Every finding on record at Greenfield Care Center of Fullerton, LLC

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for three of three sampled residents (Residents 1, 2, and 3). * The facility failed to ensure Resident 1, 2, and 3's change of conditions was monitored every shift for at least 72 hours. These failures had the potential to negatively affect the residents' health and well-being and risk of not providing the residents with appropriate and individualized care.Findings: Review of the facility's P&P titled Change of Condition dated 4/2025 showed the following:- Licensed nurses will contact the primary physician (alternate physician or Medical Director) of resident status as soon as possible when there is a significant change of condition.- Licensed nurses will inform family members of change of condition and document notification.- All nursing actions, physician order/instructions, and resident assessment information will be documented in the nursing progress notes.- The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours or until condition has stable. 1. Closed medical record review for Resident 1 was initiated on 3/27/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 7/21/25, showed Resident 1 had no capacity to understand and make medical decisions. Review of Resident 1's SBAR Communication Form dated 11/6/25 at 1046 hours, showed Resident 1 had various small areas of skin breakdown; superficial on the left and right buttocks. However, further review of Resident 1's medical record failed to show the resident's change in condition was monitored for at least 72 hours after the resident's initial change in condition was observed and documented. 2. Medical record review for Resident 2 was initiated on 3/27/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 10/13/25, showed Resident 2 had no capacity to understand and make medical decisions. Review of Resident 2's SBAR Communication Form dated 3/16/26 at 1348 hours, showed Resident 2 had MASD to sacrococcyx area. However, further review of Resident 2's medical record failed to show the resident's change in condition was monitored for at least 72 hours after the resident's initial change in condition was observed and documented. 3. Medical record review for Resident 3 was initiated on 4/2/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 7/13/25, showed Resident 3 had no capacity to understand and make medical decisions. Review of Resident 3's SBAR Communication Form dated 3/21/26 at 1354 hours, showed Resident 3 had a small area of skin breakdown on the right perianal fold. However, further review of Resident 3's medical record failed to show the resident's change in condition was monitored for at least 72 hours after the resident's initial change in condition was observed and documented. On 4/1/26 at 1358 hours, an interview and concurrent medical record review was conducted with the Treatment Nurse. The Treatment Nurse stated the SBAR/Change of Condition Report was created whenever a new skin issue was identified. The Treatment Nurse further stated she was only required to document weekly progress notes of the residents existing skin conditions undergoing treatments, unless the condition worsened or deteriorated. The Treatment Nurse further stated there was no requirement for licensed nurses to monitor and document every shift for 72 hours after a change of condition report was initiated related to skin issues. On 4/2/26 at 1115 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 acknowledged the facility's P&P to monitor the residents for at least 72 hours after a change of condition was observed. RN 2 verified Residents 1, 2, and 3 had change of condition reports related to skin issues as listed above. RN 2 stated the licensed nurses were not expected to complete a monitoring progress note every shift for 72 hours after the change of condition was initiated related to skin issues because to treatment nurses were responsible for providing the treatment and monitoring as ordered. On 4/2/26 at 1245 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented for one of 21 final sampled residents (Resident 91). * The facility failed to implement the compressive care plan for Resident 91's right upper arm AV shunt (arteriovenous shunt is a direct connection between an artery and a vein that bypasses the normal network of small capillaries). The facility failed to ensure the facility staff did not obtain Resident 91's blood pressure on his right arm, the arm with his dialysis access site/ AV shunt). This failure had the potential to damage the AV shunt and/or increase the risk of blood clots for Resident 91.Findings: Review of the facility's P&P titled Care Plan revised 4/2024 showed a care plan is the summation of the resident concerns, goals, approaches, and interventions, in order to meet the goals and help minimize if not totally eradicate residents' problems. Medical record review for Resident 91 was initiated on 9/8/25. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's care plan focus titled End Stage Renal Disease (ESRD) initiated 8/27/25, showed an intervention to not obtain Resident 91's blood pressure on his right arm, the site of his AV shunt. Review of Resident 91's Order Summary Report showed the following physician's orders:- dated 8/26/25, for the nursing staff not to obtain Resident 91's blood pressure on his right arm (location of AV shunt); and- dated 8/29/25, for Resident 91 to receive hemodialysis (a medical treatment for kidney failure that uses an artificial kidney (dialyzer) to filter waste, salts, and excess fluid from a patient's blood when the kidneys are unable to do so) twice a week on Monday and Friday at 0430 hours. Review of Resident 91's Weights and Vitals Summary showed documentation the nursing staff obtained Resident 91's blood pressure on his right arm (location of AV shunt) on the following dates and times:- on 8/28/25 at 0822 hours (blood pressure measured at 155/63 mmHg);- 8/30/25 at 0934 hours (blood pressure measured at 118/80 mmHg);- 9/4/25 at 0827 hours (blood pressure measured at 112/50 mmHg);- 9/5/25 at 0918 hours (blood pressure measured at 130/80 mmHg);- 9/6/25 at 0816 hours (blood pressure measured at 138/70 mmHg); and- 9/6/25 at 0916 hours (blood pressure measured at 134/82 mmHg). On 9/10/25 at 0922 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the findings and stated the nursing staff should not have obtained Resident 91's blood pressure utilizing his right arm, the location of Resident 91's AV shunt, in accordance with Resident 91's ESRD care plan. Cross reference F698, example # 2.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of two final sampled residents (Resident 2) reviewed for pressure injuries. * The facility failed to ensure LVN 3 administered the wound treatment as per the physician's orders to Resident 2's right heel pressure injury. This had the potential for Resident 2 not receiving the appropriate care and services to promote healing of the pressure injury.Findings: Review of the facility's P&P titled Wound Care revised 1/2025 showed it is the policy for the facility to provide guidelines for the care of wounds to promote healing. To review the resident's care plan to assess for any special needs of the resident. To use no -touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Place gauze to cover all broken skin.Remove dry gauze and apply treatments as indicated. Medical record review for Resident 2 was initiated on 9/8/25. Resident 2 was admitted to the facility on [DATE], and had a diagnosis of Stage 3 (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure injury of the right heel. Review of Resident 2's H&P examination dated 11/25/24, showed Resident 2 had no capacity to understand and make medical decisions. Review of Resident 2's plan of care showed a care plan problem dated 6/11/25, addressing Resident 2's right heel Stage 3 pressure injury. The interventions showed Resident 2 was seen by the Wound Care Physician Assistant and the right heel was reassessed and measured, with the new order to cleanse with normal saline, pat dry, apply collagen (powder, wound filler dressing topically applied and promotes wound healing), and Thera honey (sterile, medical-grade honey dressing used to treat a variety of wounds), and alginate (absorb wound fluid resulting in gels that maintain a physiologically moist environment and minimize bacterial infections at the wound site), then apply the dry sterile dressing/kerlix for 21 days. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was at risk for developing pressure injuries and had an unhealed Stage 3 pressure injury. Review of Resident 2's Order Summary Report showed a physician's order dated 9/5/25, for the right heel Stage 3 pressure injury, to cleanse with normal saline (NS), pat dry, apply collagen, Thera honey, alginate, and dry sterile dressing/kerlix every day shift for 21 days. On 9/10/2025 at 831 hours, a wound treatment observation for Resident 2 was conducted with LVN 3 and the IP. LVN 3 was observed preparing the following:- a 250 ml bottle of sterile 0.9% normal saline;- an unopened packet of calcium alginate dressing, with silver;- an unopened 1 gram packet of collagen powder; and- a 0.5-ounce tube of Thera honey gel. During the wound treatment observation, after cleaning the right heel, LVN 3 was observed using a tongue depressor to apply the Thera honey gel to the right heel wound bed. LVN 3 was then observed removing the collagen powder with a tongue depressor and applying the powder on top of the Thera honey gel. However, a significant amount of the white- collagen powder was observed on Resident 2's bed, directly under the right heel, and not on the wound bed. After performing hand hygiene and donning new gloves, LVN 3 proceeded to apply the calcium alginate (with silver) dressing. LVN 3 was stopped and verified the collagen powder on the resident's bed and the minimal amount of collagen powder observed on the right heel wound bed. LVN 3 was observed reapplying the collagen powder to the wound bed, on top of the Thera honey gel, and applied the calcium alginate (with silver) dressing, dry dressing and kerlix. On 9/10/25 at 0909 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 3. LVN 3 was asked about the resident's physician's order for the treatment medications for Resident 2's right heel pressure injury. LVN 3 stated the Thera honey gel should be applied first, followed by the collagen powder on top of the Thera honey. LVN 3 verified during the wound treatment observation for Resident 2, she applied the Thera honey gel to the wound bed, followed by the collagen powder. When asked about the treatment order for the alginate dressing, LVN 3 reviewed the physician's order and verified the physician's order showed to apply the alginate dressing, however, LVN 3 stated the order did not show to use calcium alginate with silver. LVN 3 verified during the wound treatment observation she used the calcium alginate with silver. LVN 3 stated the wound treatments should be administered as per the physician's order. On 9/10/25 at 0958 hours, a telephone interview was conducted with Physician Assistant 1. When asked about the physician's order for the treatment medications for Resident 2's right heel pressure injury, Physician Assistant 1 stated the treatment nurse was expected to first apply the collagen powder to the wound bed, followed by the Thera honey gel, and then the alginate dressing. When asked about the alginate dressing, Physician Assistant 1 stated the facility could use the calcium alginate, however, calcium alginate with silver was not needed for Resident 2's wound. On 9/11/25 at 1234 hours, an interview was conducted with the DON. The DON stated the treatment nurse was expected to administer the wound treatments as per the physician's order. The DON stated if the wound treatment order had multiple medications, the treatment nurse was expected to administer the wound treatment as listed per the physician's order. The DON further stated if the treatment nurse had any questions, the treatment nurse should obtain an order clarification. On 9/11/25 at 1248 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the environment remained free from accident hazards for one of one final sampled resident (Resident 43) reviewed for falls. * The facility failed to ensure Resident 43's post fall risk assessment was completed accurately to identify the resident's risk for fall and to prevent further falls and/or injuries. This failure posed the risk of not providing the necessary care to the resident to prevent further falls and/or injuries.Findings: Review of the facility's P&P titled Fall Management revised on 12/2024 showed the following:- the licensed nurses/designee will gather data from the resident, family of interested party about the resident's history of falling; and- the licensed nurse will evaluate, and document falls that occur while the resident is in the facility; for example, when and where the fall occurs, observations of the events, injuries, treatments, etc. Review of the facility's P&P titled Documentations revised on 1/2025 showed the following:- documentation should reflect all findings after assessment was done and reflect concern or problems of resident; and - However, it is discouraged to have a late entry, if possible, licensed nurses should be precise and accurate which will be reflected in the resident medical record. Medical record review for Resident 43 was initiated on 9/10/25. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's H&P examination dated 12/31/24, showed Resident 43 had no capacity to understand and make decisions. Review of Resident 43's MDS assessment dated [DATE], showed Resident 43's BIMS score was nine, indicating moderate cognitive impairment. Review of Resident 43's Fall Risk Assessment (post fall) dated 8/7/25, showed under the section for history of falls, no falls in the past six months was marked. In addition, the assessment showed a total score of nine, which placed Resident 43 at a low risk of fall. On 9/10/25 at 1445 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 43's Fall Risk Assessment (post fall) dated 8/7/25, and verified the above findings. RN 1 stated the resident's Fall Risk assessment dated [DATE], was inaccurate because Resident 43 had a fall episode on 8/7/25. RN 1 stated if the post Fall Risk Assessment was completed accurately, Resident 43's fall risk score would have been 10, which placed Resident 43 at a high risk of fall. Furthermore, RN 1 stated the negative outcome of the inaccurate assessment would affect Resident 43's fall prevention and plan of care. On 9/11/25 at 0944 hours, an interview was conducted with the Administrator and DON. The DON stated she reviewed Resident 43's documentation and assessments and conducted an IDT meeting after the resident's fall on 8/7/25. The DON stated she reviewed Resident 43's post Fall Risk assessment dated [DATE], however, she did not notice the inaccuracy of the assessment. In addition, the DON stated if Resident 43's Fall Risk Assessment was completed accurately, Resident 43's fall risk score would have been 10, which placed Resident 43 at a high risk of fall. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary dialysis care and services for two of two final sampled residents (Residents 10 and 91) reviewed for dialysis care. * The facility failed to follow up on Resident 10's laboratory results for the laboratory tests obtained at the dialysis center. * The facility failed to ensure the facility staff did not obtain Resident 91's blood pressure on six occasions on the arm with his AV shunt. These failures had the potential for the residents to experience medical complications and negatively affect Residents 10 and 91's physical well-being. Findings: Review of the facility's P&P titled Dialysis Services 1/2025 showed it is the policy of this facility to provide adequate and appropriate care to dialysis clients in coordination with the dialysis center. Coordination of care may include the following: information transmitted to the dialysis unit by the facility prior to dialysis through the phone and/or communication binder which resident carries when going to the dialysis center, where information regarding resident is reflected for the dialysis center awareness. The same binder is brought back by the resident to the facility where the dialysis center relayed any information regarding post dialysis findings or other concerns and/or special treatment to be followed by the facility if applicable. The facility may be required to provide the following interventions for dialysis residents” assessment of laboratory values such as: BUN, serum creatinine, sodium, potassium, calcium, magnesium, phosphate levels, hemoglobin and hematocrit. The dialysis access site is to include avoidance of blood pressure readings, venipunctures and trauma to the dialysis access extremity. 