Every finding on record at Canyon Creek Post-Acute

Based on observation, interview and record review, facility failed to report a fall incident for one of three sampled residents (Resident 1) to the State Agency when Resident 1 was being transferred from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility from one surface to the other). One of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. Resident 1 hit his left leg onto the bottom bar (base) of the Hoyer lift, sustained a laceration (deep cut in the skin) on left shin, requiring transfer to the emergency room of an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin).This failure resulted in facility being non-compliant with unusual occurrence reporting to the State Agency. (Cross Reference F689)During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 9/10/25, the assessment indicated Resident 1's Brief Interview for Mental Status (BIMS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) score was 15 out of 15, indicating normal thinking and memory. During an interview on 1/12/26 at 10:26 a.m. with Resident 1, Resident 1 stated a few months ago he fell out of the Hoyer lift while facility staff were transferring him from the wheelchair to the bed. Resident 1 stated the strap of the Hoyer lift sling broke, causing him to fall onto the floor. He got a deep cut on his leg and was sent to the hospital for treatment. During a concurrent interview and record review on 1/12/26 at 12:27 p.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Progress Notes, dated 10/30/25, were reviewed. LVN 1 stated upon inquiry, Resident 1 stated he had been dropped. LVN 1 inspected the sling and confirmed that it was broken. Resident 1 complained of 10 out of 10 pain (severe pain) and she gave Norco (pain medication) to Resident 1, and he was sent out to the acute hospital for further evaluation. During an interview on 1/12/26 at 11:10 a.m. with the Director of Nursing (DON), DON stated she was aware of Resident 1's fall related to broken loop of the Hoyer lift sling on 10/30/25. DON stated however, the incident was not reported to the State Agency (California Department of Public Health). DON stated it did not occur to her that it was an unusual occurrence requiring reporting to State Agency because they knew what caused Resident 1 to fall out of the Hoyer lift.During an interview on 1/12/26 at 1:15 p.m. with the Administrator (Adm), Adm stated it was unusual for a resident to fall or have injuries related to Hoyer lift use and unusual occurrences are reportable. Adm stated he didn't report Resident 1's fall that happened on 10/30/25 because the facility was focused on the cause of the fall and managing Resident 1's injuries. During a review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, As required by federal or state regulations, facility reports unusual occurrences which affect the health, safety and welfare of the residents.Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on observation, interview and record review, the facility failed to safely transfer one of three sampled residents (Resident 1) from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility), when one of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. This failure resulted in Resident 1 hitting his left leg onto the bottom bar (base) of Hoyer lift, sustaining a laceration (deep cut in the skin) on left shin, requiring transfer to an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin) and Resident 1 feeling lack of confidence in facility's capabilities. During a review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of bilateral Osteoarthritis of knee (natural wear and tear of the knee causing pain) and obesity (indicates a very high amount of excess body fat). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 9/10/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating normal thinking and memory. During a review of Resident 1's Care Plan for left foot ulcer (slow healing open sore), dated 9/4/25, the Care Plan indicated Resident 1 required a mechanical lift for transfers to prevent further injury. The Care Plan for falls, dated 9/5/25, indicated Resident 1 was at risk for falls due to impaired balance and decreased coordination and he required assistance with activities of daily living.During an interview on 1/12/26 at 10:26 a.m, Resident 1 stated, a few months ago he was being transferred from wheelchair to bed, when the strap of the Hoyer Lift sling broke, causing him to fall on the floor. Resident 1 stated he had a cut on his leg and went to the hospital where staples were placed. Resident 1 stated I rather forget, it did not build any confidence in them [facility staff] talking about how he felt after the incident.During an interview on 1/12/26 at 12:06 p.m., Certified Nursing Assistant (CNA 1) stated on 10/30/25, while using the Hoyer lift to transfer Resident 1 from his wheelchair to bed, the strap of the sling broke causing Resident 1 to fall straight to the floor, hitting the base (bottom bar) of the Hoyer lift. CNA 1 stated Resident 1 was bleeding. CNA 1 stated the sling used during the time of the fall seemed to be too small compared to Resident 1's body size. CNA 1 stated they used the sling that was available for use at that time.During a concurrent interview and record review on 1/12/26 at 12:27 p.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 1's progress notes, dated 10/30/25, were reviewed. LVN 1 stated that she heard a loud noise followed by a scream in Resident 1's room, upon arrival she found Resident 1 on his buttocks, sitting on the floor, in between the base of the Hoyer lift, with visible blood on the floor. LVN 1 noted a laceration (deep cut) on Resident 1's left shin, LVN 1 applied pressure and ice packs to control bleeding. Resident 1 complained of 10 out of 10 pain (severe pain) that required Norco (strong pain medication). LVN 1 indicated upon inquiry, Resident 1 stated he had been dropped. LVN 1 stated she inspected the sling and confirmed that it was broken. Resident 1 was sent out to the acute hospital for further evaluation.During a review of Resident 1's After Visit Summary from acute care hospital dated 10/30/2025, the summary indicated Resident 1 received staples to close the laceration on his left shin. During an interview on 1/12/26 at 1:08 p.m. with the Director of Nursing (DON), DON stated Resident 1's fall could have been avoidable if facility staff checked the slings, for example, for loose threads prior to the fall.During a review of Hoyer lift manual, dated 5/2011, the manual indicated Maintenance Safety Inspection Checklist; Slings and hardware - Check all sling attachment each time it is used to ensure proper connection and patient safety. Inspect sling material for wear.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete annual Minimum Data Set (MDS) assessments within 14 calendar days following the Assessment Reference Date (ARD), which affected 3 (Residents #14, #27, and #29) of 3 residents reviewed for annual MDS requirements. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal timeframes. The policy revealed, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Center for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 dated October 2024, revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA [Significant Change in Status Assessment] or an SCPA [Significant Correction to Prior Comprehensive assessment] has been completed since the most recent comprehensive assessment was completed. Its completion dates (MDS/CAA(s) [Care Area Assessment]/care plan) depend on the most recent comprehensive and past assessments' ARDs and completion dates. The manual revealed, Assessment Management Requirements and Tips for Annual Assessments included The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). 1. An Admission Record indicated the facility admitted Resident #14 on 08/18/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified dementia with behavioral disturbance. Resident #14's annual MDS, with an ARD of 08/19/2024, revealed the assessment was signed as completed (item Z0500B) on 10/25/2024. The completion date of the assessment was due by 09/02/2024. 2. An Admission Record indicated the facility admitted Resident #27 on 08/22/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of cerebral palsy. Resident #27's annual MDS, with an ARD of 08/07/2024, revealed the assessment was signed completed (item Z0500B) on 09/27/2024. The completion date of the assessment was due by 08/21/2024. 3. An Admission Record indicated the facility admitted Resident #29 on 08/22/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of benign neoplasm of the cerebral meninges (non-cancerous tumor that grows from the membranes that surround the brain and spinal cord). Resident #29's annual MDS, with an ARD of 08/15/2024, revealed the assessment was signed as completed (item Z0500B) on 09/17/2024. The completion date of the assessment was due by 08/29/2024. During an interview on 10/29/2024 at 1:18 PM, the MDS Coordinator stated that the facility had been unable to hire a consistent full-time person to assist her in completing the assessments since she started working at the facility in May 2024. The MDS Coordinator stated that the facility was without a social worker in July, which caused sections of the assessments to fall behind in completion. She stated that an influx of admissions and discharges had occurred since that time, which resulted in her inability to get assessments completed timely. During an interview on 10/31/2024 at 9:41 AM, the Director of Nursing (DON) stated that she was aware the facility had assessments completed greater than the fourteenth day following the ARD. She stated that quality assurance performance improvement (QAPI) met monthly and there were frequent conversations related to late assessments. She stated that medical records staff completed daily MDS audits. The DON stated that although multiple members of the interdisciplinary team completed sections of the MDS assessment, the MDS Coordinator was responsible for the final completion. She stated that she expected that all assessments be open, completed, and transmitted timely. During an interview on 11/01/2024 at 9:28 AM, the Administrator stated that he expected the regulation to be followed and for all assessments to be completed and transmitted timely.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within 14 calendar days following the Assessment Reference day (ARD), which affected 3 (Residents #13, #16, and #22) of 3 residents reviewed for quarterly MDS requirements. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal timeframes. The policy revealed, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Center for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 dated October 2024, revealed, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The manual revealed, Assessment Management Requirements and Tips included The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). 1 An Admission Record indicated the facility admitted Resident #13 on 11/14/2012. According to the Admission Record, the resident had a medical history that included a diagnosis of paraplegia. Resident #13's quarterly MDS, with an ARD of 09/03/2024, revealed the assessment was signed as completed (item Z0500B) on 10/10/2024. The assessment was due to be completed by 09/17/2024. 2. An Admission Record indicated the facility admitted Resident #16 on 02/12/2014. According to the Admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. Resident #16's quarterly MDS, with an ARD of 08/13/2024, revealed the assessment was signed as completed (item Z0500B) on 10/25/2024. The assessment was due to be completed by 08/27/2024. 3. An Admission Record indicated the facility admitted Resident #22 on 06/13/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of metabolic encephalopathy. Resident #22's quarterly MDS, with an ARD of 09/12/2024, revealed the assessment was signed as completed (item Z0500B) on 10/25/2024. The assessment was due to be completed by 09/26/2024. During an interview on 10/29/2024 at 1:18 PM, the MDS Coordinator stated that the facility had been unable to hire a consistent full-time person to assist her in completing the assessments since she started working at the facility in May 2024. The MDS Coordinator stated that the facility was without a social worker in July, which caused sections of the assessments to fall behind in completion. She stated that an influx of admissions and discharges had occurred since that time, which resulted in her inability to get assessments completed timely. During an interview on 10/31/2024 at 9:41 AM, the Director of Nursing (DON) stated that she was aware the facility had assessments completed greater than the fourteenth day following the ARD. She stated that quality assurance performance improvement (QAPI) met monthly and there were frequent conversations related to late assessments. She stated that medical records staff completed daily MDS audits. The DON stated that although multiple members of the interdisciplinary team completed sections of the MDS assessment, the MDS Coordinator was responsible for the final completion. She stated that she expected that all assessments be open, completed, and transmitted timely. During an interview on 11/01/2024 at 9:28 AM, the Administrator stated that he expected the regulation to be followed and for all assessments to be completed and transmitted timely.

