steps used to stop the spread of serious respiratory infections) for residents (with COVID-19 infection). The IP stated further, It protects them (residents and staff) from getting sick. If not wearing the correct one, they (staff) could be spreading it more. Particles can potentially escape or get in when they are not being covered properly.During a concurrent interview and facility document review on 4/16/26 at 1:59 PM, the IP was asked for the facility's policy for ERP. The IP provided a facility document titled, Enhanced Respiratory and Contact Precautions (ERCP), dated 3/2023, and stated, This is what we use for COVID. The IP stated she could not find a separate policy for ERP. Review of the ERCP indicated All staff must wear.respirator: N95 or higher level respirator.During an interview on 4/16/26 at 3:11 PM, the Director of Nursing (DON) stated staff need fit testing for respirators to make sure that their mask is well-fitted in a way that there is no room for contamination. The DON stated that fit testing must be done annually because people can gain or lose weight, their face can change in a year.Review of facility policy, titled Personal Protective Equipment - Face Masks, revised in 7/2009 indicated Facility personnel must wear appropriate facial protection when there is risk of exposure to blood, body fluids, splashes, or airborne infectious agents. This includes . N95 respirators when airborne protection is required. 2. N95 Respirators and Fit testing (Airborne Protection) Employees are required to wear a NIOSH-approved (National Institute for Occupational Safety and Health, a federal agency that makes sure masks like N95s work properly and helps keep workers safe from harmful exposures) N95 respirator for airborne precautions must participate in the facility's Respiratory Protection Program per OSHA standards (Occupational Safety and Health Administration, a federal agency that protect workers by creating safety rules to reduce hazards in the workplace) .Medical Evaluation and Fit Testing - Initial fit testing is required before first use on the specific model, style, and size to be worn. Annual fit testing is required every 12 months.

Based on interview and record review, the facility failed to provide appropriate services to one of three sampled residents (Resident 1) when the Registered Dietitian (RD) did not reevaluate and address Resident 1's severe weight loss (a weight loss greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months).This failure placed Resident 1 at risk for decline in nutritional status and physical health.Resident 1 was admitted on [DATE] with diagnoses that include left distal radius fracture (a break of the bone near the wrist of the left forearm) and cerebral palsy (a condition that affects a person's ability to move and maintain balance and posture). Resident 1 was transferred to acute care hospital on 7/2/25 and was discharged from the facility on 7/9/25.Review of Resident 1's weight record indicated an initial weight of 230 pounds on 5/23/25.During a review of Resident 1's Registered Dietitian Nutrition Assessment (RDNA), dated 5/21/25, the RDNA indicated Resident 1's hospital weight on 5/13/25 was 249.6 pounds. The RDNA showed Resident 1's BMI score (body mass index, a measure of body fat based on a person's height and weight) as 32.1 indicating obesity (having excessive body fat). Further review of the RDNA indicated Evaluation. He (Resident 1) endorsed having a fair appetite. He is fine with current portion sizes. He did not want snacks/supplements at this time. RD educated resident on the importance of eating to maintain strength.Interventions and Plan: Consider re-visiting snack/supplements if rt (resident) has weight loss. F/U (follow up) PRN (as needed).During a review of Resident 1's RD Medical Nutrition Therapy Note (RD Note), dated 5/28/25, the RD Note showed Resident 1's weight as 230 pounds on 5/23/25 and 227 pounds on 5/28/25. The RD Note indicated Resident 1 has a weight loss of 1.3% pounds in one week. The RD Note also indicated Resident is reviewed for inadequate intake. Resident's intake remains fair, however, calculated to meet estimated needs. Weight stable x (for) 1 (one) week with minor weight loss, may be related to swelling of fingers on admission. No edema noted at this time. No new labs (laboratory) to review. No new dietary interventions. Will continue to monitor and f/u (follow up) PRN (as needed).During a review of Resident 1's Progress Notes (PN), dated 6/19/25, the PN showed Resident 1's weight on 6/18/25 as 217 lbs., a 5.7% weight loss in in 26 days. The PN indicated Resident 1 eats 76% to 100% of his meals. The PN also indicated Weight loss of unknown etiology (cause). Beneficial for resident considering BMI now 29.4. During a review of Resident 1's PN, dated 6/26/25, the PN showed Resident 1's weight on 6/25/25 was 210.8 pounds, indicating an 8.3% weight loss in 33 days. The PN indicated Resident 1 eats 51% to 75% of his meals. The PN also indicated RD/IDT (Interdisciplinary Team) Recommendations: Weight loss of unknown etiology. Beneficial for resident considering BMI now 28.6. Continue to monitor.During a review of Resident 1's care plan (CP) titled, At Risk for Altered Nutrition Status R/T (related to) Malnourished as evidenced by Nutritional Screening Tool, created on 5/20/25 and last revised on 6/9/25, the CP included a goal of no significant weight change for 30 or 180 days. The CP interventions included monitor closely for weight gain/loss.During an interview on 8/11/25 at 11:33 AM, the RD stated, I did not really know why he was losing weight; he was eating very well. The RD stated that part of her responsibility is to assess the cause of weight loss and if the resident is not eating well, to recommend nutritional supplements, if appropriate. The RD was asked if she reassessed Resident 1. The RD stated, I was not able to. I was not able to speak with the patient (Resident 1) if he wanted supplements. The RD added, We should be investigating why they (residents) lost weight. From there, we formulate interventions.During an interview on 8/11/25 at 12:36 PM, Resident 1's attending physician stated that Resident 1's weight loss was unintentional but it was desirable for him. if it continues, the nutritionist (RD) should take a look for any reason for this (weight loss), then we go from there.Review of the facility's policy tiled, Nutrition (Impaired)/Unplanned Weight Loss -Clinical Protocol, revised on 8/2017 indicated Monitoring - 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss.)Review of the facility document, titled JOB DESCRIPTION Registered Dietitian Nutritionist, last revised on 11/2017, indicated The Registered Dietitian Nutritionist provides nutritional analysis and guidance to individual residents to treat and prevent disease. They also work closely with the Dietary Department to maintain good nutritional standards and process improvement. ESSENTIAL JOB FUNCTIONS: Assesses the nutritional needs of residents.Provides resident with ongoing nutrition assessment and outcome-oriented nutrition counseling necessary to assist resident in achieving and sustaining an effective nutritional status.Identifies malnourished residents as well as residents at risk for malnutrition and works collaboratively with interdisciplinary team to identify appropriate interventions, resources or solutions.

Based on observation and interview the facility failed to ensure windows on the 2ndfloor were: 1. Secure from opening greater than 4 inches to prevent confused residents from jumping out windows. 2. Inspected on a regular basis to ensure window securing devices were still functioning. 3. Secure window with a device that is tamper proof. Failure to secure 2nd floor windows had the potential for confused residents to sustain serious injuries if they jump out of these windows. Findings: During observation on 05/23/2025 at 11:15 AM with the Administrator, windows in rooms 209, 212, 216 on the second floor were found without any device to limit how wide they could be opened. These windows could be opened to their full limit of at least 30 inches. These observations were confirmed with the Administrator. During an interview on 05/23/2025 at 11:30 AM, the Administrator stated there should be a mechanical limiter on those windows so that the windows could not be opened fully. The Administrator was asked to: 1. Conduct an audit of the entire 2nd and 3rd floor to see if there were other windows with the same issue. 2. Provide their policy regarding securing windows. 3. Provide a sample of the device they used to limit window openings. During an interview on 05/23/2025 at 12:18 PM, the Assistant Maintenance Worker (AMW) explained the window limiting devices were a thumb screw that could be removed by staff to enable them to clean the windows. The AMW stated he checked all the windows once a week but does not document these checks. The AMW stated sometimes residents as well as visitors may remove these window limiters to open the window wider. The AMW was asked how wide these windows should opened to with a window limiter. The AMW stated 3 inches. During an interview on 05/23/2025 at 12:45 PM the Administrator stated the facility conducted an audit and out of 80 windows, only windows in rooms [ROOM NUMBER] were found without limiters and could be opened fully. The Administrator stated they have no policy regarding securing and inspecting windows. During a concurrent observation and interview on 05/23/2025 at 12:50 PM the windows on the second floor: rooms 212 and a family therapy room were inspected with the AMW. The window in room [ROOM NUMBER] opened to 5.5 inches (with the window limiter in place), the window in the second floor family therapy room could be opened to 10.25 inches. There was no window limiter in place. But there was a wood screw, screwed into the window frame to limit the opening to 10.25 inches. During the interview the AMW admitted he did no checked or measured how wide these windows could be opened to during his audit.

Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan (a detailed approach to care customized to an individual resident's needs) for one of 2 sampled residents (Residents 1) when the elopement (the act of leaving a facility unsupervised and without prior authorization) care plan was not applicable for Resident 1 after he eloped the facility on 4/14/25. This deficient practice was likely to fail to meet Residents 1's nursing needs and goals to attain his highest practicable well-being. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). Review of Resident 1's Nurse's Notes dated 4/14/25 at 7:56 PM indicated, Elopement: The patient was found at Crane Street (the street where the facility is located) being wheeled back to ***** (the facility's name) by 2 gentlemen that serves (sic) in the nearby Catholic Church @ (at) 1938 (7:38 PM). Upon Interview statement from the gentlemen, the patient was found along University Dr. (one block away from the facility) asking for help dueto (sic) being loss (sic). The writer then wheeled the patient back to ***** (the facility's name) . First time the patient eloping from facility. The patient stated that he just wanted to go outside due to the nice warm weather . During a concurrent observation and interview on 5/9/25 at 10:47 AM with Resident 1 in his room, Resident 1 was sitting in a wheelchair without an injury. He was confused with place and time, and forgetful. But he stated, he remembered the incident when asked. Resident 1 stated, he left the facility in his wheelchair without telling staff simply because he wanted to go for a walk outside. Resident 1 stated, he had to use the wheelchair because he could not walk. Resident 1 stated, he was probably out about an hour when asked. During a concurrent observation and interview on 5/9/25 at 12:38 PM with Director of Nursing (DON) and Maintenance Director in front of the main entrance of the facility building, the main entrance was observed. DON stated, after 8 PM, the main entrance automatically locks, so from the outside, staff must enter a PIN number and visitors must call the 2nd floor to get into the facility building, but people can leave from the inside. Maintenance Director demonstrated how the main entrance door works after 8 PM. There was no issue. During a concurrent interview and record review on 5/9/25 at 12:45 PM with DON, Resident 1's Care Plan Report dated 4/14/25 was reviewed. The elopement care plan indicated, . Disguise exits: cover door knobs and handles, tape floor . DON stated, this care plan meant for the main entrance when asked. DON acknowledged, there was no cover on the doorknob and no tape on the floor when asked. DON stated, this care plan was not applicable for Resident 1 when asked. She stated, Not personalized when asked about the care plan. During a concurrent interview and record review on 5/9/25 at 1:25 PM with DON, Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 1/21/25 and 4/14/25 were reviewed. The MDS dated [DATE] indicated, Resident 1 was cognitively intact, and the MDS dated [DATE] indicated, he was cognitively moderately impaired. DON stated, Resident 1's cognition varies from day to day due to his dementia. During an interview on 5/9/25 at 1:40 PM with Receptionist, Receptionist stated, she saw Resident 1 was in the lobby when she was helping one resident back to the elevator on 4/14/25 around 7 PM, then she helped another resident, then around 7:30 PM, she realized Resident 1 was missing. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered revised in March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .

Based on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment to two of two sampled residents (Resident 12, and Resident 136) when Residents 12 and Resident 136 shared the same bedroom with a resident in bed C (Resident 68) who repeatedly yelled and screamed. The facility failure to provide comfortable and homelike environment had the potential to negatively impact the psychosocial well-being of Resident 12 and Resident 136. Findings: A review of the admission records indicated Resident 136 was admitted with diagnoses including dementia (a decline in memory or other thinking skills) and hypertension (abnormally high blood pressure). A review of the Minimum Data Set (MDS, a standardized assessment tool) for Resident 136 dated 11/18/24, Brief Interview of Mental Status (a brief memory test to help determine cognitive functioning such as memory/recall ability and decision-making ability) score of 6 indicated severe cognitive impairment. During observation on 2/9/25, at 12:36 PM, Resident 136 was sitting at the foot of her bed, looking towards bed C (Resident 68), grabbing the divider curtain and throwing it back. Resident 68 was yelling and screaming. Resident 136 covered her face and was shaking her head. A review of the physician (Medical Doctor) order for 2/2025, indicated Resident 136 was under hospice services (a specialty care that focuses on comfort and quality of life for people with serious illness). During an interview on 2/12/25, at 9:45 AM, Certified Nurse Assistant (CNA) 1 stated Resident 136 does not talk too much. CNA further stated that Resident 136 spends time outside of her room sitting on her wheelchair in the hallway. CNA 1 acknowledged the resident occupying bed C, Resident 68, repetitively yells and screams. During an interview on 2/14/25, at 1:25 PM, Activity Assistant (AA) 1 stated when spending an in-room activity with Resident 136, Resident 68 was yelling a lot. AA 1 further stated Resident 68 yells even when attending group activities. A review of the admission records indicated Resident 12 was admitted with diagnoses including congestive heart failure (when the heart muscles does not pump as strong as it should), and chronic obstructive pulmonary disease (a lung disease that makes it hard to breath). A review of the MDS dated [DATE], BIMS score of 15 indicated Resident 12 was cognitively intact. During an interview on 2/12/25, at 10:04 AM, Resident 12 stated that her roommate, Resident 68, had been bothering her. Resident 12 stated, [Resident 68] yells and screams all the time. Resident 12 further stated, I wake up from my sleep and she's yelling. I don't like it. I talked to [Social Services Assistant, SSA 1] that I wanted another room. I am still waiting. It's been a long time. A review of the admission records indicated Resident 68, had diagnoses including schizophrenia (a serious mental illness that affects how a person think, feels, and behaves), mood disorder (a serious mental illness that affects emotional state), and dementia. During an interview on 2/12/25, at 2:49 PM, SSA 1 stated, [Resident 68] does not yell constantly. During an interview on 2/13/25, at 2:45 PM the Director of Nursing (DON) stated, If I move [Resident 68] I am just moving the problem. A review of the facility Policy and Procedure titled, Resident's Rights dated 2/2021, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity, .exercise his or her rights as resident of the facility .be supported by the facility in exercising his or her rights .

Based on interview, and record review, the facility failed to inform and provide written information to residents or residents' representatives to formulate advance directives (A legal document indicating resident preference on end-of-life treatment decisions) when there was no evidence of offering and educating the advance directives to 13 out of 30 sampled residents (Residents 17, 21, 29, 31, 39, 46, 67, 68, 93, 94, 136, 139, and 317). These failures were likely to result in not following the residents' desired health care decisions when they become unable to make decisions for themselves. Findings: During an interview on 2/12/25 at 11:05 AM with Social Services Assistant (SSA) 1, SSA 1 stated, when a resident comes into the facility, the Social Services asks for a copy of advance directive to the resident. SSA 1 stated, if the resident wants an assist regarding the advance directive, the Social Services helps the resident. Review of Resident 17's Physician Orders for Life-Sustaining Treatment (POLST) dated 12/7/17 indicated, there was no check mark regarding Advance Directive. Review of Resident 31's Physician Orders for Life-Sustaining Treatment (POLST) dated 7/31/20 also indicated, there was no check mark regarding Advance Directive. During a concurrent interview and record review on 2/12/25 at 11:17 AM with SSA 1, Resident 139's document titled, Physician Orders for Life-Sustaining Treatment (POLST) dated 8/22/24 was reviewed. The POLST indicated, there was no check mark regarding Advance Directive. SSA 1 stated, Not yet. No. We don't have a file for him when asked if there was evidence of offering and educating Advance directive to Resident 139. During a concurrent interview and record review on 2/12/25 at 12:26 PM with SSA 1, Resident 29's Physician Orders for Life-Sustaining Treatment (POLST) dated 11/27/24 was reviewed. The POLST indicated, there was no check mark regarding Advance Directive. SSA 1 stated, POLST was discussed but did not go into detail about Advance Directive . SSA 1 stated, No when asked again if there was evidence of offering and educating advance directive to Resident 29. During an interview on 2/12/25 at 12:47 PM with SSA 1, SSA 1 stated, No. We don't have the specific to Advance directives . when asked if there was evidence of offering and educating Advance directives to Resident 17, and Resident 31. During an interview on 2/12/24, at 2:49 PM, SSA 1 acknowledged there were no proof of documentation of advance directives for Resident 93, Resident 68, Resident 94, Resident 136, Resident 46, Resident 317, Resident 21, Resident 67, and Resident 39. Review of the facility's policy and procedure (P&P) titled, Advance Directives revised in September 2022 indicated, . The resident has the right to formulate an advance directive . The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. 4. Written information includes a description of . policies to implement advance directives and applicable state law . 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance . Review of the facility's P&P titled, Social Services revised in September 2021 indicated, . m. assisting residents with advance care planning, including but not limited to completion of advance directives .

