Every finding on record at California Park Post Acute

Based on interview, and record review, the facility failed to ensure that a resident's right to self administer medications was maintained in accordance with facility policy for one of three sampled resident (Resident 1). The facility did not assess, determine, or document through the interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, plan, and manage the medical, functional, and social needs of a resident) that Resident 1 was clinically appropriate to self administer medications.This resulted in medications being left at Resident 1's bedside, creating the potential for misuse, missed doses, or adverse drug outcomes.Findings:A review of the facility's Self Administration of Medications policy, dated December 2016, indicated that residents were to be assessed by the IDT, staff, and Practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident prior to being authorized to self administer medications A review of Resident 1's admission Record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including, high blood pressure, Major Depressive disorder (an intense, long-lasting mood disorder that makes you feel profoundly sad, empty, or hopelessness), muscle weakness, and anxiety (fear of the unknown).A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 5/12/26, indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15, demonstrating intact cognition. Resident 1 was able to make his own healthcare decisions. During an interview on 7/13/26 at 12:00 pm, with Resident 1, Resident 1 stated, the Licensed Nurse (LN) 1 left a cup of pills on his bedside table on the morning of 6/28/26, and the medications remained there until Resident 1's grandson arrived that afternoon.During an interview on 7/13/26 at 1:15 pm, with LN 1, LN 1 stated that she had left five pills, Sertraline (an antidepressant medication), Nebivolol (for high blood pressure), Tylenol (for pain), Vitamin D, and Flomax (for prostate) on Resident 1's bedside table on 6/28/26, and she had done on multiple occasions. LN 1 said she didn't know Resident 1 had not taken them until the grandson came and told her that afternoon.During a concurrent interview and record review on 7/13/26 at 2:00 pm, Resident 1's medical record was reviewed with the Director of Nursing (DON). The DON confirmed that Resident 1 had no assessment, care plan notation, or documentation reflecting IDT involvement or approval regarding Resident 1's ability to self-administer medications. The DON confirmed that leaving medications at the bedside was not acceptable and not in accordance with facility policy.

Based on interview and record review, the facility failed to ensure one Certified Nursing Assistant (CNA A) had appropriate competency and skill sets to care for residents based on their identified needs. This failure had the potential to place residents' safety at risk.Findings:On 12/10/25 the facility reported to the California Department of Public Health that a resident-to-resident altercation had occurred on12/8/25 where Resident 1 walked into the dining room and grabbed Resident 2's arm. During a concurrent interview and record review on 12/16/25 at 1:32 pm with the Administrator (Admin) and the Director of Nursing (DON), the Admin stated that residents are not to be left unsupervised while in the dining room. CNA A was in the dining room during the resident-to-resident altercation. During the facility investigation, the Admin confirmed from video footage that CNA A failed to perform their job duties by keeping residents safe when Resident 1 was able to grab Resident 2 by the arm. During a facility job description titled Certified Nursing Assistant dated 3/1/14, indicated that job functions include demonstrating respect for co-workers, having working knowledge and ability to comply with facility policies and procedure for workplace safety, and have the ability to carry out essential job function.

Based on interview, record review, and facility policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of rough care to facility management so they could carry out the facility's abuse protocol for 1 (Resident #32) of 1 resident reviewed for an allegation of staff-to-resident abuse. Findings included: A facility policy titled, Abuse, Prevention of, revised 05/10/2018, indicated, PURPOSE: To ensure that residents' rights, safety and well-being are protected by providing a method for the prevention of any type of resident abuse. POLICY: It is the policy of this facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, exploitation, mistreatment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The section of the policy titled, G. Reporting specified, 5. First responder or first staff member informed of the incident are responsible for informing their immediate supervisor and Administrator. Resident #32's Admission Record indicated the facility admitted the resident on 07/18/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, muscle weakness, difficulty walking, unsteadiness on feet, and history of falling. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/21/2025, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 03/13/2025 at 5:15 AM, CNA #12 stated last Thursday (03/06/2025) Resident #32 mentioned that they had a horrible day. According to CNA #12, the resident reported that while their usual CNA, CNA #5, was on break, CNA #17 assisted them with a transfer using a lift. CNA #12 stated the resident told her CNA #17 was a little rough. She stated she should have told the nurse about the resident's statement about CNA #17, but she did not. During an interview on 03/13/2025 at 9:57 AM, Resident #32 stated they had received care provided by CNA #17. The resident described CNA #17 as nice but stated CNA #17 was kind of rough with care and did not take his time while assisting the resident. During an interview on 03/13/2025 at 2:01 PM, the Director of Nursing (DON) stated no staff members had reported complaints from residents about rough care from CNAs. She stated if the staff had reported rough care concerns to the nurses, a note would have been made. The DON stated she reviewed Resident #32's record, and she did not find any notes concerning rough care. During an interview on 03/13/2025 at 3:26 PM, the Administrator stated CNA #12 knew better than to not report the resident's statement regarding rough care. He stated CNA #12 should have reported the resident's statement.

Based on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the classes of medications received during the assessment look-back periods for 2 (Resident #74 and Resident #70) of 2 residents reviewed as part of the Resident Assessment task and failed to ensure MDS assessments accurately reflected weight-loss statuses for 2 (Resident #8 and Resident #25) of 2 sampled residents reviewed for nutrition. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation ('look-back') period for that assessment. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.1, dated October 2024, revealed section K0300: Weight Loss specified, -Code 0, no or unknown: if the resident has not experienced weight loss of 5% [percent] or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is unavailable. - Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order. In cases where a resident has a weight loss of 5% or more in the past 30 days or 10% or more in 180 days as a result of a physician-ordered diet plan or expected weight loss due to loss of fluid with physician's orders for diuretics, K0300 can be coded as 1. The User's Manual further revealed section N0415: High-Risk Drug Classes: Use and Indication specified, -N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g. [exempli gratia, for example], aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). 1. An Admission Record indicated the facility admitted Resident #74 on 01/26/2025. According to the Admission Record, the resident had a medical history that included diagnoses of transient cerebral ischemic attack (brief stroke-like attack) and cerebral infarction (stroke) without residual deficits. Resident #74's Order Summary Report contained an active order dated 01/27/2025 for Plavix (clopidogrel, an antiplatelet medication) 75 milligrams (mg) by mouth one time a day. The Order Summary Report did not reflect any orders for anticoagulant medications. Resident #74's 01/2025 Medication Administration Record (MAR) revealed documentation that indicated the resident received their Plavix daily as ordered during the timeframe from 01/27/2025 through 01/31/2025. Resident #74's admission MDS, with an Assessment Reference Date (ARD) of 01/31/2025, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS was coded to reflect Resident #74 received an anticoagulant medication, but not an antiplatelet medication, during the seven-day assessment look-back period. Registered Nurse (RN) #20 was interviewed on 03/12/2025 at 4:23 PM. RN #20 stated she had been working in the role of MDS Coordinator for almost one month. RN #20 stated that she was responsible for completing section N of the MDS regarding medications received by the resident. She stated that when she completed Section N of the MDS, she reviewed the MAR to see what medications were administered to the resident during the seven days prior to the ARD of the assessment, and if the resident received any medications listed in section N of the MDS she would code those medications on the MDS. RN #20 stated she completed section N of Resident #74's admission MDS, and she reviewed the resident's January 2025 MAR when she completed that section. After reviewing Resident #74's admission MDS and their January 2025 MAR, RN #20 stated that Resident #74 did not receive an anticoagulant medication at the time of the assessment and further stated, I made a mistake. Nurse Consultant (NC) #21 was interviewed via telephone on 03/12/2025 at 4:33 PM. NC #21 stated that the MDS Coordinator was trained on how to complete section N of the MDS and was trained to review the relevant medications the resident received during the seven days prior to the ARD. NC #21 stated the source of information to code section N usually included the MAR for the look-back period to determine if the medications listed in section N of the MDS were taken by the resident. NC #21 stated that when she reviewed Resident #74's January 2025 MAR, she did not see that the resident received an anticoagulant medication, but that the resident received Plavix, which should be coded as antiplatelet medication. NC #21 stated that section N of Resident #74's admission MDS was coded incorrectly, because the resident did not receive an anticoagulant medication during the seven-day look-back period for that assessment, but rather received an antiplatelet medication, which was not coded. The Director of Nursing (DON) was interviewed on 03/13/2025 at 10:07 AM. The DON stated that the current MDS Coordinator was new to that role and that there were three nurse consultants available to assist with training the current MDS Coordinator. The DON stated that the nurse consultants should assist with ensuring that the MDS assessments were completed timely and accurately. The DON stated that the nurse consultants were responsible for ensuring MDS assessments were accurate, because they were paid to review MDS assessments for accuracy. The DON stated that when completing section N of the MDS, the MDS Coordinator should run a MAR to determine which medications the resident received so that the MDS was coded correctly. The DON reviewed Resident #74's MAR and stated that the resident received Plavix, which was an antiplatelet medication, and did not receive an anticoagulant. The DON stated Resident #74's MDS was not coded correctly. The Administrator was interviewed on 03/13/2025 at 10:54 AM. The Administrator stated that he expected each MDS to accurately reflect the resident's condition. He stated that the MDS Coordinator was new in that role and nurse consultants were available for assistance. He stated that MDS assessments should be coded correctly and reviewed by the nurse consultants for accuracy. 2. An Admission Record indicated the facility admitted Resident #70 on 12/31/2024. According to the Admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and essential hypertension. Resident #70's 12/2024 Medication Administration Record (MAR) revealed no evidence of orders for or the administration of an anticoagulant or antiplatelet medication. Resident #70's 01/2025 MAR revealed the transcription of an order started on 01/03/2025 for aspirin delayed release (an antiplatelet medication) 325 milligrams (mg) by mouth one time a day. The MAR revealed documentation that indicated the aspirin was administered as ordered for the timeframe from 01/03/2025 through 01/05/2025. The MAR revealed no evidence of the transcription of orders for or the administration of an anticoagulant medication. Resident #70's admission MDS, with an Assessment Reference Date (ARD) of 01/05/2025, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS was coded to reflect Resident #70 received an anticoagulant medication, but not an antiplatelet medication, during the seven-day assessment look-back period. Registered Nurse (RN) #20 was interviewed on 03/12/2025 at 4:33 PM. RN #20 stated she had been working in the role of MDS Coordinator for almost one month. RN #20 stated that she was responsible for completing section N of the MDS regarding medications received by the resident. She stated that when she completed Section N of the MDS, she reviewed the MAR to see what medications were administered to the resident during the seven-day assessment look-back period, and if the resident received any medications listed in section N of the MDS she would code those medications on the MDS. RN #20 stated she did not complete Resident #70's admission MDS assessment; it was completed by the facility's formed MDS Coordinator. Nurse Consultant (NC) #21 was interviewed via telephone on 03/12/2025 at 4:43 PM. NC #21 stated the nurse that completed Resident #70's admission MDS no longer worked at the facility. After reviewing Resident #70's admission MDS, NC #21 stated that section N of Resident #70's admission MDS was coded incorrectly, because the resident did not receive an anticoagulant during the seven-day look-back period for that assessment, but rather received an antiplatelet medication, which was not coded. The Director of Nursing (DON) was interviewed on 03/13/2025 at 10:07 AM. The DON stated that when completing section N of the MDS, the MDS Coordinator should run a MAR to determine which medications the resident received so that the MDS was coded correctly. The DON reviewed Resident #70's MAR and stated that the resident received an antiplatelet medication, and did not receive an anticoagulant. The DON stated Resident #70's MDS was not coded correctly. The Administrator was interviewed on 03/13/2025 at 10:54 AM. The Administrator stated that he expected each MDS to accurately reflect the resident's condition. He stated that MDS assessments should be coded correctly and reviewed by the nurse consultants for accuracy. 45645 3. A Transfer/Discharge Report indicated the facility admitted Resident #8 on 12/22/2019. According to the Transfer/Discharge Report, the resident had a medical history that included diagnoses of gastro-esophageal reflux disease without esophagitis, type two diabetes mellitus, chronic obstructive pulmonary disease, and iron deficiency anemia. Resident #8's Weights and Vitals Summary indicated that on 09/06/2024 the resident weighed 189.6 pounds, and on 10/02/2024 the resident weighed 174.6 pounds. The summary included an entry that noted the resident had a 15-pound weight loss, which was a 7.9 percent (%) loss in approximately one month. Resident #8's Progress Notes revealed a Dietitian Note, dated 10/09/2024, that indicated the resident underwent a dietary review due to a weight loss of 15 pounds or a 7.9% weight loss in one month. The note indicated the weight loss was unintended and was likely due to decreased intake by mouth, an increased need for oxygen, and the resident getting out of the bed for meals. The note reflected a recommendation to increase nutritional supplements to three times per day. Resident #8's quarterly MDS, with an Assessment Reference Date (ARD) of 10/10/2024, and a significant change in status MDS, with an ARD 10/28/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Section K of both MDS assessment reflected the resident weighed 175 pounds and had not experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. During an interview on 03/12/2025 at 10:28 AM, the Registered Dietitian (RD) stated Resident #8 was noted with a 7.9% weight loss in one month in 10/2024, and the MDS dated [DATE] did not reflect it. The RD further stated the resident's significant change in status MDS dated [DATE] was inaccurate because it also did not reflect the resident's weight loss. During an interview on 03/12/2025 at 11:31 AM, the Director of Nursing (DON) stated the facility's Director of Dietary (DD) was responsible for completing section K of the MDS assessments. The DON stated the DD should also consult with the RD and review the RD's documentation to ensure MDS assessments were coded accurately. During an interview on 03/13/2025 at 9:57 AM, the Administrator stated he expected MDS assessments to accurately reflect each resident's condition. 4. An Admission Record indicated the facility admitted Resident #25 on 07/03/2017. According to the Admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing), unspecified dementia, and mild protein-calorie malnutrition. Resident #25's Weights and Vitals Summary indicated that on 02/05/2025 the resident weighed 147.6 pounds, and on 02/10/2025 the resident weighed 140 pounds. The summary included an entry that noted the resident had a 7.6-pound weight loss, which was a 5.1% loss in approximately one week. Resident #25's Progress Notes revealed a Dietitian Note, dated 02/12/2025, that indicated the resident underwent a dietary review due to a weight loss of 7.6 pounds or 5.1% in one week. The note indicated the weight loss was unintended due to an acute admission (hospital admission) from 02/06/2025 to 02/10/2025. Resident #25's five-day Minimum Data Set (MDS),with an Assessment Reference Date (ARD) of 02/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Section K of the MDS assessment reflected the resident weighed 144 pounds and had not experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. During an interview on 03/12/2025 at 10:38 AM, the Director of Dietary (DD) stated Resident #25's MDS dated [DATE] should have been coded to reflect weight loss. The DD stated she completed that section of the MDS and was unsure how it happened, but it was a mistake. During an interview on 03/12/2025 at 10:44 AM, the Registered Dietitian (RD) stated that Resident #25 lost 7.6 pounds or 5.1% of their body weight in one week. Per the RD, the resident's MDS dated [DATE] should have been coded to reflect significant weight loss, and not coding the MDS to reflect the weight loss was an error. During an interview on 03/12/2025 at 11:15 AM, Registered Nurse (RN) #20, who was serving as the MDS Coordinator, stated the DD may have initially completed the weight-loss section of Resident #25's 02/14/2025 MDS, but when RN #20 signed the assessment as complete, she may have overwritten the DD's initial information, and changed the MDS to reflect no weight loss. RN #20 stated MDS assessments should accurately reflect each resident's condition at the time of the assessment. During an interview on 03/12/2025 at 11:31 AM, the Director of Nursing (DON) stated the facility's Director of Dietary (DD) was responsible for completing section K of the MDS assessments. The DON stated the DD should also consult with the RD and review the RD's documentation to ensure MDS assessments were coded accurately. During an interview on 03/13/2025 at 9:57 AM, the Administrator stated he expected MDS assessments to accurately reflect each resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of 2 sampled residents (Resident 2) was treated with dignity and respect during direct patient care when privacy was not provided, and Resident 2 was rushed. This failure resulted in Resident 2 feeling embarrassed, with increased anxiety, and difficulty sleeping. Findings: A review of the facility ' s policy revised 10/20/2017, titled, Resident Rights, indicated the purpose of this policy is to assure protection of rights for residents in the facility. This facility ' s policy also indicted all residents have the right to personal privacy. Staff will protect privacy by announcing themselves or knocking on the door before entering room or privacy curtain and closing the door and pulling the privacy curtain when providing or assisting with personal care. A review of the facility ' s policy revised 9/15/2017, titled, Activities of Daily Living, indicated the purpose of this policy is to preserve the resident ' s ability to carry out one ' s own basic activities of self-care as long as possible and to receive assistance as needed to maintain one ' s dignity. Resident 2 was admitted to the facility on [DATE] with diagnoses that included right femur and hip fracture, right ulna (ulna, bone of the forearm) fracture, Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease), difficulty walking, and heart disease. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 10/29/24, indicated that Resident 2 was cognitively intact (able to think and reason) and made her own decisions, and is her own responsible party (RP). A review of a the most recent MDS dated [DATE], indicated Resident 2 is dependent on staff for activities for daily living (ADLs-hygiene, toileting, grooming, dressing, and bathing) related to limited physical mobility and a history of falls with injury. This MDS indicated Resident 2 needed substantial/maximal assistance for toileting, showering, and dressing lower body. During an interview on 11/6/24 at 12:10 pm, Resident 2 stated, The Certified Nursing Assistant (CNA) 2 and CNA 3 rushed me during my shower and did not provide privacy with a towel or the curtain when the male CNA 5 popped in unexpectedly during my shower. I felt embarrassed, violated, and had increased anxiety which made me lose sleep that night. During an interview on 11/6/24 at 1:09 pm, the Director of Staff Development (DSD) stated, I was told CNA 2 and CNA 3 needed more education, and I was updated [Resident 2] would not allow both CNAs back into her room for any care. DSD confirmed rushing a resident and not providing privacy during a shower is a violation of resident rights. During an interview on 11/6/24 at 2:08 pm, Both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed rushing Resident 2 and not providing privacy during a shower is a loss of dignity. ADON stated, I did not know the shower curtain was not closed for privacy. During an interview on 11/6/24 at 2:15 pm, the Administrator (Admin) confirmed there was a violation of rights related to privacy, and confirmed this would be considered a dignity issue. Admin stated, I know [Resident 2] is alert and oriented, I agree her rights were violated.

