Every finding on record at Corona Post Acute Center

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag (connected to the urinary catheter to collect urine) were covered with dignity bag (a discreet cover or holder designed to conceal a Foley catheter drainage bag [which holds urine] and its connecting tube out of public view) for two of four residents reviewed with urinary catheters (Resident 2 and Resident 3). This failure had the potential to compromise the residents' dignity and privacy.Findings: On May 15, 2026, at 10:30 a.m., an unannounced visit to the facility on a complaint investigation was initiated. 1. On May 15, 2026, at 11:41 a.m., observed Resident 2's urinary catheter bag hanging on the bed frame on the left side of the bed without a dignity bag covering it. The room door was open, and the drainage bag was visible from the doorway and could be readily viewed by staff and visitors entering or passing by the room. On May 15, 2026, at 11:54 a.m., a concurrent observation and interview was conducted with the Infection Preventionist, (IP). The IP confirmed that Resident 2's urinary catheter drainage bag was not covered with a dignity bag. The IP stated residents with urinary catheters should have the drainage bag covered with a dignity bag to promote privacy and dignity. A review of Resident 2's medical records indicated the resident was admitted on [DATE], with diagnoses of urinary tract infection, (infection in the bladder) and obstructive uropathy (any structural or functional blockage that slows or stops the flow of urine through the urinary tract). A review of Resident 2's History and Physical dated April 24, 2026, indicated resident had fluctuating capacity to make decisions. A review of Resident 2's Order Summary Report dated April 26, 2026, indicated May have. foley catheter r/t [related to] obstructive uropathy . 2. On May 15, 2026, at 12:06 p.m., observed Resident 3's urinary catheter drainage bag hanging on the left side of the bed frame without a dignity bag covering it. The room door was open, and the drainage bag was visible from the doorway and could be readily viewed by staff and visitors entering or passing by the room. On May 15, 2026, at 12:13 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The LVN stated Resident 3's urinary catheter drainage bag should have been covered with a dignity bag to maintain resident privacy. A review of Resident 3's medical records indicated the resident was admitted on [DATE], with diagnoses of metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection, and obstructive uropathy (any structural or functional blockage that slows or stops the flow of urine through the urinary tract) A review of Resident 3's History and Physical dated March 12, 2026, indicated resident had fluctuating capacity to understand and make decisions. A review of Resident 3's Order Summary Report dated May 8, 2026, indicated .foley catheter.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two out of four residents reviewed (Resident 2 and Resident 3). This failure had the potential to delay residents' ability to obtain assistance for care needs, increase the risk of falls, and result in unmet needs or injury.Findings: On May 15, 2026, at 10:30 a.m., an unannounced visit to the facility on a complaint investigation was initiated. 1. On May 15, 2026, at 11:41 a.m., observed Resident 2 in bed. The call light was hanging on the wall on the left side of the resident's bed, out of his reach. On May 15, 2026, at 11:41 a.m., an interview was conducted with Resident 2. Resident 2 could answer yes and no questions by shaking his head up and down for yes, and back and forth for no. Resident 2 was asked where his call light was, Resident 2 shrugged his shoulders. When Resident 2 was asked how he calls for assistance, Resident 2 placed his hands up around his mouth and whispered he yells. Resident 2 shook his head up and down when asked whether this was frustrating and shrugged his shoulder when asked whether he felt safe. On May 15, 2026, at 11:54 a.m., a concurrent observation and interview was conducted with the Infection Preventionist, (IP). At Resident 2's bedside, the IP was asked where Resident 2's call light was. She was unable to locate the call light within the resident's reach and confirmed that the call light should have been within reach at all times for Resident 2. A review of Resident 2's medical records indicated resident was admitted on [DATE], with diagnoses which included hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following cerebral infarction, (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). A review of Resident 2's History and Physical dated April 2, 2025, indicated resident had fluctuating capacity to make decisions. A review of Resident 2's Care Plan Report initiated on April 25, 2026, indicated Focus High risk for falls.Interventions: Keep call light within reach. 2.On May 15, 2026, at 12:06 p.m., heard Resident 3 yelling for help from room (room number). Observed Resident 3 in bed, his call light was hanging at the head of his bed outside of his reach. On May 15, 2026, at 12:06 p.m., an interview was conducted with Resident 3. Resident 3 stated that he needed help and wanted to be pulled up in his bed. A review of Resident 3's medical records indicated resident was admitted on [DATE], with diagnoses of metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection, acute respiratory failure, (a serious condition that develops quickly without warning when the lungs can't get enough oxygen into the blood), COPD, and type 2 diabetes mellitus. A review of Resident 3's History and Physical dated March 12, 2026, indicated resident had fluctuating capacity to understand and make decisions. A review of Resident 3's Care Plan Report initiated January 22, 2026, indicated Focus: Risk for falls. Interventions: ensure call light, personal items and water picture side table are within reach. On May 15, 2026, at 12:13 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The LVN observed Resident 3 and stated that the call light was not within reach and confirmed that the call light should have been within reach for Resident 3. On May 15, 2026, at 12:37 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated that Resident 3 knew how to use the call light, and it was important for the call light to be within reach so the resident could call for help when needed. A review of the facility's policy and procedure titled Answering the Call Light revised May 2025, indicated .1. Resident Access Each resident shall have access to a functioning call light device at all times. Staff shall ensure the call light is within the resident's reach during routine care, after transfers, and before leaving the room.

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were maintained when the urinary catheter drainage bag, (connected to the urinary catheter - a hollow tube inserted into the bladder to drain or collect urine), was observed touching the floor for one of four residents reviewed, (Resident 3). This failure had the potential to contaminate the urinary drainage system and increase the risk of contamination of the urinary drainage system, and the development of a catheter associated urinary tract infection (CAUTI - happens when germs (usually bacteria) enter the urinary tract through a medical catheter that is placed into the bladder). Findings: On May 15, 2026, at 10:30 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On May 15, 2026, at 12:06 p.m., observed Resident 3 in bed. His urinary catheter bag was hooked onto the left side of the bed frame and was touching the floor. On May 15, 2026, at 12:13 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The LVN stated that Resident 3's urinary catheter drainage bag should not be in contact with the floor because doing so could increase the risk of contamination and infection. On May 15, 2026, at 2:56 p.m., an interview was conducted with the Infection Preventionist, (IP). The IP stated that urinary catheter drainage bags should be stored in a bath basin and should not touch the floor. The IP confirmed that contact with the floor could increase the risk of contamination of the urinary drainage system and the development of a CAUTI. A review of Resident 3's medical records indicated the resident was admitted on [DATE], with diagnoses of metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection, acute respiratory failure, (a condition in which the lungs cannot provide adequate oxygen to the blood), COPD, and type 2 diabetes mellitus. A review of Resident 3's History and Physical dated March 12, 2026, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 3's Order Summary Report dated May 8, 2026, indicated .foley catheter. A review of the facility's policy and procedure titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing revised April 2025, indicated .6. Maintain unobstructed urine flow . c. Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the floor .

Based on interview and record review, the facility failed to ensure, 13 of 15 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD and have an AD available for review in the medical record.These failures had the potential to result in the ADs for Residents (17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1.On April 10, 2026, at 3 p.m. an interview was conducted with Resident 6. Resident 6 was not sure if the facility discussed to her how to formulate an AD. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnosis which included, hemiplegia (one sided paralysis) and hemiparesis (muscular weakness). A review of the Advance Directive Acknowledgment form dated May 18, 2025, indicated, I have not executed an Advance Directive. A review of the Social Services Quarterly Evaluation. Dated March 18, 2026, indicated, .Advance Directives .unchecked space. During a review of Resident 6's Advance Directive Acknowledgement indicated on February 18, she did not execute an Advance Directive. A review of Resident 6's History and Physical indicated Resident 6 has the capacity to make decisions. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD. 2.On April 10, 2026, at 2:10 p.m., an interview was conducted with Resident 17. Resident 17 was alert and sitting up in her wheelchair. Resident 17 stated she could not recall any facility staff to on how to formulate an Advance Directive. Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnosis which included, depression and liver cirrhosis (scarring of the liver). A review of the Advance Directive Acknowledgment form dated February 8, 2026, indicated, .I have not executed an Advance Directive. A review of the Social Services Quarterly Evaluation, dated March 18, 2026, indicated, .Advance Directives .unchecked space. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD. 3.Resident 117's record was reviewed. Resident 117 was admitted to the facility on [DATE], with diagnosis which included, dementia (loss of memory) and anemia ( a condition of the blood which reduces the bloods ability to transport oxygen). A review of the Advance Directive Acknowledgment form dated November 24, 2025, indicated, .verbal by family member -I have not executed an Advance Directive. A review of the Social Services Quarterly Evaluation, dated March 4, 2026, indicated, .Advance Directives .unchecked space. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD. 4. On April 10, 2026, at 8:53 a.m. an interview was conducted with Resident 119. Resident 119 stated she was not sure if the facility discussed to her how to formulate an AD, and further stated she would like to know more about it. Resident 119's record was reviewed. Resident 119 was admitted to the facility on February November 27, 2024, with diagnosis which included, anxiety (excessive worry) and anemia ( a condition of the blood which reduces the bloods ability to transport oxygen). A review of the Advance Directive Acknowledgment form dated February 19, 2026, indicated, .I have not executed an Advance Directive. A review of the Social Services Quarterly Evaluation, dated April 3, 2026, indicated, .Advance Directives .unchecked space. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD. 5. On April 8, 2026, at 2:20 p.m., Resident 10 was observed lying in bed. Resident 10 stated he did not wish to execute an Advanced Directive and was aware of his right to not have one. Resident 10 stated he vaguely remembers staff discussing an Advance Directive. Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnosis which included cirrhosis of the liver (liver impairment). A review of Resident 10's MDS dated [DATE], indicated a BIMS score of 15 (cognitively intact). A review of the Advance Directive Acknowledgment form, dated August 6, 2024, indicated, .I HAVE NOT executed an Advance Directive. A review of the Social Service Quarterly Evaluation dated, April 3, 2026, indicated, .Advance Directives.unchecked space.Advanced Directives review with no changes.unchecked space.Advance Directives reviewed and POLST (Physician Orders for Life Sustaining Treatment) form updated. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD from August 2024 to April 2026. 6. On April 8, 2026 at 3:41 p.m., Resident 55 was asleep in bed. Resident 55's record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (blood flow restricted to the brain) and aphasia (disorder that affects speech). A review of Resident 55's MDS dated [DATE], indicated a BIMS score of 11 (moderate cognitive impairment). A review of the Advance Directive Acknowledgment form, dated September 4, 2025, indicated, .I HAVE NOT executed an Advance Directive.verbal consent obtained from name of Resident 55's RP (daughter). A review of the Social Service Quarterly Evaluation dated, February 5, 2026, indicated, .Advance Directives.unchecked space.Advanced Directives review with no changes.unchecked space.Advance Directives reviewed and POLST form updated. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD from September 2025 to February 2026. 7. Resident 97's record was reviewed. Resident 97 was admitted to the facility on [DATE], with diagnosis which included dementia (memory loss). A review of Resident 97's MDS dated [DATE], indicated a BIMS score of 12 (moderate cognitive impairment). A review of the Advance Directive Acknowledgment form, dated November 5, 2025, indicated, .I HAVE NOT executed an Advance Directive.verbal consent obtained from name of Resident 97's RP (brother). A review of the Social Service Quarterly Evaluation dated, January 18, 2026, indicated, .Advance Directives.unchecked space.Advanced Directives review with no changes.unchecked space.Advance Directives reviewed and POLST form updated. There was no documented evidence that the resident or RP was provided follow up information about the right to formulate an AD from November 2025 to January 2026. 8. On April 6, 2026, at 10:44 a.m. Resident 110 was alert observed lying in bed. Resident 110 indicated she was unsure of having an AD and would like to know more about it. Resident 110's record was reviewed. Resident 110 was admitted to the facility on [DATE], with diagnosis which included, unspecified dementia (memory loss), and anxiety disorder (excessive worry). A review of the Advance Directive Acknowledgment form dated April 20, 2020, indicated, .I have not executed an Advance Directive. The MDS dated [DATE], indicated a BIMS score of 13 (cognitively intact). A review of the Social Services Quarterly Evaluation. Dated March 15, 2026, indicated, .Advance Directives .unchecked space. A review of the Multidisciplinary Care Conference (IDT) dated March 18, 2026, indicated, .advance directive reviewed.unchecked space. There was no documented evidence the resident or RP was provided with follow up information about the right to formulate an AD from April 2020 to March 2026. 9. On April 7, 2026, at 10:10 a.m. Resident 126 was alert and observed sitting upright in a wheelchair. Resident 126 stated he believed he had an AD but could not recall if the facility had one and could not recall a time when the facility reviewed an AD with him. Resident 126's record was reviewed. Resident 126 was admitted to the facility on [DATE], with diagnosis which included, major depressive disorder (persistent, intense feeling of sadness.) A review of the Advance Directive Acknowledgment form dated November 10, 2020, indicated, .I have executed an Advance Directive. The MDS dated [DATE], indicated a BIMS score of 15 (cognitively intact). A review of the Social Services Quarterly Evaluation. Dated February 24, 2026, indicated, .Advance Directives .unchecked space. A review of the IDT dated March 4, 2026, indicated, .advance directive reviewed.unchecked space. There was no documented evidence the resident had an AD on file for review or the resident/RP was provided follow up information about the right to formulate an AD from November 2020 to March 2026. 10. On April 7, 2026, at 12:12 p.m. Resident 159 was alert and sitting up in a wheelchair. Resident 159 indicated he believed he had an AD but could not recall for sure, that is brother was the other decision maker and that the facility should have the AD on file. Resident 159's record was reviewed. Resident 159 was admitted to the facility on [DATE], with diagnosis which included, major depressive disorder, and anxiety disorder. A review of the Advance Directive Acknowledgment form dated January 17, 2020, indicated, .I have not executed an Advance Directive. The MDS dated [DATE], indicated a BIMS score of 14 (cognitively intact). A review of the Social Services Quarterly Evaluation. Dated March 26, 2026, indicated, .Advance Directives .unchecked space. A review of the IDT dated March 26, 2026, indicated, .advance directive reviewed.unchecked space. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD from January 2020 to March 2026. 11. On April 7, 2026, at 12:41 p.m. an interview was conducted with Resident 20. Resident 20 was alert and sitting up in a wheelchair. Resident 20 stated she could not recall any facility staff to inform her about her rights to formulate an AD and would like to know more. Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with diagnosis which included, anxiety disorder, legal blindness. A review of the Advance Directive Acknowledgment form dated December 23, 2024, indicated, .I have not executed an Advance Directive. The MDS, dated [DATE], indicated a BIMS score of 11 (moderate cognitive impairment). A review of the IDT dated March 18, 2026, indicated, .advance directive reviewed.unchecked space.Spoke with RP daughter. A review of the Social Services Quarterly Evaluation, dated March 18, 2026, indicated, .Advance Directives .unchecked space. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD from December 2024 to March 2026. 12. On April 7, 2026, at 3:45 p.m. Resident 155 was alert and sitting up in bed. Resident 155 stated he was unsure of having an AD and that he would like to know more. Resident 155's record was reviewed. Resident 155 was admitted to the facility on [DATE], with diagnosis which included, major depressive disorder, cerebrovascular disease (a condition that affects blood circulation to the brain). A review of the Advance Directive Acknowledgment form dated March 10, 2021, indicated, .I have executed an Advance Directive. The MDS dated [DATE], indicated a BIMS score of 13 (cognitively intact). A review of the Social Services Quarterly Evaluation, dated March 9, 2026, indicated, .Advance Directives .unchecked space. A review of the IDT dated March 9, 2026, indicated, .advance directive reviewed.unchecked space. There was no documented evidence the resident had an AD on file for review or the resident/RP was provided follow up information about the right to formulate an AD from March 2021 to March 2026. 13. On April 8, 2026, at 8:30 a.m. Resident 25 stated no staff informed him of his right to formulate an AD and that he would like to know more about it. Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnosis which included, anxiety disorder. A review of the Advance Directive Acknowledgment form dated March 5, 2021, indicated, .I have not executed an Advance Directive. The MDS, dated [DATE], indicated a BIMS score of 13 (cognitively intact). A review of the IDT dated January 29, 2026, indicated, .advance directive reviewed.unchecked space. A review of the Social Services Quarterly Evaluation, dated January 29, 2026, indicated, .Advance Directives .unchecked space. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD from March 2021 to March 2026. On February 27, 2026, at 10:14 a.m. an interview was conducted with the Social Service Director (SSD). The SSD stated upon admission, all residents received an AD acknowledgment to indicate whether they had, wanted, or refused an AD. The SSD stated, if a resident expressed a desire to have an AD, assistance was offered, including notifying the Ombudsman (an advocate who helps protect the rights and interests of residents) and facilitating completion of the necessary documents. The SSD further stated existing ADs should have been obtained and copies maintained in the medical record. The SSD stated ADs were reviewed upon admission, quarterly by Social Services and the Interdisciplinary Team (a group of healthcare staff from different disciplines who work together to plan and coordinate care). The SSD stated if a resident lacked decision-making capacity, the responsible party, power of attorney, or conservator would have been consulted. During a concurrent record review for Residents 17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159, the SSD stated for Resident 126 and 155, the AD acknowledgment forms indicated an AD had been completed; but she was unable to locate copies of the ADs in the medical record. The SSD further stated she could not identify documentation that assistance was provided, including notification to the Ombudsman for Residents 17, 20, 25, 55, 6, 97, 110, 117, 119, and 159. The SSD stated this should have been done. The SSD stated without an AD, there was a risk that residents' treatment preferences might not be known or honored. A review of the facility policy and procedure titled, Advance Directives, dated January 2026, indicated, .the facility will inform residents of their rights to formulate advance directives and will honor resident choices regarding medical treatment, including life-sustaining interventions.document the presence or absence of advance directive.place a copy in medical record.review and update.upon admission.quarterly.with any change in condition.if no advance directive.offer assistance to complete one.follow CMS.right to request/refuse treatment and advance directives.

Based on interview and record review, the facility failed to ensure five of five sampled residents (Residents 2, 16, 45, 119, 159) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 16 was administered quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) for diagnosis of schizophrenia without documentation to support the diagnosis per The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, globally recognized standard classification system for diagnosing mental disorders by the American Psychiatric Association); and manufacturer specified monitoring were not done during use of quetiapine;2. For Residents 2, 45, 119, and 159, psychotropic medications were administered without adequate documentation of behavioral monitoring. Additionally, for Residents 2, 45, and 159, psychotropic medications were administered without adequate documentation of resident specific non-pharmacological (without medication) behavioral interventions. Furthermore, Resident 45 was administered a psychotropic medication without adequate monitoring for signs and symptoms of adverse effects.These failures had the potential to result in unnecessary medications for Residents 2, 16, 45, 119, 159, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.Findings: 1a. A review of Resident 16's admission Record, dated April 9, 2026, indicated Resident 16 was elderly, originally admitted to the facility on [DATE], and had diagnoses including: schizophrenia, transient ischemic attack (TIA, mini-stroke), cerebral infarction (stroke), vascular dementia (decline in thinking and memory), psychosis (a mental health condition where a person loses touch with reality), major depressive disorder, generalized anxiety disorder, hyperlipidemia (high cholesterol or fats in the blood), and cataract (clouding of the lens of the eye causing blurred vision). A review of Resident 16's Minimum Data Set (MDS, a care area assessment and screening tool), dated March 15, 2025, June 13, 2025, and June 25, 2025 indicated the resident had active diagnoses including dementia, TIA or stroke, depression, anxiety, hyperlipidemia, and cataract; and it did not indicate the resident had an active diagnosis of schizophrenia. A review of Resident 16's history and physical (H&P), dated March 11, 2025, indicated, [past medical history] significant for Asthma, Narcolepsy, Cataracts.Assessment/Plan.acute encephalopathy (sudden altered brain function), [left] occipital ischemic infraction (stroke), vascular dementia.cataracts. The H&P did not indicate the resident had a diagnosis of schizophrenia. A review of Resident 16's Initial Psychiatric Evaluation, dated March 12, 2025, indicated the resident had diagnoses including depression and anxiety; and did not indicate the resident had a diagnosis of schizophrenia. A review of Resident 16's hospital records titled Consult - Psychiatry, dated June 26, 2025, indicated the resident was admitted to the hospital from [DATE] to June 28, 2025. Additionally, it indicated, Family reports [Resident 16] never previously was diagnosed or treated for any psychiatric or behavioral health reasons (indicating that [Resident 16's] current diagnosis of schizophrenia is likely inaccurate).Assessment/Plan.dementia.with secondary psychiatric [symptoms] and behavioral disturbance. Diagnosis of schizophrenia appears inaccurate. A review of Resident 16's hospital records titled Consult - Psychiatry, dated June 27, 2025 and June 28, 2025, indicated Diagnosis of schizophrenia appears inaccurate. A review of Resident 16's facility medical record indicated a physician's order for quetiapine 12.5 mg (milligram, unit of measurement) by mouth every 8 hours for Schizophrenia m/b (manifested by) physical aggression, dated June 28, 2025. A review of Resident 16's Psychiatric follow-up note, dated July 15, 2025, indicated Recently started on [quetiapine] at acute hospital. Additionally, the Psychiatric follow-up note indicated the resident had diagnoses including depression, anxiety, impulse control disorder, and psychosis; and it did not indicate the resident had a diagnosis of schizophrenia. A review of Resident 16's MDS dated [DATE] and most recent MDS dated [DATE] indicated a schizophrenia diagnosis without documentation to support the diagnosis according to DSM-5-TR criteria for schizophrenia. A review of Resident 16's most recent Psychiatric follow-up note, dated March 13, 2026, indicated current medications including quetiapine 12.5 mg every 8 hours; diagnoses including depression, anxiety, impulse control, and psychosis; and it did not indicate the resident had a diagnosis of schizophrenia. During an interview and concurrent record review on April 9, 2026 at 10:09 a.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 16's medical record, including physician's orders, progress notes, and Psychiatric notes. The ADON described the facility's process for administration of psychotropic medications as follows: the doctor ordered the psychotropic medication, assessed the resident, and obtained consent. The ADON stated when quetiapine was started on June 28, 2025, the doctor put the indication on the order and schizophrenia diagnosis was added to Resident 16's medical record. When asked if there was documentation in the medical record of the assessment and evaluation of the resident meeting the DSM-5-TR criteria for schizophrenia, the ADON stated she needed to review the medical record. The ADON stated Resident 16's current Psychiatric follow-up note, dated March 13, 2026 did not have documentation of a schizophrenia diagnosis. During an interview and concurrent record review on April 9, 2026 at 12:56 p.m. with the Director of Nursing (DON), Resident 16's medical record was reviewed including hospital records, Psychiatric notes dated March 12, 2025, July 15, 2025, and March 13, 2026. The DON stated when residents were admitted to the facility, all psychotropic medications were reviewed during the Clinical Meeting with the DON, ADON, Social Services, Activities, and Rehab staff. The DON stated during the meeting, the team reviewed all psychotropics for appropriate diagnosis, target behavior, monitoring of side effects and informed consent. The DON stated Resident 16 was readmitted to facility from the hospital with diagnosis of schizophrenia on June 28, 2025. When asked if there was documentation in the medical record of the assessment and evaluation of the resident meeting the DSM-5-TR criteria for schizophrenia, the DON stated none of the Psychiatric notes listed schizophrenia as a diagnosis. The DON stated the hospital record titled Consult - Psychiatry, dated June 26, 2025 to June 28, 2025 indicated .diagnosis of schizophrenia appears in accurate. The DON stated during readmission of Resident 16 from the hospital, the indication and diagnosis of schizophrenia was not appropriately evaluated. During a telephone interview on April 9, 2026 at 1:35 p.m. with the Psychiatric Nurse Practitioner (PNP), when asked if Resident 16 had a clinical diagnosis of schizophrenia, the PNP stated, No. Additionally, the PNP stated Resident 16 had psychosis symptoms but did not meet the DSM-5-TR criteria for schizophrenia. During an interview on 4/9/26 at 1:48 p.m., the DON stated it was important to ensure residents had the correct diagnosis, especially for schizophrenia, in order to appropriately treat and monitor the resident. A review of the facility's policy and procedures (P&P) titled, Subject: Psychopharmacological, dated January 23, 2026, indicated, If a resident is admitted with orders for psychopharmacological drug use, the following will occur.A licensed nurse will review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician.The admission record is reviewed within 72-hours (weekdays).This review will include the use of psychopharmacological drugs, appropriate diagnosis.The Psychopharm Committee members will review residents on psychopharmacological drugs.Committee members will ensure the following.Psychopharmacological drugs have appropriate corresponding diagnosis. 1b. During an interview and concurrent record review on 4/9/26 at 1:48 p.m. with the DON, the DON reviewed quetiapine manufacturer specifications dated February 2026 and Resident 16's medical records. The DON confirmed Resident 16 started quetiapine on June 28, 2025. DON acknowledged quetiapine manufacturer specifications indicated warnings and precautions including dyslipidemia, cataracts, and hypothyroidism. The DON stated there was no documented evidence of laboratory monitoring for manufacturer's specified monitoring for lipids (blood cholesterol levels), TSH (a thyroid hormone), or an eye exam in Resident 16's medical record. The DON stated monitoring for adverse reactions according to the manufacturer specifications should have been completed during quetiapine use. The DON stated it was important to ensure severe side effects were monitored to avoid adding comorbidities for the resident. A review of Resident 16's Care Plan Report, dated June 29, 2025 indicated, Focus: Resident is taking an antipsychotic medication. Schizophrenia m/b physical aggression.Antipsychotic Medication(s): quetiapine.Goal: Will be free from discomfort or adverse reactions related to antipsychotic medications.Interventions.Monitor adverse reactions for antipsychotic medications.Increase total cholesterol and triglycerides. A review of the manufacturer's instructions for quetiapine tablets, dated February 2026, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration.), indicated, Warnings and precautions .Dyslipidemia.fasting blood lipid testing at the beginning of, and periodically, during treatment.Cataracts: Lens changes have been observed during long-term quetiapine treatment.Hypothyroidism Adults: Clinical trials with quetiapine demonstrated dose-related decreases in thyroid hormone levels.The mechanism by which quetiapine effects the thyroid axis is unclear.measurement of TSH alone may not accurately reflect a patient's thyroid status. Therefore, both TSH and free T4, in addition to clinical assessment, should be measured at baseline and at follow-up .Some patients with TSH increases needed replacement thyroid treatment. A further review of the facility's P&P titled, Subject: Psychopharmacological, dated January 23, 2026, indicated, Monitoring.The primary care physician will be responsible for ordering appropriate lab tests to assure adequate monitoring of psychopharmacological drugs. 2a. A review of Resident 45's admission Record, dated April 9, 2026, indicated Resident 45 was originally admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses including major depressive disorder and anxiety. A review of Resident 45's medical record indicated the following physician's orders: Xanax 0.5 mg (milligram, unit of measurement) Give 2 tablets by mouth two times a day for anxiety m/b (manifested by) self report of anxiety, dated February 20, 2026; Trazodone 50 mg Give 1 tablet by mouth at bedtime for depression m/b inability to sleep, dated December 23, 2025; Behavior Monitoring - Antidepressant (trazodone) Document Number of episodes of Target Behavior, intervention(s) attempted and effectiveness Target Behavior: 1. [left blank] 2. [left blank].Intervention: a. Redirection, b. 1:1, c. Diversional Activity, d. Offer to call family/friend, e. Other - document in progress notes.Effective: Y - Yes, N - No every shift, dated December 21, 2025; and Monitor Antidepressant (trazodone) ASE (adverse side effect) Code by the Number Indicated: every shift 0) None, 1) Sedation, 2) Drowsiness, 3) Dry mouth, 4) Blurred vision, 5) Urinary Retention, 6) Tachycardia, 7) Muscle Tremor, 8) Agitation, 9) Headache, 10) Skin Rash, dated December 21, 2025. A review of Resident 45's MARs dated December 21, 2025 to April 8, 2026, indicated Resident 45 was administered trazodone as prescribed by the physician. Additionally, the MARs indicated documented behavior monitoring for trazodone did not indicate the number of episodes of target behaviors and did not indicate the specific non-pharmacologic behavior intervention attempted as ordered by the physician. A review of Resident 45's MARs dated February 2, 2026 to April 8, 2026, indicated Resident 45 was administered Xanax as prescribed by the physician. A review of Resident 45's medical record on April 8, 2026 indicated there was no documented evidence of physician's orders for: Non-pharmacologic behavior interventions for Xanax; Monitoring of target behavior for Xanax; and Monitoring for adverse side effects related to the use of Xanax. During an interview and current record review on April 9, 2026 at 9:08 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 45's medical record was reviewed. LVN 4 confirmed Resident 45 was started on Xanax in February 2026. LVN 4 stated the target behavior for Xanax should have been documented in the resident's Medication Administration Record (MAR) and nursing staff should have documented the number of episodes during each shift. LVN 4 stated side effects of Xanax should have been monitored and documented on the MAR. LVN 4 stated prior to starting Xanax non-pharmacologic interventions such as turning/repositioning, going outside, or listening to music should have been attempted and documented on the MAR. LVN 4 acknowledged there was no documented evidence in Resident 45's medical record that side effect monitoring, target behavior monitoring, or non-pharmacologic interventions were documented during Xanax use and stated there should have been documentation. During an interview and current record review on April 9, 2026 at 10:25 a.m., Resident 45's medical record was reviewed with the ADON. The ADON confirmed Resident 45 was started on Xanax in February 2026. The ADON stated all psychotropic medications needed to have an order on the MAR for monitoring side effects and target behaviors, and documentation of non-pharmacologic interventions. The ADON stated when nursing staff received the order for Xanax, the orders for side effect/behavior monitoring and non-pharmacologic interventions should have been added to the MAR at the same time. ADON stated she was unable to locate documented evidence in Resident 45's medical record of any non-pharmacologic interventions, side effects or target behavior monitoring during Xanax use. The ADON stated I don't see it. During an interview and current record review on April 9, 2026 at 2:16 p.m., Resident 45's medical record including physician's orders and MARs dated December 2025 to April 2026 were reviewed with the DON. The DON acknowledged there was no documented evidence of physician's orders for non-pharmacologic behavior interventions for Xanax, monitoring of target behavior for Xanax, and monitoring for adverse side effects related to the use of Xanax. Additionally, the DON stated regarding trazodone behavior monitoring documentation on the MARs between December 2025 to April 2026, nursing staff had not documented the number of target behaviors, or which non-pharmacologic interventions were attempted as ordered by the physician. The DON stated the expectation was for nurses to document the number of target behavior and the specific non-pharmacologic intervention that was attempted during each shift. DON added, it was important to document the number of behaviors the resident had during each shift to effectively evaluate if the medication was working or not so the dose could be appropriately adjusted if needed. A review of the manufacturer's instructions for Xanax tablets, dated January 2023, retrieved from DailyMed indicated, Adverse reactions.impaired coordination, hypotension (low blood pressure), dysarthria (slurred or slowed speech). 2b. A review of Resident 2's admission Record, dated April 9, 2026, indicated Resident 2 was elderly, originally admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses including: dementia and psychosis. A review of Resident 2's medical record indicated the following physician's orders: Quetiapine 50 mg Give 1 tablet by mouth four times a day for Psychosis m/b unprovoked physical aggression, dated February 3, 2026; and Behavior Monitoring - Antipsychotic (Quetiapine) Document Number of episodes of Target Behavior, intervention(s) attempted and effectiveness Target Behavior: 1. [left blank] 2. [left blank].Intervention: a. Redirection, b. 1:1, c. Diversional Activity, d. Offer to call family/friend, e. Other - document in progress notes.Effective: Y - Yes, N - No every shift, dated February 3, 2026. A review of Resident 2's Care Plan Report, dated February 4, 2026 indicated, Focus: Resident is taking an antipsychotic medication r/t (related to) Psychosis m/b unprovoked physical aggression.Antipsychotic Medication(s): quetiapine.Goal: Will be free from discomfort or adverse reactions related to antipsychotic medications.Interventions.Administer medications as ordered and monitor for effectiveness.Monitor behavior and assess [every] shift (see MAR [Medication Administration Record] for tracking). A review of Resident 2's MARs dated February 3, 2026 to April 8, 2026, indicated Resident 45 was administered quetiapine as prescribed by the physician. Additionally, the MARs indicated documented behavior monitoring for quetiapine did not indicate the number of episodes of target behaviors and did not indicate the specific non-pharmacologic behavior intervention attempted as ordered by the physician. During an interview and concurrent record review on April 9, 2026 at 9:40 a.m. with LVN 4, Resident 2's medical record was reviewed. LVN 4 confirmed Resident 2 was started on quetiapine for February 2026. LVN 4 stated nursing staff should have documented on the MAR the specific type of non-pharmacologic interventions that were attempted, not just Y (yes) or N (no). LVN 4 stated on the MAR dated April 2026, only one nurse documented the types of non-pharmacologic interventions attempted during the shift but on all other days, nurses documented Y or N. During an interview and concurrent record review on April 9, 2026 at 10:34 a.m. with the ADON, Resident 2's medical record was reviewed. The ADON stated for all Psychotropic medications, all residents required documentation of target behavior monitoring and non-pharmacologic intervention specific for the resident. The ADON stated documentation on the MAR needed to indicate the specific non-pharmacologic intervention attempted, not Y or N. The ADON acknowledged the behavior monitoring order for quetiapine as listed above was missing the specific target behavior and stated the order should have specified the target behavior for quetiapine. Regarding documentation of target behaviors on the MAR, the ADON stated nursing staff needed to document the number of times the behavior was exhibited during the shift. The ADON acknowledged Resident 2 did not have documentation of the number of episodes of the target behavior Psychosis m/b unprovoked physical aggression. During an interview and concurrent record review on April 9, 2026 at 1:58 p.m. with the DON, Resident 2's medical record was reviewed. The DON stated Resident 2 had been on and off quetiapine since 2024. The DON acknowledged that when quetiapine was restarted in February 2026, the behavior monitoring order as listed above did not indicate the target behavior specified. Additionally, the DON stated nursing staff did not document on the MAR the number of behaviors exhibited by Resident 2, instead nursing staff were documenting Y (yes) or N (no). The DON stated the expectation was for nursing staff to have documented the number of behaviors and it was important to know how many behaviors were exhibited to evaluate the effectiveness of psychotropic medications during IDT (interdisciplinary team, a group of healthcare professionals from different specialties) meetings. Additionally, the DON acknowledged nursing staff did not document the specific non-pharmacologic interventions attempted on Resident 2's MAR and stated they should have. 2c. A review of Resident 159's admission Record, dated April 9, 2026, indicated Resident 159 was originally admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses including: major depressive disorder, anxiety, and insomnia (difficulty sleeping). A review of Resident 159's medical record indicated he had been receiving buspirone (used to treat anxiety) in various doses since October 2025 and trazodone (used to treat depression, insomnia, or anxiety) in various doses since May 2025. Resident 159's current Order Summary Report, dated April 9, 2026, indicated the following provider orders: Buspirone 7.5 mg tablet, Give 1 tablet by mouth two times a day for Anxiety M/B verbalization of feeling anxious, dated March 30, 2026; Trazodone 100 mg tablet, Give 2 tablet by mouth at bedtime for Inability to sleep, dated March 28, 2026; and Behavior Monitoring- Antidepressant (trazodone ) Document Number of episodes of Target Behavior, intervention(s) attempted and effectiveness Target Behavior: 1. [left blank] 2. [left blank] Intervention: a. Redirection b. 1:1 c. Diversional Activity d. Offer to call family/friend e. Other- document in progress notes Effective: Y- Yes N- No, every shift, dated January 11, 2026. A review of Resident 159's medical record on April 8, 2026 indicated there was no documented evidence of physician's orders for: Non-pharmacologic behavior interventions for buspirone; and Monitoring of target behavior for buspirone. A review of Resident 159's MARs dated January 1, 2026 to April 8, 2026, indicated Resident 159 was administered buspirone and trazodone as prescribed by the physician. Additionally, the MARs indicated documented behavior monitoring for trazodone did not indicate the number of episodes of target behaviors and did not indicate the specific non-pharmacologic behavior intervention attempted as ordered by the physician. A review of Resident 159's Care Plan Report, dated January 12, 2026 indicated, Focus: The resident uses anti-anxiety medications [related to] Anxiety M/B verbalization of feeling anxious. at risk for [adverse side effects]: buspirone.Goal: The resident's risk for discomfort or adverse reactions related to anti-anxiety therapy will be minimized. Interventions.Administer anti-anxiety medications as ordered. Monitor.effectiveness.Behavior Monitoring for anti-anxiety medication.Offer Nonpharmacological Interventions. During an interview and concurrent record review on April 9, 2026 at 9:48 a.m. with LVN 4, Resident 159's medical record was reviewed. Regarding behavioral monitoring and non-pharmacological interventions for buspirone, LVN 4 stated she didn't see an order for it and added there should have been an order. During an interview and concurrent record review on April 9, 2026 at 10:31 a.m. with the ADON, Resident 159's medical record was reviewed. The ADON stated Resident 159 should have had an order for behavioral monitoring and non-pharmacological interventions and said I don't see it, there should be. During an interview and concurrent record review on April 9, 2026 at 2:24 p.m. with the DON, Resident 159's medical record was reviewed. DON acknowledged when Resident 159 was administered trazodone, nursing staff did not appropriately document number of behaviors exhibited each shift and did not document the specific non-pharmacologic interventions attempted. Additionally, the DON stated for buspirone, there was no documented evidence of a provider order for behavioral monitoring and non-pharmacologic interventions and stated it should have been ordered and monitored with documentation on the resident's MAR. 2d. A review of Resident 119's admission Record, dated April 9, 2026, indicated Resident 119 was admitted to the facility on [DATE] and had diagnoses including: anxiety. A review of Resident 119's medical record indicated the following physician's orders: Buspirone 7.5 mg tablet, Give 1 tablet by mouth two times a day for anxiety m/b self verbalization of feeling anxious, dated March 30, 2026; and Behavior Monitoring- Antianxiety- Document number of episodes of target behavior, intervention attempted and effectiveness: Target Behavior: 1. Verbalization of feeling Anxious Intervention: a. Redirect b. 1:1 c. Activity d. Low stim environment e. Toilet f. Offer Snack g. Offer Fluids h. Position Change i. Assess Pain j. Other-document in progress notes Effective Y- Yes N- No two times a day for Buspirone use; dated March 30, 2026. A review of Resident 119's MARs dated March 1, 2026 to April 8, 2026, indicated Resident 119 was administered buspirone as prescribed by the physician. Additionally, the MARs indicated documented behavior monitoring for buspirone did not indicate the number of episodes of target behaviors and did not indicate the specific non-pharmacologic behavior intervention attempted as ordered by the physician. During an interview and concurrent record review on April 9, 2026 at 2:36 p.m. with the DON, Resident 119's medical record was reviewed. DON acknowledged documentation of behavior monitoring was inconsistent. The DON stated behavior monitoring for buspirone was not complete as documented on the MAR. The DON stated nursing staff should have documented the number of behavior episodes for buspirone, not yes or no or a check mark because IDT would not be able to quantify the episodes of behavior to adjust doses if needed and unable to tell if the medication effective or not. A further review of the facility's P&P titled, Subject: Psychopharmacological, dated January 23, 2026, indicated, admission procedures.The licensed nurse of designee will document any known target behaviors and potential interventions.Monitoring.Licensed nurses and additional staff will monitor and document any targeted behaviors that occur.