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for four of 30 sampled residents (Residents 77, 143, 93, and 136) when: 1. For Resident 77, there was no evidence of comprehensive care plan for his hearing difficulty. 2. For Resident 143, there was no evidence of comprehensive care plan for the use of Eliquis (anticoagulant, commonly known as a blood thinner, drugs that prevent blood clots from forming). 3. For Resident 93, there was no evidence of comprehensive care plan for suicidal ideation. 4. For Resident 136, there was no evidence of comprehensive care plan for depressed mood. These deficient practices were likely to fail to meet the residents' nursing needs and goals to attain their highest practicable well-being. Findings: 1. Review of Resident 77's clinical record indicated, Resident 77 was admitted to the facility with diagnoses including influenza (commonly known as the flu, a contagious respiratory illness caused by influenza viruses), diabetes (high blood sugar), and hypertension (high blood pressure). Review of Resident 77's Minimum Data Set (MDS, resident assessment tool) dated 1/8/25 indicated, he was cognitively moderately impaired. During an interview on 2/11/25 at 12:38 PM, with Resident 77, Resident 77 stated, he could not hear well when asked. During an observation on 2/12/25 at 2:09 PM, in Resident 77's room, Licensed Vocational Nurse (LVN) 2 was changing Resident 77's pressure ulcer dressings on the sacral area. When LVN 2 spoke to the resident, because Resident 77 was hard of hearing, she had to get close to his ear and speak to him per his request. During a concurrent interview and record review on 2/12/25 at 2:38 PM, with LVN 1, Resident 77's care plans were reviewed. There was no care plan for Resident 77's hearing difficulty. LVN 1 stated, No care plan that I saw, when asked if Resident 77 had a care plan for his hearing problem. LVN 1 acknowledged, Resident 77 was somewhat hard of hearing, and needed a care plan for his hearing difficulty. 49373 2. Review of Resident 143's Admission Record, indicated Resident 143 was admitted with diagnoses including long term use of anticoagulants. Review of Resident 143's Physician's Progress Note, dated 12/18/24, indicated Resident 143 had a history of Deep Vein Thrombosis (DVT, a blood clot that forms in a deep vein, usually in the leg, which can cause swelling, pain, and redness). Review of Resident 143's Order Summary, dated 12/24/24, indicated an order for Resident 143 to receive, Eliquis Oral Tablet 5 MG (milligram, unit of weight) .Give 1 tablet by mouth two times a day for DVT. During a concurrent interview and record review on 2/11/25 at 2:12 PM, with the Director of Nursing (DON), Resident 143's care plan titled, The resident is on anticoagulant therapy (use of ASPIRIN [a medication to treat pain, fever, reduce the risk of heart attack and stroke]) r/t (related to) DVT, last revised on 12/17/24 was reviewed. The care plan indicated Resident 143 uses Aspirin and not Eliquis for DVT. The DON stated the resident was never on Aspirin and Eliquis is the anticoagulant medication Resident 143 has been taking since admission. The DON further stated, the care plan is not person centered and the resident's specific medication should reflect on the care plan for proper implementation of the intervention. 40454 3. A review of the face sheet indicated, Resident 93 was admitted with diagnoses including major depressive disorder (a mental illness characterized by severe sadness, loss of interest, and hopelessness). A review of Minimum Data Set (MDS, a standardized assessment tool) Brief interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning including memory/recall and decision-making ability) score of 15 indicated Resident 93 was cognitively intact. During observation and interview on 2/10/25, at 2:24 PM, Resident 93 claimed severe no interest to do things, does not want to socialize, and has no appetite. A review of the physician order dated 2/2025, indicated, Resident 93 receives duloxetine (a medication used to treat depression) and quetiapine ( a medication used to treat severe mental illness) and was monitored for insomnia (difficulty falling asleep or staying asleep), verbalization of sadness and paranoid delusion (fixed irrational thoughts and beliefs). A review of the psychiatrist consultation notes dated 1/8/25, indicated, Resident 93 had anxiety symptoms that included excessive worry, anxious, and feeling nervous or on edge . During an interview on 2/13/25, at 2:45 PM, with Director of Nursing (DON), DON stated that the psychiatrist consultation reports were handles by the facility (Case Manager, CM). The DON acknowledged the psychiatrist communication report was not communicated with the interdisciplinary team members. 4. A review of the admission records indicated Resident 136 was admitted with diagnoses including dementia (a decline in memory or other thinking skills) and hypertension (abnormally high blood pressure). During observation on 2/9/25, at 12:36 PM, Resident 136 was sitting at the foot of her bed, looking towards bed C, grabbing the divider curtain and throwing it back. Residents romate in bed C was yelling and screaming. Resident 136 covered her face and was shaking her head. During an observation on 2/13/25, at 10:04 AM, Resident 136 has flat affect (no expression of emotion). Registered Nurse (RN) 1 stated Resident 136 does not talk too much. A review of the Minimum Data Set (MDS, a standardized assessment tool) dated 11/18/24, Brief Interview of Mental Status (a brief memory test to help determine cognitive functioning such as memory/recall ability and decision-making ability) score of 6 indicated severe cognitive impairment. Resident 136's mood indicated: Feeling down, depressed, or hopeless. Trouble falling asleep or staying asleep or sleeping too much. Feeling tired or having little energy. Trouble concentrating on things such as reading newspaper or watching television. A review of the physician (Medical Doctor) order for 2/2025, indicated Resident 136 was under hospice services (a specialty care that focuses on comfort and quality of life for people with serious illness). During an interview on 2/13/25, at 3:47 PM, Social Services Assistant (SSA) 1 acknowledged the assessment completed indicating Resident 136 experiencing distressed mood. SSA 1 acknowledged there were no care plan developed with interventions implemented for the identified signs of distressed mood for Resident 136. During an interview on 2/14/25, at 2:45 PM, the Director of Nursing acknowledged there were no care plan developed, and no intervention implemented to address the signs of distressed mood for Resident 136. A review of the facility Policy and Procedure titled Behavioral Assessment, Intervention and Monitoring dated 3/2019, indicated, The facility will provide, and residents will receive behavioral health services as needed to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment . As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical records . The nursing staff will identify, document, and inform the physician about specific details, regarding changes in an individual's mental status, behavior, and cognition, including onset, duration, intensity and frequency of behavior symptoms .The interdisciplinary team with thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the residents change in condition . A review of the facility Policy and Procedure titles, Care Plans, Comprehensive Person -Centered dated 3/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, mental, psychosocial and functional needs is developed and implemented for each resident. The IDT, in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety when the chopping boards were in poor condition. The facility failure had the potential to cause food borne illness for 153 residents who received food from the kitchen. Findings: During concurrent observation and interview on 2/9/25, at 10:01 AM, with Dietary Aide 1, three cutting boards were found with significant amount of deep scratch marks. The three cutting boards were discolored with dark brown and black residue. DTA 1 acknowledged the cutting boards were scratched and had rough surfaces, with dark brown and black discolorations, and stated, It's old and these are stains. According to the 2017 Federal Food Code, food contact surfaces are to be smooth, free of inclusions, pits and similar imperfections, and are to be clean to sight, and touch.

Based on observation, interview, and record review, the facility failed to provide adequate plan for staff monitoring and intervention for Resident 93 who had suicidal ideation when the facility did not develop a plan and coping skills and update assessments which should have led to timely updating of resident care plan for safety. The facility failure had the potential for resident harm. Findings: A review of the face sheet indicated, Resident 93 was admitted with diagnoses including major depressive disorder (a mental illness characterized by severe sadness and hopelessness). A review of Minimum Data Set (MDS, a standardized assessment tool) Brief interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning including memory/recall and decision-making ability) score of 15 indicated Resident 93 was cognitively intact. During observation and interview on 2/10/25, at 2:24 PM, Resident 93 stated experiencing severe depression. Resident 93 further stated having no interest to do things, does not want to socialize, and has no appetite. A review of the physician order dated 2/2025, indicated, Resident 93 receives duloxetine (used to treat depression) and quetiapine (used to treat severe mental illness) and was monitored for insomnia (difficulty falling asleep or staying asleep), verbalization of sadness and paranoid delusion (fixed irrational thoughts and beliefs). A review of the psychiatrist notes dated 1/8/25, indicated, Resident 93 has been experiencing persistent depression. The psychiatrist notes further indicated, .They report feeling very depressed, rating their depression as a 10 on a scale of 1 to 10, with 10 being the worst. They expressed feelings of hopelessness and worthlessness, and also report significant anxiety (excessive and persistent worry and fear) . She has been more isolative and reports amotivation (lack of interest). Depressive symptoms including . thoughts of wanting to die . During an interview on 2/24/25, at 2:45 PM , Director of Nursing (DON) acknowledged Resident 93 had thoughts of wanting to die and stated that the psychiatrist consultation notes was not communicated to the Interdisciplinary Team (IDT). A review of the facility Policy and Procedure titled Behavioral Assessment, Intervention and Monitoring dated 3/2019, indicated, .Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations .The interdisciplinary Team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm . Intervention and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior .

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 138) understood the arbitration agreement (a contract in which parties agree to resolve disputes), signed during admission to the facility. This deficient practice resulted in Resident 138 signing the facility's arbitration agreement without full understanding. Findings: Review of Resident 138's Admission Record, indicated Resident 138 was admitted with diagnoses including Cerebral Infarction (a condition when a blood clot stopped the blood flow to the brain) and Cognitive Communication Deficit (difficulty in communicating clearly due to problems with speaking and understanding). Review of Resident 138's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/7/25, Brief Interview for Mental Status (BIMS, MDS tool that measures resident cognition) score of 2 indicated severe cognitive impairment. During an interview on 2/12/25 at 12:00 PM, Resident 138 responded with sounds that cannot be understood and no words were spoken when asked about knowing an arbitration agreement and remembering signing one at the facility. During a concurrent interview and record review on 2/12/25 at 2:19 PM with the Administrator (ADM), the Arbitration Agreement (AA), was reviewed. The AA indicated Resident 138 signed the agreement on 1/7/25. The ADM stated the resident's BIMS score is 2 and the AA will be terminated. During a concurrent interview and record review on 2/12/25 at 2:35 PM with the Director of Admission and Marketing (DAM), the Arbitration Agreement (AA), was reviewed. The AA indicated Resident 138 signed the agreement on 1/7/25. The DAM stated it was inappropriate for a resident with a BIMS score of 2 to sign an AA, as the resident was not cognitively aware, and did not comprehend the agreement. During an interview on 2/13/25 at 3:28 PM, the DON stated BIMS score of 2 indicated severe cognitive impairment with the resident being alert and oriented only to self. The DON further stated the resident did not understand what was being signed when asked if the resident with a severe cognitive impairment could sign an agreement.

Based on observation, interview and record review, the facility did not ensure that Resident 1 was provided pain management based on a comprehensive assessment after the incident, incident 1, when her right foot got caught while CNA wheeling resident in her wheelchair without foot rest inside the room, incident 2, while coming out of third floor elevator, right foot got caught again in the wheel of the wheelchair, incident 3, resident complained of pain, wanted to go back to bed, not able to do bike exercise due to pain. Resident 1 called 911 due to pain. This failure resulted in Resident 1 suffering from severe pain. Findings: Review of Admission Record, dated 6/26/2024, indicated, admitted on [DATE], readmitted on [DATE], with diagnoses including: Fracture of Right Femur (a break in the right upper leg), Type 2 Diabetes( a condition with poor controlled blood sugar), Peripheral Vascular Disease(a slow progressive disorder and narrowing of blood vessels). Review of facility Summary of Investigation, undated, indicated, On May 20th, resident called 911 herself to report uncontrolled pain in her right leg which was spreading to her left leg. The patient was transferred to acute setting for further evaluation and treatment. Based on hospital records, it was noted that resident presented with a closed fracture of distal end of right femur. This patient hasn ' t had any falls during her entire stay in this facility. However, the only potential event that could be related to this injury happened last Thursday 5/16/24, the patient had an incident while being wheeled in her wheelchair and her right leg was caught between one of the wheels and the floor . The patent was taken to her room, was assessed, VS ., no physical injuries noted besides pain 8/10 in her right knee. MD/NP informed, STAT x-rays ordered for right leg and ankle .no visualized acute fracture or dislocation in the right ankle .Patient was stable without concerns until 5/20/24 when she called herself 911 . returned 5/21/24, no surgery done, referred to orthopedic follow up in two weeks, the patient has new pain management, but no further precautions or orders. Will monitor. Review of hospital document, Progress Notes, dated,6/13/24 visit, indicated, patient is three weeks now status post injury . treated non operatively. She is essentially bedbound. She does endorse knee pain, 9/10 and is only taking Tylenol and oxycodone as needed. Right knee range of motion was deferred due to pain. Instructions: take 1000 mg Tylenol every 6 hrs, add 600mg Motrin, take with food, prescribed Opiate narcotic medication every 6 hrs for pain. Wear knee immobilizer for comfort and pain, may participate in PT as tolerated maintain non weight beating status of the leg, elevate leg when resting ffup with ortho in 2 weeks. During an interview on 6/26/24 at 11 AM with Certified Nursing Assistant (CNA)1, CNA 1 was in resident ' s room, stated, she was not my patient on 5/20/24, heard her screaming from a lot of pain. I told the nurse, CNA assigned to her was doing her care, was yelling at the patient. Patient said, you ' re breaking my leg don ' t do that. I told the nurse, a male nurse came about 9 PM then I left. During an interview on 6/26/24 at 11:15 AM, with Resident 1, stated, I was up in a wheelchair in the morning, CNA 3 pulled the wheelchair and twisted my leg, around 9 AM to go to bicycle in rehab gym. Not able to do bicycle because my leg was twisted, they put me back to bed, I was in pain. The PM shift CNA was changing my diaper and I told her don ' t push my leg like that. During an interview on 6/26/24, at 12:30 PM, with Resident 1, per Resident 1, that night my regular CNA 4 needed help to change me. Lady CNA 2 came to help, she was pushing me to his side. They finished cleaning me and I was in a lot of pain. I called 911 myself, they don ' t do anything for me. Took me to the hospital and took a lot of tests then came back here. During an observation on 6/26/24 at 12:30 PM, Resident 1 in bed, with a leg immobilizer on right leg, a bandage on right foot. Resident alert and has food on the bedside table. My friend brought me home cooked meal. Per patient, she stays most of the time in bed due to pain, taking Tylenol Arthritis for pain on my own. Resident 1 took out 4 bottles from her purse that is hanging on her overbed table. One unlabeled bottle, resident stated is Tylenol Arthritis. I keep them here so I can take it myself, they don ' t give me pain medication. They don ' t want to take care of my legs. Sometimes I don ' t feel secure with the CNAs but better now. ' I have fallen a lot at home but never broke a bone. I want to get better and go home. During an interview on 6/27/24 at 1:20 AM, with CNA 2, per CNA2, patient needs two persons assist to change and clean her. That day CNA 4 asked me to help him, could be Sunday 5/19/24. Patient was in pain and knee and legs were swollen. After dinner patient needed change of diaper, CNA 4 is her regular PM CNA. He was cleaning and I was helping turn to my side. Patient was not yelling but complaining of pain. Patient told me that her leg got hit on the wheelchair by CNA 3. During an interview on 6/27/24 at 11:20 Am, with CNA 3, per CNA 3, who has worked for three months, she was assigned to resident on 5/16/24 AM shift. Patient was up in the wheelchair using Hoyer lift with two-person transfer. Patient has as appointment to rehab gym for bicycle exercise on the third floor. Going out of the room, her foot went inward the wheel, no footrest. The second time, on the third floor getting out of the elevator, her foot got caught again in the wheelchair. Told RNA about the incident and the RN on the second floor. Patient did not go for her exercise, came back to the room and wanted to go back to bed complaining of pain. During an interview on 6/27/24 at 2:24PM, with CNA 4, per CNA 4, on 5/19/24, CNA 2 was the morning shift, worked double so I asked her for help with Resident 1. Resident 1 has been in pain since 5/16/24. That day, resident was not yelling but complaining of pain, ouch when touched. The Licensed nurse knows. Review of clinical document, Progress Notes, dated 5/16/24 at 13:18, indicated, Resident accidentally caught her right leg from chair and into the floor, while CNA wheeling her to RNA room. Currently c/o 8/10 knee pain, no redness or swelling at this moment. VS .RP (brother) made aware and also MD/NP notify. NP came and visit and assess patient with order of STAT leg/ankle x-ray to R/O fracture. No nursing assessment and pain documentation that address the 5/16/24 incident, from 5/17/24 to 5/20/24. Review of Progress Notes, dated 5/20/24 at 16:00, indicated, patient called 911 and has been taken to acute due to right leg pain which she states has spread to her left. She did not report to AM nurse or myself. When I went to check in on her at start of PM shift she was already on the phone with 911. MD aware. During an interview on 6/27/24 at 2:14PM, with Director of Nursing (DON), per DON, she is one of our long term care patient, I go visit her sometimes. She is a Hoyer lift 2 person -assist during transfer. Incident on her leg was twisted on 5/16/24 and was stable till 5/20/24 when sent to ER, patient called 911 self. There was no daily documented assessment of the incident prior to resident calling 911. I did not further investigate as I linked the cause of fracture to the 5/16 incident. Review of Care plan, no care plan found for 5/16/24 incident. Review of facility Policy and Procedure, Pain Assessment and Management, dated 10/22, indicated, 4. Comprehensive pain assessments are conducted upon admission to facility .whenever there is a significant change of condition, and when there is onset of new pain or worsening of existing pain. Review of facility Policy and Procedure, Comprehensive Assessments, dated 10/22, indicated, Comprehensive assessments are conducted to assist in developing person-centered care plans. 5. A significant change is a major decline or improvement in a resident ' s status: a. will not normally resolve itself without intervention . b. impacts more than one areas the resident ' s health status and 3. Requires interdisciplinary review and/or revision of the care plan. Review of facility Policy and Procedure, Change on a Resident ' s Condition or Status, dated 2/21, indicated, 9. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted as required by current OBRA regulations .

