Every finding on record at Eureka Rehabilitation & Wellness Center, LP

Based on observation, interview, and record review, the facility failed to comply with federal regulations related to dietary staffing when the facility did not have a full-time Registered Dietitian (RD, food and nutrition experts with a minimum of a graduate degree from an accredited dietetics program, who completed a supervised practice requirement, and passed a national exam) or a full-time Supervisor of Food and Nutrition Services for a census of 91 residents.This failure had the potential to compromise dietary services rendered to the facility's residents.During a concurrent observation and interview on 8/18/26 at 10:30 a.m. with the Certified Dietary Manager (CDM), CDM stated she was responsible for onsite management of the facility kitchen. CDM stated she worked at the facility three (3) days a week, because she had to also oversee the kitchen operations of another nearby nursing facility. CDM also stated her current employment was only temporary, and a full-time kitchen manager was to start work at the facility in the coming weeks. The kitchen staff was preparing for lunch during this time, and CDM stated lunch was served to residents daily at noon.During a concurrent observation and interview on 8/18/26 at 12:20 p.m. with the Administrator (ADM) in the facility dining room, approximately 12 residents were seated around dining tables, but lunch had not been served yet. Residents began to ask when lunch would be served. The ADM stated a QAPI (Quality Assurance and Performance Improvement, a data-driven, mandatory framework used in long-term care facilities to continuously enhance the quality of care and resident safety) project had been started for more timely meal service to residents.During a phone interview on 8/19/26 at 9:25 a.m. with RD, she stated she worked remotely for 16 hours weekly, spending no physical time at the facility. RD stated she worked at 2 to 3 other facilities during the week. RD stated she spent 16 hours doing dietary assessments and plans for facility residents. When asked when she found time to collaborate or oversee kitchen or clinical staff, she stated she sent her orders and recommendations to the facility electronically or by phone. During an observation on 8/19/26 at 12:20 p.m. in the dining room, lunch was still not served to residents waiting there. A live musical performer began to sing and play music in the dining room, after which a wheelchair-bound resident began to cry. Staff then relocated this resident to her bedroom. Lunch carts were not brought into the dining room until just after 12:25 p.m.During an observation on 8/19/26 at 1:13 p.m. in the memory care unit, staff were just beginning to bring lunch trays from the mobile heat carts and started delivering lunch meals to residents' rooms.A review of the Facility Assessment, dated 1/26/26, indicated, Staffing plan - Overall number of facility staff members needed to ensure a sufficient number of qualified staff is available to meet each resident's needs.Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services: Dietitian, Director of Nutrition Services.if we are facing staffing challenges in the dietary department, we have a Certified Dietary Manager and Dietary Supervisor that are able to step up and cook.In the instance they are not available, the Registered Dietitian can step in and assist/cook.A review of the facility's undated Job Description titled, Dietary Supervisor/Certified Dietary Manager, indicated, Principle Responsibilities: Operational/Clinical, ensures the timely preparation and delivery of nutritious and attractive meals, and supplements to all Residents according to physician's orders, Resident preferences and in compliance with Federal and State of California and facility policy and procedures.supervises food preparation.implements and revises menus with Registered Dietitian.completes purchasing of food and supplies.ensures food is received, stored, prepared, held and served.collaborates with the Registered Dietitian to meet the health goals of the Residents.monitors staff performance.A review of the facility's undated Job Description titled, Registered Dietitian, indicated, Position Summary: Provides medical nutrition therapy and works with the Dietary Services/Certified Dietary Manager to ensure that quality food, service and nutritional care are being provided.conducts meal rounds and interviews staff and residents to ensure residents are receiving foods in the amount, type, consistency, and frequency required to maintain or improve nutritional status.routinely inspects the food service areas.

Based on interview and record review, the facility failed to ensure the electronic submission of the Payroll Based Journal (PBJ, a system by which skilled nursing facilities submit staffing information to the Centers for Medicare and Medicaid [CMS]) data as required quarterly when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time reports that allows SNFs the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the fourth quarter (Q4-10/25 through 12/25). This failure prevented regulatory agencies, residents, and residents' families from being able to verify that facilities had enough staff to provide necessary care to residents. A review of CMS' PBJ Staffing Data Report indicated, No Data Submitted for Quarter. During an interview on 7/9/26 at 1:51 p.m., the Administrator (ADM) confirmed quarterly PBJ data must be submitted to CMS and stated the corporate office was responsible for submitting the PBJ data. In a further interview at 4:54 p.m., the ADM stated the corporate office made an error and acknowledged the PBJ data was not submitted for the 1st quarter of 2026.

Based on observation, interview and record review, the nursing staff failed to ensure appropriate treatment for an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for one resident (Resident 1) of three sampled residents when Resident 1's indwelling urinary catheter bag was found on the floor.This failure placed Resident 1 at risk to develop an infection.A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Retention of Urine (inability to fully or partially empty the bladder).A review of Resident 1's physician orders dated 6/15/26 indicated, Foley Catheter Care to be provided every shift.During an observation in Resident 1's room on 7/8/26 at 8:46 a.m., Resident 1's indwelling catheter bag (collection bag) was observed to be lying on its side directly on the floor beneath his bed. During a concurrent observation and interview in Resident 1's room on 7/8/26 at 11: 23 a.m., Certified Nursing Assistant 1 (CNA 1) confirmed the collection bag was directly on the floor and stated a collection bag on the floor could cause an infection in the resident's bladder. CNA 1 did not attempt to move the collection bag from the floor.During a concurrent observation and interview in Resident 1's room on 7/8/26, at 11:41 a.m., Licensed Nurse 1 (LN 1) confirmed the collection bag seen directly on the floor and stated due to Resident 1's bed being in the lowest position the collection bag had nowhere to hang on the bed frame. LN 1 stated the collection bag should not be on the floor for cleanliness, the floor is so dirty. LN 1 moved the collection bag from a side lying position to an upright one on the floor.During a concurrent observation and interview on 7/8/26 at 12:45 p.m., the Director of Nursing Services (DON) confirmed the collection bag was directly on the floor and stated, It is in a privacy bag at least. The DON directed CNA 1 and another staff member to raise the bed enough to appropriately hang the collection bag, so it did not touch or rest on the floor. During an interview on 7/8/26 at 2:20 p.m., the Infection Preventionist (IP) was shown the picture taken depicting Resident 1's collection bag left on the floor. The IP stated, I do not approve of this. The IP further stated leaving a collection bag on the floor could result in bacteria entering the system via the catheter tubing, leading to an infection. The IP stated it did not matter that the collection bag was in a cloth privacy bag; the bacteria could still travel up the catheter tubing and work their way into the urethra (the tube which carries urine from the bladder to the outside of the body).During an interview on 7/8/26 at 3:10 p.m., the Director of Staff Development (DSD) stated nursing staff were taught never to leave urine collection bags on the floor during orientation. The DSD stated ensuring the collection bag was appropriately hanging was a part of the foley care provided each shift. The DSD stated because the floors were so dirty, leaving a collection bag on the floor was an opportunity for an infection to develop.A review of facility policy titled Indwelling Catheter - Insertion, Maintenance and Discontinuation of, revised 7/22/25, indicated, Position the drainage bag below the level of the patient's bladder, but don't place the drainage bag on the floor.

Based on observation, interview, and record review, the facility failed to implement measures to prevent an avoidable fall for one resident (Resident 1) for a census of 71 residents, when Resident 1 was transferred from his bed to a chair using a Hoyer lift (a brand of portable patient lift (mechanical lift) designed to help caregivers safely transfer individuals with limited mobility between beds, chairs, and wheelchairs) with a one person assist and a frayed (material that is worn or unraveled at the edges) Hoyer lift sling (the crucial fabric interface that attaches a patient to a mechanical or hydraulic lift for safe transferring).This failure resulted in Resident 1 falling from the Hoyer lift and sustaining left rib fractures, a transverse process fracture (a break in the wing like bony projections on the sides of the vertebrae (the bones that make up the spine), and a hemothorax (the accumulation of blood in the pleural space between the lungs and chest wall). These injuries caused the resident significant pain and distress. A review of Resident 1's admission record indicated that the resident was initially admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a progressive, long-term lung disease that makes breathing difficult by restricting airflow), muscle weakness, and the presence of an unspecified artificial hip joint (indicating the resident had a hip replacement, though the side-left or right-was not specified).A review of Resident 1's Minimum Data Set (MDS- a federally mandated clinical assessment tool used in Medicare and Medicaid-certified nursing homes and skilled nursing facilities), dated 5/20/26 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a standardized assessment used in nursing homes to evaluate memory, attention, and orientation). The resident scored 14, which indicates cognition is intact. The BIMS scoring range is 0 to 15, with 13-15 indicating intact cognition, 8-12 indicating moderate impairment, and 0-7 indicating severe impairment.A review of Resident 1's MDS Section GG- Functional Abilities dated 3/31/26 indicated Resident 1 had limited mobility and was dependent on two-person assistance for bed to chair transfers, lying-to-sitting on side of bed, toileting, and tub/shower transfers.A review of Resident 1's Change In Condition (CIC) form dated 5/10/26, indicated Resident 1 fell from the Hoyer lift on 5/10/26, when the Hoyer sling straps broke. The resident had pain in the left side, neurological checks (neuro checks; a clinical evaluation used to assess the function of the brain, spinal cord, and nervous system) were monitored, and the resident was transferred to the hospital by Emergency Medical Services (EMS).During a concurrent observation and interview on 6/4/26 at 10 a.m., Resident 2 was transferred from the bed to a wheelchair with two-person assistance from Certified Nursing Assistant (CNA) 2 and CNA 3 in Resident 2's room. CNA 2 and CNA 3 positioned a Hoyer lift sling under the resident, and Resident 2 was lifted and transferred to the wheelchair, with CNA 3 providing additional support to ensure a safe transfer. The sling used for Resident 2 appeared to be in new condition. During an interview, CNA 2 stated that all residents require a two-person assist when using the Hoyer (mechanical) lift. When asked about the condition of the slings used at the time of Resident 1's fall, CNA 2 stated the slings were old and worn, likely due to frequent laundering. CNA 2 further stated that, to their knowledge, staff had not reported the condition of the slings to management. CNA 2 also stated that all staff received in-service training on the use and management of the Hoyer lift and slings, and that residents are measured by weight to ensure the correct sling size is used. CNA 2 reported as of May 22, 2026, the facility had replaced all the Hoyer slings with new ones.During an interview on 6/4/26 at 11 a.m., the Director of Staff Development (DSD) stated that transferring or weighing a resident with the mechanical lift requires a two-person assistance. The DSD explained that all staff who use the Hoyer lift are responsible for checking the lift's function and the integrity of the sling. Sling sizes are listed on a chart, and each resident is measured by weight to ensure the correct size is used. When asked about the slings used prior to the current incident, the DSD stated they were old, worn, and not well maintained, and noted that the facility purchased and received all new slings on May 22, 2026. The DSD acknowledged that CNA 5 was alone when transferring Resident 1 on 5/10/26 and should have had another staff member assisting. The DSD reported that in service training and retraining on the use of the Hoyer lift and sling assessment were conducted for all staff between May 10, 2026 and May 15, 2026.During an interview on 6/4/26 at 1:45 p.m., Resident 1 was lying in bed with the head of the bed elevated. The resident stated on 5/10/26 (Mother's Day), he was preparing to go to church when someone, not aware of what he was doing, placed him in the Hoyer lift. He reported that one of the straps broke, causing him to fall to the floor. Resident 1 stated he was injured and experienced pain in his ribs, chest, tail bone, and the muscles on the left side of his chest. He confirmed that CNA 5 transferred him alone. When asked if he had pain Resident 1 stated Yes, I still have pain. The nurses gave me pain medicine, but I need something stronger. During a telephone interview on 6/9/26 at 9:40 a.m., Licensed Staff (LS) 4 stated on 5/10/26 she heard yelling coming from room [ROOM NUMBER]. The door was closed, and when she opened it, she saw Resident 1 on the floor, lying on the base of the Hoyer lift. LS 4 immediately assessed the resident who was awake, alert, and in pain. LS 4 called Emergency Medical Services (EMS) and Resident 1 was transferred to the hospital. LS 4 stated that CNA 5 was working alone, even though two staff members are required when using the Hoyer lift. LS 4 stated the sling was in poor condition and all the straps were frayed, likely from repeated laundering. LS 4 stated she believed staff were aware of the sling condition but did not report it to management. LS 4 stated she conducted an in-service on 5/10/26 for the staff assessing and using Hoyer slings with the Hoyer lift.A review of the facility's policy and procedure titled, Total Mechanical Lift, dated 5/4/23, indicated, .3. Staff must check the sling, bindings and loops for fraying, wear and tear, and damage. 6. Place the sling under resident: a. Two staff required.These findings represent past noncompliance with this regulatory requirement. Observation of the newly purchased slings in new condition was conducted, and staff interview confirmed direct care staff in-services had been conducted with regards to the use of the 2-person assist lift/transfer device. Staff competency verification and in-service attendance was also documented. There was sufficient evidence that the facility corrected the violation as of 5/22/26, and no other occurrences of noncompliance were identified. At the time of the survey, the facility was in substantial compliance with this regulatory requirement, and therefore, this violation does not require a plan of correction.

Based on interview and record review, the facility failed to ensure an allegation of resident-to-resident sexual abuse was timely reported to the California Department of Public Health (CDPH) for two of two sampled residents (Resident 1 and Resident 2).This failure had the potential to delay state agency awareness and oversight of an alleged abuse incident.A review of a facility reported incident received by the Department on 3/26/26 at 8:00 a.m., indicated that on 3/20/26 at approximately 10:00 p.m., staff observed Resident 1 placing Resident 2's hand on Resident 1's genital area while Resident 2 was asleep.During an interview on 4/22/26 at 11:45 a.m., the Regional Administrator stated the incident occurred at approximately 10:00 p.m. on 3/20/26 and the SOC 341 (a standardized reporting form used in California to notify authorities about suspected cases of abuse) was submitted at 7:11 a.m. on 3/21/26 (approximately nine hours after the incident was identified). The Regional Administrator stated the charge nurse notified the Director of Nurses, who instructed staff to notify the Administrator. According to the Regional Administrator, the Administrator was ill, did not answer the phone that night, listened to the message the following morning, came to the facility, and then completed the report.During interviews on 4/22/26 at 12:40 p.m., and 12:55 p.m., Licensed Nurse A and CNA B stated they would separate residents and notify supervisors if abuse occurred; however, both stated they were unaware the allegation required timely notification to CDPH.A review of the facility policy titled, Abuse Prevention and Management, last revised on 5/30/24, indicated, The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than two (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on interview and record review, the facility failed to ensure one licensed nurse (Licensed Nurse 1 (LN 1)) of two licensed nurses maintained an appropriate Cardiopulmonary Resuscitation (CPR) certification when LN 1 did not obtain CPR certification through a provider with hands on training.This failure decreased the facility's potential to be able to implement of life saving measures and effective clinical interventions for all residents residing in the facility in the event of a respiratory or cardiac emergency.A review of LN 1's employee file indicated LN 1 was hired as a registry (agency that employs nursing staff for facilities with urgent staffing needs) nurse. Further review of LN 1's file indicated LN 1 obtained CPR certification through an online provider on [DATE].A review of the online provider's website indicated candidates were trained to the AHA [American Heart Association] (R) 2020 cognitive guidelines where course modules may be purchased and accessed 24 hours per day, 365 days per year. The test may be taken at any time, in an unlimited amount. There was no validation of skills technique indicated with this online provider. The site offers instant certification based solely on a written exam, which bypasses the critical hands-on component.During an interview on [DATE] at 8:01 a.m., the Administrator (ADM) stated all licensed nurses needed to maintain CPR certification with hands-on training and further stated, This means performing the skills on a mannequin. This also applied to registry nurses. The ADM stated hands-on assessment during CPR certification was important as it validated the proper techniques that were being used.A review of facility policy titled Cardiopulmonary Resuscitation, dated 2022, indicated, The facility shall ensure properly trained personnel (and certified in CPR for Healthcare Providers are available immediately to provide basic life support, including cardiopulmonary resuscitation (CPR).The facilities procedure for administering CPR shall incorporate the guidance from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Licensed Nursing staff shall maintain current CPR for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor led setting, in accordance with accepted national standards.

Based on interview and record review, the facility failed to ensure a professional standard of nursing care was provided to one resident (Resident 1) of two sampled residents when:- Licensed Nurse 1 (LN 1) did not document an assessment and Change of Condition (COC) of Resident 1 after Certified Nurse Assistant 1 (CNA 1) notified her that Resident 1 had a change in his breathing on [DATE] at approximately 3 p.m.;- LN 1 administered a medicated breathing treatment to Resident 1 without a physician's order and documented she administered the breathing treatment on the wrong day; and,- LN 1 called for a non-emergent ambulance when Resident 1 was found unresponsive with labored breathing and a faint pulse. These failures decreased the facility's potential to ensure care provided to Resident 1 met professional standards of quality nursing care and may have contributed to a delay in Resident 1 being transferred to a higher level of care sooner.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a progressive, irreversible lung disease that restricts airflow, making it hard to breathe) and asthma (a chronic, respiratory condition caused by swelling and mucus production that narrows the airways of the lungs resulting in wheezing, chest tightness, and shortness of breath).A review of Resident 1's care plan related to his diagnosis of COPD and asthma, initiated [DATE], indicated licensed nurses were expected to implement the following interventions when Resident 1 had a concern regarding difficulty breathing, Give aerosol or bronchodilators as ordered. Monitor/document side effects and effectiveness. Monitor for s/sx [signs and symptoms] of acute respiratory insufficiency: Anxiety [persistent fear or worry], Confusion, Restlessness, SOB [shortness of breath] at rest, Cyanosis [blue skin], Somnolence [excessive drowsiness].Monitor/document/report PRN [as needed] any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing.A review of the facility's document titled Contract Services Orientation Information signed on [DATE] by LN 1 indicated, Change in Resident Condition: It is of the utmost importance that our clinical staff are able to detect and report changes in a resident's physical.condition in a timely manner.The assigned [licensed] nurse shall complete the S-BAR [Situation- Background, Assessment, and Recommendation] and notify the licensed independent practitioner immediately upon identification of a change in condition.A review of Resident 1's order listing report indicated Resident 1 had the following physician's orders:-Starting on [DATE], staff was supposed to provide Resident 1 with Cardiopulmonary Resuscitation (CPR) in the event Resident 1's heart stopped beating or Resident 1 stopped breathing; and,- Starting on [DATE], staff was supposed to add a progress note during every shift regarding Resident 1's lung sounds.The order listing report further indicated both of these orders were discontinued on [DATE] at 3: 26 p.m.A review of Resident 1's progress notes dated [DATE] indicated no documented evidence of: an assessment, a COC related to Resident 1's respiratory status between 3 p.m. and 6:30 p.m., notification of Resident 1's COC to the physician, treatment provided, and monitoring of effectiveness of the treatment.A review of Resident 1's progress note dated [DATE] at 7:43 p.m., LN 1 documented, Approx: [6:40 p.m.] [LN 1] was notified by [CNA 1] that.[Resident 1] was breathing rapidly. [LN 1] went in to see [Resident 1] O2 sats [saturation, the percentage of oxygen in a person's blood] were 93% .[LN 1] asked [Resident 1] if resident wanted to go to hospital [Resident 1] said no.Approx [7:05 p.m.] [CNA 1] came and said O2 levels dropped to 63%. Both [LN 1] and [LN 2] went to assess [Resident 1] and decided to send resident out [to hospital]. Approx [7:05 p.m.] [LN 1] called non emergent [ambulance].A review of Resident 1's progress note dated [DATE] at 7:50 p.m., LN 2 documented, [LN 2] arrived on shift at [6:53 p.m.].[CNA 1] came to nurses [sic] station approximately [7 p.m.] reporting that [Resident 1] reports SOB [shortness of breath], and has O2 level of 63% RA [room air].O2 SAT on the monitor was recorded at 72% RA, [LN 2] instructed [LN 1] to call 911 [EMS]. [Resident 1] was unresponsive with labored, rapid breathing, resident had a very faint pulse.[Resident 1's] breaths became shorter and shorter in between and pulse was fading.Tx [treatment] nurse had began chest compressions.[LN 2] took over compression for Tx nurse while oxygen was placed on the resident via mask.EMS arrived and placed.pads on resident, called to clear, and took over CPR.A review of Resident 1's emergency room (ER) provider note dated [DATE] at 8:13 p.m. indicated, .Per EMS report, [Resident 1] was found down and apneic [not breathing] by [facility] staff 30 minutes prior to arrival [in ER].Reportedly, [Resident 1's] last known normal was [6:30 p.m.] today .albuterol 2.5 mg [milligrams, a unit of measurement]/ 3 mL [milliliters, a unit of measurement] nebulizer solution [medication used to treat COPD and asthma].Take 3 mL by nebulization [the use of a medical device that converts a liquid medication into a fine mist allowing residents to inhale the medication into their lungs] every 4 hours as needed for shortness of breath. ([Resident 1] not taking: Reported on [DATE].).A review on Resident 1's progress note dated [DATE] at 3:34 p.m. indicated that LN 1 documented, Late entry. At approx. [6:45 p.m.] on [DATE] [sic] writer administered breathing treatment [medication used to treat COPD and asthma]. While writer was on phone the resident started to code [cardiac or respiratory arrest] and the non-emergent transferred call to 911. There was no documented evidence what medication LN 1 gave to Resident 1 as a breathing treatment or that it was administered on [DATE].A review of Resident 1's physician's order dated [DATE] at 3:57 p.m. indicated the following order was placed for Resident 1, Created [DATE] [at 3:27 p.m.].Albuterol Sulfate Nebulization Solution (2.5 MG/3ML).1 vial inhale orally via nebulizer one time only for SOB until [DATE] [7 p.m.].Discontinue [DATE] [at 3:26 p.m.].Discontinue.Reason: Resident expired at ED [Emergency Department].During an interview on [DATE] at 1:41 p.m., CNA 1 stated she had worked with Resident 1 since he was admitted to the facility. CNA 1 stated when she started her shift on [DATE] at 3 p.m., she noticed Resident 1 appeared to have some difficulty breathing. CNA 1 stated, He sounded like he had a lot of mucus in his lungs, it was noisy breathing. CNA 1 stated Resident 1 reported shortness of breath and when CNA 1 checked Resident 1's O2 saturation (the amount of oxygen in the blood), she found it fluctuated between 85-95% on room air. CNA 1 escalated this concern to LN 1 but LN 1 responded Resident 1 was fine. CNA 1 further stated, As time passed, the sound of his breathing got worse. I told LN 1 three or four more times that Resident 1 was getting worse, but she [LN 1] kept telling me he [Resident 1] was fine. CNA 1 stated when Resident 1's O2 saturation read 35%, she asked CNA 2 to assist her in getting LN 1 to physically go into Resident 1's room and assess him. CNA 1 stated LN 1 finally assessed Resident 1 and administered a breathing treatment for him nearly four hours after she initially notified her of Resident 1's difficulty breathing. CNA 1stated, I told him [Resident 1] I was trying to help him. He looked so scared.During an interview on [DATE] at 9:01 a.m., the surveyor attempted to interview LN 1, but LN 1 stated, Unless I have the [Electronic Medical Record (EMR)] in front of me, I cannot answer your question. I no longer work at that facility and unless they want to pay me to go in there and look up my notes, I cannot help you. LN 1 then hung up the phone on the Surveyor.During an interview on [DATE] at 3:32 p.m., CNA 2 stated CNA 1 had been worried about Resident 1 at the beginning of the shift on [DATE]. CNA 2 stated CNA 1 had told her Resident 1 was acting differently and was making an awful sound while breathing. CNA 2 stated at one point she entered Resident 1's room with CNA 1 and Resident 1 was gurgling. CNA 2 stated CNA 1 measured Resident 1's vital signs and his O2 saturation was really low and further stated it was the lowest O2 saturation she had ever seen. CNA 1 then asked CNA 2 to notify LN 1 of Resident 1's condition because LN 1 had not been listening to CNA 1's concerns. CNA 2 stated she did alert LN 1 but was not sure what happened after that.A review of Resident 1's Medication Administration Record dated [DATE] and printed on [DATE] at 1:54 p.m. indicated no documented evidence that albuterol sulfate nebulization solution was administered to Resident 1 on any day in [DATE].During an interview on [DATE] at 8:01 a.m., the Administrator (ADM) stated licensed nurses were expected to assess residents when a CNA reported a resident abnormality or concern regarding resident safety or health. The nurse was also expected to document the assessment in the EMR, and to keep an eye on the resident during the remainder of the shift. The ADM further stated nursing staff were expected to call 911 (EMS) for residents who were not breathing or had no pulse.During an interview on [DATE] at 4:20 p.m., Resident 1's physician (MD) stated she had concerns with the nurse caring for him that shift. The MD stated on [DATE], LN 1 had not provided any notification to the physician of Resident 1's complaints or symptoms of shortness of breath. The MD confirmed she had not received a call from LN 1 to request a respiratory treatment order for Resident 1 that day. The MD further stated she was unsure if nurses could initiate treatment without physician orders but added a respiratory treatment would be ineffective for a resident who was coding (experiencing a cardiac or respiratory arrest). The MD stated she had only received one call from LN 1 that day and it was to notify her that Resident 1 had already coded and had been sent to the hospital.A review of an e-mail from the facility's medical records department dated [DATE] at 12 p.m. indicated there were no other notes documented by LN 1 on [DATE] and confirmed the only documented COC was time-stamped at 7:43 p.m.During an interview on [DATE] at 9:23 a.m., CNA 1 stated Resident 1 stated he was so tired on [DATE] and was not feeling well. CNA 1 stated she had not heard LN 1 ask Resident 1 if he wanted to go to the hospital.During an interview on [DATE] at 9:33 a.m., the Director of Nursing (DON) stated nurses were expected to always document a COC and include what occurred, what they did about it, who they contacted, and the resident's response. The DON further stated Resident 1 had medicated breathing treatment in the medication cart but did not have an active order for them to be administered. The previous order for the medicated breathing treatment expired on [DATE].During an interview on [DATE] at 1:42 p.m., the DON stated if a resident had an O2 saturation of 63% she expected the LN to assess the resident, apply oxygen, notify the MD, get an order for a breathing treatment, and update the MD on the resident's condition. The nurse would be expected to document all of this in the EMR and carry out any additional orders the MD gave.During an interview on [DATE] at 5:12 p.m., LN 2 confirmed she had instructed LN 1 to call 911 and not a non-emergent ambulance for Resident 1. LN 2 stated LN 1 told her she had called for a non-emergency ambulance and LN 2 asked her why she would do that in an emergency, but LN 1 did not respond. LN 2 acknowledged LN 1 had informed her she gave Resident 1 a breathing treatment, but LN 1 saw that there was no active order and when she asked if it was effective LN 1 was unable to answer. LN 2 stated that two CNAs had already reported to her that Resident 1 did not look right and when they had notified LN 1 about it, she did not act. So, when LN 1 told LN 2 she had asked Resident 1 if he wanted to go to the hospital and he replied no, she did not trust what LN 1 had stated.A review of the facility's policy and procedure (P&P) titled Change in Condition dated 2022 indicated, The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. Before notifying the physician.the licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review.the licensed nurse will notify the physician when there is.A significant change in the resident's physical.status e.g., deterioration of health.or clinical complications.the licensed nurse will document.Date, time and pertinent details of the event and subsequent assessment in the medical record.The time the Physician.was contacted.and whether or not orders were received.A review of the facility's P&P titled Cardiopulmonary Resuscitation reviewed [DATE] indicated, Responding to Cardiopulmonary Emergency.Check the victim for responsiveness, respirations, and pulse.call 911.A review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised [DATE] indicated, The Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety.needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.A review of the facility's P&P titled Medication- Administration revised [DATE] indicated, All medication shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.The time and dose of the medication or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the medication or treatment.