Based on record review, interview, and a review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #26) of 1 resident reviewed for hospice services. Findings included: On 10/31/2024 at 1:19 PM, the MDS Coordinator stated the facility followed the MDS 3.0 Resident Assessment Instrument manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated October 2024 revealed, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. An Admission Record indicated the facility admitted Resident #26 on 04/27/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cirrhosis of the liver, chronic viral hepatitis C, hepatic encephalopathy (a brain dysfunction caused by a liver dysfunction), protein-calorie malnutrition, and palliative care (onset 09/06/2024). Resident #26's Order Recap Report for orders from 07/01/2024 through 10/30/2024 revealed a physician's order dated 09/07/2024 to admit the resident to hospice services. A SCSA MDS, with an ARD of 09/10/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was receiving hospice services. The MDS revealed the Registered Nurse (RN) Assessment Coordinator had not signed and dated Resident #26's MDS, verifying assessment completion. Resident #26's care plan revealed no documented evidence the facility had developed a care plan with a focus area and interventions for hospice services. Resident #26's Progress Notes revealed a Nurse Practitioner Note dated 10/09/2024 that indicated Resident #26 was receiving hospice care. During an interview on 10/31/2024 at 10:24 AM, the Social Service Supervisor (SSS) stated she had worked at the facility since 08/01/2024 and had just learned how to identify when an MDS was open. The SSS stated a SCSA MDS should be completed if a resident was admitted to hospice services. She stated she was unsure why the facility MDS assessments were so far behind. During an interview on 10/31/2024 at 1:19 PM, the MDS Coordinator stated a SCSA MDS should be completed when a resident went on or came off hospice services. She stated some of the RNs and the Director of Nursing (DON) signed an MDS when it was completed. She stated Resident #26's SCSA MDS was opened on 09/10/2024; however, the MDS was incomplete because an MDS nurse had not finished a section of the MDS. During an interview on 11/01/2024 at 9:26 AM, the DON stated a SCSA MDS should be completed if a resident was admitted to hospice services. The DON stated she was attempting to get additional staff assistance for the MDS Coordinator. During an interview on 11/01/2024 at 9:50 AM, the Administrator stated MDS assessments should be completed. He stated that there had been some transitions in the MDS department that had resulted in a back log of assessments.

Based on observation, record review, interview, and facility policy review, the facility failed to transcribe and carry out treatment orders for 1 (Resident #42) of 21 sampled residents. Findings included: A facility policy titled, Medication and Treatment Orders, revised 07/2016, revealed no information on transcribing and carrying out written physician orders. An Admission Record indicated the facility admitted Resident #42 on 05/14/2024. According to the Admission Record, the resident had a medical history that included diagnoses of encephalopathy (disorder of the brain) and non-traumatic intracerebral hemorrhage (brain bleed). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident required substantial to maximal assistance with lower body dressing and putting on/taking off footwear. Resident #42's care plan, included a focus area revised 06/02/2024, that indicated the resident was at risk for pressure ulcer development and skin breakdown. Interventions directed staff to administer treatment as ordered and monitor for effectiveness and assess for any skin breakdown during activities of daily living (ADLs) and report to the physician/nurse any significant findings. During an observation on 10/31/2024 at 8:54 AM, Resident #42's paper chart had a Physician's Orders form flagged (sticking out the top) in the paper chart. The Physician's Order form revealed handwritten podiatry orders dated 10/01/2024 to examine and apply triple antibiotic to the left big toe and cover with a bandage twice daily for 10 days and to call for any questions or problems. Resident #42's New/Follow-up Visit Podiatry Visit note dated 10/01/2024 indicated the resident had a lytic (lifting from the nail bed) toenail on the left big toe that was removed, and treatment was for a triple antibiotic ointment and dry sterile dressing twice a day. Resident #42's Order Recap [Recapitulation] Report, for the timeframe from 07/01/2024 through 10/30/2024, revealed no evidence that the podiatry treatment orders dated 10/01/2024 were transcribed and entered into the resident's electronic health record. During an interview on 10/30/2024 at 2:03 PM, Licensed Vocational Nurse (LVN) #4 stated she did not know why the podiatrist's orders were not transcribed to the electronic health record and implemented. During a follow-up interview on 10/30/2024 at 2:18 PM, LVN #4 stated that when the doctors wrote orders, they would flag the order in the chart and leave the chart on the nurse's desk so that it could be noted and transcribed. She stated she would then put the order in the medical records basket to be scanned; the medical records were supposed to be put back into the paper chart. During an interview on 10/31/2024 at 9:59 AM, Registered Nurse (RN) #2 stated that when physicians visited, they would hand any new orders to the nurse. She stated she had not been at the facility when the podiatrist was there. She stated the podiatrist had contact with social services, and the podiatrist assistant would give the orders to the nurse. She stated she was not aware of the order for Resident #42 from the podiatrist, but she stated she was going to follow up with the podiatrist to ensure they were giving the orders to the nurse and not just leaving them in the chart. She stated they did not have a system in place to check paper charts. During an interview on 11/01/2024 at 9:26 AM, the Director of Nursing (DON) stated the nurses and supervisors were to check the paper charts for orders, get clarification if needed, and carry out the orders that day. She stated the paper charts should be checked every shift. The DON stated Resident #42's orders should have been implemented. During an interview on 11/01/2024 at 9:50 AM, the Administrator stated that when the physician came in, the process should be that the physician was communicating with the nurses that there was an order. He stated the nurse should double check to make sure there were no new orders.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for 1 (Resident #167) of 21 sampled residents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, specified, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy indicated, 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. An Admission Record indicated the facility admitted Resident #167 on 07/14/2023. According to the Admission Record, the resident had a medical history that included diagnoses of vascular dementia, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, alcohol dependence with alcohol induced persisting amnestic (memory loss) disorder, encephalopathy (disorder of the brain), and other specified disorder of the brain. A quarterly MDS, with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #167 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident did not exhibit the behavior of wandering during the assessment timeframe. The MDS indicated the resident required setup or clean-up assistance with toileting hygiene. The MDS revealed the resident did not receive antipsychotic medication since admission/entry or reentry, or the prior assessment. Resident #167's care plan, included a focus area revised 04/21/2024, that indicated the resident was receiving medications with a black box warning that included quetiapine fumarate (an atypical antipsychotic) and was at significant risk of serious or life-threatening adverse effects. Interventions directed staff to administer the resident's medications as ordered (initiated 07/16/2023). Resident #167's care plan, included a focus area revised 07/18/2024, that indicated the resident received psychotropic medications that included quetiapine. Interventions directed staff to administer the resident's medication as ordered (initiated 07/16/2023). Resident #167's Order Recap [Recapitulation] Report, for the timeframe from 07/01/2024 through 10/30/2024, revealed the resident had an order dated 12/29/2023 for quetiapine 25 milligrams (mg), with instructions to give a half a tablet by mouth at bedtime. The Order Recap Report revealed the order was discontinued on 08/22/2024. The Order Recap Report revealed no active order for quetiapine. The resident's care plan was not updated to exclude the use of the medication. During an interview on 10/31/2024 at 1:19 PM, the MDS Coordinator stated that if an antipsychotic medication was discontinued, the use of the medication should be taken off the care plan. During an interview on 11/01/2024 at 9:26 PM, the Director of Nursing (DON) stated if an antipsychotic medication was discontinued, the use of the medication should be removed from the care plan. She stated that any time something was resolved, it needed to be resolved on the care plan. Resident #167's care plan, included a focus area revised 07/18/2024, that indicated the resident was occasionally incontinent of bowel and bladder with a need for assistance with personal care. Interventions directed staff to adapt to the resident's toileting habit (initiated 07/16/2023); assess the resident's bowel and bladder status at least quarterly (initiated 07/16/2023); assess the resident's skin condition and perineal area daily and as needed (initiated 07/16/2023); check the resident for wetness at least every two hours (initiated 07/16/2023); consider a bowel and bladder retraining program if appropriate/indicated (initiated 07/16/2023); continuously monitor the resident for a decline in function (initiated 07/16/2023); keep the resident clean and dry, and provide clean and dry linens (initiated 07/16/2023); monitor and document intake and output as per facility policy (initiated 07/16/2023); monitor and document for signs and symptoms of a urinary tract infection (initiated 07/16/2023); and monitor, document, and report as needed any possible causes of incontinence (initiated 07/16/2023). During an interview and observation on 10/28/2024 at 10:32 AM, Resident #167 had a strong odor of urine. Resident #167 stated they had a catheter, but the facility took it out and now they had to sit in wet briefs all the time. Resident #167's Bowel & Bladder Retraining 14-Day Evaluation & Reevaluation, dated 07/14/2023, revealed the resident was continent or had an indwelling catheter, could walk to the bathroom or transfer to the toilet, and could manage their clothes, could clean their self, or use the urinal alone with reasonable speed. The assessment indicated that the resident was forgetful but could follow prompts and was always mentally aware of their toileting needs. During an interview on 10/30/2024 at 2:12 PM, CNA #3 stated that Resident #167 was continent most of the time but when they were incontinent, the staff had to remind the resident to change their brief. She stated sometimes it would get on the resident's linens and cause an odor in the room. She stated Resident #167 was capable of changing their own brief; they just needed reminding. During an interview on 11/01/2024 at 8:33 AM, CNA #5 stated that Resident #167 was incontinent sometimes, but would say that they would take care of it. She stated that she thought the resident's room had an odor because the resident put their wet briefs in the drawers. She stated they had to try and go into the room when the resident was not in there to take the soiled briefs out; otherwise, the resident thought they were stealing their stuff. She stated they would go to the laundry room to get clothes for the resident daily so that their clothes did not smell like urine. During an interview on 10/30/2024 at 2:03 PM, LVN #4 stated Resident #167 wanted a catheter and because they would not give it to them, the resident would urinate all over the place. She stated the resident agreed to be assisted with toileting at times, but other times refused. She stated the resident would take off their incontinence brief and put it in a drawer, causing all the other clothes in the drawer to have an odor. She stated that staff would have to take out all the clothes and wash them frequently; they usually kept the resident's clothes in the laundry room, so they did not get dirty. She stated that she did not know if that behavior had been documented or care planned. During an interview on 10/31/2024 at 9:59 AM, RN #2 stated that Resident #167's incontinence was related to their dementia. She stated they would offer to provide incontinence care or assist the resident to the toilet, and they would refuse, stating they were fine, and they did not need any help. She stated she did not think the resident was incontinent; it was a behavior and a small sanitation issue. She stated the resident would get very defensive when they tried to assist the resident with toileting. She stated the resident was capable of changing their own briefs. She the resident's incontinence was behavioral. During an interview on 10/31/2024 at 1:19 PM, the MDS Coordinator stated that the care plan was used to inform staff of how to care for a resident. She stated that target behaviors should be addressed on the care plan. She stated that refusal of care should be addressed on a care plan. Resident #167's care plan revealed it did not reflect the behavior of Resident #167 putting their soiled incontinence briefs in the drawers, refusing to be assisted with toileting, or the need for the resident's clothes to be kept in the laundry room. During an interview on 11/01/2024 at 9:26 AM, the DON stated the care plan should be updated by the nurses and then reviewed by the MDS staff to make changes as needed. She stated that target behaviors and the reason for the behaviors should be included on the care plan. During an interview on 11/01/2024 at 9:50 AM, the Administrator stated that behaviors should be included on the resident's care plan.