1. Medical record review for Resident 10 was initiated on 9/8/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE], with the diagnosis of renal dialysis dependence. Review of Resident 10's H&P examination dated 9/1/25, showed Resident 10 had the capacity to understand and make decisions. The H&P also showed Resident 10 had ESRD and received hemodialysis treatments. Review of Resident 10's Order Summary Report for September 2025 showed a physician's order dated 8/27/25, for hemodialysis treatment on Mondays, Wednesdays, and Fridays at 0900 hours, pick-up at 0830 hours. Review of Resident 10 ‘s Nurse's Dialysis Communication Record for 9/3/25, showed the dialysis center documented the monthly laboratory tests for Resident 10 were obtained. However, further review of Resident 10's medical record failed to show if the laboratory test results were obtained from the dialysis center and/or placed in the resident's medical record. On 9/9/25 at 1413 hours, an interview and concurrent medical record review for Resident 10 was conducted with the ADON. The ADON reviewed Resident 10's Nurse's Dialysis Communication Record for 9/3/25, and verified the dialysis center documented the monthly labs for Resident 10 was obtained. The ADON reviewed Resident 10's medical record and verified Resident 10's monthly laboratory test results were not in Resident 10's medical records. On 9/9/25 at 1442 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON stated for any laboratory tests obtained at the dialysis center, the RN supervisor was responsible for following up to ensure the laboratory results were in the resident's medical records. The DON stated the RN supervisor should follow up as soon as possible, within 24 hours. On 9/11/25 at 1234 hours, a follow up interview was conducted with the DON. The DON stated if any laboratory tests were drawn at the dialysis center and documented in the communication record, the receiving licensed nurse at the facility should follow up and obtain the laboratory results. On 9/11/25 at 1248 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 91 was initiated on 9/8/25. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's Order Summary Report showed the following physician's orders: - dated 8/26/25, to monitor Resident 91's AV shunt on his right upper arm every shift; - dated 8/26/25, for the nursing staff not to obtain Resident 91's blood pressure on his right arm (location of AV shunt); and - dated 8/29/25, for Resident 91 to receive hemodialysis twice a week on Monday and Friday at 0430 hours. Review of Resident 91's Weights and Vitals Summary showed documentation the nursing staff obtained Resident 91's blood pressure on his right arm (location of AV shunt) on the following dates and times: - on 8/28/25 at 0822 hours (blood pressure measured at 155/63 mm Hg); - 8/30/25 at 0934 hours (blood pressure measured at 118/80 mm Hg); - 9/4/25 at 0827 hours (blood pressure measured at 112/50 mm Hg); - 9/5/25 at 0918 hours (blood pressure measured at 130/80 mm Hg); - 9/6/25 at 0816 hours (blood pressure measured at 138/70 mm Hg); and - 9/6/25 at 0916 hours (blood pressure measured at 134/82 mm Hg). On 9/10/25 at 0922 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she was assigned to provide care for Resident 91. LVN 1 was asked what arm she utilized to obtain Resident 91's blood pressure. LVN 1 stated she would obtain Resident 91's blood pressure utilizing his left arm (the arm without the AV shunt). LVN 1 stated she would not and should not obtain Resident 91's blood pressure utilizing his right arm, due to the location of his AV shunt, which was located on his right arm. LVN 1 stated obtaining the blood pressure on Resident 91's right arm (location of AV shunt) had the potential to damage Resident 91's dialysis access site (right arm AV shunt). LVN 1 then reviewed Resident 91's medical record and verified the nursing staff documented having obtained Resident 91's blood pressure on his right arm, on the following dates and times: 8/28/25 at 0822 hours, 8/30/25 at 0934 hours, 9/4/25 at 0827 hours, 9/5/25 at 0918 hours, 9/6/25 at 0816 hours, and 9/6/25 at 0916 hours. LVN 1 stated the nursing staff should not have obtained Resident 91's blood pressure utilizing his right arm, where Resident 91's AV shunt was located. On 9/11/25 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated the nursing staff should not obtain Resident 91's blood pressure having utilized his right arm, the location of Resident 91's AV shunt. The DON stated obtaining the blood pressure on the arm in which Resident 91's AV shunt was located had the potential to damage Resident 91's AV shunt.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate treatment and services designed to help attain and maintain a resident's highest practical physical, mental, and psychosocial well-being for one of one final sampled resident (Resident 24) reviewed for dementia (group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking and reasoning) care. * The facility failed to obtain the neurologist's progress notes and develop a dementia care plan for Resident 24. This failure had the potential for Resident 24 to not receive the appropriate treatment and services needed for her dementia.Findings: Review of the facility's P&P titled Dementia - Clinical Management revised 1/2025 showed the staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. For the individual with confirmed dementia, the staff and physician will identify a resident-centered care plan to maximize remaining function and quality of life. Medical record review for Resident 24 was initiated on 9/8/25. Resident was admitted to the facility on [DATE]. Further review of Resident 24's medical record showed on 7/30/25 (after her admission to the facility), Resident 24 had the diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident 24 's H&P examination dated 11/18/24, showed Resident 24 had no capacity to understand and make medical decisions. Review of Resident 24's progress note for a licensed nurse's entry dated 7/30/25 at 1630 hours, showed Resident 24's returned to the facility from her neurology appointment with the physician's note and orders. Review of Resident 24's Physician's Progress Note dated 7/30/25, showed a full progress note would be sent to the facility in a day or two. The preliminary clinical conclusion showed the following:- Should start anti-dementia medications.- For arrhythmia, two options are to be presented to the current cardiologist for his decisions. Review of Resident 24's Order Summary Report for September 2025 showed the following physician's orders:- dated 7/30/25, to administer galantamine hydrobromide (dementia medication) 4 mg one tablet by mouth two times a day for unspecified dementia, and- dated 7/30/25, to administer memantine (dementia medication) 5 mg, one tablet by mouth two times a day related to unspecified dementia. Review of Resident 24's MAR for 9/2025 showed Resident 24 was administered the galantamine hydrobromide and memantine medications from 9/1 to 9/9/25 at 0900 and 1700 hours, except on 9/6 and 9/7/25. Review of Resident 24's medical record failed to show the facility had developed or implemented a plan of care to address Resident 24's dementia. Further review of Resident 24's medical record failed to show Resident 24's complete neurology progress notes from 7/30/25. In addition, the resident's medical record failed to show the documentation the facility had attempted to obtain the progress notes from the neurologist. On 9/10/25 at 1403 hours, an interview and concurrent medical record review for Resident 24 was conducted with RN 2. RN 2 stated Resident 24 was alert and oriented to person and place but was forgetful and confused at times. RN 2 verified Resident 24 was diagnosed with dementia; however, the facility did not develop a care plan addressing the resident's dementia. RN 2 stated for the residents diagnosed with dementia, there should be a care plan developed specific to the resident's dementia. RN 2 reviewed Resident 24's medical record and verified the above findings. On 9/10/25 at 1601 hours, an interview and concurrent medical record review for Resident 24 was conducted with the DON. The DON stated when the resident was seen by a consultant, the facility was responsible for obtaining the consultation progress notes and the progress notes should be placed inside the resident's medical record within 24 hours. The DON stated for the residents with a new diagnosis of dementia, while at the facility, there should be monitoring of the residents' behaviors. The DON stated the interventions for the residents were dependent on the behaviors the residents were exhibiting. The DON further stated the facility should review the resident's neurology progress notes to determine certain behaviors to monitor for. The DON reviewed Resident 24's medical record and verified the neurology progress notes was not in Resident 24's medical record. The DON stated the IDT meeting should have been conducted specific to the resident's diagnosis of dementia to determine what needs Resident 24 may have at the facility and a care plan should have been developed specific to Resident 24's dementia. On 9/11/25 at 1248 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for two of two final sampled residents (Residents 10 and 91) reviewed for dialysis care. * The facility failed to ensure accurate monitoring for the administration of Resident 10's blood pressure medications on the days Resident 10 had dialysis treatments. Resident 10's BP medications were sent with the resident to be administered by the dialysis nurse, however the facility's licensed nurses documented the administrations in Resident 10's MAR (Medication Administration Record). * The facility failed to ensure Resident 91's carvedilol (used to treat high blood pressure) and calcium acetate (supplement) medications were administered on time, in accordance with the facility's P&P. These failures had the potential to negatively affect Residents 10 and 91's health condition.Findings: Review of the facility's P&P titled Medication Administration revised 1/2025 showed medications shall be administered in accordance with the facility's established policies and procedures. Medications must be administered by the same person preparing the dosage for administration. Medications must not be prepared in advance and must be administered within one hour before or after the administration time per the physician's order. The medications should be immediately charted following the administration by the licensed nurse who administered the medication. In the event that the resident is not in the facility during the scheduled medication administration time (i.e. out on pass, on dialysis services, appointment services and other emergencies), the physician will be notified for any orders and will be documented. 1. Medical record review for Resident 10 was initiated on 9/8/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 9/1/25, showed Resident 10 had the capacity to understand and make decisions. The H&P further showed the resident had ESRD and received hemodialysis treatment. On 9/9/25 at 1413 hours, an interview and concurrent medical record review for Resident 10 was conducted with the ADON. When asked about the facility's process for the administration of the BP medications to Resident 10 on the days the resident was scheduled for dialysis treatment, the ADON stated the dialysis center had called and informed her of Resident 10's BP dropping during the dialysis treatment. The ADON stated she had instructed the licensed nurses assigned to Resident 10, to send the scheduled 0900 hours blood pressure medications with Resident 10, to be administered at the dialysis center. The ADON stated she did not document the call from the dialysis center in Resident 10's medical record or informed Resident 10's physician. Additionally, the ADON reviewed Resident 10's medical record and stated there were no physician's orders to send the BP medications with Resident 10 to the dialysis center. The ADON stated for the BP medications that were sent with Resident 10, the dialysis center should document the administration of the BP medications in the resident's Nurse's Dialysis Communication Record. However, review of Resident 10's Nurse Dialysis Communication Record dated 8/29, 9/1, 9/3, and 9/5/25 failed to show documented evidence Resident 10's BP medications scheduled at 0900 hours were administered in the dialysis center during the resident's scheduled dialysis days. The ADON reviewed Resident 10's listed Nurse Dialysis Communication Record and verified the dialysis center did not document the administration of any BP medication during the dialysis treatment. Review of Resident 10's Order Summary Report for September 2025 showed the following physician's orders: - dated 8/27/25, for hemodialysis treatment on Mondays, Wednesdays, and Fridays at 0900 hours, pick-up at 0830 hours; - dated 8/27/25, to administer amlodipine (blood pressure medication) 10 mg one tablet by mouth daily; and - dated 8/27/25, to administer hydralazine (blood pressure medication) 100 mg one tablet by mouth three times a day. Review of Resident 10's MAR for 8/2025 and 9/2025 showed the following: * For the amlodipine 10 mg one tablet by mouth one time a day, the amlodipine medication was administered to Resident 10 from 8/28 to 9/9/25 at 0900 hours. * For the hydralazine 100 mg one tablet by mouth three times a day, the hydralazine medication was administered to Resident 10 from 8/1 to 8/22/25 and from 9/1 to 9/8/25 at 0900, 1300, and 1700 hours. * For the clonidine 0.1 mg one tablet three times a day dated 6/21/25, and discontinued 8/26/25, the clonidine medication was administered to Resident 10 from 8/1 to 8/22/25 at 0900, 1300, and 1700 hours. Review of Resident 10's Medication Admin Audit Report for 9/3/25, showed the following documentation: * For the amlodipine 10 mg one tablet by mouth one time a day, RN 4 documented the amlodipine medication was administered at 0800 hours. * For the hydralazine 100 mg one tablet by mouth three times a day, RN 4 documented the hydralazine medication was administered at 0800 hours. On 9/9/25 at 1505 hours, an interview was conducted with Resident 10. Resident 10 stated she had dialysis treatments on Mondays, Wednesdays, and Fridays. Resident 10 stated on the days she had dialysis treatment, the facility sent the BP medications: clonidine, hydralazine, and sometimes amlodipine with her, to be administered by the dialysis nurse. On 9/10/25 at 1045 hours, a telephone interview was conducted with RN 4. RN 4 stated Resident 10 received dialysis treatment on Mondays, Wednesdays, and Fridays, left the facility at around 0800 hours and returned around lunch time. When asked about Resident 10's BP medications scheduled on 9/3/25 at 0900 hours, RN 4 stated he did not administer Resident 10's BP medications scheduled at 0900 hours but instead, placed Resident 10's BP medications in the medication pouch and sent the medications with the resident, to bring to the dialysis center. When RN 4 was asked how he knew the BP medications were administered to Resident 10, RN 4 stated he asked Resident 10, and she told him she took the medications at the dialysis center. On 9/10/25 at 1552 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON stated she spoke with RN 4 and RN 4 had informed the DON on 9/3/25, he sent Resident 10's BP medication with her to the dialysis center. The DON reviewed Resident 10's Nurse's Dialysis Communication Record for 9/3/25, and verified the dialysis nurse did not document the administration of the BP medications. The DON also reviewed Resident 10's MAR for 9/2025 and verified RN 4 documented he administered Resident 10's amlodipine 10 mg and hydralazine 100 mg on 9/3/25 at 0900 hours. On 9/11/25 at 1234 hours, a follow up interview was conducted with the DON. The DON stated the licensed nurse who prepared the resident's medication and removed the medication from the medication pack should be the person to administer the medication. The DON stated once the medication was administered to the resident, the licensed nurse should sign/document the administration of the medication in the resident's MAR. On 9/11/25 at 1248 hours, a follow up interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 91 was initiated on 9/8/25. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's Order Summary Report showed the following physician's orders: - dated 8/26/25, to administer calcium acetate (medication to lower phosphate in the blood) 667 mg orally three times a day (scheduled at 0730 hours, 1230 hours, and 1730 hours). - dated 9/2/25, to administer carvedilol (anti-hypertension medication) 6.25 mg orally two times a day (scheduled at 0730 hours and 1730 hours). Review of Resident 91's Nurse's Dialysis Communication Record dated 9/8/25, showed Resident 91 left the facility for his dialysis appointment on 9/8/25 at 0400 hours, and had returned to the facility at 0840 hours. Review of Resident 91's Medication Administration Audit Report dated 9/8/25, showed the following documentations: - the licensed nurse administered Resident 91's carvedilol 6.25 mg medication orally on 9/8/25 at 0841 hours. Resident 91's carvedilol 6.25 mg medication was scheduled to be administered at 0730 hours. - the licensed nurse administered Resident 91's calcium acetate 667 mg medication orally on 9/8/25 at 0840 hours. Resident 91's calcium acetate 667 mg medication was scheduled to be administered at 0730 hours. In accordance with the facility's P&P, the carvedilol and calcium acetate medications should have been administered within one hour of the scheduled administration time. On 9/9/25 at 1554 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified Resident 91's Nurse's Dialysis Communication Record dated 9/8/25, showed Resident 91 left the facility for his dialysis appointment on 9/8/25 at 0400 hours, and then returned to the facility at 0840 hours. RN 3 stated the facility did not send any medications with Resident 91 to be taken at the dialysis center. RN 3 stated Resident 91's carvedilol 6.25 mg and calcium acetate 667 mg medications (scheduled for 0730 hours) should have been administered within one hour of the scheduled administration time, in accordance with the facility's Medication Administration P&P, however, the facility failed to do so.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. Two of the three licensed nurses (LVN 1 and RN 1) observed were found to have made errors during the medication administration observation for two final sampled residents (Residents 33 and 54). * LVN 1 did not administer Resident 54's Creon (medication used to help digest food) medication with meals or food as ordered by the physician. * RN 1 did not administer Resident's 33's artificial tears ophthalmic solution (used for dry eye) as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes and posed the risk of possible complications.Findings: Review of the facility's P&P titled Policy and Procedure in Medication Administration revised 1/2025 showed the medications shall be administered in accordance with our established policies and procedures. The drugs must be administered in according with the written orders of the attending physicians (Five Rights). 1. Review of the facility's P&P titled Policy and Procedure on Administration of Eye Drops revised 1/2025 showed to ensure that eyecare/medication are appropriately provided based on the physician's order in consideration with OBRA regulation.The following procedures will be undertaken in eye drop administration:- Check the label and follow the physician's instructions. On 9/9/25 at 0911 hours, a medication administration observation for Resident 33 was conducted with RN 1. RN 1 prepared the following medications for Resident 33:- one capsule of aspirin-dipyridamole (anti-platelet medication) 25 - 200 mg;- one tablet of amlodipine (medication to treat high blood pressure) 5 mg, hold if the systolic blood pressure was below 110 mmHg;- one tablet of Lasix (diuretic medication) 20 mg;- one tablet of losartan potassium (medication to treat high blood pressure) 50 mg, hold if the systolic blood pressure was below 110 mmHg;- one tablet of multi-vitamins with minerals (supplement);- one tablet of potassium chloride (supplement) extended release 20 mEq;- one patch of lidocaine (local anesthetic medication) 5%, to apply topically to both knees and right shoulder;- one nasal spray of fluticasone propionate nasal spray (nasal spray primarily used to relieve symptoms associated with allergies and other conditions affecting the nasal passages) to each nostril;- two tablets of acetaminophen (an analgesic medication used to relieve mild pain) 325 mg;- two tablets of bisacodyl (laxative) 5 mg;- two tablets of docusate sodium (stool softener) 100 mg; and- artificial tears ophthalmic solution (eye drop, use for dry eye) to both eyes. RN 1 was observed administering two drops of the artificial tears ophthalmic solution to Resident 33's right eye and then administered two drops of the artificial tears ophthalmic solution to the resident's left eye. Medical record review for Resident 33 was initiated on 9/8/25. Resident 33 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Order Summary Report dated 9/9/25, showed a physician's order dated 12/27/22, to administer one drop of the artificial tears ophthalmic solution in both eyes two times a day for dry eyes. On 9/9/25 at 1053 hours, an interview was conducted with Resident 33. Resident 33 verified she always got two drops of the artificial tears ophthalmic solution to her left and right eye from the licensed nurses during the medication administration. On 9/9/25 at 1425 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the findings. RN 1 stated she did not follow the physician's order when she administered the artificial tears ophthalmic solution to Resident 33 during the medication observation. 2. Review of the facility's P&P titled Medication Administration Schedule revised 1/2025 showed the medications are administered according to established schedules. Scheduled medications that must be given around mealtimes may fluctuate based on delivery and consumption of meals. Time critical medications are designated by the pharmacy and include medications that need to be administered before, with, or after meals. On 9/9/25 at 1201 hours, a medication administration observation for Resident 54 was conducted with LVN 1. During the medication administration observation, Resident 54 was not observed with a lunch tray or food at the bedside. LVN 1 prepared the following medications for Resident 54:- artificial tears lubricant (eye drop, use for dry eye);- one tablet of carbidopa-levodopa (medication to treat Parkinson's disease) 25-100 mg; and- one capsule of Creon delay-release 24,000 units, to give with meals. LVN 1 was observed administering the Creon medication to Resident 54 without food. Medical record review for Resident 54 was initiated on 9/8/25. Resident 54 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 54's Order Summary Report dated 9/9/25, showed the following physician's order dated 8/20/22, to administer Creon capsule delayed release particles 24,000 units by mouth with meals for peptic ulcer, do not crush, chew or break open a capsule. Swallow the capsule whole with a full glass of water. On 9/9/25 at 1401 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the Creon medication was not administered to Resident 54 with meals nor food. On 9/11/25 at 0919 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage and disposal of medications. * The facility failed to ensure Resident 78's medication was stored properly and safely. * The facility failed to ensure the opened package of the [NAME] collagen powder (sterile, medical grade wound dressing, manage wounds by providing a moist healing environment) medication was stored properly in Medication Cart A. * The facility failed to dispose of the expired supply from the Medication Storage Room A. These failures had the potential to alter the efficacy of the stored medications, infection risk to the residents, and result in inappropriate administration of the prescription medications.Findings: Review of the facility's P&P titled Labeling and Storing Medications revised 1/2025 showed it is the policy of this facility that resident's medication will be properly labeled and stored in the locked medication room/carts. In addition, the medications no longer in use or medications which have expired will be disposed of in accordance with the Federal and State Laws. 1. Medical record review for Resident 78 was initiated on [DATE]. Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's Quarterly MDS assessment dated [DATE], showed Resident 78 has a BIMS score of six, indicating severe cognitive impairment. On [DATE] at 0917 hours, during the initial tour of the facility, Resident 78 was observed sitting on his wheelchair. There was a medication box container labeled with each day of the week, on the resident's overbed table. Resident 78 stated he was not aware of the medication box container on his overbed table. On [DATE] at 0941 hours, an observation, interview, and concurrent medical record review for Resident 78 was conducted with LVN 2. LVN 2 verified the medication box container labeled with each day of the week contained the following:- Monday compartment: two white capsules and one gray capsule;- Tuesday compartment: two white capsules and two gray capsules;- Wednesday compartment: two white capsules and two gray capsules;- Thursday compartment: empty;- Friday compartment: empty;- Saturday compartment: two white capsules and two gray capsules; and- Sunday compartment: two white capsules and two gray capsules. LVN 2 verified the above findings and stated she was not familiar with the medications inside the medication box container. LVN 2 further stated there was no need to have the medications at Resident 78's bedside. On [DATE] at 1526 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated there was no need to have the medications at the resident's bedside. 2. a. On [DATE] at 1526 hours, an inspection for Medication Cart A was conducted with RN 5. During the inspection of Medication Cart A, the following was observed: - one opened individual pack of the [NAME] collagen powder. The package's description showed the medication was a single use only. On [DATE] at 1534 hours, an interview was conducted with RN 5. RN 5 verified the above findings. RN 5 was asked regarding the facility's process when opening an individual package of medication. RN 5 stated the individual package was single use only and needed to be discarded after the single use. b. On [DATE] at 1018 hours, an inspection of Medication Storage Room A was conducted with RN 6. During the inspection of Medication Storage Room A, the following was observed:- nine sealed individual packages of BBL culture swab (used to collect and transport clinical samples, such as from the wounds, throat or skin to a laboratory for culture and testing) with an expiration date of [DATE]. On [DATE] at 1041 hours, an interview was conducted with RN 6. RN 6 verified the above findings. On [DATE] at 0919 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed in the kitchen. * The facility failed to ensure the blender used for meal was air dried prior to storing. * The facility failed to ensure the food preparation utensil was not clean and in good working condition. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Order List dated 9/8/25, showed 85 of 88 residents consumed the food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. Review of the facility's P&P titled General Food Preparation and Handling revised 1/2025 showed all the equipment should be cleaned, sanitized, air-dried and reassembled after each use. On 9/8/25 at 0753 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. The following was observed:- one clean blender was observed stored wet with visible water inside and the lid on. The DSS verified the inside of the blender and the lid was not air-dried. The DSS stated the dietary aide used it earlier and washed it. 2. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled General Food Preparation and Handling revised 1/2025 showed the plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of. On 9/9/25 at 0950 hours, during the kitchen observation, an observation and concurrent interview was conducted with the DSS. The following was observed:- one serving scoop with food residue and melted white handle. The DSS verified the above findings. On 9/11/25 at 0944 hours, an interview was conducted with the Administrator and DSS. The Administrator and DSS were informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to ensure the medical record was accurately maintained for one of 21 final sampled residents (Resident 91). * The facility documented (on three separate days) having obtained Resident 91's blood sugar, however, Resident 91 was out of the facility for his dialysis appointment, during the times the facility documented having obtained Resident 91's blood sugar. This failure resulted in Resident 91's medical record containing inaccurate information.Findings: Medical record review for Resident 91 was initiated on 9/8/25. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's Order Summary Report showed the following physician's orders:- dated 8/29/25, for Resident 91 to receive hemodialysis twice a week on Monday and Friday at 0430 hours.- dated 8/26/25, to obtain Resident 91's blood sugar once daily and to contact the physician if Resident 91's blood sugar was less than 60 mg/dL or greater than 250 mg/dL. a. Review of Resident 91's Nurse's Dialysis Communication Record dated 9/1/25, showed Resident 91 left the facility for his dialysis appointment on 9/1/25 at 0345 hours, and returned to the facility at 0750 hours. Review of Resident 91's Vitals Summary dated 9/1/25, showed documentation Resident 91's blood sugar was obtained on 9/1/25 at 0530 hours (measured at 115 mg/dL). However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0345 hours, and returned to the facility at 0750 hours). Review of Resident 91's MAR dated 9/2025 showed documentation Resident 91's blood sugar was obtained on 9/1/25 at 0630 hours (measured at 115 mg/dL). However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0345 hours, and returned to the facility at 0750 hours). b. Review of Resident 91's Nurse's Dialysis Communication Record dated 9/5/25, showed Resident 91 left the facility for his dialysis appointment on 9/5/25 at 0400 hours, and returned to the facility at 0830 hours. Review of Resident 91's Vitals Summary dated 9/5/25, showed documentation Resident 91's blood sugar was obtained on 9/5/25 at 0533 hours (measured at 117 mg/dL). However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0400 hours, and returned to the facility at 0830 hours). Review of Resident 91's MAR dated 9/2025 showed documentation Resident 91's blood sugar was obtained on 9/5/25 at 0630 hours (measured at 117 mg/dL) . However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0400 hours, and returned to the facility at 0830 hours). 3. Review of Resident 91's Nurse's Dialysis Communication Record dated 9/8/25, showed Resident 91 left the facility for his dialysis appointment on 9/8/25 at 0400 hours, and returned to the facility at 0840 hours. Review of Resident 91's Vitals Summary dated 9/8/225, showed documentation Resident 91's blood sugar was obtained on 9/8/25 at 0533 hours (measured at 107 mg/dL). However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0400 hours, and returned to the facility at 0840 hours). Review of Resident 91's MAR dated 9/2025 showed documentation Resident 91's blood sugar was obtained on 9/8/25 at 0630 hours (measured at 107 mg/dL). However, Resident 91 was at the dialysis center at this time (Resident 91 left the facility at 0400 hours, and returned to the facility at 0840 hours). On 9/9/25 at 1534 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified the above findings. RN 3 verified Resident 91 was at the dialysis center on 9/1, 9/5, and 9/8/25, during the times the facility documented (on the Vitals Summary and MAR) having obtained Resident 91's blood sugar.