Every finding on record at Fortuna Rehabilitation and Wellness Center, LP

Based on observation, interview, and record review, the facility's licensed nurses failed to ensure medication was reordered timely for one resident (Resident 1) of three sampled residents when his itraconazole (antifungal medication used to treat serious fungal infections) had not been reordered before the medication ran out which caused Resident 1 to miss a dose.This failure had the potential to result in the worsening clinical conditions of Resident 1. Findings:A review of Resident 1's admission record indicated admission to the facility in June 2019 with the diagnosis of granulomatous disorder (an infection whereby the fighting white blood cells do not work properly preventing the white cells from being able to protect the body from bacterial and fungal infections) of the skin and subcutaneous tissue (beneath the skin), infections of the central nervous system (the main control center of the body, consisting of the brain and the spinal cord [carries nerve signals from your brain to the rest of your body and back again]), immunodeficiency (a state in which the immune system does not work the right way, making it hard or impossible for the body to fight off germs like bacteria, viruses, and fungi), and traumatic brain injury (results from a violent blow or jolt to the head or body).A review of Resident 1's Order Summary Report (OSR), dated July 2026, indicated the following physician's (MD) order Itraconazole Oral Capsule 100 mg[milligrams] Give 1 capsule by mouth two times a day for Granulomatous Disorder BID [twice a day] before meals.Start Date 5/12/25.A review of Resident 1's Medication admission Record (MAR) dated July 2026, indicated licensed nurses were expected to administer itraconazole on 7/28/26 at 6 a.m.; however, a 9 indicated the medication was not given.A review of Resident 1's progress note dated 7/28/26 at 6 a.m., indicated, [Resident 1] is out of itraconazole.Medication on order.A review of Resident 1's care plan regarding his diagnosis of Granulomatous Disorder revised on 1/21/25, indicated licensed nurses were expected to administer itraconazole per MD order to prevent Resident 1 from experiencing any complications related to an infection.During an interview on 8/6/26 at 10:15 a.m. with the Director of Nursing (DON), the DON stated the night nurse noticed Resident 1's itraconazole was unavailable to administer on 7/28/26 at 6 a.m. The DON stated residents' medications were expected to be reordered when there was either a three- or four-day supply left which was indicated by a blue area on the medication bubble packet (pre-sorted cards that organize pills by day and time).During a concurrent observation and interview on 8/6/26 at 12:55 p.m. with License Nurse 1 (LN 1), LN 1 exhibited a medication bubble packet to show this surveyor the dark blue mark which indicated to the nurse when it was time to reorder the resident's medication. LN 1 stated any nurse could reorder medication. LN 1 stated if the nurse placed the medication order to the pharmacy by 9 p.m., the facility would receive the medication by 9 a.m. the following morning. because the pharmacy made deliveries daily by 9 a.m.During an interview on 8/6/26 at 1:40 p.m. with the DON, the DON stated Resident 1's itraconazole medication should have been reordered by the day nurse who last gave the medication on 7/27/26 at 5 p.m., but the medication was not reordered.During an interview on 8/6/26 at 3:40 p.m. with the DON, the DON agreed that any of the nurses who were assigned to administer itraconazole to Resident 1 should have noticed when it was time to reorder the medication. The DON stated there were several nurses who could have reordered Resident 1's itraconazole within the three-to-four-day window prior to the medication running out but they did not.During a review of the facility's Policy & Procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated May 2025 indicated, .A licensed nurse.Assures medications are incorporated into the resident's specific allocation prior to the next medication pass.These findings represent past noncompliance with this regulatory requirement. A record review of Resident 1's Order Summary Report, dated 7/28/26, indicated: 1. Itraconazole 100 mg was ordered: Give one capsule by mouth at bedtime for fungal infection prevention for one administration, one-time catch-up dose to be given and 2. Renewal order of itraconazole 100 mg had instructions for the nurse to call the pharmacy when there was seven doses left. Resident 1's MAR, dated 7/28/26, indicated Resident 1 received his missed 6 a.m. dose of Itraconazole 100 mg at 10 p.m. Resident 1's care plans were updated, and in-services were provided to licensed nurses on 7/28/26. There was sufficient evidence that the facility corrected the violation as of 7/28/26, 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 observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 87 residents when trash dumpsters were observed overflowing with rubbish and filled rubbish bags were left on the ramp next to the container.This failure decreased the facility's potential to prevent a nuisance or breeding ground for insects and rodents.Findings:In an observation on 6/23/26 at 5:46 a.m., the trash dumpster was observed open due to too much rubbish in the container. In a concurrent observation and interview with the Certified Dietary Manager (CDM) on 6/23/2026 at 10:42 a.m., the CDM stated, The trash bin [covers] should be closed at all times. Someone should have put the bags in the other container. The concern is rodents could move in.On three separate observations on 6/23/26 at 5:46 a.m., 6/24/26 at 6:59 a.m., and 6/26/26 at 7:06 a.m., the trash dumpsters were observed open due to over filling. On 6/26/26 at 7:06 a.m., a bag of rubbish was observed on the ground next to the trash bins. In a concurrent observation and interview on 6/26/2026 at 7:25 a.m. with the Administrator (ADM), we observed a maintenance staff throwing the rubbish that was sitting next to the bin into a dumpster on security camera. The ADM stated, That's not right. They [staff] know better than that. No, [this] does not meet expectation. A review of the facility's policy titled, Waste Management, dated 4/21/22 indicated, Containers must be CLOSABLE, puncture resistant and leakproof. Food waste will be placed in covered garbage and trash cans.

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for a census of 92 residents when:1. Certified Nursing Assistants (CNAs) did not offer or remind residents to clean their hands before lunch service or eating;2. Resident glucometers (a small, portable electronic device used to measure the amount of sugar [glucose] in your blood) were not sanitized using the appropriate sanitizing agent;3. An Infection Prevention and Control Program (IPCP) with written standards, policies, and procedures was not maintained, reviewed and regularly updated;4. Oxygen concentrators (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) had visible dust and debris in the vents and another had a dirty filter; and,5. Transmission-based precaution was not initiated for Resident 35 when she was prescribed an antibiotic for pneumonia (a lung infection that can be caused by many germs) and was actively coughing.These failures decreased the facility's potential to prevent the spread of germs and infection among residents. Findings: 1. During an interview and concurrent observation of Resident 75 on 6/23/26 at 12:58 p.m., Resident 75 was about to eat lunch at bedside. Resident 75 stated staff had not offered or reminded him to clean or wash his hands before serving his lunch tray. Resident 75 stated he will go to the restroom and wash his hands himself. During interview and concurrent observation on 6/23/26 at 1:03 p.m., Resident 72 was observed eating her lunch at bedside and stated nobody came in to offer to wash or clean her hands. Resident 72 pointed to her roommate and stated nobody came to clean her roommate's hands either. The Director of Rehabilitation (DOR) overheard the conversation and brought hand wipes into the room and wiped both residents' hands. During a series of interviews in successive rooms in one hallway, the following interviews were obtained on 6/23/26: -At 1:13 p.m. Resident 94 stated staff had not reminded her to wash or sanitize her hands today, but that she used her own hand sanitizer. At 1:15 p.m., Resident 48 stated staff have never reminded her to wash or sanitize her hands and had not done so prior to lunch service today. -At 1:17 p.m., Resident 99 stated staff have never reminded him to wash or sanitize her hands and had not done so prior to lunch service today. -At 1:18 p.m., Resident 5 stated staff did not offer to wash, wipe or clean his hands before lunch service. -At 1:19 p.m., Resident 13 stated staff have never offered to wash or wipe his hands before meals. Resident 13 stated he uses his own wet wipes to clean his hands before eating. During an interview on 6/23/26 at 1:20 p.m., CNA 6 verified she was assigned to the odd numbered rooms in the hall the survey had just interviewed residents in and confirmed she had not offered hand hygiene to her residents today. CNA 6 stated not doing Hand Hygiene (HH) can spread infection. CNA 6 said everyone should wash hands before eating. During an interview on 6/23/26 at 1:25 p.m., CNA 7 verified she was assigned to the even-numbered rooms in the hall the survey had just interviewed residents in and acknowledged he had not offered HH to her residents. CNA 7 stated germs on hands can cause illness. During an interview on 6/23/26 at 1:32 p.m., the Infection Preventionist 1 (IP 1) stated staff was expected to offer HH to residents before meal trays were served; washing hands is best practice. A review of the facility policy titled, Hand Hygiene revised 9/1/20 indicated, The facility considers hand hygiene as the primary means to prevent the spread of infection.The following situations require appropriate hand hygiene.before eating. 2. During a concurrent interview and observation on 6/25/26 at 7:27 a.m. Licensed Nurse 4 (LN 4) removed a glucometer from the top drawer of a medication cart and took a blood sample from Resident 76. LN 4 cleaned the glucometer with wipes from a Super Sani-cloth (a disposable wipe soaked in germicidal solution in a container with a purple top) container and immediately replaced the glucometer back in the top drawer of the medication cart. LN 4 stated she was unaware she needed to keep the surface of the glucometer visibly wet (dwell time) for at least two minutes for the germicide to effectively kill germs. During a concurrent interview with LN 5 and observation on 6/25/26 at 10:51 a.m., a Sani-cloth Plus wipes container (a container with a red top) was on top of Medication Cart 2. LN 5 stated the Sani-cloth Plus wipes were used to clean the glucometers. During an interview with the IP 2 on 6/26/26 at 1:19 p.m., the IP 2 stated the glucometers should be cleaned after each use. The IP 2 stated staff could use either the Super Sani-cloth wipes or the Sani-cloth Plus wipes to clean the glucometers. IP 2 stated that not cleaning between resident use had the potential to spread germs to other residents and staff. During an interview with the Director of Staff Development (DSD) on 6/26 at 1:25 p.m., the DSD stated nursing staff have been instructed to clean the glucometers with either the Super Sani-cloth wipes or the Sani-cloth Plus wipes The DSD also confirmed all the glucometers in the facility were the Assure Platinum glucometers. A review of the manufacturer's manual of the Assure Platinum Blood Glucose Monitoring System revised September 2024, indicated Super Sani-cloth Germicidal Disposable wipes were the recommended wipes that should be used to clean and disinfect the Assure Platinum glucometers. A review of the facility's undated document titled, Glucometer Cleaning Instructions indicated, .use. Super Sani-cloth germicidal disposable wipes to wipe down Glucometer, then allow 2 minute wet time. 3. During consecutive observations on 6/25/26 at 2:55 p.m. and 3:01 p.m., staff could not find the IPCP binder in both Nurse's Station 2 and Nurse's Station 1 respectively. During an interview on 6/25/26 at 3:31 p.m., the facility Administrator (ADM) confirmed she could not find the facility's IPCP bind. The ADM was unable to provide documented evidence that the facility had reviewed the IPCP at least annually. 4. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses of COPD (long term lung condition where the lungs cannot adequately transfer oxygen into the blood, causing persistent low oxygen levels) and Dependence on Supplemental oxygen. In an observation in Resident 58's room on 6/23/26 at 8:25 a.m., Resident 58 was sitting up in bed with a nasal cannula in place to both nostrils. The oxygen concentrator was noted to be administering oxygen at 1.5 liters per minute. The outside vent had dust buildup. A review of Resident 99's face sheet indicated admission to the facility in June 2026 with diagnoses which included COPD. During an observation on 6/23/26 at 10:04 a.m., Resident 99's oxygen condenser filter was noted with brown dirt and dust buildup and photographed. During a concurrent observation and interview in Resident 58's room, on 6/26/26, at 8:30 a.m., with the Director of Nursing (DON), the DON stated the Treatment Nurse is supposed to change the oxygen tubing and humidifiers on the condensers every Sunday. The DON stated it was the Treatment Nurse's responsibility to clean the filters when they changed everything else. Clearly, they missed the filters. The implications were that the residents could inhale dust and increase the risk of infection. The DON stated, It's a concern. In an interview on 6/26/2026 at 8:35 a.m., the IP 2 stated, There are a lot of concerns with dusty filters. inhaling dust, not getting the O2 concentration the residents need, infection possibilities. I used to be the Treatment Nurse on Sundays. I knew that that was part of the job, rinsing out the filers. A review of facility policy titled Oxygen Therapy, revised 10/10/2025, indicated the policy was if oxygen concentrators are used, the filters will be cleaned per manufacturer's guidelines. 5. During an observation inside Resident 35's room on 6/23/26 at 8:24 a.m., Resident 35 was observed to be coughing and was not wearing a mask for source control (a strategy for reducing disease transmission by blocking respiratory secretions produced through breathing, speaking, coughing, sneezing or singing). Resident 35 had two roommates in the room during this observation. A review of Resident 35's Order Summary Report, for June 2026 indicated the physician ordered Resident 35 to receive an antibiotic for seven days for a diagnosis of pneumonia and COPD. A review of Residet 35's Progress Notes, dated 6/22/26 at 5 p.m., indicated she was administered guaifenesin oral syrup (cough syrup) as needed for cough. A review of Resident 35's Progress Notes, authored by LN 2 on 6/22/26 at 10:51 p.m., indicated, Resident [Resident 35] on alert charting x [for] 10 days. Started on Doxycycline [antibiotic on] 6/19 [at 5 p.m.] for LLL left lower lobe Pneumonia and COPD Exacerbation. A review of Resident 35's Care Plan, initiated by the DON on 6/22/26, indicated, Resident 35 has altered respiratory status AEB [as evidenced by] Chest X-ray with PNA [Pneumonia] and COPD exacerbation. During an interview on 6/26/26, at 9:32 a.m., IP 2 stated Resident 35 may have COPD exacerbation and did not require droplet precaution. IP 2 stated the x-ray result did not indicate pneumonia, so she was not placed on droplet precaution. A review of Resident 35's hospital chest x-ray results dated 6/18/26 indicated, Mild left basilar airspace opacities, which may represent atelectasis, infection, or aspiration. During an interview on 6/26/26 at 9:36 a.m., the DON stated if Resident 35 had an infection, she could transmit it to her roommates. The DON stated she did not have enough information at this time to determine what precautions Resident 35 had to be on but stated she would talk with IP 2. A review of Centers for Disease Control and Prevention (CDC) guideline titled Transmission Based Precautions, dated 4/23/24 indicated, Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking.Source control: put a mask on the patient.Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives.

Based on observation, interview and record review, the dietary staff failed to follow recipes during meal preparation for 87 residents who ate meals from the kitchen on 6/23/26 and 6/24/26.This failure resulted in unpalatable meals and decreased the facility's potential to prevent malnutrition and weight loss.Findings:In an interview on 6/23/26 at 6:52 a.m. Resident 28 stated, I don't like the food. It's the same thing every day. The flavor is okay, but no variety.In an interview on 6/23/26 at 7:40 a.m., Resident 97 stated, The food is bad, indescribable it's so bad.In an interview on 6/23/26 at 7:54 a.m., Resident 98 stated, The food is okay, not what I am used to. In an interview on 6/23/26 at 8:38 a.m., Resident 38 stated, I don't like the food much.In an interview on 6/23/26 at 10:13 a.m., Resident 75 stated, The food is not very good.In an interview on 6/23/26 at 10:25 a.m. Resident 22's family member stated, She [Resident 22] doesn't like the food. It's pretty bad.In an observation on 6/23/26 beginning at 10:46 a.m., the [NAME] (CK) put frozen chicken breasts on a baking tray and placed the tray in the oven. The CK stated, This is a convection oven, not a conventional one. We can put frozen [food] in the oven. In an observation and concurrent interview on 6/23/26 at 11:02 a.m. as the CK made the pureed bread, the CK started putting bread in the food processor and the Certified Dietary Manager (CDM) pulled the recipe book out for him to follow. The CK looked at it and continued. The CK added more bread to the food processor then obtained a container of white liquid on the bottom and yellow liquid floating at the top. The CK stated he was making enough pureed bread for eight portions. The CK also stated there was a half-gallon of milk and half a cube of butter in the container. The CK said, I like to add more milk because if it's to the recipe, it's not the consistency we need. The CK stated there was about half of a loaf of bread in the food processor, maybe 12 slices. The CK added approximately half of the milk-and-butter liquid and blended it up. The CK confirmed he was making the recipe by sight and clarified, I'm looking for a smoothness. The CK stated he thought the nutritional value of the pureed bread was the same regardless of the ratio of ingredients in a recipe. In an interview on 6/23/26 at 11:12 a.m. with the CDM, the CDM stated, If the ratios are not as the recipe states, the nutritional value could be different. In an interview on 6/23/26 at 11:40 a.m. with the California Department of Public Health Nutrition Consultant (CDPH NC), the CDPH NC stated recipes needed to vary based on the use of a convection oven versus a conventional one because there was a difference between the length of cooking time and temperature. The CDPH NC also stated placing frozen chicken directly into a convection oven will cause the chicken to come out dry and rubbery. In an observation on 6/23/26 at 11:52 p.m., the survey team tasted the baked chicken the CK made and identified it was dry, tough, and had no flavor.In an interview on 6/23/26 at 12:40 p.m. in the dining room, Resident 71's family member stated, The meat [chicken] was super tough, couldn't eat it. [Resident 71] spit it out! And the apples are hard. It's one or the other. The food hasn't been good for a long time. In an observation and interview with CNA 8 on 6/24/26 at 8:34 a.m. CNA 8 was removing Resident 38's food tray out of her room. Resident 38's food was observed to have been untouched. CNA 8 stated, She doesn't like to eat [it].In an interview on 6/24/26 at 9 a.m., Resident 79 stated, Oh god, the food is awful. It's bad.In an observation on 6/24/26 beginning at 9:38 a.m. the CDM was making scalloped potatoes for lunch. The CDM stated he followed the recipe when he made the sauce. The CDM spooned an unmeasured amount of potatoes into the cooking pan and filled it with an unmeasured amount of sauce. The CDM added more potatoes and stated, I am looking for there to be enough sauce in here, so the potatoes don't get dry. The CDM then put paprika on top of the potatoes, covered the cooking pan, and put the pan in a convection oven. In an observation on 6/24/26 beginning at 9:47 a.m. the CDM made pureed scalloped potatoes. The CDM put an unmeasured amount of potatoes in the food processor, added two scoops of unmeasured sauce and mixed it to a visual consistency he liked. The CDM then added more sliced potatoes in the food processor and stated, This is for minced/moist. The CDM then covered the potatoes and put the pan in the oven. In an observation on 6/24/26 beginning at 10:23 a.m. the CDM made Italian Herb Vegetables and did not add butter or seasonings. The CDM also did not add butter or seasoning to the mashed vegetables. In an observation on 6/24/26 beginning at 10:43 a.m. the CDM made Fish Italiano. The CDM lightly spread out the sauteed onions on the base of the pan and placed the fish on top of the sauteed onions. The CDM stated, They're [the fish] not all the way frozen. They've been thawing in the fridge for a day and a half. The CDM then sprinkled salt, pepper, and garlic powder on the fish, covered the pan, and put the pan on top of the oven. The CDM then made two additional pans of fish following the same steps. The CDM stated, There won't be enough and obtained frozen fish from the freezer. The CDM then placed frozen fish filets directly into a pan without adding sauteed onions, then sprinkled salt, pepper, and garlic powder on it. In an observation on 6/24/26 beginning at 11:11 a.m. the CDM made mashed potatoes from a box. The CDM placed an unmeasured amount of mashed potato flakes in the mixer, used the same liquid mixture he used for the scalloped potatoes, not measuring, and added it to the potatoes as they mixed. The CDM confirmed he was cooking by sight when he stated, I'm looking for consistency, no lumps, smooth texture.A review of the facility's recipe for baked chicken indicated, .Chicken breasts take less cooking time than thighs.Place chicken on sprayed sheet pans or pans lined with foil. Blend all ingredients [melted margarine, salt, pepper]. Brush over chicken. Bake at 350 F [Fahrenheit, a measurement of temperature] for 30-50 minutes (check temperature at 30 minutes). Chicken breasts cook about 30-40 minutes and thighs 40-50 minutes. Internal temperature must register at least 165 F for 15 seconds.A review of the facility's recipe for scalloped potatoes indicated, If using dehydrated potatoes, reconstitute in boiling water 20-30 minutes. Drain potatoes. If using fresh, peel potatoes and slice 1/4 [inch, a measurement of length] or less. Place potatoes dehydrated or fresh, in greased pans.Pour sauce over potatoes and stir to blend. Sprinkle paprika over potatoes. For dehydrated potatoes, bake 25 minutes at 400 F. For fresh potatoes, bake about 1 1/2 hours at 350 F. Cover first hour and then uncover. Potatoes are done when tender. Internal temperature must register at least 145 F for 15 seconds.[For] Minced & Moist: Mince potatoes before preparing recipe, no skin. Mince until the food is in pieces= 4 mm [millimeters, a measurement of length] by 15 mm. Moisten with additional sauce as needed. Utilize the critical tests and IDDSI [International Dysphagia Diet Standardization Initiative, a global framework that standardizes terminology and testing methods for texture-modified foods and thickened liquids for individuals with swallowing disorders characterized by specific numbers, colors, and descriptors to ensure safe consumption] audit to confirm texture meets level #6 specifications.[For] Pureed: Puree #8 [1/2 cup], following the pureed recipes in the Food Safety/Misc. section of Book #1. Utilize the critical tests [i.e. Fork Drip Test, using a fork, place a small amount of the pureed food on the fork. Liquid should not continuously drip through the fork prongs. Spoon Tilt Test, the food holds its shape on the spoon and falls off fairly easily when the spoon is tilted or lightly flicked.] and IDDSI audit to confirm texture meets level #4 specifications.A review of the facility's recipe for Italian Herb Vegetables indicated, .Cooks- taste vegetables and add more Italian Seasoning if needed. If using fresh vegetables, wash well under cool running water. [NAME] vegetables until tender. Add margarine and seasonings.A review of the facility's recipe for Fish Italiano indicated, Wash and rinse onions under cold running water. Saute onions in margarine until transparent. Divide among pans (24 servings/ pan). Place fish on top of the onions, sprinkle lightly with salt, pepper, and garlic powder. Place tomatoes on top of fish, sprinkle with basil, oregano, and parsley. Cover and bake at 375 F for 15-25 minutes. Spoon juice over the fish and serve. Internal temperature must register at least 145 F for 15 seconds.A review of the facility's menu system guide indicated, .IF YOU HAVE A CONVECTION OVEN: A good rule of thumb is to reduce the temperature stated in the recipe by 25-50 F. Also, reduce the total bake/roast time by approximately 10-15 percent.In an interview on 6/25/26 at 8:08 a.m., the CDM stated, I misread the recipe. I did not see the tomato was to be cooked with the fish in the pan. Yes, it could have affected the palatability of the food. It is important to follow the recipe. In an interview on 6/25/26 at 3:26 p.m. with the Director of Nursing (DON), the DON stated it was important for food to be tasty and pleasing to look at so the residents do not lose weight and the facility can be as homelike as possible.A review of facility's Policy and Procedure titled, Standardized Recipes, revised 7/1/14 indicated, Food products are prepared and served by the dietary department will utilize standardized recipes.Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications.A review of the facilities job description of [NAME] indicate that a Principal Responsibility included, Prepares, in a timely manner, nutrition and attractive meals and supplements for all residents according to Provider orders, menus and recipes. Ensuring accuracy with therapeutic diet modifications and texture modifications.

Based on observation, interview and record review, the dietary staff failed to store food in a sanitary manner for a census of 87 residents when:The kitchen floor and mats appeared dirty;Silver storage shelves had dried white matter on the surface of the shelves and its legs;The [NAME] (CK) did not wear a hair net;Expired food was in the refrigerator;The hand-washing sink appeared dirty;The recipe holder was sticky; and,There was food splatter observed under a shelf above the cooking station. These failures decreased the facility's potential to ensure a sanitary kitchen and prevent foodborne illnesses.Findings:During an initial observation of the kitchen on 6/23/26 starting at approximately 5:43 a.m., this surveyor observed:-CK wearing a baseball cap with exposed hair, and no hairnet.-Black/brown footprints on the red/brown floor tiles, dried white water build-up under the sanitizer and rinse sinks, built-up black dirt was embedded on the edge and engrained into the wood threshold between the red/brown tiles and the white laminate flooring; dried spots of brown liquid throughout the red/brown kitchen floor and between large silver storage shelves.-At the corners of the room, the white laminate flooring had layered black/brown dirt with speckles of crusted yellow, orange, and red dots.-The black floor mats had dried white matter throughout the crevices.-The surface of the silver shelves had dried white substance throughout the shelving and the legs.-Several expired foods were in the refrigerator, including:A bag of cut cabbage with a use by date of 6/20/26;A bag of greens with a use by date of 6/17/26;A container of shredded coconut, opened, with an open date of 12/4/25 and a use by date of 8/27/26;A container of Choco Pudding was labeled good from 6/22/36 to 6/13/26;A Chef Salad dated 6/21/26, but the date did not indicate if it was the date the salad was made a use by date; and,A resident's cereal was not dated when opened.- The handwashing sink had a brown/yellow substance along the back edge of the sink and the grouting between the sink and wall was crusted with a brown/yellow substance.In a concurrent observation and interview on 6/23/26 beginning at 5:49 a.m. the CK confirmed the floor, and floor mats did not look clean. The CK stated, It's usually the nighttime dishwasher's job. They tried to clean it but no this doesn't look clean.In an interview on 6/23/26 at 10:42 a.m., the Certified Dietary Manager (CDM) observed the photos of the CK not wearing a hair net under his cap and stated, No that is not common practice. He should be wearing a hairnet.In an interview and concurrent observation on 6/23/26 at 10:46 a.m., the CDM observed the photos of the expired food. The CDM stated he had observed the expired food earlier that morning and threw the items away. However, the CDM acknowledged the container of shredded coconut was expired and stated he was going to throw it away now. During an observation of CK cooking a sticky substance on the recipe holder was observed. The CDM confirmed the sticky substance on the recipe holder and brought it to the sink to have it cleaned.During an observation of the CDM cooking on 6/24/26 at 9:47 a.m., food splatter was observed on the underside of a shelf located above a food preparation station.In a concurrent interview and observation of the handwashing sink in the kitchen on 6/24/26 at 3:37 p.m. with the CDM and the Registered Dietitian (RD), the RD examined the sink and stated, Yes, that is dirty. The RD added the issue has been identified and reported.During an interview and concurrent observation on 6/25/26 at 8:52 a.m., the CDM observed the underside of the shelf located above the food preparation station and stated, I never noticed that. It needs to be cleaned.A review of the Food & Drug Administration [FDA] Food Code 2022 indicated, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils.Equipment, food contact surfaces, and utensils shall be clean to sight and touch.Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Cleaning, Frequency and Restrictions.PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.A record review of the facility's Produce Storage Guidelines indicated cut cabbage is good for 1 to 2 weeks, greens for 3 to 5 days and the coconut 6 months after opening.

Based on interview and record review, the facility failed to develop and implement a care plan for one resident (Resident 9) of five sampled residents.This failure decreased the facility's potential to ensure Resident 9 can result in missed or delayed interventions in Resident 9's plan of care and cause the resident's suffering or her condition to worsen.Findings:A review of Resident 9's face sheet indicated she was admitted to the facility on [DATE] with diagnoses which included diabetes, and severe protein-calorie malnutrition.During a concurrent observation of Resident 9's wound dressing change and interview with the Wound Nurse on 6/24/26 at 11:16 a.m., the Wound Nurse cleansed and covered Resident 9's pressure ulcer located on her coccyx (tailbone). The Wound Nurse stated Resident 9 had an unstageable pressure ulcer (UTD - serious bed sore where the true depth and severity of the wound cannot be seen because the bottom of the wound is completely covered by thick layers of dead, hardened, or mushy tissue) that recently evolved to a Stage 4 (a very deep, severe open pressure sore that goes completely through all the outer layers of skin, deep into the fat, and all the way down to expose your muscles, tendons, or bones) pressure ulcer.A review of all of Resident 9's care plans did not show a care plan for the UTD or Stage 4 pressure ulcer Resident 9 had upon admission on [DATE].During an interview with the Director of Nursing (DON) on 6/24/26 at 3:22 p.m., the DON confirmed licensed nurses had not initiated a care plan for Resident 9's UTD upon readmission. The DON stated the lack of a care plan did not ensure continuity of care for Resident 9's wound.A review of the facility's policy titled Person-Centered Care Planning effective 5/22/25 indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.that describe.the services that are to be furnished to attain the resident's highest practical physical, mental, and psychosocial well-being

Based on interview and record review, the Interdisciplinary Team (IDT, a collaborative group of healthcare professionals that assess and manage a resident's medical, functional, and social needs) failed to review and revise the comprehensive care plan for one resident (Resident 5) of five sampled residents.This failure decreased the facility's potential to ensure new interventions were included in a resident's person-centered care plan.Findings:A review of Resident 5's face sheet indicated he was admitted to the facility on [DATE] for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety disorder among other medical conditions.A review of Resident 5's care plans to improve his psychosocial well-being, initiated on 12/15/23, indicated there were no updates or revisions made to the original care plans to incorporate the plans or interventions in the recent IDT discussions.A review of IDT's notes dated 5/28/26 and 6/1/26 in Resident 5's electronic medical record (EMR), indicated the IDT met to discuss Resident 5's behavior management related to his increased need for assistance and rehabilitation placement causing marked distress that is out of proportion to the severity and intensity of the stressors and causing significant difficulties with social relationship and social isolation. The IDT's plan was for Resident 5 to receive psychotherapy (often called talk therapy, a process where a patient talk about their thoughts and feelings with a trained mental health professional to help the resident feel better, handle stress, and change habits that make life hard) to decrease depressive and anxious symptoms.During a concurrent interview with the Minimum Data Set (MDS) Nurse and review of Resident 5's care plans on 6/25/26 at 9:26 a.m., the MDS Nurse acknowledged she could not find an updated care plan that reflected the IDT's intervention of obtaining psychotherapy for Resident 5. The MDS Nurse also could not find documented evidence that a referral for psychotherapy was initiated. The MDS Nurse stated care plans were expected to be updated after weekly IDT meetings as appropriate.During a concurrent interview with the Social Services Director (SSD) and review of Resident 5's recent IDT notes and care plans on 6/25/26 at 9:41 a.m., the SSD confirmed she did not update Resident 5's care plan after the IDT meetings. The SSD acknowledged outdated care plans did not ensure residents' care needs were implemented.A review of the facility's policy titled Person-Centered Care Planning effective 5/22/25, indicated, Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment.