Based on interview, observation, facility document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 35 resident rooms. Findings included: A facility policy titled, Bedrooms, revised 05/2017, indicated, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The policy revealed, 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. A Client Accommodations Analysis document dated 10/28/2024 revealed room [ROOM NUMBER] had a total floor area that measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident. Further review revealed room [ROOM NUMBER] had a total floor area that measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident. During an observation on 10/30/2024 at 9:11 AM, the Maintenance Director measured room [ROOM NUMBER] and room [ROOM NUMBER] and confirmed the following dimensions: In room [ROOM NUMBER], the total floor area measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident; In room [ROOM NUMBER], the total floor area measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident. Residents' rooms had closets, nightstands, bedside tables, and some had wheelchairs in them, along with bathrooms. At no time were any of these items observed to be blocking doorways, closets, or bathroom doors. Residents were observed being able to move freely around their rooms, and rooms also had privacy curtains. Staff were observed during the measuring of the rooms going in and coming out of residents' rooms providing care to the residents. At no time was care of residents observed to be impeded by the size of the rooms. During an interview on 10/30/2024 at 9:50 AM, Resident #15 stated they liked their room and had plenty of space and storage for their belongings. Resident #15 stated staff had no problem providing care due to the size of the room. During an interview on 10/30/2024 at 9:53 AM, Resident #40 stated they had no concerns with the size of their room. Resident #40 stated they had room for their belongings and wheelchair. Resident #40 stated staff were able to provide proper care regardless of the size of the room. During an interview on 10/30/2024 at 11:10 AM, Certified Nursing Assistant (CNA) #1 stated she had worked at the facility since 08/28/2024. She stated the size of room [ROOM NUMBER] did not prevent her from providing proper care to the resident. During an interview on 10/30/2024 at 11:15 AM, Registered Nurse (RN) #2 stated she had worked at the facility for a year. She stated she had no problem with the size of room [ROOM NUMBER] and stated the size of the room did not prevent her from providing proper care. During an interview on 10/30/2024 at 11:24 AM, the Director of Nursing (DON) stated she was familiar with room size requirements. She stated that she expected rooms to meet minimum requirements. The DON stated room sizes were important for patient comfort and proper patient care. During an interview on 10/30/2024 at 11:28 AM, the Administrator stated that it was important rooms met minimum size requirements for residents to have room to move around and for staff to be able to provide proper care. He stated that he expected rooms to at least meet minimum requirements. During random observations of care and services from 10/28/24 through 11/1/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/ or safety concerns in the two rooms. Granting of room size waiver recommended.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers per shower schedule. Resident 1 received only one shower in more than two weeks long stay at the facility. This failure placed Resident 1 at risk for lack of cleanliness and comfort. Findings: During a review of Resident 1 ' s Admission Record, printed on 3/27/24, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 2/09/24. During a record review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/13/24, the MDS assessment Section GG - Functional Abilities and Goals showed Resident 1 needed a setup or clean-up assistance (the helper assists prior to or following the activity) for shower. During a review of Resident 1 ' s Activities of Daily Living (ADL) Care plan dated 3/27/24, the care plan showed Resident 1 had an ADL self-care performance deficit and was at high risk for decline in functional limitations and contractures; and the facility was to keep Resident 1 clean, dry and well-groomed. During an interview on 3/27/24 at 12:28 p.m., Licensed Vocational Nurse (LVN 1) stated providing showers to residents and documenting their refusal of showers was only Certified Nursing Assistants (CNA) ' s responsibility. LVN 1 stated CNAs would notify her residents ' refusal of care only if they needed her help convincing the resident to take shower. During an interview on 3/27/24 at 12:41 p.m. with Certified Nurse Assistant (CNA 2), CNA 2 stated when a resident refused a shower, she would inform the nurse, document resident ' s refusal on the shower sheets and in residents ' electronic health record. CNA 2 stated providing showers to residents was important to prevent skin issues and infection; and for them to smell good. During an interview on 3/27/24 at 2:14 p.m., with the Director of Nursing (DON), DON stated when a resident refuses a shower, the CNAs should notify the nurses and they must document it in their nurse ' s progress notes. DON also stated the nurses should inform the resident ' s responsible party and their attending physician if the resident keeps refusing to receive showers. During a concurrent interview and record review on 3/27/24 at 2:50 p.m., with DON, Resident 1 ' s shower sheet dated 1/29/24 and 2/5/24 and Nursing Progress notes from 1/25/24 thru 2/8/24 were reviewed. The DON stated the record showed Resident 1 refused to receive shower on 1/29/24 and 2/5/24. The DON stated however she was unable to find documentation if nursing staff explained the risks and benefits and/or interventions taken to address Resident 1 ' s refusal. During a concurrent phone interview and record review on 4/5/24, at 12:58 p.m., with the DON, Resident 1 ' s Bathing/Shower record in the Electronic Health Record (EHR) for 1/2024 and 2/2024, and the facility ' s Shower Schedule revised on 3/6/24 were reviewed. The DON stated Resident 1 was scheduled to receive shower every Monday and Thursday in evening shift (between 3pm-11pm), indicating, Resident 1 should have received his showers on 1/25/24, 1/29/24, 2/1/24, 2/5/24 and 2/8/24. Bathing/Shower record showed Resident 1 did not receive his showers on 1/25/24, 1/29/24, 2/1/24, 2/5/24 and 2/8/24. Record also showed Resident 1 only received his shower on 2/7/24 during his over two weeks stay in the facility. During a review of the facility ' s policy and procedure (P&P) titled, Bath, Shower/Tub, revised February 2018, the P&P indicated, Purpose - to promote cleanliness, provide comfort to the resident and to observe the condition of the resident ' s skin. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken including the signature and title of the person recording the data.

