Every finding on record at Crescent City Care Center

Based on interview and record review, the facility failed to implement its abuse policies and procedures for three residents (Resident 1, Resident 2, Resident 3) of eight sampled residents after an allegation of abuse was made when:There was no documented evidence that the Physician (MD) was notified; and,There was incomplete documentation of the 72-hour monitoring of the residents by nursing and social service staff.These failures decreased the facility's potential to ensure residents' psychosocial needs were met after an allegation of abuse.Findings:A review of Resident 1's admission record indicated admission to the facility in June 2024, with a diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity and slow, imprecise movements).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/17/26, indicated severe memory impairment.A review of Resident 1's progress note dated 8/4/26 at 12:30 p.m. indicated, DON [Director of Nursing] received report regarding alleged abuse at approximately [7:42 a.m.].A review of Resident 1's progress notes dated 8/4/26 to 8/7/26 indicated there was no documented evidence of monitoring during third shift on day 8/4/26 nor on the third shift on 8/6/26.A review of Resident 2's admission record indicated she was admitted in July 2026 with the diagnosis of Osteoarthritis of the Right Knee (a progressive disorder of the joints caused by a gradual loss of cartilage) and mild cognitive impairment.A review of Resident 2's MDS indicated the resident had mild memory impairment.A review of Resident 2's progress note dated 8/14/26 at 11:41 a.m. indicated, Per resident CNA [Certified Nursing Assistant] was speaking to her 'Like an animal, like a dog'.A review of Resident 2's undated care plan regarding the potential to have a psychosocial well-being problem related to alleged abuse indicated nursing staff was expected to monitor and document Resident 2's feelings relative to the alleged abuse.A review of Resident 2's progress notes dated 8/14/26 to 8/17/26 indicated there was no documented evidence that the MD was notified after Resident 2 reported an allegation of abuse. There was also no documented evidence Resident 2 was monitored for psychosocial harm on the first shift on 8/15/26.A review of Resident 3's admission record indicated he was admitted in April 2017 with a diagnosis of diffuse traumatic brain injury.A review of Resident 3's MDS dated [DATE], indicated the resident had mild memory impairment.A review of Resident 3's progress note dated 8/3/26 at 1:21 p.m. indicated, At approximately [10:30 a.m.] DON received report of possible abuse allegation regarding resident and CNA.A review of Resident 3's undated care plan regarding his experience of alleged verbal abuse from a CNA on 7/31/26 indicated nursing staff was expected to monitor Resident 3's feelings of not being safe, sadness, agitation/anger towards staff and inform the MD for Resident 3's psychosocial well-being.A review of Resident 3's chart indicated there was no documented evidence that the MD was notified after Resident 3 was allegedly abused by a CNA. There was also no documented evidence Resident 3 was monitored for psychosocial harm on the third shift on 8/3/26, the second shift on 8/4/26, and the first shift on 8/6/26.In an interview on 8/26/26 at 2:23 p.m. with the Director of Nursing (DON), the DON stated she expected nursing staff to notify the MD when a resident was involved in an allegation of abuse, and to monitor for any change in condition or physical or mental distress during each shift with help from the social service staff during the first 72 hours after an incident. The DON confirmed charting in Resident 1, Resident 2, and Resident 3's charts were incomplete and did not meet her expectations. The DON stated that without monitoring, staff would not know how the patient was doing, and care could be delayed resulting in potential harm to the resident. A review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/ Neglect/ Exploitation, revised 12/19/22, indicated, Licensed Nurse will notify the attending physician.[and] monitor and document the resident's condition.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one resident (Resident 2) of eight sampled residents when an allegation of abuse was not reported to the state agency within two hours.This failure had the potential result in delay resident care and protection.Findings:A review of the facility's investigation summary and conclusion report dated 8/19/26, indicated, .the incident that was reported to the administrator on 8/14/26 at 5:48 a.m. via text regarding [Resident 2] and CNA [Certified Nursing Assistant]. CDPH [California Department of Public Health].notified via phone at 9:30 a.m. on 8/14/26.In an interview on 8/26/26 at 4:30 p.m. with the Administrator (ADM), the ADM confirmed CDPH was not notified of the 8/14/26 allegation of abuse within two-hour required timeframe.A review of the facility's policy titled, Abuse Neglect and Exploitation, revised 12/19/22, indicated, Reporting of all alleged violations to the. state agency.Immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involved abuse.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (the Department) within the required timeframe for one (1) of four (4) sampled residents (Resident 1), when the facility did not report an allegation of abuse involving Resident 1 within two (2) hours after the allegation was made.This failure had the potential to result in delayed abuse identification and intervention, compromising the well-being and protection of vulnerable residents within the facility.A review of Resident 1's admission Record (a facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain function loss caused by a chemical imbalance or illness in the body), depression (a persistent feeling of sadness, emptiness, and a loss of interest in life that lasts for weeks or longer and affects how you think, feel, and act), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels), and anxiety.A review of SOC-341 (a state form used by mandated reporters to report suspected abuse, neglect, or exploitation of elders or dependent adults), dated 7/07/26, indicated Resident 1 made the report of facility staff giving care in a potentially abusive manner on 7/07/26 between the hours of 1 a.m. and 2 a.m. There was no evidence this abuse allegation was reported to the Department until 7/20/26.During an interview on 7/29/26 at 9:30 a.m. with the Social Services Aide (SSA), she stated she completed the SOC-341 on 7/07/26, and thought someone called the Department to make a report of the abuse allegation. The SSA and the facility medical records department did not provide chart documentation or fax confirmation indicating the abuse allegation was reported to the Department within two (2) hours of its occurrence.A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, dated 12/19/22, indicated, it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .all alleged violations are to be reported to the Administrator, state agency, adult protective services and to all other required agencies.immediately, but not later than 2 hours after the allegation is made.

Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation involving staff and one (1) of four (4) sampled residents (Resident 1).This failure had the potential to delay the implementation of necessary protective measures and oversight to safeguard the health and safety of Resident 1 and other residents of the facility.A review of Resident 1's admission Record (a facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain function loss caused by a chemical imbalance or illness in the body), depression (a persistent feeling of sadness, emptiness, and a loss of interest in life that lasts for weeks or longer and affects how you think, feel, and act), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels), and anxiety.A review of SOC-341 (a state form used by mandated reporters to report suspected abuse, neglect, or exploitation of elders or dependent adults), dated 07/07/26, indicated Resident 1 made the report of facility staff giving care in a potentially abusive manner on 07/07/26 between the hours of 1 a.m. and 2 a.m. A review of facility document titled #2978 Alleged Abuse, dated 7/07/26, indicated Certified Nursing Assistant 1 (CNA 1) made the statement, 2 CNA's [Certified Nursing Assistant 2 (CNA 2 ) and Certified Nursing Assistant 3 (CNA 3] that mistreated [Resident 1]. [Resident 1] alleged that they pulled their arm and refused to cover them with a blanket stating you can do it yourself.During a phone interview on 7/29/26 at 12:22 p.m. with the Administrator (ADM), the ADM stated when the abuse allegation was under investigation, CNA 3 was placed on suspension, but CNA 2 was not placed on suspension during the course of the investigation, potentially placing Resident 1 at risk for additional harm.A review of facility policy and procedure titled, Abuse, Neglect and Exploitation, dated 12/19/22, indicated, the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to.responding immediately to protect the alleged victim and integrity of the investigation.room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.

Based on interviews and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when a certified nurse assistant (CNA 1) disregarded the resident's right to refuse care and showered her despite her clear refusal.This failure resulted in a diminished sense of dignity and autonomy for Resident 1, causing anger, frustration, and anxiety, undermining her trust in caregivers, and creating the potential for psychological trauma and future reluctance to accept necessary care.A record review of Resident 1's admission Record (facility demographic), indicated her admission to the facility on 1/24/23 from an acute care hospital with diagnoses including but not limited to the following: muscle weakness, unsteadiness on feet, difficulty in walking, anxiety disorder (a mental health condition characterized by persistent and irrational worry, fear, or dread), post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event), and claustrophobia (an intense irrational fear of confined or enclosed spaces).During an interview on 7/01/26 at 10:10 a.m., Resident 1 reported that on 5/27/26 she was forced to shower by facility staff despite clearly refusing and repeatedly telling them to stop. Resident 1 stated she yelled multiple times, but staff did not honor her refusal, leaving her feeling angry, fearful, and distrustful of caregivers. Resident 1 explained that she had previously developed trust with a specific certified nurse assistant (CNA 4) and had informed nursing staff that she preferred only CNA 4 to shower her. Resident 1 further reported having chronic shoulder pain and a history of childhood trauma related to bathing, which contributed to the emotional impact of the incident.A review of the 5 Day Investigation Report, submitted to the Department on 6/02/26 indicated that on 5/27/26 the facility initiated an investigation after Resident 1 reported being showered against her wishes by CNA 1. According to this report, the Director of Nursing (DON 1) and Administrator interviewed Resident 1 and notified the Department and local law enforcement. The report indicated Resident 1 stated she had refused the shower, and certified nurse assistant (CNA 2), confirmed Resident 1 was heard shouting during the incident. This report also indicated multiple witnesses, including CNA 1, substantiated that Resident 1 was showered despite her refusal. The facility completed safety checks, suspended CNA 1, and monitored Resident 1 following the report. After the investigation, CNA 1 was terminated. CNA 2 and a third certified nurse assistant (CNA 3), who witnessed portions of the incident, were counseled on their responsibilities in advocating for residents.During an interview on 7/01/26 at 3:11 p.m., the facility's new Director of Nursing (DON 2), reported her expectations for nursing staff following a resident's refusal of showering or bathing were to immediately stop, honor the resident's right to refuse care, report the refusal to the charge nurse, and for the staff involved to document the incident in the resident's medical record for follow up. DON 2 confirmed the risk in not honoring a resident's right to refuse shower care could result in a loss of dignity and diminished trust in care providers, and could have the potential to result in psychosocial harm.During an interview on 7/01/26 at 3:27 p.m., with the Social Services Director (SSD), the SSD stated every person should have the right to autonomy concerning their body, to direct the care of their body, and to refuse care. The SSD said prior to the showering incident that it was well known that Resident 1 generally only preferred one staff member, CNA 4, to shower her which was still Resident 1's preference, even after the incident. The SSD confirmed Resident 1's care plan was updated after the showering incident to include an intervention specifically instructing staff to honor Resident 1's right to refuse shower care and to offer alternative hygiene methods as appropriate. Additionally, a psychiatry consult was performed for Resident 1 on 6/02/26. When queried, the SSD acknowledged Resident 1's rights, consent, and psychological protections were not recognized, assessed, and acted upon appropriately during the showering incident.A review of a psychiatry progress note dated 6/02/26 indicated Resident 1's clinical assessment by nurse practitioner (NP 1): CHIEF COMPLAINT. Follow-up after 05/27/2026 shower-care complaint. Today she reports anxiety/frustration around persistent left shoulder pain, painful handling during care. Anxiety/depressive burden appears amplified by pain, care-related distress. During an interview on 7/01/26 at 4:26 p.m., certified nurse assistant 5 (CNA 5) stated she had been trained by the facility during her orientation when a resident at any time refused care, to honor the resident's choice and stop immediately, report the refusal of care to the charge nurse and document the incident accordingly.A review of the Certified Nursing Assistant job description dated 2023, indicated, Major duties and responsibilities. Keeps nurse and supervisor informed of factors that interfere with being able to perform the work as assigned (i.e. resident refusal, .) . Additional Assigned Tasks. Treats all residents with dignity and respect. Promotes and protects all residents' rights.A review of the facility policy titled, Provision of Quality Care revised 12/19/22, indicated, Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.A review of the facility policy titled, Residents' Rights Regarding Treatment and Advance Directives revised 12/19/22, indicated, The facility will provide the resident. about the right to refuse. treatment. Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart: a. What the resident refused. b. The reason for the refusal. c. The advice given to the resident about the consequences of refusing. d. The offering of alternative treatments. e. The continuation of providing all other services. 12. Any services that would be otherwise required, but are refused, will be documented in the resident's comprehensive care plan.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) received treatment and care in accordance with the resident's goals of care and professional standards when Resident 2's skin treatment ordered by the physician was not provided for 11 days of the month. This failure had the potential to result in worsening of the skin condition and leaving the skin unprotected and broken rendering it susceptible to secondary infection. Findings:A review of Resident 2's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bleeding between the brain and its surrounding membrane, heart and lung failures, and other infectious diseases (illnesses caused by tiny organisms-such as bacteria, viruses, fungi, or parasites).A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/3/26, indicated Resident 2 was admitted with one unstageable pressure sore (UTD - a deep, serious skin wound covered by dead tissue {slough or eschar} that prevents doctors from seeing how deep it actually goes), two deep tissue injuries (DTIs - a localized area of maroon or purple discolored intact skin, or a blood-filled blister, resulting from intense pressure or shear) and moisture associated skin damage (MASD) caused from prolonged exposure to moisture.A review of Resident 2's care plan (written roadmap or personalized action plan that outlines a resident's medical, personal, and emotional needs) for the DTI on the coccyx (a small, triangular area located at the very bottom of the spine often called a tailbone) and UTD on the right sacrum (a triangular-shaped area located toward the base of the spine, between lower back and the tailbone), dated 3/31/26, indicated interventions included administering medications/treatment as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown.A review of Resident 2's care plan for the potential for impaired skin integrity, dated 3/31/26, indicated interventions including, provide skin care per facility guidelines and as needed. A review of Resident 2's Treatment Administration Record (TAR) for 4/26, indicated a treatment order for bilateral buttocks with zinc and 3x3 foam dressing that was not provided by the afternoon shift for 11 days of the month on 4/1/26, 4/5/26, 4/6/26, 4/12/26, 4/14/26, 4/15/26, 4/17/26, 4/18/26, 4/19/26, 4/20/26, and 4/21/26. During an interview on 4/23/26 at 3:55 p.m., with the DON, the DON confirmed 11 of Resident 2's zinc treatments had not been completed as ordered in April 2026. The DON stated not giving the treatment as ordered poses the danger of infection and delay of healing.During a concurrent interview and record review on 4/23/26 at 5:25 p.m., with the DON, the facility policy titled, Medication Administration, dated 12/19/22, was reviewed. The DON pointed to item #14 of the policy which indicated, Medication are administered by licensed nurses., as ordered by the physician and in accordance with professional standards or practice. and stated that is what the facility failed to do.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (the Department) within the required timeframe for one of two residents (Resident 1) when the facility did not report an allegation of abuse involving Resident 1 within two hours after the allegation was made.This failure had the potential to result in the allegation not getting investigated timely, and can result in physical, mental, or psychosocial harm to the residents. Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and corticobasal degeneration (a rare, progressive brain disease that causes nerve cells to shrink and die, affecting movement, speech, and memory, often leading to immobility).A review of Resident 1's Nursing Progress Notes, dated 4/7/26, indicated during Resident 1's telepsychiatry visit (telepsych - mental health care-such as psychiatric evaluations, therapy, and medication management-from a doctor or therapist remotely via secure video calls or phone, rather than in a physical office), Resident 1 reported that some people in the facility tried to hurt him. A review of SOC 341 (a state form used by mandated reporters to report suspected abuse, neglect, or exploitation of elders or dependent adults), dated 4/7/26, indicated Resident 1 made the report the people that work here try to hurt me during the telepsych appointment on 4/7/26 at 11:30 a.m.During a concurrent interview and record review on 4/22/26 at 5:12 p.m., with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the SOC 341, dated 4/7/26, was reviewed. The ADON stated she was with Resident 1 during the telepsych visit and heard Resident 2's report that some people in the facility tried to hurt him. The ADON stated she then informed the Administrator and had prepared the SOC 341 that the Administrator sent to the Department. The DON confirmed the SOC 341 indicated the allegation occurred on 4/7/26 at 11:30 a.m. The DON stated the SOC 341 was sent out to the Department by the Administrator electronically.During a follow-up interview with the DON on 4/22/26 at 6:01 p.m., the DON confirmed the date and time the SOC 341 was electronically sent by the Administrator to the Department was on 4/7/26 at 3:17 p.m. The DON did not respond when she was asked to confirm they reported the incident more than 3 hours after it was first reported. A review of the facility policy titled Abuse, Neglect and Exploitation dated 12/19/22, indicated, it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .all alleged violations are to be reported to the Administrator, state agency, adult protective services and to all other required agencies.immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 87, when:Several food items were found in the walk-in refrigerator past their use by dates;Several food items were found in the dry storage area past their use by dates;The scoop was left in the large bin container which stored the flour;Facility provided snacks were found in the resident refrigerator past their use by date; andFacility provided snacks were found in the resident refrigerator without date labels.These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.1. During a concurrent observation and interview on 3/23/26 beginning at 8:34 a.m. with the Registered Dietitian (RD), the following items were found inside the Walk-In Refrigerator with the following marked dates: a 32 ounce container of Liquid Whole Eggs with a use by date of 3/22; a half gallon container of soy sauce with a use by date of 3/18; an opened plastic bag containing lettuce with a use by date of 3/18; and an opened plastic bag containing red seedless grapes which was unlabeled. The RD confirmed all items were past their use by dates and the grapes were unlabeled and proceeded to remove all items and threw them directly into the garbage can.2. During the initial kitchen tour on 3/23/26 at 8:48 a.m., the following items were observed to be in the facility's dry storage area with the following marked dates: Two plastic bag containers of hamburger buns, containing 12 hamburger buns in each bag, with a date of 3/9; a large plastic container filled with approximately 80 to 100 individually packaged saltine crackers with a use by date of 1/20/25; a large plastic container filled with individually packaged diet cookies with a date of 12/15/25; a 1.8 liter container of Kikkoman Sweet [NAME] Seasoning with an open date of 7/15/25 and a use by date of 10/15/25; and a one gallon container of Honey with a use by date of 6/15/25.3. During an observation on 3/23/26 at 9:08 a.m., a blue scoop was observed stored inside the large plastic container used for holding flour.4. During an observation conducted on 3/24/26 at 8:20 a.m., a container holding individually wrapped, facility prepared peanut butter and jelly sandwiches and meat and cheese sandwiches, cut into triangles, was observed stored in the resident refrigerator labeled with printed dates of 3/20/26. In addition, two burgundy containers containing a pudding like substance were observed stored in the same refrigerator, each covered with a gray lid and labeled with handwritten dates of 3/20/26.5. During an observation conducted on 3/24/26 at 8:20 a.m., a container holding individually wrapped, facility prepared peanut butter and jelly sandwiches and meat and cheese sandwiches, cut into triangles, was observed stored in the resident refrigerator without any date labels indicating when the items had been prepared. In addition, two clear, scalloped plastic dessert bowls containing a piece of bread or cake topped with sliced strawberries and a dollop of white cream, and one clear, scalloped plastic dessert bowl containing a single serving of a dark chocolate cake or brownie, were observed stored in the resident refrigerator without any date labels indicating when the items had been prepared.During an interview on 3/26/26 at 5:30 p.m. with the Certified Dietary Manager (CDM), the CDM stated that expired food items and unlabeled foods have been a persistent issue in the kitchen. When shown photos of the facility provided snacks, the CDM acknowledged the outdated snacks found in the resident refrigerator should have been discarded no later than three days after preparation. The CDM also confirmed the unlabeled facility provided snacks should have been discarded immediately because staff could not verify their freshness or safety. The CDM further stated these practices increased the risk of residents being served expired, spoiled, or unsafe foods, potentially resulting in foodborne illness.During an interview on 3/27/26 at 10:45 a.m. with the Director of Nursing (DON), the DON stated expired food items, unlabeled foods, and improperly dated facility provided snacks pose a significant safety concern for residents. The DON explained that expired or outdated food should not be available to residents and must be discarded because it may be unsafe to consume. The DON further stated that undated snacks also must not be kept, as staff cannot verify whether the items remain fresh or within safe timeframes. The DON stated these practices increase the risk of residents being served spoiled or unsafe foods, potentially resulting in foodborne illness, resident decline, or other adverse health outcomes.A review of the facility's policy and procedure (P&P) titled Labeling and Dating for Safe Storage of Food, revised 4/23, the P&P stipulated, All products should be dated upon receipt. All products should be dated when opened. Use Use-By dates on all food once opened and stored under refrigeration.A review of the facility's P&P titled Refrigerated Leftover Storage, revised 8/21, the P&P stipulated, .Date container with use by date (lids may be misplaced).Do not save fresh fruits -cut, puddings or custards, and sandwiches. The P&P also indicated food items such as breads, cakes, and luncheon and deli meats can be stored for 1 to 3 days.A review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies, dated 2017, indicated that dry bulk foods, such as flour, must be stored in plastic containers with tight fitting covers, and scoops are not to be left inside the containers. The P&P also required that all food items be dated with the month, day, and year, and that food products be used according to the timeframes outlined in the Dry Food Storage Guidelines, which specify that bread may be stored for five to seven days after receipt.