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment, and help prevent the development and transmission of diseases and infections. * The facility failed to ensure Kitchen Aide 1 performed proper hand hygiene after picking up trash off the floor. * The facility failed to ensure LVN 3 followed the infection control practices during the wound observation for Resident 2. LVN 3 placed Resident 2's right heel on the pillow after cleaning the wound. * The facility failed to ensure the facility staff performed hand hygiene after handling soiled linen. These failures posed the risk of the transmission of communicable diseases to the residents and employees throughout the facility.Findings: 1. Review of the facility's P&P titled Sanitation and Infection Control – Handwashing dated 2018 showed the Food Service workers will keep their hands and exposed portion of their arms clean. Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment. On 9/10/25 at 0934 hours, during the kitchen observation with the DSS, an observation and concurrent interview was conducted with the DDS and Kitchen Aide 1. Kitchen Aide 1 was observed picking up a small piece of white paper off the floor with her bare hand, touching the lid of the gray trash receptacle, and throwing the piece of paper in the trash receptacle. Kitchen Aide 1 then touched the empty metal cart. Kitchen Aide 1 was not observed washing her hands after touching the floor and the trash receptacle. Kitchen Aide 1 and the DSS verified the above findings. In addition, Kitchen Aide 1 stated the importance of proper hand washing was to prevent contamination. The DSS stated all the kitchen staff must wash their hands after picking up anything from the floor. The DSS stated the floor was not considered clean. Furthermore, the DSS stated the negative outcome of failing to perform proper hand washing would contaminate the food and kitchen areas. On 9/11/25 at 0944 hours, an interview was conducted with the Administrator and DSS. The Administrator and DSS were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Wound Care revised 1/2025 showed it is the policy for the facility to provide guidelines for the care of wounds to promote healing. To position the resident and place a disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Medical record review for Resident 2 was initiated on 9/8/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 11/25/24, showed Resident 2 had no capacity to understand and make medical decisions. On 9/10/25 at 831 hours, a wound treatment observation for Resident 2 was conducted with LVN 3 and the IP. During the wound treatment observation, LVN 3 was observed cleaning Resident 2's right heel Stage 3 pressure injury with normal saline and gauze. After cleansing the right heel pressure wound, LVN 3 was observed placing Resident 2's right heel on the pillow and performing hand-hygiene. The pillow was observed making direct contact with the wound bed of Resident 2's right heel pressure wound. The IP verified the above findings. LVN 3 was then observed using a dry gauze to pat dry the right heel pressure wound and applying the Thera Honey gel to the right heel wound bed. On 9/10/25 at 0909 hours, an interview was conducted with LVN 3. LVN 3 stated after cleaning the resident's wound bed, if the wound touched anything in the resident's environment, the wound should be cleansed again to ensure a clean environment for the wound bed prior to the administration of the medication. On 9/10/25 at 0942 hours, an interview was conducted with the IP. The IP stated for the residents with wounds, the goal was for the wounds to not have any infections. The IP stated when providing wound treatments, after the wound bed was cleaned, the wound should be kept clean prior to the application of the topical treatments. The IP further stated if the wound was observed touching the bed or linen, the treatment nurse was expected to cleanse the wound again to prevent any possible infection. On 9/11/25 at 1248 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 1/2025 showed the facility considers hand hygiene the primary means to prevent the spread of infection. On 9/9/25 at 1128 hours, during the observation in the hallway in front of Room A, the Activity Assistant was observed going into Room A. The Activity Assistant was observed taking the soiled linen with her bare hand from Resident 14, who was standing in the room. The Activity Assistant then took the soiled linen to Shower Room A and went back to the Activity Room without washing or sanitizing her hands. On 9/9/25 at 1130 hours, an interview was conducted with the Activity Assistant. The Activity Assistant verified she did not perform hand hygiene after taking the soiled linen to Shower Room A. On 9/10/25 at 1526 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the facility staff were supposed to perform hand hygiene after handling soiled linens. On 9/11/25 at 0919 hours an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 21 final sampled residents (Resident 43) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise Resident 43's long-term care plan addressing the resident's high risk for fall when Resident 43 sustained a fall on 8/7/25. This posed the risk of not providing Resident 43 with an individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Plans revised on 4/2025 showed the assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Care Plan revised on 1/2025 showed the following:- Long term care plan: this is a problem or concern of the residents that has been ongoing for longer periods of time;- A short-term problem that has been noted twice should be included in the long-term care plan;- The resident care plan is developed within seven days upon resident's admission, reviewed quarterly, annually or as often as needed as there is a change of condition; and- The evidence of a care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented or carried out. Medical record review for Resident 43 was initiated on 9/10/25. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's H&P examination dated 12/31/24, showed Resident 43 had no capacity to understand and make decisions. Review of Resident 43's MDS assessment dated [DATE], showed Resident 43's BIMS score was nine, indicating moderate cognitive impairment. Further review of Resident 43's medical record showed Resident 43 had a recent fall on 8/7/25. However, review of Resident 43's plan of care revised 7/15/25, failed to show the resident's long-term care plan addressing the resident's high risk for fall reflected the resident's recent fall on 8/7/25. On 9/10/25 at 1445 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 43's plan of care. RN 1 verified Resident 43's long term care plan addressing the resident's high risk for fall was not revised to reflect the resident's fall episode on 8/7/25. RN 1 stated for new fall episodes, the licensed nurses must revise the residents' long-term care plan. On 9/10/25 at 1520 hours, an interview and concurrent medical record review was conducted with the MDS Assistant. The MDS Assistant reviewed Resident 43's plan of care and verified Resident 43's long-term care plan addressing the resident's high risk for fall was not revised to reflect the resident's recent fall episode on 8/7/25. The MDS Assistant stated she did not revise Resident 43's long-term care plan when the resident had a fall episode on 8/7/25. The MDS Assistant stated the negative outcome for not revising the resident's care plan would result in not having the current recommendations from the resident's recent fall episode. Furthermore, the MDS Assistant stated when revising the long-term care plan addressing the residents' risk for fall, the licensed nurses must add the new interventions and recommendations from the physician to prevent future falls. On 9/11/25 at 0944 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's instructions. This failure posed the risk of the residents contracting the illnesses from the ice served to them. Findings: Review of the facility matrix showed 93 of 93 residents residing in the facility received food prepared in the kitchen. On 9/3/24 at 0951 hours, a concurrent observation, interview, and facility document review was conducted with the Maintenance Director. The facility was equipped with one ice machine. When asked about cleaning and sanitizing the ice machine, the Maintenance Director showed an inner panel on the ice machine containing the instructions on how to clean and sanitize. Review of the instructions on the panel included the descaling and sanitizing solutions were to be mixed with water. On 9/4/24 at 1544 hours, a concurrent interview and facility document review was conducted with the Maintenance Director. The Maintenance Director verified he was not mixing the descaling and sanitizing solutions correctly as per the manufacturer's instructions.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to plan and implement the control measures to prevent the growth of the Legionella (a bacteria that can cause a serious type of lung infection) in the facility's water system. * The facility failed to ensure LVN 2 performed hand hygiene in between glove change while providing wound care to Resident 486. These failures had the potential for the spread of infection in the facility. Findings: According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease revised 7/6/2018, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; - Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC (Center for Disease Control and Prevention) tool kit; and, - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Legionella Water Management Program revised 7/2017 showed as part of the infection prevention and control program, the facility has a water management program which is overseen by the water management team. The P&P further stated water management program included specific measures used to control the introduction and/or spread of legionella (e.g. temperature, disinfectant), the control limits or parameters that are acceptable and that are monitored, and a diagram where the control measures are applied. On 9/6/24 at 0834 hours, a concurrent interview and facility document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the facility had a legionella risk assessment with areas of possible legionella growth in the water system and tested the water for legionella every six months; however, the Maintenance Supervisor was not able to show if the facility had planned and implemented the control measures to prevent the growth of the legionella or other opportunistic waterborne pathogens in the facility's water system. On 9/6/24 at 0840 hours, a concurrent interview and facility document review was conducted with the Administrator. The Administrator verified and acknowledged the above findings. 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 8/2019 showed to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: - Before handling clean or soiled dressings, gauze pads, etc.; - After handling used dressings, contaminated equipment, etc.; and, - After removing gloves. Further review of the facility's P&P showed the use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Medical record review for Resident 486 was initiated on 9/3/24. Resident 486 was admitted to the facility on [DATE]. Review of the Resident 486's Physician Order Summary dated 9/4/24, showed to cleanse sacrococcyx Stage III with normal saline, pat dry, apply thera honey gel (a gel that supports removal of dead tissue and promotes wound healing), barrier, lotrizone (antifungal ointment) cream to fungal dermatitis periwound (tissue surrounding a wound) and a foam dressing once a day for 30 days. On 9/6/24 at 0734 hours, a wound care observation for Resident 486 was conducted with LVN 2 and RN 5. RN 5 was observed assisting LVN 2. Resident 486 was observed awake in bed. LVN 2 performed hand hygiene, donned gloves and gown, and entered the room with prepared medications on the tray. LVN 2 removed the dressing from Resident 486's sacrococcyx area. LVN 2 doffed her gloves, washed her hands with soap and water, and donned a clean pair of gloves. LVN 2 then cleaned Resident 486's wound with normal saline and patted it dry with a gauze. LVN 2 changed her gloves without performing hand hygiene in between and was observed donning a clean pair of gloves without performing hand hygiene. LVN 2 proceeded to apply thera honey on the wound, barrier cream, and lotrizone to the periwound of Resident 486. Finally, LVN 2 covered and secured Resident 486's wound with a foam dressing. On 9/6/24 at 0754 hours, an interview was conducted with LVN 2. LVN 2 verified the above observation and stated she should have performed hand hygiene in between glove change and before donning another pair of clean gloves. On 9/6/24 at 0757 hours, an interview was conducted with RN 5. RN 5 verified the above observation and stated LVN 2 should have performed hand hygiene in between glove change during wound care. On 9/6/24 at 1110 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to facilitate the residents' preferences and choices for food for three of 19 final sampled residents (Residents 22, 61, and 70). * Residents 22, 61, and 70 were not offered Korean breakfast. In addition, the Korean menu was posted in English. These failures posed the risk of the residents not being able to choose food items according to their ethnic preferences. Findings: Review of the facility's P&P for Nutrition Care - Resident Food Preferences revised 2018 showed the resident food preferences should be reviewed with the resident by the DSS and ethnic food preferences should be taken into consideration. 1.a. On 9/3/24 at 0951 hours, an interview was conducted with the DSS. When asked about breakfast served to residents, the DSS stated all residents were served breakfast from the American menu. On 9/4/24 at 0851 hours, Resident 22 was observed with her breakfast tray of scrambled eggs, toast, oatmeal, orange slice, and milk. On 9/4/24 at 1218 hours, an interview was conducted with Resident 22 and Resident 22's RP. When asked about Resident 22's breakfast, the RP verbalized when Resident 22 lived at home Resident 22 would have Korean breakfast. The RP stated Resident 22 would like Korean breakfast and to have the Korean menu in Korean language. Resident 22 could read the Korean menu if provided in Korean language. On 9/4/24, medical record review for Resident 22 was initiated. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 4/1/24, showed Resident 22 was able to understand and express herself in Korean. b. On 9/4/25 at 0730 hours, Resident 70 was observed with her breakfast tray of eggs, oatmeal, orange slice, milk, and a red liquid. When asked about being served a Korean breakfast, Resident 70 stated she would like Korean breakfast if possible. When asked if the staff had offered her a Korean breakfast, Resident 70 stated no. On 9/4/24, medical record review for Resident 70 was initiated. Resident 70 was readmitted [DATE]. Review of Resident 70's H&P examination dated 12/21/23 showed Resident 70 was able to understand and express herself in Korean. On 9/4/24 at 1418 hours, a concurrent interview and medical record review was conducted with the DSS. The DSS verified Korean menus were not provided to the residents and Korean menus posted in the hallway outside the kitchen and in the dining room were posted in English. The DSS verified the majority of residents in the facility were Korean. On 9/6/24 at 1503 hours, an interview was conducted with the DON. When asked about the ethnic population of the residents at the facility, the DON stated 89 residents spoke and read primarily Korean. The DON stated 91 residents received meals prepared by the kitchen. 49780 c. Review of Resident 61's medical record showed the resident was admitted to the facility on [DATE], with diagnosis of unspecified protein-calories malnutrition. On 9/4/24 at 0735 hours, a breakfast observation was conducted with Resident 61. Resident 61 had poured scrambled eggs into a bland rice porridge and taken out a Korean Soy paste from the drawer and ate with the porridge. Resident 61 did not eat the sandwich. On 9/4/24 at 1215 hours, an interview was conducted with Resident 61 with a translator. Resident 61 stated she did not like the sandwich or toast so she did not eat them. Resident 61 stated nobody asked her what she preferred to eat or if she liked to eat the sandwich or toast. Resident 61 preferred Korean food but the facility always gave her American breakfast. On 9/4/24 at 1626 hours, an interview was conducted with RN 3. RN 3 stated most Korean residents liked to eat Korean food, and if they liked to eat American food, she could change it for them. RN 3 confirmed Resident 61 liked to eat Korean food and did not like American food.