Based on observation, interview, and record review, the facility failed to ensure for five of 32 residents reviewed for quality of care (Residents 4, 19, 101, 178, and 180) when:1.For Resident 4, the intravenous (IV- specific location on the body where a small, flexible tube (catheter) is inserted into a vein to deliver medication) medications Meropenem (type of antibiotic) and Linezolid (type of antibiotic) were not documented as administered according to the physician orders.This failure had the potential to result in ineffective treatment of infection, worsening of the resident's condition, and development of antibiotic resistance; and2.For Resident 19, the IV medication Ceftriaxone (type of antibiotic) was not documented as administered according to the physician orders.This failure had the potential to result in ineffective treatment of infection, progression of urinary tract infection (when germs get into the urine system and cause infection), and potential complications such as sepsis (life-threatening condition caused by the body's extreme response to an infection); and3.For Resident 178, the facility did not schedule the ENT (Ear, Nose, and Throat) consultation according to the physician orders.This failure resulted in a delay in medical evaluation and had the potential to cause worsening of the resident's condition and prolonged pain; and 4.For Resident 101, the facility did not identify a significant change in the meal intake of less than 50% for multiple days between March 2026 to April 2026.This failure increased the risk of the resident not receiving the services necessary for her nutrition and health status; and 5. For Resident 180, a timely implementation of physician-ordered speech therapy services for one of three residents (Resident 180).This failure had the potential to place the resident at risk for aspiration, choking, and receiving an inappropriate diet texture.Findings: 1.A review of Resident 4's physician's order dated February 23, 2026, indicated the following: .Meropenem Intravenous Solution Reconstituted 1GM (gram- unit of measurement) Use 1 gram intravenously every 12 hours for s/p (status/post) coccyx (tailbone) wound debridement until March 10, 2026. and; .Linezolid Intravenous Solution 600 MG/300 ML (milligram/milliliter - unit of measurement) (Linezolid) Use 600 mg intravenously every 12 hours for s/p coccyx wound debridement until March 11, 2026. There was no documented evidence in Resident 4's Medication Administration Record (MAR) that Linezolid doses were administered. On April 9, 2026, at 10:10 a.m., a concurrent interview and record review of Resident 4's MAR (medication administration record) was conducted with the Infection Preventionist (IP), the IP stated there was no documentation in the MAR that Linezolid was administered on February 27, 28, March 4, 5, and 10, 2026, (6 a.m. doses), and no documentation that Meropenem was administered on March 1, 2026 (9 p.m. dose). The IP stated the if a medication was not documented as administered, it was considered not given. 2.On April 6, 2026, at 3:51 p.m., Resident 19 was observed alert, oriented, and watching television. In a concurrent interview with Resident 19, she stated the IV was placed when she was in the hospital for a UTI (urinary tract infection). Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included UTI. The history and physical, dated April 1, 2026, indicated Resident 19 had the capacity to make decisions. The physician order dated March 31, 2026, indicated ceftriaxone sodium 1 gm intravenously one time a day for UTI for 5 days. A review of the electronic Medication Administration Record (eMAR) for the month of April 2026, indicated the 6 a.m. dose of Ceftriaxone was not administered on April 2, 2026. There was no documented evidence the medication was administered as ordered. On April 8, 2026, at 3:35 p.m., a concurrent interview and record review was conducted with the Registered Nurse (RN 2). RN 2 stated the EMAR (electronic medication administration record) indicated the 6 am dose of the medication Ceftriaxone 1 gm intravenously was not administered on April 2, 2026. RN 2 stated the medication Ceftriaxone should have been administered as ordered and the physician should have been notified of the missed dose. On April 10, 2026, at 8:31 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated licensed nurses were expected to administer medications as ordered, document administration in the eMAR, and notify the physician when medications were not administered. The DON stated licensed nurses should have administered the 6 am dose of the IV medication Ceftriaxone according to the physician order and documented in Resident 19's EMAR. The DON stated the facility process for following physician's orders for administration of medication was not followed and should have been followed. A review of the facility policy and procedure titled Administering Medications, revised April 2019, indicated .The individual administering the medication initials the residents' MAR on the appropriate line after giving each medication and before administering the next ones.as required or indicated for a medication, the individual administering the medication record s (sic) in the resident's medical record: The date and time the medication was administered.The signature and title of the person administering the drug. A review of the facility policy and procedure titled Physician Orders, dated January 23, 2026, indicated .Ensure orders are followed correctly .Responsibilities Nursing .Receive, verify, and implement orders .ensure documentation accuracy . 3. On April 7, 2026, at 10:44 a.m., Resident 178 was observed alert, oriented, lying upright in bed. Resident 178 stated during her care conference on April 2, 2026, she informed the care team of right ear pain. Resident 178 stated the team informed her an ENT consultation would be scheduled. Resident 178 stated five days had passed and she had not been informed of a scheduled appointment. Resident 178's records were reviewed. Resident 178 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of pancreas (cancer tumor of the pancreas), obstruction of duodenum (intestinal blockage), major depressive disorder (intense feeling of sadness), and anxiety disorder (excessive fear of real or perceived thought). The history and physical dated March 29, 2026, indicated Resident 178 had the capacity to understand and make medical decisions. The physician order dated April 2, 2026, indicated .Refer to ENT Consultation per patient request. The IDT Note dated April 2, 2026, indicated .ENT referral right ear issues . There was no documented evidence that an ENT consultation appointment was scheduled from April 3 through April 8, 2026. On April 9, 2026, at 1:01 p.m., a follow up interview was conducted with Resident 178. Resident 178 stated the facility had still not provided an update regarding the ENT consultation appointment and she continued to experience increased right ear pain. On April 9, 2026, at 1:40 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated she was responsible for scheduling the resident's ENT consultation. The SSD stated ENT physician scheduled visits was every six months and Resident 178 was scheduled to be seen on the next visit. The SSD stated she should have asked Resident 178 if she would like to be seen by an outside physician since the physician already visited within the six-month window. The SSD stated the possible outcome of not scheduling resident for her acute ear pain as soon as applicable had the potential to result in a delay in medical care and a worsening of pain. On April 10, 2026, at 12:49 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated there was no documentation that the ENT consultation appointment was scheduled between April 3 and April 8, 2026. The ADM stated the consultation should have been arranged in a timely manner to address the resident's condition. The ADM stated the SSD should have offered Resident 178 to arrange for a visit from the outside physician and arranged the ENT consultation appointment to address her pain prior to April 9, 2026. A review of the facility policy and procedure titled Resident Appointments (Scheduling and Management), dated January 23, 2026, indicated, .The facility will ensure that all resident appointments are scheduled, coordinated, and completed in a timely manner to support continuity of care, resident safety, and regulatory compliance To: Ensure residents receive necessary medical services.prevent missed or delayed appointments.Appointments may be scheduled for.Specialty care.staff will schedule appointments promptly per physician order.Document appointment details (date, time, provider, location).Notify resident and/or responsible party of: appointment date and time.purpose of visit.document notification in medical record. 4. A review of Resident 101's record indicated Resident 101 was admitted to the facility on [DATE], with diagnoses including morbid obesity (severe fat accumulation), chronic kidney disease (reduced kidney function), and anemia (a condition of the blood which reduces the blood's ability to transport oxygen). The Minimum Data Set (MDS - an assessment tool), dated March 15, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). A review of the Food and nutritional assessment dated March 18, 2026, indicated, .resident consumes mostly 25% for all meals (breakfast, lunch, and dinner). Nutrition intervention/recommendations: 4oz (ounce – a unit of measurement) Health Shake TID (three times a day) w (with) /meals x (for) 14 days for inadequate PO intake.Current weight over IBWR (ideal body weight ration).Continue to monitor PO (by mouth) intake, skin integrity, weight trends, labs.Reassess as needed. A review of the nutrition report from March 18 to April 8, 2026, indicated an average meal percentage of 41%. A review of the meal intake percentage tasks documented by the facility staff from March 14 through April 8, 2026, indicated ongoing poor intake, including: -Meal intake of 25-50%: 18 instances. -Meal intake of 0-25%: 4 instances. -Meal percentage with refusal: 18 instances. Despite ongoing poor intake following initiation of nutritional interventions, there was no evidence the facility evaluated or addressed the resident's continued nutritional decline. There was no documented change of condition, no reassessment by the Registered Dietitian. A review of the progress note dated March 19, 2026, at 9:12 a.m. indicated, .MD (physician) and RD (registered dietitian) .health shake with meals for inadequate po intake for 14 days.start date.March 19, 2026.End date April 2, 2026. Further review of Resident 101's record, indicated no evidence of follow-up or reassessment after the completion of this intervention despite continued poor intake. On April 8, 2026, at 3:55 p.m., an interview was conducted with Registered Nurse (RN 1). RN 1 stated that changes in intakes should be reported to the physician and reflected in the care plan and stated this was not done. On April 9, 2026, at 1:28 p.m., an interview and record review were conducted with the Registered Dietitian (RD). The RD stated he was not notified of Resident 101's continued poor intake after his initial recommendation and did not reassess the resident. On April 9, 2026, at 2:03 p.m., a concurrent interview and record review were conducted with LVN 1. LVN 1 stated if an intake falls below 75% on 3 occasions, initiate a Change of Condition (COC), update the care plan, notify MD (physician) and monitor for 72 hours. LVN 1 stated there was no documentation of ongoing nutritional monitoring for Resident 101, no progress notes reflecting deteriorating intake, and no COC or care plan updates. On April 9, 2026, at 2:48 p.m. a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated that intake consistently below 50% on three occasions should trigger a COC and physician notification. The DON stated the facility did not recognize and address the resident's ongoing poor intake. A review of the facility policy and procedure titled, Change in Condition, dated January 23, 2026, indicated, .the facility will promptly identify, assess, and report any change in a residents condition to ensure timely intervention and appropriate care.monitor for changes.physical, mental, and functional decline.immediately report to the nurse.assess the resident.notify physician and responsible party as appropriate.implement new orders/interventions.document.description of the change.notifications, physicians/family.new orders.resident response.all staff are responsible for recognizing and reporting changes.licensed nurses are responsible for assessment, notification, and follow-up. 5. A review of Resident 180's admission Record dated April 10, 2026, indicated an admission date of April 4, 2026, with diagnoses which included hemiplegia (paralysis of one side of the body) and dysphagia (difficulty in swallowing). A review of Resident 180's Order Summary Report dated April 4, 2026, indicated an order for Speech Therapy Evaluation and Treatment [refers to professional services to assess and manage problems related to communication and swallowing]. A review of Resident 180's History and Physical dated April 6, 2026, indicated the resident did not have the capacity to make medical decisions. A further review of Resident 180's record indicated the resident was not evaluated by speech therapy until April 8, 2026, four days after the physician order dated April 4, 2026. On April 10, 2026, at 10:12 a.m., an interview was conducted with the Speech Therapist (ST). The ST stated residents were usually evaluated the day after a physician order was placed. The ST stated if the order was placed on a weekend, the expectation was for the resident to be evaluated on the following Monday. The ST stated Resident 180 should have been evaluated on Monday April 6, 2026. The ST stated Resident 180 was not evaluated until Wednesday, April 8, 2026. On April 10, 2026, at 1:55 p.m., an interview was conducted with the Director of Rehab (DOR). The DOR stated ST evaluations were expected within one to two days of the order. The DOR stated Resident 180 was not evaluated in a timely manner and could have been evaluated earlier. The DOR stated it was important to evaluate residents timely to ensure their diet was appropriate. On April 10, 2026, at 2:47 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated if a speech therapy order was placed on a Saturday, the resident should be evaluated by Monday. The ADON stated Resident 180 should have been evaluated sooner to ensure the correct diet and texture and to prevent aspiration. A review of the facility policy and procedure titled, Therapy Evaluations Timing Policy, dated January 23, 2026, indicated, .Evaluations should be completed as soon as possible (best practice 24-72 hours).Therapy staff: complete evaluations timely.

Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for two of three residents reviewed for nutrition (Residents 117 and 101), when:1. a. The facility failed to follow its policy Oral Nutritional Supplement (ONS) Use for monitoring the effectiveness of nutrition interventions for Resident 117. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach.b. The facility failed to follow physician diet ordered providing Fortified diet for Resident 117 during lunch on April 7, 2026, and April 9, 2026. This failure resulted in Resident 117 did not get extra calories to help improve her weight and wounds. (Cross reference 803) c. The facility failed to ensure Resident 117's food preference was honored during lunch on April 9, 2026. This failure had the potential to result in decreased food intake and could result in Resident 117's weight not improving. (Cross reference 806)d. The facility failed to follow its policy Care Plans, Comprehensive Person-Centered involving Resident 117's Legal guardian to discuss goal weight.e. The Registered Dietitian did not follow its policy Nutrition Support and Interventions: Nutrient Needs for Wound Healing to assess the Resident 117 nutrition's needs.These failures resulted in Resident 117 experiencing a 55-pound (33 percent) severe unplanned weight loss during a 4-months period from November 2, 2025, to April 5, 2026, and which may further impair nutrition and health status. 2. For Resident 101, the facility failed to ensure nutritional interventions were implemented, monitored, and adjusted in response to ongoing poor intake to maintain acceptable nutritional status.This failure had the potential to result in malnutrition, unplanned weight loss, and decline in health status. Findings: During a review of Resident 117's admission Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 117 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 117's diagnoses included Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of Sacral Region (is located at the base of the spine, just above the coccyx) , Malignant Neoplasm of Cecum (Colon Cancer), Unstageable Pressure Ulcer Right heel, Dysphagia Oropharyngeal phase (refers to impairment in the ability to initiate a swallow and efficiently move a bolus from the mouth through the pharynx to the upper esophagus), Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Chronic Kidney Disease stage 3 [ (CKD) means that your kidneys are damaged and can't filter blood as they should]. A record review of Resident 117 was conducted. During a review of Resident 117 's Minimum Data Set (MDS), a standardized assessment and care-planning tool, indicated as following: - Dated November 30, 2025, indicated 117 with active Diagnoses Cancer, Hypertension, Renal insufficiency, Non Alzheimer' Dementia, Malnutrition, Unstageable Pressure ulcer of sacral region. It is very important to have family involved in discussion care. - Dated February 7, 2026, February 25, 2026 and March 2, 2026, indicated Resident 117 had a weight loss of 5 % or more in the last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight-loss regimen [a program that is supervised by a medical professional that specializes primarily in weight loss for individuals that have a hard time losing weight despite their efforts]. - Dated March 2, 2026, the MDS indicated Resident 117 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated severely impaired cognition. Family and Legal guardian were active participated in Assessment and Goal setting. During a review of Resident 117's physician's order, dated April 10, 2026, the physician's order indicated, Diet: Fortified diet (diet with added nutrients to increase the calories and/or protein density to promote improvement in residents nutrition status), Soft and Bite Size-level 6 texture (food texture that requires a reduced amount of chewing), ordered on 2/24/2026; Dietary Supplement: Oral Nutrition supplement [(ONS)Nutrition drinks that has high calories and protein] three times a day as snacks ordered on 3/20/2026; Ice cream two times a day for weight management ordered on 2/24/2026; pudding with meals for weight management with meals ordered on 3/16/2026 During a review of Resident 117's weight record, the weight indicated as the following: 11/25/2025: 165 lbs. (pounds - a unit of measurement) admission weight 12/3/2025: 158 lbs. 12/17/2025: 156 lbs. 12/24/2025: 152 lbs. 1/1/2026: 149 lbs. 1/13/2026: 145 lbs. 1/21/2026: 127 lbs. 1/26/2026: 119 lbs. 2/5/2026: 119 lbs. 2/20/2026: 109 lbs. Readmit weight 3/5/2026: 109 lbs. 3/11/2026: 108 lbs. 3/18/2026: 107 lbs. 4/5/2026: 110 lbs. Based on the weight history from 11/25/25- 1/26/26 it was noted Resident 117 lost 46 pounds (28 %), is considered as severe weight loss in 2 months. Resident 117 lost 55 pounds (33 %) from 11/25/25- 4/5/26, is considered as severe weight loss in 4 months and 1 week. During a review of Resident 117's Nutrition assessment dated [DATE], completed by the Registered Dietitian (RD) indicated, Resident 117's estimated nutritional needs were 1400 -1800 calories based on 20 -25 kcal/body weight and 72-86 grams of protein based on 1.0 -1.2 gram/body weight. Resident 117 was also admitted with one unstageable Sarum pressure injury. The documented nutrition diagnosis listed the need for increased nutrition needs related to the need for wound healing. Weight: admit weight 11/25/25: 165 lbs.; 12/3/25: 158 lbs.: loss 7 lbs. for 1 week (4.2%). The documented weight loss unavoidable due to underlying medical conditions and varied meal intake, fluid shifts, therapeutic/mechanically altered diet, and advanced aging. RD recommended 4 ounce (oz) ONS (lunch/Dinner) for 30 days for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 12/18/2025, indicated, Weight: 12/3/25: 158 lbs.; 12/17/25: 156 lbs.: loss 2 lbs. for 2 weeks. Diet: No added salt; ONS 4 oz (lunch/Dinner) until 1/6/26. Meal intake: 0-100 %, mostly 26 -75 % with 3 meal refusals. RD recommended pudding lunch and dinner for 30 days for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 12/25/2025, indicated, Weight: 12/3/25: 158 lbs.; 12/17/25: 156 lbs.; 12/24/25: 152 lbs.: loss 6 lbs. for 3 weeks. Diet: No added salt; ONS 4 oz (lunch/Dinner) until 1/6/26; Pudding (lunch/Dinner) until 1/18/26. Meal intake: 0-100 %, mostly 26 -75 % with 4 meal refusals. RD recommended add double serving Protein with breakfast, discontinue ONS 4 oz (lunch/Dinner) and change to ONS 8 ounce (lunch/Dinner) x 30 days for weight management During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 1/2/2026, indicated, Weight: 12/3/25: 158 lbs.; 12/17/25: 156 lbs.; 12/24/25: 152 lbs., 1/1/2026:149 lbs.: Loss 3 lbs. for 1 week (2.0%); loss 9 lbs. for 1 month (5.7 %). Diet: No added salt, double serving Protein with breakfast; Ice cream twice per day, ONS 8 oz one time per day, Pudding one time per day (morning). Meal intake: 0-100 %, mostly 26 -75 % with 4 meal refusals. Skin: Sacrum stage 4, Right heel Deep Tissue injury (DTI). Plan: Reassess as needed During a review of Resident 117's Food and Nutrition Progress Notes, dated 1/9/2026, indicated, updated beverage preference (prune juice and coffee with breakfast) from daughter. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 1/13/2026, indicated, Weight: 12/17/25: 156 lbs.; 12/24/25: 152 lbs., 1/1/2026:149 lbs., 1/13/26: 145 lbs.: Loss 4 lbs. for 1 week; loss 11 lbs. for 1 month (7 %). Diet: No added salt, double serving Protein with breakfast; Ice cream twice per day, ONS 8 oz one time per day, Pudding one time per day (morning). Meal intake: 0-100 %, mostly 26 -75 % with 3 meal refusals. Skin: Sacrum stage 4, Right heel Deep Tissue injury (DTI). RD recommended add double serving Protein with all meals. During a review of Resident 117's Food and Nutrition Progress Notes, dated 1/13/2026, indicated, Daughter stated Resident enjoys soups, cottage cheese, and fruit cups. Daughter also would like Resident to have ONS 8 oz three time per day. RD recommended discontinue ONS one daily and changed to ONS 8 oz three times per day with meals for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 1/22/2026, indicated, Weight: 12/24/25: 152 lbs., 1/1/2026:149 lbs., 1/13/26: 145 lbs., 1/21/26: 127 lbs.: Loss 18 lbs. for 1 week (12.4%); loss for 3. for 3 weeks (14.8 %). Diet: No added salt, double serving Protein with breakfast; Ice cream twice per day, ONS 8 oz one time per day, Pudding one time per day (morning). Meal intake: 0-100 %, mostly 51 -75 %. Skin: Sacrum stage 4, Right heel Deep Tissue injury (DTI). RD recommended remove No added salt diet and change to regular diet and double serving Protein with all meals for weight management During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 1/29/2026, indicated, Weight:12/24/25: 152 lbs., 1/1/2026:149 lbs., 1/13/26: 145 lbs., 1/21/26: 127 lbs., 1/26/26: 119 lbs.: Loss 8 lbs. per 1 week (6.3%), loss 33 lbs. for 1 month (22%). Diet: Regular, double serving Protein with breakfast; Ice cream twice per day, ONS 8 oz three time per day, Pudding one time per day (morning). Meal intake: 0-100 %, mostly 51 -75 %. Skin: Sacrum stage 4, Right heel Deep Tissue injury (DTI). Visited Resident at bedside, Resident states that she may have some problems with chewing the food. No Remeron approval from doctor per RD recommendation on 1/22/26. RD recommended Speech Therapy evaluation. Add large portions for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 2/6/2026, indicated, Weight: 1/1/2026:149 lbs., 1/13/26: 145 lbs., 1/21/26: 127 lbs., 1/26/26: 119 lbs., 2/5/26: 119 lbs.: loss 30 lbs. for 1 month (20.1%), 46 lbs. (27.9 %) for 3 months. Diet: Regular diet, double serving Protein for all meals Large portions; Ice cream twice per day, ONS 8 oz three time per day, Pudding one time per day (morning). Meal intake: 26-100 %, mostly 51 -100 %. Skin: Sacrum stage 4, Right heel Deep Tissue injury (DTI). RD recommended add fortified diet for weight management. During a review of Resident 117's Readmit Nutrition assessment dated [DATE], completed by the RD indicated, Resident 117's estimated nutritional needs were 1500 -1750 calories and 60-75 grams of protein. Resident 117 was also admitted with stage 4 Sarum pressure injury and left/right heel Deep tissue injury. Weight: 2/5: 119 lbs.; readmit weight: 2/20: 109 lbs.: loss 10 lbs. for 2 weeks (8.4%). Current weight noted with 40 lbs. loss (26.8%) for 1 month, loss 56 lbs. (33.9%) for 3 months. Varied PO intake with 26-50 %. The documented weight loss unavoidable due to underlying medical conditions and advanced aging. RD recommended add fortified diet, pudding with breakfast, ice cream with lunch and dinner for weight management. During a review of Resident 117's Food and Nutrition Progress Notes, dated 2/27/2026, indicated, Per nursing, Resident's appetite has improved since readmission and tends to eat well during Breakfast/Lunch times. Resident still enjoys Pudding and Ice cream nourishment, and nursing states that Resident may benefit from ONS as well. RD recommended ONS 8 oz during breakfast for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 3/12/2026, indicated, Weight: 3/11/26: 108 lbs., 3/5/2026:109 lbs.: loss 10 lbs. (8.4%) for 1 month, loss 49 lbs. for 3 months (31.0%). Diet: Fortified diet; Ice cream twice per day, ONS 8 oz one time per day, Pudding one time per day (morning). Meal intake: 0-100 %, mostly 26-50 %. Skin: Sacrum stage 4, Right heel stage 3; Left heel DTI. RD recommended change pudding three times per day for weight management. During a review of Resident 117's Food and Nutrition Progress Notes for weight review, dated 3/19/2026, indicated, Weight: 3/18/26: 107 lbs., 3/11/26: 108 lbs., 3/5/2026:109 lbs Diet: Fortified diet; Ice cream twice per day, ONS 8 oz one time per day, Pudding three time per day. Meal intake: 0-100 %, mostly 26-50 % with meal refusals. Skin: Sacrum stage 4, Right heel stage 3. RD recommended change ONS 8 oz from one daily to three times per day per family request. On April 9, 2026, at 8:25 a.m., visited Resident 117 at bedside. Unable obtain information due to her mental status. On April 9, 2026, at 10:11 a.m., a concurrent interview and electronic medical record (EMR) review were conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated Resident 117's meal intake was variable; her meal intake was dependent on Resident 117's mood. CNA 6 stated average breakfast intake was 65 % and lunch 50 %. CNA 6 stated Resident 117 did not like ONS, she only sip on it. Concurrent review EMR, CNA 6 showed surveyor she included the amount intake of ONS with total amount intake of fluid during the day. CNA 6 stated there was no individual documenting the amount intake of ONS. CNA 6 also showed surveyor when she documented ice cream and pudding intake, she documented them as part of total meal intake. CNA 6 stated there was no individual documenting the amount intake of ice cream and pudding. On April 9, 2026, at 10:25 a.m., a concurrent interview and electronic medical record (EMR) review were conducted with Licensed Vocational Nurse (LVN) 6. Concurrent review EMR, LVN 6 stated Resident 117 received ONS scheduled at 10:00 a.m., 1400 and 2000. LVN 6 unable located the amount intake of ONS. On April 9, 2026, at 10:25 a.m., a concurrent interview and electronic medical record (EMR) review were conducted with LVN 5. LVN 5 stated she had been taking care Resident 117 since 2022. LVN 5 stated Resident 117 had a history of poor po intake like 25 %. Appetite improving after receiving appetite stimulator which ordered on 2/24/2026. Current meal intake with average 50 -75 with breakfast and lunch. Concurrent review EMR, LVN 5 unable located the amount intake of ONS. LVN 5 stated she did not know how much Resident 117 drank from ONS because ONS was provided by CNA. LVN 5 stated ice cream and pudding were documented as part of the total meal. 1. a. During a review of the facility's P&P titled, Oral Nutritional Supplement (ONS) Use, dated January 23, 2026, the P&P indicated, Policy Oral Nutritional Supplement (ONS) are used to promote adequacy of the diet and as a nutrition intervention for at risk or nutritionally impaired residents to prevent or reduce deterioration of nutritional status. Procedures: .A variety of supplements are offered and may include liquid drinks, . Regular documentation of the amount supplement consumed and tolerance is completed by designated personnel to monitor the effectiveness of supplement use.Effectiveness of supplement intervention is documented in the resident's medical record under dietary progress notes and addressed on the care plan.acceptance to be added to the medication administration record (MAR). On April 9, 2026, at 2:21 p.m., a concurrent interview and EMR review were conducted with the RD. The RD stated the nutrition interventions for Resident 117 were ONS between meal three times per day, ice cream with lunch and dinner, pudding with breakfast and fortified diet. The RD unable locate in EMR the amount intake of ONS, ice cream and pudding for Resident 117. The RD unable to answer how many extra calories Resident 117 obtain from ONS, ice cream and pudding. The RD unable to answer whether Resident 117 like ONS. The RD acknowledged without monitoring and documenting nutrition interventions, it was unable to determine the effectiveness of nutrition interventions. 1.b On April 7, 2026, at 11:57 a.m., a concurrent observation and Therapeutic Spreadsheets dated 4/7/26 (the document used to guide dietary staff on food items, portions, and therapeutic diet) review were conducted at the trayline (the process of plating resident meals according to physician ordered diets). Therapeutic Spreadsheets indicated, Fortified diet served 1 oz melted margarine. There was no melted margarine available at the steamtable or trayline. Observed [NAME] (CK) 2 plated fortified diet, no melted margarine served to Residents on fortified diet. On April 7, 2026, at 1:07 p.m., an interview was conducted with CK 2. CK 2 admitted she forgot to serve melted margarine to all fortified diet residents. On April 8, 2026, at 10:05 a.m., a concurrent interview and Therapeutic Spreadsheets dated 4/7/26 review were conducted with the RD and DFN. After review Therapeutic Spreadsheets, the DFN stated Resident who on fortified diet should serve 1 oz melted margarine on entree with lunch. The RD explained Resident on Fortified diet was prescribed by doctor for helping weight gain and promote wound healing. The RD stated Resident who on Fortified diet did not get melted margarine with lunch means he or she did not get extra calories. The RD stated his expectation was Cooks follow Therapeutic Spreadsheets and meal ticket served melted margarine (extra calories) to Fortified diet Residents. On April 9, 2026, at 12:45 p.m., a concurrent observe and Resident 117's meal ticket review with Resident 117's LG and CNA 6 at bedside. Resident 117 meal ticket indicated Resident 117 on Fortified diet with 1 oz melted margarin. CNA 6 and Resident 117's LG confirmed Resident 117's meal tray missing 1 oz melted margarin. During a review of the facility's P&P titled, Therapeutic Diets, dated January 23, 2026, the P&P indicated, Therapeutic Diets -Preparation and Service. Policy: All therapeutic diets .are references in the current diet manual and are prepared and served in the community daily written instructions. Procedures: .Specific therapeutic diets .are referenced in the diet manual with specific content and preparation. so accurate diets are served . 1 c. On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD. The RD was interview regarding tray card (meal ticket) and honoring food preference for residents. The RD stated resident's food preference was indicated in the meal ticket. Dietary staff should honor food preference and follow instruction as indicated in the meal ticket. The RD stated not honoring food prefer potential to result in decreased food intake. The RD explained decreased food intake could result in resident not getting enough nutrition, weight loss and compromise nutrition status. On April 9, 2026, at 12:49 p.m., a concurrent observe and Resident 117's meal ticket review with Resident 117's LG and CNA 6 at bedside. Resident 117's meal ticket indicated, Fortified diet. Tray instruction: Give soup; Likes Grill cheese with Tomatoes soup. CNA 6 and Resident 117's LG confirmed Resident 117's meal tray missing soup. Resident 117's LG stated there was always some missing food items in the meal tray provided. During a review of the facility's P&P titled, Resident Food Preferences, dated January 23, 2026, the P&P indicated, Purpose To ensure resident food preferences are identified, honored, and incorporated into care while maintaining needs and safety. Policy The facility will provide meals that respect each resident's preferences, .and dietary needs, consistent with physician orders and nutritional requirements. Procedure .Preferences will be .communicated to dietary staff .Meal Service Residents will receive meals: In accordance with preferences . During a review of the facility's P&P titled, Therapeutic Diets, dated January 23, 2026, the P&P indicated, Therapeutic Diets -Preparation and Service. Policy: All therapeutic diets .are references in the current diet manual and are prepared and served in the community daily written instructions. Procedures: .Each resident has specific food .preferences detailed on a tray card (meal ticket) ., so accurate diets are served. 1 d. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated January 23, 2026, the P&P indicated, Policy Statement A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy interpretation and Implementation 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.4. Each resident's comprehensive person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan care, including the right to: .participate in establishing the expected goals and outcomes of care .7. The comprehensive, person-centered care plan: includes measurable objectives .professional services are responsible for each element of care includes the resident's stated goals .and desired outcomes . During a review of the facility's P&P titled, Weight Management, dated January 23, 2026, the P&P indicated, Policy: .Dietitian and nursing management personnel are advised to review interventions and progress toward measurable resident care goals. On April 9, 2026, at 12:45 p.m., a concurrent interview was conducted with Resident 117's LG at bedside. Resident 117's LG stated Resident 117 admitted to this facility with weight 165 lbs. and her weight kept dropping. Resident 117's LG concerned Resident 117's significant unplanned weight loss and pressure injury. Resident 117's LG stated nobody including the RD from this facility was discussing with her regarding Resident 117's goal weight. Resident 117's LG stated she did not want Resident 117 to lose any more weight. During a review of the Resident 117's Weight Care Plan, initiated date 1/13/2026, Resident 117's Weight Care Plan indicated, Goal: Will be able to stabilize weight loss in 90 days On April 9, 2026, at 2:21 p.m., a concurrent interview and Resident 117's Weight Care Plan review were conducted with the RD. RD stated he did not do any care plan for Resident 117. The RD unable locate any documentation that he had been discussed with Resident 117's LG regarding Resident 117 's goal weight. The RD acknowledged, stabilize weight loss was not measurable goal for Resident 117. 1 e. During a review of the facility's P&P titled, Nutrition Support and Interventions: Nutrient Needs for Wound Healing, dated January 23, 2026, the P&P indicated, Policy: Residents with wound healing needs are considered to be at high nutritional risk and are assessed for optimal intervention to promote healing. Procedures: 1. Residents with pressure injuries of any stage .are refereed to the Registered Dietitian (RDN) for review of information to determine nutrition interventions. 2. Information reviewed for nutritional intervention will be include the following: .Percent eaten at meals, Estimate of calories, protein eaten, .Revised calories, protein and fluid needs, .5. Daily protein needs are estimated to increase depending on severity of wound. 6. Daily calories needs are estimated to increase depending on severity of wound.8. When severe malnutrition is present .additional nutrition support may be considered to temporarily increase nutritional intake to prevent further deterioration. During a review of Resident 117's Nutrition assessment dated [DATE], completed by the RD indicated, Resident 117's estimated nutritional needs were 1400 -1800 calories based on 20 -25 kcal/body weight and 72-86 grams of protein based on 1.0 -1.2 gram/body weight. Resident 117 was also admitted with one unstageable Sarum pressure injury. The documented nutrition diagnosis listed the need for increased nutrition needs related to the need for wound healing. On April 9, 2026, at 2:21 p.m., a concurrent interview and EMR review were conducted with the RD. Concurrent review Resident 117's Nutrition assessment dated [DATE], completed by the RD. The RD admitted the estimated nutritional needs (calories and protein) were too low for Resident 117. The RD 1 stated Resident 117 weight loss was unplanned and undesired. The RD continue following the Resident 117 significant weight loss weekly, but the RD unable locate the documentation of revised calories, protein needs of Resident 117 to ensure Resident obtained sufficient nutrition. 2. On April 6, 2026, at 3:49 p.m., Resident 101 was observed lying in bed, alert. Resident 101 stated the facility food was very poor. Resident 101 stated she rarely eat facility meals and preferred outside food. A review of Resident 101's record indicated Resident 101 was admitted to the facility on [DATE], with diagnosis which included, morbid obesity (severe fat accumulation), chronic kidney disease (reduced kidney function), and anemia (a condition of the blood which reduces the blood's ability to transport oxygen). The Minimum Data Set (MDS - an assessment tool), dated March 15, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). A review of the physicians orders indicated the following: - .Regular diet Regular -Level 7 texture (no restrictions), Thin Level 0 consistency (flows quickly through a straw) Low fat/Low Cholesterol NAS (no added salt) diet.start date March 13, 2026 . - .Health Shake with meals for inadequate PO intake for 14 days.start date March 19, 2026.end date April 2, 2026 . A review of the Medication Administration Record (MAR) for April 2026, indicated Resident 101 did not receive a health shake after April 2, 2026, and was not evaluated from April 2, 2026 to April 8, 2026, for poor PO intake. A review of Resident 101's Food and Nutrition preferences assessment dated March 16, 2026, indicated, .Eats three meals a day.Good intake 76-100% (percent).Resident likes most food/snacks at this time.Resident is alert and oriented is able to verbalize food likes and dislikes.aware of menu and substitutions eats in room independently no adaptive equipment. There are no food preferences listed and no food habits listed where questions are listed to be asked of the resident. A review of Resident 101's Food and nutritional assessment dated March 18, 2026, indicated, .resident consumes mostly 25% for all meals (breakfast, lunch, and dinner). Nutrition intervention/recommendations: 4oz (ounce – a unit of measurement) Health Shake TID (three times a day) w (with) /meals x (for) 14 days for inadequate PO intake.Current weight over IBWR (ideal body weight ration).Estimated fluid intake needs 2340-3120 (1ml (milliliters – a unit of measurement) /1kcal (kilocalorie – a unit of measurement).Continue to monitor PO (by mouth) intake, skin integrity, weight trends, labs.Reassess as needed. A review of the nutrition report from March 18 through April 8, 2026, indicated an average meal percentage of 41%. A review of Resident 101's meal intake records from March 18 through April 8, 2026, indicated ongoing poor intake including: -Meal intake of 25-50%: 18 instances. -Meal intake of 0-25%: 4 instances. -Meal percentage with refusals: 18 instances. A review of the fluid intake nutrition report from March 18, 2026, to April 8, 2026, indicated average fluid intake of 871 milliliters per day. This is below the expected value calculated by the RD upon admission. A review of the progress note dated March 19, 2026, at 9:12 a.m. indicated, .MD (physician) and RD (registered dietitian) .health shake with meals for inadequate po intake for 14 days.start date.March 19, 2026.End date April 2, 2026. Further review of Resident 101's record indicated no documented evidence the facility consistently implemented, monitored, or evaluated the effectiveness of this intervention, and no additional or modified nutritional interventions initiated despite continued poor intake. On April 9, 2026, at 1:28 p.m., an interview and record review were conducted with the Registered Dietitian (RD). The RD stated that residents are reassessed based on weight changes and no follow-up was conducted for Resident 101. The RD stated he was not notified by nursing of continued poor intake and was unaware of ongoing concerns after his initial recommendation. The RD stated Resident 101 was not flagged for concern or reassessment during weekly weight meetings and that nursing was responsible for communicating ongoing intake concerns. On April 9, 2026, at 2:48 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that poor oral intake should be monitored and addressed regardless of weight changes. The DON stated nursing staff should communicate ongoing intake concerns to the physician and the RD, document the resident's intake, and implement and adjust interventions as needed. The DON stated for Resident 101, there was no documentation of ongoing monitoring of poor intakes, no communication with the RD for reassessment, and no adjustment of nutritional interventions despite continued intake below 50%. The DON stated this placed the resident at risk for nutritional decline.