Based on interview and record review, Licensed Nurse 1 (LN 1) failed to ensure one (Resident 1) of two residents' medical records were complete and accurate when:-LN 1 did not document an assessment and Change of Condition (COC) of Resident 1 after Certified Nurse Assistant 1 (CNA 1) notified her that Resident 1 had a change in his breathing on [DATE] at approximately 3 p.m.; and,- LN 1 administered a medicated breathing treatment to Resident 1 without a physician's order and documented she administered the breathing treatment on the wrong day.These failures decreased the facility's potential to facilitate communication among healthcare staff and decreased the facility's potential to investigate and determine if there was a correlation between facility staff's response to Resident 1's COC and Resident 1's need for cardiopulmonary resuscitation (CPR).Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a progressive, irreversible lung disease that restricts airflow, making it hard to breathe) and asthma (a chronic, respiratory condition caused by swelling and mucus production that narrows the airways of the lungs resulting in wheezing, chest tightness, and shortness of breath).A review of Resident 1's care plan related to his diagnosis of COPD and asthma, initiated [DATE], indicated licensed nurses were expected to implement the following interventions when Resident 1 had a concern regarding difficulty breathing, Give aerosol or bronchodilators as ordered. Monitor/document side effects and effectiveness. Monitor for s/sx [signs and symptoms] of acute respiratory insufficiency: Anxiety [persistent fear or worry], Confusion, Restlessness, SOB [shortness of breath] at rest, Cyanosis [blue skin], Somnolence [excessive drowsiness].Monitor/document/report PRN [as needed] any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing.A review of the facility's document titled Contract Services Orientation Information signed on [DATE] by LN 1 indicated, Change in Resident Condition: It is of the utmost importance that our clinical staff are able to detect and report changes in a resident's physical.condition in a timely manner.The assigned [licensed] nurse shall complete the S-BAR [Situation- Background, Assessment, and Recommendation] and notify the licensed independent practitioner immediately upon identification of a change in condition.A review of Resident 1's order listing report indicated that starting on [DATE], staff were supposed to add a progress note during every shift regarding Resident 1's lung sounds. The order listing report further indicated that this order was discontinued on [DATE] at 3: 26 p.m.A review of Resident 1's progress notes dated [DATE] indicated no documented evidence of: an assessment, a COC related to Resident 1's respiratory status between 3 p.m. and 6:30 p.m., notification of Resident 1's COC to the physician, treatment provided, and monitoring of effectiveness of the treatment.A review of Resident 1's progress note dated [DATE] at 7:43 p.m., LN 1 documented, Approx: [6:40 p.m.] [LN 1] was notified by [CNA 1] that.[Resident 1] was breathing rapidly. [LN 1] went in to see [Resident 1] O2 sats [saturation, the percentage of oxygen in a person's blood] were 93% .[LN 1] asked [Resident 1] if resident wanted to go to hospital [Resident 1] said no.Approx [7:05 p.m.] [CNA 1] came and said O2 levels dropped to 63%. Both [LN 1] and [LN 2] went to assess [Resident 1] and decided to send resident out [to hospital]. Approx [7:05 p.m.] [LN 1] called non emergent [ambulance].A review of Resident 1's progress note dated [DATE] at 7:50 p.m., LN 2 documented, [LN 2] arrived on shift at [6:53 p.m.].[CNA 1] came to nurses [sic] station approximately [7 p.m.] reporting that [Resident 1] reports SOB [shortness of breath], and has O2 level of 63% RA [room air].O2 SAT on the monitor was recorded at 72% RA, [LN 2] instructed [LN 1] to call 911 [EMS]. [Resident 1] was unresponsive with labored, rapid breathing, resident had a very faint pulse.[Resident 1's] breaths became shorter and shorter in between and pulse was fading.Tx [treatment] nurse had began chest compressions.[LN 2] took over compression for Tx nurse while oxygen was placed on the resident via mask.EMS arrived and placed.pads on resident, called to clear, and took over CPR.A review of Resident 1's emergency room (ER) provider note dated [DATE] at 8:13 p.m. indicated, .Per EMS report, [Resident 1] was found down and apneic [not breathing] by [facility] staff 30 minutes prior to arrival [in ER].Reportedly, [Resident 1's] last known normal was [6:30 p.m.] today .albuterol 2.5 mg [milligrams, a unit of measurement]/ 3 mL [milliliters, a unit of measurement] nebulizer solution [medication used to treat COPD and asthma].Take 3 mL by nebulization [the use of a medical device that converts a liquid medication into a fine mist allowing residents to inhale the medication into their lungs] every 4 hours as needed for shortness of breath. ([Resident 1] not taking: Reported on [DATE].).A review on Resident 1's progress note dated [DATE] at 3:34 p.m. indicated that LN 1 documented, Late entry. At approx. [6:45 p.m.] on [DATE] [sic] writer administered breathing treatment [medication used to treat COPD and asthma]. While writer was on phone the resident started to code [cardiac or respiratory arrest] and the non-emergent transferred call to 911. There was no documented evidence what medication LN 1 gave to Resident 1 as a breathing treatment or that it was administered on [DATE].A review of Resident 1's physician's order dated [DATE] at 3:57 p.m. indicated the following order was placed for Resident 1, Created [DATE] [at 3:27 p.m.].Albuterol Sulfate Nebulization Solution (2.5 MG/3ML).1 vial inhale orally via nebulizer one time only for SOB until [DATE] [7 p.m.].Discontinue [DATE] [at 3:26 p.m.].Discontinue.Reason: Resident expired at ED [Emergency Department].During an interview on [DATE] at 1:41 p.m., CNA 1 stated she had worked with Resident 1 since he was admitted to the facility. CNA 1 stated when she started her shift on [DATE] at 3 p.m., she noticed Resident 1 appeared to have some difficulty breathing. CNA 1 stated, He sounded like he had a lot of mucus in his lungs, it was noisy breathing. CNA 1 stated Resident 1 reported shortness of breath and when CNA 1 checked Resident 1's O2 saturation (the amount of oxygen in the blood), she found it fluctuated between 85-95% on room air. CNA 1 escalated this concern to LN 1 but LN 1 responded Resident 1 was fine. CNA 1 further stated, As time passed, the sound of his breathing got worse. I told LN 1 three or four more times that Resident 1 was getting worse, but she [LN 1] kept telling me he [Resident 1] was fine. CNA 1 stated when Resident 1's O2 saturation read 35%, she asked CNA 2 to assist her in getting LN 1 to physically go into Resident 1's room and assess him. CNA 1 stated LN 1 finally assessed Resident 1 and administered a breathing treatment for him nearly four hours after she initially notified her of Resident 1's difficulty breathing. CNA 1stated, I told him [Resident 1] I was trying to help him. He looked so scared.During an interview on [DATE] at 9:01 a.m., the surveyor attempted to interview LN 1, but LN 1 stated, Unless I have the [Electronic Medical Record (EMR)] in front of me, I cannot answer your question. I no longer work at that facility and unless they want to pay me to go in there and look up my notes, I cannot help you. LN 1 then hung up the phone on the Surveyor.During an interview on [DATE] at 3:32 p.m., CNA 2 stated CNA 1 had been worried about Resident 1 at the beginning of the shift on [DATE]. CNA 2 stated CNA 1 had told her Resident 1 was acting differently and was making an awful sound while breathing. CNA 2 stated at one point she entered Resident 1's room with CNA 1 and Resident 1 was gurgling. CNA 2 stated CNA 1 measured Resident 1's vital signs and his O2 saturation was really low and further stated it was the lowest O2 saturation she had ever seen. CNA 1 then asked CNA 2 to notify LN 1 of Resident 1's condition because LN 1 had not been listening to CNA 1's concerns. CNA 2 stated she did alert LN 1 but was not sure what happened after that.A review of Resident 1's Medication Administration Record dated [DATE] and printed on [DATE] at 1:54 p.m. indicated no documented evidence that albuterol sulfate nebulization solution was administered to Resident 1 on any day in [DATE].During an interview on [DATE] at 8:01 a.m., the Administrator (ADM) stated licensed nurses were expected to assess residents when a CNA reported a resident abnormality or concern regarding resident safety or health. The nurse was also expected to document the assessment in the EMR, and to keep an eye on the resident during the remainder of the shift.During an interview on [DATE] at 4:20 p.m., Resident 1's physician (MD) stated she had concerns with the nurse caring for him that shift. The MD stated on [DATE], LN 1 had not provided any notification to the physician of Resident 1's complaints or symptoms of shortness of breath. The MD confirmed she had not received a call from LN 1 to request a respiratory treatment order for Resident 1 that day. The MD further stated she was unsure if nurses could initiate treatment without physician orders but added a respiratory treatment would be ineffective for a resident who was coding (experiencing a cardiac or respiratory arrest). The MD stated she had only received one call from LN 1 that day and it was to notify her that Resident 1 had already coded and had been sent to the hospital.A review of an e-mail from the facility's medical records department dated [DATE] at 12 p.m. indicated there were no other notes documented by LN 1 on [DATE] and confirmed the only documented COC was time-stamped at 7:43 p.m.During an interview on [DATE] at 9:23 a.m., CNA 1 stated Resident 1 stated he was so tired on [DATE] and was not feeling well. CNA 1 stated she had not heard LN 1 ask Resident 1 if he wanted to go to the hospital.During an interview on [DATE] at 9:33 a.m., the Director of Nursing (DON) stated nurses were expected to always document a COC and include what occurred, what they did about it, who they contacted, and the resident's response.During an interview on [DATE] at 1:42 p.m., the DON stated if a resident had an O2 saturation of 63% she expected the LN to assess the resident, apply oxygen, notify the MD, get an order for a breathing treatment, and update the MD on the resident's condition. The nurse would be expected to document all of this in the EMR and carry out any additional orders the MD gave.A review of the facility's policy and procedure (P&P) titled Change in Condition dated 2022 indicated, The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. Before notifying the physician.the licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review.the licensed nurse will notify the physician when there is.A significant change in the resident's physical.status e.g., deterioration of health.or clinical complications.the licensed nurse will document.Date, time and pertinent details of the event and subsequent assessment in the medical record.The time the Physician.was contacted.and whether or not orders were received.A review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised [DATE] indicated, The Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety.needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.A review of the facility's P&P titled Medication- Administration revised [DATE] indicated, All medication shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.The time and dose of the medication or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the medication or treatment.

Based on observation, interview, and record review, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a dedicated Registered Dietitian (RD, food and nutrition experts with a minimum of a graduate degree from an accredited dietetics program, who completed a supervised practice requirement, and passed a national exam) for a census of 87 residents.This failure had the potential to compromise dietary services rendered to the facility's residents.During the recertification survey conducted from 1/26/26 through 1/29/26, multiple dietary issues were identified including recipes not being followed (Cross Reference F803), dumpster lid not being closed (Cross Reference F814), and issues pertaining to kitchen sanitation, cleanliness, maintenance, equipment, and food storage (Cross Reference F812).During an interview on 1/26/26 at 10:20 a.m., the Dietary Supervisor (DS) stated one Registered Dietitian (RD 1) worked remotely (off site) and attended weekly meetings by video call or email to discuss resident weight changes and diets. The DS confirmed RD 1 did not physically come to the facility to assess residents' nutritional status or to provide consultation with him about the kitchen operation.During an interview on 1/28/26 at 1:08 p.m., the DS stated the last time the facility hired an onsite RD was over a year ago. The DS stated in 2025, the facility had a travel RD (an RD contracted through another agency) that worked full-time in the facility from January to June. The DS further stated that a Regional Registered Dietitian (RRD, a Registered Dietitian that oversees the company's nutrition programs, companywide menu planning and regulatory compliance across multiple locations) came to the facility infrequently, with the last visit earlier in 2025.During an interview and record review on 1/28/26 at 2:43 p.m., the Regional Consultant (RC) confirmed RD 1 reviewed resident weights virtually with the Director of Nursing (DON) weekly. The RC confirmed RD 1 did not visit the facility for assessments. The RC stated the last full-time RD (RD 2) was hired from 3/11/25 to 6/7/25 through a staffing agency. The RC confirmed the last onsite visit by RRD was on 3/20/25. The RC stated it was required that an RD be physically present at the facility once a week.During an interview on 1/29/26 at 11:16 a.m., the RRD stated she visited the facility periodically to support the kitchen, address dietitian questions, and ensure systems were in place. The RRD confirmed having no set visitation schedule and managed 30 facilities. The RRD mentioned her visits varied, sometimes occurring every few months and other times every six months.A review of the facility's undated document titled, [name of facility] Kitchen Training for IDDSI, indicated a kitchen training was conducted on 11/30/25, in which only the DS and 1 cook were present. The document further indicated RD 3 focused on the updated systems, reviewed menu planning, and ensured compliance with IDDSI dietary requirements.A review of the facility's job listing indicated that the Registered Dietitian was responsible for the following duties, Will oversee the nutritional clinical operations and survey kitchen and dining programs for a facility.Provide Medical Nutrition Therapy and work with the Dietary Supervisor to ensure that quality food, service and nutritional care are being provided to residents by performing the following duties.Evaluates the Medical Nutrition Therapy needs of the residents and implements appropriate interventions to improve their nutritional status.Coordinates resident care with the Interdisciplinary Team.Coordinates with the Nutrition Services Supervisor/Manager the review and customization of the regular and therapeutic menus.Conducts meal rounds and interviews staff and residents to ensure residents are receiving foods in the amount, type, consistency, and frequency required to maintain or improve nutritional status.Routinely inspects the food service area(s) and practices for compliance with company policies, procedures, standards, and applicable federal, state, and local regulations.Participates in the long-term care survey process.Provides in-service training to Nursing Center staff on topics related to Nutrition and Foodservice.A review of the facility's document titled, Regional Dietitian Job Description, revised on 6/14/16, indicated the Regional Dietitian was responsible for the following duties, Visits facilities on a regular basis to ensure systems are in place and to monitor sustainability to ensure appropriate care is provided to all residents.Establish rapport (relationship) with residents.Make rounds and identify Food Safety and Sanitation, Clinical Nutritional practice, Environmental and regulatory violations.Provide education.Assure that the dietary department functions as a member of the health care team.Assure that residents with nutritional problems are identified and monitored by the facility Registered Dietitian.Assure that food served is safe, nutritious, and palatable.Assist the dietary department in oversight of the sanitation reviews and dining programs.Assure continuing quality in food and nutrition services.Ensure the dietary department continues to function within departmental and facility policies and complies with State and Federal regulations.