Based on observation, interview, and record review, the facility failed to store resident food in a safe and sanitary manner for a census of 87 when staff stored several perishable food items unlabeled and undated in the facility pantry designated for resident food.This failure had the potential to cause foodborne illnesses in a vulnerable resident population.During an observation on 3/24/26 at 8:23 a.m. in the clean utility room, which contained cabinets designated for resident personal food items, one clear plastic scalloped edge bowl containing three large porous pieces of bread sat directly on the cabinet shelf. The bread remained unprotected and exposed to the environment because the container was uncovered. At the same time and location, one large red and white commercially wrapped food item rested on the same shelf approximately two inches from the uncovered bread. The paper wrap, marked in large black lettering JACK CHEESEBURGER, did not include a room number or a date indicating when staff received it.During an interview on 3/24/26 at 8:28 a.m., with Unlicensed Staff H (US H), US H stated only foods for residents were to be stored in the clean utility room. US H also confirmed the bread and cheeseburger were not labeled or dated.During an interview on 3/26/26 at 5:30 p.m., with the Certified Dietary Manager (CDM), the CDM stated he expected staff to label all resident food items according to facility policy.During a review of the facility policy and procedure titled, Food For Residents From Outside Sources, dated 2018, the policy stipulated, .If opened, the food must be sealed, dated to the date opened.During a review of the policy titled Bringing In Food For A Resident, dated 2018, the policy stipulated, Food or beverages should be labeled and dated to monitor for food safety.Foods in unmarked or unlabeled containers will be marked with the current date and the resident's name.

Based on observation, interview, and record review, the facility failed to ensure that essential kitchen equipment was in safe operating condition for a census of 87 residents when:1. The low temp dishwashing machine was operated at 108 degrees Fahrenheit multiple times; and2. A food thermometer was not readily available for use.These failures had the potential to compromise the facility's ability to maintain effective sanitation practices for all residents and increase the risk of serving food that had not been verified to be at a safe temperature.1. During an observation on 3/25/26 at 10:37 a.m., the Dishwasher (DW) operated the low temp dishwasher multiple times, and the temperature gauge showed 108 degrees to 110 degrees Fahrenheit.2. During a concurrent interview and observation on 3/25/26 at 10:59 a.m. with the [NAME] (CK I), CK I was calibrating the food thermometers per facility policy and observed the thermometer was not reading the required temperature of 212 degrees Fahrenheit as it was immersed in boiling water. The CK I confirmed the temperature was reading at 203 degrees Fahrenheit.During an observation on 3/25/26 at 11:30 a.m., the food thermometer continued to read at 203 degrees Fahrenheit.During an observation on 3/25/26 at 11:39 a.m., the CK I brought in a different food thermometer which read at 208 degrees Fahrenheit.During an interview on 3/26/26 at 5:30 p.m., with the Certified Dietary Manager (CDM), the CDM stated the low temp dishwasher should be operated between 120 to 140 degrees Fahrenheit. The CDM also stated it is important to have working thermometers in the kitchen to ensure food was cooked and served at correct temperatures.During an interview on 3/27/27 at 10:45 a.m., with the Director of Nursing (DON), the DON stated any staff who operated the dishwashing machine should know the correct operating temperature and how to check for proper sanitation. The DON also stated operating the dishwashing machine without knowledge of how to operate it properly could pose an infection control risk to all residents.During a review of the facility's policy and procedure (P&P) titled Dishwashing, undated, the P&P stipulated, Use the machine at a range of 120 degrees F to 140 degrees F. The chlorine should read 50-100 ppm on dish surfaces in final rinse.During a review of the facility's procedure titled, Weekly Thermometer Calibration Chart, dated 2023, the procedure stipulated, all thermometers should be calibrated once a week and boiling water may also be used in the same manner to calibrate the thermometer, with the thermometer to read 212 degrees Fahrenheit.

Based on interview and record review the facility failed to ensure all responsibilities of the Medical Director were effectively performed to ensure resident attained and maintained the highest practicable physical, mental and psychosocial well-being when the Medical Director did not fulfill his responsibility for the coordination of medical care in the facility. This failure resulted in Gradual Dose Reductions (GDR) not being addressed and communication between the Medical Director and care teams being ineffective which could result in delayed resident care, unnecessary medication use, and potentially poor resident outcomes. During a phone interview, on 3/24/26 at 11:19 a.m., with Guardian A (legal decision maker for Resident #4 and Resident #14), she stated she felt like she had to pester Medical Director with repeated phone calls and requests to speak with him about the medical care for Resident #4 and Resident #14. She stated he would seldom call her back. She stated he was unresponsive and it made her angry because she could not speak to him on behalf of the residents she was responsible for. During a phone interview on 3/25/26 at 3:16 p.m., Family Member of Resident #78 stated she had tried to speak with Medical Director but could never get through to him. During an interview and concurrent record review on 3/26/26 at 8:26 a.m., DON stated monitoring of the Anti-Psychotic Medication Program was conducted monthly with the Consultant Pharmacist, Medical Director and herself. The Gradual Dose Reduction (GDR) documentation for the facility for the last 3 months was reviewed and indicated no documented response by the Medical Director for recommendations by the Consultant Pharmacist for mandated Gradual Dose Reductions for Resident #4, Resident #86 and Resident #78. DON stated the Medical Director should have approved the GDR recommendations from the Consultant Pharmacist. She stated there was no monitoring of the GDR medications for facility residents by the Medical Director. She stated he was consistently difficult to get him to respond to emails, phone calls and requests to perform the GDR review. She stated he was only in the facility once a month for only a couple of hours. She stated he did not attend committee meetings in person and rarely by phone. She stated he was actually in the facility he would just initial documents for attendance and reviews and spend no time reviewing or discussing any facility related issues with her. During a phone interview on 3/26/2026 at 9:59 a.m. Consultant Pharmacist stated her responsibilities included review and recommendations for any medications that included GDRs, labs, and pain medication use. She stated she collaborated with Administrator and DON to monitor Antipsychotic medication through the GDR review and participate in the Quality Committee presentation of that information. She stated Anti-psychotic medication use in the facility was Probably a little above the national level. She stated the facility did a good job getting Pharmacy Recommendation done, but we don't always hear back from physician. She stated the Medical Director was non-compliant. She stated, The biggest challenge is the medical director and his timely responses. During a phone interview on 3/26/2026 at 3:15 p.m., Medical Director stated his responsibility as the facility Medical Director was Everything medical in the building, that included attending meetings, administrative duties and working on issues with Administrator and DON. He stated he reviewed the care that residents were supposed to receive and if there were on appropriate medications. He stated he usually attended committee meetings by phone. He stated once a month he reviewed GDR recommendations via documents sent to him. He stated when he was in the facility, he would review the paper forms and always sign the paper documentation for GDR recommendations. MD could not relay what projects the QAPI team was working on. During an interview with Administrator on 3//27/27 at 9:40 a.m., she stated working with Medical Director was challenging. She stated he did not consistently review the Pharmacy Recommendations for recommendations for GDRs. During an interview on 3/27/26 at 11:10 a.m. with the Director of Nursing(DON), and the Administrator (ADM) in the ADM's office, the ADM stated the MD attended maybe three QAPI meetings a year, usually by conference call, and that the ADM or DON called the MD following the QAPI meetings to update him but he did not offer any additional input or suggestions. The ADM further stated the MD signed the attendance logs when he came into the facility and she had no way to prove he attended by conference call. The ADM continued stating the MD was disconnected, both the ADM and DON stated they did not feel supported by the MD. A review of a document titled SKILLED NURSING FACILITY MEDICAL DIRECTOR AGREEMENT, signed 11/4/25, indicated DUTIES AND RESPONSIBILITIES As Medical Direcctor, Physician shall be responsible for standards, coordination, surveillance, and planning for improvement of medical care in the Facility. Apprising the Administrator as to recommendations, proposed plans for implementation, and continuing assessments of, the clinical care of patients, through dated and signed reports. A review of a facility Policy and Procedure titled Gradual Dose Reduction of Psychotropic Drugs, Revise 3/17/25 indicated Resident who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or other wise modified include: i. During the monthly medication regimen review by the pharmacist. Ii. When the physician or prescribing practitioner evaluates the resident's progress. Iii. During the quarterly MDS review by the interdisciplinary team. A review of a facility policy titled, 2026 QAPI Plan for Crescent City Care Center, undated, indicated, The QAPI committee, which includes the medical director, is ultimately responsible for assuring compliance with the federal and state requirements and continuous improvement in quality of care and customer satisfaction.

Based on observation, interview, and record review, the facility failed to ensure that residents requiring oxygen were provided humidifiers (bottled water that attaches to an oxygen concentrator and moistens the oxygen, preventing dry nose and throat), clean concentrators (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) and orders for therapy for 13 of 15 residents (Residents: #18, #20, #23, #22, #25, #31, #40, #41, #98, #48, #55, #76, #81) observed receiving oxygen therapy when thirteen residents did not have humidifiers in use as required for their oxygen delivery systems, seven residents had visibly soiled or dirty oxygen concentrator filters, and eleven residents did not have physician orders for oxygen therapy, despite actively receiving oxygen during the survey.These deficient practices placed residents at risk for inadequate humidification, ineffective oxygen delivery, respiratory compromise, and potential infection due to unmaintained equipment.Findings:A review of Resident 18's admission record indicated admission to the facility on [DATE] for pneumonia (an infection / inflammation in the lungs). An observation on 3/24/26 indicated she had no humidifier on her concentrator and record review revealed no orders for oxygen therapy.A review of Resident 20's admission record indicated admission to the facility on 7/7/2025 for an encounter for orthopedic aftercare following surgical amputation and he has no memory impairment. An observation on 3/24/26 indicated he had no humidifier on his concentrator.A review of Resident 23's admission record indicated admission to the facility on 3/16/2022 for intervertebral disc degeneration (wear and tear of the spine). An observation on 3/24/26 indicated she had no humidifier, a dirty filter on her concentrator and record reviewed revealed no orders for oxygen therapy.A review of Resident 22's admission record indicated admission to the facility on 1/29/2026 for dysphasia (difficulty swallowing). An observation on 3/24/26 indicated he had a dusty concentrator and record review revealed no orders for oxygen therapy.A review of Resident 25's admission record indicated admission to the facility on 2/8/2020 for an unspecified open wound, left thigh. An observation on 3/24/26 indicated she had no humidifier on her concentrator.A review of Resident 31's admission record indicated admission to the facility on [DATE] for cellulitis of the left lower limb. An observation on 3/24/26 indicated he had no humidifier on her concentrator and record review revealed no orders for oxygen therapy. A review of Resident 40's admission record indicated admission to the facility on 1/11/2025 for encounter for surgical aftercare following surgery on the digestive system. An observation on 3/24/26 indicated she had no humidifier and a dusty filter on her concentrator and record review revealed no orders for oxygen therapy.A review of Resident 41's admission record indicated admission to the facility on 1/11/2025 for encounter for surgical aftercare following surgery on the digestive system. An observation on 3/24/26 indicated she had no humidifier on her concentrator.A review of Resident 98's admission record indicated admission to the facility on 3/17/2026 for a fracture of the neck of the right femur. An observation on 3/24/26 indicated she had no humidifier and a dusty filter on her concentrator and record review revealed no orders for oxygen therapy.A review of Resident 48's admission record indicated admission to the facility on 5/16/2025 for acute respiratory failure. An observation on 3/24/26 indicated she had no humidifier and a dusty filter on her concentrator.A review of Resident 51's admission record indicated admission to the facility on [DATE] for chronic obstructive pyelonephritis (a serious kidney infection). An observation on 3/24/26 indicated a concentrator and record review revealed he had no orders for oxygen therapy.A review of Resident 55's admission record indicated admission to the facility on 1/18/2025 for acute respiratory failure. An observation on 3/24/26 indicated he had a dusty filter on his concentrator and record review revealed no orders for oxygen therapy.A review of Resident 76's admission record indicated admission to the facility on 4/28/2024 for encounter for Huntington's Disease (a disorder that causes the progressive breakdown of nerve cells in the brain). An observation on 3/24/26 indicated she had no humidifier and a dusty filter on her concentrator.A review of Resident 81's admission record indicated admission to the facility on 1/24/2023 for myopathies (a breakdown of the muscles). An observation on 3/24/26 indicated she had no humidifier on her concentrator and no orders for oxygen therapy.A review of Resident 83's admission record indicated admission to the facility on [DATE] for cellulitis of the right lower limb. An observation on 3/24/26 indicated she had no humidifier on her concentrator and record review revealed no orders for oxygen therapy.A review of Resident 86's admission record indicated admission to the facility on 8/16/2026 for acute and chronic respiratory failure. An observation on 3/24/26 indicated she had no humidifier on her concentrator and record review revealed no orders for oxygen therapy.During a review of the rooms with concentrators on 03/25/2026 from approximately 9:30 AM to 9:45 AM with the Director of Nursing (DON) and the Facility Maintenance Manager (FMM) when visiting Resident #40, the DON stated, That is awfully dirty, my concern would be respiratory injury. The FFM stated, I buy them and maintain them if they break, but I do not clean them. I can provide a copy of the user's manual.During a concurrent observation and interview when visiting Resident #55, the DON stated, No water in humidifier, no filter in machine. More respiratory injury. I don't know if there is a cleaning regiment for these. The DON checked with housekeeping and returned and stated, Housekeeping cleans the outsides of these, but they don't open them, nor do they deal with the filters.The DON confirmed that having no water in the humidifier could dry out respiratory track and make breathing uncomfortable, that dirty filters could leave to respiratory injury and that all Resident's on oxygen therapy should have an order from the physician. A review of the policy and procedure entitled, Oxygen Administration. Revised 5/20/2024, states, oxygen is administered under orders of a physician. The policy stated the facility will follow manufacturer recommendations for the frequency of cleaning equipment filters, and to change humidifier bottles when empty.A review of the DeVilbus 5-Liter Oxygen Concentrator Instruction Guide provided by the facility stated, inspect the vents periodically and wife with a dry cloth as needed to remove dust. Recommends a cleaning interval of every 7 days.