Based on observation, interview, and record review, the facility failed to ensure dietary staff were trained and competent to carry out the functions of the department safely and effectively when1.Food and Nutrition Specialist 1 did not know the right concentration of the Dish machine sanitizer. 2. Food and Nutrition Specialist 1 did not know the right location to check dish machine sanitizer.3. Several dietary staff did not follow manufacturer's guideline time length dipping the test strip into sanitizer (sanitizing solution used for sanitizing food contact surfaces) for testing the concentration of the sanitizer. This failure resulted in false reading of the concentration of sanitizer. Failure to have right concentration of sanitizer may result in ineffective sanitizer food contact surface which could cause foodborne illnesses.4. Several dietary staff and Registered Dietitian did not know the right concentration of the sanitizer. Failure to have right concentration of sanitizer may result in ineffective sanitizer food contact surface which could cause foodborne illnesses.5. [NAME] 3 and Registered Dietitian did not know how to calibrate thermometer.6. Two dietary staff did not know the cooling process and monitoring temperature for egg salad and Tuna salad. (Cross reference 812)7. Food and Nutrition Specialist 3 did not know how long she needed to submerge kitchenware in the sanitizer.8. [NAME] 1 prepared wrong texture for Mince and Moist meat during lunch on 4/7/2026. (Cross reference 805)9. Food and Nutrition Specialist 4 did not know manual washing wash temperature.These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), choking, and further harm in a medically compromised 146 out of 150 sampled residents who received foods from the kitchen.Findings:1. A review of the dish machine manufacturer's guidelines indicated, Chlorine (sanitizer for dish machine) 50 ppm (parts per million - a unit of measurement) On April 6, 2026, at 10:07 a.m., an interview was conducted with Food and Nutrition Specialist (FNS) 1 in the dishwasher area. FNS 1 was asked to demonstrate how to check the concentration of dish machine sanitizer (Chlorine). FNS 1 dipped the test strip into dish machine water tank and compared the result to the sanitizer indicator color chart on the test strip container. FNS 1 stated the concentration of the sanitizer was 200 ppm and it was the right concentration of the dish machine.On April 8, 2026, at 10:05 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the concentration of dish machine sanitizer (Chlorine) should be 50 -100 ppm per manufacturer guidelines. The RD stated the dietary staff were expected to follow these manufacturer guidelines. During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Mechanical washing: Low temperature dish machine .50 to 100 ppm chlorine (sanitizer) .2. On April 6, 2026, at 10:07 a.m., an interview was conducted with FNS 1 in the dishwashing area. FNS 1 was asked to demonstrate how to check the concentration of the dish machine sanitizer. FNS 1 dipped the test strip into dish machine water tank to check the concentration of sanitizer.On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD. The RD stated dietary staff should test sanitizer concentration on the dish surface, not by dipping the test strip into the water tank, otherwise this could result in inaccurate reading of sanitizer.During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Mechanical washing: Low temperature dish machine .50 to 100 ppm chlorine (sanitizer) on the dish surface.3. A review of manufacturer guideline poster for Sanitizer, posted above the three-compartment sink (use for wash, rinse and sanitize kitchenware), indicated, Dip test paper (strip) for 10 seconds in the test solution.On April 7, 2026, at 11:03 a.m., an interview was conducted with FNS 3 in the kitchen in front of three compartment sinks. FNS 3 was asked to demonstrate how to check the concentration of sanitizer in the sink. FNS 3 dipped the test strip into the sanitizer solution for 3 seconds and stated the test strip should be dipped for 20 seconds to check the concentration of sanitizer. On April 7, 2026, at 11:26 a.m., an interview was conducted with FNS 4 in the kitchen in front of the three compartment sinks. FNS 4 was asked to demonstrate how to check the concentration of sanitizer in the sanitizer sink. FNS 4 dipped the test strip into the sanitizer solution for 30 seconds and stated it should be dipped for one minute to check the concentration of sanitizer. On April 7, 2026, at 3:33 p.m., an interview was conducted with [NAME] (CK) 3 in the cooking area. CK 3 was asked to demonstrate how to check the concentration of sanitizer in a red bucket. CK 3 dipped the sanitizer test strip into the solution for two seconds and stated it should be dipped for 20 seconds to check the concentration of sanitizer. On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and the Director of Food and Nutrition (DFN). The RD stated dietary staff should dip the test strip [NAME] the sanitizer for 30 seconds to one minute to check the concentration of sanitizer. The DFN stated dietary staff should dip the test strip for 15 to 20 seconds. A concurrent review of the test strip manufacturer's guidelines printed on the test strip container with the RD and the DFN indicated that the test strip should be dipped for 10 seconds. The RD stated not following the manufacturer's guideline for dipping time could result in an inaccurate reading of the concentration of sanitizer. The RD explained that an inaccurate reading could lead to ineffective sanitizing food-contact surfaces, which may result in lack of removal of inadvertent growth on surfaces of microorganisms which may contaminate food and cause food borne illness.4. A review of manufacturer guideline poster for Sanitizer posted above 3 compartment sink, indicated, Testing solution should be between 150 -400 ppm.On April 7, 2026, at 11:26 a.m., an interview was conducted with FNS 4 in the kitchen in front of three-compartment sinks. FNS 4 was asked to demonstrate how to check the concentration of sanitizer in the sanitizer sink. FNS 4 dipped the test strip into the solution, and the result showed 400 ppm. FNS 4 stated she was not sure whether 400 ppm was the correct concentration.On April 7, 2026, at 3:33 p.m., an interview was conducted with [NAME] (CK) 3 in the cooking area. CK 3 was asked to demonstrate how to check the concentration of sanitizer in a red bucket. CK 3 dipped the sanitizer test strip into the solution for two seconds, and the result indicated 150 ppm. CK 3 stated the correct concentration of sanitizer should be in the range of 150 -200 ppm. CK 3 stated he did not know what to do if the sanitizer concentration was 500 ppm.On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and DFN. The RD stated he could not remember the appropriate sanitizer concentration range. The DFN stated per sanitizer manufacturer guidelines, the acceptable range for sanitizer concentration is 150 -400 ppm. The DFN further stated if the sanitizer concentration exceeds 400 ppm, the sanitizer solution would be too strong and could contaminate kitchenware and food-contact surfaces.5. On April 7, 2026, at 3:33 p.m., an interview was conducted with CK 3 in the cooking area. CK 3 was asked to demonstrate how to calibrate a thermometer. CK 3 filled a small cooking pan with ice water and stated the thermometer should be calibrated to 35 degrees Fahrenheit ( F - a unit of measurement).On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and the DFN. The RD stated the thermometer should be calibrated to 0 F. The DFN verified the thermometer should be calibrated to 32 F. The RD explained that if a cook did not know how to properly calibrate a thermometer, it would result in inaccurate temperature readings. The RD further stated inaccurate thermometer readings could result in incorrect food temperature measurements, which may lead to food being unsafe for residents. During a review of the facility's provided documentation titled, Calibration Instruction: Bimetallic Stemmed Thermometer, Ice point method, dated January 23, 2026, indicated, .put the thermometer stem into ice water so the sensing area is completely submerged.Leave the stem in the ice water 30 seconds until the dial stops moving .rotate the head of the thermometer until it reads 32 F.6. On April 8, 2026, at 9:24 a.m., an interview was conducted with FNS 7. FNS 7 was asked to demonstrate how to monitor the cooling process (is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135 F to 41 F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If left out to cool, cooked food can become unsafe to eat in a matter of hours.) for egg salad or tuna salad. FNS 7 was unable to demonstrate the cooling process. FNS 7 stated she had worked at the facility for 5 years and had never performed the cooling process for egg salad or tuna salad and had never seen a cooling log used to document the cooling process.On April 8, 2026, at 2:34 p.m., an interview was conducted with FNS 4 and the RD. FNS 4 was asked to demonstrate how to monitor cooling process for tuna salad and egg salad. FNS 4 was unable to demonstrate, stating she had never performed the cooling process. The RD stated it was important that dietary staff understand and monitor the cooling process, which was monitoring time and temperature for foods such as tuna salad and egg salad. The RD stated there was a potential risk of food borne illnesses if the cooling process for egg salad and tuna salad was not monitored. During a review of the facility provided job description titled, Food and Nutrition Specialist, updated on 11/1/2024. The job description indicated, The Food and Nutrition Specialist's main responsibility is to assist with all dietary functions as directed and in accordance with established dietary policies and procedures. DUTIES AND RESPONSIBILITIES 1. Ensures dietary procedures are followed according to established policies, .7. A review of manufacturer guideline for sanitizer, posted above three-compartment sink, indicated Submerge in sanitizer for one minuteOn April 7, 2026, at 11:03 a.m., an interview was conducted with FNS 3 in the kitchen in front of three-compartment sink. FNS 3 was asked how long kitchenware should be submerged in the sanitizing solution. FNS 3 stated she needed to submerge the kitchenware for 30 minutes.On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and the DFN. During a concurrent review of the manufacturer guidelines, the RD and the DFN stated the dietary staff should submerge kitchenware in the sanitizer for one minute. The RD and the DFN explained that submerging kitchenware for less than the required time could result in improper sanitization, which may lead to cross-contamination and foodborne illness. During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Manual Washing Three Compartment Sink Method: .submerse in the sanitizing compartment according to the chemical vendor's time requirements.8. A review of the poster for the International Dysphagia Diet Standardization Initiative (IDDSI) posted in the cooking area, indicated, Mince and Moist: Fork Pressure Test: Food separates and comes through prongs of dinner fork easily.On April 7, 2026, at 9:37 a.m., a concurrent observation and interview were conducted with the RD, the DFN and CK 1 in the cooking area. CK 1 stated he had finished preparing all modified texture diets for lunch. CK 1 was asked to demonstrate how he used the fork test to check the appropriate texture of Mince and Moist meat. The meat size he prepared was observed larger than the prongs of a fork. After CK 1 performed the Fork Pressure Test for Mince and Moist meat, the RD and the DFN claimed it was the wrong texture. The DFN stated CK 1 needed to process the meat in the blender for a longer time to make the size smaller. The RD stated serving the wrong texture placed the residents at risk for choking.During a review of the facility provided job description titled, Cook, updated on 11/1/2024. The job description indicated, The [NAME] is responsible for the preparation of food in accordance with current applicable federal .standards, guidelines and regulations with established policies and procedures, and as may be directed by the Registered Dietitian, to assure that quality food service is provided at all times. DUTIES AND RESPONSIBILITIES 1. Prepares meals in accordance with planned menus, standard recipes, therapeutic diets .9. On April 7, 2026, at 11:26 a.m., an interview was conducted with FNS 4 in the kitchen in front of the three-compartment sink. FNS 4 stated she did not know the required wash temperature for manual dishwashing in the wash sink. During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Manual Washing Three Compartment Sink Method: 1. Wash: Fill compartment wash sink .with hot water at approximately 110 F .

Based on observation, interview, and record review, the facility failed to ensure1. The Fortified diet received melted margarine per Therapeutic Spreadsheets during lunch on 4/7/2026. (cross reference 692)2. The Food and Nutrition Department had recipes for alternate meals.3. One dietary staff used right scoop served pureed dessert during lunch on 4/7/2026.4. [NAME] 2 used right scoop served Mince and Moist meat during lunch on 4/7/2026.These failures had the potential to negatively impact on the residents' nutritional status and further compromising residents' medical status. Findings:1. On April 7, 2026, at 11:57 a.m., a concurrent observation and Therapeutic Spreadsheets dated on 4/7/26 (the document used to guide dietary staff on food items, portions, and therapeutic diet) review were conducted at the trayline (the process of plating resident meals according to physician ordered diets). Therapeutic Spreadsheets indicated, Fortified diet served 1 oz melted margarine. There was no melted margarine available at the steamtable or trayline. Observed [NAME] (CK) 2 plated fortified diet, no melted margarine served to Residents on fortified diet.On April 7, 2026, at 1:07 p.m., an interview was conducted with CK 2. CK 2 admitted she forgot to serve melted margarine to all fortified diet residents. On April 8, 2026, at 10:05 a.m., a concurrent interview and Therapeutic Spreadsheets dated 4/7/26 review were conducted with the RD and DFN. After review Therapeutic Spreadsheets, the DFN stated Resident who on fortified diet should serve 1 oz melted margarine on entree with lunch. The RD explained Resident on Fortified diet was prescribed by doctor for helping weight gain and promote wound healing. The RD stated Resident who on Fortified diet did not get melted margarine with lunch means he or she did not get extra calories. The RD stated his expectation was Cooks follow Therapeutic Spreadsheets and meal ticket served melted margarine (extra calories) to Fortified diet Residents.During a review of the facility's provided Diet Type Report (same as physician diet order), dated April 8, 2026, the Diet Type Report indicated, 21 Residents (Resident 16, 27, 30, 36, 46, 49, 55, 65, 88, 89, 93, 102, 116, 117, 118, 119, 130, 135, 146, 151, and 157) on fortified diet.During a review of the facility's P&P titled, Therapeutic Diets, dated January 23, 2026, the P&P indicated, Therapeutic Diets -Preparation and Service. Policy: All therapeutic diets .are references in the current diet manual and are prepared and served in the community daily written instructions. Procedures: .Specific therapeutic diets, .are referenced in the diet manual with specific content and preparation. During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, and consistent manner using approved recipes and established food preparation standards. Procedure: 1. Dietary staff shall prepare food according to .menu guidelines .2. On April 7, 2026, at 11:09 a.m., a concurrent observation and interview were conducted with Assistant [NAME] (AC) in cook area. AC was observed making grilled cheese without refer to recipe. Ak stated he was making 4 grilled cheese as an alternate meal (substitution meal that serve to resident if resident does not like provided menu on the day) for Residents.On April 7, 2026, at 11:10 a.m., a concurrent observation and interview were conducted with CK 2 in cook area. CK 2 was observed making cheese quesadilla without refer to recipe. CK 2 put a hand full of Mozzarella cheese into 8 inch white corn tortilla. CK 2 stated she was making 8 cheese quesadilla as an alternate meal for residents.On April 7, 2026, at 11:36 a.m., a concurrent observation and interview were conducted with Food and Nutrition Specialist (FNS) 6 and FNS 7 in Prep area. FNS 6 was observed preparing Chef salad. When asked how many slide Turkey she need to put in Chef salad. FNS 6 not sure she needed to put 2 slices or 3 slices Turkey. FNS 6 stated there was no Chef salad recipe for her to refer to. FNS 7 stated she had been working here for 5 years. She never seen Chef salad recipe, and she had been trained making Chef salad without recipe.On April 8, 2026, at 9:38 a.m., confirmed with CK1, CK 2 and AC. There was no recipe for alternate meals for grilled cheese and cheese quesadilla.On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD. The RD did not know there was no recipe for Chef salad, grilled cheese and cheese quesadilla. The RD stated the alternate meals should have recipe. The RD stated it was important to have recipe for Dietary staff to follow, to ensure prepare correct portion and adequacy nutrition for alternate meals.During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, and consistent manner using approved recipes and established food preparation standards. Procedure: 1. Dietary staff shall prepare food according to standardized recipes .3. A review Therapeutic Spreadsheets dated on 4/7/26 indicated, Puree diet: pureed yellow cake used number 12 scoop [2.5 ounce (oz - a unit for measurement)]On April 7, 2026, at 11:33 a.m., a concurrent observation and interview were conducted with FNS 5 in the kitchen at Prep area. FNS 5 was observed using blue scoop (number 16; 2 oz) portioned out individual serving pureed cake into single serving containers. FNS 5 stated she was going to serve the pureed cake for today lunch.On April 8, 2026, at 10:05 a.m., a concurrent interview and Therapeutic Spreadsheets dated 4/7/26 were conducted with the RD and DFN. After the DFN reviewed the Therapeutic Spreadsheets, the DFN stated FNS 5 used smaller scoop to portion the pureed cake. The RD stated the mistake resulted in the Pureed Residents received less calories which could lead to not getting adequate nutrition.During a review of the facility's policy and procedure (P&P) titled, Portion Size, Reviewed January 23, 2026, the P&P indicated, Policy: The menu adopted by the community will illustrate portion sizes for each diet to meet the nutritional standards as set forth in the community's diet manual. Procedure: .Daily Menu spreadsheet demonstrate the regular portion size and .portion is allowed on this diet.4. On April 7, 2026, at 11:57 a.m., a concurrent observation and Therapeutic Spreadsheets dated on 4/7/26 review were conducted at trayline. A review Therapeutic Spreadsheets dated on 4/7/26 indicated, Mince and Moist meat 3 oz. CK 2 was observed used grey scoop (4 oz) plating Mince and Moist meat.On April 8, 2026, at 10:05 a.m., a concurrent interview and Therapeutic Spreadsheets dated 4/7/26 were conducted with the RD and DFN. After the RD reviewed the Therapeutic Spreadsheets, the RD stated CK 2 should use number 10 Ivory scoop (3 oz) to plate Mince and Moist meat. The RD stated CK 2 served larger portion protein which overfed the residents on Mince and Moist diet.During a review of the facility's policy and procedure (P&P) titled, Portion Size, Reviewed January 23, 2026, the P&P indicated, Policy: The menu adopted by the community will illustrate portion sizes for each diet to meet the nutritional standards as set forth in the community's diet manual. Procedure: .Daily Menu spreadsheet demonstrate the regular portion size and .portion is allowed on this diet.

Based on observation, interview, and record review, the facility failed to:1. Follow its policy titled Point of Service Food Temperature Guide to provide appetizing food at appropriate temperatures according to residents' preferences for five of 146 sampled residents (Resident 8, 10, 21, 84 and126).This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.2. Ensure that 11 of 11 residents receiving a pureed diet (a type of diet where all foods are blended until they are smooth, soft, and lump free) were provided foods that were prepared in a manner which preserved nutritional value. This failure placed residents receiving a pureed diet at risk for compromised nutritional status.1. On April 6, 2026, at 9:52 a.m., an interview was conducted with Resident 84 in her room. Resident 84 stated, Breakfast is consistently cold On April 6, 2026, at 10:45 a.m., an interview was conducted with Resident 8 in her room. Resident 8 stated she receives cold breakfasts and dinners. On April 6, 2026, at 1:17 p.m., an interview was conducted with Resident 10 in his room. Resident 10 stated, Eggs are cold, sometimes the butter they provide doesn't melt in the oatmeal because the oatmeal is cold, and pancakes are cold. On April 7, 2026, at 11:00 a.m., during a Resident Council meeting, multiple residents reported concerns that food was served cold, including statements that served sausage appeared refrigerated, and breakfast items were not served at appropriate temperatures. On April 8, 2026, at 7:35 a.m., a meal cart containing a test meal was observed leaving the kitchen and was placed outside room [ROOM NUMBER] at 7:36 a.m., where it remained while awaiting staff to distribute meal trays to residents requiring feeding assistance. On April 8, 2026, at 7:55 a.m., a test meal was conducted for food temperature of the fortified regular diet and puree diet with the DFN, at the nursing station. The following food temperatures were obtained: Fortified Regular diet: Egg: 89.7 degrees Fahrenheit ( degrees F - a unit of measurement); Turkey sausage patties: 84 degrees F; Toast: 80.6 degrees F. Puree diet: cream of wheat: 119.4 degrees F; egg: 92.3 degrees F; bread 91 degrees F. The DFN verified these temperatures and stated the food items were cold. On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and the DFN. The DFN acknowledged that breakfast foods were served cold. The DFN explained hot cereal cooled because dietary staff stacked individual servings outside of the steam table, which did not maintain adequate heat. The DFN claimed it took a long time for nursing passing residents' meal tray which resulted in Residents receiving cold breakfast. The RD stated serving cold foods may decrease residents' intake and negatively impact nutritional status, including potential weight loss. During a review of the facility's policy and procedure (P&P) titled, Point of Service Food Temperature Guide, Reviewed January 23, 2026, the P&P indicated, Food temperature will be at an appropriate temperature at point-of-service (POS) to ensure food quality and resident satisfaction. Procedure: . The following are guidelines that may be used to enhance food palatability .: Hot Foods- 120 – 155 degrees F . 2. During a review of the facility's Diet Type Report, dated April 8, 2026, indicated, 11 Residents (Resident 6, 7, 24, 65, 66, 93, 113, 121, 135, 157, and180) were receiving a pureed diet. On April 7, 2026, at 9:37 a.m., a concurrent observation and interview were conducted with [NAME] (CK) 1 in the cooking area. CK 1 stated he had prepared all modified texture diets and stored them in oven at 200 -250 degrees F. CK 1 stated his usual practice was to prepare pureed diets between 9 a.m. and 9:30 a.m. and store them in the oven until service. On April 7, 2026, at 10:33 a.m., an interview was conducted with CK 2. CK 2 stated her usual practice was to prepare pureed diets between 9 a.m. and 9:30 a.m. and stored finished pureed food items in oven. On April 8, 2026, at 9:21 a.m., an interview was conducted with Assistant [NAME] (AC). AC stated he completed preparation of pureed diets before 10 a.m. and stored them in the oven at 200 - 250 degrees F. On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD and the DFN. The RD stated he was not aware cooks prepared pureed foods so early. The RD and the DFN acknowledged cooks prepared pureed foods too early. The DFN stated prolonged holding of pureed foods in the oven could lead to loss of nutrients and compromise the integrity, taste, and quality of the food. During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, and consistent manner using approved recipes and established food preparation standards. Procedure:.Food shall be prepared in a manner that preserves nutritional value, palatability.

Based on observation, interviews, and record review, the facility failed to ensure the appropriate food textures was provided when1. 11 out of 11 sampled Residents on pureed texture received grainy pureed beef and pureed bread during lunch on 4/7/2026.2. 13 out of 13 sample Residents on soft and bite sized received wrong texture for green bean and beef during lunch on 4/7/2026.These failure had the potential to place the residents at risk of choking.Findings:1. On April 7, 2026, at 1:10 p.m., with the Director of Food and Nutrition (DFN), at the RNA dining room, a test meal was performed for the pureed diet. The DFN verified the pureed beef and bread tasted grainy. The DFN stated pureed diet supposed to be smooth consistency. The DFN stated cooks should have left the beef and bread in the blender for a longer period with adding some broth to reach the smooth consistency. The DFN stated Resident could choke with this kind of grainy texture. During a review of the facility's provided Diet Type Report (same as physician diet order), dated April 8, 2026, the Diet Type Report indicated, 11 Residents (Resident 6, 7, 24, 65, 66, 93, 113, 121, 135, 157, and180) on pureed diet.During a review of the facility provided pureed diet definition from diet menu, revised February 2025, the diet menu indicated, Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Recommendations: .They should have a pudding like smooth consistency.During a review of the facility provided recipe, Roast Beef/Gravy. Puree: Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Add thickener and process until smooth.During a review of the facility provided recipe, Pureed Bread.Place portions of bread into a food processor.Process until smooth.During a review of the facility's P&P titled, Therapeutic Diets, dated January 23, 2026, the P&P indicated, Therapeutic Diets -Preparation and Service. Policy: All therapeutic diets .are references in the current diet manual and are prepared and served in the community daily written instructions. Procedures: .Specific .texture modifications .are referenced in the diet manual with specific content and preparation. During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, and consistent manner using approved recipes and established food preparation standards. Procedure: 1. Dietary staff shall prepare food according to standardized recipes and menu guidelines .2. On April 7, 2026, at 9:37 a.m., a concurrent observation and interview were conducted with [NAME] (CK) 1. CK 1 took out a pan of beef from oven and stated he was going to serve this pan of beef for regular diet and soft and bite sized during lunch. Observed the size of beef, it appeared wrong texture (bigger size) for the soft and bite sized.On April 7, 2026, at 1:10 p.m., with the DFN, at the RNA dining room, a test meal was performed for the texture of soft and bite sized diet. The DFN stated the served beef was not properly chopped to the right size for soft and bite size. The DFN stated the size of beef served is bigger which was for easy to chew diet. The DFN verified the served green bean which was not right texture (some green bean pieces bigger than 1.5 cm (centimeter - a unit of measurement) x 1.5 cm). The DFN stated cook should use rubber spatula scrape downside green bean of the food processor and put green bean in processor longer to make the green bean size smaller. The DFN stated there was potential choking hazard serving bigger food texture for soft and bite size residents.During a review of the facility's provided Diet Type Report (same as physician diet order), dated April 8, 2026, the Diet Type Report indicated, 13 Residents (Resident 16, 23, 30, 35, 54, 55, 68, 85, 86, 117, 125, 158, and 170) on Soft and Bite Sized diet.During a review of the facility provided Soft and Bite sized diet definition from diet menu, revised February 2025, the diet menu indicated, Definition: A diet used in the dietary management of dysphagia with the food texture to be prepared as soft, tender .The particle size of the food should be no greater than 1.5 cmx 1.5 cm for adults. Biting is not required but chewing is required.During a review of the facility provided recipe, Seasoned [NAME] Bean: Soft and Bitew Sized: Chop regular portions. Make sure all particles are no more than 1.5 cm x 1.5 cm in size .During a review of the facility's P&P titled, Therapeutic Diets, dated January 23, 2026, the P&P indicated, Therapeutic Diets -Preparation and Service. Policy: All therapeutic diets .are references in the current diet manual and are prepared and served in the community daily written instructions. Procedures: .Specific .texture modifications .are referenced in the diet manual with specific content and preparation. During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, and consistent manner using approved recipes and established food preparation standards. Procedure: 1. Dietary staff shall prepare food according to .menu guidelines .

Based on observation, interview, and record review, the facility failed to ensure residents' food preference was honored for two of 146 sampled residents (Resident 10 and Resident 117) when1. Resident 10 had food preferences for double protein and dislikes included carrots on the meal ticket but Resident 10 did not receive double protein and received carrots during lunch service on April 6, 2026.2. Resident 117 had food preference as soup on the meal ticket but Resident 117 did not receive soup during lunch on April 9, 2026. (Cross reference 692)This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 10 and 117's nutritional and medical status.Findings: 1. A review of Resident 10's admission Record dated April 8, 2026, indicated the resident was admitted on [DATE], with diagnosis which included cirrhosis of the liver (liver impairment). A review of Resident 10's Minimum Data Set (MDS – an assessment tool) dated April 3, 2026, indicated a Brief Interview for Mental Status (BIMS – an assessment tool for cognition) score of 15 (cognitively intact). A review of Resident 10's lunch meal tray ticket dated April 6, 2026, indicated, .Tray Instructions: DOUBLE PROTEIN.Dislikes.carrots. On April 6, 2026, at 1:24 p.m., a concurrent observation and interview were conducted in Resident 10's room. Resident 10's lunch tray was observed to contain one portion of protein (pork chop). Resident 10 stated he informed staff of the single portion of protein, and a second lunch tray was delivered. The second lunch tray included carrots. Resident 10 stated he frequently received single portions of protein and food he dislikes, including carrots. On April 8, 2026, at 10:05 a.m., an interview was conducted with the Registered Dietitian (RD) regarding tray card (meal ticket) and honoring food preference for residents. The RD stated resident's food preference was indicated in the meal ticket and dietary staff should honor food preference and follow instruction as indicated in the meal ticket. The RD stated not honoring food preferences could result in decreased intake. The RD stated decreased food intake could result in resident not getting enough nutrition, weight loss and compromise his or her nutrition status. On April 9, 2026, at 2:15 p.m., a concurrent interview and record review were conducted with the Dietary Supervisor (DS). The DS stated Resident 10 should have received double portion and should have not been served carrots. The DS stated not following meal ticket instructions could result in decreased intake and negatively affect the resident's nutritional status. 2. On April 8, 2026, at 10:05 a.m., an interview was conducted with the Registered Dietitian (RD) regarding tray card (meal ticket) and honoring food preference for residents. The RD stated resident's food preference was indicated in the meal ticket and dietary staff should honor food preference and follow instruction as indicated in the meal ticket. The RD stated not honoring food preferences could result in decreased intake. The RD stated decreased food intake could result in resident not getting enough nutrition, weight loss and compromise his or her nutrition status. A review of Resident 117 admission Record dated April 9, 2026, indicated the resident was admitted on [DATE], with diagnoses including dysphagia (difficulty in swallowing). A review of Resident 117's lunch meal tray ticket dated April 9, 2026, indicated, .Tray Instructions .GIVE SOUP .Likes Grill cheese with Tomatoes soup . On April 9, 2026, at 12:49 p.m., a concurrent observation and interview were conducted at the bedside with Resident 117's Legal Guardian (LG) and CNA 6. Resident 117's meal tray was observed without soup. CNA 6 confirmed Resident 117's meal tray was missing soup. The LG stated food items were often missing from the resident's meal trays. A review of the facility policy and procedure titled, Resident Food Preferences, dated January 23, 2026, indicated, .Purpose To ensure resident food preferences are identified, honored, and incorporated into care while maintaining needs and safety. Policy The facility will provide meals that respect each resident's preferences.and dietary needs, consistent with physician orders and nutritional requirements Procedure.Preferences will be.communicated to dietary staff.Meal Service Residents will receive meals: In accordance with preferences.

