Every finding on record at Fallbrook Commons

Based on observations, interviews, record reviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the residents' environment was free of accident hazards relating to the storage of chemicals being properly secured for 2 of 22 resident rooms (321, 322) on 1 of 3 units ([NAME]). In addition, the facility failed to provide adequate supervision and complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking (R1, R2). Findings: 1.On 6/30/26 at 9:30 a.m., a surveyor observed resident room [ROOM NUMBER] on the [NAME] unit, and noted on the nightstand for bed 2, were: 2 cans of Wizard Double Action 2 in 1 Air Freshener, and 4 cans of Power Stick body spray. In the center of the bed was a cigarette lighter. During this time, the items were observed by CNA1 and LPN1. CNA1 proceeded to strip the bed and wipe the mattress down with purple-top Super Sani-Wipes Disposable Wipes. On 6/30/25 at 1:35 p.m., a surveyor toured the unit again and noted the above items remained on the nightstand in room [ROOM NUMBER], bed 2, as well as the canister of Sani-Wipes. A review of the SDS for Wizard Double Action 2 in 1 air freshener noted the following: 4. First Aid Measures: Inhalation: Move to fresh air in case of accidental inhalation of vapours. Skin contact: Wash off immediately with soap and plenty of water. If irritation occurs and persists, seek medical attention. Ingestion: Rinse mouth with water and drink afterwards plenty of water. DO NOT INDUCE VOMITING! Eye contact: Immediately flush with plenty of water. After initial flushing, remove any contact lenses and continue flushing for at least 15 minutes. If eye irritation persists, consult a physician. Notes to physician: Contains: Propellants, petroleum solvent and fragrance oils. Aggravated Medical Conditions: NOTE TO PARENTS: Intentional misuse by deliberately concentrating and inhaling aerosol products may be harmful or fatal. Help stop inhalation abuse. For information visit www.inhalant.org. An internet search for the Power Stick Body Spray SDS could not be located. However, a review for Power Stick Body Spray Product Safety Information stated: For external use only - Do not apply to broken or irritated skin. Do not use on damaged or freshly shaved skin - This can cause stinging, burning, or rashes. Avoid contact with eyes - If contact occurs, rinse thoroughly with water. Flammable - Do not use near open flames or while smoking. A review of the SDS for Super Sani-Cloth Germicidal Disposable wipe noted the following: 4. First Aid Measures: Inhalation: No first aid should be needed. Eye contact Immediately flush eyes with water for 15 minutes, while holding the eye lids open to be sure the material is washed out. Get medical attention if irritation persists. Skin contact: No first aid should be needed. Ingestion: Ingestion is unlikely for solid products. No first aid is required for small amounts transferred from hands to mouth. The active ingredient in the product was noted to be Isopropyl Alcohol. 2. On 6/30/26 at 9:50 a.m., a surveyor discussed the observations of room [ROOM NUMBER], bed 2, with the nurse manager of the [NAME] unit, who confirmed that R1 goes outside to smoke, has been offered smoking cessation products, and has had falls outside. The unit manager stated a safe smoking assessment has not been completed as the facility is a smoke-free campus. A review of R1's clinical record revealed a history of stroke with left-sided hemiplegia. A review of Minimum Data Set (MDS) 3.0 Annual Assessment, with an assessment reference date (ARD) of 5/10/26, noted R1's Brief Interview of Mental Status (BIMS) score was 15, indicating R1 was cognitively intact. R1's care plan, last revised 3/23/26, noted R1 was a smoker and had received education regarding the facility's no smoking policy and risks of hazards associated with smoking. One intervention included observe clothing and skin for signs of cigarette burns. Further review of R1's record lacked evidence that an assessment for R1's abilities to smoke safely had been completed. On 6/30/26 at 10:00 a.m., in an interview with R1, a surveyor observed burn holes on the wheelchair cushion. The surveyor asked R1 where his/her cigarettes and lighter are stored. R1 stated in the drawer of the nightstand, which has a lock, but he/she does not use. R1 confirmed he/she goes off the property to smoke and stated he/she has had 3 falls outside. 3. On 6/30/26 at 10:30 a.m., a surveyor observed R2 in his/her room. The surveyor observed a pack of cigarettes on a nearby desk and a pack on a nightstand. R2 stated the cigarettes are stored in the nightstand but he/she does not lock it. A review of R2's clinical record noted a history of stroke with left-sided hemiplegia. The MDS, Quarterly Assessment, with an ARD of 5/3/26, indicated a BIMS score of 15, indicating R2 was cognitively intact. Section GG, Functional Abilities, noted R2 requires substantial/maximum assistance with transfers. A review of R2's care plan, last revised 5/3/26, did not include interventions related to safe smoking. Further review of R2's record lacked evidence that an assessment for R2's abilities to smoke safely had been completed. On 6/30/26 at 3:00 p.m., in an interview with the Administrator, Director of Nursing, Clinical Coordinator and [NAME] Unit Nurse Manager, a surveyor discussed concerns with hazardous chemicals stored at R1's bedside and accessible to other residents, as well as observation of a lighter on R1's bed, and cigarettes observed improperly stored in R2's room. Additionally, burn holes were noted in R1's wheelchair cushion. The Administrator discussed having conversations with R1 and R2 regarding the facility being smoke free and stated it was the residents' choice to disregard the policy and smoke off the premises. The surveyor discussed the facility's lack of completing a safety assessment of the resident's capabilities, deficits, and whether or not supervision is required. Review of the facility's Resident No Smoking Policy, developed April 2017, stated I. Policy. To maintain the safety and well-being of residents, staff and visitors, Smoking and 'Tobacco Use' will be prohibited on Fallbrook Commons campus. Note: Residents of North Country Associates who are permitted to smoke/use tobacco products will be allowed to continue supervised smoking in areas designated for resident smoking. Please be advised that non-compliance with the resident smoking policy and the smoking contract places many others in danger and could lead to possible discharge from the facility. Current residents are allowed to continue smoking in a designated area, outside, weather permitting. Residents admitted after the policy change will be informed, during the admission process, of the policy prohibiting smoking.