Based on observation, interview, and record review, the facility failed to prepare meals using methods that conserved nutritive value, flavor, and appearance when the recipes were not followed for a facility census of 87 residents. This failure had the potential for leading to malnutrition, weight loss, impaired wound healing, and increased susceptibility to disease. During an observation in the kitchen on 1/27/26 at 9:35 a.m., [NAME] 2 (CK 2) was observed preparing food for the lunch menu, which included herb crusted beef roast, mashed potatoes with gravy, zesty spinach, and garlic bread. No recipes were present at the cook's station.During a concurrent observation and interview on 1/27/26 at 11:15 a.m. in the kitchen, CK 2 was seen adding an unmeasured amount of butter to a mixture of butter, garlic, and parsley using a spatula, without using any measuring tools. CK 2 stated she estimated it was about one fourth cup of butter for the garlic toast. Subsequently, CK 2 was observed combining four tablespoons of garlic powder with one pound of melted butter in a container. According to CK 2, this mixture, which did not include red pepper flakes or salt, was going to be used in the zesty spinach recipe intended to serve 72 residents. Next, CK 2 poured an unmeasured amount of milk into a container of dry breadcrumbs, stating there was no specific recipe for pureed garlic bread. The Dietary Supervisor (DS), who was also present, confirmed the existence of such a recipe. CK 2 continued without using it, pouring another unmeasured amount of milk and claiming it was half a cup. CK 2 stated both containers of breadcrumbs with milk were meant to make 13 servings. No measuring tools were observed being used.During a concurrent observation and interview on 1/27/26 at 11:30 a.m. in the kitchen during meal preparation, CK 2 took boiled spinach from the stovetop and attempted to drain it using a strainer in a sink. CK 2 accidentally spilled some of the spinach into the sink, leaving portions in the pot, strainer, and sink. The DS then intervened and strained the remaining spinach for the zesty spinach recipe. Subsequently, CK 2 was observed adding the unmeasured powdered garlic and butter mixture to the remaining spinach. When asked how much garlic butter mixture was added to the spinach, CK 2 replied, Seriously, I don't know! Then, CK 2 and the DS stated they did not add salt to anything. The DS further stated, Yeah, we don't use salt.During an interview on 1/28/26 at 1:08 p.m., the DS stated that the recipe must be visible to the cook while preparing food and must be used and followed. The DS stated he could not confirm if CK 2 had or followed recipes during the lunch preparation on 1/27/26. The DS stated he did not approve of cooking staff, eyeballing it, when preparing food. The DS explained that eyeballing it meant adding ingredients by sight rather than using measuring tools. The DS stated his expectation was that cooking staff use measuring tools when preparing food. The DS further stated, It's important that measuring tools are used so that the right amount of ingredients are used in the recipe. The DS confirmed that not using measuring tools affected the taste, appearance, and nutrition of the food. The DS could not confirm if measuring tools were used during 1/27/26 lunch meal preparation. The DS further stated, I was just trying to save the spinach after it spilt.During an interview on 1/28/26 at 2:07 p.m., CK 2 stated that she did not always follow the recipes. CK 2 further stated, It depends what it is. I don't like the recipe book sitting on the table because it gets in the way. CK further stated, It is typically not ok to eyeball food measurements. It is supposed to be precise because that's the measurements you are following.During an interview on 1/29/26 at 11:16 a.m., the Regional Registered Dietitian (RRD, Registered Dietitian who oversees the company's nutrition programs, companywide menu planning and regulatory compliance across multiple locations) stated recipes should be followed and utilized. The RRD further stated her expectation was that measuring tools be used during food preparation. The RRD stated spices could be an exception, and stated, If salt is in the recipe, it should be included and measured. The RRD verified salt should not be with-held if the recipe called for it. The RRD further stated measuring ingredients during meal preparation was important To make sure the nutrient content is equivalent to the menu calculations and analysis. A review of the facility's document titled, RECIPE: ZESTY SPINACH, dated 2025, indicated, Serve 72 [residents].Spinach, frozen 20 lb 4 oz (ounce- a unit of weight).Margarine 1 1/ cups.Garlic powder 1 1/2 to 3 tbsp.Salt 2 1/4 tsp (teaspoon- a unit of measure).Red pepper flakes 1 to 1 1/2 tbsp.Saute margarine, garlic, salt and red pepper flakes together for 1-2 minutes.A review of the facility's document titled, RECIPE: PUREED (IDDSI LEVEL #4) BREADS, CAKES, COOKIES, PANCAKES, FRENCH TOAST, SWEET ROLLS, WAFFLES, TORTILLAS, SANDWICHES, And Other BREAD PRODUCTS, dated 2025, indicated, Serves 12 [residents].Warm milk or cold milk if product is to be served cold.1 1/2 to 3 cups.Puree on low speed adding milk gradually.A review of the facility's policy and procedure titled, Standardized Recipes, revised on 7/01/14, indicated, Food products prepared and served by the dietary department will utilize standardized recipes.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, sanitary conditions, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety for a census of 87 residents when:1. Kitchen staff did not protect food from physical contaminants (e.g. hair nets and beard nets were not worn, and cook was wearing jewelry), 2. Kitchen environment was not maintained (e.g. kitchen walls had areas of missing paint),3. Sanitary conditions of the kitchen floor and kitchen wares was unkept (three-drawer storage bin used to store cooking utensils with black scuffs and sticky residue on the outside, and with crumb particles on the inside, textured kitchen floors with blackened debris, garbage remnants, food crumbs, and paint chips along the bottom of the walls and around stationary equipment, and one utility cart used for food and beverage delivery with debris and dust particles on shelf surfaces),4. Approximately four scoops used for food preparation and tray-line were stored wet, 5. Small wares were not discarded when damaged (e.g. tip of the can opener had missing metal, and four cutting boards discolored and with deep cut groves), and6. Emergency water was expired.These findings had the potential to cause food borne illness and infections to the residents consuming facility-prepared meals. 1.During a concurrent observation and interview in the kitchen, on 1/26/26 at 8:15 a.m. with the Dietary Supervisor (DS), three kitchen staff (DA 1, DA 2, and CK 1) were observed without hair nets. The DS confirmed this observation.During a kitchen observation on 1/26/26 at 12:34 p.m., CK 3 was observed with facial hair and without a beard net.During an interview on 1/26/26 at 2:30 p.m., the DS confirmed CK 3 should have worn a beard net as his facial hair was longer than 1 inch. The DS stated the beard net was necessary, To keep the hair out of the food.During a kitchen observation on 1/27/26 at 9:35 a.m., CK 2 was observed wearing a hoop earring in each ear, and a watch while preparing meals.During an interview on 1/28/26 at 1:08 p.m., the DS stated that kitchen staff should always wear hair nets and avoid jewelry or watches while preparing food to minimize contamination risks. The DS further stated, Especially a watch, it's near the hand area.During an interview on 1/28/26 at 2:26 p.m., the Infection Preventionist (IP) stated she expected all kitchen staff to wear hair nets and beard nets while in the kitchen. The IP further stated, So, hair doesn't fall into the food. The IP stated watches and dangly earrings should not be worn by kitchen staff. The IP further stated something could break off the dangly earring and go into the food. The IP stated, Jewelry, you can't be sure it can be cleaned properly. It could harbor bacteria.A review of the facility's policy and procedure (P&P) titled, Dietary Department-Infection Control, revised on 2/29/24, indicated, Cover hair, beard, and mustache with an effective hair restraint.while in any kitchen and food storage area.watches are not permitted to be worn while working in the food service area or while preparing food.To ensure that the dietary department is maintained in a sanity condition in order to prevent food contamination and the growth of disease producing organisms and toxins.A review of the facility's undated document titled, Dietary Services Supervisor/Certified Dietary Manager- Job Description, indicated, Maintains a safe and sanitary working environment in compliance with Federal and State of California Guidelines.A review of the facility's undated document titled, Cook-Job Description, indicated, Performs duties in a safe and sanitary manner.A review of the facility's undated document titled, Dietary Assistant/Dishwasher-Job Description, indicated, Maintains a safe and sanitary work environment.2. During an initial kitchen observation on 1/26/26 at 8:15 a.m., the wall to the left of the stovetop and oven in the main cooking area was observed with rough-textured scratches and patches of missing paint. The wall was observed to have three different tones of wall paint: white, beige, and yellow toned beige. The largest scratch of paint was above an electrical outlet and measured approximately 7 inches (in.) in length and 5 in. wide and exposed white paint under a beige wall. Scattered areas of peeled or scratched paint were observed to the left of the same electrical outlet in variable sizes. One measured approximately 1 in. in length and 3 in. in width and exposed white paint under a beige wall. Another mark located just above the previous one measured approximately 7 in. in length and 1 in. wide and exposed white paint under a beige wall. Further up on the wall and to the left a 2 in. by 2 in. patch of missing paint exposed a yellow toned beige paint under a beige wall. Above, and directly under a light switch, another patch of missing paint exposed white paint under a beige wall and measured approximately 2 in. by 2 in. Paint chips were observed on the floor directly under the scratches and patches of missing paint on the wall.During an interview on 1/29/26 at 7:30 a.m., the DS confirmed the paint was scratched and chipped around the stovetop and oven in the main cooking area. The DS further stated, It [the wall] should be repainted because the paint chips could fall and possibly get in the food.A review of the Food and Drug Administration's 2022 Food Code, section 4-202.16, titled, Nonfood-Contact Surfaces, indicated, NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. It further stated that, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms.3. During a concurrent observation and interview with the DS in the kitchen on 1/26/26 at 8:15 a.m., a three-drawer storage bin used to store measuring cups, spoodles (a cross between a serving spoon and a ladle [a long-handled spoon with a cup-shaped bowl]), spatulas, and scoops was observed with gray to dark brown and black smears and scuffs that covered the exterior. All three drawer handles were sticky to the touch. The drawer holding the spatulas and spoodles contained a dry, crumbly substance in shades of light beige, beige, and black. The DS confirmed the entire three-drawer storage bin was, dirty, on the outside and inside. The DS further stated, Yea, we probably need a new one.it's dirty. It looks like food crumbs.During an observation on 1/26/26 at 8:15 a.m., within the initial kitchen tour, the floor below the handwashing sink and around a surrounding food preparation table against the wall was observed with black residue and grime (dirt ingrained on the surface of something), dark brown and dark beige colored particles of an unknown substance, a paper clip, and a dime. Concentrated areas of black residue and grime surround the area where the legs of the table touched the floor. Observed under another food preparation table across the room was black residue and grime where the floor met the wall, a paper clip, a rubber band, and a bread closure tab. Behind the table, brown, dried fluid was observed dripping down the wall. Wall paint chips were observed on the floor to the left of the stovetop and oven.During an interview on 1/26/26 at 10:30 a.m., the DS confirmed the floor under the handwashing sink, the surrounding food preparation table, under the food preparation table across the room, and the wall behind that table was unkept. The DS stated, Yea, the floor is dirty and it looks like crumbs. It's a slip resistant floor and hard to clean. The DS confirmed the paint chips on the floor to the left of the stovetop and oven. The DS stated, The floors need to be deep cleaned.During a concurrent observation and interview on 1/26/26 at 11 a.m. with the DS present, a three-tiered utility cart was observed in a corner of the dining room with two empty pink beverage pitchers, and approximately one eighth (1/8) full pitcher with clear liquid stored on the second shelf. The cart was observed with crumbs, dried, orange-colored crusted particles, and large dust particles on all three shelves. The DS stated the utility carts in the dining room were used for the delivery of drinks and pitchers of water to the residents. The DS confirmed the utility cart was, dirty, and stated the dirty carts should not be used for food and beverage services. The DS stated the utility cart should be cleaned after each use. The DS further stated he did not know who was responsible for cleaning the utility carts used for food service.During an observation on 1/26/26 at 12:27 p.m. in the dining room during meal service, the same utility cart was observed uncleaned.During an interview on 1/28/26 at 1:08 p.m., the DS stated kitchen cleaning was completed daily. The DS confirmed a log was available for kitchen staff to document the cleaning tasks once completed. The DS stated it was his responsibility to review the cleaning log to ensure the cleaning tasks were completed. The DS was unable to provide a cleaning log. The DS stated, I don't know what happened to it [the cleaning log].During an interview in the dining room on 1/29/26 at 7:40 a.m., the Director of Staff Development (DSD) stated the utility carts in the dining room were used for beverage and food service to residents. The DSD further stated some of the utility carts were used to collect dirty dishes. The DSD stated the utility carts were returned to the corner of the dining room after each use and it was expected that kitchen staff would clean the utility carts after each meal service.A review of the facility's P&P titled, Cleaning Schedule Operational Manual-Dietary Services, revised on 10/1/14, indicated, The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager (DM).The DM will develop a cleaning schedule that included the frequency of which equipment ad areas are to be cleaned.cleaning schedule is posted weekly.includes tasks assigned to specific positions within the dietary department.The DM monitors the cleaning schedule to ensure compliance.A review of Food and Drug Administration's 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, The objective to cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.4. During a concurrent observation and interview in the kitchen on 1/26/26 at 8:15 a.m., with the DS present, approximately four scoops used for food preparation and tray line were observed stored wet in the three-drawer storage bin. The DS confirmed the scoops were stored wet. The DS stated the scoops should not have been stored wet because it [a wet environment] could increase the growth of bacteria.A review of Food and Drug Administration's 2022 Food Code, section 4-901.11, titled Equipment and Utensils, Air-Drying Required, indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items.prevents them from drying and may allow an environment where microorganisms (living organisms such as bacteria, fungi, and viruses) can begin to grow.5. During the initial kitchen observation on 1/26/26 at 8:15 a.m., a can opener stationed on a food preparation table was observed with white label remnants on the pointed blade tip. The pointed blade had visible signs of metal peeling and was worn.During an interview on 1/26/26 at 10:45 a.m., the DS stated the can opener should be cleaned daily. The DS stated, Yea, it's dirty and needs to be cleaned. The DS further stated the can opener blade needed to be changed because metal could come off and go into the food.During a concurrent observation and interview in the kitchen, on 1/26/26 at 10:50 a.m., with the DS present, a light brown, green, light blue, and red cutting boards were observed with black discolored surfaces and stored in the cutting board rack. Deep blade markings could be felt digitally on all four boards. The DS confirmed these observations, and stated, Cutting boards with deep groves are hard to clean and can harbor bacteria. The DS confirmed all four cutting boards should not be used.A review of Food and Drug Administration's 2022 Food Code, section 4-202.15, titled, Can Openers, indicated that Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized.A review of Food and Drug Administration's 2022 Food Code, section 4-501.11, titled, Good Repair and Proper Adjustment, indicated, The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury.A review of Food and Drug Administration's 2022 Food Code, section 4-501.12, titled, Cutting Surfaces, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.6. During a concurrent observation and interview on 1/28/26 at 1:08 p.m. with the Maintenance Director (MAIN D), and the DS, the facility's emergency water was stored with an expiration date of 12/15/25. The DS and MAIN D confirmed the emergency water was expired and needed to be replaced.A review of the facility's P&P titled, Disaster Planning Operational Manual-Dietary Services, revised 11/1/14, indicted, The disaster food supply shall be.Rotated a minimum of every six months to assure continued quality food items.A review of the facility's P&P titled, Food Storage and Handling, revised on 2/29/24, indicated, Dry storage area.rotate stock.

Based on interview, and record review, the facility failed to provide services according to professional standards of practice for three of 21 sampled residents (Resident 4, Resident 14, and Resident 40) when:Medication was not administered to Resident 14 according to the recommended guidelines.72-hour monitoring was not performed for Residents 4 and 40 following a change of condition (COC),A care plan was not initiated for Resident 40 following a COC, and; Neurological (related to the nervous system, which includes the brain, spinal cord, and nerves that control body functions, movement, and sensation) checks were not completed for Resident 4 post-fall. These failures had the potential for:Resident 14 to experience a reduced therapeutic effect from the medication and increased fatigue, muscle aches and low heart rate, Increase Resident 4 and Resident 40's chance of experiencing further complications after a COC,Placing Resident 4 at risk for unmet care needs and inadequate care planning, and;Decreasing the facility's potential to recognize a COC for Resident 4, which could have led to a delay in treatment with other negative outcomes. A review of Resident 14's admission record indicated, Resident 14 was admitted 8/2023 with a diagnosis of hypothyroidism (low activity of the thyroid gland). A review of Resident 14's order summary report dated 1/29/26 indicated Resident 14 had physician's orders for: Famotidine (a medication to reduce stomach acid) oral tablet 20 mg (mg-a unit of measurement). Give one tablet by mouth in the morning for gastroesophageal reflux disease (GERD- stomach acid flows back up into the esophagus and causes heartburn), and; Levothyroxine (a medication to regulate thyroid levels) 88 micrograms (mcg – a unit of measurement) by mouth in the morning for hormone. A review of the medication review regimen (MRR) dated 12/26/25, indicated famotidine can be given without regards to meals. However, it should not be given at the same time as levothyroxine. Please consider changing the administration time of famotidine 20 mg to 9 a.m. A review of Resident 14's 12/21/25 to 1/29/2026 medication administration records (MAR) indicated that famotidine and levothyroxine were both given at 6 a.m. to Resident 14. During a concurrent phone interview and record review on 1/29/26 at 9:12 a.m., the Consultant Pharmacist (CP) confirmed he made the recommendations on the MRR and stated levothyroxine shouldn't be given together with other medications because it could bind with those medications and could decrease effectiveness. During an interview and record review on 1/29/26 at 10:45 a.m., Licensed Nurse 2 (LN 2) reviewed Resident 14's 12/21/25 to 1/29/2026 MAR and confirmed that both medications have been administered at 6 a.m. LN 2 stated that levothyroxine should not be given with other medications and if he saw that order he would discuss it with the physician or pharmacist for clarification. He further stated that giving levothyroxine with other medications could decrease the effectiveness of the medication. A review of a facilities policy and procedure (P&P) titled, Medication – Administration, dated 8/19/25, indicated, All medications shall be administered by licensed nursing staff according to .current best practice and state and federal regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner. 2: A review of Resident 40's admission record indicated he was admitted to the facility in December 2025 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (a brain injury caused by blocked or reduced blood flow to the brain), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 40's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/26/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 15, which indicated his cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). During an interview on 1/26/26 at 2:32 p.m., Resident 40 stated he had diarrhea a few days in a row. Resident 40 further stated on 1/24/26 his brief had to be changed at least three times during episodes of diarrhea. Resident 40 stated he had not been eating much because of the diarrhea and upset stomach. A review of Resident 40's SBAR (Situation, Background, Assessment and Recommendation- a communication technique used in healthcare to facilitate clear and concise information following a change of condition) Communication form dated 1/23/26 at 9:30 p.m. indicated, [Resident 40] reported five episodes of diarrhea, green mucus like with no foul odor. A review of Resident 40's progress notes, type, System Note, dated 1/23/26 from 9:30 p.m. thru 1/26/26 11:34 p.m., indicated Resident 40 was only monitored on 1/25/26 at 11:50 p.m., and 1/26/26 at 11:34 p.m. following his COC related to diarrhea. A review of Resident 4's admission record indicated he was admitted to the facility in January 2026 with medical diagnosis which included fracture of first cervical vertebra (neck bones), fracture of the left pubis (the front part of each side of the hip bone), and multiple rib fractures. A review of Resident 4's MDS dated [DATE], indicated his BIMS score was 13, which indicated his cognition was moderately impaired. A review of Resident 4's progress notes titled, eINTERACT SBAR Summary for Providers, dated 1/14/26 at 6 a.m. and 1/17/26 at 1:16 p.m., indicated he had an unwitnessed fall on both occasions. A review of Resident 4's progress notes, type, System Note, dated 1/14/26 6 a.m. thru 1/20/26 11:20 p.m., indicated Resident 4 was monitored only on 1/14/26 at 1:51 p.m., 1/14/26 at 11:35 p.m., 1/16/26 at 3:49 a.m., 1/18/26 at 11:35 p.m., 1/19/26 at 11:50 p.m., and 1/20/26 at 11:20 p.m., following his COCs related to falls. 3. A review of Resident 40's undated care plan report, indicated no evidence that a care plan was initiated following his COC related to diarrhea. During an interview on 1/28/26 at 3:56 p.m., the Treatment Nurse (TXN) stated that after a COC was initiated in a resident's electronic medical record, it triggered 72-hour monitoring every shift. When asked if a change to the resident's care plan was required following a COC, the TXN stated, Definitely, every COC requires a care plan to be initiated and or updated. The TXN stated it was important to monitor Resident 40 because he was at risk for developing dehydration due to having diarrhea. The TXN further stated it was important that the issues Resident 40 was experiencing not be exacerbated (to make a problem worse).The TXN stated care plans guided staff on how to care for residents, what to expect, and what to monitor. The TXN further stated, Care plans paint a picture of what is going on with the patient and what is needed so that the necessary care can be provided. During a concurrent interview and record review on 1/29/26 at 10:36 a.m., the DON was asked if a COC was required to be care planned. The DON responded, Absolutely, so that there is a plan of care in place so we know how to treat the COC. The DON stated it was her expectation that 72-hour monitoring was performed every shift for a resident following a COC. The DON confirmed nursing staff worked 12 hr. shifts, so she would expect two progress notes per day from nursing staff regarding COC monitoring. The DON stated monitoring was important, To see if there are any changes- if the resident's condition is worsening or better. To see if the care plan is working, or communicating any monitored change with the doctor. The DON confirmed Resident 40's care plan was not initiated or revised following his COC dated 1/23/26. The DON confirmed that no 72-hr monitoring was completed on either day shift or night shift on 1/24/26, day shift on 1/25/26, and day shift on 1/26/26. Subsequently, the DON reviewed Resident 4's record and provided evidence that 72-hr monitoring was completed day shift on 1/15/26, and 1/19/26. The DON confirmed that no 72-hr monitoring was completed for Resident 4 night shift on 1/15/26, or on day shift 1/16/26. The DON confirmed Resident 4 fell again on 1/17/26 at 1:16 p.m. The DON further confirmed that no 72-hr monitoring was completed on day shift on 1/18/26 or on 1/19/26 for this last fall. A review of the facility's P&P titled, Change in Condition, dated 8/2022, indicated, The Licensed Nurse will.Update the care plan to reflect the resident's current status.Document each shift for at least seventy-two (72) hours when there is a change in the resident's condition. A review of the facility's document titled, LVN STAFF NURSE JOB DESCRIPTION, no date, indicated, Completes all required documentation including resident observations, interventions, and patient response(s) in the medical record in accordance with policy.Assists in developing, reviewing, revising, and updating resident plans of care as indicated. 4. A review of Resident 4's neurological check lists indicated post fall neuro-checks were completed on 1/14/26 at 7:55 p.m. and 11:55 p.m., and on 1/15/26 at 3:55 a.m. and 1:12 p.m., due to his fall on 1/14/26 at 6 a.m. (above) A review of Resident 4's Skilled Nursing Facility (SNF) Hospital Transfer Form indicated he transferred to the hospital post fall on 1/14/26 at 6 a.m. A review of Resident 4's progress note type, Alert Note, dated 1/14/26 at 9:37 a.m., indicated Resident 4 had returned from the hospital. During a concurrent interview and record review on 1/29/26 at 10:36 a.m., the DON stated her expectations following a fall was the following, If it's an unwitnessed fall- always do neuro-checks. The DON further stated neuro-checks were ongoing for 72-hrs after a fall. The DON confirmed she expected nursing staff to follow the timing flow chart on the neurological flow sheet. The DON stated neuro-checks were important because, If there is some sort of neurological change the MD (Medical Doctor) needs to be notified immediately. Subsequently, the DON reviewed Resident 4's neurological check lists and confirmed the assessments were not completed to her expectation. The DON further stated she would expect the neuro-checks to begin immediately post-fall and when the resident returned from the hospital for 72-hours. A review of the facility's document titled, Neurological Flow Sheet, revised 7/2016, indicated, Vital Signs and Neuro Checks.every (q) 15 min (minutes) x (for) one hour.q 30 min x one hour.q one hour x four hours.q four hours x 24 hour/total (72) hours. A review of the facility's P&P titled, Fall Management Program, dated 2022, indicated, Neurological Assessment.For an unwitnessed fall.the licensed nurse will complete 72 hours following the fall incident.Perform neurological checks at the ordered frequency or as listed below equaling 72 hours.every 15 minutes x 1 hour, then every 30 minutes x two hours, then every one hour x four hours, then every four hours x 65 hours OR until the physician states it is no longer necessary OR after 72 hours if the resident's condition is stable.

Based on interview and record review, the facility failed to ensure completed annual performance reviews, commonly known as competency/skills checks, for two of five sampled Certified Nursing Assistants (CNAs, unlicensed healthcare staff providing direct, hands-on nursing or nursing-related services to the residents of the facility) (CNA 4 and CNA 6). Additionally, the facility did not ensure abuse and dementia training was provided for two CNAs in this same sample (CNA 3 and CNA 7). Cross reference F947. This failure placed facility's residents at risk for receiving substandard quality of care, which could have resulted in harm. During a concurrent interview and record review on 1/28/26 at 2:02 p.m. with the Director of Staff Development (DSD), CNA 4's employee training file was reviewed. The DSD acknowledged CNA 4's last annual skill/competency assessment was completed on 9/16/24, which was four months overdue for a required annual skill/competency assessment.During a concurrent interview and record review on 1/28/26 at 2 p.m. with the DSD, CNA 6's employee training file was reviewed. There was a skills/competency checklist that had no employee signatures or dates on it. The DSD could not confirm that CNA 6 completed this or any other annual skills/competency assessment.During a concurrent interview and record review on 1/28/26 at 2:06 p.m. with the DSD, CNA 3's and CNA 7's training files were reviewed. The DSD acknowledged there was missing evidence of abuse and/or dementia training for each of these CNAs, indicating these employees might not be able to respond properly to abuse situations, or have the knowledge to effectively communicate and care for certain residents in the facility. The DSD stated it was known that there were training issues that needed to be addressed at the facility, and that this area was being currently addressed by the quality improvement committee.A review of the facility policy and procedure titled, Staff Competency Evaluation, effective 6/04/24, indicated, staff are required to have competency validation based on their job description or assigned duties .re-education will be provided to the employee who is unable to satisfactorily perform the skill, followed by a re-evaluation of the competency.During a review of [Name of facility] Facility Assessment, reviewed on 1/26/26, indicated under training requirements, Staff training/education and competencies - yearly review of select clinical competency and as needed for competency .include dementia management training and abuse prevention training.

Based on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) recommendations in a timely manner for Residents 1, 3, 6, 14, 16, 17, 18, 19, 24, 57, 76, 83, and 85, out of a census of 87 residents. This failure had the potential to result in medication-related problems or errors, such as prolonged use, excessive doses or unmonitored usage, due to the irregularities identified and reported by the CP.1.A review of Resident 1's admission record indicated Resident 1 was admitted on 9/2025 with a diagnosis of Benign Prostatic Hyperplasia (BPH- enlarged prostate).A review of Resident 1's order summary report dated 1/29/26 indicated Resident 1 had a physician's order for tamsulosin HCI (medication to treat an enlarged prostate gland) oral capsule 0.4 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). The order indicated, Give one capsule by mouth, one time a day for BPH.A review of the Pharmacist Recommendation to Prescriber medication regimen review (MRR) for 12/01/25 to 12/31/25, indicated a recommendation to administer tamsulosin 0.4 mg 30 minutes after the same mealtime each day. The MMR indicated, Capsules should be swallowed whole; do not crush, chew, or open.2. A review of Resident 3's admission record indicated Resident 3 was admitted on 9/2025 with a diagnosis of hereditary spastic paraplegia (a group of rare and progressive inherited disorders that cause weakness and stiffness of the legs).A review of Resident 3's order summary report dated 1/29/26 indicated Resident 3 had a physician's order for docusate sodium (medication for constipation)100 mg. The order indicated, Give two capsules by mouth two times a day for constipation.A review of the MRR indicated to update the orders to include, Hold for loose stool.3. A review of Resident 6's admission record indicated Resident 6 was admitted on 7/2021 with a diagnosis of BPH.A review of Resident 6's order summary report dated 1/29/26 indicated Resident 6 had a physician's order for finasteride oral tablet five mg. The order indicated, Give one tablet by mouth one time a day for BPH.A review of the MRR indicated that this medication was classified as a hazardous medication and could not be manipulated, crushed or opened during administration without appropriate personal protective equipment (PPE). The MMR indicated, Please use appropriate precautions for receiving, handling, storage, preparation, administration and disposal .Please add to order: Hazardous Drug - Please use appropriate PPE.4. A review of Resident 14's admission record indicated Resident 14 was admitted on 8/2023 with a diagnosis of hypothyroidism (low activity of the thyroid gland). A review of Resident 14's order summary report dated 1/29/26 indicated Resident 14 had a physician's order for famotidine (a medication to reduce stomach acid) oral tablet 20 mg. The order indicated, Give 1 tablet by mouth in the morning for gastroesophageal reflux disease (GERD- stomach acid flows back up into the esophagus and causes heartburn) and levothyroxine ( a medication to regulate thyroid levels) 88 micrograms ( mcg - a unit of measurement) by mouth in the morning for hormone.A review of the MRR indicated famotidine could be given without regards to meals however, it should not be given at the same time as levothyroxine. The MMR indicated, Please consider changing the administration time of famotidine 20 mg to 9 a.m.5. A review of Resident 16's admission record indicated Resident 16 was admitted on 3/2025 with a diagnosis of hypertension (HTN - high blood pressure).A review of Resident 16's order summary report dated 1/29/26 indicated Resident 16 had a physician's order for lisinopril (a medication to lower blood pressure) oral tablet 20 mg. The order indicated, Give 20 mg by mouth at bedtime for HTN.A review of the MRR indicated to consider the addition of monitoring parameters to high blood pressure orders. The MMR indicated, Please consider adding - Hold if: HR (heart rate) less than 60 bpm (beats per minute) or SBP (systolic blood pressure) less than 100 mmHg (millimeters of mercury, a unit of measurement), to these orders.6. A review of Resident 17's admission record indicated Resident 17 was admitted on 12/2025 with a diagnosis of constipation.A review of Resident 17's order summary report dated 1/29/26 indicated Resident 17 had a physician's orders for senna (medication to treat constipation) oral tablet 8.6 mg. The order indicated, Give two tablets by mouth one time a day for constipation and acetaminophen (a medication for pain) 325 mg oral tablet. Give two tablets by mouth every 24 hours as needed for pain at bedtime.A review of the MRR indicated to update the senna order to include, Hold for loose stool and to update acetaminophen order to include, do not exceed three grams of acetaminophen in 24 hours from all sources.7. A review of Resident 18's admission record indicated Resident 18 was admitted on 7/2024 with a diagnosis of gout (form of severe arthritis in the joints).A review of Resident 18's order summary report dated 1/29/26 indicated Resident 18 had a physician's order for allopurinol (medication to treat gout) oral tablet 300 mg. The order indicated, Give one tablet by mouth one time a day for gout.A review of the MRR indicated to consider changing allopurinol order to include, give with food/meals .Add to the directions to ensure compliance.8. A review of Resident 19's admission record indicated Resident 19 was admitted on 10/2023 with a diagnosis of metabolic encephalopathy (a general term for any disease, damage, or malfunction of the brain that alters its structure or function).A review of Resident 19's order summary report dated 1/29/26 indicated Resident 19 had a physician's orders for docusate sodium100 mg. The order indicated, Give one capsule by mouth one time a day for constipation, polyethylene glycol (medication for constipation)17 gm/scoop. Give one scoop by mouth one time a day for constipation, and senna oral tablet 8.6 mg. Give one tablet by mouth two times a day for constipation.A review of the MRR indicated to update the orders to include, Hold for loose stool and add to the polyethylene glycol order, Stir in four to eight ounces juice or other liquids.9. A review of Resident 24's admission record indicated Resident 24 was admitted on 8/2024 with a diagnosis of Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks).A review of Resident 24's order summary report dated 1/29/26 indicated Resident 24 had a physician's orders for finasteride oral tablet five mg. The order indicated, Give one tablet by mouth one time a day for BPH.A review of the MRR indicated that this medication was classified as a hazardous medication and could not be manipulated, crushed or opened during administration without appropriate personal protective equipment (PPE). The MMR indicated to consider adding to the order, Hazardous Drug - Please use appropriate PPE.10. A review of Resident 57's admission record indicated Resident 57 was admitted on 1/2021 with a diagnosis type 2 diabetes (a chronic condition where the body doesn't produce enough insulin and the glucose level in the blood is high).A review of Resident 57's order summary report dated 1/29/26 indicated Resident 57 had a physician's orders for melatonin (supplement for regulating sleep cycles) three mg. The order indicated, Give three mg by mouth at bedtime for supplement.A review of the MRR indicated to update the orders to consider changing the indication of use to, for Circadian Rhythm Regulation (the body's natural 24-hour clock for sleepiness at night and alertness during the day).11. A review of Resident 76's admission record indicated Resident 76 was admitted on 11/2023 with a diagnosis of type 2 diabetes with diabetic polyneuropathy (a common, progressive complication of diabetes caused by chronic high blood sugar damaging peripheral nerves).A review of Resident 76's order summary report dated 1/29/26 indicated Resident 76 had a physician's order for docusate sodium 100 mg. The order indicated, Give one by mouth two times a day for constipation.A review of the MRR indicated to update the orders to include, Hold for loose stool.12. A review of Resident 83's admission record indicated Resident 83 was admitted on 7/2003 with a diagnosis of constipation.A review of Resident 83's order summary report dated 1/29/26 indicated Resident 83 had a physician's order for senna oral tablet 8.6 mg. The order indicated, Give one tablet by mouth two times a day for constipation.A review of the MRR indicated to update the orders to include, Hold for loose stool.13. A review of Resident 85's admission record indicated Resident 85 was admitted 3/2025 with a diagnosis of acute pancreatitis (inflammation of the pancreas).A review of Resident 85's order summary report dated 1/29/26 indicated Resident 85 had a physician's order for docusate sodium 100 mg. The order indicated, Give two capsules by mouth two times a day for constipation.A review of the MRR indicated to update the orders to include, Hold for loose stool.During an interview and record review on 1/29/26 at 8:30 a.m., the Director of Nursing (DON) confirmed none of the MRR recommendations dated 12/26/25 were implemented and had been given to the physician. The DON stated the CP recommendations should be followed because they prevented potential medication errors from happening.During an interview and record review on 1/29/26 at 9:12 a.m., the CP confirmed he performed a MRR on 12/26/25. The CP stated his expectations were that the recommendations were reviewed within two weeks of being submitted, and if not they should be escalated by the DON to be implemented.During an interview and record review on 1/29/26 at 9:30 a.m., the Administrator (ADM) stated 11/21/25 was the last MRR review which was signed by the physician. The ADM stated her expectation was that the 12/26/25 CP recommendations should have been followed and implemented in a timely manner.A review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, reviewed in 2024, indicated, All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the Administrator .Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's [active record] and reported to the Director of Nursing, Medical Director and prescriber as appropriate.A review of the facility's P&P titled, Documentation and communication of consultant pharmacist recommendations, reviewed in 2024, indicated, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review .Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