Based on observation, interview, and record review, the facility failed to ensure beverages were served in accordance with residents' meal tickets for four out of seven sampled residents (Resident 90, 102, 139, 146) during lunch service. This failure had the potential to result in decreased fluid intake, which may lead to dehydration and compromise residents' hydration and overall medical status. Findings:On April 6, 2026, at 12:31 p.m., a concurrent observation and meal ticket review were conducted with Resident 90 in the RNA dining room. Resident 90's meal ticket indicated an 8 fluid ounce (oz-unit for measurement) beverage. Resident 90 was observed being served a 4 oz beverage.On April 6, 2026, at 12:33 p.m., a concurrent observation and meal ticket review were conducted with Resident 102 in the RNA dining room. Resident 102's meal ticket indicated an 8 oz beverage. Resident 102 was observed not being served 8 oz beverage.On April 6, 2026, at 12:34 p.m., a concurrent observation and meal ticket review were conducted with Resident 146 in the RNA dining room. Resident 146 meal ticket indicated an 8 oz beverage. Resident 146 was observed not being served 8 oz beverage.On April 6, 2026, at 12:46 p.m., a concurrent observation and meal ticket review were conducted with Resident 139 in the RNA dining room. Resident 139 meal ticket indicated an 8 oz beverage. Resident 139 was observed being served a 4 oz beverage.On April 7, 2026, at 12:07 p.m., an interview was conducted with the Director of Food and Nutrition (DFN). The DFN stated Food and Nutrition Service Department would supply pitchers of beverage like coffee, juices, and water in the dining room and nursing staff would serve the beverage in accordance with each resident's meal ticket.On April 7, 2026, at 12:49 p.m., a concurrent observation and meal ticket review were conducted with Resident 146 and Certified Nursing Assistant (CNA) 5 in the RNA dining room. Resident 146's meal ticket indicated an 8 oz beverage. Resident 146 was observed not served the required amount. CNA 5 confirmed the resident did not receive 8 oz.On April 7, 2026, at 12:56 p.m., a concurrent observation and meal ticket review were conducted with Resident 102 and CNA 5 in RNA dining room. Resident 102 meal ticket indicated beverage 8 fluid oz. Resident 102 not being served 8 oz beverage. CNA 5 confirmed Resident 102 not being served 8 fluid oz beverage.On April 8, 2026, at 10:05 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated nursing staff should serve beverages in accordance with resident's meal ticket. The RD stated dehydration risk could happen without following Resident's meal ticket serving fluid. The RD stated the expectation was for nursing staff to follow the meal ticket instructions to ensure adequate hydration. During a review of the facility's policy and procedure (P&P) titled, Hydration, dated January 23, 2026, the P&P indicated, Policy Residents will be offered adequate hydration based on their assessed needs. Procedures: .The Food and Nutrition Service Department will supply fluids on trays or with meals as is appropriate for assessed needs.

Based on dietary observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. A food preparation sink in Prep area did not have an air gap (refers to a fixture that provides back-flow prevention.)2. Two dietary staff did not know cooling process for egg and tuna salad. 3. Ice machine in kitchen found brown grime buildup on ice maker.4. [NAME] splash spots found on the wall and ceiling in dishwashing area and food Prep area.5. Cooking pans did not air dried before stacked and stored.6. Four broken plastic containers and covers found in kitchen.7. Trash found on floor in several area in kitchen.8. Grease buildup on hood.9. Grime buildup found on several pieces of equipment.10. Several dietary staff had exposed facial hair during meal preparation.11. Dust found on several pieces of equipment and area in the kitchen.12. An expired soy sauce found in cook area. 13. Opened food items exposed to the air in walk in freezerThese failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 146 out of 150 sampled residents who received foods from the kitchen. Findings:1. On April 6, 2026, at 11:29 a.m., a concurrent observation and interview were conducted with the Registered Dietitian (RD) in Prep area at the kitchen. There was a Prep sink (sink used for preparation of foods) observed did not have an air gap. The RD confirmed the Prep sink did not have an air gap.During a review of the facility's policy and procedure (P&P) titled, Policy: Air Gap and Backflow Prevention-Dietary Services, Reviewed January 23, 2026, the P&P indicated, Air Gap and Backflow Prevention in kitchen Equipment.Policy Statement The facility maintain proper air gaps and backflow devices on all applicable kitchen equipment and plumbing fixtures to prevent contamination of the potable water supply and ensure compliance with infection control and sanitation standards.Procedure .Air gaps shall be maintained on: .Food Prep sinks.2. During a review of the FDA (Food and Drug Administration) Food Code 2022, the FDA Food Code indicated, 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled:(1) Within 2 hours from 135 F to 70 F; and(2) Within a total of 6 hours from 135 F to 41 F or less.(B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna.On April 7, 2026, at 3:24 p.m., a concurrent observation and interview were conducted with the Director of Food Service (DFS) in walk-in refrigerator 1. There was one-half steam pan of Tuna salad that was labeled with a preparation date of 4/6/26. And another one-half steam pan of egg salad that was labeled with a preparation date of 4/7/26. The DFS checked the Tuna salad temperature indicated 44 F and egg salad temperature 51.6 F. The DFS discarded the Tuna and egg salad because both food items were in dangerous temperature zone.On April 8, 2026, at 9:24 a.m., an interview was conducted with Food and Nutrition Specialist (FNS) 7. FNS 7 was asked to demonstrate how to monitor cooling process (is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135 F to 41 F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If left out to cool, cooked food can become unsafe to eat in a matter of hours.) for egg salad or Tuna salad. FNS 7 unable to demonstrate cooling process for egg and Tuna salad. FNS 7 stated she had been working here for 5 years; she never did cooling process for Tuna and egg salad. FNS 7 stated she never seen a cooling log.On April 8, 2026, at 2:34 p.m., an interview was conducted with FNS 4, and the RD. FNS 4 was asked to demonstrate how to monitor cooling process for Tuna and egg salad. FNS 4 unable to demonstrate because she never did cooling process. The RD stated it was very important dietary staff should know cooling process and monitor temperature for egg and Tuna salad. The RD stated there was potential food bone illnesses without monitoring cooling process for egg salad and Tuna salad.During a review of the facility's policy and procedure (P&P) titled, Food Production Policy, Reviewed January 23, 2026, the P&P indicated, Food shall be prepared in a safe, sanitary, . and established food preparation standards. Procedure: .2. Food preparation shall follow safe sanitation and infection prevention practices. 5. Food shall be prepared in a manner that .safety3. On April 7, 2026, at 4:06 p.m., a concurrent observation and interview were conducted with the DFN and Director of Maintenance (DM) in front of ice machine at the kitchen. The ice maker inside ice machine was observed had brown grime buildup. The DFN stated the brown grime buildup could cross contaminate the ice. The DFN stated dietary staff used the ice for residents' beverage and food preparation.During a review of the facility's policy and procedure (P&P) titled, Receiving and Food Storage Policy, Reviewed January 23, 2026, the P&P indicated, All food and dietary supplies shall be .stored safely to maintain quality and prevent contamination. Procedure: .Ice shall be stored and handled in a sanitary manner.4. On April 6, 2026, at 4:06 p.m., a concurrent observation and interview were conducted with the DFN in dishwasher area. There was brown spots splash on wall and ceiling. The DFN stated those brown spots splash could promote bacteria growth. The DFN stated wall and ceiling supposed to be clean without splash.On April 6, 2026, at 4:06 p.m., a concurrent observation and interview were conducted with the RD in Prep area. There was brown spots stain on ceiling. The RD stated it definitely needed to be clean otherwise there was a potential risk growth mold and bacteria.During a review of the Federal Food and Drug Administration (FDA) 2022 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractions for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions.5. On April 6, 2026, at 3:57 p.m., a concurrent observation and interview were conducted with the RD in Prep area. Three stacks of hotel pans (cooking pans) were observed stacked wet and stored on rack. The RD stated cooking pans needed to air dried before stacked and stored otherwise would promote bacteria growth.During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Allow clean dishes to air dry completely before storing .6. On April 6, 2026, at 10:56 p.m., a concurrent observation and interview were conducted with the DFN in the kitchen. Four plastic containers and covers were observed broken being used to store utensils. The edge of broken area was sharp. The DFN stated broken plastic containers, and covers were not safe to use.7. On April 6, 2026, at 9:47 p.m., during a general kitchen tour was concurrent with the DFN. Several areas on the kitchen's floor found trash. These areas were hot beverage station, dishwasher area, and walk-in freezer. The DFN stated floor should kept clean to prevent attract pests.During a review of the facility's policy and procedure (P&P) titled, General Safety Rules/Operations, dated January 23, 2026, the P&P indicated, Food and Nutrition Service employees will practice safe handling practices for themselves and the equipment. Procedure: The following rules apply to Nutrition Services safety operations: Floors are to be kept clean .8. On April 6, 2026, at 3:31 p.m., a concurrent observation and interview were conducted with the DFN in cook area in front of griddle. Grease buildup was observed accumulated above griddle. The DFN stated it was fire hazard issue and grease could drip on foods while preparing meals on griddle.During a review of the facility's policy and procedure (P&P) titled, General Safety Rules/Operations, dated January 23, 2026, the P&P indicated, Food and Nutrition Service employees will practice safe handling practices for themselves and the equipment. Procedure: The following rules apply to Nutrition Services safety operations:.Wash grease filters in hoods over ranges at regular intervals to prevent grease build up that could result in a fire.9. On April 6, 2026, at 9:47 p.m., during a general kitchen tour was conducted with the DFN. Several kitchen equipment found had grime buildup including underneath storage shelves of the reach-in refrigerator number (#) 2's, can opener based, plastic dark blue dish rack in prep area; plastic drying rack in front of 3 compartment sinks and walk-in refrigerator # 3's door frame. The DFN stated kitchen equipment's needed to keep clean to prevent cross contamination.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Policy, dated January 23, 2026, the P&P indicated, Dietary staff shall follow infection prevention and control practices during food handling, preparation, and service. Procedure: .Food contact surfaces and equipment shall be cleaned . 10. During a review of the FDA (Food and Drug Administration) Food Code 2022, the FDA Food Code indicated, Food employees shall wear hair restraints such as, hair coverings, nets, or bears restraints to cover body hair to keep hair from contacting exposed food, clean equipment, and utensils. On April 6, 2026, at 11:12 a.m., an observation was conducted with FNS 2. FNS 2 with mustache did not cover while working in Prep area.On April 6, 2026, at 11:35 a.m., an observation was conducted with [NAME] (CK) 1.CK 1 with facial hair did not cover while working in cook area.On April 6, 2026, at 11:36 a.m., an observation was conducted with Assistant [NAME] (AC). AC with facial hair did not cover while working in cook area.On April 6, 2026, at 3:10 p.m., a concurrent observation and interview were conducted with the DFN and FNS 2. The DFN confirmed FNS 2 with mustache needed to wear a beard guard while working in kitchen.On April 7, 2026, at 9:29 a.m., a concurrent observation and interview were conducted with the DFN and AC. The DFN confirmed AC needed to wear a beard guard while working in kitchen. The DFN stated dietary staff who had facial hair needed to wear beard guard while working in kitchen, otherwise facial hair could fall into food.11. On April 6, 2026, at 9:47 p.m., during a general kitchen tour was concurrent with the DFN. Several kitchen equipment found had brown debris (dust per the DFN) including rack stored cleaned plastic containers in prep area; utensil hanger; outside top reach-in refrigerator #2 and ventilator in prep area. The DFN stated dust could contaminate clean equipment and foods.During a review of the FDA (Food and Drug Administration) Food Code 2022, the FDA Food Code indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.12. On April 6, 2026, at 3:49 p.m., a concurrent observation and interview were conducted with the DFN in cook area. There was a 64 ounce sauce soy with expired date [DATE], found in cook area. The DFN discard the expired soy sauce.During a review of the facility's policy and procedure (P&P) titled, Policy: Expired Food Management -Dietary Services, dated January 23, 2026, the P&P indicated, The facility shall ensure that all food .are safe .and within manufacturer .use by dates. Expired .food items are strictly prohibited from use or service.Removal and Disposal Expired food .13. On April 7, 2026, at 3:49 p.m., a concurrent observation and interview were conducted with the DFN in walk-in Freezer. Several opened food items (Country Fried Beef Steak Fritters, Salisbury steak, fried chicken) were observed exposed to the air. The DFN stated open food items needed to be seal to protect from freezer burn.During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated January 23, 2026, the P&P indicated, Policy: .The Nutrition Service Manager is responsible for proper storage of nutrition service food and supplies.Procedure: .all opened and partially used foods shall be .sealed before being returned to storage area.b. Frozen .Wrap all food well to prevent freezer burn.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the compactor dumpster.This failure had the potential to attract pests and rodents.Findings:On April 7, 2026, at 4:01 p.m., a concurrent observation and interview were conducted with the Registered Dietitian and Director of Food and Nutrition (DFN) at the outside back building. There was a compactor dumpster. On the floor, trash was observed surrounding the dumpster with strong unpleasant odor. Unknown liquid was observed on the ground near the compactor dumpster. The DFN stated surrounding the compactor dumpster should keep clean and without any smell, otherwise it was going to attract pests.During a review of the facility's policy and procedure (P&P) titled Food - Related Garbage and Rubbish Disposal, dated January 23, 2026, indicated, Outside dumpsters provided by garbage pickup services will be kept . free of surrounding litter.During a review of FDA (Food and Drug Administration) Food Code 2022, Section 5-502.11, the FDA Food Code indicated, Refuse shall be removed from the PREMISES at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment when:1. One walk-in refrigerator was maintained in good working condition.2. Walk-in freezer was maintained in good working condition with ice condensation buildup.3. The dish machine wash temperature was not maintained per manufacturer guideline.These failures had the potential to cause food borne illnesses and poor quality of food served to a population of 146 of 150 residents who received food from the kitchen.Findings:1. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.11, Equipment Good Repair and Proper Adjustment, the FDA Food Code indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.On April 6, 2026, at 4:06 p.m., an observation was conducted with the walk-in refrigerator number (#) 3. Water condensation was observed on the copper pipes.On April 7, 2026, at 10:05 a.m., a concurrent observation and interview were conducted with the DFN in the walk-in refrigerator # 3. Water condensation was observed on the copper pipes. Observed some of the condensation water dripping into the foods stored under the copper pipe. The DFN stated condensation water could contaminate the foods.2. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.11, Equipment Good Repair and Proper Adjustment, the FDA Food Code indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.On April 7, 2026, at 3:51 p.m., a concurrent observation and interview were conducted with the DFN and RD in the walk-in Freezer. There was ice condensation on storage shelves under ventilator and ice all over the place on the floor. An opened box of country fried steak stored on the storage shelves under the ventilator covered with a layer of ice. The RD and DFN stated this could result in poor quality of the fried steak.3. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.15, Warewashing Machines, Manufacturers' Operating Instructions, the FDA Food Code indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved.During a review of the data plate affixed on the dish machine, the manufacturer's instructions indicated, The wash water to reach 120 degrees Fahrenheit ( F - a unit of measurement)On April 6, 2026, at 10:08 a.m., an observation was conducted in dishwasher area. The data plate affixed on the dish machine indicated 90 F while operating.On April 6, 2026, at 3:22 p.m., a concurrent observation and interview were conducted with Food and Nutrition Specialist (FNS) 8 in dishwasher area. FNS 8 stated the data plate affixed on the dish machine always indicated lower than 120 F. Therefore, the facility installed water booster for the dish machine. FNS 8 stated dietary staff being trained monitoring water booster out temperature instead of focusing on the data plate affixed on the dish machine. Surveyor checked the dish machine while operating at plate level which indicated 100 F.On April 8, 2026, at 9:45 p.m., a concurrent observation and interview were conducted with the Dish Machine Service Vendor (DMSV) in front of dish machine. DMSV stated about 3 months ago, this dish machine was not able maintain water temperature per manufacturer guideline, so the facility installed water booster. The DMSV checked the dish machine temperature at plate level while operating, it indicated 106.9 F. The DMSV stated the dish machine needed to maintain manufacturer guideline water temperature otherwise the kitchenware was not able clean properly.On April 8, 2026, at 9:45 a.m., an interview was conducted with the RD. The RD stated couple month ago, there was a problem with the data plate affixed on the dish machine which always indicated low. The facility installed water booster and dietary staff including him depending on water booster out temperature for monitoring the dish machine. The RD stated he did not check the dish machine water temperature. The RD stated the dish machine needed to maintain manufacturer guideline water temperature otherwise the kitchenware was not able clean and sanitize properly. The RD expectation was following manufacturer guideline.During a review of the facility's policy and procedure (P&P) titled, Ware Washing, dated January 23, 2026, the P&P indicated, .Mechanical washing: Low temperature dish machine 120 -140 F with chemical sanitizer .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when drain flies and a house fly were found in the kitchen.This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for 146 out of 146 sample residents who eat food prepared in the kitchen. Findings:On April 6, 2026, at 10:07 a.m., a concurrent observation and interview were conducted with the Director of Food and Nutrition (DFN) in the dishwashing area. Five flies were seen on the wall of the dishwasher room. The DFN stated he could not identify the type of flies. The DFN stated flies were not supposed to be present in the kitchen. The DFN stated flies could fly throughout the kitchen, causing cross-contamination and posing a food safety concern. On April 7, 2026, at 10 a.m., a concurrent observation and interview were conducted with the DFN in the dishwashing area. Five flies were again observed on the dishwashing room wall. The DFN confirmed the flies were not the same flies as those observed the previous day, and dietary staff had eliminated the flies seen in April 6, 2026.On April 7, 2026, at 10:34 a.m., an observation was conducted with the Registered Dietitian (RD) in the kitchen preparation area. The RD confirmed a house fly was observed flying in the preparation area. On April 7, 2026, at 1 p.m., an interview was conducted with the Pest Management vendor, who identified the flies observed on the dishwashing room wall as drain flies. On April 8, 2026, at 9:46 a.m., a concurrent observation and interview were conducted with the DFN at the dishwashing area. The DFN confirmed another 3 drain flies were observed on the wall.On April 8, 2026, at 10:05 a.m., an interview was conducted with the RD. The RD stated the kitchen should not have any pests because pests could cause cross contamination by spreading bacteria and viruses, which may result in food borne illness. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated January 23, 2026, the P&P indicated, Policy Statement: Our facility shall maintain an effective pest control program.This facility maintain an on-going pest control program to ensure that the building is kept free of insects .

Based on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team ( IDT- a collaborative group of healthcare professionals who work together to develop and implement a comprehensive care plan tailored to a resident's specific physical, mental, and psychosocial needs) determined that self-administration of medications was clinically appropriate and safe before allowing a resident to keep a prescribed Ciclesonide inhaler (inhaled medication used to prevent asthma [lung disease that cause airway inflammation] at the bedside for self-administration for one of one residents reviewed for self-administration of medications (Resident 177).This failure had the potential to result in medication mismanagement by the resident which could compromise asthma control and delay needed medical intervention. Findings:On April 7, 2026, at 8:46 a.m., Resident 177 was observed alert, oriented, and sitting on the edge of his bed. One medication inhaler Ciclesonide 160mcg (micrograms - a unit of measurement) was observed on the bedside table available for use. During a concurrent interview, Resident 177 stated the inhaler was for emergency use and that he kept it at his bedside.Resident 177's record was reviewed. Resident 177 was admitted to the facility on [DATE], with diagnoses which included asthma and dementia (loss of memory)The history and physical dated March 29, 2026, indicated Resident 177 had fluctuating capacity to make and understand medical decisions.The BIMS (Brief Interview Mental Status - standardized tool used to assess cognitive function) dated March 28, 2026, indicated a score of 13 (intact cognition).The physician order dated March 27, 2026, indicated Ciclesonide Inhalation Aerosol Solution 80 MCG/ACT (mcg/ACT - actuation each pump) 2 puff inhale orally two times a day for SOB (shortness of breath).There was no documented evidence that Resident 177 was evaluated by the IDT for self-administration of the medication inhaler Ciclesonide.On April 7, 2026, at 9:39 a.m., a concurrent observation, interview, and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the facility policy for self-administration of medication was to call the physician for an order to evaluate a resident for self-administration, have the resident seen by the IDT document the evaluation in the resident's chart, and, if approved by the IDT, allow the resident to have medication at the bedside. LVN 2 observed one medication inhaler Ciclesonide on Resident 177's bedside table available for use. LVN 2 stated the medication inhaler Ciclesonide should not have been at the bedside. LVN 2 stated there was no documented evidence that Resident 177 had an assessment completed by the IDT for self-administration of inhaler medication. LVN 2 stated the potential outcome for medication at bedside without an assessment for self-administration could result in medication mismanagement.On April 10, 2026, at 8:31 a.m., an interview was conducted with DON. The DON stated the facility process for self-administration was for residents to have a physician order to be evaluated by the IDT team to determine if the resident could safely self-administer their medication. The DON stated if a resident was deemed safe, the resident could administer their medication. The DON stated Resident 177 should not have had the medication inhaler Ciclesonide at the bedside without an evaluation. A review of the facility policy and procedure titled Self-Administration of Medications, revised December 2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.As a part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administration is clinically appropriate for the resident.Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents.A review of the facility policy and procedure titled Administering Medications, revised April 2019, indicated, .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on interview and record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs) was accurately updated when the resident's Level 1 screening was not corrected to reflect the resident's diagnoses of psychosis (symptom involving the distortion or loss of contact with reality) and anxiety (a strong feeling of worry, fear, or nervousness that is hard to control and can affect how you think, feel, and act in everyday life), for one of two residents reviewed for PASRR (Resident 145).This failure had the potential to result in the inappropriate admission of the residents to the facility and for Resident 145 to not receive necessary specialized services.Findings:A review of Resident 145's PASSR dated January 3, 2025, completed by the (name of hospital) indicated .Level 1-Negative for SMI (serious mental illness).Does the individual have a serious diagnosed mental disorder such as.anxiety.psychosis.mood disorder.NO.Psychotropic medications (mind-altering medications) .NO.A review of Resident 145's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included anxiety (excessive worry), psychosis, and mood affective disorder (mental illness).A review of Resident 145's History and Physical, dated January 9, 2025, indicated .does not have the capacity to understand and make decisions.A review of the Physician order, dated December 8, 2025, indicated .buspirone hcl (hydrochloride ) oral tablet 5 mg (milligram -unit of measurement) (buspirone hcl) give 1 tablet by mouth three times a day for anxiety m/b (manifested by) unprovoked physical and verbal aggression.Further review of Resident 145's record indicated no documented evidence that the facility corrected PASRR Level I or a Level II evaluation to address Resident 145's documented psychosis and anxiety or the ongoing use of medication for anxiety. On April 8, 2026, at 4:16 p.m., a concurrent interview and record review were conducted with MDSN (MDS- [assessment tool] Nurse), MDSN stated the PASRR completed by the hospital on January 3, 2025, should have been reviewed and updated upon resident's admission to reflect the diagnosis of psychosis and the use of medication for anxiety. The MDSN further stated, the failure to correct the PASRR could result in the resident being inappropriately admitted to the facility and not receiving appropriate mental health services. A review of the facility policy and procedure titled PASRR Policy, dated January 23, 2025, indicated, .The facility shall ensure that all residents are screened for mental illness (MI) and.through the PASRR process prior to admission and as required post admission, in compliance with state and federal regulations.To ensure.appropriate placement in the less restrictive setting.

Based on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) for one of five sampled residents (Resident 45) had adequate interventions in accordance with facility policy when Resident 45 was prescribed a psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication. This failure had the potential to result in delays in treatment and care for Residents 45. Findings: A review of Resident 45's admission Record, dated April 9, 2026, indicated Resident 45 was originally admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses including major depressive disorder and anxiety. A review of Resident 45's medical record indicated a physician's order for Xanax 0.5 mg (milligram, unit of measurement) Give 2 tablets by mouth two times a day for anxiety m/b (manifested by) self report of anxiety, dated February 20, 2026. A review of Resident 45's MARs dated February 2, 2026 to April 8, 2026, indicated Resident 45 was administered Xanax as prescribed by the physician. A review of Resident 45's Care Plan Report, dated October 31, 2025 indicated, Focus: Alteration in Mood State [related to] Anxiety.Goal: Will minimize side effects from medication.Interventions.Xanax Oral Tablet 0.5 mg (Alprazolam) Give 2 tablets by moth two times a day for anxiety m/b self report of anxiety.Date initiated: 02/26/2026. During an interview and current record review on April 9, 2026 at 9:08 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 45's medical record was reviewed. LVN 4 confirmed Resident 45 was started on Xanax in February 2026. LVN 4 stated the care plan intervention for Xanax initiated on February 26, 2026 was not complete and should have included interventions such as monitoring for side effects, target behavior, and non-pharmacologic interventions. LVN 4 confirmed Resident 45's care plan interventions for Xanax dated February 26, 2026 only listed the medication order but no other interventions were documented. During an interview and current record review on April 9, 2026 at 10:25 a.m., Resident 45's medical record was reviewed with the ADON. The ADON confirmed Resident 45 was started on Xanax in February 2026. ADON stated Resident 45's care plan interventions for Xanax initiated on Feburary 26, 2026 was not complete because it needed to include monitoring for side effects, target behaviors, and non-pharmacologic interventions. The ADON confirmed Resident 45's care plan interventions for Xanax initiated February 26, 2026 only listed the medication order but no other interventions were documented. During an interview on April 9, 2026 at 2:21 p.m., the DON stated the expectation was for nursing staff to complete the care plan including interventions such as side effect monitoring, behavioral monitoring, and non-pharmacological interventions. The DON confirmed Resident 45's care plan interventions for Xanax dated February 26, 2026 only listed the medication order but no other interventions were documented. A review of the manufacturer's instructions for Xanax tablets, dated January 2023, retrieved from DailyMed indicated, Adverse reactions.impaired coordination, hypotension (low blood pressure), dysarthria (slurred or slowed speech). A review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated May 2019 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the facility's P&P titled, Subject: Psychopharmacological, dated January 23, 2026, indicated, If a resident is admitted with orders for psychopharmacological drug use, the following will occur.licensed nurse and/or Social Service Director will make every effort to determine if there are any potential behavior symptoms that may require special monitoring and/or care planning. The licensed nurse of designee will document any known target behaviors and potential interventions.This will help assure certified nursing assistants receive communication related to the initial plan of care as appropriate.admission Meeting: The admission record is reviewed within 72-hours (weekdays).This review will include the use of psychopharmacological drugs, appropriate diagnosis, behavioral symptom(s) and the initial plan of care.Psychotropic Care Plan.1. The interdisciplinary team will proceed to care planning for the use of psychopharmacological drugs, and the Care Plan for psychopharmacological medications will be implemented. 2. The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals will be utilized and approaches will include alternatives to psychopharmacological drug use. 3. The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate.Monitoring.Licensed nurses and additional staff will monitor and document any targeted behaviors that occur.

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided for one of three sampled residents (Resident 1) when Resident 1 was served a hot beverage by a Certified Nursing Assistant (CNA 1) without checking the safe serving temperature on April 10. 2025. This failure resulted in the hot beverage spilling on Resident 1 causing burn injuries, second degree burn [partial thickness burn - affects both the outer layer and part of the underlying layer of the skin] to third degree burn [most severe type of burn that damages all layers of the skin] on her right breast and shoulder that required medical intervention. Findings: On May 7, 2025, Resident 1's admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis of metabolic encephalopathy (a brain disorder that results from a disturbance in metabolism, causing brain dysfunction) and multiple strokes with residual hemiplegia (persistent weakness or paralysis on one side of the body), right side. A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated April 23, 2025, indicated, Resident 1 ' s Brief Interview for Mental Status (BIMS - short, structured interview to assess memory, attention, and orientation) score was 13 (cognitively intact). The MDS indicated Resident 1 required supervision or touching assistance when eating and needed some help with need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness. A review of Resident 1's care plan dated April 22, 2025, indicated, .The resident has an ADL (activities of daily living) self-care performance deficit r/t [related to] Hx [history] of cerebral infarction [a type of stroke] with hemiplegia/hemiparesis [weakness or partial loss of strength on one side of the body] .Interventions .Eating: The resident requires set up assistance with eating . A review of Resident 1's progress note indicated: - On April 10, 2025 at 8:59 a.m., the Licensed Nurse (LN) documented, patient got burned related to she spelled (sic.) coffee herself on her right side .patient noted crying and stated she missed cup grip and spilled coffee herself and assessed with slight redness on right arm right breast and right ribcage area and Patient c/o (complaint of) pain 8/10 [pain rating scale of 8 - severe pain] and CNA directed to change clothes to loose hospital gown and pain medication administered by LVN [licensed vocational nurse] and MD [medical doctor] Informed and Staff educated to make rounds every 15 min to assess for further changes . - On April 10, 2025, at 2:31 p.m., the LN documented., .Patient had blister [fluid-filled sac beneath or within the skin caused by burn] on right side of arm and breast and c/o pain 10/10 and Np [Nurse Practitioner] made aware and new orders noted and carried out, give extra dose of [pain medication] and send out for Evaluations . - On April 10, 2025, at 9:42 p.m., the LN documented, .Resident returned from [name of hospital] at approximately 8:45 .with no new orders. upon arrival patient was assessed vitals within in normal limits with a pain scale 7/10 Ordered pain medication given to patient [Resident 1]. Patient has wounds wrapped on left arm from shoulder to elbow and also wrapped with bandage on left breast. skin assessment was done no new marks or bruises noted. care plan on going . A review of Resident 1's hospital admission records dated April 10, 2025, indicated, .ER [emergency room] visit .F [female] .presenting with burn to right arm and breast. She reports that at her facility somebody dropped hot coffee on her arm and her breast and she has sustained a burn that occurred earlier today .Physical Examination .Skin: Burn over proximal medial [inner upper part of the right arm, near the shoulder and close to the chest] right arm and right breast with bullae [fluid filled blisters] over the right breast and abrading skin over the right elbow .Patient is presenting with burn to right arm as well as right breast .Burns appear to be superficial partial [2nd degree burn] versus deep partial thickness burn [2nd degree burn] .She will require wet to dry dressing and follow up with the burn clinic as an outpatient I have advised that the patient follow up with the local burn center either [name of the hospitals] for outpatient follow up with the burn specialist .Will prescribe pain control . A review of Resident 1's Weekly wound Note, indicated: - April 14, 2025, .RT [right] breast - 3rd degree burn [full thickness burn - destroys all layers of the skin] RT anterior forearm - 3rd degree burn RT posterior forearm - 3rd degree burn .Site of Wound and current measurement: RT Breast - 20.0x [by]10.0x0.1cm [centimeters] RT anterior forearm - 6x5x0.1 RT posterior forearm - 11x12xUTD [unable to determine] . - April 29, 2025, .Type of Wound .Burn .Site of wound and current measurements: R breast 3x6xUTD R anterior arm - 1.5x3xUTD RT posterior arm - 1.5x3xUTD . A review of Resident 1's Change in Condition Evaluation, dated April 14, 2025, indicated, .Signs & [and] Symptoms identified .cellulitis [infection of the skin and the underlying soft tissue] .on (R [right]) breast & R upper arm . On May 7, 2025, 1:37 p.m. an interview was conducted with CNA 1. CNA 1 stated, she was assigned to Resident 1 on April 10, 2025, morning shift. CNA 1 stated, Resident 1 asked for a cup of tea while eating breakfast. CNA 1 stated, she placed a tea bag in a cup and placed the cup in a microwave to heat the water up to a warmer temperature. CNA 1 stated, she did not check the temperature of the hot tea prior to serving it to Resident 1. CNA 1 stated she was not aware the temperature of the hot beverage needed to be checked prior to serving it to the resident. CNA 1 stated, she should have checked the temperature of the hot tea before serving it to Resident 1 as there was a risk of burn injury with serving hot beverages. On May 7, 2025, at 2:11 p.m., an interview was conducted with CNA 2. CNA 2 stated, she assisted CNA 1 on the morning of April 10, 2025, when Resident 1 was heard to be screaming. CNA 2 stated, she noticed a cup of hot water and not coffee, had spilled to the right breast and right shoulder of Resident 1 and that she was in pain. CNA 2 stated, she and CNA 1 immediately changed the soiled clothes and Resident 1 stated I am sorry I spilled on me. CNA 2 stated, Resident 1 did not appear to be confused at that time. CNA 2 stated, she was instructed upon hire that hot food and beverages should not be served by reheating unless the temperature was checked to be within a specified range. CNA 2 stated, she would not serve hot food or beverages to residents without having the kitchen to verify it first as there was a risk for injury and burn. On May 7, 2025, at 3:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated it was the policy of the facility that nursing staff including CNA's and nurses should check for safe serving temperature before serving it to the resident. The DON stated this was not done by CNA 1 when she served the hot tea to Resident 1 on April 10, 2025, and the hot liquid was accidentally spilled on Resident 1 which resulted to Resident 1 sustaining second degree burns on her right breast and right shoulder. On May 8, 2025, at 10:40 a.m. a concurrent observation and interview were conducted with Resident 1 in the resident's room. Resident 1 was observed to be alert and up in her wheelchair. Resident 1 had a clean white bandage on her right upper arm and right chest area. Resident 1 stated, she recalled the incident on April 10, 2025. Resident 1 stated, she asked a CNA for tea. Resident 1 stated, she was not fully awake when CNA 1 served tea and was awoken by the hot beverage spilled on her Resident 1 stated she screamed in pain and the staff responded. Resident 1 stated, she was experiencing pain and she was provided pain medication. Resident 1 stated she did not recall being warned by CNA 1 before being served the hot beverage. Resident 1 stated the hot beverage was brought to her and placed on the bedside table within her reach, but she could not recall if it was spilled on her by staff or by accident after she awoke from a brief sleep. A review of the facility policy and procedure titled, Food Service Temperature Control, dated, 2024, indicated, .Beverages .brewed coffee and hot water .will be portioned in small batches to retain the temperature .served at or below 155 degrees F (Fahrenheit) to prevent burns . A review of the facility policy and procedure titled, Hot Beverage Preparation and Service, undated, indicated, .Hot Beverages will be prepared following food safety standards and served at a safe temperature to prevent burns or injury .Measure beverage temperatures prior to service using a calibrated food thermometer to ensure compliance with the safe serving temperature .