Based on observations and interviews, the facility failed to maintain a clean/sanitary environment in 2 of 22 resident rooms (321, 322), on 1 of 3 units observed ([NAME] unit).Findings: On 6/30/26 at 9:30 a.m., a surveyor observed room [ROOM NUMBER] on the [NAME] unit. A strong odor of urine was noted. Bed 1 was unmade, however the bedding was noted to be clean and without concerns. The nightstand was free of clutter and a fall mat was on the floor next to the bed. No personal items were observed. The floor under and around bed 2 was noted with debris, including a white powder spilled onto the nightstand and floor. The nightstand was covered with cans of air freshener, body spray, creams, food items, and the drawer was left open. The overbed table had packages of open food. The bed was unmade and the sheet on the mattress was soiled with a black substance. Unfolded clothing was observed in piles on the floor, bed and chair near the window. A red laundry bag was observed on the floor. During this observation, CNA1 was present. LPN1 entered the room and confirmed the findings and stated R1 was now allowing staff to wash his/her clothes which were placed in the red bag. On 6/30/26 at 10:10 a.m., a surveyor asked the CNA-M if the roommate of room [ROOM NUMBER], bed 2, ever complains about the condition of his/her room. The CNA-M stated R3 was not able to verbalize if the condition of the room bothered him/her, but assumed it would. The CNA-M stated he/she can still smell. On 6/30/26 at 10:30 a.m., a surveyor observed R2 in room [ROOM NUMBER], bed 2. On top of a computer keyboard on a nearby desk, the surveyor observed an extinguished cigarette butt. The right armrest on R2's wheelchair was noted to be worn and torn, exposing the foam padding and creating an uncleanable surface. On 6/30/26 at 3:00 p.m., in an interview with the Administrator, Director of Nursing, Clinical Coordinator, and [NAME] Unit Nurse Manager, the surveyor discussed the findings.

Based on record reviews and interviews, the facility failed to develop and implement a resident's care plan in the area of smoking for 1 of 2 residents reviewed for smoking (R2). Findings: A review of the clinical record revealed R2 was admitted in September, 2024, and had diagnoses which included Left-sided Hemiplegia due to stroke and nicotine dependence. The Minimum Data Set 3.0, Quarterly Assessment, with an ARD (Assessment reference date) of 5/3/26, Section C, Cognitive Patterns, Brief Interview of Mental Status resulted in a score of 15, indicating R2 was cognitively intact. Section GG, Functional Abilities, noted R2 requires substantial/maximum assistance with transfers, is dependent on staff for dressing, bathing, and personal hygiene, and requires the use of a wheelchair for mobility. A review of R2's care plan, last revised 5/3/26, noted a focus area of COPD (chronic obstructive pulmonary disease) related to smoking. However, no interventions were included which addressed R2's capabilities or deficits affecting his/her ability to smoke safely. On 6/30/26 at 10:30 a.m., in an interview with a surveyor, R2 confirmed he/she smokes and has someone bring cigarettes in to the facility for him. On 6/30/26 at 3:00 p.m., in an interview with the Administrator, Director of Nursing, Clinical Coordinator, and [NAME] Unit Nurse Manager, the surveyor discussed R2's care plan had not been developed to include safety related to smoking.

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for medication errors (Resident #3). Finding: On 3/4/25, during a review of medication error reports, a surveyor noted on 2/13/25, a report for Resident #3 which stated, It was reported to this writer that last evening around 8:30 p.m., on 2/12/25, that at least 2 of resident's medications were administered twice, pregabalin 75 mg (milligrams) and oxycodone 10 mg. These were signed out of the narcotic/control book for 1904 (7:04 p.m.), but the nurse that signed it out had left facility earlier in the shift around 5:30 p.m. - 6:00 p.m. Medications were not signed out in EMAR (electronic medication administration record). Med tech (medication technician) reported that Nurse (#2) reported that Nurse (#1) had given medications before he/she left for the night. Med tech had given bedtime medications before this as medication administration was not passed on to med tech. Further concerns were noted that Resident #3 may have received double doses of bedtime medications. The report indicated that on 2/13/25, the resident's provider was notified of the error, as well as the resident's guardian. A review of Resident #3's clinical record noted he/she was admitted in March, 2023. Physician block orders, signed on 2/10/25 included Pregabalin 75 mg by mouth twice daily, and Oxycodone 10 mg by mouth 3 times daily. A review of the EMAR noted these medications were administered on 2/12/25 at bedtime and signed by the medication technician. A review of the facility's controlled medication (bound) book, confirmed both medications had been signed out as given on 2/12/25 at 19:04 by Nurse #1 and also on 2/12/25 at 19:00 by the med tech. On 3/4/25 at 3:00 p.m., in an interview with a surveyor, the Nurse Manager stated that Nurse #1 had not signed out that he/she had given the oxycodone at 19:04, but he/she left at 6 pm. The only way we knew it happened was he/she did sign it out in the bound book. He/she didn't sign out on the EMAR. The person following him/her discovered it when they were doing count after he/she had left. We suspected (the resident) got all his/her meds in duplicate. We are only sure of the ones he/she signed out - the oxycodone and the Lyrica (pregabalin). Those were due at bedtime. A review of the facility's policy, 6.0 General Dose Preparation and Medication Administration, with a revision date of 1/1/13, stated Section 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.5 Document the administration of controlled substances in accordance with applicable law; 6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are given) on appropriate forms. On 3/6/25 at 1:36 p.m., in a telephone interview with a surveyor, the Director of Clinical Services confirmed that Nurse #1 had not followed the facility's policy for medication administration when he/she didn't sign Resident #3's EMAR for administration of the controlled medications before leaving.