Based on interview and record review, the facility failed to ensure the licensed nurses reported changes of condition to the physician for 1 of 3 residents (Resident 1) when: 1. Resident 1 had edema (swelling) that went from mild lower leg edema to deep pitting (leaves an indent in skin for a period of time) to the hips. This resulted in a transfer to hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) his congestive heart failure. 2. Resident 1 had sudden new onset of 7/10 pain (severe pain) with as needed (PRN) pain medication given for first time on 8/18/24 and 8/19/24. This resulted in increased pain and discomfort. Findings: A review of facility's policy titled, Change in Condition Policy Assessment, revised on 9/17/17, indicated residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated in a timely manner. This includes any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient. The licensed nurse is responsible for notifying the attending physician regarding all changes in a resident's condition. A review of Resident 1's record indicated he was admitted into this facility on 7/4/24 to rehabilitate from a hip replacement. Resident 1 had Parkinson's Disease (disorder of the nervous system), high blood pressure, and heart failure. Resident 1 was his own health care decision maker. During a record review of acute care hospital discharge notes for 7/4/2024, Resident 1 had +1 (mild) pitting (when one presses on the site, there is a pit or indentation) edema to right lower extremity and +2 (moderate) pitting to the left lower extremity. During record review of the physician admission orders on 7/4/24, Resident 1 had orders from Physician 1 for monitoring edema (swelling from fluid overload) every shift. During a record review of the Resident 1's medication orders, indicated on 8/2/24, a new order for Lasix (a medication used to release excess fluid from the body by urination along with a release of potassium) 20 milligrams (mg) every day for edema. On 8/17/24, a new order was placed for Lasix 40 mg every day, a dose increase for the worsening edema. During a record review of the Medication Administration Record (MAR) for August 2024 indicated Resident 1 had +2 pitting edema in both lower extremities from 8/3/24 through 8/15/24. On 8/16/24, Resident 1 advanced to +3 pitting (when one presses on the site, there is a deep pit that lasts for 30 seconds before going away) edema. There was no change in condition reported by nursing staff to the physician found in the record. During a review of the MAR for August 2024, on 8/18/24 and 8/19/24, Resident 1 had sudden 7/10 severe pain and was administered a strong narcotic pain medication. This was the first time in August of 2024 that Resident 1 reported pain. There was no physician notification about the new onset of severe pain by licensed nurses found in the record. During a review of a Nursing Note dated 8/19/2024 at 11:30 am, Licensed Vocational Nurse (LVN 1) documented that Resident 1's wife insisted on sending Resident 1 out to the hospital to be evaluated. LVN 1 documented Physician 2 spoke with the family and agreed that if the family and Resident 1 wanted to have an emergency room (ER) visit, then it is okay. LVN 1 documented that around 12 pm Resident 1 was sent with nonemergent transport for evaluation at the emergency room (ER) due to the family insisting that he had a decline in health. During an interview on 8/30/24 at 2:04 pm, Family Member (FM 1) stated that she had to insisted for two days for Resident 1 to go to the hospital. FM 1 stated nursing staff told her, If we send him out, they are just going to send him right back here because there is nothing, they can do for him. FM 1 stated the nurse did not attempt to send Resident 1 out, even after family's insistence. FM 1 stated Resident 1 was in severe pain, and it appeared like he was going to be dead within one day if not sent out to hospital. During a concurrent interview and record review on 10/9/24 at 1:30 pm, Director of Nursing (DON) confirmed that the edema went from slight +1, to moderate +2, then to severe pitting edema +3. DON confirmed there was no change of condition reported by nursing staff to the physician. DON confirmed that Resident 1's new sudden onset severe pain on 8/18/24 and 8/19/24 along with the increased edema, these changes should have been reported to the physician. DON also confirmed it was by the insistence of the family that the Resident 1 was sent out to hospital for evaluation not the licensed nursing staff. DON stated the licensed nurses should have reported these changes to the physician and that their policy was not followed. During a record review of acute care hospitals ER admission assessment on 8/19/2024, indicated Resident 1 had multiple severe health issues such as infection, low potassium (regulates a regular heart rate), diminished breath sounds, edema both lower extremities extending all the way up to Resident 1's hips, anasarca, bilateral pleural effusions, fluid overload, and was ill and weak appearing. Resident 1 received emergent care and treatment and returned to the long-term care facility on 8/27/24, eight days later.

Based on interview and record review the facility failed to ensure licensed nursing staff had the skills and competencies to ensure the medical needs for one of three sampled residents (Resident 1) were met when significant changes of condition were not identified and reported to the physician. This resulted Resident 1 to be transferred to the hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) congestive heart failure. Findings: A review of Resident 1's record indicated he was admitted into this facility on 7/4/24 to rehabilitate from a hip replacement. Resident had Parkinson's Disease (movement disorder of the nervous system), high blood pressure, and heart failure Resident 1 was his own health care decision maker. During a record review of acute care hospital discharge notes for 7/4/2024, Resident 1 had +1 (mild) pitting (when one presses on the site, there is a pit or indentation) edema to right lower extremity and +2 (moderate) pitting to the left lower extremity. During record review of the facility admission orders on 7/4/24, Resident 1 had orders from Physician 1 for monitoring edema every shift. During a record review of the Medication Administration Record (MAR) for August 2024, indicated Resident 1 had +2 pitting edema in both lower extremities from 8/3/24 through 8/15/24. On 8/16/24, Resident 1 advanced to +3 pitting (when one presses on the site, there is a deep pit that lasts for 30 seconds before going away) edema. There was no change in condition reported by nursing staff to the physician found in the record. During a record review of the Resident 1's medication orders, indicated on 8/2/24, a new order for Lasix (a medication used to release excess fluid from the body by urination along with a release of potassium) 20 milligrams (mg) every day for edema. During record review of Resident 1's medication orders dated 8/17/24, indicated a new order was placed for Lasix 40 mg every day, a dose increase. During a record review of Resident 1's record, there were no physician laboratory (lab) orders found to draw a baseline blood potassium (regulates a regular heart rate), level before or any monitoring after starting Lasix from 7/4/24 through 8/19/24. There were also no physicians order for any supplemental oral potassium. A review of an online resource National Institutes of Health (nih.gov) DailyMed, indicated Lasix is a potent diuretic (increases amount of urine produced) which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte (essential for basic life functioning) loss. Therefore, careful medical supervision is required and dose and dose schedule must be adjusted to the individual patient's needs laboratory tests serum electrolytes (particularly potassium), should be determined frequently during the first few months of Lasix therapy and periodically thereafter. A review of Resident 1's record, indicated a physician order dated 8/19/24, indicated labs to drawn for electrolyte (potassium) blood levels. The lab results dated 8/19/24, indicated a low potassium level of 3.1 millimoles per liter (mmol/L, normal blood potassium level for adults is between 3.5 and 5.5 mmol/L). During a review of the MAR for August 2024, on 8/18/24 and 8/19/24, Resident 1 had sudden 7/10 (severe) pain and was administered a strong narcotic pain medication. This was the first time in August of 2024 that Resident 1 reported pain. There was no physician notification about the new onset of severe pain by licensed nurses found in the record. During a review of a Nursing Note dated 8/19/2024 at 11:30 am, Licensed Vocational Nurse (LVN 1) documented that Resident 1's wife insisted on sending Resident 1 out to the hospital to be evaluated. LVN 1 documented Physician 2 spoke with the family and agreed that if the family and Resident 1 wanted to have an emergency room (ER) visit, then it is okay. LVN 1 documented that around 12 pm Resident 1 was sent with nonemergent transport for evaluation at the emergency room (ER) due to the family insisting that he had a decline in health. During record review of acute care hospital records dated 8/19/24, indicated Resident 1 had a low blood potassium level of 3.2 mmol/L (low). He was treated with potassium chloride. The ER admission assessment on 8/19/2024, indicated Resident 1 had multiple severe health issues such as infection, low potassium, diminished breath sounds, edema both lower extremities extending all the way up to Resident 1's hips, anasarca, bilateral pleural effusions, fluid overload, and was ill and weak appearing. Resident 1 received emergent care and treatment and returned to the long-term care facility on 8/27/24, eight days later. During an interview on 8/30/24 at 2:04 pm, Family Member (FM 1) stated that she had to insisted for two days for Resident 1 to go to the hospital. FM 1 stated nursing staff told her, If we send him out, they are just going to send him right back here because there is nothing, they can do for him. FM 1 stated the nurse did not attempt to send Resident 1 out, even after family's insistence. FM 1 stated Resident 1 was in severe pain, and it appeared like he was going to be dead within one day if not sent out to hospital. During an interview on 10/9/24 at 1:30 pm, Director of Nursing (DON) confirmed that the edema went from minor +1 to moderate +2 to severe pitting edema +3, and no change of condition was reported by nursing staff to the physician. DON confirmed that the patient had sudden onset severe pain on 8/18/24 and 8/19/24 which was a change in condition along with the increased edema. DON also confirmed it was by the insistence of FM 1 that the patient was sent out to an acute care facility. DON confirmed when nursing staff received the new order of Lasix, there should have been a conversation with the physician about monitoring potassium levels. DON explained nursing staff were expected to assess residents and report changes of condition to the physician timely. DON confirmed a baseline potassium level and ongoing monitoring should have happened at the facility for Resident 1 when Lasix was started, and this put Resident 1 as risk for cardiac irregularities. A review of facility's policy titled, Change in Condition Policy Assessment, revised on 9/17/17, indicated residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated in a timely manner. This includes any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient. The licensed nurse is responsible for notifying the attending physician regarding all changes in a resident's condition.

Based on interview and record review, this requirement was not met when the facility failed to provide pain medication as ordered to one of five sampled residents (Resident 1). This caused Resident 1 to have significant back pain, interrupted his sleeping patterns, and had the potential to negatively affect his health. Findings A review of Resident 1's Admission Record, dated 1/12/24, indicated he was admitted to the facility after being hospitalized for pneumonia (an infection of the lungs), and he had a history of back pain. A review of Resident 1's discharge medication list from an acute care hospital on 1/12/24 indicated that Resident 1 should continue to receive pain medication Norco (a narcotic pain medication) Oral Tablet 5-325 MG (milligrams, a unit of measure), give 1 tablet by mouth every 6 hours as needed for pain 4-10 (a scale from zero to ten, used to measure pain) for 14 days. Begin 1/13/24 11:15 AM. A review of the facility's policy titled Pain Management, Dated 11/24/17, indicated, Pain medication is to be given before pain becomes severe. Response to pain is to be documented on the Medication Administration Record. Review of that record for Resident 1 for 1/13/24 indicated Resident 1 reported a back pain level of 7, or Severe. A review of the facility's medication administration record (MAR) for Resident 1, dated 1/12/24 to 1/16/24, indicated Norco Oral Tablet 5-325 MG, give 1 tablet by mouth every 6 hours as needed for pain 4-10 for 14 days. Begin 1/13/24 11:15 AM. No administrations of this medication were recorded up to and including Resident 1's discharge, on 1/16/23. During an interview on 1/16/24 at 3:30 PM, Resident 1's family member (FAM 1) stated, [Resident 1] didn't get hydrocodone so he was in pain for most of the weekend, Friday to Monday. He was so miserable that I had to bring in his medications from home on Sunday night 1/14/23 so that he would have them. He was so uncomfortable that he couldn't sleep. During a concurrent interview on 1/17/24 at 10:45 AM, with the facility's administrator (ADMIN A) and director of nursing (DON B) on 1/17/23 at 10:45 AM, ADMIN A stated that they were aware of pharmacy issues and were working to resolve them. ADMIN A indicated that earlier that day he had sent a letter to the pharmacy being used, terminating their contract. DON B stated that the facility was aware some medications were not being delivered, and staff had been educated to replace the meds through various means such as checking emergency drug kits. DON B reviewed the MAR and confirmed that the Norco had not been given to Resident 1 as needed, as ordered. During an interview on 1/17/24 at 11:15 AM, licensed vocational nurse (LVN C) confirmed problems with the pharmacy, They say they are going to deliver them, then we don't receive them for a few days. During an interview on 1/18/24 at 12:09 PM, Resident 1 stated that he was unable to explain how the facility's nursing staff recorded his pain rating as 0 on 1/14/24 and 1/15/24, up until discharge, since he was in pain, I was having pain in my back starting from when I first got there. I'd ask for something and they'd give me Tylenol which is nothing for me. I'd ask for something stronger-- I take hydrocodone (generic name for Norco) at home which I've been taking for years for chronic pain. The nurses would tell me that it was ordered the day before and they were waiting for it to come later in the morning. Then it never came, the next day and so on. The pain in my back would keep me up all night, just lying there wide awake. Finally, my wife had to bring some of my prescription in from home.

Based on interview and record review, this requirement was not met when the facility failed to be free of significant medication errors when a necessary heart medication was not provided to one of five sampled residents (Resident 1) after it was ordered by a physician. This had the potential to put Resident 1 at risk of heart failure, further hospitalization , or death. Findings Resident 1 was admitted to the facility after being hospitalized for pneumonia, and severe peripheral artery disease following a history of heart surgery. During his hospitalization , he was diagnosed with atrial fibrillation (Afib, a heart condition that causes the heart chambers to be chaotically and out of rhythm, dysrhythmia) and he was prescribed digoxin, an important medicine to correct this dysrhythmia, to be continued by the long-term care facility. Review of the facility's policy titled, Medication Administration, dated 11/24/17, indicated that licensed nurses must administer medications in accordance with physician orders. Review of Resident 1's record titled Discharge Summary dated 1/12/24, indicated that the acute care hospital had diagnosed Resident 1 with atrial fibrillation (chaotic, disorganized heart beats) and ventricular ectopy, (missed or extra heartbeats), which was new, from Resident 1's baseline. The record further noted that Resident 1 was then started on digoxin for better rate control. (Digoxin is a medicine that improves heart contractions, lowers heart rate, and decreases strain on the heart). Review of Resident 1's hospital discharge summary dated 1/12/24 also indicated that Resident 1 had a CHA2DS2-VASc score more than two. (CHA2DS2-VASc score is a point-based system used to determine the risk of stroke and death in heart patients. Resident 1's score of more than two indicated that he was a High risk patient. Review of the hospital discharge summary also indicated that Resident 1 was to continue to take Digoxin, 125 micrograms, 1 tablet by mouth daily, start date 1/13/24. Review of the facility's Medication Administration Record (MAR) for Resident 1 indicated that Resident 1 did not receive digoxin on 1/13/24 or 1/14/24 per the prescriber's order, a period of two days. Review of The American Journal of Cardiology dated 7/15/07, indicated that discontinuation of digoxin is associated with worsening heart failure (HF) symptoms and that outcomes improved with continued therapy of digoxin. In an interview on 1/16/24 at 3:30 PM, Resident 1's family member (FAM1), stated, [the facility] was having pharmacy issues and told me they ordered his medication, but the bottom line is that he was not supposed to interrupt his digoxin, it's for his heart, and he could have gone into Afib again. In an interview on 1/17/24 at 10:45 AM, the facility's administrator (ADMIN A) and director of nursing (DON B) both acknowledged that the facility's current pharmacy had been having delivery issues since they were contracted with, in December 2023, and provided written evidence that the facility is withdrawing its contract with that pharmacy and were working to resolve them. ADMIN A indicated that previously that day he had sent a letter to the pharmacy being used, terminating their contract. In an interview on 1/17/24 at 11:25 AM, LVN D further acknowledged the facility's issues with its pharmacy and that the record showed that doses of Resident 1's digoxin were missed on 1/13 and 1/14/24. LVN D further stated that one of the meds was digoxin, a really important heart medication. LVN D stated, I'm not sure what they could have done, but they could have found a way to get it. LVN D added that digoxin is not in the facility's emergency kit, and she would have called an outside community pharmacy for the commonly prescribed medication and had someone pick up the missing doses. In an interview on 1/18/24 at 12:09 PM, Resident 1 acknowledged that he had not received all his medication, including digoxin.

Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 3: (April - June 2023), indicated the facility had no RN on duty for: 4/29/23 Saturday (Sa), 5/20/23 (Sa), 5/27/23 (Sa), 6/3/23 (Sa), 6/4/23 Sunday (Su), 6/10/23 (Sa), 6/11/23 (Su), 6/12/23 Monday (M), 6/13/23 Tuesday (T), 6/14/23 Wednesday (W), 6/15/23 Thursday (Th), 6/17/23 (Sa), 6/18/23 (Su), 6/24/23 (Sa), 6/25/23 (Su) During a review of the RN monthly schedule, dated April, May, and June 2023, indicated there was no RN coverage for Saturdays or Sundays during the month of June. During an interview on 10/18/23 at 2:30 pm, the Assistant Director of Nursing (ADON) confirmed, We have had just a few shifts without a RN. During an interview on 10/19/23 at 10:00 am, the Interim Director of Nursing (IDON) confirmed, We had a few shifts during that time period we were short, but we have hired more RNs. The PBJ is linked to each facility's personnel payroll system. If an RN is even late to sign-in, the system determines there is not a RN on for that time period.

Based on interview and record review, the facility did not report a failed water heater to state and local agencies for 12 days. This failure had the potential to place all residents at risk for exposure to germs and illness related to a lack of hot water. Findings: A facility policy, titled, Unusual Occurrences, reviewed 4/30/22, was reviewed. The policy indicated a list of unusual occurrences that should have been reported to the California Department of Public Health (CDPH) within 24 hours by telephone and confirmed in writing. Among the reportable occurrences was any that, constituted an interference with facility operations, or which threatened the welfare, safety or health of residents, personnel, or visitors. During a concurrent interview and record review, on 10/17/23, at 11:30 AM, in the facility laundry room, Housekeeper (HSK) A stated the hot water had been off for one and a half weeks. HSK A confirmed a temperature log for the month of October 2023 contained a last recorded water temperature of 151 degrees Fahrenheit on 10/5/23 at 4:30 AM. No further temperatures had been recorded on the log. During an interview, on 10/20/23, at 10:03 AM, the Dirrector of Plant Operations (DPO) stated the kitchen notified them of no hot water on 10/5/23. DPO stated there were three water heaters on the roof of the facility, one for the kitchen and laundry, and two smaller tanks for residents' showers. The tank supplying the kitchen and laundry was the one that had failed. During an interview, on 10/17/23, at 11:50 AM, the Administrator (ADMIN) stated they hadn't called the County Health Department or CDPH about the water heater failure on 10/5/23. ADMIN stated they were still deciding on whether to repair or replace the failed water heater.