Based on interviews and record reviews, the facility failed for one of three sampled residents (Resident A), to ensure Resident A's discharge plan to an assisted living facility (provides support with daily activities but does not offer extensive medical care) was re-evaluated and modified when the resident developed a Stage 4 pressure injury (bed sore with severe tissue damage with exposed bone, tendon [tissue that connects the muscle to the bone], and muscle). This failure resulted in Resident A being transferred to a lower level of care facility (designed for residents who did not require specialized medical attention) leading to the worsening of the Stage 4 pressure ulcer and requiring acute hospitalization . Findings: On April 4, 2024, at 10:10 a.m., an unannounced visit to the facility was conducted to investigate a quality of care and treatment issue. A review of Resident A's document titled Admission record, dated April 4, 2024, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included paraplegia (paralyzed legs). A review of Resident A's Nursing Progress Notes, dated May 19, 2023, indicated, .resident has old white scar from his open sore on his back was closed prior to fall now has opening . During a review of the facility document titled, Change in Condition Evaluation, dated May 19, 2023, indicated, .s/p (status post) fall .area of fragile scar tissue to coccyx (tailbone) noted as reopened .site .coccyx .length- 2 cms (centimeters- unit of measurement) x width 1.5 cms x depth- 0.2 cms .Stage- 4 . A review of Resident A's Weekly Pressure Ulcer Report, indicated the following: -Dated May 19, 2023, .Pressure Sore Description .Coccyx .Length . 2 .Width .1.5 .Depth 0.2 .Stage IV (Stage 4) . -Dated May 26, 2023, .Pressure Sore Description .Coccyx .Length .2 .Width .1.5 .Depth 0.1 .Stage IV . A review of Resident A's Physician Order, dated May 19, 2023, indicated .coccyx: cleanse w/NS (with Normal Saline - a mixture of salt and water used for cleaning wound), pat dry, apply collagen (to help make tissue strong and resilient), cover w/dry dressing once daily .for re-open of pressure injury stage 4 . A review of Resident A's Discharge Summary, undated, indicated, .discharge date .5-28-23 (May 28, 2023),,,Skin Condition at Discharge .blank (no entry) .Home Nursing .Pending . A review of Resident A's Administration Note, dated May 28, 2023, indicated, .discharged . A review of Resident A's Social Service Note, dated May 29, 2023, indicated, .Resident discharged [DATE] (May 28, 2023) to (name of the assisted living facility) . A review of Resident A's Physician Order, dated May 30, 2023, indicated, .May discharge to (name of the facility) Assisted Living Facility .ON 5/28/23 (May 28, 2023) . Further review of Resident A's progress notes did not indicate that the presence of a Stage 4 pressure ulcer was discussed with the accepting facility prior to discharge on May 28, 2024. There was no documentation that Resident A ' s discharge plan was discussed by the Interdisciplinary Team (IDT - integrating multiple disciplines through collaboration) to modify the discharge plan due to the presence of Resident A ' s Stage 4 pressure ulcer. During an interview on May 20, 2024, at 1 p.m., with the Assisted Living Assistant Administrator (AA), the AA stated the facility provided her with a copy of the Physician ' s Report for Residential Care Facilities for the Elderly, for Resident A on April 12, 2023, to provide information on the status of the resident, his diagnosis, and other medical conditions. The AA stated, she went to the facility to evaluate Resident A two days prior to the resident ' s discharge. The AA stated she asked the Certified Nursing Assistant and the Charge Nurse about the skin condition of Resident A. The AA stated the staff told her Resident A had no wound. The AA stated, if she had been aware of Resident A ' s wound, she would not have admitted the resident to their facility. The AA stated, before admitting a resident, the referring facility would provide information about the resident including diagnosis and medical concerns such as pressure injuries. The AA stated if a resident developed pressure injury, like Stage 4 pressure ulcer, prior to discharge, the facility should have communicated the resident ' s current skin condition to them. The AA further stated she would not have admitted the resident if she had known the resident had a pressure ulcer. The AA stated the assisted living is a non-medical facility. The AA stated their facility could not provide care for a resident with a Stage 4 pressure ulcer. The AA stated Resident A was admitted to their facility on May 28, 2023, and was transferred to acute on May 30, 2023. A review of Resident A's document provided to the assisted living facility titled, PHYSICIAN ' S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE), undated, indicated, . (name of the facility) .PRIMARY DIAGNOSIS .ESSENTIAL HYPERTENSION .PHYSICAL HEALTH STATUS .History of Skin Condition or Breakdown .NO . A review of Resident A's document from assisted living facility titled Narrative Notes, dated May 30, 2023, indicated, .Resident has an open wound in tailbone she asked resident if he was informed and resident didn ' t know anything about it .went to check on resident and immediately informed resident that .have to sent him out to ER (emergency room ) . A review of Resident A's document from acute hospital titled, ED (Emergency Department) Physician Record, dated May 30, 2023, indicated, .from (name of assisted living) to the ED for the evaluation of a coccyx wound .the patient has a bed sore that progressively worsened which staff noticed this morning .Physical Examination .back .sacrum (lower part of the back between the tailbone [coccyx] and the pelvis [bony structure at the base of the spine]) .green fibrinous exudate in wound approx. (approximately) 5cm in diameter .Impression and Plan .Sacral decubitus (bedsore) ulcer .Infected decubitus ulcer A review of Resident A's document from acute hospital titled, Wound Care Note, dated May 31, 2023, indicated, .Dx (Diagnoses) .Sacral Wound .Sacral Stage 4 Pressure Injury .6.0 x (by) 4.0 x 3.3 cm with undermining (tissue damage beneath the surface of the skin surrounding a wound) present from 8:00-12:00, deepest at 10:00 measuring 5.2 cm . During an interview with the Registered Nurse (RN) on May 20, 2024, at 4:20 p.m., the RN stated, the IDT has to re-evaluate and update the discharge plan if the resident has a change in medical condition. The RN stated Social Services had to coordinate with the assisted living staff. The RN stated, when a resident is discharged to another facility, the resident ' s representative would be provided with a recapitulation of the resident ' s stay at the facility, including information on medications and skin conditions. During a concurrent interview and review of Resident A ' s progress notes dated April 19, 2023 to May 28, 2023, on May 20, 2024, at 4:40 p.m., with the Director of Nursing (DON), the DON stated the discharge planning was initiated on April 19, 2023. The DON further stated Resident A developed a Stage 4 pressure ulcer on May 19, 2023. The DON stated the presence of Resident A ' s pressure ulcer should have been coordinated with the assisted living facility. The DON stated the facility did not have documentation showing that nursing staff communicated the presence of Stage 4 pressure injury to the assisted living facility. The DON stated, there was no documentation of Resident A ' s discharge plan being discussed and re-evaluated. The DON stated, Resident A should not have been discharged to assisted living. During an interview with the Social Service Assistant (SSA) on May 21, 2024, at 8:41a.m., the SSA stated, she was in-charge of Resident A's discharge planning. The SSA stated, she coordinated with the assisted living staff regarding Resident A's discharge. The SSA stated Resident A expressed to be discharged to an assisted living. The SSA stated prior to discharging resident to a lower level of care like the assisted living, she would send the resident's information including medical condition, skin condition, and medications to makes sure that the receiving facility could provide care for the resident. The SSA she had to make sure that it would be a safe discharge. The SSA stated, if there was a change in resident's condition, such as the presence of a Stage 4 pressure ulcer, the nursing would inform her and she would communicate with the accepting facility. The SSA stated, she was not aware that Resident A had developed a pressure ulcer. The SSA stated, if she had been aware of the resident ' s skin condition, she would have called the assisted living to inform them of the resident's current condition. The SSA stated she would have held the discharge to modify the discharge plan. During a review of the facility ' s policy and procedure titled, Transfer and Discharge, dated April 1, 2023, indicated, .Purpose: .to provide complete, safe and appropriate discharge planning and necessary information to the continuing provider .Discharge planning continues throughout the stay .If the information in the notice changes prior to the transfer or discharge , the Facility will provide updated information to the recipients of the notice as soon as practicable .if the changes to the notice are significant .a new notice must be given that clearly describes the change(s) .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident A) received treatment and care in accordance with professional standards of practice and consistent with the resident's comprehensive care plan when: a. Licensed staff failed to perform and document pain assessments on multiple shifts as indicated in the care plan and as per the facility's policy and procedure, and administer pain medications as ordered to address Resident A's discomfort; and b. Licensed staff failed to conduct immediate investigation and address Resident A's allegation of a fall incident in the facility. These failures increased the potential for the resident to not receive immediate care and appropriate assessment, timely interventions and necessary medical services. Resident A was transferred out to the general acute care hospital (GACH) for surgical interventions of a [MEDICAL CONDITION] (broken hip bone). Findings: On (MONTH) 4, 2019, at 9:03 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care concerns. The resident was no longer in the facility during the visit. Resident A's record was reviewed. Resident A was admitted to the facility on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. The undated history and physical indicated Resident A had fluctuating capacity to understand and make decisions. The care plan titled, At risk for fall/injury due to Dx (diagnosis) of muscle weakness, decreased mobility, Dx of [MEDICAL CONDITION] and used (sic) of [MEDICAL CONDITION] (chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), dated (MONTH) 20, (YEAR), indicated, Goals .will reduce the risk of falls .will be free from fall-related injuries . The care plan titled, .At risk for pain/discomfort due to Dx of DJD ([MEDICAL CONDITION] joint disease- chronic condition of inflammation, breakdown and eventual loss of the cartilage of the joints) ., dated (MONTH) 20, (YEAR), indicated, .Interventions: Monitor for pain Q (every) shift . Monitor/record/report to nurse any S/S (signs and symptoms) of non-verbal pain .Administer pain medication as ordered .Evaluate effectiveness of pain interventions and notify MD (physician) if additional measure are required . A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The pain assessment and monitoring documentation in the MAR indicated [REDACTED] - 7 a.m. to 3 p.m. (AM shift): (MONTH) 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, 2019; - 3 p.m. to 11 p.m. (PM shift): (MONTH) 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, 2019. The physical therapy notes, dated (MONTH) 1, 2019, indicated, .Patient verbalized pain level .Pain limits the following functional activities: standing .pain with movement = 4/10; frequency = constant; location: left leg (generalized); pain description/type: distressing .Pt had (a) fall (on) 8/30/2019 (August 30, 2019) during PM shift. Nsg (nursing) cleared for therapy in NWB (no weight-bearing pending X-ray results . The SBAR (Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication in healthcare setting) charting, dated (MONTH) 1, 2019, at 10:06 a.m., indicated, .s/p (status [REDACTED].things that make the condition worse are: ambulating, walking . Things that make the condition better .immobilize lower extremities .Cognitive status: alert, oriented to person, place .resident alert and aware with hx (history) of confusion and episodes of [MEDICAL CONDITION] behavior (disruption to a person's thoughts and perceptions) manifested by hallucination and making up stories .complained of GBP (generalized body pain) 6/10 but refused pain medication when offered .resident stated that she fell on Friday 8/30/2019 during PM shift and could not recall the exact time. (The resident) also stated that the charge nurse helped her get on the bed and told the charge nurse that she was trying to get on the bed when she fell and she forgot that she had fallen until yesterday night when she felt pain on her body. PM shift and N[NAME] shift (11 p.m. to 7 a.m.) aware and texted the dr (doctor). MD replied this morning to send the resident out to ER (emergency room ) for further evaluation . There was no documented evidence an investigation or a comprehensive physical assessment was conducted to address the resident's allegation of a fall incident on (MONTH) 30, 2019. There was no documented evidence in the MAR indicated [REDACTED]. Resident A's GACH record was reviewed. The Emergency Department (ED) Physician Record, dated (MONTH) 1, 2019, at 12:04 p.m., indicated, .History of Present Illness: hip injury-pain .BIBA (brought in by ambulance) coming from (name of skilled nursing facility), presents to the ED with complaints of right hip pain onset 3 days ago. Patient states that at this time she fell and has had the hip pain since. She has not been able to bear weight on her leg since the fall .her right leg is shortened and externally rotated .right foot is externally rotated (and) shortened . The x-ray of the right hip, dated (MONTH) 1, 2019, at 12:28 p.m., indicated, .impression: acute intertrochanteric (bony protrusions of the thigh bone) [MEDICAL CONDITION] . The history and physical, dated (MONTH) 1, 2019, at 6:22 p.m., indicated, .patient had a(n) accidental fall and subsequently complained of right hip pain .the patient is referred to emergency room (ER). In ER work-up done suggest a right [MEDICAL CONDITION] and basically orthopedic (field of medicine that focuses on surgery on, or manipulation of, the musculoskeletal system) was called through the emergency room .Numeric pain scale: 9 .physical exam: mental status: oriented to person, place and time . The operative (surgical operation) report, dated (MONTH) 3, 2019, at 12:29 p.m., indicated: Indication for Surgery: right hip intertrochanteric fracture Postoperative Diagnosis: [REDACTED].The plan is for touchdown weight-bearing only on the right leg for 4 weeks .Follow-up in orthopedics in 2 weeks for staple (specialized surgical staples used in surgery in place of sutures to close skin wounds) removal and sooner for any problems. On (MONTH) 4, 2019, at 10:36 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed and stated she was the nurse assigned to Resident A during the AM shift on (MONTH) 30, 31, and (MONTH) 1, 2019. She stated on (MONTH) 1, 2019, she received a report from the N[NAME] shift (11 p.m. to 7 a.m.) nurse (LVN 4) that Resident A had an alleged report of a fall incident during the PM shift of (MONTH) 30, 2019. She stated the resident complained to LVN 2, who worked the PM shift on (MONTH) 31, 2019, that she had a fall incident in the facility. She stated the resident was sent out to the hospital on (MONTH) 1, 2019, due to the resident's complaints of pain. In a concurrent review of Resident A's record, LVN 1 confirmed there was no documentation of an SBAR, an incident charting or investigation after the resident reported the alleged fall incident. She also confirmed the pain assessment documentation sections in the Medication Administration Record [REDACTED]. On (MONTH) 5, 2019, at 10:44 a.m., LVN 2 was interviewed and stated he was the nurse assigned to Resident A during the PM shift on (MONTH) 31, 2019. He stated Resident A was alert with episodes of confusion and ambulated independently with the use of a walker. He stated on (MONTH) 31, 2019, during the PM shift, the resident requested for Tylenol. He stated, I asked her why she needed Tylenol, and the resident replied, I fell the other night (August 30, 2019). When asked why there was no documentation of an investigation or assessment regarding the resident's allegation, he stated he told the incoming nurse about it since it was the end of shift already. He stated he had no time to assess the resident. When asked if he administered pain medication to the resident, LVN 2 stated he did not. On (MONTH) 5, 2019, at 11:49 a.m., LVN 3 was interviewed and stated he was the nurse assigned to Resident A during the PM shift on (MONTH) 30, 2019 (the alleged date of the incident). LVN 3 denied the resident had a fall incident during his shift. He stated the resident had no complaints during his shift. On (MONTH) 5, 2019, at 1:47 p.m., Certified Nursing Assistant (CNA) 1 was interviewed and stated he was the CNA assigned to Resident A during the PM shift on (MONTH) 31, 2019. He stated the resident made a complaint during his shift (August 31, 2019) that she had a fall incident in the facility the previous day (August 30, 2019). He stated he reported it immediately to his charge nurse (LVN 2). On (MONTH) 11, 2019, at 8:17 a.m., LVN 4 was interviewed and stated she was the nurse assigned to Resident A during the N[NAME] shift on (MONTH) 31, 2019. She stated the resident was lying in bed that time and was yelling during the beginning of her shift. She stated she asked LVN 2 why the resident was yelling and heard LVN 2 telling the resident, I already gave you pain medications. She stated the resident mentioned of an alleged fall incident that occurred during the PM shift on (MONTH) 30, 2019. She stated, towards the end of her shift, the resident complained of pain at level of 7 in a scale of 0-10. She stated the resident requested for [MEDICATION NAME] (pain medication) as she had it before at the hospital. LVN 4 stated she did not remember giving the resident any pain medications. She told the resident she would inform her physician about it. She stated she texted the resident's attending physician about the resident's complaints and that the physician did not reply to the facility until the next shift. In a concurrent review of the resident's records, she confirmed there was no documentation of pain medication administration to the resident on (MONTH) 30, 31, and (MONTH) 1, 2019. On (MONTH) 11, 2019, at 3:49 p.m., CNA 2 was interviewed and stated she was the CNA assigned to Resident A during the N[NAME] shift on (MONTH) 30, 2019. She stated the resident was alert and oriented, independent with transfers, and had episodes of mood changes. She stated the resident told her during her shift on (MONTH) 30, 2019, that she had a fall incident. CNA 2 stated she immediately reported the resident's fall allegation to LVN 3 and LVN 4. On (MONTH) 11, 2019, at 3:49 p.m., CNA 3 was interviewed and stated he was the CNA assigned to Resident A during the N[NAME] shift on (MONTH) 31, 2019. He stated the resident was ambulating around the facility independently as her baseline condition. He stated when he came in to work on (MONTH) 31, 2019, the resident was not herself .not up and about. He stated, Usually when I come to work she's usually up. He stated the resident slept during the N[NAME] shift on (MONTH) 31, 2019, until around 5 a.m. when the resident was noted crying in bed. CNA 3 stated, When I spoke to her she said she a had a fall .and wanted [MEDICATION NAME] .she said her knees were hurting . He stated the resident stated the fall incident happened 2 to 3 days ago (August 29 or 30, 2019). CNA 3 stated he reported it LVN 4 and the nurse (LVN 4) came back and told him, It was her hip hurting . On (MONTH) 25, 2019, at 2:44 p.m., Resident A's record was reviewed with the Director of Nursing (DON) and confirmed there was no documentation in the record of an investigation or assessment regarding the resident's allegation of the fall incident until the AM shift on (MONTH) 1, 2019 when the resident was transferred out to the acute care hospital for evaluation. She stated whenever there is an allegation of a fall incident, the staff should do a head-to-toe assessment and investigate the allegation. When asked about the facility's process on pain assessment, she stated licensed staff should perform pain assessment every shift and document it in the resident's clinical record. She stated the resident should be assessed for pain and provided pain medications as ordered as part of pain management. She further stated the resident should also be re-assessed for the effectives of the pain medications following pain medication administration or the interventions provided. The facility's policy and procedure titled, Pain Assessment and Management, dated (MONTH) (YEAR), indicated: .The pain management program is based on a facility-wide commitment to resident comfort . 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain . Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools .and relevant criteria for measuring pain management . Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record . Report .to the physician or practitioner .significant changes in the level of the resident's pain . The facility's policy and procedure titled, Assessing Falls and Their Causes, dated (MONTH) 2010, indicated: .Review the resident's care plan to assess for any special needs of the resident . Identify the resident's current medications and active medical conditions . Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury . Residents must be assessed in a timely manner for potential causes of falls . Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame . Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record . The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found . According to Potter, Perry, Stockert, and Hall, authors of Fundamentals of Nursing, Ninth Edition, Copyright (YEAR), Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care . During the assessment process thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. A comprehensive assessment of pain aims to gather information about the cause of a person's pain and determine its effect on his or her ability to function . Assessment of the characteristics of pain allows you to understand the type of pain, its pattern, and the types of interventions that bring relief .

Based on interview and record review, the facility failed to notify the physician, and responsible party of changes in condition, request further evaluations/interventions for the changes, and complete full assessments for one of three sampled residents (Resident A) with repeated unwitnessed falls when: a. Resident A had a new onset of right hip pain that made her unable to stand and walk, b. Resident A's neurological assessments were incomplete and not done according to professional standards, and c. Resident A's responsible party was not informed of changes in Resident A's condition. These failures caused changes in Resident A's condition, that included a fractured pelvis and sacrum, to not be identified, delayed medical care and treatment of [REDACTED]. Findings: On (MONTH) 30, 2019, at 3:34 p.m., Resident A's family members (FM 1 and FM 2) were interviewed by telephone, and stated they got a call from the facility on (MONTH) 24, 2019, and a facility nurse told them Resident A had a fall at the facility. FM 1 and FM 2 stated they asked if Resident A needed to go to the hospital to be evaluated and the nurse said No Resident A was, OK, It was a courtesy call. FM 1 and FM 2 stated Resident A was sent out to the hospital the next day on (MONTH) 25, 2019, and passed away 11 hours later. FM 1 and FM 2 stated the hospital (HOSP 2) called them on (MONTH) 25, 2019, and told them Resident A had fractures of her pelvis that were new. FM 1 and FM 2 stated Resident A was able to walk when she was admitted to the facility, and they felt if Resident A had been evaluated when the fractures first occurred she may not have gone into shock and passed away. FM 1 and FM 2 stated they did not know why Resident A passed away. Resident A's record from (name of hospital) HOSP 1 was reviewed and indicated Resident A was admitted to HOSP 1 on (MONTH) 13, 2019, after a fall at home. The History and Physical, dated (MONTH) 13, 2019, indicated Resident A was, .Awake, responsive, frail .able to move all 4 extremities without difficulty . The Discharge Summary dated (MONTH) 16, 2019, indicated Resident A had, .subacute stroke . and a blood clot in the left leg. The Discharge Summary indicated Resident A was to be discharged to a skilled nursing facility for physical and occupational therapy. On (MONTH) 10, 2019, at 11:25 a.m., an unannounced visit was made to the facility for the investigation of the complaint. On (MONTH) 10, 2019, at 1:15 p.m., Resident A's SNF record was reviewed and indicated Resident A was admitted to the facility on (MONTH) 17, 2019, with [DIAGNOSES REDACTED]. The record indicated Resident A had a BIMS score of 01 (Brief Interview of Mental Status-an assessment of cognitive ability with 0 being lowest and 15 highest). The History and Physical (H & P), dated (MONTH) 25, 2019, indicated Resident A did not have the capacity to make decisions due to dementia, and her surrogate decision maker was her family. The H & P indicated Resident A was a fall risk, had a soft abdomen, no swelling of her back, arms, or legs, was able to move all extremities, and had a normal pelvis on examination. The physician's orders [REDACTED]. The Nurse's Admission Assessment, dated (MONTH) 17, 2019, at 12:30 a.m., indicated Resident A was alert and oriented to person (normal is person, place, time and situation), pupil responses were normal, and lung sounds were clear and not diminished. The form titled, Safe Resident Handling Screening Tool dated (MONTH) 17, 2019, indicated Resident A was able to bear weight on both legs, required one person assistance, and, .here for PT/OT (physical and occupational therapy treatment) need supervision all the time when get out of bed (sic) and during daily activities. The Physical Therapy Evaluation, dated (MONTH) 17, 2019, indicated Resident A had, . no pain present per .verbal and nonverbal communication . had equal strength and was able to move both lower extremities. The form titled, Pain Evaluation dated (MONTH) 17, 2019 at 5:03 a.m., indicated, . Does the resident demonstrate any .of the following that may impeded his/her ability to report pain .Cognitive Impairment: Yes .reluctant to verbalize or express pain? Yes . The Nurses Progress Notes, dated (MONTH) 23, (YEAR), at 10:08 p.m., indicated, .Started having anxiety at 7 pm, stating that she needed to get away because she felt unsafe .[MEDICATION NAME] (an anti-anxiety medication) given with relief. Spoke with patient for an hour and reassured her that she was safe . The Nurses Progress Notes, dated (MONTH) 26, 2019, at 6:46 a.m., indicated Resident A had an unwitnessed fall, .at around 12:45 a.m resident found lying on the floor .able to move all extremeties (sic). neuro chk (sic) done, resident unable to describe the incident, stated she bumped her head on the wall .able to stand .with full assisst (sic) . There was no documented indication Resident A's physician ordered or nursing staff requested further evaluation for Resident A after the unwitnessed fall and complaint that she hit her head on the wall on (MONTH) 26, 2019. The Neurological Assessment Flowsheet (used to document specific assessments including level of alertness, hand grips, response to pain, range of motion, and pupil responses done after unwitnessed fall to check for signs of head injury) dated (MONTH) 26 (no year indicated), was reviewed, and had no documented indication if Resident A's pupil response was normal or abnormal, or if her response to pain was normal, abnormal, or absent. The Pain Evaluation Nurses Notes, dated (MONTH) 26, 2019 at 12:45 a.m., indicated Resident A had, .Post-fall .location of pain .back of head . and was signed by the nurse on (MONTH) 29, 2019 (three days after the unwitnessed fall). The Physical Therapy Treatment Encounter Notes, dated (MONTH) 29, 2019, indicated Resident A had, .Pain at Rest .2/10 .Intermittent .R hip .aching (mild right hip pain off and on at rest) .Pain-with Movement .5/10 .Intermittent .aching (moderate right hip pain off and on when moving) .pain during ambulation, no c/o (complaint of ) pain noted before standing and ambulation. Upon ambulation, patient (Resident A) was noted to have difficulty walking and c/o pain. Ambulation was then deferred for now. Charged (sic) nurse (name) was informed of pain. The Occupational Therapy Treatment Encounter Note, dated (MONTH) 29, 2019, (untimed) indicated Resident A had, Pain with Movement 4/10 .Constant .R hip .Ache .nursing informed . The Nurses Progress Notes, dated (MONTH) 29, 2019, at 6:42 a.m., indicated Resident A was, .alert to self with confusion .had c/o R leg pain 6/10. Administered pain med .elevated legs on pillow . There was no documented indication nursing staff notified Resident A's attending physician of her new onset of right hip pain that caused her to be unable to stand and walk, requested further evaluation, asked the RN on duty to assess Resident A's condition, or notified Resident A's responsible party of the change in her condition. The Health Status Note Nurses Notes, dated (MONTH) 3, 2019, at 10:22 p.m. indicated Resident A had a second un-witnessed fall, Resident (Resident A) was found laying on the floor in the room on the right side .(Name of doctor) was notified of .un-witnessed fall. Neuro checks were started . The Neurological Assessment Flowsheet dated (MONTH) 3 (no year), starting at 10:15 p.m., had no documented indication of Resident A's level of consciousness, pupil response, or response to pain for the entire list of assessments. There was no documented indication Resident A's physician ordered or nursing staff requested further evaluation for Resident A, or that Resident A's responsible party was notified after her second unwitnessed fall at the facility. The Nurses Progress Notes, dated (MONTH) 4, 2019, at 6:29 a.m., indicated, .on monitoring for .fall .Able to move all extremities except RLE (right leg) with limitation r/t an existing chronic contusion to R knee (bruise to right knee) . There was no documented indication nursing staff notified Resident A's physician or responsible party and requested further evaluation when Resident A could not move her right leg after the second fall. The Nurses Progress Notes, dated (MONTH) 24, 2019, at 4:06 p.m., indicated Resident A had a third unwitnessed fall, resident was observed on the floor, family is informed by nurse, (name of doctor) was notified of the residents un-witnessed fall. Neuro checks were started .Will continue monitor (sic) . The Neurological Assessment Flowsheet dated (MONTH) 24, 2019, had no documented indication of Resident A's level of consciousness for 11 of 14 assessments done, no documented indication whether her pupil response was normal or abnormal, and no indication of her response to pain. There was no documented indication Resident A's physician ordered or nursing staff requested further evaluation for Resident A after her third unwitnessed fall at the facility. The C[NAME]/SBAR Change of Condition Nurses Notes the next day, dated (MONTH) 25, 2019, at 5:58 p.m., indicated, .At 5:30 While assisting residents roommate, resident was noted lying in bed with eyes open .non responsive to verbal/painful stimuli. Pupils non reactive to light .The notes indicated the nurse was unable to get a blood pressure or oxygen saturation reading for Resident A, oxygen was given, 911 was called, and Resident A was transferred to (name of hospital) HOSP 2 at 5:47 p.m. Resident A's record from HOSP 2 was reviewed. The Emergency Department Physician's Notes, dated (MONTH) 25, 2019, at 6:13 p.m., indicated Resident A was, .Unresponsive .Diminished breath sounds with very poor air movement .Possible abdominal distention . The CT Abdomen/Pelvis Report (radiology imaging test done to check for injuries or abnormalities of specified body parts) dated (MONTH) 25, 2019, at 8:09 p.m., indicated, .Reason for exam Abdominal Distention . The Report indicated Resident A had, .acute/subacute .[MEDICAL CONDITION] sacral ala (tailbone) .acute/subacute mildly displaced fractures of the right superior and inferior pubic rami (right pelvic bones) .age indeterminate compression [MEDICAL CONDITION] (third lumbar spine) vertebral body . The Emergency Department Physician's Addendum Notes, dated (MONTH) 26, 2019, at 6: 15 a.m., indicated Resident A went into cardiopulmonary arrest (heart and breathing stopped) and passed away on (MONTH) 26, 2019 at 5:18 a.m. On (MONTH) 10, 2019, at 1:30 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed and stated Resident A was very confused, weak, and had balance problems. LVN 1 stated if a resident had a fall at the facility, the nurses were supposed to assess the resident, call the physician and resident's family, look for visible injuries, signs of pain, and ask the doctor for X-rays for the resident. On (MONTH) 10, 2019, at 2:15 p.m., the Director of Nursing (DON) was interviewed and stated any change in a resident's condition had to be addressed. The DON stated the nurses were supposed to initiate the change of condition process, notify the physician and resident's responsible party, assess for injuries, and document on the SBAR form. The DON stated if a resident was found on the floor, the nurses were supposed to do neuro-checks, vital signs, assess, and observe the resident's behavior. The DON stated if a fracture was suspected, the resident should be sent to the hospital for evaluation. The DON stated neuro-checks included assessment of the resident's level of alertness, pupil response, movement, pain response, and hand grips, and if the checks were abnormal, the nurses should call the physician. During a concurrent record review, the DON verified Resident A's Neurological Assessment Flowsheet(s) related to Resident A's unwitnessed falls were incomplete, and not marked . On (MONTH) 10, 2019, at 4:10 p.m., LVN 2 was interviewed and stated Resident A was alert and confused. LVN 2 stated Resident A's right knee was deformed and Resident A acted uncomfortable when she was positioned by staff. LVN 2 stated Resident A said it hurts when her right knee and hip were touched. LVN 2 stated she did not talk to Resident A's family until (MONTH) 25, 2019, when Resident A was found non-responsive in her bed. LVN 2 stated on that day she went into Resident A's room about 5 p.m., spoke to Resident A and Resident A didn't respond, and Resident A's eyes were fixed (no movement). On (MONTH) 10, 2019, at 4:25 p.m., LVN 3 was interviewed and stated if a resident had an unwitnessed fall, the nurses should notify the doctor of the fall and if the resident hit their head, they should be sent out to the hospital to be evaluated and she did not know why Resident A was not sent out to the hospital after she fell . On (MONTH) 14, 2019, at 10:30 a.m., a follow-up visit was made to the facility for further investigation of the complaint. On (MONTH) 14, 2019, at 12:40 p.m., the Assistant Director of Nursing (ADON) was interviewed and stated neurochecks should be initiated by the licensed nurse who found the resident after a fall. The ADON stated the nurse should call for the RN supervisor, check the resident's position, vital signs, eye movement (pupil response), pain, guarding, or facial grimacing, and note what time the resident was found. The ADON stated the nurse should also check the resident's level of alertness, and response to painful stimuli and document on the resident's condition on the progress notes, SBAR form, and neuro-check form. On (MONTH) 14, 2019, at 2:25 p.m., the Radiologist (MD who specializes in reading x-rays) 1 at HOSP 2 was interviewed. During a concurrent review of Resident A's CT scan of the abdomen and pelvis, dated (MONTH) 25, 2019, MD 1 stated Resident A had multiple fractures that included fractures of the right pelvis, right sacrum, and bilateral rib fractures. MD 1 stated Resident A's pubic rami (right pelvis) fracture was not chronic and looked subacute which meant the fracture likely occurred 7 to 14 days prior. MD 1 stated Resident A had a subtle fracture of her right sacrum (tailbone) that was acute or subacute, and Resident A's rib fractures were subacute to chronic-a lot older. MD 1 stated the biggest complication when a resident had a fractured pelvis was loss of mobility (inability to walk/move). MD 1 further stated the fracture in Resident A's sacrum was located medially (toward midline) and could affect the nerves of the spine. On (MONTH) 9, 2019, the Coroner's Investigation Report, dated (MONTH) 29, 2019, was received and reviewed. The Report indicated, Cause of death Hypertensive and [MEDICAL CONDITION] Cardiovascular Disease ([MEDICAL CONDITION]) .Other significant conditions contributing to death but not related to cause given . Recent Pelvic Fractures .Injury .Unwitnessed mechanical fall . The facility policy and procedure titled Change in a Resident's Condition or Status last revised (MONTH) (YEAR), was reviewed and indicated, Our facility shall promptly notify the resident .Attending Physician, and representative .of changes in the resident's medical/mental condition .The nurse will notify the .physician .when there has been an .accident or incident involving the resident .significant change in .condition .need to alter the resident's medical treatment .need to transfer .to a hospital .A significant change of condition is a major decline .that Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .A comprehensive assessment will be done . The facility policy and procedure titled, Neurological Assessment last revised (MONTH) 2010, was reviewed and indicated, .this procedure is to provide guidelines for a neurological assessment .following an unwitnessed fall .subsequent to a fall with a suspected head injury .when indicated by resident condition .Perform neurological checks with the frequency as ordered .Determine resident's orientation to time, place, and person .Observe .pattern of speech .Take temperature, pulse, respirations, blood pressure .Check pupil reaction .Determine motor ability .Note strength bilaterally .Check eye opening, verbal, and motor responses using Glascow Coma Scale (a standardized assessment) .Record observations .Notify the physician of any change in a resident's neurological status .Report other information in accordance with facility policy and professional standards of practice .