Based on interview and record review, the licensed nurses failed to ensure three residents (Resident 11, Resident 9, Resident 30) of seven residents were fully informed in advance of the risks and benefits of their proposed psychotropic medication (any prescription drug that changes how the brain works and alters the mood, thoughts, behavior, or feelings) when:Resident 11's informed consent was not signed by the resident who was his own Responsible Party (a person appointed to make decisions when a person is no longer able to make them for themselves);Resident 9's informed consent (a conversation between patient and physician where treatment, its risks and benefits and options are explained before the patient agrees to the treatment) was not obtained for the resident's psychotropic medication to treat anxiety disorder and insomnia (trouble falling asleep or staying asleep); and,Resident 30's informed consents were not obtained before the resident's psychotropic medications were administered to treat depression and anxiety disorder. These failures deprived the residents of their right to be informed of the risks and benefits of their treatment and their right to decline and choose an alternative treatment. Findings: A review of Resident 11's face sheet indicated admission in April 2019 with a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression [a mood disorder that causes persistent feelings of sadness and emptiness] to elevated periods of emotional highs), other psychotic disorder not due to a substance or known physiological condition, adjustment disorder with mixed anxiety (a mental health condition characterized by persistent, excessive, and uncontrollable fear or worry) and depressed mood, depression, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) type. This document also indicated Resident 11 was his own responsible party. A review of Resident 11's Minimum Data Sets (MDS- a federally mandated resident assessment tool), dated 6/24/26, indicated Resident 28 had no memory impairment. A review of Resident 11's Psychotherapeutic Drug Informed Consent forms for trazodone (a prescribed medication used to treat major depressive disorder), escitalopram (a prescribed medication used to treat major depressive disorder and anxiety), and divalproex sodium (a prescribed medication used to treat bipolar disorder), dated 4/1/26, indicated Resident 11's RP signed the consent form. Further review of Resident 11's five informed consent forms indicated two of them did not indicate the drug name for which consent was supposedly obtained. In a concurrent interview and record review on 6/26/26 at 12:31 p.m. with the DON, the DON stated Resident 11 did not have capacity. The DON then reviewed Resident 11's chart and stated Resident 11 did have capacity to make his own decisions. The DON then reviewed Resident 11's informed consents for trazodone, escitalopram, and divalproex sodium and stated, These consents are not valid. Further, the DON confirmed Resident 11 was not informed of his own care. In an interview on 6/26/26 at 3:13 p.m. with Resident 11's RP who signed Resident 11's informed consent form on 4/1/26, the RP stated she was hired by Resident 11 to be an advocate but he can answer for himself. A review of Resident 9's face sheet indicated she was admitted to the facility on [DATE] with a diagnosis of depression. A review of Resident 9's order summary indicated she was prescribed lorazepam (a prescription medication used to relieve anxiety, panic attack or trouble sleeping) on 5/8/26. A review of Resident 9's chart showed no documented evidence that informed consent was obtained before Resident 9 was started on lorazepam. A review of Resident 30's face sheet indicated admission to the facility on 2/21/25 with a diagnosis of depression. A review of Resident 30's order summary indicated Resident 30 had orders for licensed nurses to administer mirtazapine (a prescribed medication used to treat major depressive disorder) and lorazepam on 4/29/26. A review of Resident 30's Medication Administration Record (MAR) dated May 2026 indicated Resident 30 received mirtazapine 15 milligrams (mg- metric unit of measurement) at bedtime from 5/1/26 to 5/31/26 and Lorazepam 0.5 mg at least once. A review of Resident 30's chart indicated the informed consents for both Mirtazapine and Lorazepam were obtained on 5/28/26. During an interview with the Director of Nursing (DON) on 6/26/26 at 2:35p.m., the DON stated Resident 9's informed consent for lorazepam could not be found and acknowledged Resident 30's informed consents for mirtazapine and lorazepam were obtained after the medications were first administered. The DON stated informed consents should have been obtained before the medication was started to ensure residents were properly informed about their medications' purpose, possible side effects, and options. A review of the facility's policy titled Informed Consent effective 1/30/26, indicated, the licensed nurse will confirm that the Healthcare Practitioner obtained informed consent. before the first dose.of psychoactive medication. informed consent will be placed in the resident's medical record. A review of the facility's policy titled, Behavioral/Psychoactive Medication Management, dated 1/30/26, indicated, .facility must obtain a resident's written informed consent for treatment using psychoactive drugs.

Based on interview, and record review, the licensed nurses failed to ensure the admission Minimum Data Set (MDS - an assessment tool) was accurately documented for two residents (Resident 6 and Resident 51) of four sampled residents when residents' use of hearing aids and glasses were incorrectly documented.This failure placed Residents 6 and Resident 51 at potential risk for not receiving appropriate care and services for hearing and vision impairments.Findings:A review of Resident 6's face sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD, a progressive, incurable lung disease that blocks airflow and makes breathing difficult), Parkinsonism (an umbrella term for a group of neurological disorders that cause movement problems), and Schizoaffective Disorder, Bipolar type ( a chronic mental health condition combining schizophrenia symptoms-like hallucinations or delusions-with severe mood swings, specifically featuring episodes of mania and sometimes major depression).A review of Resident 6's MDS dated [DATE], indicated Resident 6 had minimal difficulty with hearing. The MDS did not indicate Resident 6 wore a hearing aid This MDS also indicated Resident 6 had a Brief Interview for Mental Status (BIMS, an assessment tool that helps determine an individual's memory and orientation) score of 13, which meant Resident 6 was cognitively intact.During an observation and concurrent interview on 6/23/26 at 9:30 a.m., Resident 6 was sitting up in bed and stated the surveyor must speak louder because he did not hear well. Resident 6 further stated he wore his hearing aids during the day.A review of Resident 6's care plan initiated 4/10/24 did not indicate Resident 6 wore a hearing aid.During an interview on 6/25/24 at 2p.m., the MDS Nurse stated she conducted the initial assessments along with the other licensed nurses and initiated care plans for newly admitted residents. The MDS Nurse reviewed the hearing impairment section of Resident 6's MDS and acknowledged there was an error in the use of hearing aids because Resident 6 did use them. The MDS Nurse stated if correct information is not assessed or obtained, the staff would not be able to provide the residents with their proper care needs.A review of Resident 51's admission record indicated Resident 51 was admitted to the facility on [DATE] with a diagnosis that included Chronic Diastolic Congestive Heart Failure (CHF, occurs when the heart muscle stiffens and cannot relax adequately to fill with blood between beats, leading to fluid backup and congestion), Chronic Obstructive Pulmonary Disease (COPD, a progressive, incurable lung disease that blocks airflow and makes breathing difficult), and Pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus).A review of Resident 51's admission inventory list dated 5/20/26, indicated Resident 51 had a hearing aid in and over back of ear.A review of Resident 51's MDS dated [DATE], indicated Resident 51 had minimal difficulty hearing and vision impairment. The MDS did not indicate he wore a hearing aid and corrective lens for vision impairment. This MDS also indicated a score of , which meant Resident 51 was cognitively intact.A review of Resident 51's care plan dated 5/29/26, did not indicate Resident 51 wore a hearing aid or corrective lenses.During an observation and concurrent interview on 6/23/26 at 10 a.m., Resident 51 was lying in bed wearing glasses and stated, I cannot hear you. Resident 51 stated he wore a hearing aid, but it did not currently work because it needed the batteries to be replaced. This surveyor observed Resident 51's hearing aid lying in a case on the resident's bedside table.During an interview and concurrent record review on 6/25/26 at 9a.m., Licensed Nurse 6 (LN 6) acknowledged she was taking care of Resident 51 today. LN 6 stated she was not familiar with taking care of Resident 51 and would have to look at Resident 51's care plan to determine if he wore a hearing aid. LN 6 reviewed Resident 51's care plan and verified it did not indicate he wore a hearing aid.During an interview on 6/25/26 at 10:30 a.m., LN 7 stated she was not aware that Resident 51 wore a hearing aid. LN 7 confirmed that Resident 51's belongings list did indicate Resident 51 had a hearing aid.During an interview on 6/26/26 at 9:45 a.m., the MDS Nurse acknowledged there was an error in Resident 51's MDS as it indicated he did not use a hearing aid or used glasses, but he did.A review of the facility's policy and procedure titled, Resident Initial admission Assessment, revised date 3/23/23, indicated, Upon admission to the facility, licensed nursing staff will complete an initial admission assessment, to identify the Resident's needs and develop plans of care. The assessment will be documented in the medical record.

Based on observation, interview, and record review, the Director of Nursing (DON) and Consultant Pharmacist failed to ensure controlled drugs (drugs or other substances that are tightly controlled by the government because it may be abused or cause addiction) that were ready to be disposed of, were securely stored inside the facility, when 30 tablets of hydrocodone (a semi-synthetic opioid prescribed to manage severe chronic pain) and 19 tablets of hydromorphone hydrochloride(a potent opioid used to treat moderate-to-severe pain) were discovered missing from the facility's locked box of controlled medications.This failure decreased the facility's potential to prevent drug diversion (the unlawful channeling of regulated pharmaceuticals from legal medical sources to the illicit marketplace or for personal, unauthorized use) of controlled drugs.Findings:A review of a facility document titled, Controlled Substance Disposition Log, dated May 2026, indicated the DON received hydrocodone and hydromorphone from a licensed nurse on 5/5/26. This document also indicated that the DON and the Consultant Pharmacist destroyed other controlled drugs on 5/21/26, except for two missing controlled drugs.During an interview on 6/23/26 at 7:30 a.m., the DON stated she was the only person who had the keys to the lock boxes that stored controlled medication that needed to be destroyed.During a concurrent observation and interview with the DON on 6/26/26 at 9:02 a.m. the DON stated on 5/21/26 the Consultant Pharmacist arrived to assist her to destroy the narcotics and other medications. The DON stated that it was at that time that she observed the bar lock on the file cabinet was broken at the bottom. After opening the top drawer, the DON found that the internal lockbox was not fully closed. Inside the lockbox, multiple bubble pack (also known as blister packs used to organize medications into individual, sealed compartments according to the exact day and time they need to be taken) cards were still present; however, the partially closed lid raised concern. The DON noted that the internal lockbox in the file cabinet drawer had been loose and needed to be pushed down to fully engage the lock prior to the discovery. The DON stated as she and the Consultant Pharmacist reviewed the narcotic count sheets and cards to begin the narcotic destruction, they identified 30 tablets of hydrocodone and 19 tablets of hydromorphone were missing. The DON stated that during the facility's internal investigation, she reported that the office door did not meet double lock requirements and could be opened using a credit card. In a video recorded observation with the DON, the DON demonstrated that the internal lock box could be opened by a spoon if the lid was not firmly pushed down to engage the lock.A review of a facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated May 2022 indicated, Medication in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, disposal, and record keeping in the facility .Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed.

Based on interview, and record review, the licensed nurses failed to ensure communication care needs between facility staff and the hospice provider for one resident (Resident 98) of two sampled residents when the facility did not have a care plan for hospice care. This failure placed Resident 98 at a potential risk of not having her care needs met.Findings:A review of Resident 98's face sheet indicated she was admitted to the facility in June 2026 on hospice care (care for the terminally ill) with a diagnosis of adult failure to thrive and dementia (a progressive state of decline in mental abilities).A record review of the hospice binder at the nurse's station on 6/25/26 indicated there was no hospice care plan for Resident 98.In an interview on 6/25/26 at 11:38 a.m. with the Hospice Admitting Nurse (HAN), the HAN stated when a resident is placed on hospice, she does an assessment, develops a care plan, and evaluates and orders medications. The HAN then sends all the documents to her office where the medications are ordered and the medication list and care plan are faxed to the facility. The HAN stated, Every hospice patient has a care plan.In an interview on 6/25/26 at 3:40 p.m. with the Director of Nursing (DON), the DON stated, The ball was dropped by both parties. Her [Resident 98's] care plan was not sent to us, but I did not monitor to follow up. In an interview on 7/1/26 at 10:21 a.m. with the Hospice Agency (HH), the HH stated, Per our notes, on 6/11/26, the medical records coordinator faxed the face sheet, plan of care, medication list, initial admin note, initial orders and the CTI [Certification of Terminal Illness] to the facility. A review of the facility's Hospice and Nursing Facility Services Agreement, indicated, .the Director of Nursing at the Facility shall be responsible for working with the Hospice representative to coordinate care for each Hospice Patient. A review of the facility's policy and procedure, titled, Hospice Care of Residents, indicated, The Hospice and Facility will collaborate on a Care Plan for the resident.

Based on observation, interview and record review the facility failed to ensure the safety of one of five sampled residents, Resident #1, when they did not provide adequate supervision and monitoring to prevent Resident #1 from leaving the facility. This failure resulted in Resident #1 to leave the facility unnoticed and walk down a public sidewalk on the road in front of the facility. This had the potential for Resident #1 to experience a fall, wander into the street with traffic or become confused and scared.On 5/11/26 at 8 a.m., the Department was notified that Resident #1 had eloped from the facility on 5/9/26 at 7:45 p.m. The facility indicated the DON was notified by the facility nurse on 5/9/26 at 7:45 p.m., that Resident #1 had been observed on the sidewalk on the public road outside the facility. Resident #1 was easily redirected by staff back into the facility. The nurse completed an assessment and did not observe any physical injuries. During a record review, a document titled Face Sheet (resident demographics) dated 5/5/26, indicated Resident #1 was admitted on [DATE] with diagnoses that included Severe Dementia (the most debilitating stage of dementia that include profound mental decline, physical decline and behavioral problems). During an interview on 5/21/26, at 10:30 a.m., the Director of Nursing stated on 5/9/26 she was called at 7:45 p.m. and informed Resident #1 had eloped. She stated Resident #1 was observed by staff to have walked on the sidewalk on the street outside the facility. She stated Resident #1 was redirected by the staff to come back to the facility. The Director of Nursing stated Resident #1 was a newly admitted resident and staff were unfamiliar with her. She stated staff thought she was a visitor when she walked out the front doors and let herself out of the secure front gate. The Director of Nursing stated she was unaware that Resident #1 had any risk for elopement. She stated Resident #1 was admitted [DATE] and eloped on 5/9/26. During a concurrent medical record review and interview on 5/21/26 at 11:30 a.m. with the Director of Nursing, the Case Manager and the Administrator in Training (AIT), the DON stated the Interdisciplinary Team Meeting (IDT) had met the day after Resident #1 eloped on 5/9/26. The Case Manager stated the care plan for elopement was not completed until 5/12/26. The Case Manager stated if Resident #1 had the signaling device (A bracelet worn by cognitive impaired residents to prevent wandering incidents by initiating an alarm near doorways and exits when the person wearing the device is within a certain distance of an alarm sensor.) on when her elopement assessment was completed, she would not have eloped. The Case Manager stated an elopement assessment for Resident #1 was completed upon her admission on [DATE] and indicated a score of 5. She stated any score above 0 was a high risk for elopement. She stated a care plan for elopement had not been initiated and a signaling device was not applied. She stated with a high risk of elopement score of 5 a signaling device should have been applied. The Case Manager stated there was not enough supervision or monitoring for Resident #1. The AIT stated Resident #1 should have been put in a room where more staff could supervise and monitor her, but staff did not know her or that she had a high risk for elopement. She stated, They were unfamiliar with her. During a record review and interview on 5/21/26 at 1 p.m., the Minimum Data Set (MDS) (An assessment tool) staff stated Resident #1's elopement assessment was not completed and so it did not trigger a care plan with interventions to prevent her from eloping. She stated nurses never complete it and so she was the only one who would trigger that care plan during her completion of the admission assessment documentation. She stated it would not be completed until she arrived at work. She stated she did not work evenings or weekends, so if a resident is admitted at those times, they would not have a care plan for elopement if they needed one. She stated Resident #1 had a high-risk score of 5 for elopement on her admission and if she had a care plan maybe she would not have eloped. She stated it should have been done, and maybe it would have stopped Resident #1 from eloping. Review of a facility Policy and Procedure titled Wandering and Elopement, revised 1/31/23, indicated The IDT will develop a plan of care considering the individual risk factors of the resident. A signaling device is an intervention that can be utilized as part of a Resident's plan of care when they have been identified as being at risk for elopement. Review of a facility Policy and Procedure titled Signaling Device, dated 4/22/26, indicated A signaling device is an intervention that can be utilized as part of a Resident's plan of care when they have been identified as being at risk for elopement.

Based on observation, interview and record review, the facility failed to implement comprehensive care plan interventions for one of two residents (Resident 1) when the facility failed to provide documentation that fall risk and post fall care plan (written, and personalized document outlining a resident's medical, physical, and emotional needs, along with specific goals and treatment strategies) interventions were implemented.These failures resulted in Resident 1 experiencing repeated falls with potential for more severe injuries.Findings:During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated he was admitted to the facility on [DATE] with diagnoses including progressive decline in mental abilities with anxiety (a feeling of fear, dread, and uneasiness), generalized muscle weakness, trouble falling asleep or staying asleep, impaired ability to communicate effectively, and abnormalities of gait (walking) and mobility.During a review of Resident 1's Minimum Data Set (MDS - federally mandated resident assessment tool), dated 12/25/25, indicated he had memory impairment based on the Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement), and had two or more falls since the previous assessment.During a review of Resident 1's SBAR Communication Form (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/15/25, 4/28/25, 5/3/25, 7/24/25, 10/3/25, and 10/12/25, each of these forms indicated Resident 1 had a fall incident accounting for Resident 1 falling six times in 2025.During a review of Resident 1's care plan titled, [Resident] is at high risk for falls., initiated 3/5/25 with a target date of 5/19/26, indicated interventions the facility would implement included: .Verify and document resident location every 2 hours Date Initiated: 05/27/2025 .Resolved date 7/30/25.offer toileting Q [every] 2 hours while awake r/t [related to] fall on 7/24/25. Date initiated 7/30/25.resolved date 1/28/26.Review information on past falls and attempt to determine cause of falls. Record possible root causes [this is known as a root cause analysis]. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 10/04/25. A review of Resident 1's care plan titled, [Resident 1] has had an actual unwitnessed fall with no injury., initiated 1/26/26, indicated, .continue interventions on the at-risk [for falls] plan [care plan] .A review of Resident 1's care plan titled, [Resident 1] has had a an unwitnessed fall with serious injury., initiated 1/28/26, indicated, continue interventions on the at-risk [for falls] plan [care plan]. and new intervention .PT [physical therapy- treatment that helps you improve how your body performs physical movements] eval [evaluation].During a concurrent record review and interview on 3/5/26 at 3:29 p.m., with the Director of Nursing (DON), Resident 1's fall risk evaluations (Standardized screening instrument used by healthcare professionals to evaluate a patient's likelihood of falling. Where a score of 10 or higher indicates the resident is at high risk of falls), dated 3/4/25 to 12/12/25, were reviewed. The DON verified the scores ranged from 10 to 20, which indicated Resident 1 was at high risk of falls. During an interview on 3/6/26, at 11:42 a.m. the Administrator confirmed, despite searching, the facility was unable to produce documentation indicating Resident 1's root cause analysis was performed. The Administrator acknowledged the absence of documentation indicated Resident 1's specified interventions from the care plan of care was not done.During an interview on 3/6/26, at 12:25 p.m., the Administrator confirmed, despite searching, the facility was unable to provide the documentation to indicate Resident 1's location was monitored and toileting was offered every two hours. The Administrator also acknowledged the facility was unable to produce documentation that Resident 1 had a PT evaluation completed as the care plan indicated should have been done.During a review of the facility's policy titled, Person-centered care planning, effective 5/22/25, indicated, the facility must develop and implement a comprehensive person-centered care plan for each resident.and describe services that are to be furnished to attain or maintain the resident's well-being.

Based on interview, and record review, the facility failed to provide services according to professional standards of practice for one of six sampled residents (Resident 1) when 72-hour monitoring was not completed following a change of condition (COC).This finding had the potential to result in psychological distress, physical injury, and worsening mental health symptoms for Resident 1.A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included dementia (severe decline in memory and thinking), major depressive disorder (intense sadness for at least two weeks), post-traumatic stress disorder (a mental health disorder triggered by trauma, causing lasting symptoms like flashbacks, anxiety, and avoidance), and suicidal ideations (thoughts of self-harm).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/4/25, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 11 which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). Resident 1's MDS also indicated he had felt down, depressed or hopeless nearly every day during this period.A review of Resident 1's Progress Note, dated 1/11/26 at 3:45 p.m., indicated Resident 1 was struck in the left front shoulder twice, with a closed fist, by another resident.A review of Resident 1's Interdisciplinary Team (IDT, a team of professionals from different fields who work together, sharing expertise and information to provide comprehensive care or solve complex problems through collaboration ) Note, dated 1/12/26 at 1:19 p.m., indicated Resident 1 told facility staff, I don't know if I am hurt or just upset.A review of Resident 1's Progress Note, dated 1/13/26 at 8:35 a.m., indicated Resident 1 stated he was upset about the altercation with the other resident. The note also indicated, [Resident 1] is very worried the other resident will continue to bother him.During an interview and record review on 2/26/26 at 11:45 a.m. with the Director of Nursing (DON), Resident 1's documentation following the 1/11/26 altercation was reviewed. The DON acknowledged that although a COC had been initiated for Resident 1 following the altercation, continuous 72-hour monitoring notes were not charted for every shift following the assault incident of 1/11/26, and therefore the monitoring could not be verified as completed. The DON stated close supervision of Resident 1's condition was important as he had expressed worry and anxiety about further assaults, and because of Resident 1's many serious psychological diagnoses, including suicidal ideations.A review of facility's policy and procedure (P & P) titled, Change in Condition, effective 8/25/22, indicated, a licensed nurse will document each shift for at least seventy-two (72) hours when there is a change in the resident's condition.

Based on interview and record review, the facility failed to implement their abuse policy for one (Resident 1) of nine sampled residents when a licensed nurse did not immediately document an assessment and conduct 72-hour monitoring for Resident 1 after an alleged abuse incident.This failure had the potential to deny physician and family involvement in the residents' care and result in unmet nursing needs for the resident.A review of Resident 1's admission record indicated he was admitted in October 2025 with the diagnosis of encounter for palliative care (specialized medical care for individuals living with serious, chronic or life threatening illness that focuses on providing relief from the symptoms, pain and stress), acute chronic systolic (congestive) heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), muscle weakness, hearing loss and absence of left leg, below the knee.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/26, indicated Resident 1 had slight memory impairment.In an interview on 1/29/26 at 10:41 p.m. with the Director of Nursing (DON), the DON confirmed she was aware of the allegation of abuse that occurred on 1/9/26. The DON stated she expected licensed nurses to have charted a Change of Condition (COC) on the resident's chart, documented when the MD and family were notified, updated the residents' care plan and monitor the residents for 72 hours after the alleged abuse incident. The DON further stated she also expected the Social Services Director (SSD) to follow-up with the resident and document what occurred during the conversation.In a concurrent interview and record review on 1/29/26 at 10:25 a.m., the DON confirmed the social services 72-hour checks were lacking and there was no assessment documented or progress notes.A review of the facility's undated Abuse Reporting and Documentation lesson plan indicated LNs were to, complete assessment. and skin assessment of alleged victim.notify MD. add to alert charting x [for] 72 hours with appropriate monitors in place for increased distress. LN to document psychosocial q [every] shift and Social Services to document psychosocial q [every] day. IDT [Interdisciplinary Team, a group of healthcare professionals from different fields who collaborate and coordinate a resident's care needs] to review allegations promptly. A review of the facility's policy titled, Abuse Prevention and Management, revised 5/30/24, indicated, the resident will be assessed by the licensed nurse for any physical injuries or emotional distress. Notify the physician and provide treatment as ordered.

Based on interview and record review, the facility failed to ensure one (Resident 1) of nine sampled residents was free from abuse when Resident 1 became the victim of an alleged abuse event.This failure had the potential to negatively impact the resident's psychosocial well-being.A review of Resident 1's admission record indicated he was admitted in October 2025 with the diagnosis of encounter for palliative care (specialized medical care for individuals living with serious, chronic or life threatening illness that focuses on providing relief from the symptoms, pain and stress), acute chronic systolic (congestive) heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), muscle weakness, hearing loss and absence of left leg, below the knee.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/26, indicated Resident 1 had slight memory impairment.In an interview, on 1/29/26 at 10:41 a.m. the Director of Nursing (DON) stated the facility substantiated the allegation of abuse and CNA 1 was terminated from her position. A review of a Termination Request email dated 1/12/26 at 12:30 p.m. by the Administrator and written to the corporate office stated, I am requesting to terminate employee [CNA 1] for abuse. The employee was overheard while providing a shower to a resident yelling and swearing. The resident was visibly bothered upon the interview. An interview on 1/29/26 at 1:21 p.m. with Resident 1, Resident 1 stated CNA 1 yelled and sweared [sic] at him and he did not like how he was treated.A review of Resident 1's care plan, dated 1/12/26 indicated Resident 1 was a victim of alleged abuse secondary to CNA [1] yelling at him when in the shower and calling him an asshole. During a review of the facility's policy titled, Abuse Prevention and Management, effective 2024, the policy stipulated, The facility does not condone any form of resident abuse., include[ing] verbal abuse. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes despairing and derogatory terms directed to resident.

Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) was treated with respect and dignity when a licensed nurse (LN) took her call light and bed remote away from her.This failure had the potential to result in Resident 1 being unable to request assistance when needed.Findings:A review of Resident 1's admission record indicated she was admitted in March 2023 with the diagnosis of chronic kidney disease.A review of Resident 1's nursing note, dated 11/30/25 and written by LN 1, indicated LN 1 had taken the resident's call light and bed remote away from her while in her room. LN 1 indicated Resident 1 had been moving her bed up and down and pushing her call light repeatedly and she expected the behavior to stop.During an interview, on 1/22/26 at 12:50 p.m. with the Director of Nursing (DON), the DON stated LN 1 had acted inappropriately when she took Resident 1's call light and bed remote away from her. The DON stated the facility is Resident 1's home, she considered the call light and bed remote Resident 1's personal property and agreed it was a resident's rights issue.During a review of the facility's policy titled, Resident Rights, revised 1/1/12, the policy stipulated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

Based on interview and record review, the facility failed to report an allegation of abuse timely for one of two sampled residents, Resident 1, when Resident 1's allegation of harm was not reported to the Department within two hours. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.On 1/31/25 at 4:40 p.m., the Department received a document titled Report of Suspected Dependent Adult/Elder Abuse (a critical document used by mandated reporters to report allegations of abuse of elders; also called SOC 341) from the facility that indicated, On 1/31/25 at 2:45 pm during chart review Nurse Consultant identified a progress note written that a resident felt that she was abused by the nurse who did her treatment on Sunday on 1/26/25 . The report further indicated that Resident 1 was the resident who reported the abuse.During a record review on 12/23/25 at 4 p.m., Resident 1's face sheet indicated an admission date of 11/18/24, age of 81 years, and multiple diagnoses including heart failure (heart is too weak to adequately pump blood and oxygen out to meet the needs of the body) and venous insufficiency (failure of the veins to adequately circulate the blood, especially from the lower extremities). Resident 1's nurse progress note written by Licensed Nurse (LN) A, dated 1/30/25 at 5:14 p.m., indicated, This nurse was assisting the treatment nurse with treatments 1/29/25 at about 1130 AM. Resident brought up that someone had came [sic] by at about 10:30 at night to speak with her about the incident that occurred on Sunday with the fill in treatment Nurse [staff named], who on 1/26/25 performed the wrong treatment, by using scissors to 'debride' [remove damaged tissue] the thick dry skin on her legs, that the resident expressed muliple times for her to stop because she was having 9/10 pain screaming and gripping onto the bed, [staff named] refused to stop. After providing education the resident stated what happened to her was abuse . This resident expressed she feels unsafe . This nurse and [treatment] nurse immediately reported this to our administrator . both [treatment] nurse and this nurse felt more needed to be done to protect our resident who expressed multiple times she doesn't feel safe, and feels she was abused during this [treatment] error.During a phone interview on 12/30/25 at 9:24 a.m., LN A stated she remembered speaking with Resident 1 and writing the progress note dated 1/30/25 about the conversation. LN A stated she felt what Resident 1 told her on 1/29/25 about the painful treatment and feeling abused was reportable to the Department. LN A stated Administrator was responsible for reporting allegations of abuse and it needed to be reported to the Department within two hours.During a phone interview on 1/13/26 at 3:14 p.m., Administrator stated allegations of abuse needed to be reported to the Department within two hours.Review of facility policy Abuse Prevention and Management, last revised 6/30/24, indicated, Policy: . The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. Definitions: . 'Covered Individual' and 'mandated reporter' are defined as anyone who is an . employee . of the facility. Notification of Outside Agencies for All Allegations of Abuse: The Administrator or designated representative will . send a written SOC341 report to . [the Department] within (2) hours.Review of the General Instructions page of the document Report of Suspected Dependent Adult/Elder Abuse, last revised 2/2024, indicated Any mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting abuse or neglect, or reasonably suspects that abuse or neglect has occurred, shall complete this form for each report of known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult immediately or as soon as practicably possible.

Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when Resident 1 was administered an incorrect dose of Oxycodone Hydrochloride (medication used to relieve severe pain).This failure decreased the facility's potential to correctly and safely administer medication and prevent adverse side effects.Findings:A review of Resident 1's admission record indicated admission to the facility on 8/18/24 with diagnoses which included dementia (a progressive state of decline in mental abilities) and Asthma (a chronic lung disease which causes arrowed airways and difficulty breathing).A review of Resident 1's progress note dated 11/10/25 at 7:05 p.m., indicated, [Resident 1] was given 20 mg [milligrams, a unit of measurement] oxycodone tab [tablet] that belongs to [Resident 2]. [Resident 1] actual dose ordered is 5 mg. This error was made on AM [morning] shift given by nurse prior.This error was caught during shift change report 11/10/25 at 7 p.m.A review of Resident 1's order summary report indicated Resident 1 had a physician's order dated 4/29/25 to receive 5 mg of oxycodone hydrochloride (HCL) by mouth two times a day.A review of Resident 1's Medication Administration Record (MAR) dated November 2025 indicated Licensed Nurse 1 (LN 1) administered 5mg of oxycodone HCl to Resident 1 at approximately 9 a.m.During an interview on 11/24/25 at 2:39 p.m., LN 1 acknowledged she administered the wrong medication to Resident 1 and stated it was because she verified Resident 1's name on the MAR but did not look at the medication to verify that it was Resident 1's medication. LN 1 stated she may have picked Resident 2's oxycodone medication instead of Resident 1's.During an interview on 11/24/25 at 3:20 p.m., the DON (Director of Nursing) acknowledged the medication error occurred. The DON stated LN 1 did not look at the bubble pack (blister pack cards that contain the medications) a second time and popped the wrong medication from Resident 2's bubble pack. The DON stated when she investigated, she found out that the two medications were right next to each other. The DON provided copies of the oxycodone bubble packs for Resident 1 and Resident 2 where the size difference between the two medications was observed.A review of the facility's policy and procedure titled, Medication Administration, dated 6/26/25, indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.The Licensed Nurse will verify the resident's identity before administering the medication using the 6 rights of medication administration.Right Resident: Confirm with two identifiers.Right Medication: Verify against the MAR and pharmacy label.Right Dose: Ensure accuracy based on provider order.

Based on interviews and record review, the facility failed to ensure an RN (Registered Nurse) provided services at least 8 consecutive hours a day, 7 days a week for 6 days in the month of April 2025.This failure decreased the facility's potential to ensure qualified staff were present to conduct resident assessments, develop and evaluate plans of care, and administer medications that must be administered by an RN.Findings:A review of the facility's current license to operate issued by the California Department of Public Health (CDPH) indicated the facility had a license to operate 104 skilled nursing beds.A review of the Payroll Based Journal (PBJ) Staffing Data Report dated April 1-June 30, 2025, indicated an RN did not work at the facility on the following dates: 4/5/25, 4/6/25, 4/12/25, 4/13/25, 4/19/25, and 4/20/25.During an interview on 9/16/25 at 8:21 a.m., the Administrator (ADM) acknowledged the facility did not have RN coverage on the above listed dates as the facility was struggling to find RNs in April 2025. The ADM stated the facility was unable to admit residents with procedures only RNs could perform.A review of a facility policy and procedure (P&P) titled, Nursing Department- Staffing, Scheduling, & Postings, dated July 2018, 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 the residents admitted for care.If the facility is licensed for 100 or more beds, it will have.At least one Registered Nurse, awake and on duty, in the facility at all times, day and night, in addition to the DONS (Director of Nursing Service).The director of nursing service will not have charge nurse responsibilities.

Based on interview and record review, the facility failed to provide supervision to prevent a fall for one resident (Resident 1) of two sampled residents when Certified Nursing Assistant B (CNA B) left Resident 1 on the toilet unsupervised then left Resident 1 ' s room to attend to another resident. This failure resulted in Resident 1 sustaining a fracture (a complete or partial break of the bone) of the right distal fibula (smaller long bone of the lower leg) and the right distal tibia (larger long bone of the lower leg). Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness and paralysis of the body) affecting the left dominant side, epilepsy (a nerve disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden temporary bursts of electrical activity in the brain that can cause changes in body movement, function, or awareness]), and memory deficit following a cerebral infarction (a stroke caused by disrupted blood flow to the brain). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/13/24, indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or assistance touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for toilet transfers. The MDS further stated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports limbs, but does half the effort) for toileting hygiene (the ability to maintain perineal [genital and anal area] hygiene, adjust clothes before and after voiding [emptying the bladder] or having a bowel movement). A Fall Risk Care Plan, initiated 8/1/23 indicated Resident 1 was at high risk for falls related to confusion, deconditioning (a decline in the physical functioning of the body), gait (a person ' s manner of walking)/balance problems, urinary urgency and incontinence (inability to control the flow of urine from the bladder), poor communication/comprehension, psychoactive drug use (drugs which affect mental processes), unaware of safety needs, desire to be independent with ongoing overestimation of actual abilities, severe bilateral lower extremity (both right and left legs and feet) neuropathy (weakness, numbness, and pain from nerve damage), history of many falls here, at home, and at previous Skilled Nursing Facility. Fall Risk Assessments, dated 7/30/24, 9/4/24, 9/21/24 and 11/17/24 all indicated Resident 1 was a high risk for falls. Resident 1 ' s progress notes between 8/1/24 and 11/30/24 indicated Resident 1 had 4 falls, 3 of which were unwitnessed. An Interdisciplinary Team (IDT, a group of people with different areas of expertise who work together to ensure care) Progress note dated 8/1/24 indicated the Root Cause of Resident 1 ' s fall was, Slipped, and fell to the floor - plus resident has a history of frequent falls. Resident has neuro cognitive deficits [a decline in mental function that is caused by a medical condition] - legs have neuropathy - decreased safety awareness. Resident is very forgetful. Resident has poor judgement. A review of written statement dated 11/17/24 from CNA B about his account of Resident 1 ' s fall indicated, .assisted [Resident 1] by wheelchair to restroom on 11/16/24 around 2235 [11:35 p.m.]. Once [Resident 1] was positioned on the toilet I removed her wheelchair out of restroom to prevent her to attempt to transfer on her own. Before leaving [Resident 1] I reminded her to use call light in restroom when she was finished. While waiting on her I went to assist another resident. On coming back [CNA C] and I heard a resident in room [ROOM NUMBER]B asking for a blanket. While [CNA C] was in room [ROOM NUMBER]B she heard a knock on the wall. On investigating she found [Resident 1] on restroom floor. I proceeded to get charge nurse. A Progress Note, dated 11/17/24 at 00:30 indicated, .this writer called to resident ' s bathroom. Upon arriving, resident was found lying on the floor in the bathroom. Upon assessing resident .there was an obvious ankle injury with severe pain .[Physician] called, informed of situation. Orders received to send to ER [emergency room ] for evaluation . A discharge summary from the hospital dated 11/17/24, indicated Resident 1 was diagnosed with a closed fracture of the right ankle. Resident 1 was discharged back to the facility with a splint (a medical device that immobilizes the ankle joint to help with healing)on the right ankle, pain medications, and instructions to follow up with an Orthopedic Physician (a medical professional who diagnoses and treats conditions of the bones, muscles, and joints). During an interview on 1/7/25 at 11:32 a.m., the Director of Nursing (DON) stated she was notified by staff Resident 1 had fallen after she requested privacy while on the toilet. The DON verified Resident 1 had a history of falls. The DON also stated the best practice was for staff to stay within eyesight, so residents did not try to transfer on their own and fall. The DON further stated CNA B could have provided privacy and still stayed in the room. During an interview on 1/7/25 at 1:43 p.m., Licensed Nurse D (LN D) stated Resident 1 required assistance and supervision in the bathroom as she was a fall risk. LN D stated Resident 1 had a history of noncompliance with using the call light. LN D further stated staff should stand by the bathroom door when a resident requested privacy; staff could not have supervised a resident if they left the room. During an interview on 1/7/25 at 2:15 p.m., the Director of Staff Development (DSD) stated best practice when toileting a resident who requests privacy was to be able to see the resident without them seeing you. The DSD further stated staff could not have provided supervision when they were out of the room. During a review of a facility policy titled, Fall Management Program, last revised 11/7/2016, the policy indicated, A resident who sustains multiple falls will be considered a high risk to fall and as a result may sustain a major injury.

Based on observation, interviews and record reviews, the facility failed: 1. to ensure skin assessments (process of examining entire skin for any abnormalities) was provided thoroughly, accurately documented and ensure treatment was provided when there were skin assessments forms completed but the assessment were inaccurate for one out of two sampled residents (Resident 1) 2. to provide showers regularly and as scheduled for one out of two sampled residents (Resident 1). These failures resulted in: A. inaccurate documentation of Resident 1's skin status, staff not identifying Resident 1 wound on top of his right shoulder, thereby no treatment was rendered on the wound on Resident 1's right shoulder, B. top of Resident 1's right shoulder developed a wound infection (invasion or growth of germs in the body) at the facility that was missed by the staff and, C. Resident 1's hospitalization on [DATE] with a diagnosis of sepsis (life threatening condition, a severe form of infection) secondary to cellulitis (bacterial infection of skin and tissue beneath your skin) and small abscess (a sign of infection, an enclosed collection of pus) of the right superior (towards the head end of the body) shoulder. Findings: A review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high) and Essential Hypertension (HTN, high blood pressure). Resident 1 had an additional diagnosis of Cellulitis (a deep bacterial infection of the skin) of upper limb when he came back from the hospital on 8/12/24. A review of Resident 1's Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 6/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13 out of 15 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1's MDS assessment indicated he was dependent on staff during dressing, toileting, bathing or showering and putting on or taking off footwear. A review of Resident 1's Clinical Admission assessment (the process where nurses identify current and future care needs of the patient and identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient) conducted by the facility nurse dated 6/26/24 indicated Resident 1 had no wound on top of his right shoulder. A review of Resident 1's weekly skin checks completed by the nurses dated 6/26/24, 7/4/24,7/12/24, 7/19/24, 7/29/24, 8/5/24, and 8/12/24 did not indicate Resident 1 had a wound on his right shoulder. During a concurrent interview and weekly skin check record review on 8/15/24 at 12:00 p.m., the treatment nurse stated these weekly skin check documentations were inaccurate. A review of Resident 1's weekly skin checks completed by the nurses dated 7/19/24, 7/29/24, and 8/5/24, indicated Resident 1's skin was intact with no identified skin impairments. During a concurrent interview and weekly skin check dated 7/19/24, 7/29/24 and 8/5/24, record review on 8/15/24 at 12:00 p.m., the treatment nurse stated these weekly skin check documentations were incorrect. A review of Resident 1's electronic treatment administration record (ETAR, a report that serves as a legal record of the treatment administered to the residents) for 6/2024, 7/2024, 8/1/24 up to 8/6/24 indicated there was no treatment ordered and rendered for the wound on top of Resident 1's right shoulder. A review of Resident 1's electronic medication administration record (EMAR- electronic medical administration record) for 6/2024, 7/2024, 8/1/24 up to 8/6/24 there was no medication prescribed to indicate Resident 1 received any medication to treat the wound on top of his right shoulder . A review of Resident 1 hospital admission flow sheet wound note entry dated 8/7/24 indicated the wound on his right shoulder was present when Resident 1 was admitted at the hospital on 8/6/24. A review of Resident 1's hospital discharge note dated 8/12/24 indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. A review of Skilled Nursing Facility Physician Transfer Orders dated 8/12/24 indicated Resident 1 had an order to treat Resident 1's right shoulder wound every Monday, Wednesday and Friday and an order for antibiotic (ABX, medicines that fight bacterial infections) for skin and soft tissue (refers to muscles, fats, or other supporting tissue of the body) infection. A review of the Clinical Admission assessment conducted by the facility nurse dated 8/12/24 indicated Resident 1 had no abscess or wound on top of his right shoulder noted on Resident 1's admission skin sheet. A review of shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers. Based on the documentation, Resident 1 only received 2 bed baths (washing someone in bed) out of 9 showers on these dates: 7/13/24 and 7/31/24. The shower sheet provided for 8/2024 indicated Resident 1 did not receive shower nor bed bath between 8/2/24 and 8/6/24. During an interview on 8/15/24 at 11:00 a.m., Resident 1 stated he had a wound on his shoulder for a while now and they were treating it now. Resident 1 stated no one looked at the wound on his shoulder before. During an interview on 8/15/24 at 11:00 a.m., Certified Nursing Assistant (CNA) A who was assigned to his care today, stated that as far as she knew, Resident 1 had no skin concern and had no wound on top of his right shoulder. During a concurrent observation in Resident 1's room and interview on 8/15/24 at 11:16 a.m., Licensed Nurse (LN) B stated Resident 1 had no wound on top of his right shoulder. CNA A and LN B appeared surprised to find Resident 1 had a dressing on top of his right shoulder. Visualization underneath the dressing on top of Resident 1's right shoulder indicated there was a circular wound with greenish thickened discharge. CNA A and LN B were surprised to learn Resident 1 had a wound on top of his right shoulder. When asked how come they did not know Resident 1 had abscess/ wound on top of his right shoulder, they did not respond. During an interview on 8/15/24 11:27 a.m., LN B, stated she was not aware of the abscess on Resident 1's right shoulder and did not know Resident 1 had abscess/ wound on top of his right shoulder until today. During a concurrent interview and record review of Resident 1's face sheet, discharge hospital note dated 8/12/24, weekly skin assessments on 8/15/24 at 12:00 p.m., the Treatment Nurse (TN C) verified Resident 1 was initially admitted on [DATE] and was readmitted on [DATE]. TN C stated initial skin assessment on 6/26/24 indicated Resident 1 had no wound noted on top of his right shoulder at that time. TN C stated the wound/abscess on top of Resident 1's right shoulder was acquired at the facility. When asked how Resident 1 might have acquired it, TN C did not respond. TN C stated Resident 1's hospital discharge note dated 8/12/24, indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. TN C verified there was no abscess or wound on top of his right shoulder noted on Resident 1's facility admission skin sheet dated 8/12/24. TN C stated she only caught the abscess/wound on top of Resident 1's shoulder yesterday (8/14/24) and did not know it was there when he was readmitted to the facility on [DATE]. TN C stated she did not do a full skin assessment on Resident 1 when he returned from the hospital and did not read the hospital discharge note that was why she did not know about the abscess/wound on top of Resident 1's right shoulder. TN C verified the weekly skin checks by the nurses at the facility dated 6/26/24, 7/4/24,7/12/24, 7/19/24, 7/29/24, 8/5/24 and 8/12/24 were inaccurate and the weekly skin checks completed by the nurses dated 7/19/24, 7/29/24, 8/5/24 indicating Resident 1's skin was intact with no identified skin impairments were incorrect . TN C stated upon review of Resident 1 electronic medical record, she could not determine how and when this abscess/wound on Resident 1 right shoulder started at the facility. TN C stated that when Resident 1 was sent to the hospital, he already had an infected wound and was septic. TN C stated while Resident 1 was still at the facility, Resident 1 did not have a thorough and accurate skin assessments, so the nurses missed the wound on top of his right shoulder, the wound on top of his right shoulder got infected because no one was looking into it and there was no one cleaning and treating the wound at the top of Resident 1's right shoulder. TN C stated the nurses missed the wound infection, the infection worsened and Resident 1 probably already had sepsis before he was sent to the hospital. TN C stated Resident 1's sepsis resulted in hospitalization . TN C stated sepsis could be life threatening. TN C stated on Resident 1's initial admission on 6/26/24 up to when he was sent out to the hospital on 8/6/24, there was no mention of a wound on top of Resident 1's right shoulder on the skin assessments and no treatment rendered on the wound on top of his right shoulder and could be the reason why the wound got infected. When asked why Resident 1's wound on top of his right shoulder was missed, she stated Resident 1 was hard to assess and a lot of staff were scared of him. TN C stated accurate skin assessment were important to ensure residents were receiving the correct and appropriate treatment, to heal the wound, to prevent worsening of wound and to prevent infection. During an interview on 8/15/24 at 1:10 p.m., Licensed Nurse D stated if a resident was sent to the hospital and was diagnosed with sepsis at the hospital, it meant the resident already had an infection at the facility that was missed, not treated with ABX and had worsened. Licensed Nurse D stated untreated urinary tract infection (UTI, illness in any part of the urinary tract, the system of organs that makes urine) and infected wound could be a source for sepsis. LN D stated Resident 1 was scheduled to receive showers twice a week and more often as needed. LN D stated not providing regular showers to residents could result in skin impairment, development of wound, wound infection, missed skin impairment, low self-esteem, and bad odor. LN D stated accurate assessment and accurate documentation of skin impairments ensured quality care, decreased the risk of miscommunication and ensured residents received the right care to decrease risk of complication. During an interview on 8/15/24 at 1:13 p.m., CNA E stated sepsis could be a result of an infection that had worsen because it was missed and not treated. CNA E stated residents were scheduled to receive showers at the facility twice a week and more often as needed. CNA E stated it was important for residents well-being to receive showers as scheduled regularly. CNA E stated not providing showers to residents regularly as scheduled could lead to wound infection, skin impairment, development of wound or pressure ulcer (bed sores, injury to skin and underlying tissue resulting from prolonged pressure on the skin), worsening of wound or pressure ulcer or missed skin impairment. During an interview on 8/15/24 at 1:15 p.m., CNA F stated sepsis was a severe form of infection and it was an infection of the blood. CNA F stated it was a life-threatening condition. CNA F stated sepsis could be a result of UTI or an infected wound that was not treated. CNA F stated residents were scheduled to receive showers twice a week and more often as needed. CNA F stated part of giving bed bath/showers were looking at resident's skin and notifying the nurse of any wound or skin impairment. CNA F stated not providing showers regularly as scheduled could result in skin impairment, development of wound, wound to worsen, wound infection, sepsis, and missed skin impairment. During an interview on 8/15/24 at 1:21 p.m., LN B stated residents were scheduled to receive showers twice a week and more often as needed. LN B stated not receiving showers regularly and as scheduled could lead to wound infection, missed skin impairment, development or worsening of wound or pressure ulcer. LN B stated residents would also have low self-esteem or they might feel uncomfortable. LN B stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and was not treated with ABX. LN B stated sepsis was life threating and source could be from untreated UTI or infected wound. During an interview on 8/15/24 at 1:25 p.m., when asked how come the staff did not know Resident 1 had a wound on top of his right shoulder before until today, the Assistant Director of Nursing (ADON) was silent. The ADON stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant the infection started at the facility, was not treated, and had worsened. The ADON stated sepsis could be a result of untreated, infected wound or UTI. The ADON stated sepsis could result in hospitalization and death. During an interview on 8/15/24 at 1:35 p.m., LN G stated residents were scheduled to receive showers twice a week or more often as needed. LN G stated not providing showers or bed bath to residents regularly placed them at risk for skin impairments, for staff to miss residents skin impairments, wound to become infected, development of sores or worsening of sores. LN G stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and not treated. LN G stated sepsis could be a result of untreated UTI or wound infection. During a concurrent interview and shower sheet record review on 8/15/24 at 1:50 p.m., the ADON stated residents were scheduled to receive showers twice a week and more often as needed. The ADON stated residents should receive at least 8 to 9 showers in a month. The ADON verified Resident 1 was scheduled to receive showers on Mondays and Thursdays. The ADON verified the shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers, but only received 2 bed baths out of 9 showers on these dates 7/13/24 and 7/30/24. The ADON verified that from 8/2/24 up to 8/6/24, Resident 1 did not receive any showers or bed bath at all. The ADON verified the shower documentation indicated Resident 1 was not receiving shower/bed bath regularly. The ADON stated CNAs providing showers or bed baths were supposed to document skin impairments and report to nurses their findings. The ADON stated not providing showers regularly and not assessing resident's skin thoroughly was a contributing factor on why Resident 1's wound on top of his right shoulder was missed and why the wound on top of his right shoulder became infected. The ADON verified there was no treatment initiated for Resident 1's wound on top of his right shoulder until he was back from the hospital on 8/12/24. A review of the facility 's policy and procedure (P&P) titled Skin and Wound Management, revised 1/1/12, the P&P indicated the staff will take appropriate measure to prevent and reduce the likelihood that residents will develop pressure ulcer and or other skin conditions .CNAs will complete body checks on residents shower days and report unusual findings. A review of the facility 's policy and procedure (P&P) titled Showering and Bathing revised 1/1/2012, the P&P indicated observing the skin is performed during bathing. A review of the The Cleveland Clinic publication on skin care on 4/27/2020 indicated . we come in contact with thousands of allergens every day. Showering rinses off those allergens, as well as bacteria and viruses. A review of Healthline published skin care dated 1/29/2019 indicated .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 interviews and record reviews, the facility failed to regularly provide showers for one out of two sampled residents (Resident 1). This failure was a contributing factor for: 1.staff not identifying Resident 1 wound on top of his right shoulder, 2. the wound on top of Resident 1's right shoulder to become infected (having an infection- invasion or growth of germs in the body) that later developed into sepsis (life threatening condition, a severe form of infection). Findings: A review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high) and Essential Hypertension (HTN, high blood pressure). Resident 1 had an additional diagnosis of Cellulitis (a deep bacterial infection of the skin) of upper limb when he came back from the hospital on 8/12/24. A review of Resident 1's Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 6/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1's MDS assessment also indicated he was dependent on staff during dressing, toileting, bathing or showering and putting on or taking off footwear. A review of shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers. Based on the shower documentation, Resident 1 only received 2 bed baths (washing someone in bed) out of 9 showers on these dates: 7/13/24 and 7/31/24. There was no shower sheet provided for 8/2024 which indicated Resident 1 did not receive shower nor bed bath between 8/2/24 and 8/6/24. A review of Resident 1's hospital discharge note dated 8/12/24 indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. During an interview on 8/15/24 at 1:10 p.m., Licensed Nurse D stated Resident 1 was scheduled to receive showers twice a week and more often as needed. LN D stated shower refusal should be documented. LN D stated when care was not documented, it meant the care was not provided. LN D stated not providing regular showers to residents could result in impaired skin, wound development and infection, low self-esteem, and bad odor. During an interview on 8/15/24 at 1:13 p.m., Certified Nursing Assistant (CNA) E stated residents were scheduled to receive showers at the facility twice a week and more often as needed. CNA E stated it was important for residents' well-being to receive showers as scheduled regularly. CNA E stated not providing showers to residents regularly as scheduled could lead to infection, development of wound or pressure ulcer (bed sores, injury to skin and underlying tissue resulting from prolonged pressure on the skin), worsening of wound or pressure ulcer or missed skin impairment. During an interview on 8/15/24 at 1:15 p.m., CNA F stated residents were scheduled to receive showers twice a week and more often as needed. CNA F stated not providing showers regularly as scheduled could result in wound to worsen, wound infection, sepsis, and missed skin impairment. During an interview on 8/15/24 at 1:21 p.m., LN B stated residents were scheduled to receive showers twice a week and more often as needed. LN B stated refusal should be documented. LN B stated not receiving showers regularly and as scheduled could lead to wound infection, development or worsening of wound or pressure ulcer. LN B stated residents would also have low self-esteem or they might feel uncomfortable. LN B stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and was not treated with antibiotics (ABX, a type of antimicrobial substance active against bacteria). LN B stated sepsis was life threating and source could be from untreated Urinary Tract Infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine) or infected wound. During an interview on 8/15/24 at 1:35 p.m., LN G stated residents were scheduled to receive showers twice a week or more often as needed. LN G stated refusals should be documented. LN G stated if not documented, it meant showers or bed bath was not provided. LN G stated not providing showers or bed bath to residents regularly placed them at risk for staff to miss residents skin impairments, wound to become infected, development of sores or worsening of sores. LN G stated sepsis could be a result of untreated UTI or wound infection. During a concurrent interview and shower sheet record review on 8/15/24 at 1:50 p.m., the Assistant Director of Nursing (ADON) stated residents were scheduled to receive showers twice a week and more often as needed. The ADON stated residents should receive at least 8 to 9 showers in a month. The ADON verified Resident 1 was scheduled to receive showers on Mondays and Thursdays. The ADON verified the shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers, but only received 2 bed baths out of 9 showers on these dates 7/13/24 and 7/30/24 . The ADON verified that from 8/2/24 up to 8/6/24, Resident 1 did not receive any showers or bed bath at all. The ADON stated if Resident 1 was refusing, staff were not documenting. The ADON stated staff should be documenting refusals. The ADON stated if it was not documented, it meant the care was not rendered. The ADON verified the shower documentation indicated Resident 1 was not receiving shower/bed bath regularly. The ADON stated not providing showers regularly and not assessing residents' skin thoroughly was a contributing factor on why Resident 1 's wound on top of his right shoulder was missed and why the wound on top of his right shoulder became infected. A review of the facility ' s policy and procedure (P&P) titled Skin and Wound Management, revised 1/1/12, the P&P indicated CNAs will complete body checks on residents ' shower days and report unusual findings . A review of the facility ' s policy and procedure (P&P) titled Showering and Bathing revised 1/1/2012, the P&P indicated observing the skin is performed during bathing. A review of the The Cleveland Clinic publication on skin care dated 4/27/2020 indicated Dr. Khetarpal says We come in contact with thousands of allergens every day. Showering rinses off those allergens, as well as bacteria and viruses. A review of the Healthline publication on skin care dated 1/29/2019 indicated 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 record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was at high risk for falls and had a history of falls, was provided supervision by direct care staff, and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Facility policies (Titled, Resident Safety, Fall Management Program, and Comprehensive Person-Centered Care Planning) on safety and management of falls were not followed. As a result, Resident 1 suffered a fall that resulted in a 15 cm (Centimeter) laceration (deep cut) to the scalp, which required him to be transferred to a General Acute Care Hospital (GACH) emergency department (ED) to receive 14 staples to repair the laceration. Findings: During a review of Resident 1's ADMISSION RECORD, dated 3/28/23, the record indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Alzheimer's Disease (A brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and Complete Traumatic Amputation (The loss of a body part that occurs as the result of an accident or injury) at Knee Level of the Right and Left Lower Legs. Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 1/21/23 indicated his BIMS (Brief Interview of Mental Status-A cognition [ the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 4, which indicated his cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 1's MDS also indicated he required extensive assistance of one person for bed mobility and toilet use, and limited assistance of one person for transfers. During an interview with the Director of Nursing (DON) on 3/29/23 at 8:55 a.m., she stated Resident 1 would not use the call light to request assistance, could get hurt with self-transfers, and his judgment was poor. She also stated he forgot to lock the brakes of his wheelchair. During a concurrent interview and observation on 3/29/23 at 9:09 a.m., in the conference room of the facility, a laceration the size of a tennis ball was observed on Resident 1's scalp. The entire area was black in color and appeared to be covered with dried blood. 14 staples were observed on the laceration. When asked if it was painful, he stated that if touched, it did hurt pretty bad. During an interview with Licensed Staff A, on 3/29/23 at 10:03 a.m., she stated Resident 1 was confused and had impaired judgment due to dementia (Memory loss). She sated she checked on him routinely every two hours, but there was no specific time requirement to check on him, and no log to document visual checks. During an interview with Unlicensed Staff B on 3/29/23 at 10:08 p.m., she stated she had known Resident 1 for about [AGE] years. Unlicensed Staff B corroborated Licensed Staff A's story, stating on some days Resident 1 was very confused, and he would not use the call light to request assistance. Unlicensed Staff B stated she checked on Resident 1 every hour, but there was no log to document visual checks. During a review of Resident 1's Fall Risk Evaluation, dated 6/20/22, the evaluation indicated he was at risk for falls. During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find a care plan for prevention of falls for Resident 1. Resident 1 had been determined to be at risk for falls on the Fall Risk Evaluation dated 6/20/22. First Fall: Record review of an IDT (Interdisciplinary Team- Team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Note dated 8/18/22 at 9:38 a.m., indicated, resident [Resident 1] had actual unwitnessed fall 8/17 [8/17/22] with minor injury r/t [Related to] poor short-term memory/recall; transferred to [GACH] ED for eval [Evaluation] and tx [Treatment], cleared, returned to facility approx. [Approximately] 2000 [8:00 p.m]. Record review of a care plan for falls initiated on 8/17/22 after the fall, indicated, Continue interventions on the at-risk plan [Difference between the at-risk plan and regular care plan unkown, but no care plans for fall prevention were found prior to 8/17/22, as indicated by an e-mail sent by the DON on 5/12/23 at 3:44 p.m.] .Provide activities that promote exercise and strength building where possible. There were no other interventions in the plan of care to prevent falls, as other interventions were aimed at providing post-fall care to Resident 1 such as monitoring for bruises and notifying the doctor for any changes in level of consciousness. Record review of a facility document titled, Fall Risk Evaluation, dated 9/01/22 at 2:33 a.m., completed two weeks after Resident 1's fall at the facility, which occurred on 8/17/22, indicated he was at risk for falls. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 a.m., the DON indicated, The risk assessment should be updated post fall as soon as possible. During a review of an e-mail sent by the DON on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find a neurological checks (A series of tests to determine whether the nervous system is impaired) performed at different time intervals after the fall, which was a requirement for unwitnessed falls in the facility policy titled, Fall Management Program, last revised in March 13, 2021. The e-mail from the DON indicated, A paper neurocheck (A nursing assessment documented in paper to check for injury to the brain or spine after a fall) is not located. It appears that the resident was cleared at the Emergency Department and neuro checks did not resume upon return. Record review of an e-mail sent by the Surveyor to the DON on 5/10/23 at 11:54 a.m., the DON was asked what type of supervision was provided to Resident 1 after the fall on 8/17/22. The DON responded through an e-mail sent on 5/12/23 at 3:44 p.m., that indicated, The attached Nurse's notes describe the assigned visual supervision post fall. The nursing notes the DON attached (Nursing notes from 8/21/22 to 3/12/23) did not indicate Resident 1 was getting visual checks or seen more than once per shift; for example, one of the notes documented on 8/20/22 at 3:34 p.m., indicated, Resident is alert and oriented. Was well cared for, ate his meal. Due medications were administered as prescribed with good effect. Second Fall: Record review of an incident report dated 10/06/22 at 7:06 p.m. indicated, Resident [Resident 1] found sitting in wheelchair, with an abrasion on his forehead, stating he'd fallen from his chair. Resident stated he was attempting to transfer from his bed to his wheelchair, and his stump got caught on the lever under the bed, and he fell , sliding over and hitting his head on the bedside table. Record review of a Fall Risk Evaluation dated 10/06/22 at 10:06 p.m. indicated Resident 1 was at low risk for falls, although he had just fallen earlier that evening. One of the questions in this evaluation was left unanswered, possibly giving it an incorrect score. This was confirmed by the DON, through an e-mail sent on 5/12/23 at 3:44 p.m., in which she indicated, The fall risk dated 10/6/22 is not accurate. During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find an updated or revised care plan for prevention of falls, created after the fall on 10/06/22. Record review of a facility document titled, Neurological Flow Sheet, initiated on 10/06/22 at 5:45 p.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 8:30 p.m., 9:30 p.m., 10:30 p.m. and 11:30 p.m. on 10/06/22, but instead, the neurological checks were performed at 8:30 p.m., 9:30 p.m., 10:30 p.m., on 10/06/22, and at 2:30 a.m. on 10/07/22. For a time lapse of 4 hours from 10:30 p.m. on 10/06/22 to 2:30 a.m. on 10/07/22, there was no data showing Resident 1 received the scheduled neurological checks, although he had an unwitnessed fall, where he hit his head. Third Fall: Record review of an IDT note dated 11/08/22 at 9:51 a.m., indicated, [Resident 1] had an unwitnessed, non-injury fall 11/8 [11/08/22] @ [At] approx. 0115 [1:15 a.m.] r/t dementia, poor safety awareness, recall. He was self transferring after using the bathroom and slipped out of w/c [Wheelchair] because w/c brake was not engaged. Record review of a Fall Risk Evaluation dated 11/08/22 at 3:05 a.m., did not indicate he was at risk for falls since he received a score of 9, due to inaccurate data entry. The second question in this evaluation asked how many falls this resident had in the last three months. The question was answered as, 1-2 falls in past 3 months, when, in reality, Resident 1 had three falls since 8/17/22, according to documentation provided by the facility (Fall on 8/17/22, fall on 10/06/22 & fall on 11/08/22). Record review of a facility document titled, Neurological Flow Sheet, initiated on 11/08/22 at 1:00 a.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 11:00 p.m. on 11/10/22 and at 2:00 a.m. on 11/11/22 but these neurological checks were incomplete, missing essential information including level of consciousness, hand grasps, and pupil reactions (Pupillary dilation [Increase in diameter] and pupillary constriction [Decrease in diameter] in response to light or absence of light). During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find an updated or revised care plan for prevention of falls, created after the fall on 11/08/22. Fourth Fall: Record review of a facility incident report dated 11/20/22 at 2:30 p.m., indicated, At approx. 1530 [3:30 p.m.] Side 1 assigned charge nurse and another resident heard a loud noise. Upon reaching residents [Resident 1's] room, he was found lying on the floor by his TV stand flat on his back. Resident's forehead was bleeding and (Sic) a small abrasion (Wound to the top layers of the skin) on L [Left] Hand. Charge nurse observed blood on TV stand and floor. Residents motorized w/c was by his feet and his headphones were by his head. He started to lean forward and grab his headphones and fell out of the chair or the chair moved, [Resident 1] was unsure. Resident advised to lay still, not moving neck until EMS [Emergency Medical Services] arrived .bleeding from mouth noted that resident had bitten his tongue. EMS arrived approx. 1540 [3:40 p.m.] .Resident transported to [GACH] ED for eval and tx [Evaluation and treatment]. Record review of a Fall Risk Evaluation dated 11/20/22 at 5:30 p.m., indicated Resident 1 was at risk for falls. Record review of the care plan for falls dated 11/20/23 indicated the plan was revised to prevent further falls, but the care plan did not mention anything related to supervision of Resident 1, or increased safety monitoring to prevent reoccurrence of the fall. The revisons to the care plan included, Anticipate [Resident 1's] needs and meet his needs as requested .Ensure call light is within reach .[Resident 1] needs a safe environment with even floors free from spills and/or clutter. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 p.m., indicated no neurological checks were found for this fall, although the fall was unwitnessed, and Resident 1's forehead was observed bleeding, which indicated he may have hit his head, per the facility incident report dated 11/20/22 at 2:30 p.m. Fifth Fall: Record review of a facility incident report dated 3/09/23 at 3:15 p.m., indicated, Resident [Resident 1] slid out of w/c participating in activities playing kick ball witnessed by activities coordinator. Not wearing seat belt in W/C .refuses. Record review of a Fall Risk Evaluation dated 3/14/23 at 1:59 p.m., indicated Resident 1 was at risk for falls. Record review of a plan of care for falls initiated on 3/10/23 indicated appropriate interventions were implemented to prevent further falls for Resident 1 but did not mention anything in regard to supervision of the resident. Sixth Fall: Record review of an IDT Progress Note dated 3/20/23 at 5:02 p.m., indicated, Resident had a fall next to his bed 3/19/23 around 3am .During this event, wheelchair was tipped over and it is unclear exactly what resident was doing. It appeared to the nurse he was self-transferring, but his (Sic) Alzheimer's dementia he does not recall .He sustained a laceration to his left posterior scalp. First aid and stabilization provided and 911 called. Resident returned from ED with the laceration stapled and report of no other injury. Record review of a document titled, ED Prov [Provider] Note, dated 3/20/23 at 12:02 a.m., from the GACH where Resident 1 was transferred on 3/19/23 after the fall, indicated, This is a [AGE] year old male who was sent in from the nursing home for mechanical fall .Patient suffered a large laceration to the top of his scalp .Laceration details: Location: Scalp .Scalp location: Crown Length (cm): 15 Depth (mm): 10 .Repair method: Staples Number of staples: 14. Record review of a Fall Risk Evaluation dated 3/19/23 at 4:22 p.m. indicated Resident 1 was at risk for falls. Record review of the care plan for prevention of falls initiated on 3/19/23 listed interventions to prevent further falls but did not indicate the need for increased supervision of Resident 1, or anything regarding increased safety monitoring for prevention of further falls. Record review of a facility document titled, Neurological Flow Sheet, initiated on 3/19/23 at 3:30 a.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 9:00 a.m., 1:00 p.m. and 5:00 p.m. on 3/20/23, but these neurological checks were either undocumented or incomplete (Example: No documentation of hand grasps or pupil reactions on 3/20/23 at 9:00 a.m., 1:00 p.m., and 5:00 p.m., and no documentation in general of neurological checks on 3/20/23 at 1:00 p.m.), although Resident 1 had just suffered a fall on 3/19/23 that resulted in a 15 cm laceration to the scalp area during an unwitnessed fall. During a phone interview with Unlicensed Staff C on 5/22/23 at 1:09 p.m., he stated the night of the fall on 3/19/23, he was assigned to Resident 1. Unlicensed Staff C stated he was also assigned to two other residents at risk for falls that required very close supervision, whose rooms where in another hallway of the facility. Unlicensed Staff C stated he could not clearly remember if they were having a staffing shortage that night, but knew the facility needed more certified nursing assistants given the number of residents that were at risk for falls, including Resident 1. Unlicensed Staff C stated he had at least 10 residents assigned to his care that night, so he did the best he could. During a phone interview with Licensed Staff D on 5/22/23 at 1:25 p.m., she stated she was the assigned nurse for Resident 1 the night of the fall on 3/19/23. Licensed Staff D stated Resident 1 was using his electric wheelchair that night, driving up and down the hallways of the facility. Licensed Staff D stated she last rounded on him sometime between 1:30 a.m. to 2:00 a.m. (The fall happened at approximately 3:00 a.m. according to the IDT Progress Note dated 3/20/23 at 5:02 p.m.). Licensed Staff D stated she hear a loud thump and found him on the floor in his room in-between his wheelchair and the bed, alert but confused as to what was going on. Licensed Staff D stated that since this fall, Resident 1 had been experiencing a steady decline. Record review of a posting dated 3/20/23, attached to Resident 1's door, indicated, CARE ALERT .RESIDENT MAY NEVER SELF TRANSFER HE REQUIRES SUPERVISION .RESIDENT MAY NOT BE IN W/C IN ROOM. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 a.m., the DON responded to a question by the Surveyor on how she ensured the instructions in the posting attached to Resident 1's door was being followed. The DON indicated, The Care Alert is posted in the resident's room and on his door. A clipboard in-service was done 5/15/23 to make sure care staff have read the Care Alert, proof attached. Verbal training has been done on this Care Alert since the fall, however I cannot provide proof of verbal training done by myself and the MDS nurse. There is no log or sign in/sign out. Record review of the facility policy titled, Resident Safety, last revised on April 15, 2021, indicated, During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident's safety risk (e.g., fall) .After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors .The IDT will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors. Record review of the facility policy titled, Fall Management Program, last revised on March 13, 2021, indicated, A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed .The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change in condition, post fall and as needed .Perform neurological checks at the ordered frequency or as the listed below equaling 72 hours a. Every 15 minutes x 1 hour, then b. Every 30 minutes x 1 hour, then c. Every hour x 4 hours, then d. Every 4 hours x 66 hours OR until the physician states it is no longer necessary OR after 72 hours if the Resident's condition is stable .A Resident who endures more than one fall in a day, week or month, will be considered at high risk for falls B. Monthly, for those identified as high risk for falls, the IDT will meet to review the fall risk interventions for appropriateness and effectiveness until the frequency of their falls diminishes C. The Residents' care plans will be updated with the IDT's recommendations. Record review of the facility policy titled, Comprehensive Person-Centered Care Planning, last revised in November of 2018, indicated, Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed .The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment .the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition .v. Other times as appropriate or necessary.

