Every finding on record at Eastern Plumas Hospital- Portola Campus Dp/Snf

Based on observation, interview, and record review, the facility failed to ensure that residents were protected from accidents and hazards when: One of two residents sampled for falls with injuries (Resident 9), was transferred by staff from her bed to her wheelchair, without using the proper equipment. Two of three shower rooms were observed to have unlocked, open cabinets that contained disposable razors and a sharps container (a plastic safety container for needles and sharp objects), that was over spilling with used razors.These failures resulted in Resident 9 sustaining a broken ankle and had the potential for residents who used the shower rooms to be injured by cuts from razors which could negatively impact residents physical and emotional well-being. 1. Resident 9 was admitted to the facility for heart disease with heart failure, lymphoma (a form of blood cancer), a history of falling, cervicalgia (back pain), osteoporosis (brittle bones), and an above the knee amputated (surgically removed) left leg. Review of Resident 9’s care plans (undated) indicated that staff should use Resident 9's, “Procedures for Transfer,” which were printed and taped near Resident 9's bedside with instructions for the Certified Nursing Assistants (CNAs) on how to safely transfer Resident 9 using a slide board (a plastic or wooden flat board that assists those who cannot stand by sliding across the board to transfer in and out of bed). Resident 9’s care plan indicated, “7. [Resident 9] can lean to the left while using slide board,” and that slide board was necessary to transfer Resident 9 safely. Review of Resident 9’s Minimum Data Set (MDS, a panel of assessments to determine the level of care needed for a resident), section GG “Functional Abilities,” performed on 4/27/25 indicated that Resident 9 was “dependent” (needed complete assistance) for a bed-to-chair transfer. Review of the facility’s record titled, “Shift Report” (undated), an informational sheet CNA's used for the level of care a resident needs, indicated that Resident 9 was a “two person assist,” using a “slide board.” Review of the facility’s Occupational Therapy department’s record titled, “OT Daily Documentation,” dated 11/25/24, indicated that Resident 9 required a slide board for CNA staff to transfer her and that education and demonstration using the slide board had been provided to staff. A review of Occupational Therapy notes from 12/1/24 to 7/1/25 indicated Resident 1 was a, “moderate” to “maximum assist” with transfers using a slide board in all instances. Review of Resident 9’s Nurses Notes dated 7/1/25, indicated that on 7/1/25 at 11:30 AM CNA A was attempting to transfer Resident 9 from her bed to a wheelchair without the use of a slide board, the resident [Resident 9] slid to the bed, injuring her ankle. A review of Resident 9’s progress notes dated 7/11/25 at 11:30 AM, indicated that CNA A was helping transfer Resident 9 from her bed to her wheelchair. CNA A directed Resident 9 to stand up on her right leg to make the transfer, instead of using the slide board. Resident 9 was not able to bear her weight on one leg, her only leg, and fell and broke her right ankle. The progress note indicated that Resident 9’s right ankle became swollen and bruised and she had to go to the hospital emergency room for treatment. Review of the hospital emergency room notes, dated 7/12/25, indicated that Resident 9 had sustained a, “fracture [broken] of the right ankle.” Resident 9's right ankle was put in an orthopedic boot (a splint that keeps the ankle from moving), and returned back to the facility. In an interview on 7/21/25 at 1:39 PM, Resident 9’s family member (FAM) N confirmed that Resident 9 was always transferred using a slide board and that the instructions were posted right next to Resident 9's bed. In an interview on 7/22/25 at 10:05 AM, CNA A confirmed that she had transferred Resident 9 on 7/11/25, without using a slide board, and confirmed she had been instructed to always use the slide board when transferring Resident 9. CNA A confirmed that she had not asked another staff to help her transfer Resident 9 and confirmed that she knew two staff were required but attempted to transfer Resident 9 by herself. CNA A stated that on 7/11/25, Resident 9 expressed she did not want to use the slide board and CNA A chose to stand Resident 9 up on one leg to transfer her. CNA A stated that she should have asked the nurse what to do when Resident 9 didn't want to use the slide board, because there were no instructions on what to do if Resident 9 refused to be transferred with the slide board. In an interview on 7/22/25 at 10:27 AM, Occupational Therapist (OT) B stated, When we worked with [Resident 9], we recommended a slide board be used because of her knee pain and having only one leg, it relieved the pressure on her knee. She is at least a two-person assist for patient and staff safety. If a resident refuses to use the board to transfer, they should 1) Get help, or 2) speak to their resident and let her know that we would need to use a Hoyer (mechanical) lift, which is also a two person assist. In an interview on 7/24/25 at 11:00 AM, OT C stated that she worked with Resident 9 for nine months on transferring safely. OT C stated, “She needed the slide board because of her knee pain, we shouldn’t be doing ‘stand and pivot’ transfers because they torque [twist] the knee and ankle, and she only had that leg to stand on.” OT C stated that the slide board was recommended for Resident 9’s safety and for staff safety. “We did in-services [training] with nursing assistant staff working with the resident [Resident 9], to transfer her safely. Somedays she refused, the remedy was just to spend more time with resident to persuade her to allow the slide board to be used.” In an interview with Director of Nursing (DON) on 7/22/25 at 3:00 PM, DON indicated that the standard of care used by the facility for transferring residents is the, “Lippincott procedures” (undated), an online nursing resource. A review of Lippincott procedures, “Transfer from Bed to Wheelchair,” (undated) provided by the facility indicated, “For a patient who can’t stand, a transfer board allows safe transfer from a bed to a wheelchair;” and; “Assess the patient’s needs and abilities when making decisions about the necessary equipment for transfer, because different patients require varying levels of assistance with transfer.” The [NAME] further indicated, “A lateral patient transfer can pose risks to the patient and health care worker. Safe patient transfer may require the assistance of one or more coworkers as well as the use of assistive patient handling equipment, such as a sliding board.” 2. During a review of the facility’s policy and procedure titled, “Resident Safety”, dated last revised 5/2022, the policy indicated, “It is the policy of [the facility] to ensure the optimum safety for all residents at all times…” During an observation on 7/22/25 at 7:30 AM, the resident shower rooms were observed for adherence to overall cleanliness and safety. Shower room [ROOM NUMBER] was observed to have an open container of new razors in an unlocked and open cabinet. Shower room [ROOM NUMBER] was observed to have multiple uncovered, used razors sticking out from the opening of an almost full sharp’s container easily accessible to residents, and an open container of new razors in an unlocked cabinet. During a concurrent observation and interview on 7/23/25 at 12:40 PM, with Licensed Nurse (LN) K in shower room [ROOM NUMBER] and 2, LN K agrees that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. During a concurrent observation and interview on 7/23/25 at 2:00 PM, with Assistant Director of Nursing (ADON) I, outside shower room [ROOM NUMBER], pictures of the shower rooms [ROOM NUMBERS] were observed. ADON I confirms that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. During a concurrent interview and picture review on 7/23/25 at 5:00 PM, with DON in the office the surveyors were utilizing, pictures of shower rooms [ROOM NUMBERS] were observed. DON confirmed that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. This is a matter of resident safety.

Based on observation, interview, and record review the facility failed to maintain a clean, homelike environment when three of three shower rooms were found to be less than adequately maintained when paint was chipping from walls and ceiling, door jambs were missing paint with hints of rust, shampoo, and/or other products had spilled and dried in an open cupboard with clean towels placed on top, bolts, screws, and nuts that adhere the tub and toilet to the floor were rusty, the foot of the tub and around the toilet was unclean, and hard bristle brushes to scrub the floor were left hanging on hand rails in the shower.This failure had the potential to result in disease transmission, with increasing health and overall wellbeing concerns to those residents utilizing the common space.During a review of the facility's policy and procedure titled, Cleaning and Sanitizing Shared Equipment, dated Last Revised 06/2024, the policy indicated, To prevent disease transmission.of shared patient care equipment (and areas) used throughout [the facility name] .All patient common equipment should be cleaned and disinfected.between each and every patient use.During an observation on 7/22/25 at 07:30 am, the resident shower rooms were observed for adherence to overall cleanliness. Findings are as follows:1. Shower room [ROOM NUMBER], with a tub, was found to have a substance, possibly shampoo, that appeared to have leaked out onto the bottom shelf of an open cupboard. The substance was dry and flaky and clean towels were stacked on top of the substance. There was paint missing and the appearance of rust spots around the door jamb. Screws, bolts, and nuts that adhered the tub and toilet to the floor appeared rusty, and the foot of the bathtub and around the toilet were unclean.2. Shower room [ROOM NUMBER] was found to have multiple used razors sticking out of an almost full sharp's container, paint missing and the appearance of rust around the door jamb, and a used hard bristle brush was hanging from the shower safety handrail.3. Shower room [ROOM NUMBER] was found to have paint chipping on the walls and ceiling, paint missing and the appearance of some rust around the door jamb, and a used hard bristle brush hanging from the shower safety handrail.During a concurrent observation and interview on 7/23/25 at 12:30 pm, with Certified Nurse Assistant (CNA) L , in shower room [ROOM NUMBER], CNA L stated the hard bristle brush was for floor cleaning and should not be hanging on the shower safety rails where residents could come in contact with it, nor was the room maintained at acceptable standards with noted paint chipping on walls, ceiling, and door jamb, and rust appearing on spots on the door jamb.During a concurrent observation and interview on 7/23/25 at 12:40 pm, with Licensed Nurse (LN) K , in shower rooms [ROOM NUMBERS], LN K confirmed the shower rooms were not adequately maintained, or clean to acceptable standards.During a concurrent observation and interview on 7/23/25 at 2:00 pm, with Assistant Director of Nursing (ADON) I, outside shower room [ROOM NUMBER], shower room [ROOM NUMBER] was observed as well as pictures of shower rooms [ROOM NUMBERS]. ADON I confirmed the shower rooms were not adequately maintained, or clean to acceptable standards.During a concurrent interview and picture review of shower rooms [ROOM NUMBER] on 7/23/25 at 5:00 pm, with Director of Nursing (DON), the DON confirmed the shower rooms were not adequately maintained, or clean to acceptable standards.

Based on observation, interview, and record review, the facility to protect four of four sampled residents (Resident 3, 16, 20, and 45) from abuse by chemical restraints when Haldol (an antipsychotic medication used to alter mood and behavior) intramuscularly (IM, a shot) was used in excessive doses, without adequate indications for use, and without trying non-pharmacological interventions (redirection without using medication) first.This subjected the residents to potentially harmful and irreversible unwanted adverse side effects from antipsychotic use and violated their rights for alternative treatment methods prior to the use of medication. This had the potential to seriously impair their ability to attain or maintain their highest practicable level of physical, emotional and psychosocial well-being. Findings:According to Lexicomp an online National Library of Medicine information site for professionals, Haldol is not approved for the use of dementia-related psychosis. Haldol used in patients with dementia over [AGE] years old, can cause sudden death by heart failure. No more than 2 mg of Haldol should be administered to patients over 65 with dementia. Haldol has a Black Box Warning (BBW), this is the most stringent Food and Drug Administration (FDA) warning for drugs that have dangerous side effects.During a review of the facility's policy and procedure (P&P) titled, informed Consent for use of Psychotherapeutic Drugs dated 2025, the P&P indicated, before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent and non-pharmacological approaches that could address the resident's needs.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 2025, the P&P indicated, unnecessary drugs shall be avoided. The facility shall monitor all psychotherapeutic medications for effectiveness and side effects according to Omnibus /budget Reconciliation (OBRA) guidelines. Psychotropic drugs shall only be utilized with a physician order and shall never be used for the convenience of staff. The physician shall write a progress note describing the behaviors and the reason for ordering the psychotropic drug. A review of the medical record for Resident 3 indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), without behaviors, and anxiety.During a concurrent interview and record review on 7/23/25 at 10:00 a.m., with Director of Nursing (DON), Resident 3's, Medication Administration Record (e-MAR), dated July 2025, was reviewed. The DON confirmed Resident 3 was given Haldol 2.5 milligrams (mg, a unit of measure), IM on 7/15, 7/16, 7/17, and 7/21/25. During a concurrent interview and record review on 7/23/25 at 10:10 a.m., with DON, Resident 3's Progress Notes (PG), April and May 2025 was reviewed. The DON confirmed PG there were no physician PG notes describing the behaviors and reason for ordering Haldol.During a concurrent interview and record review on 7/23/25 at 10:20 a.m., with DON, Resident 3's Behavior Monitoring and Interventions Report, (BMIR) dated July 2025 was reviewed. The DON confirmed Resident 3's BMIR indicated there were no behaviors or non-pharmacological interventions charted for Resident 3 on 7/15/25, at 5:04 a.m.A review of the medical record for Resident 16 indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, with behavioral disturbance.During a concurrent interview and record review on 7/24/25 at 10:00 a.m., with DON, Resident 16's e-MAR, dated May 2025 was reviewed. The DON confirmed Resident 16 was given Haldol 5mg IM on 5/24, 5/25, 5/27, 5/30, 5/31/25. During a concurrent interview and record review on 7/24/25 at 10:10 a.m., with DON, Resident 16's PG, dated April and May 2025 were reviewed. The DON confirmed there were no physician PG notes describing the behaviors and reason for ordering Haldol. During a concurrent interview and record review on 7/24/25 at 10:20 a.m., with DON, Resident 16's BMIR dated May 2025 was reviewed. The DON confirmed Resident 16's BMIR indicated, there were no non-pharmacological interventions charted for 5/25/25 and no behaviors, or no non-pharmacological interventions charted for 5/24/25 and 5/30/25. During a review of Resident 16's PG, dated 5/24/25 at 1:48 a.m., and 5/24/25 at 2:06 a.m., the PG indicated Resident 16 was given Haldol 5 mg IM for agitation and being combative toward nursing staff. At 4:45 p.m., the PG indicated Resident 16 did not get his morning medications because he was sleepy. During a record review of Resident 16's PG dated 5/27/25 at 11:38 p.m., the PG indicated Resident 16 was refusing care and sitting in his wheelchair leaning dangerously forward and tried to get out of his chair and walk. Haldol was given IM by nursing staff. During a record review of Resident 16's PG dated 5/30/25 at 6:34 p.m., 7:15 p.m., and 7:35 p.m., the PG indicated, Resident 16 became physically combative with staff when they attempted to give him a shower, Haldol 5 mg IM was given twice, for a total of 10 mg. A review of the medical record for Resident 20 indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, with agitation, and falls.During a concurrent interview and record review on 7/24/25 at 10:22 a.m., with DON, Resident 20's e-MAR, dated February and March 2025 was reviewed. The DON confirmed that Resident 20 was given Haldol 2 mg IM on 3/12/25, 4 mg IM on 3/13/25, 5 mg IM on 2/22 and 3/27, and 15 mg on 3/29/25. During a concurrent interview and record review on 7/24/25 at 10:25 a.m., with DON, Resident 20's PG for February and April 2025 was reviewed. The DON confirmed Resident 20's PG had no physician PG notes describing the behaviors and reason for ordering Haldol.During a concurrent interview and record review on 7/24/25 at 10:29 a.m., with DON, Resident 20's BMIR dated March 2025 was reviewed. The DON confirmed Resident 20's BMIR indicated there was no behaviors, or no non-pharmacological interventions charted for 3/29/25.During a record review of Resident 20's PG, dated 4/1/24, at 2:32 p.m., the PG indicated Resident 20 had been lethargic (drowsey) and slept for three hours through her lunch time and that staff attempted to wake her up, without success and she missed her 2 p.m. routine medications.A review of the medical record for Resident 45 indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity with agitation.During a concurrent interview and record review on 7/24/25, at 10:35 a.m., with DON, Resident 45's e-MAR dated July 2025, was reviewed. The DON confirmed Resident 45 was given of Haldol 5 mg IM on 7/20/25. During a concurrent interview and record review on 7/24/25 at 10:45 a.m., with DON, Resident 45's PG dated July 2025, was reviewed. The DON confirmed Resident 45's PG had no physician PG notes describing the behaviors and reason for ordering Haldol.During a record review of Resident 45's PG dated 7/20/25 at 3:14 p.m., the PG indicated Resident 45 showed combative behavior towards nursing staff and Certified Nurse Assistants (CNAs). Due to escalating aggression towards staff and not willing to be taken to the restroom, Resident 45 was placed in her room for safety and given Haldol 5 mg IM.DON confirmed for residents 3, 16, 20, and 45, the medical doctor did not chart any progress notes describing the behaviors (target symptoms) and reason (justification, such as the resident being harmful to themselves or other residents) for ordering Haldol. The DON confirmed that Haldol was given in doses beyond that of the manufacturer's recommendations (excessive doses) and staff had not attempted redirection and non-pharmacological interventions (go for a walk outdoors, snack, drink, music, toileting, check for pain, or excessive light and noise are some examples), which could reflect and that the residents were medicated for the staff's convenience.