Based on observation, interview, and record review, the facility failed to ensure medications were stored safety and within accepted professional standards of practice for a census of 87 residents when:Loose pills were found in a medication cart,Medications were found without open dates, and;Used insulin pens were found comingled in the same drawer.These findings had the potential to result in medication errors, decreased medication therapy, and harm to the residents of the facility. During a concurrent interview and C wing medication cart inspection on 1/28/26 at 1:14 p.m., with the Director of Nursing (DON), the DON confirmed the following: 10 loose pills were found in the medication cart. The DON stated loose pills could potentially be given mistakenly to residents or be taken by staff.Six medications were found without open dates. The DON stated open dates were necessary to ensure that medications were not outdated. The DON further stated that if these medications were administered to residents, they could potentially cause adverse effects or be less therapeutic.Six used insulin pens belonging to different residents were found comingled in the same drawer. The DON stated the insulin pens should be prevented from touching each other because that could cause cross contamination.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, reviewed in 2024, the P&P indicated, Medications are stored safely and properly .Medication storage areas are kept clean and free of clutter .When the original seal of a manufacturer's container is initially broken. the nurse shall place a date opened sticker on the medication and enter the date opened.

Based on observation, interview, and record review, the facility failed to ensure garbage was properly contained for a census of 87 residents when one out of two dumpsters were observed with open lids, was overflowing with trash, and the area around it was littered with garbage.This failure had the potential to expose the facility environment to odors, insects, pests, and disease, which could have caused harm to the residents. During a concurrent observation and interview on 1/26/26 at 10:40 a.m. with the Dietary Supervisor (DS), one of the two facility dumpsters was left open with plastic bags filled with garbage piled above the top of the dumpster. The dumpster was observed without the lids on to provide closure to the dumpster. One bag of garbage and a box was on the ground next to the dumpster. The DS confirmed the dumpster was overflowing and was too full to close the lids. The DS confirmed there was garbage in the surrounding area outside of the dumpster. The DS further stated, The lids are supposed to be closed to keep the pests and critters out.During an interview on 1/29/26 at 9:58 a.m. with the Maintenance Director (MAIN D), he stated, They are supposed to be able to close the lids- birds can get into it [the dumpster], and because of infection control reasons. The MAIN D further stated, The lids are to remain closed the whole time.A review of the facility's policy and procedure titled, Medical Waste-Containers & Storage- Infection Control Manual, revised on 1/1/12, indicated, Medical waste containers are located throughout the facility and are kept covered at all times.Medical waste containers used by the facility are.closable.Medical waste is stored so that it is protected from animals and does not provide a breeding place or a food source for insects and rodents.

Based on observation, interview, and record review, the facility failed to maintain a safe and functional environment for one of 21 sampled residents (Resident 70) when Resident 70's light was not in working condition. This failure had the potential to increase Resident 70's risk for accidents, feelings of frustration and lack of independence. A review of Resident 70's admission record indicated she was admitted to the facility in July, 2025, with medical diagnosis which included spinal stenosis (a narrowing of the spinal canal which puts pressure on the spinal cord and nerves), strabismus (eyes are misaligned and do not point in the same direction) and vascular dementia (when damaged blood vessels reduce blood flow and oxygen to the brain, impairing thinking, memory, and function).A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 1/07/26, indicated Resident 70 had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment, and required partial to moderate assistance (helper does less than half the effort) to lie down from a sitting position, sit to stand, transfers in and out of bed, and ambulation.During a concurrent observation and interview on 1/27/26 at 8:30 a.m., Resident 70 stated there was no pull cord on her light behind the head of her bed. The pull cord was observed to be approximately 3 inches (in.) long. Resident 70 stated she could not reach the pull cord and even if she could, the switch on the wall by the door would need to be turned on first. Resident 70 stated this was frustrating because she required assistance to walk and used a wheelchair. Resident 70 explained that if the light switch was not on and the cord was pulled, nothing would happen (the light would not turn on). Observations confirmed that even when the switch was turned on, the light did not function. Resident 70 stated she had no control over turning her light on or off. Resident 70 expressed she found it particularly frustrating when the sun set, saying, I have to get used to no continuous light. Resident 70 stated she consistently had to ask someone else to operate the light for her. Resident 70 further stated that she would like her light to work more than anything. Resident 70 stated maintenance was aware and had not returned to fix the light.During an interview on 1/27/26 at 8:45 a.m., Certified Nurse Assistant 9 (CNA 9) confirmed that Resident 70 could not reach the light switch. CNA 9 verified the pull cord on the light switch was approximately 3 in. in length. CNA 9 confirmed when cord was pulled, the light did not turn on.During a concurrent observation and interview on 1/29/26 at 9:58 a.m., the Maintenance Director (MAIN D) stated it was never brought to his attention that Resident 70's light was not in working condition. After observing Resident 70's light, MAIN D confirmed it was only partially working. MAIN D confirmed that Resident 70 could not reach the pull cord.During an interview on 1/29/26 at 2:15 p.m., the Business Office Manager (BOM) stated MAIN D was aware that Resident 70's light required to be repaired. The BOM stated the issue was mentioned on multiple occasions during staff morning meetings and stand-down meetings. The BOM stated the issue had been in discussion for approximately four months. The BOM reported that as of today, Resident 70's light and pull cord had still not been fixed. The BOM further stated, The resident [Resident 70] is really trying to make this her home.During an interview on 1/29/26 at 2:20 p.m., the Regional Consultant (RC) confirmed MAIN D was aware that Resident 70's light required repair. The RC stated it was important that Resident 70 had access to her light, to promote quality of life. The RC stated this issue affected Resident 70's independence. The RC further stated, It's a hazard for her [Resident 70] to not be able to see. It is not a home-like environment. The RC stated MAIN D had been failing to perform maintenance repairs and following up on the overall condition of the building.A review of the facility's policy and procedure (P&P) titled, Resident Safety, revised 4/2021, indicated, To provide a safe and hazard free environment.A review of the facility's P&P titled, Resident Rights- Personal Property, revised in January of 2012, indicated, To ensure a quality of life of all residents by allowing residents to create a home-like environment.A review of an undated facility document titled, DIRECTOR OF ENVIRONMENTAL SERVICES JOB DESCRIPTION, indicated, Ensures a safe, comfortable, sanitary environment for residents.in accordance with Federal, State and Corporate requirements.Orders and maintains supplies and equipment necessary to meet center needs.

Based on interview and record review, the facility failed to provide nursing services that met professional standards of quality for three residents (Resident 1, Resident 2, Resident 3) out of a sampled seven residents when licensed nurses did not:1. Initiate a care plan that included a recent occurrence of resident-to-resident abuse for Resident 1 and Resident 2; and,2. Conduct 72-hour monitoring following Resident 3's fall.These failures had the potential to place Resident 1, Resident 2, and Resident 3 at risk for serious harm, health deterioration and a loss of quality of life.1.A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with Alzheimer's Disease (a disease characterized by progressive decline in mental abilities).A review of Resident 1's care plans indicated the following:- On 10/25/24 a care plan was initiated and indicated Resident 1 had the potential to be physically aggressive related to dementia (a decline in memory, reasoning, thinking and judgement). Staff were expected to implement interventions which included monitoring Resident 1 for signs and symptoms of posing a danger to himself or others. -On 5/19/25 a care plan was initiated and indicated Resident 1 had a behavior problem with spontaneous short bursts of anger which was evidenced by striking out at other residents. Staff were expected to intervene as necessary to protect safety and rights of others and to de-escalate when behavior is triggered.A review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool), dated 6/2/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- an assessment used to measure cognition (a person's ability to process information and understanding)) score of 6 which indicated severe impairment. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis (paralysis or weakness on one side of the body) following other non-traumatic intracranial hemorrhage (bleeding within the skull) affecting left non-dominant side. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 3 which indicated severe impairment. A review of Resident 1's Progress Notes dated 8/12/25 at 8 p.m., indicated Resident 1 was standing in the corner of the hallway near the double doors.[Resident 1] grabbed [Resident 2's] arm and it provoked or possible (sic) scared [Resident 2]. During an interview on 8/26/25 at 10:05 a.m., Licensed Nurse 1 (LN 1) stated she witnessed the occurrence between Resident 1 and Resident 2. She stated Resident 2 was propelling himself down the hallway near the double door entrance while Resident 1 was standing in the corner by the entrance. As Resident 2 approached the entrance, Resident 1 grabbed Resident 2's arm, scaring Resident 2. LN 1 immediately separated Resident 1 and Resident 2. During an interview on 8/26/25 at 12:10 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD) stated that staff should have created or edited care plans for Residents 1 and 2 following their occurrence. The DON and DSD confirmed no care plans were ever created or updated to reflect the occurrence; therefore, staff were provided with no guidance on appropriate interventions. 2. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of Metabolic Encephalopathy (a condition in which the brain function is impaired due to chemical imbalances in the body, usually resulting from liver or kidney failure). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS score of 0 which indicated severe impairment. A review of Resident 3's Progress Notes dated 8/15/25 at 10:03 a.m., indicated Resident 3 was found on the bathroom floor, unable to state what happened when questioned by facility staff. Resident 3 was sent to the Emergency Department for evaluation and returned to the facility with a report of no injuries. During an interview on 8/26/25, at 4:10 p.m., the DON and DSD stated the a monitoring period of 72 hours was expected to be completed and documented by licensed staff for any resident with a change in condition, after the resident was evaluated and safe. The DON and DSD confirmed Resident 3 was missing 48 hours of monitoring for dates of 8/16/25 and 8/17/25. A review of facility policy titled Change in Condition, dated 8/25/22, indicated, The Licensed Nurse will document the following.update the care plan to reflect the resident's current status .A licensed nurse will document each shift for at least seventy-two (72) hours when there is a change in the residents condition.

Based on observation, interview, and record review, the facility failed to accurately assess a resident's fall risk status and ensure a care plan was person-centered for one resident (Resident 1) of four sampled residents when Resident 1 was admitted to the facility with a history of falls These failures decreased the facility's ability to supervise and prevent Resident 1's fall on 5/24/25 which resulted in a right nondisplaced (not shifted out of place) distal radius (bone that is near the wrist of your lower arm) fracture (a break) to the right arm, limiting use of her dominant hand. Findings: A review of Resident 1's hospital History and Physical , dated 4/7/25 at 4:30 p.m., indicated Resident 1 fell at home and sustained a right distal femur (thigh bone) fracture. A review of Resident 1's admission record indicated Resident 1 was admitted from a local hospital on 4/14/25 for orthopedic (musculoskeletal) aftercare for a fracture of the right femur and a fracture around an internal prosthetic (artificial) knee joint. A review of Resident 1's Fall Risk Evaluation dated 4/14/25 at 6:06 p.m., indicated, Upon admission .observe the resident status in the 11 clinical condition parameters .by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Resident 1 was assessed as a moderate risk of falls with a score of 6. A review of Resident 1's Care Plan Report dated 4/15/25 indicated Resident 1 had a goal to be free of falls . The interventions to reach her goal included: Anticipate and meet the resident's needs; ensure call light is in reach and encourage resident to use for assistance; use of bedside Commode (BSC) for facility toileting; educate the resident about safety reminders; ensure the resident is wearing appropriate footwear when mobilizing; follow facility fall protocol; and Physical Therapy (PT) and treat as ordered. A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/21/25, indicated 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 7 which indicated moderate cognitive (relating to processes of thinking and reasoning) impairment. A review of Resident 1's Care Plan Report dated 4/25/25 indicated Resident 1 had limited physical mobility due to her femur fracture. Resident 1's goal was to, will remain free from complications related to immobility including .fall related injury. Interventions staff were to implement to help Resident 1 reach her goal was to, .provide .assistance with mobility as needed. A review of Resident 1's Physical Therapy Treatment Encounter Report dated 5/21/25 at 6:49 p.m., indicated Resident 1 required a helper to provide partial/moderate assistance (the helper provides less than half of the effort required to help the resident complete the task) while she completed the activity of transferring from a bed to a chair. A review of Nursing Notes dated 5/24/25, at 1:30 a.m., Licensed Nurse 1 (LN 1) indicated Resident 1 had her call light on while her roommates were calling for help. After entering the room, Resident 1 was noted to be lying on her side and stated, I was pulling my pants up and slid down on my butt and landed on my arm .I think I broke my arm. It hurts so bad. A review of a hospital document titled Radiology Results dated 5/24/25, at 3:52 a.m., an X-ray of Resident 1's hand and forearm indicated a nondisplaced distal radial fracture. During a concurrent observation and interview on 6/11/25, at 2:19 p.m., Resident 1 stated she was getting up from the commode, lost her balance and fell. Resident 1 also stated her right leg was still weak and, gives out on her sometimes. During an interview on 6/11/25 at 2:57 p.m., Physical Therapy Assistant (PTA) stated Resident 1 was forgetful and believed she was too confident in her skills to transfer without assistance. The PTA stated Resident 1 needed moderate assistance while transferring from bed to chair. During an interview on 6/11/25 at 3:17 p.m., LN 1 stated Resident 1 was not a fall risk prior to the fall. LN 1 stated fall risk information was reported during shift change and it could be found in the care plan, and the resident's chart. During an interview and concurrent record review on 6/11/25 at 4:02 p.m., the Regional Quality Management Consultant (RQMC) stated care plan interventions were different for a resident that was a low risk for falls than that of a high risk fall resident, and that it was dependent upon the nursing assessment of the resident. The RMQC stated Resident 1's fall risk evaluation dated 4/14/25 was incorrect because it did not include Resident 1's fall at her home which contributed to her stay at the facility. The RQME confirmed Resident 1 should have been assessed as a high risk for falls upon admisison. The RQMC stated the facility's fall prevention protocol was a document titled Fall Prevention and Management which indicated, Assess the fall risk of each resident, implement measures to prevent a fall, and initiate a care plan that is resident specific. The RMQC confirmed this practice was not followed for Resident 1 upon admission. A review of facility policy titled Fall Management Program dated 3/13/21 indicated As part of the admission Assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on Resident's care plan.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were labeled and dated. This had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Food Storage and Handling, revised 02/29/2024, revealed the sections titled 6. Fresh Fruit Storage and 9. Fresh Vegetable Storage specified, Label and date all food items. An initial tour of the kitchen was conducted with the Dietary Manager (DM) on 02/17/2025 at 8:36 AM. The following items were observed in the reach-in refrigerator with no labels to identify what the items were or the open or use-by dates: a quart-sized bag of sliced carrots, a quart-sized bag of vegetable patties, and a covered bowl of fruit. During an interview on 02/17/2025 at 8:36 AM, DM confirmed the food items should have been dated and labeled. A follow-up tour of the kitchen was conducted with the DM on 02/19/2025 at 10:30 AM. During this tour, a gallon-sized bag of Salisbury steaks was in the reach-in freezer with no label identifying what the item was or an open or use-by date. During an interview on 02/19/2025 at 10:30 AM, the DM stated they did not have an explanation as to why the food items were not dated or labeled. During an interview on 02/19/2025 at 10:32 AM, [NAME] #2 stated all opened food items were to be labeled with open and discard-by dates. [NAME] #2 further stated that everyone was responsible for discarding non-dated and unlabeled food items. During an interview on 02/19/2025 at 10:47 AM, [NAME] #3 stated that opened food items should be labeled with the name of the product and the date the food item was opened. [NAME] #3 further stated that staff were to refer to their guideline sheet to determine the use-by dates. During an interview on 02/19/2025 at 10:59 AM, the DM stated that leftover and opened items should be labeled with an open date, description of the product, and a use-by date. During an interview on 02/19/2025 at 2:03 PM, the Director of Nursing (DON) stated that it was their expectation that all opened food items be labeled with an open date and expiration date. During an interview on 02/19/2025 at 2:11 PM, the Administrator stated they expected all food items to be properly labeled and stored.