Based on observation, interviews and records review, the facility failed to provide required physical assistance to transfer one of two sampled residents (Resident 1) when Resident 1's Minimum Data Set (MDS -health status screening and assessment tool used for all residents) indicated Resident 1 required two or more person physical assistance with transfer. This failure resulted to Resident 1 falling on her right foot sustaining a right fibula fracture (a break to the fibula (A lower-leg bone that extends from the knee to the outside of the ankle parallel to the tibia [shinbone]) caused by a forceful impact that results in injury) which caused Resident 1 to experience constant pain and not being able to bear weight to her right foot when standing. Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with a diagnoses including but not limited to Muscle Weakness; Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems); and Rheumatoid Arthritis (a chronic (long-lasting) autoimmune disease [condition in which the body's immune system mistakes its own healthy tissues as foreign and attacks them] that mostly affects joints). During a record review for Resident 1, the MDS dated [DATE] indicated Resident 1 had a BIMS score of 14 out of 15. (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 had a body weight of 211 lbs. (pounds - a unit for measuring weight) requiring extensive (resident involved in activity; staff provide weightbearing support) two or more person physical assistance with transfer. During a record review for Resident 1, the document titled, Fall Risk Evaluation dated 5/30/23 indicated Resident 1 had a balance problem while standing. During a record review for Resident 1, the Progress Note titled, Alert Note dated 6/29/23 at 7:00 a.m. indicated, a CNA reported to Licensed Staff A that CNA tried to transfer Resident 1 to her wheelchair; however, the CNA could not make a successful transfer and lowered Resident 1 to the floor. During a record review for Resident 1, the Progress Note titled, IDT (Interdisciplinary Team - group of health care professionals who work together toward the goals of the resident) Progress Notes - Fall dated 7/03/23 at 2:28 p.m. indicated, Fall 6/29/23 early morning as CNA attempted to assist resident to transfer bed to wheelchair. During transfer resident was wearing grip socks (footwear designed to provide extra traction on slippery surfaces), [Resident 1] suddenly lost ability to stand and was lowered to ground gently by the CNA. Resident denied pain and was able to continue the day with therapy. Later however her right ankle was turning purple, and [Resident 1] sent to ED (Emergency Department). Returned with finding right fibular fracture. During a record review for Resident 1, the Progress Note titled, Post Fall Evaluation dated 07/10/2023 at 5:17 p.m. indicated Resident 1 had bruising to her right shin and ankle. The document indicated Resident 1 was in constant pain. During a record review for Resident 1, the Progress Note titled, Health Status Note dated 7/11/23 at 4:46 a.m. indicated Resident 1 returned from Orthopedic (is a specialized medical field with a primary focus on the musculoskeletal system) with her right ankle casted (orthopedic device used to protect and support broken or injured bones and joints). The document indicated, NWB (Non Weight [NAME] means that you can't put any weight on your injured lower leg for a period of time, which can be anything from weeks to months) to RLE (Right Lower extremity - hips, legs, ankles, and feet are all considered lower extremities) and no ankle ROM (Range of Motion - the extent or limit to which a part of the body can be moved around a joint or a fixed point). During a record review for Resident 1, the Medication Administration Record (MAR) had an entry order to assess for pain every shift. The MAR from 7/01/23 to 7/12/23 indicate Resident 1 experienced moderate pain on 7/2/23, 7/04/23, 7/05/23, 7/07/23, 7/08/23, 7/10/23, 7/11/23 and 7/12/23. During an interview with Unlicensed Staff B on 7/13/23 at 12:26 p.m., Unlicensed Staff B stated Resident 1 required two-person assist with transfer before she fractured her foot. During an interview with the Physical Therapy Assistant (PTA - work under the direction and supervision of Physical Therapists [a healthcare provider who helps you improve how your body performs physical movements]) on 7/12/23 at 12:36 p.m. The PTA stated Resident 1 required maximum assist of two-person with transfer prior to the 6/29/23 fall. The PTA stated CNAs were aware that Resident 1 required two-person assist with transfer since her initial admission to the facility. During an observation and concurrent interview with Resident 1 in her room on 7/13/23 at 12:38 p.m., Resident 1 was observed with a leg cast to her right foot. Resident 1 stated a female CNA was transferring her in the morning of 6/29/23 to a rolling chair (wheeled chair) when her left foot lost balance, fell down and landed on her right foot. Resident 1 stated she broke one of her bones on her right foot and had been hurting pretty bad. Resident 1 stated she would ask for pain medication at least three times a day to relieve the pain. Resident 1 also stated, it is more difficult to stand now with just one foot. During an interview with Unlicensed Staff C on 7/13/23 at 12:44 p.m., Unlicensed Staff C stated Resident 1 always required two-person assist even prior to her breaking her foot. When asked about the risk for Resident 1 if she was transferred with one person, Unlicensed Staff C stated Resident 1 could fall which could result to an injury. Review of the Facility policy and procedure titled, Transfer of Residents, revised on 4/27/23 indicated, Residents will be lifted or transferred according to the assessment and needs of residents and To provide the form of transfer best suited to the residents' needs and to maintain resident/staff safety during the procedure.

Based on observation, interview and record review, the facility failed to ensure one of six residents sampled for pressure ulcer (a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure) review (Resident 199) received care, treatment, and services consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For Resident 199, admitted on [DATE], bed-bound and immobile, with paralysis, admitted with a pre-existing Stage 3/Unstageable pressure ulcer (a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible) on his coccyx (tail bone): (1) The facility failed to complete a risk assessment for developing pressure injuries (Braden Scale) upon admission for Resident 199. The first Braden Scale was completed on 7/12/22 (14 days after admission and after the resident had developed five pressure ulcers); (2) The facility failed to accurately assess Resident 199's skin when licensed nurses did not document all of Resident 199's pressure ulcers during skin assessments, with one skin assessment, completed one week after Resident 199's admission, indicating he had no pressure injuries or skin wounds; (3) The facility failed to timely develop an individualized care plan (a document instructing staff on how to care for the resident) for the prevention of pressure ulcers. The first pressure ulcer care plan was developed on 7/19/22 (22 days after admission) (after the resident had acquired 10 pressure ulcers); (4) The facility failed to develop an individualized care plan for prevention of pressure and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer care plan (7/19/22) did not include key interventions pertinent to the resident's situation, such as turning and repositioning the resident every two hours, use of heel protectors, use of wedge pillows for positioning and pressure relief, and off-loading heels; interventions that had been recommended by the wound specialist physician starting on 6/29/22; (5) The facility failed to timely implement standard interventions to prevent and treat Resident 199's pressure ulcers, such as turning and repositioning the resident every two hours, use of heel protectors, use of wedge pillows for positioning and pressure relief, and off-loading heels These interventions that had been recommended by the wound specialist physician starting on 6/29/22, with the key intervention of turning and repositioning Resident 199 only consistenly documented as implemented starting on 7/19/22 (22 days after admission); (6) The facility failed to timely implement a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LAL was ordered on 6/29/22 but the facility provided it to the resident on 7/8/22 (10 days later), even though the facility had a LAL in stock at the time it was ordered; during this delay the resident developed five pressure ulcers; (7) The facility failed to timely and consistently implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] (8) The facility failed to take steps to timely remove the resident's cervical collar (neck brace). The resident's transfer orders dated 6/28/22 indicated the cervical collar was to be removed on 7/4/22 (one week after admission), and the wound specialist physician recommended it removed on 7/7/22, but by 7/27/22 (30 days after admission) no steps were taken to remove the cervical collar. (9) The facility failed to develop and implement a system for monitoring and documenting the turning and repositioning of residents at risk for pressure ulcers, with documentation of the date and time and position the resident was turned. These failures resulted in Resident 199 developing a total of 10 pressure ulcers within two weeks of admission to the facility. Five pressure ulcers (one Stage I on the nose, one Stage II on the clavicle, one Unstageable on the left buttock, and one bilateral Deep Tissue Injury on each heel) were developed between within nine days of admission, from 6/29/22 to 7/7/22, and another five pressure ulcers (one Deep Tissue Injury on right leg, one Deep Tissue Injury on left leg, one Stage II and two Deep Tissue Injuries on the right buttock) were developed in the next five days, from 7/8/22 to 7/13/22. Findings: Review of the National Pressure Injury Advisory Panel revealed a pressure injury (also called a bedsore, pressure ulcer, pressure sore, or decubitus ulcer) is a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure. Pressure injuries are classified into four stages, depending on the severity of the wound. A Stage 1 pressure injury is characterized by skin that is intact but with redness that is non-blanchable (does not turn white when pressed). A Stage 2 pressure injury shows a shallow ulceration (a break in the skin) with a red/pink wound bed, with only the superficial layers of the skin destroyed. A Stage 3 pressure injury indicates a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible. A Stage 4 pressure injury is a wound where the both the skin and the fat tissue are destroyed, and it is possible to visualize the bones, muscles, ligaments and/or cartilage. (National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages, 2022, https://npiap.com/page/PressureInjuryStages) Review of theNational Pressure Injury Advisory Panel revealed there are also two additional types of pressure injuries: Unstageable Pressure Injures and Deep Tissue Injuries. An Unstageable Pressure Ulcer occurs when, as a result of unrelieved pressure on the skin, the whole skin is destroyed but the area is covered with slough or eschar (dead tissue), making it impossible to determine the exact stage without debridment (removal of the dead tissue). Once debrided, a Stage 3 or Stage 4 pressure injury will be revealed. A Deep Tissue Injury is also a skin wound resulting from unrelieved pressure. In a Deep Tissue Injury, there is no open wound or ulceration, but there is a non-blanchable are with a deep red and purple discoloration that indicates extensive damage to the underlying tissues, often evolving into a Stage 3 or Stage 4 pressure ulcer. (National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages, 2022, https://npiap.com/page/PressureInjuryStages). Review of the American Association of Family Physicians,revealed [Pressure] ulcers are difficult to resolve. Although more than 70 percent of stage II ulcers heal after six months of appropriate treatment, only 50 percent of stage III ulcers and 30 percent of stage IV ulcers heal within this period . and because skin wounds are colonized with bacteria, pressure ulcer place patients at risk of serious, life-threatening infectious complications such as bacteremia and [CONDITION(S)] (systemic infection), [CONDITION(S)] (skin infection), endocarditis (heart infection), meningitis (spinal cord infection), [CONDITION(S)] (bone infection), septic arthritis, and sinus tracts or abscesses. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). A review of Resident 199's Facesheet indicated he was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 199's SKILLED NURSING FACILITY TRANSFER ORDERS (Transfer Orders), dated 6/28/22, at 3:05 p.m., indicated Resident 199 was Bed bound due to paralysis from cancer [CONDITION(S)] and needed frequent turnings to prevent ulcerations. The Transfer Orders also indicated Resident 199 had a cervical collar (a neck brace) which was to be worn through 7/4/22. A review of Resident 199's clinical record indicated a consultant report from WOUND MD (a wound care specialist physician on contract with the facility) dated 6/29/22, titled WOUND ASSESSMENT AND PLAN. This report consisted of an assessment of Resident 199's pre-existing coccyx pressure ulcer and contained treatment recommendations. The report indicated Resident 199 had an Unstageable Pressure Ulcer on his coccyx measuring 7 cm [centimeters] in length and 8.5 cm in width. The report contained the following TREATMENT ORDER: Daily cleanse the wound with normal saline or sterile water, then apply Santyl (an ointment that removes dead tissue), then cover wound with a moist dressing. The Report also indicated: Preventative Wound Recommendations: Air mattress . Type: low air flow . and Need low air loss mattress and off load and reposition [turn and reposition resident] per facility's protocol. No other pressure injuries were documented. A review of the facility's WEEKLY PRESSURE INJURY REPORT [a tally of all residents with pressure ulcers at the facility], dated for week of 6/29/22, indicated Resident 199 had one unstageable pressure ulcer in the coccyx, as documented in the WOUND MD assessment. The Report indicated orders given. No other pressure injuries were documented. Review of the American Association of Family Physicians (AAFP) revealed pressure reduction to preserve microcirculation is a mainstay of [pressure unjury] preventive therapy and the two most important interventions are frequent turning and repositioning and the application of pressure relieving devices to redistribute localized pressure: Patients who are bedridden should be repositioned every two hours and Pressure-reducing surfaces [such as low air loss mattress] lower ulcer incidence by 60 percent compared with standard hospital mattresses. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). A review of Wound Care Solutions revealed low air loss mattress is a mattress designed to prevent and treat pressure wounds. The mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds. (Wound Care Solutions, How a Low Air Loss Mattress Can Keep Patients Wound Free, 2022, https://www.woundcareinc.com/resources/low-air-loss). A review of Resident 199's PROGRESS NOTES indicated note dated 7/1/22, at 3:51 p.m., titled SKIN ONLY EVALUATION, indicating: Resident has current skin issues and documented three Stage 2 pressure ulcers: one Stage 2 pressure injury on the left anterior neck measuring 3 cm (length) x 2 cm (width), one Stage 2 pressure ulcer on the left medial neck measuring 2 cm (length) x 1 cm (width) and one Stage II pressure ulcer on the left posterior (outer) neck measuring 1 cm (length) x 1 cm (width). There was no documentation of Resident 199's coccyx pressure ulcer or other pressure ulcers. A review of Resident 199's PROGRESS NOTES indicated note dated 7/4/22, at 3:50 a.m., titled SKIN ONLY EVALUATION, indicating no skin wounds, as follows: Skin warm and dry, skin color WNL [within normal limits], mucous membranes moist, turgor normal. No current skin issues noted at this time. A review of Resident 199's PROGRESS NOTES indicated note dated 7/5/22, at 1:41 a.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and documented four pressure ulcers: one Deep Tissue Injury on his left heel, two Deep Tissue Injuries, one on each buttock, and one Stage 2 pressure injury on his left clavicle (collar bone). There was no documentation of Resident 199's coccyx pressure ulcer or other pressure ulcers. A review of Resident 199's clinical record indicated a SECOND report from WOUND MD, dated 7/7/22, 8 days after the first report, titled WOUND ASSESSMENT AND PLAN. This report indicated Resident 199 had acquired five additional pressure ulcers, in addition to the pre-existing coccyx pressure ulcer, as follows: 1) COCYX Pressure Ulcer, Unstageable, Wound Measurements: 8 cm length x 6.6 cm width. Date of onset: 6/29/22. [Treatment order unchanged]. 2) LEFT CLAVICLE Pressure Ulcer related to medical device, Stage 2, wound measurement: 0.7 cm length x 0.5 cm width x 0.1 Depth. Date of onset: 7/7/22. TREATMENT ORDER: Daily cleanse wound with normal saline or sterile water, apply [MEDICATION(S)] (a healing ointment) then cover wound with foam dressing for pad/protection. Need to discuss with neurosurgery clinic ASAP (as soon as possible) about collar causing wound and see if safe to be removed now. If it cannot be removed, need to ask neurosurgery about their recommendation on how to prevent further skin injury. 3) LEFT BUTTOCK Pressure Ulcer, Unstageable, Wound Measurements: 3.5 cm length x 1 cm width. Date of onset: 7/7/22. TREATMENT ORDER: Daily cleanse the wound with normal saline or sterile water, then apply Santyl, then cover would with a moist dressing. The Report also indicated: Preventative Wound Recommendations: Air mattress . Type: low air flow . 4) LEFT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 4.5 cm length x 4.5 cm width. Date on onset: 7/7/22. TREATMENT ORDERS: Leave open to air and off load heel (place pillow, foam, soft boots or any other material that redistributes the pressure around the heels). 5) RIGHT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 2.5 cm length x 1.5 cm width. Date on onset: 7/7/22. TREATMENT ORDERS: Leave open to air and off load heel. 6) NOSE Pressure Ulcer Stage 1, Wound Measurements: not listed. Date on onset: 7/7/22. TREATMENT ORDERS: Off load area and do not use glasses if able for 7 days. Recommend eye clinic evaluation with new glasses that would not cause more pressure to the area . A review of the facility's WEEKLY PRESSURE INJURY REPORT, dated for week of 7/7/22, indicated Resident 199 had six pressure ulcers, as documented in the second WOUND MD report dated 7/7/22. A review of Resident 199's PROGRESS NOTES indicated note dated 7/11/22, at 00:28 a.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and noted two pressure ulcers: an Unstageable Pressure Ulcer on Left Heel and a Deep Tissue Pressure Injury on buttock. A review of Resident 199's PROGRESS NOTES indicated note dated 7/12/22, at 3:21 p.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and noted two pressure ulcers: Stage 3 Pressure Ulcer on Coccyx and Stage 2 Pressure Ulcer on Left Clavicle. A review of Resident 199's clinical record indicated the first assessment of Resident 199's risk for pressure ulcers, the BRADEN SCALE for Predicting Pressure Ulcer Risk, was completed on 7/12/22, 14 days after his admission, and indicated Resident 199 had a score of 9, meaning he was at a VERY HIGH RISK of developing pressure ulcers. The 7/12/22 Braden Scale indicated Resident 199's sensory perception (the ability to respond meaningfully to pressure-related discomfort) was very limited; skin moisture (the degree to which skin is exposed to moisture) was very moist; activity (degree of physical activity) was confined to bed, mobility was completely immobile (does not make even slight changes in body or extremity position without assistance); nutrition was probably inadequate; and friction was problem (requires moderate to maximum assistance in moving .requires frequent repositioning with maximum assistance .). A review of Resident 199's clinical record indicated a THIRD report from WOUND MD, dated 7/13/22, and titled WOUND ASSESSMENT AND PLAN. This report indicated the presence of 11 pressure ulcers, five more than present during the SECOND report dated 7/7/22, as follows: 1) COCYX Pressure Ulcer, Unstageable, Wound Measurements: 7.5 cm Length x 7.5 cm. [Present upon admission - Noted on First and Second Report - Treatment orders unchanged]. 2) LEFT CLAVICLE Pressure Injury related to Medical Device, Stage 2, Wound Measurement: 0.5 cm Length x 0.1 cm Width. [Noted on Second Report - Treatment orders unchanged]. 3) LEFT BUTTOCK Pressure Ulcer, Unstageable, Wound Measurements: 1.5 cm Length x 1 cm Width. [Noted on Second Report - Treatment orders unchanged]. 4) LEFT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: N/A. [Noted on Second Report - Treatment orders unchanged]. 5) RIGHT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 2.5 cm Length x 1.5 cm Width. [Noted on Second Report - Treatment orders unchanged]. 6) NOSE Pressure Ulcer Stage 1, Wound Measurements: N/A. [Noted on Second Report - Treatment orders unchanged]. 7) RIGHT LATERAL LEG Deep Tissue Pressure Ulcer, Wound Measurements: 6 cm length x 3 cm width. Date of onset: 7/13/22. TREATMENT ORDERS: Daily cleanse wound with normal saline or sterile water, apply Santyl and cover with moist gauze and apply foam dressing to the area for pad/protection. Off load and reposition per facility's protocol. Preventative Wound Recommendations: Air mattress . Type: low air flow . 8) LEFT LATERAL LEG Deep Tissue Pressure Ulcer, Wound Measurements: 4 cm length x 3 cm width. Date of onset: 7/13/22. TREATMENT ORDER: Daily cleanse wound with normal saline or sterile water, apply Santyl and cover with moist gauze and apply foam dressing to the area for pad/protection. Off load and reposition per facility's protocol. Preventative Wound Recommendations: Air mattress . Type: low air flow . 9) RIGHT BUTTOCK (DISTAL) Pressure Ulcer Stage 2, Wound Measurement: 2 cm length x 1.5 cm width x 0.1 cm depth. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . 10) RIGHT BUTTOCK (PROXIMAL INNER) Deep Tissue Pressure Injury, Wound Measurement: 2 cm length x 2 cm width. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . 11) RIGHT BUTTOCK (PROXIMAL LATERAL) Deep Tissue Pressure Injury, Wound Measurements: 5.5 cm Length x 2.5 cm Width. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . A review of the facility's WEEKLY PRESSURE INJURY REPORT, dated for week of 7/13/22, indicated Resident 199 had 11 pressure ulcers, as documented in the WOUND MD'S report dated 7/13/22. A review of Resident 199's PRIMARY CARE physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Several decubital ulcers on coccyx region and left heal (sic) . Must rotate him every 2 hours to prevent these ulcers. During an observation and interview on 7/18/22, at 10:50 a.m., Resident 199 had a cervical collar was lying on his back in his room. Resident 199 stated he could not move his legs or reposition himself in bed without assistance. During an interview on 7/27/22, at 8:24 a.m., the Director of Nursing (DON) stated Resident 199 was admitted to the facility on [DATE] from the hospital and had one Stage III pressure ulcer on his coccyx area (tailbone). The DON stated all the other pressure ulcers documented in his clinical record had been acquired at the facility. The DON stated Resident 199 was immobile, completely dependent on staff assistance for movement, and was at high risk for developing pressure ulcers. The DON was asked for the dates and scores of Resident 199's Braden Scale for Assessing the Risk of Pressure Ulcers evaluations. The DON reviewed Resident 199's record and stated the first Braden Scale for Resident 199 was completed on 7/12/22 and indicated a score of 9, meaning the resident was at a VERY HIGHT RISK of developing pressure ulcers. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked, given Resident 199's risk for developing pressure ulcers, what pressure ulcer prevention care plans had been developed for him. The DON reviewed Resident 199's record and stated two pressure ulcer care plans were created for Resident 199, both on 7/19/22. The first care plan indicated, Resident has potential/actual impairment to skin integrity . and Resident will have no complications related to pressure ulcers on coccyx, clavicle, buttocks and heels. This care plan listed the following interventions: encourage good nutrition, monitor pressure ulcers, use draw sheets to lift/move resident, use caution during transfers, treatment documentation, and resident needs pressure relieving mattress. The second care, also created 7/19/22, indicated Documented Pressure Ulcer and Management of Pressure Ulcer. This care plan listed the following interventions: educate resident about skin care to prevent skin breakdown, encourage resident to frequently shift weight, evaluate skin, evaluate ulcer characteristics, monitor bony prominences for redness, and monitor nutritional status. No other interventions were listed. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked what could have been done to prevent Resident 199's pressure ulcers. The DON stated two key preventative measures for Resident 199 were the use of a low air loss mattress and turning and repositioning Resident 199 at least every two hours. The DON was asked if Resident 199 had been given on a low air loss mattress. The DON stated yes. The DON was asked when. The DON reviewed Resident 199's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the Director of Staff Development (DSD) knew. During a concurrent interview, the DSD stated she entered the order for Resident 199's low air loss mattress on 7/8/22 and stated the low air loss mattress was given to him at the same time of the order, because we have them [low air loss mattresses] in stock here [at the facility]. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked if Resident 199 had been turned and repositioned every two hours. The DON stated yes. The DON was asked to provide documentary evidence this intervention had been implemented. The DON stated staff did not usually document turning and repositioning of residents at risk for pressure ulcers. The DON stated the facility did not have a system for tracking when and how residents at risk for pressure ulcers are turned and repositioned. The DON stated Resident's 199's Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained documentation of turning and repositioning. The DON asked the Medical Records Director to print Resident 199's MAR and TAR for June and July 2022. A review of the MAR June and July 2022 indicated documentation of turning and repositioning Resident 199 every two hours starting on 7/20/22 (23 days after his admission). This documentation consisted of a check mark three times a day in which the staff attested the resident was turned and repositioned every two hours. It did not contain documentation of the specific times Resident 199 was turned and repositioned or the specific side the resident was placed on (left, right, back). According to the AAFP, The basic components of pressure ulcer management are reducing or relieving pressure on the skin, [MEDICATION(S)] necrotic tissue, cleansing the wound, managing bacterial load and colonization, and selecting a wound dressing. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). During the same interview on 7/27/22, at 8:24 a.m, the DON was asked for documentary evidence that the WOUND MD's treatments and interventions had been provided to Resident 199. The DON stated the treatments were documented in Resident 199's MAR and TAR. During a concurrent interview, the Medical Records Director was asked for a copy of Resident 199's MAR and TAR for June and July 2022. A review of these records indicated the WOUND MD orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND MD's order for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the same interview on 7/27/22, at 8:24 a.m., the DON stated Resident 199's clavicle pressure ulcer had been caused by his cervical collar. The DON was asked why the cervical collar had not been removed. The DON stated it was not removed because the facility had been unable to obtain a neurology consult and have an x-ray done to ensure it was safe to remove it. The DON stated there were no neurology specialists available in the area and no mobile x-ray services able to come to the facility. A review of facility policy and procedure titled PRESSURE INJURY PREVENTION, revised September 1, 2020, indicated: A risk assessment for developing pressure injuries will be completed upon admission . Regardless of the risk score, the Licensed Nurse will develop an individualized care plan for the Resident's risk factors . The Licensed Nurse will develop a care plan that contains interventions for Residents who have risk factors for developing pressure injuries or for those Residents who have pressure injuries and [are] at risk of developing additional pressure injuries. The care plan will be initiated on admission and updated as necessary. The nursing staff will implement interventions identified in the care plan which may include, but are not limited to, the following . pressure redistributing devices for bed and chair . repositioning and turning .heel and elbow protectors . off-loading pressure from heels .use of (wedge) pillows for positioning and pressure relief . A review of facility policy and procedure titled SKIN AND WOUND MANAGEMENT, revised January 1, 2022, indicated: Facility staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. The Licensed Nurse will complete the Braden Scale for predicting pressure score risk upon admission . A Licensed Nurse will complete the Weekly Skin Evaluation. The Licensed Nurse will develop a Care Plan to identify interventions to prevent the development of pressure ulcers. Treatments for skin problems, wounds, and non-pressure ulcers will be assessed and documented by a Licensed Nurse. A review of facility policy and procedure titled PRESSURE INJURY AND SKIN INTEGRITY TREATMENT, revised August 12, 2016, indicated: Treatments to pressure injuries or other skin integrity problems will be ordered by the physician. Treatments administered will be documented on the Treatment Administration Record.