Based on observation, interview and record review, staffing was not sufficient to meet the needs of thirteen Sampled Residents (Resident #6, Resident #29, Resident #55, Resident #9, Resident # 35, Resident #86, Resident #53, Resident #3, Resident # 34, Resident 54, Resident 81, Resident #5, and Resident #67 when:There was no staff assistance with dining for Sampled Residents #9, #86 and #35 and resulted in no lunch eaten by all three residents; and Sampled Resident #86 was not turned every two hours. Staff did not provide activities of preference for Sampled Resident #34, did not provide nail care for Residents #6, #29. #55, #54 and Resident #81, and did not get Resident #81, Resident #5 and Resident #67 out of bed.Sampled Residents #3, #6 and #53 were observed to not have call lights lights within reach on multiple occasion.These failures had the potential to result in:Resident potential for or worsening of malnutrition for Resident 9, Resident 86, and Resident 35, and a potential for development of skin issues like rashes and skin ulcers for Resident 86. Resident frustration and boredom for Resident 34, decreased self-esteem, injury, infection, decreased mobility and range of motion for Residents 6, 29, 55, 54, 81, 5 and 67, and Residents not being able to call for help due to call lights being inaccessible with could result in frustration and anger, and had the potential to result in falls and injuries 1. Resident #9 was admitted [DATE] with diagnoses that included Malnutrition (inadequate protein intake), Adult failure to Thrive (functional decline, weight loss, malnutrition) and Diabetes (An inability to produce enough insulin to metabolize sugar in the blood) among others. His Brief Interview for Menal Status (BIMS) (A cognitive assessment to determine how mental intact a resident was. A score of 0-9 indicated severe impairment, 10-12 indicated moderate impairment and 13-15 indicated no cognitive impairment.), score indicated 14. Resident #35 admitted [DATE] with diagnoses that included Malnutrition, Adult Failure to Thrive and Diabetes. His BIMs indicated a score of 15. Resident #86 was admitted [DATE] with diagnoses that included Malnutrition, Diabetes, Adult Failure to Thrive, Cellulitis (A potentially serious infection affecting the skin's deeper layers) among others. Her BIMs indicated a score of 8. During an observation on 3/23/26 at 9:06 a.m., 11 a.m., 12:58 a.m., and 4:45 p.m. Resident #86 was observed sitting up in bed on her back , at a 90 degree angle. Her head was observed to lean onto her right shoulder. During an observation on 3/23/26 at 12:58 p.m., lunch trays were delivered to #86. Resident #86 was sitting up in bed and she was not eating her lunch. During an observation on 3/23/26 at 1:10 p.m. Resident #9 and was sleeping on his left side and Resident #86 was sitting up in bed with the head of the bed at 90 degrees and had not eaten any lunch. During an observation on 3/23/26 at 1:15 p.m. Resident #9 and Resident 35's lunch trays were delivered to their room. Resident #35's tray was observed on his bedside table and the warming lid removed. He was observed to be sleeping on his left side. Resident #35's lunch tray was placed on his bedside table with the warming lid off. Resident #35 was seated on the left side of the bed facing the window with his back to his lunch tray. During an observation on 3/23/26 at 2:30 p.m. Resident #9 was sleeping on his left side and his lunch had not been eaten. Resident #35 was observed to be seated on the left side of bed with the lunch tray untouched on the left side of the bed. His lunch was observed not to have been eaten. Resident #86's lunch tray was observed to have been removed and placed in the tray cart, with 0% consumed. During an observation on 3/23/26 at 3:12 p.m. and 4:45 p.m Resident #9 was sleeping on his left side. During an observation and interview on 3/23/26 at 12:58 p.m. Resident #86 was observed lying in bed on her back, at a 90 degree angle. Her head was observed to lean onto her right shoulder. A lunch tray had been placed in front of her. She stated she needed help with cutting her food. An observation of the hallway and nursing station indicated no staff were available to assist Resident #86. During an interview with US C on 3/23/26 at 1 p.m., he stated the process for serving residents lunch was to make sure they are sitting up and ready to eat. He stated he usually started to help residents cut up their food right away. During an observation and interview with Resident #35 on 3/23/26, at I:30 PM, he was seated on the left side of the bed and his lunch tray had been placed on the bedside table on the right side of the bed. He stated he was unaware his lunch had been delivered. He stated he was not hungry and was not offered any substitutions. He stated he did not know you could ask for substitutions. During an observation and interview on 3/24/2026 at 8:20 a.m. US E was observed to go into Resident 86's room at 8:18 a.m. and ask how her breakfast was. She stated not good. Her breakfast tray was observed to not indicate any breakfast had been eaten. He was observed to not go back and not ask Resident # 86 if she wanted a substitution. At 8:20 a.m. he stated he was in a rush. He stated he normally got an assignment of 12-16 residents every day and he could not help them with meals, and he could not take the time to turn them every two hours. He stated staffing was a struggle. He stated with his assignment he could not turn residents every two hours, change their briefs, give them all showers, assist with meals and get resident out of bed and dressed. During an interview on 3/24/26 at 2:15 p.m. with LS A stated all residents should be turned every two hours. During an interview on 3/24/2026 at 11:36a.m., Visitor stated when she was in the facility to visit residents, she had observed that residents were neglected, left in their beds, not participating in activities. She stated Resident #14's fingernails were long and dirty, and it took multiple calls to the facility to get someone to address the issue. She stated his television was not working and he did not leave his room. She stated he told her without the television he would listen to his roommate's music and listen to the people in the hall talk. Visitor stated it was a Sad situation for all the residents. During an interview on 3/25/26 at 11:55 a.m., US B stated she was assigned 12 residents. She stated she works a lot of overtime and double shifts because the facility was short staffed. She stated on the night shift you would be assigned 20 residents or more. She stated the staffing was so low she Cannot provide care like showers, hydration, turning every two hours. During an interview on 3/25/26 at 11:35 a.m., DSD stated the facility was unable to meet the required staffing requirements. She stated staffing was assigned according to the census and not only by resident acuity. She stated without the staff you could not provide more than one or two showers a week for residents. A review of a facility policy titled, Activities of Daily Living, revised 12/19/22, indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services may include transfer and ambulation. 2. A review of Resident 34's admission record indicated he was admitted on [DATE] with a diagnosis of Parkinson's Disease among others. A review of Resident 24's MDS indicated he had a BIMS score of 11, indicating mild cognitive impairment. A record review of resident 34's care plan indicated he had a decline in functional mobility and his preferences for activities were to be invited to group activities and outdoor activities. During a concurrent observation and interview on 3/23/26 at 9:20 a.m. with resident 34 in his room, Resident 34 had contractures of arms and legs. Resident 34 stated staff did not do what he asked and never got him out of bed, and he was so bored and wanted to go outside. During a review of Resident 34's Activities log indicated he was offered in-room activities and refused or was not available for activities. During an interview on 3/26/26 at 4:30 p.m. with the Activities Director (AD), AD stated she had two new assistants and the refusals marked were incorrect. AD stated Resident 34 did not refuse but got frustrated with not being able to do what he used to be able to do and likes company the most. AD stated that activities staff could not move Resident 34 on their own and other staff were unavailable to assist him out of bed for activities. During an interview on 3/27/26 at 8:53 a.m. with the Director of Nursing (DON), DON stated, activities on the care plan should be attempted, if it was their preference and they voiced it, staff should facilitate it, and if not, it could affect their mood and could contribute to depression. A review of a facility policy titled, Activities, revised 12/19/23, indicated, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. It further indicated, Activities will include individual, small and large group activities, as well as Indoor and Outdoor activities and social activities. A review of Resident #6's admission record indicated the resident was admitted on [DATE] with a diagnosis of paraplegia. A review of Resident #6's MDS indicated the resident had no memory impairment. During a concurrent observation and interview on 3/27/26 at 10:51 a.m., Resident #6's toenails appeared thick, long, and discolored, with visible dirt and debris under the nails. Resident #6 stated, I've asked to have my toenails done, but I'm a diabetic so they don't like to do them. A review of Resident #29's admission record indicated the resident was admitted on [DATE] with a diagnosis of paralytic syndrome. A review of Resident #29's MDS indicated the resident had no memory impairment. During a concurrent observation and interview on 3/23/26 at 10:03 a.m., Resident #29's fingernails were observed to be long with pointed ends. Resident #29 stated, I have a hard time getting them to brush my teeth and do my nails. A review of Resident #55's admission record indicated the resident was admitted on [DATE] with a diagnosis of acute respiratory failure. A review of Resident #55's MDS indicated the resident had no memory impairment. During a concurrent observation and interview on 3/23/26 at 9:08 a.m., Resident #55's toenails appeared thick, long, and discolored. On 3/25/26 at 4:12 p.m., Resident #55 stated, I've asked, but they don't do them. A review of the facility policy titled Nail Care, revised 12/19/22, indicated: Routine cleaning and inspection of nails will be provided during ADL care on a routine basis, and routine nail care including trimming and filing will be provided on a regular schedule. A review of Resident 54's admission record indicated she was admitted on [DATE] with diagnosis of Encephalopathy, Dementia, and repeated falls with unsteadiness on feet. A review of Resident 54's MDS dated [DATE] indicated she could not complete the assessment. During a concurrent observation and interview on 3/23/26 at 10:19 a.m. in Resident 54's room with Licensed Nurse B (LN B) , Resident 54 was observed with yellow discolored very long fingernails and toenails and dry skin on her feet. LN B confirmed presentation of fingernails and toenails and stated Resident 54 was feisty and uncooperative at times and when we offer nail care she refuses. LN B offered Resident 54 nail care and she replied, yes, that would be very nice. A review of Resident 81's admission record indicated she was admitted [DATE] with diagnoses of unspecified myopathies, unsteadiness on feet, osteoporosis with falls, A-Fib, PTSD and anxiety. A review of Resident 81's MDS indicated she had a BIMS score of 12 indicating mild cognitive impairment. During a concurrent observation and interview on 3/23/26 at 10:27 a.m. in Resident 81's room, Resident 81 is seen with long discolored fingernails with dirt and debris under nails and long thick toenails with dry skin on feet. Resident 81 stated staff took her clippers away and when she asked staff to provide nail care they say they do not have the time and the nurses would not do it either. During an interview on 3/26/26 at 8:50 a.m. with LN B, LN B stated they had been short staffed for some time and with the increase in acuity of residents some days it was not possible to get to nail care. During an interview on 3/26/26 at 9:52 a.m. with Unlicensed Staff B (US B), US B stated many staff call out and quit and sometimes she has as many as 20 residents (assigned to her per shift). Today US B had 12 residents, and on average US B had around 15 residents. US B further stated some days US B only has time to focus on the minimum and that nail care and oral care would be low priorities, During an interview on 3/26/26 at 10:04 a.m. with Unlicensed Staff A (US A), US A stated they did not feel they had enough time to get to everything and US A focused on incontinence care and that nail care and oral care fell off the list. During an interview on 3/27/26 at 8:53 a.m. with the DON, DON stated nail care should be done on weekly rounds and should be clipped, filed and clean. DON further stated she knew the CNA's found it difficult to find the time and it put residents at risk for infection, injury and could affect self-esteem. During a review of a facility policy titled, Nail Care, revised 12/19/22 indicated, Routine cleaning and inspection of nails will be provided during ADL care on a routine basis and routine nail care including trimming and filing will be provided on a regular schedule. A review of Resident 81's admission record indicated she was admitted [DATE] with diagnoses of unspecified myopathies (muscle diseases), unsteadiness on feet among others. A review of Resident 81's MDS indicated she had a BIMS score of 12 indicating mild cognitive impairment. A review of Resident 5's admission record indicated he was admitted on [DATE] with diagnoses of alcohol induced persisting dementia, Bi-polar disorder among others. A review of Resident 5's MDS dated [DATE] indicated he had a BIMS score of 00 indicating severe cognitive impairment. A review of Resident 67's admission record indicated she was admitted on [DATE] with diagnoses of cerebral infarction (stroke) among others. A review of Resident 67's MDS dated [DATE] indicated she had a BIMS score of 06 indicating severe cognitive impairment. During an observation on 3/24/26 at 8:15 a.m, Residents 81,5, and 67 are all seen in bed. During an observation on 3/24/26 at 11:00 a.m, Residents 81,5, and 67 are all seen in bed. During an observation on 3/25/26 at 7:50 a.m. Residents 81, 5, and 67 are all seen in bed. During an observation on 3/25/26 at 12:20 p.m. Residents 81, 5, and 67 are all seen in bed. During an observation on 3/25/26 at 2:55 p.m. Residents 81, 5, and 67 are all seen in bed. During an observation on 3/25/26 at 4:35 p.m. Residents 81, 5, and 67 are all seen in bed. During an observation on 3/25/26 at 5:40 p.m. Residents 81, 5, and 67 are all seen in bed. During an observation on 3/26/26 at 7:55 a.m. Resident 81, 5, and 67 are all seen in bed. During an observation on 3/26/26 at 10:00 a.m. Resident 81, 5, and 67 are all seen in bed. During an observation on 3/26/26 at 1:49 p.m. Resident 81, 5, and 67 are all seen in bed. During an observation on 3/26/26 at 4:15 p.m. Resident 81, 5, and 67 are all seen in bed. During an interview on 3/25/26 at 12;35 p.m. with Resident 81 in her room, Resident 81 stated, she is in bed all day, she was out of bed once a week for shower if the lift was available, if not staff did a bed bath. Resident 81 stated she watched TV to stay entertained and hadn't been out of the facility since 7/4/24. During an interview on 3/26/26 at 9:52 a.m. with US B, US B stated, they did not have time to get residents out of bed, and this often required two people and a lift, and this was not often available. US B stated they were aware of Resident 67 and that she should be up in her wheelchair daily, but this does not happen. During an interview on 3/26/26 at 10:34 a.m. with US A, US A stated they would like to get residents up, but it depends on which resident and how they need to be transferred. US A stated they could not do it independently. US A stated they were not sure about the policy but ideally residents should be out of bed once a day at least. During an interview on 3/27/26 at 8:53 a.m. with the DON, DON stated, bed bound residents could be really difficult, and she would like to see everyone up in a chair at least once a day, but time and staff were a factor. DON stated you needed time and two people, and this may fall to the bottom of the list of resident care needs. A review of a facility policy titled, Activities of Daily Living, revised 12/19/22, indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services may include transfer and ambulation. 3. During an observation on 3/23/26 at 9:31 a.m., Resident #3 was sitting in bed with the call light on the ground, wrapped around the bed handrail. The IP (Infection Preventionist) confirmed the resident could not use the call light in its observed position.During an observation on 3/25/26 at 4:31 p.m., Resident #3 was asleep in bed. The call light was observed on the floor.During an observation on 3/26/26 at 9:31 a.m., Resident #3 was awake in bed. The call light was observed on the floor. During an observation on 3/27/26, Resident #6 was sleeping in bed with the call light lying on the ground. During an observation on 3/23/26 at 8:32 a.m. Resident #53 was in bed, and the call light was observed on the neighboring resident's bedside table. At 8:37 a.m., the ADON was asked to enter the room to locate Resident #53's call light. The ADON found it on the neighboring resident's bedside table and stated, I don't know how it got to the other side of the room. It should always be available to the resident. During an observation on 3/25/26 at 4:32 p.m. Resident #53 was asleep in bed; the call light was on the floor. A review of the facility's policy titled Call Lights: Accessibility and Timely Response, revised 12/22, indicated that Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observations, interviews, and record review, the facility failed to provide a census of 87 residents with a well balanced diet that met their daily nutritional and special dietary needs, while honoring individual food preferences when:The facility did not maintain current and complete dietary preference documentation, as only 5 of 87 residents had documented preferences; and The facility did not provide staff with accurate and up to date diet order information, as dining room staff relied on a diet roster that was two weeks outdated.These failures had the potential to place residents at risk for decreased meal satisfaction, leading to reduced intake and missed therapeutic diets, potentially resulting in medical complications.1. During a record review of the facility's 85 lunch tray tickets dated 3/24/26, only five of the tray tickets had documented preferences.2. During an observation on 3/23/26 at 12:08 p.m., in the main dining room, one facility staff member was observed walking around the dining room offering residents hot drinks such as coffee or tea and another staff member was observed walking around offering residents a bowl of chicken soup.During an interview on 3/23/26 at 12:20 p.m. with the Infection Preventionist Nurse (IP), the IP stated if staff assigned to help in the dining room during meal times is unsure of a resident's diet, dining room staff are trained to refer to a report called Diet Type Report which was printed daily by the Certified Dietary Manager (CDM). The report indicates the current diet type and texture orders for all residents currently residing in the facility.During a concurrent interview and record review on 3/23/26 at 12:23 p.m. with the IP, the IP confirmed the Diet Type Report available for the dining room staff to refer to was dated 3/9/26. The IP stated she would let the CDM know a current report was needed immediately.During an interview on 3/27/26 at 10:45 a.m. with the Director of Nursing (DON), the DON stated she expected all residents to receive meals according to their current diet order. The DON further stated using an outdated Diet Type Report places residents at risk of receiving incorrect diet types and textures which can lead to choking and aspiration, medical complications, and decreased meal intake.A review of the facility's policy and procedure (P&P) titled Therapeutic Diet Orders, revised 5/23, the P&P indicated, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, interview, and record review, the facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 87 residents when the Dishwasher (DW) operated the dishwashing machine at 108 degrees Fahrenheit and could not identify the required operating temperature or describe how to test for chlorine sanitation.This failure had the potential to affect the facility's ability to maintain effective sanitation practices for all residents and to cause foodborne illnesses in a vulnerable resident population.During an interview on 3/25/26 at 10:33 a.m., with the DW, the DW stated he was a new employee and remained in training. The DW could not specify the temperature at which the dishwashing machine should operate. The DW also could not describe how to test for chlorine sanitation. During an observation on 3/25/26 at 10:37 a.m., the DW operated the dishwashing machine, and the temperature gauge showed 108 degrees Fahrenheit.During an interview on 3/26/26 at 5:30 p.m., with the Certified Dietary Manager (CDM), the CDM stated DW had been employed at the facility for three weeks and had not completed the required competency checks yet. The CDM also mentioned that using the dishwashing machine incorrectly could create safety concerns for facility residents because of inadequate sanitation.During an interview on 3/27/27 at 10:45 a.m., with the Director of Nursing (DON), the DON stated she expected all dietary staff to prove competent in their assigned positions. The DON agreed any staff who operated the dishwashing machine should know the correct operating temperature and how to check for proper sanitation. The DON also stated operating the dishwashing machine without this knowledge could pose an infection control risk to all residents.A review of the policy and procedure (P&P) titled Dishwashing, undated, the P&P stipulated, Use the machine at a range of 120 degrees F to 140 degrees F. The chlorine should read 50-100 ppm on dish surfaces in final rinse.A review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated, No Food & Nutrition Services employee shall operate any major piece of equipment without knowing how to operate it correctly.A review of the facility's procedure titled Competencies for Food and Nutrition Services Employees, undated, the procedure indicated food and nutrition services employees must show competence in following all manufacturer's instructions for the proper use and care of equipment.

Based on interviews, and record review the facility failed to ensure an effective system was in place to accurately identify and communicate residents' food allergies, preferences and substitutes for a census of 87 residents when the facility's tray tickets listed residents' allergies under the dislikes section rather than under a clearly defined allergies designation, and preferences were not assessed, documented on meal tickets or honored for three residents (Resident 35, Resident 86, and Resident 89). This failure placed residents at risk for exposure to allergens due to staff's inability to reliably identify and accommodate allergy restrictions, and left residents frustrated due to their preferences not being honored. During an interview on 3/23/26 at 9:15 a.m. Resident #35 stated he did not get what he needed for breakfast. He stated he told someone and he still didn't get it. He stated he needed raisin bran cereal with two non-sugar sweeteners and more milk. He said they kept bringing him oatmeal and he kept telling them he wanted raisin bran and they never brought. He stated no one offered him anything else to eat and he got tired of asking. During a document review and interview on 03/24/2026 7:59 AM Resident #35 was eating breakfast of pancakes and sausage. He stated he did not get Raisin Bran cereal and he wanted to eat it everyday. A review of his meal ticket and under preferences it did not include Raisin Bran. During a document review and interview on 3/24/26 at 8:18 a.m., Resident #86 stated her breakfast was not what she liked. A review of her meal ticket indicated nothing under preferences or dislikes. During an observation and interview on 3/25/26 at 7:55 a.m., Resident #35 did not receive Raisin Bran for breakfast. During an observation on 3/25/26 at 2:30 p.m. the lunch tray preference cards on the lunch trays for Resident #35 and Resident #86 did not have any preferences of dislikes documented. Resident #35 was admitted [DATE] with a BIMS (Brief Interview of Mental Status-- an assessment tool) a score of 15, indicating intact cognition. Resident #86 was admitted [DATE] with a BIMS score of 8, indicating moderate cognitive impairment. During a record review of the facility's 85 lunch tray tickets dated 3/24/26, all tray tickets reviewed indicated Allergies: NONE. During an interview on 3/26/26 at 8:29 a.m. with Resident 89, Resident 89 stated her tray ticket lists Macadamia Nut Oil under dislikes, but this is actually a life threatening allergy for her. During an interview on 3/26/26 at 5:30 p.m., with the Certified Dietary Manager (CDM), the CDM stated the dietary software used by the facility does not allow allergies to print directly on the tray tickets. The CDM further stated when allergies are not accurately displayed, dietary staff may mistake a true allergy for a preference. As a result, a resident could be given an unsafe food item, creating a significant risk for an adverse allergic reaction, including potentially life threatening outcomes. During an interview on 3/27/26 at 10:45 a.m., with the Director of Nursing (DON), the DON stated residents' food allergies should be indicated on the tray tickets. The DON further stated if a resident's allergies are not clearly indicated on the tray tickets, staff may unknowingly serve a food containing the allergen which poses a severe safety risk, including the potential for an allergic reaction that could lead to serious harm or death. During an e-mail correspondence on 4/7/26 at 11:04 a.m. with Medical Records, Medical Records stated the facility does not currently have a policy on Allergies.