Based on interviews, observations and record review the facility failed to ensure essential equipment was maintained in safe working order when: 1. The temperature of the nourishment refrigerator located in nursing station one was above 41 degrees Fahrenheit ( F, a unit of measuring temperature). 2. The manufacturer guidelines were not followed for cleaning and sanitizing the ice machine. 3. A walk-in freezer located in the large storeroom in the basement had ice build-up on the inside of the door, around the fans and around a pipe. These failures had the potential for the equipment to not be maintained to ensure proper functioning. Findings: During a review of facility's policy and procedure titled Maintenance Shop dated 2023, it indicated it was the policy to maintain a Maintenance Log of service visits, repairs and inspections of the facility's fixtures, equipment, systems and buildings. 1. According to the US Food and Drug Administration titled Keep your appliances at the proper temperatures dated 1/18/23. Keep the refrigerator temperature at or below 40 F or 4 Celcius (C, metric unit of measuring temperature). The freezer temperature should be 0 F (-18 C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. http://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely According to facility's Nourishment Refrigerator log sheet, the maximum temperature of the refrigerator should be 41 F. On 10/19/23 at 9:06 AM, a concurrent interview and observation was conducted with Director of Staff Development (DSD), at Nurses Station #1 medication room. A nourishment refrigerator located in medication room was noted to be 46 F. All temperature entries in the log for the month of October were above 41 F. When asked if it was safe to store food above 4 F, the DSD stated she was not sure. The DSD confirmed that the Director of Plant Operations (DPO) should be notified that the refrigerator was not within approved temperature range. On 10/19/23 at 9:18 during a concurrent interview and observation with the DPO, he verified that the temperature in Nourishment Refrigerator on Station #1 was above 41 F. The DPO confirmed that the nourishment refrigerator was not noted in maintenance log. 2. During a review of the ice machine's manufacturer's descaling and sanitizing procedure instructions located on the inside cover of the ice machine showed to use [Manitowoc] ice machine descaler and sanitizer. On 10/17/23 at 3:09 PM during a concurrent interview and observation with the DPO stated the ice machine was new, purchased April 2023. Upon inspection of the ice machine cleaning and descaling chemicals provided by the DPO, it was noted that they were not the correct chemicals recommended by the manufacturer. The DPO stated he would obtain correct chemicals to clean/descale and sanitize the machine. 3. On 10/19/23 at 3:25 PM during a concurrent interview and observation with DPO in large walk-in freezer located in the basement storeroom, he confirmed the presence of ice build-up on a pipe and the ceiling above the ventilation fans and on the inside vent of door. He stated he was not aware of the ice buildup, and it should have been documented on the maintenance log. On 10/19/23 at 3:32 PM during a concurrent interview and observation with the Certified Dietary Manager (CDM) in large walk-in freezer, she confirmed the presence of ice build up on pipe and the ceiling above the ventilation fans and on the inside vent of door. She confirmed she had not entered it on the maintenance log. 39856

Based on observation, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 10/18/23 at 9:25 AM an interview was conducted with the CDM. The CDM was asked for documentation she had received six hours of California dietary service requirements contained in Title 22 of the California Code of Regulations. The CDM was not able to provide evidence of six hours of California dietary service requirements contained in Title 22 of the California Code of Regulations as specified in the HSC 1265.4.

Based on observation, interview, and record review, the facility failed to ensure that care plans for three of 17 sampled residents (Resident 25, 62, and Resident 275) were revised and updated to identify resident specific needs. This failure had the potential for residents individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status related to weight loss, communication needs, and proper transfers required to for pain management. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans, revised 1/31/22, the P&P indicated that it is the policy of this facility that the care plan is to be reviewed and revised after the resident's initial assessment, quarterly, and more often as warranted by the changes in a resident's condition. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 9/15/17, the P&P indicated that the licensed nurse is to update the care plan to reflect any change in condition. During a review of Resident 62's clinical record, Resident 62 was admitted to the facility on [DATE] for diagnoses that included fracture of the left femur (broken thigh bone), diabetes, high blood pressure, and Dementia (a general term for impaired thinking, remembering, reasoning and fucntional ability). During a review of 62's clinical record, Resident 62's Care Plan, dated 9/27/23, indicated a problem [Resident 62]'s preferred language was Spanish with no interventions for communication or translation line needed for specific resident needs to be met. During a concurent observation and interview on 10/17/23 at 11:00 AM, Resident 62 stated, No English, shaking her head no, and unable to answer any questions. During an interview on 10/17/23 at 11:12 AM, the Family Member (FM) of Resident 62 stated, I interpret English and my other family members do when they are here, [Resident 62] does not speak any English. During an interview on 10/20/23 at 11:55 am, the Assistant Director of Nursing (ADON) confirmed Resident 62 only spoke Spanish, and stated, I am bilingual, but I will change this immediately. I know [Resident 62] only speaks Spanish, and I will add the interpretor line to the care plan for the staff to use if needed. I have interpreted for [Resident 62], but we need access to the language line if there is a medical problem. [Resident 62]'s family can interpret also, she is not her own responsible party (RP). 2. During a review of Resident 275's clinical record, Resident 275 was admitted to the facility on [DATE] with diagnoses that included a stroke, high blood pressure, dysphasia (difficulty swallowing), and Chondrocostal junction syndrome (inflammation and pain to the upper ribs). During a review of Resident 275's clinical record, an assessment titled Brief Interview for Mental Status, dated 10/11/23, indicated Resident 275 was alert and oriented, scored 15 out of 15 (able to think and reason), and Resident 275 was her own RP for decisions. During a review of Resident 275's clinical record, Resident 275's Care Plan, dated 10/5/23, indicated a problem Resident 275 had a functional decline, needed one person assistance for activities of daily living (ADLs) such as toileting, bathing, grooming, and bed mobility. During a review of Resident 275's clinical record, Resident 275's Care Plan, dated 10/19/23, indicated a problem Resident 275 is at risk for pain with no interventions added to assist all transfers with one person, avoiding the rib area as needed for the diagnosis of Chondrocostal junction syndrome. During an interview on 10/18/23 at 8:50 AM, Resident 275 stated, I wish the staff knew how to help me transfer, it is painful if I am not helped correctly. I have to remind all the staff when they come in and help me in the bathroom or anytime they help me in and out of the bed. During an interview on 10/19/23 at 8:30 AM, the ADON confirmed Resident 275 needed new interventions for proper transfers related to chronic pain, disease process, and to not exacerbate Resident 275's pain in her rib area to update all staff providing direct care. 39856 3. Medical record review for Resident 25 was initiated on 10/18/23. Resident 25 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), mild protein-calorie malnutrition (the condition of lack of energy due to the deficiency of all the macronutrients and many micronutrients), hyperlipidemia (elevated fat in the blood), hypertension (high blood pressure) and major depressive disorder. Review of the facility document titled Weights and Vitals Summary from 9/11/23 through 10/11/23, showed the following weights and comparisons for Resident 25: * On 9/11/23 = 130.6 pounds (lbs.), * On 9/30/23 = 121.4 lbs. -9.2 lbs., a 7% severe weight loss since 9/11/23, less than one month [comparison weight on 9/11/23, 130.6 lbs.], * On 10/6/23 = 117.6 lbs., -13 lbs., a 10% severe weight loss since 9/11/23 [comparison weight on 9/11/23, 130.6 lbs.]. On 10/19/23 at 10:33 AM a review of Resident 25's electronic medical record and concurrent interview was conducted with the ADON. The ADON confirmed when a resident experiences a significant weight change, the resident centered plan or care should be updated to reflect the weight change. The ADON confirmed the care plan for Resident 25 had not been updated to reflect the -9.2 lbs., 7% unplanned severe weight loss on 9/30/23 or the -13 lbs., a 10% unplanned severe weight loss on 10/6/23. The ADON added it was the RD's responsibility to update the resident care plan with any significant weight changes. On 10/20/23 at 9:02 AM, a phone interview was conducted with the RD. The RD confirmed she was responsible to update resident care plans with significant weight changes. The RD confirmed she had not updated the care plan for Resident 25 to reflect the unplanned severe weight loss of -9.2 lbs., 7% on 9/30/23 or the -13 lbs., 10% unplanned severe weight loss on 10/6/23.

Based on observation, interview, and record review the facility failed to ensure safe handling of prescription medications with census of 66, based on standards of practice and regulatory requirements when: 1. The Emergency Kit (or EKit, an emergency supply of drugs that used based on a doctor order for urgent needs of a resident) for injectable (or a shot) drugs was not safely secured after use and was not replaced on timely manner in the main medication room. 2. The disposition of discontinued or unusable prescription medications were not cosigned by two licensed staff in both medication rooms. These unsafe medication handling practices could contribute to risk of diversion (abuse of prescription drugs) and drug loss. Findings: 1. During an inspection of the facility's medication room, at Station 1, on 10/18/23, at 12:45 PM, accompanied by Licensed Nurse D (LN D), the Ekit for injectable medication was observed to be open and unsealed. The EKit container had a yellow carbon copy of a slip indicating it was used on 10/10/23 for a new medication order by the doctor. LN D acknowledged the finding and stated the EKit should have been re-sealed after use and replaced by the pharmacy provider. In an interview with Assistants Director of Nursing (ADON), at DON's office, on 10/18/23, at 3:22 PM, the ADON stated the EKit should have been sealed right after the use with the temporary blue tag provided inside the EKit. ADON stated when the nurse faxed the EKit usage paper to the provider pharmacy, it should have alerted the pharmacy to replace the kit with the next delivery. Review of the facility's policy, titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, the policy indicated Emergency medication and supplies are kept secure, checked periodically for integrity . stored in accordance with State Board of Pharmacy and federal regulations. The policy further indicated Upon removal of any medication . from the emergency kit, the nurse document the medication or item on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy . The faxed log sheet will inform the pharmacy of items used from the emergency kit. This will notify the pharmacy to replace the kit . The policy on section 11 indicated before reporting off duty, the charge nurse indicates the opened or sealed status of the emergency kit at the shift change report . 2. During inspection of the facility's medication room, in the locked unit at Station 2, on 10/17/23, at 9:59 AM, accompanied by Licensed Nurse and Infection preventionist (IP), the two-drawer black container stored discontinued drugs and on the top of that a binder that had pages of Drug Destruction Log indicating drugs were disposed by one licensed nurse. During inspection of the facility's medication room, at the main Station 1, on 10/18/23, at 12:47 PM, accompanied by Licensed Nurse D (LN D), the three-drawer container was observed to be full of discontinued medications. LN D stated she was not sure when they got disposed and who documented in the medication destruction log. Review of the facility's document binder, at the main Station 1, titled Drug Destruction Log, on 10/18/23, at 2:30 PM, the log had pages of prescription medication destruction signed by one nurse most recently on September 2023. In an interview with ADON, on 10/18/23, at 3:40 PM, the ADON stated the disposed prescription medication were placed in a pharmaceutical waste bin and they poured coffee ground over them. ADON stated the medication destruction was recorded in a log with signature of a licensed nurse. ADON was not aware of any regulation that required two-person co-signature for prescription drug disposition. In an interview with Interim Director of Nursing (IDON) and ADON, on 10/20/23, at 10:11 AM, the IDON stated the non-narcotic prescription medications required no witness for destruction. IDON stated the risk of prescription medication loss and diversion during disposition was no different than a loss or diversion from a medication cart. Review of the facility's policy, titled Disposal of Medications, dated 2007, the policy was provided by the facility on 10/18/23, indicated non-controlled medications shall be destroyed by the nursing care center in the presence of a pharmacist or nurse. And one other witness as per state regulation. Documentation of non-controlled medication may be completed on . a medication disposition log . and shall be retained as per federal and state regulations. The policy on page 3 further indicated The medication disposition log or form shall contain the following information: a. For the State of _________(blank line), the appropriate method non-controlled medication destruction is as follows: . b. For the State of _____ (blank Line), these non-controlled medications shall be disposed of by the nursing care center in the presence of appropriately titled professional (check appropriate line): . (no line was marked). The fill in the blank section was not marked in the copy provided by the facility. In an interview with IDON and ADON, in DON's office, on 10/20/23, at 1:25 PM, when asked about the medication disposal policy provided on 10/18/23, the IDON stated the facility had a best practice policy without a co-signature for disposal of the prescription medications. The ADON stated they will look and provide the policy they are following. Review of the facility's policy, provided on 10/20/23, titled Disposal of Medications, dated 2007, last revised on 1-31-22, the policy indicated non-controlled medications shall be destroyed by the nursing care center in the presence of a pharmacist or nurse. And one other witness as per state regulation. Documentation of non-controlled medication may be completed on . a medication disposition log . and shall be retained as per federal and state regulations. The policy on page 3 further indicated The medication disposition log or form shall contain the following information: a. For the State of California (blank space handwritten), the appropriate method non-controlled medication destruction is as follows: ____ (blank space hand marked by an X) Transfer to a container for release to a pharmaceutical waste contractor . b. For the State of California (handwritten), these non-controlled medications shall be disposed of by the nursing care center in the presence of appropriately tiled professional (check appropriate line): . _______ (blank space hand marked by an X) Others as listed: ________ Lic nurse employed by nursing care center ( blank space handwritten note; Lic means licensed). The policy on page 4, indicated c. a non-controlled medication disposition log or form shall be used for documentation and shall be retained as per federal privacy and state regulations. The log shall contain the following information: . Signatures of the required witnesses. Attempts to reach to facility's Consultant Pharmacist (CP) on 10/20/23 at 12:38 PM, 1:14 PM and 1:57 PM, was not successful. 47884

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 66 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 38 opportunities which resulted in a facility wide medication error rate of 13.16 % in two out of nine residents (Resident 8 and Resident 15) during medication administration observation. These failures may result in unsafe medications use, medication error, and not following the doctor's orders. Findings: 1. During a medication pass observation of Resident 15, with Licensed Nurse A (LN A), on 10/17/23, at 9:13 AM, LN A administered a total of 10 medications and called the doctor's office on not having two medications not available to administer. LN A stated a blood thinner called Eliquis and a pain medication called Meloxicam was out of supply and not available to administer. Review of Resident 15's medical record, titled Medication Administration Record (or MAR, a legal document that listed medications ordered by doctor and administered by licensed nurse), dated October 2023, the MAR record and medication observation timing indicated the following irregularities: a. Carafate Oral Tablet 1 GM (or Sucralfate, used treat and prevent stomach ulcers; GM is unit of measure); Give 1 tablet by mouth before meals and at bedtime for GERD (or Gastroesophageal Reflux Disease; when stomach contents come back up into your esophagus and causes pain) -Start Date- 3/21/23. Carafate was due to be given at 7 AM before meal and was given after the breakfast at 9:13 AM. b. Senna Oral Tablet 8.6 MG (or Sennosides, a laxative); Give 2 tablet by mouth two times a day for Bowel maintenance Hold for loose stools -Start Date- 5/07/23. Medication observation indicated LN A administered Senna-S instead (a combination product of laxative Senna and stool softener Docusate) that was a different product than what was ordered. c. Aldactone Oral Tablet 25 MG (or Spironolactone; water pill for heart disease); Give 1 tablet by mouth one time a day related to . HEART FAILURE (a type heart disease); Hold for SBP (or Systolic Blood Pressure; type of blood pressure with normal number between 80-120) less than 110 -Start Date- 1/25/23. Medication observation indicated LN A did not administer the Aldactone. The MAR was marked as given at 9 AM. Resident's SBP number was more than 110 and recorded as 138. d. Biotin Oral Tablet 5 MG (Biotin, A B vitamin Supplement); Give 1 tablet by mouth one time a day for supplement -Start Date- 4/14/23. Medication observation indicated LN A did not administer Biotin. The MAR was marked as given at 9 AM. In an interview with LN A, at the main nursing station, on 10/17/23, at 4:58 PM, LN A stated the pharmacy provider delivered the Eliquis and the Meloxicam was to be delivered during the evening shift. LN A acknowledged that she missed giving Aldactone and Biotin pills. LN A stated that she realized that she gave Senna-S instead of regular senna laxative. LN A stated she was running late on giving the 7 AM dose of Carafate before meal (breakfast). 2. During a medication pass observation of Resident 8, with Licensed Nurse C (LN C), on 10/18/23, at 8:35 AM, LN C administered a total of 11 medications. Review of Resident 8's medical record, titled Medication Administration Record (or MAR, a legal document that listed medications ordered by doctor and administered by licensed nurse), dated October 2023, the MAR record and medication observation timing indicated the following irregularities: a. Oyster-Cal 500 Tablet (Calcium supplement); Give 1 tablet by mouth one time a day for Supplement -Start Date-9/27/23. b. Ferrous Sulfate Tablet 325 MG (or iron pill, a supplement used to treat anemia or low blood iron); Give 1 tablet by mouth two times a day for supplementation; Give with Food to Minimize GI (stomach) Upset. Do Not Crush or Chew. Do not administer w/ (With) Calcium, Milk or Milk products. -Start Date- 3/27/23. Medication observation indicated both iron pill and calcium were given together at the same time on 10/18/23 at 8:35 AM. The MAR documentation was marked as given at 9 AM. In an interview with Interim Director of Nursing (IDON), on 10/20/23, at 10:29 AM, the IDON stated doctor's order and instruction on the MAR should be followed during medication administration. Review of the facility's policy, titled Nursing Responsibility, last reviewed on 1/31/22, the policy under section 17 indicated Licensed nurses are responsible for administering medications and treatments as follow: . Medications and treatments are to be administered as prescribed; Review of the facility's policy, titled Medication Administration, last reviewed on 1/31/22, the policy under Administration of Medications to Residents indicated Medications are to be administered according to physician's orders using the Six Rights of Medication Administration . Read the resident's medication administration record (MAR) in its entirety . Select appropriate medication from the medication cart . 47884