Based on record reviews and interviews, the facility failed to ensure a resident was free from a significant medication error when controlled medications were administered in excess of prescribed doses ordered by a physician for 1 of 3 (#3). Finding: On 3/4/25, during a review of medication error reports, a report for Resident #3 was noted which stated, It was reported to this writer that last evening around 8:30 p.m., on 2/12/25, that at least 2 of resident's medications were administered twice, pregabalin 75 mg (milligrams) and oxycodone 10 mg. These were signed out of the narcotic/control book for 1904 (7:04 p.m.), but the nurse that signed it out had left facility earlier in the shift around 5:30 p.m.- 6:00 p.m. Medications were not signed out in EMAR (electronic medication administration record). Med tech (medication technician) reported that Nurse (#2) reported that Nurse (#1) had given medications before he/she left for the night. Med tech had given bedtime medications before this as medication administration was not passed on to med tech. Further concerns were noted that Resident #3 may have received double doses of bedtime medications. The report indicated that on 2/13/25, the resident's provider was notified of the error, as well as the resident's guardian. A review of Resident #3's clinical record noted Physician block orders, signed on 2/10/25 included Pregabalin 75 mg by mouth twice daily, and Oxycodone 10 mg by mouth 3 times daily. A review of the EMAR noted these medications were administered on 2/12/25 at bedtime and signed by the medication technician. A review of the facility's controlled medication (bound) book, confirmed both medications had been signed out as given on 2/12/25 at 19:04 by Nurse #1 and also on 2/12/25 at 19:00 by the med tech. Resident #3's clinical record contained a progress note dated 2/13/25 at 12:12 p.m., which stated It was reported that resident received at least an additional dose of Lyrica and Oxycodone last evening on 2/12/25. Medications were signed out in narcotic and control book at 1900 but staff member who signed out left facility early. Med tech unknowingly gave all HS (bedtime) medications as did not realize that nurse who left early had reportedly given them. Another nurse reported to med tech around 8:30 p.m., that the nurse who left had given HS medications but did not sign them out. This writer was notified on 2/13/25 at 7:00 a.m. On 2/13/25, a provider evaluated Resident #3 and stated, seen today for medication error. Nursing notified me this morning that nursing had given duplicate night medications last night. This included additional dose of Lyrica 75 mg and oxycodone 10 mg definitively as these were signed out of narcotic count. The provider note stated facility staff strongly believed that he/she received additional doses of bedtime medications. Vitals with tachycardia 108-112 (beats per minute) but otherwise stable. As a result of the error, the provider ordered increased staff monitoring of vital signs, an electrocardiogram, and lab work. On 3/5/25, in an interview with a surveyor, Nurse #2 stated that when Nurse #1 left early on 2/12/25, he/she stated all the medications for Resident #3 had been given, and within that time, the med tech had given (Resident #2) the oxycodone. (Nurse #1) did not sign off the meds, so the med tech thought it was not given. The surveyor asked if staff can view residents' medications when they are not due on the electronic medical record (EMAR). Nurse #2 stated when a resident's name is pulled up, all the meds ordered for the day are listed. A medication is highlighted yellow and able to be signed off 1 hour before and after the time it is due to be given. On 3/6/25 at 2:14 p.m., in a telephone interview with a surveyor, Nurse #1 stated he/she had given Resident #3 medication outside of the window prescribed by the doctor. Nurse #1 stated the resident had requested medication for pain, and that the medication as ordered, did not adequately address the pain. Nurse #1 stated when he/she left early on 2/12/25 at 6:00 p.m., he/she told the charge nurse (Nurse #2) to contact the resident's physician to have the medication order changed. Nurse #1 stated he/she had signed all medications administered in residents' EMARs but had not signed the controlled medications given to Resident #3, as it was before the 1 hour administration window and the EMAR was locked. A review of the facility's policy, 6.0 General Dose Preparation and Medication Administration, with a revision date of 1/1/13, stated Section 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.5 Document the administration of controlled substances in accordance with applicable law; 6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are given) on appropriate forms. On 3/7/25 at 9:50 a.m., in a telephone interview with the Clinical Services Director, the surveyor confirmed that Nurse #1 had failed to follow accepted standards of practice for medication administration, resulting in Resident #3 receiving additional doses of prescribed medications.

Based on interviews and reviews of the attendance from the facility Quality Assurance meetings, the facility failed to ensure the Quality assessment and assurance (Qaa) committee consisted of the required members. Findings: A review of the signed attendance list for Qaa meetings held on 6/11/24 and 7/2/24 showed that the administrator, owner, board member or other individual in a leadership role did not attend either meeting. On 8/22/24 at 9:15 a.m. a surveyor discussed the above finding with the Director of Nursing (DON) and learned the Qaa committee meets weekly but the Administrator (or owner, board member or other individual in a leadership role) does not ever attend the Qaa meetings.

