Every finding on record at Herman Health Care Center

Based on observation, interview and record review, the facility failed to ensure to follow their standard infection control practices when: 1. CNA A carried uncovered resident's soiled clothes and linens in hallway;2. CNA A donned (applied) double gloves and did not perform hand hygiene after removed double gloves;3. CNA C did not wear gown (covers staff's clothing and skin to prevent spread of infection, part of the personal protective equipment [PPE]) when provided care to a resident with contact precautions (CP, infection control steps to stop germs from spreading through direct or indirect touch with resident, room and resident's items);4. Licensed vocational nurse D (LVN D) did not wear gown when provided g-tube (GT, a flexible medical device tube placed through the belly skin directly into the stomach to provide liquid nutrition and medications to resident) bolus feeding (a method of providing nutritional formula through GT in several times throughout the day, rather than providing slow continuous drip) to a resident with contact precautions.These failures had the potential for spread of infection and cross-contamination among 96 residents, who currently reside in facility. Findings:1. During an observation on 8/11/2206 at 10:50 a.m., noted CNA A carried uncovered soiled linens in hallway from Resident room [ROOM NUMBER] to laundry hamper, located at the end of the hallway.During an interview with CNA A on 8/11/2026 at 10:55 a.m., CNA A confirmed she carried uncovered soiled linens in hallway to discard in laundry hamper located at the end of the hallway. CNA A stated she should carry soiled linens in a plastic bag. CNA A also stated she should not have carried soiled linens uncovered in hallway for infection control practice.During an interview with LVN B on 8/11/2026 at 11:30 a.m., LVN B stated CNA staff should not have carried soiled clothes and linens in hallway uncovered. LVN B also stated staff should have covered in a plastic bag to discard in a hamper carry soiled clothes and linens for infection control.During an interview with facility's assistant director of nursing (ADON) on 8/11/2026 at 12:15 p.m., ADON stated nursing staff should always carry soiled resident's clothes and linens in a plastic bag to carry to laundry hamper for infection control practice.2. During an observation on 8/11/2026 at 10:50 a.m., observed CNA A discard soiled linens in laundry hamper, walked in hallway with gloves on to Resident room [ROOM NUMBER], removed double gloves for both hands, discarded in garbage bin, next to Resident room [ROOM NUMBER]'s door, placed her left hand in her uniform's left pocket, no hand hygiene.During an interview with CNA A on 8/11/2026 at 10:55 a.m., CNA A confirmed above observation. CNA A stated she should not have used double gloves and washed hands after removed gloves for infection control.During an interview with ADON on 8/11/2026 at 12:15 p.m., ADON stated staff should not have used double gloves and did performed hand hygiene after removed gloves each time.3. During an observation on 8/11/2026 at 11:01 a.m., noted CP sign posted on wall outside of the Resident 1's room and was observed CNA C putting socks on for Resident 1 while standing next to Resident 1's bed. CNA C noted with gloves on, no PPE gown on.Review of posted sign Resident 1 for CP indicated, Put on gown before room entry.During review of Resident 1's FS indicated Resident 2 was admitted to facility on 1/17/2025.Review of Resident 1's FS also indicated diagnoses included carbapenems-producing organisms (CPO, specific types of bacteria [tiny, single cell living thing, make residents to get sick] that have become resistant to powerful, last resort medications to known as carbapenems, making illnesses hard to treat).Review of Resident 1's order summary report indicated, Contact/Isolation Precautions every shift for CPO, dated 7/24/20026.During an interview with CNA C on 8/11/2026 at 11:10 a.m., CNA C confirmed Resident 1 with CP to follow. CNA C also confirmed CP included PPE for gloves and gown while provided care to Resident 1. CNA C stated she made a mistake of not wearing gown when she assisted Resident 1 with socks. CNA C also stated she should wear gown to follow infection control for CP for Resident 1.During an interview with ADON on 8/11/2026 at 12:30 p.m., ADON stated staff should wear gown to follow CP to prevent the risk of spreading infections between residents in the facility.4. During an observation on 8/11/2026 at 11:32 a.m., noted CP sign posted on wall outside of the Resident 2's room and observed LVN D provided bolus liquid formula via GT for Resident 2. LVN completed the bolus feeding procedure for Resident 2 while standing next to Resident 2's bed. LVN B noted with gloves on, no PPE gown on.Review of posted sign Resident 2 for EBP indicated, Put on gown before room entry.During review of Resident 2's FS indicated Resident 2 was admitted to facility on 1/17/2026.Review of Resident 2's FS also indicated diagnoses included gastrostomy (a medical procedure that creates an opening through the skin of the abdomen directly into the stomach to place a feeding tube to deliver nutrition and medications) and CPO.Review of Resident 2's order summary report indicated, Contact/Isolation Precautions every shift for CPO, Gastrostomy tube, dated 7/16/20026.During an interview with LVN D on 8/11/2026 at 11:40 a.m., LVN D confirmed Resident 2 with CP included PPE for gloves and gown. LVN D also confirmed she did not wear gown while provided GT feeding for Resident 2. LVN D stated she should have wear gown to follow CP for Resident 2.During an interview with ADON on 8/11/2026 at 12:30 p.m., ADON stated all staff should wear disposable gown when providing care for residents with CP to prevent spread of infections among residents in the facility.Review of facility's policy and procedure (P&P) titled, Departmental (Environmental Services)-Laundry and Linen, revised January 2014, the P&P indicated, Place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper.Review of facility's P&P titled, Handwashing/Hand Hygiene, revision date December 2025, the P&P indicated, Always perform hand hygiene after gloves are removed.Review of facility's P&P titled, Personal Protective Equipment-Using Gowns, revision date September 2010, the P&P indicated, When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident.Review of facility provided copy of contact precautions [NAME] indicated, PROVIDERS AND STAFF MUST ALSO: Put on gown before room entry.

Based on interview and record review, the facility failed to include specific and resident-centered interventions in the post fall care plan in a timely manner for 1 of 2 sampled residents (Resident 1).This failure put Resident 1's at risk for potential fall and injury. Findings:Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities ), mild intellectual disability (limitation in mental functioning and skills), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and muscle weakness, and cognitive communication deficit (difficulty in communication). Review of X-ray of left shoulder on the day admission [DATE]) indicated, a degenerative change (a natural, age-related wear and tear body tissues such as joints and cartilage over time).Review of Resident 1's minimum data set (MDS, a federally mandated resident assessment tool) dated 3/20/26 indicated his brief interview for mental status score (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 6 which means he had a severe cognitive impairment (profound problems in remembering things, concentrating, making decisions and solving problems). He had no impairment of both upper arms and lower legs but needed some partial assistance in using toilet from another person. He used wheelchair to translocate from one location to another. Review of Resident 1' Fall Risk Assessment (FRA, an assessment to determine a resident's risk of falling) dated 3/21/26, indicated he had a score of 15 which means he was at high risk for potential fall. Review of Resident 1's medical record indicated that Resident 1 had the first incident of unwitnessed fall on 3/23/26 at 2:15 p.m. in facility's courtyard. Resident 1 was found lying in prone position. Resident 1 was transferred to the hospital by Physician's order for further evaluation and treatment. Resident 1 sustained contusion of right knee. Review of Resident 1's FRA after the unwitnessed fall on 3/23/26 indicated a score of 11 which means he was at high risk for potential fall. Review of Resident 1's second incident of unwitnessed fall at the facility indicated that on 3/27/26 at 10:30 p.m., during initial round of Licensed Vocational Nurse A (LVN A) Resident 1 was found face down on the left side of his bed. There were no injuries observed. LVN A asked Resident 1 what happened, Resident 1 stated I don't know, I've been here for a while. Review of Resident 1's post fall care plan after the incident of second fall dated 3/27/26 indicated, will prevent Resident 1 injury through individualized care plans, ensuring a safe environment and educating Resident 1/families to manage risk. Monitor vital signs, neurological assessment, assess for any injuries, assess cause of fall incident and conduct a comprehensive fall risk assessment. The care plan did not include additional specific/detailed resident-centered interventions to prevent potential fall from happening again. Review of Resident 1's medical record indicated that an updated post fall comprehensive resident-centered care plan with specific interventions was developed/created by the facility on 4/2/26, 6 days after Resident 1's second episode of fall on 3/27/26.Review of Resident 1's medical record indicated that on 4/1/26 at 2:19 p.m., Resident 1 had third incident of witnessed fall in the common bathroom. Resident 1 fell on the floor facing forward from wheelchair. Resident 1 sustained scratch on right cheek and complained of dizziness. Resident 1 was sent to hospital for evaluation. Resident 1 did not remember what happened on the fall incident on 4/1/26.During an interview