Based on observation, interview and record review, the facility failed to ensure one resident (Resident A), received adequate supervision to prevent fall accidents. This failure resulted in injury and hospitalization s due to ten fall episodes within four months. Findings: On (MONTH) 28, (YEAR), at 11 a.m., an unannounced visit was conducted at the facility to investigate a complaint. On (MONTH) 28, (YEAR), at 11:15 a.m., Resident A was observed in bed. Resident A was asleep on a low bed and had a c-collar around his neck (cervical collar - medical device used to support a person's neck). On (MONTH) 28, (YEAR), at 11:17 a.m., Resident A's record was reviewed with Licensed Vocational Nurse 1 (LVN 1). The record indicated [AGE] year old Resident A, was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. The history and physical dated (MONTH) 2, (YEAR), .Developmental delay .does NOT have the capacity to understand and make decisions . The record further indicated Resident A was a client of Department of Developmental Services - Inland Regional Center (provides services for individuals with developmental disabilities). In a concurrent interview with LVN 1, she stated Resident A was alert and oriented to person. LVN 1 stated Resident A was developmentally disabled. LVN 1 stated Resident A had to have the c collar at all times since he came back from his last hospitalization . On (MONTH) 28, (YEAR), at 12 noon, the Director of Nursing (DON) was interviewed. The DON stated Resident A has had five falls in July. The DON stated the last one (fall) was due to [MEDICAL CONDITION]. The DON stated, His mental capacity puts him at high risk (for falls). On (MONTH) 28, (YEAR), at 12:10 p.m., Resident A's record was reviewed with the Quality Assurance Nurse (QA). The record indicated the following: -SBAR dated (MONTH) 2, (YEAR), at 10:30 a.m., .Unwitnessed fall in room [ROOM NUMBER]B .At approximately 0750am .observed resident lying on his back on the floor mat near the side of the bed .At approximately 0940am resident noted pale, lethargic and with [MEDICAL CONDITION] (low blood pressure), also complained of headache .send to (hospital initial) ER (emergency room ) for further evaluation . -SBAR dated (MONTH) 25, (YEAR), at 11:13 p.m., .The patient fell while rising up from his wheelchair .I think the patient is more ambulatory and active. But it also increases his chance of falling . -Incident report dated (MONTH) 26, (YEAR), at 1:56 a.m., Resident was walking in room near room door and sink and states he slipped .unwitnessed fall in resident's room . Predisposing factors include confusion, incontinence, gait imbalance, impaired memory, weakness and ambulating without assistance. -Nurses progress note dated (MONTH) 27, (YEAR), at 2:22 p.m., .Educated resident on importance of using call light when needs assistance resident didn't comply resident continues to get up on own without supervision . -Nurses progress note dated (MONTH) 4, (YEAR), 5 p.m., UNWITNESSED FALL, SENT TO HOSPITAL .went to find resident lying on the floor, verbalizing pain. Pt was in left side lying position .He stated he hit his head .Sent out to (hospital initials) . -Nurses progress note dated (MONTH) 4, (YEAR), at 8:45 p.m., RESIDENT RETURNED FROM (hospital initials) S/P (status [REDACTED].contusion visible 3 x 2 to upper deltoid (arm) . -Nurses progress note dated (MONTH) 5, (YEAR), at 10:20 p.m., Pt (patient) was observed down on the floor of the bathroom near the toilet with his whole left forearm inside toilet with left wrist bent inward .wrist appeared to be red and swollen/puffy .was sent out to ER at (hospital initials) . -Nurses progress note dated (MONTH) 6, (YEAR), at 1:54 a.m., Resident returned from hospital .wrist strain and placed in an immobilizer brace . -Nurses progress note dated (MONTH) 7, (YEAR), at 6:44 a.m., .Unsteady on his feet since fall .Tries to ambulate on his own. Bruising still noted to left shoulder, hand and hip. Left wrist has immobilizer brace . -Nurses progress note dated (MONTH) 11, (YEAR), at 5:02 p.m., witnessed fall .While doing rounds charge nurse was paged to the front lobby .according to RPT (registered physical therapist) and receptionist patient chair shuffled (sic) when patient was trying to sit down and patient fall . -Nurses progress note dated (MONTH) 19, (YEAR), at 1:26 p.m., un-witnessed fall .1000 tx (treatment) nurse notified charge nurse that patient had fallen and was on the floor. student found patient on floor .blanchable redness to right ear . -Incident report dated (MONTH) 19, (YEAR), at 3:32 p.m., Witnessed fall .This undersigned was standing on North station facing hallway south and seen resident walking .all of a sudden fell unto (sic) his rt (right) side of his hip unable to prevent fall due to distance .c/o (complained of) pain rt side of his head .send resident to hospital via 911 . -Nurses progress note dated (MONTH) 20, (YEAR), at 2:06 p.m., unwitnessed Fall .walk by in hallway .seen resident inside his room next to his bed . --Nurses progress note dated (MONTH) 22, (YEAR), at 4:02 p.m., Unwitnessed fall, x3 [MEDICAL CONDITION], send out 911 .1000: Resident was found on the floor by bed in [MEDICAL CONDITION] which lasted 1 min (minute) .large knot on R (right) forehead . -At risk for fall care plan initiated (MONTH) 4, (YEAR), poor Safety awareness, abnormal posture, Poor Balance, weakness .Resident constantly Ambulate without use any device .inspite of Constant redirection and reinforcement. Resident Refuse to follow staff direction for safety. Resident have very short attention span .Refused to attend activity. Resident also preference To walk in hallway, resident refuse to listen staff direction . The interventions included: Encourage resident to call for assistance as needed; Adjustable high-low beds; Keep bed at lowest position and wheels locked, and; Invite, encourage, remind, escort to activity programs. In a concurrent interview with the QA she stated Resident A had been falling because he had an infection that caused more confusion. The QA stated Resident A required constant redirection. On (MONTH) 28, (YEAR), at 12:50 p.m., Registered Physical Therapist 1 (RPT 1) was interviewed. RPT 1 stated she had evaluated Resident A after his fall on (MONTH) 12, (YEAR) and (MONTH) 20, (YEAR). RPT 1 stated she documented her evaluation and recommendation on the Rehab REFERRAL and SCREENING Form. RPT 1 stated the fall committee was aware of her recommendation. RPT 1 stated Resident A was functionally mobile with a walker. RPT 1 also stated Resident A was impulsive and required close and constant supervision. RPT 1 stated Resident A did not get enough staff supervision. On (MONTH) 28, (YEAR), at 1:05 p.m., LVN 1 was re interviewed. LVN 1 stated they were not able to provide closer supervision to Resident A. LVN 1 stated Resident A required one to one supervision. On (MONTH) 28, (YEAR), at 1:10 p.m., LVN 2 was interviewed. LVN 2 stated they did not provide one on one care for Resident A. On (MONTH) 28, (YEAR), at 3:32 p.m., a telephone interview was conducted with LVN 3. LVN 3 stated Resident A required constant supervision. LVN 3 stated constant supervision was not provided because that can only be provided if one to one. LVN 3 stated Resident A was never provided one to one supervision. On (MONTH) 25, (YEAR), at 11:12 a.m., a telephone interview was conducted with Minimum Data Set Coordinator (MDS Coordinator) and MDS Nurse. The MDS Coordinator and the MDS Nurse confirmed the following fall episodes from Resident A's record: 1. (MONTH) 2, (YEAR), at 7:50 a.m., un-witnessed, sent to ER 2. (MONTH) 25, (YEAR), at 11:13 p.m., un-witnessed 3. (MONTH) 26, (YEAR), at 1:56 a.m., un-witnessed 4. (MONTH) 4, (YEAR), at 5 p.m., un-witnessed, sent to ER 5. (MONTH) 5, (YEAR), at 10:20 p.m., unwitnessed, sent to ER 6. (MONTH) 11, (YEAR), at 5:02 p.m., witnessed 7. (MONTH) 19, (YEAR), at 10 a.m., unwitnessed 8. (MONTH) 19, (YEAR), at 3:32 p.m., unwitnessed, sent to the ER 9. (MONTH) 20, (YEAR), at 2:06 p.m., unwitnessed 10. (MONTH) 22, (YEAR), at 4:02 p.m., unwitnessed, sent to the ER Resident A's Admission Comprehensive MDS (an assessment tool) dated (MONTH) 31, (YEAR) was reviewed with the MDS Coordinator and MDS Nurse. Resident A had a BIMS (brief interview for mental status - screening test used for mental and cognitive status) score of 5 (a score of 0-7 means severely impaired). The MDS indicated Resident A balance during transition and walking was Not steady, only able to stabilize with staff assistance. The MDS further indicated that Resident A was able to walk and move in his room, the corridor and the unit with extensive assistance during his admission to the facility. The MDS Coordinator stated Resident A should have been provided more supervision. The MDS Coordinator stated Resident A actually required constant supervision which is one to one. The MDS Coordinator stated the intervention that the IDT recommendations of resident teachings, redirection and reeducation was not appropriate for Resident A since He is not able to cognitively retain education on safety, and call light usage . The MDS Coordinator stated the interventions should have been individualized and appropriate for Resident A's cognitive status. The MDS Coordinator and MDS Nurse both confirmed that as of the Significant Change in Status MDS dated (MONTH) 30, (YEAR), Resident A was not able to walk and move in his room, the corridor and the unit (significant decline from his admission functional status). Review of the Department of Developmental Services eligibility record for Resident A dated (MONTH) 18, 2003, indicated Resident was eligible for services based on [MEDICAL CONDITION]. The document Resident A's deficits included mobility, self-direction and capacity for independence. The Department's Client Development Evaluation Report for Resident A dated (MONTH) 9, (YEAR), indicated .Requires constant supervision during waking hours to prevent injury/harm in all settings . Review of the facility policy and procedure Falls and Fall Risk, Managing revised (MONTH) 2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling 4. If falling recurs despite initial interventions, staff will implement additional or different interventions .

Based on interview and record review, the facility failed to ensure provision of safety and supervision for one of six sampled residents (Resident A) when: 1. Resident A, who had elopement (when a resident leaves the facility without authorization or supervision necessary for his or her safety) risk behaviors, did not have an elopement assessment upon his re-admission to the facility, and did not have an interdisciplinary team (IDT- group of health care professionals) evaluation or reassessment for elopement/wandering risks after multiple incidents of elopement. This failure resulted in Resident A's multiple elopement incidents, which had the potential to result in accidents, injuries, or even death; and, 2. Resident A was not provided adequate supervision by the facility's staff after an incident of starting a fire on the facility's grounds. This failure had the potential to result in fire accidents for Resident A, other residents, staff, and visitors in the facility. Findings: On (MONTH) 7, (YEAR), an unannounced visit to the facility was conducted to investigate a complaint related to admission, transfer, and discharge rights. Resident A's record was reviewed on (MONTH) 7, (YEAR). Resident A was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Resident A was transferred to the acute care hospital on (MONTH) 22, (YEAR), and was readmitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Resident A's progress notes indicated the following: - Nurses Progress Notes, dated (MONTH) 20, (YEAR), at 11:40 p.m., .new admit .Patient for most of the sift (sic) was having loud auditory hallucinations . - Nurses Progress Notes, dated (MONTH) 21, (YEAR), at 12:06 a.m., .talking to himself most of (the) night as stated by roommate . - Nurses Progress Notes, dated (MONTH) 25, (YEAR), at 11:25 a.m., .verbally responsive with episodes of confusion and episodes of speaking to himself . - Nurses Progress Notes, dated (MONTH) 25, (YEAR), at 11:27 a.m., Resident is very disorganized, not able to received (sic) any message. Resident found writing on bed sheets. Resident is not focus (sic) and constantly talking, hyperverbal and incoherent speech unaware of what is wrong with him . - Nurses Progress Notes, dated (MONTH) 25, (YEAR), at 11:02 p.m., Resident was noted making inappropriate sexual exposoure (sic) in presence of female residents between 7:30-8:00 p.m. ouside (sic) in the smoking patio . - SBAR/C[NAME] (Situation, Background, Assessment, Recommendation/Change of Condition; a technique used to facilitate prompt and appropriate communication in healthcare setting), dated (MONTH) 1, (YEAR), at 4:09 p.m., .Unwitnessed fall .inability to concentrate .inappropriate social behaviors .wandering .Resident was found outside in smoking area, on the floor by staff - Nurses Progress Notes, dated (MONTH) 13, (YEAR), at 2:24 p.m., .inappropriate behavior .Resident continues to urinate and defecate in the smoking patio .Administrator and MD have been made aware of behavior .ask(ed) resident why he continues to defecate and urinate out in facility smoking patio, resident stated, 'I don't know .' - Nurses Progress Notes, dated (MONTH) 16, (YEAR), at 3:51 p.m., .Resident had to defecation (sic) X3 first two time(s) in the front of the facility and third time in the outside smoking patio .resident verbalized .'I don't know why I did it .' - SBAR/C[NAME], dated (MONTH) 21, (YEAR) at 12:28 p.m., .Patient had episode X1 of elopement at 0730 (7:30 a.m.) in parking lot. Patient expressed to staff that he .will bite the heads off animals .patient then urinated in bushes .Patient has a hx (history) of [MEDICAL CONDITION] .Mood .restless/fidgety/anxious .self-deprivation/suicidal thoughts . - Nurses Progress Notes, dated (MONTH) 21, (YEAR), at 2:58 p.m., .Resident found in parking lot around 8 am by staff member. Staff member insist patient to came (sic) in facility .but patient keep (sic) refusing for 30 min (minutes) . - Nurses Progress Notes, dated (MONTH) 21, (YEAR), at 9:37 p.m., .Resident in w/c (wheelchair) alert with multiple episodes of confusion and talking to self, verbally responsive .Resident also attempted to harm self/kill self by trying to walk onto commercial street .Resident attempted to leave facility multiple times. MD aware of situation since this morning . - Nurses Progress Notes, dated (MONTH) 22, (YEAR), at 10:50 a.m., .Resident is on 1:1 with CNA (certified nursing assistant) present at all times this morning . Resident A was transferred to the acute care hospital on (MONTH) 22, (YEAR). The acute care hospital's psychology consultation notes, dated (MONTH) 25, (YEAR), indicated, .The patient is being admitted due to acute agitation. According to staff at the patient's facility, the patient had become very agitated and was unable to be redirected or deescalated. The patient continued to have yelling episodes and was unredirectable and unattainable .Insight is impaired. Judgment is impaired . Resident A was readmitted to the facility on (MONTH) 5, (YEAR). There was no elopement assessment completed on Resident A's readmission to the facility. Resident A's smoking care plan, dated (MONTH) 9, (YEAR), indicated, Resident is a smoker at risk for injury to self . Resident A's progress notes indicated the following: - Nurses Progress Notes, dated (MONTH) 7, (YEAR), at 11:19 a.m., .Patient alert but disoriented at times .Episode X1 of urination and defecation outside . - Nurses Progress Notes, dated (MONTH) 18, (YEAR), at 6:29 a.m., .Resident continues to go outside (the) building throughout the night and is seen by staff urinating and defecating. Resident is redirected back to the facility to use the restroom in his room. - SBAR/C[NAME], dated (MONTH) 19, (YEAR), at 6:38 p.m., .Resident was noted to light a fire in the corner of the building in front .this started on (MONTH) 18, (YEAR) .cognitive status: alert, confused and forgetful .behavior: .noted with hallucinations, talking to himself and responding also, laughing by himself . - Nurses Progress Notes, dated (MONTH) 24, (YEAR), at 7:22 a.m., Received call at approximately 0600 (a.m.) from (name of police department) re: (regarding) a call from this facility. The 911 operator was unable to understand what the caller was saying and wanted to know if we needed assistance. (Resident A) has been calling 911 from the phone outside at the delivery door. (Facility) was informed by the 911 operator that 12 (twelve) 911 hang-up calls have been made from this facility in the last 4 days . - SBAR/C[NAME], dated (MONTH) 27, (YEAR), at 8:03 a.m., AWOL (absence without leave- leaving facility premises without authorization) .@ (at) 0630 (6:30 a.m.) (staff) asked the patient permission to smoke outside (and) seen patient smoking outside the parking lot near to the main street(.) After a few minutes we can't find the patient .we look(ed) around the building and outside the building .around 0730 (7:30 a.m.) we found (Resident A) in front of the facility smoking (sic) .Patient history of [MEDICAL CONDITION], anxiety and [MEDICAL CONDITION] . - Nurses Progress Notes, dated (MONTH) 3, (YEAR), at 10:58 a.m., .charge nurse recieved (sic) a call from DON (director of nursing) stating resident was out at bus station at 1015 (10:15 a.m.) . - Nurses Progress Notes, dated (MONTH) 4, (YEAR), at 6:51 a.m., .Was unable to keep him (Resident A) from going outside and coming back in during shift d/t (due to) lack of staff on shift . There was no documented evidence an interdisciplinary team (IDT- group of health care professionals) evaluation was conducted to address Resident A's fire incident and multiple elopement episodes. There was no IDT evaluation to address if Resident A needed a sitter on his re-admission to the facility. There was no documented evidence an elopement assessment was completed after Resident A's multiple elopement/AWOL incidents. On (MONTH) 7, (YEAR), at 1:33 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned to Resident A several times. CNA 1 stated Resident A was pretty confused. CNA 1 stated she had to repeat her questions to Resident A to get a response. CNA 1 stated she saw Resident A smoking by himself or with other residents in front of the facility. CNA 1 stated she didn't know where Resident A got his lighters. CNA 1 stated she didn't know about Resident A's elopement and fire incidents. On (MONTH) 7, (YEAR), at 1:44 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A was forgetful and had wandering behaviors. LVN 1 stated Resident A can be here this time and next in another place since he was ambulatory. On (MONTH) 7, (YEAR), at 2:09 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident A had poor safety awareness of self and others. The ADON stated Resident A hoarded the lighters and cigarette buds (tail end of the cigarette left over after someone has smoked). The ADON stated nobody knew where Resident A got his lighters. The ADON stated Resident A did not have a sitter. On (MONTH) 7, (YEAR), at 2:36 p.m., LVN 2 was interviewed. LVN 2 stated she was the nurse in-charge of Resident A on (MONTH) 3, (YEAR). LVN 2 stated she received a call from the DON around 10:15 a.m. on (MONTH) 3, (YEAR) that the resident was at the bus station. LVN 2 stated she did visual checks for Resident A on an hourly basis. LVN 2 stated, I believe he (Resident A) needs to be on 1:1 sitter. LVN 2 stated Resident A was confused and forgetful. Resident A's record was reviewed with LVN 2, and she confirmed there was no elopement assessment after the incident on (MONTH) 3, (YEAR). LVN 2 stated it was missed .I should have done it. On (MONTH) 7, (YEAR), at 3:33 p.m., the Quality Assurance (QA) Nurse was interviewed. The QA nurse stated Resident A's mentation fluctuates. The QA nurse stated an elopement assessment is completed during a resident's admission to the facility, on a quarterly basis, and after each episode or incident of an elopement. Resident A's record was reviewed with the QA nurse, and she confirmed there were no elopement assessments completed for Resident A on the elopement incidents on (MONTH) 21, (YEAR), (MONTH) 27, (YEAR), and (MONTH) 3, (YEAR). The QA nurse confirmed there was no elopement assessment completed on Resident A's readmission to the facility. On (MONTH) 9, (YEAR), at 11:11 a.m., the facility's record of staff in-services were reviewed with the Director of Staff Development (DSD). In a concurrent interview with the DSD, he stated there were no previous in-services regarding elopement. The DSD further stated, I didn't know there were issues. On (MONTH) 9, (YEAR), at 12:38 p.m., the Activities Assistant (AA) was interviewed regarding the fire incident on (MONTH) 19, (YEAR). The AA stated they were doing night out program in the activity room when she witnessed the resident through the glass window holding a paper plate on fire with about 3-4 inches of flame. The AA stated Resident A was walking around with it, then she lost sight of him. The AA stated she told the receptionist about it. The AA stated the receptionist had to stamp out the fire, and her shoe almost caught on fire. The AA stated the receptionist took the lighter from Resident A. On (MONTH) 15, (YEAR), at 4:03 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility would conduct elopement assessments for residents who had history of elopements. The DON stated an elopement risk reassessment and IDT evaluation should be completed after an episode of resident elopement. The DON stated there should have been an elopement assessment on Resident A's readmission to the facility and after each episode of elopement. The DON further stated an IDT evaluation should have been conducted to address concerns regarding Resident A's behavior after a fire incident. The facility's policy titled, Elopements, indicated: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: examine the resident for injuries; notify the attending physician; notify the resident's legal representative (sponsor) of the incident; complete and file Report of Incident/Accident; and document the event in the resident's medical record .

Based on observation, interview, and record review the facility failed to provide adequate supervision to Resident A during her shower on (MONTH) 19, (YEAR), at 3:20 p.m., when a Certified Nurse Assistant (CNA) stepped away and turned her back from Resident A to change her gloves. This failure resulted in Resident A to fall off the shower chair, sustained a left hip fracture, a laceration (a deep cut or tear in skin) above her left eye and a small subdural hematoma (a collection of blood outside the brain) which caused Resident A to be admitted to the acute hospital. Findings: On (MONTH) 25, (YEAR), at 1:45 p.m., an unannounced visit was made to the facility to investigate a facility reported incident related to a fall. On (MONTH) 25, (YEAR), Resident A's record was reviewed. Resident A was admitted to the facility on (MONTH) 22, 2014, with [DIAGNOSES REDACTED]. The facility form titled, history and physical examination [REDACTED]. Resident A's Minimum Data Set (MDS: an assessment tool) dated (MONTH) 31, (YEAR), indicated the following: Section C (Cognitive Status): a) Resident A had difficulty with orientation to year, and month; and b) Resident A was unable to recall three words after cueing that was expressed to her at an earlier interview by a facility staff. Section G (Functional Status): a) Resident A required extensive assistance by two staff for bed mobility and transfer; b) Resident A required extensive assistance by one staff for dressing, eating and toilet use; and c) Resident A required total dependence by staff to move around the unit. Resident A's fall risk assessments indicated the following: a. On (MONTH) 23, (YEAR), score of 18; b. On (MONTH) 27, (YEAR), score 16; and c. On (MONTH) 12, (YEAR), had a score of 18. The assessment form indicated a total score of ten or above represented a high risk for falls. Resident A's Progress Notes, were reviewed and indicated the following: a. On (MONTH) 19, (YEAR), at 3:25 p.m., .13:25 (1:25 p.m.) CNA (CNA 1) called for help in shower room, upon arriving to shower room, observed resident laying (sic) on floor in shower stall. CNA (CNA 1) states (sic) she was (sic) finished giving sho wer (sic), turned to change her gloves, resident leaned forward and fell on to floor. Resident is (sic) noted to have 3 inch laceration to left eye brow, 1 inch deep, abrasion noted to left side of head, discoloration noted to left eye . ; and b. On (MONTH) 19, (YEAR), at 3:30 p.m., . Assessed resident for other injury aside from bleeding from her left eyebrow and no other obvious injury noted, able to move all her upper and lower extremities with no problem, and no complaints of pain upon movement. No swelling or bruising noted at this time of assessment. On (MONTH) 27, (YEAR), at 1:40 p.m., CNA 2 was interviewed. She stated when a resident had a tendency to lean over, staff would use the shower chair with the lap bar. CNA 2 stated the shower chair without the lap bar was used for alert residents. On (MONTH) 27, (YEAR), at 1:44 p.m., CNA 3 was interviewed. She stated the facility had shower chairs with and without a lap bar. CNA 3 stated the shower chair with a lap bar was for residents who did not have upper support strength. She stated the shower chair without a lap bar was intended for the alert residents. On (MONTH) 27, (YEAR), at 1:55 p.m., CNA 1 was interviewed. She stated it was her first time taking care of Resident A. CNA 1 stated she did not have a huddle (a report on residents care by licensed vocational nurse) prior to start of work the day of the incident. She stated she placed Resident A in a shower chair that did not have a lap bar, and further stated she used the shower chair that was available in the shower room. CNA 1 stated she turned to get a clean pair of gloves from the glove box, and when she turned back towards Resident A, she (Resident 1) was already leaning forward and fell out of the chair. CNA 1 stated she tried to stop her (Resident A) but couldn't. On (MONTH) 27, (YEAR), at 3:45 p.m., CNA 4 was interviewed. She stated the shower chairs with a lap bar were used for residents with no lower extremities (amputations) and for residents with weak upper body. CNA 4 further stated a special need list were located on the inner side of the residents' linen closet. On (MONTH) 1, (YEAR), at 3:53 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated CNA 1 told her (LVN 1), she (CNA 1) went to change her gloves and when she turned around, she saw Resident A falling, and it was too late to catch her. LVN 1 stated she (CNA 1) should not have turned away from Resident A while in the shower. She stated CNA 1 knew she was supposed to get a care report from the charge nurse, which included: Resident A had a weak upper body strength, totally dependent on bed mobility, transfers, dressings, eating, shower, and toilet use. CNA 1 should have waited for the report. On (MONTH) 3, (YEAR), at 3:36 p.m., the Director of Nursing (DON) was interviewed. She stated CNA 1 turned her back to change her gloves and when she turned around, Resident A was falling. Resident A fell too fast and CNA 1 was unable to stop the fall. She further stated, CNA 1 should have waited for shift report. The CNA's were given instructions on safety and special needs on residents. DON further stated, CNA's were not supposed to turn their back away from the resident. A review of an undated facility form titled, Special Needs List located on the inner side of Resident A's closet door indicated; .Cognition: Disoriented Locomotion: Wheelchair Transfer: Two Person with Gait Belt Devices: Wheelchair Bed mobility: Dependent Eating: Dependent . On (MONTH) 7, (YEAR), at 4:04 p.m., LVN 2 was interviewed. She stated Resident A was not able to ambulate and was always in the wheelchair while on the unit and during meals. She further stated Resident A needed to be watched because she was a fall risk. On (MONTH) 7, (YEAR), at 4:15 p.m., CNA 5 was interviewed. She stated Resident A was totally dependent and required two staff to transfer her. She further stated Resident A had a star at her name plate by the room door and on her wheelchair which indicated she was a fall risk. CNA 5 further stated she always uses the shower chair with the lap bar for safety of the residents. In a phone interview with the Director of Staff Development (DSD) on (MONTH) 23, (YEAR), at 2:45 p.m., she stated showers were given to the patients according to the facility's shower list. On (MONTH) 7, (YEAR), at 2:48 p.m., an observation of the shower was conducted. Observation revealed the emergency call light switch with a dangling cord was located within the shower stall, and measured approximately two feet two inches from the center of the shower valve. The emergency call light was operational. Further observation revealed the distance from the shower where Resident A was to the glove box (mounted on the wall) where CNA 1 went to was approximately ten feet. A review of Resident A's Physician order [REDACTED]. A review of the acute hospital x-ray dated (MONTH) 19, (YEAR), indicated Resident A had a fracture of her left hip. The acute hospital Computerized Tomography (CT- picture of an internal body part) of the brain dated (MONTH) 19, (YEAR), indicated Resident A had a small subdural hematoma (bleeding in the brain) along the right side of the brain. Resident A was transferred back to the facility on (MONTH) 20, (YEAR), for comfort measures only, and expired on (MONTH) 27, (YEAR) (8 days after the fall incident). Resident A's Certificate of Death obtained on (MONTH) 3, (YEAR), indicated, .date of death : (MONTH) 27, (YEAR) .Cause of Death .Immediate cause Aspiration pneumonia .Other significant conditions contributing to death .Left hip fracture, subdural hematoma . A review of the facility's policy titled, Shower/Tub Bath revised in (MONTH) 2010, indicated, .General Guidelines . .2. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 3. Use the emergency call signal to summon assistance, if needed .Equipment and supplies The following equipment and supplies will be necessary when performing this procedure. . 10. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure 1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached .

Based on interview and record review, the facility failed to attain the highest practicable health and psychosocial well-being for one of three sampled residents (Resident A), as evidenced by: -Resident A had consistent and severe pain levels after a fall. The facility nurses did not effectively manage his severe pain and/or assess his left leg pain. After seven days of severe pain, Resident A was transferred to an acute care hospital where he was diagnosed with [REDACTED]. This failure caused Resident A to have unresolved pain from the [MEDICAL CONDITION] for one week without treatment, undergo surgery to repair a fracture, and have an unnecessary hospitalization for four days. Findings: On May 31, 2017, at 10:10 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care issue. The intake indicated Resident A had fallen from his wheelchair on May 9, 2017, and complained of pain. After seven days, he was transferred to an acute care hospital due to a left [MEDICAL CONDITION]. On May 31, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident A's physician admission orders [REDACTED].Monitor Level of Pain Q (every) Shift (Scale 0-10): (0 = No pain, 1-3 = Mild pain, 4-5 = Moderate Pain, 6-9 = Severe pain, 10 = Excruciating Pain). The orders included [MEDICATION NAME] (Tylenol) Tablet 325 MG (milligrams) two tablets by mouth every 4 hours as needed for mild pain 1-3/10 (a 1-10 scale used to rate pain with 1 being the mildest pain the person has ever had to 10 being the worst pain ever felt by the person), and [MEDICATION NAME] tablets 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) one tablet by mouth every six hours for moderate pain of 7-10/10. A review of Resident A's facility record titled HISTORY AND PHYSICAL, dated May 6, 2017, indicated Resident A had the capacity to understand and make decisions. Resident A's facility record titled PHYSICIAN'S PROGRESS NOTES, dated May 9, 2017, indicated, Called by nursing staff about the patient's fall on his R (right) hip. Patient complained of increased pain that has not been relieved by current meds (medications). X-ray was ordered & pain medications were adjusted. The patient was noted not to have fracture after all. Will continue to monitor patient & enforce fall precautions. Resident A had a care plan developed and titled, actual fall on 05/09/2017 getting up unassisted, poor safety awareness forgetting to lock wheelchair. The care plan was initiated on May 9, 2017, and indicated that facility staff was to monitor for signs and symptoms of pain and discomfort and to call the doctor. Further review of Resident A's facility record titled Nurses Progress Notes, dated May 10, 2017, revealed the following entries written by licensed nurses (LN): 5/10/2017 06:47 (6:47 a.m.) .Pt (patient) has been medicated for pain on PM shift per MD (medical doctor) orders and Pt states it is not effective. Pt later was heard to be calling out for help and than (sic) started dry heaving. NP (nurse practitioner) was at the facility and saw pt, it was stated to me Pt is detoxing from Drug use. PT has no tremors, no hyperthermia (elevated body temperature) or constant N/V (nausea/vomiting). Pt is alert and orientated (sic) and able to make needs known at this time Pt has been placed in high fowlers at this time with no N/V and at this time he is laying in bed with eyes closed supine. Pt was later heard vomiting. Pt was attended to and had vomited aprox (approximately) 200 cc (cubic centimeters - approximately six ounces) green bile-like vomitus; MD notified, new orders received and carried out for [MEDICATION NAME] (medication for nausea and vomiting) 4 mg IM (intra-muscular) given and tolerated well and effective. Pt has been yelling out all night continuously gagging. Pt has been given an order of one time [MEDICATION NAME] (medication used for sedation associated with behavioral problems) 5 mg/ml IM per MD orders and tolerated well, effectiveness shown after 2 hours for [MEDICATION NAME] . 5/10/17, at 1:14 a.m., indicated, Topic: fall Assessed resident. 5/10/2017 13:22 (1:22 p.m.) .IDT (interdisciplinary team) met to discuss 05/09/2017 s/p fall. Resident attempted to transfer by himself but forgot to lock wheelchair .monitor for s/s (signs and symptoms) of pain and discomfort . At 1545 (3:45 p.m.) the licensed nurse (LN) documented, resident was alert, pupil responsive to light, able to move right and left arm, right leg, but pain to move left leg/hip. 1815 (6:15 p.m.) the LN documented, x-ray tech came and performed X-ray. 1830 (6:30 p.m.) the LN documented, PRN pain medication gave (sic). At 1930 (7:30 p.m.) The NP assessed resident and ordered a one time dose of [MEDICATION NAME] 10/325 (mg) and [MEDICATION NAME] 0.5 mg to be given for pain and anxiety. 2015 (8:15 p.m.) the LN documented, able to move right and left arm, right leg, but in pain to move left leg/hip. 2030 (8:30 p.m.) the x-ray results were back and a copy was sent to the NP 2215 (10:15 p.m.) The LN documented, able to move right and left arm, right leg, but in pain to move left leg/hip. 5/11/2017 05:29 (5:29 a.m.) .C(NAME) (change of condition) for unauthorized MED (medication) being monitored d/t (due to) narcotics being found in pt belongings. Pt has only asked for pain MED x (times) 1 on shift . 5/13/2017 23:24 (11:24 p.m.) .resident complained that the [MEDICATION NAME] 5/325 mg PRN Q 6 h (as needed every 6 hours) wasn't effective and needed a more frequent time. NP (nurse practitioner's name omitted) was notified and order for [MEDICATION NAME] 10/325 mg PRN q4h (every 4 hours) was made. Hes (sic) in bed at this time at the lowest position with call light within reach . 5/15/2017 11:32 (11:32 a.m.) .IDT Progress Notes .IDT met to discuss resident noted to have home medication at bedside that appears to be pain medications, Resident stated that it was left from his jacket upon admission but was not declared during inventory. Resident with history of pain seeking and drug abuse. MD and family notified . On May 15, 2017, a care plan titled Intractable pain on lower back, left hip and left thigh was developed due to Resident A's comminuted (bone broken into pieces) left intertrochanteric (area between upper and lower thigh bone) femoral neck fracture with mild displacement and mild [MEDICAL CONDITION] changes. The care plan indicated that, Resident is at risk for further spontaneous fracture d/t (due/to) [MEDICAL CONDITION] changes with osteopenia, The plan indicated facility staff was to monitor for signs and symptoms of pain and efficacy of treatment and to notify the doctor if pain was unrelieved. Late entry 05/16/2017 .IDT met regarding resident results of xray done 05/15/2017 Has acute comminuted left intertrochanteric femoral neck fracture and mild displacement with mild [MEDICAL CONDITION] changes with osteopenia. Resident with recent fall on 05/09.2017 with xray done showing no fracture post fall osteopenia, which will be risk factors for further falls with injury and spontaneous fracture. Resident on 05/15/2017 noted to have decline while in rehab d/t to excessive pain, affected area was immobilized until further evaluation and pain assessment and management initated .Resident was transferred to hospital for further treatment per MD order . Resident A's facility record titled Medication Administration Record [REDACTED]=no pain, 10=severe pain), from the day of Resident A's fall on May 9, 2017, until May 15, 2017, when the resident was transferred to the acute hospital: -May 9, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10 -May 10, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 10/10 -May 11, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 7/10 -May 12, 2017 (3-11 pm shift) 5/10, (11-7 am shift) 8/10 -May 13, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10 -May 14, 2017 (3-11 pm shift) 8/10, (11-7 am shift) 7/10 -May 15, 2017 (3-11 pm shift) 9/10 The back of the Medication Administration Record, [REDACTED]. On May 31, 2017, at 2:52 p.m., the Director of Nursing (DON) was interviewed. The DON stated when residents were in pain, the nurses would try non-pharmacological interventions first. The nurses should check for pain effectiveness using a numeric pain scale. If the pain levels were consistently 6-10, severe pain levels, then the nurses should call the doctor. The DON stated Resident A was negative for [MEDICAL CONDITION] during the fall of May 9, 2017. He continued to experience pain, and another x-ray was ordered on May 15, 2017. The results showed a left [MEDICAL CONDITION]. The DON stated the nurses should document and assess Resident A's pain using the pain scale and the doctor would only order pain medications one time only. The DON stated Resident A had a history of [REDACTED]. On June 8, 2017, the acute hospital records were reviewed. The acute care hospital records titled ED (Emergency Department) Physician Record, dated May 16, 2017, indicated: The patient presents with left hip pain. The onset was 1 weeks (sic) ago. The course/duration of symptoms is constant. Type of injury: fall. Location: Left hip. The character of symptoms is pain .male was brought in by ambulance from a convalescent home and presents to the ED complaining of left hip pain, onset 1 week ago after he missed his wheelchair and fell . Pt has been lying in bed since his fall and had an x-ray today which showed an upper femoral head (hip) fracture. Left hip pain is rated 10/10 in severity. Pt denies new trauma since his fall .Pt was given 15 of [MEDICATION NAME] ([MEDICATION NAME] sulfate extended release 15 mg by facility's medications) and 2 mg of [MEDICATION NAME] ([MEDICATION NAME] tablet 10-325 mg every four hours as needed from facility's medications) en route by EMS . A review of Resident A's acute hospital record titled Operative Reports, dated May 17, 2017, indicated a procedure was performed. The surgical procedure indicated Hip Trochanteric Fixation Nail, LEFT INTRAMEDULLARY NAILING, Left LONG . On June 28, 2017, at 1:23 p.m., Resident A's family member (FM) was interviewed. The FM said Resident A was paralyzed on one side, and fell while attempting to get into his wheelchair. Resident A's wheelchair was not locked so he fell and hurt his hip. The FM stated Resident A was yelling for a nurse after the fall. The facility did an x-ray that day and it was negative for a fracture but he complained of severe pain for one week. The FM stated the nurses thought he was only drug seeking but he was in severe pain and needed pain medications. The FM further stated Resident A was screaming in pain because of a possible fracture the next day after the fall. The FM talked to a nurse that night and the nurse only gave him a sedative ([MEDICATION NAME] was ordered one time only on May 9, 2017). The FM stated Resident A really needed pain medication for the fracture. The FM stated one week later, she showed the nurses Resident A's one leg was more swollen than the other and his knee was very swollen. That was when the facility decided to order another x-ray. The FM stated Resident A was transferred to the hospital after one week of severe pain. On July 18, 2017, at 9:52 a.m., Resident A was interviewed. Resident A stated he had a stroke and was admitted to the facility to get rehabilitated. Shortly after his stay began at the facility, he fell and broke his hip. Resident A stated the facility was not handling his severe pain. Resident A stated the nurses looked at him and laughed when he was screaming in pain the following day of the fall. Resident A further stated the nurses said he was negative for a [MEDICAL CONDITION] and they were giving him [MEDICATION NAME] for pain. Resident A stated [MEDICATION NAME] was doing no good for his severe pain. Resident A stated he could not stand the pain and the doctor was not answering the nurses' page. Resident A stated the nurse practitioner did not come to evaluate his continued and consistent pain after the fall. Resident A stated one nurse just laughed at me and stated they already took an X-ray so stop it, you are lying, nothing is wrong with you. Resident A stated the first x-ray did not show a fracture. Then seven days later, the facility agreed to do another x-ray. Resident A stated he was screaming in pain and really wanted to be transferred to a hospital for an immediate evaluation after the fall. On July 18, 2017, at 11:29 a.m., the Nurse Practitioner (NP) was interviewed. The NP stated Resident A's case was an unusual one because he had a history of [REDACTED]. The NP stated the nurses made their own judgements and tended to ignore his pain during that time. The NP stated Resident A was very upset and the nurses should have addressed his severe and consistent pain levels. The NP stated he was on call 24 hours a day and if Resident A was complaining of pain levels 5-10, consistently for seven days, then Resident A should have been evaluated sooner and transferred to an acute care hospital. The NP further stated the nurses should not wait until Resident A's pain level was 10/10. The NP stated the facility should make the resident as pain free as much possible. The NP stated the facility tried to medicate him once only at a time because they did not want to overdose him. The NP stated the nurse disregarded his pain because of a negative X-ray. The NP stated he would take this complaint up to Administration at the facility. On May 31, 2017, the facility's policy titled Pain Assessment and Management, revised March 2015, had been reviewed. The policy indicated: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . General Guidelines . Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in level of chronic pain . Monitoring and Modifying Approaches . Monitor the following factors to determine if the resident's pain is being adequately controlled . The resident's response to interventions and level of comfort over time . The status of the underlying cause(S) of pain . Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales, etc.) and relevant criteria for measuring pain management (e.g., target signs and symptoms) . Reporting . Report the following information to the physician or practitioner . Significant changes in the level of the resident's pain . Prolonged, unrelieved pain despite care plan interventions .