Based on observation, interview and record review, the facility failed to ensure three of six sampled residents (Resident 26, Resident 54 and Resident 81) remained free of accidents when they did not received adequate supervision to prevent falls, resident-centered nursing care plans were not developed prior or after the falls, post-fall assessments or neurological checks (rapid nursing assessments to detect brain injuries or spinal issues after a fall) were not completed, and interdisciplinary team meetings (IDT) were not held to identify the root cause of the falls.These failures could have resulted in serious harm or injury to the residents, including increased risk of falls, potential physical trauma, prolonged recovery times, and diminished quality of life. Additionally, the lack of proper supervision, individualized care planning, and post-fall assessments may have prevented the facility from identifying and addressing the underlying causes, thereby increasing the likelihood of future incidents. Resident 26 Record review of Resident 26's admission Record (facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses which included dementia (general term for decline in memory, thinking, and reasoning skills severe enough to interfere with daily life), history of falls, and difficulty walking. Record review of a fall risk assessment for Resident 26 dated 3/19/26 indicated he was given a score of 21, which indicated he was at high risk for falls. Record review of a nursing progress note dated 3/19/26 at 2:20 a.m. indicated Resident 26 was found on the floor next to the bathroom door. According to this note, Resident 26 was unable to state how the fall occurred. This progress note also indicated Resident 26 sustained a small bump to the right side of the head, neurological checks were initiated, and the physician and administrator were notified. Record review of Resident 26's progress notes following the fall did not identify evidence of a comprehensive post-fall assessment including range of motion, mobility or transfer assessment, evaluation for possible musculoskeletal injury or detailed pain-focused interventions. Record review of Resident 26's Medication Administration Record (MAR) indicated Tylenol (a medication used to treat mild to moderate pain) 500 milligrams (mg, a unit of measurement) was administered after the fall; however, the MAR did not indicate a pain score, description of pain, location of pain, or other detailed pain assessment at the time the medication was given. The MAR also did not indicate reassessment of Resident 26's pain following administration to determine whether the medication was effective. Record review of an occupational therapy note dated 3/19/26 at 2:29 p.m. stated the resident remained at prior level of function; however, the note did not include documentation of functional reassessment, such as standing ability, strength, coordination, or mobility following the fall. Record review of progress notes dated 3/23/26 at 7:24 p.m., indicated Resident 26 was transferred to the hospital due to complaints of back pain following the fall on 3/19/26. Record review of hospital records dated 3/24/26 at 3:14 a.m., indicated Resident 26 was diagnosed with a T12 (middle section of vertebral column) compression fracture and returned to the facility with a Thoracic-Lumbar-Sacral Orthosis (TLSO, a brace that wraps around the torso) brace. During an interview on 3/25/26 at 2:25 pm, CNA G stated she assisted Resident 26 with breakfast but had not returned to the resident's room due to workload demands. CNA G stated staffing levels made it difficult to consistently monitor residents and identify changes in condition. During an interview on 3/25/26 at 1:05 pm, LN C stated the last time he saw Resident 26 prior to the change in condition regarding the fall was during morning medication administration at approximately 8 a.m. During an interview on 3/25/26 at 3:55 pm, the Assistant Director of Nursing stated that she observed Resident 26 exhibiting abnormal responsiveness when delivering lunch to the resident's room. The Assistant Director of Nursing stated she attempted to stimulate Resident 26, including performing a sternal rub, which elicited minimal response. She added that at that point, emergency medical services were contacted. A review of the facility policy titled, Fall Prevention Program, developed on 12/19/22 and revised on 12/28/23, indicated that when a resident experienced a fall, the facility would, assess the resident .complete a post-fall assessment, and, review the resident's care plan and update as indicated. The same policy indicated that staff would, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Resident 54 A review of Resident 54's admission record indicated she was admitted to the facility on [DATE] with diagnoses of encephalopathy (any disease or dysfunction of the brain that alters its structure or function, often causing altered mental state, confusion, personality changes, or dementia) and dementia (a progressive state of decline in mental abilities), and repeated falls with unsteadiness on feet. A review of Resident 54's Minimum Data Set (MDS, an admission assessment) indicated she was unable to complete her Brief Interview of Mental Status assessment (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). A review of Resident 54's nursing care plan initiated on 12/21/25 and revised on 3/03/26 indicated she was at risk for falls and interventions were minimal/standard/generalized and indicated interventions to anticipate resident's needs, keep call light in reach and maintain a safe environment. A review of Progress Notes, Alert Charting dated 2/27/26 at 3:12 pm indicated Resident 54 was showing new behaviors and confusion, and the Falls Care Plan was not updated. A review of Resident 54's SBAR report dated 3/06/26 at 6:53 a.m. indicated she had an unwitnessed fall on 3/06/26 while ambulating to the other side of the room per her roommate report and sustained a superficial cut above her right eye. A review of Physician Progress indicated the Medical Director (MD) had seen Resident 54 on 3/06/26 at 7:11 p.m., the same day and time she was in the ED after sustaining the fall with no mention of the fall or injury. Physician progress note indicated a, quiet first month. A review of Resident 54's General Acute Care Hospital (GACH) report dated 3/06/26 indicated Resident 54 had been found on the ground next to her bed by facility staff and minimal additional information was provided by facility staff. CT Pelvis (imaging of the Residents pelvis and hips), imaging showed a fracture of her right femoral neck. A review of Resident 54's Care Plan indicated the Care Plan was updated the day of the fall 3/06/26 with no new interventions. The interventions in the care plan remained general/non-individualized and indicated to alert the provider, assess for injuries from fall and educate on the importance of maintaining a safe environment. A review of Resident 54's Clinical admission progress note indicated she returned to the facility on 3/09/26 at 3:21 p.m. with a surgical incision to right hip and was disoriented and required queues. The Falls Care Plan was not updated upon her return. A review of Resident 54's nursing progress notes dated 3/10/26, 4 days after the fall, indicated she had a black eye from the fall and continued to try and get out of bed and required one-to-one supervision. The Falls Care plan was not updated to reflect the need for one-to-one supervision. A review of Resident 54's progress notes did not indicate an IDT meeting was held to discuss the root cause of the fall that occurred on 3/06/26. Resident 81 A review of Resident 81's admission record indicated she was admitted to the facility on [DATE] with diagnoses of Myopathies ( a group of diseases that primarily affect skeletal muscle structure, metabolism, or function, resulting in weak, stiff or painful muscles), unsteadiness on feet, falls, osteoarthritis (degeneration of join cartilage and the underlying bone, most common from middle age onward, causing pain and stiffness, especially in the hip, knee, and thumb joints), and osteoporosis (a disease characterized by weakened, porous bones, leading to a high risk of fractures) with multiple fractures. A review of Resident 81's MDS dated [DATE] indicated Resident 81 had a BIMS of 12 indicating moderate cognitive impairment. A review of Resident 81's MDS dated [DATE] Section GG Functional Abilities indicated Resident 81 could walk with a walker and had full ROM (range of motion) in her upper or lower extremities. A review of Resident 81's Progress Notes, Alert Note dated 4/25/25 at 5:45 p.m., indicated Resident 81 was found on the floor in her room and stated she had fallen and hit her head and her left arm and reported pain of 10/10. Resident 81 requested to go to the hospital. A review of Resident 81's Progress Notes, Alert Note dated 4/25/25 at 11:32 p.m., indicated Resident 81 returned from the hospital with a diagnosis of left closed fracture of her left humerus and the MD was notified. No hospital report was available. A review of Resident 81's GACH emergency department (ED) visit report dated 5/12/25 indicated Resident 81 fell at the facility on 4/25/25 while trying to make her bed, tripped over her shoes, and fell on her left side. The X-Ray reports indicated the left closed impacted left proximal humerus fracture. A review of Resident 81's Fall IDT Reports indicated IDT fall meetings were held 2/12/23, 4/8/23 and 8/25/25. There was no indication in the progress notes that an IDT meeting was held after Resident 81's Fall on 4/25/25. A review of Resident 81's Care Plan indicated one intervention was added for falls on 4/25/25 and indicated to assess for pain. A review of Resident 81's Falls Risk Evaluation dated 8/25/25 indicated she was at risk for falls related to Psychotropic Medications (chemical substances that alter brain function, affecting mood, perception, thoughts, or behavior), Narcotics (often referred to as opioids, are natural or synthetic substances that reduce pain, induce sleep, and create euphoric effects by binding to opioid receptors in the brain), Antihypertensive (medications for high blood pressure), Antiseizure ( medications to treat seizure disorders), and Cathartic (induce, prompt, or increase bowel movements, often acting as strong laxatives medications). The Care plan was not updated following this assessment. A review of Resident 81's Care Plan indicated goals and interventions related to fall risk due to medications were not added until 3/26/26 during the survey. A review of Resident 81's MDS dated [DATE] section GG indicated she could no longer walk and that ROM in shoulders was not impaired. During an interview on 3/27/26 at 8:53 a.m., the Director of Nursing stated when a fall occurred, they should document immediately what was done, IDT review for root cause analysis, and review the care plan and update or change to more appropriate falls interventions. DON further stated it did not meet her expectation to keep the same interventions on the care plan as residents could continue to fall and care plans should be individualized and updated as needed, especially after an injury. A review of a facility document titled, Fall Prevention Program, revised on 12/28/23, indicated, The interdisciplinary team will initiate interventions on the Resident's care plan, in accordance with their level of risk. Fall interventions include but are not limited to universal environmental interventions; clear pathway; bed is locked and in low position; call light and frequently used items in reach; adequate lighting; assistive devices in good repair; monitor for changes in cognition, gait, ability to rise/sit, and balance, shoes or non-slip soles, eye glasses, monitor vitals signs. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent changes in functional status. Provide additional interventions including but not limited too; assistive devices, increased rounds, sitter if indicated, medication review; low bed, alternate call system access, scheduled ambulation or toileting assistance, family and caregiver or resident education, therapy services referral. When a resident experiences a fall the facility will; assess the resident; complete a post fall assessment, complete an incident report, notify physician and family, review the resident's care plan, document all assessments and actions, obtain witness statements in the case of injury.

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered nursing care plans for two of two sampled residents (Resident 26 and Resident 43), related to:Lack of post-fall care plan interventions for Resident 26,Repeated medication refusals by Resident 26, and;Resident 43's fluctuating psychosocial (define) and behavioral patterns, including prolonged bed stay and limited activity participation.These findings may have resulted in Resident 26 being placed at increased risk for additional falls, injuries, or even death. The lack of appropriate interventions could have contributed to ongoing medication refusals, which may have worsened Resident 26's chronic health issues. Additionally, these deficiencies may have led to physical deterioration for Resident 43, such as muscle weakness, joint stiffness, pressure sores, and a heightened risk of infection due to prolonged bed rest.A review of Resident 26's admission Record (facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses which included dementia (significant decline in memory and thinking abilities that disrupts daily activities), history of falls, and difficulty walking.A review of Resident 26's risk assessment dated [DATE] indicated he was given a score of 21, which indicated he was at high risk for falls.1). Record review of a nursing progress note dated 3/19/26 at 2:20 a.m., indicated Resident 26 was found on the floor next to the bathroom door. According to this note, Resident 26 was unable to state how the fall occurred.Record review of an interdisciplinary care conference note dated 3/19/26 at 9:04 a.m. indicated the fall was likely related to confusion and unassisted ambulation. Interventions identified during the meeting included: reminding Resident 26 to use the call light, keeping the call light within reach, ensuring non-skid footwear, providing staff supervision, and ensuring the tab alarm was activated.Record review of Resident 26's updated care plan initiated on 3/19/26 indicated interventions that were general in nature and did not clearly reflect the specific interventions identified during the interdisciplinary team meeting.2).Record review of Resident 26's medication administration record (MAR) indicated she regularly declined her prescribed Seroquel (a prescription medication used to treat mental health conditions). According to Resident 26's MAR, between 3/01/25 and 3/25/25, Resident 26 refused the medication 11 times in the morning (8 a.m.) and 16 times in the evening (6 p.m.), which indicated he received Seroquel less than half of the time it was ordered. Record review of Resident 26's nursing care plans did not indicate a care plan was created to address Resident 26's repeated medication refusals. As a result, there were no interventions describing approaches to encourage medication acceptance, alternative interventions, physician notifications of refusals and follow-up, and evaluation of effectiveness of the medication.During an interview on 3/26/26 at 1:05 pm, LN C confirmed that Resident 26's MAR accurately reflected that Resident 26 had refused the 8 a.m. and 6 p.m. Seroquel doses most of the time.During an interview on 3/26/26 at 2:25 pm, CNA G stated that due to workload demands and staffing challenges, it was difficult to consistently monitor residents and identify changes in condition.During an interview on 3/26/26 at 2:05 pm the Assistant Director of Nursing (ADON), stated that after further review, she found interdisciplinary notes indicating the facility had begun to address medication refusal for Resident 26; however, these interventions were not clearly reflected in the care plan at the time of survey. The ADON was unable to find in Resident 26's medical record that the physician was made aware of the refusals.3).Record review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with medication diagnoses which included Dementia, Major Depression (a mental health disorder characterized by persistent feelings of sadness and loss of interest in activities), and Diabetes Mellitus (a condition characterized by high levels of sugar in the blood).Record review of Resident 43's Minimal Data Set (MDS, an assessment tool) dated 2/3/26 indicated his Brief Interview of Mental Status (BIMS, a cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 8, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). This document also indicated Resident 43's Family Member XX was Resident 43's responsible party.During observations made at different times from 3/22/26 through 3/26/26, Resident 43 was noted to be transferred out of bed only twice in four days.During an interview on 3/24/26 at at 9:43 a.m., the MDS coordinator stated Resident 43 went through cycles where she remained in bed for extended periods and other times was up, wandering into rooms, and requiring a wander guard (a wearable electronic security system used in nursing homes and memory care units to prevent at-risk residents from elopement) due to wandering and exit seeking behaviors. The MDS Coordinator acknowledged this cyclical pattern and confirmed Resident 43's care plan did not clearly reflect individualized interventions to address it.Record review of Resident 43's active care plans indicated one of her interventions for psychosocial well-being and activity participation was for staff to take Resident 43 outside on beautiful sunny days.During an interview on 3/25/26 at 4 p.m., the Assistant Director of Nursing and IP stated that Resident 43's behavior of staying in bed for extended periods of time was considered her baseline, and that she had reportedly been up for meals twice during the week but returned to bed afterward.During an observation on 3/26/26 at 2:06 p.m., the weather was sunny and pleasant; however, Resident 43 was not observed outside, and the care plan intervention to take the resident outside on beautiful sunny days was not observed implemented.During an interview on 3/25/26 at 4:45 p.m., the Assistant Activities Director stated Resident 43 was often in bed and did not want to get up even with encouragement, and although she attended some activities, she was mostly in bed.During a phone interview on 3/25/26 at 4:14 p.m., Resident 43's Family Member #2 stated this pattern was not unusual for Resident 43 and described periods when the resident remained in bed and other periods when she was more active and attended activities.A review of the facility policy titled, Fall Prevention Program, developed on 12/19/22 and revised on 12/28/23, indicated, Interventions will be monitored for effectiveness .The plan of care will be revised as needed. The same policy indicated that when a resident experiences a fall, the facility will, review the resident's care plan and update as indicated.

Based on interviews and record reviews, the facility failed to honor the rights of three residents (Resident 81, Resident 34 and Resident 54) out of twelve residents sampled for Advanced Directives (ADR), when they neglected to provide the Resident's and/or their representatives with a consultation upon admission to the facility. This failure had the potential to result in the resident's wishes for life sustaining treatment during an emergency not being honored. A review of Resident 81's admission record indicated she was admitted on [DATE] with the diagnoses of history of breast cancer, repeated falls, osteoarthritis and osteoporosis ( diseases causing decrease in bone density and pain in joints), and Bipolar Disorder (a chronic mental health condition characterized by intense, alternating mood swings between extreme high energy (mania or hypomania) and deep depression). A review of Resident 81's clinical record indicated no POLST ( Physicians orders for Life Sustaining Treatment) or ADR ( Advanced Directives) were on record.A review of Resident 34's admission record indicated he was admitted on [DATE] with the diagnoses of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dysphagia (difficulty swallowing) and unspecified dementia ( a progressive state of decline in mental abilities).A review of Resident 34's admission record indicated no POLST or ADR were on record.A review of Resident 54's admission record indicated she was admitted on [DATE] with diagnoses of Encephalopathy (any disease or dysfunction of the brain that alters its structure or function, often causing altered mental state, confusion, personality changes, or dementia), and repeated falls with unsteadiness on feet.A review of Resident 54's clinical record indicated no POLST or ADR were on record.During an interview on 3/26/26 at 12:31 p.m. with Medical Records, Medical Records stated they could not find the POLST or ADR records for Resident 81, 34 and 54, and had asked the Social Services Director (SSD) to make notes about why these records were not available.A review of Resident 81's clinical record indicated she had signed a POLST declination form on 1/24/23 and was not offered an ADR at that time and the SSD was to follow up Quarterly.A review of SSD Progress Notes for Resident 81 indicated no ADR consultation had been provided until 3/26/26 during the survey.A review of SSD Progress notes for Resident 34 indicated no ADR consultation had been provided until 3/26/26 during the survey.A review of SSD Progress Notes for Resident 54 indicated no ADR consultation had been provided until 3/26/26 during the survey.During an interview on 3/27/26 at 8:53 a.m. with the Director of Nursing (DON), the DON stated, ADR and/or POLST should be completed on admission, and the Resident and/or Resident Representative should have had consultation. The DON further stated the risk was not honoring the Residents' wishes if there was a life threatening event.A review of a facility policy, titled, Residents Rights Regarding Treatment and Advanced Directives, revised 12/29/22, indicated, On admission the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident, if cognitively able to do so, would like to formulate and advanced directive. In the event the resident is unable to formulate an ADR due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative.

Based on interview and record review, the facility failed to ensure two allegations of abuse were reported to the Department within the required timeframe for three of 38 sampled residents (Resident 12, Resident 84 & Resident 99) when:The facility did not report an allegation of abuse involving Resident 99, and;The facility did not report a resident-to-resident altercation between Resident 12 and Resident 84.These failures had the potential to result in delayed identification and intervention regarding abuse, increased risk to resident safety, and noncompliance with regulatory reporting requirements, potentially compromising the well-being and protection of vulnerable residents within the facility. A review of Resident 99's admission Record (facility demographic) indicated Resident 99 was admitted to the facility on [DATE] and passed away on 3/13/26. A review of the Social Services Progress Note dated 2/03/26 at 9:08 a.m., indicated the facility was made aware of an allegation relayed by Life Partner 1 that Resident 99 reported 2 staff members were arguing, got into her face, and spit in her face. A review of Resident 99's electronic medical record (EMR) did not indicate a completed investigation was conducted after the allegation was made. Documentation of an interdisciplinary team (IDT) meeting reportedly scheduled to occur on or about 2/04/26 regarding the allegation was not found in the EMR. During an interview on 3/25/26 at 3:35 p.m., Life Partner 1 stated that Resident 99 told him staff had gotten into her face and spit on her. Life Partner 1 stated that at the time of the allegation, Resident 99 was still able to understand what was happening and clearly communicate concerns, and he believed what she told him. Life Partner 1 stated he reported this concern to facility staff and administration. During an interview on 3/25/26 at 4:25 p.m., the Administrator (ADM) stated that no investigation had been conducted regarding the abuse allegation made by Resident 99. The ADM stated she did not believe the incident occurred and believed Resident 99 may have been experiencing confabulations or delusions. The ADM also stated she was unable to locate documentation of the IDT meeting reportedly held regarding the allegation. During an interview on 3/25/26 at 5:05 p.m., the ADM and Infection Prevention Nurse (IP) stated they would begin identifying staff members who had cared for Resident 99 on the date of the alleged incident and would attempt to obtain additional information, including contacting the ambulance company. During an interview on 3/26/26 at 9:04 a.m., the ADM stated she submitted the SOC 341 (a state form used by mandated reporters to report suspected abuse, neglect, or exploitation of elders or dependent adults) the previous night during the survey regarding the alleged incident and was in the process of gathering staff information related to the event. A review of the facility policy titled, Abuse, Neglect and Exploitation, revised 12/19/22, indicated under Section V.A., An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse [occur]. The same policy indicated that investigating included identifying and interviewing all involved persons and providing complete and thorough documentation of the investigation. Findings: A record review on March 31, 2026, showed Resident 12's clinical record contained a nursing note dated 3/18/26 by LVN F stating: verbal altercation R/t miscommunication between [Resident 12] and his roommate [Resident 84]. Will monitor X 72 hrs (hours) for aggressive behavior towards each other. Nursing staff made aware and notified the administrator. A review of Resident 12's admission record indicated he was initially admitted in October 2025 with a diagnosis of chronic kidney disease. A review of Resident 12's Minimum Data Set (MDS) a federally mandated resident assessment tool, indicated Resident 12 had no memory impairment. A review of Resident 84's admission record indicated he was initially admitted in May 2024 with a diagnosis of encounter for surgical aftercare following surgery on the nervous system. A review of Resident 84's MDS indicated Resident 84 had no memory impairment. A review of IQIES (data system) entries from March 18, 2026, through March 31, 2026, confirmed the altercation was not reported to the Department. An interview on 3/24/26 at 3:45 p.m., with the Director of Nursing (DON), the DON stated, All altercations are reported to [the Administrator]. She makes the decision as to if an altercation is to be reported or not. Resident #84 grabbed Resident #12's arm while Resident #12 was walking out of the room. The DON further acknowledged that no assessment or 72 hour monitoring checks were completed. An interview on 3/25/26 at 12:53 p.m. with the Administrator (ADM), the ADM stated, I didn't report it because the [SOS 341] form says to report if it 'reasonably appears to be abuse or neglect.' I thought it unsubstantiated. The Administrator confirmed that allegations of abuse are required to be reported to the Department within two hours and acknowledged the 3/18/26 allegation was not reported until 3/24/26. A review of the facility's policy titled Abuse, Neglect and Exploitation, revised 12/22, indicated that reports of physical abuse must be made to the Department within two hours.