Based on observation, interviews and record review, the facility failed to ensure one of two sampled residents (Resident 1): 1. Received showers as scheduled every Sunday and Wednesday. 2. A treatment was requested and initiated once Resident 1 was noted with moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool) when he was admitted on [DATE]. 3. Treatments for pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure on the skin) were consistently and regularly rendered per physician ' s order. 4. Resident 1 was being turned and repositioned (T&R, the movement of patients from one position to another to alleviate or redistribute any pressure) every 2 hours and more often as needed. 5. A care plan was developed (CP, a form that summarizes a resident ' s condition, current needs and treatment necessary for their care) to address Resident 1 ' s skin breakdown when he was initially admitted on [DATE]. 6. Licensed nurses (LNs) were accurately documenting the skin impairment and its location. These failures resulted in: A. Resident 1 developing a Stage 3 pressure injury on his sacrum (st 3 PI, full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) on 5/23/24, B. Resident 1 developing a wound infection on 5/30/24 which needed intravenous (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) antibiotics (medicines that fight bacterial infections) to be administered at the hospital, and C. Resident 1 developing a st 4 PI on his sacrum (a full thickness tissue loss with exposed bone, tendon, or muscle). Findings: A review of Resident 1 ' s face sheet (demographics) indicated Resident 1 was admitted on [DATE]. Resident 1 ' s diagnoses included muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 4/9/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 6 out of 15 indicating severely impaired cognition. Resident 1 ' s MDS dated [DATE] indicated he needed substantial assistance from staff during dressing and personal hygiene, but was dependent on staff during toileting, bathing or showering and putting on or taking off footwear. Resident 1 ' s Clinical admitted d 4/5/24 and Weekly Skin Wound assessment dated [DATE] indicated Resident 1 ' s skin was intact with no identified skin impairment. 1. A review of Resident 1 ' s shower sheet (SS) indicated that for 4/2024, Resident 1 received 1 shower out of 8 scheduled showers on 4/19/24 and 1 bed bath on 4/5/24. Resident 1 ' s SS for 5/2024 indicated Resident 1 received 0 out of 9 scheduled showers and only received 3 bed baths: on 5/1/24, 5/8/4 and 5/15/24. 2. A review of Resident 1 ' s electronic treatment administration record (ETAR, an electronic record on what, when and who provided the treatment) for 4/2024, indicated no order to regularly treat Resident 1 ' s MASD that was noted upon admission. 3.The following treatment orders for Resident 1 were missing nursing signatures indicating the treatment was administered: a. 4/2024 ETAR: Sacral foam dressing to the tail bone area as needed and the treatment nurse to follow up for further assessment every 8 hours as needed for risk of pressure injury, dated 4/12/24: -no signatures from 4/12/24-4/26/24 b. 5/2024 ETAR: apply wound dressing to coccyx topically daily for PI and wound dressing to wound bed and peri wound (around the wound) area; apply skin protectant to intact surrounding skin and cover with foam dressing, dated 5/8/24: -no signatures 5/10/24, 5/11/24, 5/12/24 c. 7/2024 ETAR: apply wound dressing, apply topical wound treatment to peri wound, apply skin barrier film to surrounding intact tissue, cover with dressing daily when treating sacral/coccyx st 4 PU, dated 7/10/24: -no signatures on 7/11/24, 7/12/24, 7/17/24, 7/18/24 d. 7/2024 ETAR: apply topical ointment to peri wound area, apply skin barrier film to surrounding tissue, apply gauze to wound bed, cover with foam dressing every day for st 4 PI, dated 7/10/24: -no signatures on 7/11/24, 7/12/24, 7/17/24, 7/18/24. 4. A review of Resident 1 ' s ETAR for 6/2024 indicated an order for turning Resident 1 every 2 hours to offload pressure on buttocks, every shift, for wound care with a start date of 6/12/24, was missing a signature on 6/30/24 morning shift. Resident 1 ' s Telemedicine Wound Assessment and Plan showed the following: -5/16/24 indicated a st 2 PI on distal sacrum. -5/23/24 indicated a st 3 PI on distal sacrum with 50% slough and 50% eschar. -6/13/24 indicated Resident 1 was hospitalized for 2 weeks due to wound infection with Methicillin Resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to several antibiotics) and had increased the PI to st 4 post debridement (removal of damaged tissue or foreign objects from a wound). During an interview on 8/14/24 at 9:50 a.m., the Director of Nursing (DON) stated Resident 1 had an MASD and not a PI when he was admitted to the facility on [DATE]. The DON stated Resident 1 had acquired the PI while at the facility. During an observation on 8/14/24 at 10:00 a.m., Resident 1 was lying on his back. During an observation on 8/14/24 at 12:00 p.m. Resident 1 was lying on his back. During an observation on 8/14/24 at 2:03 p.m., Resident 1 was lying on his back. During an observation on 8/14/24 at 3:55 p.m., Resident 1 was still lying on his back. During an interview on 8/14/24 at 10:41 a.m., the Infection Preventionist stated residents should be turned and repositioned (T&R) every 2 hours or more often as needed to prevent PI to develop or to prevent an existing PI to worsen. The IP stated per nursing standards, anything that was not documented meant it did not happen. The IP stated missing nurse signature on the ETAR meant a treatment wasn ' t done as ordered and could result to wound infection, wound to worsen, and decreased quality of life. The IP stated staff should initiate and follow the skin breakdown CP to decrease the risk of developing PI or worsening of PI. The IP stated weekly skin sheets and skin assessments documentation should be accurate and complete because this will track residents ' wound on whether it was progressing or deteriorating so the nurses could request a treatment that would be more appropriate to treat the residents ' wound. The IP stated it was the facility ' s policy to provide shower to the residents ' twice a week or more often as needed. The IP stated not providing showers regularly or as scheduled could result to missed skin impairment, impaired skin, wound infection and worsening of wounds. During an interview on 8/14/24 at 11:23 a.m., Certified Nursing Assistant I (CNA I) stated residents should be T&R every 2 hours and more often as needed per facility policy to prevent skin breakdown and to prevent worsening of PI. CNA I stated it was important to follow the CP to provide safe care to the residents. CNA I stated residents ' were scheduled to receive showers twice a week or more often as needed. CNA I stated refusals should be documented. CNA I stated it was important to provide showers to the residents consistently, regularly and as scheduled to ensure skin breakdown was not missed, wound does not get infected, and PI does not worsen. During an interview on 8/14/24 at 1:12 p.m., Licensed Nurse H (LN H) stated to prevent skin breakdown, residents should be T&R every 2 hours and as needed and showers should be provided twice a week to ensure skin remains free of skin breakdown. LN H stated not T&R residents every 2 hours and not providing regular showers could lead to missed skin breakdown, development of new wound or PI and wound infection. LN H stated T&R every 2 hours or more often as needed does not really happen because there ' s just not enough staff to do this task consistently. LN H stated missing nurse signature on ETAR could mean treatment was not rendered which could also contribute to worsening of wound or PI and development of wound infection. LN H stated it was important to ensure an individualized CP was initiated and followed by staff because this would provide staff an idea on how to prevent a resident from acquiring further skin impairment and worsening of PI. LN H stated it was important to ensure nurses were accurately documenting location and type of wound the resident had to ensure accurate treatment and to ensure correct treatment was rendered on the correct site. During an interview on 8/14/24 at 1:28 p.m., LN F stated Resident 1 had pain on the left side of his back, so he needs a lot of help turning on his sides. LN F stated once a resident was noted to be a high risk for skin breakdown and if a resident was noted to have a st 3 PI, a low air loss mattress (LAL, a pressure redistributing mattress) should be in place right away. LN F stated LAL mattress help to ensure pressure was distributed evenly and could prevent skin breakdown or worsening of skin breakdown. LN F stated it was still recommended to turn and reposition residents as often as needed to prevent PI to develop or worsen. LN F stated Resident 1 was dependent on staff for provision of personal care. LN F stated it was important that skin CP be initiated, be individualized and followed for residents ' safety, to prevent further skin breakdown, and to prevent development of PI. LN F stated if there were missing signature on ETAR, it meant treatment was not provided and could lead to worsening of wounds, infection and development of new wounds. LN F stated residents should receive showers twice a week regularly and as requested. LN F stated not receiving showers regularly could lead to missed skin impairment, worsening of wound or PI, wound infection and development of PI. 5. During a concurrent interview and document review on 8/14/24 at 2:05 p.m., the DON stated Resident 1 ' s Braden Scale (PI risk evaluation) score on 4/12/24 was 15, meaning he was at mild risk for skin impairment due to decreased sensory perception, very moist skin requiring linen change once every shift, only ambulates occasionally and had limited mobility, inadequate nutritional intake and potential friction and shearing. On 4/29/24, Resident 1 ' s Braden Scale score was 13 indicating moderate risk for skin impairment due to the same reasons as above and additionally Resident 1 was chair bound. The DON verified that during this time, there was no skin CP initiated for Resident 1 based on the Braden scale risk evaluation, although a skin CP should have been initiated then. The DON stated the skin CP was initiated on 5/15/24. The DON stated on 5/21/24, Resident 1 ' s Braden Scale score was 12 indicating high risk for skin breakdown. The DON verified Resident 1 was transferred to the emergency department on 5/30/24 for wound evaluation, debridement (surgical removal of devitalized or contaminated tissue) and recommendations for IV antibiotics for sacral wound with Methicillin-resistant staphylococcus aureus (MRSA, a super bug, a form of contagious bacterial infection). The DON stated she was not sure how the wound got infected. 6. On 8/14/24 at 2:35 p.m., the DON verified the information on the weekly skin and wound assessment on these dates was inaccurate: 4/5/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. 4/9/24- when there was no mention of Resident 1 ' s MASD. 4/16/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. 4/23/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. 5/14/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. 5/28/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. 7/4/24, indicated Resident 1 ' s skin was intact with no identified skin impairment, however on the narrative, it indicated Resident 1 had a PI on his buttocks. 7/14/24, indicated Resident 1 ' s skin was intact with no identified skin impairment. The DON verified there were conflicting documentation on the PI site between the weekly skin/wound assessment and the telemedicine wound assessment on these dates: 6/11/24, PI site was coccyx on weekly skin/wound assessment, however on 6/13/24, the telemedicine wound assessment indicated the PI site was the distal sacrum. During a concurrent interview and document review on 8/14/24 at 2:35 p.m., the DON stated Resident 1 had MASD upon admission and it was on 5/16/24 that Resident 1 was initially seen by the wound specialist via telemedicine and the wound on the sacrum was at st 2, measuring 2.8 centimeters (cm, measure of length) by 2.0 cm by 0.2 cm. On 5/23/24, the st 2 PI on the sacrum worsened to st 3 PI measuring 3.5 cm by 2.5 cm with 50 percent slough, 50% eschar. The DON stated the deterioration of the wound probably prompted the doctor to order culture and sensitivity of the wound. The DON stated it was important nurses were documenting accurately and consistently to improve outcome for resident with wounds. The DON stated inaccurate documentation raises the issue if nurses were even looking at the wound, assessing the resident or if the nurses were assessing the residents with wound appropriately. The DON stated inaccurate wound documentations could result to inadequate patient care. During a concurrent interview and record review on 8/14/24 at 3:26 p.m., the DON verified there was no treatment order for Resident 1 ' s MASD when he was admitted on [DATE]. The DON stated the ETAR dated 5/2024 indicated the earliest treatment to the coccyx was initiated on 5/8/24. The DON stated the treatment should have been to the sacrum, which could create confusion. The DON stated nurses need further education on the correct anatomical position. The DON stated if a PI had no treatment in place, it could lead to wound to deteriorate and wound infection. The DON verified Resident 1 did not have an at risk for skin breakdown CP, and had no MASD CP. The DON verified Resident 1 did not have a PI CP created until 5/15/24. The DON stated there should absolutely be one created for Resident 1 so the nurses and CNAs could follow the plan and prevent further deterioration of wound. The DON stated not having a CP in place could contribute to wound deterioration. The DON stated the facility discovered the st 3 PI on Resident 1 ' s distal sacrum on 5/22/24 and should have transitioned to an LAL mattress then, however it was not until 5/28/24 that Resident 1 transitioned to a LAL mattress. When asked about the delay, the DON stated she was not sure why the delay. The DON stated the delay could have been detrimental to Resident 1 ' s wound healing. The DON stated residents on LAL mattress should still be T&R. The DON stated Resident 1 would still need to be T&R every 2 hours. The DON stated T&R every 2 hours was important to ensure Resident 1 ' s wound does not deteriorate and to prevent development of new PI or skin issues. The facility did not have a policy and procedure (P&P) specific for T&R, shower and ADL care. A review of the facility ' s P&P titled Pressure Injury Prevention, revised 3/30/24, the P&P indicated, .to develop a plan of care based on the residents ' risk factors, implement interventions identified in the plan of care such as T&R . A review of the facility ' s P&P titled Pressure Ulcer Management, revised 1/1/2012, the P&P indicated a resident with pressure ulcer will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing .CNAs will complete body checks on residents ' shower days and report unusual findings to the Licensed Nurse . A review of the facility ' s P&P titled Skin Integrity Management, revised 10/26/23, the P&P indicated, .treatment administered will be documented in the residents ' medical record The Cleveland Clinic published on 4/27/2020 on skin care where Dr. Khetarpal says We come in contact with thousands of allergens every day. Showering rinses off those allergens, as well as bacteria and viruses. Healthline published on 1/29/2019 on skin care: Poor hygiene or infrequent showers can cause a buildup of dead skin cells, dirt, and sweat on your skin. Showering too little can also trigger an imbalance of good and bad bacteria on your skin and too much bad bacteria on your skin also puts you at risk for skin infections.

Based on observation, interview and facility document review the facility failed to ensure safe and sanitary food storage, food preparation, and food service when: 1. There was not a safe food storage system for time temperature control for safety (TCS) foods (foods such as meat and milk that have a high potential for bacteria growth especially if stored between 135 degrees (*) Fahrenheit (F) and 41* F (this is also referred to as the food danger zone) for more than 4 hours. The ingestion of the bacteria can result in foodborne illness and in severe instances may result in death when) and 5 turkey sandwiches potentially stored above 41 *F over 6 hours were available for resident consumption in 2 of 3 utility room refrigerators used to hold resident food. In addition, there was no system to ensure TCS foods stored in these refrigerators were held at or below 41 *F in a facility census of [AGE]. On [DATE] at 6:55 p.m., Immediate Jeopardy (IJ) was called. The Administrator, the Director of Nursing, and the Regional Quality Consultant Registered Nurse Supervisor (RQC), were verbally notified of the IJ regarding temperatures of food potentially stored above 41 *F for over 6 hours. An acceptable plan of action was provided by the facility Administrator on February 11, at 8:00 p.m. The actions to remove the immediate jeopardy situation included: removal of and discarding the food stored in two unit refrigerators that held resident food; removal of one unit refrigerator and adjusting the temperature of one unit refrigerator that held resident food; revision of the refrigerator temperature log to include directions on what to do if refrigerator temperatures are above 41 * F and corrective action taken; use of only non-perishable snacks for residents until the refrigerators are replaced and tested to ensure safe holding temperatures; the use of non-perishable snacks until staff are trained on the use of the revised temperature log; when food storage unit refrigerator are back in use, the temperature of a test item (a food stored in the refrigerator for the sole purpose of measuring the temperature with a thermometer to assess proper food storage temperatures) will be measured before serving TCS foods to residents; a charge nurse will monitor the test item log and the refrigerator temperature log for 3 months or until 100 percent compliance; will monitor all residents who were potentially effected, for 24 hours for gastro intestinal (GI) signs and symptoms of food borne illness such as nausea, vomiting, diarrhea, and abdominal pain; and the medical director was notified of potential GI issues to food stored at an unsafe temperature. While on-site, the surveyors confirmed the IJ was removed. 2. The inside of the ice machine was dirty; 3. Drain pipes from the ice machine and the drinking fountain were dirty; 4. Equipment and utensils stored in the kitchen were dirty and in poor condition; 5. A pot filler water nozzle was dirty; 6. A large mixer base and wheels were dirty; 7. An air vent in the kitchen was dirty; 8. Food in the dry storeroom was not stored 6 inches off the ground; 9. Wall/floor tiles in the kitchen were broken and cracked; 10. The stove hood and filters were dirty with black and greasy build-up; 11. Condiment containers were dirty; 12. Raw, thawing meat was not stored safely; 13. Expired food items were available for use; 14. Equipment and utensils were not air dried; 15. Proper hand hygiene procedures were not followed; 16. Food items were not properly labeled and dated in utility room refrigerators; 17. Utility room cabinets, that stored single use food service items, were dirty; 18. Microwaves used to heat resident food located in the utility rooms were dirty and one also had missing plastic and scratch marks on the inside surface. 19. Staff personal items were stored on counters and other open areas in the utility room and not contained in a closed area; 20. A spray bottle filled with a liquid, found in a utility room, was not labeled to identify the contents. These lapses in safe and sanitary food storage, preparation, and service had the potential to result in bacterial or physical contamination of resident food and cause food borne illness further compromising medical status of [AGE] residents out of a facility census of [AGE]. Findings: 1. According to the Federal Food Code (2017) refrigerated time/temperature control food also known as PHF is to be 41* F or less and when the food temperature increases above 41*F it is to be discarded within 4 hours. Perishable foods such as meat and milk are capable of supporting bacterial growth associated with foodborne illness. Review of the policy and procedure titled Refrigerator/Freezer Temperature Records dated [DATE], and provided as a current policy, showed the refrigerator temperature must be 41 *F or below and corrective action should be taken to correct the temperature or the items should be moved to another storage area to maintain an acceptable temperature. An observation on [DATE] at 9:52 a.m., showed a countertop refrigerator located in the utility room on Wing C. The refrigerator held TCS food items including 4 sandwiches wrapped in plastic wrap and labeled turkey sandwich and all were dated ,[DATE]. The temperature of one turkey sandwich was 51.3 * F measured with a surveyor's calibrated thermometer. A cup of orange juice was also stored in the refrigerator with a measured temperature of 50 *F. In an interview on [DATE] at 9:56 a.m., Certified Nursing Assistant (CNA) 20 stated the turkey sandwiches were served to residents for snacks. An observation on [DATE] at 10:09 a.m., showed a countertop refrigerator located in the utility room in Wing A. The thermometer located inside the refrigerator indicated the temperature was 48 * F. The surveyor's digital thermometer was placed in the refrigerator for 10 minutes, with the refrigerator door closed. After 10 minutes the thermometer read 46.8 *F. The surveyor's thermometer was left inside the refrigerator again in order to check at a later time. Review of the document titled Utility Refrigerator Log A wing showed there were 3 temperatures above 41 *F documented for the month of February. These temperatures were as follows: [DATE] at 1:30 p.m., 45 *F; [DATE] at 9:25 a.m., 43 *F; and [DATE] at 7:10 a.m., 42 *F. It was noted that all of the entries were initialed by the same person. It was also noted that there was temperature documentation once a day and there was no documentation on the log to indicate corrective action was taken on the days the refrigerator temperatures were over 41 *F. An interview and concurrent observation on [DATE] at 10:21 a.m., showed the surveyor's thermometer left in the countertop refrigerator in A wing was 45.9 *F. The Director of Environmental Services (DES) confirmed the temperature and stated it was high but when she checked it that morning at 8 a.m., it was 40 *F. She confirmed temperatures were logged one time each day. She stated she looked at the refrigerator temperature logs daily and did not notice anything logged over 40 *F in the last month. She said refrigerator temperatures should be 29 *F to 40 *F. If the thermometer temperature was higher, she turned the thermostat dial inside the refrigerator to make it colder and discard any food. She stated any corrective action taken due to high refrigerator temperatures was not documented. She also confirmed the temperatures above 41 *F documented on the Utility Refrigerator Log A Wing, were documented by House Keeping Staff (HKS) 1. An observation on [DATE] at 10:33 a.m., showed the countertop refrigerator in A Wing held TCS foods including 2 sandwiches labeled turkey sandwich dated ,[DATE], a plate with deli meat and cheese covered with plastic wrap labeled with Resident # 27's name and room number. The temperature of the food was measured with the surveyor's calibrated thermometer. The temperature of the turkey sandwiches, which were stored on the lower shelf of the refrigerator, were 48.4 *F and 51.8 *F. It was noted the plastic bags the sandwiches were wrapped in, were open and did not fully cover the sandwiches. The plate of meat and cheese was located directly under the small freezer compartment in the refrigerator and the temperature of the meat was 42.1 *F. It was noted that water was dripping from the freezer compartment onto the plate of meat and cheese. The temperature of a cup of orange juice dated ,[DATE] was also measured and was 44.6 *F. On [DATE] at 4:40 p.m., an observation inside the countertop refrigerator located in the C wing utility room showed the internal refrigerator temperature was 41 *F. Temperatures of food were taken with the surveyor's calibrated thermometer and were as follows: 3 turkey sandwiches dated ,[DATE], 53* F, 53.6 *F, and 52.3 *F. It was noted that there was one less turkey sandwich compared to when the refrigerator was observed over 6 hours earlier and the pudding was no longer there. There was also a cup of milk stored in the refrigerator with no date. On [DATE] at 5 p.m., an observation inside the countertop refrigerator located in A wing utility room showed the thermometer inside the refrigerator showed 41 *F. Temperatures of food measured with the surveyor's thermometer included two turkey sandwiches dated ,[DATE], 43.3 *F and 46.6 *F; applesauce dated ,[DATE], 44.6 *F; pudding dated ,[DATE], 46.4 *F; and a cup of orange juice, 43.5 *F. It was noted there were the same amount of turkey sandwiches dated ,[DATE] as observed the over 6 hours earlier and the meat and cheese plate for Resident # 27 was no longer in the refrigerator. In a concurrent interview, Nursing Staff 1 stated the refrigerator was identified as not working properly at 3:30 p.m., but she did not have time to discard the food stored in the refrigerator. In an interview on [DATE] at 5:25 p.m., CNA 21 stated she was working in A wing that evening ([DATE]) and turkey sandwiches could be given to residents who requested them. She stated she was not aware that the refrigerator in the A wing utility room was broken and she would still serve food stored in the refrigerator. In an interview and concurrent observation on [DATE] at 5:35 p.m., Registered Dietitian (RD) 1, measured the temperature of the food in the countertop refrigerator located in the A wing utility room. The TCS foods measured included 2 turkey sandwiches dated ,[DATE] and were 46.9 *F and 48.2 *F; orange juice 46.2 *F; pudding prepared on site 47.3 *F; and applesauce in a plastic bowl covered with plastic wrap 46 *F. The RD stated she would not serve those foods because they weren't in our range. In an interview on [DATE] at 5:45 p.m., CNA 23 confirmed she was assigned to care for residents on C Wing that evening ([DATE]) at she would serve a turkey sandwich to a resident upon request. In an interview on [DATE] at 5:47 p.m., CNA 22 confirmed he was assigned to care for residents on C Wing that evening ([DATE]) and that he would serve a resident a turkey sandwich upon request. He stated he might look at the internal thermometer of the refrigerator but he never took the temperature of a food stored in the refrigerator. In an observation on [DATE] at 5:59 p.m., RD 1 measured the temperature of a turkey sandwich dated ,[DATE] stored in the C wing utility room refrigerator. She confirmed the temperature of the sandwich was 48.9 *F. Concurrently, she measured the temperatures thickened water which was 50.9 *F and a peanut butter and jelly sandwich which was 48.3 *F. On [DATE] at 6:05 p.m., in the presence of RD 1 and the Regional Quality Consultant Nurse Supervisor (RQC), all the thermometers used to measure the temperature of food in the refrigerators were placed in an ice bath to show the accuracy of the thermometers used. When the thermometers were placed in the ice bath, the digital thermometer used by RD 1 read 32.9 *F and the surveyor's thermometer fluctuated between 31.9 and 32.4 It is a standard of practice to use ice baths to calibrate thermometers. 32 *F is the temperature that thermometers are calibrated to when properly calibrated in an ice bath. (United States Department of Agriculture, Food Safety Inspection Service, 2015) In a phone interview with RD 1 on [DATE] at 5:05 p.m., the RD stated the responsibilities Food and Nutrition Services (FNS) staff had in regard to the utility rooms were limited to stocking the refrigerators with labeled and dated food items. The FNS staff did not monitor the refrigerators. She said that nursing and housekeeping staff serve the food to residents and discarded food stored in the utility room refrigerators. In an interview on [DATE] at 8:25 a.m., HKS 1 confirmed she documented temperatures on the Utility Refrigerator Log for A wing on [DATE], [DATE], and [DATE] with respective temperatures of 45 *F, 43 * F, and 42 * F. HKS 1 stated she started working at the facility in [DATE] and was trained regarding refrigerator temperatures by the DES on the 3rd day she worked at the facility. She said that she looked at the unit food refrigerator internal thermometers and documented a temperature one time per day. If the temperature was above 40 *F she let the DES know. She stated she did not do anything as far as corrective action regarding the temperature of the refrigerator on ,[DATE] for the documented temperature of 45 *F because the DES was there that day. She stated on ,[DATE] and ,[DATE] when she documented temperatures of 43 *F and 42 *F she did not take any corrective action. Then she stated she was taught that refrigerator temperatures between 40 *F and 45 *F were ok. She confirmed she was not aware that food was not discarded from the A wing refrigerators due to a high refrigerator temperature on those days ([DATE], [DATE], and [DATE]). In an interview on [DATE] at 8:41 a.m., the DES stated when she had a new hire she trained them on monitoring unit food refrigerator temperatures and her training included that the temperature for the food refrigerators had to be 40 *F and under. She stated housekeeping staff did not take the temperature of food to ensure it was stored at a safe temperature. She stated if the refrigerator temperature was high, she turned the internal thermostat knob to make the refrigerator temperature colder and rechecked the temperature an hour later. She stated there was no documentation of corrective action when a refrigerator temperature was high. She stated on [DATE], [DATE], and [DATE], HKS 1 was expected to discard the food from the refrigerators because she documented high refrigerator temperatures. The DES said she was not informed that HKS 1 threw away food on those days. She continued to say that she reviewed the logs for the utility food refrigerators only if she was on the wing. She confirmed she worked at the facility on [DATE], [DATE], and [DATE]. She also stated she did not have documentation of an in-service or a competency evaluation for training staff about monitoring refrigerator temperatures. Review of the undated job description for Housekeeper/Janitor showed a checklist with suggested topics for orientation. The checklist covered tasks such as cleaning areas throughout the facility such as patient rooms, lounge areas, dining rooms, and bathroom. The checklist did show that it included utility rooms where resident food refrigerators were located, monitoring of refrigerators, and/or storage of refrigerated food. Review of the policy and procedure titled Housekeeping - General dated [DATE], provided as a current policy, showed it covered proper procedures for ensuring all areas of the facility were clean and sanitary, but it did not include food safety and monitoring refrigerators. On [DATE] at 10:23 a.m., the Director of Staff Development (DSD) stated she provided a 2-day orientation for all new staff. She was not able to show documentation that nursing staff and certified nursing assistants (CNA) were trained regarding safe food temperatures and/or safe refrigerator temperatures. She stated after the orientation, new staff shadowed a seasoned staff on the floor. She stated she was not sure if shadowing included training on the refrigerators. She reviewed the undated checklist titled C.N.A. Core Clinical Competencies and Licensed Nurse Orientation Skills Check revised [DATE], checklists that were used during shadowing and she confirmed they did not indicate if refrigerators were included. 2. The inside of the ice machine was dirty; During a concurrent observation and interview on [DATE], at 3:30 p.m., with Maintenance Supervisor ([CONDITION]), in the ice machine room located at the corner of C hall and lobby, the chute (where ice moves through to dispense the ice) from the ice dispenser rim had a yellow/dark orange thick slimy, gelatinous residue. [CONDITION] confirmed there was residue removed from inside the chute. Then [CONDITION] opened the ice machine to observe the inside components. There was a significant amount of visible black residue around the plastic surrounding the evaporator plate (where water runs over and ice is formed). When wiped with a white napkin, the residue easily came off onto the napkin. When the inside surface of the bin (where formed ice is stored inside the ice machine) was wiped with a white napkin, a significant amount of a light yellow slimy, gelatinous residue easily came off onto the paper towel. [CONDITION] confirmed the black and light yellow residue that was inside the ice machine. He stated the facility only had one ice machine and agreed the ice machine was not clean. He stated an outside vendor cleaned the ice machine on a regular basis so he did not know why it was dirty inside. During a concurrent observation and interview on [DATE], at 3:35 p.m., with Certified Nursing Assistant 24 (CNA 24), CNA 24 entered the ice machine room and stated he needed ice from the ice machine to give out to residents for their ice water to drink. He confirmed all CNA's obtained ice from the ice machine to provide ice water to their residents. During a facility record review, on [DATE] at 8:39 a.m., the [CONDITION] provided documentation from the ice machine cleaning vendor that the ice machine had been cleaned monthly since ,[DATE]. The documentation indicated, Sanitize interior of ice machine per manufacturer's instructions. The facility was not able to provide the manufacturer's instructions for cleaning or sanitizing the internal components of the ice machine. According to the Federal Food Code (2017), Food contact surfaces are to be clean to sight and touch. 3. During a concurrent observation and interview, on [DATE], at 9:20 a.m., the Maintenance Supervisor ([CONDITION]) stated the ice machine drain area was cleaned once a year but he had no documentation. The [CONDITION] explained that condensation from the ice machine drained through the two white [MEDICATION NAME] chloride (PVC) pipes from the ice machine. [CONDITION] stated the [MEDICATION NAME] pipe was the drain from the two drinking fountains on the other side of the wall in the lobby. During a concurrent observation and interview, on [DATE], at 9:51 a.m., three drainpipes drained into water into a floor sink under the ice machine. The PVC pipes, [CONDITION] confirmed drained condensation from the ice machine, had a thick black and beige color sludge on the surface of the ends of the pipes. The metal pipe, [CONDITION] confirmed was the drain pipe for the water fountains, had a thick black sludge on the surface of the end of the pipe. The sludge from this pipe came into contact with the sludge on the white PVC pipe and also hung down coming into contact with the floor drain grate. A white napkin was wiped across the ends of the three drainpipes chunks of black sludge and white, tan, and pink residue easily wiped off onto the napkin. The [CONDITION] confirmed the sludge from the drainpipes. He stated this was not a concern and that the substance at the end of the drainpipes could not go up the pipes. During a concurrent observation and interview, on [DATE], at 9:51 a.m., the ice machine drainpipes and air gap (space between the drainpipe and the drain) were examined with the [CONDITION]. The [CONDITION] confirmed the measurement of the half-inch white PVC pipe from the ice machine: one was about ,[DATE] inch from the floor drain, and one was about ,[DATE] inch from the floor drain. The [CONDITION] agreed that the air gap distance between the drainpipes and the drains did not meet the requirement for the air gap to be twice the distance of the diameter of the drainpipe. The drainpipe was ,[DATE]-inch diameter so there must be a minimum 1-inch gap. According to standards of practice within the foodservice industry, an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system (2017 FDA Food Code). During a concurrent observation and interview, on [DATE], at 9:51 a.m., with the Director of Staff Development (DSD) (supervisor of the infection control nurse) and Regional Quality Consultant Nurse Supervisor (RQC), the DSD stated the sludge on the drainpipes from the ice machine and drinking fountain were an infection control problem. DSD stated the pipes needed to be cleaned and that the black residue could cause infection (illness) by migrating up into the pipes. The RQC stated the facility had a water management program and that they were part of the Legionella (germs that live in water) program. It was later confirmed the facility did not have a Water Program that included the ice machine and the water fountains (Cross-reference F8[AGE]). During an observation with concurrent interview on [DATE] at 12:40 PM, the [CONDITION], Administrator (Admin), Director of Nursing (DON), RQC, and Registered Dietitian (RD) were present. [CONDITION] removed a section of one of the PVC pipes that drained the ice machine. The pipe had a 45-degree elbow at both ends. The inside of both ends of the pipe were visible, and both had black residue and white bumpy substance on the inside surface. The [CONDITION] stated I'm not going to guess the color (of the substance inside the pipe) - that's outside my scope. He refused to state if the inside of the pipe was clean or dirty. The inside of the [MEDICATION NAME] drainpipe was not visible. According to the Federal Food Code (2017), nonfood-contact surfaces of equipment are to be kept free of an accumulation of dirt and other debris and are to be cleaned at a frequency to preclude accumulation of soil residues. 4. Equipment and utensils stored in the kitchen were dirty and in poor condition; a. An observation and interview during the initial tour of the kitchen on [DATE], at 8:45 a.m., with the Certified Dietary Manager (CDM) and Cook 3, showed a food preparation table had multiple equipment stored. The blades inside of a food processor had an orange residue on the surface. The CDM stated that the food processor was not clean and not okay to use. Four lids for food processors had a thick residue on the inside surface. The residue wiped off with a paper towel. The CDM confirmed the residue. A small blender had a dry residue on the inside surface. Three blender bases had food debris on the surface. The CDM stated the food debris was probably not just from today. CDM stated that the small blender was not in good condition for use, and the blades for the blender were not clean. CDM stated that the blender pourer rim was cracked, and dietary staff used the blender pourer every meal. A handheld mixer had orange residue on the food-contact surface. The CDM stated that blender needed cleaning after every use and hand mixer as well. Also stored on the preparation table were two frying pans. The frying pans had a coating on the food-contact surface that was scratched and peeling. The CDM confirmed the pans had scratches and were dirty. Another larger frying pan had food debris on the food-contact surface. The CDM confirmed the pan needed cleaning. Three double boilers were also stored under the preparation table. Cook 3 stated the boilers were used to make gravy. Also stored on the preparation table was a large plastic container that contained 2 opened sleeves of plastic, single-use lids. The container had crumbs and debris on the inside surface. The CDM stated the lids were for plastic bowls and Styrofoam bowls and said the container should be emptied and cleaned out. When asked how often the containers were cleaned, he stated probably when the lids were all used and the container was empty. A commercial grade manual can opener was attached to the end of the preparation table. The can opener blade was peeling and was rough to the touch. The CDM confirmed the blade was peeling and needed to be replaced. A drawer attached to the preparation table that stored utensils, had a brown/orange residue on the inside surface and felt rough and gritty to the touch. The CDM confirmed the drawer was not clean and could use a cleaning. A plastic liner constructed with holes, partially covered the bottom surface of the drawer. The utensils stored in the drawer came into contact with the residue on the drawer surface that was not covered with the plastic liner. CDM stated the drawer was probably [AGE] years old. Inside the metal drawer were multiple utensils that had residue and crumbs on the surface that included: two knife sharpeners that had an orange residue on the surface; a chopper with blades that had a dried residue on the surface; three ice cream scoops with food particles on the inside surface; one vegetable peeler that had brown residue; seven rubber spatulas that were discolored, had residue and crumbs on the rubber surface, and were cracked; one large metal spatula was completely covered with brown/orange residue and was rough to the touch; a pastry brush that had yellow residue and was worn-out; a handheld manual can opener that had residue on the surface; and a set of measuring spoons that had crumps on the surface. The CDM confirmed all of the utensils were dirty stated they had to be thrown out. A knife holder that held several knives was attached to the wall behind the preparation table. Two of four knives on the knife holder had residue on them. One large knife with a white plastic handle was discolored with a dark brown and black residue and was misshapen and rough and appeared it was melted at some point. The CDM confirmed the residue on the knives and stated the knife with the white handle had to be replaced due to poor condition. Above the preparation table was a metal shelf that ran the length of the preparation table. Stored on top of the shelf was equipment such as the blenders, food processor, and other utensils. On the underside of the shelf was a significant amount of caked on residue. The CDM stated the top of the shelf was cleaned but not the underside. Continuing the initial tour of the kitchen on [DATE] at 9:28 a.m., an observation and concurrent interview with the CDM showed the microwave had orange residue on the interior all along the length of the seam where the back wall of the microwave and the bottom surface met. In addition, the exterior surface of the microwave there was a build-up of dry residue. The CDM confirmed the residue and stated the microwave was cleaned daily, at night. Also during the initial tour on [DATE] at 9:30 a.m., a plastic container stored on a table in front of the microwave held various items such as scissors, a thermometer, an eraser and pens. The outside surface of the bowl was covered with residue. The CDM stated the container was dirty. Continuing the initial tour of the kitchen on [DATE] at 9:32 a.m., showed white plates stacked in a lowerator (a piece of equipment for storage of plates). Ten plates had dried food residue on the surface. The CDM confirmed the plates had residue and stated if dishes were not clean when removed from the dishmachine, they should be rewashed. Continuing the initial tour of the kitchen, an observation and concurrent interview on [DATE], at 9:35 a.m., showed a black metal rack hung from the ceiling toward the end of the preparation table. The rack had a thick layer of gray fuzzy residue all over the entire surface. CDM confirmed that dietary staff did not clean the rack and stated it was not on the cleaning schedule assigned to dietary staff. Utensils that included to large metal strainers, hung from the rack. The CDM stated the strainers were used to drain cooked vegetables and pasta. The rims of the strainers were bent and had open seams and crevices. The metal around the seams was discolored with an orange residue. The CDM confirmed the residue. In a concurrent observation on [DATE] at 9:35 a.m., a wall located behind the black metal utensil hanging rack and between the stove and a produce washing sink had a significant amount of orange splatter marks. The CDM confirmed the residue on the wall and stated walls were not on the cleaning schedule. As the initial tour continued, a concurrent observation and interview on [DATE], at 9:45 a.m., with CDM, in the facility kitchen, 7 of 10 adaptive scoop plates stored near the stove and were discolored with a yellow residue on the top surface and bottom surface. There was also a significant amount of scratches on the top food-contact surface. The CDM confirmed the plates were used for residents and they were in poor condition. During the initial tour an observation and concurrent interview on [DATE], at 9:40 a.m., showed another preparation long metal preparation table with shelving underneath. The shelving held food service and cooking utensils. There were five (5) pitcher lids found on a shelf with dark discoloration on the surface. The CDM stated were used to cover pitchers of milk or juice and it did not look like they were clean. On the same shelf, were a white and a tan pitcher which were scratched and discolored on the inside surface. The CDM stated they were used for milk. He stated they were old and had to be thrown away. Three clear plastic pitchers were cracked and the CDM referred to their appearance as crackled and not in good condition. There was also 1 metal sheet pan with a build-up of black residue on the surface and 3 large roasting pans with a significant amount of build-up of black residue on the inside surface. The CDM stated the sheet pan was used for baking chicken and should be thrown out and the roasting pans were used to cook roasts and were really old as well as hard to clean. There were 3 large, plastic measuring cups one of which was cracked and the other had a scratches and had a cloudy appearance from residue. The CDM stated the measuring cups should be thrown away. Two plastic food storage containers were cracked. The lids to the containers had a sticky residue on top, one had a significant amount of white residue on the inside surface, and two were cracked. The CDM confirmed the cracked items and stated they should be discarded. Then he stated he did not know what the white residue was from. The CDM also said the sticky residue on top of the lids was from stickers used to label the containers and it was tough to get the residue off. The lids were stored in a large plastic container. The bottom surface of the container had crumbs and what appeared to be food particles and other debris. When the surveyor asked about how often the container holding the lids was cleaned, he stated probably when the container was empty. Also stored on a shelf was half sized, 4-inch deep metal pan which had a brown residue on the inside surface and a 2-inch deep half pan which had a build-up of residue. The CDM stated they needed to be thrown out. In addition, there was a metal mixing bowl with crumbs on the inside surface. The CDM confirmed the crumbs. The shelf that stored the metal mixing bowls had a gray fuzzy layer of residue that resembled d (TRUNCATED)