Based on observation, interview, and record review the facility failed to maintain sanitary, clean kitchen equipment when the ice machine acquired a large amount of mineral buildup (white coating that harbors bacteria) on the tray and the spout, debris was noted in the internal cabinet area of the machine, and the cupboard the ice machine sat upon did not appear clean.This failure had the potential to result in ice that was contaminated with bacteria which could negatively impact the health and overall well-being to residents, staff and visitors.During a review of the facility's policy and procedure titled, Cleaning and Sanitizing Ice Machines, dated revised 9/2024, the policy indicated, It is the policy of [the facility name] that all ice machines will be properly maintained and cleaned.They should be clean to the sight and touch.including ice machine tray and spout.They also remove exterior scaling as needed.During an observation on 7/22/25 at 5:00 pm, the ice machine was observed to have a great deal of mineral buildup on its tray and on the inside of the ice spout. The internal cabinet to the functioning area of the machine was noted to have buildup and debris on the bottom of the cabinet, and the cupboard that the entirety of the ice machine sat upon was unclean with buildup, water and splash marks, and debris.During an observation and interview on 7/23/25 at 8:50 am, with Maintenance (Maint) in the space where the ice machine was located, Maint stated the mineral buildup on the ice machine is difficult to remove and agreed the machine and the cupboard it sits upon appears unclean.During an observation and interview on 7/23/25 at 11:00 am, with Director of Plant Management (DPM) in the space where the ice machine was located, the DPM stated the newly hired maintenance crew cleaned the machine recently, but confirmed there was a great amount of buildup in the tray and in the spout, the actual interior of the ice machine cabinet had loose debris, and the cupboard the ice machine sat upon appeared less than adequately cleaned.

Based on observation, interview, and record review, the facility failed to follow infection control standards for 2 out of 5 sampled residents during a medication pass and dining (Resident's 1 and 23) when: 1. Staff did not sanitize a potentially contaminated instrument used to puncture and remove a safety seal on a medication.2. A medication container was brought into a resident's room and placed on a potentially contaminated surface without a barrier.3. Staff did not sanitize their hands after touching potentially contaminated surfaces while feeding residents in the dining room. This had the potential to spread a communicable disease and cause cross-contamination. 1.The facility’s policy titled, “Standard Precautions”, last approved 09/2024, was reviewed and indicated, It is the policy of [the facility name] that standard precautions be followed for all patient care .to reduce risk of transmission from both recognized and unrecognized sources of infections . and to prevent the spread of infection from patient to patient. A review of Resident 1’s record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (impairment of memory, thinking and social abilities), Multiple Sclerosis (damage to the protective cover around nerves causing muscle weakness, vision changes, numbness and memory issues), and muscle wasting and atrophy (loss of muscle mass and strength). Review of the most recent Minimum Data Set (MDS, a resident assessment tool), for Resident 1 dated 6/22/25, indicated that Resident 1 had a severe cognitive deficit, with a brief interview for mental status (BIMS) score of 00 out of 15. During an observation on 7/23/25 at 8:27 am, Licensed Vocational Nurse (LN) K, during the medication pass on cart 1, retrieved a new, unopened liquid medication from the medication room (room where extra medications are stored). LN K took the lid off of the medication and could not remove the safety seal. LN K used a writing pen to puncture the seal and to scrape along the inside edge of the opening of the bottle to loosen the safety seal enough to enable her to pull it off. During an interview with LN K on 7/23/25 at 12:38 pm, at the nurse's station, LN K confirmed that using the writing pen to open the new medication, “was not appropriate and this could cause an infection control issue.” 2. A review of Resident 23’s record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (a medical condition where bones become brittle and fragile from loss of tissue), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways and difficulty or discomfort with breathing). Review of the most recent MDS for Resident 23, dated 7/03/25, indicated that Resident 1 had no cognitive deficits, with a BIMS score of 15 out of 15. During an observation on 7/23/25 at 8:56 am, LN O, during the medication pass on cart 2, took a medication in the manufacturer’s box into the room of Resident 23. The medication box was placed on the bedside table without a barrier. After the medication was administered to the resident, LN O put the medication back into the medication box, and put the medication box back into the medication cart drawer with other boxed medications. During an interview with LN O on 7/23/25 at 12:52 pm, at the nurse's station, LN O confirmed that the medication box is, “porous and cannot be thoroughly cleaned, and this is an infection control issue.” During an interview with the Assistant Director of Nursing (ADON) I on 7/23/25 at 2:28 pm, in the ADON I's office, the ADON I confirmed, “Inserting a pen into a medication to open the safety seal is an infection control issue. Also, bringing in a box for a medication into a resident’s room without a barrier is an infection control issue, too. These things should not happen.” During an interview with the Director of Nursing (DON) on 7/23/25 at 3:55 pm, in an office, the DON confirmed that opening a medication’s safety seal with a writing pen and bringing a boxed medication into a resident’s room without a barrier, “is an infection control problem.” 3. During a review of the facility policy and procedure titled, “Hand Sanitizing”, dated Last Revised 4/2024 , the policy indicated, “It is the policy of [the facility's name] to practice hand hygiene in compliance with standards set forth by the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH) in order to prevent transmission of infectious diseases via health care providers’ hands and to decrease the chance of health care provider colonization. When to perform hand hygiene…after touching patient…after touching a patient’s surroundings, including…surfaces…before eating (feeding)…”. During observations on 7/22/25 at 08:10 am and 12:15 pm, in the dining room. Certified Nursing Assistant (CNA) M was observed assisting two residents to eat at the assisted dining table. CNA M was observed touching wheelchair handles, chairs, other residents’ trays after they had finished eating, and countertops. No hand sanitizing was observed amongst these actions prior to returning to feeding the two assisted dining residents. During an interview on 7/22/25 at 2:00 pm, in the hallway outside of room [ROOM NUMBER], with CNA M, CNA M confirmed they had not thought about the result of touching surfaces such as wheelchair handles, and other trays, and then not sanitizing before continuing feeding the residents. During an interview on 7/23/25 at 4:00 pm, with ADON I, in the ADON I's office, ADON I stated the expectation for staff is to follow hand sanitizing guidelines and standards of care and to hand sanitize after touching potentially contaminated surfaces and prior to assisting to feed residents in the dining room. During an interview on 7/23/25 at 5:00 pm, with the DON, the DON confirmed the expectation was for staff to follow appropriate hand sanitizing guidelines and standard of care and to hand sanitize after touching potentially contaminated surfaces and prior to assisting to feed residents in the dining room.

Based on observation, interview, and record review, this requirement was not met when staff were inadequately trained in resident care for two of two sampled residents (Resident 9 and 36) when:1. Certified Nursing Assistant (CNA) failed to follow policy and the resident's care plan when transferring Resident 9 from bed, which resulted in Resident 9 sustaining a broken right ankle.2. A Registered Nurse (RN), delegated her responsibility to a CNA to administer oxygen to Resident 36. 1. Resident 9 was admitted to the facility for heart disease with heart failure, lymphoma (a form of blood cancer), a history of falling, cervicalgia (back pain), osteoporosis, and an amputated (surgically removed) left leg. Review of Resident 9's care plans (undated) indicated that staff should use Resident 9's, Procedures for Transfer, a printed sign in a plastic sleeve that was taped near Resident 9's bedside to instruct CNAs in safely transferring Resident 9. Resident 9's care plan indicated, 7. [Resident 9] can lean to the left while using slide board, and that slide board was necessary to transfer the resident safely. Review of Resident 9's Minimum Data Set (MDS, an assessment tool), section GG Functional Abilities, performed on 4/27/25, indicated that Resident 9 was dependent (needed complete assistance) for a bed-to-chair transfer. Review of the facility's record titled, Shift Report (undated), a sheet used for CNAs to provide care to residents, indicated that Resident 9 was a two person assist, using a slide board [an assistive device that reduces a resident's need to support their weight while being transferred from one surface to another by staff].Review of the facility's Occupational Therapy department's record titled, OT Daily Documentation, dated 11/25/24, indicated that Resident 9 required a slide board for CNA staff to transfer her, Educated and modeled [demonstrated] for staff transfers with slide board.A review of Occupational Therapy notes from 12/1/24 to 7/1/25 indicated Resident 9 was a moderate to maximum assist using slide board in all instances.Review of Resident 1's Nurses Notes, dated 7/1/25, indicated that on 7/1/25 at 11:30 AM, CNA A was attempting to transfer Resident 9 from her bed to her wheelchair without the use of a slide board, and had asked Resident 9 to stand on her only leg. Resident 9 slid to the bed, injuring her right ankle.In an interview with Director of Nursing (DON) on 7/22/25 at 3:00 PM, DON indicated that the standard of care for transferring residents in the facility is Lippincott procedures (undated), an online nursing resource as follows: A review of Lippincott procedures, Transfer from Bed to Wheelchair, (undated) provided by the facility indicated: For a patient who can't stand, a transfer board allows safe transfer from a bed to a wheelchair; and; Assess the patient's needs and abilities when making decisions about the necessary equipment for transfer, because different patients require varying levels of assistance with transfer. [NAME] further indicated, A lateral patient transfer can pose risks to the patient and health care worker. Safe patient transfer may require the assistance of one or more coworkers as well as the use of assistive patient handling equipment, such as a sliding board.Review of progress notes dated 7/11/25, indicated that Resident 9's right ankle became swollen and bruised and she was transferred to the hospital emergency room for an examination and treatment.Review of the hospital emergency room notes for Resident 9's visit, dated 7/12/25, indicated that Resident 9 sustained a fracture [broken] of the right ankle.In an interview on 7/21/2025 at 1:39 PM, Resident 9's Family Member (FAM) N stated that Resident 9 sometimes refused to use the slide board, but it's easy to redirect her and ask her to use the board. FAM N stated that if Resident 9 refused the board, staff should not be transferring her under any circumstances since she has to bear all her weight on one weak leg and has osteoporosis (weak, calcium-poor bones prone to breakage). In an interview on 7/22/2025 at 10:05 AM, CNA A confirmed that she had transferred Resident 1 without using a slide board or two-person assist as she had been instructed. CNA A stated that she should have alerted a nurse to help her when Resident 1 refused to use the slide board, and that she should have used a two-person assist and got another CNA to help. She confirmed that the using the sliding board for Resident 9 to transfer is listed on the rounding sheet, (shift report) that we are provided. CNA A stated that she was trained to get help and to use the slide board, and would do that next time.In an interview on 7/22/2025 at 10:27 AM, Occupational Therapist (OT) B stated, When we worked with [Resident 9], we recommended a slide board be used because of her knee pain and having only one leg, it relieved the pressure on her knee. She is at least a two-person assist for patient and staff safety. If a resident refuses to use the board to transfer, they should 1) Get help, or 2) speak to the resident and let her know that we would need to use a Hoyer (mechanical) lift, which is also a 2 person assist. In an interview on 7//24/25 at 11:00 AM, OT C stated that she worked with Resident 9 for nine months on transferring safely. She needed the slide board because of her knee pain, we shouldn't be doing ‘stand and pivot' transfers because they torque [twist] the knee and ankle, and she only had that leg to stand on. OT C stated that the slide board was recommended for Resident 1's safety and for staff safety. We did training with nursing assistant staff working with the resident, to transfer her safely. Somedays she refused, the remedy was just to spend more time with resident [Resident 9] to persuade her to allow the slide board to be used. 2. Resident 36 was admitted to the facility for brain injury, late-stage chronic (ongoing) kidney disease, heart failure, and a history of stroke. Review of the facility's policy titled, Safety guidelines and usage training for medical gases and cylinders, (undated) indicated, Oxygen is a drug and requires a physician's order.Review of the facility's policy titled, Oxygen Therapy SNF [Skilled Nursing Facility] indicated, Licensed nurse on night shift is responsible for changing and dating the equipment and documenting the process on the Electronic Medical Record (EMR). 7. Respiratory Therapy or Nursing is to be contacted when portable tanks need to be refilled. CNAs may not regulate flow rates but are responsible for checking that cannulas are placed properly on residents attached to an oxygen source. The licensed nurse shall monitor oxygen administration and record the resident's response to oxygen therapy in the medical record.Review of Resident 36's physicians orders indicated an order for, Oxygen at two liters (liters, a unit of measure), continuously by way of nasal cannula [a soft flexible tube in the nose] to keep oxygen saturation at 90 percent or greater every day and night shift for hypoxia 9 (low oxygen level in the blood). In a concurrent interview and observation on 7/21/25 at 3:30 PM, Resident 36 was observed in a wheelchair in the facility's activities room with an oxygen tank attached to his wheelchair and a nasal cannula in his nose. The valve on the oxygen tank was halfway within the Red, or Empty zone. In an interview on 7/21/2025 at 3:33 PM, CNA D confirmed that he was supervising Resident 36, who should be on continuous oxygen and that the tank was empty. CNA D immediately went to find a full replacement tank. CNA D stated that he is usually the one to do rounds to check tanks. CNA D replaced the oxygen tank and continued oxygen administration at 2 liters per minute without nursing oversight. In an interview on 7/21/2025 at 3:50 PM, Registered Nurse (RN) E confirmed that she was Resident 36's nurse, RN E confirmed that Resident 36 should have been on continuous oxygen and that usually CNAs do rounds on the oxygen tanks and that Resident 36's tank should not have been left empty. In an interview and concurrent record review on 7/23/25 at 2:49 PM, with the DON, she stated that the facility educated CNAs in oxygen management but was unable to provide evidence that CNA D had that education.