Based on observation, interview, and record review, the facility failed to ensure one of five residents sampled for falls review (Resident 4) received care and services to prevent falls in accordance with Resident 4's fall risk factors and professional standards of practice. For Resident 4, who had a documented history of falls, poor gait, poor balance, and muscle weakness: (1) The facility failed to perform a fall risk evaluation after Resident 4 fell on [DATE] while Resident 4 was attending physical therapy, and after a nursing assessment on 5/22/22 indicated Resident 4 had poor balance and unsteady gate; (2) The facility failed to accurately evaluate Resident 4's risk for falls when a nursing assessment dated [DATE] indicated Resident 4 had no previous falls, when Resident 4 had fallen two days earlier on 5/20/22; (3) The facility failed to review, update, and develop a fall prevention care plan after Resident 4 fell on [DATE], leaving in place an outdated fall care plan dated 12/31/21; (4) The facility failed to accurately document Resident 4's falls when a nursing note dated 6/5/22, at 2:46 a.m., indicated Resident 4 had a fall on 6/5/22, at 3:30 a.m., and the Director of Nursing was notified of the fall on 6/5/22 at 2:58 a.m; (5) The facility failed to review, update, and develop a fall prevention after Resident 4 fell again on 6/5/22, relying on an Occupational Therapy care plan created on 6/16/22 to address Resident 4's muscle weakness; (6) The facility failed to timely and accurately evaluate Resident 4's risk for falls when a fall risk assessment for the 6/5/22 fall was completed on 6/20/22, 15 days after the fall, and the fall risk assessment indicated Resident 4 had no gait and or balance problems and no decreased muscular coordination; (7) The facility further failed to accurately evaluate Resident 4's risk for falls when Resident 4's MDS ASSESSMENTS (a standardized, federally mandated clinical assessment tool that drives the creation of care plans and interventions for residents), dated 3/25/22 and 6/24/22, did not indicate Resident 4 had falls at the facility since admission; (8) The facility failed to implement fall prevention interventions for Resident 4 to address her fall risk factors of poor balance, poor gait, and muscle weakness after Resident 4's second fall on 6/5/22, and (9) The facility failed to ensure Resident 4 was properly supervised and assisted during transfers and ambulation in her room on 7/15/22 when a Physical Therapy Student (PTS) assigned to escort Resident 4 to the gym did not assist, supervise, and apply a gait belt to Resident 4 during her transfer and ambulation from her bed to the hallway, which resulted in Resident 4 falling to the floor, breaking her leg and experiencing severe pain; this failure was compounded by the fact that Resident 4 had previously sustained another fall with injury, also while ambulating and in the care of physical therapy staff, two months earlier, on 5/20/22, which should have alerted the PTS of the need for increased supervision and assistance for Resident 4 during physical therapy. These failures resulted in Resident 4 sustaining two falls at the facility, on 6/5/22 and on 7/15/22, with the last fall resulting in Resident 4 breaking her left leg and experiencing sustained severe pain for up to seven days after the fall. Findings: A review of Resident 4's FACESHEET indicated she was admitted on [DATE] with diagnoses including diabetes mellitus, hypertension, memory deficit following [CONDITION(S)] disease and chronic pain. A review of Resident 4's PROGRESS NOTES indicated physician note dated 12/23/21, at 12:58 p.m., titled SNF VISIT NOTE, indicating Resident 4 had sustained a fall, as follows: Called by RN [Registered Nurse] due to fall and pain and [Resident] was reaching and fell on to her right wrist and right shoulder. A review of Resident 4's care plans (documents instructing staff on how care for residents) indicated one nursing care plan related to falls, dated 12/23/21, titled The resident has had an actual fall . poor balance . The care plan listed the following interventions: determine and address causative factors, monitor for pain, bruises and change in mental status, and physical therapy consult. A review of Resident 4's FALL RISK EVALUATION dated 12/29/21, at 2:37 p.m., performed after Resident 4's fall on 12/23/22, indicated Resident 4 was not at a high risk for falls and had normal gait and balance. A review of Resident 4's MDS ASSESSMENT (a standardized, federally mandated clinical assessment tool that drives the creation of care plans and interventions for residents), dated 3/25/22, indicated Resident 4 needed the supervision and assistance of one person to transfer out of bed and for ambulation and locomotion. The MDS section titled FALL HISTORY had no falls documented for Resident 4. A review of Resident 4's FALL RISK EVALUATION dated 4/5/22, at 2:37 p.m., indicated Resident 4 was not at a high risk for falls and had normal gait and balance. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 5/20/22, at 7:37 p.m., titled ALERT NOTE, indicating Resident 4 had a fall that day while under the care of physical therapy staff. The note indicated Resident 4 fell outside on the sidewalk into the grass. The note further indicated Resident 4 suffered an abrasion on the left upper forehead, complained of headache, left knee pain, and bilateral wrist pain. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 5/22/22, at 2:53 a.m., titled WEEKLY EVALUATION, indicating the following: gait is unsteady, balance is poor, and range of motion impairment (how far you can move or stretch a part of your body) on both legs. The note indicated Resident 4 had no falls since previous WEEKLY EVALUATION. A review of Resident 4' PROGRESS NOTES indicated nursing note dated 6/5/22, at 2:46 a.m., titled POST FALL EVALUATION, indicating Resident 4 had a fall in her room on 6/5/22, at 3:30 a.m., while ambulating from the toilet to the bed in her room. The note indicated: Resident states she was coming out of the restroom and was weak and fell . The note indicated the fall was unwitnessed. The note further indicated: Reason for the fall was evident: .weakness. The note further indicated the fall resulted in hip injury/discomfort and required emergency room /hospitalization . The note indicated Resident 4 had a history of falls. The note concluded Resident [4] was weak and unable to make it back to bed after coming out of restroom. A review of Resident 4's PROGRESS NOTES indicated physician note dated 6/9/22, but signed on 6/10/22, at 8:48 a.m., written by Resident 4's physician, titled FU [Follow Up] COVID and Fall, indicating: FU Fall . [Resident 4] is tearful and worried about her weakness . Has been feeling more weaker and with balance difficulty . A review of Resident 4's CARE PLANS indicated care plan created by the Occupational Therapist (OT) dated 6/16/22, titled, The resident has a decreased ability to perform self-care related to decreased ROM [range of motion], impaired activity tolerance, weakness . and contained the following interventions: Activities of Daily Living retraining, discharge planning, establish functional maintenance plan, OT treatment as indicated, pain modalities as needed, resident/family/caregiver education, and upper extremity therapeutic exercises . A review of Resident 4's FALL RISK EVALUATION, dated 6/20/22, at 1:44 p.m., indicated Resident 4 was at a HIGH RISK for falls. The evaluation, however, indicated Resident 4 had no balance problems standing or walking, had no decreased muscular coordination, had no change in gait when walking through doorways, and did not require the use of assistive devices (cane, walker, etc.) A review of Resident 4's MDS assessment dated [DATE] but completed on 6/11/22, indicated Resident 4 required STAFF SUPERVISION during transfers and locomotion and used a walker (a mobility device). The MDS section titled FALL HISTORY was blank, with no falls documented for Resident 4 in the past 6 months. Review of the Journal of the American Medical Association, Prevention of Falls in Older Adults, [NAME] 2018, a specialized literature, indicated that a recent history of falls is the single best predictor of future falls. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/15/22, at 9:32 a.m., titled POST FALL EVALUATION, indicating Resident 4 had a fall in her room on 7/15/22 at 9:32 a.m. while ambulating with physical therapy. The note indicated the fall was witnessed. The note further indicated the fall resulted in a fracture of her left fibula (calf bone), pain and the hospitalization of the resident. The note further indicated Was a safety evaluation completed/documented prior to the fall: No and Safety teaching documented before the fall: No. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/15/22, at 11:54 p.m., titled SYSTEM NOTE, indicating: Resident was sent to [Hospital] for X-rays of Left Foot and ankle . [Hospital] called the facility approximately at 4:30 p.m. to report Resident was found to have a left Fibula fx [fracture] and she would be returning with a walking boot, a walker, and a prescription for pain medications. Resident returned to the facility at 1740 hours [5:40 p.m.] A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/16/22, at 4:04 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10, with 0 being no pain, and 10 the worst pain]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/16/22, at 9:59 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/17/22, at 4:41 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/17/22, at 6:55 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 8 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/18/22, at 11:30 a.m., titled IDT NOTE, indicating Resident had assisted fall w/injury 7/15: was in room, walked to doorway to meet with therapy and stated that she became light-headed and felt legs weak and would not support her, was supported/guided to floor by therapy. C/o [complains of] LLE [lower left extremity] pain; transferred to [Hospital] ED for eval and tx [treatment]; confirmed fibula fragility fracture . A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/19/22, at 00:49 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/20/22, at 2:37 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 8 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/21/22, at 6:08 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/22/22, at 9:48 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/24/22, at 4:17 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated physician note dated 7/25/22, at 6:22 p.m., written by Resident 4's physician, titled PHONE NOTE, indicating Received a call from [DON] [Resident 4] is in a lot of pain. During an interview on 7/25/22, at 2:05 p.m., the DON stated Resident 4 fell on [DATE], at 9:30 a.m., and broke her left fibula (the calf bone) because of the fall. The DON described the incident as follows: in the morning of 7/15/22 Resident 4 was in her room waiting for physical therapy; a Physical Therapy Student (PTS) went to Resident 4's room and stood at the doorway; the PTS called Resident 4 and waited for her at the doorway; Resident 4 got out of bed and started walking towards the doorway, unassisted and unsupervised by staff, and without a gait bell (belt used by a caregiver on a patient with mobility issues to assist with transfers); when Resident 4 reached the door her legs gave way and she fell to the floor; the PTS assisted Resident 4 to the ground. During the same interview on 7/25/22, at 2:05 p.m., the DON reviewed Resident 4's clinical record. The DON stated Resident 4 had a history of falls, muscle weakness, unsteady gait, and poor balance. The DON stated for a resident with these risk factors appropriate fall interventions included increased staff supervision, frequent checks, and educating the resident to use the call light and requesting staff assistance prior to getting up and ambulating. The DON was asked if these interventions were part of Resident 4's care plans and were implemented. The DON reviewed Resident 4's clinical record and confirmed there were only two fall care plans created for Resident 4, the first created on 12/23/21 by nursing staff, and the other on 6/16/22 by the Occupational Therapist. The DON confirmed none of the care plans contained the fall prevention interventions of increased staff supervision, frequent checks, and educating the resident to use the call light and request staff assistance prior to getting up and ambulating. The DON confirmed the only three fall prevention evaluations completed for Resident 4, on 12/29/21, 4/5/21 and 6/20/21. During an observation on 7/26/22, 9:30 a.m., Resident 4 was lying in bed. During a concurrent interview, Resident 4 was alert and oriented, and described the 7/15/22 fall as follows: she was in bed waiting for physical therapy; the PTS came to her room but did not come in, she stood outside the doorway; physical therapy staff did not enter resident rooms because they did not want to go through the trouble of applying gowns, gloves, mask and faceshield (required of staff when entering resident rooms in the facility); from the door, the PTS indicated it was time for physical therapy; there was no staff in the room to help her get out of bed; she got out of bed and started walking unassisted towards the PTS who was waiting at the door; she had no gait belt; when she reached the doorway she felt weakness in her legs, lost her balance, and fell to the floor; the PTS did not assist her to do the floor; Resident 4 tried to grab the door frame for support but to no avail; after the fall she felt severe pain on her left leg, 12 on a 0-10 scale. During an observation on 7/26/22, at 9:55 a.m., the Physical Therapy Assistant (PTA) was outside Resident 21's room, standing in the doorway. During a concurrent interview, the PTA stated she was waiting for Resident 21 to come out to take him to physical therapy. While PTA was waiting outside resident's room, Resident 21 transferred himself unassisted to a wheelchair and was pushing himself towards the door. During an interview on 7/26/22, 10:08 a.m., the Occupational Therapist (OT) stated he was treating Resident 4 and was familiar with her health conditions and physical limitations. The OT stated he started treating Resident 4 on 6/16/22, after her 6/5/22 fall, to improve her range of motion. The OT stated Resident 4 always complained of weakness. The OT stated Resident 4 needed a gait belt (a speciazlied belt placed by a caregiver around a person with mobility issues during transfers to prevent and mitigate falls) during transfers and close staff supervision when ambulating because of her muscle weakness and poor strength. A review of facility policy and procedure 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 the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score. A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of significant change in condition, post fall and as needed. The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root causes . The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. The licensed nurse will evaluate the Resident's response to the interventions on the Weekly Summary and update the Resident's care plan as necessary. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the Resident's care plan as necessary. The IDT will review the circumstances surrounding the fall then summarize their conclusions on an IDT note. In an effort to prevent more falls, the IDT will review and revise the care plan as necessary.

Based on observation, interview and record review, the facility failed to ensure one of six residents (Resident 6) was free of significant medications errors when Resident 6 was administered 28 units (how insulin doses are measured) of [MEDICATION(S)] Insulin 70/30 (a medication that lowers blood sugar and starts working within 15 minutes of administration) subcutaneously (under the skin) on 7/20/22 one hour before Resident 6 was served dinner and without ensuring Resident 6 ate dinner or had a snack after the insulin administration. As result, Resident 6, who did not eat dinner or had a snack after receiving insulin and on 7/20/22, felt shaky and had a blood sugar reading of 49 mg/dl [milligrams per deciliter] (normal range is between 70 and 100 mg/dl) at 9:30 p.m This failure placed Resident 6 at risk of [CONDITION(S)] or becoming unresponsive due to [CONDITION(S)] (low blood sugar). Findings: A review of Resident 6's Facesheet indicated she was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & [MEDICATION(S)]) [two types of insulin combined] Inject 28 units subcutaneously [under the skin using a small needle attached to the insulin pen] in the evening for DIABETES. BEFORE DINNER. IF B.G.[Blood Glucose] < 70 HOLD INSULIN, IF B.G. >450 CALL M.D. During an observation on 7/20/22, at 4:30 p.m., Licensed Nurse A administered 28 units of [MEDICATION(S)] Mix 70/30 to Resident 6 subcutaneously. During an interview on 7/21/22, at 6 a.m., Licensed Nurse G stated Resident 6 reported feeling shaky the night before, on 7/20/22, at around 9:30 p.m. Licensed Nurse G stated he checked Resident 6's blood sugar and it was 49 mg/dl [milligrams per deciliter] (normal range between 70 and 100 mg/dl). During an interview on 7/21/22, at 7:55 a.m., the Director of Nursing (DON) stated Resident 6 refused dinner the previous evening, on 7/20/22, and had a low blood sugar reading later that night, of 49 mg/dl. The DON stated the low blood sugar was because she received insulin but did not eat afterwards. A review of Resident 7's Activities of Daily Living flowsheets (where staff document resident meal consumption) for July 2022 indicated no dinner or night snack consumption on 7/20/22. During an interview on 7/21/22, at 9:04 a.m., the Dietary Services Manager stated she was at the facility all day on 7/20/22 and stated dinner was served to residents starting at 5:30 p.m. During an interview on 07/26/22, at 9:40 a.m., Resident 6 was alert and oriented and stated she recalled the day her blood sugar was low the previous week. Resident 6 stated she did not remember if she ate dinner or not that night. Resident 6 stated that at around 9 p.m. she felt dizzy and shaky. Resident 6 stated she immediately knew her blood sugar was low. Resident 6 stated she called the nurse who checked her blood sugar level, and it was low. Resident 6 stated the nurse gave her juice and snacks and she recovered. During an interview and record review on 7/22/22, at 9:15 a.m., the Director of Nursing (DON) reviewed the PHYSICIAN ORDERS [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/22/22, at 10 a.m., the facility's Consultant Pharmacist (CP) stated [MEDICATION(S)] Mix 70/30 is a mixture of short and long-acting insulin and has an onset of 15 minutes (meaning the medication starts producing its intended effects - lowering blood sugar - within 15 minutes of administration) and a peak period (where the medication effects are strongest) of 3-4 hours. The CP stated this medication should be given within 15 minutes of the resident eating, with the meal, or immediately after. The CP stated a meal should follow the administration of this medication, and that staff should ensure that a resident consumes food following the administration; otherwise, the resident will become hypoglycemic (with a low blood sugar). The CP stated a blood sugar of 49 mg/dl is considered low and places the resident at risk of [CONDITION(S)] and becoming unresponsive. A review of the [MEDICATION(S)] Mix 70/30 manufacturer's safety information indicated its onset is between 10 and 20 minutes, the peak activity is between 1.7 and 3.6 hours, and duration of action as long as 24 hours. The safety information further indicated: Administer [the medication] within 15 minutes before meal initiation . and [CONDITION(S)] is the most common adverse effect of . [MEDICATION(S)](R) Mix 70/30 . Severe [CONDITION(S)] can cause seizures, may lead to unconsciousness, may be life threatening or cause death. (https://www.novomedlink.com/diabetes/products/treatments/novologmix70-30.html). According to the Centers for Disease Control and Prevention (CDC), [CONDITION(S)] occurs when the blood sugar drops below 70 mg/dl. Severe [CONDITION(S)] occurs when the blood sugar drops below 54 mg/dl. (CDC, Low Blood Sugar, 2022, https://www.cdc.gov/diabetes/basics/low-blood-sugar.html). During an interview on 7/22/22, at 9:15 a.m., the DON stated the facility did not have a policy and procedure on insulin administration.

Based on kitchen observations, dietary staff interviews, management and administration interviews, and facility document and policy review, the facility failed to ensure sufficient and competent staffing in the dietetic service department when the facility did not have enough trained cooks and enlisted the Activity Director (Director B), Dietary Aide C (a dietary aide, not a trained cook) and Aide F to cook resident meals; Director B, Aide C and Aide F did not possess cooking competencies (verification of skills needed by staff to perform a task); dietary staff were not supervised per facility policy; and dietary staff were not adequately trained prior to cooking independently. Failure to ensure sufficient and competent staff and supervise staff caused potential for staff burn out (related to over-work/staff inability to take a day off) and for food production and meal distribution errors, that could compromise the medical and nutritional status of 52 residents in a census of 52; resident activities were suspended when Director B was cooking, and residents were not provided their scheduled activities on 3/3/2022 and 3/4/2022. An IMMEDIATE JEOPARDY was identified on 3/4/2022 at 4:35 p.m. under Food and Nutrition Services; §483.60, F802. The IMMEDIATE JEOPARDY was abated on 03/08/2022 at 5:26 p.m. Findings: During an interview on 3/4/2022 at 12:30 p.m., the Interim Administrator (IA) and Director of Nursing (DON) discussed staffing in the Dietary Department. The IA stated the facility's three cooks (Cook D, Cook E and the dietary supervisor [DS], who acted as a relief cook) were suspended two days earlier. The IA stated the cooks had left the facility Wednesday afternoon (3/2/22) and a dietary aide had cooked dinner that night. When asked how many cooks remained at the facility, the IA stated the facility was filling in (for the cooks). The IA stated the Activity Director (Director B, currently cooking at the facility) had worked at a restaurant but did not have experience cooking in a healthcare facility; the IA stated Aide C was experienced. When asked if Director B and Aide C were trained to cook, the IA stated he was, pretty sure they had been. The IA stated the Registered Dietitian (RD) had been in the kitchen the previous day (Thursday, 3/3/2022). The IA stated Director B and Aide C had cooked breakfast and lunch (on 3/4/2022) and a cook from a sister facility was coming in to cook dinner. The IA stated the facility did not yet have a cooking schedule confirmed for the following two day (Saturday and Sunday, 3/5/22 and 3/6/2022). When asked who was supervising Director B and Aide C's cooking, the IA stated the Administration was supervising them. Review of facility job description titled, Director of Nutritional Services (undated) indicated the Director of Nutritional Services (not Administration), Monitors staff performance .Evaluates quality .of services accomplished by staff. During a tour of the kitchen and concurrent interviews on 3/4/2022 at 1:10 p.m., Director B and Aide C were in the facility's kitchen. When queried who had cooked breakfast and lunch that day, Director B stated she had cooked with Aide C's help. When asked if she was trained to cook at the facility, Director B stated she had previously owned a restaurant. When asked if she was trained to prepare therapeutic diets (diets deviating from regular food such as pureed foods, mechanically chopped foods, etc.), Director B stated, yes, and stated the dietary supervisor (DS) had trained her when she (the DS) had broken her foot, approximately nine weeks earlier. (Pureed food is smooth, with no lumps and a texture like pudding; requires no chewing. Mechanically chopped food is soft, easy to chew and swallow and excludes foods with a hard texture; requires little chewing). Director B stated the RD had observed her cook breakfast and lunch. Director B stated the RD had been supervising in the kitchen the previous day (Thursday, 3/3/22) and stated the RD had come to the kitchen after breakfast was prepared and stayed until after 4 p.m. Director B stated she was scheduled to cook breakfast and lunch on Monday, 3/7/22. When queried about resident meal orders, Aide C stated seven residents needed their food pureed, one resident required liquid pureed food, twenty residents had mechanical texture (foods finely chopped, blended, or ground to make them smaller, softer, and easier to chew), and twenty-four had regular food preparations. During the same interview on 3/4/2022 at 1:10 p.m., Director B was queried how her need to cook meals (versus run the activity program) impacted resident activities at the facility. Director B stated residents had missed scheduled activities that day (3/4/22) and the prior day (3/3/22). Director B stated Bingo, painting, and arts and crafts were some of the activities that she was not able to offer the residents. Review of the facility's activity calendar (dated March, 2022) indicated the following activities were scheduled on 3/3/2022: Painting class from 10:30 a.m. to 12 noon and Bingo from 2:20 p.m.-4 p.m. On 3/4/2022 the following activities were scheduled: Window Art (arts and crafts) from 10:30 a.m. to 12 noon and Room to Room (room visit activities) from 2:30 p.m.-4 p.m. During an interview on 3/4/2022 at 1:35 p.m., the IA stated he did not yet have cooks for Saturday and Sunday (3/5/22 and 3/6/22). During an interview and concurrent record review on 3/4/2022 at 1:35 p.m., the Infection Preventionist (IP) reviewed Director B's employee files. The IP stated Director B had been hired as the Activity Director. When asked if Director B's file indicated she possessed verified cooking competencies, the IP stated, No. When queried is she should have had cooking competencies verified prior to preparing meals independently for residents, the IP stated she did not orient staff (to the kitchen). She stated the dietary supervisor would have oriented her. During an interview on 3/4/2022 at 1:45 p.m., the RD stated she normally works approximately one day a week at the facility. The RD stated she observed Director B cook the previous day, but did not give her cooking competencies. During an interview on 3/4/2022 at 2:05 p.m., the IA, DON, and RD described their plan to provide cooking and meal services in the coming days. The IA stated that evening's dinner would be prepared by a cook from their sister facility (in a nearby town). The IA stated Aide C (who did not have verified cooking competencies) would be cooking breakfast and lunch on Saturday and Sunday (3/5/22 and 3/6/22) and dinners would be prepared by their sister facility's cook. The RD stated Aide C and Director B did not possess cooking competencies. The IA stated Cook D would be back at the facility the following Monday. Review of facility policy titled, Staff Competency of Skills Checks, subtitled, Policy (revised 8/22/2019) indicated, Competency evaluations or skills checks will be performed upon hire . annually, anytime a new procedure is introduced and as needed. During an interview on 3/4/2022 at 2:55 p.m., Aide C was asked if she was comfortable cooking for the residents. Aide C stated she was not comfortable cooking alone (unsupervised) or with another aide to assist her. Aide C stated she was, very stressed out and exhausted. When asked if she had been trained to cook, she stated she was trained in 1984 (when she started working at the facility). She stated she worked a couple of weeks as a cook (in 1984) but did not like it, and had been working as a dietary aide since that time. Aide C stated she was last educated about therapeutic diets approximately two years prior (approximately 2020). Aide C stated she had helped the DS approximately one month prior, when the DS had broken her foot. Aide C stated the DS was in a wheel chair (in the kitchen) giving Aide C cooking instructions. Aide C stated last week she had prepared a therapeutic meal alone (unsupervised) for the first time. An IMMEDIATE JEOPARDY was identified on 03/04/2022 at 4:35 p.m. under §483.60 Food and Nutrition Services. The Interim Administrator and Consultant A were notified of the IJ in the Administrator's office. A Plan of Action (POA) to abate the IJ was emailed to the department on 3/4/2022 at 6:15 p.m. The POA was determined to be not acceptable on 3/5/2022 at 9:21 a.m. and the facility was notified via email. During an onsite visit and interview on 3/5/2022 at 11:20 a.m., the dietary supervisor (DS) was working in the kitchen. The DS stated she was back to work.The DS stated Cook D was also back to full-time work and Cook E would return to work on Monday. The DS stated Cook E was a new cook in training, Cook D was the p.m. (afternoon) cook, and she (the DS) was the supervisor and relief cook. A revised POA was submitted by the IA on 3/5/2022 at 11:25 a.m. The POA was determined to be unacceptable to abate the IJ. A revised POA was submitted on 3/5/2022 at 12:45 p.m. and was determined to be unacceptable to abate the IJ. During an interview on 3/5/2022 at 11:40 a.m., Cook D was in the kitchen and stated he was the p.m. (afternoon) cook. He stated he had been suspended until yesterday, 3/4/2022, but was now back working full-time as the p.m. cook. Cook D stated the facility needed another cook. During an interview on 3/5/2022 at 11:45 a.m., the DS stated she had not had days off in nine months except a few days off in November (2021) and three days off when she broke her foot (approximately nine weeks earlier). When queried who cooked in her absence, the DS stated she, remotely cooked. The DS stated Dietary Aide F (no longer working at the facility) cooked the meals but, I was on the phone talking him through. When queried how Aide F prepared therapeutic diets, the DS stated, I did it with him over the phone. During an interview on 3/5/2022 at 12:42 p.m., the IA stated he was not aware a dietary aide had cooked meals in the past with telephone support from the DS. Review of facility dietary staff list indicated Aide F's worked at the facility for less than four weeks, from 12/23/2021 through 1/18/202. A facility Plan of Action (POA, dated 3/7/2022) to abate the IJ was received via email on 3/7/2022 at 12:41 p.m. The Plan of Action was accepted on 3/7/2022. The Plan of Action indicated: Immediate Corrective Actions revealed that the DS, Cook D and Cook E were placed on suspension. The POA indicated the facility was able to contact the DS and Cooks D and E on 3/4/2022 and notified them they were eligible to return to work and all three staff were scheduled to return to work and cover the shifts for 3/5/2022 and 3/6/2022. The dietary aide and Director B were no longer assigned to cook meals. The DS would update the schedule to ensure there was a cook for each shift. On 3/4/2022, the RD was present and overseeing dinner service. With the return of the DS and Cooks D and E, the facility had supervision and cooks as well as the RD's scheduled visits. The DS would ensure adequate daily dietary coverage with a qualified cook. If a qualified cook was not available, the facility would reach out to one of two sister facilities; the sister facility would utilize any available staff to float to the facility to cover open shifts. Both sister facilities had been informed of the agreement and had agreed. The facility would also secure a contract with (company name) Staffing Agency to serve as an additional back up when the facility was unable to get a qualified cook. Finally, the facility was actively recruiting and evaluating wages to recruit qualified staff. The facility has reached out and were awaiting agreements from for two additional staffing services to be sent to the facility. The IMMEDIATE JEOPARDY was abated onsite on 03/08/2022 at 5:26 p.m. Review of RD Reports - September through December, 2021: 1) Review of RD report titled Dietary Quality Control Review, (dated 9/23/21) indicated, DSS (DS) has been working shifts without days off and has not been able to keep up with all managerial duties .2 new employees going through orientation .DSS currently having to work most days as cook or diet aide. 2 staff training and 1 cook out on paternity leave . 2) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 9/30/2021) indicated, No weekly weights (resident weights) available since Sept .RNA (restorative nurse assistant) who previously obtained weights no longer at facility. 3) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 10/14/2021) indicated, Due to staffing issues, no weekly weights obtained; 4)Review of RD report titled Dietary Quality Control Review, (dated 11/4/21) indicated, DSS has been cooking or working in the kitchen most days and has not been able to complete all tasks .1 cook recently hired .still need 1 aide position . 5) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 11/11/2021) indicated, Met with the DSS and Administrator to discuss staffing in the kitchen . New diet aide recently hired and will replace the aide who is moving to work in the laundry . 6) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 12/20/2021) indicated, Assisted in the kitchen for meal prep; currently only 1 cook and the DSS (DS) are cooking every day without breaks . Review of RD Reports - January through February, 2022: 1) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 1/10/2022) indicated the DS was, currently out with a work injury. Stable PM cook position and a recently hired diet aide had been training to be the cook and did work as the AM cook today and on-going as able. Currently have a diet aide who will be off for the next month Applicant for the cook or diet aide position will be coming in on Thursday to interview .Spoke to the Regional RD consultant about desperate needs for dietary staff . 2) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 1/13/2022) indicated, Contract for staffing agency sent to the Regional RD and Administrator for completion; looking to fill at least a temp cook position while the DSS (DS) is on light duty .Diet aide recently started training as a cook and continues to do so filling in as AM cook until alternative staffing found. 3) Review of the RD's report titled, Consultant Dietitian Visit Report (dated 1/27/2022) indicated, Continuing to try recruiting a cook. Potential hire did not show up for scheduled interview .The PM Cook continues to work without days off . 4)Review of RD report titled Dietary Quality Control Review, (dated 2/26/22) indicated, DSS has been cooking daily with no days off due to staffing shortages and unable to complete managerial duties (monthly in-service records not completed and up-to-date) . Recently hired a new cook and diet aide. DSS still having to cook/train but will hopefully be able to resume more clinical documentation . Still looking for a relief cook . During a telephone interview on 3/10/2022 at 2:37 p.m., the IA and Consultant A were further queried about staffing in the dietary department. When asked what steps the facility had taken to address staffing shortages, the IA stated the facility had ads out (advertisements) for cooks and aides and stated that was, all I know. When asked why the facility was not able to attract and maintain staff in the kitchen, the IA stated he did not know why, but a recent applicant cited low wages as an issue. When queried what management duties the DS may have been unable to complete as she was frequently cooking, the IA stated he was not aware if any duties were missed. When queried if the Medical Director had been notified of staffing issues in the kitchen, the IA stated per the QI (Quality committee) minutes, the Medical Director had not been notified. When asked if the Medical Director should have been notified, the IA stated, they (leadership/management) all should be notified. During a telephone interview on 3/10/2022 at 3:56 p.m., the RD was asked if the facility had conducted a root cause analysis (RCA) to determine possible causes of the dietary staffing shortage. The RD stated she did not know if an, official RCA had been conducted and stated the facility had talked about looking into compensation for dietary staff. The RD stated she hoped it continued because it was a help to have, adequate compensation (for staff). When asked if the dietary staffing issue had been brought up to the Medical Director, the RD stated she was not sure. When queried how the DS's frequent cooking in the kitchen impacted the dietary department, the RD stated normally the DS helped with clinical duties, provided training in the kitchen, and attended weight meeting. The RD stated the DS's attendance at weight meetings was not required but stated it was nice to have her input. Review of the facility job description titled, Director of Nutritional Services, subtitled, Principal Responsibilities (undated) indicated, .Maintains all records and documentation .Participates in assigned meetings and in-services (staff education) .Ensures exchange of information necessary with all departments as necessary for quality resident care . Review of the dietary aide job description titled, Dietary Assistant/Dishwasher, subtitled, Job Description, further subtitled, Principal Responsibilities, further subtitled, Technical . Administrative . Qualifications . Consumer Service . (undated) revealed the document did not contain information indicating dietary aides cooked meals as part of their job duties. Review of facility policy and procedure titled, Dietary Department - General, subtitled, Policy (revised June 01, 2014) indicated, The dietary department is responsible for establishing a program that meets the nutritional needs of the residents . Under subtitle, Procedure, the policy indicated, I. The primary objectives of the dietary department include . D. Procurement, production and service with economical use of labor and food . II. Organizational Structure . A. the Administrator is responsible for the overall operation of the facility. The Dietary Manager (DS) reports to the Administrator .