Based on observation, interview, and record review, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plan, follow fall protocol for post fall assessment and management to prevent accidents for seven of 16 sampled residents (Resident 1, 2, 3, 4, 5, 6, and 14) when: 1. Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture which required admission to an acute care hospital for treatment. 2. Resident 2 had five falls during a one month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16 which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16. 3. Staff did not follow their fall protocol for post fall assessment and notify the physician of a fall when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days after the fall). 4. Resident 5 had six falls during a six and a half months period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom which was wet with urine. A fall on 11/23/16 resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose on 11/23/16 at 9:35 p.m. (which was the second fall on the same day 11/23/16). 5. Resident 4 had three falls during a one month period from 8/16/2016 to 9/17/2016. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/2016 and reopened a skin tear on the right hand from a fall on 8/21/2016. Resident 4 had three more falls during a one week period from 10/13/2016 to 10/17/2016, which resulted in a nasal bone (nose) fracture from a fall on 10/13/2016. 6. Resident 6 had multiple falls in a six months period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16. 7. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis) Fall Care Plan to indicate Resident 14 was to be on one on one with staff at all times starting 11/5/16 per physician's orders [REDACTED]. Findings: 1. Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's minimum data set (MDS, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/29/16, revealed a BIMS (brief interview for mental status) score of 14, which indicated that Resident 1 was cognitively intact. The MDS assessment indicated that Resident 1 required limited assistance of one person with physical assistance for walking in the corridor and toilet use. The fall risk assessment dated [DATE], indicated Resident 1 was at high risk for fall due to multiple problems including intermittent confusion, one to two falls in past three months, and being legally blind. Resident 1's care plan for fall risk prevention and management initiated on 1/22/16 and re-evaluated on 7/16, indicated approaches for fall risk prevention and management including Orient resident to environment each time changes are made and provide an environment that supports minimized hazards over which the Facility has control . The care plan did not specify how the facility would provide supervision to prevent the resident from falling. Resident 1's care plan for visual impairment initiated on 1/22/16 indicated Provide environment with items kept in consistent location, free from obstacles and clutter .uses handrails in hallway . The care plan for activities of daily living initiated on 1/22/16 indicated Resident 1 required assistance for toilet use. The nurse's note dated 8/28/16, revealed Resident 1 had an unwitnessed fall at 9:10 a.m. when Resident 1 was ambulating to the restroom and walked onto wet floor sign. The IDT (interdisciplinary team) Conference Record dated 8/29/16, indicated on 8/28/16, at 9:10 a.m., Resident 1 walked to the bathroom and stopped at the restroom doorway. Resident 1's hands grabbed the spring rod, which the housekeeper placed in the doorway for cleaning, and simultaneously leaned her weight backward expecting the rod to be stable like a hand rail. Resident 1 fell to her left side and had left shoulder pain and left hip discomfort. Resident 1 was sent to an emergency department and admitted to an acute care hospital. The CT (computerized tomography, combines of X-ray images using computer process to create images) examination result dated 8/28/16, and the history and physical report from the acute care hospital dated 8/28/16, indicated Resident 1 sustained a non operable left humeral neck (upper arm bone) fracture and was admitted to the hospital for pain control and evaluation. During an interview on 10/26/16 at 10:02 a.m., regarding Resident 1's fall on 8/28/16, Licensed Staff A stated Resident 1 usually used the handrails in the hallway when Resident 1 was walking. Licensed Staff A stated Resident 1 had visual impairment. Resident 1 liked to grab the handrail and leaned backward while talking to the staff or other resident. Licensed Staff A stated on the day Resident 1 fell , Resident 1 walked to the restroom in the hallway and grabbed the spring rod, which the housekeeper placed in the doorway for cleaning. Licensed Staff A stated Resident 1 thought the rod was the handrail, so Resident 1 leaned her body backward while grabbing the rod. Licensed Staff A stated Resident 1 fell on the floor because the rod was not stable and fell off the doorway. Licensed Staff A stated no staff walked with Resident 1 because it was Resident 1's routine to walk to the restroom by herself using the handrails. Licensed Staff A stated the biggest mistake was lack of communication. Licensed Staff A stated the housekeeper did not tell her (Licensed Staff A) about placing the rod in the restroom doorway,otherwise she would have educated Resident 1 and let her feel the rod or walked with her. Licensed Staff A stated the rod was a new product but they should not use it on the floor because it was dangerous. During an interview on 10/26/16, at 11:50 a.m., regarding Resident 1's fall on 8/28/16, Housekeeping Staff P stated she put the rod with a sign across the restroom doorway and two signs on the floor when she was mopping the restroom. Housekeeping Staff P stated she told Resident 1 the restroom was closed. Housekeeping Staff P stated after she cleaned the restroom, she left the rod with a sign across the restroom doorway and went to another hall. Housekeeping Staff P stated she did not tell Resident 1 that the rod was left in the doorway. Housekeeping Staff P stated she did not tell any staff about the rod because they could see it. Housekeeping Staff P stated from the beginning of using this type of rod, she told the housekeeping supervisor that the rod was terrible and not good for use because the rod did not have spring and was easy to fall off. She stated the rod was not stable and when people grabbed the rod, the rod fell . During a concurrent observation and interview on 10/26/16, at 11:25 a.m., in the housekeeping supervisor's office, Housekeeping Supervisor Q showed a yellow rod with a yellow sign CLOSED FOR CLEANING hanging to the rod. Housekeeping Supervisor Q stated this was the rod with the sign Housekeeping Staff P used when she cleaned the restroom where Resident 1 fell . Housekeeping Supervisor Q stated the housekeeper put the rod across the doorway to indicate the room was being cleaned. Housekeeping Supervisor Q stated the housekeeper should tell the nurse when the rod was placed. Housekeeping Supervisor Q stated the rod was light metal and was not strong. Housekeeping Supervisor Q stated the facility had been using the rod for about six to seven months, but they did not have a policy and procedure regarding the use of the rod. Upon request for the manufacturer's guidelines for the rod, Housekeeping Supervisor Q provided a page documentation titled FACILITY MAINTENANCE, undated, under A. Site Safety Hanging Sign, which did not indicate how to use the rod and sign safely. The CT (computerized tomography, combines of X-ray images using computer process to create images) examination result dated 8/28/16, and the history and physical report from the acute care hospital dated 8/28/16, indicated Resident 1 sustained a left humeral neck fracture and was admitted to the hospital for treatment. 2. Resident 2's admission record indicated Resident 2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's MDS assessment dated [DATE] indicated Resident 2 was not able to complete the brief interview for mental status (BIMS). The MDS assessment indicated staff interview for mental status was conducted and indicated Resident 2's cognitive skills for daily decision making was moderately impaired - decisions poor; cues/supervision required. Resident 2's fall risk evaluation dated 8/12/16 indicated Resident 2 was at high risk for fall due to multiple problems including mental status, history of falls, ambulatory and elimination status, and gait/balance problems. The care plan for fall risk prevention and management initiated on 8/12/16 with approach started date 8/11/16 indicated approaches including Bed in low position, pad alarm (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) in bed . The care plan did not specify how the facility would provide supervision to prevent the resident from falling. First Fall: The nurse's note dated 8/12/16 at 12 a.m., revealed Resident 2 had an unwitnessed fall in the resident's room. Resident 2 sustained a 3 cm X 3 cm skin tear with bruising at left elbow. The care plan for the actual fall on 8/12/16, indicated a goal No serious injury from fall (for 7 days). The approaches included observing and monitoring for 72 hours, mobility alarm, pads at bedside, and visual monitor just for one shift. The IDT (Interdisciplinary Team) Conference Record, dated 8/12/16, regarding Resident 2's fall on 8/12/16 at midnight, did not indicate new approaches to the fall risk care plan to prevent further falls. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Second Fall: The nurse's note dated 8/29/16, at 7 a.m., indicated nursing staff from the last two work shifts reported Resident 2 had a fall at 7:15 a.m., on 8/28/16. However, there were no documentation of nurses' notes on 8/28/16 regarding the fall. The IDT Conference Record, dated 8/30/16, indicated Resident 2 had a fall with no injury on 8/28/16. The IDT note indicated to resume Risperdal (an antipsychotic medication, which works by changing the effects of chemicals in the brain), which was discontinued, due to increased agitation, re-emergence of aggressive verbal outbursts, pressured speech, and etc. The care plan for the actual fall on 8/28/16 included to teach the new nurses on fall follow up process and continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Third Fall: The nurse's note dated 9/5/16, at 4:20 p.m., indicated Resident 2 fell out from the wheelchair when Resident 2 was watching TV in the TV room with other residents. The IDT Conference Record, dated 9/6/16, regarding Resident 2's fall on 9/5/16, indicated the Resident 2 had very poor safety awareness. The IDT determined to continue using the alarm with a goal no serious injury (with) fall. The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/5/16 was to continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fourth Fall: The nurse's note dated 9/10/16 with unknown time of the note indicated Am shift reports fall (with) no injury 10:30 Am . The nurse's note did not describe how Resident 2 fell . The IDT Conference Record, dated 9/12/16, indicated Resident 2 stood up and fell at the nurse's station. The IDT note indicated Resident 2 to continue having poor safety awareness. The IDT note indicated Comfort is goal and (with) regard to falls, minimizing serious injury is goal . The IDT note indicated Will continue use of alarm, encourage wheelchair . The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/10/16 was to continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fifth Fall: The nurse's note dated 9/14/16, at 7:55 p.m., revealed Resident 2 had an unwitnessed fall and sustained a skin tear at left elbow and injury in Resident 2's back of the head that required Resident 2 to be sent to an emergency room for evaluation. The IDT Conference Record, dated 9/15/16, indicated on 9/14/16, at 7:55 p.m., Resident 2 was found on the floor next to the bed. The IDT note indicated alarm presented but was not engaged. The IDT note indicated fall prevention plan included care alert posted in Resident 2's room. The IDT note did not specify how the facility would provide supervision to prevent Resident 2 from further falls. The Care Alert dated 9/15/16 posted in Resident 2's room indicated (Resident 2) is a high fall risk with a recent fall requiring a trip to the ER. Please make sure (Resident 2) has his loud alarm attached at all times! Check frequently as he is able to inadvertently remove the alarm . The Care Alert did not specify how frequently to check the alarm or the resident. During an interview on 11/3/16, at 2:35 p.m., regarding Check frequently for the alarm indicated in the Care Alert, the DON (director of nursing) stated she expected the staff checked the alarm when staff made rounds every two hours; the Hall Monitor (an employee) walked back and forth in the hall and when walked to Resident 2's room, the Hall Monitor could look inside the room from the hallway to see if the alarm was intact. When asked if the Hall Monitors were trained on how to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff if anything was out of the ordinary. The DON stated a Hall Monitor was a staff, but was not a care giver. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. The IDT Conference Record, dated 9/16/16, for safety review related to the fall on 9/14/16 indicated to evaluation Resident 2's room to reconfigured room to have bed at a slight angle decreasing the likelihood of striking head during a fall. Mats at both side of bed. The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. During a concurrent observation and interview on 10/25/16, at 10 a.m., Resident 2 was in bed and awake. One floor mat was placed on Resident 2's right side and one mat was up leaning against the wall below the window. When asked about his fall on 9/14/16, Resident 2 stated he did not remember the fall. During an interview on 10/25/16, at 3 p.m., regarding Resident 2's fall on 9/14/16 at 7:55 p.m., Licensed Staff C stated a Hall Monitor found Resident 2 on the floor. Licensed Staff C stated when she arrived at the scene, Resident 2 was laying on the floor mat with the head against the wall on the left side of the bed. Licensed Staff C stated she did not hear the alarm. She stated Resident 2 took off the alarm all the time. When asked about fall prevention, Licensed Staff C stated when Resident 2 was not in bed, sit Resident 2 at the nurse station. When Resident 2 was in bed, staff would listen to the alarm or Resident 2 yelling. Licensed Staff C stated they did not have a set time to check on Resident 2 because Resident 2 was not on an every 15 minutes check. During a concurrent observation and interview on 10/25/16, at 3:05 p.m., in Resident 2's room, one floor mat was on the right side of the bed and one mat was up against the wall. Licensed Staff C stated the floor mat should be on the left side because Resident 2 got out of the bed from his left side. During a concurrent interview and record review of Resident 2's care plans for fall and fall risk on 10/25/16, at 3:13 p.m., Licensed Staff C stated a care plan described what best care provided to the resident and communication with the care team. Licensed Staff C stated all nurses should review the care plans. When asked if the care plans specify providing supervision to Resident 2, Licensed Staff C reviewed the care plans initiated on 8/12/16 and 8/15/16 and stated the supervision was to observe and monitor Resident 2 for 72 hours. When asked what happened after 72 hours, Licensed Staff C stated none and the care plans did not specify supervision. During an interview on 10/25/16, at 4:40 p.m., Unlicensed Staff O stated when Resident 2 was in bed, she would check Resident 2 approximately every five minutes. When asked how she knew about the five minutes, Unlicensed Staff O stated from the text book. When asked how she knew the care needed for a resident, Unlicensed Staff O stated she would ask other staff or look at the care plans, which would tell her about the resident. When reviewed Resident 2's care plan, which indicated Resident 2 had four falls from 8/12/16 to 9/10/16, Unlicensed Staff O stated she did not know Resident 2 had so many falls like constantly falling. Unlicensed Staff O stated by looking at the falls indicated in the care plan, Resident 2 should not be left alone. Unlicensed Staff O stated the care plan did not specify the frequency of checking Resident 2. During a concurrent interview and record review on 10/26/16, at 2:50 p.m., the DON stated they tried different interventions including alarm, pad, and visual monitor for one shift only. The DON reviewed the fall and fall risk care plans and stated the care plans did not specify providing supervision to Resident 2 to prevent falls. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated he did not witness Resident 2's fall. Unlicensed Staff L stated he was not assigned to Resident 2, but he still helped check on Resident 2 and the alarm function at least every hour. Unlicensed Staff L stated when Resident 2 had repeated falls (4 - 5 times in a month), staff should be with Resident 2 all the times. Unlicensed Staff L stated they did not have enough CNA (certified nursing assistant) in the hall where Resident 2 resided. Unlicensed Staff L stated because of short staffing, they were not able to check residents as frequently as they could to prevent residents from falling. The Emergency Department Report dated 9/14/16, indicated Resident 2 sustained a wound 2 cm in length in the head and the wound was repaired with staples. The emergency department report indicated Resident 2 did not receive any imaging or extensive workup because Resident 2 was on hospice with comfort measures only. Resident 2 had three more falls after 9/14/16 as follows: a. The IDT note dated 10/26/16 indicated Resident 2 fell from a wheelchair to the floor in the TV room; b. The IDT note dated 11/7/16 indicated Resident 2 fell on [DATE] witnessed by a Hall Monitor; and c. The IDT note dated 11/28/16 indicated Resident 2 fell on [DATE], slid out of a wheelchair. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to us (certified nursing assistants). Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and hoping us would know what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote keep bed low, keep bed at an angle. During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent resident from injuries from falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. 3. During a concurrent observation and interview on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 stated she fell approximately at 3 a.m. four days ago from her bed to the floor. Resident 3 stated she climbed back to bed because no staff were around to assist her. Resident 3 stated she told a nurse about the fall at approximately 5:30 a.m., the day she fell . She stated the nurse just told her to go back to bed. Resident 3's MDS dated [DATE], indicated Resident 3's BIMS (brief interview for mental status) score was 13, which indicated Resident 3 was cognitively intact. Resident 3's Fall Risk Evaluation dated 8/4/16, indicated Resident 3 was at high risk for fall due to multiple problems including history of falls, ambulatory and elimination status, and gait/balance problem. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately 7 hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head to toe assessment. Licensed Staff B stated he documented the assessment. The nurse's note dated 10/20/16 at 10:15 a.m., indicated (Resident 3) (up out of bed) in (wheelchair). Denies any residual pain (secondary to fall). (Resident 3) in wheelchair, going up and down hallway (without) difficulty. Will continue to monitor. The note did not indicate a head to toe assessment. There was no documentation of physician notification. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated no specific document for the head to toe assessment. Licensed Staff B stated he documented the head to toe assessment in the nurse's note. When asked about the nurse's note, Licensed Staff B stated the nurse's note dated 10/20/16 at 10:15 a.m. was written by him. When asked for the fall protocol, Licensed Staff B stated they filled out the information forms which the night shift nurse should have done and turned it in to the DON. During a concurrent interview and record review on 10/26/16, at 8:35 a.m., the DON reviewed Licensed Staff B's nurse note dated 10/20/16 at 10:15 a.m., and stated it was not well documented and did not show the head to toe assessment. The DON stated the post fall protocol included completing the incident report, post fall assessment, post fall huddle, and neurological check flow sheet for unwitnessed fall. The DON stated staff had not notified her of Resident 3's fall. The DON stated staff did not complete the post fall protocol procedures for Resident 3's fall on 10/20/16. Review of the Fall Management Program Policy No. FA-01 documented following each fall, the licensed nurse will perform a post fall assessment, the licensed nurse will notify the Director of Nursing and / or Administrator and the Licensed Nurse will notify the resident's attending physician and responsible party of the fall incident. 4. Resident 5's admission record indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 5's fall risk evaluation dated 10/10/16, 11/24/16, and 12/6/16, indicated Resident 5 was at high risk for falls due to multiple problems including mental status (disoriented or intermittent confusion), history of falls, gait and balance problems, and medications. Resident 5 was on Risperdal (an antipsychotic medication which works by changing the effects of the chemicals to the brain. Common side effects includes dizziness, drowsiness, and tired feeling) 0.5 mg by mouth every day and haldol (an antipsychotic medication which may work by blocking some chemical effects in the brain. Major common side effects include loss of balance control, muscle spasms, and shuffling walk) 70 mg intramuscularly every month for dementia with psychosis. Resident 5's MDS dated [DATE] and 9/16/16, indicated Resident 5's cognition was moderately to severely impaired. First fall: The nurse's note dated 5/24/16 at 11 p.m. and the IDT note dated 5/25/16 indicated Resident 5 had an unwitnessed fall on 5/24/16 at 7:45 p.m. in the bathroom. Resident 5 was found in the bathroom sitting on the floor wet with urine. Resident 5 complained of left shoulder pain and treated with Norco (pain medication). The IDT note indicated Resident 5 received antipsychotic (Haldol injection) prior to the fall. The IDT note indicated the charge nurse's plan to increase monitoring for a few hours after the monthly Haldol injection and recommended non-slip shoes for Resident 5. Resident 5's care plan for fall risk prevention and management initiated on 3/11/16 and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position . The care plan indicated an intervention started on 11/7/16: Continue B-wing for increase supervision. The fall risk care plan did not reflect nor specifiy how to increase monitoring after the monthly Haldol injection. Second fall: The IDT note dated 10/3/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 10/3/16 at 1:15 a.m. The IDT note indicated referring for physical and occupational therapy and continued to encourage wearing the hipster (Padded pants that cover the hip to cushion a fall to prevent injuries of the hip) when ambulating. The IDT note did not specify providing supervision to Resident 5. Third fall: The nurse's note dated 10/9/16 at 2:30 a.m. and the IDT note dated 10/10/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 10/9/16 with unknown time of fall. The IDT note indicated referring for physical and occupational therapy and continued to encourage wearing the hipster when ambulating. The IDT note did not specify providing supervision to Resident 5. Fourth fall: The IDT note dated 11/24/16 indicated Resident 5 had a fall on 11/23/16 at 12 p.m. The IDT note indicated Resident 5 was walking in the hallway but still asleep. The Hall Monitor headed toward Resident 5 but before she got to him he fell on to his (left) hip and elbow. The IDT note indicated will make a referral to PT/OT (physical therapy/occupational therapy) . The IDT note did not specify providing supervision to Resident 5. Fifth fall: The nurse's note dated 11/23/16 and the IDT note dated 11/24/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 11/23/16 at 9:35 p.m. Resident 5 sustained a small skin tear on the top ridge of the nose. The IDT note indicated observe and monitor for 72 hours and on 15 (minutes check). Sixth Fall: The nurse's note dated 12/6/16 at 3 a.m. and the IDT note dated 12/6/16, indicated Resident 5 was found on the floor in the room. The IDT note indicated every 15 minutes check was initiated after the first hour of neuro checks. Resident 5's care plan for fall risk prevention and management initiated on 3/11/16 and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including Call light within reach, Remind resident to use call light - unable to use call light due to dementia, bed in low position . The care plan indicated an intervention started on 11/7/16: Continue B-wing for increase supervision. The fall risk care plan did not reflect the 15 minutes check and how/who to check the resident. During a concurrent interview and record review on 12/8/16, at 8:35 a.m., regarding supervision for Resident 5, Unlicensed Staff CC stated she checked on Resident 5 whenever she saw the resident. Unlicensed Staff CC stated every staff in the hall was responsible to check on Resident 5. Unlicensed Staff CC stated she also reviewed the care plan for resident care. When she reviewed Resident 5's fall risk care plan and asked her what did .increase supervision . mean to her, Unlicensed Staff CC stated To me, may need one-to-one . When asked her if Resident 5 was on one-to-one supervision, Unlicensed Staff CC stated she needed to check the documentation and found Resident 5 was on every 15 minutes check. Unlicensed Staff CC stated all staff were responsible for monitoring and documentation. During a concurrent interview and record review on 12/8/16, at 8:55 a.m., Licensed Staff NN reviewed the fall risk care plan and stated .increase supervision . meant every 15 minutes check. Licensed Staff NN stated the DON or ADON was responsible to review and update the care plans. Licensed Staff NN stated the care plan was used for following up on residents and making goals for resident care. During an interview on 12/9/16, at 7:20 a.m., reviewed Resident 5's fall risk care plan with the DON, the DON stated the care plan did not specify supervision for Resident 5 and she understood that staff could have interpreted differently for .increase supervision. 5. Resident 4's MDS, dated [DATE] documented Resident 4 was admitted [DATE]. Resident 4's [DIAGNOSES REDACTED]. Resident 4's MDS, dated [DATE], revealed the BIMS (brief interview for mental status) score was 3, which indicated Resident 4 was severely cognitively impaired. The MDS assessment indicated Resident 4 required supervision with one person physical assist with transfers and walking in his room. The MDS assessment indicated Resident 4 required one person physical assist for walking in the corridor and toilet use. The care plan for Resident 4 for fall risk prevention and management, initiated on 10/04/2016, indicated fall risk prevention and management approaches included, Orient resident to environment each time changes are made, remove hazards from environment, maintain bed in low position and continue alarms in place on bed . The care plan did not specify providing supervision to prevent Resident 4 from falling. The short term care plan (written care plan done for the actual fall) initiated on 10/14/2016 indicated fall risk prevention and management approaches including hipsters (padded type pant