Based on observation, interview and record review, the facility did not ensure the resident is informed of her rights and her rights are protected when: Resident 1 did not have a signed admission agreement and resident received opened mails and packages. This failure resulted in resident in resident feeling disrespected. FINDINGS: Review of Admission Record, dated, 6/26/24, indicated, admitted on [DATE] and readmitted [DATE] with diagnoses including: Osteoarthritis Left Hip(a common disease of the hip due to wear and tear with progressive loss of cartilage), Anxiety Disorder, Post- Traumatic Stress Disorder, Unspecified, Morbid Obesity. During an interview on 6/27/24 at 11:15 AM, with resident in her room, per resident, she got the record she requested on 5/1/24, stated, I did get my records, what I ' m concerned about what they don ' t put in the record. Started February 2024, they don ' t bring me my mail, if ever they come with opened mail. Ordered from Amazon, was given notice delivered already, looking all over nobody knows about it. You did not receive it because you ' re not in compliant, you cannot order alcohol The package was with DON. It was eggnog powder, on the package says its nonalcoholic. To be disrespected and spoken to in that manner. I never received rules and regulations here. : you blasted to your group chat, that [NAME] brought alcohol here She never came to apologize. Patient crying in between. mad at opening my mail Don ' t remember getting an admission agreement. I have depression, and this is affecting my mental health. I did not tell my doctor cause I thought they all know about this in their chat Did not receive Rules and Regulations here so I don ' t know what not to do and people coming after me why I ' m doing what I ' m doing. why no mention of group chat visit with DON about alcohol. Administrator does not know about alcohol because he does not read our group chat according to the lady downstairs in the front. Books are my life, they took away my books. I can stay in my room and read books and be happy. During an interview on 6/26/24 at 1:25 PM, with ADON (Assistant Director of Nursing) per ADON, we try to clean her room, a friend came to help and talk her into it. She gets upset at times. She orders packages from Amazon, someone brings it to her room, either the activity or social service brings her mail. She has the eggnog powder with her. During an interview on 6/26/24 at 1:28PM, with CNA, per CNA, she has been working for nine years in facility, AM shift. No problem with resident, not complaining, mostly in the room, goes out sometimes. Has daughter coming to visit sometimes. Every Sunday she goes to church someone picks her up. During an interview on 6/27/24 at 11:33AM, with Admissions Director, per AD, resident was given the admission packet on 8/2023 and 4/2024 No follow up and no protocol for when to go back to resident for the signed agreement. Regarding receiving packages, policy is with Social Services, verbal given to patient. When a package comes for her, the team is made aware thru the chat, that includes the Kaiser Case manager and all department heads. Administrator does not usually read the chat but he is in the group. During an interview on 6/27/24 at 12:08 PM, with Social Services, per SS, resident is a hoarder, we had a plan to clean her room a team plus a friend. Friend took knives and sharp objects that she ordered, that was mistakenly given to a different patient. That patient opened the package and stated it ' s not hers. Was then delivered to resident already opened, was educated about safety. February 2024, when she ordered from Amazon again, plan by Administrator to have nursing give her package and open in front of her. Resident was told verbally about plans but none in writing. Regarding PTSD, patient declined to share her traumatizing event. Per SS, I will start with an apology and rebuild the trust with her, sorry to hear that made her upset. Review of clinical records on 6/27/24 with SS, per SS no signed admission agreement found on chart. No written policy on online ordering and receiving packages. NO IDT (Interdisciplinary Team) meeting documented but we have met with family and resident and discussed these issues. During an interview on 6/27/24 at 1 PM, with Administrator, per Administrator, I see the patient almost every day, put in a lot of time to this resident. She was not paying the share of cost and buying a lot from online orders. Daughter is applying for POA to be able to have control over her credit card use. She is paying her share of cost now. About the chat group, I don ' t know why someone would tell a resident about it, it ' s an internal communication. The plan is if she receives a package, the AIT (Administrator in Training) will bring to her and take out one item from her room to avoid hoarding and clutter. Had family meetings about this and the expectation from the resident, no documentation of those meetings. Review of MDS, section C- indicates, BIMS (Brief Interview for Mental Status) result is 15, as of May 2024 quarterly assessment. Review of facility Policy, Admission Agreement ,dated 8/2018, indicated, All residents have a signed and dated Admission Agreement on file. 1. At the time of admission, the resident must sign an Admission Agreement (contract). 4. A copy of the Admission Agreement is provided to the resident or his/her representative (sponsor), and a copy placed in the resident ' s permanent file. Review of facility Policy Resident Rights and Responsibilities, dated 3/2017, indicated, Our facility shall inform the resident both orally and in writing of his or her rights as a resident, and the rules and regulations governing the resident ' s conduct and responsibilities during his or her stay in the facility. 1. Prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident ' s rights and a copy or synopsis of rules and regulations governing the resident ' s conduct and responsibilities during his /her stay in the facility. 2. A representative from Social Services will be responsible for reviewing these rights and responsibilities orally with the resident. 3. The resident will be required to sign a statement acknowledging that he or she was informed of his or her rights and responsibilities .

Based on observations, interviews and record reviews, the facility failed to assess the resident for self -administration of medications for Resident 1, when four bottles of medications found in her purse. This failure could result in medication overdose or medication interaction, as these medications are not in MD order. Findings: Review of Admission Record, dated 6/26/2024, indicated, admitted on [DATE], readmitted on [DATE], with diagnoses including: Fracture of Right Femur(a break in the right upper leg), Type 2 Diabetes( a condition with poor controlled blood sugar), Peripheral Vascular Disease(a slow progressive disorder and narrowing of blood vessels). During an observation on 6/26/24 at 12:30 PM, Resident 1 in bed, with a leg immobilizer on right leg, a bandage on right foot. Resident alert and has food on the bedside table. my friend brought me home cooked meal. Per patient, she stays most of the time in bed due to pain, taking Tylenol Arthritis for pain on my own. Resident 1 took out 4 bottles from her purse that is hanging on her overbed table. One unlabeled bottle, resident stated is Tylenol Arthritis. I keep them here so I can take it myself, they don ' t give me pain medication. They give Oxy in the morning and no more. The following are the medication bottles found and showed by the resident: 1. Senna-Time 8.6 tablet, Rx take 2 tablets at bedtime- 10 tablets 2. A white unlabeled bottle with whilte caplets inside, per resident is Tylenol Arthritis -8 tablets 3. [NAME] Omega 50+ with CoQ10 - empty bottle 4. Zegerid OTC - 12 tablets During an interview on 6/26/24 at 12:30 PM, with Resident 1, per resident, I did not tell them , they will take it and not give to me my pain pill. During a concurrent interview and record review on 6/26/24 at 1 PM, with DON, per DON, Not aware of her having meds in her purse at her bedside. I will go and check. No self -administration assessment found in chart. No care plan for self -administration and no IDT meeting and recommendation found in chart. Review of MDS, section C dated 5/22/24, BIMS (Brief Interview for Mental Status) result is 8, has cognitive impairment. Review of facility Policy, Self-Administration of Medications, dated 2/2021, indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the IDT assesses each resident ' s cognitive and physical abilities to determine whether self -administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan .9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party .

Based on observation, interview, and record review, the facility failed to ensure a pre employment background check was completed for a Certified Nurse Assistant (CNA) 1 before allowing to work at the facility. The facility's failure had the potential for residents to experience abuse and psychosocial harm. Findings: Resident 1 was admitted with diagnoses including dementia (a decline in memory or other thinking skills and). A review of the Minimum Data Set (MDS, a standard Assessment tool) dated 1/23/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning [includes memory, thinking, and decision making abilities]) score of 3 indicated severe cognitive impairment (rarely makes decisions). During an observation and interview on 2/9/24, at 10:12 AM, Resident 1 was in bed awake, verbally responsive, calm and pleasant. Resident 1 stated, The other night, around midnight, a black guy came into the room and started pounding on my chest and stomach. I told him to stop. I told him to leave. I reported it to the people here in the morning. During an interview on 12/9/24, at 10:52 AM, Social Services Assistant stated, CNA 1 was identified as the CNA that worked with the Resident 1 during the night shift. During an interview on 2/9/24, 11:01 PM, Human Resources Director (HRD) stated, that he was not involve in the pre-employment screening of the applicants. HRD reviewed CNA 1's file and acknowledged there was no criminal background check completed. During an interview on 2/14/24, at 11:35 AM, the Administrator acknowledged there was no pre-employment background check completed and on file for CNA 1. A review of the Policy and Procedure titled, Licensure, Certification, and Registration of Personnel dated 4/2007, indicated, .Our facility conducts employment background screening checks, reference checks, license verifications and criminal conviction investigation checks in accordance with current federal and state laws. Personnel undergoing background investigation, if employed, will not be permitted to perform any duties that require a license/certificate registration until such investigation reveals a current unencumbered licence/certification/registration. Other duties performed during the investigation process must be performed under the direct supervision of a duly licensed/certified/registered employee .

Based on interview and record review the facility failed to develop and implement a baseline care plan for one of 34 sampled residents (Resident 1) that includes the instructions needed to provide effective and person-centered care when there was an intervention which was not applicable upon admission for Resident 1 who was at risk for fall. This failure had the potential to place Resident 1 at risk not to receive the appropriate intervention to prevent fall. Findings: Review of Resident 1's Admission Record indicated, she was admitted to the facility on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), presence of left artificial hip joint, and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a standing position). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/19/23 indicated, she was cognitively intact. The MDS also indicated, Resident 1 had hip fracture (a partial or complete break in the bone), displacement intertrochanteric fractures of left femur (a kind of the change in position and fracture of thigh bone), and history of falling. During a concurrent interview and record review on 1/10/24 at 10:45 a.m. with Director of Nursing (DON), Resident 1's fall score and Radiology Report were reviewed. DON stated, She fell at home, then she had a hip fracture. She had ORIF (Open Reduction and Internal Fixation, a type of surgery used to stabilize and heal a broken bone), then she came to us for rehab . DON stated, the resident's fall score was 13 upon admission on 3/16/23. DON stated, a fall score above 10 was at risk for fall. DON stated, Resident 1 had unwitnessed fall on 4/12/23 around 4:45 p.m. DON stated, Resident 1 was sitting in wheelchair, and it was locked for her safety. DON stated, her bed was next to Resident 1, and a table was in front of her because she was waiting for her dinner, then she had unwitnessed fall. DON stated, We don't know why. She couldn't tell us why she fell . DON stated, there was a small skin tear on the left thumb, and it was not bleeding. Otherwise, there was no injury. DON stated, during the neuro check (an evaluation of a person's nervous system), Resident 1 was noted skin discoloration on her right mid back, and that's why the doctor ordered stat X-ray. DON stated, otherwise Resident 1 was fine. DON stated, We ordered stat X-ray on 4/12, then it was done next day, then had a result on 4/14. Radiology Report dated 4/13/23 indicated, . Right 7th rib fracture . DON stated, they sent her to the hospital, but she refused treatment, so she returned the same day. So, we monitored her for her safety. DON stated, Resident 1 left the facility at 10:30 a.m. on 4/14/23 without chief complaint, then came back from the hospital at 5:30 p.m. on 4/14/23. DON stated, CT scans (a computerized x-ray imaging procedure to check any part of the body) were offered in the hospital, but Resident 1 and her son refused. DON stated, the resident had history of orthostatic hypotension. Review of Resident 1's clinical record titled, Provider Note from the hospital, dated 4/14/23, indicated, . Patient recently sustained a rib fracture on the right side after a fall on 4/12 . Medical Decision Making . status post recent hip fracture who sustained unwitnessed fall on 4/12 with right seventh rib fracture transferred here today from SNF (Skilled Nursing Facility) without clear chief complaint and no endorsed symptomatology or focal complaints by patient (other than right rib pain at site of fracture) . son . at bedside . He is a physician and felt he would be better to forego scanning/radiographs . Patient discharged to SNF . with recommendation to follow-up with primary care provider and return precautions given . Son declines CT scans for pt (patient) . Long discussion with son who is a physician . During a concurrent interview and record review on 1/10/24 at 11:40 a.m. with DON, Resident 1's fall care plan (CP) upon admission reviewed. The CP indicated, . The resident is at risk for falls . Hx (history) of repeated falls . Date initiated: 03/16/2023 . Review information on past falls and attempt to determine cause of falls. Record possible root causes . Resident is HIGH FALL RISK . DON stated, it was for falls at the facility, not the previous falls at home, so she did not have the record when asked if there was a documentation for root causes and information on past falls for Resident 1 upon admission. DON stated, this care plan was intended to remind staff to check for possible root causes when a resident falls at the facility. When asked if it was applicable care plan for the resident upon admission, DON stated, it was not applicable care plan for the resident at that time. Review of the facility's Policy and Procedure titled, Care Plans-Baseline revised in March 2022 indicated, . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident . 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident .

Based on interview, and record review, the facility failed to ensure the director of dietary services is employed when there was no kitchen manager at the facility after 10/31/23. This failure had the potential for inadequate supervision of the dietary department for 153 residents who ate food from the kitchen out of a census of 153. Findings: During a concurrent observation and interview on 12/11/23 at 10:14 a.m. with Registered Dietitian (RD) and Assistant Kitchen Manager (AKM) in the kitchen, there was no kitchen manager. RD stated, We don't have a manager. Currently we don't have the manager . We are interviewing (the manager) . when asked. AKM also acknowledged, they don't have the kitchen manager. During an interview on 12/12/23 at 11:09 a.m. with Director of Nursing (DON), DON stated, they interviewed several candidates for the kitchen manager, but it was hard for them to find the right person. DON stated, she didn't know when asked how long they would not have the kitchen manager. During an interview on 12/12/23 at 12:45 p.m. with DON, DON stated, the last time the kitchen manager was at the facility was on 10/31/23. During an interview on 12/13/23 11:43 a.m. with RD, RD stated, Manage the staff in the kitchen, scheduling the kitchen staff . when asked about the role of the kitchen manager. RD stated, It can affect the accountability . For emergency situation in the kitchen, it's hard to come up with solution . when asked how the lack of the kitchen manager would affect the kitchen. Review of the facility's organizational chart, undated indicated, the director of dietary services was under the administrator. The chart indicated, the assistant director of dietary services, cooks, prep cooks, and dishwasher dietary staff were under the director of dietary services. Review of the facility's job description, dated 2023 indicated, . FNS (food and nutrition services) Director . DUTIES AND RESPONSIBILITIES: 1. The supervisor will confer regularly with the Administrator, Director of Nursing, and Facility Registered Dietitian, and keep them informed of both the problems and progress of the Food & Nutrition Services Department. 2. Schedule and supervise the Food & Nutrition Services staff . 3. Is responsible for the preparation and service of all food . 4. Plan kitchen procedure to have food ready on time . 6. Is responsible for maintaining cleanliness of kitchen equipment, and follows all department of health regulations. 7. Maintain weekly inventory of food assuring that sufficient supplies are on hand to meat state and federal regulations . 14. Review, update, and follow policies & procedures . Review of the facility's policy and procedure (P&P) titled, Personnel Management dated 2023 indicated, . A qualified FNS (Food and Nutrition Services) Director, chosen by the Administrator, is responsible for the total operation of the Food & Nutrition Services Department. All Food & Nutrition service is performed under their direction . RESPONSIBILITIES OF FNS DIRECTOR . Department orientation, staffing, supervision, staff training, and in-servicing . Maintaining acceptable standards of sanitation and food safety . Review of the facility's policy and procedure (P&P) titled, Sanitization revised October 2008 indicated, . 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. There were no expiration dates on two chicken flavored base and cranberry flavored juice cocktails in a box in the refrigerator, and one box of the beef patty in the freezer. 2. There were no dates on the ranch dressing on a tray in the refrigerator and ice creams in a cup on a tray in the freezer. 3. There were two boxes of FRESH SHELL EGGS, not pasteurized eggs in the refrigerator. 4. There were expired items in the refrigerator such as one low fat cottage cheese, mayonnaise, and hot sauce. 5. Dish machine temperature logs were not filled completely for November and [DATE]. 6. Pot and pan test strip/sanitation bucket logs were not filled completely for November and [DATE]. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on [DATE] at 10:40 a.m. with Registered Dietitian (RD) and Assistant Kitchen Manager (AKM) in the kitchen, there were no expiration dates on the two containers of chicken flavored base in the refrigerator. One container's seal had already been removed and it's received date was [DATE]. And the other container's received date was [DATE] and its seal had not been removed. But there were no expiration dates on the two containers. RD stated, there should be an expiration date on the containers when asked. She stated, they had to label the container with the expiration dates. RD and AKM acknowledged there was no label on the container indicating the expiration dates. During a concurrent observation and interview on [DATE] at 11:01 a.m. with RD and AKM in the kitchen, there were cranberry flavored juice cocktails in a box in the refrigerator. The box indicated, the items' received dates were [DATE], but there was no expiration date on the box. RD, stated, We should have a label when asked. AKM also acknowledged there was no label on the box indicating the expiration date. During a concurrent observation and interview on [DATE] at 11:11 a.m. with RD and AKM in the kitchen, there was a box of the beef patty in the walk-in freezer without expiration date on it. RD and AKM stated, No when asked if they could see the expiration date. During an interview on [DATE] at 12:05 p.m. with RD, RD stated, You can't tell when the food will be expired . Potentially hazard . when asked what it means for food items to have no expiration dates on them. Review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage dated 2023, indicated, . 9. Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice . Review of the facility's P&P titled, Labeling and Dating of Foods dated 2023, indicated, . All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . Newly opened food items will need to be closed and labeled with an open date and used by the date . Review of the facility's P&P titled, Labeling and Dating of Foods dated 2023, indicated, . All prepared foods need to be covered, labeled, and dated . 2. During a concurrent observation and interview on [DATE] at 10:50 a.m. with RD and AKM in the kitchen, there were no dates on the ranch dressing on a tray in the refrigerator. RD stated, We should put the date on them when asked about the policy. During an interview on [DATE] at 10:56 a.m. with Dietary Aide (DA) 1, DA 1 stated, the date label was not well attached to the tray, so she could not put the label on the tray for the ranch dressing in the refrigerator. She stated, We will find the way to fix it. During a concurrent observation and interview on [DATE] at 11:03 a.m. with DA 1, RD, and AKM in the kitchen, there were no dates on the ice creams in a cup on a tray in the freezer. DA 1 stated, Same thing (like the ranch dressing) when asked why there were no dates on them, then she threw them away. RD and AKM acknowledged there were no dates on the ice creams. Review of the facility's P&P titled, Labeling and Dating of Foods dated 2023, indicated, . All prepared foods need to be covered, labeled, and dated . 3. During a concurrent observation and interview on [DATE] at 10:50 a.m. with RD and AKM in the kitchen, there were two boxes of FRESH SHELL EGGS in the refrigerator. RD stated, I don't think so when asked if the eggs were pasteurized. During an interview on [DATE] at 9:58 a.m. with RD, RD stated, Germs on the shell can get into the edible portion can contaminate when asked about not using pasteurized eggs. Review of the facility's P&P titled, Procedure for Refrigerated Storage dated 2023, indicated, . 11. Raw eggs shall be obtained pasteurized . 4. During a concurrent observation and interview on [DATE] at 10:40 a.m. with RD and AKM in the kitchen, there was a low-fat cottage cheese container marked USEDDBYDEC,d+[DATE] in the refrigerator. RD stated, Yes when asked if it was expired. During a concurrent observation and interview on [DATE] at 11:20 a.m. with RD and AKM in the kitchen, there was a mayonnaise container with expiration date of [DATE], and hot sauce in a container with expiration date of [DATE] in the refrigerator. RD and AKM acknowledged the mayonnaise and hot sauce were expired and should not be used. During an interview on [DATE] at 12:05 p.m. with RD, RD stated, Potentially hazardous . could lead to illness . when asked what expired food means. Review of the facility's P&P titled, Procedure for Refrigerated Storage dated 2023, indicated, . 9. Food items should be arranged so that older items will be used first . 5. During a concurrent interview and record review on [DATE] at 10:32 a.m. with RD and AKM in the kitchen, the facility's documents titled, Dish Machine Temperature Log (High-Temp Machine), dated November and [DATE] were reviewed. The dish machine logs indicated, there were no entries on the following dates: 1) [DATE] for dinner; 2) [DATE] for dinner; 3) [DATE] for dinner; 4) [DATE] for dinner; 5) [DATE] for dinner; 6) [DATE] for breakfast/lunch/dinner; 7) [DATE] for breakfast/lunch/dinner; 8) [DATE] for dinner; 9) [DATE] for dinner; 10) [DATE] for dinner; 11) [DATE] for dinner; 12) [DATE] for dinner; 13) [DATE] for breakfast/lunch/dinner; 14) [DATE] for breakfast/lunch/dinner; 15) [DATE] for dinner; 16) [DATE] for breakfast/lunch/dinner; 17) [DATE] for dinner; 18) [DATE] for breakfast/lunch/dinner; 19) [DATE] for breakfast/lunch/dinner; 20) [DATE] for dinner; [DATE] for dinner; 21) [DATE] for dinner; 22) [DATE] for dinner; 23) [DATE] for dinner; 24) [DATE] for breakfast/lunch/dinner; 25) [DATE] for breakfast/lunch/dinner; 26) [DATE] for dinner; 27) [DATE] for dinner; 28) [DATE] for dinner; 29) [DATE] for dinner. RD stated, the kitchen staff might forget to check the dish machine after their previous kitchen manager had left when asked. AKM stated, the kitchen staff should check the dish machine and fill out the dish machine logs every day. AKM acknowledged their practice was not correct. AKM stated, It should be done daily, every single breakfast, lunch and dinner when asked. During a concurrent interview and record review on [DATE] at 11:09 a.m. with Director of Nursing (DON), the dish machine logs dated November and [DATE] were reviewed. DON acknowledged that staff did not check the dish machine every shift. During an interview on [DATE] at 12:05 p.m. with RD, RD stated, It means they are probably not doing it . The result would be the improper sanitation . when asked what it means that the dish machine logs were not documented every breakfast, lunch, and dinner. Review of the facility's P&P titled, Sanitization revised [DATE] indicated, . The food service area shall be maintained in a clean and sanitary manner . 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas . 6. During a concurrent observation and interview on [DATE] at 11:10 a.m. with RD and AKM in the kitchen, the facility's documents titled, Pot and Pan Test Strip/Sanitation Bucket Log dated November and [DATE] were reviewed. The logs indicated, there were no entries on the following dates: 1) [DATE] for dinner; 2) [DATE] for dinner; 3) [DATE] for dinner; 4) [DATE] for dinner; 5) [DATE] for dinner; 6) [DATE] for dinner; 7) [DATE] for dinner; 8) [DATE] for dinner; 9) [DATE] for dinner; 10) [DATE] for dinner; 11) [DATE] for dinner; 12) [DATE] for dinner; 13) [DATE] for dinner; 14) [DATE] for dinner; 15) [DATE] for dinner; 16) [DATE] for dinner; 17) [DATE] for dinner; 18) [DATE] for dinner; 19) [DATE] for dinner; 20) [DATE] for dinner; 21) [DATE] for dinner; 22) [DATE] for dinner; 23) [DATE] for dinner; 24) [DATE] for dinner; 25) [DATE] for dinner; 26)[DATE] for dinner; 27) [DATE] for breakfast/lunch/dinner; 28) [DATE] for breakfast/lunch/dinner; 29) [DATE] for breakfast/lunch/dinner; 30) [DATE] for dinner; 31) [DATE] for dinner; 32) [DATE] for dinner; 33) [DATE] for dinner; 34) [DATE] for lunch/dinner; 35) [DATE] for breakfast/lunch/dinner; 36) [DATE] for dinner; 37) [DATE] for dinner; 38) [DATE] for dinner; 39) [DATE] for dinner; 40) [DATE] for breakfast/lunch/dinner; 41) [DATE] for dinner. RD stated, It probably means that they didn't do it . Since they are not doing it . improper sanitation . when asked what it meant by no entries on these dates. Review of the facility's P&P titled, Quaternary Ammonium Log Policy, dated 2023 indicated, . The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution . The concentration will be tested at least every shift . Review of the facility's P&P titled, Sanitation dated 2023 indicated, . 1. The FNS Director is responsible for instructing employees in the fundamental of sanitation in food service . 23. Quaternary Ammonium Log Policy and corresponding logs are included .

Based on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. Licensed Vocational Nurse (LVN) 3 did not remove her N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect your eyes, nose, mouth and face from flying objects and liquids) after leaving a Resident 22's room who was on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. Certified Nursing Assistant (CNA) 7 did not remove her face shield after leaving a Resident 33's room who was on droplet precautions. 3. A used, green colored respirator mask was stored inside a linen cart on the third floor. 4. CNA 1 left the door wide open while assisting Resident 80 with lunch, who was on TBP. Failure to implement infection prevention practices may contribute to the cross contamination of infection that can jeopardize the health of residents, staff, and visitors. Findings: 1. During an observation on 12/11/23 at 1:13 PM, LVN 3 went out of a Resident 22's room wearing an N-95 respirator and face shield. LVN 3 closed the door and continued to walk in the hallway towards the medication cart. Personal protective equipment (PPE) supply set-up was observed outside Resident 22's door. Resident 22's door was closed and had a sign posted indicating, Enhanced Respiratory and Contact Precautions . All Staff Must Wear: Gown, Respirator: N95 or higher level respirator, Eye protection: Goggles or face shield, Gloves. During an interview on 12/11/23 at 1:15 PM, LVN 3 acknowledged wearing N-95 respirator and face shield after leaving Resident 22's room who was on TBP and stated, It wouldn't hurt if I wear it. LVN 3 explained, Resident 22 was on COVID-19 isolation in which staff are required to wear a gown, face shield, N95 mask, and gloves when providing care. LVN 3 further stated, N95 changed every after room entered. Face shield supposed to take it off after leaving the room. During concurrent observation, LVN 3 then discarded the face shield in the medication cart trash bin. During an interview on 12/11/23 at 1:20 PM, Infection Preventionist (IP) stated, all PPEs including gown, gloves, N95 respirator, and face shield must be removed before leaving the resident's room who's on TBP. 2. During an observation on 12/13/23 at 2:45 PM, CNA 7 went out of a Resident 33's room with her face shield on and walked towards the linen cart parked in the hallway. PPE supply set-up was observed outside Resident 33's door. Resident 33's door was closed and had a sign posted indicating, Droplet Precautions - Everyone Must: Clean their hands, including before entering and when leaving the room . Remove face protection before room exit. During an interview on 12/13/23 at 12:47 PM, CNA 7 stated Resident 33 was on isolation due to RSV (respiratory syncytial virus or RSV - is a common respiratory virus that usually causes mild, cold-like symptoms). CNA 7 further stated, Visor, gown, N95, and gloves are required when entering Resident 33's room. CNA 7 acknowledged she's supposed to remove her face shield before leaving the resident's room. 3. During concurrent observation and interview on 12/13/23 at 2:46 PM, CNA 7 was walking towards the linen cart parked in the hallway and started pushing it towards the linen storage room. A green colored N95 respirator was observed inside the linen cart. CNA 7 confirmed the green colored N95 respirator in the linen cart was used and stated, I don't know who it is. CNA 7 then removed the green colored N95 respirator from the linen cart. During an interview on 12/14/23 at 4:05 PM, IP stated used PPEs should not be stored but discarded in the provided trash bins in the resident's room. IP also stated that everyone should don (put on) PPE before going in to the resident's room on TBP and doff (remove) before going out of the room. IP added, Remove everything before going out of the room. IP further stated, used or soiled PPEs including N95 respirator should be discarded immediately after use and before leaving the resident's room. Review of facility's policy and procedure titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, revised May 2023, indicated, .1. All Staff will follow standard precautions (and transmission-based precautions if required based on resident's condition). 2. When caring for a resident with suspected or confirmed SARS-CoV-2 infection, personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. - a. Respirator: . (2) Disposable respirators are removed and discarded after exiting the resident's room or care area and closing the door . b. Eye Protection: . (2) Eye protection is removed after leaving the resident room or care area . 44477 4. During an observation on 12/11/23 at 1:04 p.m. in the hallway, CNA1 entered Resident 80's room , where a transmission-based precaution (TBP: infection-control precautions, known as isolation, in health care) sign was posted at the door. The TBP sign titled, Enhanced Respiratory and Contact Precautions indicated, . Keep Door Closed at All Times . CNA1 did not close the door, but instead left it wide open and entered the room. Review of the facility's census, dated 12/11/23 indicated, Resident 80 was on isolation for COVID-19. During a concurrent observation and interview on 12/11/23 at 1:06 p.m. with Infection Preventionist (IP) in the hallway, CNA1 left the door wide open while assisting Resident 80 in the room with lunch, who was on isolation for COVID-19. IP stated, No. He is not, when asked if the CNA's practice was acceptable for taking care of COVID-19 infected resident, then acknowledged that the CNA should have closed the door. Review of Resident 80's record untitled indicated, . 12/6/2023 Detected . SARS-CoV-2 RNA (highly infectious RNA coronavirus responsible for COVID-19) . Review of the facility's policy and procedure (P&P) titled, Facility COVID-19 Mitigation Plan, updated 10/30/23, indicated, . Residents with active COVID-19 infection will be placed on quarantined on their respective room with doors closed . identified by a sign that says Enhanced Respiratory Precaution on the door .

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for two of 31 sampled residents (Resident 23, 73, and 63). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents. Findings: Review of the MDS Summary in the electronic health record (EHR) on 12/15/23, indicated the following: 1. Resident 23 was admitted on [DATE]. Review of Resident 23's quarterly MDS assessment dated [DATE] indicated, the Registered Nurse (RN) Assessment Coordinator signed the assessment as complete on 12/14/23, 64 days after the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). 2. Resident 73 was admitted on [DATE]. Review of Resident 73's quarterly MDS assessment dated [DATE] indicated, the RN Assessment Coordinator signed the assessment as complete on 12/14/23, 64 days after the ARD. During an interview on 12/15/23, at 12:43 PM, MDS Coordinator (MDSC) stated, the quarterly MDS assessment should be completed 14 days after the ARD. MDSC acknowledged the quarterly MDS assessments for Resident 23 and Resident 73 were signed as complete on 12/14/23 and stated, This is one instance that the completed assessments were not submitted timely. During further interview, MDSC stated the quarterly MDS assessment must be submitted within 14 days of the MDS completion date. Review of the facility's transmittal document titled Batch #1057, dated 12/15/23, indicated, the quarterly MDS assessments for Resident 23 and Resident 73 were accepted on 12/14/23. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type . The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . Review of facility policy and procedure titled, MDS Completion and Submission Timeframes, revised July 2017, indicated, .1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements and published in the Resident Assessment Instrument Manual .