Based on observation, interview and record review, the facility failed to provide adequate supervision to reduce the risk of falls for one of four sampled residents at risk of falls (Resident 58). This failure likely contributed to Resident 58 having five falls in a three-month period from 1/1/2019 to 4/1/2019, which resulted in multiple unwitnessed falls, one with injury. Findings: During an interview with Resident 58 alone in her room on 04/09/19 at 3:55 p.m.: Have you had any falls? I did Can you tell me what happened? I don't remember During an interview with Unlicensed Staff P on 04/09/19 at 4:16 p.m. He confirmed he was working on 3/8/19, but stated he was not assigned to the Resident 58 when she fell . She has a self-release seatbelt, also a mat alarm on her wheelchair, a mat alarm in her bed, padded floor mat, room close to the nurses' station to hear the alarms. During a review of the clinical record for Resident 58, the annual MDS dated [DATE], Sections A, G, H and J indicated Resident 58 was independent with bed mobility, supervision with limited assistance with transfers, walking in room, locomotion off unit. ADL support provided. Resident 58 is not steady, but able to stabilize without staff assistance. Resident 58 using wheelchair. Resident is occasionally incontinent, Resident had two or more falls with no injury. During a review of the clinical record for Resident 58, the quarterly MDS dated [DATE], Sections A, G, H and J indicated Resident was limited assistance with bed mobility. Supervision and limited assistance with transfers. Limited assistance with walking in room. Limited assistance with toilet use. Resident 58 is not steady, but able to stabilize without staff assistance. Resident 58 uses a wheelchair. No urinary toileting program. Resident 58 is always continent. No bowel toileting program. Resident had two or more falls with no injury. Resident had one fall with injury. During a review of the clinical record for Resident 58, the significant change MDS dated [DATE], Sections A, C, G, H and J indicated Resident needs limited assistance with bed mobility and extensive assistance with transfers. Resident 58 needs extensive assistance walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, personal hygiene. Resident 58 is not steady, only able to stabilize with staff assistance. Resident uses walker and wheelchair. Resident is always continent. No toileting program. Resident had two or more falls with no injury. Resident had one fall with injury. Resident had one fall with major injury. During interview with Unlicensed Staff Q on 04/10/19 at 08:24 a.m. she stated: I have worked here for one year, I am a [MEDICATION NAME]. I went into her room and Resident 58 was sitting on her bed crying, she said she had just fallen in the bathroom. I went to the nurse, told her, Licensed Nurse R went in to assess her and they sent Resident 58 out. Resident 58 has a bed alarm that she has had the whole time I've been here, because she has always been a fall risk. Resident 58 has a Tab alarm(The use of bed and chair alarms proliferated in the 1990s, when physical restraints were banned, and are intended to go off when a resident's weight shifts, indicating they may be trying to stand without assistance.) on wheelchair. The hard part is Resident 58 is able to turn off her Tab alarm on wheelchair. Resident 58 turns off her alarm, we repeatedly remind her to use her call-light, but she is non-compliant with that. Resident 58 gets upset when we try to help her. Resident 58's room has been by the nurses' station, her roommate is a fall risk also. Resident 58's roommate's alarm would go off and it would concern Resident 58. When her roommate gets agitated, we encourage Resident 58 to join us in the dining room for coffee so we can keep an eye on her. During an interview on 4/10/19 at 08:53 a.m. with Lisensed Nurse R. She confirmed she was the nurse for Resident 58 on 3/8/19. She stated that Resident 58 was up in wheelchair, she self transfered back into bed, we heard a noise and we ran in there. One of the CNA's found her and called me into the room. Resident 58 is so forgetful, she has been on bed and chair alarms for months/years. I asked her what were you doing? Resident 58 stated she was going to bed. Resident 58 is a quick little thing. Resident 58 was complaining of pain in her right hip. When I got in there, Resident 58 was sitting on the edge of the bed. The aide told me she had gotten up. Resident 58 has had so many falls. I called 911 and the MD. When Resident 58 came back later that day, we tried to keep her on bedrest using a bedpan, that didn't work because she kept getting up. Resident 58 had a bed alarm on. Resident 58 was a two person assist for a couple of days. We gave her multiple reminders, she couldn't remember. Then she was a one person assist, she had a self-releasing seatbelt, now she has a pull tab, she can turn it off. We run in there. We do walkby checks. During a review of the clinical record for Resident 58, the record indicated: Resident with multiple falls 3/8/2019, 2/4/2019, 1/25/2019, 1/18/2019, 1/1/2019. Resident with [MEDICAL CONDITION]. During review of the clinical record for Resident 58, the Resident Admission assessment dated [DATE] indicates Resident is alert and oriented, incontinent and uses a walker. Resident needs supervision with ambulating and transfers. During review of the clinical record for Resident 58 for IDT notes dated: 3/8/19 fall, which indicated at 0615 resident was sitting on her bed and indicated she had fallen a few minutes prior. Transferred to Redwood Memorial Hospital for eval and treat. 2/5/19 fall, hx of falls. Resident was getting up from toilet and foot slipped. Resident fell backwards and hit head on sink. Nurse was present but unable to prevent fall. 1/28/2019 (fall 1/25/19) at 1350 Resident was standing up from wheelchair and lost balance and fell back and landed on her bottom and hit posterior head. 1/2/2019 Quarterly review: No mention of falls During review of the clinical record for Resident 58, the Post Fall Huddle dated11/15/18 indicated an unwitnessed fall on 11/15/18 at 0820 a.m. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/1/19 indicated fall in room at 0700 a.m. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated no pain, no injury. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/18/18 indicated fall in room at 1845 p.m. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in her head 10/10, fall was unwitnessed During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain posterior head 6/10, Resident found on floor. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/25/19 indicated Resident had a fall in her room at 1350 p.m. Refer to RNA for strengthening. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in the right occipital area During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 2/4/19 indicated Resident fell in bathroom at 0730 a.m. Currently on RNA program During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in Right Hip and Right Leg During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 3/8/19 indicated Resident fell in her room at 0615 a.m. Resident continues to self-transfer and not use call light. Resident with [MEDICAL CONDITION]. During review of the clinical record for Resident 58, the SBAR Communication Form, dated 1/18/2019 indicates unwitnessed fall in bathroom on 01/18/19. During review of the clinical record for Resident 58, the SBAR Communication Form, dated 1/1/19 indicates fall, Resident turns off bed alarm During review of the clinical record for Resident 58, the SBAR Communication Form dated 2/4/19 indicates the Resident fell in the bathroom. During review of the clinical record for Resident 58, the SBAR Communication Form dated 3/8/19 indicates the Resident stated she had fallen, sent to Redwood Memorial Hospital. During review of the clinical record for Resident 58, the Nurses Notes, dated 1/28/19 night shift indicated s/p fall day 3 Neuro checks WNL. Resident continues to self-transfer despite numerous reminders to use call light and wait for assistance. During review of the clinical record for Resident 58, the Nurses Notes dated 2/4/19 at 2200 p.m. indicates witnessed fall this a.m. During review of the clinical record for Resident 58, the Nurses Notes dated 3/8/19 indicated Resident fell in her room. Resident sent to ER. Resident returned to facility with [MEDICAL CONDITION]. During review of the clinical record for Resident 58, the report from Redwood Memorial Imaging Ground level fall with right hip pain Impression: Moderately comminuted right greater trochanteric fracture. Dated 3/8/2019. During review of the clinical record for Resident 58, the Fall Risk Care Plan dated 3/19/2019. Dementia Care Plan dated 3/19/2019. MD order to start RNA program dated 1/21/19 for 3X week transfer training, ambulate with FWW. MD order ok to place seat belt alarm on wheelchair for increase safety measures. Understanding restraint use 12/1/14. informed consent 3/15/18 self-releasing seat belt in wheelchair. During interview on 04/10/19 at 11:04 a.m. with the Director of Nurses stated: Alarms, we continually remind her call bell is in her reach, fall mat in place, every 2 hours needs assistance, more often most of her falls are transferring from bed to wheelchair, wheelchair to bed, going to bathroom by herself. Resident 58 never asks for assist. She doesn't remember. Resident 58 came from a place in Fresno that was closed, mostly dementia, psych dx. Resident 58 has a friend here, who came with her. Resident 58 has severe dementia. We have her as close to the nurses' station as we can, it's an all hands on deck. We had her on the RNA program for strength training and balance. We have done every 2 hours. But could not state when and documentation requested to support. She hasn't had any med changes. I would have to go back and look. Resident 58 has a self-releasing seatbelt, we encourage her to go to the dining room for activities. During observation on 04/10/19 at 11:35 a.m. Resident 58 in bed in room, alone, no one in hallway. 04/10/19 at 12:00 p.m. Resident 58 got up and wheeled out to dining room. No one assisted resident. When Resident got to dining room, a CNA asked if she needed assistance.

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment when: 1. Multiple residents (Resident 23, 24, 25, 29, 36, 62, 50, 66 and eight confidential residents) out of 68 residents complaint of being cold inside the facility for weeks, and the facility did not maintain comfortable facility temperatures ranging from 71 to 81 degrees Fahrenheit (°F). On 2/27/28, at 1:47 p.m., due to the facility's failure to provide comfortable facility temperature, the Administrator and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurses informed the Administrator and the DON of the interviews with residents complaining of being cold and facility thermometer indicating being 60- 69 °F. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (Standard Operation Manual, Appendix Q). On 2/28/18, at 11:30 a.m., the facility presented a corrective plan of action, including but not limited to: 1) servicing the boiler system, 2) in-servicing staff to monitor residents for signs and symptoms of being cold, providing warm clothing and extra blankets, offering and assisting with warm beverages to residents. On 2/28/18 11:48 a.m., the Administrator, Area Vice President, Quality Assurance Personnel, were notified of substandard quality of care identified and that the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.10 resident rights that constitute to immediate jeopardy to resident health or safety (level J, K, or L) (Standard Operation Manual, Appendix P). On 3/06/18, at 1:49 p.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of the Administrator after interviews and observations confirmed the facility implemented the corrective plan of actions. The Administrator understood the facility would continue to complete plan of action to fix the boiler system and ventilation system to maintain comfortable facility temperature without using temporary blowers. 2. Multiple of resident's toilets had sharp rusty bolts anchoring the base of the toilet, caulking missing around the base of the toilet, bathroom brown rubber cove baseboard was marked, chipped, and/or peeling, room [ROOM NUMBER]'s bathroom wall's paint was peeling and light bulbs were burnt out in two resident bathrooms (room [ROOM NUMBER] and 54). 3. Privacy curtain and window drape in room [ROOM NUMBER]B had multiple grayish and brownish/red splatter marks. 4. Bathroom sink and toilet in room [ROOM NUMBER] and 55 were dusty/dirty with hair and multiple particles/substance. 5. room [ROOM NUMBER]C, 52C, 54C, 55 linoleum floor and room [ROOM NUMBER], 54, 55, and 56's bathroom linoleum floor were unkept; dirty with multiple splatter/spots, brown and rusty stains, purplish colored stains, and/or tissue/cotton balls or food particles on floor. 6. Resident 23's electric chair's left arm rest and left back rest upholstery was torn preventing the electric chair from being cleaned and sanitized thoroughly. 7. Resident's belongs were stored on unoccupied made up resident beds. These failures had the potential to cause: 1. Resident's susceptibility to loss of body heat and risk of hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce, causing dangerous low body temperature), or susceptibility to respiratory ailments and colds, 2. Environmental hazards due to sharp surfaces, 3. Cross-contamination and spread the infection among residents, and 4. Negatively impact residents comfort and homelike environment. Findings: 1. During a concurrent observation and interview on 2/26/18, at 8:16 a.m., in Resident 24's room, Resident 24 was eating breakfast in bed. Resident 24 was wearing a gown, and stated she was cold. When asked if she could request extra blanket, she shook her shoulders. Resident 24'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 1/12/18, revealed Resident 24's BIMS (brief interview for mental status) score was 15, which indicated Resident 24 was cognitively intact. During an interview on 2/26/18 at 9:25 a.m., Resident 36 stated the biggest complaint was being cold. During a concurrent observation and interview on 2/26/18 at 9:30 a.m., Resident 23 (who resided in the same room as Resident 36) was lying in bed and wearing a lightweight nightgown. Resident 23 stated she was very cold. During an interview in the dining room on 2/26/18 at 10:05 a.m., Resident 62 stated that besides getting in and out of the bathroom with his walker, another issue was the temperature. Resident 62 stated, Sometimes at night it can get pretty cold here, and once you get chilled you can't get warm, even with another blanket. During an interview in the dining room on 2/27/18 at 8:30 a.m., Resident 29 asked if surveyor had a thermometer. When confirmed, Resident 29 stated, Could you take the temperature in here? The temperature read 67 °F. Resident 29 stated, I'm freezing and the furnace has not been working for months .When complaint was made about it, the staff said the furnace was too old to get parts for it .They have given me three blankets for my bed, but I am still cold, especially at night. I think they should just buy a new one. During an observation on 2/27/18 at 8:50 a.m., the wall thermometer at the end of the 40's hall was 66 °F. The wall thermometer in the 60's hallway at the end of the hallway read 61 °F. During an interview on 2/27/18 at 9 a.m. in the main dining room, 4 confidential residents out of 6 residents stated they were cold despite having blankets over their laps. During a concurrent observation and interview on 2/27/18 at 9:13 a.m., Resident 25 stated she was very cold. Resident 25 said, That is why I have multiple blankets on. Resident 25's room was the last resident room on the right side of Lytle North hallway right near the exit door. The thermometer located on the wall right of the exit door in the Lytle North hallway read 60 °F. During a concurrent observation and interview on 2/27/18 at 9:16 a.m., Licensed Staff J was asked to read the thermometer located in Lytle North hallway. Licensed Staff J stated the thermometer read 62 °F. Licensed Staff J stated he had heard there were issues with the heat, but maintenance could answer the issue better. During an interview on 2/27/18 at 11:30 a.m., Maintenance Supervisor was asked to provide documentation that the furnace was in working condition. The Administrator overhearing the conversation interrupted and stated, the boilers are working, but our boiler system cannot keep up with the severe weather. The temperatures in the last few weeks have dropped below freezing. Maintenance Supervisor stated, I don't have documentation, but I can show you the boilers are working, and started a tour of the heating system. During a resident council interview on 2/27/18, at 11:30 a.m., four of nine attended residents stated they had been being cold for months. Two residents stated they were told that the hallway temperature were 60, 61, or 67 °F. One resident stated the heater was broken for months. The resident stated the facility staff told him that they could not find the parts for replacement because the heater was old. During an observation and concurrent interview on 2/27/18 at 11:40 a.m., Maintenance Supervisor opened the entryway to boiler room in the front hall of the building. There were 2 boilers inside. Maintenance Supervisor stated, these were new boilers, but that one operated at a time and the second was for a back-up in-case the first one failed. The second boiler room was located at the back of the building (in the 60's hall). After entering 2 doors a huge boiler system with cobwebs, rust around pipes, algae on the side of it was observed. An 8.5 by 11 inch sign titled, Boiler Failure Procedure was observed. Maintenance Supervisor stated that the boiler was very old and heated to a certain degree, and then would shut off automatically. Maintenance Supervisor stated that the rooms in the 40's and 60's halls were at the end of the heat system, which caused the temperatures to drop in those areas. During an interview on 2/27/18 at 11:50 a.m., Administrator stated the temperatures were maintained in the facility between 64 to 74 °F. On 2/27/18 at 11:50 a.m., the facility provided a document, with no title and no date, indicating Procedure 'comfortable and safe temperature' levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. Although there are no explicit temperatures standards for facilities certified on or before (MONTH) 1, 1990, these facilities still must maintain safe and comfortable temperature levels . During an interview on 2/27/18 at 12:05 p.m., Maintenance Supervisor was questioned regarding the sign titled, Boiler Failure Procedure and stated, when the boiler shuts itself off, this is the procedure we use to turn it back on again. During a concurrent observation and interview on 2/27/18 at 1:13 p.m., surveyor went around facility with Maintenance Supervisor to check hall and room temperatures using infrared temperature gun. Lytle Nurse's Station (located central to room [ROOM NUMBER]'s 50's, and 60's hallways) thermometer read 70 °F, Lytle North Hall at mid end of hall read 65-66 °F, room [ROOM NUMBER] read 67 °F, room [ROOM NUMBER] read 66 °F, room [ROOM NUMBER] read 65 °F (room [ROOM NUMBER] and 48 are last rooms on Lytle North hallway closest to Exit door). Hall Temperature down East Lytle was (Rooms 60 Hall) ranged from 65-67 °F. Maintenance Supervisor read the temperature in Lytle West temperature, by aiming gun at the end of the hallway where the sun was beaming, and it was 69 °F. Maintenance Supervisor stated boiler kicked on a lot slower in the summer due to hotter outside, but in the winter the boiler would kick on a lot faster due to colder outside, between 100-120 °F. When Maintenance Supervisor was asked the last time the heater unit was serviced, he could not recall and he could not provide the last invoice. When Maintenance Supervisor was asked for temperature logs for the facility, he could not provide the temperature logs. Maintenance Supervisor stated he monitored the room and hall temperatures with the infrared temperature gun every morning by picking random rooms. Maintenance Supervisor could not recall the last time the heating unit was serviced. Maintenance Supervisor had worked at the facility 4 and a half years, but could not recall the last time the heating system had been serviced. Maintenance Supervisor stated the servicing of the heating system had fallen through the cracks. Maintenance Supervisor stated he had never called for the heating system to be service by an outside vendor. Maintenance Supervisor stated the recommendation for the heating unit was for it to be service on an annual basis. Maintenance Supervisor stated he was responsible for the maintenance of the heating system at the facility. On 2/27/18, at 1:47 p.m., the State Health Facilities Nurse Evaluators notified the Administrator and the Director of Nursing (DON) of the Immediate Jeopardy situation. The Administrator stated, Where's the jeopardy? Our system can't handle this cold temperature. During an observation on 2/28/18 at 11:51 a.m., the thermometer at Lytle North hallway read 66 °F. During an observation on 2/28/18 at 4:25 p.m., the thermometer located at the end of Lytle East hallway indicated the temperature in the hallway was 68 °F. During an interview on 2/28/18 at 4:25 p.m., Resident 25 stated she felt a lot warmer, but she said, I still have a shirt and a warm sweat shirt and two blankets on me. During a concurrent observation and interview on 3/02/18 at 8:50 a.m., Resident 50 was dressed in a lightweight nightgown and had a bed coat over her shoulders. Resident 50 was up in her wheel chair and eating breakfast next to her bed. When Resident 50 (roommate with Resident 50) was asked if she was cold, Resident 50 said, It was cold this morning. Resident 66 was resting in bed. When Resident 66 was asked if she was cold, Resident 66 said, It seemed warmer, but I have a lot more blankets on as well. It was still cold. I asked a Certified Nursing Assistant (CNA) to bring me another blanket. The facility policy and procedure titled Resident Rooms and Environment no date, indicated, Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: Comfortable levels of ventilation .Comfortable temperatures . 2. During multiple observations on 2/26/18 from 8:47 a.m. to 12:07 p.m. toilets located in the bathrooms shared by the residents in Rooms 43, 47, 51, 52, and 53 had rusty bolts anchoring the base of the toilets; no toilet bolt caps for the protruding rusty bolts. The protruding bolts anchoring the toilet base in room [ROOM NUMBER] were sticking up 1 inch on both sides. room [ROOM NUMBER]'s left bathroom wall had peeling paint a yard in length. The bathroom brown rubber cove baseboard located in room [ROOM NUMBER], 47 and 56 was marked, chipped, and/or peeling away from the wall. The caulking around the base of the toilets in room [ROOM NUMBER], 47 and 52's bathrooms was missing and/or the linoleum around the base of the toilet was dirty and had rust color stains. The left light bulb was burnt out in room [ROOM NUMBER] and 54's bathroom. During an environment tour on 3/01/18 at 1:00 p.m.: · Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom rubber cove baseboard was rotten and needed to be replaced. Maintenance Supervisor stated a lot of the resident's bathroom rubber cove baseboards needed to be replaced, which he was doing gradually, but he is the only maintenance person for the entire facility, so he had to prioritize his work load. · Maintenance supervisor stated the caulking around room [ROOM NUMBER]'s bathroom toilet should be reapplied due to it was missing and the linoleum was stained/old and needed to be replaced. Maintenance Supervisor state room [ROOM NUMBER]'s bathroom linoleum had brown stains due to some of the residents had fall mats in the bathroom and if housekeeping mopped the bathroom floor and placed the fall mat back down before the linoleum floor was dry, the fall mat would cause the floor to become stained. · Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom rubber cove baseboard was rotten and needed to be replaced. Maintenance Supervisor stated a lot of the rubber cove baseboard in resident's bathrooms were [AGE] years old. Maintenance Supervisor was able to pull the rubber cove baseboard by hand of the wall and the rubber would just crumble. Maintenance Supervisor again stated the rubber cove baseboard was rotten. Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom rubber cove baseboard was rotten and again pulled the baseboard off the wall by hand showing how rotten the baseboard had become. · When Maintenance Supervisor was asked how he knew when something in a resident's room need to be fixed/tended to, he stated there was a Fixed Book at each of the nurse's station. The staff member would write down the item needed to be tended to in the Fixed Book. Maintenance Supervisor stated he checked the Fixed Book first thing every morning. Maintenance Supervisor stated often the nurse or CNA would just stop him in the hallway to let him know when something needed to be fixed in a resident's room. Maintenance Supervisor state there was also chalkboard in his workshop where staff could write down something needing to be tended to. · Maintenance Supervisor stated all the bolts securing the base of the toilets should have caps on them. Maintenance Supervisor stated after he fixed a resident's toilet he just forgot to cap the bolts. Maintenance Supervisor stated the base of the resident's toilets looked a lot nicer with the caps because the area around the bolts would become rusty in color. Bolt caps were missing on the base of the toilets in the bathrooms shared by the residents in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]'s, which had bolts sticking up 1 inch. Maintenance Supervisor stated the bolts anchoring the toilet in room [ROOM NUMBER]'s bathroom should have been cut and capped. Maintenance Supervisor stated he worked on the toilet and then forgot to cut and cap the bolts; all bolts should be capped. · Maintenance Supervisor stated the back base of room [ROOM NUMBER]'s toilet needed to be caulked and the linoleum was rusty in color due to the toilet leaked at times. Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom linoleum needed to be replaced, it was old and had multiple rust colored stains. · Maintenance Supervisor stated the left light bulb in room [ROOM NUMBER] and 54's bathroom was burnt out. Maintenance Supervisor stated staff needed to let him know when a light bulb was burnt out because he did not make daily room rounds; he was the only maintenance person for the entire building and did not have time to make daily room rounds. The facility document titled, Maintenance Assistant, undated, indicated maintenance was to ensure: 1. A safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State and Corporate requirements and 2. Maintains written records and documents of services performed according to Federal, State and Corporate requirements. 3. During an observation on 2/26/18 at 9:59 a.m., room [ROOM NUMBER]B's privacy curtain and window drape had multiple grayish and brownish/red stains. During an observation on 3/02/18 at 8:50 a.m., room [ROOM NUMBER]B's privacy curtain and window drape were dirty with multiple grayish and brownish/red stains. During a concurrent observation and interview on 3/02/18 at 9:00 a.m., when Housekeeping Supervisor was asked about room [ROOM NUMBER]B's privacy curtain and window drape, which surveyor had noticed had been dirty with multiple grayish and brownish/red stains since 2/26/18, Housekeeping Supervisor stated they were both very dirty and needed to be cleaned. When Housekeeping Supervisor was asked if the housekeeper cleaning the resident's room should notice if privacy curtains and/or window drapes needed to be cleaned, Housekeeping Supervisor stated when the housekeepers make their daily cleaning rounds they should have inspected the resident's privacy curtains and window drapes, and have them cleaned as needed. Housekeeping Supervisor stated privacy curtains and window drapes were cleaned as needed; a resident's room was deep cleaned when a resident was transferred out of the room and as needed. Housekeeping Supervisor stated the residents rooms were not routinely deep cleaned monthly; the residents rooms were deep cleaned if needed. Housekeeping Supervisor stated nursing staff should also let housekeeping know when a resident's privacy curtain and/or window drape became dirty, so housekeeping could have the privacy curtain and/or window drape cleaned. Housekeeping Supervisor stated room [ROOM NUMBER]B's privacy curtain and window drape should have been noticed by the nursing staff and housekeeping, and the privacy curtain and window drape should have been cleaned. Housekeeping Supervisor stated department heads made daily resident room rounds and the department heads should have also noticed the dirty privacy curtains and window drapes, and notified housekeeping. Housekeeping Supervisor stated the housekeepers do not have a checklist to go by when they clean a resident's room. Housekeeping Supervisor stated the housekeepers were trained for a couple of days and were instructed on how and what they were to clean. Housekeeping Supervisor stated there was also a learning manual the housekeepers went by to clean the resident's rooms as well. 4. During multiple observations from 9:20 a.m. to 10:14 a.m., room [ROOM NUMBER] and 55 bathroom sink/faucet/knob area and toilet (tank, toilet bowl, and base) was dirty (hair/dust and other substance). During an environment tour on 3/01/18 at 1:00 p.m., Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom sink did not look like it has been cleaned, very dirty. Maintenance Supervisor stated dirty sinks were a housekeeping issue. Maintenance Supervisor stated room [ROOM NUMBER]'s bathroom was dirty; a dirty glove was noted on the bathroom floor and there was stool in the toilet bowel. 5. During multiple observations on 02/26/18 from 10:14 a.m. to 3:24 p.m., room [ROOM NUMBER]C's linoleum floor had food particles all around the front of the bed and the overbed table had water spilled all over the top. room [ROOM NUMBER] and 47's bathroom linoleum floor was dirty (dust and ground in dirt) and rust colored stains around the base of the toilet. room [ROOM NUMBER]'s bathroom linoleum floor had multiple brown stains. room [ROOM NUMBER]'s linoleum floor was dirty under the sink and right/left of the sink with dust and small debris. room [ROOM NUMBER]C's linoleum floor was covered with tissue, cotton balls, and food particles. room [ROOM NUMBER]'s bathroom linoleum floor was dirty (multiple of ground in stains). room [ROOM NUMBER]C's linoleum floor had multiple cotton balls near resident's bed and room [ROOM NUMBER]'s bathroom linoleum floor was dirty (splatter/ground in spots) and smelled of urine. room [ROOM NUMBER]'s linoleum floor and resident's bathroom floor was dirty: splatter/ground in spots throughout the linoleum floors. room [ROOM NUMBER]'s bathroom linoleum floor had purplish colored stains under the sink and right side of the sink. During an observation on 03/01/18 at 10:50 a.m., Unlicensed Staff N was in room [ROOM NUMBER]C changing the resident's bed linen and helping the resident get cleaned up. Food particles were all over the floor in front of the resident's bed, but Unlicensed Staff N did not clean up the mess or call housekeeping to sweep/mop up the mess. Unlicensed Staff N continued tending to the resident and ignored the mess on the floor as she walked on the mess. When Unlicensed Staff N was done tending to the resident, she left the room and the multitude of food particles remained on the floor. During a housekeeping tour on 3/01/18 at 2:25 p.m.: · When Housekeeping Supervisor was asked about the linoleum floor in front of room [ROOM NUMBER]C's bed, Housekeeping Supervisor stated the floor was very dirty, a lot of food spilled. Housekeeping Supervisor stated if housekeeping has already cleaned the resident's floor, nursing needed to call the housekeeper to sweep/remop the floor or nursing staff could have picked up the food the resident spilled. Housekeeping Supervisor stated the sink in room [ROOM NUMBER] was very dirty and needed to be cleaned. Housekeeping Supervisor stated looked like housekeeping did not scrub the sink, which needed to be done. · Housekeeping Supervisor stated room [ROOM NUMBER]C's floor was messy; a lot of tissue all over the floor. Housekeeping Supervisor stated if a resident dropped tissue, food particles, etc. or if a nurse/CNA dropped an item such as cotton balls, gloves, etc., the nurse/CNA should pick up the mess in the resident's room/bathroom. Housekeeping Supervisor stated any staff member who went into a resident's room and saw a garbage on the floor should have cleaned up the garbage/mess or call housekeeping if the floor needed to be swept and/or mopped. Housekeeping Supervisor stated the housekeepers cleaned the room daily, but it was the nursing staff who needed to notify the housekeeper if a resident's floor needed to be re-cleaned or if the resident had an accident in the bathroom. Housekeeping Supervisor stated it was every staff member's responsibility to help with cleaning up residents' spills/messy floor. · Housekeeping Supervisor stated the residents' rooms and bathrooms were routinely cleaned daily and as needed. Housekeeping Supervisor stated there were three housekeepers for the facility, one housekeeper started at 6 a.m., another housekeeper started at 7 a.m., and the third housekeeper started at 8 a.m. Housekeeping Supervisor stated the facility had been short staffed 2 housekeepers and it had not been until 1 to 3 months ago when two more housekeepers were hired; prior to the two new hirers there had only been one housekeeper and himself cleaning the building. During an interview on 03/02/18 at 02:50 p.m., Housekeeper M stated if a resident's room needed to be cleaned after he had already cleaned the room, a staff member would page him overhead. During a concurrent observation and interview on 3/01/18 at 2:55 p.m., room [ROOM NUMBER]C's floor had food particles all around the front of the bed since 1:00 p.m. Nurses and CNAs were walking on the food particles and then left the room. No staff member cleaned up the mess on the floor. When Licensed Staff A was shown room [ROOM NUMBER]C's messy floor, Licensed Staff A stated when the resident was finished with his/her meal, it was the CNA's responsibility to clean up the floor. Licensed Staff A stated CNAs did not have brooms, but they should call housekeeping and pick up what they can using gloves. Licensed Staff A said, yes, the floor was dirty and should have been cleaned. Licensed Staff A stated it was every staff member's job to help keep residents rooms clean and picked up. During an observation on 3/02/18 at 9:10 a.m. room [ROOM NUMBER]'s bathroom sink was still dusty/dirty around the hot/cold handles and a dirty glove was on the floor next to the sink. The facility document titled, Housekeeper/Janitor Job Description, undated, indicated: 1.A housekeepers principle responsibilities was to perform tasks to ensure a safe, comfortable and sanitary environment for all residents, staff and visitors according to established policies and procedures and 2. Maintains written records and documents of services performed according to Federal, State and Corporate requirements. The facility training manual for housekeepers, no title/undated, Module 3 titled, Safety for Healthcare Housekeepers, indicated one of the eight rules of safety was when you see something on the floor that does not belong there, either a spill or an object, mop or pick it up immediately. Module 4 titled, Cleaning the Occupied Patient Unit, indicated the housekeepers were to perform high dusting, clean ledges and seals, spot clean malls, clean furniture, and dust mop floor and wet mop floor. Module 6 titled, Cleaning the Resident Bathroom, indicated the housekeepers were to disinfect the toilet bowl, perform high dusting, clean toilet outer surfaces, clean sink and counter, clean wall splash marks, and dust mop floor and wet mop floor. The facility policy/procedure titled, Housekeeping - Resident Rooms, revised 1/1/12, indicated daily cleaning of residents' room included: 1. overbed table a damp wiped, 2. bathroom is cleaned, sanitized, and disinfected, and 3. floor is swept or vacuumed and then damped mop with disinfectant solution. 6. During an observation on 02/26/18 09:30 AM, Resident 23's electric chair's upholstery was torn at left arm rest and left side of back rest. During an interview on 3/01/18 at 2:30 p.m., when Social Services was asked who would be responsible for maintaining Resident 23's electric chair and repairing the ripped upholstery, Social Services stated maintenance would handle this issue. Social Services stated most of the residences who have an electric chair are veterans, Resident 23 was a private pay. Social Services stated she was aware of the upholstery being torn at the left arm rest and left side of the back rest and would check out what could be done to get the chair repaired. Social Services agreed it would be hard to keep Resident 23's electric chair clean/sanitized because of the torn upholstery. 7. During multiple observations on 02/26/18 from 9:20 a.m. to 10:31 a.m., wheel chair leg rests were stored on room [ROOM NUMBER]A and 56A's unoccupied made up resident bed. Multiple clothing and personal items belonging to the resident in room [ROOM NUMBER]B were stored on room [ROOM NUMBER]A's unoccupied made up resident bed. Multiple personal items were stored on 55A unoccupied resident made up bed. The facility document titled, Certified Nursing Assistant Job Description, undated, indicated CNAs were to make resident's bed, clean bedside and overbed tables.