Based on interview, medical record review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation to the local law enforcement for one of one final sampled resident investigated for abuse (Resident 47). This failure had the potential for a delay in law enforcement response to the allegation. Findings: Review of the facility's Abuse and Neglect Prevention Management revised August 2018 showed all allegation of abuse or mistreatment will be reported per state law including the local law enforcement. Medical record review for Resident 47 was initiated on 9/3/26. Resident 47 was admitted to the facility on [DATE]. On 9/3/24 at 1455 hours, an interview was conducted with Resident 47 at their bedside. Resident 47 made an abuse allegation that three staff members were mean to her and rough. On 9/3/24 at 1523 hours, the Administrator was informed of Resident 47's allegations. Review of the facility's Report of Suspected Dependent Adult/Elder Abuse faxed to CDPH on 9/3/24, failed to show the report was submitted to the local law enforcement. Review of the facility's Follow Up Abuse Investigation Report for the Facility Reported Incident on 9/3/24, the report faxed to CDPH on 9/5/24, failed to show the local law enforcement agency was notified of the abuse allegation. On 9/5/24 at 1552 hours, an interview was conducted with the Administrator. The Administrator verified the facility did not notify the local law enforcement of the abuse allegation.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight for one of two final sampled residents (Resident 486) reviewed for pressure ulcer (skin injury caused by prolonged pressure on an area of the body). This failure had the potential of Residents 486 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: Review of the facility's P&P titled Pressure Reducing Mattresses revised 1/2024 showed specialized mattress/beds are to be utilized according to suppliers' direction for use. Review of the facility's document titled Operating Instruction Comfy Aire Series, undated, showed the Comfy Aire system is designed for patient weighting between 35- 145 pounds, using the comfort control. Depending on the desired resident comfort level the micro-controller/sensor will set appropriate air pressure in the mattress and maintain the desired pressure in the mattress. On 9/3/24 at 0849 hours, 9/4/24 at 0931 hours, and 9/5/24 at 1250 hours, Resident 486 was observed lying on a low air loss mattress. The low air loss mattress was observed set to comfort level 4 which corresponded to the weight of 175 pounds. Medical record review for Resident 486 was initiated on 9/3/24. Resident 486 was admitted to the facility on [DATE]. Review of Resident 486's Weekly Skin Integrity Assessment for Pressure Sore dated 8/28/24, showed Resident 486 had a Stage 3 pressure ulcer (full-thickness skin loss that extends into deeper tissue and fat) to the sacrococcyx area. Review of Resident 486 's Order Summary Report showed a physician's order dated 8/1/24, for a low air loss mattress for wound management. Review of Resident 486's MDS dated [DATE], showed Resident 486 was totally dependent on the staff for bed mobility. Further review of the MDS showed Resident 486 had memory problem. Review of Resident 486's History and Physical Examination dated 7/23/24, showed Resident 486 did not have the capacity to understand and make medical decisions. Further medical record review for Resident 486 showed Resident 486's weight was documented as 99 pounds on 8/12/24. On 9/5/24 at 1301 hours, an observation, interview, and concurrent medical record review for Resident 486 was conducted with LVN 2. LVN 2 verified Resident 486's low air loss mattress was set to level 4. LVN 2 verified Resident 486 was 99 pounds and did not have the capacity to understand and verbalize comfort level of the mattress. LVN 2 further stated Resident 486's comfort level for the low air loss mattress was supposed to be set to Resident 486's weight of 99 pounds at level 2, not at level 4 (175 pounds). On 9/5/24 at 1318 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated if the resident could not verbalize the comfort level for the low air loss mattress, then it should be set to the resident's weight.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician order for oxygen therapy was followed for one of one final sampled resident reviewed for oxygen therapy (Resident 17). This failure had the potential for Resident 17 to not to receive appropriate respiratory care and posed the risk to negatively affect Resident 17's medical condition. Findings: Review of the facility's P&P titled Oxygen Therapy revised 1/2024, showed it is the policy of the facility that oxygen to be administered as ordered by the physician or as an emergency measure until the order could be obtained. Under the section Procedure showed to adjust oxygen flow as ordered by the physician. On 9/3/24 at 0940 hours, an observation was conducted for Resident 17. Resident 17 was observed lying in bed and receiving oxygen at six liters per minute via nasal cannula. Medical record review for Resident 17 was initiated on 9/3/24. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Order Summary Report dated 9/4/24, showed the following physician's orders: - dated 8/24/24, to administer oxygen at two liters per minute via nasal cannula continuously. - dated 8/24/24, may titrate up to five liters per minute via mask for respiratory comfort if oxygen saturation level less than 90%. On 9/3/24 at 0951 hours, an observation, interview and concurrent medical record review for Resident 17 was conducted with the IP. Resident 17 was observed lying in bed and receiving oxygen at six liters per minute via nasal cannula. The IP verified the observation and Resident 17's physician order for oxygen. The IP further stated Resident 17 was not receiving oxygen as per the physician order and Resident 17 should have received oxygen at two liters per minute via nasal cannula continuously as per the physician's order. The IP stated if the residents' condition needed an increase in oxygen, then the physician should be notified and documented in the medical record. On 9/5/24 at 1028 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41% (for two medication errors out of 27 total opportunities). * The facility failed to ensure LVN 1 administered Resident 63's medication as ordered. This failure had the potential to cause the negative outcomes to Resident 63. Findings: Review of the facility's P&P titled Policy and Procedure In Medication Administration revised January 2024 showed medications must be administered in accordance with the physicians' orders. On 9/4/24 at 0838 hours, a medication administration observation was conducted with LVN 1 for Resident 63. LVN 1 administered the following medications: - one tablet of Extra Strength Glucosamine Hcl (hydrochloride) with MSM (methylsulfonylmethane). - one softgel of Vision Formula 50+ dietary supplement with Lutein, Zeaxanthin, and Omega 3. LVN 1 stated Resident 63's family member brought the supplements to the facility. Review of the medication labels showed the following: -For the Extra Strength Glucosamine Hcl with MSM medication, the dosage showed for two tablets to provide 1500 mg of glucosamine and 1500 mg of MSM. The medication did not contain chondroitin. -For the Vision Formula 50+ dietary supplement with Lutein, Zeaxanthin and Omega 3 medication, the label showed one softgel contained Lutein 5 mg, Omega-3 fatty acids 250 mg, Zeaxanthin Isomers 1 mg. Medical record review for Resident 63 was initiated on 9/3/24. Resident 63 was admitted to the facility on [DATE]. Review of Resident 63's Order Summary Report dated 9/4/24, showed the following physician's orders: -dated 7/28/24, to administer glucosamine-chondroitin (a supplement) one tablet by mouth daily. -dated 8/4/24, to administer lutein (a supplement) 20 mg by mouth daily. On 9/4/24 1058 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 reviewed the medication labels for the Extra Strength Glucosamine Hcl with MSM, and Vision Formula 50 + dietary supplement with Lutein, Zeaxanthin, and Omega 3 medication. LVN 1 compared the labels for the above medications to Resident 63's physician's orders and verified the physician's orders did not match what LVN 1 administered to Resident 63.

Based on interview and clinical record review, the facility failed to honor the multiple requests of Resident 1's family member to call emergency services (911) for Resident 1. Resident 1 had an acute (rapid) onset of severe abdominal pain with nausea and vomiting. Resident 1's family member stated the resident's family repeatedly asked facility staff to call emergency services (911) but the request was denied. Resident 1 was eventually transferred to the acute care hospital and diagnosed with [REDACTED]. Resident 1 had surgery to repair the ischemic bowel, but died 12 days later due to cardiopulmonary arrest (when the heart and lungs stop working) and [MEDICAL CONDITION] (an infection that has entered the blood stream) due to the ischemic bowel. Findings: According to California Code of Regulations Title 16, 2518.5, "The LVN performs services requiring technical and manual skills which include the following: basic assessment, which the LVN Scope of Practice defines as data collection. The LVN may not perform an assessment that requires analysis or synthesis (evaluation) of data. Data collected by the LVN can be used by the RN to assist in the assessment process. LVNs are not independent practitioners, but may implement components of patient care assigned to them by the RN responsible for the patient." On [DATE] at 0900 hours, during an interview with Resident 1's responsible party, he stated Resident 1 had acute abdominal pain and the family requested multiple times that 911 be called, but the request was denied by facility staff. He stated staff told him they needed a physician's orders [REDACTED]. According to a declaration written by Resident 1's family member, Resident 1's pain on [DATE], did not subside. The pain was so bad, the resident could not sit or lie down; he "tried to crawl out of bed." LVN 3 checked the resident and told the family it was probably a stomach ache from something the resident ate. On [DATE] at approximately 1500 hours, a family member asked staff for Resident 1 to be sent to the emergency department via 911, but 911 was not called. Later the same day, around 1900 hours, Resident 1 asked to go to the emergency department again because his stomach hurt so bad. Staff told them it was just a stomach ache. The declaration showed Resident 1 vomited many times throughout the evening. Staff told the family the resident's blood pressure was fine and the resident was not in any danger. Around 2100 hours, Resident 1 again asked to be sent to the emergency department and staff agreed, but told the family they needed a physician's orders [REDACTED]. After about 20 minutes passed, a family member went to the nurses' station and asked what was taking so long for emergency services to come; staff told the family it was not a 911 case and a regular ambulance (one used in non-emergency situations for routine transportation) was called. On [DATE], clinical record review for Resident 1 was initiated. Resident 1 was admitted to the facility on [DATE], and was dependent on staff for activities of daily living. Resident 1 was described in nurses' notes dated ,[DATE], ,[DATE] and [DATE] as alert, oriented/awake with some forgetfulness. He was able to make his needs known. Review of the licensed nurses notes dated [DATE] at 1500 hours, showed Resident 1 complained of moderate pain. The note showed Resident 1 vomited once and then felt better. On [DATE] at 1630 hours, staff documented Resident 1 again complained of nausea and abdominal pain. The note did not show the resident's rating (intensity) and characteristics of the pain (such as dull, throbbing, stabbing etc). The note showed at 1640 hours, the physician was called and a message was left. At 1655 hours, the physician called back and ordered Pepto Bismol (a medication used to treat upset stomach, nausea and diarrhea). At 1700 hours, the nurse's note showed Pepto Bismol two tablets were administered; the resident complained of moderate pain. At 1720 hours, staff documented Resident 1 complained of severe abdominal pain. One [MEDICATION NAME] (a narcotic pain medication) 5 mg/325 mg was administered. At 1900 hours, Resident 1's pain was rated zero out of 10 (indicative of no pain); but at 2050 hours, the resident again complained of nausea and moderate abdominal pain. At 2145 hours, the note showed the physician called and ordered [MEDICATION NAME] (a medication used to treat nausea and vomiting) and the resident continued to complain of moderate pain. At 2230 hours, the resident complained of severe abdominal pain and nausea. The physician was called at 2235 hours. At 2245 hours, the physician called back and ordered the resident be transferred to the acute care hospital. On [DATE] at 0900 hours, during an interview with Resident 1's family member, he stated Resident 1 had acute abdominal pain and the family asked staff multiple times that 911 be called, but they were denied. He stated staff told him they needed a physician's orders [REDACTED]. On [DATE] at 1600 hours, during an interview with LVN 1, the LVN stated two family members of Resident 1 complained to her the resident had abdominal pain. LVN 1 stated the first complaint she received was at around "lunch time." LVN 1 stated, later in the afternoon, Resident 1's physician was notified and he ordered Pepto Bismol (note shows at 1640 hours). When asked if the family had requested 911 services for Resident 1, she stated, yes, twice that she was aware of. LVN 1 stated the family member told her he thought Resident 1 needed to go to the hospital via 911, and he requested the facility call 911. However, LVN 1 stated she assessed Resident 1 and stated "in my opinion, it was not a 911 case." LVN 1 stated the resident was not in respiratory distress and his face looked fine (not grimacing in pain). LVN 1 stated just because 911 is requested does not mean 911 is called. The LVN stated she called LVN 2 (not assigned to the resident) to come and assess Resident 1. LVN 1 stated, if LVN 2 thought it was a 911 case, she would have called, but LVN 2 agreed with her that it was not a 911 case. When asked if an RN was notified. LVN 1 stated, no. On [DATE] at 1620 hours, during an interview with the DON, the DON stated she learned about Resident 1 later in the day. She told the nurse to monitor the resident and to follow up with the physician. When asked if she assessed Resident 1, she stated she went into Resident 1's room, but did not perform a full assessment. The DON stated she checked his vital signs and pain level and spoke to the resident. The DON stated she did not document these vital signs, pain level or interaction with the resident. On [DATE] at 0845 hours, during an interview with RN 1, the RN stated LVN 4 reported to her Resident 1 had nausea and indigestion at the end of the day shift (the day shift ends at 1530 hours). RN 1 stated she took the resident's