Based on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure Food and Nutrition Services followed food safety and sanitation guidelines when: 1. Two of two hand washing sinks didn't not reach 85 degrees Farenheight ( F, a unit of measuring temperature). 2. The temperature in the nourishment refrigerator located on Nursing Station 1 was 4 F above the recommended temperature range. 3. The ice machine located in kitchen was not clean. 4. The sanitizer solution in the third compartment of the manual dishwashing sink was less than 200 parts per million. 5. Time temperature control for safety foods (TCS) prepared at ambient temperature (room temperature) were not monitored on the cool down log. 6. Food preparation equipment was not air dried. 7. Food service utensils were not in sanitary condition. 8. Food service utensils were not of approved material. 9. Food was not stored properly in 1 of 2 walk in freezers. 10. The floor drain next to the ice machine was not clean. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 66 who received food prepared in the kitchen. Findings: 1. According to USDA Food Code 2022, Section 5-202.12 Handwashing Sink, Installation (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 85 F During a review of facility's policy, Titled Hand Washing Procedure dated 2023, indicated that staff should use warm running water at 100 F to 108 F. On 10/17/23 at 8:52 AM during a concurrent interview and observation with Certified Dietary Manager (CDM) in the kitchen, she stated that the hot water heater that supplies hot water to the kitchen had been broken for a week. CDM confirmed that hot water temperature at handwashing sinks #1 was 70 F and at hand washing sink #2 hot water temperature was 62.4 F according to surveyor's digital thermometer. On 10/17/23 at 9:11 AM during an interview and with the Director of Plant Operations (DPO), he confirmed the hot water heater has been broken for a week. DPO stated he had one quote for repair and a second repair company was coming that day. On 10/17/23 at 9:13 AM during a concurrent interview and observation with the CDM, she stated that staff would mix hot water from the coffee maker and cold water in a bowl to make warm water for hand washing. No bowl was observed. Dietary Aide B (DA B) was asked to demonstrate how he washed his hands. DA B demonstrated by washing his hands with water from the faucet in sink #1 with water temperature at 70 F. 2. According to the US Food and Drug Administration titled Keep your appliances at the proper temperatures dated 1/18/23, keep the refrigerator temperature at or below 40 F or 4 Celcius (C, a metric unit of measuring temperature). The freezer temperature should be 0 F (-18 C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. http://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely A review of a facility's Nourishment Refrigerator log sheet, the maximum temperature of the refrigerator should be 41 F. On 10/19/23 at 9:06 AM, a concurrent interview and observation was conducted with Director of Staff Development (DSD) at Nurses Station #1 medication room. A nourishment refrigerator located in medication room was noted to be 46 F. All temperature entries in the log for the month of October 2023 were above 41 F. When asked if it was safe to store food above 41 F, the DSD stated she was not sure. The DSD confirmed that DPO should be notified that the refrigerator was not within approved temperature range. On 10/19/23 at 9:18 during a concurrent interview and observation with the DPO, he verified that the temperature in Nourishment Refrigerator on Station #1 was above 41 F. The DPO confirmed that the nourishment refrigerator was not noted in maintenance log. 3. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of the facility's policy and procedure titled, Ice Machine Cleaning Procedures dated 2023, indicated, the ice machine needed to be cleaned and sanitized monthly. During a review of the ice machine's owner's manual, it indicated to descale and sanitize the ice machine every 6 months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company. On 10/17/23 at 3:09 PM during a concurrent interview and observation with the DPO he stated he cleaned the ice machine every month. The DPO stated the ice machine was new, purchased April 2023, and the manufacturer said it didn't need to be cleaned for six months. Upon inspection of the interior of the ice machine, a white powdery substance was noted on the outside of the harvester curtain and the inside of the ice storage bin. The DPO verified white substance. When wiped with a paper towel a black substance was removed from the water trough (a tray that holds the water before it is frozen during the ice making process. The DPO confirmed the ice machine was not cleaned and he planned to clean it every three months. 4. During review of facility's policy titled 3-Compartment Procedure for Manual dishwashing it indicated that the third compartment is for sanitizing, test the concentration with the appropriate test strip, which is dipped in the sanitizer solution for 1-2 seconds before reading. Must read 200 parts per million (PPM) of sanitizer solution. On 10/17/23 at 9:40 AM during a concurrent interview and observation of the manual dish washing procedure in the kitchen with the CDM and Dietary Aide A (DA A), the DA A demonstrated the process to check the sanitizing solution concentration in the third compartment. When tested , the sanitizing solution test strip indicated 100 PPM. The CDM confirmed the sanitizing solution was not at correct concentration. 5. According to the USDA Food Code 2022 Section 3-501.14 3-501.14 Cooling (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient temperature . A review of the facility policy and procedure titled Cooling and Reheating of Potentially Hazardous or Time/Temperature for Safety Food dated 2023 showed, Ambient Temperature Food: TCS food shall be cooled within four hours to 41 F or less if prepared from foods at ambient temperature . On 10/17/23 at 12:44 PM an observation and concurrent interview was conducted with Cook 2 with the CDM present. Cook 2 was preparing coleslaw for the dinner meal. The coleslaw temperature was 48.1 F, according to the surveyor's digital thermometer. Cook 2 stated he only took a temperature of the coleslaw before dinner tray line. When asked if Cook 2 was familiar with a cool down log for TCS foods, Cook 2 obtained a binder with a log titled, Cool Down Log. The CDM stated there was a separate log for foods prepared at ambient temperature but confirmed the log for ambient foods was not in the binder. On 10/17/23 at 3:13 PM the CDM provided a blank copy of the ambient cooling log. The CDM stated she forgot to put the log in the binder. The CDM was unable to provide any completed cooling logs for ambient foods. 6. According to the USDA Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . During review of facility's Policy labeled Dishwashing it indicated dishes are to be air dried before stacking and storing. All items are air-dried which means no water droplets are present. On 10/18/23 at 10:52 AM in kitchen, five steam table pans were noted to be stacked and stored wet. The CDM verified the steam table pans should be air dried. 7. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of facility's policy titled Sanitation dated 2023, it indicated all utensils, counters, shelves and equipment shall be kept clean . On 10/17/23 at 9:11 AM during concurrent interview and observation in kitchen with CDM, 3 skillets were noted to have a thick, hard black substance on the cooking surface of the skillets. The CDM verified and stated she was planning on ordering new skillets. 8. According to the USDA Food Code, Section 4-101.17 Wood, Use Limitation. (A) . wood and wood wicker may not be used as a FOOD-CONTACT SURFACE. On 10/18/23 at 10:52 AM during a concurrent interview and observation in the kitchen with CDM, three wooden spoons were noted in utensil storage bin. CDM asked Cook A if he used them, and he stated he does use them. The CDM discarded the wooden spoons. 9. During a review of facility's policy titled Storage of Food and Supplies dated 2023, it indicated all shelves and storage racks or platforms should be in accordance with federal regulations to facilitate air circulation and promote easy and regular cleaning. On 10/17/23 at 10:05 AM during concurrent interview and observation with the CDM in the walk-in freezer located in the large storeroom, three empty plastic milk crates were noted to be used to elevating food supplies off the floor. CDM stated there wasn't enough shelf space to store food. 10. During a review of the facility's policy titled General Cleaning of Food and Nutrition Services Department dated 2023 it indicated that floor drains must be scheduled for routine cleaning in order to be maintained in a functional condition. Food and nutrition staff should remove large debris as it accumulates and are encouraged to clean drains weekly. Maintenance department will assist with more thorough cleanings to ensure the viability of the plumbing features. On 10/17/23 at 3:09 PM during concurrent interview and observation with DPO in kitchen the floor drain next to the ice machine was noted to have an encrustation of a hard white substance around the drain perimeter with scattered black, grey and tan discoloration. DPO verified presence of substance, stated he will clean.

Based on interviews, observations and record review the facility failed to ensure the policy for resident food brought from the outside allowed food to be reheated. In addition, family members, and visitors who brought food from the outside were not informed of safe food handling practices, and employees were not educated on safe food handling practices. This failure had the potential for food brought in from the outside to not be handled in a safe manner. Findings: During review of facility's policy and procedure titled Food from Outside Source reviewed on 1/31/22, indicated facility staff are not allowed to reheat foods brought in from outside the facility. Nursing and/or dietary staff are to discuss proper food storage and handling with the family to promote food safety. On 10/18/23 at 9:11 AM during interview with Assistant Director of Nursing (ADON) when asked how families get educated on safe food handling, she stated she refers to Certified Dietary Manager (CDM). On 10/18/23 at 12:57 PM during interview with Registered Dietician (RD) she stated she is not involved with educating the family members on food brought into facility and nursing takes care of it. On 10/19/23 at 8:30 AM during interview with Director of Staff development (DSD) when asked about any education on safe food handling for staff and family, the DSD confirmed there was a sign in sheet for an in-service completed on 7/14/23, however, there was no documentation of a lesson plan which showed what was covered in the in-service. On 10/19/23 at 8:51 AM during interview with CDM she stated she is not involved with educating family on safe food handling of outside food and refers to nursing. On 10/20/23 at 12:20 PM during interview with ADON when asked if staff was allowed to reheat food brought in from outside the facility. The ADON confirmed the policy stated food could not be reheated by staff.

Based on observation, interview, Policy and Procedure review, the facility failed to ensure refuse was stored in a sanitary manner when: One of three outdoor refuse dumpsters was not closed, and the surrounding area was not maintained in a sanitary manner. This failure had the potential to attract vermin. Findings: During review of facility's policy titled Sanitation, dated 2023, it indicated kitchen wastes .should be kept in leak proof, non-absorbent and tightly closed containers and shall be disposed of as necessary to prevent a nuisance or unsightliness. According to USDA Food Code, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered .with tight-fitting lids or doors if kept outside the food establishment. According to USDA Food Code, Section 5-501.115 Maintaining Refuse Areas and Enclosures: A storage area and enclosure for REFUSE .shall be maintained free of unnecessary items . and clean. On 10/18/23 at 9:40 AM an observation of the outdoor refuse storage area and concurrent interview was conducted with the Director of Plant Operations (DPO). One of three dumpsters was overfilled with trash preventing the lid from closing completely. The DPO confirmed all dumpsters should be completely closed. The area surrounding the dumpsters was littered with used gloves, empty food containers, paper and vegetation. The DPO confirmed the area was not clean and could attract vermin

Based on observation, interview, and record review the facility failed to ensure safe medication storage practices in three out of five medication and treatment Carts (cart or container on a wheel that stored immediate use medications) with census of 66 residents when medications were not marked with beyond use date (the date a product should no longer be used) based on manufacturer recommendations. These failed practices may result in unsafe and spoiled medication use in the facility. Findings: 1. During a concurrent inspection of facility medication Cart #2, at facility's Station 1, accompanied by Licensed Nurse D (LN D), on 10/17/23, at 10:17 AM, the medication cart stored medications with no markings for when it was first opened or with a beyond use date per manufacturer recommendations as follow: a. Basaglar Insulin pen (also known as Glargine; a shot medicine used to treat blood sugar disease; the medicine in pen shape for ease of administration) was stored in the medication cart for daily use and the label on the medications was missing the Date Opened. The insulin pen had a label with handwritten note to discard after 28 days after opening. b. Latanoprost eye drop (used to treat an eye disease called glaucoma) bottle was stored in the medication cart for daily use and the not dated when first was opened. The pharmacy label for Date Opened was not marked with any date. Product label indicated that Once a bottle is opened for use, it may be stored at room temperature . for 6 weeks. c. Four boxes of single use inhalation medication called ipratropium Bromide and albuterol Sulfate Inhalation solution (or DuoNeb- a breathing treatment for asthma and lung disease) for different residents were open and out of foil with no marking for the date opened. The product label indicated once removed from the foil pouch, the individual vials should be used within two weeks. d. An opened container of inhalation medication called Fluticasone Furoate/Vilanterol inhalation Powder (or Ellipta, breathing medication to treat asthma or lung disease), was not dated when first opened. The label on the container indicated Discard the inhaler 6 weeks after opening the moisture-protective foil ray . LN D acknowledged the findings and stated she was not sure why the products were not marked with open date when it was first opened. 2. During a concurrent inspection of facility treatment Cart at Station 1, accompanied by Licensed Nurse B (LN B), on 10/17/23, at 10:39 AM, the treatment cart stored four opened containers of prescription medication called triamcinolone 0.1% Cream (also called TAC cream, % a measure of potency; used to treat rash or skin disease), marked as RX Only (means prescribed by a doctor's order) in the active storage area of the cart. The TAC cream tubes had no pharmacy label on them to show who it was belonged to or how to use them. Further inspection of the treatment cart at Station 1, indicated a bottle of medicated shampoo called Ketoconazole 2% (a medicated shampoo used to treat yeast infections), marked as RX Only, and a handwritten note indicating house supply. The bottle did not have a pharmacy label with a resident name on it. LN B acknowledged the finding and was not sure why the prescription labels were missing, or how the products were used without a label or resident name. 3. During a concurrent inspection of facility medication Cart #1 at Station 1, accompanied by Licensed Nurse B (LN B), on 10/17/23, at 10:50 AM, the medication cart stored the following medications with no markings for when it was first opened per manufacturer recommendations: a. one container of a medication called Combivent Respimat inhalation spray (a breathing medicine used to treat asthma or other respiratory diseases) was stored in active storage area with no marking on when it was first opened. The pharmacy label for beyond use date was not marked. The label on the container indicated Discard 3 months after insertion of cartridge into inhaler. b. one opened container of test strip called Evencare G2 Blood Glucose Test Strips (a testing strip used to measure blood sugar by using a device called glucometer) was not dated when it was first opened. The label on the bottle indicated Use within 6 months after first opening or before the expiration date. LN B acknowledged the findings. In an interview with Assistant Director of Nursing (ADON), on 10/18/23, at 3:22 PM, the ADON stated the nursing staff should mark the multidose container of medications with the date opened and follow the label instruction for beyond use date. ADON stated the pharmacy services provided a table with list of products with short dating that required marking the date it when opened. Review of the facility's policy, titled Medication Storage, last reviewed on 1/31/22, the policy indicated it is the policy of this facility that all medications, drugs and biologicals (class of medicines which are grown and purified) to be stored in a safe, . manner . as directed by the manufacturer . in accordance with federal and state regulations. Review of the facility's policy, titled Medication Administration, last reviewed on 1/31/22, the policy indicated Medications are to be administered from containers, . that are clearly marked with the name of medication, concentration, dose, route and expiration date. 47884