Based on observation, interview, and record review, the facility failed to provide adequate nursing staff to provide quality care to their residents. This failure had resulted in resident care needs not being met and contributed to resident falls and injuries due to inadequate staff supervision of residents. This failure also had the potential to prevent residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Cross reference F 241 and F 323 Findings: During a concurrent observation and interview on 10/25/16, at 8:05 a.m., Resident 17 was in bed and alert. Resident 17 stated sometimes she had to wait for a long time, up to approximately 30 minutes, for staff answering her call light and assisting her. Resident 17 stated this long waiting time happened anytime of the day. Resident 17 stated she felt really bad when she needed to go to the bathroom. When asked what would happen if she needed to go to the bathroom, Resident 17 stated just have to wait. During a concurrent observation and interview on 12/5/16, at 3:05 p.m., Resident 17 was sitting in a wheelchair at bedside. Resident 17 stated she usually had to wait for more than 30 minutes for staff answering her call light and assisting her. Resident 17 stated she felt bad when she had to urinate on herself and stayed wet for a long time. Resident 17 also stated she told the CNAs (certified nursing assistant) every day that she (Resident 17) wanted to be out of the bed by 9:30 a.m. She stated the CNAs said they would help her as soon as they could, but they were always late until 10 a.m. or after 10 a.m. Resident 17 stated they did not have enough CNAs. Resident 17's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/19/16, revealed Resident 17's BIMS (brief interview for mental status) score was 14, which indicated Resident 17 was cognitively intact. During a concurrent observation and interview on 12/5/16, at 2:17 p.m., Resident 18 was in bed and awake. Resident 18 stated sometimes he had to wait for 5 to 10 minutes for the staff to answer the call light. When asked how the 5 to 10 minutes wait time affected Resident 18, Resident 18 stated depends what I needed. Resident 18 stated they did not have enough CNA to help the residents. Resident 17 and 18 were deemed by the facility to be interviewable. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated they did not have enough CNA. Unlicensed Staff L stated the facility reduced the number of CNAs from three to two CNAs on B wing (a memory unit for residents who have memory problems). Unlicensed Staff L stated it was very stressful because Unlicensed Staff L could not do things for the residents as he wanted to do (i.e. brush their teeth, wash their hands, giving a bed bath, and other things) because of short staffing. Unlicensed Staff L stated they were not able to check residents as frequently as they would to prevent residents from falling. Unlicensed Staff L stated two CNAs were not enough and they needed three CNAs. Unlicensed Staff L stated the Hall Monitors (staff) could not provide any resident care; they just watched the residents and walked with the residents. During an interview on 10/26/16, at 2:50 p.m., regarding staffing for fall prevention and management, the DON stated they increased Hall Monitor to B wing. During an interview on 11/3/16, at 2:35 p.m., when asked if the Hall Monitors were trained to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff for anything was out of ordinary. The DON stated a Hall Monitor was a facility staff member but was not a care giver. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. During an interview on 11/10/16, at 10:40 a.m., the Administrator stated B wing was the memory unit (residents had memory problems). The Administrator stated originally they had a total of three Hall Monitors covering from 6 a.m. to 8:30 p.m, but not at one time. The Administrator stated the first Hall Monitor worked from 6 a.m. to 2:30 p.m.; the second Hall Monitor worked from 9 a.m. to 5:30 p.m.; and the third Hall Monitor worked from 12 p.m. to 8:30 p.m. The Administrator stated about a week ago they increased the Hall Monitor to a total of four to cover 24 hours. She stated now the third Hall Monitor worked from 2:15 p.m. to 10:45 p.m., and the fourth Hall Monitor worked from 10:45 p.m. to 7:15 a.m. the next day. During an interview on 12/6/16, at 5:20 p.m., in B wing. Unlicensed Staff K stated she usually worked in C-Wing where residents were more stable. Unlicensed Staff K stated she worked PM (afternoon/evening) shift from 2:45 p.m. to 11:15 p.m. and cared for 10 to 12 patients each work shift. Unlicensed Staff K stated she felt they had enough staffing and she could stay with and help the residents as long as she needed. When asked what tasks included in one work shift for 10 to 12 residents, Unlicensed Staff K itemized the routine tasks with time required as following: (the numbers in parentheses at the end of each task were used for calculation of the minimum minutes required for one work shift) 1. Changing briefs (cloth protectors): 30 min (minutes) per resident for 3-4 residents every 1.5-2 hours equals to 90 - 120 min (90) 2. water round: 15 - 20 min (15) 3. Dinner set up: 5 min per resident for 4 - 5 residents equaled to 20 - 25 min (20) 4. feeding resident: 15 min for set up and 30 min for feeding for one resident equaled to 45 min (45) 5. changing and emptying urinals: 10 min per resident for 2 - 3 residents equaled to 20 - 30 min (20) 6. emptying urinary catheter bags: 10 min per resident for 2 residents equaled to 20 min (20) 7. routine changing/making beds: 5 min per resident for 2 - 3 residents equaled to 10 - 15 min (10) 8. changing wet beds: 5 min per resident for 2 residents equaled to 10 min (10) 9. taking vital signs (blood pressure, temperature, etc.): 5 min per resident for 3 - 4 residents equals to 15 - 20 min (15) 10. recording intake and output: 5 min (5) 11. documentation of activities of living flow sheet: 20 min (20) 12. shift change report: 15 min each for 2 reports equals to 30 min (30) 13. breaks: 10 min each for 2 breaks equals to 20 min (20) 14. meal break: 30 min (30) 15. shower for residents: 20 - 30 min per resident for 2 - 3 residents equaled to 40-90 min (40) 16. cleaning resident after meals: 20 min for total of 4 residents (20) 17. assisted resident to bed: 10 min per resident for 4 - 5 residents equaled to 40-50 min (40) 18. oral care: 5 - 10 min per resident for 2 residents equals to 10 - 20 min (10) 19. toileting: 5 - 10 min per resident for 6 residents equals to 30 - 60 min (30) 20. nail care: 10 min per resident for 3 resident equals to 30 min (30) 21. peri care: 5 min per resident for 4 residents 4 times per shift equals to 80 min (80) 22. grooming/shaving: 10 min for 4 residents equals to 40 min (40) 23. dressing: 10 min per resident for 6 residents equals to 60 min (60) 24. snack: 10 min (10) 25. hand washing: before and after resident care: uncalculated 26. answering call light: uncalculated The calculation revealed: One CNA had a total of 510 minutes per shift from 2:45 p.m. to 11:15 p.m including breaks. A minimum of 710 minutes were required to complete the routine tasks in one work shift including breaks. This 710 minutes did not include the time for hand washing, answering call lights, reporting change of condition, and other unexpected circumstances. There were 200 minutes short for the staff to complete the routine tasks. During an interview on 12/7/16, at 9:44 a.m., Unlicensed Staff PP, who worked in A wing (one of the resident care unit), stated she worked both AM (morning) and PM shift. Unlicensed Staff PP stated they usually had three CNAs in morning shift and each CNA had eight residents; they had two CNAs PM shift and each CNA had 13 residents. Unlicensed Staff PP stated they needed three CNAs for PM shift. Unlicensed Staff PP stated they had not been had enough CNA since she returned to work on June 2016. Unlicensed Staff PP stated they needed adequate staffing to feed residents properly and ensure safety and prevent falls. When asked about the tasks and time required for caring the residents for one work shift, Unlicensed Staff PP provided the time for the routine tasks. The calculation of the time required for completion of the routine tasks revealed a minimum of 754 minutes for AM shift and 1052 minutes for PM shift including all tasks and breaks. The CNAs shifts (AM, PM, & Nights)consisted of a total of 510 minutes, which included the breaks. There were a minimum of 244 minutes short for AM shift and 542 minutes short for PM shift. This calculation did not include time for hand washing, answering call lights, reporting change of condition, other unexpected situations, and toileting as she stated toileting required 6 - 10 minutes per one resident and assisted different residents through out 8 hours. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB, who worked in B wing, stated they never staffed sufficiently. Unlicensed Staff BB stated they had two CNAs and she had 12 residents. Unlicensed Staff BB stated they needed at least three CNAs. During an interview on 12/7/16, at 4:45 p.m., Staffing Coordinator DD stated she did the schedules for all CNAs and RNAs (restorative nursing assistant). Staffing Coordinator DD stated she scheduled staff according to the resident census and number of falls. Staffing Coordinator DD stated for full census, she usually scheduled three CNAs for AM and PM shifts in one unit (facility had three units: A wing, B wing, C wing) and each CNA had 12 residents; two CNAs for night shift each unit and each CNA had 22 residents. Staffing Coordinator DD stated if there were a lot of falls (on 12/8/16 at 10:35 a.m., she stated to her, one fall was a lot) in a unit, she would schedule more CNAs or Hall Monitors to that unit. Staffing Coordinator DD stated Hall Monitors walked back and forth in the hallway. If the Hall Monitor saw a resident getting out of bed, the Hall Monitor reported to the CNA or the nurse. The Hall Monitors were not certified for resident care. Staffing Coordinator DD stated the Hall Monitor might not be able to prevent the fall because when the CNA or nurse arrived to the resident's room, the resident might have already fallen. Staffing Coordinator DD stated the staffing one CNA to 12 to 22 residents was doable because the resident census and care fluctuated. She stated she was also a CNA. When asked about the routine tasks required for one CNA in one work shift, Staffing Coordinator DD provided time required for each routine task. She stated AM and PM shifts were about the same. The calculation of the time revealed a minimum of 850 minutes for one CNA to complete the routine tasks in a given AM or PM shift; each CNA had a total of 510 minutes per shift, which was 340 minutes short. Staffing Coordinator DD did not provide details of all tasks for night shift but stated the tasks for night shift were more on repositioning, toileting, catheter care, and peri care (cleaning the urinary, vaginal, and rectal areas). Upon requested for the days and shifts when Staff Coordinator DD scheduled more CNAs than a routine schedule because of a lot of falls, twice on 12/8/16 at 10:35 am., and 6:40 p.m., Staff Coordinator DD did not provide the days and shifts. During an interview on 10/26/2016, at 8:45 a.m., Licensed Staff E stated she doesn't use the care plan/update as it is difficult to use and she was not sure how to use it. Licensed Staff E stated, sometimes there's a 1:1(person who cares for just one resident), but not often. Licensed Staff E stated the staff at the facility kept an eye on residents in the hallway. She stated, This is how we manage. During an interview on 10/26/2016, at 11:05 a.m., Licensed Staff F stated 1:1 care doesn't occur too often-because of census and staffing issues, not enough staff available and low census. During an interview on 10/26/2016, at 12:01 p.m., Unlicensed Staff M stated, Especially on PMs there is not enough staff to watch everyone so a 1:1 for a resident really helps. During an interview on 12/8/16, at 9:40 a.m., Unlicensed Staff QQ, who worked in Wing A (one of the resident care units), stated she worked AM (morning) shift. Unlicensed Staff QQ stated they usually had two CNAs in morning shift and each CNA had 14 residents, and she had 14 residents today. Unlicensed Staff QQ stated they needed more staff for each shift to provide good care for the residents. Unlicensed Staff QQ also stated they needed adequate staffing to feed, shower, and bath residents properly and ensure safety and prevent falls. When asked about the tasks and time required for caring the residents for one work shift, Unlicensed Staff QQ stated it was a lot of work and it was very hard to complete all the work adequately. When asked, how long each of the routine daily tasks she performed took her to complete? She stated the following: 1. Shower per resident: 25/30 minutes times (2/ 3) residents equaled to 50-90 (50). 2. Bathing bed path per resident: 25/30 minutes X (2/3) residents equaled to 50-90 (50). 3. Oral care: 10minutes X (14) residents equaled to (140) minutes. 4. Making a bed when resident is out: 10 minutes X (10) residents (100) minutes. 5. Making a bed when resident is in bed: 20 minutes X (2) residents equaled to (40) minutes. 6. Meal tray setup/document %: 10 minutes X (4/5) resident equaled to 40-50 (40) minutes. 7. Hand feeding: 40 minutes X (2/3) residents equaled to 80-120 (80) minutes. 8. Toileting residents: 10 minutes X (5/6) residents equaled to 50-60 (50) minutes. 9. Nail care: 15 minutes x (3/4) residents equaled to 45-60 (45) minutes. 10. Peri-care: 15 minutes X (4/5/) residents equaled to 80-100 (60) minutes. 11. Grooming/shaving: 15 minutes X (3/4) residents equaled to 45-60 (45) minutes. 12. Dressing residents: 20/30 minutes X (4) residents equaled 80-120 (80) minutes. 13. Catheters (empty/measure): 10 minutes X (3) residents equaled to (30) minutes. 14. Vital signs: 10 minutes X (14) residents equaled to (140) Minutes. 15. Charting each resident at the end of the shift: 5 minutes X (14) residents equaled to (70) minutes. 16. Serving supplements: 3 minutes X (10) residents equaled (30) minutes. 17. Massage to bony prominence: 10 minutes X (4/5) residents equaled to 40-50 (40) minutes. 18. Reposition each resident: 10 minutes X (7) residents equaled to (70) minutes. 19. Handwashing prior to each resident: 2 minutes X (14) residents equaled to (28) minutes. 20. Reporting change in condition: 10 minutes X (3) residents equaled to (30) minutes. 21. Answering call lights: 5 minutes X (14) residents equaled to (70) minutes. 22. Changing wet beds: 10 minutes X (3) residents equaled to (30) minutes. 23. Breaks: 10 minutes X 2 equaled to (20) minutes. 24. Meal break: 30 minutes X (1) equaled (30) minutes. 25. Assisted residents in bed: 5 minutes X (5) residents equaled to (25) minutes. 26. Recording in and output: 10 minutes (10) minutes. 27. Recording of activities of daily living: 20 minutes (20) minutes. 28. Water rounds not included. The calculation indicated a minimum of 1593 minutes were required for one CNA to complete all the tasks including breaks for an AM shift. The 510 minutes allotted for the morning Shift starting from 7:15 a.m. to 2:45 p.m. was not enough; it required more than 3 times of that (1593) minutes to provide an adequate care for the residents. During an interview on 12/8/16, at 2:20 p.m., Unlicensed Staff RR stated she worked on C Wing for a long time, mostly on AM shift. Unlicensed Staff RR stated working on C Wing was a lot of work, but she got used to it. Unlicensed Staff RR had 13 Residents today. During an interview on 12/8/16, 2:45 p.m., Unlicensed Staff SS stated she worked morning shifts on B wing for a long time and she always had 12 residents except this week. Unlicensed Staff SS stated this week she had 8 residents because the State was here. Unlicensed Staff SS stated they need to have more staffing on the B Wing because there were a lot of confused residents who required more help and care. Unlicensed Staff SS added even though there were hall monitors on this floor they could not do a lot of things the CNAs could do such as caring, cleaning, bathing, assisting residents to bed, and making beds. During an interview on 12/7/16, at 8:15 a.m., a family member of Resident 6, who was there everyday, stated he was not complaining, but he thought the facility needed more staffing for the B wing because of the large number of confused residents in the wing. During an interview on 12/7/16 at 5:50 p.m., when Unlicensed Staff MM was asked how long it took her to do her CNA duties on the PM Shift for the 13 residents she was assigned to on C wing, Unlicensed Staff MM stated: 1. Shower depended on if the resident was a total lift or just needed supervisions: Total lift: 25-30 min, Bed bath: 20-30 min, wheel chair/stand: 15-20 min, or supervised: 20 min. Unlicensed Staff MM had two residents whose baths were scheduled: 40 mins 2. Oral care: 5-15 min depending if residents were mobile, had dentures, or bedridden: 2 bedridden (30 min) plus if 11 residents were mobile (55 min): 85 min 3. Meal tray set-up: 20 min 4. Feeder: 20-30 min. Unlicensed Staff MM had one feeder: 20 min 5. Toilet resident at least 3 times: 10 min. Unlicensed Staff MM had one resident that used the toilet: 30 min 6. 12 residents were incontinent: checked each resident 3 times per shift; if residents were dry it took 15 min and if half the residents are wet it took 40 min. 1 round all dry: 15 min and, 2 rounds whereby half the residents were wet: 40 x 2= 80 min for a total of 95 min 7. Dress for bed: 12 min per resident x 13 residents = 156 min 8. Empty a Foley catheter: 2 min (Unlicensed Staff MM had 1) 9. Vital Signs: on average 3/4 residents took 15-20 min: 15 min 10. Passing Snack/Supplements: 20 min 11. Changing residents' water cup for the entire hall took 30-40 min: 30 min 12. Charting on 13 residents took 30-40 min: 30 min 13 Unlicensed Staff MM breaks include a 30 min meal break and two 10 min breaks: 50 min The calculation revealed if Unlicensed Staff MM was to perform all the above PM tasks on her own during a total of 510 minutes per shift from 2:45 p.m. to 11:15 p.m. including breaks for 13 residents, it would have taken her a minimum of 593 min. This did not account for hand washing in between each resident, reporting change of condition, reposition residents every two hours (Unlicensed Staff MM had 2 bedridden residents), answering call lights, and other unexpected circumstances. The facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Postings, revised 1/1/12, indicated The Facility will employ Nursing Staff that will be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care.