Based on interview, observation and record review, the facility failed to meet this requirement when staff failed to follow a physician ordered therapeutic diet and fortify (add extra calories) one of six sampled residents who were on therapeutic diets. (Resident 12)This had the potential to cause undesired weight loss, delayed wound healing and malnutrition for Resident 1 and other residents who had physician ordered fortified diets. A review of the facility's record titled, Policy and Procedures Manual: High Calorie/High Protein Supplements, Nutrition Interventions dated 2021 indicated, Individuals needing supplemental nutrition will be served a suitable high calorie/high protein diet, and Nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record. A review of the facility's diet manual used by kitchen staff, Fortified Diet was defined as Foods that have protein, carbohydrates, and/or fats added to increase the total nutritional value of the food. A review of the facility's physician-ordered diet for Resident 12 (undated report) indicated Fortified diet. In a concurrent observation and interview on 7/22/25 at 12:16 PM, Dietary Manager (DM) G was observed plating food for residents on fortified diets. No fortification was observed being made to the Beef with Roasted Vegetables entree that DM G plated for Resident 12. When brought to DM G's attention, DM G stated that the fortification for today's entree was an extra pat of margarine. The margarine was observed to be placed alongside Resident 12's napkin on the tray with a pat of margarine for the roll that was presented.In an observation on 7/22/25 at 12:35 PM, Certified Nursing Assistant (CNA) D was observed presenting Resident 12's tray for lunch; CNA D did not offer the margarine that was on his tray that was intended as required fortification. We present butter if they ask for it. CNA D stated that he was unaware that the additional pat of margarine was part of the fortified diet ordered for Resident 12.In an interview on 7/22/25 at 12:48 PM, CNA H was unaware that fortification for residents' diets that day was a butter pat. CNA H stated, They can eat whatever they want.In an interview on 7/23/25 at 10:05 AM, the Director of Nursing (DON) stated that nursing staff was not aware that butter pat was a part of the therapeutic diet, therefore no training was given to CNAs to ensure extra margarine pat was used and given to each resident requiring a fortified diet.In an interview on 7/24/25 at 3:30 PM, Registered Dietitian (RD) J stated that it is her expectation that additional calories for fortified diets should be part of each recipe for the food presented, not to be presented as margarine pats on the tray.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) sampled for post-fall pain received the treatment and care to manage pain when: * Staff did not promptly assess Resident 1 for a change of condition for a new onset of pain in her left arm and left hip after she was found on the floor. Staff picked Resident 1 up off the ground and put her into a chair while she complained of pain. * Staff gave Resident 1 medication ordered for mild pain when she experienced moderate pain. * The Physician (MD) was not immediately notified of Resident 1's fall and complaint of pain with movement. These failures caused Resident 1 to experience moderate and severe left arm and left leg pain for eight hours, prevented her from eating lunch or dinner. Findings A review of the facility's policy, Change in Condition and Alert Charting, revised November 2024, indicated, A change in condition is defined as anytime an accident involving the resident results in injury which requires provider's intervention; there is a significant change in the resident's physical, mental, or psychosocial status or behavioral condition changes; or a need to alter treatment or add a new medication. The policy indicated, The following are some examples of adverse changes in resident condition: .Fall: witnessed or reported, .Any sudden and/or marked adverse change in signs/symptoms, or behavior exhibited by a resident The policy indicated, It is the policy of [name of facility] to promptly recognize any resident changes in condition and implement alert charting, and that The nurse will conduct an assessment and notify the resident's primary provider, resident representative and the resident. A review of the facility's policy, Pain Management in the Skilled Nursing Facility, revised November 2024, indicated, The goal of pain management is to minimize the amount, duration and intensity of pain The policy indicated, Residents will be assessed for the presence or absence of pain during the initial assessment and periodically thereafter. If pain is present at any initial assessment or following a pain producing event, it will be managed in accordance with this policy. The policy indicated, Pain level will be reassessed within 30-60 minutes after each pain management intervention with the post intervention pain rating documented on the Medication Administration Record (MAR). The policy indicated, Pharmacological (pertaining to medication) Management. a. Pain medication shall be administered utilizing the appropriate dosage as indicated by the provider's medication order and the 10-point Pain Scale: mild pain 0-3, moderate pain 4-7, severe pain 8-10. The policy indicated, Non-pharmacological (treatments other than medication) techniques will be used as appropriate and may include but not be limited to: Repositioning of the resident The policy indicated, Collaborate with the provider as needed regarding use of adjuvant medications (the use of other medications to aid in pain relief) The policy indicated, Initial pain assessments, b. Medication administration, c. Evaluation of the effectiveness of pain management interventions. D. Reportable conditions or adverse reactions on the appropriate event for and in the record. A review of the facility's policy, Fall Prevention and Post Fall Guidelines, revised September 2024, indicated a Post Fall Protocol that included, Perform an initial assessment immediately: 1. Vital signs (a group of the four to six most crucial medical signs that indicate the status of the body's vital functions) . 2. Initial Neuro Assessment (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) . d. mobility (movement of extremities .). 3. Obvious injuries (e.g., . new pain with movement or palpation). C. Contact the physician immediately so that he/she can reassess the patient. A review of Resident 1's undated admission Record indicate she was admitted to the facility on [DATE], with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities), parkinsonism (a syndrome characterized by tremors, bradykinesia [slowness of movement], rigidity (stiffness), and postural instability [difficulty maintaining an upright posture and balance]), hearing loss, osteoporosis (weak and brittle bones), and traumatic brain injury (an injury to the brain caused by an external force, such as a blow, jolt, or impact to the head). Resident 1 had a responsible party (RP) who made health care decisions for her. A review of Resident 1's Quarterly Minimum Data Set (MDS- a standardized resident assessment) dated 2/28/25, indicated a Brief Interview for Mental Status (BIMS- a numerical representation of a person's ability to think and reason, assessed through a structured interview) score of 03, signifying severe cognitive impairment. Section GG (a standardized assessment used to evaluate a patient's self-care and mobility abilities) indicated that Resident 1 walked independently and could sit and stand with set-up help. During an interview on 5/12/25, at 11:02 am, the Assistant Director of Nursing (ADON) confirmed Resident 1 fell on 5/2/25, around 11:15 am. A review of Resident 1's progress note titled Alert Note dated 5/2/25, at 4:51 pm (5.5 hours after the incident), Licensed Nurse (LN) C documented on alert charting for left leg pain. resident (Resident 1) sat on the floor with no initial c/o (complaint) of pain. One hour later she stated pain, ACETAMINOPHEN ( Tylenol) was given and effective. Re-eval 5/5/25. A review of Resident 1's progress note titled Alert Note dated 5/2/25, at 8:49 pm, LN F documented, When coming into this shift (I) received report from off going nurse (LN C) about resident (Resident 1) sitting on the floor, having pain in left leg and arm, (and) to monitor. Resident (Resident 1) was still c/o (complaining of) pain at 6:31 pm, this nurse gave Acetaminophen to resident c/o pain in left leg and arm. (Resident 1) Refusing care and vital signs. The medication was ineffective at 7:10 pm. This nurse then informed Dr (MD's name) of these findings.Dr (MD's name) gave orders to this nurse to send resident out to ED (Emergency Department) for pain. A review of Resident 1's ED CT (computerized x-ray) scan of her left femur results, dated 5/2/25, at 9:52 pm, indicated an Acute Displaced sub capital left femoral neck fracture (a broken left hip bone). During an interview on 5/12/25, at 12:35 pm, Housekeeper (HSK) A stated that on 5/2/25, at approximately 11:00 am, she observed Resident 1 fall onto her left side in the hallway near the nurse's station. HSK A stated she heard a thud and ran to check for blood. HSK A stated she observed no staff in the hallway or at the nurse's station. HSK A stated she found LN C in the medication room, knocked on the door, and informed LN C that Resident 1 fell. HSK A stated, Resident 1 was laying down on her left side and she never straightened her legs. HSK A stated, The nurse (LN C) said (to Resident 1) 'why you lay down on the floor this is not nice.' HSK A replied, I said (to LN C) she (Resident 1) did not lay down she fell. HSK A witnessed Certified Nursing Assistant (CNA) B lift Resident 1 by placing her arms under Resident 1's armpits, and LN C push Resident 1 onto the chair with her knee. HSK A heard Resident 1 cry and say, leave me alone it hurts. HSK A informed LN C three times that Resident 1 had fallen. HSK A also noted that Resident 2 witnessed the event. A review of Resident 2's undated admission Record indicated she was admitted to the facility on [DATE], with diagnoses including conduct disorder, dysphagia (difficulty swallowing), high blood pressure, and seizures. Resident 2's annual MDS dated [DATE] indicated a BIMS score of 14, signifying intact cognition. During an interview in Resident 2's room on 5/12/25, at 1:30 pm, Resident 2 stated, I saw lady (Resident 1's name) fall and I saw (LN C's name) and another person (unnamed) get her off the floor and she (Resident 1) said my leg, my back hurts then she spent the rest of the day in her room. Resident 2 stated, I saw (Resident 1) fall, I told (LN) that she fell. Resident 2 stated, They (LN C and another person) picked her up and put her in a regular chair and then later they transferred her to a wheelchair and took her to her room. Resident 2 stated she heard Resident 1 say, let me go lay down I'm in pain; I want to lay down. Resident 2 stated, When she (Resident 1) was sitting in the chair I was rubbing her back because she kept saying 'it hurts.' During a phone interview on 5/13/25, at 4:00 pm, CNA B stated that on 5/2/25, around 11:00 am, she saw Resident 1 on the floor after returning from answering a call-light. CNA B and LN C picked Resident 1 up from the floor and placed her back in the chair. CNA B stated that Resident 1, who had walked earlier, was unable to bear any weight and said, it hurts! with a tight, uncomfortable expression. CNA B stated, I did not take her vitals. You're supposed to make sure she (Resident 1) is ok (before moving a resident), but I do not know if that happened. CNA B stated, around noon (Resident 1) was unable to walk because of the pain so we (LN C and CNA B) helped her lay down on the bed and she (Resident 1) was saying it hurt but she was not specific to where the pain was. CNA B stated, LN C and I tried to move her (Resident 1) in the bed and that's when she was saying it hurts, it hurts. During an interview on 5/13/25, at 4:11 pm, LN C stated that on 5/2/25, around 11:00 am, she returned from the Medication Room to find Resident 1 on the floor. LN C stated that Resident 1's At Risk For Falls care plan indicated she would sit herself on the floor. LN C stated, I did not know if she (Resident 1) fell or if she sat intentionally. LN C stated, I did not know if it was witnessed or unwitnessed. LN C stated she witnessed CNA B quickly lift Resident 1 by placing her arms under Resident 1's armpits. LN C stated, CNA B put Resident 1 on my knee then I pushed her onto the chair with my knee and hands. LN C stated she touched Resident 1's left shoulder and left hip, and Resident 1 was tense and pushed her away. LN C stated, (Resident 1) was rigid on the floor and was tense so I did not move her extremities (assess range of motion of her arms and legs). She would not move anything for me. I should have assessed her. I gave her [Acetaminophen] because she said it hurt. LN C stated that 20 minutes later, at lunchtime, Resident 1 stated, I do not want lunch. LN C stated that at noon, Resident 1 was wheeled to her room and stated, leave me alone and don't move me, but two staff members transferred her to her bed. LN C stated she did not notify the primary physician or Resident 1's responsible party at that time and should have. LN C stated she informed the DON of the incident, and the DON told her that because Resident 1 had a care plan to sit on the ground, this was not considered a fall. LN C stated she waited until the end of her shift on 5/2/25, at 5:33 pm (6 hours after the incident), to email the Physician (MD). LN C stated she did not take vitals or assess Resident 1 while she was on the floor because Resident 1's care plan indicated she sat herself on the ground. LN C stated she did not see Resident 1 sit herself on the ground and did not remember anyone saying Resident 1 fell. LN C stated Resident 1 had pain, and she should have assessed Resident 1 and notified the MD at the time of the incident, but she did not. During an interview on 5/14/25, at 1:29 pm, HSK D stated that on 5/2/25, around 11:00 am, she saw Resident 1 lying on the floor on her left side. HSK D stated she heard HSK A tell LN C that Resident 1 had fallen. HSK D stated she observed LN C and CNA B pick up Resident 1 and place her in the chair, and Resident 1 screamed that it hurt. HSK D stated that around noon, she saw the DON and LN C trying to help Resident 1 stand up, and Resident 1 resisted, saying, It is hurting. During an interview on 5/14/25, at 1:42 pm, CNA E, stated she was assigned to care for Resident 1 on 5/2/25. CNA E stated that around 12:00 pm, Resident 1 and Resident 2 were sitting in a chair at the nurse's station with LN C and the DON also present. CNA E stated, Resident 2 said 'she (Resident 1) fell, she fell.' CNA E stated she observed Resident 1 sitting in a chair with her legs curled up to the left. CNA E stated Resident 1 was not her normal self, not smiling, engaging, or looking back. CNA E stated she attempted to help Resident 1 walk to her room, which usually worked, but Resident 1 would not. CNA E stated she, LN C, and the DON tried to help Resident 1 stand up and transfer her to a wheelchair. CNA E stated, She (Resident 1) was holding her left hip. She was making moaning noises We (DON, LN C, and CNA E) then transferred Resident 1 to her bed, and she was moaning, and she said no, no, no. CNA E stated, When she (Resident 1) was in bed she had her legs curled up and was leaning to the right. The DON felt (Resident 1's name) left leg but we did not move her. Resident 1 did not want her legs straightened so we supported her back and left her lying there and she was moaning. She was saying no.no. no. CNA E added, At 2:00 pm she was still moaning and said the hip hurt and was still in the same position. I informed LN C, and she said they gave her (Resident 1) Acetaminophen. CNA E stated she felt Resident 1 was in more pain at 2:00 pm. CNA E continued to say that at 4:00 pm, she (CNA E) tried to get Resident 1 up for dinner, but she (Resident 1) was still curled up in the same position and she was holding her left hip, was moaning and did not eat lunch or dinner that day. During an interview at a Local Hospital (LH) with Resident 1's Hospital Occupational Therapist (OT) on 5/14/25, at 10:30 am, the OT stated that Resident 1 arrived at LH's emergency department (ED) on 5/2/25 and was diagnosed with a broken left hip. The OT stated that Resident 1 was then transferred to another hospital for surgery and subsequently returned to LH. The OT stated Resident 1 was in significant pain and unwilling to participate in therapy, taking OxyContin (a strong narcotic pain medication used to relieve severe ongoing pain, which may lead to severe psychological or physical dependence and has abuse potential and can cause serious or life-threatening breathing problems and death) 5 milligrams (mg-a unit of measure) for pain. During an interview with Resident 1's Hospital Nurse (HN) at the LH on 5/14/25, at 10:35 am, HN stated that Resident 1 was in significant pain and completely dependent on staff for assistance. HN stated that OxyContin made Resident 1 very sleepy and foggy, so hospital staff were attempting to adjust her pain medication. During an observation and interview on 5/14/25, at 10:55 am, Resident 1 lay in bed at LH with her right leg bent at the knee and her left leg flat. Resident 1 slightly moved her right leg but not her left. When asked how she was doing, Resident 1 stated, Not very good without opening her eyes. Resident 1's speech was weak and slow. Resident 1 stated, I do not feel good It hurts in different places I cannot pinpoint it (where the pain was). Resident 1 never opened her eyes, smiled, or turned her head during the visit. A review of Resident 1's Amount Eaten record for 5/2/25, indicated she did not eat lunch or dinner on that day. A review of Resident 1's Physician orders dated May 2025, indicated an order for Acetaminophen Tablet 325 mg (two tablets by mouth every six hours as needed for mild pain rating of 1-3), written on 10/25/24, by the MD. Physician orders for 5/2/25, contained no other physician orders for moderate pain levels (4-7) or severe pain levels (8-10). A review of Resident 1's May 2025 Medication Administration Record (MAR) indicated that on 5/2/25, at 12:00 pm, LN C administered Acetaminophen tablet 325 mg, ordered for mild pain (1-3), two tablets for Resident 1's pain level of six (moderate pain). On 5/2/25, at 6:30 pm, LN F administered another Acetaminophen tablet 325 mg, two tablets, for Resident 1's pain level of seven (moderate pain). During a concurrent phone interview and review of Teams messages on 5/14/25, at 11:12 pm, the MD stated that on 5/2/25, at 5:33 pm (6 hours after the incident), he received a Teams message from LN C that read, [Resident 1] sat herself on the ground and had pain one hour after that and that Acetaminophen helped. The MD stated he received another Teams message on 5/2/25, at 7:10 pm (8 hours after the incident), from LN F, which stated, [Resident 1] has been in pain, I administered Acetaminophen at 6:31(pm) when she complained of 7/10 (moderate) pain. [Resident 1] c/o (complained of) pain in left arm and left leg. The medication is ineffective, [Resident 1's] pain has increased 9/10 (severe), she has been lying in bed on her right side (7 hours since placed in bed). She is in so much pain, staff and I are unable to touch her or obtain VS (vital signs) or to get an assessment she cries out when we attempt care. [Resident 1] didn't touch her dinner tray and refused ensure. The MD stated that after the second Teams message, he immediately called the nurse and had [Resident 1] sent to the ED. The MD stated, Later I found out that a fall (by Resident 1) was witnessed by the housekeeper. There was a lack of documentation about this. The (first) message was misleading. The nurse did not convey that it happened hours before (the 5:33 pm Teams message). She (LN C) indicated that she knew that [Resident 1] intentionally sat on the floor. I had no indication that [Resident 1] had a fall. If the nurse did not witness the incident, then she should have indicated that. If there was pain, then a fall assessment should have been done. If there was pain with movement then they (staff) should not have gotten [Resident 1] up. The MD indicated that if he had been notified right away of the situation, this would have minimized the time [Resident 1] was in pain. During an interview with the DON and record review on 5/14/25, at 3:41 pm, the DON reviewed Resident 1's May 2025 MAR, physician orders, and nurses' progress notes. The DON stated [Resident 1] should have been assessed for a fall when she was on the floor, and the physician should have been promptly notified of [Resident 1's] pain but was not. A review of Resident 1's MAR and physician orders for 5/2/25, indicated that Resident 1 had a pain level of six and seven and received Acetaminophen, which was not ordered for pain above a level of three, and the MD should have been notified to obtain an order for appropriate pain medication, but was not.

Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 1) sampled for falls was free from an avoidable fall. According to the facility's assessments, Resident 1 had difficulty maintaining an upright posture and poor safety awareness. Certified Nursing Assistant (CNA) B observed Resident 1 leaning over and reaching for the floor but did not help Resident 1 to a safe position and left Resident 1 unsupervised. Resident 1 had no post fall assessment and Resident 1's care plan did not provide interventions for what to do if Resident 1 was found on the floor unwitnessed. This fall resulted in Resident 1 falling and sustaining a broken left hip. Resident 1 required hospital admission for surgery. Resident 1 had a decline in her physical, social, and mental well-being due to increased pain. Findings: A review of the facility's policy, Resident Safety, dated 7/1/24, indicated, It is the policy of [name of facility] to ensure the optimum safety for all residents at all times by increasing staff awareness and encouraging strict adherence to practices that ensure optimum resident safety. A. Be alert for, and report promptly, any unsafe conditions or practices that you see. A review of Resident 1's undated admission Record indicated her admission to the facility on [DATE]. Her diagnoses included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Parkinsonism (a condition causing tremors, slow movements, stiffness, and difficulty with balance), hearing loss, Osteoporosis (weak and brittle bones), and a traumatic brain injury (an injury to the brain caused by an external force, such as a blow, jolt, or impact to the head). A review of Resident 1's Quarterly Minimum Data Set (MDS, a data-driven resident clinical assessment), dated 2/8/25, indicated a score of 3 out of 15 on her Brief Interview for Mental Status (BIMS, an assessment of memory, thinking, and problem-solving that is scored from 0/worst to 15/best). This score indicated severe memory and decision-making problems. Resident 1 walked independently and could sit and stand with set up help (the helper assists the resident prior to, or after sitting or standing). A review of Resident 1's Fall Risk Evaluation, dated 1/28/25, indicated a score of 12, which was High Risk for falls. The Fall Risk Evaluation indicated the factors contributing to this risk included: sustaining 1 to 2 falls in the past three months, a balance problem while standing, disorientation to person, place, and time, and taking risperidone (an antipsychotic medication) that had potential adverse side effects of tremor, stiffness, restlessness, and involuntary movements. A review of Resident 1's At Risk for Falls care plan, revised on 4/6/25, indicated, [Resident 1] is [at] risk for falls r/t [related to] confusion, unaware of safety needs. Interventions included providing a safe environment, anticipating and meeting Resident 1's needs, providing activities to minimize falls, watching for signs of weakness and unstable gait (how a person walks), notifying the Physician (MD), and directing Resident 1 to a quiet area if she showed fatigue and sat or lay on the floor. During an interview on 5/2/25, at approximately 11:00 am, Housekeeper (HSK) A stated she observed Resident 1 fall from her chair onto her left side in the hallway. HSK A stated she heard a thud and ran to check for blood. HSK A stated she saw no staff in the hallway or at the nurse's station. HSK A stated she found Licensed Nurse (LN) C in the medication room and informed her of the fall. HSK A stated, Resident 1 was laying down on her left side and she never straightened her legs. HSK A stated, The nurse [LN C] said [to Resident 1] 'why you lay down on the floor this is not nice.' HSK A stated, I said [to LN C] she [Resident 1] did not lay down she fell. HSK A stated she witnessed Certified Nursing Assistant (CNA) B lift Resident 1 by placing her arms under Resident 1's armpits, and LN C push Resident 1 onto the chair with her knee. HSK A stated she heard Resident 1 cry and say, leave me alone it hurts. HSK A stated she informed LN C three times that Resident 1 had fallen. HSK A stated They (LN C and CNA B) did not assess her [Resident 1] or do vitals. HSK A stated that Resident 2 also witnessed the event. A review of Resident 2's undated admission Record indicated she was admitted to the facility on [DATE], with diagnoses including conduct disorder, dysphagia (difficulty swallowing), high blood pressure, and seizures. A review of Resident 2's Annual MDS dated [DATE] indicated a BIMS score of 14, signifying intact cognition (ability to think and reason). During an interview in Resident 2's room on 5/12/25, at 1:30 pm, Resident 2 stated, I saw lady [Resident 1's name] fall and I saw [LN C's name] and another person [unnamed] get her off the floor and she [Resident 1] said my leg, my back hurts then she spent the rest of the day in her room. Resident 2 stated, I saw her fall, I told [LN C's name] that she fell. During a telephone interview on 5/13/25, at 4:11 pm CNA B stated that on 5/2/25, around 11:00 am, just before Resident 1 was on the ground, she witnessed Resident 1 in a chair bending over, reaching for the ground like she was picking up something off of the floor. CNA B stated, I told her to sit up straight and told the nurse [LN C] at the desk that she was bending over then went into another resident's room [unknown]. CNA B indicated that Resident 1 would sit at the nurse's station for better supervision. CNA B stated, When I went by her and told her to sit up, I did not stop to make sure she was sitting up and in a safe position. CNA stated, I should have made sure she [Resident 1] was safe before I left her. When CNA B returned, Resident 1 was on the floor. CNA B stated that she and LN C picked Resident 1 up from the floor and placed her back in the chair. CNA B stated that Resident 1, who had walked earlier, was unable to bear any weight and said, it hurts! with a tight, uncomfortable expression. During an interview on 5/13/25, at 4:11 pm LN C stated that around 11:00 am on 5/2/25, she returned from the Medication Room to find Resident 1 on the floor. LN C stated Resident 1's care plan indicated she would sit herself on the floor. LN C stated, I did not know if she [Resident 1] fell or if she sat intentionally. LN C stated, I did not know if it was witnessed or unwitnessed. LN C stated she witnessed CNA B quickly lift Resident 1 by placing her arms under Resident 1's armpits. LN C stated, CNA B put Resident 1 on my knee then I pushed her onto the chair with my knee and hands. LN C stated she touched Resident 1's left shoulder and left hip, and Resident 1 was tense and pushed her away. LN C stated, [Resident 1] was rigid on the floor and was tense, so I did not move her extremities [assess range of motion of her arms and legs]. She would not move anything for me. I should have assessed her for a fall, but I did not. I gave her Tylenol because she said it hurt. LN C indicated that 20 minutes later, at lunchtime, Resident 1 stated, I do not want lunch. LN C stated that at noon, Resident 1 was wheeled to her room and stated, leave me alone and don't move me, but two staff members transferred her to her bed. LN C stated she did not notify the primary physician or Resident 1's responsible party at that time and should have. LN C stated she informed the Director of Nursing (DON) of the incident, and the DON told her that because Resident 1 had a care plan to sit on the ground, this was not considered a fall. LN C waited until the end of her shift on 5/2/25, at 5:33 pm to email MD. LN C stated she did not take vitals or assess Resident 1 while she was on the floor because Resident 1's care plan indicated she sat herself on the ground. LN C stated she did not see Resident 1 sit herself on the ground and did not remember anyone saying Resident 1 fell. LN C stated Resident 1 had pain, and she should have assessed Resident 1 and notified the MD at the time of the incident, but she did not. During an interview on 5/14/25, at 3:41 pm the Director of Nursing (DON) indicated that CNA B should have helped Resident 1 back into a safe sitting position before leaving her unsupervised, and she did not. The DON stated, There should have been an assessment when she (Resident 1) was on the floor and there was not. The DON stated that if staff found a resident on the floor and were unsure how it happened, they should consider it a fall. However, because Resident 1 had a care plan that said she sits herself on the ground, interventions to assess Resident 1 for a fall and injury did not happen. The DON stated, we did not follow our post fall policy, and we should have. A review of Resident 1's progress note titled Alert Note dated 5/2/25 LN F indicated on May 2, 2025, at 8:49 pm, When coming into this shift [I] received report from off going nurse [LN C] about resident [Resident 1] sitting on the floor, having pain in left leg and arm, [and] to monitor. Resident [1] was still c/o (complaining of) pain at 6:31 pm, this nurse gave Tylenol to resident c/o pain in left leg and arm. [Resident 1] refusing care and vital signs. The medication was ineffective at 7:10 pm. This nurse then informed Dr [MD's name] of these findings.Dr [MD's name] gave orders to this nurse to send resident out to ED (Emergency Department) for pain. A review of Resident 1's ED's CT (computed tomography- a computerized x-ray) scan of her left femur (large bone of the upper left leg) results, dated 5/2/25, at 9:52 pm, indicated Resident 1 had an Acute Displaced sub capital left femoral neck fracture (a broken left hip bone). During an interview at a Local Hospital (LH) with Resident 1's Hospital Occupational Therapist (OT) on 5/14/25, at 10:30 am Resident 1's Hospital Occupational Therapist (OT) indicated that Resident 1 came to LH's emergency department (ED) on 5/2/25 and was diagnosed with a broken left hip. The OT stated Resident 1 was then transferred to another hospital for surgery and then transferred back to LH. The OT stated Resident 1 was in significant pain and unwilling to participate in therapy and was taking OxyContin (a strong opioid [narcotic] pain medication used to relieve severe ongoing pain, which may lead to severe psychological or physical dependence and has abuse potential and can cause serious or life-threatening breathing problems and death) 5 mg (milligrams) for pain. During an interview with Resident 1's Hospital Nurse (HN) at the LH on 5/14/25, at 10:35 am, Resident 1's Hospital Nurse (HN) stated that Resident 1 was in significant pain and completely dependent on staff for assistance. The HN noted that OxyContin made Resident 1 very sleepy and foggy, so hospital staff were attempting to adjust her pain medication. During an observation and interview at LH on May 14, 2025, at 10:55 am, Resident 1 lay in bed with her right leg bent at the knee and her left leg flat. Resident 1 slightly moved her right leg but not her left. When asked how she was doing, Resident 1 replied, Not very good without opening her eyes. Resident 1's speech was weak and slow. She stated, I do not feel good. It hurts in different places. I cannot pinpoint it (where the pain was). Resident 1 never opened her eyes, smiled, or turned her head during the visit. Three hospital staff entered Resident 1's room to change her left hip dressing.

Based on interview and record review, the facility failed to promptly identify and notify the physician and responsible party of a change of condition for one of two residents (Resident 1) when Resident 1 had a fall which resulted in a new onset of pain. This resulted in an eight-hour delay in treatment for Resident 1 which caused unnecessary pain and suffering. Findings: A review of the facility ' s policy titled Change in Condition and Alert Charting revised 11/24, indicated A change in condition is defined as anytime an accident involving the resident results in injury which requires provider ' s intervention; there is a significant change in the resident ' s physical, mental, or psychosocial status or behavioral condition changes .It is the policy of [name of facility] to promptly recognize any resident changes in condition and implement alert charting. The nurse will conduct an assessment and notify the resident ' s primary provider, resident representative and the resident. A review of Resident 1 ' s admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (loss of memory, language, problem-solving and other thinking abilities), parkinsonism (a syndrome characterized by tremors, bradykinesia [slowness of movement], rigidity (stiffness), and postural instability [difficulty maintaining an upright posture and balance]), hearing loss, osteoporosis (weak and brittle bones) and traumatic brain injury. Resident 1 had a responsible party (RP) who made health care decisions for her. During an interview on 5/12/25, at 11:02 am, the Assistant Director of Nursing (ADON) indicated Resident 1 had a fall on 5/2/25 around 11:15 am. A review of Resident 1 ' s pain vitals (documentation of residents ' complaint of pain on a scale from 0-10 with 0 being no pain and 10 being the worst pain) from 4/24/25 at 4:13 am, through 5/2/25 at 5:27 am, showed that Resident 1 did not complain of pain for these eight days prior to the fall. On 5/2/25 Resident 1 complained of pain rating a six at 12:00 pm, a seven at 6:31 pm, and a nine at 7:10 pm. During an interview on 5/12/25, at 12:35 pm, Housekeeper (HSK) A indicated that on 5/2/25 at around 11:00 am, she saw and heard Resident 1 fall from her chair and land on her left side while sitting at the nurse ' s station. HSK A indicated she went to get help from a nurse and then returned to Resident 1. HSK A indicated that as Licensed Nurse (LN) C and Certified Nursing Assistant (CNA) B was assisting Resident 1 back into her chair, Resident 1 was crying and stated, Leave me alone it hurts. HSK A indicated she informed LN C that Resident 1 had fallen. During an interview on 5/13/25, at 4:11 pm, LN C indicated that Resident 1 was noted to be sitting on the floor in front of the nurse ' s station on 5/2/25 around 11:00 am. LN C indicated that CNA B and herself lifted Resident 1 up off the floor and placed her back in a chair. LN C indicated Resident 1 had pain in her left side, was rigid and tense all over. LN C indicated that at noon that same day Resident 1 was wheeled to her room and stated, leave me alone and don ' t move me but was transferred to her bed by two staff members. LN C indicated that she did not notify the primary physician or Resident 1 ' s RP at that time and she should have. LN C indicated that she waited until the end of her shift to send an email to the Medical Director (MD, her primary physician). During an interview on 5/14/25, at 11:12 pm, MD indicated that he was first notified that anything was wrong on 5/2/25 at 5:33 pm, by a TEAM message and the message said that Resident 1 sat herself on the ground and had pain one hour after that and that Tylenol (Acetaminophen, a mild pain medication) helped. MD indicated that there was no time noted for the incident and no assessment included and there should have been. MD indicated that he had no idea that Resident 1 had fallen or had pain with movement. MD indicated he should have been notified right away, but instead he got an email on 5/2/25 at 7:10 pm (8 hours after incident), LN F wrote Resident 1 has been in pain, I administered Tylenol at 6:31(pm) when she complained of 7/10 (strong) pain. She (Resident 1) c/o (complained) pain in left arm and leg. The medication is ineffective, her (Resident 1 ' s) pain has increased 9/10 she has been lying in bed on her right side. She is in so much pain, myself and staff are unable to touch her or obtain VS (vital signs) or to get an assessment she cries out when we attempt care. She didn ' t touch her dinner tray and refused ensure. A review of Resident 1 ' s Emergency Department (ED) results dated 5/2/25 at 9:52 pm, indicated Resident 1 had an Acute Displaced subcapital left femoral neck fracture (left hip fracture). During an interview on 5/14/25, at 2:30 pm, RP indicated that she received a call on 5/2/25 at 7:30 pm, about what happened that day and that her mother was going to the emergency room. RP said it was her understanding that the facility was supposed to notify her when something happened to her mother. RP indicated that she was not notified earlier when her mother had fallen and was in pain. During a review of the facility ' s document titled Alert Charting -For Changes in Condition dated 5/2/25, Resident 1 was identified as having left leg pain and the sections identified as MD informed and documented and Family informed and documented was not signed as done. During an interview and record review with the Director of Nursing (DON) on 5/14/25, at 3:41 pm, the document titled Alert Charting-For Changes in Condition dated 5/2/25 and Resident 1 ' s progress notes dated 5/2/25 were reviewed. DON indicated there was no documentation in Resident 1 ' s progress notes or on the Alert Charting-For Changes in Condition that LN C had notified the primary physician of the change of condition when the incident happened, and she should have. The DON indicated that the RP should have been notified when Resident 1 had a change in condition.

Based on Interview and Record Review, the facility failed to meet this requirement when a staff member spoke to a resident (Resident 1) in a manner the resident perceived as disrespectful. This had the potential to result in psychological harm to Resident 1 and compromised the resident's sense of well-being and feeling of being in a home-like environment. Resident 1 was admitted to the facility for conditions including age-related debility (unable to perform tasks that are part of daily living), arthritis, and heart disease. A review of the facility's policy titled, Elder or Dependent Adult Abuse Reporting indicated that each resident shall be treated as an individual with dignity and respect and shall not be subject to abuse of any kind. The policy further defined abuse as including verbal abuse. Review of Resident 1's Minimum Data Set (a series of tests for residents' functional and mental abilities) that was performed by the facility on 12/7/24 (Section GG) indicated that she needed Substantial/Maximal Assistance for most activities, including toileting. Her functional and mental abilities test (MDS Section C) indicated that she was cognitively intact (no memory or communication problems). In an interview on 3/25/25 at 1:00 PM, Resident 1 confirmed that she is frequently incontinent (unable to control her bowel and bladder) and relies on staff assistance. Resident 1 stated that because she is often vocal about her concerns, she has a history of conflicts with the facility's Director of Nursing (DON A) that in some instances had to be mediated by an outside community advocate for the aging. Resident 1 stated that on or around 2/27/25, Director of Nursing (DON A) and LVN B both responded to her request to have her disposable brief changed. Resident 1 stated that she had joked with the two nurses, stating, Well, here come Wonder Woman and Hercules. Resident 1 stated that DON A's response to this was: I could let you sit in a wet diaper . Resident 1 stated that her history of butting heads, with the DON and that she interpreted the remark as disrespectful in light of their poor relationship. Resident 1 stated that she felt angry about the situation because this is my home. I have to be here for the rest of my life. Resident 1 further stated that she wanted to report the incident and was surprised that someone else reported it for her, and that she had disclosed it to certain nursing staff but could not remember to whom. In an interview on 3/25/25 at 2:10 PM, Assistant Director of Nursing (ADON B) stated she had not witnessed the incident, but that the statement I could let you sit in a wet diaper, would be disrespectful and awful, and is not aligned with the facility's abuse prevention policy. ADON B denied ever having heard any staff use that language. In an interview on 3/26/25 at 9:15 AM, volunteer community advocate for the aging (ADV C) acknowledged that she had been involved in navigating several disagreements initiated by Resident 1 with DON A, including a previous incident during which DON A requested to take the plants off of Resident 1's windowsill and Resident 1's objection that it denied her a homelike environment. ADV C stated that Resident 1 was an incredibly reliable source of information and stated emphatically, If she [Resident 1] said it, it happened. ADV C stated that while arbitrating these situations, she witnessed an amount of tension between the Resident 1 and DON A over several past incidents, and that there is no love lost between [Resident 1 and DON A].