vital signs and endorsed the care of the resident to the oncoming nurses, LVN 1 and LVN 3. On [DATE] at 1535 hours, during an interview with LVN 3, the LVN stated Resident 1 vomited once, and the DON told him to monitor the resident. LVN 3 stated the resident's family member requested 911 be called, but he did not call 911. LVN 3 stated Resident 1's vital signs were within normal range and he was not in any acute distress, so there was no reason to call 911. On [DATE] at 1645 hours, during an interview with LVN 2, the LVN stated she was on duty on [DATE], evening shift (1500 hours to 2330 hours), but was not assigned to care for Resident 1. LVN 2 stated LVN 1 did ask her to check Resident 1. LVN 2 stated she checked the resident and the resident was comfortable; 911 did not need to be called. The LVN stated she did not document this interaction with the resident in the resident's clinical record. When asked why the acute onset of severe abdominal pain was not considered acute distress, the LVN stated the resident's face looked fine. LVN 2 stated LVNs can independently assess residents. On [DATE] at 1615 hours, during an interview with Physician 1, he stated he received two phone calls from the facility on [DATE], regarding Resident 1. The physician stated the first phone call was late in the afternoon when LVN 1 notified him Resident 1 had an upset stomach, possibly from eating lunch brought from home, but with no abdominal pain. Physician 1 stated he gave the nurse an order for [REDACTED]. He ordered [MEDICATION NAME] (a medication used to treat nausea and vomiting). Physician 1 stated the nurse told him the family members were not comfortable with the resident staying in the facility and wanted the resident to go to the hospital, so he told them okay, send the resident to the hospital. When asked if 911 could be called by the nursing staff without a physician's orders [REDACTED]. On [DATE] at 1405 hours, during a follow up interview with the DON, the DON stated pain is considered a vital sign. The DON stated a pain level of moderate to severe is not normal. When asked why Resident 1's family's request for 911 to be called due to the resident's severe abdominal pain was not honored, the DON stated it depended on the resident's tolerance; calling 911 is based on "our own assessment." When asked who made that assessment, the DON stated LVN 1, LVN 2 and LVN 3. When asked if the LVNs are qualified to conduct independent assessments of residents, the DON stated, yes. The DON was asked what the facility's policy is regarding when a resident or their family member requests 911 be called. The DON stated, if the resident is in acute distress, and if the physician orders [REDACTED]. Review of the acute hospital's ED (Emergency Department) Summary note dated [DATE], showed Resident 1 had nausea, vomiting and abdominal pain with no relief from medications given. The resident complained of severe abdominal pain and was treated with intravenous fluids, narcotic pain medication, antibiotics and antiemetics (medications used to treat nausea and vomiting). The emergency room Report form dated [DATE], showed Resident 1 was transferred to the hospital for sharp [MEDICAL CONDITION] (upper middle region of the abdomen) abdominal pain with multiple episodes of vomiting. The NP consultation dated [DATE], showed Resident 1 was transferred to the hospital for nausea, vomiting and abdominal pain since 1300 hours after eating lunch. A computed tomography scan (a test like an x-ray) of the resident's abdomen was done "since the patient was in such severe abdominal pain." The resident was diagnosed with [REDACTED]. Review of the Death Summary dated [DATE], showed Resident 1 died due to cardiopulmonary arrest with significant [MEDICAL CONDITION] due to ischemic bowel. On [DATE] at 1315 hours, during an interview with Physician 2, the physician stated, getting the resident to the hospital as soon as possible is better because then they can operate sooner.

Based on observation, interview and clinical record review, the facility failed to protect residents by not properly securing the building during the early morning hours. The facility failed to provide supervision for two of 19 sampled residents (Residents 18 and 19) who are both identified as cognitively impaired. The facility has two emergency exit doors (Door 1 and Door 2) which lead into an outside patio/porch. This patio/porch has a gate which leads to an eleven step staircase leading down to a public sidewalk and a heavily traveled six lane street. Resident 18 was able to open Door 1, unobserved. Surveillance Camera 9, which had been identified to monitor Door 1 was positioned towards the nurses' station, away from Door 1. Resident 19 was observed in the formal dining room, unsupervised, and self-propelling aimlessly in her wheelchair. Emergency exit door (Door 2) located inside the formal dining room leads directly into the same patio/porch as Door 1. When Door 2 was opened there was no audible alarm to alert staff someone has exited the emergency door. The alarm had been deactivated. In addition, the surveillance camera which would have alerted staff to a resident exiting Door 2 into the porch/patio was turned off. Staff were observed to enter the facility through Door 1 on two occasions without needing to ring a door bell, entering a code or wait for staff to open the door from the inside. This has the potential for residents to wander and/or elope from the facility and the potential for intruders to enter the facility unnoticed. On 6/20/11 at 1405 hours, CNA 1 was observed entering the facility from the public street through Door 1. On 6/20/11 at 1410 hours, while accompanied by the Director of Maintenance, inspection of Door 1 found it could be opened from inside and outside without any auditable alarm sounding. Upon exiting Door 1 into the patio/porch a metal gate was observed approximately six feet away from Door 1. Just beyond this gate are eleven steps staircase leading directly into a public sidewalk and busy street. The metal gate latch was found to not securely close and easily open when pushed. When asked, the Director of Maintenance verified Door 1 did not alarm since the alarm had been deactivated. In addition, he verified the metal gate latch was not properly aligned, preventing it from securely closing properly. This has the potential for any resident entering into the porch/patio unnoticed to fall down the staircase sustaining serious injuries. In addition, an intruder could enter the building unnoticed through the unsecured door (Door 1). On 6/20/11 at 1500 hours, during an interview with ADON, she stated the facility emergency exit doors are constantly monitored by video surveillance cameras located throughout the facility. It was identified there is a video surveillance monitor inside the physician's office, which is a room located inside the nurses' station. Observation of the surveillance monitor showed no camera(s) positioned towards Door 1. The surveillance camera in the formal dining room had been deactivated. This camera would have alerted staff to someone leaving the dining room into the porch/patio. On 6/20/11 at 1515 hours, an interview with the Administrator and the Director of Maintenance was conducted. When asked what mechanisms the facility uses to provide residents supervision and security, the Director of Maintenance stated the facility is not a locked facility. The Administrator stated they only admit residents that are appropriate for their facility, adding "We do not admit wanderers as a rule." The Administrator also stated they don't need door alarms activated during the day because they visually inspect residents and monitor doors using video surveillance to detect the presence of residents near exit doors. She also stated there is always a nurse in the nurses' station to monitor the video surveillance monitor adding, "it is never vacant." On 6/21/11 at 0550 hours, the SSD was observed entered the facility through Door 1 by entering the patio/porch from the public street. The emergency exit door was observed to be unlocked from the outside; the employee was not witnessed to knock, use a doorbell, key or pad code to open the door before entering the facility. During an interview with CNA 2 on 6/21/11 at 0610 hours, she stated the door (Door 1) near the nurses' station is not locked by a licensed nurse until around midnight each night. She added the door is not locked until the evening shift goes home and the night shift has arrived. On 6/21/11 at 0615 hours, during an interview with RN 4, he stated the facility disarms the emergency exit door (Door 1) every morning at 0600 hours. On 6/21/11 at 0618 hours, during an interview with CNA 4, she stated the staff enters the building using the stairs (from the public street into the patio/porch) and through the emergency exit door (Door 1). She stated the door is always unlocked and she has never found the door locked. On 6/22/11 at 0800 hours, the Director of Maintenance was observed repairing Door 1. When asked he stated the door was not closing all the way since the latch was not functioning properly. On 6/21/11 at 0920 hours, no staff was observed inside the nurses' station. Therefore, there was no one monitoring the surveillance cameras. On 6/21/11 at 0922 hours, the ADON stated she had stepped away from the nurses' station to answer a resident's call light. She confirmed no one was at the nurses' station to monitor Door 1 or the video surveillance monitor. On 6/22/11 at 0805 hours, Resident 18 was observed self-propelling in his wheelchair towards Door 1. Resident 18 pushed the door open and started going out into the patio/porch but the emergency exit door alarm sounded, alerting staff, who then assisted the resident back to his room. On 6/22/11 at 0810 hours, during an interview with the Director of Maintenance, he stated the reason Door 1 alarm sounded was because staff are repairing the door. On 6/22/11 at 0830 hours, Resident 19 was observed unsupervised, self-propelling her wheelchair aimlessly in the formal dining room. The emergency exit door (Door 2) was inspection and found no alarm sounded when the door was opened. On 6/22/11 at 0835 hours, the Administrator verified Resident 19 was in the dining room unattended and Door 2 did not trigger an alarm when opened. On 6/22/11 at 0840 hours, during an interview with the Director of Maintenance, he stated the surveillance camera located in the formal dining room had been deactivated. On 6/22/11 at 0845 hours, during an interview with the Administrator, when asked about the surveillance camera in the dining room, she stated the surveillance camera in the formal dining room (Door 2) is "generally" activated. On 6/22/11 at 0850 hours, during an interview with the Director of Maintenance, he stated we turned off the surveillance camera in the formal dining room approximately two weeks ago. When asked who told him to turn the camera off, he state "no one." In addition, he stated two weeks ago we also redirected the camera which had been facing emergency exit door (Door 1) towards the nurses' station. On 6/22/11 at 0950 hours, the Administrator and DON were notified that Immediate Jeopardy was identified due to the lack safety and security of the residents. On 6/23/11 at 1600 hours, the Administrator and DON were notified Immediate Jeopardy was abated. The actions taken by the facility to abate the Immediate Jeopardy include: A. Immediate action done: Identification and assessment of all residents who can ambulate with assistance or who self-propel. Door latches were repaired and checked for operational function. Camera was reactivated in the dining room. Alarms and sensors were checked. Director of Maintenance was reminded of strict monitoring of door alarms, surveillance cameras, to make sure that they are in good operating condition. A log for daily checking of alarms and surveillance cameras to ensure that they are functioning properly. Director of Activities was instructed by the Administrator not to leave any resident alone in the dining room before or after activities. All activity staff inserviced on this policy. Director of Maintenance checked all doors to see if they were in working condition and any issued immediately corrected. B. How to identify other residents that might be affected: A list of incidents in the past six months will be reviewed by the IDT to find out if any concern about elopement or attempted to leave the facility unassisted. C. Systems to be put into place to prevent reoccurrence: Administrator will inservice all departments heads regarding responsibility in proper identification of resident(s) who have a tendency to leave the facility whether ambulatory with assistance or self-propelling their wheelchair and ensure proper interventions are in place. Each department head will inservice their respective department staff to ensure identify and report any resident noted to be leaving the facility unassisted and do every possible measure to ensure resident safety. Department heads and staff will be alerted to the list of identified residents to be closely monitored and redirect behaviors. The DON will inservice licensed nurses on a systematic approach in assessing and constant observation, every shift while passing medications or making rounds. Immediate action will be taken as staff identify any behaviors, tendency to elope or if any resident gets out of the facility unassisted. In addition, the DSD will inservice the CNA staff on the complexity of the residents under their care. Facility doors will be alarmed at all times. The main door will be alarmed and locked at 1700 hours, during winter hours; and at 2000 hours during summer hours. This will be the main entrance and exit for visitors and staff. We have installed an additional monitor next to the call light system. Another monitor was installed inside the business office for monitoring residents when nurses are passing medication or attending to other duties. Staff will be inserviced on the door alarms by the DSD and Director of Maintenance on alarm activation and what to do when a door alarms. Further inservice will be done on how to work the keypad and to report any issues immediately to maintenance staff. Doors and cameras will be checked daily by the Director of Maintenance and/or his designee, and repaired immediately upon finding any issues. A daily log will be maintained for cameras and door sensors. The Director of Maintenance was inserviced by the Administrator for strict compliance with checking the surveillance cameras, door alarms, sensors, daily maintenance log for operating condition. All activity personnel were inserviced by the Administrator, DSD and DON. They must ensure while the residents are in the dining room for an activity program, an employee has to be there all times. The business office manager/receptionist will be inserviced by the Administrator to monitor the activity of the residents through the surveillance monitoring system during business hours and to immediately report to the Administrator or Director of Nurses any unusual activity that could endanger a resident such as a resident attempting