Based on observations and interviews, the facility failed to ensure that residents who required feeding assistance were aided with feeding in a dignified manner for 2 of 3 dining observations. (#42) Findings: 1. On 8/19/24 between 12:27 p. m. and 12:34 p.m., a surveyor observed the lunch meal service in the C - Unit dining room. A surveyor observed Certified Nursing Assistant #3 (CNA#3) standing over Resident #42 while feeding him/her. In addition, the CNA did not engage in any conversation with the resident while feeding him/her. In an interview, a surveyor confirmed the above findings with CNA #3 on 8/19/24 at 12:34 p.m., and also confirmed the above findings on 8/19/24 at 1:45 p.m. with the Director of Nursing (DON). 44049 2. On 8/20/24 at 8:15 a.m. a surveyor observed CNA#1 in Unit C dining room, standing over a resident while aiding him/her feeding. A surveyor observed CNA #2 in the hallway at the nurse's station, standing over a resident while aiding him/her with feeding. This was confirmed with the Unit Manager at the time.

Based on record review, and interviews, the facility failed to inform and provide written information concerning the right to formulate an advance directive for 4 of 16 residents reviewed for advanced directives. ( #62, #65, #40, #21) Findings: 1. On 8/20/24 at 9:22 a.m. a surveyor reviewed Resident #62's clinical record and was unable to locate an advance directive. Also, documentation was not found that the resident was informed and provided information they had the right to formulate an advance directive. An Advance Care Planning Tracking form was located in Resident #62's clinical record but the document was unsigned and blank other than Full Code being selected. On 8/20/24 at 9:34 a.m. a surveyor reviewed Resident #65's clinical record and was unable to locate an advance directive. Also, documentation was not found that the resident was informed and provided information they had the right to formulate an advance directive. A form was located in Resident #65's clinical record titled Advance Care Planning Tracking form This form was signed by their representative but in the section Date of Discussion the representative had written was none. The rest of the form was blank other than Do Not Resuscitate (DNR) being selected. On 8/20/24 at 1:55 p.m. a surveyor reviewed Resident #40's clinical record and was unable to locate an advance directive. Also, documentation was not found that the resident was informed and provided information they had the right to formulate an advance directive. On 8/21/24 at 2:45 p.m. a surveyor met and discussed the above findings with the Director of Nursing who was also unable to locate the requested documentation. 44049 2. On 08/19/24 at 1:38 p.m., a surveyor was unable to locate documentation of an Advanced Directive discussion with Resident #21. On 8/20/24 at 12:40 p.m. After an extensive search of the electronic record and the hard copy of the clinical record, the charge nurse of Unit A stated that she could find no documentation that advanced directive documentation was ever given to the resident. She confirmed, You are correct, I do not see it anywhere.