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall, in accordance with the Fall Risk care plan, for one of three sampled residents (Resident 1) when Resident 1 was left alone, unsupervised in the bathroom while toileting by Certified Nursing Aide (CNA) A. This resulted in Resident 1 sustaining a fall, a cut above her left eye, and a fracture to her left femur (broken thigh bone of the upper leg), requiring hospitalization and surgery, and resulted in subsequent pain and a decline in her ability to perform activities of daily living. Findings: Review of a facility policy titled, Fall Program, reviewed 8/1/15, indicated the resident's environment will remain as free from accidents and hazard as is possible and all residents will receive adequate supervision to prevent accidents. Prevention will include more individualized interventions on a care plan for resident's with a higher risk of falls. The interventions are not limited to alarms on bed or chair, bed in low position, floor mat, non skid well fitting shoes that provide resident with adequate support, and supervised walking program. A review of Resident 1's records indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS, a resident assessment), dated 7/2/16, indicated Resident 1 had a brief interview for mental status score of nine, which indicated she was moderately cognitively impaired. Resident 1 was occasionally incontinent of urine and always continent of bowel. Resident 1 required extensive assistance with transferring, walking, and toilet use. Review of the Fall Risk care plan, dated 9/9/15, indicated Resident 1 was at moderate fall risk due to impaired cognition with safety awareness deficits. The interventions were to anticipate and meet needs for Resident 1's toileting and mobility and Do not leave (Resident 1) alone in the bathroom while toileting. Review of the current Kardex (interventions and care directives for direct care nursing staff) report for Resident 1 was reviewed. The safety category indicated Resident 1 had interventions that included the falling star program (high risk fall prevention program), bed and wheelchair alarms (notifies staff when resident gets up on own) and to ensure Resident 1 was wearing proper footwear when ambulating and out of bed. The toileting category indicated Resident 1 required staff assistance for the use of the toilet and transfers. Review of a physician's orders [REDACTED]. According to Lexicomp, an online pharmacy resource, Ativan was identified on the Beers Criteria (high risk list of medications) as a potentially inappropriate medication to be avoided in patients [AGE] years and older (independent of [DIAGNOSES REDACTED]. Review of the Medication Administration Records (MAR) for August 2016, indicated Resident 1 was given the Ativan at 11:04 am, on 8/12/16. Review of a progress note, dated 8/12/16 at 3:09 pm, indicated Resident 1 refused her dental treatment. Review of an incident progress note, dated 8/12/16 at 9:02 pm, indicated Resident 1 had a fall with injury while returning to bed from the restroom unassisted, at 6:05 pm. Resident 1 sustained a cut above her left eye and a possible hip fracture. The Medical Doctor (MD) was notified. Resident 1 was sent to the hospital for evaluation. The hospital record was reviewed. A report of the operation (surgery) dated 8/14/16, indicated Resident 1 had a [DIAGNOSES REDACTED]. The post surgery plans indicated Resident 1 was to be non weight-bearing on the left leg for at least three months. The MAR for August 2016 indicated Resident 1 reported mild to moderate pain from 8/01-8/18/16, 18 days prior to her fall. Resident 1 reported moderate to severe pain after readmission post fall from 8/21-8/31/16. The Kardex post fall for August 2016, indicated Resident 1 was now totally dependent on staff for all activities of daily living. An Interdisciplinary team (IDT) summary note, dated 8/16/16, timed at 11:38 am, indicated Resident 1 stated she was tired and wanted to go to bed and if Certified Nursing Aide (CNA) A did not do it right then she would do it herself. CNA A assisted Resident 1 to the bathroom with her walker and changed her into her bed clothes and removed her shoes. Resident 1 fell while walking back to her bed from the bathroom, unassisted. Resident 1 did not have her shoes on at the time of her fall. During a concurrent interview and record review on 8/23/16 at 10:30 am, the Director of Nursing (DON) stated Resident 1 should not have been left unsupervised in the bathroom and the plan of care was not followed by the nursing staff. During an interview on 8/23/15 at 12:15 pm, CNA B stated she cared for Resident 1 often and she should not be left alone in the bathroom unsupervised, due to her requiring alarms to reduce fall risk. CNA B stated Resident 1 was continent of bowel and bladder before the fall and now was mostly incontinent. CNA B stated Resident 1's pain has increased since the fall and she has less of an appetite. CNA B stated Resident 1 was less alert and more confused since the fall. CNA B stated Resident 1 had an increase in pain since the fall. During a concurrent observation and interview on 8/23/16 at 12:20 pm, Resident 1 was observed lying in bed, grimacing (a facial expression that indicates discomfort or pain). Resident 1 when questioned about her pain and the management of it, stated she gets relief most of the time and when it returns made her feel stressed and said she was Stressed out. Resident 1 stated she felt like she needed to have a bowel movement all the time and had lost her appetite. Resident 1 said she gets some relief from pain, but hurts right now. During an interview on 8/23/16 at 12:25 pm, LN E stated she was aware Resident 1 was having breakthrough pain and was going to give her some pain medication, then call the MD to report her changes in pain. LN E reviewed the bowel movement records and confirmed Resident 1 was having bowel movements daily, and confirmed Resident 1 felt she was not getting pain relief. During an interview on 8/23/16 at 2:45 pm, CNA A stated Resident 1 seemed more tired than normal on the day of the fall and that she wanted to go to bed right after dinner. CNA A stated she tried to redirect Resident 1 to allow the CNAs to finish with the evening meal. Resident 1 stated, If she did not get help right now, she would do it herself. CNA A stated she assisted Resident 1 to the bathroom, placed her on toilet, removed her shoes, and placed her bed clothes on her. CNA A stated Resident 1 wanted to have a bowel movement. CNA A stated Resident 1's roommate was yelling to have her dinner tray removed and there were call lights ringing in the hallway. CNA A stated she gave the call light to Resident 1 with instructions to pull when finished having a bowel movement. CNA A stated she was gone about 5 minutes assisting other residents and when walking back to Resident 1's room, she heard a thump come from Resident 1's room. CNA A stated Resident 1 was more confused, had less bowel and bladder control, increased pain, and required more assistance from nursing staff since the fall. CNA A stated she should have not left Resident 1 alone in the bathroom. During an interview on 8/26/16 at 2:30 pm, CNA C stated Resident 1 was unable to use her call light consistently due to her dementia, and should not have been left alone in the bathroom, due to her impulsiveness. CNA C stated Resident 1 was able to walk a short distance to the bathroom with a walker and one person assist prior to her fall. CNA C stated after her fall, Resident 1 required full bed care and was unable to put weight on her fractured leg. CNA C stated Resident 1 was rarely incontinent prior to her fall, and now requires adult incontinence pads, due to urine and bowel incontinence. CNA C reported this seems to bother Resident 1 because she does not like to be placed on a bedpan, due to pain, and also Resident 1 repeatedly stated, I want to use the bathroom when CNAs placed her on a bedpan. During an interview on 8/26/16 at 2:46 pm, CNA D stated that Resident 1 was not normally one of her residents, due to mainly working in other resident care areas. CNA D stated she would not leave Resident 1 unattended because Resident 1 wears an alarm and residents with alarms are not to be left alone. CNA D stated she does not know what Resident 1's functional status was prior to her fall, but now she requires two CNAs to provide care including turning, bathing, and incontinence care.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accidents and hazards for one of 19 resident's receiving oxygen therapy (Resident 1). Safety precautions were not in place to prevent residents, receiving oxygen, from being in close proximity to persons who were smoking and/or using other devices with open flames. This failure resulted in injury and burns to Resident 1 who required oxygen, when, while sitting in the designated smoking area, a visitor sitting next to Resident 1 used a lighter, igniting the oxygen delivered in Resident 1's nasal cannula (device used to deliver supplemental oxygen). Following this accident the facility failed to implement safety precautions to prevent a similar incident from occurring. Findings: On 05/16/16, at 11:12 am, the facility reported to the Department an incident from 05/15/16, involving Resident 1 who was receiving continuous oxygen. The facility reported the Resident 1, his son, and a friend went to the courtyard. The son's friend lit a cigarette while sitting next to Resident 1. The oxygen caught fire causing facial burns to Resident 1. Resident 1's admission record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set (MDS - an assessment tool), dated 05/15/16, indicated Resident 1 required limited assistance with moving in bed, dressing, and with hygiene. Resident 1 used a walker or wheelchair to move about the facility. The MDS also indicated Resident 1 gets short of breath with walking, bathing, or moving. The facility care plan dated 5/16/16, identified Resident 1 as a non-smoker. Following the incident on 5/15/16, Resident 1 was transported to the hospital via ambulance. Resident 1's Emergency Department Report dated 05/15/16 at 4:34 pm, indicated Resident 1 sustained burns to his face, nose, and lips. Resident 1 had wheezing and increased difficulty breathing. He required breathing medications, albuterol and Atrovent (medications used to relax muscles in the airway) while in the emergency department. The Emergency Department Chart, dated 05/15/16 at 12:30 pm, indicated that upon arrival to the emergency department Resident 1 reported pain at a level of 10/10 (1 - 10 scale used to assess level of pain with 10 being the worse). Resident 1 required intravenous (IV) pain medication to help relieve the pain. A review of the physician's admission History and Physical dated 05/15/16 at 2:14 pm, indicated Resident 1 Sustained second degree burns to his cheeks, nares (nostrils), and lips and The patient states that since this incident he has been coughing a bit more. Photographic documentation obtained by hospital staff, on 05/15/16 at 8:00 pm, indicated Resident 1 had fluid filled blisters present on each side of his nose. Nine days after the incident, on 05/24/16 at 10:10 am, an observation and interview was conducted with Resident 1 while he remained in the hospital. Resident 1 had one oval, reddened, open area 1 inch x 1/4 inch on the right side of his nose and one smaller, round, reddened, scabbed area 1/4 inch x 1/4 inch on the left side of his nose. Resident 1 stated on 05/15/16, his son came to the facility to visit and brought a friend. All three went to the patio. Resident 1 stated he did not see signs on the patio stating No smoking, Smoke Free, or No smoking while oxygen in use. Resident 1 stated that his son's friend sat next to him, lit a cigarette, igniting his oxygen and melting the nasal cannula that was on his face. Resident 1 stated his son took him to a nearby fountain to splash water on his face, then wheeled him inside to the nurse's station for treatment. Resident 1 stated that the fire blackened and melted the nasal cannula that was on his face. He felt scared and was in pain. On 05/24/16 at 1:15 pm, the Director of Staff Development (DSD), stated she assessed Resident 1 immediately after the incident. The DSD stated Resident 1 had burns to the outside of his nose, blisters on his lips, the inside of Resident 1's mouth and nose were black, and his moustache was singed. The DSD also stated she removed the black and melted nasal cannula and replaced it with a mask that covered Resident 1's nose and mouth. During a concurrent observation and interview, on 05/24/16 at 1:10 pm, the Administrator (AD) confirmed that there were no No smoking or No smoking while oxygen in use signs present in the patio area. The AD confirmed the patio area remained the designated smoking area and all residents have access to the patio. The AD stated the facility currently has no residents who smoke but visitors are allowed to smoke in the designated smoking area. During an observation, on 05/24/16, at 1:25 pm, three out of four doors exiting from the residential living quarters to the patio area had a sign posted on them. The sign stated Warning: You are entering a designated smoking area .Smoking is permitted only in designated smoking areas. There was no sign posted on the fourth door that exited to the patio from the lobby. A resident was seen on the patio, the designated smoking area, visiting with another person. The resident was observed sitting in a wheelchair with an oxygen tank attached to the back of the wheelchair. Although no one was observed smoking at this time, the resident was still at risk for injury, harm, or death because he was in an oxygen-rich environment where smoking was permitted. Oxygen causes fire to burn faster and hotter. During an interview on 05/24/16, at 1:50 pm, the DSD confirmed although there are currently no residents living in the facility who smoke, visitors are allowed to smoke on the patio and potentially in the presence of residents receiving oxygen. The DSD confirmed there were 19 residents requiring oxygen, either full time or as needed, living in the facility on 05/16/16. Immediate Jeopardy was called on 05/24/16 at 4:00 pm with the AD and CCO(Corporate Compliance Officer) present. Nine days after the incident occurred, safety precautions were not in place to prevent residents, receiving oxygen, from being in close proximity to persons who were smoking and/or using other devices with open flames. The facility maintained posted signage directing persons wishing to smoke to use the patio area, which was also used by residents receiving oxygen. On 05/24/16, at 4:40 pm, the AD presented a plan of action. The plan of action consisted of the following elements: 1. The signs identifying the patio as the designated smoking area were removed from the three doors exiting from the residential area doors to the patio. 2. No Smoking signs were placed on all entrances to the facility and the patio area. 3. All residents requiring oxygen were reassessed, education provided, and care plans updated regarding oxygen safety, avoiding open flames, visitors smoking precautions, caution when using electrical equipment, oxygen cylinder storage and handling, and petroleum based product use. 4. Staff in-service training was scheduled for 05/30/16 and 05/31/16 and was to include education about oxygen use and safety, as well as the patio being a non-smoking area. 5. The facility was awaiting non-smoking designation from the corporate legal department and pending notification to the family members. On 05/24/16, at 4:51 pm, the surveyors met with the AD and CCO and informed them the Immediate Jeopardy was abated.