Based on interview and record review, the facility failed to follow up on an identified pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), to evaluate, and intervene in a timely manner to prevent an avoidable pressure ulcer for one of three residents (Resident 1) sampled for pressure ulcers. This resulted in Resident 1 developing a 1-centimeter (cm) x 1.25 cm pressure ulcer on her left heel. Findings: During a review of National Pressure Injury Advisory Panel (a global driver of quality improvement and patient safety in health care) website newsletters titled, Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, updated 2/25/25, indicated: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin - Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis - Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration - Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries. Other interventions that influence an individual's healing process may include identifying nutritional needs, repositioning and early mobilization, skin care, use of support surfaces, cleansing and debridement, pain assessment and management, psychological and spiritual support, and family support. Skin care - Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen: Inspect the skin upon admission and at least daily for signs of pressure injuries; Assess pressure points, temperature, and the skin beneath medical devices; Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers; Avoid positioning the patient on an area of pressure injury. Positioning and Mobilization - Turn and reposition at-risk patients, if not contraindicated; Plan a scheduled frequency of turning and repositioning the patient; Consider using pressure-relieving devices when placing patients on any support surface; Consider the patient's body size, level of immobility, exposure to shear, skin moisture and perfusion when choosing a support surface. During a review of Resident 1's medical record, indicated that Resident 1 was admitted to the Loyalton campus on 9/23/24 with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) without behavioral disturbance, personal history of (healed) traumatic fracture. Resident 1 was transferred to the facility's Portola Campus on 1/30/25. Resident 1 was not her own healthcare decision maker. During a review of Resident 1's Admission Minimum Data Set (MDS - an assessment and care screening tool), dated 10/3/24, in the section M - Skin conditions, the MDS indicated that Resident 1 did not have a pressure ulcer/injury, a scar over bony prominence, or unhealed pressure ulcers/injuries. During a review of Resident 1's most recent MDS, dated [DATE], indicated that Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15, indicating her cognition (ability to think and reason) was severely impaired. During a review of Resident 1's most recent MDS, dated [DATE], section GG (a section which stands for Functional Abilities and Goals; it specifically assesses a patient's ability to perform self-care tasks and mobility activities, including their admission performance, discharge goals, and how much assistance they require for these functions), indicated that Resident 1 needed maximal assistance (the staff does more than half the effort) from the staff for her mobility (the ability to move or be moved freely and easily). During a concurrent interview and review of Resident 1's medical record with the Director of Nursing (DON) A on 2/11/25 at 1:39 pm, DON A stated that she did not know when Resident 1 started developing the pressure injury on the left heel. DON A confirmed that Resident 1's progress note, dated 12/6/24 at 6:36 pm, written by Licensed Nurse (LN) D, indicated that LN D wrote She [Resident 1] had an old area on her left heel. We are going to watch the area and make sure we float her feels when she is in the bed. DON A confirmed that LN D initiated a care plan on 12/6/25 for Resident 1's left heel lesion, the plan indicated, Left heel has a hard black callous, and the interventions were to, Float her heels while she is in the bed; monitor for signs of infection; notify the MD if becoming infected or becomes open; perform any treatments that are ordered by medical provider; use the booties for her feet while she is in the bed. The DON A confirmed that there was no record indicating that the staff were floating the Resident1 's heel and applied the booties as indicated on the care plan. DON A confirmed that the Care Conference, held on 1/8/25 at 9:44 am, in the section of Nursing Summary, indicated that Resident 1's Responsible Party (RP) Was concerned over her [Resident 1] decline She [Resident 1] also has a pressure injury to her left heel. She doesn't like to converse much anymore. She requires more care and participates less in her cares DON A also confirmed that there was no plan/intervention initiated to treat Resident 1's pressure injury after the meeting. DON A confirmed that the Care Conference, held on 1/22/25 at 12:02 pm, in the section of Nursing Summary, indicated that the family Expressed concern about a sore on her [Resident 1] left heel . DON A confirmed that the physician was then notified, and wound care order was obtained on 1/22/25 after this care conference. A delay of 47 days after the wound was identified by LN D on 12/6/24. During an interview on 3/6/25 at 2:11 pm, Family Member (FM) C confirmed that Resident 1 did not have any skin lesion before Resident 1 was admitted to the facility. The FM C stated, I wanted to say I found that sore two weeks before she [Resident 1] was transferred to another facility, right around Christmas. It was always wrapped with bandage. I had asked before when I came in, and she was not wearing her shoes, no shocks. They said, 'Ya, that happened'. During a concurrent interview and record review on 3/10/25 at 9:45 am with the MDS Registered Nurse (MDS RN), the MDS RN confirmed that Resident 1's MDS, dated [DATE], completed by RN G, in the section M -Skin, the MDS indicated that Resident 1 was not at risk of developing pressure ulcers/injuries. The MDS RN stated, I did not do Resident 1's admission MDS. RN G who did it was retired. MDS RN stated that Resident 1 was clearly at risk of developing pressure ulcer, and she did not have an answer as to why RN G marked it as No. MDS RN also stated that Once a resident was marked as at risk of developing pressure ulcer in MDS, the pressure ulcer prevention care plan would be initiated. The MDS RN confirmed the Resident 1 did not have pressure ulcer prevention care plan developed when she was admitted . During a concurrent interview and record review on 3/10/25 at 10 am with DON A, Resident 1's record was reviewed. DON A confirmed that there was a discrepancy in which RN G marked Resident 1 was not at risk of developing pressure injury in Resident 1's MDS, dated [DATE], but RN G assessed Resident 1 with a score of 18 at BRADEN Scale for Predicting Pressure Ulcer Risk (a tool used to assess a patient's risk of developing pressure injuries), dated 10/15/24, indicating Resident 1 was at risk for developing pressure ulcers. During a concurrent interview and record review on 3/10/25 at 10:45 am, with DON A, and LN D. LN D recalled that Resident 1 did not have any skin issue when she assessed Resident 1 during admission assessment on 9/23/24. The LN D stated, When Resident 1 had a bowel movement on 12/6/24, I assisted the Certified Nursing Assistant (CNA) to clean up Resident 1. The CNA told me, 'Did you see that?' I then saw a black, and dry blister about the size of 2 cm X 2 cm on Resident 1's left heel. I talked to the RP and reported it to the DON A, the DON A said, 'document it', so I did, and care planned it. I did not report it to the physician because it was dry. The LN D confirmed that Resident 1's care plan indicated, floating feet, however, there was no floating feet task initiated to indicate the staff was providing such service to Resident 1. LN D stated, We just started PCC (a software platform used to manage and streamline various aspects of facility operations, including resident care, documentation, and billing) in September 2024. No one was checking whether Resident 1's feet were floated or not. The DON A agreed and said, we should have better communication on the wound care. During a concurrent interview and record review on 3/10/25 at 12:14 pm, with DON A, LN D and LN E, a facility's document titled, Alert Charting - for changes in condition, dated 12/2024, was reviewed. Resident 1's name appeared on the record, dated 12/6/24, the reason for Resident 1 on alert charting was blackened area on L heel highlighted in yellow. Both LN D and E stated that this Alert Charting was how the nursing staff documented the wound care/condition and gave report to the next shift. They admitted that they did not document/update the wound condition in the resident's progress note, or weekly skin assessment. Both LNs agreed that there was no wound assessment on the alert chart, and there was no way to know Resident 1's wound condition such as the stage, the size, the color, any discharge, etc. since the nursing staff did not document it anywhere else. The LN E stated, I was never told that I have to document the wound condition in the weekly skin assessment. The DON A stated the facility did not have skin assessment, wound care, or pressure ulcer policy because the facility did not have wound care nurse, and did not provide wound care training even though the facility had been providing wound care service to the residents, the DON A said, We don't need it, we just looked it up online. The DON A stated that someone cancelled Resident 1's alert charting on 12/9/24 and highlighted it in yellow. She said, When an alert charting - change condition was resolved, we highlighted it to indicate that it's resolved. I believe that was why Resident 1's pressure sore was missed. We did not know who marked it, but it's too late now! During a concurrent interview and record review on 3/10/25 at 2:31 pm with DON B, in the Portola campus, Resident 1's admission progress note was reviewed. DON B stated Resident 1 was transferred from the Loyalton campus to her facility (Portola campus) on 1/30/25, she said, Resident 1 came with a pressure ulcer on her left heel, it was measured 1 cm X 1.25 cm. DON B stated, We have a wound management policy. The Loyalton and Portola campuses are both distinct part skilled nursing facilities of the same hospital, so we [Loyalton Campus and Portola campus] share the same policy. DON B confirmed that the Wound Management policy, revised 2/2022, indicated: It is the policy of the facility to follow guidelines for the preservation of skin, prevention of skin disruption and the identification, assessment, appropriate treatment and documentation of injuries to the skin including, but limited to, wounds. Assessment should: be done and documented daily .; should include alteration or disruptions of the skin, paying special attention to bony prominences and areas of increased moisture, pressure of sheering; include a skin risk assessment by using the Braden Scale Assessment in admission assessment or shift assessment in the electronic medical record. Documentation should include wound base; wound drainage; wound odor, wound edges; pain; edema; pulses; staging of wound (only if the wound has been determined to be caused by pressure) - refer to Medline Wound and Skin Care Reference Guide in Wound Care to stage wound. Interventions - wounds should be managed as soon as they are identified. Notify the overseeing provider. Contact Physical Therapy or a Certified Wound Nurse for a consultation, if available and as directed by the overseeing provider.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS, a standardized resident assessment) accurately reflected the status of two of three sampled residents (Resident 1 and 3) when the skin assessments did not accurately reflect their skin status. This failure had the potential for staff to not be fully informed of the residents ' health status to determine the need for further assessment and care interventions. Findings: During a review of the facility ' s policy titled, Minimum Data Set and Resident Assessment Instrument Process, revised 5/2022, indicated, It ' s the policy of this facility to complete the Resident Assessment Instrument (RAI) and/or the Minimum Data Set (MDS) in accordance with the utilization guidelines set forth in Federal regulations. During a review of Long -Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, version 1.18.11, updated 10/2023, indicated: 1. The Long-Term Care Facility Resident Assessment Instrument User ' s Manual for Version 3.0 is published by the Centers for Medicare & Medicaid Services (CMS) and is a public document. 2. The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. 3. The RAI helps nursing home staff gather definitive information on a resident ' s strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident ' s status. 4. The RAI consists of three basic components: The Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines. The utilization of the three components of the RAI yields information about a resident ' s functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified. 5. Minimum Data Set (MDS). A core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for the residents of nursing homes. 6. The Resident Assessment Instrument (RAI) Manual offers clear guidance on how to complete the MDS correctly and effectively. The RAI helps nursing home staff gather definitive information on a resident ' s strengths and needs, which must be addressed in an individualized care plan. 7. The RAI Version 3.0 Manual, Section L, skin condition, indicated, it ' s to document the risk, presence, appearance, and change of pressure ulcers as well as other skin ulcers, wounds or lesions. Also includes treatment categories related to skin injury or avoiding injury. Resident 1 During a review of Resident 1 ' s medical record, indicated that Resident 1 was admitted to the facility's Loyalton campus on 9/23/24 with diagnoses which included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) without behavioral disturbance, personal history of (healed) traumatic fracture. Resident 1 was transferred to Facility's Portola campus on 1/30/25. Resident 1 was not her healthcare decision maker. During a review of Resident 1 ' s Admission Minimum Data Set (MDS - an assessment and care screening tool), dated 10/3/24, in the section M - Skin conditions, the MDS indicated that Resident 1 did not have a pressure ulcer/injury, a scar over bony prominence, or unhealed pressure ulcers/injuries. During a review of Resident 1 ' s most recent MDS, dated [DATE], the MDS indicated that Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15, indicating her cognition was severely impaired. During a concurrent interview and record review on 3/10/25 at 9:45 am with the MDS Registered Nurse (MDS RN), the MDS RN confirmed that Resident 1 ' s MDS, dated [DATE], completed by RN G, in the section M -Skin, the MDS indicated that Resident 1 was not at risk of developing pressure ulcers/injuries. The MDS RN stated, I did not do Resident 1 ' s admission MDS. RN G who did it was retired. MDS RN stated that Resident 1 was clearly at risk of developing pressure ulcer, and she did not have an answer as to why RN G marked it as No. MDS RN also stated that Once a resident was marked as at risk of developing pressure ulcer in MDS, the pressure ulcer prevention care plan would be initiated. The MDS RN confirmed the Resident 1 did not have pressure ulcer prevention care plan developed when she was admitted . During a concurrent interview and record review on 3/10/25 at 10 am with DON A, Resident 1 ' s record was review. The DON A confirmed that there was a discrepancy in which RN G marked Resident 1 was not at risk of developing pressure injury in Resident 1 ' s MDS, dated [DATE], but RN G assessed Resident 1 with a score of 18 at BRADEN Scale for Predicting Pressure Ulcer Risk (a tool used to assess a patient's risk of developing pressure injuries), dated 10/15/24, indicating Resident 1 was at risk for developing pressure ulcer. Resident 3 During a review of Resident 3 ' s medical record, indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). Resident 3 was diagnosed with pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, and pressure ulcer of left buttock on 12/9/24. Resident 3 was not her healthcare decision maker. During a review of Resident 3 ' s most recent Minimum Data Set, dated dated [DATE], the MDS indicated that Resident 3 had a BIMS score 15 out of 15, indicating Resident 3 was cognitively intact. During a concurrent interview and record review on 3/10/25 at 10 am with DON A, Resident 3 ' s MDS, dated [DATE], completed by RN G, was reviewed. In the section M - Skin conditions, the MDS indicated that Resident 3 did not have a pressure ulcer/injury, a scar over bony prominence, or unhealed pressure ulcers/injuries, the MDS also indicated that Resident 3 did not have one or more unhealed pressure ulcers/injuries. The DON A confirmed that Resident 3 had been diagnosed with pressure ulcers on his buttocks since 12/9/24 and was still under the treatment. The DON A confirmed that Resident 3 ' s MDS assessment was inaccurate.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident ' s needs and choices for personal hygiene - oral care were met for two of three sampled residents (Resident 1 and 2) when, Yellow thickened substance on the surface of the tongue of Resident 1 and 2. Resident 1 was observed to have the food from the day before stuck in between her teeth and on her tongue. Resident 2 was observed to have blue cake that she ate the night before smearing around her mouth. This deficient practice had the potential to adversely affect the resident's psychosocial well-being by not receiving hygiene and feeling dirty. Findings: Resident 1 During a review of Resident 1 ' s medical record, indicated that Resident 1 was admitted to the facility's Loyalton compus on 9/23/24 with diagnoses which included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) without behavioral disturbance, personal history of (healed) traumatic fracture. Resident 1 was transferred to the facility's Portola on 1/30/25. Resident 1 was not her healthcare decision maker. During a review of Resident 1 ' s most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 1/2/25, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15, indicating her cognition was severely impaired. During a review of Resident 1 ' s most recent MDS, dated [DATE], at the section GG (a section which stands for Functional Abilities and Goals; it specifically assesses a patient's ability to perform self-care tasks and mobility activities, including their admission performance, discharge goals, and how much assistance they require for these functions), the MDS indicated that Resident 1 needed maximal assistance (the staff does more than half the effort) from the staff for her oral hygiene (the ability to use suitable items to clean teeth.) During an interview on 2/10/25 at 3:35 pm, with Family C, the Family C stated that she had visited Resident 1 while she was resided in Facility L and had never seen the staff provided personal hygiene for Resident 1. The Family stated, I saw food stuck in between her teeth and on her tongue. There were some yellowish buildups on the top of the tongue. It was really gross! It ' s like they had never cleaned her teeth for month. Resident 2 During a review of Resident 2 ' s medical record, indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses which included Alzheimer ' s disease, dementia without behavioral disturbance, weakness. Resident 2 was not her healthcare decision maker. During a review of Resident 2 ' s most recent Minimum Data Set, dated dated [DATE], the MDS indicated that Resident 2 had a BIMS score of 99, indicating Resident 2 was unable to complete the interview. During a review of Resident 2 ' s most recent MDS, dated [DATE], at the section GG, the MDS indicated that Resident 2 refused oral hygiene. During a review of Resident 2 ' s Activities of Daily Living (ADL) care plan, the care plan indicated that Resident 2 had an ADL self-care performance deficit related to activity intolerance, aggressive behavior, Alzheimer ' s, confusion, dementia, and the goals were that Resident 2 Will be clean, well-cared for, well groomed, nourished and comfortable through the review date. The intervention did not indicate a plan when Resident 2 refused her oral care. During a concurrent observation and interview on 2/11/25 at 10:32 am, in Resident 2 ' s room, Resident 2 was observed lying in bed awake. Resident 2 was observed with her mouth open which exposed the tongue with thick yellowish substance. Observed a small bottle of water (100 milliliter) placed on the bedside table that was positioned near the end of Resident 2 ' s bed. When asked, Resident 2 was able to state her first name, and stating that she was not thirty at this moment, but she did not know how to get the water bottle when she was thirty because it was far from her reach. Resident 2 was not able to locate the call light. During an interview on 2/11/25 at 12:13 pm, with Director of Nursing (DON)A. The DON A stated Facility L did not have ADL policy, and Certified Nursing Assistant (CNA) provided ADL for the residents. The expectation was the CNA had to provide the ADL service at each shift, which meant that oral care had to be provided at least two times a day. If the resident refused the care, they would notify the nurse, and the nurse would document it, and the service would be offered to the resident again. If the resident continued refusing it, it would then be documented as Refusal. During a concurrent interview and record review on 2/11/25 at 12:27 pm, with CNA F, Resident 1 and 2 ' s ADL sheets - oral care record, from 10/10/24 to 1/30/25, were reviewed. The CNA F confirmed that there was a total of 22 shifts that indicated Resident 1 did not receive oral care. The CNA F also confirmed that Resident 2 ' s oral care record was not accessible for unknow reason. The CNA F stated, Ya, the travelers (a CNA who takes on temporary assignments in various healthcare facilities) did not do ADL. During a concurrent interview and record review on 2/11/25 at 1:39 pm, with DON A, Resident 1 and 2 ' s ADL sheets - oral care record, from 10/10/24 to 1/30/25, were reviewed. The DON A confirmed that there was several days missing on the ADL sheet - oral care record for Resident 1, and she was also unable to access Resident 2 ' s ADL - oral care record. During a review of Facility ' s job posting website titled, CNA Full time - Days/Nights, dated 2/27/25, indicated the principal accountabilities for CNA were: .Provides morning care, which may include bed bath, shower or tub bath, oral hygiene, combing hair, back care, dressing residents, changing bed linen, cleaning over the bed table and bedside stand, straightening room and other general care as necessary throughout the day .Provides evening care which includes hands/face washing as needed, oral hygiene, back rubs, perineal care, freshening linen, cleaning over the bed tables, straightening room and other general care as needed . During an interview on 3/10/25 at 11:29 am with CNA F, the CNA F stated, I had noticed that some oral care did not get done. We could tell by seeing the Buildup on the residents ' teeth, like some food from yesterday . the CNA F stated that she had seen food stuck in Resident 1 ' s teeth and on her cloth when CNA F started the day shift. The CNA F said, I did not report it to anyone, I just cleaned it up. The CNA F stated the night shift also need to provide oral care, But I don ' t think they did it! I reported it to the nurses, they said they would pass it on. During an interview on 3/10/25 at 12:45 pm, with CNA K, the CNA K stated she found it happened very often in which residents ' teeth not been cleaned and found food on the residents ' teeth. The CNA K stated, The night shift did not provide oral care. Last Tuesday was Shrove Tuesday, we celebrated it with the residents. The residents were having blue cake that night. Next morning, when I came in, all my assigned residents (10 residents), including Resident 2, had blue color around their mouths. I reported it to the Assistant Director of Nursing, I did not know what happened after.