Based on observation, interview and record review, the facility failed to provide the necessary care and services related to significant and/or severe weight loss or gain for five out of 23 sampled residents (Resident 12, 20, 25, 29 and 227) to ensure the residents maintained an acceptable nutritional status because: 1. The RD (Registered Dietician) was making quarterly visits (once every three months), which led to minimal in person resident assessments, 2. The RD failed to fully tailor the resident's nutritional interventions to the resident's needs and monitor the continued relevance of those interventions such as residents' functional factors and lack of adequate assistance or supervision during meals, 3. The Dietary Manager who has no professional scope of practice was completing the resident's Annual and Quarterly Dietary Progress Notes which included recommendations and initiating resident's Nutritional Risk care plan, 4. The Dietary Manager incorrectly coded residents who had either lost or gained a significant amount of weight in their MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) under Section K (Swallowing/Nutritional Status). The coding for Residents 20 indicated, a physician-prescribed weight gain regimen when the physician had not written an order. The coding for Resident 12 indicated, not on physician-prescribed weight-loss regimen when there was a physician's order for a weight loss regimen, 5. The weekly Weight Variance Meeting document titled, Skin and Weight Review, the Clinical section, which was supposed to filled out by the RN (Registered Nurse) on the committee, was not consistently completed, 6. Residents' meal and fluid intake was not being monitored closely, and 7. Residents who needed supervision with their meals and fluid intake were not consistently supervised. These failures had the potential to place Resident 12, Resident 20. Resident 25, Resident 29, and Resident 227 at risk for altered nutritional status and/or dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions) that could lead to further health complications, hospitalization and even death. Findings: Review of a Practice Paper published by the American Dietetic Association, dated 2010, indicated In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost.that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). Involuntary weight loss can lead to muscle wasting depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) A publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated: the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). The State Operations Manual (SOM) provides these parameters for significant weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Gradual unintended weight loss over time is known as insidious weight loss. This can be where an older adult loses only 1-2 pounds per month, but for a continued period. When addressing unintentional weight loss, one needs to figure out why, if possible, the root cause of unintended weight loss (Geriatric Dietitian, 3/31/22). A Nutrition-focused physical findings assessment, often referred to as clinical assessment, are findings from evaluation of body systems, muscle and subcutaneous fat wasting, oral health, hair, skin and nails, signs of edema, suck/swallow/breath ability, appetite and affect. The intent of this assessment is to intervene in findings that are relevant to patient care. (Journal of the Academy of Nutrition and Dietetics, 2013). The National Library of Medicine defines the care planning process as a systematic process to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. The assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Critical thinking skills are essential to assessment. Patient assessment is reserved for those professionals who have a legal scope of practice. The Certified Dietary Manager does not have a scope of practice in California Law. CMS (Centers for Medicare/Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 indicates under Section K: Swallowing/Nutritional Status states The assessor should collaborate with the dietitian .to ensure that items in the section have been assessed and calculated accurately . 1. A review of Resident 29's Administration Record, indicated Resident 29 was admitted [DATE], with a diagnosis of sequelae of cerebral infarction (stroke caused by disruption of blood flow to the brain), convulsions (involuntary contracture of the muscles), feeding difficulties, muscle weakness, blindness right and left eye, dementia (more confused and forgetful), psychotic disturbances (confused thinking, delusions - false beliefs that are not shared by others, hallucinations - hearing, seeing, smelling or tasting something that isn't there, changed behaviors and feelings), anxiety, major depression, and hemiplegia (paralysis of one side of the body), amongst others. Resident 29's Primary language was Spanish. A review of Resident 29's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/12/24, indicated Resident 29 could not complete a BIM (Brief Interview of Mental Status), had a memory problem and cognitive skills for daily decision making was severely impaired, one upper extremity and both lower extremities had functional limitation of range of motion, Resident 29 needed supervision or touching assistance with eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or once the meal is placed before the resident), and Section K - Swallowing/Nutritional Status, indicated Resident 29 had weight loss of 5% or more in the past month or loss of 10 % or more in the last six months. and Resident 29 was not on a physician-prescribed weight loss regimen. Weight Review A review of Resident 29's Weights and Vital s Summary, documented from 11/9/23 through 6/3/24, indicated the following: 11/9/2023: 141.9 lbs. 12/5/2023: 142.5 lbs. 1/4/2024: 139.6 lbs. 2/6/24: 130 lbs. 2/8/24: 127.1 lbs. 2/12/24: 126.4 lbs. 2/20/24: 131.1lbs. 2/26/24: 131.7 lbs. 3/4/2024: 130.0 lbs. 3/1/2024: 131.7 lbs. 3/11/2024: 129.5 lbs. 3/19/2024: 130.4 lbs. 4/8/2024: 121.5 lbs. 4/15/2024: 122.3 lbs. 4/22/2024: 118.4 lbs. 4/29/2024: 120.6 lbs. 5/6/2024: 120.5 lbs. 5/13/2024: 119.4 lbs. 5/22/2024: 113.5 lbs. 5/28/2024: 114.0 lb. 6/3/2024: 115.1 lbs. A review of Resident 29's Weights and Vitals Summary, indicated Resident 29 weighed 141.9 pounds (lbs.) on 11/9/23. On 5/13/24 (six months later), Resident 29's weight was recorded as 119.4 lbs., indicating a 15.86 % (percent) weight loss, which is considered severe. Resident 29's weight on 6/3/24 was 115.1 lbs. an additional loss of 4.3 pounds in three weeks. Residents 29's cumulative weight loss in 7 months was 26.8 lbs. or 18.8% During an observation on 6/11/24 at 9:53 a.m., Resident 29, who was in bed, had no straw in her water pitcher and no cup next to her water pitcher, preventing her from being able to drink her water. During an observation on 6/12/24 at 12:40 p.m., there were two staff members (Unlicensed Staff C and a nurse) for nine residents in the Total Assisted Dining (TAD) Room. Resident 29 was trying to communicate in Spanish but was being ignored. Unlicensed Staff C and the nurse in the TAD Room did not speak Spanish, so Unlicensed Staff C and the nurse could not understand Resident 29 in order to meet her dining needs. Unlicensed Staff C nor the nurse got someone who could communicate in Spanish with Resident 29. Resident 29 was legally blind. There was no staff member sitting next to Resident 29 to guide her on where her food was on her plate. Unlicensed Staff C and the nurse were both sitting at the other end of the table feeding a resident. Unlicensed Staff C did place a plate guard (helps prevent food from accidentally being pushed off the plate while eating, minimizing spills at mealtime) on Resident 29's plate and handed her a fork. Resident 29 started eating her pasta with her fingers. Resident 29 did not receive staff assistance to guide her with using her fork or where food items were on her plate. During an observation on 6/14/24 at 11:15 a.m., Resident 29 was in bed with her head covered with a blanket. There was a light yogurt with a spoon in it, container indicated worth 100 calories, zero consumed, and a chocolate shake with a straw, container indicated worth 200 calories, 75% consumed. There was no straw in Resident 29's water pitcher, which felt almost empty and no cup to pour water into. Resident 29 was legally blind and her overbed table was at the side of her bed out of reach. Through multiple observations while Resident 29 was in bed from 6/11/24-6/13/24, never observed a nurse or CNA go into Resident 29's room and offer her fluids. A review of Resident 29's Nutritional Data Collection and Assessment, dated 5/8/24 (6 months after the resident began to lose weight) was completed by the RD. Resident 29's estimated needs were listed as 1917 calories, 68 grams of protein and 1373-1585 cc's of fluid (cubic centimeters-a metric unit of measure). The assessment indicated Resident 29 was on a nutritional supplement three times/day, with meals which was initiated on 2/20/24, and was receiving Mirtazapine (an antidepressant which may increase appetite), which was initiated on 2/2/24. The assessment: acknowledged an unplanned weight change, however did not recognize it as a severe weight change and included the need for adaptive equipment (a divided plate and plate guard). The assessment indicated Resident 29 had inadequate intakes. The RD also commented Resident 29 liked coffee. There were no additional recommendations or assessment of the effectiveness of current interventions. There was no plan to develop nutritional implementations that emphasized Resident 29's preference for coffee, such as coffee flavored high calorie beverages. The note also indicated Resident 29 thinks the food is poisoned, refuses everything, however there was no indication the facility attempted to assess the rationale of these comments. The RD indicated a referral to the physician regarding Resident 29's statements, however the facility was unable to validate the referral. There was no additional follow up from the Registered Dietitian despite continued weight loss. A review of Resident 29's At Risk for Nutritional Problems, care plan, the Focus section was created and initiated by the Dietary Manager on 4/3/2019. There was no revision of the nutritional risk care plan by the RD (Registered Dietitian) until 5/9/24 (six months after the start of severe weight loss). Interventions initiated by the Dietary Manager, dated 4/3/19 were as follows: encourage fluids and encourage oral intake. The Dietary Manager continued to initiate interventions dated, 5/23/22 as follows: assist resident with meals as needed, assistive devices as ordered: divided plate/plate guard and describe the location of food on resident's plate/tray, and offer meal alternate if less than 50% of meal eaten, provide between meal feedings and supplement as ordered. There were no additional updates or evaluation of effectiveness of the care plan despite continued weight loss. A RD initiated a note, dated 5/22/23, Continue current diet (mechanically altered diet) and POC (Plan of Care). Resident regaining weight toward initial admission weight. Interventions were not revised by the RD from 11/9/23-6/3/24 when Resident 29 had three-month and six-month severe weight loss. It was noted the RD indicated the resident was regaining weight, despite continued weight loss. A review of Resident 29's Order Summary Report, indicated Resident 29 was on a NAS (No Added Salt) Mechanical Soft with chopped meat texture, thin liquids consistency, fortify (extra nutrients added) cereal at breakfast and milk three times a day and provide a divided plate and plate guard at each meal, start date 9/28/22, Mirtazapine (used to increase appetite and weight gain) 7.5 milligrams (mg) one tablet by mouth at bedtime, started date 2/20/24 and HPN (High Performance Nutrition) shakes three times per day with meals started, 2/20/24. Hydration Review A review of Resident 29's Medication Administration Record (MAR), dated 4/24, 5/24, and 6/24, indicated Resident 29 was given HPN with meals but did not indicate amount consumed. A review of Resident 29's quarterly Dehydration Risk Evaluation-V3. dated 11/18/23, score of 4 and quarterly Dehydration Risk Evaluation-V3. dated 5/8/23, score of 6, indicated Resident 29 was Moderately at Risk for dehydration (A condition that occurs when the body loses to much water and other fluids that it needs to work normally). Resident 29's quarterly Dehydration Risk Evaluation-V3 for 2/2024 was not completed. An interview on 6/14/24 at 10:50 a.m., the Administrator was asked about resident's missing quarterly 2/2024 Dehydration Risk Evaluation. The Administrator stated the dedicated nurse assigned to the task of doing the resident's quarterly Dehydration Risk Evaluations had quit and the DON (Director of Nursing) did not realize it needed to be reassigned so there was a gap. A review of Resident 29's Potential Fluid Deficit care plan, initiated 1/21/19, interventions included: encourage resident to drink fluids, resident was blind and only spoke Spanish, needed assistance with fluid intake in order to meet daily requirements and monitor and document all intake in resident's electronic medical record. A review of Resident 29's Fluid Intake, task in Resident 29's electronic medical record, dated 3/19/24 -6/19/24, did not indicate if Resident 29 consumed her HPN at breakfast, lunch, and dinner time. A review of Resident 29's Fluid Intake. task, indicated Resident 29's fluid intake was not monitored per Resident 29's Potential Fluid Deficit care plan. Resident 29's documented 24-hour fluid intake, for the period of 3/22/24-6/10/24 was 240 ml or less for 40 of 78 days, a daily deficit range of 1133-1345 ml. During an interview on 6/19/24 at 5:18 p.m., the Director of Staff Development (DSD) stated the Fluid Intake task only showed the fluids residents consumed on their meal tray. The DSD stated the CNAs (Certified Nursing Assistants) should be documenting the fluids residents consumed on their meal tray or document refusal. A review of Resident 29's Meal Intake task, dated 3/19/24 -6/19/24, indicated there was no documentation of Resident 29's percentage of breakfast meal intake for 46 of 78 days. No documentation of Resident 29's percentage of lunch intake as for 58 of 78 days. No documentation of Resident 29's percentage of dinner intake for 9 or 78 days. It was also noted Resident 29 refused 27 meals (breakfast, lunch or dinner) in 78 days. There was no indication the facility attempted to determine a reason for the refusals. Similarly, there were 10 lunch and 12 dinner refusals. A review of Resident 29's Meal Intake task, dated 3/19/24 -6/19/24, indicated per refusals for breakfast and lunch on 3/21/24, refusal for breakfast on 3/29/24, and refusal for dinner on 3/25/24, 4/12/24, 4/19/24, 4/27, 5/8/24, 5/23/24, 6/4/23, and 6/10/23, and because of lack of documentation of Resident 29's meal intake for her other meal(s) on those same days, indicated Resident 29 ate zero food for ten days. Per fluid intake documentation during this time period, Resident 29 drank 250 ml (milliliters) or less of fluids on five of those ten days, 3/25/24, 4/12/24, 5/5/24, 6/4/24 and 6/10/25. A review of Resident 29's Meal Intake task, dated 3/19/24 -6/19/24, indicated on the days Resident 29 refused meals and because of lack of documentation for meal intakes, on 3/23/24, 3/24/24, 3/30/24, 3/31/24, 4/1/24-4/3/24, 4/6/23-4/8/24, 4/14/24, 4/23/24, 4/26/24, 4/30/24, 5/5/24-5/7/24, 5/12/24-5/13/24, 5/18/24, 5/20/24-5/22/24, 5/26/24, 5/30/24, 6/1/24-6/3/24, 6/6/24, and 618//24, Resident 29 only consumed 0-25% of her meals for the entire day. Per fluid intake documentation, Resident 29 drank 250 ml or less for 13 of 30 meal intakes (4/2/24, 4/6/24-4/7/24, 5/6/24-5/7/24, 5/12/24, 5/18/24, 5/26/24, 5/30/24, 6/1/24-6/2/24, 6/6/24, and 6/8/24) whereby Resident 29 consumed 0-25% of her meals for the entire day, and zero fluid intake for nine of the 30 days, 3/31/24, 4/1/24, 4/14/24, 4/23/24, 4/26/24, 5/5/24, 5/20/24-5/21/24 and 6/3/24. During a concurrent phone interview and record review on 6/14/24 at 8:50 a.m., the RD stated the last time she was at the facility was 4/2024. The RD stated she came to the facility quarterly. The RD stated since the Dietary Manager was seasoned, she relied on him to identify and implement interventions. The RD stated the Dietary Manager along with the ADON (Assistant Director of Nursing) did the weekly Skin and Weight Reviews or NAR (Nutrition Assessment Review), which was the weekly weight variance. When asked how she would do a Nutrition Focused Physician Exam, the RD stated she would have to be in the facility to do an assessment on the resident. The RD stated she did the resident's Initial Nutritional Assessment based a lot on the information she gathered from the Resident's Nursing Admission Assessment, which was done by the admitting nurse. The RD stated Resident 29 did not eat but preferred coffee per information gathered from the facility staff. During a concurrent phone interview and record review on 6/14/24 at 8:50 a.m., Resident 29's Nutritional Data Collection and Assessment, dated 5/5/24, indicated a score of 4, which meant Resident 29 was at Moderate Risk for nutritional issues. The RD stated Resident 29 was not having any weight loss issue, no chewing/swallowing issues and ate 50-100% of her meals. It was pointed out to the RD Resident 29 had triggered for severe weight loss. The RD stated Resident 29 did go to the TAD (Total Assistant Dining) and the RD would rely on the RNA (Restorative Nursing Assistant: interacts with the resident and provides skill practice in such activities as eating) to determine the level of assistance Resident 29 needed. The RD stated she knew Resident 29 had an issue about thinking her food was poisoned and acknowledged she had not observed Resident 29 during dining. The RD stated the weekly Weight Variance, included the RD by phone, the ADON and the Dietary Manager, and she referred to the ADON during their weekly Weight Variance meetings to pass on her recommendations to the resident's physician to help improve the resident's weight. The RD relied on the Dietary Manager, the ADON, and the Resident's nurse along with record review to figure out why the resident was losing weight. During a concurrent phone interview and record review on 6/14/24 at 8:50 a.m., a review of the RD onsite facility visits requested titled, Dietician Consultant Monthly Report, which the Dietary Manager hand delivered, indicated there was only one, dated 4/18/24 (Note: RD started 7/2023). During the six-month period of Resident 29's severe weight loss, there was no documentation of a nutritional assessment by a RD. The RD was not able to recall if she saw Resident 29. The RD stated the resident's care plan was generated by nursing and the Dietary Manager updated the resident's care plan. The surveyor indicated to the RD the Dietary Manager has no professional clinical license or professional scope of practice when initiating and/or adding to a resident's care plan. Note: Concurrent review of Resident 29's At Risk for Nutritional Problems, care plan indicated the initial plan was created and initiated by the Dietary Manager on 4/3/2019. A review of Resident 29's Skin and Weight Review, dated 2/10/24, 2/15/24, 2/24/24, 3/8/24, 3/14/24, 4/12/24, 4/19/24, and 5/10/24, noted the Clinical section was signed by the Assistant Director of Nursing (ADON) and the Dietary, section was signed by the Dietary Manager. There was no indication the RD participated in the recommendations to help improve Resident 29's weight. The clinical section indicated Resident 29 had Significant Weight Loss and was to eat in the Restorative Dining (TAD: Total Assisted Dining). The ADON clinical notes indicated Resident 29 needed assistance with cueing and prompting when eating, and Mirtazapine (an anti-depression medication with a potential benefit of appetite stimulation) and health shakes were started. The ADON did not address Resident 29 being legally blind and her primary language being Spanish. The Skin and Weight Review document dated 3/1/24, indicated the Administrator, who was a licensed clinical professional, signed the Clinical section, but the area was left blank. The Skin and Weight Review, dated 5/31/24, the Clinical area was left blank. Only the Dietary Manager filled out the Dietary section on 5/31/24 and indicated to Continue with the current plan of care. Note: By the Dietary Manager documenting, Continue with the current plan of care, and Add to weekly weights, the Dietary Manager, who was not a licensed healthcare professional, was giving recommendations for Resident 29's Nutritional plan of care. On 5/10/24, the Dietary Manager did not fill out the Dietary section, so there was no indication of average meal intake and average supplement intake. There was no documentation of a Skin and Weight review occurring for Resident 29, who was still losing weight on 5/3/24, 5/17/24/ and 5/24/24. The Dietary Manager indicated Resident 29 was drinking on average 0-25% of her supplement on 4/1/24, on average 25-50% on 2/24/24, 3/1/24, and 5/31/24, on average 50-75% on 3/8/24 and 3/14/24, and on average of 75-100% on 4/19/24, and 4/26/24. Note: There was no accurate system in place for documentation of supplement to know how much supplement a resident consumed. A supplement was documented on the MAR as given (did not indicate how much was consumed) and fluid intake documentation did not detail the type of fluid intake, such as water, supplement, juice, etc. The Dietary manager indicated on 4/19/24 Resident 29's average meal intake was 51-75%, however, a review of Resident 29s Meal Intake from 4/11/24-4/18/24, revealed her meal intake was not documented for 11 of 21 meals. A review of Resident 29's Quarterly Dietary Progress Note, dated 5/8/24, indicated, Resident 29 was eating 25- 50% of her meals, but there was no Skin and Weight Review done by the Dietary Manger, ADON and the RD since 4/26/24, almost 2 weeks ago and a review of Resident 29 Meal Intake, dated 4/26/24-5/9/24, Resident 29 breakfast intake was not documented 11 times, lunch 10 times and one dinner refusal during this time period. The Dietary Manger was documenting Resident 29 lacks the capacity but is alert, her care plans have been reviewed and revised, and will continue with current plan of care. A Dietary Manager, who was not a licensed clinical professional, cannot do assessments and cannot give recommendations. A review of the RD Dietary Progress Notes, indicated the RD reviewed Resident 29's weight loss 2/14/24, 2/18/24, 2/21/24, 4/27/24 and 5/23/24. Note: Resident 29's weight on 3/1/24 was 131.7 lbs. and Resident 29's weight on 4/22/24, seven weeks later, was 118.4 lbs., which indicated a 10.10% weight loss. A review of the RD document titled, Consultant Dietitian Monthly Report, dated 4/18/24, indicated the RD made her quarterly visit that day, but a review of Resident 29's RD Dietary Progress Notes, indicated the RD did not do an in-person assessment to observe why Resident 29 was not eating. The RD's Dietary Progress Note, dated 4/27/24 and 5/23/24, Contributing Factors to Resident 29's weight loss looked identical, no changes and the RD was relying on staff who stated, She just did not eat well, prefers to drink coffee and thinks her food is poisoned, just refuses everything. For the RD to complete a Resident's Nutritional Data Collection due upon admission and yearly, the RD was relying a lot on the documentation of Health Care Personal and the Dietary Manager, which was often incomplete or inaccurate. Reviewing Resident 29's medical record, there was no indication the RD did an in-person assessment on Resident 29. During an interview on 6/19/24 at 8:45 a.m., the ADON stated she was not familiar with the MDS. The ADON stated the Dietary Manager filled out Section K (Swallowing and Nutritional Status) of the MDS. The ADON stated she had nothing to do with the Quarterly Dietary Progress Note and confirmed the Dietary Manager wrote the resident's Quarterly Dietary Note. The ADON stated she along with the Dietary Manager and the RD, who teleworked, and attended by phone, participated in the Weight Variance weekly meetings. The ADON stated she completed the Clinical section of the Skin and Weight Review, but if the resident did not have any skin issues, she did not complete that section. During an interview on 6/19/24 at 1:25 p.m., the Administrator stated the Dietary Manager was just regurgitating what the RD recommended for residents with weight loss/gain and what the resident's physician ordered. When pointing out one of the Dietary Manager's Quarterly Progress Note indicating a recommendation for Resident 12, dated 5/15/24, Resident care plans has been reviewed and revised. Will continue with the current plan of care. The Administrator stated the Dietary Manager did 75% of the resident's care plan and the RD goes after the Dietary Manager, reviews the resident's chart and updates the Resident's 'Nutritional care plan accordingly. The Dietary Manager did the Quarterly Dietary Progress Note by reviewing the resident's chart and inputted the data according to the nurse, RD, and resident's physician's progress notes. During an interview on 6/21/24 at 9:42 a.m., the ADON stated she met with the Dietary Manager and RD every Wednesday for the Weight/Skin Variance but she was way behind inputting her information into the Clinical section of the Skin and Weight Review document. 2. A review of Resident 12's Admission Record indicated Resident 12 was admitted on [DATE], with a diagnosis that included paranoid schizophrenia (feeds into delusions believes something that isn't true no matter how much evidence you give to the contrary), and hallucinations (involve the senses: seeing, feeling, or hearing something that isn't there), it's common for them to feel afraid and unable to trust others), chronic pain, borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), altered mental status (acute confessional state), amongst others. A review of Resident 12's Annual MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/15/24, indicated Resident 12 was severely cognitively impaired (causes serious issues with memory and our ability to reason, make decisions or even care for ourselves). Section K: Swallowing/Nutritional Status, indicated Resident 12 was 180 pounds, had lost 5% or more in the last month or 10% or more in the last six months, and Resident 12 was not on physician-prescribed weight-loss regimen. A review of Resident 12's Order Summary Report, dated 6/19/24, indicated Resident 12 the following order: MD (Doctor of Medicine: physician) directed weight loss recommendation from RD. Current BMI (Body Mass Index: BMI screens for weight categories that may lead to health problems, BIM ranging from 18.5 to 24.9 was a healthy weight range) is 26.9 for height and weight. Ideal weight below 200 lbs., (160-190 lbs.), order date 2/21/23. A review of Resident 12's Weights and Vitals Summary, 12/10/2022: 219.6 lbs. 1/4/2024: 194.3 lbs. 2/6/2024: 183.4 lbs. 3/4/2024: 180.8 lbs. 3/19/2024: 175.9 lbs. 3/25/2024: 180.6 lbs. 4/2/2024: 180.2 lbs. 4/8/2024: 180.2 lbs. 5/6/2024: 180.2 lbs. A review of Resident 12's Potential Nutritional Risk care plan, initiated on 7/8/2016 by a Dietary Manager and revised on 5/8/24 by the RD. Focus indicated, weight loss past 12 months, desirable likely resident meal consumption, diuresis (an increase in the amount of urine made by the kidney and passed by the body), and per MD: weight goal160-190 lbs. Current BMI 28.2. Diet No Added Salt (NAS), regular texture, and thin liquids. Supplement: Health shake three times per day. Goals included weight goal: 160-190 lbs., initiated 5/8/24 by the RD. Interventions initiated 7/8/2016 and/or revised 6/2/1018, encourage adequate fluid intake and intake of nutrition, monitor and document intake, nutrition prescription as ordered and weight per orders. Intervention initiated 6/2/18, identify food preferences and try to offer them. Intervention initiated 5/22/23, continue current diet and plan of care. A Review of Resident 12's Skin and Weight Review' dated 3/21/24, 3/29/24, 4/5/24, and 4/11/24, under the Clinical section completed by the ADON, indicated Resident 12 had a Significant Weight Loss, but his weight was 175.9-180.6 lbs., which was within the MD directed weight loss recommendation from the RD and care planned. During a phone interview on 6/13/24 at 3:42 pm., the RD stated she did a Weight Variance meeting with the ADON and Dietary Manager every Wednesday at 1 p.m. They looked over weekly and monthly weight concerns. When asked about Resident 12's Annual Dietary Progress Note, dated 5/15/24, completed by the Dietary Manager, which included Resident 12's BMI, mentioned Resident 12 being on diuretics and anti-psych medication and included side effects, and made a recommendation, Will continue with the current plan of care. The RD stated the Dietary Manager pulled the weights and diagnosis. The RD stated she did not sign for the Dietary Manager. It was pointed out to the RD the Dietary Manager was not a licensed clinical professional and was therefore not qualified to document clinical information or give recommendations for Resident 12. During an interview on 6/18/24 at 10:45 a.m., the RD stated she flew in on Sunday and was at the facility Monday and today (Tuesday). The RD stated she reviewed the resident's weight gain and weight loss [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents (Resident 28 and Resident 15) and one discharged resident (Resident 233) who were at risk for falls and had a history of falls, were provided with supervision by direct care staff, and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 28, Resident 15 & Resident 233 suffered falls with major injuries at the facility. This may have contributed to Resident 233's death, and Resident 28's dramatic decline, as she is now expected to pass away within 6 months. In addition, 2 of 24 sampled residents suffered falls without major injuries (Resident 227 and Resident 51), due to lack of supervision, creation, revision, and implementation care plans to prevent falls. This had the potential to result in injuries with major injuries, including death to the residents involved. Findings: Record review indicated Resident 28 was admitted to the facility on [DATE] with medical diagnoses including History of Falling (History of having suffered falls, which may indicate increased risk for future falls), Difficulty in Walking, and Muscle Weakness, according to the facility Face Sheet (Facility Demographic). Record review of Resident 28's MDS (Minimum Data Set-An assessment tool) area GG (Section of the MDS that evaluates the amount of assistance a patient needs) dated 4/29/24 indicated she required supervision or touching assistance from staff to transfer to the toilet, transfer to the chair from bed, and walking 10 feet. Record review of a General Acute Care Hospital (GACH) physician progress notes dated 7/08/22 at 5:05 p.m. indicated Resident 28 underwent surgery to repair a left femoral (thigh bone) neck (Upper section of the bone below the head) fracture, which occurred as a result of a fall at the facility. This note indicated, [Resident 28] is a [AGE] year old female . who resides at [Name of Facility], who usually ambulates (Ability to walk) with a walker complaining of left hip pain after ground level fall yesterday. She presented to the ER (emergency room ) today where x-rays demonstrated a impacted left femoral neck fracture. Orthopedics was consulted and she was admitted to the hospitalist service in anticipation of surgical treatment. During an interview with the Medical Records Director on 6/18/24 at 1:40 p.m., she was asked to provide the following documents for every fall Resident 28 has sustained at the facility after January 1st, 2024 (Resident 28 had a long history of falls, therefore, a decision was made to concentrate on the falls suffered this year for the succinctness of this investigation): Fall Risk Evaluation Post-Fall Assessment Neurological assessments (A healthcare provider's evaluation of a person's nervous system after a fall to help determine the extent of damage from head trauma and understand its effects) if applicable During an interview with the Director of Nursing (DON) on 6/18/24 at 4:46 p.m., she provided some of the documents requested above for every fall for Resident 28, but not all the documents. The DON stated the ones not provided were not found. 1st Fall: Record review of Resident 28's progress note dated 1/18/24 at 12:45 a.m., indicated, Responded to resident's room after a CNA (Certified Nursing Assistant) stated that the resident was observed on the floor. Resident was sitting on her bottom on the floor at the foot of her bed. Record review of the Fall Risk Evaluation dated 1/18/24 at 2:31 p.m., indicated Resident 28's fall risk score after the fall on 1/18/24 was 21, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] (No time documented) indicated that as a result of this fall, Resident 28 suffered a laceration to the back of the head and the right elbow, with bleeding. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among these documents was the neurological assessment documentation after this fall on 1/18/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 1/18/24 with the Director of Staff Development (DSD) on 6/20/24 at 5:10 p.m., she stated that after the fall on 1/18/24, a care plan for falls had been developed with the following interventions, 72 hour Neuro (Neurological assessments) started (The DON could not find neurological checks for this fall, above) .[GACH] evaluation offered and refused .Wound care provided. The DSD confirmed there were no interventions were present in the care plan for increased supervision of Resident 28 to prevent further falls. 2nd Fall Record review of a nursing progress note dated 2/12/24 at 12:44 p.m., indicated, Resident was observed, sitting on the ground with her arm and elbow stuck in the bed rail of the bed. The resident stated she just slipped trying to get up causing her arm to get stuck in the bed rail. An abrasion is present on her right elbow. Record review of the Fall Risk Evaluation dated 2/12/24 at 1:22 p.m., indicated Resident 28's fall risk score after the fall on 2/12/24 was 29, which indicated she was at high risk for falls. Record review indicated a Post-Fall Assessment was completed after the fall on 2/12/24. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among these documents was the neurological assessment documentation after this fall on 2/12/24. During a concurrent interview and record review of Resident 28's care plans for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/12/24. The DSD confirmed there were no new interventions were added, included increased supervision. 3rd Fall Record review of a nursing progress note dated 2/16/24 at 3:05 p.m., stated, resident was observed on the floor in her bathroom, when asked what happened the resident stated that she slipped in water or something and landed on her knee. Record review of a Fall Risk Evaluation dated 2/16/24 at 3:08 p.m., indicated Resident 28's score was 13, which indicated her she was at moderate risk for falling, although she had just fallen twice for the month of February 2024. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment or neurological assessment documentation after this fall on 2/16/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/16/24. The DSD confirmed there were no new interventions were added, included increased supervision. 4th Fall Record review of a facility report titled, #2214 Fall, dated 2/24/24 (No time documented) indicated, Resident was observed sitting on her bottom at bed side. Her bed was in the lowest position and she appeared to slid off the bed onto the floor when trying to get up. Record review of a Fall Risk Evaluation dated 2/24/24 at 7:45 a.m., indicated Resident 28's score was 20, which indicated she was at high risk for falls. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 2/16/24. The DSD confirmed there were no new interventions added, including increased supervision. 5th Fall Record review of a progress note dated 3/17/24 at 3:15 a.m., stated, Resident [Resident 28] was observed sitting on her bottom on the floor by the side of the bed. Resident stated that she slid right of the bed. Record review of a Fall Risk Evaluation dated 3/17/24 at 7:06 a.m., indicated Resident 28 received a score of 20, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] indicated the resident sustained a 2 cm (Centimeter) right elbow laceration as a result of this fall. Record review of a neurological flowsheet dated 3/17/24 indicated neurological checks were initiated for this fall on 3/17/24 and completed on 3/20/24. During a concurrent interview and record review of Resident 28's care plans with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 3/17/24. The DSD stated the care plan for falls did get revised on 4/02/24 (16 days after the fall on 3/17/24) with the following intervention, Hourly Rounding. 6th Fall Record review of a progress note dated 4/04/24 at 3:39 p.m., indicated, called to resident room STAT (Immediately), upon getting to room resident noted on the floor in the sitting position .resident stated she was standing eating her Peanut Butter and jelly sandwich, then fell to the ground hitting her Right elbow. Record review of a Fall Risk Evaluation dated 4/15/24 at 2:33 p.m. (More than 10 days after the fall on 4/04/24) indicated Resident 28's fall risk score was 14, which indicated she was at moderate risk for falls, despite having just fallen on 4/04/24 according to the progress note dated 4/04/24 at 3:39 p.m. (above) During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment or neurological assessment documentation after this fall on 4/04/24. During a concurrent interview and record review with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 4/04/24. The DSD confirmed no new interventions were added, including increased supervision. 7th Fall Record review of a progress note dated 5/10/24 at 9:39 p.m., indicated, Resident had a fall this shift around 9pm. Observed on her R (Right) side on the [NAME] hallway with only one shoe on. Voiced that she lost her balance. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Fall Risk Evaluation or neurological assessment documentation after this fall on 5/10/24. A Post-Fall assessment was completed on 5/10/24 and indicated there were no obvious signs of injury. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 4/04/24. The DSD confirmed there were no new interventions added, including increased supervision. 8th Fall Record review of Resident 28's progress note dated 5/13/24 at 9:53 p.m., indicated, resident had an unwitnessed fall in her room. Resident was observed on the ground outside her bathroom. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Fall Risk Evaluation or neurological assessment documentation after this fall on 5/13/24. Record review of a Post-Fall Assessment completed on 5/13/24 indicated there were no obvious signs of injury. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/13/24. The DSD confirmed there were no new interventions added, including increased supervision. 9th Fall Record review of a progress note dated 5/19/24 at 5:48 p.m., indicated, This writer went in to check on resident and observed the resident with her RT (Right) knee on the ground holding on to her wheeled walker trying to come to a standing position. When resident was asked what happened she stated that she had fallen like that multiple time (The documentation did not indicate what time this occurred) today. Record review of a Fall Risk Evaluation dated 5/19/24 at 7:13 p.m., indicated Resident 28's score was 25, which indicated she was at high risk for falls. Record review of a Post-Fall assessment dated [DATE] indicated the resident had pain of 8/10, All over, although no obvious signs of injury were present. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the neurological assessment documentation after this fall on 5/19/24. During a concurrent interview and record review of Resident 28's care plans for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/19/24. The DSD confirmed there were no new interventions added, including increased supervision. 10th Fall Record review of a progress note dated 5/26/24 at 1:25 p.m., indicated, Resident [Resident 28] had a fall this afternoon. Found on the floor lying in front of her bathroom. Stated that she lost her balance. Record review of a Fall Risk Evaluation dated 5/26/24 at 1:29 p.m. indicated her score was 12, which indicated she was at moderate risk for falls, although she had fallen 10 times in five months. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment after the fall on 5/26/24. Record review of neurological assessments initiated on 5/26/24 after the fall, indicated several boxes were not documented on and left blank; therefore, the neurological assessment was incomplete. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/26/24. The DSD confirmed there were no new interventions added, including increased supervision. 11th Fall Record review of a progress note dated 5/31/24 at 8:07 a.m. indicated, Responded to a nurse stat. Resident was laying on her stomach on the floor with her arms out in front of her and her wheeled walker out in front of her. Resident stated that she fell to her knees and then the walker kept going without her. Record review of the Fall Risk Evaluation dated 5/30/24 at 4:25 p.m., indicated Resident 28's score was 27, which indicated she was at high risk for falls. During an interview on 6/18/24 at 4:46 p.m., the DON stated being unable to find several documents requested, among them was the Post-Fall Assessment after the fall on 5/31/24. Record review of a progress note dated 5/31/24 at 4:35 a.m. indicated Resident 28 refused neurological assessments after the fall on 5/31/24. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated there was no evidence the care plan for falls for Resident 28 had been revised or updated after the fall on 5/26/24. The DSD confirmed there were no new interventions added, including increased supervision. 12th Fall, with Major Injury Record review of a progress note dated 6/12/24 at 4:25 a.m., indicated, 0320 (3:20 a.m.) CNA found resident sitting on floor, stat called resident stated she slipped out her wheelchair onto the floor .resident c/o (Complained of) right hip pain 8/10 (Pain level of 8 out of 10, where 0 signifies no pain, and 10 is the worst pain experienced in a person's lifetime. A level of 8 out of 10 indicates severe pain) has history of right hip FX (Fracture), sent resident out to [GACH] for assessment. Record review of a Fall Risk Evaluation dated 6/12/24 at 8:35 a.m., indicated Resident 28 score was 22, which indicated she was at high risk for falls. Record review of neurological flow sheets indicated no neurological assessments were documented, probably because Resident 28 was transferred to a GACH right away. Record review of a GACH after visit summary dated 6/17/24 (No time documented) indicated Resident 28 was diagnosed with a fracture of the right femoral neck on 6/12/24 (After the fall on 6/12/24 at 3:20 a.m.) This GACH after visit summary indicated Resident 28 underwent surgery to repair the fracture to the right hip. Record review of a Post-Fall assessment dated [DATE] indicated resident 28 developed pain on her right hip as a result of the fall. During a concurrent interview and record review of Resident 28's care plan for falls initiated on 8/22/22 with the DSD on 6/20/24 at 5:10 p.m., she stated the care plan for falls was updated on 6/16/24 with the following interventions, continue to offer safety equipment and devices in the event resident changes her preferences .encourage resident to make safe choices to minimize risk for injury .patient education. The DSD confirmed there was no mention of increased supervision. The DSD reviewed all of Resident 28's active care plans and could not find a care plan for care of the right hip fracture. Record review of all care conferences conducted for Resident 28 since January 1st to the present (6/21/24) indicated only one care conference was conducted for Resident 28 in 2024, and this was on 1/15/24, despite all her falls. This care conference did not include any documentation on falls. During an interview with Unlicensed Staff H (Resident 28's assigned nursing assistant) on 6/19/24 at 5:35 p.m., she stated she checked on Resident 28 every hour. Unlicensed Staff H stated Resident 28 thought she could do more than she was capable of doing, and sometimes she would forget things. Unlicensed Staff H also stated Resident 28 needed supervision for toileting. During an interview on 6/19/24 at 5:45 p.m., Licensed Staff I, (Resident 28's assigned nurse) stated that prior to Resident 28's last fall with fracture (Which occurred on 6/12/24) Resident 28 was very wobbly because she was recovering from a urinary tract infection. Licensed Staff I stated she did not check on the resident at regular time intervals. During a concurrent observation and interview with Resident 28 on 6/20/24 at 10:05 a.m., she stated she could not remember any falls and did not know anything about fractures. Resident 28 did state she felt very uncomfortable, and her pain level was a 10/10. Resident 28 stated the pain came from her pelvic area. Resident 28 was observed with fresh sutures from the hip surgery on the right hip. Resident 28 was observed in bed at the time of the interview. During an interview with Anonymous Witness J on 6/14/24 at 4:15 p.m., he/she stated Resident 28 had fallen frequently because administration would not institute a one to one (One staff assigned to only one resident for increased care or supervision) to work with her, and in addition, Resident 28 did not have tab alarms (Alarms that detect motion and notify staff that a resident is on the move). Anonymous Witness YY stated certified nursing assistants were assigned 16 to 20 residents per shift, which did not provide them enough time to perform all activities of daily living (Activities for personal care, such as showering, toileting, etc.) and supervise residents at risk for falls. Anonymous Witness J also stated that even if the facility had enough certified nursing assistants to work as a one to one with a resident at risk for falls, the Administrator would send them home, and only once, in his/her employment at the facility, had he/she observed a one to one, and it was because the resident was extremely aggressive. Record review of a progress note dated 6/13/24 at 11:16 a.m., indicated, Resident RP (Patient representative) mailed a letter for IDT (Interdisciplinary team) conference to discuss falls and 6 month or less to live prognosis. Record review of a progress note dated 6/19/24 at 1:01 p.m., indicated, resident [Resident 28] appears to be declining. The resident needed her medication put in applesauce and she never has before. The residents teeth kept shaking uncontrollably. The resident has been resting for most of the shift. Resident 15 Record review indicated Resident 15 was admitted to the facility on [DATE] with medical diagnoses including Muscle Weakness, and Difficulty in Walking, according to the facility Face Sheet. Record review of an untitled and undated facility report for falls, indicated Resident 15 had suffered 18 falls at the facility since her admission, with the first one occurring on 10/11/20 at 1:30 p.m., (6 days after her admission), and the last one on 4/08/24 at 7:45 p.m. The investigation below focuses on the last three falls suffered at the facility. Record review of a care plan for falls initiated on 7/02/22 indicated, Anticipate my needs Assist with transfers as needed .Hourly Rounding checks for safety. First Fall: Record review of a progress note dated 8/24/23 at 1:51 p.m., indicated, Patients roommate came out of the bathroom and observed her roommate lying on the floor and came and got a nurse. Observed resident sitting on floor next to bed. No visible injuries noted. Record review of a Fall Risk Evaluation dated 8/24/23 at 2:56 p.m., indicated Resident 15 was at low risk for falls (although she had just fallen) because no questions in this form were answered, in fact, nothing was filled out. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of the care plan for falls for Resident 15 indicated it was not revised or updated after the fall on 8/24/23, and no new interventions were added, including increased supervision. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 2nd Fall Record review of a progress note dated 9/13/23 at 7:46 a.m., indicated, S/P (Status post [After]) fall, day #1. There were no other progress notes or documentation indicating how the fall occurred, or the circumstances surrounding the fall. Record review of a Fall Risk Evaluation dated 9/12/23 at 1:38 p.m., indicated Resident 15 received a score of 16, which indicated she was at high risk for falls. Record review of the care plan for falls for Resident 15 indicated it was not revised or updated after the fall on 9/13/23, and no new interventions were added, including increased supervision. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 3rd Fall Record review of a facility report titled, 2263 (Unknown what this number means) Fall, dated 4/08/24 at 7:45 p.m., indicated, [Resident 15] Observed on floor in resident's bathroom. Lying on left side, head up against the wall, feet at the toilet area. Floor was wet .Resident stated that her right ankle hurt. Record review of a progress note dated 4/09/24 at 1:26 a.m., indicated, Resident arrived back at the facility around 12:46 am from [GACH] via stretcher .Dx (Diagnosis) of closed ankle fracture (Broken bone that does not protrude through the skin at the level of the ankle) .Rt (Right) ankle with splint and compression bandage intact. Record review of a Fall Risk Evaluation dated 4/09/24 at 12:02 a.m., indicated Resident 15's score was 5, which indicated she was at low risk for falls (although she had just fallen and fractured her right ankle). During an interview with the DSD on 6/20/24 at 10:30 a.m., she confirmed this Fall Risk Evaluation had been answered inaccurately as it indicated Resident 15 had no history of falls. Record review of neurological assessments initiated for Resident 15 on 4/08/24 (after the fall) were initiated but not completed as several boxes were left without documentation and were blank. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. During a concurrent interview and record review or Resident 15's care plans for falls with the DSD on 6/20/24 at 10:30 a.m., the DSD confirmed no new interventions were added after the fall on 4/08/24 (including increased supervision). The DSD confirmed she could not find a care plan for care of the fracture. Resident 233 Record review indicated Resident 233 was admitted to the facility on [DATE] with medical diagnoses including Dementia (Memory loss), Difficulty in Walking, and Muscle Weakness, according to the facility Face Sheet. Record review of Resident 35's MDS dated [DATE] indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 5, which indicated her cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). In this assessment, Resident 233 was asked to repeat the words, sock, blue and bed, after they were spoken by the MDS evaluator and Resident 233 was only able to repeat one word after the first attempt. Resident 233 was unable to remember the word, blue, according to this assessment. 1st Fall Record review of a progress note dated 3/27/24 at 11:45 p.m., indicated, Witnessed fall, by one of the aids. Slow decent to the floor after tripping over wheelchair when trying to pick up something up off the floor. Record review of a Fall Risk Evaluation dated 3/27/24 at 11:54 p.m., indicated Resident 233 received a score of 2, which indicated she was at low risk for falls, although she had just fallen hours earlier at the facility. A section of this Fall Risk Evaluation titled, Gait Analysis, was left blank by the person filling out the form, therefore, the fall risk score was inaccurate, according to the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of a care plan initiated on 3/27/24 after the fall, had only one intervention. The intervention indicated, Staff will continue to educate resident about waiting for staff to help pick up items off of floor when they fall. Resident 233 had been unable to recall the word, blue, during the MDS assessment dated [DATE] (above) and her cognition was noted to be severely impaired. There were no interventions to increase Resident 233's supervision added to the care plan. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 2nd Fall with Major Injury Record review of a facility report titled, #2254 (Unknown what this number indicates) Fall, dated 3/29/24 at 10:19 p.m., indicated, Resident was observed lying beside her bed on her bottom .Resident Unable to Give Description. Record review of a Fall Risk Evaluation dated 3/29/24 at 11:24 p.m., indicated Resident 233 received a score of 10, which indicated she was at moderate risk for falls, despite having just fallen twice in less than one week according to the facility report titled #2254 Fall, dated 3/29/24 at 10:19 p.m., and progress note dated 3/27/24 at 11:45 p.m. Record review indicated neurological assessments were initiated after the fall on 3/29/24 but portions of the form were not completed. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. Record review of a progress note dated 4/02/2024 at 11:41 a.m., indicated that as a result of the fall on 3/29/24, Resident suffered a left femur (Thigh bone) fracture. Record review of a progress note dated 4/14/22 at 8:13 a.m., indicated, Resident has passed away on 4/14/24. Her death occurred 16 days after the fall with fracture, suffered at the facility. Record review of a care plan initiated on 3/29/24 after the fall, had only one new intervention. The intervention indicated, Hourly Rounding. There were no care plans created to care for the fracture. This was confirmed by the DSD during an interview on 6/20/24 at 10:30 a.m. 35842 Resident 227 A review of Resident 227's Admission Record, indicated resident 227 was admitted on [DATE], with a diagnosis including cerebral infarction (stroke), difficult walking, dysphagia (difficulty in swallowing), age-related osteoporosis (causes bones to become weak and brittle), tremor (involuntary quivering movement), restless leg syndrome (an overwhelming urge to move your legs), high blood pressure, hemiplegia (paralysis), aphasia (trouble communicating or understanding), osteoarthritis (wear and tear disease on the joints in one's hands, legs, knees, hips, lower back and neck causing pain and stiffness), amongst others. A review of Resident 227's admission Fall Risk Evaluation, dated 5/10/24, indicated Resident 227 was at moderate risk for falls. Fall 1 A review of Resident 227's Change of Condition Summary, dated 5/11/24 at 1:30 a.m., indicated Resident 227 had an unwitnessed fall in the bathroom, which caused a skin tear to Resident 227's right arm below her elbow. A review of Resident 227's care plan indicated no Fall care plan was implemented after Resident 227's fall on 5/11/24. A review of Resident 227's Admission MDS, dated [DATE], indicated Resident 227 had a BIM score of 3, which meant Resident 227's cognitive skills for decision making was severely impaired. Section J - Health Condition indicated Resident 227 had a fall in the last month prior to admission/entry or reentry into the facility and Resident 227 had a fall in the last two-six months prior to admission/entry or reentry into the facility. Section V- Care Area Assessment (CAA) Summary of Resident 227's MDS, indicated the Care Area for Falls triggered. Fall 2 A review of Resident 227's Change of Condition Summary dated 5/26/24, indicated Resident 227 had an unwitnessed fall at 6 a.m. A Certified Nursing Assistant (CNA) found Resident 227 on the floor in the bathroom and alerted Resident 227's nurse. An assessment was performed. Resident 227 was complaining of pain to her right arm and Resident 227 had a small bump assessed at the back of her head. Resident 227 did not want to go to hospital. A review of Resident 227's care plan indicated no Fall care plan was implemented after Resident 227's second fall. A review of Resident 227's Change of Condition Summary, dated 5/26/24 at 10:33 p.m., indicated Resident 227 went to the hospital to be assessed for further evaluation after falling that morning at 6 a.m. A review of Resident 227's Change of Condition Summary, dated 5/27/24 at 1:53 a.m., indicated Resident 227 had gone to the hospital to have her right shoulder checked. Resident 227 returned from the hospital via a non-emergency ambulance at 12:25 a.m. with a diagnosis Contusion of Right Shoulder. The Administrator, DON, and Resident 227's physician was notified about the diagnosis from the 5/26/24 post fall. Fall 3 A review of Resident 227's Change of Condition Summary, dated 5/28/24 at 6:39 a.m., indicated the nurse was notified by a staff employee Resident 227 was on the floor next to her bed. The nurse found Resident 227 in a semi sitting position, an assessment was performed, a minor skin tear noted at Resident 227's left forearm, and no other injuries noted. Resident 227 had denied any pain. The facility unwitnessed fall protocol was implemented, which included neuro checks for 72 hours. A review of Resident's 227's care plan, indicated Resident 227 had an Fall care plan, initiated 5/28/24 for the actual fall. Focus: (Specified: No Injury, minor injury, serious injury), poor balance, and unsteady gait. Goal: Resident 227 will resume usual activities without further incident through the review date. Interventions: [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility's Administrator failed to ensure effective oversight and necessary resources to ensure the residents' quality of care, safety, dignity, and dietary services, which include maintenance of the resident's nutrition and hydration were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all 81 residents when: 1. The Quality Assurance and Performance Improvement Committee, whose members included the Administrator did not make sure an action plan was implemented to reduce the number of falls in the facility and promote a resident safety plan by monitoring trends and implementing changes through careful analysis of the falls, which led to 134 falls from January 2024 through May 2024. Three of these falls had resulted in major injuries, Resident 15, Resident 28, and Resident 233 (Cross-Reference to F689 - Substandard Care). 2. The Administrator did not ensure the RD (Registered Dietician) was making frequent scheduled visits to oversee the day-to-day operations of the kitchen, which led to multiple issues in the kitchen including errors in plating prescribed diets and lack of dietary staff competencies in the cool down process, thawing process and three sink washing process. Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness (Cross-Reference F800, F801, F804, & F812). 3. The Administrator did not ensure the RD made routine visits to residents with significant weight loss or gain in order to observe/interview residents to find out why they were having severe nutritional changes, and make sure new admission's nutritional assessments were done in person to minimize nutritional complications. This resulted in multiple residents, including Resident 12, Resident 20. Resident 25, Resident 29, and Resident 227, having various nutritional complications leading to further compromising the resident's medical state (Cross-Reference 692 - Substandard Care). 4. The Administrator did not ensure there were staff in sufficient numbers to meet the individual care needs of residents resulting in residents having to wait long periods for call lights to be answered and lack of ADLs (Activities of Daily Living: are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and assisted with eating or needing to be fed), which led to a resident being left in a soiled brief for a long period causing breakdown in the resident's skin, lack of dignity for multiple residents, and had the potential for residents to become dehydrated and weight loss to occur because of not being offered water and assistance during meals or with snacks, feeling unkept and unclean, loss of self-worth and feeling of low self-esteem, which could further impacting residents' physical and psychosocial wellbeing. Residents impacted included Resident 2, Resident 3, Resident 4, Resident 6, Resident 12, Resident 14, Resident 20, Resident 21, Resident 25, Resident 29, Resident 35, Resident 40, Resident 46, Resident 50, Resident 55, Resident 58, Resident 65, Resident 67, Resident 68, and Resident 232, but not limited to (Cross-Reference F550, F677, and F725). 5. The Administrator did not ensure charting for fluid and meal intake was being documented consistently, which had the potential for residents to become dehydrated and nutritional concerns causing one's health to be compromised, which could lead to residents being hospitalized and even death, which included Resident 25, Resident 29, and Resident 227 (Cross Reference F692 and F842). 39621 Findings: Multiple observations, interviews and record reviews (Reference Federal Tags F550, F674, F584, F641, F656, F657, F658, F677, F687, F695, F710, F725, F761, F791, F800, F801, F804, F812, F835, F842, F865, F867, F868, F880 and Substandard Quality of Care Federal Tags F689 & F692) during the recertification survey conducted from 6/10/24 at 8:45 a.m. to 6/24/24 at 4:48 p.m., demonstrated the facility's actions, inactions and decisions, contributed to a facility in which residents were seriously harmed (F689 & F692), residents were not treated with dignity and respect (F550 and F584), residents did not receive the care and services they needed (F677, F687, F791 & F725), meals were not palatable, stored or prepared in a sanitary manner (F800, F804 & F812), medications were not stored properly (F761) and resident care plans were not created or revised (F657 & F658). In addition, despite inadequate staffing levels, they continued to accept new residents (F725 & F550). During an interview with the Director of Nursing (DON) on 06/21/24 at 5:01 p.m., the QAPI (Quality Assurance and Performance Improvement) program was presented and discussed. The DON stated there had been 28 resident falls in January 2024, 34 falls in February 2024, 35 falls in March 2024, 12 falls in April 2024 and 25 falls in May 2024 for a total of 134 falls for the first five months of the year. Three of these falls had resulted in major injuries. The DON stated that although the number of falls were being tracked, interventions for fall prevention measures were not being tracked. The DON stated Department Heads had not had a meeting to discuss falls specifically and decide what they were going to do to reduce the incidences of falls. The fall QAPI project presented to the Surveyors through the DON's computer had several areas that were blank or empty. The DON stated that although she was the person coordinating the QAPI plan, the Administrator was present during the meetings, therefore, she was aware of the recurrent falls. During this interview with the DON on 6/21/24 at 5:01 p.m., she was asked if they had a QAPI project regarding weight loss issues for the residents. The DON stated the Assistant Director of Nursing was responsible for tracking information regarding this issue but had not provided her with any information to enter into the QAPI plan. The DON presented the plan on her computer which was blank, as no data had been entered. The DON stated the Administrator was aware of the weight loss issues among the resident population of the facility. The DON stated no decisions had been made as to what they were going to measure regarding weight loss issues, in the QAPI plan. The DON was also asked if they were tracking staffing issues in the QAPI plan. The DON stated staffing was not being tracked. The DON stated that although she was the person coordinating the QAPI program, she was not being assisted by the Department Heads who were supposed to provide her with their reports. During a phone interview with Anonymous Witness O on 6/13/21 at 4:15 p.m., she stated staff at the facility were constantly being threatened by the Administration to not provide any information to family members or staff from the Department of Public Health about the care or lack of care the residents were provided, and in fact, staff had been terminated from the facility for speaking up about the unfair treatment residents were receiving. Anonymous Witness O stated incidents of abuse involving residents were not being reported to the required authorities, and staffing was so bad there were times when Certified Nursing Assistants were assigned up to 20 residents per shift. Anonymous Witness O also stated staff would get in trouble for entering the Administrator's office if not called by her, and if they discussed resident care concerns with the Administrator, she would look at them, deflect the situation, and made the staff member bringing up the concern, responsible for the issue being brought up. During an interview with Anonymous Witness J on 6/14/24 at 4:15 p.m., he/she stated certified nursing assistants were assigned 16 to 20 residents per shift, which did not provide them enough time to provide all needed services and supervise residents at risk for falls. Anonymous Witness J also stated that even if the facility had enough certified nursing assistants to work as a one to one (One staff working with only one resident) with a resident at risk for falls, the Administrator would send them home, and only once, in his/her employment at the facility, had he/she observed a one to one, and it was because the resident was extremely aggressive. Anonymous Witness J also stated staff were threatened by Administration against speaking to the Surveyors during this survey, and were told the Surveyors would, twist their words and take their CNA certificates away. They were also forbidden from entering the conference room where Surveyors were working without an Administrator present. The facility job description titled, Administrator, undated, indicated: Principal Responsibilities: . *Ensures Center compliance with all Federal, State and company regulations and policies. * Ensures that all practices and policies are carried out in the highest ethical manner. *Ensures that all Standard of Care and service provided is of the highest quality . Qualifications: .*Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives, and the community at large. *Ability to implement facility and company philosophy of care. *Current knowledge of local, state and federal guidelines and regulations .