Based on interview and record review the facility failed to provide care and services necessary to meet the individual needs of two of 18 sampled residents (Residents 7 and 4) when: 1. Resident 7 had a change in condition (lack of bowel movements with associated severe abdominal pain and abdominal distention/bloating) that was not comprehensively assessed/identified, reported to the physician, or evaluated and treated, timely and effectively. These failures resulted in Resident 7 suffering severe abdominal pain and distention, requiring transfer to the hospital emergency room (ER) where he was diagnosed with [REDACTED]. Resident 7 was hospitalized for [REDACTED]. Hospital discharge documentation indicated Resident 7 needed an improved bowel care program due to his medical condition and use of constipating narcotic (strong pain relief) medication. 2. Resident 4 had ineffective pain management causing anxiety and delaying physical therapy progress. Findings: 1. Resident 7's record was reviewed. Admission records indicated that Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7 was able to make health care decisions for himself. Resident 7 had a history of [REDACTED]. The physician orders [REDACTED]. Order dated [DATE], [MEDICATION NAME] S Tablet (stool softener) 8XXX,[DATE] milligrams (mg) give one tablet by mouth two times a day for constipation. Order dated [DATE], Milk of Magnesia (MOM, laxative to promote bowel movements-BM) 30 milliliters by mouth every 24 hours as needed for no BM in 3 days for constipation. Order dated [DATE], [MEDICATION NAME] suppository (promotes BM) 10 mg rectally once a day if MOM ineffective. Order dated [DATE], Fleet enema rectally once a day as needed if MOM and suppository ineffective for constipation. Order dated [DATE] [MEDICATION NAME] give 100 milligram by mouth every 24 hours as needed for constipation. The facility policy titled Bowel and Bladder Program dated [DATE], indicated the LN will collect all the data and a plan will be established and reviewed with resident by the Interdisciplinary Team (IDT, a group of varied disciplines which develop the plan of care). A care plan will be created based on assessment findings, data collection and will be reviewed at least quarterly. The bowel and bladder status will reviewed in the weekly progress note by the licensed nurse. The residents determined to have decreased bowel mobility or inability to have a normal bowel movement (BM) will be on a re-training program. The goal of the program is to restore dignity, relieve discomfort, and prevent constipation or other bowel related problems. Identification of the causative factor and develop treatment plan of care to relieve or eliminate cause. Introduce natural laxative foods in diet and increase roughage. The care plan for Resident 7 for constipation, indicated to monitor, document and report to the physician the signs and symptoms of complications related to constipation such as abdominal distention, small or loose stools, bowel sounds and change in mental status. The Bowel continence report for Resident 7 for [DATE] was reviewed as follows: On [DATE] at 6:15 am, Resident 7 had a large loose diarrhea bowel movement (BM). Six days later on [DATE] at 2:12 pm, Resident 7 had a small putty like BM followed by a medium normal BM at 7:59 am. Four days later on [DATE] at 6:29 am, Resident 7 had a small loose/diarrhea BM. The Nursing progress notes for Resident 7 for [DATE] were reviewed and indicated the following: On [DATE] at 3 pm, the bowel and bladder assessment indicated Resident 7 did not have an an elimination pattern and to see the care plan for intervention details. On [DATE] at 8:54 pm, the eMAR (electronic Medication Administration Record) note indicated Resident 7 refused the Milk of Magnesium (MOM, medication used for constipation to promote bowel movements). On [DATE] at 4 pm, the eMAR note indicated Resident 7 had no bowel movement in three days. There was no physician nor family notification by the Licensed Nurse (LN). On [DATE] at 5:41 pm, the eMAR note indicated Resident 7 complained of abdominal pain and refuses medication. There was no record of LN assessment of the abdomen. On [DATE] at 11:09 pm, the eMAR noted the [MEDICATION NAME] suppository (medication via rectum assists with bowel movements) was ineffective. On [DATE] at 2 am, the eMAR indicated Resident 7 received [MEDICATION NAME] (strong narcotic pain medicine with side effect of constipation) 20 milligrams (mg) for severe pain. The pain was rated at a 7 out of 10 (severe on a pain scale) and located at the abdomen. The LN did not assess the abdomen nor notify the physician or family. On [DATE] at 2:42 pm, the nursing note indicated Resident complains of constipation, requesting [MEDICATION NAME], informed resident no order for as needed [MEDICATION NAME], resident with increased anxiety and agitation stating you are not giving me my medication, offered MOM/Suppository/Enema, resident refused. Last bowel movement [DATE]. The care plan for Resident 7 for pain indicated to monitor and record pain severity and location. The physician should be notified if current complaint is a significant change for Resident 7's past experience of pain. There was no care plan created to address Resident 7's non-compliance or refusal of the prescribed bowel protocol. A physician notification form, dated [DATE] at 1:30 pm, indicated Resident complains of constipation requesting as needed [MEDICATION NAME], no order in place offered MOM/Suppository/Enema refused, last BM [DATE]. Two days later on [DATE] order was signed by physician. The Medication Administration Record [REDACTED]. The MAR for Resident 7 for [DATE] was reviewed and indicated the following for bowel protocol: The [MEDICATION NAME] suppository was given on one day, [DATE]. MOM was given on [DATE]. [MEDICATION NAME] was given once on [DATE]. Fleets enema was not given. There was no documentation that the physician ordered bowel protocol was correctly implemented and there was no documentation that the ineffectiveness and pain were reported to the physician by the licensed nursing staff. According to Lexicomp online (a drug reference site for health professionals, an adverse side effect of [MEDICATION NAME] is constipation. The Bowel continence report for Resident 7 for [DATE] were as follows: Six days since the last BM recorded on [DATE], Resident 7 had a large loose BM on [DATE] at 9:27 pm. Six days since the last BM recorded on [DATE], Resident 7 had a large loose BM on [DATE] at 1:31 am. Five days since the last BM recorded on [DATE] at 4:56 pm, Resident 7 had a small putty like BM on [DATE] 2:08 pm. The Nursing progress notes for Resident 7 for [DATE] were reviewed and indicated the following: On [DATE] at 3:07 pm, the weekly nursing summary indicated Resident 7 had occasional episodes of constipation. From ,[DATE] to [DATE], six doses of [MEDICATION NAME] were given and they were ineffective. On [DATE] at 1:35 pm, Resident 7 received a [MEDICATION NAME] suppository. On [DATE] at 1:36 pm, Resident 7 complained of abdominal discomfort related to constipation and a suppository was given. The LN did not include any abdominal assessments and the physician was not notified of ineffectiveness of bowel protocol. On [DATE] at 4:43 pm, Resident 7 complained of severe back pain for and received [MEDICATION NAME] (constipating) 20 mg. On [DATE] at 10:46 am, a Social services note indicated Resident 7 had a resident care conference was to be held at his bedside. Resident 7 stated I would rather wait until (son) can be here. The note indicated no changes per nursing and resident is stable at this time. On [DATE] at 1:02 am, the weekly nursing summary indicated Resident 7 refused MOM and requested stool softener and he complained of abdominal discomfort related to constipation. On [DATE] at 10:58 pm, Resident 7 complained of severe abdominal pain and received 20 mg of [MEDICATION NAME] (constipating). The LN did not assess the abdomen and the physician was not notified. On [DATE] at 2:01 am, Resident 7 had a [MEDICATION NAME] suppository and it was ineffective. On [DATE] at 10:29 am, Resident 7 had a Fleets enema and it was ineffective. Resident 7 had a hard distended abdomen. The LN did not notify the physician of the ineffective bowel protocol and chronic constipation. On [DATE] at 2:03 pm, Resident 7 had a Fleets enema and it was ineffective. The LN did not notify the physician of the ineffective protocol and chronic constipation. On [DATE] at 1:28 am, Resident 7 complained of severe gut pain and was given 20 mg of [MEDICATION NAME] (constipating). The LN did not notify the physician of the ineffective bowel protocol and severe abdominal pain. On [DATE] at 3:50 pm, the weekly nursing summary indicated Resident 7 had occasional episodes of anxiety and there was no abdominal assessment. On [DATE] at 8:32 am, Resident 7 complained of severe pain. The LN did not record a location of the pain. Resident 7 received 20 mg of [MEDICATION NAME] (constipating). On [DATE] at 10:55 pm, Resident 7 had abdominal distention, stomach non tender, had positive bowel sounds, passing gas, and the last BM was on [DATE]. On [DATE] at 10 pm, Resident 7 had seven pain in his stomach and was given 20 mg of [MEDICATION NAME] (constipating). On [DATE] at 11:28 pm, the LN noted the pain medication was ineffective. On [DATE] at 11:28 pm, Resident 7 was given 20 mg [MEDICATION NAME] (constipating) for severe pain. There was no LN abdominal assessment or physician notification of the change of condition. On [DATE] 10:51 am, a late entry incident note indicated Resident 7's abdomen was distended. Resident 7 refused suppository and enema and he wanted to talk to his son first. Resident agreed to suppository. On [DATE] at 12:03 pm, the first primary care physician (Medical Director) was notified of Resident 7's increased abdominal pain and distention. The MD ordered an immediate abdominal x-ray. On [DATE] at 3:21 pm, Resident 7 was sent out to the hospital after the x-ray returned a critical finding, after several weeks of chronic constipation and severe abdominal pain. The facility policy titled Change of Condition Notification dated [DATE] indicated the purpose was to keep residents, family and physicians informed of changes in resident's condition in a timely manner. A facility must immediately inform the resident, consult with the resident's physician and interested family member when there is a significant change or a need to alter treatments. Physician should be notified for emergent, urgent and routine issues. For example an emergent reason would be intense pain. Family notification should be done by Licensed Nurse for any changes in condition as soon as possible. Documentation should include Licensed Nurse's assessment and pertinent details of the incident. Licensed Nurse will document time physician contacted, response time and whether or not orders received. Licensed Nurse will document any update to care plans, complete an incident report, and communicate any changes in interventions to the Certified Nursing Assistants. Licensed Nurses will document each shift for at least 72 hours. The radiology results of the abdominal x-ray impression dated [DATE], indicated a large fecal impaction and suggested an urgent CT (computerized tomography x-ray) scan of the abdomen and pelvis to determine possible bowel perforation (hole in the intestines). The hospital emergency report dated [DATE] indicated Resident 7 came in with a complaint of abdominal distention and increasing abdominal pain, which has now been ongoing now the past several months. The patient complained of severe pain. The laboratory studies revealed an elevated white count (blood cells to fight infection) at 12,000 revealing potential infection. The CT revealed a rectal fecal impaction resulting in mechanical bowel obstruction. The history and physical completed at the hospital dated [DATE], indicated the patient will need a good bowel regimen and his [MEDICAL CONDITION] and pain medication contributed to his constipation and could be certainly developing a paralytic ileus (slowing or stopping the movement of food and fluid through the digestive system.) The Mayo clinic online definition under Diseases and Conditions for Intestional obstruction dated [DATE], indicated Paralytic ileus can cause signs and symptoms of intestinal obstruction, but doesn't involve a physical blockage. In paralytic ileus, muscle or nerve problems disrupt the normal coordinated muscle contractions of the intestines, slowing or stopping the movement of food and fluid through the digestive system. Paralytic ileus can affect any part of the intestine. Causes can include muscle and nerve disorders, such as [MEDICAL CONDITION]. The six day hospital course of treatment from ,[DATE] to [DATE], indicated Resident 7 was treated with laxatives to remove the stool from his bowels. Repeated x-rays confirmed the clearance of stool in his bowels. The discharge plan was to improve his bowel regimen. During an interview on [DATE] at 9 am, Resident 7 stated the facility staff do not record and monitor his BMs accurately. Resident 7 admitted to refusing the bowel protocol at times though he stated he would request laxatives, suppositories and enemas, when he had abdominal discomfort or was constipated. Resident 7 stated the only time he had taken pain medications was when his stomach hurts. Resident 7 stated they give him foods that bind his bowels like macaroni and cheese. Resident 7 stated the Registered Dietician just recently had discussions about foods that assist with BMs. Resident 7 stated he wanted to have natural ways to move his bowels for example, diet. Resident explained that he almost died because of his constipation. During an interview on [DATE] at 3:15, the Registered Dietician (RD) stated Resident 7 received prune juice at every meal. The RD stated nursing staff should notify her if there was a need to re-evaluate a resident's diet for constipation and she would offer more vegetables in the diet. There was no entry in the nutritional assessments which indicated a discussion about foods that prevent constipation. The RD explained she was not aware of Resident 7's chronic constipation or the bowel obstruction that required hospitalization , though she did not have the medical record in front of her while on the phone during the interview. During an interview on [DATE] at 2 pm, Resident 7's Primary Care Physician (Medical Director) stated he was unaware of the days and weeks that Resident 7 was chronically constipated and had severe abdominal pain. The MD stated he expected the LN staff to contact him in 2 to 3 days if a resident's bowel protocol was ineffective and if severe pain with abdominal distention had been assessed. The MD stated there was no discussion with the resident or son about the risks and benefits of refusing bowel protocol interventions. The MD was not aware of the hospital course of treatment for [REDACTED]. During an interview on [DATE] at 7:20 am, Certified Nursing Assistant (CNA) D stated Resident 7 can refuse bowel care at times but not always, it depended on the nursing staff communicating with him. CNA D stated Resident 7 was capable of informing staff that he was constipated. During an interview on [DATE] at 7:40 am, LVN C stated Resident 7's abdomen should be assessed after three days of no BM's and this should be documented in the medical record. LVN C confirmed Resident 7 was at high risk for constipation due to his medical condition. LVN C stated it should have been a red flag when Resident 7 started having severe pain in his abdomen after having months of no pain and the physician should have been made aware of this change in condition. LVN C stated giving [MEDICATION NAME] for severe abdominal pain and not looking for the root cause of the pain was inappropriate. LVN C stated Resident 7 had refused bowel protocol because he likes to control his care. During an concurrent interview and record review on [DATE] at 8 am, the Director of Nursing (DON) stated the physician should have been notified of Resident 7's change in condition related to his constipation and severe abdominal pain. The DON stated the physician ordered bowel protocol had not been followed. The DON stated the care plans and the Interdisciplinary team (IDT) did not address the refusals of the ordered bowel protocol, dietary preferences of the resident related to natural food laxatives, and the high risk of constipation related to his paralysis agitans diagnosis. The DON confirmed the Licensed staff did not consistently assess Resident 7's abdomen. The DON stated the severe abdominal pain was not identified as constipation and the pain assessments did not include location and enough information to determine effectiveness. The DON stated the change in condition and bowel and bladder facility policies had not been followed. 2. A review of the facility's admission records indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 was able to make health decisions for herself. The physician orders [REDACTED]. The facility policy titled Pain Management dated [DATE], indicated the purpose was to assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication. The Licensed Vocational Nurse (LVN) will review residents for pain including origin, location, severity, alleviating or exacerbating factors, and current treatment and response to the treatment. Assessment of pain will be based on the pain scale (pain measurement ,[DATE] mild pain, ,[DATE] moderate pain and ,[DATE] severe pain.) The LN will administer the pain medication and document on the Medication Administration Record [REDACTED]. If the pain is new onset, changed in nature, or not relieved with current medication, the LN will notify the physician for a review of the medications. Follow the change in condition policy for contacting the physician. During an interview on [DATE] at 10:40 am, Resident 4 and family member (Fam) J stated the only issue at the facility was the pain management. Resident 4 stated her pain at its worst was 8 out of 10 (pain scale severe) and after pain medication it was a 6 out of 10 (pain scale moderate). Fam J stated he did not understand why they only gave her one tablet for her pain medication then an hour later could not give her another one. Resident 4 stated her pain was interfering with her therapy progress. During an interview on [DATE] at 9:30 am, CNA G stated when Resident 4 was agitated, anxious and restless, this indicated she was in pain. CNA G stated the pain and fidgeting could interfere with her activities of daily living. During an interview on [DATE] at 10:10 am, LVN A stated Resident 4 was difficult to assess for pain due to her mental health diagnosis. LVN A stated if pain medication was not meeting Resident 4's needs, the physician should be notified within 3 to 4 days. An Occupational therapy plan of care dated [DATE], indicated patient reports complaints of severe pain, severe anxiety and decreased functional abilities of self care and mobility. The physical therapy treatment notes were as follows: On [DATE], Resident 4 had many complaints of left knee pain. On [DATE], Resident 4 had many complaints of left knee pain. On [DATE], Resident 4 stated at 9:15 am, come back later I hurt too much, reminded the patient and son, she needs to ask for pain medication and be ready for therapy treatment. The MAR for the date of [DATE], indicated Resident 4 received two [MEDICATION NAME] tablets at 5 am and at 9:40 am for severe pain. During an interview on [DATE] at 2 pm, the Physical Therapist (PT) F stated Resident 4 had bone on bone pain in her right knee as well as pain in her newly replaced left knee. PT F stated Resident 4 has physical therapy scheduled everyday at 9 am and that Resident 4 was responsible for making sure she was premedicated before therapy. The discharge summary from the hospital dated [DATE], indicated apply ice or the ice therapy pack, 4 times a day for 20 minutes. The Treatment Administration Record (TAR) for [DATE], indicated Left knee apply ice 4 times a day for 20 minutes every day and evening shift. This treatment order was implemented on [DATE], four days after admission. The nursing summary dated [DATE], indicated under pain management current pain levels 4 to 8 and takes 1 to 2 tabs of [MEDICATION NAME] every four hours as needed. The summary of pain management program indicated, resident requires daily pain medications approximately every four hours. During an interview on [DATE] at 9:50 am, Resident 4 stated the ice packs helped with her knee pain, especially before going to sleep. The social services note dated [DATE] at 10:06, indicated that resident is somewhat reluctant to do therapy and to be ready in the morning. The family was present and discussed the manic and depressed episoded and the psychiatric medications being prescribed. During an concurrent interview and record review on [DATE] at 1 pm, the Social Services (SS) stated the IDT team did discuss the mental health issues affecting Resident 4's therapy progress. The SS stated Resident 4 had been seeing a psychiatrist 2 times a month prior to this admission. The SS stated the family was going to contact the psychiatrist. The SS stated the facility had not contacted the psychiatrist to arrange or discuss current counseling nor psychiatric medications. The MAR indicated [REDACTED]. A care plan dated [DATE], twelve days after admission, indicated to administer pain medication ,[DATE] hour before treatments of care. During a concurrent interview and record review on [DATE] at 1 pm, the DON stated her expectation of the licensed staff was to evaluate the pain management for residents weekly. The DON stated it was not the residents responsibility to remind nursing staff to medicate prior to physical therapy and the pain medication could have been regularly scheduled prior to therapy. The DON stated the pain management policy was not followed for Resident 4.

Based on interview and record review, the facility failed to implement its policies for Abuse Allegation and Reporting, Unusual Occurrences, and Incident and Accident Reports by failing to report, thoroughly investigate, and provide the results of their investigation of incidents involving patient harm and injury, unusual occurrences, and major accidents (unwitnessed accident, falls, lacerations, bruises), to the State Agency (The California Department of Public Health, CDPH) for four of nine sampled residents (Residents 1, 2, 3, and 7) over a six month period ([DATE] to [DATE]). There was no report to the State Agency concerning the possibility that Residents 1, 2, 3, and 7) may have been injured as a consequence of abuse, neglect, or mistreatment when: 1. Resident 1 was found on the floor in his bathroom with a broken pelvis and tailbone and severely lacerated ear, requiring hospitalization where he subsequently died related to those injuries. 2. Resident 2 was found on the floor in her bedroom doorway with a broken hip, requiring hospitalization where she subsequently died related to the injury. 3. Resident 3 was found on the floor outside of a dining room, sustaining a broken left hip which required hospitalization and surgery. 4. Resident 7 was found on the floor next to her bed, sustaining a broken back, requiring hospitalization where she required surgery. The situation of not reporting and investigating incidents involving patient harm and injury, unusual occurrences, and major accidents, or providing investigative reports to the CDPH, was pervasive throughout the facility and represented a systemic failure that had the potential to affect a large portion or all of the facility's residents, placing them at risk for serious injury, harm, impairment or death. An Immediate jeopardy (IJ) was declared on [DATE] at 1:45 pm with the Administrator. The IJ was abated on [DATE] at 5:15 pm with the Administrator, who confirmed in writing, the facility would report injuries, as required. Refer to F279, F323, F353, F490, F493, F501, F520. Findings: On [DATE], the CDPH received a complaint alleging a resident (Resident 1) had an unwitnessed fall with significant injury at the facility, where he was found in the bathroom on the floor. The resident was hospitalized , required surgery, and subsequently died . The CDPH began an onsite investigation for this complaint on [DATE]. The CDPH had not received a report (entity reported incident) from the facility of During an interview with the Administrator on [DATE] at 8:45 am, he stated that he did not report the injuries of unknown origin of Resident 1 on [DATE] to the state agency because he did not think he had to. He stated that he had been the administrator for five years and he's never been told he had to report injuries of unknown origin to rule out abuse or to send a copy of the investigation report to the State Agency within five days, as required by regulation. Review of the facility's Abuse Allegation and Reporting policy, effective [DATE], indicated the facility is to ensure all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source (such as unwitnessed accidents with injury), are reported immediately to the Administrator and, if unavailable, the Administrator's designee and to other officials in accordance with State Law through established procedures (including the CDPH). The policy directed the facility must have evidence that all alleged violations are thoroughly investigated and the results of all investigations must be reported to the Administrator, designated representative and to other officials in accordance with State Law (including CDPH) within 24 hours of the incident. All internal investigations must be reported to the Administrator or designee, and to other officials in accordance with State Law (including CDPH) within 24 hours of the incident. If the alleged incident involves patient harm/injury, an unusual occurrence must be completed, per policy. Ensure all required reporting, investigating per State requirements are completed. Review of the facility's Unusual Occurrences policy, effective [DATE] and last reviewed [DATE], read, It is the policy of this facility to report unusual occurrences to the CDPH. The administrator or designee will report the following unusual occurrences to the CDPH within 24 hours by telephone and confirm in writing: i. Major accidents and j. Death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety, or health of residents, personnel, or visitors. Review of the facility's Incident and Accident Reports policy, effective [DATE] and last reviewed [DATE], under PURPOSE: To investigate all unusual occurrences to determine causes and take action to prevent harm or injury. Under POLICY: It is the policy of this facility to ensure that the resident environment remains free of accident hazards as is possible and to document all unusual occurrences that cause injury or harm to the resident, staff, or visitor. Incidents and accidents of unknown origin that cause injury or harm to the resident will be reported to the local district office of CDPH within 24 hours of knowledge of the incident by telephone and confirmed in writing. Under the section titled, Reportable Occurrences, falls are listed as number one. Under DEFINITIONS: Incident: An unusual event or happening involving a resident, visitor, volunteer with unintended, undesirable, and/or unexpected results or outcomes. Serious illness or injury: Those that are life threatening, result in permanent impairment to a resident's body structure or function or need any immediate medical attention or surgical intervention to prevent permanent illness or injury. Unusual Occurrence: .major accidents, death from unnatural causes or other catastrophes or unusual occurrences which threaten the welfare, safety, or health of residents, personnel, or visitors. REPORTABLE OCCURRENCES: 1. Falls, .3. Lacerations, 4. Bruises. The Director of Nursing or designee will complete a thorough investigation of the incident, assessing for any unusual occurrences, changes in condition or trends that require further assessment of the interdisciplinary team, including the physician. Review of the facility's Fall Prevention policy, effective [DATE] and last revised [DATE] indicated, the goal of investigation, to be completed by the Director of Nursing, shall be to determine causal factors, if possible, and to rule out abuse. Completed investigations are referred to the Corporate Compliance Officer. 1. Resident 1's record was reviewed. He had [DIAGNOSES REDACTED]. He sustained an unwitnessed incident on [DATE] at 3:50 am, when he was found on the floor of his bathroom with a severely lacerated right ear and severe hip and back pain. He was unable to move from the floor. He was sent to the hospital where he was diagnosed with [REDACTED]. The Resident died in the hospital. According to the Certificate of Death, Resident 1's underlying cause of death was a fractured pelvis due to mechanical fall. The facility failed to report, thoroughly investigate, and provide the results of their investigation involving harm and injury to Resident 1, to the CDPH, that ruled out abuse, neglect or mistreatment. 2. The facility's fall log was reviewed on [DATE] for the period of time from [DATE] to [DATE]. It indicated that Resident 2, a resident with dementia, was found on the floor in her doorway on [DATE] at 6:40 am, that resulted in left shoulder and elbow pain, swelling, and bruising, and left hip pain that radiated to her knee. Resident 2 had sustained a broken hip. The fall was one of the factors listed as a cause of death on her death certificate. Review of a Physician's Progress Notes, dated [DATE] (there was no time of documentation) and documented by a registered nurse (RN), indicated, two direct care staff (the RN and a certified nursing assistant) had just responded to the bed alarm to check on Resident 2 (who had gotten up from bed without help and was at risk for falling). The record indicated the resident was found standing at her bedside and stated she wanted to go to the bathroom. The note indicated the resident liked privacy when using the bathroom, and told staff she did not need help (Resident 2 had dementia). The note indicated the two staff left Resident 2's room, leaving Resident 2 unattended and unsupervised, without ensuring her safety ambulating to the bathroom. Resident 2 was then found on the floor, injured, in the entry doorway to her room, not the bathroom door. The facility failed to report, thoroughly investigate, and provide the results of their investigation involving harm and injury to Resident 2, to the CDPH, that ruled out abuse, neglect or mistreatment. 3. Resident 3's record was reviewed. Resident 3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Nursing note documentation showed on [DATE], Resident 3 was found on the floor outside the dementia unit dining room with a skin tear to his left elbow, redness to his scalp, left knee pain, and had sustained a broken left hip. The facility failed to report, thoroughly investigate, and provide the results of their investigation involving harm and injury to Resident 3, to the CDPH, that ruled out abuse, neglect or mistreatment. 4. Resident 7's record was reviewed. Resident 7 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Nursing note documentation showed that on [DATE], Resident 7 was heard yelling for help and found on the floor next to her bed with a skin tear to her right index finger, an abrasion to her left ankle, had hit her head, and fractured her lower back. The facility failed to report, thoroughly investigate, and provide the results of their investigation involving harm and injury to Resident 7, to the CDPH, that ruled out abuse, neglect or mistreatment. On [DATE] at 3:30 pm, the Director of Nursing (DON) was interviewed. The DON stated, regardless if a resident has a dementia diagnosis, poor safety awareness, or episodes of disorientation and confusion, the resident's stated reason for the cause of an unwitnessed incident and/or injury will be accepted by the facility as the causal factor, and therefore, not investigated to rule out abuse. The DON confirmed that the facility considered Resident's 1, 2, 3 and 7's unwitnessed incidents involving harm and injury were considered falls and not investigated to rule out abuse or neglect, as the facility's Abuse policy directed.