Based on interview and record review, the facility ' s nursing staff failed to update and maintain the facilities Antibiotic Steward Program. (Log used to identify, track, and monitor infections and antibiotic use for the residents.) This failure had the potential to result in an inadequate antibiotic stewardship program to identify potential inappropriate antibiotic use and antibiotic resistance. Findings: A review of Resident 2 ' s medical records indicated a urinalysis (UA-test for bacteria in the urine) was ordered on 12/5/24. Laboratory results indicated a culture and sensitivity (C&S- test to determine the type of bacteria and what antibiotic would treat the infection) which showed positive Escherichia coli. (E.coli-bacteria). A review of Resident 3 ' s medical records indicated a UA was ordered on 12/9/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 4 ' s medical records indicated a UA was ordered on 12/10/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 5 ' s medical records indicated a UA was ordered on 12/19/24. Laboratory results indicated C&S positive for Citrobacter freundii.(bacteria) A review of Resident 6 ' s medical records indicated a UA was ordered on 12/20/24. Laboratory results indicated C&S positive for polymicrobic growth (multiple types of microorganism), probable skin contamination per lab. A review of Resident 7 ' s medical records indicated a UA was ordered on 12/22/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 8 ' s medical records indicated a UA was ordered on 12/25/24. Laboratory results indicated C&S indicated minimal growth. A review of Resident 10 ' s ' medical records indicated a UA was ordered on 12/28/24. Laboratory results indicated C&S positive for Staphylococcus aureus (bacteria). A review of the facility ' s record, [Facility Name] Antibiotic Steward Program (ASP), dated December 2024, indicated 15 residents were monitored for antibiotic use. The record indicated that each resident was to have 10 criteria monitored. The record indicated the following criteria were missing or incomplete: Date: 3 out of 15 missing. (Residents 1,2,3) Residents Medical Record number: 1 out of 15 missing. (Resident 3) Dose and Duration: 2 out 15 missing (Resident 1,8) and 1 out of 15 was incomplete (Resident 3). Start and Stop Date: 3 out of 15 missing (Residents 1,2,3) and 4 out 15 was incomplete. (Residents 1,3,4,10) Clinical Indications Document signs and symptoms, date of culture: 7 out of 8 were missing date of culture. (Residents 2,4,5,6,7,8,10). Diagnosis: 1 out of 15 was missing. (Resident 2) Date and initial of nurses that faxed to outside pharmacy: 2 out of 15 were missing (Residents 1,8) and 4 out of 15 were incomplete (Residents 3, 4, 5, 10). Date that culture and sensitivity results faxed and to pharmacist: 7 out of 8 were missing. (Residents 2,4, 5,6,7,8,10). During an interview on 1/7/25 at 2 pm with Infection Preventionist (IP), IP stated, the ASP was the log used to track and investigate infections and antibiotic use for the residents. IP confirmed information on the ASP was missing and incomplete. IP confirmed that all the information needed to be complete and updated on the ASP log to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance (bacteria that becomes resistant to antibiotics due to overuse or use of the wrong antibiotic) and to ensure safe and appropriate use of antimicrobial agents. During an interview on 1/7/25 at 2:10 pm with Director of Nursing (DON), DON confirmed all the boxes should be filled out and be updated by the nurses. DON confirmed information on the ASP was missing and incomplete. DON confirmed that all the information needed to be complete and updated on the ASP log to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance and to ensure safe and appropriate use of antimicrobial agents. A review of facility Policy and Procedure (P&P) titled Infection Prevention and Control Plan (IPCP), dated 11/2024, indicated: A. The facility shall develop and implement an IPCP with a goal of reducing risk of acquiring and transmitting Healthcare-Associated Infections (HAIs) and to investigate and manage communicable (spread from person to person) disease outbreaks. B. Systems to provide access to information will be provided to support infection prevention and control (IPC) activities. C. Department managers and/or designees are responsible for monitoring employees and assuring compliance with IPC P&Ps. Healthcare workers will adhere to the infection prevention policies. D. IPC management functions are delegated to the Infection Preventionist (IP)/Infection Control Committee (ICC) to investigate and follow up on clinical issues. Duties include: 1. Reviewing surveillance data monitoring for trends in infections, clusters, infections due to unusual pathogens (an organism that can produce disease), or any occurrences of HAIs. 2. Reviews trends in antibiotic susceptibility/resistance (if the pathogen will be killed by an antibiotic or resist it). E. Prevention and/or risk reduction includes identifying and preventing HAIs by monitoring the appropriate use of antibiotics and other antimicrobials (something that kills growth of bacteria, mold, fungi, and viruses). F. Managing Critical Data and Information: Surveillance data will be analyzed appropriately and used to monitor and improve infection control and healthcare outcomes. A review of facility P&P titled Antimicrobial Stewardship Program (ASP), dated 9/2024, indicated: A. The Antimicrobial Stewardship Committee has been formed to evaluate, report, and monitor the use of antimicrobial agents. Members include a Medical Director, Clinical Pharmacist, Microbiologist, representatives from Quality/Performance Improvement and other vested practitioners, including the Chief Nursing Officer. B. The facility maintains an ASP to minimize the emergence and spread of antimicrobial resistance and to ensure safe and appropriate use of antimicrobial agents. C. The ASP interventions will include conducting retrospective (looking back) and prospective (looking forward) antimicrobial use evaluations and review/track trends in microbial resistance/susceptibility.

Based on observation, interview, and record review the facility failed to: 1). Maintain the Ice/Water Dispensing machine per manufacturer recommendations allowing a buildup of moist, black residue to collect on the water supply nozzle and; 2). Maintain a functioning drain for the dishwashing machine allowing water to spill out of the drain and onto the floor. These failures had the potential to negatively impact resident health. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Cleaning and Sanitizing Ice Machines, revised 7/1/21, indicated, Ice machines will be cleaned and sanitized per manufactures guidelines. During a concurrent observation, interview, and record review, on 8/14/24 at 9:25 AM, located in the resident's kitchenette (a small kitchen), the Ice/Water Dispensing machine was observed with Biomed (BM). A white paper towel was used to wipe the water supply nozzle and a moist, black residue was observed. BM stated, the water supply nozzle should be clean and was not. BM stated, the facility utilized an outside contractor to clean the Ice/Water Dispensing machine every six months, per the manufacture's recommendations. BM reviewed the Job Invoice, dated 2/12/24, and stated, the Ice/Water Dispensing machine was last cleaned on 2/1/24. A review of the Ice/Water Dispensing machine's Service Manual, revised 9/24/14, indicated, the maintenance schedule was to be used as a guideline and more frequent maintenance could be required. During an interview on 8/14/24 at 9:30 AM, the Activities Director confirmed, resident drinking water was obtained from the Ice/Water Dispensing machine located in the resident's kitchenette area. 2. A review of the facility's P&P titled, Equipment Management Program, revised 10/1/21, indicated, when there was an equipment failure, facility staff would report the failure to the appropriate department. During a concurrent observation and interview on 8/14/24 at 2:09 PM, located in the kitchen, the drain for the dishwashing machine was observed. Dietary Aide (DA) stated, when draining the dishwasher, DA was required to release the water down the drain, using a stop and go method, so the water would not overflow the drain. DA demonstrated what would happen if DA did not utilize a stop and go water release method and the water overflowed the drain and onto the floor. Dietary Manager (DM) was present and confirmed there had been an ongoing issue with the drain under the dishwasher. DM stated, when there was an equipment failure, DM was responsible to report the failure to the facility's Maintenance Director (MD). DM stated, she did not report the equipment failure to the MD and should have. During a concurrent interview and observation on 8/14/24 at 3:00 PM, MD took a picture of the drain under the dishwashing machine. The picture showed a moist, thick, black residue in the drain and MD stated, the drain was clogged and that was what caused the water to overflow the drain and onto the floor. MD stated, approximately six months ago, there had been a water overflow issue and it had been repaired. MD confirmed, DM had not notified MD that the dishwashing machine drain had a water overflow issue

Based on interview and record review the facility failed to protect Resident 1 (R1) from abuse when a facility Housekeeper (HK1) took R1's jewelry, posed for pictures wearing R1's jewelry then pawned R1's jewelry. This failure created anxiety and stress for Resident 1 which could lead to adverse clinical outcomes. Findings: R1 was admitted to the facility on [DATE] with a diagnosis that included heart failure and falling. R1 requires assistance of staff when getting out of bed and for daily needs. R1 is alert and oriented. R1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS Test) indicating decreased mental functioning. On approximately [DATE], R1 noticed her two gold necklaces were missing. R1 remembered placing the two necklaces in a Dixie cup before going to an X-ray department procedure and they were missing after. R1' daughter reported the missing necklaces to the facility. Facility staff began to search for the necklaces. On [DATE] at 11:00 AM during a concurrent interview and record review the Assistant Director of Nursing (ADON) stated, .we searched. So, then we weren't able to find them and felt there was a possibility they were thrown I the trash because of the cup (being in a Dixie Cup). We still looked and that is when a Restorative Nurses Aid (RNA1) came in with the Facebook pictures. There was (Housekeeper 1[HK1]) wearing similar looking necklaces. So, we went to R1, and she identified them. The photos were provided for review. The ADON continued to state that the Sheriff .went out and spoke to (HK1) and he admitted taking the two necklaces. HK1 then said he had pawned them locally and that he didn't have them anymore. According to the ADON there were further discussions, and the necklaces were returned to R1. On [DATE] at 12:00 PM during a concurrent interview and record review the Director of Nursing (DON) stated, Yes it was reported to us, and we looked high and low for them. All the staff knew and were looking everywhere, and it was RNA1 that found it online. The DON identified photos of the resident wearing the necklaces and online photos of HK1 wearing necklaces identical in appearance. The DON added, She (RNA1) brought in the pictures, and we showed them to R1, and she identified them as hers. On [DATE] during a concurrent record review and interview RNA1 stated, I was looking at Facebook and saw a picture of him and he is wearing two necklaces that looked like (R1's). RNA1 identified printed pictures represented as being from Facebook depicting HK1 wearing the two necklaces. In addition, photos of R1 wearing two substantially similar necklaces were identified. RNA1 stated, Yes, he was wearing them, and I saw it on Facebook. On [DATE] during an interview R1 stated, I don't really know what happened to them after I took them off and put them in a cup. I forgot I had put them in there and my daughter reminded me. Everyone looked for them, but he had taken them while I was out to x-ray. This one (pointing to the shorter necklace) my husband gave me years ago before he died .

Based on observation and interview, the facility failed to maintain handrails in the corridors for a 10.5 month period, from June 6, 2023 until April 25, 2024. Finding: During an onsite visit on 4/24-4/26 2024, the surveyor noted that there were sections of the corridors that had no handrails affixed to the corridor walls. In an interview on 4/25 at 2 pm with the Director of Plant Operations, he confirmed that all the handrails were removed on 6/6/2023, as the facility was embarking on a major renovation to the corridor walls. He stated that over the past two weeks, the facility had been replacing the old handrails with the new ones, but the project was not completed yet. He also stated, I was not aware that the regulations require that corridor handrails be in place.

Based on observation, interview, and record review, the facility failed to prevent abuse for two of seven residents (Residents 1 and 5) when: 1. Resident 2 struck Resident 5 with a cane; 2. Resident 7 grabbed Resident 1's wrist and threatened to hit them. This failure had the potential to threaten the residents' health and well-being and could have caused serious injury. Findings: A facility policy, titled, Abuse Prevention, revised 7/1/22, was reviewed. Its stated purpose was to assure that the Skilled Nursing Facility (SNF) units were doing all within their control to prevent any abusive occurrences. Prevention included a thorough analysis of the physical environment, staff deployment, and staff supervision in order to meet the needs of the residents. The Skilled Nursing Interdisciplinary Team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) would have identified the residents' needs and behaviors by care planning appropriate interventions and assessed a history of aggressive behaviors. These interventions would have been reviewed and revised a minimum of every three months, or as needed by the IDT. A State of California Health and Human Services document, titled, Resident Rights, dated 5/1/11, was reviewed. Among the rights listed was number 10, To be free from mental and physical abuse. A facility policy, titled, Resident Safety, revised 5/1/22, was reviewed. The policy indicated that the facility was to ensure the optimum safety for all residents at all times by increasing staff awareness and encouraged strict adherence to practices that ensured optimum resident safety. 1. A review of Resident 5's clinical record indicated they were admitted to the facility on [DATE]. Resident 5's diagnoses included cerebral infarction (stroke), atrial fibrillation (an irregular heart rhythm), and generalized muscle weakness. Included in Resident 5's prescribed medications was Eliquis (apixaban, a blood thinner) which had the potential to increase the risk of bleeding or bruising. Resident 5 was not able to make their own healthcare decisions. A review of Resident 2's clinical record indicated they were admitted to the facility on [DATE]. Resident 2's diagnoses included cerebral infarction, hemiplegia (weakness affecting one side of the body) and depression. Record review showed a Nurses note, dated 6/12/23, at 4:23 pm, by Licensed Nurse (LN) A. LN A wrote about an incident that occurred on the same date at 12:50 pm in the activities room. Staff saw on a camera monitor that Residents 5 and 2 were seated next to each other, and Resident 5 was picking at their arm. Resident 2 said something to Resident 5, then raised their cane and hit Resident 5 in the left thigh. Record review showed a Social Service note, dated 6/12/23, at 3:45 pm, by LN B. LN B wrote that Resident 2, when asked about hitting Resident 5, stated they knew it was wrong. Resident 2 stated that Resident 5 was being mean, though Resident 2 couldn't remember what Resident 5 had said that was mean. During an interview, on 7/31/23, at 3:47 pm, Resident 2 admitted they struck Resident 5 with their cane. During an interview, on 7/31/23, at 4 pm, Resident 5 stated that Resident 2 had struck them in the thigh with a cane, and it hurt. 2. A review of Resident 1's clinical record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included Alzheimer's disease (a long-term disease that caused a loss of intellectual function), Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought and mood), and osteoarthritis (a disease that caused joint pain). A review of Resident 7's clinical record indicated they were admitted to the facility on [DATE]. Resident 7's diagnoses included dementia, (a mental disorder that caused confusion and memory loss), chronic pain, and anxiety. Resident 7 was not able to make their own healthcare decisions. A document from Resident 7's record, titled, Annual Care Area Assessment (CAA), dated 3/13/23, was reviewed. Under the topic of ' behavior,' staff wrote about an increase in behaviors since Resident 7's spouse passed. Resident 7 wandered, attempted to leave the building, got very angry, attempted to swing at staff, and got upset and confused. Record review of a Nurse note, dated 3/14/23, at 4:53 pm, by LN C, indicated Resident 7 continued to wander, attempted to leave the facility, and became angry when staff tried to redirect the resident to come inside. Record review of a Nurse note, dated 3/15/23, at 2:19 pm, by LN C, indicated Resident 7 eloped (exited the building) three times and was agitated and aggressive. Record review of a Nurse note, dated 3/19/23, at 11:31 am, by Registered Nurse (RN) E, indicated Resident 7 eloped three times and stated they were not able to relax. Record review of a Nurse note, dated 3/21/23, at 4:39 pm, by LN C, indicated Resident 7 eloped five times, was aggressive and combative, and hit, punched, kicked and grabbed at staff members. Record review of an Activities note, dated 3/24/23, at 5:16 pm, by Activities Staff (ACT) G, indicated Resident 7 had become obsessed with a new (unnamed) resident, and was angry and pacing near the resident. Record review of an Activities note, dated 4/8/23, at 3:28 pm, by ACT G, indicated Resident 7 was confused, had garbled speech, and slapped a male staff member's hand who pointed to a Bingo number the resident overlooked. Record review of Nurse note, dated 5/2/23, at 5:28 pm, by LN A, indicated Resident 7 was delusional (imagining things that weren't true) and expressed being chased by a man. Record review of Nurse note, dated 5/3/23, at 9:24 am, by LN D, indicated Resident 7 showed increased signs of aggression, walking around visibly agitated with hands balled up into fists. Record review of a Nurse note, dated 5/5/23, at 2:49 pm, by RN F, indicated Resident 7 exited the building and kicked a male staff member. Record review of a Nurse note, dated 5/7/23, at 12:59 pm, by LN C, indicated Resident 7 eloped 10 times, became aggressive, and pushed at staff. Record review of a Nurse note, dated 5/9/23, at 4:58 pm, by LN C, indicated Resident 7 had increased behaviors, wandered the facility and eloped 12 times. LN C wrote, This afternoon (Resident 7) grabbed ahold of another resident (Resident 1) strongly and would not let go of the resident's arm. (Resident 7) then attempted to hit (Resident 1) as well, staff member intervened to protect (Resident 1). Resident (7) is becoming more aggressive, agitated, and angry. A handwritten note, dated 5/9/23, by Certified Nursing Assistant (CNA) H, was reviewed. CNA H wrote, (Resident 7) was pushing a fell ow resident (Resident 1) down the hallway. I asked if she can let go of her wheelchair. Resident (7) became angry and released the wheelchair and grabbed (Resident 1's) right wrist and threatened to hit (Resident 1). I placed my upper body to protect her. Other nurses came to help and (Resident 7) released (Resident 1's) wrist and put her right arm down. During a concurrent observation and interview, on 7/31/23, at 3:25 pm, Resident 7 was walking in the hallway accompanied by the Activities Coordinator (AC). Resident 7 was constantly moving. AC stated, We're doing our best to keep a one-to-one (one staff member devoted to the care of one resident). During an interview, on 7/31/23, at 3:30 pm, CNA I stated they had witnessed Resident 7 try to hit staff in the past. CNA I stated that they all, had to be vigilant, and, everyone has been watching (Resident 7) constantly. During an interview, on 7/31/23, at 4:05 pm, CNA J stated that Resident 7 pulled from everyone and that made caring for the other residents more difficult. During an interview, on 7/31/23, at 4:12 pm, the Director of Nursing (DON) stated that they didn't do any documented monitoring of Resident 7's activity or location, it was just a team effort, and somebody was always with Resident 7. During a telephone interview, on 8/11/23, at 2:10 pm, DON stated they were aware of the documentation about Resident 7 hitting and kicking staff. DON stated they notified the Medical Director (MD) about the behaviors and MD adjusted Resident 7's medications. It was difficult because Resident 7 had severe dementia. DON did not have a record of any psychiatric evaluation done for Resident 7 prior to being sent to the Behavioral Health Treatment facility on 6/30/23. When asked about the incident that occurred on 5/9/23, DON stated that Resident 7 did constant laps around the facility, and Resident 1 may have been in Resident 7's path and that's why Resident 7 pushed Resident 1's wheelchair.