Based on interviews and record review the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included but is not limited to, the attending physician, a registered nurse and Certified Nurses Aid (CNA) with responsibility for the resident, a member of nutrition services and to the extent possible, include the participation of the resident and/or resident's representative, after each Minimum Data Set (MDS) assessment for 16 of 29 residents whose care plans were reviewed (#9, #13, #18, #30, #31, #40, #54, #55, #62, #65, #67, #71, #75 #78, #88, #93 and #95). Findings: 1. Review of Resident #9's medical record, the surveyor noted IDT meetings held on 7/13/23, and 4/11/24 where the only IDT members in attendance were a registered nurse and nutrition services. The IDT held on 7/13/23 and 10/11/23 only had nutrition services in attendance. 2. Review of Resident #13's medical record, the surveyor noted an IDT meetings held on 1/4/2024, with only Dietary & Nursing in attendance. No documentation of resident or family invitation or attendance. Review of Resident #13's medical record, the surveyor noted an IDT on 3/27/2024, with only Dietary & Nursing in attendance. A note stated resident has no complaints or concerns. goes to dialysis x3 wk scheduled for cataract surgery 4/22/24. dialysis is concerned with residents eating consumption (high K+/Ca+ foods & fluid intake) resident has been educated numerous times. No documentation of resident or family invitation or attendance. Review of Resident #13's medical record, the surveyor noted an IDT on 7/2/2024 with only Dietary in attendance. A note stated, Renal, large portions protein tid with meals, regular consistency (level 4) thin liquids, 1500cc fluid restriction. Allergic to raw carrots, celery and peaches. No documentation of resident or family invitation or attendance 3. Review of Resident #18's medical record, the surveyor noted IDT meetings held on 11/3/23, 2/3/24, and 5/3/24 where the only IDT members in attendance were a registered nurse and nutrition services. The IDT held on 8/3/24 only had a registered nurse in attendance. 4. Review of Resident #30's medical record, the surveyor noted IDT meetings held on 11/23/23 and 2/14/24 where the only IDT members in attendance were a registered nurse and nutrition services. The IDT held on 5/15/24 only had a registered nurse and activities in attendance. The IDT held on 8/14/24 only had a registered nurse in attendance. 5. On 8/19/24 at 1:53 p.m., during an interview, Resident #31 was asked if he/she was invited or participated in their plan of care meetings with the IDT team, he/she stated, not sure if he/she was invited. Review of Resident #31's medical record, the surveyor noted IDT meetings held on 10/30/23 and 1/29/24 where the only IDT members in attendance were a registered nurse and nutrition services. An MDS Quarterly assessment was completed on 5/20/24. The medical record lacked evidence that a care plan meeting had been held by the IDT after the 5/20/24 assessment. All past 3 IDT meetings lacked documentation of resident #31 being invited or attending his/her IDT. 6. Review of Resident #40's medical record, the surveyor noted IDT meetings held 3/6/24 and 2/27/24 where only dietary attended. An IDT meeting held 11/21/23 where only nursing and dietary attended. 7. Review of Resident #54's medical record, the surveyor noted IDT meetings held on 1/26/24 and 7/23/24 where the only IDT members in attendance were a registered nurse and nutrition services. The IDT held on 7/27/23, 10/26/23 and 4/25/24, only had nutrition services in attendance. 8. Review of Resident #55's medical record, the surveyor noted IDT meetings held on 9/7/23 and 12/7/23 where the only IDT member in attendance was nutrition services. The IDT held on 3/6/24 only had a registered nurse, activities and nutritional services in attendance and the IDT held on 6/5/24 only had a registered nurse and nutritional services in attendance. 9. Review of Resident #62's medical record, the surveyor noted IDT meetings held 10/4/23, 1/30/24, 4/26/24 and 7/29/24 where only nursing and dietary attended. 10. Review of Resident #65's medical record, the surveyor noted IDT meetings held 2/10/23, 8/10/23, 11/9/23, 3/15/24 where only nursing and dietary attended. An IDT meeting held 5/12/23 where nursing, dietary, wife and resident attended. A meeting held 6/13/24 where only activities attended. 11. Review of Resident #67's medical record, the surveyor noted IDT meetings held on 3/21/24 and 6/11/24 where the only IDT members in attendance were a registered nurse and nutrition services. 12. On 8/19/24 at 10:14 a.m., during an interview, Resident #71 was asked if he/she was invited or participated in their plan of care meetings with the IDT team, he/she stated, No, nobody said anything about it. Review of Resident #71's medical record, the surveyor noted IDT meetings held on 11/6/23 and 2/2/24 where the only IDT members in attendance was a registered nurse and nutrition services. The IDT held on 5/10/24 only had nutrition services in attendance and the IDT on 8/7/24 only had a registered nurse in attendance. All past 4 IDT meetings lacked documentation of resident #71 being invited or attending his/her IDT. 13. Review of Resident #75's medical record, the surveyor noted IDT meetings held on 6/29/23 where the only IDT members in attendance were a registered nurse and nutrition services. The IDT held on 6/29/23 and 9/14/23 only had nutrition services in attendance. 14. Review of Resident #78's medical record, the surveyor noted IDT meetings held 9/21/23 where only dietary attended. IDT meetings held 6/22/23, 12/21/23, 3/26/24 where only nursing and dietary attended. 15. Review of Resident #88's medical record, the surveyor noted IDT meetings held 5/1/24 and 8/1/24 where only dietary attended. IDT meetings held 8/4/23, 11/3/23 and 2/1/24 where only nursing and dietary attended. 16. Review of Resident #93's medical record, the surveyor noted IDT meetings held on 4/17/24 and 7/24/24 where the only IDT member in attendance was a registered nurse and nutrition services. 17. On 8/19/24 at 10:32 a.m., during an interview, resident #95 was asked if he/she was invited or participated in their plan of care meetings with the IDT team, he/she stated, I don't think I've had one for quite a while. Review of Resident #95's medical record, the surveyor noted IDT meetings held on 9/22/23 and 12/22/23 where the only IDT member in attendance was a registered nurse and nutrition services. The IDT held on 3/22/24 only had nutrition services in attendance and the IDT on 6/21/24 only had activities and nutritional services in attendance. All past 4 IDT meetings lacked documentation of Resident #95 being invited or attending his/her IDT. 33639 44049 48648

Based on observations, record reviews, facility policy, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 4 of 4 residents reviewed for respiratory care (#30, #60, #93 and #70) Findings: Facility policy and procedure Oxygen Use and Storage effective 3/2023 states under Respiratory Care, A sanitary environment must be maintained to prevent the transmission of disease and infection. Nasal cannula should be discarded and changed weekly. A label indicating the date and the initials of the staff changing the cannula/tubing should be applied to the nasal cannula. Nebulizer parts should be wrenched after each use and discarded every week. A label indicating the date in the initials of the staff changing the parts/tubing should be applied to the tubing . Staff changing the tubing should document on the treatment administration record (TAR) when the tubing has been changed following the policy. 1. On 8/19/24 at 9:22 a.m., on 8/20/24 at 2:45 p.m., and on 8/21/24 at 10:02 a.m., observations of Resident #30's oxygen (O2) nasal cannula tubing unlabeled/undated, an oxygen tubing connected to the CPAP (continuous positive airway pressure) machine with the open end hanging of the bedside table and resting on the floor and a nebulizer pipe stored on the bedside table amongst personal belongings unlabeled/undated. Review of the clinical record lacked documentation of both the O2 and nebulizer tubing change weekly. 2. On 8/19/24 at 9:46 a.m., and on 8/21/24 at 10:04 a.m., observations of Resident #60's nebulizer tubing unlabeled/undated with the mouthpiece hanging down the backside of the bedside dresser and wall. Review of the clinical record lacked documentation of the nebulizer tubing change weekly. 3. On 8/19/24 at 10:30 a.m., and on 8/20/24 at 2:47 p.m., observations of Resident #93's nebulizer tubing unlabeled/undated with the mask stored on the bedside table amongst personal belongings and another nebulizer pipe hanging off the top between the dresser and wall. 08/19/24 at 1:59 p.m., During observation and discussion with Resident #70, a surveyor observed that his Oxygen was running at 2L and that there was no date on the tubing. He stated, I don't wear it that much. Review of the clinical record lacked documentation of the oxygen tubing change weekly. This was verified with the LPN passing meds and with the charge nurse at that time. On 8/21/24 at 10:08 a.m., during an interview, the Licensed Practical Nurse stated, O2 tubing and nebulizers are changed weekly, should be signed off on the TAR and the tubing should be initialed. On 8/21/24 at 10:35 a.m., both the surveyor and the Director of Clinical Services observed the above O2/nebulizer tubing and storage. The Director of Clinical Services stated the tubing is usually stored coiled up and stored on top of the machines and should be changed weekly and documented on the Treatment Administration Record (TAR). 44049