Based on interview and record review, the facility failed to administer Heparin Sodium Injection Solution 5000 Unit/ml (a medication used to prevent and treat blood clots and other clotting-related conditions) for one (Resident 1) of four sampled residents. This failure resulted in Resident 1 not receiving medications as per physician's orders and placing Resident 1 at high risk for developing a blood clot. Findings: During a review of Resident 1's Admission record, printed on 9/20/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1's Physician orders dated 8/23/23, the Physician orders indicated to administer Heparin Sodium (Porcine) Injection Solution 5000 Unit/ml subcutaneously (injected into the tissue between the skin and muscle) every 12 hours (9:00 a.m. and 9:00 p.m.) for DVT (Deep vein thrombosis -a condition in which the blood clots form in veins located deep inside the body, usually in the thigh or lower legs) Prophylaxis. During a concurrent interview and record review on 9/20/23, at 2:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication administration record (MAR), dated 8/2023 and Progress notes , dated 8/23/23 and 8/24/23 were reviewed. The MAR indicated, on 8/23/23, for the 9 a.m. administration time and for 8/24/23 at 9 .00 p.m., administration time, the MAR was coded 9 . LVN 1 stated that code 9 indicated the medication was not administered. LVN 1 stated the progress notes dated 8/24/23 indicated that the medication Heparin sodium was not available. During a concurrent observation and interview on 9/20/23, at 2:24 p.m. with LVN 1, in the Medication room, the facility's emergency kit was observed. LVN1 stated that Heparin Sodium Injection was available in the facility's Emergency Kit (Ekit) and should have been given to the resident as per Physician orders if unavailable in the medication cart. LVN 1 stated it was important to provide Heparin Sodium to Resident 1 to prevent blood clots. During an interview on 9/20/23, at 2:52 p.m. with LVN 2, LVN 2 stated on 8/24/23 she was not able to find the medication in the medication cart and called pharmacy to follow up but did not check the Ekit at the facility and did not administer Heparin sodium from the Ekit. During an interview on 9/20/23, at 2:30 p.m. with Director of Nursing (DON), the DON stated it was not acceptable that the Licensed Nurses did not administer Heparin Sodium to Resident 1 when it was available in the Ekit. DON also stated Heparin Sodium should be given continuously as per doctor's orders and missing the dose placed Resident 1 at a high risk for developing a blood clot. During a review of the facility's policy and procedure (P&P), revised on 04/2019, titled, Administering Medications , was reviewed. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .

Based on observation, interviews and record review, the facility failed to store and prepare food under sanitary conditions when the hand washing sink had a pinkish brownish substance around the faucets and the trash cart had a brownish substance around the open area. These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 7/19/21, at 9:33 a.m., accompanied by the Dietary Supervisor (DS), the hand washing sink was observed with pinkish brownish substance around the faucet and one trash can with brownish substance around the open area. During an interview on 7/19/21, at 9:33 a.m., DS stated the pinkish material accumulated around the faucet may be dirt or mold. During an interview on 7/21/21, at 12:08 p.m., DS stated dietary staff are expected to keep the hand washing sink and other items in the kitchen clean, but staff are not particularly assigned to clean the hand washing sink.

Based on observation, interviews and record review the facility failed to ensure food was served at a safe temperature when during lunch tray line curry lemon chicken was not served at appropriate temperature. This deficient practice placed residents at risk of non appetizing food temperature and a potential for food borne illness. Findings: During tray line observation on 7/20/21, at 11:08 a.m., the Cook (CK) in the presence of the Dietary Supervisor (DS) and Registered Dietician (RD) prepared and served for lunch mashed potato with gravy, curry chicken and puree chicken . The curry chicken's temperature was 146 -151 degrees Fahrenheit (F). During an interview on 7/20/21, at 11:27 a.m., the RD stated the chicken temperature of 145-151 degree (F) could be served but stated the chicken may be cold by the time it got to the resident. During an interview on 7/20/21, at 11:39 a.m., CK stated he had adjusted the oven to 180 to 200 degrees when cooking the chicken and he was sorry. During an interview on 7/21/21, at 12:08 p.m., DS stated the CK adjusted the oven down to 180 degrees, DS stated kitchen staff are not expected to adjust the oven gauge. DS said the CK was nervous that was why the gauge was turned down to 180 instead of 200 degrees. Review of the facility record titled, Recipe: Curry Lemon Chicken; indicated , Internal temperature must reach 165 F for 15 seconds when cooking. Serve on trayline at the recommended temperature of 160-180 degree F.

Based on interviews and record review the facility failed to ensure the person designated to serve as Dietary Supervisor (DS) of food and nutrition services had the federal and/or state educational qualifications for the position. This deficient practice had the potential for lack of competency and skill set necessary to carry out all the functions of the food and nutrition services. Findings: During an interview with DS on 7/20/21, at 9:06 a.m., (DS) stated she did not have a dietary supervisor certificate. DS stated she was enrolled in a dietary program. DS stated the Registered Dietitian (RD) visits the facility twice a month to complete residents' nutrition assessments, review weekly weights and inspects kitchen sanitation. During an interview with Registered Dietician (RD) on 7/20/21, at 11:27 a.m., RD stated she was not full time staff at the facility. RD stated she visits the facility twice a month as a contracted Dietician Consultant. RD stated her responsibilities included review of admissions, significant weight changes, and inspect kitchen sanitation During an interview with Administrator (ADMIN) on 7/22/21, at 10:00 a.m., Admin stated the DS had no certificate as dietary supervisor but was enrolled in school. Admin stated the facility had a dietician that visits twice a month.

Based on interviews and record review, the facility failed to ensure one (Resident 20) of 12 sampled residents were free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of [MEDICATION(S)] {([MEDICATION(S)]) an antipsychotic drug} for appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 20 to receive unnecessary drugs and suffer adverse medication side effects. Findings: During a review of Resident 20's Physician Orders (PO) dated 7/9/20, the PO indicated [MEDICATION(S)] ([MEDICATION(S)]) 50 mg(milligrams) tablet by mouth in the evening for [CONDITION(S)] (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of the Annual Minimum Data Set - (MDS - an assessment screening tool used to guide care), dated 5/9/21, indicated Resident 20's Basic Interview of mental status (BIMS) score was 01 meaning poor cognitive impairment. Resident 20 had no delusions or hallucinations and had not exhibited wandering. Resident 20's diagnoses included Alzheimer's Dementia (loss of mental ability severe enough to interfere with normal activities of daily living). During a review of the Medication Administration Record (MAR), dated May, June and July 2021, indicated Resident 20 was administered [MEDICATION(S)] 50 mg tablet by mouth in the evening for behavior manifestations(abstract ideas) that included screaming, yelling, wandering and combativeness. During a review of the behavior care plan initiated 1/4/2020 ,indicated Resident 20 had Alzheimer dementia (memory disorders) with behavior of wandering, entering offices, resident rooms, combative and hitting staff. During an interview on 7/21/21, at 11:30 a.m., Certified Nursing Assistant (CNA1) stated Resident 20 was Spanish speaking and was able to communicate. CNA1 stated Resident 20 was pleasantly confused, and able to feed herself. CNA1 stated Resident 20 wanders in and out of rooms. During an interview on 7/21/21, at 12:56 p.m., the Director of Nursing (DON) stated he would need to clarify the order with the physician. DON stated staff had not met to review Resident 20's use of [CONDITION(S)] medication since 2020 because of COVID-19 pandemic. During an interview on 7/22/21, at 9:11 a.m., the Director of Nursing (DON), stated Interdisciplinary Team ( multiple disciplines) (IDT) did not evaluate Resident 20's use of [MEDICATION(S)] for appropriate clinical indication. According to the manufacturer, [MEDICATION(S)] is not approved for use in older adults with dementia-related [CONDITION(S)]. Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. Although causes of death varied, most of the deaths appeared to relate to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.drugs.com/pro/seroqueul.html].

Based on observation and interviews, the facility had two resident (Rt) rooms (Rooms A and B) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents' belongings. Findings: During an observation on 7/22/21, at 8:38 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area A Rt room 159.5 sq. ft 79.08 sq. ft/bed B Rt room 155.52 sq ft 79.56 sq. ft/bed During random observations of care and services from 7/19/21, to 7/22/21, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment kept in the rooms that might interfere with residents care. Each resident had personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings There were no negative consequences attributed the decreased space and safety concerns in the seven rooms. During an interview on 7/22/21, at 8:55 a.m., Resident 4 and 18 stated they had enough space in room B for privacy and provision of care. During an interview on 7/22/2,1 and 9:51 a.m., Certified Nursing Assistant (CNA 2), stated there was enough space for providing residents care in room A and 15. CNA 2 stated residents in room A and B are ambulatory.

Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent spread of infection in the facility during a novel Coronavirus Disease (COVID-19 - a mild to severe respiratory (lung) illness) outbreak (an occurrence of disease greater than expected at a particular time and place) when the following were observed: 1. The facility did not screen the staff and visitors upon entry to the facility for signs and symptoms of COVID-19. 2. The facility co-mingled residents who tested positive (Residents 1,2,3,4,5,6,7,8,9) with COVID-19 in the same unit with Patients Under Investigation (PUI - residents being isolated and observed for Covid 19 symptoms and waiting for Covid 19 testing results). 3. Failed to post signage on or near the door of each room of COVID positive residents and each room of PUI residents indicating type of PPE (personal protective equipment such as masks, eye shields, gloves and gowns) required. 4. Staff assigned to the COVID area used the same breakroom and bathroom facilities as the PUI and COVID negative assigned staff. 5. Room door of a resident who tested positive with COVID-19 was left open. 6. Failed to have trash receptacles inside each room of COVID-19 positive residents and PUI residents for staff to dispose of used PPE's. These cumulative failures to follow transmission-based precautions resulted in cross contamination and has lead to significant numbers of positive COVID-19 cases at the facility including five residents, one facility staff, and one resident death in the facility. The Administrator, Director of Nursing (DON), and Infection Preventionist (IP) were verbally notified of the Immediate Jeopardy (IJ) On 7/9/2020 at 3:42 P.M., due to the facility's failure to maintain Infection Control and Prevention protocols and guidelines. Through observation, interviews with the staff members and record reviews of the facility's documents, the facility showed they initiated the plan of action through in-services of employees regarding infection control. The IJ was abated on 7/10/2020 10:30 a.m Findings: 1. During an observation on 7/7/20 at 10:10 a.m., the front door of the facility was observed to be locked. Housekeeper (HK) 1 opened the door for Visitor 1. HK did not speak to Visitor 1 and walked over to the housekeeping cart. Visitor 1 stood inside, near the front door, and called out for staff and the staff did not respond. Visitor 1 walked to Nurse Station A, where Licensed Vocational Nurse (LVN) 1 was standing. During an interview on 7/7/20 at 10:18 a.m., with LVN 1, LVN 1 stated all staff and visitors needed to be screened and observed for Covid 19 symptoms. LVN 1 stated, before the visitors and staff enter the facility, they should have their temperature taken and asked questions regarding exposure to COVID-19 to determine if it is safe for them to enter facility. LVN 1 stated Visitor 1 should have been screened before he entered the facility. During an observation on 7/7/20 at 10:25 a.m. Dietary Aide (DA) 1 and DA 2 walked through the front door and immediately walked towards the administrative offices. DA 1 and DA 2 were not screened for Covid 19 before they entered the facility. During an interview on 7/7/20 at 10: 26 a.m., with DA 1, DA 1 stated she entered the front door each day when she arrived at work and clocked-in in the administrative office. DA 1 stated she next would exit the facility through the front door, re-enter the facility through the door near the kitchen, and be screened in the kitchen. During an interview on 7/7/20 at 11:30 a.m., with Housekeeper (HK) 1, HK 1 stated he had entered the facility at approximately 9 a.m., through the front door. HK 1 stated he then walked to nurse station A, where the nurse screened him. During an interview on 7/7/20 at 10:32 a.m., with AD, AD stated she was responsible to screen everyone who entered the facility. AD stated kitchen staff enter the facility through the front door, clock-in in the administrative office, exits through the front door, re-enter the facility at the back and then screened in the kitchen. During an interview on 7/7/20 at 11:55 a.m., with Director of Nursing (DON), DON stated staff and visitors should be screened for COVID-19 before entering the facility and were to enter through the front door. DON stated kitchen staff should be screened before they came in the front door. DON stated facility policy was violated if anyone came into the facility without first being screened. During a telephone interview on 7/8/20 at 9:54 a.m., with Infection Preventionist (IP), IP stated facility policy required all staff and visitors to be screened before entering the facility. 2. During an observation and an interview with the Infection Preventionist (IP) on 7/9/2020 at 10:25 A.M., IP stated, The facility has a COVID unit wing located at the western part of the building from rooms 28, 29, 30, 31, 32, 33, 34 and 35. PUI residents who were roommates of those residents who tested positive with COVID-19 were placed in rooms 28, 29, 30 and31, while Residents who tested positive for COVID-19 were placed in rooms 32, 33, 34 and 35. There was no sign nor barrier at the COVID care area unit wing indicating the locations of PUI rooms and rooms of residents who tested positive for COVID-19. Review of the facility's undated policy and procedure titled,Cohorting Residents indicated To minimize interactions of infectious individuals from non-infected individuals as much as possible. 1) Create a separate wings, units or floor that can serve the isolation units. 2) Consolidating and cohorting residents into separate dedicated COVID-19 and non-covid unit. Review of the facility's electronic medical record Point Click Care indicated the following: Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 1 tested positive with COVID-19 on 6/26/20 and later transferred from room [ROOM NUMBER]B to the facility's COVID care area unit room [ROOM NUMBER]B. Resident 2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 2 previously shared a room with Resident 1 prior to COVID-19 diagnostic testing. Resident 2 tested negative on 6/26/20 and later transferred from room [ROOM NUMBER]A to the facility's COVID care area unit 28B as PUI. Resident 3 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 3 tested positive with COVID-19 on 6/29/20 and later transferred from room [ROOM NUMBER]A to the facility's COVID care area unit room [ROOM NUMBER]B. Resident 4 was initially admitted to the facility on [DATE] and was readmitted with multiple [DIAGNOSES REDACTED]. Resident 4 previously shared a room with Resident 3 prior to COVID-19 diagnostic testing. Resident 4 tested negative on 6/29/20 and later transferred from room [ROOM NUMBER]B to the facility's COVID care area unit room [ROOM NUMBER]B as PUI. Resident 5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 5 tested positive with COVID-19 on 7/3/20 and later transferred from the facility's COVID care area unit room [ROOM NUMBER]B to room [ROOM NUMBER]A. Resident 6 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 6 previously shared a room with Resident 5 prior to COVID-19 diagnostic testing. Resident 6 tested negative on 7/3/20 and later transferred from the facility's COVID care area unit room [ROOM NUMBER]A to room [ROOM NUMBER]A as PUI. Resident 7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 7 tested positive with COVID-19 on 7/3/20 and later transferred to the facility's COVID care area unit room [ROOM NUMBER]A to room [ROOM NUMBER]A. Resident 8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 8 previously shared a room with Resident 7 prior to COVID-19 diagnostic testing's. Resident 8 tested negative on 7/3/20 and later transferred to the facility's COVID care area unit room [ROOM NUMBER]B to room [ROOM NUMBER]B as PUI. Resident 9 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 9 tested positive on 7/3/20 and remained in the facility's COVID care area unit room [ROOM NUMBER]B. During an interview with IP on 7/9/20 at 10:45 a.m., IP stated, All residents in our facility are vulnerable in contracting [MEDICAL CONDITION] because of their co-morbidities (presence of one or more conditions with a primary condition). IP further stated, When residents become symptomatic or have tested positive with COVID-19, residents were transferred to the COVID-19 unit along with their roommates who were exposed with COVID-19. A review of the Centers for Disease Control and Prevention (CDC) guidance titled,Responding to Coronavirus (COVID-19) in Nursing Homes dated 4/30/20 revealed Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 .Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID 19 .the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. 3. During an observation on 7/7/20 at 10:50 a.m., in the COVID-19 positive and persons under investigation unit, each room door had a sign stating the residents' names and COVID-19 status. A break room was located in the hallway adjacent to the COVID-19 positive unit. COVID-19 negative residents occupied the rooms on the hallway adjacent to the COVID-19 positive unit. During an interview on 7/7/20 at 10:54 a.m. with LVN 2, LVN 2 stated staff that worked in the COVID-19 positive and PUI rooms took off their gown and gloves when they left the rooms and put them in the large barrel in the hallway. LVN 2 stated staff working with Covid 19 positive and PUI residents took their breaks in the facility break room located on the hallway adjacent to the Covid positive and PUI unit and used the restroom inside of that breakroom. LVN 2 stated that staff, who did not work with Covid 19 positive and PUI residents, also used this breakroom and the bathroom off the breakroom. During an interview on 7/7/20 at 11:47 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that staff who worked on the Covid unit, as well as staff who did not work on the Covid unit, used the facility breakroom adjacent to the Covid unit and the bathroom off the breakroom. During a telephone interview on 7/8/20 at 9:54 a.m., with Infection Preventionist (IP), IP stated signs on the Covid 19 positive and PUI rooms did not list the types of precautions in place and the PPE required, which violated facility policy. IP stated the breakroom adjacent to the Covid unit was in a hallway with Covid 19 negative resident rooms. IP stated that staff working with Covid 19 positive and PUI residents should have been taking their breaks and using the bathroom in an empty resident room on the Covid unit. During a review of the facility's policy and procedure titled, Covid-19 Mitigation Plan, approved on 6/19/20, indicated staff with contact with Covid-19 positive residents were limited to specific wings, the facility screened and documented every individual entering the facility for Covid-19 symptoms, signs were posted immediately outside of resident rooms indicating appropriate infection control and prevention precautions and required PPE, trash bins were distributed inside the rooms near the exit doors of Covid-19 positive and PUI resident rooms to allow easy disposal of PPE when leaving the room, the facility had policies in place for dedicated spaces within the facility to ensure separation of infected patients and for eliminating movement of staff among those spaces to minimize transmission risk, staff caring for Covid-19 positive and PUI residents were to use the employee lounge as their breakroom, and non- Covid staff were to use the TV Room as their breakroom. 4. During an observation and interview with Licensed Vocational Nurse (LVN) 1 on 7/9/20 at 10:39 a.m., a medication cart was parked five feet near the nurses station of the facility's COVID care area unit wing. LVN1 stated the medication cart near the nurses station was a shared medication cart for residents tested positive with COVID-19 and PUI's. When LVN1 was asked regarding facility staff rendering direct care to residents tested positive with COVID-19 and residents identified as PUI, LVN 1 admitted he and another CNA were assigned to take care of all the residents placed in the facility's COVID care area unit for both positive residents and PUI's. A review of the facility's Assignment Sheet dated 7/6/20-7/9/20 revealed LVN 1 was scheduled as the Nurse Supervisor for A.M. shift. LVN 1 clarified and verified he was the Nurse Supervisor and at the same time was assigned as Charge Nurse for the COVID care area unit to render direct care and administer medications for residents who tested positive for COVID-19 and PUI's. Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9's Medication Administration Records dated 7/6/20, 7/7/20/, 7/8/20, 7/9/20 revealed LVN3's administered the medications during his a.m. work shift. An undated and untitled facility's policy and procedure indicated, Designation of Staffing when taking care of COVID residents: 1) There should be a consistent staff working and taking care of COVID residents only, in the COVID area every shift. (Nurses and CNA as well). The Centers for Medicare and Medicaid Services' COVID-19 Long-Term Care Guidance dated 4/2/20 indicated, #5. To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19 positive residents .Long-term care facilities should exercise as best as possible consistent assignments for all patients and residents regardless of symptoms of COVID-19 status. 5. During the facility tour observations and interview with IP on 7/9/20 at 10:30 a.m., Resident 5's room door was found to have left open. IP stated, All resident doors here in the COVID-19 unit should be closed at all times after staff enters a room to provide care to residents, and when after staff are done with their direct resident care tasks. It is important to follow guidelines so as not to affect other residents. Review of clinical records dated 7/9/20 indicated Resident 5 was located in room [ROOM NUMBER]A and was tested positive for COVID-19 on 7/3/20. Resident 5's room was adjacent to Resident 4's room who was a PUI with multiple [DIAGNOSES REDACTED]. Review of CDC's Morbidity and Mortality Weekly Report titled, Coronavirus Disease Surveillance-United States-January 22-May 30, 2020 revealed Surveillance data reported to CDC through April 2020 indicated that COVID-19 leads to severe outcomes in older adults and those with underlying conditions .the most common underlying conditions were cardiovascular disease ([MEDICAL CONDITION]), diabetes, and [MEDICAL CONDITION]. IP confirmed Residents tested positive with COVID-19 and PUI's in the facility's COVID care area unit were mostly older adults with underlying conditions. A review of the CDC's undated guidance titled, Transmission-Based Precaution indicated In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patients and placing the patients in private room with the door closed will reduce the likelihood of airborne transmission. 6. During an observation on 7/7/20 at 10:50 a.m., in the COVID-19 unit, a large barrel was observed near the wall in the middle of the unit. During an interview on 7/7/20 at 10:54 a.m. with LVN 2, LVN 2 stated no trash cans were inside Covid 19 positive and PUI rooms for staff to discard PPE. During a telephone interview on 7/8/20 at 9:54 a.m., with Infection Preventionist (IP), IP stated trash cans should have been placed inside each room with Covid 19 positive or PUI residents, for staff to discard PPE. During a review of the facility's policy and procedure titled, Covid-19 Mitigation Plan, approved on 6/19/20, indicated trash bins were distributed inside the rooms near the exit doors of Covid-19 positive and PUI resident rooms to allow easy disposal of PPE when leaving the room, the facility had policies in place for dedicated spaces within the facility to ensure separation of infected patients and for eliminating movement of staff among those spaces to minimize transmission risk.