Based on interview and record review, the facility failed to provide supervision/assistance to Residents 62, 71, and 81, three of thirty-one sampled residents, to minimize their fall risks. Due to this failure, all three residents had multiple falls, and each sustained a fracture due to their falls. Additionally, lack of supervision resulted in an injury of unknown origin to Resident 105. Resident 105 was found with bleeding to his face. Findings: 1). Review of Resident 62's records titled, Minimum Data Set (MDS, a standardized resident assessment tool), dated 11/15/23, indicated his Brief Interview for Mental status (BIM) score was 13 out of 15. BIM is a standardized test for memory and reasoning functions. A score of 13 to 15 indicates no impairment in memory and reasoning. His MDS indicated he needed: 1. supervision or touch assistance with: toileting hygiene (removing clothing to urinate or to have a bowel movement and cleaning up self), lower body dressing, sit to stand, chair/bed transfers, and toilet transfers. 2. partial/moderate assistance with: shower/bathing. tub/shower transfers, walking 50 feet, and walking 50 feet with two turns. 3. Setup or clean-up assistance with personal hygiene (activities such as combing hair, washing face, and shaving) Review of Resident 62's record titled Progress Notes, dated 05/30/2023, indicated Resident 62 had multiple diagnoses including: unsteadiness on feet, need for assistance with personal care, and history of falling. Review of Resident 62's records titled Fall Risk Evaluation, dated 06/06/2023, indicated he was . at high risk of fall . Review of Resident 62's records titled FALL CARE PLAN, printed on 12/12/2023, indicated the facility formulated these interventions to minimize Resident 62's fall risks .Anticipate and meet the resident's needs.Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter (or) remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes.safety checks every 4 hours .(for) 14 days.Toileting schedule: Assist resident with toileting every 2 hours while awake. Further review of Resident 62's fall care plan indicated he had four unwitnessed falls on 05/01/2023, 05/29/2023, 06/10/2023, and 12/09/2023. The facility was asked to search Resident 62's record and provide fall data from January 2023 to December 2023. The Director of Nursing (DON) emailed on 12/13/2023 at 5:02 PM that Resident 62 had a total of eight falls, and Resident 62 sustained a spinal fracture due to his fall on 05/29/2023. Review of Resident 62's record titled Emergency Department Provider Note, dated 05/29/2023, indicated Resident 62 .acute appearing compression fracture of (one of the spine bones near the bottom of the last rib) . Acute conditions are severe and sudden in onset. A compression fracture is a type of fracture or break to the bones in your spine. Review of Resident 62's record titled Progress Notes, dated 05/31/2023, indicated . unwitnessed fall, .(Resident 62) complains of pain, .and is using back brace when out of bed. Review of Resident 62's record titled Progress Notes, dated 06/11/2023, indicated . (Resident 62) was in pain when raising .(head of bed) for medication administration. During an interview on 12/12/23 at 8:43 AM, Resident 62 was asked about his falls. Resident 62 stated he has a history of not asking for assistance I fell when I was reaching for something on the floor. They gave me hell for not calling for help. The lack of supervision resulted in an unwitnessed fall and Resident 62 sustaining a spinal fracture on 05/29/2023. 2). Review of Resident 71's records titled, Minimum Data Set, dated dated [DATE], indicated his BIM score was 6 out of 15. A score of 0-7 indicates severe impairment in memory and reasoning. His MDS indicated he needed: 1. supervision or touch assistance with: toileting hygiene, upper and lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying on his bed, sitting to standing, chair/bed transfers, toilet transfers, and walking 10 feet. 2. partial/moderate assistance with shower/bathing. Review of Resident 71's record titled Progress Notes, dated 11/04/2023, indicated Resident 71 had multiple diagnoses including: hemiplegia and hemiparesis (muscle weakness or partial paralysis) on the right side of the body, generalized muscle weakness, and history of falling. Review of Resident 71's records titled Fall Risk Evaluation, dated 11/08/2023, indicated he was . at high risk of fall . Review of Resident 71's records titled FALL CARE PLAN, printed on 12/12/2023, indicated the facility formulated these interventions to minimize Resident 71's fall risks .Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes.Initiated on 7/18/23 Increase safety checks to .(every) 30 minutes .(for) 14 days. Additionally, review of Resident 71's fall care plan indicated he had four unwitnessed falls on 04/09/2023, 05/30/2023, 07/17/2023, and 11/04/2023. The facility was asked to search Resident 71's record and provide fall data from January 2023 to December 2023. The DON emailed on 12/13/2023 at 5:02 PM that Resident 71 had a total of four falls. The emailed data indicated that Resident 71 sustained a skin abrasion (a superficial scrape to the skin) to his cheek due to his fall on 05/30/2023 and a hip fracture due to his fall on 11/04/2023. Review of Resident 71's record titled Emergency Department Provider Note, dated 11/04/2023, indicated Resident 71 .recalls being unbalanced before fall .(the facility) did Xray showed broken right hip . X-ray imaging is using radiation to generate an image of the internal structure of the body. Review of Resident 71's record titled Progress Notes, dated 11/06/2023, indicated .resident at hospital for further . (evaluation) and treatment .(related to an) unwitnessed fall with .(right) hip .(fracture) . The lack of supervision resulted in an unwitnessed fall on 11/04/2023 and Resident 71 sustaining a hip fracture. 3). Review of Resident 81's records titled, Minimum Data Set, dated dated [DATE], indicated her BIM score was 3 out of 15. A score of 0-7 indicates severe impairment in memory and reasoning. Her MDS indicated she needed: 1. supervision or touch assistance with personal hygiene. 2. partial/moderate assistance with toileting hygiene, upper body dressing, sitting to lying on her bed, sitting to standing, chair/bed transfers, toilet transfers, and walking 10 feet. 3. Substantial/maximal assistance with shower/bathing, lower body dressing, putting on/taking off footwear, tub/shower transfers. Review of Resident 81's record titled Progress Notes, dated 11/29/2023, indicated Resident 81 had multiple diagnoses including: hemiplegia and hemiparesis affecting her right side, generalized muscle weakness, and unsteadiness on feet. Review of Resident 81's records titled Fall Risk Evaluation, dated 11/08/2023, indicated she was . at high risk of fall . Review of Resident 81's records titled FALL CARE PLAN, printed on 12/12/2023, indicated the facility formulated these interventions to minimize Resident 81's fall risks: 1. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 2. Safety checks every 30 minutes for 14 days, initiated on 06/13/2023; Safety check every 4 hours for 14 days, initiated on 11/29/2023; Safety checks every 1 hour and as needed for 14 days, initiated on 11/30/2023. 3. Offer to sit up on wheelchair and keep in visible area when awake. 4. Care conference completed with family and discussed possible 1:1 care or increase visitation from familiar faces. 5. continue on every 30 minutes monitoring and keep in visible area while awake. 6. Offer to attend activities of choice. Keep bed in lowest position and locked. 7. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes. 8. Offer toileting every 1 hour while awake assist resident to go to bathroom. Further review of Resident 81's fall care plan indicated she had four unwitnessed falls on 04/04/2023, 06/14/2023, 06/15/2023, and 11/29/2023. The facility was asked to search Resident 81's record and provide fall data from January 2023 to December 2023. The DON emailed on 12/13/2023 at 5:02 PM that Resident 81 had a total of 11 falls. The email indicated Resident 81 sustained these injuries as a result of her falls. 1. A skin tear to her left elbow on 06/13/2023. 2. A bleeding skin tear to her left arm on 06/14/2023. 3. A painful swelling to the back of her head on 10/11/2023. 4. A fracture of her left fifth finger on 11/29/2023. Review of Resident 81's record titled Progress Notes, dated 11/29/2023, indicated .Received x-ray result of the .(left) finger. Findings: Slightly fracture at the base . of the fifth finger . Review of Resident 81's record titled Progress Notes, dated 12/05/2023, indicated Resident expresses pain only upon touch in left fifth (finger) of .(her) hand. The lack of supervision resulted in an unwitnessed fall and Resident 81 sustaining a fracture to her finger. 4). Review of Resident 105's records titled, Minimum Data Set, dated dated [DATE], indicated his BIM score was 4 out of 15. A score of 0-7 indicates severe impairment in memory and reasoning. His MDS indicated he needed: 1. Limited assistance of one staff with bed mobility, transfers, 2. Extensive assistance of two staff with locomotion on and off unit, dressing, toilet use, personal hygiene 3. Totally dependent on two staff with walking in room. Review of Resident 105's record titled Progress Notes, dated 11/27/2023, indicated Resident 105 had multiple diagnoses including: need for assistance with personal care, acquired absence of right foot, acquired absence of left toe, epilepsy (seizure disorder) and generalized muscle weakness. Review of Resident 105's records titled Fall Risk Evaluation, dated 11/13/2023, indicated he was . at high risk of fall . Review of Resident 105's records titled Progress Notes, dated 11/1/2023 at 7:58 AM, indicated .resident came out of room on w/c with blood flowing from the forehead, nose and mouth. Noted blood spots on bed sheets and blood on the side table corner. Blood trail noted from bed to outside of room. Review of Resident 105's records titled Progress Notes, dated 11/1/2023 at 8:08AM, indicated .Resident was sent out for uncontrolled bleeding on 2 inch laceration above left eyebrow. Review of Resident 105's records titled Emergency Department Provider Note, dated 11/1/2023, indicated .staff saw him come out of his room with a .(cut) to the left forehead.(resident) recalls trying to get out of bed to wheelchair, which he usually does unassisted, and falling and hitting face on metal bar. No .(loss of consciousness). Complains of head/face pain and diffuse body discomfort. During an interview on 12/12/2023 at 2:17 PM, the Director of Nursing (DON) stated that the facility investigated the incident and classified it as an injury of unknown origin because there were no witness, it was not officially classified as a fall because Resident 105 was not found on the floor. The lack of supervision resulted in Resident 105 sustaining an uncontrolled bleeding injury to his face. During an interview with CNA (Certified Nursing Assistant) 6 on 12/12/2023 at 1:32 PM, she stated she worked day shift only and usually cares for 10 residents. CNA 6 stated sometimes it can be as many as 13 residents. CNA 6 was asked if 13 is too many residents to care for and/or supervise. CNA 6 stated Yeah. During an interview on 12/14/2023 at 2:08 PM, the Director of Nursing( DON) was provided a summary of ongoing discussions/interviews between Surveyor 31922 and the DON regarding falls, fractures and adequate supervision within the facility. The DON was given an opportunity to comment and edit these items if she felt any statements were inaccurate. The DON did edit the original text and these seven items are the final product of the interview/edit. 1. The most restrictive interventions the facility implement to minimize fall risks were: every 2 hours checks for 14 days, every 1 hour checks for 14 days, or every 1/2 hour checks for 14 days. 2. If the family agrees, the family pays for a sitter. A sitter is a hired staff to watch and supervise challenging residents so that they do not injury themselves from falls or other self-inflicted injuries. 3. The facility does not have the resources to implement a sitter. The facility try to provide as much as possible but not all the time. Trials of 2-3 days with a sitter are typical. The longest sitter trial was 2-3 weeks. It depends on the result and then the facility evaluate the need to continue using a sitter. 4. The facility does not utilize any alarm/motion and/or monitoring devices to alert staff regarding unassisted transfers. Mainly because these were noisy and may irritate residents. Additionally, some residents can disable these devices. 5. The facility has not explored other more advanced monitoring devices (such as silent alarm, infra-red triggers, tamper proof monitors ) to minimize fall risks. 6. At times, staffing may be an issue as staff may not be consistently implementing supervision or are not able to supervise at risk residents to minimize fall risks as evident by number of falls and fractures discussed. 7. No sitters were ever implemented for Residents 62,71, 81 or 105. During an interview on 12/14/2023 at 2:08 PM, the DON was asked about the decision process in implementing a sitter to supervise residents with high fall risks. The DON stated the decision to implement a sitter is dependent on a family's agreement to hire and pay for a sitter. The DON was asked if the facility's decision not to implement a sitter was based on a family's ability to pay versus the clinical needs of a resident. The DON did not answer directly but stated that the decision was resource based. Additionally, the DON added the facility had not utilize more advance monitoring/alarm devices to see if these devices could have helped minimize fall risks for these residents. Review of the facility's policy titled Falls and Fall Risk, Managing, revised on March 2018, indicated .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Review of the facility's policy titled Falls Prevention - Potential Interventions, revised on April 2012, found no mention of utilizing a sitter to minimize fall risks. The document did reference the use of a .bed alarm .(and) chair alarm . as potential interventions to minimize fall risks.