Based on facility policy, observations, record review and interviews the facility failed to ensure controlled drug records are in order and an account of all controlled drugs is maintained to enable reconciliation and failed to ensure that two people who are authorized to administer medications signed the controlled substance cycle count once daily for 1 of 1 Omnicell (automated medication dispensing cabinet) reviewed. Findings Facility policy and procedure for Omnicell Inventory & Cycle Count, dated 7/2018 states, Controlled medications will counted at least once daily by two licenses nurses. This specific count will be signed off as complete using the accountability log sheet. On 8/21/24 at 8:14 a.m., observation of the Unit A medication storage room with the Registered Nurse Manager (RN #3) to have an Omnicell machine which contained emergency box medications including controlled drugs. At this time, the RN #3 stated the controlled medications in the Omnicell should be counted daily. The Daily Omnicell Controlled Substance Cycle Count log indicated controlled substances are counted once daily by outgoing and incoming nurse. A review of the logs from 1/2024 through 8/21/24 showed the following missing controlled substance count daily: 1/2024 missing count for 9 of 31 days 2/2024 missing count for 11 of 28 days 3/2024 missing count for 14 of 31 days 4/2024 missing count for 12 of 30 days 5/2024 missing count for 17 of 31 days 6/2024 missing count for 22 of 30 days 7/2024 missing count for 20 of 31 days 8/2024 missing count for 14 of 20 days reviewed On 8/21/24 at 8:50 a.m., the above was discussed with the Director of Clinical Services.

Based on facility policy, observation, interview and record review the facility failed to ensure biologicals were stored at appropriate temperatures in 2 of 2 refrigerators observed (Unit A, #1 and #2 refrigerators). Findings: Facility policy and procedure for Omnicare Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 8/24 states, Facility should ensure that medications and biologicals are stored at their appropriate temperatures . refrigeration: 36 to 46 F. 1. On 8/21/24 at 8:14 a.m., observation of the Unit A medication storage room with the Registered Nurse Manager (RN #3) which contained 2 refrigerators #1 (containing insulin, Ozempic and Tuberculin Purified Protein) and #2 (containing insulins). At this time, the RN #3 stated the refrigerators temperatures should be monitored once or twice daily, she could not remember. The Medication Fridge Temperatures Log for refrigerators #1 and #2 indicated temperatures are to be monitored twice daily. Review of the temperature logs from 1/2024 through 8/21/24 showed temperatures were only being monitored once daily, with the following daily temperatures missing: 1/2024 missing temp for 6 of 31 days 2/2024 missing temp for 7 of 28 days 3/2024 missing temp for 6 of 31 days 4/2024 missing temp for 4 of 30 days 5/2024 missing temp for 3 of 31 days 6/2024 missing temp for 2 of 30 days 7/2024 missing temp for 6 of 31 days 8/2024 missing temp for 7 of 20 days reviewed On 8/21/24 at 8:50 a.m., the above was discussed with the Director of Clinical Services. 2. On 8/21/24 at 10:24 a.m., both surveyor and Director of Clinical Services observed the vaccine refrigerator in the Infection Control office which contained 22 boxes of influenza vaccine and 3 boxes and 7 syringes of pneumococcal vaccines. Review of the Temperature Logs which were attached to the front of the refrigerator stated July 2024 temperatures were monitored only once daily for 14 out of 31 days and August 2024 temperatures were monitored only once daily for 12 out of 21 days reviewed. At this time, the Director of Clinical Services confirmed the lack of temperature monitoring.

Based on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 2 observations. Findings: 1. On 8/19/24 at 9:10a.m. during the initial observation of the kitchen, this surveyor found undated and unlabeled pie and other deserts in the reach-in refrigerator. 2. Also, on a cart that the 'person in charge' stated was the breakfast cart observed three different packages of cheese with no dates, and a package of French toast with no date. These were confirmed with the 'person in charge' at the time. 3. On 8/21/24 at 11:30a.m. Observation of Unit A Kitchenet - Observed that the freezer contained a moderate to heavy amount of dirt and the refrigerator contained a light to moderate amount of dirt and it was extremely full. All items observed did have resident names and dates. Observation of Unit B Kitchenet - observed a small to moderate amount of dirt and the temperature log on the outside of the fridge was lacking documentation of temperature checks for 13 of 31 days in July of 24 and for 3 of 21 days in August of 2024. The were confirmed with the person in charge of the Dietary Department at 12:45p.m. 4. On 8/21/24 at 3:45p.m. in an interview with the Food Service Consultant, she reviewed the Dish Machine Temp log with this surveyor that showed when the dish machine needed repair and would no longer record the temp of the wash and rinse, the company told them to add bleach and they were doing it, but never recorded the parts per million (ppm) that they added. The log lacks documentation from 6/7/24 - 7/9/24, this was confirmed with her at that time.