Based on observation, interview, and record review, the facility failed to ensure resident safety for two of 15 sampled residents (Resident 7 and 8) when: 1. Staff did not properly transfer Resident 7 using a shower sling and a mechanical lift causing Resident 7 to fall on the floor and sustain a right hip fracture; 2. Staff did not follow the care plans to provide adequate supervision and assistance to Resident 8 causing Resident 8 to fall and sustain a subdural hematoma (a mass of blood inside the head). Resident 8 had two falls from 8/30/15 to 9/1/15. Theses failures also caused Resident 7 to undergo right hip surgery and Resident 8 to be hospitalized for [REDACTED]. Findings: 1. Resident 7's admission record indicated Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 7's MDS (minimum data set, an assessment tool), dated 6/27/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. Resident 7's plan of care for ADL (activities of daily living), initiated on 8/8/15, indicated Resident 7 required 2 staff participation using a lift with transfers. During a concurrent observation and interview on 9/15/15, at 11:15 a.m., Resident 7 was in bed and alert. Resident 7 stated on 8/29/15, at approximately noon, she was transferred from the shower bed to her own bed by Unlicensed Staff J and K. Resident 7 stated when Unlicensed Staff J and K lifted (using a mechanical lift) her up at approximately to the height of a calendar of the wall (53 3/4 inches to the floor, measured by Administrative Staff A on 9/15/15 at 2:10 p.m.), Unlicensed Staff K stood on her (Resident 7) back and pulled the sling from the back and her buttock causing her to fall on the floor. Resident 7 stated her buttock hit the floor and had pain greater than 10/10 on the pain scale (10 indicating most severe pain). Resident 7 stated she was sent to the hospital for a fracture and surgery. During an interview on 9/15/15, at 10:50 a.m., Unlicensed Staff J stated on 8/29/15, she was helping Unlicensed Staff K to use a mechanical lift and a shower sling to transfer Resident 7 from a shower bed to resident's own bed. Unlicensed Staff J stated while they lifted Resident 7 up on air (resident was not on a surface), Resident 7 was tilted to her right side on the shower sling. She stated Unlicensed Staff K tried to push the resident and reposition resident to her (Resident 7) back while Resident 7 was lifted up in the air. Unlicensed Staff J stated she told Unlicensed Staff K to stop pushing resident but Unlicensed Staff K already pushed the resident causing Resident 7 to slip out of the sling. Unlicensed Staff J stated staff should not reposition the resident while the resident was lifted up in the air. During an interview on 9/16/15, at 10:30 a.m., Administrative Staff C stated staff should not reposition the resident on the sling while the resident was lifted up from the bed or wheelchair because all resident's weight would be on the sling. She stated if the sling was not balanced, the resident would fall. Administrative Staff C stated staff must put resident back to bed or a surface to reposition the resident and the sling. During an interview on 10/14/15, at 6 p.m., Administrative Staff C stated she did not find any in-service record for use of mechanical lifts and slings prior to the incident up to 2011. She stated she only had the in-service record after the incident. Administrative Staff C stated she did not find any observation for staff competency of using lifts and slings. During a concurrent observation and interview on 10/13/15, at 12:20 p.m., Unlicensed Staff J stated they used the lift #1 and the shower sling for transferring Resident 7 on the day Resident 7 fell out from the sling. Unlicensed Staff J stated she did not feel safe to use the lift #1 because the spaces of the hooks were too narrow. She stated she preferred the lift #8 but Unlicensed Staff K already had Resident 7 on lift #1. During a concurrent interview and record review with the Care Coordinator Director (CCD) and Administrative B on 9/16/15, at 12:30 p.m., the incident report, dated 8/29/15, indicated Nursing Description: RT (resident) WAS BEING TRANSFERRED FROM THE SHOWER BED TO RT BED BY THE CNA'S AND SLID OUT OF THE SLING TO THE FLOOR. The acute care hospital x-ray report, dated 8/29/15, and the discharge summary, dated 9/4/15, indicated Resident 7 sustained a right hip fracture from the fall and underwent a surgical repair of the right hip fracture. The (name of company/brand) Manual/Electric Portable patient Lift Owner's Installation and Operating Instructions, dated 2001, indicated Adjustments for safety and comfort should be made before moving the patient. Patient's arms should be inside of the straps. The facility policy and procedure titled Safe Lifting and Movement of Residents, revised December 2013, indicated In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Staff responsible for direct resident care will be trained in the use of manual .and mechanical lifting devices .Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 2. Resident 8's admission record indicated Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 8's MDS (minimum data set, an assessment tool), dated 8/5/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. The Care Area Assessment (CAA, a tool used to identify resident concerns and develop an individualized care plan), dated 8/5/15, indicated Resident 8 is at risk for falls because she has trouble with balancing, she has a history of falls and she is taking an antidepressant. The fall risk evaluation, dated 7/31/15 and 8/30/15, indicated Resident 8 was at moderate risk for fall due to problems including use of diuretics (water pills), antihypertensive (medication for high blood pressure), and gait balance problems, and history of falls. Resident 8's care plan for ADL (activities of daily living), initiated on 8/10/15, indicated Resident 8 required 1 staff participation to use toilet .require assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet and to use toilet .require 1 staff participation with transfers .require supervision, cueing, encouragement, specify physical assistance with transferring . Resident 8's care plan for fall risk, initiated on 8/10/15, indicated interventions for Resident 8 including Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance . The incident report, dated 8/30/15, indicated Nursing description: Rt (resident) had unwitnessed fall. Heard loud thump noise, followed by a loud yell for help. Rt was found on bathroom floor . The progress note, dated 8/31/15, indicated IDT (interdisciplinary team) met and care plan updated. Encourage resident to ask for assistance during transfers, and we will evaluate a raised sit for the commode. The progress note, dated 9/1/15, at 6:46 a.m., indicated Resident was found on the floor @ 0540 in the doorway of her room, unconscious with minimal/abdominal breathing, ambulance called . During a concurrent observation and interview on 9/15/15, at 2:20 p.m., Resident 8 was in bed and awake. Resident 8 stated she fell in the early morning when she got up and walked to the bathroom by herself. She stated she fell on the floor and hit her head. She stated she did not remember if she used the call light in that morning. Resident 8 stated when no staff in the room, she would use the call light for help, but she had to wait for the staff for one hour or longer. Resident 8 stated on 9/14/15, she had to wait for more than one hour for staff to assist her to bed. During an interview on 9/16/15, at 7:15 a.m., Unlicensed Staff Q stated she was not assigned to Resident 8 on 9/1/15. Unlicensed Staff Q stated she walked by Resident 8's room and saw Resident 8 was not in her bed and thinking Resident 8 was in the bathroom. Unlicensed Staff Q stated she continued walking pass Resident 8's room and about two resident's rooms away, she heard a loud thud. Unlicensed Staff Q stated she immediately went to check Resident 8 and found Resident 8 was on the floor by the door and was not responsive. She stated she called stat and yelled for help. During an interview on 9/16/15, at 11:30 a.m., Licensed Staff N stated prior to the fall on 9/1/15, Resident 8 used walker to go to the bathroom and needed supervision for transfer and toileting. When asked what supervision meant, Licensed Staff N stated I think she (Resident 8) did not need supervision. During an interview on 9/16/15, at 3:45 p.m., Licensed Staff O stated she was Resident 8's nurse on 9/1/15 when Resident 8 fell . Licensed Staff O stated she heard CNA (certified nursing assistant) yelled for help when she was in another hall, she went to Resident 8's room and saw Resident was on the floor and was not responsive. She stated prior to the fall on 9/1/15, Resident 8 was independent. Licensed Staff O stated the physical therapist permitted Resident 8 to use walker. She stated Resident 8 used walker to go to the bathroom and walk in the hallway by herself. When asked if Resident 8 should transfer and walk by herself, Licensed Staff O stated I think so. She was pretty independent and physical therapist permitted her to use walker. Licensed Staff O also stated she would go into Resident 8's room and check on the resident if she saw Resident 8 was not in her bed in the early morning. She further stated resident might not really awake in the morning and would not be safe for resident to get up and look for things by herself. During a concurrent interview and record review on 10/14/15, at 2:30 p.m., the Physical Therapist (PT) stated prior to Resident 8's first fall on 8/30/15, Resident 8 could transfer and ambulate herself with a wheelchair and front wheel walker (FWW) with staff's supervision. The PT stated staff had to be with the resident but not physically assist the resident while transferring and ambulating. The PT provided the Therapist Progress and Updated Plan of Care, dated 8/28/15, which indicated Resident 8's current level of function The patient ambulates 200 feet and on level surfaces requiring supervision (needs verbal cueing but no physical assist) with rolling walker for safety .The patient is able to safely transition from sit < > stand (sit to stand and wise versus) requiring supervision . The PT stated he also verbally communicated Resident 8's needs to the staff. During an interview on 10/15/15, at 12:03 p.m., Administrative Staff B stated she expected staff to stay with the resident and watch the resident when resident needed supervision for transfer and ambulating. The acute care hospital CT (computerized tomography, special x-ray imaging) result dated 9/1/15, and the History and Physical, dated 9/10/15, indicated Resident 8 sustained a subdural hematoma from the fall. Resident 8 was admitted to an acute care hospital on [DATE] for medical interventions for the subdural hematoma. The facility policy and procedure titled Fall Prevention Program, dated 2014, indicated (facility name) are to develop a culture of safety for our residents to thrive. The (facility) Watch Program (LWP) was designed to assist facility staff in this development. Steps include: review of at-risk residents, prevention through addressing risks, appropriate fall response, and initiation of effective interventions .The DON (director of nursing) oversees all steps in the Falls Response and coordinates implementation of individualized care plans .For those assigned Moderate Fall risk, identify causative factors and care plan interventions as appropriate, but not added to the LWP . The policy and procedure did not specify how staff would implement the care plan.