Based on observation, interview, and record review, the facility failed to prevent accidents for one of three sampled residents (Resident 3) when the resident's lower legs were not secured to a mechanical lift (a device used to lift and transfer residents) and the resident began to slip off the lift. Staff lowered the lift to the floor which caused Resident 3 to suffer broken bones in both legs. Findings: Review of Resident 3's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought, and mood), dementia (a mental disorder that caused memory loss and confusion), and generalized muscle weakness. Review of Resident 3' Physician's orders for the month of 12/2022, indicated an order dated 3/5/20, that Resident 3 was not capable of making her own healthcare decisions and was dependent on a wheelchair for mobility. Review of Resident 3's Minimum Data Set (a standardized resident assessment), dated 12/8/22, showed Resident 3 had severe cognitive impairment (loss of intellectual function). Resident 3 required assistance with transfers and eating and could not walk. A manual from ARJO Medical AB Limited, titled, [NAME] 3000: Operating and Product Care Instructions, dated 2/1/2004, was reviewed. [NAME] was the name of the sit-to stand mechanical lift used to transfer Resident 3 from the chair to the bed. The manual listed steps for using the lift with the Standing Sling. The sling was placed around the resident's lower back so that the bottom of the sling lied horizontally about two inches above the resident's waist with their arms outside the sling. Staff were to ensure the support strap was brought loosely around the body and fastened securely by pressing the buckles together. Once the sling had been fitted, the [NAME] 3000 was brought toward the front of the resident, facing the resident. When the resident was ready, staff were to assist or allow the resident to place their feet on the foot support and carefully push the [NAME] 3000 closer toward the resident to make full lower leg contact with the knee support. The manual cautioned that an assessment would have been needed to determine whether the resident required the lower leg straps. Staff were to apply the lower legs straps if necessary. The manual cautioned that the resident's feet should always have remained in full contact with the foot support. When lifting, staff were instructed to check to ensure that the resident's feet did not lift from the support or floor. If this happened inadvertently, staff were instructed to lower the resident immediately until full foot contact with the support or floor was achieved. During a concurrent interview and observation, on 12/19/22, at 2:55 pm, the Assistant Director of Nursing (ADON) and Certified Nursing Assistant (CNA) A demonstrated use of the [NAME] Lift on themselves as they would have done when moving residents from a seated to a standing position. ADON stated that use of this lift did not require two CNAs. A Nurses Note from Resident 3's record, dated 12/9/22, at 8:30 pm, by CNA B, was reviewed. The note read, When attempting to put resident to bed using [NAME] lyft [sic], resident wouldn't let me put straps on keeping her legs closed tight together, so I hurried to put her on her bed, and she moved legs off [NAME] lyft. So, I attempted to put her back in her chair and to try again and she wouldn't cooperate so lowered her safely to ground and called for help. A review of radiologic (medical imaging) images of Resident 3's knees, done on 12/10/22, showed a rod with screws in the left thigh bone and an artificial knee joint in the right knee from prior surgeries. A Radiology Report from Resident 3's record for bilateral (both sides) knee x-rays, dated 12/10/22, at 9:31 am, by the Radiologist, was reviewed. The report indicated that Resident 3's right knee had a comminuted (broken into small pieces) distal right femur (bottom of the thigh bone) fracture with posterior angulation (backward displacement). The report also listed osteopenia (loss of bone mass). The report indicated Resident 3's left knee had comminuted proximal left tibia and fibular (top of both lower leg bones) fractures. During an interview, on 12/19/22, at 4:05 pm, the Director of Nursing stated lifts were a nursing decision and the facility didn't get physician orders for specific lifts. During a telephone interview, on 2/2/23, at 4:44 pm, CNA B described the incident that occurred on 12/9/22. When attempting to transfer Resident 3 into bed, the resident stated, no, no, no and held her knees together which prevented applying the leg straps. When CNA B raised the lift, Resident 3 bent her knees backward and began to slide off the lift. CNA B couldn't leave Resident 3 hanging, so she lowered the device all the way to the floor and called for help.

Based on interview and record review, the facility failed to ensure residents were free of accidents for one of eight residents (Resident 1). Activities Staff A (AS A) gave a cup of hot coffee to Resident 1, who should not have been left unsupervised, without ensuring the temperature was no more than 140 degrees Fahrenheit (°F). As a result, on 2/5/21, Resident 1 sustained blisters (second degree [CONDITION(S)] - skin damage that extend beyond the top layer of the skin) to her left inner thigh, her right inner thigh, on the tips of her fingers and some redness to her left abdomen and left thigh from exposure to the scalding (burn from hot liquid) water temperature of the coffee. Resident 1 required wound care treatment for the blisters and medication for pain. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE]. The Minimum Data Set (MDS-a standardized resident assessment) revealed that on 1/19/2021 Resident 1 had a Brief Interview for Mental Status (BIMS- a test of cognitive function) score of 8/15. This score indicated that the resident has moderate cognitive impairment (ability to think and comprehend). During an interview on 3/26/21 at 8:30 am, the Director of Nursing (DON) stated that on 2/5/21 at 7:15 am, Resident 1 was given a cup of coffee at a table in the Activity Room by AS A. As she walked away from Resident 1, the resident apparently spilled the hot coffee on her lap. The DON stated Resident 1 sustained the following [CONDITION(S)]: 3.75 x 1 centimeter (cm) reddened area on her left abdomen, 4 cm x 1.5 cm reddened area on her left thigh, 11 cm x 6 cm reddened area with two intact blisters on her left inner thigh, 15 cm x 6 cm reddened area with one blister on her right inner thigh and some redness to the tips of her fingers. During an interview on 3/26/21 at 1:35 pm, Resident 1 stated that she remembers spilling hot coffee on herself but I'm ok now. She was unable to describe the circumstances of the incident. She stated that she had some pain with the [CONDITION(S)] but it wasn't too bad. During a review of Resident 1's Medication Administration Record (MAR) for February 2021, it was documented, that after she was burned on 2/5/21, Resident 1 had received [MEDICATION(S)] (a narcotic to treat pain) for moderate pain (7/10 on the pain scale) on 2/11/21, plus Tylenol 325 mg (milligrams) two tablets for mild pain, on 2/6/21 (8/10 on the pain scale), 2/9/21 (5/10 on the pain scale), 2/12/21 (4/10 on the pain scale) and 2/20/21 (5/10 on the pain scale). A review of Resident 1's Nurse's Notes dated 2/5/21 at 12:20 pm, indicated [Resident 1] does have some pain related to the [CONDITION(S)] on her inner thighs. During a review of Resident 1's Nurse's Notes dated 2/11/21 at 12:06 am, indicated [MEDICATION(S)] was given for She has pain on her inner thighs where she got [CONDITION(S)]. During a review of Resident 1's Nurse's Notes dated 2/11/21 at 11:27 am, indicated Resident complaining of pain to the left thigh area, medicated as ordered for this pain. During an interview on 3/26/21 at 10:50 am, Certified Nurses Assistant (CNA) 1 stated that her routine when taking care of Resident 1 was to get her up in the morning and serve her coffee with one cream and one sugar. CNA 1 stated I always put ice in her coffee because I saw lots of steam coming off the coffee and I knew she could get excited and sometimes spill her coffee. In an interview with Licensed Nurse (LN) A on 3/26/21 at 11:10 am, she stated that after Resident 1 spilled coffee on herself, she immediately took the temperature of the pot of coffee and it registered 170 °F. A fresh pot of coffee was made and it measured a temperature of 180 °F. She stated that it was routine to check coffee temperatures at Campus A (part of this facility) prior to serving, but was not done at Campus B, and she did not know why. She further stated that Resident 1 should not have been left alone, unsupervised with a cup of coffee, and the root cause of this accident was a new employee who did not know the resident and did not know that the coffee was too hot to serve without it being cooled down. A review of the American Burn Association's website (referenced Jun 22, 2015), indicated at 118 °F, human skin can sustain first-degree [CONDITION(S)]; a second-degree burn injury can occur at a temperature of 131 °F. Human skin is destroyed when temperatures reach 162 °F. In an interview with the Dietary Manager (DM) on 3/26/21 at 11:45 am, she verified that she oversaw both campuses. She also verified that it was the policy at Campus A to check coffee temperatures prior to serving residents, with the serving temperature to be no more than 140 °F. She reviewed the policy and procedure including temperature logs to be completed prior to serving residents. When asked what the rationale was for not following the policy at Campus B, she replied, There is no excuse. It was an oversight on my part and it is a shame that a resident was harmed due to this oversight. In an interview with CNA 2 on 3/26/21 at 2:00 pm, she stated, I do put ice in (the coffee) to cool it down as I see steam come off the coffee and I just know it is too hot.

Based on interview and record review, the facility failed to provide supervision for one of one sampled residents during weekly Church services (Resident 1). This failure allowed Resident 1 to leave the services un-noticed and release her seat belt (a device that the resident was able to release that alarms, designed to alert the staff when the resident was attempting to exit their chair), which lead to her falling from her wheelchair and sustaining a right femoral neck (the bone in the leg, that is above the knee) fracture requiring surgery and hospitalization . Findings: Resident 1's medical record was reviewed on 3/21/14, after the facility reported to the California Department of Public Health (CDPH) that she had sustained a fall with associated injury on 2/5/14. According to the report received by CDPH written by the Director of Nurses (DON), Resident 1 fell and sustained a fracture of the right femoral neck on 2/5/14 at approximately 9:15 am. Resident 1 was in the dining room with other residents attending Bible/Church services. Resident 1 left the room and went up to the facility's front doors in the lobby in her wheelchair. She had on a self-release seat belt and a chair alarm (a device that alarms when the resident attempts to exit their chair). Resident 1 stood up from her wheelchair and fell . The chair alarm sounded, but due to the excessive volume (singing and multiple musical instruments) of the Bible/Church services, no staff heard the alarms. The report stated that care conferences were going on right across the hall from the Bible/Church service, down the hall from the front doors and no one in those areas heard the chair alarm as well. The report indicated that another resident's family member found Resident 1 on the floor and reported it to the staff. The report described Resident 1 as a wanderer who was continually on the move. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's MDS (minimum data set, an assessment tool) dated 1/25/14, described Resident 1 with memory loss as well as impaired decision making abilities (unable to make safe decisions). Licensed Nurse (LN) A was interviewed by phone on 3/21/14 at 11:46 am, she explained that she was in the breakroom at the time of Resident 1's fall, as most of the residents were gathered in the dining room for Bible/Church service. LN A reported that the service was especially loud with singing and musical instruments. LN A reported that no facility staff were present in the dining room, providing supervision when Resident 1 exited the room. LN A reported that staff were meeting for care conferences across the hall, but had the door closed due to the noise. LN A reported that she was notified by staff that Resident 1 had been found on the floor. LN A acknowledged that Resident 1 should have been supervised once she left the room to prevent this kind of accident from occurring. During an interview with LN B on 3/21/14 at 12 pm, she reported that she was involved in care conferences in the room across the hall from the dining room and confirmed that the door was closed due to the noise. LN B confirmed that no facility staff was present in the dining room providing supervision during the Church service. LN B explained that Resident 1 was very fast in her wheelchair and must have self propelled out of the room and to the front doors of the lobby, before anyone noticed. Resident 1 was interviewed on 3/21/14 at 12:15 pm, she had no recall of the incident that had transpired on 2/5/14. During an interview with the DON on 3/21/14 at 12:40 pm, she reported that a root cause analysis meeting was held on 2/12/14, to determine the factors involved with Resident 1's fall and injury on 2/5/14. The DON acknowledged that the residents in the dining room participating in Church services were not being supervised by any facility staff members and that Resident 1 left that room without being noticed. The DON reported that the new procedure was to have facility staff present in all activities in the dining room when residents are present, that way if a resident leaves, then staff can alert another staff member so that they can come assist that resident. All staff have been trained in this new procedure.