Based on observation, interview, and record review, the facility failed to have a Fall Prevention program that ensured residents who were at risk for falls and injuries were supervised, evaluated, monitored, and reviewed by the Interdisciplinary Team (IDT-usually consists of the Director of Nurses (DON), Therapy personnel, Social Service, Activity and Dietary personnel, a Licensed Nurse (LN), and the Consulting Pharmacist and Dietitian, when necessary). The IDT failed to conduct post fall investigations to determine trends and root causes for falls and use that information to make recommendations and update care plans, to prevent further avoidable falls and injuries for nine of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9). Between [DATE] and [DATE] falls had occurred in the facility, 46 of those falls were sustained by the nine sampled residents and the facility failed to intervene and prevent those avoidable falls with injuries: 1. Resident 1 sustained one unwitnessed fall which resulted in a broken pelvis, tailbone, and a severely lacerated (cut) ear that required surgery, and subsequently contributed to his death. 2. Resident 2 sustained one unwitnessed fall which resulted in a broken left hip and arm that required surgery, and subsequently contributed to her death. 3. a. Resident 3 sustained four unwitnessed falls, twice he hit his head and one fall resulted in a broken left hip that required surgery. b. Resident 7 sustained four unwitnessed falls and one resulted in a right shoulder bruise and another resulted in a broken back which required surgery. c. Resident 4 sustained 13 unwitnessed falls and one witnessed fall. One fall resulted in reddened areas to her head and knee. d. Resident 5 sustained three unwitnessed falls and one witnessed fall, all of which resulted in skin tears and abrasions (scrapes) to his forehead, arm, elbow, and knee. e. Resident 6 sustained five unwitnessed falls from repeatedly rolling out of bed at night and one witnessed fall out of her wheelchair. One fall resulted in a skin tear to her elbow. f. Resident 8 sustained three unwitnessed falls and one witnessed fall. One fall resulted in a hospital evaluation of her condition. g. Resident 9 sustained eight unwitnessed falls out of her wheelchair and sustained abrasions. These failures resulted in falls and injuries which could have been prevented for Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9, and had the potential to adversely affect the health and safety of residents and prevent them from attaining or maintaining their highest practicable level of physical and emotional well-being. Refer to F353 for additional information. This situation represented a systemic failure which had the potential to affect a large portion of the facility's residents, resulting in an Immediate Jeopardy (IJ) situation and Substandard Quality of Care. The Administrator (Admin) was informed of the IJ on [DATE] at 1:45 pm, and an immediate corrective action plan was requested. On [DATE] at 5:20 pm, the Admin presented an acceptable immediate corrective action plan which ensured that resident falls were investigated, evaluated, and monitored with the oversight of the IDT, and high risk residents had bed and wheelchair alarms applied, and the IJ was abated. Findings: 1. Resident 1's record was reviewed. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Fall assessment dated [DATE], identified the resident as a moderate risk for falls. The physician statement of Risk verses benefit for fall dated [DATE], identified that due to a recent fall, weakness, and recent hospitalization , the resident was at risk for falls which may lead to a fall with injury or hospitalization . The IDT recommended that a bed alarm be put on the resident's bed, which it was. Resident 1 was identified in the nursing notes on [DATE], as needing one person to physically assist with his activities of daily living (ADLs). In an interview on [DATE] at 11:00 am with the night shift charge nurse, Licensed Nurse (LN) A, she stated she heard a loud thud coming from Resident 1's room between 3 and 4 am on [DATE]. She ran into the pitch black room and found Resident 1 lying on the bathroom floor on his back with his right ear all bloody and he complained of back pain. His bed alarm did not go off because it was found to be turned off. She stated that the Certified Nurse Assistants (CNA's) are supposed to check the resident's alarms when they come on shift and when they make their rounds every two hours. She stated that she did not think the facility had a policy for alarms, but the CNA's get that information during their orientation. Resident 1 was sent to the hospital by ambulance at 4:20 am. In an interview on [DATE] at 4:00 pm with CNA A, she stated on [DATE], she was assigned to care for Resident 1 during her night shift. She said, I was in another room when I heard a sound coming from the bathroom in Resident 1's room. She confirmed the bed alarm was not on when the fall occurred and she did not check to see that it was on and functioning when she started her shift. In an interview with Resident 1's family member (FM) on [DATE] at 12:15 pm, FM stated Resident 1's bed had an alarm, he would use the call light to get a nurse to help him get up to go to the bathroom, and he did not try to get up on his own. He never touched the alarm. Resident 1's FM stated that after he went to the hospital, he was diagnosed as having a broken pelvis and broken tailbone in four places, as well as, a severely torn ear. He had two surgeries in two days and he was in a lot of pain. He really suffered the last two weeks of his life. Resident 1 died at the hospital on [DATE], seven days after he fell in the facility. Review of the death certificate indicated, Acute Respiratory Failure as the immediate cause of death with Fractured Pelvis due to mechanical fall as one of the conditions leading to his demise. In an interview with the DON on [DATE] at 8:50 am, she stated that she did investigate Resident 1's fall and the bed alarm was functioning, but not turned on. She verified that the CNA's are supposed to check the bed alarms when they come on duty. She verified that she did not interview CNA A who was assigned to care for Resident 1 to find out the reason that the bed alarm was not checked. She stated that the facility did not have a policy for alarm use or checking of bed alarms. There was no evidence that an investigation was completed for this fall. The DON stated, during an interview on [DATE] at 8:50 am, that her investigative report was the same as the facility's Incident Report, which is an internal document sent to their corporate office. On [DATE] at 4:00 pm, the facility gave a copy of the internal Incident Report to the survey team for review. The Incident Report was completed and signed by the night shift charge nurse and there was no evidence that the DON did an investigation. On [DATE] at 3:00 pm, the Corporate Compliance Officer (CCO) stated the facility does have an Alarm, Bed and Chair policy. The policy was reviewed and read, C.N.A.s are to check the function of each alarm at the beginning of their shift to ensure all are in good working condition and turned on. The policy included, The resident's care plan should reflect the use of a bed and/or chair alarm as part of the fall prevention interventions. The Physician Statement of Risk vs Benefits for Falls, dated [DATE] (day of admission), in the record showed that Resident 1 was able to demonstrate the use of a call light and that the bed alarm would be in place. Further review of the record showed on [DATE] (the day before the fall), the Physical Therapist (PT) Progress note documented that Resident 1 has continued deficits in impaired memory/dementia, weakness and fall risks. 2. Resident 2's record was reviewed. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was not able to make her own decisions. She had sustained one non-injury fall since her admission to the facility. Review of the MDS (Minimum Data Set-a standardized resident assessment), dated [DATE], showed Resident 2 required limited assistance with staff providing guided maneuvering of her limbs and one person to physically assist her to walk in her room. A review of Resident 2's Social Service quarterly note, dated [DATE], reflected that Resident 2 was, alert, confused and disoriented at all times, and needed one person to assist her with transfers and mobility. A review of Resident 2's Care Conference, dated [DATE], showed staff to continue to encourage and assist with frequent toileting. A review of Resident 2's Weekly Nursing Summary, dated [DATE], showed that she needed one person to assist with her ADLs and required safety reminders for her moderate falls risk. Resident 2's FM was interviewed on [DATE] at 3:30 pm. She said Resident 2 would walk slow and was wobbly as her gait was not normal. I did think it was strange that staff was there and did not stay. It was early and (Resident 2) had just gotten up. She may have needed more help. On [DATE] at 11:20 am, Resident 2's FM stated the death certificate identified the broken hip (left hip fracture) as a significant contributing factor in Resident 2's death. A copy of the Death Certificate was obtained and reviewed, and confirmed that the left hip fracture and left elbow fracture were other significant conditions contributing to Resident 2's cause of death. In an interview with LN B on [DATE] at 12:00 pm, she stated that she had just come on duty on [DATE] (about 6:40 am) when she heard the bed alarm in Resident 2's room. She and CNA B responded to the sound of the bed alarm and found the resident standing beside her bed. When the resident was asked if she needed anything or if she had to use the restroom the resident stated, no and LN B and CNA B left Resident 2 alone and unassisted in her room (although the facility had identified the resident required limited assistance with staff providing guided maneuvering of her limbs, one person to physically assist her to walk in her room and assist with her ADLs, and required safety reminders for her moderate falls risk). Just a couple of minutes later we heard her yell. She must have followed us. We found her on the floor in the doorway to the hall. The resident stated that she had pain from the top of her left hip to her left knee and pain in her left shoulder and left elbow. The ambulance took her to the hospital where it was confirmed that Resident 2 had a broken left hip and broken left arm. Resident 2 had surgery to fix her left hip. She returned to the facility after 8 days in the hospital, on [DATE]. She died 8 days later, on [DATE]. When asked to explain why this resident who was confused, disoriented, and at moderate risk for falls was left alone after the alarm sounded, LN B stated, I was under the impression that she's ok to do as she pleases during the day because she had a signed Risk versus Benefit form. The resident only needed the bed alarm at night as she was up during the day. In an interview with CNA B on [DATE] at 12:20 pm, CNA B confirmed what LN B stated. CNA B stated, She (the resident) gets more agitated when we try to help her and she has signed a form about the risks, so it is OK that we leave her alone (although the facility had previously identified Resident 2 was not able to make decisions for herself and was confused and disoriented at all times). 3. a. Resident 3's record was reviewed. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 3 was readmitted on [DATE] following the surgical repair of his broken left hip from a fall he had sustained at the facility. The most recent MDS, dated [DATE], showed that Resident 3 required limited assistance and one person to physically help him transfer and extensive assistance with one person to toilet. On [DATE] at 2 pm, an observation and interview was conducted with Resident 3. Resident 3's room was one of 10 rooms located in a hallway just outside of the facility's locked dementia care unit (DCU). The nurses station, and the LN responsible for the supervision and care of Resident 3, was on the other side of the facility designated as the skilled care unit SCU and was not able to see his room. Resident 3 had no recall regarding the circumstances of his falls but stated, I'm better now than I was, I'm more careful and ask for help. On [DATE] at 2:20 pm, LN C, the charge nurse for the DCU, confirmed during an interview that she was unable to visualize the resident rooms on the other side of the locked doors. LN C stated she supervised half of the rooms in that hallway and the SCU nurse supervised the other. On [DATE] at 3:05 pm, LN D confirmed during an interview that she could not see the five rooms near the DCU that she was responsible to supervise. LN D stated that she goes over to those rooms to pass the resident's medications and check on them at least twice in her shift, otherwise, the CNAs will come get me if I'm needed. Nursing Progress notes reviewed from [DATE] to [DATE], showed that Resident 3 had four unwitnessed falls: On [DATE] at 1:58 pm, Resident 3 was found on the floor outside the DCU dining room with a fractured left hip, skin tear to his left elbow and redness to his scalp. Resident 3 stated that he felt dizzy and had fallen over and did not know how he hit his head and injured his elbow. Resident 3 spent five days at the hospital having surgery on his hip. On [DATE] at 8 pm, (one day after he returned from having his hip surgery), he was found on his bathroom floor after he had been given a suppository by the nurse (a laxative which usually takes about 20 minutes to work). There was no nursing documentation that his toileting needs had been addressed after he was given the laxative. There was no documentation regarding what potential circumstances had contributed to his fall or what interventions might prevent another fall and how continued falls would affect his newly repaired hip. On [DATE], at 4:35 am, he was found on the floor next to his bed in urine soaked underwear and confused. There was no documentation which addressed that perhaps he needed a scheduled toileting plan, as that was his second fall while attempting to get to the bathroom. On [DATE] at 9:48 am, five hours after the last fall, he was again found on the floor next to his bed with a red mark to the back of his head and was confused and not able to explain what happened. There was no documentation of what contributing factors may have caused him to fall twice in one morning. Resident 3's medical record contained no evidence that his unwitnessed falls were investigated to determine the root cause. There were no documented IDT post fall reviews, recommendations, evaluations or monitoring to determine the cause for Resident 3's repeated falls and prevent further occurrences. There were no effective fall prevention care plan interventions developed, and he continued to fall. b. Resident 7's record was reviewed. Resident 7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 7 required extensive assistance and one person to physically help her transfer and toilet. Nursing Progress notes reviewed from [DATE] to [DATE], showed that Resident 7 had four unwitnessed falls: On [DATE] at 4:51 am, Resident 7 was found on her bedroom floor with a left shoulder contusion (bruise) and was sent to the emergency room to be evaluated and although not fully oriented, stated she had gotten out of bed. There was no documentation regarding what safety measures were in place such as a low bed or a bed alarm. On [DATE] at 5:05 am, she was found on the floor next to her bed with a skin tear to her right index finger, an abrasion to her left ankle, had hit her head, and fractured her lower back and could not state her name and stated she was in a city on the coast. Resident 7 spent four days in the hospital having back surgery. On [DATE] at 7:10 pm, she was found on her bedroom floor and stated she was getting birds out of the kitchen window. There was no documentation that the underlying cause for her delusional state had been assessed or whether or not it had contributed to her fall. On [DATE] at 11:35 am, she was found on her bedroom floor, with a skin tear to her left arm and pain in her left wrist and was confused. Resident 7's medical record contained no evidence that her unwitnessed falls were investigated to determine the root causes. There was no documented IDT post fall reviews, recommendations, evaluations or monitoring. There were no effective fall prevention care plan interventions developed, and she continued to fall and sustain injuries. c. Resident 4's record was reviewed. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 4 required limited assistance and one person to physically help her transfer and extensive assistance with one person to toilet. On [DATE] at 4:05 pm, an observation and interview was conducted with Resident 4. Resident 4's room was in the same hallway as Resident 3's, outside of the DCU and behind closed locked doors and not visible to LNs. LN C was Resident 4's supervising nurse, but unable to see her room due to the closed double doors. A pole, to assist with transfers, was next to Resident 4's bed. No bed or wheelchair alarms were observed. Resident 4 stated that if the facility applied a bed or wheelchair alarm, I would get rid of it. On [DATE] at 2:50 pm, LN C was interviewed. LN C confirmed that she was not able to see Resident 4's room behind the closed doors. LN C stated that Resident 4, would not allow the staff help her transfer and toilet and she would not always use her call light. LN C stated that Resident 4 wanted to maintain her independence but was becoming increasingly weak due to a medical condition, and confirmed that by doing so, she has sustained numerous repeated falls and is at risk for injuries. Nursing Progress notes reviewed from [DATE] to [DATE], showed that Resident 4 had 13 unwitnessed falls and one witnessed fall: On [DATE] at 10:25 pm, Resident 4 was found on her bedroom floor; On [DATE] at 9:45 pm, she was found on her bedroom floor; On [DATE] at 7:15 am, she was found on her bathroom floor; On [DATE] at 7:15 pm, she was found on her bedroom floor; On [DATE] at 9:25 pm, she was found on her bedroom floor; On [DATE] at 9:30 pm, she was found on her bedroom floor with a urine soaked brief (adult incontinent wear); On [DATE] at 10:24 pm, she was found on her bedroom floor with her pants and brief around her ankles; On [DATE] at 9:30 pm, she was found on her bedroom floor and her wheelchair brakes were not locked; On [DATE] at 9:40 pm, she was found on her bedroom floor; On [DATE] at 10:30 pm, she was found on her bedroom floor; On [DATE] at 12:10 pm, she was found on her bathroom floor; On [DATE] at 10:40 pm, she was found on her bathroom floor and her wheelchair was unlocked; On [DATE] at 10:30 am, she was found on a bathroom floor on the SCU, covered in feces; and On [DATE] at 9:15 am, she fell out of her chair in the shower hitting her right shoulder. A CNA was assisting her but was unable to prevent the fall. On [DATE], the facility completed a Physician Statement of Risk vs Benefits document which described Resident 4 as, Resident at risk for serious injury secondary to self transfers without assist, refusal of nursing assessment after falls, and not following recommendations made by MD and facility after falls. The Risk vs Benefit document was signed by Resident 4, her family member, a nurse and the physician. On [DATE] at 11:30 am, the DON stated in an interview that Resident 4, has the right to fall. The DON stated the facility had Resident 4 sign the Risk vs Benefit statement because they could not prevent her from continuing to fall. Resident 4's medical record contained no evidence that her numerous unwitnessed falls were investigated to determine the root causes and diligently attempt to prevent recurrences. There was no documented IDT post fall reviews, evaluations, recommendations or on-going monitoring. There was no evidence that outside resources had been sought to assist the facility in ensuring Resident 4's safety. There were no effective fall prevention care plan interventions developed, and she continued to fall. d. Resident 5's record was reviewed. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], showed that Resident 5 required supervision and one person to physically assist him with transfers and toileting. Nursing Progress notes reviewed from [DATE] to [DATE], showed that Resident 5 had three unwitnessed falls and one witnessed fall: On [DATE] at 3:47 pm, Resident 5 was found on his bedroom floor with his walker tipped over and skin tears to his right arm, elbow, and eyebrow. The nurse documented that the resident knew how he fell but the reason was not given; On [DATE] at 9:23 pm, a LN observed him squatting next to his walker and lost his balance falling to the floor and sustained an abrasion to his right knee. There was no documentation of the events that led up to him squatting.; On [DATE] at 3:40 pm, he was found sitting on the floor next to his bed with skin tears to his right arm and hand, and an abrasion to his back. Resident 5 stated he was attempting to sit on his bed. There was no documentation of what safety measures were in place or needed to be in place to prevent Resident 5 from continuing to fall; and On [DATE] at 6:15 am, Resident 5 told staff that he had lost his balance and fell on his right side sometime during the night and was noted to have a dried skin tear to his right forearm. Resident 5's medical record contained no evidence that his unwitnessed falls were investigated to determine the root cause. There was no documented IDT post fall reviews, evaluations, recommendations or monitoring. There were no effective fall prevention care plan interventions developed, and he continued to fall. e. Resident 6's record was reviewed. Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 6 required two people to physically transfer her. On [DATE] at 10:45 am, an observation was conducted of Resident 6's room. Her room was the last room in the hallway, the farthest from the nurses station. Nursing Progress notes reviewed from [DATE] to February 2015, showed Resident 6 had five unwitnessed falls and one witnessed fall: On [DATE] at 1:23 am, Resident 6 was found on her bedroom floor after having rolled out of bed (assumed) and no explanation was offered; On [DATE] at 5:26 am, she was found on her bedroom floor next to her bed and stated she was trying to get warm. There was no documentation of what safety measures were in place or should be in place to prevent Resident 6 from falling out of her bed again; On [DATE] at 3:53 am, she was found on her bedroom floor next to her bed and stated that she was getting ready for school; On [DATE] at 11:09 pm, she was found on her bedroom floor with an abrasion to her left elbow and stated that she was trying to go to bed; On [DATE] at 11:05 am, a LN entering Resident 6's room saw her fall out of her wheelchair and land on her hands and knees, but was unable to reach her to prevent the fall; and On [DATE] at 4:06 am, she was found on the floor in her bedroom next to her bed and no explanation was offered. This was Resident 6's fifth fall out of her bed, four of which were during the night shift and there was no documentation on what interventions the facility had tried, what safety measures were in place, or that it had been recognized that there was a pattern to Resident 6's falls. Resident 6's medical record contained no evidence that her repeated unwitnessed falls were investigated to determine the root cause. There was no documented IDT post fall reviews, evaluations, recommendations or monitoring. There were no effective fall prevention care plan interventions developed, and she continued to fall. f. Resident 9's record was reviewed. Resident 9 was admitted on [DATE] with [DIAGNOSES REDACTED]. In an interview with the ADON on [DATE] at 3:45 pm, she stated, (Resident 9) spends most of the time in her wheelchair, including sleeping in it at night with her head resting on the bed. The MDS, dated [DATE], identified that Resident 9 had three falls with no injuries. She was considered a moderate falls risk per the Fall Risk Assessment, dated [DATE]. During an interview with Resident 9 on [DATE] at 4:30 pm, she stated that she really was not aware that she had fallen. I'll have to have staff refresh me. I can't remember. When asked why she likes to sleep in her wheelchair at night, the resident replied, I like to sleep in my wheelchair with my head on the pillow on the edge of the bed. The bed is terribly uncomfortable and hurts my back. I think I have a special bed but it's not comfortable. Nursing Progress notes reviewed from [DATE] to [DATE], showed Resident 9 sustained eight falls on the night shift as a result of her sliding out of her wheelchair: On [DATE], she was found on floor on the right side of her bed with small abrasion to her right elbow and knee. She said she fell out of bed; On [DATE], she was found on the floor next to her bed and stated she had slid out of her wheelchair; On [DATE], she was found sitting on the floor next to her bed and stated that her wheelchair had rolled out from under her; On [DATE], she was found on floor on left side of bed and stated she slid out of her wheelchair; On [DATE], she slid out of her wheelchair and was found on her bedroom floor; On [DATE], she slid out of her wheelchair and was found on her bedroom floor; On [DATE], she slid out of her wheelchair and was found on her bedroom floor; and On [DATE], she slid out of her wheelchair and was found on her bedroom floor. The Weekly Nursing Summary of [DATE] read, resident refuses to lay down in bed and opts to sit and sleep in her w/c. On [DATE] at 3:45 pm, an interview was conducted with the Assistant Director of Nurses (ADON). The ADON stated that the resident really likes to sleep in her wheelchair with her head on the bed and she will slip down as her wheelchair is not locked and she will slide out of the chair onto the floor. The record was reviewed with the ADON and she confirmed that there was no adaptive equipment used to try to prevent the Resident 9 from sliding out of her wheelchair. The ADON stated that the Occupational Therapist (OT) evaluated Resident 9 after the fourth fall, but did not reevaluate her when she fell four more times. A review of the OT's note, dated [DATE], revealed without therapy the patient is at risk for continued falls and injury risk, as well as risk of serious complications if injured in a fall due to diabetes mellitus complications. On [DATE], after ten days of OT treatment, the OT documented adjustments were made to Resident 9's wheelchair and bed and Resident 9 had met her goals. Resident 9 continued to fall another four times, and OT had not intervened. During an interview on [DATE] at 8:30 am, the Medical Director (MD) stated Resident 9 was his patient and he was not aware that she had fallen eight times, or that her falls were at night and directly related to her sleeping in her wheelchair. The MD stated he did not know what interventions had been care planned or what alternatives had been tried in an effort to mitigate the fall risk for Resident 9. g. Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 was identified on her admission care plan as being high risk for falls due to her being unaware of her safety needs, confusion, deconditioning (undescribed) and balance problems. Resident 8 took Coumadin, a medication that thins the blood, making her at risk for excessive bleeding with falls and/or injuries. Resident 8 required moderate to maximum assistance by one staff person for all transfers and mobility. Nursing Progress notes were reviewed from [DATE] to [DATE], and showed during Resident 8's seven week stay at the facility, she sustained four falls, without injury: On [DATE] at 7:15 pm, five days after admission, she was found on the floor in her doorway; On [DATE], she was found on the floor in her room and sent to the hospital to have her low blood pressure evaluated; On [DATE], she fell while walking during physical therapy; and On [DATE], there was no nurses notes to describe this incident. There were no nurses notes documenting the specifics of the fall of [DATE]. Four of four falls, had no indications as to whether or not the resident had a bed or chair alarm or the reason she was moving about without one staff member to help her. There were no care plan updates after each fall that identified causal factors or resident-specific interventions to prevent further avoidable falls. On [DATE] at 4 pm, during an interview and concurrent record review, the ADON verified there were no neuro assessments (conducted by licensed nurses to check for signs and symptoms of internal head injury/bleeding which could quickly lead to death) completed or specific care plan interventions as their fall prevention policy directed. The facility's Fall Prevention Program policy, revised [DATE], was reviewed and summarized the Purpose of the policy was to identify resident's who are at risk for falling. The Policy was, each resident will be evaluated upon admission, quarterly and as needed by a Licensed Nurse to assess his/her individual level of risk. A care plan approach will be developed by the interdisciplinary team. All resident's environment will remain as free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents. The Procedure section directed the following: 3. The results of the Fall Risk Assessment will be scored to identify the resident's risk category. The Fall Risk Assessment will be utilized to identify preventive measures specific to the resident. Nursing personnel will begin implementation of the interventions within 24 hours. 5. The Director of Nursing/designee will be responsible for tracking resident falls. This tracking will be completed and maintained in the facility's Incident Log. 6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place. 7. If the Director of Nursing/designee identifies a trend in falls she/he will be responsible for implementing a weekly Fall Committee Meeting consisting of the Interdisciplinary Team members. If the trend indicates multiple falls by one or more residents, t