Based on observation, interview, and record review, the facility failed to ensure: 1. One of three sampled residents (Resident 1) receive a medication accurately and in a safe manner in accordance with the manufacturer's specifications and professional standards of practice to meet the needs of the resident. Upon the resident's re-admission to the facility from the hospital, the facility staff received information Resident 1 was applied a fentanyl transdermal patch (a potent narcotic/opioid applied to the skin, to treat moderate to severe pain) 25 micrograms per hour (mcg/hr)but the facility failed to ensure the hospital-dispensed patch was removed before a new fentanyl 25 mcg/hr patch one was applied. The failure resulted in Resident 1 being transferred to the Emergency Department (ED) with symptoms of somnolence (abnormally drowsy), hypotension (low blood pressure), and oversedation; and identified with two fentanyl patches on her body. She was administered two doses of Narcan (a life-saving medication to reverse an overdose from opioids) 0.04 milligrams (mg, unit of measurement) to relieve symptoms of opioid overdose, and was transferred to hospice care three days after being hospitalized . 2. A controlled medication (those with high potential for abuse and addiction) was accurately reconciled for one of four residents (Resident 2). This failure had the potential for abuse or diversion of controlled medications. Findings: 1. A review of the United States Drug Enforcement Administration (DEA) Drug Fact Sheet, dated 10/2022, Fentanyl is a potent synthetic opioid drug approved by the Food and Drug Administration [FDA] for use as an analgesic (pain relief) and anesthetic [substance inducing insensitivity to pain]. It is approximately 100 times more potent than morphine and 50 times more potent than heroin as an analgesic. A review of the Prescribing Information (PI; detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for fentanyl transdermal patch (brand name: Duragesic), revised 3/2021, indicated it is a potent narcotic applied to the skin, to treat moderate to severe pain. It is designed to release the drug in a slow, steady manner over 72 hours. It can be applied to intact, non-irritated skin on a flat surface such as the chest, back, flank, or upper arm; and that each patch may be worn continuously for 72 hours. The next patch is applied to a different skin site after removal of the previous transdermal system. The PI indicated, A considerable amount of active fentanyl remains in DURAGESIC even after use as directed. Death and other serious medical problems have occurred when children and adults were accidentally exposed to DURAGESIC. The PI indicated acute overdose with fentanyl patch can be manifested by symptoms including breathing problems, somnolence, slow heart rhythms, hypotension, sedation, and death. A review of the FDA Drug Safety Communication, posted 4/13/2023, regarding Fentanyl Transdermal Patch, it indicated, Fentanyl patches that have been worn for 3 days still contain enough medication to cause serious harm or death to adults or children who are not being treated with the medication and Be sure to remove your used patch before applying a new patch. On 6/20/23, a review of Resident 1's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including end-stage renal disease (ESRD; the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) with kidney dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), hyperlipidemia (high lipids in the blood), diabetes (disease that impairs the body's ability to regulate blood sugar), upper gastrointestinal bleeding, congestive heart failure (condition in which the heart does not pump blood as well as it should), ischemic cardiomyopathy (heart muscle that can not pump well because of damage from a lack of blood supply to the muscle), recent right above knee amputation (AKA), and AKA wound. A review of Resident 1 ' s physician ' s orders indicated she had been receiving fentanyl 25 micrograms/hour (mcg/hr; the patch delivers 25 mcg of fentanyl per hour continuously) 1 patch on the skin every 72 hours since 12/6/22. A review of Resident 1 ' s clinical record showed Resident 1 was transferred to Hospital A on 5/17/23 due to abnormal lab results. On 6/6/23, she was readmitted to the facility. A review of Hospital A's Interagency Discharge Summary and Orders, date of service 6/6/23, indicated a list of medications to be continued after hospitalization . The list included: Fentanyl 25 mcg/hr patch, apply 1 patch to skin every 72 hours. This order had a hand-written note indicating patch applied on 6/6/23. A review of Hospital A's medication administration record (MAR) during the 5/17/23 admission for Resident 1 indicated she had been receiving fentanyl (Duragesic) 25 mcg/hr 1 patch every 3 days (or 72 hours) since 5/26/23. The MAR showed a new patch was applied on 6/6/23 at 10 a.m. after the used patch was removed on the same day at 10 a.m. A review of the facility's Admission Notes, written by the admitting nurse, Licensed Vocational Nurse (LVN) A, on 6/6/23 at 7:08 p.m., indicated, admitted . female from [Hospital A] . Writer received report from [name of nurse from Hospital A] . Patient is incontinent for both B/B [bowel and bladder]. Last BM [bowel movement] on 6/6/23 . Per nurse, fentanyl patch was placed on L [left] shoulder and to be removed after 72 hours with a new patch after. Further review of Resident 1's physician ' s orders indicated, on day of re-admission of 6/6/23, Resident 1's physician placed an order for fentanyl 25 mcg/hr, apply 1 patch transdermally every 72 for pain mgt [management] and remove per schedule on 6/6/23, to be started on 6/9/23 (or 3 days later). A review of Resident 1's June 2023 MAR indicated LVN B applied a new fentanyl patch, based on the order above, on 6/9/23 at 8:59 a.m.; the documented application site was left chest. During an interview with the Director of Nursing (DON) on 6/20/23 at 11:20 a.m., she stated, for medications that come in patch, the nursing staff has to remove the used patch before applying a new patch. Specifically for fentanyl patch, because it is a potent narcotic medication, she stated the staff would remove it from the resident, fold it in half, place the used patch in a small plastic bag, log it in the Controlled Drug Record (CDR; aka the Count Sheet, an inventory record) that it is removed, and place the plastic bag in the locked narcotic box until it is picked up by her for destruction. She stated they need to do so because the used patch still contains active medication after 3 days use, which has potential for abuse. During another interview on 6/20/23 at 1:30 p.m., the DON stated, even though Resident 1 came back to the facility wearing the hospital-dispensed patch, the nursing staff would still need to remove the used patch, document the removal in the CDR, and keep in the locked narcotic box before applying a new patch. The CDR for Resident 1's fentanyl patch was requested for review. During an interview with LVN B on 6/20/23 at 1:46 p.m., he stated he worked the morning shift on 6/7, 6/8, and 6/9/23; and Resident 1 was under his care during those days. He stated he recalled the resident had a lot of pain issues and had been on a fentanyl patch even before she went to the hospital. He stated he assessed the resident on 6/7/23 (one day after the resident returned from the hospital) and did not see any fentanyl patch on her body. On the day of a new application, on 6/9/23, he stated he assessed the resident again and there was none. He stated, I did not remove the used patch. I assume they didn't put it on. When asked whether he documented he assessed the resident for the patch, he said he would not normally document such assessment. During a concurrent interview and record review on 6/20/23 at 2:17 p.m., the DON provided Resident 1's CDR for fentanyl 25 mcg/hr patch. Under Applied column, the CDR indicated LVN B removed 1 patch on 6/9/23 at 8 a.m. There was no corresponding removal of the used patch on 6/9/23 under the Removed column. The DON verified there was no documented evidence the hospital-dispensed patch was removed. During an interview with Certified Nursing Assistant (CNA) C on 6/20/23 at 2:25 p.m., she stated she cared for Resident 1 on 6/7 and 6/8/23 during the morning shift. She stated Resident 1 needed total assistance from staff for all activities of daily living such as bathing and personal hygiene. She stated Resident 1 had large BMs, requiring a full-body bed bath every day on those days. When asked if she recalled seeing a medication patch on the resident during care, CNA C pointed to her left shoulder and stated she recalled seeing a small patch on left side. She explained she did not recall the exact location but it was on the left chest or arm, during those two days. During an interview with the wound nurse, LVN D, on 6/20/23 at 2:33 p.m., LVN D stated her role as a wound nurse was to assess the resident's skin from head to toe, but focusing more on the wounds. She stated she assessed Resident 1 shortly after she was readmitted to the facility on [DATE]. When asked whether she recalled seeing a fentanyl patch on her body, LVN D replied, I really don't recall if she had or not. I don't mark it on the assessment form, just the skin and wound thing. During an interview with LVN A on 6/20/23 at 2:40 p.m., she stated she was the admitting nurse the day Resident 1 was readmitted on [DATE]. She stated she did the admitting procedures for Resident 1 and recalled the conversation with the nurse from Hospital A regarding fentanyl patch being placed on the resident's left shoulder on 6/6/23, that it was to be removed and replaced with a new one 3 days later. LVN A stated she also did the physical head-to-toe assessment on the resident on 6/6/23. When asked if she recalled seeing the fentanyl patch on the resident, LVN A responded, I can't recall but I believe it was on her left side. An interview was conducted with the evening shift nurse, LVN E, on 6/20/23 at 4:02 p.m. LVN E stated she worked the evening shift (from 3:30 - 11:30 p.m.) from 6/6 to 6/9/23. She stated she received Resident 1 the evening she came back on 6/6/23, and Resident 1 was under her care the next three days. She stated she did not get endorsement from LVN A or anyone that Resident 1 was on the fentanyl patch from the hospital, and she did not see a patch on the resident until 6/9/23, after LVN B had applied a new one in the morning. An interview with the evening shift CNA, CNA F, was conducted on 6/20/23 at 4:26 p.m. She stated she cared for Resident 1 the day she returned, the next day, and on 6/9/23. She stated she remembered the resident had a huge BM and had to be changed. She stated the resident had multiple skin tears and a dialysis shunt (an access point to allow direct access to the bloodstream for dialysis), so she needed to be careful during the resident's care. She said she did not recall seeing a patch on the resident as she only bathed her from the waist down. She also stated she was not made aware the resident was wearing a patch from the hospital. Another interview was conducted with the DON on 6/20/23 at 4:36 p.m. When asked what should have taken place when a resident came in on a fentanyl patch, she stated the first thing is to acknowledge that there was an actual patch. She continued, They [the nurses] should have looked for it, then endorsed it to the charge nurse, and created a POC [point-of-care] task for the CNAs to look for it during care. Sometimes from transfer, those patches may have fallen off. She stated the admitting nurse was to endorse it the charge nurse, then charge nurse to the next shift nurse, and so on. She said, Fentanyl is a heavy med and needs to be handled with caution. During another interview with LVN A on 6/20/23 at 5:01 p.m., she stated, It's been a while and I had so many admissions on that day so she did not recall if she verified the resident was actually wearing a patch. She stated she did endorse to the evening nurse, LVN E; and asked her to refer to her admission progress notes. She stated, They can always refer to the admission notes for information, and they are to endorse it to the next shift. During an interview with the DON on 6/20/23 at 5:15 p.m., she explained the nurse-to-nurse endorsement is a verbal, shift-change report where the outgoing nurse explaining residents' needs that the incoming nurse needs to be aware of when taking over the next shift. She stated she could not find any policy and procedures related to staff endorsement or nursing reporting. A review of Resident 1's clinical record indicated a nursing progress notes, written on 6/10/23 at 9:42 p.m., indicating Pt [patient] was not feeling well and was slumped over in her wheelchair since the CNA placed her in her chair to be ready for dialysis. Dialysis did not want to transport the pt if she was not feeling well. pt was feeling 10/10 [10 out of 10 pain score, meaning worst pain] R [right] knee (phantom) pain Called son . and son spoke to pt and they decided for pt to go to [Hospital A] ED. A review of Hospital A's ED Provider Notes, dated 6/10/23, indicated Resident 1 arrived in the ED on 6/10/23 at 11:04 a.m. Under Chief Complaint, the ED record indicated: BIBA [brought in by ambulance] from SNF [skilled nursing facility], c/o [complaint of] R knee pain, s/p [status post] R BKA on 6/6/23 . Arrives lethargic, hypotensive en route. Reportedly missed dialysis today. Under HPI [History of Present Illness], it indicated, [Resident 1] . presenting from SNF for hypotension, AMS [altered mental status], and knee pain. Under Medical Decision Making, a review of the above ED Provider Notes indicated, Patient presenting with acute illness with systemic symptoms, namely hypotension secondary to sedation versus sepsis [a serious medical condition caused by an overwhelming immune response to infection] . patient required admission to the hospital Patient presenting with increased somnolence, hypotension, found to have 2 fentanyl patches on, removed and given Narcan with significant improvement in mental status and blood pressure . also consider possible sepsis. Empirically started on antibiotics [course of treatment for suspected infection before lab results] given hypotension . Given patient's life-threatening hypotension, discussed goals of care with patient and son, confirmed DNR [do not resuscitate] . thus we will admit to medicine. A review of the ED's clinical record indicated Resident 1 received a dose of Narcan 0.04 milligram (mg, unit of measurement) on 6/10/23 at 11:55 a.m.; and another dose on 6/10/23 at 2:58 p.m. while in the ED. A review of the Inpatient Medicine: Admission History and Physical [H&P] with date of service 6/10/23 at 4:10 p.m., indicated the Chief Complaint was Hypotension/oversedation. Under History of Present Illness, a review of the above hospital H&P indicated the following: .female . who presented with foot pain and leukocytosis [an increase in the number of white cells in the blood, especially during an infection] found to have worsening osteomyelitis [inflammation or swelling that occurs in the bone] . who presented from SNF somnolent and hypotensive, c/f [concerning for] oversedation . Recently was admitted ,d+[DATE] - 6/6/23 and under went AKA with ortho[pedic] on 5/25/23. Briefly, her son . called her phone multiple times on 6/9 but she did not pick up. [Son's name] called the SNF . who recognized that she was quiet [quite] somnolent. Was due for ESRD [dialysis] today . Upon arrival to the ED she was noted to have two fentanyl patches (one on mid-chest, one on L arm). When speaking with her son, prior to admission, she communicated that she would not want procedures or artificial lengthening of her life. She communicated to him that she was at peace and ready to pass. A review of the Assessment/Plan, in the hospital ' s above-mentioned H&P, indicated in part: At time of admission, patient was found to have two fentanyl patches (prescribed as one patch every 72hr). Family believes she had new fentanyl patch placed 6/9 (day prior to admission). She received Narcan 0.04 mg x2 with increased alertness. She was noted to be hypotensive . Narcan drip was started but pressures did not improve. Discussed potential short-term stay in ICU [Intensive Care Unit] for pressors [medications to treat blood pressure] . After multiple discussions between family and medicine . team, family . opted to pursue comfort care. A review of the Acute Issues, of the H&P, it indicated, Oversedation w/ opiates [meaning opioids] and Hx [history of] R foot ulcer, sacral wound, leukocytosis s/p R AKA. A review of the Mission Hospice Inpatient Referral Note, dated 6/13/23, indicated Resident 1 was accepted to GIP on 6/13/23. A review of the hospital's Discharge Summary, dated 6/15/23, indicated Resident 1 was admitted on [DATE], and discharged on [DATE]. It indicated, Primary team reached out to GIP [General Inpatient Care, a hospice level of care] 6/13/23 . She is planned to be discharged from primary service then readmitted under GIP, Hospice. A review of the Hospital Course and Discharge Plan, By Issue, of the Discharge Summary, it indicated the medical issues of: Comfort Care, hypotensive like mixed 2/2 [secondary to] opioid overdose and comorbidities [presence of two or more diseases or medical conditions] of ESRD and hx of bacteremia [bacteria in the blood] and Oversedation w/ opiates. During a concurrent interview and record review with the DON on 6/20/23 at 5:07 p.m., the DON reviewed the 6/10/23 H&P (as mentioned above) from Hospital A and verified the fentanyl patch location documented in the SNF (left shoulder on 6/6/23 and left chest on 6/9/23) matched the two locations documented by Hospital A (one on mid-chest, one on left arm) on 6/10/23. A telephone interview was conducted with the facility's consultant pharmacist (CP) on 6/21/23 at 12:46 p.m. The CP stated, given the fentanyl patch is a potent narcotic medication with active medication remaining in the patch after 3-day use, it would be advisable to have an order to remove the used fentanyl patch (one the resident came with) before a new one is applied to make sure there is no confusion. When presented with Resident 1's symptoms of somnolence, sedation, and hypotension, he stated somnolence is consistent with opioid overdose symptoms. He stated the hypotension is more rare with opioid overdose, and could be related to the resident's other medical conditions. During a telephone interview with the facility's Medical Director (MD) on 6/22/23 starting at 4:38 p.m., he stated he was told by the facility staff the resident was in pain and possibly had an infection, that was the reason why he ordered to have her sent to the hospital on 6/10/23. He stated he did not know about the hospital finding two patches on the resident. He stated, prior to the interview with the surveyor, he was told the nurse who applied the patch on 6/9/23 said they did not see any patch before the application. When relayed the investigation revealing CNA C seeing the small patch on the left shoulder area for two days, and the facility's documentation of the patch placement matching the location documented by Hospital A, the MD stated, I think the hospital put the patch on the left shoulder on 6/6, and the facility put the patch on 6/9 on the chest, but they didn't remove the patch on the 6th, on the shoulder one. I think that happened. He continued, Fentanyl is a strong pain medication, it can kill people. You have to remove the prior patch before the new one. He stated, When the patient comes from the hospital, or even during nurse to nurse signing out, they should report the patient use the medication and the location of the patch. It's not something to be missed. He added, You don't know the dose remaining in the patch, that's why you remove the patch. During the interview with the MD above, on 6/22/23 at about 4:50 p.m., he stated he had remote access to Resident 1's clinical record from Hospital A. After a brief review, the MD stated, They said patient was quite somnolent, did not go to dialysis, found two fentanyl patches one on mid chest, one on left arm, communication with family, transfer patient to hospice. He reviewed the resident's presenting symptoms at the ED and stated, For sedation, at least we can say sedation because of too much narcotic. For the hypotension, it's hard because the patient had ESRD and also sepsis, I'm not sure that component is due to the narcotic; how much was due to the narcotic and how much due to her other conditions. He stated, If the resident received Narcan and she improved, then that's part of the somnolence at least. A review of the facility's policy and procedures (P&P) titled Administering Medications, revised April 2019, indicated, Medications are administered in a safe . manner, and as prescribed. A review of the facility's P&P titled Administering Topical Medications, revised October 2010, indicated the following for transdermal patches, Clean and dry a selected area that is approved for application of the patch . Remove old patch. 2. On 6/20/23 at 10:14 a.m., medications in the 2B Medication Cart was observed with the DON. She was asked to reconcile controlled medications for four random residents. At this observation, Resident 2's oxycodone (a potent narcotic medication to treat pain) 5 milligrams (mg, unit of measurement) was observed in a clear 6-ounce cup, inside the locked narcotic compartment. There were 7 tablets inside the cup. A review of Resident 2's controlled drug record (an inventory sheet) for oxycodone 5 mg with the DON indicated: on 6/20/23 at 5:30 a.m., one tablet was removed; the remaining amount was 9 tablets. Four hours later, on 6/20/23 at 9:30 a.m., Licensed Vocational Nurse G (LVN G) removed 1 tablet, but the quantity remaining was 7 tables (instead of 8 tablets). The DON acknowledged the math was incorrect. On 6/20/23 at 10:21 a.m., the DON asked LVN G to explain what happened. LVN G stated she gave 2 tablets in the morning but mistakenly documented she removed 1 tablet, hence the wrong math. A review of Resident 2's physician's order, dated 6/14/23, for oxycodone 5 mg, 1 tablet by mouth every 4 hours as needed for moderate pain, and 2 tablets every 4 hours as needed for severe pain. A review of Resident 2's medication administration record (MAR) with the DON on 6/20/23 at 10:24 a.m. revealed LVN G did not document the administration of 2 tablets of oxycodone to Resident 2 at 9:30 a.m. The DON stated the nurse needed to document right away to avoid another nurse giving the medication too soon because the previous one was not documented on the MAR. A review of the facility's P&P titled Documentation of Medication Administration, dated 11/2022, indicated, A nurse . documents all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication is documented immediately after it is given.

Based on interview and record review, the facility failed to provide standby assist (the presence of another person within arm's reach during the performance of one of the activities of daily living) for one of three sampled residents (Resident 1) to prevent fall. This failure had resulted in Resident 1's unwitnessed fall from the toilet to the bathroom floor on 11/15/21, sustaining a thigh fracture. Findings: Review of Resident 1's admission record, indicated Resident 1 was admitted on [DATE] with diagnoses including dementia (memory loss), traumatic subdural hemorrhage (bleeding in the area between the brain and skull), and [CONDITION(S)] (a condition in which bones become weak and brittle). Review of Resident 1's minimum data set (MDS, resident assessment tool) dated 11/3/21, indicated, Resident 1 was severely cognitively impaired and required extensive assistance with one person physical assist with bed mobility and transfer. Review of Resident 1's fall risk assessment dated [DATE], showed Resident 1 was high risk for fall. Review of Resident 1's interdisciplinary meeting note dated 11/15/21, at 10:00 AM, indicated, Certified Nursing Assistant 1 (CNA 1) left Resident 1 unattended in the toilet and went to help another resident. Resident 1 was found on 11/15/21 at 12:30 AM, sitting against the wall on bathroom floor, after having an unwitnessed fall. During an interview with Registered Nurse Supervisor 1 (RNS 1) on 3/15/22, at 3:30 PM, RNS 1 stated that on 11/15/21, at 12:30 AM, CNA 1 left the resident unattended while he was seated on the toilet because he had to assist another resident next door. Review of Resident 1's physician's progress notes, dated 11/23/21, at 12:00 A.M. , indicated, Resident 1 had nondisplaced fracture of neck of left femur ( a fracture where the bone did not move out of it's original position on left thigh) without any surgical intervention sustained from the fall on 11/15/21 at 12:30 AM Review of Resident 1's nurses' notes dated 11/15/21, at 3:33 AM, indicated, CNA 1 had asked RNS 1 to assist with Resident 1. Upon entering room by RNS 1` and CNA 1, Resident 1 had unwitnessed fall on the bathroom sitting against the wall. Resident 1 stated he got off toilet, slipped and fell . Nurses notes further indicated that CNA 1 must be present the entire time when Resident 1 use the bathroom. RNS 1 stated Resident 1 fell because CNA 1 left Resident 1 unattended on toilet to go help with other resident. Review of Resident 1's history and physical dated 11/17/21, indicated Resident 1 presented to the emergency department with chief complaint of hip pain. Resident 1 reports ground level fall, slipped 2 days ago. History of present illness (HPI) dated 11/17/21, indicated Patient was reported to suffer a fall in the early morning of Monday at his skilled nursing facility after being left unsupervised. He was noted to have some bruising in the back. Upper left femoral fracture noticed on mobile imaging for which he was brought into the ED for further imaging Review of Resident 1's Radiology Results Report dated 11/17/21 indicated fracture of the left femoral neck with impaction. During a concurrent interview and record review on 4/26/22, at 2:53 PM, with CNA 1, CNA 1 stated, I told resident to press the call light when done, did not press the call light, stood up and fell . Resident 1's fall care plan dated 10/8/21, interventions indicated Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . The facility's policy and procedure titled Falls and Fall Risk, Managing revised date 3/2018, indicated, Resident-centered approaches to managing falls and fall risk include 1. The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .

Based on observation, interview and record review the facility failed to ensure safe and sanitary conditions were met for food storage and service, and in and out of the Food and Nutrition Services department when: 1) Expired Potentially Hazardous Food (PHF)/Time and Temperature Control for safety (TCS) food items were stored in the reach-in-refrigerator 2) Freezer was overstocked with boxes of food and had ice accumulation 3) Expired food items were stored in the Dry food storage 4) Two staff were not wearing a beard cover and did not wear a hairnet 5) Plate covers were stacked wet 6) Food Carts were dirty and covered with old dried food and food crumbs 7) Unit refrigerators that stored resident food brought in from the outside were dirty with brown stains inside the door 8) An air gap under the tray line was not secured 2 inches above the floor drain This deficient practice had the potential to put residents at risk for foodborne illnesses. The facility census was 134. (Cross reference F802, F803, F805) Findings: 1) During the initial kitchen tour observation and concurrent interview with the Registered dietitian (RD), on [DATE] at 8:30 A.M., the following expired or undated items were found inside the reach-in refrigerator: One case of Mighty honey shakes, received by date of [DATE] without a date for when it was pulled from freezer and placed in the reach-in refrigerator; One case of Vanilla shakes (50), received on [DATE], without a date of when it was pulled from the freezer and placed in the reach-in refrigerator; One case of Vanilla shakes (75), received date of [DATE], without a date of when it was pulled from freezer and placed in the reach-in refrigerator; A tray of jello with fruit, without a date or time; cups of strawberries, uncovered without a date or time; shredded yellow cheese in a clear tub with use by date [DATE] with white cheese on bottom of the tub; and 2 plastic bags with water, fruit and sandwich, for a resident snack without a date. During an interview with Sous Chef (SC) 1, on [DATE] at 8:40 A.M., about the undated food in the reach-in refrigerator, SC 1 stated, I am not sure when the mighty shakes went into the refrigerator. SC 3 stated she poured the yellow cheese inside the tub on top of the old white cheese already inside the tub, SC 3 stated she should not have poured the new cheese on top of the old cheese. The RD stated SC 3 should have used FIFO for the yellow cheese storage. During an interview with the RD on [DATE] at 9 AM, about the cases of undated mighty shakes in the reach in refrigerator, the RD stated, they are safe for a long time. An inspection of a mighty shake carton, indicated, Mighty shake is good for 14 days. Review of the Food Storage policy, dated [DATE], it indicated under Procedure, .All products should be inspected for safety and quality and be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators . During an observation of the walk-in refrigerator and freezer on [DATE] at 9:30 AM, there was a large metal sheet pan with chicken thawing in a brown cardboard box on the floor. Blood and chicken juice leaked on the floor from the box of chicken. The chicken was dated [DATE]. The Assistant Food Service Director, (AFSD) stated, the chicken was put to thaw on Saturday, [DATE]. Other expired items found included: Turkey sausage with Use by Date (UBD) of [DATE] and Silver tray of jello, with UBD of [DATE]. 2) During an observation of the walk-in freezer on [DATE] at 10 AM, the freezer had 2 inches of free space from the top because of stacked cases and boxes of frozen food. During an observation and concurrent interview with the Maintenance Supervisor (MS) on [DATE] at 2 P.M., there was ice build up on pipes at the top of freezer on the right side and on the cases of food. The MS stated, I check the freezer every month, if there is a lot of ice build-up I spray it with warm water. A review of the facility maintenance (YEAR) request log binder indicated maintenance requests was not submitted for the ice build-up on the pipes in the walk-in freezer. According to Refrigeration and Freezer Mechanics, the build-up of ice on the interior freezer components may be the result of issues within the condenser evaporator or issues with the defrost cycle (Humitec Corporation, 2013). According to the (YEAR) Federal Food Code, section ,[DATE].11, titled, Preventing Food and Ingredient Contamination, Packaged and Unpackaged Food, it indicated, .the freezer equipment should be designed and maintained to keep foods in the frozen state .Corrective action should be taken if the storage or display unit .fails 3) During an observation of the dry storage room on [DATE] at 2 P.M., there were potatoes with no date of arrival noted, several potatoes had green sprouts growing from them, a few potatoes were with brown moldy spots, several large containers that didn't close with white powder on top of the lids, au jus with UBD of [DATE], vanilla pudding with no received or expiration date, lentils in a container with no received or expiration date, confection sugar with expiration date of [DATE]. There was no thermometer in the dry storage room to monitor temperature. Surveyor's thermometer had a temperature reading of 80 degrees in the dry storage room. The standard of practice is a dry storage room with non-perishable foods have a temperature between ,[DATE] degrees. 4) During an observation on [DATE] at 8:32 A.M. SC 1 was with facial hair, he did not have a beard cover on. During an interview on [DATE] at 9 A.M., with the Food Service Director (FSD), the FSD stated, My expectation is that staff with facial hair wear beard covers. During an observation and concurrent interview on [DATE] at 12:01 P.M., SC 4 did not have a beard cover. He stated, he usually wears a beard cover but forgot to wear it today. A review of the facility policy titled Personal Hygiene, dated [DATE], indicated, Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. Beards or any body hair that may be exposed must be covered. According to the (YEAR) FDA Federal Food Code, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens: and unwrapped single-service and single-use articles. 5) During an observation and concurrent interview, in the kitchen on [DATE] at 10:30 AM, the staff were stacking the plate covers which had water dripping from them. The Assistant Food Service Director (AFSD) stated, the plate covers should not be stacked wet. According to the (YEAR) Federal Food Code, section ,[DATE].11 titled Equipment and Utensils, Air-Drying Required; .After cleaning and sanitizing, equipment and utensils shall be air-dried . 6) During an observation and concurrent interview in the kitchen on [DATE] at 11:30 AM, the food trays were being placed into carts that had old dried food and crumbs on the rails of the cart and at the bottom of the cart. The FSD stated, these carts need to be cleaned before they go out. 7) During an observation on [DATE] at 9:45 A.M. of the Nutrition Refrigerators on the 2nd and 3rd floor, there were expired ice cream and Med Pass 2.0 vanilla, and unlabeled sour cream and staff's bottles of water. Both of the refrigerators were dirty. During an interview with the Housekeeping Supervisor (HKS) on [DATE] at 9:50 A.M., she stated, we clean the refrigerators every day and after three days we throw out the food. During an interview with the Assistant Director of Nursing, (ADON), on [DATE] at 9:50 A.M., he acknowledged that the Med Pass 2.0 Vanilla, with an expiration date of [DATE] should not be in the nutrition refrigerator and that the staff bottles should not be in with the patient's food. 8) During an observation and concurrent interview on [DATE] at 3 P.M., with the Maintenance Supervisor (MS), there was a white plastic pipe extending from the tray line into a drain on the floor. The MS stated, it should not be lying on the ground going into the drain. It should be at least 2 inches above the drain. According to the (YEAR) FDA Federal Food Code, section ,[DATE].13 Backflow Prevention, Air Gap. An air gap is between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT or non - FOOD Equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, interview, and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for one of 47 residents (Resident 115) with orders for Restorative Nurse Assistant (RNA) program when the physician's order for RNA program was not implemented. This deficient practice resulted in Resident 115's inability to grasp an object, such as a water container, and had the potential to limit the ROM or possible development of a contracture. The Medical Dictionary defines contractures as, The shortening of muscles and joints which limit and interfere with daily functioning. Review of the facility's Rehabilitative Nursing Care policy dated (MONTH) 2013, indicated, .3. The facility rehabilitative nursing care (RNC) program (also known as Restorative Nurse Assistant (RNA) program) is designed to assist each resident to achieve and maintain an optimal level of self care and independence . Findings: 1. Resident 115 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a medication pass observation, on 3/22/18, at 9:41 AM, Registered Nurse (RN) 2 offered Resident 115 a white Styrofoam cup filled with water. Resident 115 stated, This container is huge. I can't hold it. It's too big and heavy, my hand is crooked. Review of Resident 115's Minimum Data Set (MDS, an assessment tool) quarterly assessment, dated 11/21/17 and 2/21/18, indicated, ROM on one side of upper extremities is impaired. Review of Resident 115's physician's order dated 2/2/18, indicated, Discontinue skilled OT (Occupational Therapy) services .Pt (patient) to begin RNA program 3 5 x/wk (three to five times a week) to maintain shoulder ROM, UE and LE (upper and lower extremities) strength, and endurance. Review of Resident's 115's Therapy Communication Form, completed on 2/2/18, indicated, .ROM .Bilateral shoulder ROM deficits, R (right) severe. The assessment did not indicate that Resident 115 hand grasp was impaired. Further review of the form, under Problems, indicated, Pt at risk of functional decline w/ (with) sedentary lifestyle. Goal: Maintain ROM (shoulders) and strength and endurance for continued safety .and maximal independence with ADL's . Review of Resident 115's care plan for Patient has a [DIAGNOSES REDACTED].Patient will have an understanding of how to manage pain and prevention of further decline of ROM . indicated, under Approach, .Encourage physical activity and daily ambulation. Use assistive device if necessary .PT to evaluate and treat PRN . Further review of the resident's medical record did not indicate other care plan addressing resident's ROM. During an interview, on 03/23/18, at 10:56 AM, Certified Nursing Assistant (CNA) 2 stated, (Resident 115's) arms are weak. Lower extremities are sometimes ok. During an interview, on 3/23/18, at 11:02 AM, Physical Therapist Assistant (PTA) 1 stated, Resident 115 Has limited flexion that's why she cannot lift even the water container. She has [MEDICAL CONDITION] ([MEDICAL CONDITION]. Although she can walk, it's very limited. PTA 1 also stated Resident 115 was discharged from PT (Physical Therapy) and was referred to the RNA program. During an interview, on 3/23/18, at 11:41 AM, MDS Coordinator 2 reassessed the resident and stated, She cannot fully raise her arms, only halfway. Bilateral upper extremities ROM should be coded as impaired. During an interview, on 3/23/18, at 11:31 AM, RNA 1 stated, I haven't seen her for RNA (referring to Resident 115). RNA 1 stated that she was new in the facility (less than a month) and presented a copy of her RNA certificate dated 3/17/18. The RNA 1 also stated that she was not able to do the RNA treatment because she helps in passing lunch trays, answering the call light, and taking residents' weights. At 11:40 AM, the RNA 1 presented the RNA binder and stated, Resident 115 was not on the list of residents for RNA program. RNA 1 also explained, Most of the residents on RNA program was on second floor and those on third floor are usually seen by PT. During an interview, on 3/23/18, at 1:50 PM, Registered Nurse (RN) 1 confirmed Resident 115 has not been doing RNA exercises because of the turnover of RNA staff. During an interview, on 3/26/18, 9:47 AM, the MDS Coordinator 1 stated, Resident 115 will be referred to PT for re-evaluation and he will do significant change of condition MDS assessment if necessary. Review of Resident 115's Physical Therapy Plan of Care, dated 3/27/18, indicated, .Reason For Referral: Patient referred to PT due to recent decline in functional mobility . Further review of the document, indicated, Completes up to 50% of normal range for left and right upper extremities ROM. During an interview, on 3/26/18, at 11:28 AM, RNA 1 stated, I can only see two or three residents a day (for RNA program) because I help out on the floor. During an interview, on 3/26/18, at 1:22 PM, the Director of Nursing (DON) acknowledged the RNA program was not provided to the resident. The DON confirmed that there was an issue with the turn over of RNA staff and stated, The plan is to hire two more staff, and train other CNA (to do RNA program). Review of the facility policy titled, Rehabilitative Nursing Care, dated (MONTH) 2013, indicated, .2. Nursing personnel are trained in rehabilitative nursing care .3. The facility's rehabilitative nursing care (RNC) program (also known as Restorative Nurse Assistant (RNA) program) is designed to assist each resident to achieve and maintain an optimal level of self care and independence. 4. Rehabilitative nursing care is performed daily for those residents who require such services. Such program includes, but is not limited to .e. Assisting residents to carry out prescribed therapy exercises .f. Assisting residents with their routine range of motion exercises .h. Others as prescribed by the resident's Attending Physician . According to a Medical Dictionary, retrieved from http://medical dictionary.thefreedictionary.com/range+of+motion+exercise, on 3/29/18, indicated, . Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part, such as a leg or arm, throughout the available range. Injury, surgery, or immobilization of a joint may affect the normal joint range of motion .