Base on observation, interview, and record review, the facility failed to ensure the right to be free from verbal and mental abuse for one of 15 sampled residents (Resident 3) when the occupational therapist (OT) directed abusive language towards Resident 3. This failure negatively impacted the resident's psychosocial well-being when Resident 3 felt hurt and angry. This failure had the potential to continue to cause anger and anxiety to Resident 3 and other residents who might hear about the incident when the perpetrator was not removed from resident care immediately following the incident. Findings: A review of Resident 3's clinical chart revealed that Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (minimum data set, an assessment tool), dated 3/23/15 and 10/2/15, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. During a concurrent observation and interview on 10/13/15, at 4:45 p.m., Resident 3 was in bed and alert. Resident 3 stated that on April, 2015, the OT came in her room when a CNA (certified nursing assistant) was in the room. Resident 3 stated she told the OT to leave the room because the OT should not be in her (Resident 3) room. Resident 3 stated she did not get along well with the OT because the OT pushed her too much on the therapy. Resident 3 stated she could not tolerate the therapy when the OT pushed too much. Resident 3 stated the OT made a face and said to the CNA that She (Resident 3) was a [***] and F*** her. Resident 3 stated she felt hurt and angry. During an interview on 10/14/15, at 2:10 p.m., the Physical Therapy Assistant (PTA) stated she remembered Resident 3 stated that the OT was too pushy, but she did not recall that the OT should not go into Resident 3's room. The PTA stated she knew another resident had refused working with the OT. During an interview on 10/13/15, at 9:45 a.m., Administrative Staff A stated Unlicensed Staff G witnessed the incident. Administrative Staff A stated Unlicensed Staff G was no longer an employee of the facility. Administrative Staff A stated she escorted the OT out of the facility when she was notified of the incident on 4/16/15. During a concurrent interview and record review of the facility investigation report on 10/14/15, at 9:20 a.m., Administrative Staff A stated she did not remember who brought to her attention of the incident. According to the facility investigation report, the incident occurred on 4/14/15 and reported to her on 4/16/15 by Administrative Staff B. Administrative Staff A stated she did not find any statement for the incident from Unlicensed Staff G. Administrative Staff A stated Unlicensed Staff G was written up for failure to report the incident timely. The facility investigation report, dated 4/16/15, indicated the incident occurred on 4/14/15 and was reported to the administrator on 4/16/15. The report indicated Resident was visiting with a CNA when the OT came to ask if she could work with her. (Resident 3) told the OT no because they did not work well together. The OT .made a facial expression to the CNA .and told the CNA that (Resident 3) is a b*** .(Resident 3) and this OT have a previous history, according to (Resident 3), where they did not work well together. Therapy stated that (Resident 3) had agreed to give it another try . The facility investigation resulted .OT, willfully used inappropriate and offensive language toward a resident .and not permitted on facilities premises . The facility policy and procedure titled Abuse Prevention Program, revised August 2006, indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual .

Based on observation, interview, review of clinical records, manufacturer's prescribing information, professional medication online resources, and review of facility policy and procedure, the facility failed to assure one of four sampled residents, Resident 4, was free of unnecessary medications when staff administered [MEDICATION NAME], (synthetic narcotic used to relieve pain), outside the manufacturer's guidelines that it be used only for those patients that demonstrated opioid, (narcotic), tolerance, and continued to administer the [MEDICATION NAME] in the presence of adverse side effects, and administered oral [MEDICATION NAME], (a short acting narcotic used for pain relief), in escalating amounts, which contributed to Resident 4 developing confusion and hallucinations due to overmedication. Findings: During review of the clinical records for Resident 4, on 6/6/12 at 8:20 a.m., the resident information sheet indicated Resident 4 was admitted to the facility on [DATE] following the surgical repair of a femoral head, (top of the thigh bone), fracture sustained during a fall. Resident 4 had a history of [REDACTED]. The Minimum Data Set (MDS), a resident assessment tool, dated 5/31/12, indicated Resident 1 was alert and oriented with mild short term memory loss. Physician admission orders [REDACTED]. During an interview, on 6/5/12 at 4:05 p.m., Resident 4's family member stated Resident 4 was [AGE] years old, and had lived independently in an assisted living community prior to falling and fracturing the femur. Resident 4's family member stated Resident 4 had been confused and hallucinating since the facility gave Resident 4 a [MEDICATION NAME] for pain relief the past Monday, (5/28/12). Resident 4's family member stated that today, 6/5/12, she had convinced the facility to discontinue the [MEDICATION NAME]. During an observation, on 6/5/12 at 4:20 p.m., Resident 4 lay on her side, eyes closed, with the window curtains pulled shut. During a follow up observation and concurrent interview, on 6/6/12 at 8:10 a.m., Resident 4 sat upright in bed, holding an empty bath basin. Resident 4 stated she was afraid she was going to be sick but hadn't been. Resident 4 stated she did not have any pain. The [MEDICATION NAME], also called [MEDICATION NAME] system, or [MEDICATION NAME], contains [MEDICATION NAME], a potent synthetic opiate, (narcotic), medication used to treat pain. In June 2005, the manufacturer of [MEDICATION NAME]es issued an " Important Drug Warning " to healthcare professionals, which included an updated " Boxed Warning ". A boxed warning, (also called "black box" warning), is the most serious warning required by the Food and Drug Administration, (FDA), to be placed on a product label for a medication. Boxed warnings document potential problems with the specified medication that can lead to serious injury or death. The boxed warning for the [MEDICATION NAME] documented that it has an associated risk of fatal overdose due to respiratory depression. In addition, the Boxed Warning stated [MEDICATION NAME]es should only be used in patients who already were receiving opioid therapy, and had demonstrated opioid tolerance. The manufacturer stated opioid tolerant patients were those patients that had been taking, for seven days or more, a total daily dose of opioid medication at least equivalent to [MEDICATION NAME] 25 mcg/hr.; at least 60 mgm of [MEDICATION NAME] daily, or at least 8 mg of oral [MEDICATION NAME], ([MEDICATION NAME]) daily. In July 2005, the FDA issued a Public Health Advisory on [MEDICATION NAME], prompted by deaths and other serious side effects, reported to be due to overdoses of [MEDICATION NAME]. The FDA Advisory stated [MEDICATION NAME] should only be used by patients that were opioid tolerant and who had chronic pain that is not well controlled with other, shorter acting opioids. The FDA stated healthcare professionals who prescribed [MEDICATION NAME] skin patches, patients that used [MEDICATION NAME]es, and their caregivers, should be aware of signs of [MEDICATION NAME] overdose which included troubled or shallow breathing, tiredness, inability to think, talk, or walk normally, and feeling faint, dizzy or confused. The FDA directed that patients and/or caregivers should get immediate medical attention if any of these signs or symptoms appeared. These warnings appeared again in an Institute for Safe Medication Practices Safety Alert in June, 2007, and in a FDA Public Health Advisory issued in 2009. These warnings continue to appear on every [MEDICATION NAME] package insert, additional warnings have been added as problems with [MEDICATION NAME], (disposal of used patches and use with an elevated body temperature), continue to occur. During an interview, on 8/27/12 at 1:40 p.m., Licensed Staff B stated shortly after Resident 4's admission, she had a discussion with Resident 4's family member regarding the management of Resident 4's hip pain. Resident 4's family member was concerned because Resident 4 had a lot of pain. Licensed Staff B stated she remembered discussing prior pain medication usage with the family member but didn't remember any specifics of the conversation. Licensed Staff B stated she discussed the possibility of a [MEDICATION NAME] with the family member, including that [MEDICATION NAME] was a longer acting pain medication. When the family member agreed, Licensed Staff B stated she sent a facility form to Resident 4's physician requesting an order to start a [MEDICATION NAME]. Licensed Staff B stated that after 72 hours, (when the patch was due to be changed), the effectiveness of the [MEDICATION NAME] would be assessed, by review of the amount of supplemental medication required to relieve Resident 4's pain, and review of Resident 4's pain levels. Review, of the May Medication Administration Record, [REDACTED]=the most severe pain): in the following total dose amounts: On 5/22/12, 6 mg (milligrams), on 5/23/12, 4 mg., 5/24/12 8 mg, on 5/25/12, 6 mg, on 5/26/12 4 mg, on 5/27/12 6 mg, and on 5/28/12, 4 mg; an average daily dose of 5.4 mg of [MEDICATION NAME],(83/7=5.4 mg), not the manufacturer's specified minimum dosage of 8 mg of [MEDICATION NAME]. Review, of Physician orders, dated 5/25/12, in response to Licensed Staff B's request, indicated Resident 4 was to receive a [MEDICATION NAME] Patch 25 mcg (micrograms) per hour, changed every 72 hours, for chronic pain. The [MEDICATION NAME] was noted as started at 2000 (8 p.m.) on 5/28/12, on the MAR. Review of the MAR for 5/28/12 indicated that on 5/28/12 and 5/29/12, Resident 4 received two doses of [MEDICATION NAME] 2 mg, each day, in addition to 25 mcgs per hour of [MEDICATION NAME]. The MAR indicated [REDACTED]. However, nurses notes dated 5/28/12 at 1400 ( p.m.) noted, "pain relieved with prn, (as needed), [MEDICATION NAME].", and at 1730 (5:30 p.m.), "(no) c/o (complaint) of pain this shift-...". Nurse's notes, dated 5/29/12 at 1230 (12:30 p.m.) noted "c/o achy mild pain to L(eft) hip this am which was relieved with APAP(Tylenol)...c/o severe pain during transfer" with physical therapy, and at 2300 (11 p.m.), "...(one) c/o pain". During an interview, on 8/14/12 at 11:35 a.m., Licensed Staff A stated she had a conversation with Resident 4's daughter regarding Resident 4's pain medication after initiation of the [MEDICATION NAME]. Licensed Staff A stated that Resident 4's family member told her Resident 4 was shy and that she might not ask for pain medication. The family member reportedly told Licensed Staff A that Resident 4 had been using [MEDICATION NAME] around the clock prior to admission to the facility. Licensed Staff A stated Resident 4 was alert and believed Resident 4 had confirmed that to be true. During an interview, on 8/14/12, at 8:40 a.m., Resident 4's family member stated Resident 4 had [MEDICAL CONDITION] in the back and hips that caused chronic pain. Prior to the fall, Resident 4's family member stated Resident 4 had been taking [MEDICATION NAME], (a narcotic pain reliever taken by mouth), about 4 times a day for her chronic pain. Resident 4's family member stated she remembered very clearly that facility staff had told her after the [MEDICATION NAME] was started that they would, "cut back on the [MEDICATION NAME]". Resident 4's family member stated Resident 4, "didn't know a thing about pain medication", and it was "weird" that facility staff said Resident 4 had requested that [MEDICATION NAME] be administered around the clock. A fax, sent to the physician, on 5/29/12 at 1043 (10:43 a.m.), by facility staff stated; "Rt (resident) would like prn, (as needed), 2 mg [MEDICATION NAME] po (oral) Q (every) 4 hours to be routine every 4 hours to control her pain.", despite indication that Resident 4 was requiring less pain medication after initiation of the [MEDICATION NAME]. Physician orders [REDACTED]. Further review of the MAR indicated [REDACTED]. During a confidential interview, on 6/6/12 at 7:55 a.m., it was stated that facility staff had been informed on 5/31/12, that Resident 4 was newly confused. Nurse's notes, dated 5/31/12, 0530-1400 (5:30 a.m. to 2 p.m.), noted "Rt (resident) intermittently confused", however there was no indication the physician was notified or that any other action was taken regarding the confusion. Review, of the June MAR, indicated Resident 4 received [MEDICATION NAME] 2 mgm every four hours, for total doses per day of 12 mg. on 6/1/12 and 6/2/12, in addition to the [MEDICATION NAME]. Further review of the clinical record, revealed a fax to the physician, dated 6/2/12, which noted Resident 4 was confused, with hallucinations and shaking. The fax indicated facility staff were, "holding the [MEDICATION NAME] to see if pain meds (were) causing the problem". There was not a physician order [REDACTED]. The June MAR beginning 6/3/12, indicated facility staff started to hold some of the ordered doses of [MEDICATION NAME], so that on 6/3/12, Resident 4 received only two doses of the [MEDICATION NAME], and on 6/4/12, Resident 4 received only one dose. The physician response, dated 6/4/12 at 5:04 p.m., to the 6/2/12 fax, discontinued the around the clock administration of [MEDICATION NAME], however did not address the [MEDICATION NAME]. The new order to discontinue the around the clock [MEDICATION NAME] was not noted by facility staff until 6/5/12 at 7:40 a.m.,(fourteen hours after the physician response). Nurses' notes, dated 6/3/12 indicated Resident 4 continued to be confused with hallucinations. Nurses' notes 6/5/12 at 12 p.m., noted the physician was again notified of Resident 4's confusion and lethargy. At 1445 (2:45 p.m.), the nurses' notes documented the receipt of a telephone order to discontinue the [MEDICATION NAME]. During an interview, on 8/14/12 at 3:45 p.m., the Assistant Administrator stated the standard order sheet for [MEDICATION NAME] administration had been implemented by a former Director of Nurses, after approval of the form by the facility Quality Assurance committee. The Assistant Administrator stated the medications listed on the form were "pretty standard and were what the facility physicians were prescribing. The Assistant Administrator stated the former Director of Nurses would have done an introduction and training for the licensed staff regarding the medication order form.

Based on observation, interview, and review of clinical records and facility policy, the facility failed to provide one of four sampled residents, Resident 4, whom the facility initially assessed as at risk for altered skin integrity, with ongoing skin assessments, an individualized care plan, and monitoring of effectiveness of prevention strategies, which resulted in development of two avoidable pressure ulcers with potential for subsequent infection and increased pain. (A pressure ulcer is a localized injury to the skin, and/or underlying tissues, as a result of compression of the tissues by external forces causing decreased circulation and oxygenation and resultant (skin) cell death.) Findings: During review of the clinical records for Resident 4, on [DATE] at 8:20 a.m., the resident information sheet indicated Resident 4 was admitted to the facility on [DATE], following the surgical repair of a femoral head (the top of the thigh bone) fracture sustained during a fall. The Minimum Data Set (MDS), a resident assessment tool, dated [DATE], indicated Resident 1 was alert and oriented with mild short term memory loss, and required assistance with all activities of daily living except eating. During an interview, on [DATE] at 4:05 p.m., Resident 4's family member stated Resident 4 had no skin issues when transferred to the facility from an acute care hospital, however, now Resident 4 had developed pressure ulcers. Resident 4's family member stated Resident 4 had complained she hadn't been bathed, but also stated Resident 4 was forgetful. During an observation, on [DATE] at 4:20 p.m., Resident 4 lay on her side, with the window curtains pulled closed and her eyes shut. During a follow up observation and concurrent interview, on [DATE] at 8:10 a.m., Resident 4 sat upright in bed, holding an empty bath basin. Resident 4 stated she was afraid she was going to be sick but hadn't been. Resident 4 stated she did not have any pain. During review, on [DATE], of the Admission Nursing Assessment, dated [DATE], Resident 4's skin assessment indicated Resident 4 had scars on the right shoulder and right ankle, and a surgical incision on the left hip. There was no indication of any other skin problems. A Braden Scale-For Predicting Pressure Sore Risk, dated [DATE], indicated Resident 4 scored 14 points, which indicated Resident 4 was at moderate risk for developing pressure ulcers. ( Braden Scale Scores: Severe Risk: Total score less or equal to 9, High Risk: Total score ,[DATE], Moderate Risk: Total Score ,[DATE], Mild Risk: Total score ,[DATE]). The Braden Scale indicated Resident 4's risk was due to very limited mobility, being bedfast, and probable inadequate nutrition. An Alteration in Skin Integrity Care Plan, dated [DATE], indicated interventions to maintain skin integrity for Resident 4 included assistance with turning and positioning every two to three hours, a daily skin check during care, and the use of lotion on dry skin. The plan of care did not address the potential need for a nutritional assessment. Review, of the [DATE] ADL (Activities of Daily Living) Record, completed by facility Certified Nurse Assistants,(CNAs), indicated Resident 4 had been assisted by facility staff to bathe in bed, on [DATE], six days after admission, as well as on [DATE]. During an interview, on [DATE] at 9:15 a.m., CNA A, introduced as the "bath specialist" since she assisted with most of the showers with residents, stated the standard in the facility for bathing was twice a week. CNA A stated she assessed the resident(s) skin during showers. Concurrent review, of the Whirlpool/Shower Log for Resident 4 indicated Resident 4 had been assisted with a shower on [DATE], ten days after admission, and again on [DATE]. Resident 4 had been bathed a total of 3 times in twenty days. Review, of a fax to the physician, dated [DATE] and timed as FAXed to the physician's office "[DATE] 01:40 a.m.", indicated Resident 4 had developed two pressure ulcers on the coccyx, (tailbone). One ulcer measured 4.5 centimeters (cm) by 3 cm., the other measured 2 cm by 2 cm. A drawing accompanied the fax depicted two distinct pressure ulcers, one above and to the right of the first. The top layer of skin was noted as absent over both areas. Nurses' notes dated [DATE] documented the condition of Resident 4's skin. "...has 2 Stage 2 open areas, 1 on L (left) gluteal fold measures 2.0 x 1.8 cm, epith(ial) tissue. 2nd on coccyx 4.8 cm x 1.1 cm, surrounding tissue ecchymosis, (bruising)". The physician response, dated [DATE] at 10:44 a.m., indicated facility staff were to clean the ulcers with wound cleanser, dry and then apply [MEDICATION NAME] every three days, and as needed if the dressing was soiled or dislodged. The order was signed as noted by facility staff on [DATE]. Review, of the Medication Administration Record, [REDACTED]. Online research, on [DATE] at National Pressure Ulcer Advisory Panel website, indicated a pressure ulcer is a localized injury to the skin, and/or underlying tissues, as a result of compression of the tissues by external forces causing decreased circulation and oxygenation and resultant (skin) cell death. Stage 2 referred to the extent of damage to the skin, a partial thickness loss of epidermis (top layer of skin) and/ or the dermis, which presents as a shallow open ulcer. (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. Washington DC. National Pressure Ulcer Advisory Panel: 2009.) A plan of care, for Resident 4, titled Pressure Ulcer, dated [DATE], ten days after the pressure ulcers were discovered, did not note that Resident 4 had pressure ulcers, did not indicate that any pressure reducing device had been considered, that a turning, positioning schedule be implemented or that a nutritional consult be obtained. During a confidential interview, on [DATE] at 8:10 a.m., it was noted that the day before ([DATE]), Resident 4 had a body odor, which was reported to facility staff. When Resident 4 was examined by staff, on [DATE], she was wearing the same clothes she had worn the day before. The dressing on her coccyx was dated [DATE], indication that the dressing had not been changed every three days per the physician's orders [REDACTED]. Review, of a fax to the physician, dated [DATE], sent on [DATE], indicated that Resident 4's pressure ulcers had an odor and were covered with yellow slough, dead tissue debris, indication that further tissue had died at the sites of the pressure ulcers. Review, of an undated facility policy, titled Wound and Skin Management, indicated that a Licensed Nurse would assess each resident's skin daily, with care, and weekly, and document the findings. The policy additionally stated the CNAs would "...complete body checks on resident's daily, with care, and on shower days and report findings to the charge nurse". The policy addressed prevention of pressure ulcers. Prevention measures included application of a pressure reducing device in bed and/or chair, assurance that residents were turned and repositioned based on the residents' risk factors, and nutritional intake was monitored by licensed staff. Page 3 of the policy addressed interventions specific to a Stage 2 pressure ulcer which included a request for high protein supplements. During a review of the clinical record on [DATE], there were not any physician orders [REDACTED]. During an interview, on [DATE] at 10:40 a.m., the Director of Nursing stated the development of Resident 4's pressure ulcers was unacceptable, and never should have happened.