with the Certified Nursing Assistant B (CNA B) on 4/6/26 at 1:24 p.m., stated she was assisting Resident 1 in the common bathroom for toileting. Resident was sitting in a wheelchair, but his upper body was leaning forward with his buttocks situated on the edge of the wheelchair. CNA B supported Resident 1's upper body with both CNA B's hands from the back of wheelchair. CNA B tried to assist and encouraged Resident 1 to straighten his body and scoot back to prevent sliding from wheelchair but Resident 1 was resistive and uncooperative. CNA B immediately called for help from another staff. CNA C and another staff immediately came for help but Resident 1 already slid from the wheelchair to the floor. Resident was transferred to the hospital for evaluation. Review of Resident 1's Hospital Discharge summary dated [DATE] indicated discharge diagnoses that included Anterior (front side) dislocation of left shoulder. A successful closed reduction (medical procedure used to return a dislocated joint) of left shoulder was done on the same day on 4/1/26.Review of the subsequent X-ray of Resident 1's left shoulder dated 4/7/26 indicated there was no acute facture or dislocation. Mild osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage).During an interview and review of Resident 1's medical record with the Assistant Director of Nursing (ADON) on 4/13/26 at 9:41 a.m., she confirmed there was no specific/detailed resident-centered care plan developed by the facility after Resident 1's fall on 3/27/26 prior to falling again on 4/1/26. She acknowledged new specific interventions should have been created and included in the post fall care plan for Resident 1.During an interview and review of Resident 1's medical record with the Director of Nursing (DON) on 4/13/26 at 10:18 a.m., she confirmed there was no additional specific/detailed resident centered care plan interventions developed by the facility on 3/27/26 to minimize or prevent the risk of Resident 1's from falling again on 4/1/26. DON acknowledged the facility should have updated and developed a resident-centered care plan after the fall on 3/27/26.Review of the revised facility's policy and procedure dated 03/2018 titled, Managing Falls and Fall Risk indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try minimizing complications from falling . If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Review of the revised facility's policy and procedure dated 3/12/21 titled, Job Description: Licensed Vocational Nurse indicated, contributes to formulation /review of nursing care plans weekly and PRN (as needed).

Based on observation, interview, and record review, the facility failed to ensure safety for one of nine sampled resident (Resident 1). Resident 1 was evaluated and identified at risk for elopement (unauthorized and unsupervised departure from facility), the facility failed to develop a person-centered care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, interventions, and preferences) and failed to implement person-centered interventions with effective strategies to prevent elopement for Resident 1. This failures resulted in Resident 1 eloped from the facility on 12/14/2025 and unable to locate Resident 1 as of 3/9/26. Findings:Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 12/10/2025. This FS also indicated Resident 1 was assigned to a conservator (a person appointed by a judge to manage the financial affairs, personal care or both for a resident who cannot care for him/herself due to physical or mental limitations).Review of Resident 1's diagnoses included paranoid schizophrenia (a chronic mental health disorder by intense, irrational delusions [false beliefs] and auditory hallucination [hearing voices and sounds in the absence of external stimulus, perceived as real sounds]), schizoaffective disorder, bipolar type (a chronic mental health condition combining hallucinations, delusions, and episodes of manic [elevated mood, high energy and activity] and depression [low energy and intense sadness], and history of stimulant abuse (medication or substances, not intended for use). Review of Resident 1's order summary report indicated an order for Depakote (a medication used to treat bipolar disorder) 2500 MG (milligrams, a unit of mass or weight, equal to one thousandth of a gram) by mouth at bedtime, dated 12/10/2025, olanzapine (antipsychotic medication [a class of medication capable of affecting the mind, emotions, and behaviors] used to treat schizophrenia) 10 MG every day, 20 MG at bedtime, and 5 MG every 24 hours as needed by mouth, dated 12/10/2025, Invega ( antipsychotic medication used to treat schizophrenia) 234 MG/1.5 ML [milliliters, a unit of liquid equal to one thousandth of a liter]) intramuscularly [IM, injection used to deliver medication deep into specific muscles]) one time on 1/2/2026 for maintenance dose, dated 12/10/2025, and ziprasidone (antipsychotic medication used to treat schizophrenia) 80 MG by mouth two times a day, dated 12/10/2025.Review of Resident 1's minimum data summary (MDS, resident