Based on record reviews and interview, the facility failed to ensure that 1 of 5 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #55). Finding: Resident #55 was admitted to the facility on [DATE] with diagnosis of bipolar disorder. Resident #55's clinical record contained a PASRR Level I determination letter dated 10/18/21 that stated further PASRR evaluation was not required due to Resident #55 met the criteria for a short-term convalescence admission. Resident #55 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after the Residents stay changed from short-term to long-term. On 8/21/24 at 12:38 p.m., in an interview, the Director of Clinical Services confirmed the findings.

Based on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include trauma informed care for 1 of 5 sampled residents reviewed for trauma. (#60) Finding: Facility policy and procedure, Trauma Informed Care, revised 11/2023 states, upon admission to the facility, social services, or designee, will assess each resident using screening question on admit for a history of trauma and or post traumatic stress disorder to ensure identified residents receive appropriate treatment and services. Any additional information may be obtained from the medical record or resident representative. Identified traumatic events and triggers will be reviewed by the interdisciplinary care team, who will work with the resident/resident representative to develop methodologies and approaches to mitigate/eliminate the triggers . Trauma specific interventions will be placed on the residence care plan, and this will be reviewed quarterly, and updated as necessary. On 8/19/24 during an interview, Resident #60 stated, the facility is aware that he/she has PTSD, and he/she is not to have male caregivers. Resident #60's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The history and physical completed on 5/9/22 states under Past Medical History, Diagnosis: History of sexual abuse in childhood. The Psychosocial Assessment & History completed on 5/9/22 and on 6/6/23 - Section 6 indicates, he/she had Physical/Sexual/Emotional Abuse History. The screening for trauma informed care completed on 6/5/23 and on 5/9/24 indicate yes for facing a traumatic event or experience in the past. The clinical record lacked information that indicated what Resident #60's PTSD triggers are or what events might cause re-traumatization. On 8/20/24 at 8:59 a.m., during an interview, the Director of Clinical Services stated she could not find a care plan (goal and trauma interventions) for the above history of trauma other than, resident does not want male direct care givers (CNAs) being mentioned as an intervention under Personalized care. At this time, the Director of Clinical Services confirmed the above.

Based on interview and record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Resident #105). Findings: Resident #105 was admitted to facility on 2/1/24 for skilled services. On 6/12/24 Resident #105 was discharged to the community. The clinical record lacked evidence a recapitulation of the resident's stay was completed at discharge. On 8/22/24 at 9:41 a.m., during an interview, the Director of Clinical Services indicated that she reviewed Resident #105's clinical record and was unable to find evidence that a recapitulation of stay was completed for this resident.

Based on a review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 6/11/24, written statements by staff, facility policy, clinical record review, and interviews, the facility failed to protect residents from physical abuse for 1 of 34 sampled residents. (#91) Finding: The facility's Abuse, Neglect, Misappropriation of Resident Property and Exploitation, Effective 10/2022 .each resident will be free from abuse. Abuse can include verbal, mental, sexual or physical abuse. Corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience. And that are not required to treat the residents' medical symptoms. Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. On 6/11/24, the Division of Licensing and Certification received from the facility a Reportable Incident Form which indicated an allegation of abuse of a resident (Resident #91) by Certified Nursing Assistant #4. (CNA #4) While CNA #4 was providing 1:1 care to Resident #91. CNA #5 observed Resident #91 grabbing CNA #4's arm and CNA #4 slapping the resident's arm/hand and stating: How do you like it? A Clinical record review indicates that Resident #91 was admitted to the facility on [DATE] for long term care. Resident #91 has a diagnosis of Down Syndrome, Conduct Disorder, Alzheimer's disease and dementia with behavioral disturbance. On 8/21/24 at 3:17 p.m. a surveyor conducted a telephone interview with CNA #4. CNA #4 stated Resident #91 was being very combative, and he/she had a lot of feces on his/her hands because he/she kept digging all day long. I took him/her in the room, I cleaned him/her up, brought him/her back outside, and he/she tried to reach out to give me a hug. I took his/her hand and placed his/her hands by his/her side, and I attempted to fix his/her pants zipper at one point, and he/she kicked me, and he/she punched me. The other caregivers saw and rushed over to help. On 8/21/24 at 3:24 p.m., a surveyor conducted a telephone interview with CNA #5. CNA #5 stated she observed Resident #91 grab CNA #4's arm. She then observed CNA #4 hit Resident #91 and say, How does it feel? A statement written by CNA #5 states Resident #91 became agitated from being followed by his 1:1 (CNA #4). When Resident #91 tried to walk away from CNA #4. CNA #4 grabbed Resident #91 to redirect him/her. Resident #91 grabbed and squeezed CNA #4's arm. CNA #4 pushed Resident #91's arm away and slapped Resident #91's arm hard and said How do you like it? A statement written by CNA #6 states Resident #91 was agitated walking around the common area. CNA #6 states she heard the 1:1 (CNA #4) yell loudly at Resident #91. She then observed Resident #91 grab the 1:1's (CNA #4) arm and the 1:1 (CNA #4) removed Resident #91's hand off her arm and reached up and smacked Resident #91 in the right arm and said, How do you like it? loudly. A care plan dated 4/25/23 indicates when resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. If resisting care, stop care, ensure he/she is safe and retry care in 5-10 minutes. Attempt care 3 times, if he/she continues to refuse care, alert charge nurse for further. Observe and Document observed behavior and attempted interventions. Provide 1:1 supervision as needed. On 8/20/24 at 3:05 p.m. a surveyor discussed this finding in an interview with the Director of Nursing (DON). The DON stated that CNA #4 was immediately sent home, and the facility terminated her contract with the agency.