Based on interview and record review, the facility failed to develop, review and revise resident care plans to prevent avoidable falls with injuries for 8 of 9 sampled residents (Residents 2, 3, 4, 5, 6, 7, 8 and 9) when: 1. Resident 2's At Risk for Falls care plan was not revised with new interventions which were effective in the prevention of repeated falls when she fell twice, one of which resulted in a broken left hip and contributed to her death. 2. a. Resident 3's At Risk for Falls care plan was not developed to show the reasons for his repeated falls or revised with new interventions to prevent recurrences and he fell 4 times, one of which resulted in a broken left hip. b. Resident 7's At Risk for Falls care plan was not developed to show the reasons for her repeated falls or revised with new interventions to prevent recurrences and she fell 4 times, one of which resulted in a fractured back. c. Resident 4's At Risk for Falls care plan was not revised with new interventions which were effective in the prevention of repeated falls and she fell 14 times, one of which resulted in reddened areas to her forehead and right knee. d. Resident 5's At Risk for Falls care plan was not developed to show the reasons for his repeated falls or revised with new interventions to prevent recurrences and he fell 4 times, three of which resulted in skin tears and abrasions (scrapes) to his eyebrow, arm, elbow and knee. e. Resident 6's At Risk for Falls care plan was not developed to show the reasons for her repeated falls or revised with new interventions to prevent recurrences and she fell 6 times, one resulted in a skin tear to her left elbow. f. Resident 8's At Risk for Falls care plan was not developed to show the reasons for her repeated falls or revised with new interventions to prevent recurrences and she fell 4 times, one resulted in abrasions. 3. Resident 9's At Risk for Falls care plan was not developed to show the reasons for her repeated falls or revised with new interventions to prevent recurrences and she fell 8 times, two of which resulted in abrasions to her right elbow, knee, and shoulder blade. These failures resulted in inadequate interventions for the prevention of repeated falls and injuries for Residents 2, 3, 4, 5, 6, 7, 8, and 9, and had the potential to negatively affect the safety of all residents. Refer to F323 for additional information. Findings: 1. Resident 2's record was reviewed. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set, a standardized resident assessment), dated 12/24/14, identified that Resident 2 had impaired memory and decision making skills, balance problems, and required extensive assistance with one person to physically assist her with walking. In an interview and concurrent care plan review with Licensed Nurse (LN) B on 3/17/14 at 12 pm, she stated that Resident 2 used a bed alarm at night but not during the day. LN B confirmed Resident 2's fall prevention care plan had not contained information regarding the use of the bed alarm or when it was to be on. A review of Resident 2's fall prevention care plan showed that no individualized interventions had been developed which identified what Resident 2 needed to prevent her from falling. The care plan intervention read, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, although, Resident 2 had severe memory problems and did not know how to use her call light. 2. a. Resident 3's record was reviewed. Resident 3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 3 required limited assistance and one person to physically help him transfer and extensive assistance with one person to toilet. A review of Resident 3's Progress notes (nursing and interdisciplinary team (IDT-usually consists of the Director of Nurses (DON), Therapy personnel, Social Service, Activity and Dietary personnel, a Licensed Nurse (LN), and the Consulting Pharmacist and Dietitian, when necessary) notes) from August 2014 to March 2015, showed: On 9/11/14, Resident 3 fell coming out of the dining room and broke his left hip; On 9/22/14, he was found on his bathroom floor (one day after returning from having hip surgery); On 9/24/14 at 4:35 am, he was found on the floor next to his bed; and On 9/24/14 at 9:48 am, he was again found on the floor next to his bed. Resident 3's care plans were reviewed. Resident 3's fall prevention care plan, initiated 6/11/14, identified that he was at risk for falls due to poor safety awareness, dementia, and weakness. The fall care plan was not revised after each fall to show the reason he fell and what new interventions were tried to effectively prevent further unwitnessed falls and reduce his risk for injuries. b. Resident 7's record was reviewed. Resident 7 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 7 required extensive assistance and one person to physically help her transfer and toilet. Resident 7's Progress notes were reviewed from August 2014 to March 2015, and showed: On 10/31/14, Resident 7 was found on her bedroom floor with a left shoulder contusion (bruise); On 11/1/14, she was found on the floor next to her bed with a skin tear to her right index finger, an abrasion to her left ankle, had hit her head, and fractured her lower back; On 11/7/14, she was found on her bedroom floor; and On 11/25/14, she was found on her bedroom floor with a skin tear to her left arm, pain in her left wrist, and had hit her head. Resident 7's care plans were reviewed. Resident 7's fall risk care plan, initiated 11/14/14, identified that she was at risk for falls due to poor safety awareness, stroke, poor vision, and balance problems. The fall prevention care plan was not revised after each fall to show the reason she fell and what new interventions were tried to effectively prevent further unwitnessed falls and reduce her risk for injuries. c. Resident 4's record was reviewed. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 4 required limited assistance and one person to physically help her transfer and extensive assistance with one person to toilet. Resident 4's Progress notes were reviewed from August 2014 to March 2015, and showed that she had 13 unwitnessed falls from unassisted transfers and one witnessed fall in the shower. One fall resulted in reddened areas to her forehead and right knee. Resident 4's care plans, initiated 11/19/12 and revised 3/11/15, were reviewed. Resident 4's fall prevention care plan problems included that she refused to ask for help or use her call light to transfer and toilet. The care plan interventions repeatedly directed, encourage call light use, educate about falls, and wear non-skid shoes, even though it had already been determined that Resident 4 did not use her call light or ask for help. Resident 4's fall prevention care plan had not specified how the facility was going to keep her safe, prevent further falls, and reduce her risk for injury. d. Resident 5's record was reviewed. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], showed that Resident 5 required supervision and one person to physically help him transfer and toilet. Resident 5's Progress notes were reviewed from August 2014 to March 2015, and showed: On 9/22/14, Resident 5 was found on the floor in his room with a skin tear to his right arm, elbow, and eyebrow; On 10/4/14, a nurse observed him squat and loose his balance and fall to the floor and he sustained abrasion to his right knee; On 11/4/14, he was found on the floor next to his bed with a skin tear on his right hand and arm and an abrasion to his back; and On 12/16/14, he notified the staff that he had fallen in his room and had a skin tear to his right forearm. Resident 5's care plans were reviewed. Resident 5's fall prevention care plan, initiated 12/19/13, identified that he was at risk for falls due to dementia, high blood pressure, balance problems, and impaired safety awareness. The fall prevention care plan was not revised after each fall to show the reason he fell and what new interventions were tried to effectively prevent further unwitnessed falls and reduce his risk for injuries. e. Resident 6's record was reviewed. Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 6 required extensive assistance and two people to physically assist her with bed mobility, transfers, and toileting. Resident 6's Progress notes were reviewed from August 2014 to March 2015, and showed: On 10/23/14, Resident 6 was found on her bedroom floor after having rolled out of bed; On 12/4/14, she was found on her bedroom floor next to her bed; On 1/7/15, she was found on her bedroom floor next to her bed; On 1/21/15, she was found on her bedroom floor with an abrasion to her left elbow; On 2/5/15, a nurse observed her fall out of her wheelchair onto her hands and knees; and On 2/15/15, she was found on the floor in her bedroom next to her bed. Resident 6's care plans were reviewed. Resident 6's fall risk care plan, initiated 4/20/13, identified that she was at high risk for falls due to being unaware of her safety needs, confusion, a stroke, and balance problems. The fall care plan was not revised with information which determined why Resident 6 repeatedly fell out of her bed. There were no new individualized interventions developed after each fall which identified what Resident 6 needed to effectively prevent further unwitnessed falls and reduce her risk for injuries. f. Resident 8's record was reviewed. Resident 8 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Weekly Nursing Assessment notes she required one person to physically assist her to walk. A review of Resident 8's Progress notes from August 2014 to March 2015, showed: On 10/28/14, she was found on the floor in her doorway; On 11/9/14, she was found on the floor in her room; On 12/20/14, she fell while walking during physical therapy; and On 12/23/14, there was no nurses note to describe this incident. Resident 8's care plans were reviewed. Resident 8's fall prevention care plan, dated 10/23/14, identified that she was at high risk for falls due to being unaware of her safety needs, confusion, deconditioning (unspecified), and balance problems. The fall prevention care plan was not revised after each fall to show the reason she fell repeatedly and what new interventions were tried to effectively prevent further unwitnessed falls and reduce her risk for injuries. On 3/16/15 at 10:30 am, an interview and concurrent care plan review was conducted with the Director of Nurses (DON). The DON confirmed that the fall prevention care plans for Residents 3, 4, 5, 6, 7, and 8, were not developed to identify their specific reasons for repeated falls and were not revised with new, effective individualized interventions after their falls in order to prevent further unwitnessed falls and injuries. 3. Resident 9's record was reviewed. Resident 9 was admitted on [DATE] with a [DIAGNOSES REDACTED]. In an interview with Resident 9 on 3/11/15 at 4:30 pm, she stated that she likes to sleep in her wheelchair with her head on the pillow on the edge of the bed because the bed is terribly uncomfortable and hurts my back. I have a special bed but it's not comfortable. Resident 9's Progress notes were reviewed from September 2014 to February 2015, and showed that she fell eight times on the night shift. Seven of the 8 falls were due to sliding out her wheelchair: On 9/5/14, she was found on the floor on the right side of her bed with small abrasion to her right elbow and knee. She said she fell out of bed; On 9/10/14, she was found on the floor next to her bed and stated she had slid out of her wheelchair; On 9/17/14, she was found sitting on the floor next to her bed and stated that her wheelchair had rolled out from under her; On 9/19/14, she was found on floor on the left side of her bed and stated she slid out of her wheelchair; On 11/9/14, she slid out of her wheelchair and was found on her bedroom floor; On 12/1/14, she slid out of her wheelchair and was found on her bedroom floor; On 1/18/15, she slid out of her wheelchair and was found on her bedroom floor; and On 2/23/15, she slid out of her wheelchair and was found on her bedroom floor. The Weekly Nursing Summary of 9/21/14 read, resident refuses to lay down in bed and opts to sit and sleep in her w/c. Resident 9's care plans were reviewed. Resident 9's fall prevention care plan, initiated 5/15/13, identified that she was at high risk for falls due to deconditioning (the facility was unable to specifically describe what that term meant), vision, balance problems, and had an artificial leg. The fall care plan was not revised after each fall to show what new interventions had been tried to either make Resident 9's bed comfortable for her, or keep her safe when she slept in her wheelchair. After four falls, on 9/19/14, the Occupational Therapist adjusted Resident 9's wheelchair, but the bed mattress was not discussed and Resident 9 continued to fall out of her wheelchair. In an interview with the ADON (Assistant Director of Nurses) on 3/11/15 at 3:45 pm, she stated that Resident 9 likes to sleep in her wheelchair with her head on the bed. She will slip down as the wheelchair is not locked and then she will slide out of the wheelchair onto the floor. The ADON confirmed that Resident 9's fall prevention care plan had not specified that she fell out of her wheelchair while sleeping, and was not revised with new individualized interventions in order to prevent further avoidable falls. The facility's policy and procedure (P&P) titled, Care Plans, revised 7/1/14, was reviewed. The care plan P&P directed that resident care plans will be updated when the resident experiences acute and/or temporary changes in their medical, psychological, and functional condition. The interdisciplinary team (IDT) will develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, as often as the residents condition warrants.