assessment tool) dated 12/14/2025, section C for brief interview for mental status (BIMS) indicated Resident 1's BIMS score of 12/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition), moderately impaired cognition.Review of Resident 1's primary care physician (PCP, a medical doctor assigned as the first point contact for general health conditions and needs)'s documentation for Resident 1's history and physical, dated 12/11/2025 indicated, Resident 1 did not have capacity to understand and make healthcare decisions.Review of Resident 1's elopement evaluation dated 12/10/2025 indicated, elopement score value of 2 (score value of 1 or higher indicates, risk of elopement), Resident 1 was identified as at risk for elopement.Review of all documented care plans for Resident 1 indicated, there was no documented evidence of facility developed and implemented person centered care plan for risk for elopement with person-centered interventions and effective strategies to prevent elopement for Resident 1.Further review of Resident 1's clinical documentation of nurse's notes, MD's orders and electronic medication administration record (EMAR, an electronic system to track, manage, and document a resident's medication administration) during 12/10/2025 to 12/14/2025, while Resident 1 was in facility, indicated, there was no documented evidence of facility developed and implemented interventions and strategies to maintain safety and prevent elopement for Resident 1, who was identified as at risk for elopement on 12/10/2025.Review of Resident 1's change in condition (any significant physical, mental or functional condition change from a resident's baseline status) document dated 12/14/2025 indicated, at 4:45 p.m., facility's nursing staff noted Resident 1 was walking in courtyard, outside the facility's building (closed surroundings). At 5:20 p.m., a license nurse went to Resident 1's room to give scheduled medications, noted Resident 1 was not in room. Facility staff was not able to locate Resident 1 in the facility during the search conducted for Resident 1. Registered nurse A (RN A) informed facility's management (administrator and director of nursing) and local police department via telephone for missing Resident 1.Review of Resident 1's nursing alert note dated 12/14/2025, at 6:45 p.m., indicated, facility was contacted local hospitals (health care setting provides services for acutely ill, injured and emergency health conditions) near the facility via telephone. Facility was confirmed that Resident 1 was not admitted in any one of these hospital during this telephone communication with local hospitals.Review of Resident 1's nursing alert note dated 12/15/2025 at 2:20 p.m., indicated facility nursing staff searched downtown, local train station, liquor and gas stations, parks, and surrounding restaurants looking for Resident 1. This document also indicated, facility's staff was unable to locate Resident 1 during above searched areas.Review of Resident 1's nursing alert note dated 12/15/2025, at 4:25 p.m., indicated, facility staff was informed by local police department that, Resident 1 was remained missing person status, not been located Resident 1 yet.Review of facility's investigation summary report dated 12/19/2025 indicated, on 12/14/2025 at 8:07 p.m., conservator stated over the telephone to facility he (conservator) was not surprised by Resident 1's elopement from facility. This report also indicated on 12/15/2025 at 10:35 a.m., over the telephone, conservator informed facility, Resident 1 would most likely be found in downtown in front of a liquor store due to Resident 1's extensive history of substance abuse (medication or substances, not intended for use) and based on Resident 1's prior elopement episodes.During observation of facility with facility's maintenance director (MD) on 12/23/2025 at 3:06 p.m., noted, three separate and stand-alone buildings (Building 1, 2, and 3) with residents rooms and an open courtyard in middle of these three buildings. Right, left and back side of these buildings surrounded by locked metal fences, approximately 6 feet tall. Also noted one brick wall approximately 8 feet tall, right side in the front of the facility with locked iron gate.During an interview with facility's MD on 12/23/2025 at 3:06 p.m., MD stated facility 's front entrance gate was locked all the times and only staff had the access in and out to the facility through this gate using a key. MD also stated facility was provided a gate key to all staff. MD further stated that this facility's surroundings were secured and no in and out access from facility for all residents. MD confirmed metal fences were 6 feet tall and brick wall was 8 feet tall. MD further stated courtyard in middle of three buildings was also secured.During an interview with facility's certified nursing assistant A (CNA A) on 12/29/2025 at 2:50 p.m., CNA A confirmed Resident 1 had a behavior of wandering (aimless walking or attempts to leave a safe area) in facility. CNA A was also confirmed Resident 1 was at risk for