Based on observation, interview, and record reviews, the facility used bed rails and a position change alarm (bed alarm) for the convenience of staff, to prevent one of 13 residents (Resident 48) from voluntarily leaving his bed, and failed to re-evaluate the ongoing need for use of the restraining devices. This failure resulted in psychological and emotional distress for Resident 48, who was afraid to move around in bed, and had the potential to result in injury if he became entangled in the bed rails, or attempted to climb over the bed rails. Findings: During a review of Resident 48's Admission Record, printed 2/25/2020, the Admission Record indicated an admitted in January 2019, with included [DIAGNOSES REDACTED]. The Admission Record indicated Resident 48 had a responsible party (RP) for healthcare decisions. During a review of the Annual Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 1/18/2020, the MDS indicated Resident 48 could understand others, and was understood by others, with moderate impairment of memory and thinking skills. The MDS indicated Resident 48 had no history of falling, but was unsteady, and required assistance from one person when transferring between surfaces, moving in bed, and ambulating. The MDS also indicated Resident 48 used either a walker, or wheelchair for ambulation. During a review of Resident 48's, Incident/Accident Report, dated 2/13/2020, the Report indicated a certified nursing assistant found Resident 48 on the floor on his right side. The Report indicated Resident 48 told the certified nursing assistant that he had gotten out of bed and fell . Resident 48 had an abrasion on his right elbow, but denied hitting his head. During a review of Resident 48's nurses' notes dated 2/14/2020, the notes indicated Resident 48 went to the acute care hospital for evaluation after he developed a persistent headache. During a review of Resident 48's nurses' notes dated 2/16/2020, the notes indicated Resident 48 returned to the facility from the acute care hospital with no new orders. During a review of the care plan titled, Fall Risk-Actual Fall, dated 2/13/2020, the care plan indicated interventions included reminding the resident to call for assistance, and bed alarm intact and working properly to alert when resident trying (to) get out bed unassisted. During a review of Resident 48's, Post Fall Assessment, dated 2/13/20, indicated a bed alarm was in place, and functioning well, to alert staff when Resident 48 tried to get out of bed unassisted. During a review of Resident 48's physician orders [REDACTED]. During a concurrent observation and interview on 2/24/2020, at 10:08 a.m., with Resident 48, in his room. Resident 48 was in bed, flat on his back, watching television. Both sides of the bed had side rails elevated above the bed, along the length of the bed; a bed alarm was in place. Resident 48 stated he had fallen when he had gotten out of bed by himself to get something from his bedside table. He stated he had developed a headache after the fall, so he had gone to the hospital. Resident 48 continued, When I came back from the hospital, they (facility staff) put this thing (pointed at bed alarm) that makes noise. I don't want to move, it (bed alarm) makes noise. They (facility staff)) said it's good for me, so they can hear me when I move. I just watch TV, and try not to move so it (bed alarm) does not make noise. During an observation and interview on 2/26/2020, at 8:26 a.m., with Resident 48 and Certified Nurse Assistant (CNA 2), in Resident 48's room, Resident 48 was in bed, on his back, with both side rails up. Resident 48 told CNA 2 he was not comfortable with the bed alarm. CNA 2 stated the bed alarm, and side rails were used to alert staff, because resident (Resident 48) was a fall risk, and had a tendency to get out of bed by himself. During an interview on 2/24/20, at 10:58 a.m., with the Director of Nursing (DON), in the facility's conference room, DON stated Resident 48's bed alarm was initiated after his fall on 2/13/2020, to alert staff when Resident 48 tried to get out of bed. During a concurrent observation and interview on 2/27/2020, at 8:56 a.m., with Licensed Vocational Nurse Supervisor (LVN 1) in Resident 48's room, Resident 48 was in bed with both side rails up. LVN 1 stated the bed rails were used to enable Resident 48 to move in bed more easily. LVN 1 asked Resident 48 to demonstrate how the bed rails enabled him to move in bed, but Resident 48 was unable to grab and hold onto the right hand side rail due to his right sided weakness. During a concurrent interview and record review on 2/26/2020, at 10:06 a.m., with the Director of Nursing (DON), the DON was unable to provide evidence of any evaluation process demonstrating the need for the continued use of Resident 48's bed alarm or side rails. During a review of the facility's policy and procedure (PNP), Use of Restraints, revised 12/2007, the PNP indicated, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .'Physical restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order all include the following: the specific reason for the restrant (as it relates to the resident's medical symptoms); how the restraint will be used to benefit the resident's medical symptom; and the type of restraint, and period of time for the use of the restraint. Orders for restraints will not be enforced for long than twelve (12) hours, unless the resident's condition requires continued treatment. Reorders are issued only after a review of the resident's condition by his or her physician.

Based on observation, interview, and record review, the facility failed to ensure staff followed policy and procedures for hand hygiene for seven of 14 sampled residents (Residents 26, 35, 18, 30, 101, 2, and 49). The failure of Certified Nursing Assistant 1 (CNA) to perform required hand hygiene during the passing and setting up of the residents' lunch trays had the potential to result in illness, and the spread of illness for Residents 26, 35, 18, 30, 101, 2, and 49. Findings: During a continuous observation on 2/24/2020, at 12:10 p.m., in the dining area, CNA 1 pushed the lunch tray cart into the dining area, and without performing hand hygiene (HH), picked up a lunch tray, delivered it to Resident 26, and removed the plate cover. CNA 1 returned to the meal cart, and without performing HH, picked up a lunch tray, delivered it to Resident 35, and removed the plate cover. CNA 1 returned to the tray cart, and without performing HH, picked up a lunch tray, and delivered it to Resident 18. CNA 1 removed Resident 18's plate cover, and the covers for the milk and water glasses. Without performing HH, CNA 1 went to the tray cart, picked up a lunch tray, delivered it to Resident 30, and took off the plate cover. Registered Dietician arrived in the dining area. Without performing HH, CNA 1 went to the tray cart, bent down, with one hands on her knee and the other on the lower part of the tray cart. CNA removed a lunch tray from the cart, delivered it to Resident 101, took off the plate cover, and sliced the vegetables for Resident 101. Without performing HH, CNA 1 went to the tray cart, picked up a lunch tray, delivered it to Resident 2, and removed the covers from the plate, and milk glass. Without performing HH, CNA 1 went to the tray cart which held consumed meal trays, and touched the plate cover from a consumed meal plate. Without performing HH, CNA 1 went to the kitchen, received a meal tray, delivered it to Resident 49, and removed the plate cover. During an interview on 2/24/2020 at 1:18 p.m., CNA 1 stated there had been no sanitizer in the dining area, so she had not performed HH between serving of the residents' lunch trays. During an interview on 2/24/2020 at 1:45 p.m., Registered Dietician (RD) stated she had observed CNA 1 touch her knees, and the consumed meal tray. RD stated CNA 1 should have performed HH after touching her knees and the consumed meal tray. During a review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2015, indicated staff should use alcohol based hand rub or soap and water before and after assisting a resident with meals and after handling contaminated equipment.