Based on record review and interview, the facility failed to ensure that physician's orders were followed for 1 of 33 sampled residents (#9). Finding: Resident #9's Physician Order Summary sheet dated 4/9/24 indicated the resident was to be weighed weekly on Tuesday and Thursday for Congestive Heart Failure. There was no evidence in the resident's clinical record to indicate the resident was weighed on 4/18/24, 5/23/24, 6/6/24, 6/11/24, 7/11/24, 7/18/24 and 7/25/24. On 8/21/24 at 3:30 p.m., the surveyor confirmed this finding in an interview with the Director of Nursing (DON).

Based on observations and interview, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility in the survey folder (located in the entrance foyer). Finding: On 8/22/24 at 9:05 a.m. a surveyor went to the main lobby to review the book that contained the Latest Survey Results and the book was empty. The Director of Clinical Services was asked where the results are and she stated that she did not know and did not know how long it had been empty.

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (CMS-10123-NOMNC) form was provided for 2 of 3 sampled residents whose Medicare Part A Skilled services were discontinued. In addition, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055-SNF ABN), which included appeal rights and liability of payment was provided for 2 of 2 sampled residents who remained in the facility after Medicare Part A benefits ended. Findings: On 8/20/2024 a surveyor reviewed a random sample of 3 residents who had been discharged from Medicare Part A and found: 1. A resident's last covered day was 3/3/24 and they remained in the facility. This resident should have received a CMS-10123-NOMNC form and a CMS-10055-SNF ABN form. They received neither. 2. A resident's last day of coverage was 2/28/24 and were discharged to home on 2/29/24. They should have received a CMS-10123-NOMNC form. They did not. 3. A resident's last day of coverage was 3/29/24 and they remained in the facility. They should have received a CMS-10123-NOMNC form and CMS-10055-SNF ABN form. They did not receive a CMS-10055-SNF ABN form. On 8/20/2024 at 9:30 a.m. a surveyor discussed the missing forms with the Director of Nursing.

Based on clinical record review, review of the facility's transport training checklist, and interviews, a facility wheelchair van driver failed to follow the wheelchair unloading procedure, this failure resulted in a resident falling off the back of the wheelchair van sustaining a laceration to the right side of his/ her head that required four staples, and sustained a non-displaced fracture of superior sternum, for 1 of 3 residents reviewed for falls. (#2). Finding: Resident #2 was admitted to the facility in May of 2022, for continued rehabilitation and treatment of [CONDITION(S)] ([CONDITION(S)]) with ongoing renal [CONDITION(S)], failure to thrive at home, and for transportation to [CONDITION(S)]. He/She has limited mobility and utilizes a wheelchair. During a review of Resident #2's clinical record the surveyor noted a fall report which stated under Incident Description: Resident fell during transfer from wheelchair van, head was bleeding from striking side of ramp. Resident was conscious, breathing, and talking Additionally, under Notes a note dated 10/4/22 states an interview was conducted with staff member who stated Left building to go to break heard screaming, saw wheelchair van parked, went to back of vehicle to investigate saw resident lying on [his/her] stomach on ground wheelchair lift on the ground. Wheelchair was to the left side and wheelchair cushion was out of chair. Residents was bleeding from [his/her] head, but [he/she] was breathing as I saw [his/her] chest rise . A note dated 10/7/22 states an interview was conducted with the wheelchair van driver who stated he did not realize that the lift was not even with the bumper. He got out of the van and thought he had lower the lift into position to remove the resident. When he began to push resident toward lift the alarm sounded, the rear wheels (of Resident #2's wheelchair) were already off the back of the van. The driver tried to stop the chair but was unable and both the resident and he fell to the ground. A review of an investigation conducted by the Director of Facilities states on October 4th, at approximately 12:50 PM he was informed that one of his employees was injured He then went to the scene of the injury and noted his employee kneeling on the pavement and noted a patient lying on the wheelchair lift that was on the ground at the rear of the van. In an interview with the van driver the investigation notes state .I believe he unfolded the lift and instead of stopping at the intermediate un-fold position, which is the unloading position, he continued to lower the lift all the way to the ground Review of a provider encounter note dated 10/5/2022 indicates, as a result of the fall, Resident #2 sustained a laceration to the right side of his/her head that required four (4) staples, and sustained a non-displaced fracture of superior sternum, imaging to the left knee was negative for fracture, there was minimal pain noted with palpation, however; sternal pain more noticeable with movement. On 10/11/2022 at approximately 1:00 p.m., a Physician's Assistant (PA) was observed doing a follow-up exam with Resident #2. In an interview with the PA, she indicated that she would be prescribing a mild narcotic for [Resident #2's] pain. And in an interview with Resident #2 he/she stated they did not want anything too strong, but I have to have something to stop this pain. A review of a document titled Saint Joseph's Residence Resident Transportation Training Checklist under Unloading procedure states the following under bullet point #2: -Open the rear doors of the transportation vehicle and lower the patient lift to the intermediate position. A review of training documents states the van driver received education/training on the operation of the wheelchair van lift on 8/29/2022. On 10/11/2022 at 3:45 p.m., the surveyor discussed the failure of the van driver to follow the unloading procedure which resulted in Resident #2 falling from the wheelchair van, and sustaining injuries with the Administrator, Director of Nursing, Director of Facilities, and the Assistant Director of Facilities.