Based on interview and record review, the facility failed to provide necessary supervision to prevent a fall for one of seven sampled residents (Resident 1). This failure resulted in severe injury to Resident 1 causing his death. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident 1's record was reviewed. On [DATE] at 4:06 pm, a nursing admit note read, "Bed alarm and chair alarm in place due to risk of fall." Resident 1 had three unwitnessed falls since his admission. His first two falls occurred on [DATE] at 2:45 pm, and on [DATE] before noon. Both of these falls were in his personal bathroom area and no injury was sustained. Resident 1 had been using a self release seat belt at the time of his first two falls and no mention of chair fall alarms were noted. On [DATE] at 12:55 pm, a physician's orders [REDACTED]." This order was changed on [DATE] at 2:53 pm, and read "Change pelvic posey order for postural support." On [DATE] at 3 pm, "Chair alarm and bed alarm related to falls" was ordered. On [DATE] at 2 pm, Resident 1's pelvic posey order was discontinued and a pommel cushion (helps provide seating stability and pressure redistribution without constricting blood circulation) for positioning in chair was ordered and the physician's chair alarm order read that nursing was to document number of attempts Resident 1 made to get out of his chair. Resident 1's Minimum Data Set (MDS), an assessment tool, dated [DATE], read that he required extensive assist with toileting and was considered at risk for falls due to his history. A "Fall Risk" care plan, updated [DATE], read that Resident 1's fall risk and potential for injury was "related to impaired safety awareness, impaired mobility, weakness, history of seizures, balance problems and unable to stand on his own," and was "evidenced by history of falls." The fall risk care plan interventions included fall alarms (a sensor that alarms when a resident stands up from their chair) and "Make sure that all staff members are aware that resident is high risk for falls." The fall care plan interventions also referenced Resident 1's "Physical Mobility" care plan, updated [DATE], and included an intervention to "Provide appropriate level of assistance to promote safety..." A progress note, dated [DATE] at 4:31 pm, read that Resident 1 had a third unwitnessed fall in the hallway common bathroom and when found he was unresponsive and was spitting up clear fluid. The note read that an Emergency Medical Technician (EMT) came over to take Resident 1 to the facilities acute care emergency room (ER) for evaluation and treatment. An ER record read that he arrived at the ER at 4:13 pm on [DATE]. On [DATE] at 3 pm, Administrative (Admin) Nurse stated that when Resident 1's fall occurred "no one was supervising" the main living room area (which was located at the opposite end of the unit and at the furthest point from the nursing station). She stated Resident 1 had been watching television with his peers just prior to his fall. She stated that the living room area should never be left unsupervised when residents are present. On [DATE] at 3:45 pm, Activity Assistant (AA) F stated that she was on duty the weekend that Resident 1 had fallen. She stated that on [DATE], she had initiated a movie activity group in the main living room that involved Resident 1 prior to his fall. She stated that the movie was not over when her shift came to an end at about 3:30 pm. She stated that she left Resident 1 and other residents in the living room, unsupervised, to watch the end of the movie, and that she reported to the nurses at the nursing station that she was going home. AA F stated that nursing staff were at the nursing station when she left. AA F stated that all staff knew that Resident 1 was a high fall risk and that he had in the past used the common bathroom area, the location of his last fall, for providing assistance to Resident 1 when toileting. On [DATE] at 4:13 pm, Certified Nursing Assistant (CNA) G stated that she had been at the nurse's station when AA F went off duty, that she had clocked out for her lunch break prior to Resident 1's fall at about 3:45 pm on [DATE]. CNA G stated that she returned to the nursing station after she had clocked out for lunch. CNA G stated that she then heard an alarm and loud noise coming from down near the end of the hall. She stated that she did not see any other staff in the area. She stated that she discovered that Resident 1 had entered the common bathroom in the hall way that was adjacent to the living room. She stated that she could hear Resident 1 and his chair alarm behind the locked bathroom door. CNA G stated that upon opening the locked hallway bathroom door, with the help of the charge nurse, Resident 1 was observed on the floor leaning against the wall, behind the door, his wheel chair empty and facing a hand rail. CNA G stated that Resident 1 said that he was "not ok" to her when she asked, and then he closed his eyes. CNA G stated that it was not facility practice to ensure that staff were always supervising the living room area when residents were there and that she was aware that Resident 1 was a high fall risk. On [DATE] at 5:20 pm, CNA H stated that she was on duty at the time that Resident 1 had fallen, that she had been out of the facility for a brief break and was not supervising Resident 1 at the time of his fall. On [DATE] at 5:30 pm, Licensed Vocational Nurse (LVN) I stated that she was in charge at the time that Resident 1 had his fall on [DATE] just around 4 pm. That she had been sitting at the nurses station at the time with a CNA and that no one was supervising the living room activity when Resident 1 had exited the living room, entered the nearby common bathroom, locked the door, and fell inside the bathroom. She stated that she had to seek out a key to the bathroom that Resident 1 had entered. LVN I stated that when she and CNA G entered the bathroom Resident 1 was on the floor, was coughing, and spitting up fluid. She stated that she immediately notified the acute care emergency department and the EMTs, who arrived in about four minutes from time of Resident 1's discovery. Resident 1's discharge summary, dated [DATE], read that Resident 1 died on [DATE]. The final [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to ensure that one of 12 residents was free from physical restraints (restricts freedom of movement or normal access to one's body) that were not required to treat the resident's medical symptoms (Resident 7). This failure limited the residents mobility, created the potential for unnecessary mental distress for the resident, and contributed to the development of a Stage II pressure sore (skin breakdown that results from direct pressure to a body site, preventing normal blood flow to the site, and occurred when the body was not repositioned frequently to prevent prolonged pressure to the site) to her coccyx (tail bone). Refer to F 314 for additional information. Findings: On 6/27/13, Resident 7's record was reviewed. Resident 7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (disorganized thought process resulting in functional disabilities in carrying out activities of daily living)." On 1/28/13, three days after admission, a nurse practitioner ordered, "May have waist restraint while in wheelchair for safety." A form titled, "Informed Consent for Physical Restraints," dated 1/29/13, indicated that the restraint was for "while in wheelchair," for "safety concerns." There was no medical justification listed for the use of the restraint, and there was no physician or nurse practitioner signature on the form. Both nursing notes and a Resident Care Plan documentation on 2/19/13 indicated that Resident 7 had developed a Stage II pressure sore on her coccyx. A nurses' note, dated 2/22/13 and timed 1:42 pm read, "Resident started on [MEDICATION NAME] last evening for a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) left leg." This was three weeks after the application of the waist physical restraint. Prolonged sitting increases the risk for blood clots and pressure sores. A minimum data set (MDS, an assessment tool ), dated 4/25/13, documented that Resident 7 had poor cognition (difficulty remembering, learning, making decisions), where she had scored "4" out of a possible best of 15, that she was diagnosed as having, "depression (altered mood characterized by feelings of sadness, despair, and discouragement)," that she had hallucinations (thought and sensory distortion) and delusions (a false belief that is firmly maintained in spite of obvious proof to the contrary), and that she was unable to verbalize to direct questions regarding whether or not she was in pain. The MDS indicated that Resident 7 was able to walk with "limited assistance," and that in doing so, she was "not steady, but able (underlined) to stabilize without staff assistance." The MDS indicated that a "trunk restraint (large area of the body attached to the head and extremities was prevented from moving freely)" was "used daily" on Resident 7, and the MDS form defined physical restraint as a device that, "...the individual cannot remove easily which restricts freedom of movement or normal access to one's body." The MDS of 4/25/13, dated three months after the start of the restraint, was documented that Resident 7 had a "Stage II pressure ulcer" on the coccyx. On 6/3/13, a nurse practitioner ordered, "Change waist restraint to pelvic posey," without medical symptom justification for the restraint. On 6/25/13 at 9:30 am, Resident 7 was observed in a wheelchair, in the corridor near the dining room door. She had her arms around the waist of a resident who was standing beside her, and her head and upper body leaned against the standing resident. She had a sad withdrawn facial expression and the other resident appeared to be comforting her, as he rubbed Resident 7's back. On 6/26/13 at 3:20 pm, Resident 7 was observed in a wheelchair with a pelvic posey (a three-cornered fabric with a canvas strap at each corner, that fits across lower abdomen and pelvis). One strap was placed between her thighs, front to back, and two straps surrounded her waist, and all straps were secured behind the back of the wheelchair. The straps were not within her reach and could not be easily removed. Resident 7 self-propelled herself in the wheelchair. There was no pressure-reducing device on the seat of her wheelchair. She was not interviewable. During an interview on 6/26/13 at 4:45 pm, Director of Nursing (DON) L and Certified Nursing Assistant (CNA) I stated that Resident 7 was able to walk, could not free herself from the chair, and was being restrained to the chair so that she will not get up and fall. During an interview on 6/27/13 at 1 pm, DON L stated that Resident 1's pressure sore was on her coccyx area, and that she had gotten the pressure sore from "scooting herself up and down in her wheelchair." During an interview on 6/27/13 at 4:40 am, when asked regarding a physician's medical justification for the use of a physical restraint, DON L stated that she "was not going to let the resident fall while she was on [MEDICATION NAME] (medication to treat a blood clots)." DON L could not provide other interventions that were attempted prior to using physical restraints. During an interview on 6/28/13 at 10:30 am, Certified Nursing Assistant (CNA) M stated that Resident 7 originally had a restraint belt placed in an attempt to prevent her from getting up from the wheelchair, but that she was able to free herself by either lifting the belt up over her head, or by sliding the belt around to release it. CNA M stated that the belt was then replaced by the pelvic posey on 6/3/13 and that Resident 7 was unable to free herself from the posey. CNA M added that Resident 7 currently ambulated while a CNA assisted by having a hand on her gait belt (a standard, non- restraining, precautionary belt around the resident's waist) as a standby precaution. Resident 7 walked two to four full 250 feet "laps" inside the facility, and did so 6 times a day. CNA M stated that Resident 7 was not verbally coherent, and that she cried off and on all the time. A facility policy and procedure titled, "Restraints," dated 1/12, specified, "The resident...has the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms." It further specifies, "Use of restraints is limited to circumstances in which the resident has medical symptoms that warrant the use of restraints...If the resident is restrained for medical reasons, this must be demonstrated. Proper body position, balance, and alignment must be maintained."

Based on observation, interview, and record review, the facility failed to use a lesser restrictive alternative to restraints, for one of six sampled residents, when full bed side rails and a pelvic restraint were used for prevention of falls. (Resident 1) This failure had the potential that residents may not obtain their highest level of physical and psychosocial well being. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/10/13 at 2 pm, Resident 1 was observed watching television in the activity room while seated in a wheelchair with a pelvic posy restraint (a restraint that is wrapped around his waist and pelvic region and was attached to the back of his chair out of his reach). On 9/10/13 at 4:50 pm, Resident 1 was observed lying in his bed with a full side rail that extended the entire length of the bed in the up position on both sides of the bed. The release to lower the side rails was out of Resident 1's reach. On 9/10/13 Resident 1's record was reviewed. On 8/26/13 at 4:06 pm, a nursing admit note read "Bed alarm and chair alarm in place due to risk of fall." Resident 1 had two unwitnessed falls since his admission, one on 8/28/13 at 2:45 pm and one on 8/29/13 before noon. Both falls were in his bathroom area and no injury was sustained. Resident 1's fall care plan, dated 8/26/13, included an intervention to, "Assess need for fall interventions such as: low bed, bed or chair alarms, ... padded floor next to bed, wedge in chair." The use of a bed or chair alarm were not identified as interventions used on Resident 1's care plan. The use of a low bed or a floor pad were not identified on Resident 1's care plan as interventions for Resident 1 to lessen the potential for a fall injury from his bed. On 9/4/13, a late entry for an 8/27/13 physician's orders [REDACTED]." The order did not specify the reason for the devices. No physicians order was obtained for fall alarms for the bed or chair. On 8/29/13 at 12:55 pm, a physician's orders [REDACTED]." On 9/10/13 at 3 pm, Certified Nursing Assistant (CNA) A stated that she worked with Resident 1 on 8/28/13 at the time of his fall. She stated Resident 1 did not have an alarm in use for his chair, that he had a self releasing seat belt in place when he fell . On 9/10/13 at 3:42 pm, Licensed Vocational Nurse (LVN) B stated that she had assessed Resident 1 after his first fall on 8/28/13. She stated that she did not recall that an alarm was in use for his wheelchair. LVN B stated that the family of Resident 1 was insistent that he have full side rails for his bed. She stated that the posey pelvic restraint was a necessary use for Resident 1 because after his second fall "We can't watch him all the time." LVN B stated that Resident 1 "paddles himself around the facility in his wheelchair." LVN B stated that she did not update Resident 1's fall care plan when he fell or consider fall alarms or a low bed and pad. On 9/10/13 at 4 pm, CNA C stated that she responded to Resident 1's second fall on 8/29/13 in the afternoon. CNA C stated that no fall alarms were in use for Resident 1 at the time of his second fall. CNA C stated that she was instructed to apply a posey pelvic restraint to Resident 1 "within the same hour of his fall." On 9/10/13 at 4:30 pm, LVN D stated that she responded to Resident 1's second fall in his bathroom and thought that the incident occurred around 11:45 am on 8/29/13. She stated that she had received a physician's orders [REDACTED]. LVN D stated that she was not aware if a fall alarm had been used for Resident 1. On 9/10/13 at 5 pm, the Director of Nurses (DON) stated that Resident 1 should have had alarms in place when he fell . On 9/12/13 at 9:50 am, Resident 1's physician, the Medical Director (MD), stated that she ordered the posey pelvic restraint because she did not want Resident 1 to have any more falls. MD stated that she had not ordered fall alarms before ordering the pelvic chair restraint. The facility policy "Fall Risk Assessment," dated 5/2013, did not list restraints and full side rails among the twelve possible interventions to prevent falls. The facility policy "Restraints," dated 5/2013, reads "Bed rails can be used for mobility and transfer... Restraints must be discussed by the interdisciplinary team...Attempts to alternatives or removal of restraints must be made when at all possible" On 9/12/13 at 10:30 am, the Resident Assessment Coordinator (RAC) acknowledged that no interdisciplinary team meeting was documented to discuss Resident 1's restraint use, or alternatives such as alarms, low bed and pads on the floor.

4 Based on interview and record review, the facility failed to provide necessary supervision to prevent a fall for one of seven sampled residents (Resident 1). This failure resulted in severe injury to Resident 1 causing his death. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident 1's record was reviewed. On [DATE] at 4:06 pm, a nursing admit note read, Bed alarm and chair alarm in place due to risk of fall. Resident 1 had three unwitnessed falls since his admission. His first two falls occurred on [DATE] at 2:45 pm, and on [DATE] before noon. Both of these falls were in his personal bathroom area and no injury was sustained. Resident 1 had been using a self release seat belt at the time of his first two falls and no mention of chair fall alarms were noted. On [DATE] at 12:55 pm, a physician's orders [REDACTED]. This order was changed on [DATE] at 2:53 pm, and read Change pelvic posey order for postural support. On [DATE] at 3 pm, Chair alarm and bed alarm related to falls was ordered. On [DATE] at 2 pm, Resident 1's pelvic posey order was discontinued and a pommel cushion (helps provide seating stability and pressure redistribution without constricting blood circulation) for positioning in chair was ordered and the physician's chair alarm order read that nursing was to document number of attempts Resident 1 made to get out of his chair. Resident 1's Minimum Data Set (MDS), an assessment tool, dated [DATE], read that he required extensive assist with toileting and was considered at risk for falls due to his history. A Fall Risk care plan, updated [DATE], read that Resident 1's fall risk and potential for injury was related to impaired safety awareness, impaired mobility, weakness, history of seizures, balance problems and unable to stand on his own, and was evidenced by history of falls. The fall risk care plan interventions included fall alarms (a sensor that alarms when a resident stands up from their chair) and Make sure that all staff members are aware that resident is high risk for falls. The fall care plan interventions also referenced Resident 1's Physical Mobility care plan, updated [DATE], and included an intervention to Provide appropriate level of assistance to promote safety. A progress note, dated [DATE] at 4:31 pm, read that Resident 1 had a third unwitnessed fall in the hallway common bathroom and when found he was unresponsive and was spitting up clear fluid. The note read that an Emergency Medical Technician (EMT) came over to take Resident 1 to the facilities acute care emergency room (ER) for evaluation and treatment. An ER record read that he arrived at the ER at 4:13 pm on [DATE]. On [DATE] at 3 pm, Administrative (Admin) Nurse stated that when Resident 1's fall occurred no one was supervising the main living room area (which was located at the opposite end of the unit and at the furthest point from the nursing station). She stated Resident 1 had been watching television with his peers just prior to his fall. She stated that the living room area should never be left unsupervised when residents are present. On [DATE] at 3:45 pm, Activity Assistant (AA) F stated that she was on duty the weekend that Resident 1 had fallen. She stated that on [DATE], she had initiated a movie activity group in the main living room that involved Resident 1 prior to his fall. She stated that the movie was not over when her shift came to an end at about 3:30 pm. She stated that she left Resident 1 and other residents in the living room, unsupervised, to watch the end of the movie, and that she reported to the nurses at the nursing station that she was going home. AA F stated that nursing staff were at the nursing station when she left. AA F stated that all staff knew that Resident 1 was a high fall risk and that he had in the past used the common bathroom area, the location of his last fall, for providing assistance to Resident 1 when toileting. On [DATE] at 4:13 pm, Certified Nursing Assistant (CNA) G stated that she had been at the nurse's station when AA F went off duty, that she had clocked out for her lunch break prior to Resident 1's fall at about 3:45 pm on [DATE]. CNA G stated that she returned to the nursing station after she had clocked out for lunch. CNA G stated that she then heard an alarm and loud noise coming from down near the end of the hall. She stated that she did not see any other staff in the area. She stated that she discovered that Resident 1 had entered the common bathroom in the hall way that was adjacent to the living room. She stated that she could hear Resident 1 and his chair alarm behind the locked bathroom door. CNA G stated that upon opening the locked hallway bathroom door, with the help of the charge nurse, Resident 1 was observed on the floor leaning against the wall, behind the door, his wheel chair empty and facing a hand rail. CNA G stated that Resident 1 said that he was not ok to her when she asked, and then he closed his eyes. CNA G stated that it was not facility practice to ensure that staff were always supervising the living room area when residents were there and that she was aware that Resident 1 was a high fall risk. On [DATE] at 5:20 pm, CNA H stated that she was on duty at the time that Resident 1 had fallen, that she had been out of the facility for a brief break and was not supervising Resident 1 at the time of his fall. On [DATE] at 5:30 pm, Licensed Vocational Nurse (LVN) I stated that she was in charge at the time that Resident 1 had his fall on [DATE] just around 4 pm. That she had been sitting at the nurses station at the time with a CNA and that no one was supervising the living room activity when Resident 1 had exited the living room, entered the nearby common bathroom, locked the door, and fell inside the bathroom. She stated that she had to seek out a key to the bathroom that Resident 1 had entered. LVN I stated that when she and CNA G entered the bathroom Resident 1 was on the floor, was coughing, and spitting up fluid. She stated that she immediately notified the acute care emergency department and the EMTs, who arrived in about four minutes from time of Resident 1's discovery. Resident 1's discharge summary, dated [DATE], read that Resident 1 died on [DATE]. The final [DIAGNOSES REDACTED].