Based on observation, interview, and record review, the facility failed to provide five residents (Residents B, C, D, E, and F) in a universe of 157 residents, an environment free from verbal, physical, and sexual abuse, harassment, and intimidation from Resident A. This failure resulted in emotional distress and fear for Residents B, C, D, E, and F, placing them in jeopardy for severe, negative psychosocial response from ongoing persistent expressions of anger, harassment, and emotional trauma from the abuses by Resident A. On March 14, 2017, at 3:50 p.m., the Administrator and DON were made aware of observed and documented evidence of Resident A's ongoing and escalating behaviors towards facility residents as well as toward facility staff. The Administrator and DON were both informed of the lack of any plan or lack of any measures in place to prevent the increasing environment of abuse, harassment, and intimidation from Resident A. Due to the facility's failure to provide an environment free from harassment, verbal, sexual, and physical abuse from Resident A, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on March 14, 2017, at 3:51 p.m. The Immediate Jeopardy was removed at 4:30 p.m. on March 22, 2017, in the presence of the Administrator and the DON after the facility provided CDPH with an acceptable plan of action which indicated that Resident A had been transferred out of the facility and would not return, ensuring the residents' safety and freedom from harassment, intimidation, and abuse by Resident A. The plan of action indicated that: -Resident had been transferred out of the facility and would not be returning. -Should a resident become aggressive, abusive, hostile, assaultive, or unmanageable in any way, staff is inserviced to do the following: Every effort shall be made to calm the resident. However, personal safety must always be considered. One to one or periodic monitoring will be put into effect immediately until discharged by IDT. Provide for the safety of all concerned -Notify the resident's attending physician and facility's Medical Director. - Notify the facility Administrator and Director of Nursing. -Notify the resident's representative. -Local law enforcement agencies will be called for assistance. - Complete documentation of the incident must be recorded in the resident's medical record, and an incident report must be filed with the Administrator. Findings: On March 7, 2017, at 10:30 a.m., an unannounced visit was conducted at the facility to investigate an incident regarding a resident-to-resident altercation. On March 7, 2017, at 12:07 p.m., Resident B was interviewed in her room. Resident B stated that (Resident A's name) was in her room numerous times. Resident B stated (Resident A's name) hit two residents and nothing was being done. Resident B said she informed the Administrator more than one time. Resident B stated (Resident A's name) called her, Nigger [***] . Resident B stated the resident would follow her around and terrorize her by saying, You are going to die! On March 7, 2017, Resident B's record was reviewed. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident B's BIMS (Brief Interview for Mental Status) score was indicated as 15, on January 3, 2017. A score of greater than 13 indicates intact cognition (the process of knowing and understanding). On March 7, 2017, at 12:27 p.m., Resident C was interviewed in her room. Resident C stated she would prefer to stay in her room. Resident C stated Last night (Monday, March 6, 2017) was really bad because she heard Resident A banging in his wheelchair while going down the hallway. He (Resident A) stated he was going to cut somebody with a knife very loudly outside Resident C's room. Resident C stated she was terrified and stayed in the room. On March 7, 2017, Resident C's medical record was reviewed. Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident C's BIMS score was indicated as 15,on January 20, 2017. On March 7, 2017, at 12:27 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A wheeled around the facility in his wheelchair. LVN 1 stated Resident A had turned on the faucet of the sink and flooded his room. LVN 1 stated the resident had been moved to another room for the second time after that. LVN 1 stated Resident A had stolen medications from the medication cart on two separate occasions. LVN 1 stated the facility moved him for safety reasons. On March 7, 2017, at 12:35 p.m., Resident A was observed in bed sleeping in his room with the covers on. On March 7, 2017, at 12:55 p.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated Resident A would wander in the hallways and around the facility, mostly during the evenings. CNA 1 stated the facility had a problem with him last Sunday and was dependent on (the resident's) behavior. CNA 1 stated he would enter other residents' rooms. CNA 1 stated the resident stole a resident's radio and stated, Shut up! when told to be quiet. On March 7, 2017, at 1:15 p.m., Resident D was interviewed. Resident D stated he had a confrontation with (Resident A's name). Resident D stated the resident hit two nurses and would call them names. Resident D stated that Resident A was verbally abusive and curses a lot. On March 7, 2017, Resident D's record was reviewed. Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident D's record titled history and physical examination [REDACTED]. Resident D's BIMS score was indicated as 14. On March 7, 2017, Resident A's facility record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of Resident A's record titled history and physical examination [REDACTED]. Review of the recapitulated (a summary) physicians orders, from March 1, 2017, through March 31, 2017, indicated: -[MEDICATION NAME] Tablet 1 MG (milligram) .Give one tablet by mouth every 8 hours as needed for Anxiety m/b (manifested by) verb (verbalization) of fell ing (sic) anxious .02/05/2017 . -[MEDICATION NAME] Tablet 20 MG .Give one tablet by mouth one time a day for Depression .M/B (manifested by) Hopelessness .01/13/2017 . -[MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG .Give 8 capsule by mouth two times a day for [MEDICAL CONDITION] (mental disorder characterized by both manic and depressive episodes) m/b mood swings .02/09/2017 . -Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 200 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] .M/B of Aggressive behavior .01/13/2017 . -Pt can be sent out to Psych (psychiatric) facility if any further episodes of violent/aggressive behavior .02/07/2017 . -send resident to (hospital name) related to aggressive behavior .02/13/2017 . -readmit from (hospital name). Ok to resume all orders .02/14/2017 . There was no documented evidence that indicated Resident A was transferred to a psychiatric facility, from February 7, 2017, until March 7, 2017. A psychiatrist's (a physician who specializes in treatment of [REDACTED].S (subjective) and O (objective): Asked to assess the pt (patient) for increased mood swings, inappropriate behavior sexually, as well as med (medication) mgt (management), staff reports pt striking out after provocation .alert .speech coherent, affect-labile, thought processes (+-positive) loose assoc (association), (+) delusions, [MEDICAL CONDITION] .A (assessment): [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS] .P (plan): Increase [MEDICATION NAME] 1000 MG BID (twice daily) .continue [MEDICATION NAME] and [MEDICATION NAME], supportive treatment, case discussed with staff . There was no documented evidence of an Interdisciplinary team meeting (IDT) discussion with Resident A and facility staff related to increased behavior or any plan for Resident A to be transferred out to appropriate psychiatric facility. Review of the facility's progress notes indicated the following: 01/20/2017 .18:43 (6:43 p.m.) .Resident showing aggressive behavior towards another senior resident and using profanity. He also broke his plate after eating his dinner and didn't think it was wrong. He is not safe in this environment without supervision. He is exhibiting behavior that makes staff fear of being assaulted . 01/22/2017 .07:12 (7:12 a.m.) .I left my small bag on top of med cart. I checked 107B because she keeps calling, when decided to get my BP (blood pressure) cuff, noticed my small bag gone, asked staffs and they saw (Resident A's name) .around the nurses' station and accompanied me to search the room, I found my stethoscope on top of the dresser and my small bag inside his drawer mixed with his clothes but BP cuff was missing, all staffs & supervisor aware for his behavior . 01/22/2017 .21:26 (9:26 p.m.) .Resident continues to be aggressive and use profanity towards residents and staff at interval. Shows no remorse . 01/24/2017 .02:31 (2:31 a.m.) .Resident found wandering in the hallway at 0123 (1:23 a.m.) hours, complained that his bed was wet, observed wetness to linen in middle of the bed. Notified CNA who changed beddings, Reoriented resident to time and place, resident stated he would get himself in bed. Went in to check resident at 0230 (2:30 a.m.) hours, found resident looking through bedside drawer on opposite side of the room, asked resident why he was going through the drawer, no response from resident. Redirected back to his bed . 01/24/2017 .20:57 (8:57 p.m.) .Noted with aggressive and negative behavior towards staff and other residents. Attempted to redirect resident states, Don't start[***]with me! RN aware . 01/25/2017 .15:35 (3:35 p.m.) .resident cont (continue) on .taking belongings, no c/o (complain of) belongings taken during shift, resident is up in wc (wheelchair) all staff aware of incident . 02/04/2017 .13:51 (1:51 p.m.) .Resident was sitting in hallway exposing self to LVN (Licensed Vocational Nurse), masturbating and cursing at the nurse. Resident was sent to room and told not to come out until he could conduct self in a proper manner in public. Resident in room at this time . 02/04/2017 .15:29 (3:59 p.m.) .during med (medication) pass, resident exposed himself and continued to masturbate after being told to please stop. Resident got upset, cursed and yelled, refused to go to his room. Resident also took supplement shake without asking from med cart. Asked resident please do not take things from the med cart. Refused to give back the supplement shake. Notified RN (Registered Nurse), notified doctor, awaiting doctors approval to be sent out for further evaluation . 02/05/2017 .07:03 (a.m.) .@1030 (10:30 a.m.) pt (patient) was trying to go into female room and exposing himself to her, CN (charge nurse) happen to be in the room with the other pt, she came out to redirect his behavior and he started cursing and yelling at her, he was getting aggressive to all staff. After 20 min (minutes) of trying to calm him down, he finally went to his room . 02/08/2017 .03:00 (3 a.m.) .Awake at 0238 (2:38 a.m.), wandering down the halls in his wheelchair .Reoriented resident to time and place, returned to room and got into bed, will continue to monitor . Resident A was transferred to an acute care hospital on February 13, 2017, for aggressive behavior. Resident A punched Resident F in the face after refusing to share a cigarette in the smoking area of the facility. .02/13/2017 .23:27 (11:27 p.m.) .Received call from (hospital name) stating they did not have adequate staff to 5150 (a legal code for involuntary confinement of a person suspected to have a mental disorder that makes them a danger to themselves and/or others or is gravely disabled) resident tonight if we could transfer tomorrow morning. CN stated will transfer to RN supervisor for further assistance. ER (emergency room ) staff then transferred call to police officer asking for RN. Police officer stated they (hospital) received ok from previous shift to return and post pone 5150 till next day. CN transferred call to supervisor for further assistance . 02/14/2017 .01:31 (12:31 a.m.) .2 (hospital name) officers (hospital security officers) approached nursing station asking for RN supervisor. Staff called RN. Officers stated hospital would be transporting resident back shortly due to shortage of staff at (hospital name). Officers began to explain eviction notice not given to resident, RN explained resident was not evicted and this is a nursing facility not assisted living. RN attempted to call ED (Executive Director) and DON for further assistance on matter and further orders. Awaiting call back . 02/14/2017 .06:37 (6:37 a.m.) .Resident arrived via gurney 2 emts (emergency medical technicians). Resident (sic) was yelling and cursing at emts get me out of here! I don't want to be in this [***] ing place. EMTs explained to resident they were just transporting resident, resident yelled to emt- shut up you fat pig, don't look at me or I'll [***] you up. RN notified and was at scene. EMTs transported back to (hospital name) 02/14/2017 .06:48 (6:48 a.m.) .@0130 (1:30 a.m.) (hospital name) Called to Report and Return back our Facility I told them to call my ED and DON for Approval I can't decided for Now. That kind of Patient very aggressive and Physical Abusive it should be Monitoring w/in 72 hours for the behavior I need to protect the Other patient here and Staff in Facility I told them to wait my Superior Approval. (hospital name) Yelling at me @ 0300 Police Officers (hospital security officers) Came here Began to explain Eviction notice Not to given to resident. I spend time to them forcing me to accept the Patient, They Ask me to get my Drivers Licensed (sic) I gave it to them. I feel like Bullying from the Officers. Im said (sic) again I need approval from my DON and ED. Im only one RN this facility I have a lot things to do, Giving iv. After 30 minutes ambulance (ambulance company name) with (Resident A) .here and the Patient Become Aggressive, Screaming, Yelling over Staff, All my Staff Scared. So I decided to not Accept the Patient. I told them Need Psych. Evaluation is not enough for Less than 24 hours we all know here in Facility Patient threaten everybody and Physical Abusive (sic) . 02/14/2017 .20:19 (8:19 p.m.) .res (resident) returned from (hospital name), no new orders were given. MD contacted, ok to resume all previous orders. Res became physically and verbally aggressive again with transport team and staff on arrival, repeating himself and demanding food. Meal tray was given and res demanded more. All needs met. Res still screaming and yelling at staff and other residents, cursing and calling everyone names. Res was asked to return to his room until he could compose his behavior . Resident A's record titled Nurse Progress Notes, dated February 17, 2017, at 9:34 p.m., indicated, Resident was heard swearing and using profanity at another female resident's room for no reason. Fortunately the female resident he was verbally thrashing wasn't aware and confused. He was escorted back to his room which he was not compliant and yelling at staff about what was going. He was medicated for anxiety and eventually calmed down and went to bed . Further review of the Nurse Progress Notes, dated February 27, 2017, at 1:49 p.m., indicated, .at 1415 (2:15 p.m.) I was headed to activities for q 15 (every 15) check, resident was in activities today playing bingo, (Employee's name) stated, I seen (Resident A's name) go up to another resident and started to rub his shoulder. Employee stated that she told (Resident A's name) that he can't ask for cigarettes. (Resident A's name) began to get verbally aggressive so employee got in between (Resident A's name) and other resident, (Resident A's name) states get out the way and ran over her (unnamed employee) foot and struck her in the stomach with closed fist. He (Resident A) was escorted out by activities director. Q 15 checks are in place, and carried out. Md made aware of incident as well as administrator . The unnamed employee was not identified in the record. 02/28/2017 .13:53 (1:53 p.m.) .resident has been in bed most of the day. Resident had one episode of yelling loudly (sic) when told he couldn't attend bingo today, then quickly got over it and started laughing. Q15 checks in place at all times, will continue to monitor . 03/02/2017 .22:06 (10:06 p.m.) .Resident on monitoring for aggressive behavior. Resident had 2 episodes of verbal aggression this evening. Resident became verbally aggressive when charge nurse when (sic) she asked him to leave another resident's room, he stated You don't know anything you stupid [***] . Resident was redirected and informed that his behavior was unacceptable. Resident again became verbally aggressive with charge nurse when he received his dinner tray and was unhappy with it. He stated, You're such a stupid [***] ing [***] . You don't know what the [***] (sic) you're doing. Again, resident was redirected and informed that his behavior and language was unacceptable . Resident A's care plans were reviewed on March 7, 2017. Behavioral care plans were initiated on January 18, 2017, and January 23, 2017. Even though the Resident's behaviors continued and escalated, the behavioral care plan interventions were not updated until February 14, 2017, when Resident A asked Resident F for a cigarette. Resident F stated he did not have one. Resident A hit Resident F in the face. The care plan indicated to send Resident A to (hospital name) for behavior management and notify MD/family for any changes in behavior. There was no evidence located that the MD was notified of Resident A's behavior toward Resident F. Resident A had no family listed as a contact. Further review of Resident A's care plans located a plan for Impaired Cognitive (the process of knowing and understanding) Function, initiated January 26, 2017, due to the use of [MEDICAL CONDITION] drugs [MEDICAL CONDITION](stroke), but there documented [DIAGNOSES REDACTED]. This care plan indicated to monitor, document, and report to MD any changes in cognitive function, decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. A third care plan, entitled [MEDICAL CONDITION] Medication, was initiated January 26, 2017, and indicated Resident A was at risk for adverse reactions to the use of antipsychotic medications related to the resident's [MEDICAL CONDITION] disorder. Again the MD was to be notified if behaviors interfered with ADLs (activities of daily living). The consultant Pharmacist was to review the drug regimen monthly, and the IDT would review psychotic medications. There was no documented evidence the [MEDICAL CONDITION] Medications care plan was updated after Resident A's escalating aggressive behavior with any additional behavior modifications. On March 10, 2017, at 10:10 a.m., the Administrator was interviewed over the telephone. The Administrator stated Resident A was still at the facility. The Administrator stated Resident A was very difficult and needed to be placed (in an appropriate facility) due to safety risk of residents and staff members. On March 13, 2017, at 4:15 p.m., the Administrator and the DON were interviewed regarding Resident A's continued aggressive behavior. The DON stated Resident A was placed on 15 minute checks due to his aggressive behavior. On March 13, 2017, Resident A's record was reviewed with the DON. From February 13, 2017, until March 13, 2017, multiple days contained inaccurate or missing q15 (every 15 minute) resident checks. The DON stated the Resident A's 15 minute checks were incomplete or missing. The Administrator stated there should be complete and accurate documentation, and the 15 minute checks should have been done to protect the other residents and staff members. On March 14, 2017, at 1:24 p.m., the DON was interviewed. The DON stated Resident A's behavior was getting worse three weeks ago. The DON stated she had received lots of complaints about Resident A. The DON stated she was trying to find him appropriate placement. The DON stated social services were working on appropriate conservatorship as he did not have any family members. The DON stated Resident A had received a psychiatrist consult who increased [MEDICATION NAME]. The DON stated the increase in dosage was not helping and Resident A was still being violent towards staff and residents. The DON stated the resident was sent out to the hospital on February 14, 2017, but came back to the facility because the RN on duty at the facility that night was bullied by hospital security officers who came to the facility prior to Resident A's return. The DON further stated the facility had been trying to send Resident A out of the facility into an appropriate place. The DON stated the facility did not have enough staffing for one to one monitoring. The DON stated her nursing staff could not provide care for Resident A because they continued to be fearful. The DON stated one of the nurses said she did not want to give him his morning medications due to fear. On March 14, 2017, at 1:30 p.m., Resident A was observed alone in his room. The resident was sitting in a wheelchair with his head down. On March 14, 2017, at 2:57 p.m., the Administrator was interviewed. The Administrator stated, We tried to place him in another facility but he (Resident A) got violent and had to return to the facility. On March 14, 2017, at 3:13 p.m., LVN 2 stated (Resident A's name) assaulted many residents at the facility and threatened many staff. LVN 2 stated one night, Resident A struck a couple of residents and was escorted out to the hospital. Resident A did not meet criteria for 5150 (involuntary confinement of a person suspecting to have a mental disorder that makes them a danger to themselves and/or others or is gravely disabled), and returned back to the facility. When Resident A was returned to the facility, he was placed on every 15 minutes monitoring. LVN 2 stated Resident A was on friendly terms with the ladies in (room number), but she had warned the ladies (Residents G and H) that Resident A might strike them at any minute. LVN 2 stated the ladies (Residents G and H), would allow him to hold their hands and enter their rooms at night. LVN 2 stated that one night she called the police when (Resident A's name) was acting aggressive towards staff, but they never came. LVN 2 stated Resident A would take things that were not his and residents would not know. LVN 2 further stated Resident A would walk around without his pants on and would masturbate in the hallways and at the nursing station. LVN 2 stated he would get very violent if the nurses stopped the behavior. LVN 2 stated the staff were scared of him and scared for safety of other residents. LVN 2 stated Resident A disregarded the rules and had terrible mood swings. LVN 2 stated he would look down then look up, and his emotion had changed. On March 14, 2017, at 3:05 p.m., Resident B was interviewed for a second time. Resident B stated he (Resident A) was aggressive towards men and women. Resident B stated the resident was an evil and ugly little man. (Resident A's name) was dangerous and hit several nurses. Resident B stated a couple nights ago, he (Resident A) was at her door and screamed. Resident B stated I am very scared of him. I don't want to get hurt. This was supposed to be a safe place. Resident B stated (Resident A's name) had gotten worse and would shout Aint nothing you can do about it, [***] ! On March 14, 2017, at 3:15 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed for a second time. LVN 2 stated she had worked at the facility for three months. LVN 2 stated when (Resident A's name) was admitted to the facility in January (2017), he had an altercation with his roommate and was moved to a different room. LVN 2 stated Resident A flooded his room and threatened staff. Resident A was transferred again to a different room. LVN 2 said that last week (could not remember the exact date), she found Resident E with his oxygen turned off, and he had blue-discoloration of the skin caused by deoxygenation. LVN 2 stated she got really upset when she found Resident A was fiddling with oxygen in Resident E's room. LVN 2 was worried because Resident E could not speak for himself and could not stop (Resident A's name) from coming to his room. Resident E had pneumonia and was desatting-(lowered oxygen saturation level in the blood). On March 14, 2017, Resident E's medical record was reviewed. Resident E's record titled history and physical examination [REDACTED]. Resident E had medical [DIAGNOSES REDACTED]. On March 16, 2017, at 3:25 p.m. Resident E was observed lying flat in bed, receiving oxygen via nasal cannula (tube delivering oxygen to the nose). During the observation an interview was attempted with Resident E. Resident E was non-interviewable, non-responsive and unable to verbalize his needs. On March 16, 2017, at 2:50 p.m., Resident F was interviewed. Resident F stated he was outside on the patio when (Resident A's name) assaulted him. Resident F stated he was sharing a cigarette with another resident when Resident A came up to him and asked him to share his cigarette. Resident F stated (Resident A's name) needed to get his own cigarette. Afterwards, the resident became angry and punched him in the face. Resident F reported the incident to the charge nurse. Resident F further stated he felt very angry and disrespected when he was hit by the resident. Resident F stated he felt his rights were violated.

Based on observation, interview, and record review, the facility failed to provide the care and services to five residents (Residents B, C, D, E, and F) in a universe of 157 residents that put the residents at risk of mistreatment and abuse from one resident (Resident A) living in the facility. The facility's neglect to provide protection from Resident A's verbal, physical, and sexual abusive behaviors in addition to harassment and intimidation caused continued fear, mental distress and anguish for Residents B, C, D, E, and F. Findings: On March 7, 2017, at 10:30 a.m., an unannounced visit was conducted at the facility to investigate an incident regarding a resident-to-resident altercation. On March 7, 2017, at 12:07 p.m., Resident B was interviewed in her room. Resident B stated that (Resident A's name) was in her room numerous times. Resident B stated (Resident A's name) hit two residents and nothing was being done. Resident B said she informed the Administrator more than one time. Resident B stated he (Resident A) called her, Nigger [***] . Resident B stated the resident would follow her around and terrorize her by saying, You are going to die! On March 7, 2017, Resident B's record was reviewed. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident B's BIMS (Brief Interview for Mental Status) score was indicated as 15, on January 3, 2017. A score of greater than 13 indicates intact cognition (the process of knowing and understanding). On March 7, 2017, at 12:27 p.m., Resident C was interviewed in her room. Resident C stated she would prefer to stay in her room. Resident C stated Last night (Monday, March 6, 2017) was really bad because she heard Resident A banging in his wheelchair while going down the hallway. He (Resident A) stated he was going to cut somebody with a knife very loudly (outside Resident C's room). Resident C stated she was, terrified and stayed in her room. On March 7, 2017, Resident C's medical record was reviewed. Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident C's BIMS score was indicated as 15,on January 20, 2017. On March 7, 2017, at 12:27 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated (Resident A's name) wheeled around the facility in his wheelchair. LVN 1 stated Resident A had turned on the faucet of the sink and flooded his room. LVN 1 stated the resident had been moved to another room for the second time after that. LVN 1 stated Resident A had stolen medications from the medication cart on two separate occasions. On March 7, 2017, at 12:35 p.m., Resident A was observed sleeping in his bed with the covers on. On March 7, 2017, at 12:55 p.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated Resident A would wander in the hallways and around the facility, mostly during the evenings. CNA 1 stated the facility had a problem with him last Sunday. She said it was dependent on (the resident's) behavior-very confused. CNA 1 stated he would enter other residents' rooms. CNA 1 stated the resident stole a resident's radio and stated, Shut up! when told to be quiet. On March 7, 2017, at 1:15 p.m., Resident D was interviewed. Resident D stated he had a confrontation (verbal) with (Resident A's name). Resident D stated the resident hit two nurses and would call them names. Resident D stated that Resident A was verbally abusive and curses a lot. On March 7, 2017, Resident D's record was reviewed. Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident D's record titled history and physical examination [REDACTED]. Resident D's BIMS score was indicated as 14. On March 7, 2017, Resident A's facility record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of Resident A's record titled history and physical examination [REDACTED]. Review of the facility's progress notes for Resident A indicated the following: 01/20/2017 .18:43 (6:43 p.m.) .Resident showing aggressive behavior towards another senior resident and using profanity. He also broke his plate after eating his dinner and didn't think it was wrong. He is not safe in this environment without supervision. He is exhibiting behavior that makes staff fear of being assaulted . 01/22/2017 .07:12 (7:12 a.m.) .I left my small bag on top of med cart. I checked because she keeps calling, when decided to get my BP (blood pressure) cuff, noticed my small bag gone, asked staffs and they saw (Resident A's name) .around the nurses' station and accompanied me to search the room, I found my stethoscope on top of the dresser and my small bag inside his drawer mixed with his clothes but BP cuff was missing, all staffs & supervisor aware for his behavior . 01/22/2017 .21:26 (9:26 p.m.) .Resident continues to be aggressive and use profanity towards residents and staff at interval. Shows no remorse . 01/24/2017 .02:31 (2:31 a.m.) .Resident found wandering in the hallway at 0123 (1:23 a.m.) hours, complained that his bed was wet, observed wetness to linen in middle of the bed. Notified CNA who changed beddings, Reoriented resident to time and place, resident stated he would get himself in bed. Went in to check resident at 0230 (2:30 a.m.) hours, found resident looking through bedside drawer on opposite side of the room, asked resident why he was going through the drawer, no response from resident. Redirected back to his bed . 01/24/2017 .20:57 (8:57 p.m.) .Noted with aggressive and negative behavior towards staff and other residents. Attempted to redirect resident states, Don't start[***]with me! RN aware . 01/25/2017 .15:35 (3:35 p.m.) .resident cont (continue) on .taking belongings, no c/o (complain of) belongings taken during shift, resident is up in wc (wheelchair) all staff aware of incident . 02/04/2017 .13:51 (1:51 p.m.) .Resident was sitting in hallway exposing self to LVN (Licensed Vocational Nurse), masturbating and cursing at the nurse. Resident was sent to room and told not to come out until he could conduct self in a proper manner in public. Resident in room at this time . 02/04/2017 .15:29 (3:59 p.m.) .during med (medication) pass, resident exposed himself and continued to masturbate after being told to please stop. Resident got upset, cursed and yelled, refused to go to his room. Resident also took supplement shake without asking from med cart. Asked resident please do not take things from the med cart. Refused to give back the supplement shake. Notified RN (Registered Nurse), notified doctor, awaiting doctors approval to be sent out for further evaluation . 02/05/2017 .07:03 (a.m.) .@1030 (10:30 a.m.) pt (patient) was trying to go into female room and exposing himself to her, CN (charge nurse) happen to be in the room with the other pt, she came out to redirect his behavior and he started cursing and yelling at her, he was getting aggressive to all staff. After 20 min (minutes) of trying to calm him down, he finally went to his room . 02/08/2017 .03:00 (3 a.m.) .Awake at 0238 (2:38 a.m.), wandering down the halls in his wheelchair .Reoriented resident to time and place, returned to room and got into bed, will continue to monitor . Resident A was transferred to an acute care hospital on February 13, 2017, for aggressive behavior. Resident A punched Resident F in the face after refusing to share a cigarette in the smoking area of the facility. .02/13/2017 .23:27 (11:27 p.m.) .Received call from (hospital name) stating they did not have adequate staff to 5150 resident tonight if we could transfer tomorrow morning. CN stated will transfer to RN supervisor for further assistance. ER (emergency room ) staff then transferred call to police officer asking for RN. Police officer stated they (hospital) received ok from previous shift to return and post pone 5150 till next day. CN transferred call to supervisor for further assistance . 02/14/2017 .01:31 (12:31 a.m.) .2 (hospital name) security officers approached nursing station asking for RN supervisor. Staff called RN. Officers stated hospital would be transporting resident back shortly due to shortage of staff at (hospital name). Officers began to explain eviction notice not given to resident, RN explained resident was not evicted and this is a nursing facility not assisted living. RN attempted to call ED (Executive Director) and DON for further assistance on matter and further orders. Awaiting call back . No evidence that either ED or DON returned the call. Continued facility notes indicated: 02/14/2017 .06:37 (6:37 a.m.) .Resident arrived via gurney 2 emts (emergency medical technicians). Resident (sic) was yelling and cursing at emts get me out of here! I don't want to be in this [***] ing place. EMTs explained to resident they were just transporting resident, resident yelled to emt- shut up you fat pig, don't look at me or I'll [***] you up. RN notified and was at scene. EMTs transported back to (hospital name) 02/14/2017 .06:48 (6:48 a.m.) .@0130 (1:30 a.m.) (hospital name) Called to Report and Return back our Facility I told them to call my ED (Executive Director) and DON for Approval I can't decided for Now. That kind of Patient very aggressive and Physical Abusive it should be Monitoring w/in (within) 72 hours for the behavior (sic) I need to protect the Other patient here and Staff in Facility I told them to wait my Superior Approval. (Hospital name) Yelling at me @ 0300 Police Officers (hospital security officers) Came here Began to explain Eviction notice Not to given to resident. I spend time to them (sic) forcing me to accept the Patient, They Ask me to get my Drivers Licensed (sic) I gave it to them. I feel like Bullying from the Officers. Im said (sic) again I need approval from my DON and ED. Im only one RN this facility I have a lot things to do, Giving iv. After 30 minutes ambulance (ambulance company name) with (Resident A) .here and the Patient Become Aggressive, Screaming, Yelling over Staff, All my Staff Scared. So I decided to not Accept the Patient. I told them Need Psych. Evaluation is not enough for Less than 24 hours we all know here in Facility Patient threaten everybody and Physical Abusive (sic) . 02/14/2017 .20:19 (8:19 p.m.) .res (resident) returned from (hospital name), no new orders were given. MD contacted, ok to resume all previous orders. Res became physically and verbally aggressive again with transport team and staff on arrival, repeating himself and demanding food. Meal tray was given and res demanded more. All needs met. Res still screaming and yelling at staff and other residents, cursing and calling everyone names. Res was asked to return to his room until he could compose his behavior . Resident A's record titled Nurse Progress Notes, dated February 17, 2017, at 9:34 p.m., indicated, Resident was heard swearing and using profanity at another female resident's room for no reason. Fortunately the female resident he was verbally thrashing wasn't aware and confused. He was escorted back to his room which he was not compliant and yelling at staff about what was going. He was medicated for anxiety and eventually calmed down and went to bed . Further review of the Nurse Progress Notes, dated February 27, 2017, at 1:49 p.m., indicated, .at 1415 (2:15 p.m.) I was headed to activities for q 15 (every 15) check, resident was in activities today playing bingo, (Employee's name) stated, I seen (Resident A's name)go up to another resident and started to rub his shoulder. Employee stated that she told (Resident A's name) that he can't ask for cigarettes. (Resident A's name) began to get verbally aggressive so employee got in between (Resident A's name) and other resident, (Resident A's name) states get out the way and ran over her (employee) foot and struck her in the stomach with closed fist. He (Resident A) was escorted out by activities director. Q 15 (every 15 minutes) checks are in place, and carried out. Md made aware of incident as well as administrator . 02/28/2017 .13:53 (1:53 p.m.) .resident has been in bed most of the day. Resident had one episode of yelling loudly (sic) when told he couldn't attend bingo today, then quickly got over it and started laughing. Q15 checks in place at all times, will continue to monitor . 03/02/2017 .22:06 (10:06 p.m.) .Resident on monitoring for aggressive behavior. Resident had 2 episodes of verbal aggression this evening. Resident became verbally aggressive when charge nurse when she asked him to leave another resident's room, he stated You don't know anything, you stupid [***] . Resident was redirected and informed that his behavior was unacceptable. Resident again became verbally aggressive with charge nurse when he received his dinner tray and was unhappy with it. He stated, You're such a stupid [***] ing, [***] . You don't know what the [***] you're doing. Again, resident was redirected and informed that his behavior and language was unacceptable . Resident A's care plans were reviewed on March 7, 2017. Behavioral care plans were initiated on January 18, 2017, and January 23, 2017. Even though the Resident's behaviors continued and escalated, the behavioral care plan interventions were not updated until February 14, 2017, when Resident A asked Resident F for a cigarette. Resident F stated he did not have one. Resident A hit Resident F in the face. The care plan indicated to send Resident A to (hospital name) for behavior management and notify MD/family for any changes in behavior. There was no evidence located that the MD was notified of Resident A's behavior toward Resident F. Resident A had no family listed as a contact. Further review of Resident A's care plans located a plan for Impaired Cognitive (the process of knowing and understanding) Function, initiated January 26, 2017, due to the use of [MEDICAL CONDITION] drugs [MEDICAL CONDITION](stroke). This care plan indicated to monitor, document, and report to MD any changes in cognitive function, decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. A third care plan, entitled [MEDICAL CONDITION] Medication, was initiated January 26, 2017, and indicated Resident A was at risk for adverse reactions to the use of antipsychotic medications related to the resident's [MEDICAL CONDITION] disorder. Again the MD was to be notified if behaviors interfered with ADLs (activities of daily living). The consultant Pharmacist was to review the drug regimen monthly, and the IDT would review psychotic medications. There was no documented evidence the [MEDICAL CONDITION] Medications care plan was updated after Resident A's escalating aggressive behavior with any additional behavior modifications On March 7, 2017, at 3:15 p.m., LVN 2 stated (Resident A's name) assaulted many residents at the facility and threatened many staff. LVN 2 stated one night, Resident A struck a couple of residents and was escorted out to the hospital. Resident A did not meet criteria for 5150 (involuntary confinement of a person suspecting to have a mental disorder that makes them a danger to themselves and/or others or is gravely disabled), and returned back to the facility. When Resident A was returned to the facility, he was placed on every 15 minutes monitoring. LVN 2 stated Resident A was on friendly terms with the ladies in (room number), but she had warned the ladies (Residents G and H) that Resident A might strike them any minute. LVN 2 stated the ladies (Residents G and H), would allow him to hold their hands and enter their rooms at night. LVN 2 stated that one night she called the police when (Resident A's name) was acting aggressive towards staff, but they never came. LVN 2 stated Resident A would take things that were not his and residents would not know. LVN 2 further stated Resident A would walk around without his pants on and would masturbate in the hallways and nursing station. LVN 2 stated he would get very violent if the nurses stopped the behavior. LVN 2 stated the staff were scared of him and scared for safety of other residents. LVN 2 stated Resident A disregarded the rules and had terrible mood swings. LVN 2 stated he would look down then look up, and his emotion had changed. On March 10, 2017, at 10:10 a.m., the Administrator was interviewed over the telephone. The Administrator stated Resident A was still at the facility. The Administrator stated Resident A was very difficult and needed to be placed (in an appropriate facility) due to safety risk of residents and staff members. On March 13, 2017, at 4:15 p.m., the Administrator and the DON were interviewed regarding Resident A's continued aggressive behavior. The DON stated Resident A was placed on 15 minute checks due to his aggressive behavior. On March 13, 2017, Resident A's record was reviewed with the DON. From February 13, 2017, until March 13, 2017, multiple days contained inaccurate or missing q15 (every 15 minute) resident checks. The DON stated the Resident A's 15 minute checks were incomplete or missing. The Administrator stated there should be complete and accurate documentation, and the 15 minute checks should have been done to protect the other residents and staff members. On March 14, 2017, at 1:24 p.m., the DON was interviewed. The DON stated the facility had been trying to send Resident A out of the facility into an appropriate place. The DON stated the facility, Did not have enough staffing for one to one monitoring. The DON stated her nursing staff could not provide care for Resident A because they continued to be fearful. the DON stated one of the nurses said she did not want to give him his morning medications due to fear. On March 14, 2017, at 1:30 p.m., Resident A was observed alone in his room. The resident was sitting in a wheelchair with his head down. On March 14, 2017, at 2:57 p.m., the Administrator was interviewed. The Administrator stated, We tried to place him in another facility but he (Resident A) got violent and had to return to the facility. On March 14, 2017, at 3:05 p.m., Resident B was interviewed for a second time. Resident B stated (Resident A's name) was aggressive towards men and women. Resident B stated the resident was an evil and ugly little man. (Resident A's name) was dangerous and hit several nurses. Resident B stated a couple nights ago, (Resident A's name) was at her door and screamed. Resident B stated I am very scared of him. I don't want to get hurt. This was supposed to be a safe place. Resident B stated (Resident A's name) had gotten worse and would shout, Aint nothing you can do about it, [***] ! On March 14, 2017, at 3:13 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed for a second time. LVN 2 stated she had worked at the facility for three months. LVN 2 stated when (Resident A's name) was admitted to the facility in January (2017), he had an altercation with his roommate and was moved to a different room. LVN 2 stated Resident A flooded his room and threatened staff. Resident A was transferred again to a different room. LVN 2 said that last week (could not remember the exact date), she found Resident E with his oxygen turned off, and he had blue-discoloration of the skin caused by deoxygenation. LVN 2 stated she got really upset when she found Resident A was fiddling with oxygen in Resident E's room. LVN 2 was worried because Resident E could not speak for himself and could not stop (Resident A's name) from coming to his room. Resident E had pneumonia and was desalting-(lowered oxygen saturation level in the blood). On March 14, 2017, Resident E's medical record was reviewed. Resident E's record titled history and physical examination [REDACTED]. Resident E had medical [DIAGNOSES REDACTED]. On March 16, 2017, at 3:25 p.m. Resident E was observed lying flat in bed, receiving oxygen via nasal cannula (tube delivering oxygen to the nose). During the observation an interview was attempted with Resident E. Resident E was non-interviewable, non-responsive and unable to verbalize his needs. On March 16, 2017, at 2:50 p.m., Resident F was interviewed. Resident F stated he was outside on the patio when (Resident A's name ) assaulted him. Resident F stated he was sharing a cigarette with another resident when Resident A came up to him and asked him to share his cigarette. Resident F stated (Resident A's name) needed to get his own cigarette. Afterwards, the resident became angry and punched him in the face. Resident F reported the incident to the charge nurse. Resident F further stated he felt very angry and disrespected when he was hit by the resident. Resident F stated he felt his rights were violated.