Based on observation, interview, and record review, the facility failed to follow safe food practices when: 1. Unpasteurized eggs were used to make soft-yolk, fried eggs for residents. 2. Freezer 2 had a temperature above zero degrees Fahrenheit (F): bread, waffles, and bread rolls inside the freezer were not solidly frozen; ice cream cups were liquified. 3. The facility ice machine had a white residue on the air intake filter. 4. The following items were stored unlabeled and undated, as follows: Refrigerator 2 had one 12-ounce jar of pickles with an unsealed lid; Freezer 1 had one unsealed box of 48 rainbow sherbet cups, and two individual 4-ounce cups of vanilla ice cream; Freezer 2 had one plastic bag of frozen enchiladas, sealed by knotting the plastic bag; four frozen bags of peas; one 32-ounce bag of frozen cauliflower; and five 40-ounce bags of frozen brussel sprouts; Refrigerator 1 had one tray of four-ounce plastic glasses of both water and juice, and four trays of four-ounce plastic glasses containing milk. These failures placed all residents who ate/drank these products, or received ice, at risk of food-borne illnesses. Findings: 1. During a review of the facility, Good For You Health Menus, dated February 24 to March 1, 2020, the menu indicated breakfast included fried eggs on 2/24/2020. During a review of the facility recipe titled, Fried Egg/Hard Boiled Egg/Poached Egg, undated, the recipe indicated pasteurized eggs were to be used to make fried eggs. During an interview on 2/24/2020, at 12:45 p.m., with Cook 1, Cook 1 stated she had prepared fried eggs for 38 residents for breakfast on 2/24/2020. Cook 1 stated she used the shell eggs from Refrigerator 1 to make the fried eggs. Cook 1 stated she had prepared the fried eggs with soft yolks. During an interview on 2/24/2020, at 12:50 p.m., with Registered Dietician (RD), RD stated the eggs Cook 1 used for preparing the fried eggs for breakfast on 2/24/2020 were not pasteurized eggs. RD stated non-pasteurized eggs must have the yolk cooked to a hard consistency to avoid the risk of food-borne illness. During a review of the facility's policy and procedure (P & P) titled, Food Preparation, dated 2018, the P & P indicated pasteurized EEGs were to be used for fried eggs. 2. During a concurrent observation and interview on 2/24/2020, at 10:14 a.m., with RD, RD confirmed the outside thermometer of Freezer 2 registered 17 degrees F, while two of the inside thermometers registered 27 degrees F, and 17 degrees F, respectively. RD confirmed the status of the following items in Freezer 2: one vanilla ice cream cup contained melted ice cream; the waffles, pancakes, and bread rolls were not solidly frozen. RD stated Freezer 2's temperature should be zero degrees F, or lower, to ensure the food inside remained frozen. During a concurrent interview and record review on 2/24/20, at 10:50 a.m., with Cook 1, Freezer 2's Cold Storage Temperature Log, dated February 2020, was reviewed. The Log morning entry for 2/23/2020 indicated a value of minus 8 degrees F; the evening entry indicated a value of positive 8 degrees F. Cook 1 stated she had entered the morning Log entry, but had mistakenly entered the value as minus 8 degrees F. Cook 1 stated the thermometer had actually registered 8 degrees F. During a concurrent interview and record review on 2/24/20, at 10:45 a.m., with Cook 2, Freezer 2's Cold Storage Temperature Log, dated February 2020, was reviewed. Cook 2 stated he had entered Freezer 2's outside thermometer value of positive 8 degrees F on the Log on 2/23/20 at 6:30 p.m. During a review of the facility's policy and procedure (P & P) titled, Procedure for Refrigerated Storage, dated 2018, the P & P indicated: freezer temperatures should be maintained at 0 degrees F, or lower; maintenance of a log with documentation of freezer temperatures twice a day, when opening and closing the kitchen. 3. During a concurrent observation and interview on 2/26/20, at 8:33 a.m., with Maintenance Manager (MM), the air intake filter on the ice machine was covered with a white substance. MM stated there was too much white substance on the filter and MM 1 would clean it soon. During a concurrent interview and record review on 2/26/20 at 8:33 a.m., with MM, the Bi-Monthly Ice Machine Cleaning Log, dated 2020, was reviewed. The Log indicated the ice machine had been cleaned 1/3/2020, and 2/7/2020. MM stated he had cleaned the ice machine once a month, as indicated on the Bi-Monthly Ice Machine Cleaning Log. During an interview on 2/26/20 at 8:40 a.m., with the facility Administrator (ADM), ADM stated the ice machine should be cleaned twice a month to prevent the spread of infection. During a review of the facility's policy and procedure (P & P) titled, Ice Machine Bi-Monthly Cleaning Procedures, undated, the P & P indicated the ice machine was to be cleaned bi-monthly. 4. During a concurrent observation and interview on 2/24/2020, at 8:15 a.m., with Dietary Aid (DA), in the facility kitchen, DA confirmed Freezer 2 contained the following undated and unlabeled food: one plastic bag of unlabeled enchiladas; four plastic bags of peas; one 32-ounce bag of cauliflower; and five 40-ounce bags of Brussels sprouts. DA stated one plastic bag of enchiladas, four plastic bags of peas, one 32-ounce bag of cauliflower; and five 40-ounce bags of Brussels sprouts were undated and unlabeled. During a review of the facility's policy and procedure (P & P) titled, General Receiving of Delivery of Food and Supplies, dated 2018, the P & P indicated all food items were to be labeled with a delivery date and time, and leftovers should be labeled and dated.

Based on observation, interview and record review, the facility staff failed to close the privacy curtains around one (Resident 14) of 14 sampled residents' beds during care provision. This failure resulted in the exposure of Resident 14's genitals to her roommate, and passers-by in the hallway. This failure had the potential to result in emotional distress for Resident 14. Findings: During a review of Resident 14's, Admission Record, on 2/25/2020, the Record indicated the facility admitted Resident 14 in 2018, with included [DIAGNOSES REDACTED]. The Record also indicated Resident 14 had a responsible party for healthcare decisions. During a review of Resident 14's, Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/28/18, the MDS indicated Resident 14 was totally dependent on assistance from one person for bed mobility, eating, toileting and personal hygiene. The MDS indicated Resident 14 was non-English speaking, and was severely impaired in the ability of daily decision-making. During an observation on 2/25/2020, at 8:20 a.m., in the facility hallway, three certified nursing assistants transported Resident 14 in a Hoyer lift (a mechanical device used to transfer residents from one surface to another) from the shower room to her shared, two-bed room across the hall from the shower. Resident 14's roommate was in her own bed. Resident 14 entered her room and the certified nursing assistants prepared to transfer Resident 14 to her bed with the privacy curtains around Resident 14's bed open. Resident 14 sat in the Hoyer lift, with her genitals visible to both the roommate, and hallway occupants, and yelled. During an interview on 2/25/2020, at 8:20 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 confirmed she had participated in the transfer of Resident 14, and that the privacy curtains had been left open while Resident 14 sat in the Hoyer lift. During a review of the facility policy and procedure (P & P) titled, Quality of Life - Dignity, dated 2009, the P & P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to provide supervision to prevent one of three residents (Resident 1) from falling. The failure to provide one-on-one supervision for Resident 1 after a shower resulted in Resident 1 attempting to stand without assistance to dress herself, falling out of an unsecured shower chair (a wheeled chair used during showering), and sustaining a fractured shoulder. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide resident care) dated 1/24/19, indicated the facility admitted Resident 1 in 2011 with [DIAGNOSES REDACTED]. The MDS indicated Resident 1 had severe memory and thinking impairment, with a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is 0-15, with zero as the most impaired condition.) score of two. The MDS reflected Resident 1 was unsteady when transferring from one surface to another surface, and required extensive physical assistance from one person for such transfers. The MDS also indicated Resident 1 required physical assistance from one person for the activities of bathing and dressing. The MDS indicated Resident 1 used a wheelchair for movement within the unit, but required supervision by one person for the movement. A review of the care plan, Fall Risk, initiated 10/23/15, revised 1/31/17, indicated Resident 1 had a history of [REDACTED]. The care plan interventions included, Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A review of the facility form, Incident/Accident Report, dated 2/15/19, showed Resident 1 had a fall on 2/15/19 at 9:20 a.m., witnessed by a certified nursing assistant. The report showed Resident 1 had no sign of injury or complaint of pain immediately after the event. During a telephone interview with Certified Nurse Assistant (CNA) on 3/13/19 at 11:25 a.m., CNA stated she had assisted Resident 1 with a shower, then transported Resident 1 back to her room in a shower chair. CNA stated Resident 1's clothes were on top of her bed, when CNA told Resident 1 she would be right back, and left the room to get Resident 1's regular wheel chair, located across the hall. CNA stated when she returned to the room, Resident 1 was attempting to stand up and was reaching for her clothes on the bed. CNA stated she asked Resident 1 to sit back down, and Resident 1 started to sit back down in the shower chair, but the chair moved, and Resident 1 slid off the seat onto the floor, hitting her arm on the side of the bed as she fell . CNA stated she called the licensed nurse for assistance while Resident 1 sat on the floor. During an interview with Registered Nurse (RN) on 3/5/19 at 11:45 a.m., RN stated she and Nursing Supervisor (NS) responded to CNA's call for assistance after Resident 1 fell . RN stated when she entered the room, Resident 1 was on the floor by a shower chair. RN stated she assessed Resident 1 before moving her off the floor, and saw no sign of injury. RN stated Resident 1 had no complaint of pain, or change in her ability to move her extremities. RN stated CNA and NS transferred Resident 1 to her wheel chair with a draw sheet (a sheet used to facilitate transfer and change in position). A review of a nurse progress note dated 2/15/19 at 3:00 p.m., reflected Resident 1 had skin discoloration from under her arm to her breast. The note also reflected Resident 1 received [MEDICATION NAME] (medication used for pain relief) for complaints of pain with arm movement on 2/15/19 at 6:10 p.m. A review of nurse progress notes showed Resident 1 complained of pain in her right underarm, and received [MEDICATION NAME] on: 2/16/19 at 5:30 a.m., and 2/17/19 at 6:15 a.m. A review of the note dated 2/18/19 at 7:00 a.m., reflected RN notified the physician of Resident 1's right arm and shoulder discoloration and pain; the physician ordered X-ray studies of Resident 1's arm and shoulder. A progress note dated 2/18/19 at around 7 p.m. showed the nurse notified the physician about the X-ray results; at 8:24 p.m. the physician ordered Resident 1 to the hospital for treatment. A review of the radiology, Final Report, dated 2/18/19, showed Resident 1's upper arm was broken, with the bone ends still in proper anatomical position. Review of the Nurses Progress Note dated 2/19/18 at 3:00 a.m., indicated the hospital informed the facility that Resident 1 would return to the facility with a sling for the right arm to maintain bone alignment.