Based on observation, interview, and record review, the facility failed to provide pain management to one of seventeen residents (Resident 16) when Resident 16 complaint of pain and she did not received care based on comprehensive person-centered care plan to meet Resident 16's goals and preferences. This failure resulted to Resident 16 experiencing pain and felt like screaming. Findings: During the initial interview on 2/26/18, at 4:34 p.m. Resident 16 stated her [MEDICATION NAME] pain medicine was cut in half and it would take a while for it to build up in her system. During the record review on 2/26/18, at 4:39 p.m., the medical records indicated Resident 16 had [DIAGNOSES REDACTED]. A pain lasts longer than six months. It is the combination of chronic pain and the secondary complications that are making the original pain worse), stiffness of unspecified shoulder, muscle weakness, and [MEDICAL CONDITION] ([MEDICAL CONDITION]- is a progressive disease that makes it hard to breath that gets worse over time). The facility put Resident 16 on Hospice service (services provided to a terminally ill individual) on 12/4/17. The Hospice Clinical notes, dated 12/4/17, indicated, .I (Hospice Service Physician) expect she will survive fewer than 6 months. The most recent Minimum Data Set (resident assessment tool) dated 12/11/17, indicated Resident 16 had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.), in which Resident 16 was able to recall 2 out of 3 words without cues. During an observation and interview on 3/01/18, at 10:43 a.m. while sitting on the wheelchair, Resident 16 stated, Pain is bad. I don't know who to ask for it and talk about it. When asked how she calls for assistance, Resident 16 activated her call light. Resident 16 stated, Sometimes it takes one hour for somebody to come in and another hour to get (help with whatever she needs). During an observation on 3/01/18, at 10:46 a.m., Licensed Staff J entered Resident 16's room and answered the call light. Licensed Staff J asked Resident 16 what she needed; Resident 16 said she was in pain. Licensed Staff J asked Resident 16 where the pain was; Resident 16 stated, Everywhere, it's been quite a while, it's been increasing, and then Resident 16 pointed to her mid-lower abdomen. Resident 16 stated, It's been there two months, it hurts when I turn over. Resident 16 stated the abdominal pain was at 10 level (10/10- 10 being the highest pain) when Licensed Staff J asked. Resident 16 stated, Nothing helps, you have to find out what it is. Licensed Staff J asked Resident 16 where her other pain was. Resident 16 stated, [MEDICAL CONDITION] pain, 8 (pain level). Licensed Staff J told Resident 16 he would tell Resident 16's nurse. During an observation on 3/01/18, at 10:54 a.m., Licensed Staff J returned and told Resident 16 the nurse was coming to address Resident 16's pain complaint. During an observation and observation on 3/03/01/18 at 1:48 p.m., Resident 16 was sitting on her wheelchair. When asked about her pain, Resident 16 stated, I have to wait for 4 hours, I didn't know when the last time I got it or when can I get it (pain medicine) During an interview on 3/01/18 at, 1:55 p.m., when asked about Resident 16 experiencing pain, Unlicensed Staff N stated Resident 16 did have some pain in her abdomen this morning when she was providing care. When asked if she reported the pain, Unlicensed Staff N stated she did not report the pain and, I just assumed the nurse already knew. When asked to whom she should report the pain, Unlicensed Staff N stated she would report resident's pain to a charge nurse. During an interview on 3/01/18, at 2:09 p.m., Resident 16 stated she received pain med, but the pain is getting worse, and she asked the nurse to call hospice. During an interview on 3/01/18, at 2:21 p.m., Licensed Staff E, stated Resident 16 was on hospice. Licensed Staff E stated she gave [MEDICATION NAME] 1 ml, 20 milligram, as needed every 4 hours, for Resident 16's abdominal 8/10 pain level at 2:05 p.m. When asked how often she assessed Resident 16's pain, Licensed Staff E stated assessing Resident 16's pain after giving pain medicine. Licensed Staff E stated Resident 16 started complaining of abdominal pain around 11 a.m. but Resident 16 was not due to receive pain medicine. Licensed Staff E stated she assessed Resident 16's abdomen by listening to Resident 16's bowel sounds. During a review of the clinical record for Resident 16, the Medication Administration Record [REDACTED] Licensed Staff E stated Resident 16 had a prescribed Tylenol (pain medicine) for mild breakthrough pain, and the staff were to call hospice if Resident 16's pain medicine prescribed for severe could not control the pain. When asked if she called hospice for Resident 16, Licensed Staff E stated she would call hospice staff before the shift ends. During an interview on 3/05/18, at 4:03 p.m., Hospice Staff O stated Resident 16 had a lot of issues and over doing pain med. Hospice Staff O stated, We've had her (Resident 16) for years, on and off. Hospice Staff O stated the hospice physician changed Resident 16's [MEDICATION NAME] 20mg from every two hours to every four hours, as needed, because Resident 16 would be unresponsive if she was getting a lot. During an interview on 3/05/18, at 4:36 p.m., Hospice Staff P stated, on 2/15/18, the Hospice Service started Resident 16 on low dose [MEDICATION NAME] (synthetic, narcotic [MEDICATION NAME] (pain reliever) and used for other medical purposes such as pain relief.) and changed the [MEDICATION NAME] from every two hours to every four hours. Hospice Staff P stated the facility requested to change the [MEDICATION NAME] because Resident 16 was falling from oversedation (reduction of anxiety, stress, irritability, or excitement by administration of a sedative agent or drug.). Hospice Staff P stated hospice nurse visits Resident 16 once a week, unless Resident 16 needed more hospice services. Hospice Staff P stated the facility staff should contact Hospice Service if Resident 16 reported increasing severity of pain. During an interview on 3/06/18, at 8:26 a.m., Resident 16 stated her pain goal was to get pain level down to 5, where she did not feel like screaming all the time. When asked how often staff were addressing her pain, Resident 16 stated, Nothing really gets done about it. 1-2 nurses seems to understand and care and the rest ignore you. You can't do anything just lay in there. I haven't been ok for a long time, I tried to act like I'm ok. I tried to smile. When asked how often she have to ask for pain medicine, Resident 16 stated, I don't think if I had it. I feel stupid if I asked and then they told you, 'you had one'. (It) doesn't really help if I had one or not. When asked if the pain medicine helps, Resident 16 stated, It doesn't seem to, I can't tell if had it or not, so obviously it does not help me much During an interview on 3/06/18, at 8:35 a.m., Licensed Staff E stated she have not given Resident 16's any medications yet. Licensed Staff E stated Resident 16 received [MEDICATION NAME] on 3/5/18 at 8:45 p.m. During an interview and concurrent record review on 3/06/18, at 4:53 p.m., when asked about a tool used to assess residents with pain, the Director of Nursing (DON) stated they used pain management that includes giving pain medicine like [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]), [MEDICATION NAME], using distraction, hot pack, pain assessment using 1-10 pain scale if residents are alert and oriented, and checking for grimaces for non-verbal resident. The DON stated the Certified Nursing Assistant (CNA) would bring the information to the nurse, and the nurse would assess and do what they can to help. Regarding Resident 16's pain management, when asked how and when do staff try to identify circumstances in which pain can be anticipated, the DON stated Resident 16 started with certain amount of [MEDICATION NAME] and [MEDICATION NAME] and that they (Hospice Service) increased [MEDICATION NAME] to work long term better. The DON stated, She's (Resident 16) pretty good at telling us her pain. The DON stated the Hospice Service increased her long term (long-acting medication) so she doesn't get snowed (oversedated). The DON stated the facility put Resident 16 on Hospice Service because she likes getting extra attention as told by Resident 16 to the DON. When asked how often Resident 16's pain assessment was, the DON stated the staff should assess Resident 16's pain at the beginning of every shift, before medication, and report from other shift whether she had pain medication before. The DON stated the staff would call hospice service if Resident 16's pain appeared to be out of control, and the hospice staff could do another reassessment. When asked how staff communicates with the physician about the resident's pain status, current measures to manage pain, and the possible need to modify the current pain management interventions, the DON stated, Hospice is driving her care. When asked how the facility developed the interventions, the DON stated, the facility tried to convince her to get out of her room, to join activity, to put hot pack on shoulders, to rest, and for Resident 16 to lay on her back when sitting in wheelchair for too long. The DON stated, the facility performed conference care between Hospice Service and DON and worked conjunctively. When asked if any of Resident 16's interventions been effective, the DON stated, I think so, I don't think if she would agree with me. The DON stated Resident 16 had high tolerance of pain, that's why it's a work on progress. The DON stated, Her (Resident 16) favorite is every 1 hour pain med, even if you tell her, she forgets. The DON stated the facility have not tried communication board or visual reminders informing Resident 16 about her pain medicine. The DON verified Resident 16 Care Plan for Pain had no measureable goals, no measureable pain assessment frequency, and not Resident 16-centered. When the DON was informed Resident 16 waited for hours (from the time Resident 16 complaint of pain at 10: 46 a.m until she received pain medicine at 2: 05 p.m.) in pain until [MEDICATION NAME] was due, the DON stated the staff should have call the Hospice Service if there was no pain medicine available. During a review of the clinical record for Resident 16, the Nurses Note, dated 12/18-2/15/18, had no documentation of Resident 16 being oversedated. During a review of the clinical record for Resident 16, the Palliative Care Form signed and dated by a physician on 11/14/16, indicated, The resident will require the frequent use of narcotic/anti-anxiety/hypnotic medications (treatment for [REDACTED]. The facility/agency will plan and implement measures to maintain the appropriate levels of medication for the resident to ensure comfort. During a review of the clinical record for Resident 16, the Resident Care Plan: Pain dated 12/17, indicated planned goals of Resident will verbalize/show decreased signs and symptoms of pain, and resident will require less pain medication to alleviate pain. The facility did not mark a pre-written planned goals indicating, Resident will achieve self-reported pain goal of (1-10):___; there was no written pain goal established. The planned approach indicated, Evaluate need for routine pain medication rather than PRN (as needed medication). During a review of the clinical record for Resident 16, the Resident Care Plan: Palliative (specialized medical and nursing care that focuses on providing relief from the symptoms of pain, physical stress, and mental stress of a terminal [DIAGNOSES REDACTED]. The facility policy and procedure titled Pain Management dated 11/16, indicated, for Pain Assessment: The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions. Goals for pain management and the acceptable level of pain relief will be determined in conjunction with the resident when possible. For Pain Management: Nurses will complete the Pain Flow Sheet for residents receiving PRN (as needed) pain medication to evaluate the effectiveness of the medication regimen .Nursing staff will implement timely interventions to reduce an increase in severity of pain .Nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain . The facility policy and procedure titled Hospice Care of Residents dated 1/1/12, indicated, The resident's right to comprehensive pain and symptom management at the end of life, including but not limited to: Adequate pain medication. During a review of the Hospice Care Plan, provided by the facility on 3/13/18, the Care Plan for pain indicated to meet Resident 16's desired pain goal of 4/10. The facility policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/17, indicated, The baseline care plan must reflect the resident's stated goals and objectives, and include interventions that address his or her needs.

Based on interview and record review, the facility failed to ensure resident's safety when nursing staff did not evaluate, develop, and implement adequate interventions and did not implement adequate supervision and assistance for 3 Unsampled Residents (Resident 45 48, and 63), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to: 1. Resident 45 fell 2 times in a 5-month period from 6/27/17 to 11/24/17. 2. Resident 63 fell 3 times in a 4-month period from 9/18/17 to 1/25/18. The fall on 11/10/17 resulted in right forehead swelling and the fall on 1/25/18 resulted in a left [MEDICAL CONDITION], which required admission to an acute care facility for treatment. 3. Resident 48 fell while trying to get up on his own on 3/7/18. Resident 48's bed alarm battery was dead at the time of fall. Findings: 1. A review of Resident 45's admission record, dated 2/28/11, and readmit, dated 2/24/16, Resident 45's physician progress notes [REDACTED]. Resident 45's quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/10/17, indicated Resident 45's BIM (Brief Interview of Mental Status) of 7 (a score of 7 or less represented severely cognitively impaired), walking did not occur, and one person physical assist with moving from a seated to standing position, moving on and off the toilet, and transfer between bed and chair or wheelchair. Resident 45's Fall Risk Assessment, dated 5/9/17, indicated Resident 45 had a score of 17 (a score of ten or greater represented high fall risk). A review of Resident 45's Resident Care Plan for Fall Risk Prevention and Management, dated 2/9/17, indicated fall risk interventions included orient resident to the environment each time changes are made, call light within reach and remind resident to use call light, bed in a low position, and encourage use of wheelchair and transfer pole (A transfer device (floor-to-ceiling grab bar) used to promote independent standing and transferring for residents with weakened strength). Resident 45's Fall Risk care plan did not specify: 1. how the facility would provide reminders so Resident 45 would remember to ask for assistance with transferring, 2. how often the facility would do visual checks/supervision, and 3. the need for assistance when transferring to the wheelchair or when using the transfer pole. A review of Resident 45's Physician Recap Orders, dated 3/18, indicated Resident 45 was to have nursing assist with safety functional mobility with standing balance at transfer pole. Order originated on 3/28/16. First Fall A review of Resident 45's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 6/27/17, Licensed Nurses Notes, dated 6/28/17 and Interdisciplinary Team (a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Conference Record, dated 6/28/17, indicated Resident 45 had a unwitnessed fall on the AM shift on 6/27/17. Resident 45 was found on the floor next to his bed. Resident 45 told staff he had tried to transfer from the wheelchair to the bed on his own and ended up falling on his bottom because his wheelchair had moved from under him. Fall 2 A review of Resident 45's SBAR Communication Form, dated 11/24/17, Post Fall Assessment, dated 11/24/17, and Interdisciplinary Team (IDT) Conference Record, dated 11/27/17, indicated Resident 48 had an unwitnessed fall on 11/24/17 in the dining room. Resident 48 told staff he slipped out of his wheelchair while attempting to propel himself back to his room without assistance. Resident 45 had slight redness to back of head. A review of Resident 45's Resident Care Alert, dated 6/28/17 and Certified Nursing Assist (CNA) Instructions for Bed Mobility and Transfers, dated 6/21/17, indicated: 1. Resident 45 was not to be left in a room while in his wheelchair unattended, 2. Resident 45 was to be assisted from his wheelchair to his bed to avoid self-transfers, and 3. Resident 45 needed two person assist using a gait belt (An assistive devices used to help lift, position and secure individuals during walking and transfers) when transferring from the bed to the wheelchair while using a transfer pole. Resident 45's Fall Risk Assessment, dated 10/21/17, indicated Resident 45 had a score of 12 (a score of ten or greater represented high fall risk. Resident 45's quarterly MDS, dated [DATE], indicated Resident 45's BIM of 5 (severely cognitively impaired), needed one person physical assist with transfer between bed and wheel chair, and had one fall with no injury. A review of Resident 45's Resident Care Plan for Fall Risk Prevention and Management, revised 10/21/17, did not indicated any new fall risk interventions. The care plan for falls did not specify how the facility would provide supervision to prevent Resident 45 from falling, who was severely cognitively impaired, and continued to be left unattended in a wheelchair. A review of Physical Therapy Progress Report, dated 11/6/17, indicated Resident 45 had decreased balance, body awareness deficits, gross motor coordination deficits (skills which are important for major body movement such as walking, maintaining balance, coordination, and jumping), and strength impairments. During an interview on 3/1/18 at 10:50 a.m., when Unlicensed Staff N was asked about Resident 45's mobility, Unlicensed Staff N stated Resident 45 should not get up on his own. Unlicensed Staff N stated Resident 45 did have a transfer pole, but Resident 45 should not have a transfer pole because he tries to self-transfer himself and he is not able to. Unlicensed Staff N stated Resident 45 needed two people to assist with his shower. Unlicensed Staff N stated Resident 45 could walk approximately 20 feet (from the nurse's station (North Lytle) to his room, but needed to be assisted. When Unlicensed Staff N was asked how she was made aware of Resident 45's need for assistance with transferring, Unlicensed Staff N stated she was made aware by the CNA tending to Resident 45 from the previous shift. Unlicensed Staff N stated Resident 45 had a physical therapy evaluation and had transfer instructions located on the wall near his bed. 2. A review of Resident 63's admission record, dated 9/13/17 and readmitted d, 1/31/18, Physician Orders, dated 12/17, and an Emergency Department Report, dated 9/13/17, indicated Resident 63's [DIAGNOSES REDACTED]. These changes are severe enough to interfere with day-to-day life), muscle weakness, difficulty in walking, muscle weakness, and dysphagia. A review of Resident 63's Admission MDS, dated [DATE], indicated Resident 63 had a BIM score of 1 (severely cognitively impaired), needed two plus person physical assist with transfer, did not walk, one person physical assist while in wheelchair, and Resident 63 had an unsteady balance during transitions from seated to stand position and transfer between bed and chair or wheelchair. Resident 63's Fall Risk Assessment, dated 9/19/17, indicated Resident 62 had a score of 15 (a score of ten or greater represented high fall risk). A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/17, indicated Resident 63 had limited mobility, poor balance, cognitive deficit (resulting in confusion, poor motor coordination, and loss of short-term or long-term memory), unsteady gait, forgets to call/wait for assistance, impulsive behavior, history of falls, muscle weakness, and difficulty in walking. Fall risk interventions included orient resident to environment each time changes occur, call light within reach, remind resident to use call light, and bed in low position. A review of Resident 63's medical records indicated she had fallen on 9/18/17, 11/10/17, and 1/25/18. During an interview on 3/07/18 at 10:50 a.m., Medical Records was asked to locate SBAR/IDT notes regarding falls due Resident 63's chart was thinned out and none were in her chart. No SBAR was provided for the fall, which occurred on 9/18/17. During an interview on 3/07/18 at 11:05 a.m., surveyor asked Consultant to see Resident 63's investigation reports for falls, which occurred on 9/18/17, 11/10/17, and 1/25/18; none were provided. No SBAR was provided for the fall, which occurred on 9/18/17 and no nurse's notes were provided detailing post fall neuro checks (level of consciousness, movement, sensation .). Fall 1 A review of Resident 63's IDT Conference Record, dated 9/19/18, indicated CNA was giving care to Resident 63's roommate on 9/18/17, when CNA heard Resident 63 call out. Resident 63 was found on the left side of her bed on the floor. The fall caused a small laceration (cut, tear) on Resident 63's left shoulder. The IDT note indicated Resident 63's bed was to be moved up against the wall for safety, and when Resident 63 was in bed a floor mat (helps reduce injuries caused by resident falling out of bed) would be placed on the floor next to the bed. A review of Resident 63's Resident Care Plan Short Term, dated 9/19/17, indicated to move bed against wall and have drop mat on floor when resident is in bed. A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/18, was not updated and did not indicated any new fall risk interventions. Fall 2 A review of Resident 63's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 11/10/17, Post Fall Assessment, dated 11/10/17, and IDT Conference Record, undated, indicated Resident 63 had an unwitnessed fall on 11/10/17 at about 2:30 p.m. Resident 63 was found on her buttock (behind) next to her bed. Resident 63 sustained right side of forehead swelling from the fall. Resident 63 was unable to recall what she was doing due to her dementia. Resident 63 was not able to be educated about waiting for assistance and using call light due to severe dementia. A review of Resident 63's Resident Care Plan Short Term, dated 11/13//17, indicated to apply first aid to forehead and for Resident 63 to continue to work with physical therapy for safety. A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/18, was not updated and did not indicated any new fall risk interventions. The care plan for falls did not specify how the facility would provide supervision and how often staff should make room rounds for Resident 63, who was severely cognitively impaired. Fall 3 A review of Resident 63's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 1/25/18, Post Fall Assessment, dated 1/25/18, and IDT Conference Record, undated, indicated Resident 63 had an unwitnessed fall on 1/25/18 at about 4 p.m. Resident 63 was found lying on the floor on her left side wrapped in her blanket. Resident 63 screamed when nurse tried to assess left leg. Resident 63 was sent to an acute care emergency department for an evaluation of the left hip. A review of Resident 63's Surgery and Procedure Report, dated 1/27/18 and Discharge Summary Report, dated 1/31/18, indicated Resident 63 had sustained a [MEDICAL CONDITION] hip and had surgery. Resident 63 had to have 4 units of blood post injury due to Resident 63's hemoglobin (The main functional constituent of the red blood cell, serving as the oxygen-carrying protein); was 6.9 (Normal level was 12-16 g/dL (grams/deciliter)) During an interview on 3/6/18 at 5:15 p.m., surveyor had to ask for SBAR, care plan for falls prior to 1/25/18 fall, Fall Risk Evaluation prior to fall and Post Fall Assessment because they were not in Resident 63's chart. Investigation Report was not provided. Resident 63's chart was thinned. When DON was asked how can contracted/traveling nurses get to know the residents if the residents' charts are thinned, DON stated Resident 63 was considered a new admit because she was transferred to an acute care facility for more than one day. DON stated a resident's chart only had a 3 month window of information. DON stated Resident 63's fall with major injury was not an unusual occurrence for Resident 63, due to her [DIAGNOSES REDACTED]. During an interview on 3/7/18 at 8:45 a.m., DON (Director of Nursing) stated Resident 63 walked out near her bedroom door and DON heard the fall and went right into Resident 63's room. DON stated Resident 63 was transferred to an acute care facility for further evaluation. DON stated Resident 63 forgets she cannot walk on her own and needed assistance even with transferring from the bed to the wheelchair. DON stated the fall took place on 1/25/18 at around 3 p.m. (change of shift). DON stated Resident 63 had a drop mat and was spot checked frequently (sometimes 20, 40, 60 minute checks). When the DON was asked how a CNA could be pulled to do almost a 1:1 supervision on Resident 63 when the facility did not have enough CNAs to supervise residents who were eating in their rooms and needed to be supervised (per a concurrent observation and interview on 2/28/18 at 2:10 p.m., there was no staff supervising Resident 5 while she was eating her meal. Licensed Staff H stated the certified nursing assistant (CNA) would go between Resident 5 and Resident 38, but there was not enough staff to assist residents who were eating in their room and in the assisted dining room at the same time.); DON could not answer question. DON stated the close monitoring for Resident 63 happened at times. DON stated Resident 63 did not have a bed alarm. DON stated Resident 63 could communicate, but rarely made since. 3. During an interview on 3/7/18 at 8:30 a.m., Licensed Staff B (who worked the night shift on 3/6/18) stated Resident 48 had tried to get up on his own and was found lying on floor by the CNA making rounds near the change of shift (AM of 3/7/17). Licensed Staff B stated the bed alarm did not go off because the battery was dead. Licensed Staff B stated Resident 48 had no injury. When Licensed Staff B was asked if there was enough nursing staff scheduled for 3/6/18 night shift, she stated a CNA had called in sick on the night shift, so they were short one CNA. Licensed Staff B stated she was assigned to 38 residents; there were 2 nurses and 3 CNAs scheduled last night for 68 residents. A review of Resident 48's Quarterly MDS, dated [DATE], indicated Resident 48 had a BIM score of 3 (severely cognitively impaired), needed one person physical assist with transfer between bed, chair, and wheel chair, one person physical assist with walking, used a walker, and had one fall with a minor injury. During a concurrent record review and interview on 3/7/18, at 9:05 a.m., Licensed Staff H stated Resident 48 had a bed alarm (a device attached to the bed that triggers an alarm when the resident attempts to get up from the bed). Licensed Staff H stated nursing staff should check the battery at least daily and check bed alarm functioning at least every shift. Licensed Staff H stated this should be addressed in the care plan and in the physician order, but they lacked documentation. Licensed Staff H reviewed the MAR (medication administration record) and stated no documentation for the bed alarm. She stated it could be documented in the TAR (treatment administration record). Licensed Staff H further stated they should have care instructions in Resident 48's room for CNAs (certified nursing assistant) to check the bed alarm. Licensed Staff H reviewed all the care instructions in Resident 48's room and stated no instruction for the bed alarm. During a concurrent record review and interview on 3/7/18, at 9:09 a.m., Licensed Staff J reviewed the TAR and stated no order or documentation for the bed alarm. Resident 48's physician order list, dated (MONTH) (YEAR), did not include an order for [REDACTED].>Resident 48's care plan for fall risk prevention and management, dated on 1/10/18, indicated Resident 48 was at risk for fall due to multiple problems including history of falls, poor balance, lack of awareness, hearing deficit, vision deficit, and cognitive deficit. One of the approaches was to encourage Resident 48 to use of assistive device, bed alarm. The care plan was revised to include Replace Battery as needed on 3/7/18 (Resident 48 fell on [DATE] at 1:15 a.m.). The care plan did not specify when and how staff would check the battery or bed alarm functioning. The care plan did not specify providing supervision to Resident 48 to prevent falls. Review of the facility policy/procedure titled, Fall Management Program, revised 11/7/16, indicated: 1. The Licensed Nurse and/or IDT will develop a Plan of Care according to the identified risk factors and root cause per Care Area Assessment guidelines, 2. Following each Fall, the Licensed Nurse will perform a Post-Fall Assessment and update, initiate or revise a Plan of Care, 3. Once the post fall huddle is complete the Licensed Nurse will update the care plan with immediate recommendations, 4. The IDT will summarize conclusions after their review of the fall and circumstances surrounding the fall . The plan of care will also be reviewed and the care plan will be revised as necessary in an effort to prevent further falls with a major injury, and 5. A resident who sustains multiple falls as defined as more than one fall in a day, a week, or month, will be considered a high risk to fall and as a result may sustain a major injury. These residents may be identified by a special logo or designation to alert staff to their high risk activity, may require more frequent observation of activities and whereabouts .