to leave the facility without assistance. The DSD and the Director of Maintenance will inservice staff continuously about alarm activation, and what to do once the alarm sounds, how to work the keypad, and to report immediately issues with surveillance system to the Director of Maintenance. Inservices to prevent recurrences which are in place: All staff will be able to identify residents who are at risk for leaving the facility and how to take appropriate corrective action. The Administrator, DON, DSD and the Director of Maintenance or his designee will monitor for continued surveillance of door alarms, video cameras and the maintenance log to ensure the daily checking of door alarm, video cameras, surveillance monitors are functioning properly. If any one problems arise immediate repair or replacement of the device(s) will be done by the Director of Maintenance or designee. This information will be brought to the monthly and quarterly Quality Assurance meetings for the review of the effectiveness of the system. In addition, the facility failed to ensure elevated siderails were not used unless medically necessary for two of 19 sampled residents (Residents 5 and 11). Resident 5 has bilateral, full length elevated siderails in use. The resident was identified to be confused and tries to get out of bed unassisted. Elevated siderails created an accident hazard and the potential for abrasions, skin tears and an increased risk for serious injuries. Resident 11 sustained discolorations to her fragile skin which were related to the use of elevated siderails. Findings: According to Emergency Care Research Institute (ECRI, a federally approved resident safety organization) Continuous Care Management article dated May, 2005, Wandering is defined as "aimless or purposeful motor activity that causes problems such as getting lost, leaving a safe environment, or intruding in inappropriate places." It can be hazardous, and is frequently associated with dementia. According to the Alzheimer's Association, "dementia" is an umbrella of terms for several symptoms related to a decline in thinking skills. Common symptoms of dementia include gradual loss of memory, problems with reasoning or judgment, disorientation, difficulty learning. Alzheimer's disease is the most common cause of dementia in people age 65 and older. Review of the facility P&P titled "Surveillance for Safety of the Residents, Staff and Visitors" dated 09/2008, showed the facility is to ensure all possible measures will be taken in order to safeguard residents, staff and visitors. It includes but is not limited to installing surveillance cameras to monitor any resident who might accidentally leave the facility aimlessly, observe for any unwanted strangers who might intrude into the facility. The surveillance cameras main panel is situated at the nurses' station so nurses can monitor any unusual event(s) in the facility. Incidents of residents wandering/elopement could be monitored to prevent reoccurrence. The doors of the facility are locked at 2000 hours for safety, especially for any outside intruders who might come into the facility for no reason. Admit residents who are appropriate for nursing home placement. Being close to a busy street those wanderers seeking placement are referred to a locked/secured facility. Additional review of the policy failed to detail staff responsibilities to provide supervision. Review of the facility P&P titled "Alarm When Doors Are Locked" dated 9/2008, showed the alarm is on (activated) from 1700 hours during the winter time and 2000 hours during the summer time. However, the P&P did not address how the staff was to provide safety for the residents during the day time. Review of the CMS-672 Resident Census and Conditions of Residents form completed by the facility on 6/20/11, showed the resident census was 84. Of the 84 residents, 57 residents (68%) were identified with dementia, multi-infarct, senile, Alzheimer's type, or other than Alzheimer's type. Review of the facility evacuation plan map showed the facility is laid out in a rectangle shape and faces a busy six lane street. Emergency exit door 1 (Door 1) is located on the street side of the facility. The facility has four emergency exit doors. Door 1 leads to a patio/porch. Door 2 is located inside the formal dining room and leads to the patio/porch. Emergency exit door (Door 3) is located at the end of a hallway and exits outside near the faciltiy's laundry room and maintenance office. Finally, emergency exit door (Door 4), the main entrance into the facility opens to the parking lot. On 6/22/11 at 0950 hours, during an interview with the local Fire Marshal, he stated the sign "EXIT" is a designated area to get out and should be unobstructed. He also stated the facility can lock an emergency exit door(s) from outside, but anyone from inside should be able to open the door(s) and be able to exit the facility in an emergency. When asked about securing exit doors from the inside to prevent wandering residents from accidently getting outside. He stated the facility needs to find alternative ways "which are numerous" to keep their residents safe, and not in conflict with the fire safety codes. On 6/22/11 at 1155 hours, during an interview with the ADON, she stated, most of the time there is no one inside the physician's office (located behind the nurses' station), to watch the surveillance video monitor. She added it is not the most appropriate place to have a video monitor in the facility. No staff was observed monitoring the video monitor in the physician's office. On 6/22/11 at 1340 hours, during an interview with the Director of Maintenance, when asked how often they check the functioning of the door alarms and surveillance cameras, he stated "every day." However, the Director was unable to show documentation to reflect the daily working conditions of the devices. The Director verified there are 16 live video images monitoring through the facility. For example, there are cameras for the front lobby, parking garage, trash containers, back to the building, steps outside, the nurses' station, faciltiy hallways, and the laundry exit door. 1. On 6/22/11 at 0805 hours, Resident 18 was observed self-propelling in his wheelchair towards Door 1. The resident was able to push open the door and started going outside into the patio/porch, but the emergency exit door alarm sounded, alerting staff. It was identified the alarm sounded because maintenance staff were working on the door. Clinical record review for Resident 18 was initiated on 6/22/11, which showed the resident was admitted to the facility on [DATE]. Resident 18's [DIAGNOSES REDACTED]. Review of the Fall Risk/Restraint Assessment form dated 3/14/11, showed Resident 18 had sustained a fall on 3/2/11. Recommendations included bed and wheelchair alarms to alert staff for unassisted arising from the bed and wheelchair, visual checks to ensure safety. Review of the plan of care found the resident has a behavior of removing his wheelchair alarm. On 6/23/11 at 1355 hours, an interview and concurrent clinical record review was conducted with ADON. The ADON was asked if Resident 18 was assessed and the clinical record updated to reflect Resident 18's attempt to go outside unsupervised as evidence by him pushing open the emergency exit door (Door 1) on 6/22/11. The ADON stated Resident 18 was not reassessed and there was no evidence the plan of care was updated. In addition, there was no documentation in the nurses' notes to showed the event occurred. On 6/23/11 at 1455 hours, an interview was conducted with Resident 18's family member. Resident 18's family member stated the resident's normal daily habit is to be taken outside into the facility's patio/porch by his family member. The family stated the resident enjoy the sunshine. Resident 18's family member they were not able to visit on 6/22/11 and the resident probably was used to the routine of sitting outside. Additional clinical record review found no documentation in the resident's plan of care to address the resident's desire to go outside daily or monitoring measures in place to prevent him from going outside unattended when the family didn't visit. 2. Clinical record review for Resident 19 was initiated on 6/20/10, which showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/20/11 at 1410 hours, LVN 1 stated Resident 19 is confused, non-English speaking and when in her wheelchair she is able to self-propel and get around the facility. On 6/22/11 at 0830 hours, Resident 19 was observed alone and unsupervised in the formal dining room. The resident was self-propelling her wheelchair aimlessly. The emergency exit door (Door 2), located inside the formal dining room was inspected and identified to open without an alarm sounding. On 6/22/11 at 0835 hours, the Administrator verified Resident 19 was in the dining room unattended and Door 2 did not trigger an alarm when opened. Additional record review revealed a Fall Risk/Restraint Assessment form dated 4/7/10, showing Resident 19 had a history of [REDACTED]. Recommendations included bed alarms to alert staff for unassisted get out of bed unassisted and bilateral full length side rails for emotional security. A care plan problem dated 3/13/11, addressed the resident's being at risk for further falls/injury. One of the interventions included to provide a safe environment and visual checks every two hours. Another care plan problem dated 5/21/11, identified the resident wanders in and out of activities room. However, the facility was not monitoring the resident when she was left without supervision in the formal dining room on 6/22/11. 3. According to the U.S. Food and Drug Administration (FDA) Safety Alert: "Entrapment Hazards with Hospital Bed Side Rails," a warning has been issued regarding the use of side rails because their use may cause injuries and death. The FDA warning showed many of these incidents involving side rails involve fractures, cuts and abrasions to the arms and legs. The FDA warning also showed deaths have occurred due to entrapment of the head, neck or thorax. The majority of the deaths and injuries involved elderly residents. Residents at high risk for entrapment include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors.. Long-term care facilities reported the majority of the entrapments. Side rails present an inherent safety risk, particularly when the patient is elderly or disoriented as they may view a raised side rail as a barrier and attempt to climb over the raised rail sustaining a greater height posed by the raised side rail, with a possibility for sustaining greater injury. On 6/21/11 at 0730 hours, Resident 11 was observed lying in bed. She had bilateral ? side rails elevated at the top of the bed. Resident 11's arms were observed with gerisleeves (cotton sleeves) covering areas of discoloration on both her right and left arms. Resident 11 was identified to be non-English speaking. On 6/21/11 at 0735 hours, an interview was conducted utilizing SSD as an interrupter to speak Resident 11's native language. The resident was asked about the discolorations to her arms. The resident pointed to the side rails while the SSD stated the resident said she "banged her arms against the side rails." Clinical record review for Resident 11 was initiated on 6/21/11 which showed Resident 11 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed the resident was moderately cognitively impaired but could make her needs known. Review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. In addition, the resident had an order dated 5/2/11, for asprin 81 mg daily for blood thinner purposes. During an interview on 6/21/11 at approximately 0745 hours, LVN 5 stated Resident 11 might have hit her arms against the side rails and they applied the gerisleeves to prevent injuries to her skin. The LVN added Resident 11 has fragile skin and bleeds easily because she is on blood thinner medication (asprin). A care plan problem dated 3/2/11, to address potential for bleeding and further skin discoloration due to aspirin therapy and fragile skin showed approaches to observe for signs and symptoms of bleeding, development of skin discoloration and to handle the resident gently. However, there was intervention to address the use of the side rails. 4. Clinical record review for Resident 5 was initiated on 6/21/11, which showed the resident was admitted to the facility on [DATE]. Review of Resident 5's MDS dated [DATE], shows the resident can sometimes understands and responds to simple, direct communication and is able to make simple requests only. The resident has short and long-term memory problems and has moderate cognitive impairment with poor decision making skills. She also requires cues and supervision for daily ADLs. A physician's orders [REDACTED]." Review of the Rehab Screening form dated 2/9/11, shows Resident 5 is not steady and only able to stabilize with human assistance when moving from a seated to standing position. It shows Resident 5 has functional limited range of motion of both arms and legs. Review of the Social Service Assessment form dated 5/10/11, identified Resident 5 has a personal alarm while in bed to alert the staff when she attempts to get out of bed unassisted. Staff documented Resident 5 is alert and oriented times one (meaning she remembers time or place or person, but not more than one). She is forgetful as evidence by not being able to recall what happened 5 minutes ago. Review of the Fall Risk Assessment of Resident 5 dated 5/9/11, shows a recommendation for bilateral full length elevated side rails for emotional security. Review of pre-printed letter (undated) signed by Resident 5's family member, showed the risks of side rails was explained to the family member. The letter showed it was discussed that side rails were not to be used in bed, however, Resident 5 would like the side rails up while in bed for emotional security purposes. During an interview with the ADON on 6/22/11 at 0805 hours, she stated the only reason for bilateral full length side rails is for emotional security. The ADON stated there is no medical necessity for the side rails. When asked if there has been a trial of reducing the use of the full length side rails, the ADON said no. During an interview on 6/22/11 at 1624 hours, CNA 6 stated Resident 5 will sometimes sits up in bed by herself. CNA 6 stated sometimes the resident's bed alarm will go off because she is sitting up or because she wants to go to the bathroom. The CNA stated the resident does not use the call light. CNA 6 stated Resident 5 uses the bathroom 8 or more times during their shift. On 6/23/11 at 0910 hours, an interview with CNA 7 was conducted. The CNA stated often when Resident 5 transferred into bed she will shake her side rails and cause a lot of noise. CNA 7 demonstrated this by vigorous shaking of the side rails. CNA 7 stated she will then put the side rails down and get the resident back into her wheelchair. CNA 7 added she has observed Resident 5 trying to get out of bed while both the full side rails were elevated. CNA 7 also stated Resident 5 needs to go to the bathroom at least 6 or 7 times a shift.