Based on observation, interview, and record review, the facility failed to ensure: 1. One of 24 sampled residents, Resident 13, who had a progressive weight loss for four months, had interventions put into place to attempt to slow or stop the weight loss. As a result, the resident lost 17 pounds or 13.9 percent of her weight in three months; 2. One of 24 sampled residents, Resident 145, who had a 25.4 pound or 13.8 percent weight loss in 17 days, had interventions put into place to reverse or stop the weight loss; and 3. One of 24 sampled residents, Resident 2, who had a 10.6 pound or 9.2 percent weight gain in three months, had the weight gain assessed and had interventions put into place to slow or stop the weight gain. These facility failures increased the potential for residents to experience additional weight fluctuations without interventions to slow or halt the fluctuations. Findings: 1. During an initial tour of the facility on April 25, 2017, at 8:02 a.m., Resident 13 was observed in her bed. The head of her bed was flat. The resident was receiving oxygen administered at two liters per minute via nasal cannula (small tube in the nostrils.) Resident 13 did not demonstrate any symptoms of difficulty breathing as she talked. On April 28, 2017, Resident 13's record was reviewed. Resident 13's record indicated the following: Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On August 8, 2016, Resident 13 weighed 125.8 pounds (lbs or #), per the Weights and Vitals Summary form. On August 11, 2016, the Registered Dietician (RD) documented in the Nutritional Care note, .Resident goals: Maintain weight 110-130# x 3 months . On August 19, 2016, there was a physician's orders [REDACTED]. On November 17, 2016, the care plan titled, Alteration in Nutrition , indicated, .Noted decline in ability to feed self . On January 5, 2017, a care plan was initiated titled, .Decreased appetite noted, decreased [MEDICATION NAME] (laboratory measurement of the amount of protein in the blood indicative of nutritional status) . The care plan indicated the target weight range of 110-130 lbs, with a target date of May 19, 2017. On January 5, 2017, the RD's Dietary Progress Note indicated, .[MEDICATION NAME] in 8/2016 - 2.9 L (low). [MEDICATION NAME] in 11/2016 - 2.7 L . On January 5, 2017, the care plan titled, Alteration in Nutrition ., indicated, .Interventions .1/5/17 - House Nourishment TID (three times a day) as ordered . On January 6, 2017, the RD's Dietary Progress Note indicated, .January weight 122.6# - down 4.2#/-3.3% monthly . There were no Dietary Progress Notes in the record after January 6, 2017. On January 30, 2017, Resident 13 weighed 122 lbs, per the Weights and Vitals Summary. On February 21, 2017, the RD documented in the Care Plan Conference Summary that Resident 13's percentage of meal intake was 58%. On March 10, 2017, Resident 13 weighed 117.4 lbs, per the Weights and Vitals Summary, (a loss of 4.6 lbs/3.7% in 39 days.) On March 13, 2017, at 8:59 p.m., the SBAR/COC (situation/background/assessment/recommendation/change of condition) indicated Resident 13 was sent to the hospital for a bloody nose. Resident 13 was diagnosed with [REDACTED]. Resident 13 returned from the hospital on March 17, 2017. There was no documented evidence in the record that any new or additional interventions were initiated to address Resident 13's continued weight loss. On March 23, 2017, a document titled Nutritional Care - V 2, indicated Resident 13 had skin breakdown with a wound to her coccyx (tail bone area) described as 1 x 3 red blanchable area; her right heel, described as .with 0.5cm x0.5cm x utd (undetermined) intact purple are (sic) dry and no drainage SDTI (soft deep tissue injury) pressure injury; her left heel, described as .1.0cm x1.0cm xutd (unable to determine) intact purple SDTI pressure injury no drainage; and right lower leg skin tear 2.0cm x1.0cm xsf (superficial) red mosit (sic) with scant (small) amount serous (fluid) drainage. Further review of the document titled, Nutritional Care - V 2, dated March 23, 2017, indicated Resident 13's weight after returning from the hospital was .125.4 # (pounds), and .Risk Factors/Cause: .Resident out to hospital r/t (related to) UTI (urinary track infection). Weight may decrease as resident possibly received IV (intravenous - a small tube in the vein for medication and fluids) therapy which will temporarily increase her weight . The document indicated Resident 13's weight was 8 pounds greater than her weight prior to hospitalization . On March 28, 2017, Resident 13 weighed 111.4 lbs, per the Weights and Vitals Summary. This was an additional loss of 6 lbs/5.1% from her pre-hospitalization weight 18 days prior. There was no documented evidence in the record of any new or additional interventions to address Resident 13's continued weight loss. Resident 13's current physician's orders [REDACTED]. On April 4, 2017, Resident 13 weighed 109.2 lbs, per the Weights and Vitals Summary. This was an additional loss of 2.2 lbs/1.9% in seven days; 6.9% significant weight loss in 24 days. There was no documented evidence in the record of any new or additional interventions to address Resident 13's continued weight loss. On April 11, 2017, Resident 13 weighed 108 lbs, per the Weights and Vitals Summary form. This was an additional loss of 1.2 lbs/1% of weight loss in seven days; a weight loss of 8% in one month. On April 14, 2017, a Weight Variance Meeting was conducted. The document indicated a total loss of 11.4 pounds for a total percentage of weight loss of 8.9%. The document also indicated the Resident had eaten an average of 50% in the previous seven days. On April 14, 2017, there was a physician's orders [REDACTED]. On April 18, 2017, Resident 13 weighed 107 lbs, per the Weights and Vitals Summary. This was an additional one lb of weight loss in seven days. On April 18, 2017, Resident 13's physician documented a physician's progress note. There was no documentation regarding weight loss. On April 21, 2017, a Weight Variance Meeting was conducted. The document indicated, .Resident has gradually lost weight r/t (related to) noted decline in ability to feed self. On April 25, 2017, Resident 13 weighed 105 lbs, per the Weights and Vitals Summary. This was an additional two lbs of weight loss in seven days. From January 30 to April 25, 2017, Resident 13 lost a total of 17 pounds, or 13.9% of her weight in less than 3 months. Resident 13 did not begin receiving 2 CAL until April 15, 2017 and did not begin receiving increased staff assistance with feeding until the week of April 25, 2017. On April 28, 2017, an interview was conducted with the RD. Resident 13's weights from January 30 to April 25, 2017, were reviewed with the RD. The RD stated Resident 13 had insidious weight loss. The RD stated this week Resident 13 started receiving increased assistance in the dining room at mealtimes. During further interview, the RD was asked about Resident 13's April 4, 2017, weight loss which indicated Resident 13 lost 8.2 lbs/6.9% in 24 days. The RD was asked why the 2 CAL was not started until April 15, 2017 (11 days after the noted weight loss). The RD stated, I guess I didn't feel like she needed it. When asked why Resident 13 did not receive the 2 CAL until after the April 11, 2017, weight indicated she had lost 8% of her weight in one month, the RD stated Resident 13 might have been overloaded and eaten less of her meals if the 2 CAL was started. During further interview, the RD was asked why Resident 13 did not receive increased dining assistance until this week. The RD stated Resident 13 was already eating in the dining room, but they are giving her more assistance this week. The RD stated the facility did not have a RNA (restorative nursing assistant) for dining. The RD was unable to state why Resident 13 did not receive increased assistance with meals until this week. On April 28, 2017, the facility policy titled, Weight Assessment and Intervention, dated September 2008, was reviewed. The policy indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weight Assessment .6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month - 5% weight loss is significant; greater than 5% is severe .Interventions for undesirable weight loss shall be based on careful consideration of the following: g. The use of supplementation . 2. Resident 145's record was reviewed on April 28, 2017. Resident 145 was initially admitted to the facility on [DATE], and sent to the acute care hospital on March 30, 2017, due to an elevated white blood cell count. Resident 145 was readmitted to the facility after an acute care hospital stay on April 8, 2017, with [DIAGNOSES REDACTED]. Nursing progress notes dated April 8, 2017, at 12:10 a.m., included Original speculation was CDIFF ([MEDICAL CONDITION]- an infection of the intestines causing severe diarrhea) however stool sample proved negative result. On March 25, 2017, Resident 145's weight was recorded as 185.6 lbs (pounds). Upon re-admission of April 8, 2017, Resident 145's weight was recorded as 182.8 lbs. A facility document titled, Nutritional Care - V 2, signed by the Registered Dietician (RD) on April 14, 2017, indicated Resident 145 [MEDICAL CONDITION] and CDIFF. Resident 145's desirable weight range was 170-190 lbs, and Resident 145 had a Healing right hip so weight loss is not a priority at this time. A care plan initiated March 27, 2017, indicated the resident required assistance with eating. The document further indicated there were no new nutritional interventions and the resident goals were, Adequately nourished/hydrated x 3 months. Weight 170-190# x 3 months. Maintain/improve skin integrity during stay. A physician order [REDACTED]. On April 18, 2017, Resident 145's weight was recorded as 168.8 lbs. Resident 145 experienced a 14 lb, or 7.6% (percent) weight loss in ten days. A nurse's progress note, dated April 20, 2017, indicated, Pt (patient) is noted have weight loss of 14 lbs. Current wt 168.8 as of 4/18/17. Her last wt 182.8 was measured 4/8/2017. Will encourage nourishment and po (oral) intake. MD and family made aware. A facility document titled, SBAR/COC (a form used by nursing staff to evaluate a change in a residents condition), dated, April 21, 2017, indicated, SBAR Charting Notes .Pt is noted have wt loss of 14 lbs. Current wt 168.8 as of 4/18/17. Her last wt 182.8 was measured 4/8/2017. Will encourage nourishment and po intake. MD and family made aware. A facility document titled, SBAR/COC, dated, April 23, 2017, indicated, SBAR Charting Notes .resident with wt loss of 14# in 10 days. Resident was on isolation for cdiff with noted to have diarrhea d/t infection. PO intake of 76-100%. MD/RD aware. will closely monitor wt and encourage PO intake. no decline in functional noted. There was no documentation of an assessment by the RD or the Interdisciplinary Team (IDT), evaluating Resident 145's nutritional status and associated risk factors, or if Resident 145's weight loss was expected or desired. The physician progress notes [REDACTED]. There was no documentation from the physician addressing Resident 145's weight loss. On April 25, 2017, Resident 145's weight was recorded as 157.4 lbs. Resident 145 lost another 11.4 lbs, a 6.75% loss in seven days. Resident 145 experienced a total weight loss of 25.4 lbs, a 13.8% loss in 17 days. An interview was conducted with the Assistant Director of Nurses (ADON) on April 28, 2017, at 10 a.m. The ADON reviewed Resident 145's record and verified Resident 145's weight loss. The ADON stated, I don't see any interventions or notes from the RD. She was notified, she gets the weights too. A telephone interview was conducted with Resident 145's daughter on April 28, 2017, at 2:15 p.m. Resident 145's daughter stated she was not aware of the amount of weight her mother had lost. She further stated she had told the facility many times to give her mom a multivitamin. She stated she would bring food to her mom because they are Armenian and her mom really didn't like the food in the facility. She stated she came to visit nearly every day and during the last week her mom did not have any diarrhea. Nursing notes from April 9, 2017, through April 28, 2017, were reviewed. Resident 145 had 12 episodes of loose stools documented from April 9 through April 17, 2017. There were no episodes of loose stools documented after April 17, 2017. An interview was conducted with the RD on April 28, 2017, at 2:30 p.m., regarding Resident 145's weight loss. The RD verified Resident 145's weight loss and stated she just got to the resident that day (April 28, 2017). The RD stated the nurses told her that Resident 145 continued to have diarrhea. The RD was asked what was done for Resident 145 after the resident experienced the initial 14 lb weight loss. The RD stated Resident 145 was not put on weight variance because she had [MEDICAL CONDITION]. She stated, I told my RNA (Restorative Nursing Aide) we will just watch her and weigh her again next week. The RD verified she did not document anything regarding the 14 lb weight loss in Resident 145's record. She further stated once she found out about the new 11.4 lb weight loss she addressed it today. During further interview, the RD was asked if Resident 145's food preferences were addressed. The RD stated the Dietary Manager would complete that assessment. The RD reviewed the record and stated she did not see where Resident 145's preferences were addressed. The facility policy and procedure titled, Weight Assessment and Intervention, revised September 2008, was reviewed. The policy indicated, Weight Assessment .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification .Weight Assessment .6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month - 5% weight loss is significant; greater than 5% is severe .Interventions for undesirable weight loss shall be based on careful consideration of the following: g. The use of supplementation .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvements; and c. Time frames and parameters for monitoring and reassessment . Resident 145 continued to experience severe weight loss without comprehensive assessments by the RD and the Interdisciplinary Team (IDT) to: 1. Evaluate the resident's clinical condition and nutritional risk factors; 2. Define and implement interventions consistent with the resident's needs; and, 3. Monitor and revise interventions as appropriate. 3. On April 26, 2017, a record review was conducted for Resident 2. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 2's weight record was reviewed and included the following weights: May 2, 2016, 134.0 pounds; August 1, 2016, 136.8 pounds; October 3, 2016, 140.6 pounds; January 2, 2017, 138.6 pounds; March 10, 2017, 149.2 pounds; and April 6, 2017, 149.2 pounds. From January 2, 2017, through March 10, 2017, Resident 2 had a 10.6 pound or 9.2% weight gain. A care plan titled, Alteration in Nutrition, included the following intervention, Maintain weight at 125 to 145 pounds Q (every) every three months. The care plan was not updated with any new interventions after the resident's continued weight gains and after the resident exceeded the ideal weight parameters set by the Registered Dietician. There were no new interventions added to the care plan in order to slow the resident's weight gain. During an interview conducted with the Registered Dietician (RD) on April 28, 2017, at 5 p.m., the RD stated Resident 2's care plan was not updated and no interventions were put into place to stop the resident's weight gain.

Based on interview, and record review, the facility failed to ensure the plan of care was reviewed and revised to prevent further falls for 13 (Resident 1, 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12, and 13) of 13 residents who experienced falls for the month of December 2016. This failure increased the risk for further falls which could subsequently cause major injury and death. On December 28, 2016, at 12:40 p.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality care issues. On December 28, 2016, at 1:51 p.m., the Assistant Director of Nurses (ADON) was asked to provide a list of fall incidents for the month of December. The ADON provided the list of falls but was unable to provide evidence of monitoring and investigations had been done for the fall incidents which had occurred since December 1, 2016. The review of fall incidents which occurred since December 1, 2016, indicated the following: 1. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) change of condition documentation indicated: a. December 4, 2016, Resident 1 fell as she was walking out of her room on her way to the shower. Resident 1's fall had caused 6-7 pain (a pain scale used with a 1-10 pain level - 1 being the least pain ever experienced by the resident and 10 being the worst pain ever experienced by the resident) on the left knee; and b. December 25, 2016, Resident 1 had another fall as she attempted to go to the bathroom and slid to the floor. Resident 1's fall risk care plan dated December 4, 2016, indicated: a. Focus: Actual fall on December 4, 2016; b. Goal:(initiated on September 15, 2016) will reduce the risk of falls, will be free from fall related injuries daily, will minimize s/s (sign and symptoms) of pain, restraints used to prevent falls will be minimized/eliminated by 90 days ; c. Interventions: (initiated on September 15, 2016)included maintain bed in a safe position when resident is in bed, encourage resident to call for assistance as needed, maintain safe environment. There was no documented evidence the plan of care to prevent further falls was reviewed and revised after the first incidence of fall on December 4, 2016, nor after the second fall incident on December 25, 2016. 2. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 2's SBAR indicated: a. On December 7, 2016, Resident 2 had an unwitnessed fall inside her room; and b. On December 17, 2016, Resident 2 had another unwitnessed fall inside her room. Resident 2's nursing progress note, dated December 20, 2016, indicated another unwitnessed fall inside her room. Resident 2 had a total of three falls for the month of December alone. Resident 2's fall incidents happened during evening shift (3-11 shifts) and all were unwitnessed. Resident 2's plan of care for fall indicated the following: a. Focus: multiple falls since October 2014 and actual fall on December 17 and 20, 2016 (fall on December 7, 2016, was not reflected at the care plan); b. Goal: (initiated on December 8, 2016) will reduce the risk of falls x (times) 90 days; and c. Interventions: included, hand assist bars x 2 bed mobility and positioning (initiated on October 9, 2015), non-slip mat in wheelchair (October 8, 2014), neuro checks x 72 hours (July 28, 2016), resident will be placed on a toileting schedule to anticipate toileting needs (October 27, 2014). There was no documented evidence the plan of care was reviewed and revised to address Resident 2's fall incidences on December 7, 17, and 20, 2016. 3. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 3 's SBAR dated December 6, 2016, indicated an unwitnessed fall during evening shift. Resident 3 fell out of bed trying to use urinal. Resident 3 had swelling and discoloration to right cheek. Resident 3's plan of care initiated on December 7, 2016, indicated the following: a. Focus: At risk for fall; b, Goal: Will reduce the risk of falls, will be free from fall related injuries daily x 90 days; and c. Interventions: Call light within reach and answered promptly, encouraged residents to call for assistance as needed. Resident 3's plan of care initiated on December 7, 2016, related to risk for fall did not reflect the actual fall on December 6, 2016. The plan of care did not reflect interventions addressing the swelling and redness of Resident 3's cheek. 4. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 4's SBAR, dated December 26, 2016, indicated an incident of fall while out on pass on December 25, 2016. The SBAR indicated Resident 4 fell on his bottom and had complained of pain on his bottom when he was back at the facility. Resident 4's care plan related to fall indicated: a. Focus: actual fall on December 26, 2016 (fall happened December 25, 2016); b. Goal: will reduce the risk for falls, will be free from fall related injuries daily, restraints used to prevent falls will be minimized/eliminated by 90 days (all initiated on February 9, 2016) ; and c. Interventions: (initiated on February 10 and 12, 2016) included provide nonskid socks, encourage resident to call for assistance, keep bed at lowest position and wheels locked, anticipate toileting needs and assist resident to toilet. The IDT progress notes dated December 28, 2016, indicated an IDT recommendation to have family come in for family training (since the incident happened while out on pass), current orders will be sent to pharmacy for medication review. There was no documented evidence the plan of care addressed the fall incident which had happened while out pass. The plan of care did not reflect the complaint of pain on Resident 4's bottom area which could be related to the fall. The IDT recommendations on December 28, 2016, were not reflected in the plan of care for Resident 4. 5. Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 5's SBAR dated December 23, 2016, indicated Resident 5 had a witnessed fall while in a wheelchair. Resident 5's care plan related to fall initiated on December 3, 2016, indicated: a. Focus: At risk for fall r/t (related to): balance problem, left BKA, actual fall on December 23, 2016. b. Goal: (initiated December 3, 2015) will reduce the risk for falls, will be free from fall related injuries daily for 90 days; and There was no documented evidence the goals related to fall risks had been reevaluated since December 3, 2015. c. Interventions: (initiated on December 3, 2015) included provide nonskid socks, keep bed at lowest position and wheels locked. There was no documented evidence which reflected revised interventions addressing the fall which occurred on December 23, 2016, while Resident 5 was maneuvering his wheelchair backwards. 6. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 6's SBAR indicated the following: a. On December 19, 2016, Resident 6 was observed on the floor mat in resident's room during evening shift; The document indicated Resident 6 was noncompliant with safety precautions. b. On December 28, 2016, Resident 6 had an unwitnessed fall. Resident 6 was found on floor mat next to bed with knees on floor mat and elbows on bed. Resident 6's care plan related to fall indicated: a. Focus: At risk for fall r/t balance problem due to dementia/ poor safety awareness, actual fall on December 19 and 28, 2016; b. Goal: (initiated on June 9, 2015) will reduce the risk for falls, will be free from fall related injuries, will minimize sign and symptoms of pain x 90 days; Resident 6's goals related to being at risk for fall had not been reevaluated since June 9, 2015. c. Interventions: included mat on the floor, keep bed at lowest position and wheels locked, personal alarm keep bed at lowest positions (initiated on June 9, 2015) , neurocheck x 72 hours, PT screen, pharmacy medication regiment review (initiated November 6, 2016). The plan of care for falls did not reflect revised interventions to address the falls which occurred on December 19 and 28, 2016. 7. Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 7's SBAR, dated December 10, 2016, indicated Resident 7's fall incident during evening shift. Resident 7 tripped over his shoe and fell face first. The document indicated there were some teeth noted on the floor and blood coming from his nose and mouth. Resident 7 was transferred to the acute hospital. Resident 7's care plan related to fall initiated on November 30, 2015, indicated: a . Focus: At risk for fall r/t balance problem, had history of multiple falls, turns off sensor alarms himself; b. Goals: (initiated on November 30, 2015) included will reduce the risk of falls, will be free from fall related injuries, will minimize s/s (sign and symptoms) of pain, swelling, change in ROM (range of motion) x 90 days; Resident 7's goal related to risks for falls had not been reevaluated since November 30, 2015. Resident 7's plan of care to prevent further falls did not reflect revised interventions to address the fall and injury (loss of teeth) which occurred on December 10, 2016. 8. Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 8's SBAR, dated December 4, 2016, indicated Resident 8 had an unwitnessed fall during the evening shift (3-11 shift). Resident 8 was found sitting on the floor next to her bed. Resident 8's care plan initiated on October 26, 2016, indicated: a. Focus: At risk for fall r/t status [REDACTED]. b. Goal: will reduce the risk of falls, will be free from fall related to injuries daily, will minimize signs and symptoms of pain x 90 days (initiated on October 26, 2016); and c. Interventions: (initiated on October 26, 2016) included call light within reach and answered promptly, maintain bed in safe position. There was no documented evidence the plan of care was reviewed and revised to reflect Resident 8's actual fall on December 4, 2016. 9. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 9's SBAR, dated December 3, 2016, indicated Resident 9 had an unwitnessed fall during evening shift (3-11 shift). Resident 9 was observed on the floor from an apparent fall hitting the back of her head. Resident 9's care plan initiated on December 5, 2016, indicated: a. Focus: At risk for fall related to impaired cognition, actual fall on December 3, 2016; b. Goal: will reduce the risk of falls x 90 days (initiated on November 4, 2015), Will be free from fall related injuries x 90 days (initiated on December 4, 2016), will minimize signs and symptoms of pain (initiated on September 16, 2016), and c. Interventions: included transfer to emergency room for further evaluation, neurochecks x 72 hours (initiated on April 21, 2016) call light within reach and answer promptly (initiated on November 4, 2015). There was no documented evidence the plan of care was reviewed and updated to address Resident 9's fall from her bed on December 3, 2016. 10. Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 10's SBAR, dated December 20, 2016, indicated Resident 10 had an unwitnessed fall during evening shift (3-11 shift). Resident 10 was found down on the floor slouched against the wall lethargic. The document indicated Resident 10 was noted with low blood sugar of 27. Resident 10's care plan related to fall initiated on October 20, 2014, indicated the following: a. Focus: multiple falls since March 18, 2015, and a recent fall on December 20, 2016; b. Goal: Will reduce the risk of falls x 90 days (initiated on October 20, 2014); and There was no documented evidence Resident 10's goal related to fall risk had been reevaluated and revised since October 20, 2014. c. Interventions: included insulin adjusted (July 15, 2016), neuro checks x 72 hours (December 14, 2015), PT screen, neurochecks, x rays as ordered (November 28, 2016). There was no documented evidence the plan of care for falls was reviewed and revised to address the [DIAGNOSES REDACTED] episode which could have contributed to Resident 10' s fall incident on December 20, 2016. 11. Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11's SBAR, dated December 21, 2016, indicated Resident 11 had a unwitnessed fall during evening shift. Resident 11 slipped to the floor by his bed after feeling numbness in bilateral (both) lower extremities. Resident 11's care plan initiated on September 21, 2016, indicated the following: a. Focus: At risk for fall related to generalized weakness, an actual fall on December 21, 2016; b. Goal: Will reduce the risk of falls x 90 days (initiated on December 22, 2016); and c. Intervention: Call light within reach and answered promptly (initiated September 22, 2016). There was no evidence a plan of care addressing Resident 11's fall due to sudden numbness of lower extremities on December 21, 2016, was initiated. 12. Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 12's SBAR, dated December 2, 2016, indicated Resident 12 alleged a facility staff of dropping her to the floor during the night shift. The document indicated Resident 12 had skin tears on right shin and right knee. Resident 12's care plan related to fall initiated on July 23, 2016, indicated the following: a. Focus: had multiple falls since July 15, 2014, and a recent fall on December 2, 2016; b. Goal: Will reduce the risk of falls x 90 days (initiated on July 23, 2014), Will be free from fall related injuries x 90 days (initiated on July 23, 2014), Will minimize sign and symptom of pain (initiated on January 20, 2015); There was no documented evidence Resident 12's goal related to fall risk had been reviewed and revised since January 20, 2015. The IDT progress note dated December 27, 2016, indicated Resident 12 was found on the floor mat in a supine (lying with the face up) position with skin tear on the right shin and knee area. The IDT recommended removing sensor alarms, bladder and bowel trial training for two weeks, and pharmacy medication review. The plan of care did not reflect the recommended interventions by the IDT on December 27, 2016. 13. Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 13's SBAR, dated December 4, 2016, indicated Resident 13 had an unwitnessed fall during night shift (11-7). Resident 13 slid off from the wheelchair when he tried to go to the bathroom by himself. Resident 13's plan of care initiated on December 4, 2016, indicated the following: a. Focus: had multiple falls and a recent fall incident on December 4, 2016; b. Goal: will reduce the risk of falls x 90 days and will be free from fall related injuries daily x 90 days (initiated on March 2, 2016); and Resident 13's goal related to fall risk had not been reevaluated and revised since March 2, 2016. c. Interventions: included neuro checks x 72 hours (July 8, 2016), maintenance to assess wheelchair brakes for proper functioning (June 6, 2016). Resident 13's plan of care was not reviewed and revised to prevent further falls until December 29, 2016 (25 days after incident). On December 29, 2016, the list of fall incidents provided by the DON indicated 20 fall incidents, one fall with no injury, and one injury of unknown cause (fall). The document indicated a total of 22 incidents from December 1 to 29, 2016 (6 more incidents from the list presented on December 28, 2016). On December 29, 2016, at 10:05 a.m., the Director of Rehabilitation (DOR) was interviewed. She stated every time there was a fall incident, the IDT would meet and review the components of the fall. The DOR stated after review, the IDT would suggest recommendations appropriate to the resident. On December 29, 2016, at 10:28 a.m., the Administrator was interviewed. He stated he was not fully aware of all the fall incidents. The Administrator stated there was no person who had consistently reviewed all the fall incidents since the transition of management on December 1, 2016. On December 29, 2016, at 10:55 a.m., a MDS (minimum data set- an assessment tool) nurse was interviewed. She stated the nurses were supposed to review and revise the plan of care after each fall. On December 29, 2016, the facility policy and procedure was reviewed. The policy titled Falls and Fall Risk, Managing, revised on June 1, 2015, indicated, . Prioritizing Approaches to Managing Falls and Fall Risk . 1. The staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions ( .to try one or few at a time, rather than many at once) . 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .Monitoring Subsequent Falls and Fall Risk .1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks for falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. (examples) dizziness or weakness) has resolved .