Based on interview and record review, the facility's quality assessment and assurance committee (QAA) failed to: 1. Develop formal corrective action plans or implement the action plans to prevent falls, (Cross Reference F 323) 2. Identify staffing issues and ensure sufficient staffing to provide quality resident care, (Cross Reference F 241 and F 353) 3. Communicate QAA minutes to the staff. These failures prevented the QAA committee from implementing and evaluating an action plan to correct quality deficiencies and therefore was not able to determine effectiveness of changes to be implemented. Findings: 1. During a concurrent interview and record review regarding QAA on 10/26/16, at 2:50 p.m., regarding resident falls, the DON (director of nursing) stated the QAA committee collected data including number of falls each month, but did not develop formal action plans to prevent falls. The DON stated direct care staff including CNAs (certified nursing assistant) and nurses were not included in the QAA process and were not invited to the QAA meeting. During an interview on 11/3/16, at 2:35 p.m., when asked if the Hall Monitors were trained to prevent falls, the DON stated the Hall Monitors were trained to look if alarms (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) were intact or pads were on the floor to prevent injuries from a fall and to report to the nursing staff if anything was out of the ordinary. The DON stated Hall Monitors were facility staff but were not care givers. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. During an interview on 11/10/16, at 10:40 a.m., the Administrator stated B wing was the memory unit (residents had memory problems). The Administrator stated originally they had a total of three Hall Monitors covered from 6 a.m. to 8:30 p.m. The Administrator stated the first Hall Monitor worked from 6 a.m. to 2:30 p.m.; the second Hall Monitor worked from 9 a.m. to 5:30 p.m.; and the third Hall Monitor worked from 12 p.m. to 8:30 p.m. The Administrator stated about a week ago they increased the Hall Monitor to a total of four to cover 24 hours. She stated now the third Hall Monitor worked from 2:15 p.m. to 10:45 p.m., and the fourth Hall Monitor worked from 10:45 p.m. to 7:15 a.m. the next day. During a concurrent interview and record review on 12/8/16, at 3 p.m., regarding QAA, the Administrator stated the QAA developed an action plan for fall prevention and management and the plan was started at the end of October, 2016. The Administrator provided and reviewed the action plan. The Administrator stated they tried to find the root cause of each fall but did not find the root cause of high incidence of falls or repeated falls in the facility as a whole. The Administrator stated some of the approaches of the action plan had not been implemented. When asked the reasons for the approaches not being implemented, the Administrator did not provide an answer. Regarding the effectiveness of the action plan when the facility had 17 falls on October 2016 and 20 falls on November 2016 (numbers of falls were based on incident logs), the Administrator stated they had not evaluated the action plan because the next QAA meeting had not occurred but will be coming up soon. The action plan did not indicate a measurable goal with a target date. 2. The Administrator stated their target for staffing was to have six to seven CNAs (certified nursing assistant) in the whole building for AM (morning) and PM (afternoon/evening) shifts so each CNA took care of 9 - 11 residents in an eight-hour shift. When asked if a CNA had sufficient time to take care of 9 - 11 residents, the Administrator stated yes because the activity staff, scheduler, and RNA (restorative nursing assistant) were also CNAs and helped for dining. The Administrator further stated one CNA had more than 15 residents in night shift. The Administrator stated the facility did not have staffing problems. 3. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to us (certified nursing assistants). Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and hoping us to know what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote keep bed low, keep bed at an angle. During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent resident from injuries from falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. The facility's policy and procedure titled Quality Assessment and Assurance Committee - Composition & Duties, date revised 1/1/12, indicated under Purpose To promote the quality of resident care by overseeing, identifying, tracking, addressing and follow-up on all quality issues. The policy and procedure did not specify how to communicate the QAA minutes to other staff who did not attend the QAA meetings. During an interview on 10/26/2016, at 8:45 a.m., Licensed Staff E stated she was unsure of what QA/PI( Quality Assurance/Performance Improvement) did and what the subject was currently. She stated there were meetings where they talked about the patients and falls. During an interview on 10/26/2016, at 11:05 a.m., Licensed Staff F stated she knew that the DON (director of nursing) and the DSD (director of staff development) were involved. She stated she is not sure what they were working on at this time. She stated as a travel nurse ( a nurse who travels to work in a temporary nursing position) she did not know much about the PI (performance improvement) process at the facility. During an interview on 10/26/2016, at 12:01 p.m., Unlicensed Staff M stated she did not know what that was.

Based on observation, interview, and record review, the facility failed to: 1. Adequately assess and treat Resident 3's pain and care plan to taper [MEDICATION NAME] (a medication for pain). These failures resulted in harm to Resident 3 who cried and was in tears and had difficulties with moving around due to severe pain in her left leg, secondary to a bone condition and a recent fall. 2. Follow through with a treatment order of [MEDICATION NAME] (ear wax removal) for Resident 11. This failure caused Resident 11's left ear to be plugged up and loss of hearing. Findings: 1. Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 8/9/16 and 11/8/16, indicated Resident 3's BIMS (brief interview for mental status) score was 13 - 14, which indicated Resident 3 was cognitively intact. During a concurrent observation and interview that started on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 was sitting in her wheelchair tilted to her right side. Resident 3 stated she had to sit tilted to her right side because she was having pain 9/10 (pain scale 0-10, 0 indicates no pain and 10 indicates most severe pain) in her left hip since early morning. Resident 3 stated that it was difficult for her to move around and it made her irritable due to the pain. Resident 3 stated she already asked for pain medication but they said I am a drug addict and could not give me more medication. Resident 3 stated she fell from her bed to the floor at approximately 3 a.m. four days ago. Resident 3 stated she climbed back to bed because there were no staffs around to assist her. Resident 3 stated she told a nurse about the fall and pain at approximately 5:30 a.m. the day she fell . She stated the nurse just told her to go back to bed. Resident 3 stated she had arthritis pain 4-5/10 in her left hip down to the leg, but the pain in the left hip increased to 8-9/10 after the fall. Resident 3 stated she thought she hurt something from the fall. Resident 3 stated she told all of her nurses but nobody checked on her nor did they send her to the hospital. Resident 3 stated one of the nurses, Licensed Staff C, told her (Resident 3) she reported the fall because she wanted more pain medications. Resident 3 stated Licensed Staff C told Resident 3 that eventually all her medications would be taken away. Resident 3 stated she always had to wait for the pain medication for one to two hours after the scheduled time. Resident 3 stated that staff were mad at her and acted like she was a drug addict. When asked if she wished to have a staff member to check on her, Resident 3 started crying in tears and stated she was OK with the DON (director of nursing) or another one particular nurse but not the other nurses because they did not check on her and said she was a drug addict and that she was tired of it. During an interview on 10/25/16, at 11:45 a.m., Licensed Staff C stated last night Resident 3 asked for Narcotics (opioid pain relievers). Licensed Staff C stated she explained to Resident 3 that her pain medication was not due and explained to her that her narcotic medication needed to be tapered. Licensed Staff C stated Resident 3 mentioned about her left hip. Licensed Staff C stated she faxed a request for x-ray to the physician. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately 7 hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head to toe assessment and documented the assessment. Licensed Staff B stated no injuries noted related to the fall. Licensed Staff B stated Resident 3 usually complained of pain 8-9/10 in her left lower extremity. Licensed Staff B stated Resident 3 asked for Narcotic medications for pain no matter what. Licensed Staff B stated Resident 3 had history of drug seeking behaviors and asked for narcotic medications even though she was sleeping in her wheelchair. Once she opened her eyes, she would ask for Narcotic medication. Resident 3 had PRN (as needed) [MEDICATION NAME] order and it was now changed to regularly scheduled [MEDICATION NAME]. A nurse's note dated 10/20/16, at 10:15 a.m., indicated (Resident 3) (up out of bed) in (wheelchair). Denies any residual pain (secondary to fall). (Resident 3) in wheelchair, going up and down hallway (without) difficulty. Will continue to monitor. The note did not indicate a head to toe assessment. The nurse's note dated from 10/20/16 to 10/24/16, did not indicate a complete post fall assessment nor notified the physician of Resident 3's fall. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated no specific document was used for the head to toe assessment. Licensed Staff B stated he documented the head to toe assessment in the nurse's notes. When asked about the nurse's notes, Licensed Staff C stated the nurse's note dated 10/20/16 at 10:15 a.m. was written by him. When asked about the facility's fall protocol, Licensed Staff C stated staff would use a form which the night shift nurse should have done and should have turned in to the DON. During a concurrent interview and record review on 10/26/16, at 8:35 a.m., The DON reviewed Licensed Staff B's nurse note dated 10/20/16 at 10:15 a.m. and stated it was not well documented and did not show the head to toe assessment. The DON stated the post fall protocol included completing the incident report, post fall assessment, post fall huddle (staff meet together to discuss about the fall), and neurological check flow sheet for unwitnessed fall. The DON stated staff did not complete the post fall protocol procedures for Resident 3's fall on 10/20/16. During an interview on 11/8/16, at 9:10 a.m., the DON stated the facility's standard practice and her expectation was for the charge nurse to notify the physician on the same work shift the resident fell , either by fax or by calling the physician depending on the severity of injury. The physician's orders [REDACTED]. The care plan for pain initiated on 8/4/16, did not indicate Resident 3 was to have [MEDICATION NAME] tapered and did not indicate approaches specific for to taper the medication. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., when asked what care plan for tapering the [MEDICATION NAME] was for Resident 3, Licensed Staff B provided the MAR (medication administration record) with the [MEDICATION NAME] administration schedule. When asked again for care planning and what would he do when Resident 3 kept asking for [MEDICATION NAME], Licensed Staff B stated he would re-direct Resident 3 by telling her that physician ordered for her narcotics to be tapered and she had to wait for the next scheduled dose. Licensed Staff B stated he had not reviewed the chart if the chart contained any care plan for tapering the Narcotics. During an interview on 10/26/16, at 8:35 a.m., the DON stated she did not care plan the tapering Narcotics for Resident 3 and believed care plan was not in place. The DON reviewed Resident 3's chart and stated there was no care plan and she understood the need to care plan how the facility would help the resident in tapering the [MEDICATION NAME] besides telling her to wait. The DON stated Resident 3 had drug seeking behaviors, kept asking for [MEDICATION NAME] and staff had to tell her to wait. During an interview on 11/1/16, at 9:20 a.m., the DON stated Resident 3's recent x-ray result after the fall on 10/20/16 indicated a condition that required a physician's referral for Resident 3 to have a hip replacement. Resident 3's x-ray result dated 10/27/16, indicated Resident 3 had Severe avascular necrosis of the left hip without evidence of acute fracture. Avascular necrosis is a condition commonly occurs in the hip when there is loss of blood to the bone and could cause the bone to die and collapse. The symptoms of avascular necrosis include severe pain that interferes with the ability to use the joint when the disease progresses and the bone and joint collapse. During an interview on 11/3/16, at 2:35 p.m., when asked if the facility evaluated the underlying cause of the pain since Resident 3's admission until the x-ray on 10/27/16, the DON stated she was not aware of an evaluation of the underlying cause of the pain. The DON stated Resident 3 had been treated for [REDACTED]. The DON stated Resident 3 was not being sent out for imaging or work ups because Resident 3's insurance did not cover for rehabilitation. During an interview on 11/8/16, at 10:05 a.m., when asked what was her expectation of being notified a resident's fall, Physician S stated the facility staff usually notified her the same day or the day after the fall by fax or phone. Physician S stated staff should have notified her earlier of Resident 3's fall. Physician S stated Resident 3's avascular necrosis did not result from the fall, but avascular necrosis could cause increased pain. Physician S stated Resident 3 had chronic hip pain and after the fall, she looked deeper and found Resident 3 had avascular necrosis of the hip. Physician S stated she referred Resident 3 for a hip replacement. Physician S stated she tried to taper Resident 3's Narcotics, but now she could not taper the Narcotics because of Resident 3's left hip avascular necrosis. During a concurrent observation and interview on 12/6/16, at 8:16 a.m., Resident 3 was eating breakfast. Resident 3's face was grimacing. Resident 3 stated she was in a lot of pain and needed medications. Resident 3 put on the call light. Unlicensed Staff AA responded to the call light and told Resident 3 that she would tell the nurse about the pain. Unlicensed Staff AA left the room and came back at 8:21 a.m. and told Resident 3 that the nurse (Licensed Staff B) stated he would give Resident 3 medications when the nurse arrived here (Resident 3's room). Resident 3 stated Licensed Staff B would go room by room giving residents medications and asked what room Licensed Staff B was at this time. Unlicensed Staff AA stated the nurse was at room [ROOM NUMBER], which was about four rooms away. During an interview on 12/6/16, at 12:40 p.m., regarding Resident 3's pain, Licensed Staff B stated Resident 3 had drug seeking behaviors and made up the pain. Licensed Staff B stated after x-ray of the left hip and found avascular necrosis, Resident 3 started complaining of left hip pain. Licensed Staff B stated he saw Resident 3 was in the wheelchair and self-propelled down the hallway that morning, but Resident 3 did not complain of pain. Licensed Staff B stated when he was giving medications including pain medication to Resident 3 at approximately 9 a.m., following his sequence, Resident 3 complained of pain 9/10 but Resident 3 closed her eyes resting. Licensed Staff B stated If I have 9/10 pain, I will be screaming. The nurse's note and the MAR (medication administration record) from 12/6/16 to 12/9/16 did not indicate a nursing assessment for Resident 3's complaint of pain on 12/6/16 at 8:16 a.m. to 8:21 a.m. During an interview on 12/9/16, at 7:20 a.m., the DON stated the nurse should have assessed Resident 3 when the resident complained of pain. The DON stated the nurse should not wait for the sequence to give medication when the resident complained of pain because you don't know if it was a new onset of pain. The facility's policy and procedure titled Pain Management, date revised November 2015, indicated A Licensed Nurse will assess residents for pain on admission, quarterly, when there is a new onset of pain, or significant change in condition. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible .The Licensed Nurse will develop a Care Plan for pain management, including non-pharmacological interventions .Nursing Staff will implement timely interventions to reduce the increase in severity of pain .Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain .The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication .Upon admission, quarterly, and with significant change in condition the IDT will meet to review the resident's Pain Assessment. The IDT will document the following .i. Summary of event causing pain; ii. Root cause analysis; iii. Referrals, as necessary, and iv. Interventions to prevent future pain . The facility's policy and procedure titled Pain Management, revised November 2016, indicated .Facility Staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible .Licensed Nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain . 2. During an interview on 12/5/16 at 3:40 p.m. and 12/7/16 at 11:20 a.m., Resident 11 complained of her left ear feeling plugged. Resident 11 stated she had informed her nurse (could not recall nurse's name) about her left ear feeling plugged and has been waiting for some type of treatment. Resident 11 stated she was having difficulties hearing out of the left ear now due to it being plugged. During a concurrent interview and clinical record review on 12/7/16 at 11:25 a.m., Licensed Staff TT was asked if Resident 11 had received any ear treatment for [REDACTED]. Licensed Staff TT stated an order was written for [MEDICATION NAME] (earwax removal and treatment) to be started, but it did not look like it was ever started. Review of the Physician Telephone Orders written at 11/30/16 at 5:00 a.m. indicated [MEDICATION NAME] 2 drops was to be inserted into left ear and then irrigate with warm water every evening for three days. Review of Resident 11's Routine Medication Administration Record (MAR) for November indicated the [MEDICATION NAME] treatment was to be started 11/30/16 at bedtime and to be continued for the next two days, but there was no nurse's signature indicating it was ever started. Review of Resident 11's Routine MAR for December indicated [MEDICATION NAME] treatment should have been given on 12/1/16 and 12/2/16, but there was no signature indicating the [MEDICATION NAME] treatment was ever performed. Review of the facility's policy titled, Physician Orders revised 1/1/12, did not indicate how a licensed nurse would carry out the physician's orders [REDACTED]. Review of the facility's admission pack (given to all residents upon their admission), titled, California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities dated 5/11, indicated all residents who are admitted to the facility have a right to prompt medical care and treatment. The facility's policy and procedure titled Resident Rights - Quality of Life, revised 1/1/12, indicated Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality.

Based on observation, interview and record review the facility failed to ensure that the resident environment was as free of accident hazards as possible when facility staff served hot coffee to a cognitively impaired resident, Resident 1, left him without adequate supervision, which led to him spilling the hot beverage on himself resulting a second degree burn to his right thigh. The facility withheld appropriate care and services from Resident 1 for 72 hours during which time the burn potentially worsened, caused unnecessary pain to Resident 1 and exposed him to the potential for infection due to his exposed and open wound. The facility's failure to provide his physician with the necessary information about Resident 1's change in condition resulted in the physician prescribing Acyclovir (an anti-viral medication that is used to treat shingles) which, if given placed him at risk for possible adverse effects from an unnecessary medication. During Resident 1's delay in appropriate care, facility staff applied Peri-Gard cream to the second degree burn on his thigh. The application of Peri-Gard cream to a second degree burn with blisters was not a recommended use of this medication which potentially worsened the thermal trauma to the tissue. Findings: During an interview on 1/5/16 at 1:15 p.m., the facility's Administrator, Management Staff A (MS A) and the facility's Director of Nursing Services, (MS B) were interviewed about a burn injury that Resident 1 sustained on Saturday, 1/2/16. MS A stated that on Saturday morning, 1/2/16, Resident 1, was observed to have a reddened area with blisters on his right thigh. MS A stated that Resident 1's nurse noted the red area and believed it was a new rash from his urine incontinence and called Resident 1's attending physician, Doctor C. MS B stated that Doctor C had come in on Monday, 1/4/16, to examine the red area on Resident 1's right thigh. Doctor C who did not know that Resident 1 had spilled hot coffee on his lap, had prescribed Acyclovir (an antiviral medication) for Resident 1, because she believed the red, blistered area on Resident 1's thigh was an outbreak of a shingles rash (a viral rash). MS B stated that the facility reported to to Doctor C, on 1/5/16, that Resident 1 had sustained a burn injury by spilling hot coffee on himself on 1/2/16. MS A stated CNA's were trained to notify their charge nurse immediately when an accident or injury occurred involving a resident. During a Record Review on 1/6/16 at 10:30 a.m., Resident 1's medical record indicated [DIAGNOSES REDACTED]. His MDS report (an assessment tool) indicated severe cognitive impairment and behaviors including restlessness, poor impulse control, motor impairments including difficulty walking and holding on to cups. Review of Resident 1's nursing care plan, dated 9/23/15, indicated that Resident 1 had cognitive impairment and was unaware of his safety needs. Resident 1's nursing care plan, dated 7/22/15, indicated Resident 1 had weakness which required assistance with Activities of Daily Living (ADL's) such as eating, drinking, bathing and dressing. His nursing care plan, dated 7/23/15, indicated that he had poor safety awareness and difficulty grasping cups. Resident 1's nursing care plan, dated 10/23/15, indicated that Resident 1 required closer supervision secondary to his advanced degree of cognitive impairment and poor safety awareness. During an interview on 1/5/16 at 4 p.m., CNA G stated that she provided care to Resident 1 on Sunday, 1/3/16, Resident 1's Responsible Party, (RP 2) had observed the wound on Resident 1's right thigh, and had asked how it had happened. CNA G stated that RP 2 said that it looked like a burn and had asked, Did he spill hot coffee on himself? During an interview on 1/7/16 at 8:55 a.m., CNA D stated that, on 1/2/16, CNA E had said to her He spilled coffee in his lap. During an interview on 1/7/16 at 9:20 a.m., CNA D stated she did not report the burn injury to the Charge Nurse after the incident occurred on 1/2/16. During an interview on 1/7/16 at 11:30 a.m., CNA E stated she had served Resident 1 a cup of hot coffee and left him without direct supervision while serving coffee to other residents. She noticed that Resident 1's pants were wet when she turned her attention back to him. CNA E stated she did not notify the charge nurse when Resident 1 spilled hot coffee onto his lap. During an interview and record review on 1/6/16 at 12:25 p.m., Dietary Services Manager H (DSM H) produced the facility's Temperature Log for foods leaving the kitchen on Saturday, 1/2/16 at 6:45 a.m. The recorded temperatures indicated: 1.) other (coffee) = 171 degrees Fahrenheit. The facility's policy and procedure, Policy 5.1, from RDs for Healthcare, revised 3/13, titled Food Temps indicated: hot beverages = 170 - 190 degrees Fahrenheit. During an interview, on 1/7/16 at 10:30 a.m., Doctor C stated that the wound on Resident 1's right thigh was a second degree burn. Doctor C also stated that the burn and the broken skin should have been protected from coming into contact with the urine in this incontinent resident's groin area, which could have been a source of infection and the blisters should have been protected in a manner to ensure they did not break open. Second degree burns are described as being very painful (sensation) as classified by the International Society for Burn Injuries, University of New Mexico Hospitals http://hospitals.unm.edu/burn/classification.shtml The American Burn Association, Preventing Scald Injuries cites the following: Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees Fahrenheit/71- 82 degrees Celsius, resulting in almost instantaneous burns that will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. ttp://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf During an interview on 1/5/16 at 3:25 p.m., MS K stated that when the charge nurse, LN O, came to look at the redness and blisters on Resident 1's thigh and said she believed it had to be a new rash caused by Resident 1's incontinence of urine. During review of Resident 1's medical record, on 1/6/16 at 3:30 p.m., a document that was titled Skin Sheet, dated 1/2/16, indicated: Location - Right thigh c (with) 3 fluid filled areas at inner aspect. Preventative measures - apply Peri-Guard heavily and monitor for area to open. Review of Resident 1's physician's orders [REDACTED].O. (telephone order) (Doctor C named) apply Peri-Gard to Right inner thigh area. Heavily to blistered area. The manufacturer's recommendations for Peri-Gard contained with the cream indicated: A moisture barrier cream that prevents and helps treat skin irritation from urine, feces, perspiration and conditions associated with diaper rash. (Derma Rite Industries, North Bergen, NJ) The manufacture's recommendations did not endorse the use of Peri-Gard cream as a treatment for [REDACTED]. During an interview on 2/11/16 at 10:50 a.m., the Vice President of Product Distribution at Derma-Rite Industries, OS 3, was asked if Peri-Gard cream was recommended for use in the treatment of [REDACTED]. OS 3 quoted the packaging insert, Peri-Gard Cream is a moisture barrier cream to treat skin irritation from urine, feces, perspiration and conditions associated with diaper rash. OS 3 stated, No, we would never recommend it's use as a topical application for use on a second degree burn. During an interview and record review on 1/7/16 at 12 p.m., the facility's Registered Dietician, MS L stated, I've seen him eat. He needs assistance for meals. He needs to be supervised. This statement concurred with the Dietician's Assessment for Resident 1, dated, 7/21/15 which indicted: Ability to feed self: No. - Assisted Dining. This was supported by MS L's written assessment of Resident 1's needs, dated 7/21/15 which indicated: Requires close supervision for intake.