Based on observation, interview, and clinical record review, the facility failed to ensure two sampled residents (Residents 20 and 25) were supervised to prevent falls. Resident 25 had a history of [REDACTED]. Resident 25 fell on [DATE], 6/26/11, and 8/9/11. She received stitches at the emergency room after her fall on 8/9/11. The facility was unable to show how it provides supervision to Resident 25 to prevent falls. This puts Resident 25 at risk for further falls. Resident 20 fell and a personal alarm was ordered for her. When Resident 20 was observed in bed, she did not have an alarm as ordered by her physician. This put Resident 20 at risk for further falls. The facility failed to provide adequate supervision for Resident 2, continuous restraint assessments and adequate assistive devices to prevent the resident from sustaining a fall from the wheelchair. As a result, Resident 2 sustained a laceration and contusion of the forehead. A metal support bracket was protruding on both sides of Resident 26's bed frame. This poses the potential for injury if the resident strikes his head on the metal support bracket. Findings: 1a. Clinical record review for Resident 25 was initiated on 8/10/11. The resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. During initial tour rounds with LVN 7 on 8/10/11 at 0555 hours, Resident 25 was observed laying in bed with the head of the bed elevated approximately 30 degrees. Resident 25's right eyelid was deep purple and nearly swollen shut, making it difficult for her to open her right eye. Above her right eyebrow were stitches. Near the top of her right cheekbone was a large, swollen lump. LVN 7 explained Resident 25 had fallen out of her wheelchair the day before, was sent to the emergency room , and returned to the facility with stitches above her right eyebrow. Review of Resident 25's MDS dated [DATE], shows she has short and long term memory problems. She has moderate cognitive skills, makes poor decisions, and requires supervision. The MDS shows she is not steady and only able to stabilize with human assistance when she moves from a seated position to a standing position, when she walks, when she moves on and off of the toilet, and when she transfers between a bed and wheelchair. Review of Resident 25's initial Fall Risk assessment dated [DATE], shows she had an unsteady gait and a history of falls. The recommendation made by the IDT team was to do routine visual checks, keep her call light within reach and answer the call light promptly. Review of the IDT notes dated 11/8/10, shows Resident 25 fell on [DATE], while in the bathroom. While making rounds, the staff found Resident 25 on the bathroom floor. Resident 25 stated she stood up after using the bathroom and lost her balance. The use of a personal alarm was discussed with Resident 25 and her family member, but they declined the alarm. Further recommendations by the IDT were for Resident 25 to be seen by rehab for patient education and training for safety measures. Other recommendations included encouraging Resident 25 to ask for assistance, to use the call light, and to keep the call light within reach. Review of the Fall Risk assessment dated [DATE], shows the IDT's recommendation was to continue to do constant checks to ensure Resident 25's safety. They also recommended to maintain Resident 25's call light within reach and answer it promptly. Review of the IDT notes dated 6/27/11 at 1500 hours, shows Resident 25 was found laying on the floor in her room on 8/26/11. Her call light was within reach, but she had not used the call light to call for assistance. Recommendations made by the IDT included being seen by rehab and to continue the RNA program. Safety awareness and proper body mechanics during functional mobility and wheelchair mobility were explained to Resident 25. The staff encouraged Resident 25 to be careful and to call for assistance. Review of the Rehab Screening form dated 6/27/11, shows Resident 25's balance is not steady and she is only able to stabilize with human assistance while she is moving from a seated to standing position, walking, moving on and off the toilet, and transferring between the bed and chair or wheelchair. Review of Resident 25's care plan problem for falls updated 6/26/11, showed the call light would be placed within reach, visual checks would be done, and Resident 25 would be encouraged to call for assistance. Review of the facility's map dated 7/27/09, shows Resident 25's room is not in direct visual sight of the nurses' station. Review of the IDT notes dated 8/10/11 at 1140 hours, showed Resident 25 fell on [DATE]. Staff heard Resident 25 calling for help. When they entered the room, they found Resident 25 laying on the floor on her right ride. Resident 25 had a laceration on the right eyebrow area, approximately one inch long. The call light was within reach. Resident 25 was sent to the emergency room and received five stitches to her right eyebrow. Resident 25 was instructed to use the call light to prevent falling again. During an interview with CNA 17 on 8/11/11 at 0853 hours, she stated Resident 25 is very confused. She stated every day she sees Resident 25 transfer herself from the bed to the wheelchair and from the wheelchair back to bed. CNA 17 states she tells Resident 25 not to transfer to the wheelchair by herself and to use the call light. She stated Resident 25 never uses the call light and gets into the wheelchair by herself. During a phone interview with Resident 25's family member on 8/11/11 at 0900 hours, the family member stated she has told Resident 25 many times to use the call light, but she does not use it. The family member stated Resident 25's memory is gone, so she forgets. During an interview with LVN 1 on 8/11/11 at 0915 hours, she stated Resident 25 has short and long term memory loss and needs to be constantly reminded. LVN 1 stated she has seen Resident 25 transfer herself from the bed to the wheelchair and from the wheelchair to the bed. She stated Resident 25 will yell when she needs assistance. LVN 1 stated it is really hard for Resident 25 to transfer herself. During an interview with the ADON on 8/11/11 at 0925 hours, when asked how supervision is provided for Resident 25, she stated the facility provides constant visual checks and anticipates her needs. She stated Resident 25 has had episodes of transferring herself from the wheelchair to the bed and from the bed to the wheelchair. During an interview with the SSD on 8/11/11 at 0955 hours, she stated after Resident 25 fell the first time, the resident refused the personal alarm. Instead, Resident 25 was reminded to use the call light and the staff watched her carefully. During an interview with the DON on 8/11/11 at 1045 hours, she stated Resident 25 fell on [DATE]. During the investigation of the fall, it was determined the call light was in reach, but Resident 25 did not use it. When asked if Resident 25's care plan addresses how supervision will be provided, the DON stated she did not see anything specific in the care plan to show how the facility would provide supervision for Resident 25. b. On 8/10/11 at 0920 hours, Resident 25 was observed laying in bed with one floor mat on the right side of her bed. The left side of the bed did not have a floor mat. During an interview with the DON on 8/10/11 at 1015 hours, she stated, if a resident is assessed to be a risk for falling, they are to have a floor mat on each side of the bed while they are in bed. 2a. Clinical record review for Resident 20 was initiated on 8/10/11. Review of Resident 20's MDS dated [DATE], showed she has short and long term memory loss. She rarely or never is understood, and rarely or never understands. Resident 20 has severe cognitive impairment. The MDS showed she needs extensive assistance of one person for bed positioning. Resident 20 has impairment in all four extremities. Review of the IDT notes dated 8/2/11 at 1400 hours, showed Resident 20 was found on the floor next to her bed on 8/1/11. Review of a physician's orders [REDACTED]. On 8/10/11 at 0915 hours, no personal alarm was seen on Resident 20 or on her bed. RN 3 was asked to locate Resident 20's personal alarm. She was unable to find a personal alarm on Resident 20 or on her bed. RN 3 checked the physician's orders [REDACTED]. b. During an interview with CNA 17 on 8/11/11 at 1020 hours, CNA 17 stated she saw Resident 20 slide off of her bed onto the floor on 8/1/11. On 8/10/11 at 1358 hours, LVN 6 was observed doing Resident 20's pressure ulcer dressing change on her buttocks and right hip. Resident 20 was positioned onto her left side with CNA 17 providing support for Resident 20. At one point during the dressing change, LVN 6 ran out of gloves. She asked CNA 17 to leave Resident 20 and get some gloves. CNA 17 left Resident 20 positioned on her left side. Resident 20's right foot was over the edge of the left side of the bed. LVN 6 was not holding onto Resident 20. Resident 20 was balancing on her own until LVN 6 realized Resident 20 needed support until CNA 17 returned and held onto her. During an interview with LVN 6 on 8/11/11 at 0815 hours, she stated she told CNA 17 not to leave Resident 20 on her side alone during the dressing like she did. LVN 6 stated she would not be able to grab her if she started to fall. She stated it was not okay to leave Resident 20 without assistance while she is turned on her side away from LVN 6. 3. Review of the facility's P&P titled Procedure on Restraint revised 11/2009, showed it is the policy of the facility to have a comprehensive assessment of each resident upon admission. It includes, but is not limited to the use of any restraint as indicated. Upon change of condition, the resident is to be assessed and explained the necessary precautions which may include the use of a physical restraint. Review of the clinical record for Resident 2, initiated on 8/10/11, showed Resident 2 was admitted to the facility on [DATE], discharged on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 2 has short and long term memory problems. The resident's cognitive skills for daily decision-making are modified independence. The resident requires extensive assistance for bed mobility and transfers. Review of a Fall Risk/Restraint Assessment form dated 6/12/11, showed Resident 2 has poor safety awareness. The IDT recommendations included: a. On 6/12/11 at 1800 hours, personal alarm in bed and while in her wheelchair, as a least restrictive measure to alert the staff when the resident is trying to get up unassisted. Resident 2 is at high risk for fall secondary to cognitive impairment. b. On 6/12/11 at 1845 hours, Resident 2, while up in the wheelchair, was noted to keep leaning forward and remove the personal alarm. The IDT called the physician, who recommended a lap tray (a tray that straps onto the arms of the wheelchair to prevent the resident from rising) trial; but the resident refused. c. On 6/12/11 at 1915 hours,a lap buddy (a special cushion that fits between the arm rests of the wheelchair to prevent the resident from rising) was offered to be used while Resident 2 is up in her wheelchair, but the resident refused. d. On 6/12/11 at 1930 hours, the IDT recommended a non-release seat belt (an assistive device hooked on the metal bars on each side at the back of the wheelchair, which the resident is not able to remove). It is to be worn while up in the wheelchair for poor safety awareness and [DIAGNOSES REDACTED]. The resident agreed. The physician discontinued the personal alarm. A care plan problem dated 6/12/11, addressed the resident's risk for further falls/injuries. The interventions included to provide a safe environment, visual checks every two hours, and the use of a non-release seat belt when up in the wheelchair. Review of a Nurse Notes form dated 7/13/11 at 1230 hours, showed Resident 2 was transferred to an acute care hospital due to a change in condition. A care plan problem dated 7/18/11, to address the resident's risk for further falls/injuries showed interventions included provide assessments, visual checks every two hours, constant safety reminder, and personal alarm while in the wheelchair as the least restrictive measure to alert staff when the resident tries to get up unassisted. The need for the seatbelt was addressed in the resident's care plan dated. 6/12/11. However, the seat belt was not implemented when the resident came back from the acute care hospital. Review of an initial Fall Risk Restraint assessment dated [DATE], showed an IDT recommendation to continue to observe the resident frequently, and visual checks. On 7/25/11, the IDT implemented a personal alarm when up in the wheelchair; no other restraints were recommended. Review of a Nurse Notes dated 8/10/11 at 1845 hours, showed the personal alarm (an alarm that sends out an audible sound when the resident stands up) was heard. Resident 2 fell from her wheelchair. She was found lying in front of the wheelchair, leaning forward. The right side of her forehead was bleeding. On 8/11/11 at 0845 hours, Resident 2 was observed up in her wheelchair with a lap tray in front of her. She was awake, alert, and able to answer simple questions with limited language skills. Resident 2 was observed with a dressing to her forehead, measuring approximately 5 cm by 5 cm. The ADON stated Resident 2 had a fall on 8/10/11. The resident was sent to the emergency room where she received stitches to repair the laceration to the forehead. Review of the Acute Care Hospital Patient Visit Information form dated 8/10/11, showed the resident sustained [REDACTED]. As a result, laceration repair with stitches was necessary. Resident 2 received oral antibiotic therapy as daily treatment, and pain medication. Fall precautions were also recommended. On 8/11/11 at 0920 hours, an interview with the DON was conducted. The DON stated the IDT implemented a lap tray as a trunk restraint because Resident 2 was leaning forward when up in the wheelchair. When asked why the resident's sitting balance was not assessed when she was readmitted on [DATE], the DON stated it's the facility's policy, when the resident has a change in condition, to start a new restraint assessment, even if it's known to be ineffective. She stated they start from the least restrictive device, "the personal alarm." On 8/11/11 at 1000 hours, an interview with the PT was conducted. The PT reviewed the Physical Therapy Daily Progress Report form and stated on 7/19/11, Resident 2's sitting balance was poor, poor dynamic support while leaning forward and poor safety awareness. On 8/11/11 at 1300 hours, an interview was conducted with Resident 2's family member. The family member stated she does not understand why the staff was unable to ensure the resident's safety, especially since they were aware of Resident 2's history of falls. The family member further stated Resident 2 did not have a single fall when she was wearing the non-release seat belt. 4. On 8/10/11 at 1410 hours, during an observation and interview with the DON, the DON was asked if Resident 26 is at risk for falls. The DON stated "Yes." Inspection of Resident 26's bed frame found a side rail cross bar (metal support bracket used to hold side rails in place) attached at the head of the resident's bed. The metal side rail cross bar protruded outward on both sides of the bed approximately two inches. The DON verified Resident 26 could be injured after striking the metal bracket during a fall from the bed. On 8/10/11 at 1420 hours, while accompanied by the Director of Maintenance, he was asked about the metal side rail support bracket on Resident 26's bed frame. The Director of Maintenance stated the metal support was used to hold side rails in place. In addition, the Director of Maintenance stated all of the metal support brackets had been removed from residents' beds, "This one was missed."