Based on interview and record review, the facility failed to provide care and services necessary to maintain the highest practicable health for one (Resident 2) of four sampled residents. Resident 2, a quadreplegic, never had a podiatric consultation since admission on 7/28/11 resulting in being sent to the emergency roiagnom on [DATE] for evaluation of unrelieved leg pain. The emergency room notes indicated he had unkempt hands and feet with long nails and an untreated nail infection and [MEDICAL CONDITION] resulting in foot surgery the next day. Findings: Review of the medical record on 1/21/14 showed that Resident 2 was originally admitted on [DATE] with multiple diagnoses. These included [MEDICAL CONDITION] (paralysis of all four limbs), [MEDICAL CONDITIONS] and abscesses (localized tissue infections), and [MEDICAL CONDITION] (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). The most recent complete resident assessment, dated 10/20/13, showed a score of 15 out of 15 on the "Brief Interview for Mental Status" and total dependence on staff for all activities of daily living. The admission physician's orders [REDACTED]. Review of Skin Condition Weekly Status Reports, most recent dated 11/27/13, showed no mention of feet assessment. According to the nurses notes, Resident 2 was sent to the emergency department on 12/30/13 with complaints of unrelieved leg pain. The emergency department physician's note, dated 12/31/13, showed, "Patient's feet and hands are unkept, long toenails and fingernails." The hospital podiatrist's note, dated 12/31/13, showed "Left third toe swelling for 3 months with pain, states he thinks nail infection. Dermatology: third toe [DIAGNOSES REDACTED] (redness) to nail bed, no open wound, no drainage, [MEDICAL CONDITION] (swelling) of third toe. Upon removal of mycotic nail (a fungal infection where the actual infection is of the bed of the nail and of the plate under the surface of the nail), resulting in granular wound bed below. Vascular: pale, cool, no palpable pulses. Would recommend left foot x-ray, 3 views, to rule out possible osteo (bone infection)." During phone interview on 2/3/14 at 11:00 a.m., the medical records coordinator (MR) stated, "He never had a podiatry consult while he was here at the facility." During phone interview on 2/5/14 at 10:30 a.m., the Director of Nurses (DON) stated, "He was never seen by podiatry. The podiatrist visits every two months and sees the residents who have been referred to him by the charge nurses. We have no documentation about staff cutting his nails. There's no documentation about toes or feet on the weekly skin assessments"

Based on interview and record review, the facility failed to provide supervision to prevent fall of one (Resident 1) of three sampled residents. Resident 1 had a history of [REDACTED]. As a result of this failure, Resident 1 fell the sixth time, hit his head and sustained a brain hemorrhage (an abnormal discharge of blood resulting in lack of circulation and death to areas of the brain) and was sent to the hospital. Findings: Review of the medical record on [DATE], showed that Resident 1 was an [AGE] year old admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. There was a physician's history and physical, dated [DATE], that showed that Resident 1 did not have capacity to make health care decisions. The MDS (minimum data set, full resident assessment), dated [DATE], showed that Resident 1 walked in his room and in the hallways with supervision and a walker. The limited assistance of one staff was needed for bathing and dressing. This MDS showed that he was not steady transferring from surface to surface and moving from seated to standing. Further record review showed five "Post Fall Assessments:" 1. [DATE]- "Lost balance in activity room...and fell on buttocks- witnessed."2. [DATE]- "Walking with walker in activity room. Lost balance and fell on his buttocks. Witnessed. 3. [DATE] at 4 a.m., "Found sitting on floor by bed- unwitnessed 4. [DATE] at 10:45 p.m., .""Lost balance getting up resulting in fall on his buttocks- witnessed." 5. [DATE]- "fell at nursing station. Patient needs shoes instead of wearing slippers all the time."On [DATE]- "Found on floor with walker on top...Turned patient on side, noted discoloration- pink- purplish. Patient started to feel nauseated...The CNA informed me he had two emesis. Transferred to hospital by 911." "Nursing notes showed that on [DATE], Resident 1 returned to the facility with [DIAGNOSES REDACTED]. He died the following day. There were two care plans addressing mobility problem and falls. The one titled "Physical Mobility Impaired," originally written on [DATE], showed "Due to weakness, balance problem and sitting to standing." There were dates it was reviewed but the original list of interventions included "Identify and address underlying cause of impaired mobility." Nothing had been added since it was first written. The second care plan, dated [DATE], "Actual Fall related to getting up abruptly supporting walker lost his balance not gripping the house slipper enough" with the handwritten intervention "Request family to bring better shoes that grip the floor. Remind him to ask for assistance." During interview and concurrent record review on [DATE] at 11:50 a.m. and at 12:45 p.m., the director of nurses (DON) stated, "After every fall, we make sure they have an evaluation by the rehabilitation department. We educate him (Resident 1) about safety awareness. Sometimes he followed directions and he went to the bathroom independently. He had no tab alarm (which would alarm when rising from a chair) because he would remove it." When asked what interventions were tried to prevent falls, DON stated, "We cannot focus on one single patient" and confirmed that no new approaches had been attempted. When asked how the DON communicated safety awareness education with this Cantonese speaking resident, DON stated that there were staff on two shifts who spoke his language. During interview on [DATE] at 1 p.m., the social service designee (SSD) stated, "He was given a front wheel walker to prevent falls." During interview on [DATE] at 1:40 p.m., the supervisor of the rehabilitation department, an occupational therapist (OT), stated, "We were aware of his falls. We screened him by observation and, when he walked, there was no instability. Nurses were encouraged to assess his needs, look for triggers and check proper footwear." During phone interview on [DATE] at 10:40 a.m., Cantonese speaking certified nursing assistant (CNA 1) stated, "He fell so many times. I asked him why he thought he was falling and he said he didn't fall. He didn't like shoes. He wore slippers." During phone interview on [DATE] at 10:50 a.m., LVN 2 stated that she was in charge the night he fell , on [DATE]. LVN 2 stated, "He understood a little Mandarin and spoke Cantonese. We did not take his blood pressure sitting and standing after he fell . It was night shift. He wore slip-on slippers made of rubber." During phone interview on [DATE] at 2 p.m., the consulting pharmacist was asked if medications may have contributed to Resident 1's falls. Pharmacist stated, "I wrote letters to the physicians about the combination of medications to alert them to the possibility of low blood pressure causing falls. The DON should have copies of my letters and monthly notes from the psychotropic medication meetings. I asked for risk versus benefits of the medications." During phone interview on [DATE] at 9:05 a.m., the attending physician (MD1) stated, "I can't say I was aware of these falls. That was not a problem addressed to me. I attend the monthly interdisciplinary meetings." During second phone interview on [DATE] at 4:45 p.m., MD 1 stated, "He had a history of [REDACTED]. I am concerned that not enough diligence (focused concentration) was done." During interview on [DATE] at 1:00 p.m., LVN 1 stated that he had taken sitting and standing blood pressures after a fall and included them in the incident report but had not documented it in the medical record. He stated, "When he fell , it was when he was sitting and would get up without the walker." During phone interview on [DATE] at 1:45 p.m., Resident 1's son, his responsible party, was asked about his conversations with facility staff. He stated, "No one spoke to me about safety or footwear. They would inform me after the falls and tell me he was okay. He liked to wear rubber slippers with socks. Those gripped okay. He forgot that he fell ." Review of the facility's policy and procedure,titled "Monitoring Subsequent Falls and Fall Risk, revised ,[DATE], If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. After more than one fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approaches remain relevant."