Based on observation, interviews, and facility document review, the facility failed to ensure resident's rights were protected for five of 17 sampled residents (Resident 221, 47, 38, 16, and 5) and two confidential residents when: 1. Facility did not provide assistive devices to Resident 221 to maintain correct position after a surgery and activity items to dull or distract from the noise level in the facility, which resulted in Resident 221 suffering from the terrorizing noise level and not receiving a grabber (picker-upper) to avoid bending; 2. Staff did not respond to call lights in a timely manner, which resulted in a) residents not receiving assistance or care timely, b) Resident 221 urinating on herself, being humiliated, falling on her own urine, and requesting early discharge because she was in fear for her life, and c) Resident 16 feeling bad and embarrassed beyond words; 3. Staff did not assess or educate Resident 47 on call light use, which resulted in Resident 47 not being able to use the call light for assistance, potentially causing falls, injuries, or embarrassment; and 4. Staff did not assist Resident 5 and 38 for meals, which resulted in residents having difficulty in feeding themselves, spilling food over their clothing, and not being positioned properly for meals. These failures had negatively impacted residents' psychosocial well-being and quality of life. Findings: 1-2. During an interview on 3/6/18 at 10:00 a.m., Resident 221 (post-op right hip arthroplasty, a surgical procedure to restore joint functions) stated she left the facility prior to end of insurance coverage because she felt her life was in danger. Resident 221 stated the facility housed a majority of seniors who could not care for themselves, but were not taken care of by the staff. Many of the wheelchair residents had alarms on their wheelchairs. When they moved, or stood, these alarms went off, but no staff came to address the alarms, or check on the residents. The noise level was terrorizing. Resident 221 stated she witnessed other residents fall, and fell herself one night. When asked how she fell , Resident 221 stated she needed to go to the bathroom, and placed the call light on, no staff answered the call light, so she got up out of bed. After getting up, Resident 221 stated that she could not see a path to get to the bathroom and urinated on herself. Resident 221 stated she was humiliated, but knew she needed to get back to bed. In the time that passed, no one came to answer her call light. Resident 221 stated on attempt to get back to bed she fell in her own urine, but no one came to help get her back to bed. Resident 221 stated she got back to bed without the help of staff. When a staff member did come into the room, Resident 221 stated she told them about the fall, and having urinated on the floor. Resident 221 stated the staff member made a comment to her that housekeeping did not arrive until 6 a.m. Resident 221 asked for a grabber (picker-upper) to avoid bending, ear plugs and a radio to try to drown out the noise, none of the requests were honored. Resident 221 stated she had a prescription for a marijuana pin from her surgeon. Resident 221 stated the facility staff took the Marijuana pin from among her belongings while she was out of the room. Resident 221 stated the head nurse came to her and stated that facility had confiscated the marijuana pin, called Family 2 to pick up the marijuana pin, and planned to release it to him. Resident 221 stated despite her insistence that she had a prescription for the marijuana pin, she was told it was illegal to have it in the facility. Resident 221 stated they went into my room and took my stuff .Isn't that theft. During an interview on 3/7/18 at 8:20 a.m., DON (Director of Nursing) stated No one is allowed to have marijuana, not in my building. One of the aides picked it up from Resident 221's bedside table and brought it to me. DON stated that when she was informed it was a Marijuana pin she went directly to Resident 221, who was receiving physical therapy at the time, and told her the facility was confiscating the pin. DON stated she informed Resident 221 that she had telephoned Family 2 to come to pick up the Marijuana pin, and would release the pin to him. When questioned about her method of removing the Marijuana pin while the resident was out of the room, DON stated the former DON would have called the police in this matter. DON stated she did not remember the name of the staff member who brought the Marijuana pin to her. During a concurrent interview and observation on 3/7/18 at 8:34 a.m., of activities supplies was made. A radio was observed and Activities Director stated the radio was one of two that belonged to the facility. When asked about ear plugs. Activities Director stated the previous activity director must have ordered them because she recently threw out a box of them. Activities Director stated she did not remember any resident asking for ear plugs. During an interview on 3/7/18 at 8:42 a.m., Rehabilitation Director stated the facility kept a supply of grabbers/picker-uppers, to assist any resident who needs one. Rehabilitation Director stated that in the event the supply is depleted and a resident asked for a grabber, the rehabilitation staff taught strategies to safely obtain items until the equipment was replaced. Replacement took 2 to 3 days. During a review of the clinical record for Resident 221, the Physicians Progress Note dated, 12/9/17, indicated: .Multiple intolerances of medications/opiates trial [MEDICATION NAME] (a medication for pain) 1-2 mg (milligram). lots of questions/ long story of previous history/current condition. Complaint fell attempting to get to BR(bathroom)-3 days ago. During a review of the clinical record for Resident 221, the Interdisciplinary Team Conference Record dated, 12/11/17, indicated: .On Friday 12/8/17 resident was in possession on her over head table while out of room in Therapy of a cannabis pen which was brought to DON for safety .Resident stated, my doctor said I could use it. Pen was secured .Son was irate because pen was taken from her .Resident has hip precautions and is claiming she has fallen and got herself up without witnesses present .Resident requested pharmacist to discuss medications .then claimed he wanted to see her vagina .Therapy gave resident a shower Wednesday, Friday, CNA (Certified Nursing Assistant) reports 2 additional showers on Sunday and is demanding another shower today (Monday) . During a review of the clinical record for Resident 221, the MDS (Minimum Data Set) dated, 12/08/17, indicated: Brief Interview for Mental Status score of 15, which indicates alert and oriented. During a review of the clinical record for Resident 221, the History and Physical from local hospital dated, 11/21/17, indicated: medications: [REDACTED]. 2. Medical Marijuana. 3. [MEDICATION NAME] 4. [MEDICATION NAME]. During a review of the clinical record for Resident 221, the Resident Bill of Rights dated, 5/11, indicated: .7. To be encouraged and assisted throughout the period of stay to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination or reprisal .12. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs .16. To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients. During an interview on 3/7/18 at 8:20 a.m., DON was asked for a policy and procedure for Medical Marijuana and she stated the facility did not have one. 2a. During an initial pool sample selection interview, on 2/26/18, at 9:06 a.m., Resident 16 stated, they're always short with people. Resident 16 stated she had to wait up to an hour before staff would answer the call light because they did not have the help you need. Resident 16 stated, If you can't get into the toilet, it's bad, you have to do it in your pants. No words to describe it. Put yourself where you're laying and you can't move. You have to go; you're trying to hold it. You're embarrassed. Resident 16 stated if you were already sitting in the toilet, you have to wait until someone comes. During a review of the clinical record for Resident 16, the Minimum Data Set (Resident assessment tool) dated 12/11/7, indicated Resident 16 needed an extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer and toileting. 2b. During a confidential group interview on 2/27/18, at 11:30 a.m., regarding call light wait time, one of nine attended residents stated sometimes he had to wait for a long time. Another resident stated it depended on what they needed. The resident stated one CNA (certified nursing assistant) per hall, some CNAs helped, but some would not. 3. During a concurrent observation and interview on 2/26/18, at 8:32 a.m., in Resident 47's room, Resident 47 stated he needed help to open the window curtain. Resident 47 squeezed the call bell (a ball like call bell) a total of five times, but the call light was not on. Resident 47 stated he could not move his right arm and hand, so he used his left hand to squeeze the call bell. Unlicensed Staff C walked by the hallway and was called into Resident 47's room. Unlicensed Staff C stated Resident 47 might have not pressed the call bell hard enough. Unlicensed Staff C opened the window curtain for Resident 47. Unlicensed Staff C did not assess or educate Resident 47 on call bell use. Resident 47'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 2/1/18, revealed Resident 47's BIMS (brief interview for mental status) score was 15, which indicated Resident 47 was cognitively intact. During a concurrent observation and interview on 3/1/18, at 9:57 a.m., in Resident 47's room with Licensed Staff D regarding the call bell, Resident 47 squeezed multiple times and squeezed hard that the call bell (a ball like call bell) was dented, but the call light was not on. Resident 47 stated he would like to use the call bell for assistance. Licensed staff D tested the call bell and call light was on. Licensed Staff D stated the call bell was working, but Resident 47 was not able to use it correctly due to lack of hand coordination. The Maintenance Director came in and tested the call bell. The Maintenance Director stated he had to press down the call bell quickly to make it work. He stated if the resident pressed down slowly, it would not work. During an interview on 3/1/18, at 10:10 a.m., Licensed Staff D stated Resident 47 could use the call bell, but she did not know when his last time used the call bell. When asked how would Resident 47 able to get help when staff was not in his room, Licensed Staff D stated Resident 47 would called out loud, which could be heard in the nurse station. Licensed Staff D stated Unlicensed Staff C should have reported to her (Licensed Staff D) and she should have reported to the Maintenance Director to change the right type of call bell for Resident 47. Licensed Staff D stated they had a few different types of call bell. Upon request for facility policy and procedure, the facility provided the Resident Bill of Right, dated 05/11, indicated .Patients shall have the right .to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs . 4a. During an observation on 2/26/18 at 1:15 p.m., Resident 5 was in bed in a light weight hospital gown, which was not tied and caused her upper chest to be fully exposed. Resident 5 was positioned at approximately a 45 degree angle for lunch. Resident 5 was on a puree diet, which was over her bed, but no one was assisting Resident 5 with her meal and food particles were all over her. No straw was in her glass per physician's orders [REDACTED].>During a concurrent observation and interview on 2/28/18 at 2:10 p.m., Resident 5 was feeding herself a pureed diet. Resident 5's was positioned at a 45-degree angle while eating, napkin was not in place and food was all over Resident 5's clothes and blankets. There was no staff supervising Resident 5 while she was eating her meal. Resident 5's breathing sounded a little raspy after meal. Licensed Staff H stated Resident 5 did need assistance. Licensed Staff H stated Resident 5 did have a bib, but she had pulled it off and it was under her covers. Licensed Staff H stated the certified nursing assistant (CNA) would go between Resident 5 and Resident 38, but there was not enough staff to assist residents who were eating in their room and in the assisted dining room at the same time. Licensed Staff H stated the CNAs assisted the residents in the assisted dining room first and then the residents who wanted to eat in their room. A review of Resident 5's Physician Orders, dated 12/12/16, and Medication Administration Records (MAR), dated 1/18 and 2/18, indicated Resident 5 was on swallowing precautions and needed a straw for thin liquids. Resident 5's Annual MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/5/17, indicated Resident 5's cognitive skills for daily decision making was severely impaired (never/rarely made decision), the range of motion of upper right extremity (limb) and both lower extremities were impaired, and Resident 5 had a swallowing disorder: loss of liquids/solids from the mouth when eating or swallowing. During an interview on 3/06/18 at 3:37 p.m., Licensed Staff BB was asked why Resident 5's Quarterly MDS for 9/5/17 and Annual MDS for 12/5/17 ADLs (Activities of Daily Living) for eating indicated Resident 5 was a Set-up Help Only when Resident 5's Resident Care Plan - Nutrition -Swallowing, indicated Resident 5's swallowing interventions included staff to monitor Resident 5 for signs and symptoms of aspiration: shortness of breath, wheezing ([MEDICATION NAME] sound produced in the respiratory airways during breathing), coughing ., instruct resident to swallow after each bite, instruct/cue resident to chin tuck (tip head forward), and elevate head of bed minimum of 90 degrees during meals and for 30 minutes after, etc. Licensed Staff BB stated Resident 5's MDS should have been coded as One Person Assistant. When asked what she looked at before coding, Licensed Staff BB stated she reviewed the resident's medical records including the physician's History and Physical, Nurse's Progress Notes, and Medication Administration Record, [REDACTED] A review of Resident 5's Resident Care Plan - Nutrition-Swallowing Impairment, dated 12/17/18, indicated swallowing interventions included monitor for signs and symptoms of aspiration: shortness of breath, wheezing ([MEDICATION NAME] sound produced in the respiratory airways during breathing), coughing ., instruct resident to swallow after each bite, instruct/cue resident to chin tuck (tip head forward), and elevate head of bed minimum of 90 degrees during meals and for 30 minutes after. These care plan interventions were not being followed. 4b. During an observation on 2/26/18 at 1:19 p.m. Resident 38 was eating her pureed lunch unassisted in bed. Resident 38 was positioned at a 45 degree angle and leaning to the right side. Resident 38's overbed table was positioned to the side of the bed, so Resident 38 could not reach her tray. Resident 38's plate of pureed beans and taco casserole was uncovered and no one came to assist her. Resident 38 was holding a bowl of pureed food and was scooping the food out with her hand. Resident 38 was still in her hospital gown and there was food all over her chest. Resident 38 did have a sipping cup, but she also had a non-adaptive glass filled to the top and out of reach. During an observation on 2/28/18 at 1:55 p.m., Resident 38 was having her lunch in bed unassisted. Resident 38 was holding her sipping cup and trying to drink from it, but she was having difficulty bring the cup to her mouth. Resident 38 had no napkin on her and milk was dripping all over her. Resident 38's pureed lunch tray was on her overbed table, but Resident 38 had slid down in the bed and could not reach her lunch tray. During a concurrent observation and interview on 2/28/18 at 2:00 p.m., Licensed Staff H was asked to see Resident 38's position in bed as Resident 38 attempted to feed herself lunch. Licensed Staff H stated Resident 38 was not positioned correctly in bed for lunch in order for Resident 38 to reach her meal tray. Licensed Staff H stated Resident 38 was down to low in the bed. Licensed Staff H stated Resident 38's daughter had requested Resident 38 attempt to feed herself first. Licensed Staff H stated Resident 38 did use her fingers to feed herself and Resident 38's daughter was aware. Licensed Staff H stated Resident 38 should have been assisted with her lunch, but the CNA had to assist the residences in the assisted dining room first and then assist the residences eating in their room. Resident 38 was trying to feed her stuffed monkey the sipping cup full of milk. During an interview on 3/7/18 at 8:45 a.m., Confidential X stated the facility knew Resident 38 was total care and needed assistance with eating. Confidential X stated she/he never said it was okay for Resident 38 to use her fingers to scoop out food from a bowl. Confidential X was very upset and sounded very sad because she/he did not live near the facility and was relying on the staff to take good care of Resident 38. Confidential X stated Resident 38 was a total assist. Confidential X stated Resident 38 had severe dementia, so one did not know from one minute to the next if Resident 38 could feed herself or needed to be assisted. Confidential X stated someone really needed to supervise Resident 38 with her meals. Confidential X stated Resident 38 needed total assistance with hygiene, positioning, meals Confidential X stated Resident 38 could not even turn herself. During an interview on 3/7/18 at 9:15 a.m., DON stated Resident 38 should have been positioned upright for her meals, but Resident 38's daughter wanted her to be independent with her meals as much as possible. DON stated it would be better if Resident 38 could have finger foods, but she was on a pureed diet. DON was asked if she thought there was a dignity/safety issue regarding Resident 38 using her fingers to scoop pureed food out of a bowl. DON stated the CNA did make rounds to see if Resident 38 was okay with feeding herself. DON did not see a dignity issue with Resident 38 scooping food out of a bowl with her fingers. DON did not see a safety issue with Resident 38 eating her meals unassisted even after it was brought to her attention Resident 38 had been trying to eat her lunch unassisted on 2/26/18 while positioned at a 45 degree angle, Resident 38's plate had been uncovered, but her overbed table was out of reach, no CNA was in the hallway because the CNAs were in the assisted dining room assisting residents, and Resident 38 was care planned for needing Total Meal Assist. Resident 38's Admission MDS, dated [DATE], indicated Resident 38's cognitive skills for daily decision making was severely impaired (never/rarely made decision), and Resident 38 had a swallowing disorder: loss of liquids/solids from the mouth when eating or swallowing. A review of Resident 38's Resident Care Plan - Activities of Daily Living, dated 1/11/18 and Resident Care Plan - Nutrition and Hydration, dated 1/15/18, indicated Resident 38 needed assistance with eating and bed mobility, decreased food intake, history of weight loss, dysphagia, cognitive impairment, and decreased feeding skills. Interventions for Resident 38 included total meal assist, encourage sipping cup, offer fluids frequently, and encourage oral fluids and eating at each meal. Total meal assist was not occurring.

Based on observation, interview and document review, the facility failed to maintain the call system at station 2 in working order, leaving approximately 39 of 83 residents (three wings) potentially unable to call for help. This failure resulted in an immediate jeopardy situation being called, due to the potential for a resident emergency to go unnoticed and/or unattended. Findings: During an observation with concurrent interview, on 6/22/10 at 2:35 p.m., Staff H said the call light system was not working at Station 2. The bell was ringing at the nurses station, but the room number did not light up on the grid or on the exterior of any resident room. Staff H stated that the maintenance person was there three times that same day to repair the system, and "...it's still not working." At 2:50 p.m., a CNA walked out of the nursing station said, "I guess I'll just go and look for it." During an observation, on 6/22/10 at 8:55 p.m., nursing station 2 call bell system was ringing at the desk, but there was no light indicator, nor was there a light on in any of the three hallways over resident rooms. During concurrent interview, Staff J said, "Is there a ghost light again?" Staff J said that the call system had failed before, but not usually this often. Staff were not systematically checking rooms to determine the source of the call light. During an observation, on 6/22/10 at 9:00 p.m., a light went on at the nurses station indicator board at room 52, but the indicator light did not go on in the hallway over the resident's room. Staff were not implementing any systematic method for checking resident call lights. During an interview, on 6/22/10 at 10:10 p.m., Staff L (a registered nurse) stated, "No resident is calling. It's a problem in the system. We know who calls; who needs us." During multiple observations, on 6/22/10 between the hours of 9 p.m. and 10:22 p.m., a call bell was ringing continuously at nursing station 2, with no indicator light at the monitor or in the hallway. During an observation, on 6/22/10 at 10:27 p.m., the call light for room 65 flickered on and off three times for room 65, then went off and stayed off. Staff at the nursing station stated that the resident in room 65 was physically unable to use the call bell. Observation of the resident in room 65 confirmed that the resident had not turned on the call light, as the light was a distance away from her hand on the bed, and the resident was sleeping. Because of the facility's failure to have a system in place to ensure resident needs would be attended to in a timely manner in the event of a call bell failure, and because the failure was known to the facility and had been ongoing, Immediate Jeopardy was called on 6/22/10 at 10:30 p.m., with Staff K (RN nurse consultant). On 6/22/10 at 10:40 p.m., Staff K presented a plan of corrective action to the survey team. The plan of corrective action consisted of the following elements: (1) Staff K immediately made rounds to determine that all residents were accounted for and safe. (2) 4 Administrative staff arrived to provide support and assist with rounds. (3) Rounds were provided every 15 minutes to each resident. (4) An electrician arrived onsite to assist in identifying and correcting the problem. (5) Staff were inserviced on the process to check resident rooms and call light function. (6) One Licensed Nurse was assigned to monitor call lights and residents. (7) Implementation of every 15 minute checks for each patient on the three wings, would be continued until it was determined that call system was fully functioning. (8) Night shift was in-serviced on the action plan. (9) A plan titled Guidance to Staff in the event of Call Light Malfunction was developed and posted prominently at the nursing station. (10) All staff were inserviced to the plan. The survey team met with Staff K, the Divisional Plant Operation Director, and the Acting Administrator on 6/23/10 at 1:50 p.m. and informed them that the Immediate Jeopardy was abated.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure sore for 1 of 17 sampled residents (Resident 3), when a knee immobilizing brace caused a stage II pressure sore, resulting in unnecessary treatment and pain, and potentially further complications, such as infection. The facility failed to develop and implement a care plan with specific interventions to monitor the skin beneath the immobilizing brace, and/or measures to prevent skin breakdown. Findings: During an observation with concurrent interview, on 6/22/10 at 9:32 a.m., Resident 3 was lying on her bed, with a knee immobilizing brace on her right leg. The brace extended from her upper thigh, to the ankle area. Staff A (a wound treatment nurse) was applying padding to the lower edge of the immobilizing brace, at the right outer aspect of the lower leg. Staff A stated there was a "rubbed area" on the leg caused by the metal of the leg brace. Record review, on 6/22/10 at 12 noon, indicated that Resident 3 was admitted to the long term care facility on 6/10/10 after surgical repair of a fractured right femur (large bone of the upper leg), with [DIAGNOSES REDACTED]. A Nursing Admission and Assessment form, dated 6/10/10, reflected that on admission to the long term care facility, Resident 3's skin was free of any pressure sores. Resident 3 was admitted to the long term care facility wearing an ace wrap and a knee immobilizing splint. The comprehensive admission Minimum Data Set (dated 4/2/10) reflected that Resident 3 was totally dependent upon staff assistance for activities of daily living, including personal hygiene, bathing, and turning. Licensed Nurses Notes for Resident 3, dated 6/22/10, reflected a note written by Staff B, indicating the MD was notified, "...to request a treatment order for rubbed area 2.5 cm by 2.5 cm above right outer ankle from the metal of leg brace rubbing triangular impression..." During an observation, on 6/24/10 at 10:50 a.m., Staff D removed a shorter (extended from upper thigh to below the knee) knee immobilizing brace and performed a dressing change on a surgical wound with staples, (along the upper outer right leg) and a stage II pressure sore on Resident 3's outer ankle. Staff D measured the wound at 3 cm by 2.5 cm. The wound was above the bony prominence on the outer aspect of the lower leg, triangular shaped, a deep crater with whitish-yellowish tissue at the base, through the depth of a full skin thickness, and with reddness in the skin around the edges. The MDS manual describes a " Stage 2, a partial thickness loss of skin layers that presents clinically as an abrasion, blister, scab or shallow crater. " During an interview, on 6/24/10 at 10:50 a.m., Staff D stated that the wound was a stage II pressure ulcer. During an interview with concurrent record review, on 6/24/10 at 11:35 a.m., Staff E (Physical Therapy staff) stated that Resident 3 was admitted with a soft, straight leg brace, but it did not sufficiently immoblize the knee. Staff E stated that the Director of the Physical Therapy Department fit Resident 3 with a different brace. Staff E stated that she would expect to see a care plan in the record, for monitoring of skin and repositioning of the brace. Staff E was unable to locate a care plan addressing identification of pressure areas caused by the brace, proactive measures to prevent pressure sores, monitoring and repositioning of the brace, or skin care related to the brace, written prior to the development of the pressure ulcer. During an interview with concurrent record review, on 6/24/10 at 3:20 p.m., Staff F (Director of Physical Therapy Department) stated he fitted the knee immobilizing brace for Resident 3, and, "It was too big. It went all the way to the ankle. You can't get them smaller." Staff F stated that he would expect there to be a care plan addressing skin care beneath the brace. The DON, who was present at the interview, was unable to locate within the medical record, a nursing care plan addressing identification of pressure areas caused by the brace, proactive measures to prevent pressure sores, monitoring and repositioning of the brace, or skin care related to the brace, written prior to the development of the pressure ulcer. Review of the medical record, indicated a care plan for pressure ulcers/skin integrity, initiated 6/10/10, related to poor bed mobility and a brace on right leg. Interventions included the following: monitor nutritional status, follow turning and positioning program, observe for skin improvement/deterioration weekly, monitor for signs and symptoms of infection, teach resident good skin care techniques, encourage cooperation with caregivers, instruct use of call light, instruct resident on risk factors for development of pressure ulcer. A short term care plan, initiated 6/12/10, addressed the surgical incision with staples at the right femur. Interventions included clean and apply dressing every other day, as ordered by MD, monitor for signs and symptoms of infection, notify MD if signs and symptoms of infection. Neither care plan included specific interventions related to checking skin integrity beneath the immobilizer, or to monitoring and repositioning the immobilizer, or other proactive measures to prevent pressure ulcers related to the knee immobilizer. During an interview, on 6/25/10 at 9:15 a.m., Staff F (Physical Therapy Department Head) stated, "Of course, we should not get a pressure ulcer from an immobilizing brace." Facility staff (Staff K) provided a policy regarding pressure ulcer monitoring, but was unable to provide a policy or procedure for prevention of pressure ulcers. A treatment record flow sheet, for the month of June 2010, indicated staff were to perform weekly skin checks for Resident 3. Skin checks had been performed on the 12th and the 19th with no mention of pressure ulcer. The next scheduled skin check was to be performed on the 26th. Essentials of Medical-Surgical Nursing (fourth edition, 1998; W. B .Saunders Company) directs, "Depending on the patient's general condition, weight, and other factors, skin damage may occcur within a few hours to a few days." (page 266) and, in Table 11-5 Guidelines for the Prevention of Pressure Ulcers (IBID), "Assess the skin of all patients at risk at least once a day, paying particular attention to the bony prominences." (page 268) Internet review of a US Army Medical Course (MD0916-100) titled Medical Surgical Nursing / Orthopedic Nursing indicated, on slide #123, titled Nursing Care Related to the use of Braces and Splints, "Examine the skin daily for evidence of breakdown at pressure points."