Based on observation, interview, and record review the facility failed to maintain a safe and sanitary environment to help prevent and manage transmission of diseases and infections as defined in the facility's Infection Control Policies and Practices when: 1. Preventive measures to reduce and control transmission of Influenza (also known as flu, a contagious respiratory illness caused by the influenza virus) during a flu outbreak were not implemented. An outbreak is defined as one or more cases of laboratory confirmed influenza that occurred within a 72 hour period. These preventive measures included a combination of interventions defined in the San Mateo County Department of Public Health recommendations and the facility's policy and procedure such as: a.(i) The California Department of Public Health (CDPH, a State Health Department) was notified on 3/9/17, six (6) days after the onset of influenza outbreak. (ii) The facility did not effectively implement their Lock In (area where only staff assigned to it can enter, they must use personal protective equipment when entering the area) unit preventive measures. b. Staff should not be rotated between the affected and unaffected units. c. Antiviral (a medication that treats virus) [MEDICATION NAME] (drugs that prevent the disease) was not offered to non-ill residents as soon as the flu outbreak was declared. d. Managing visitors access and movement within the facility. e. Limiting residents' movement on the affected unit by not allowing them to go out for a day pass. f. Four of four staff (Maintenance Supervisor (MS), Registered Nurse (RN) 1, Certified Nurse Assistant (CNA) 14 and Beautician) did not perform hand hygiene before wearing and upon removal of the face mask. An Immediate Jeopardy (IJ) was identified on 3/9/17 at 3:50 PM in the presence of Administrator In Training (AIT), Director of Nursing (DON) and the Director of Staff Development (DSD). IJ is a situation wherein the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Serious outcomes of flu infection can result in hospitalization or death of the residents, staff, families, and visitors in the facility. 2. Medical device such as nasal cannula (device used to deliver supplemental oxygen placed in the nostrils) being used by Resident 11 and the nebulizer tubing were not changed within seven days. The nebulizer mask (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for Resident 11 was not covered while not in use. 3. The staff primarily responsible for the facility's Infection Control Program was not knowledgeable about infection control processes, particularly nosocomial infection. Failure to adhere to care standards for resident care equipment and staff's lack of knowledge of nosocomial infections had the potential to result in cross contamination that could jeopardize the health of residents. Findings: 1. During observation on 3/8/17 at 11:15 AM, as the CDPH Survey Team walked in the facility for the annual survey (inspection to determine compliance with health and safety standard), the Survey team was met by the Administrator In Training (AIT) at the lobby of the facility and was directed to the conference room. There was no visible signage indicating there was a flu outbreak at the facility. There was no supplies to allow hand hygiene and facemask available at the entrance or/and lobby of the facility. During the entrance conference (explanation of survey process) on 3/8/17 at 11:25 AM, the AIT did not inform the survey Team Coordinator (TC) there was a flu outbreak in the facility. During the initial tour of the 3rd floor, Wing A (room [ROOM NUMBER] to 315), accompanied by Minimum Data Set Coordinator (MDS) 2, on 3/8/17 at 11:32 AM, MDS 2 did not inform the surveyors there was a flu outbreak on Wing A. a.(i) (ii)During medication pass observation and concurrent interview on 3/9/17 at 8:19 AM, on the 3rd floor Wing A, Registered Nurse (RN) 1 was wearing a facemask. Other staff was observed walking in and out of Wing A without wearing facemask. RN 1 stated, Everyone who enters Wing A should wear facemask because the whole Wing is on quarantine (period or place of isolation) for flu outbreak. RN 1 further stated the instruction (to wear mask whenever entering Wing A) came from the Director of Staff Development (DSD) during the huddle (meeting). RN 1 also added, they (referring to the Certified Nurse Assistant who did not wear mask at Wing A) should be given another in-service (teaching). During interview on 3/9/17 at 8:22 AM, at the 3rd floor Nursing Station, Director of Nursing (DON) confirmed that Wing A is on isolation because of flu outbreak. The DON stated, Anyone who enters the Wing should wear mask. The DON also acknowledged the failure to inform the Survey Team about the flu outbreak and the practice of wearing mask whenever entering Wing A. He stated, We supposed to tell you. During observation on 3/9/17 at 8:46 AM, the Employee Relation Officer (ERO) put up two signage and a set-up of Personal Protective Equipment (PPE) at the entrance to the 3rd floor Wing A. The set-up of PPE included: gloves, yellow gown, and facemask used to protect a person from injury or infection. The signage indicated the following: i. Before entering the wing, please wear mask. ii. A Wing Isolation in addition to standard precaution. Visitors - Please report to Nursing Station Before Entering Wing. 1. Facemask upon entering the wing . During an interview on 3/9/17 at 2:24 PM, the DSD stated, there were two residents with confirmed Influenza and one resident with influenza-like illness (ILI). The San Mateo County Public Health Department (SMCPHD) was notified on 3/3/17 and the facility received flu outbreak recommendation. The DSD acknowledged that the flu outbreak was not reported to CDPH. The DSD stated, the three flu residents were quarantine to one wing (that) Wing A is a lock-in unit as part of the flu outbreak preventive measures. The DSD explained Lock-In measures included: Staff to wear mask at Wing A, residents have to wear facemask outside the unit, no movement of residents, and no movement or interchange of staffing to other unit to avoid cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object, to another, with harmful effect). The DSD added, the lock-in measures were discussed to Nursing Department during the huddle. Review of Group Huddle with a print date of 3/10/17, provided by the DSD on 3/10/17 at 6:15 PM indicated, .Please review the following policy with team: Outbreak within facility. please maintain standard precautions. Outbreak on A wing 3rd floor (more details refer to nurse on 3rd floor A wing) . During concurrent interview, the DSD showed that huddle was documented using a computer program. The DSD also explained that the print out of the huddle minutes (information) does not reflect the date and time it was discussed with the staff. Review of SMCPHD Communicable Disease Control Program dated 1/5/17, it indicated, the flu outbreak recommendation checklist was given to the facility on [DATE] which meant that the onset of flu outbreak was on 3/3/17. The checklist included General Infection Control and Prevention Recommendation that facility should implement during flu outbreak. b. Review of the facility floor plan indicated, there were three (3) wings on the third floor of the building. Wing A started from room [ROOM NUMBER] to 315; Wing B started from room [ROOM NUMBER] to 329; and Wing C started from room [ROOM NUMBER] to 341. During observation on 3/9/17 at 11:45 AM, Certified Nurse Assistant (CNA) 14 came out of a room on Wing B on the third floor, walked over to Wing A, donned a mask, entered the wing to answer a call bell, then exited the wing, removed mask and returned to Wing B. During an interview on 3/9/17 at 2:24 PM, the DSD stated, .no movement or interchange of staffing to other unit to avoid cross contamination, for lock-in unit (wing A) During an interview with Certified Nurse Assistant (CNA) 15 on 3/9/17 at 2:55 PM, when asked what the procedure was for working on the third floor during the flu outbreak, she stated when a CNA is assigned to work on Wing A where there's an outbreak, he/she cannot work on another wing. No one should be going onto Wing A unless they are assigned. Review of facility's Staffing Assignment and Sign-Out Sheet indicated the following staff was assigned to different wing and/or floor during the flu outbreak: Restorative Nurse Assistant (RNA) 1 was assigned to the 2nd and 3rd floor on 3/3/17; 3/4/17; 3/6/17; and 3/7/17 from 7 AM to 3 PM (day shift). RNA 2 was assigned to the 2nd and 3rd floor on 3/3/17 to 3/4/17 at day shift. RNA 3 was assigned to the 2nd and 3rd floor on 3/5/17 to 3/9/17 at day shift. Certified Nurse Assistant (CNA 3) was assigned to the 3rd floor Wing A and B on 3/4/17 at evening shift (3 PM to 11 PM). On 3/8/17 at day shift, CNA 3 was assigned at 2nd floor. On 3/9/17 at day shift, CNA 3 was assigned at 3rd floor Wing A and B. CNA 4 was assigned to the 3rd floor Wing A and C on 3/4/17 and 3/9/17 at night shift (11 PM to 7 AM). CNA 10 was assigned to the 3rd floor Wing A and B on 3/4/17 at evening shift. CNA 5 and CNA 6 were assigned to the 3rd floor Wing A and B on 3/5/17 at day shift. CNA 7 was assigned to the 3rd floor Wing A and B on 3/6/17; 3/7/17; and 3/8/17 at day shift. CNA 8 was assigned to the 3rd floor Wing A and C on 3/6/17 and 3/7/17 at evening shift. CNA 9 was assigned to the 3rd floor Wing A and B on 3/6/17; 3/7/17; and 3/8/17 at evening shift. CNA 11 was assigned to the 3rd floor Wing A and C on 3/6/17 and 3/7/17 at night shift. CNA 12 and CNA 13 was assigned to the 3rd floor Wing A and C on 3/8/17 and 3/9/17 at day shift. CNA 14 was assigned to the 3rd floor Wing A and C on 3/8/17, and Wing A and B on 3/9/17 at evening shift. Review of SMCPHD Influenza Outbreak Recommendation dated 3/3/17 indicated, .Staff and Health Care worker Infection Control Precautions: . Maintain the same staff to resident/patient assignment .Avoid rotating staff between nursing units until no new cases have been identified for at least on week. Exclude non-essential personnel from the affected units . Review of CDPH article titled Influenza and Other Respiratory Illness Outbreak Quicksheet dated September 2016 indicated, .Respiratory outbreak infection Control Measures in Institutional Settings .Restrict staff movement from areas of the facility having illness to areas not affected by the outbreak . c. Review of the facility Patient List (census) dated 3/8/17 indicated, there were 18 residents at the lock-in unit: Resident 9, 12, 14, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 38, 39, 40, and 41. Review of Residents 14, 26, 29, 35, 38, 39, 40 and 41 physician's orders [REDACTED]. For Residents 12, 27, 28, 30, 31, 33, and 34, [MEDICATION NAME] 75 mg was ordered on [DATE]. During an interview on 3/10/17 at 2:45 PM, the DSD acknowledged the antiviral [MEDICATION NAME] for the asymptomatic residents (no symptoms of flu) at Wing A was started on 3/8/17. Review of SMCPHD Influenza Outbreak Recommendation dated 3/3/17 indicated, . Antiviral [MEDICATION NAME] is recommended for your facility for all asymptomatic and for unvaccinated health care personnel . All residents throughout the facility should receive anti-viral [MEDICATION NAME], regardless of vaccine status. Unvaccinated health care personnel should be offered anti-viral [MEDICATION NAME] . Review of CDC (Centers for Disease Control and Prevention) article titled Interim Guidance for Influenza Outbreak Management in Long Term Care Facilities, a 2016-2017 influenza season guidance indicated, . All eligible residents in the entire long-term care facility (not just currently impacted wards) should receive antiviral [MEDICATION NAME] as soon as an influenza outbreak is determined . Review of CDC article titled Antiviral Agents for the Treatment and [MEDICATION NAME] of Influenza dated 1/21/11 at page 13 indicated, .Control of Influenza Outbreaks in Institutions. Use of antiviral drugs for treatment and [MEDICATION NAME] of influenza is a key component of influenza outbreak control in institutions that house patients at higher risk for influenza complications . d. During observation on 3/8/17 at 11:15 AM as the Survey Team entered the lobby of the facility, there was no visible signage indicating that there was a flu outbreak in the facility. There were no supplies to allow hand hygiene and facemask available at the entrance or/and lobby of the facility. During an interview on 3/9/17 at 3:32 PM, the facility Receptionist stated, she was informed of the flu outbreak on 3/6/17 by the DSD. She was instructed to wear a facemask on the third floor Wing A. During concurrent observation, there was no mask available and no sign or any information about flu outbreak at the reception desk. During observation on 3/10/17 at 7:31 AM, the door at the main entrance of the facility was open. There was no staff at the front desk to notice if visitors or families will walk into the facility. There was no facemask and supplies for hand hygiene at the front desk. During interview on 3/10/17 at 8:17 AM, the wife of Resident 25 stated that she visited her husband every day and was not aware of the flu outbreak. She added, No one told me anything (referring to flu outbreak), I did not see any sign. During an interview on 3/10/17 at 10:01 AM, the son of Resident 24 stated, he visits his mom every day. He also added that nobody told him about the flu outbreak and did not notice any signs or poster indicating that the facility had a flu outbreak. During an interview on 3/10/17 at 10:16 AM, RN 1 stated, Front desk is in charge of informing visitors. We tell visitors for Wing A (third floor) to wear mask and do hand hygiene. During an interview on 3/17/17 at 2:36 PM, the family of Resident 20 stated Resident 20 had pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid) recently and she visited Resident 20 while Resident 20 still had pneumonia. When asked what information and or things did the facility tell her to do or not to do during her visits, she stated the facility pushed for her to use the mask. When asked if there was anything else she was informed to do or not to do, she stated, No. The family then stated she was started on antibiotics on 3/15/17 because she was coughing, had a chest x-ray and was diagnosed with [REDACTED]. Review of SMCPHD Influenza Outbreak Recommendation dated 3/3/17, under General Infection Control and Prevention Recommendations indicated,, .Post visual alerts notifying all visitors of the ongoing outbreak and instructing all persons to report symptoms of influenza like illness to staff as they enter the facility. Post signs/posters regarding recommendations for hand washing, respiratory hygiene and cough etiquette. Provide written information about influenza and why precautions are necessary. Family members and friends with ILI should not visit if they currently exhibit symptoms or have it within last seven days . Review of CDPH Recommendations For the Prevention And Control of Influenza California Long-Term Care Facilities dated October 2016 indicated, .Visitor Precautions and Restrictions. Post a sign notifying visitors that adults with respiratory symptoms should not visit for 5 days and children with symptoms should not visit for 10 days following the onset of illness. Provide written information about influenza-like infections and seasonal influenza to visitors and why the infection control precautions are necessary. Provide visitors with written instructions (respiratory hygiene/cough etiquette) about the precautions implemented by the facility . Ensure that hand hygiene supplies, tissues and masks are readily available . e. During an observation on 3/9/17 at 10:14 AM Resident 25 was in a wheelchair and was brought to the main dining room, on the first floor, by a staff member. Resident 25 resided, at that time, on the third floor, Wing A, the lock-in unit. During an interview on 3/10/17 at 8:04 AM, MDS 1 stated, the resident who goes out of the facility will sign in and out for day pass. MDS 1 showed the day pass binder sign in sheet that was located at the nursing station. Review of facility record titled, Release of Responsibility For Leave of Absence indicated there were residents from the lock-in unit (third floor Wing A) who went out for a day pass during the flu outbreak. The following residents who went on day pass were as follows: On 3/3/17 at 1:30 PM, Resident 30 signed out on day pass. No time indicated when she came back. On 3/4/17 at 12:30 PM, Resident 12 signed out and came back at 2:55 PM. On 3/6/17 at 12:05 PM, Resident 12 signed out, no time indicated when he came back. On 3/8/17 at 11:45 PM, Resident 30 signed out on day pass. No time indicated when she came back. Resident 35 signed out at 1:55 PM and came back at 3:40 PM. Resident 12 signed out at 4:50 PM, no time indicated when he came back. On 3/9/17 at 4:45 PM, Resident 30 signed out, no time indicated when she came back. Review of SMCPHD Influenza Outbreak Recommendation dated 3/3/17, under General Infection Control and Prevention Recommendations indicated, .If residents are ill on specific nursing units, do not move residents or staff from the affected unit(s) . Residents may go out on pass only after clearance by CD (communicable disease) Control . f. During observation and concurrent interview on 3/8/17, Resident 9 was observed resting in bed with food untouched on bedside table in wing A on the third floor. Resident 9 stated that she wasn't feeling good with cough, chills and fatigue, and will take a bite of her food here and there but feels like sleeping most of the time. There was no sign or Personal Protective Equipment (PPE) present outside of her room to indicate the need for infection precautions (infection control practices used to prevent transmission of diseases). During review of Resident 9's diagnostic laboratory report, it indicated that Resident 9 was diagnosed with [REDACTED]. During review of Resident 9's SNF Progress Note completed by the physician on 3/3/17, it indicated that Resident 9 was in fair condition and had a cough and fever with a positive influenza swab and orders to isolate and monitor. During observation on 3/9/17 at 11 AM, the Maintenance Supervisor (MS) walked down Wing A on the third floor without washing his hands or donning a mask. During observation and concurrent interview on 3/9/17 at 11:15 AM, Registered Nurse (RN) 1, did not wash her hands after exiting wing A on the third floor. She removed her mask, sat down at the nursing station and started using the computer. When asked what the procedures were for exiting Wing A, she stated you should remove your mask and wash your hands. When asked if she washed her hands, she stated No, I forgot, I will go and do that right now. During observation on 3/9/17 at 11:45 AM, Certified Nurse Assistant (CNA) 14 came out of a room on Wing B on the third floor, walked over to Wing A, donned a mask, entered the wing to answer a call bell, then exited the wing, removed mask and returned to Wing B. CNA 14 did not perform hand hygiene after she removed the mask and before she returned to Wing B. During observation and concurrent interview on 3/9/17 at 2:50 PM, the Beautician walked from Wing C on the third floor over to Wing A without donning a mask or washing hands, and entered room [ROOM NUMBER]. When asked if she knew what the procedures were for isolation procedures on Wing A, she stated she could not take residents downstairs from the isolation wing without a mask, and she was supposed to wash her hands and put on a mask before entering the hallway or residents' room. During observation on 3/9/17 at 11:45 AM, Certified Nurse Assistant (CNA) 14 came out of a room on wing B on the third floor, walked over to wing A, donned a mask, entered the wing to answer a call bell, then exited the wing, removed mask and returned to wing B. CNA 14 did not perform hand hygiene. During observation and concurrent interview on the third floor on 3/10/17 at 3 PM, the Housekeeping Staff (HS) entered Wing A (lock-in unit) from the nurses station. HS staff was wearing gloves and carrying a clear plastic bag full of trash. She didn't have a mask on. She went straight to a room in Wing A, dumped the clear plastic bag full of trash, removed her gloves, closed the door and left wing A. The HS did not perform hand hygiene after removing her gloves. HS stated she did not work on the third floor and was going back to the first floor. Review of facility policy titled Influenza, Prevention and Control of Seasonal dated August 2014 indicated, .Standard Precautions .2. Hand hygiene: a. Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves . The Immediate Jeopardy was removed on 3/10/17 at 6:05 PM, in the presence of the Administrator and DSD. The survey team accepted and verified that the corrective actions had been implemented. 2. During the initial tour observation on 3/8/17 at 11:40 AM, the nasal cannula (device used to deliver supplemental oxygen placed in the nostrils) being used by Resident 11 was dated 2/28/17 and the nebulizer tubing was dated 2/27/17. The nebulizer mask (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for Resident 11 was uncovered while not in use. During an interview on 3/9/17 at 7:50 AM, Licensed Vocational Nurse (LVN) 6 acknowledged findings and stated, We change the cannula every 7 days and definitely, these should have been changed. Usually, the NOC (night) shift change it but the AM shift should follow-up and change it if it's not been done. LVN 6 further stated, the nebulizer mask should be in a bag if not in use. Review of facility's policy and procedure on Departmental (Respiratory Therapy)-Prevention of Infection indicated, .Infection Control Considerations Related to Medication Nebulizers .store the circuit in plastic bag, marked with date and resident's name, between uses .discard the administration set-up every seven (7) days . 3. During an interview on 3/17/17 at 11:45 AM, the Infection Control Coordinator was not able to define nosocomial infection, a dynamic that plays a key role in the infection control process.