elopement. CNA A stated she was not aware how Resident 1 was eloped from the facility. CNA A stated nursing staff did not supervise or monitor Resident 1 on routine basis for wandering and risk for elopement.During an interview with CNA B on 12/29/2025 at 3:06 p.m., CNA B stated Resident 1 was at risk for elopement and behavior of wandering. CNA B also stated only way Resident 1 could have had left the facility by jumped off the metal fence and walked away from facility since it was dark that evening on 12/14/2025. CNA B confirmed there was no continuous supervision and monitoring for wandering to prevent elopement provided by nursing staff for Resident 1. CNA B stated nursing staff should have monitored, supervised closely, and prevented elopement for Resident 1. During an interview with facility's licensed vocational nurse C (LVN C) on 12/29/2025 at 3:12 p.m., LVN C confirmed Resident 1 was identified as at risk for elopement when admitted to facility on 12/10/2025. LVN C also confirmed Resident 1 had behavior of wandering in facility. LVN C further confirmed there were no documented evidence for facility developed and implemented interventions for monitoring and supervision to prevent Resident 1's elopement. LVN C stated Resident 1 was observed wandering in courtyard one hour before Resident 1 was eloped from facility on 12/14/2025. LVN C also stated Resident 1 could have jumped out of the metal fence and left the facility. LVN C further stated Resident 1 was tall, thin build and capable of jumping off the fence. LVN C further stated it was dark outside around 5 p.m. on 12/14/2025 could be the reason for staff were not able to notice when Resident 1 eloped from facility. LVN C stated this elopement could have been prevented if nursing staff were supervised and monitored Resident 1's where abouts on regular basis. During an interview with facility's director of nursing (DON) on 12/29/2025 at 3:58 p.m., DON confirmed Resident 1's nursing evaluation for at risk for elopement, dated 12/10/2025 indicated, Resident 1 was at risk for elopement. DON also confirmed no documented evidence of facility developed and implemented interventions for continuous, scheduled supervision and monitoring as needed to prevent elopement for Resident 1. DON stated nursing staff should have supervised, monitored and documented interventions and strategies to maintain safety and to prevent elopement for Resident 1. DON also stated elopement could be prevented if facility staff provided scheduled supervision and monitoring for Resident 1. DON further stated facility unable to identify how Resident 1 was eloped from facility on 12/14/2025 and facility was unable to locate Resident 1 since then. During a concurrent record review of Resident 1's all documented care plans and interview with facility's DON on 12/29/2025 at 4:05 p.m., DON confirmed there was no person centered care plan for at risk for elopement when facility identified Resident 1 was at risk for elopement on 12/10/2025. DON stated license staff should have developed and implemented a person centered care plan for at risk for elopement with interventions and strategies to maintain safety and prevent elopement for Resident 1 on 12/10/2025.During an interview with facility's assistant director of nursing (ADON) on 3/9/2026 at 3:29 p.m., ADON stated they cannot locate Resident 1.Review of facility's policy and procedure (P&P) titled, Wandering and Elopement, revised March 2019, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.Review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure free from unnecessary antipsychotic medications (medications capable of affecting the minds, emotions, behaviors, and health conditions) for one of three sampled residents (Resident 1 and 2) when:There was no documented evidence of non-pharmacological (treatments and strategies that to manage health conditions without using antipsychotic medications) approaches attempted before administered antipsychotic medication to Resident 1 and 2.This failure had the potential to place above sampled residents at risk to receive unnecessary antipsychotic medications.Findings:Review of Resident 1's face sheet (FS: a document that gives a resident's information at a glance) indicated Resident 1 was admitted to facility on 5/14/2024 and was discharged from facility on 7/18/2025.Review of Resident 1's diagnoses included cerebral infarction (condition occurs when loss of blood flow to brain happens) and agitation (state of extreme restlessness and mental distressReview of Resident 1's order summary report indicated, an order for quetiapine (antipsychotic medication used to treat various mental health conditions) 100 MG (milligrams, a unit of mass or weight, equal to one thousandth of a gram) at bed time, dated 8/12/2024 and this order was discontinued on 2/21/2025.Review of Resident 1's electronic medication administration record (EMAR, a digital system used in healthcare settings to track and document the administration of medications to residents) for December 2024, January 2025, and February 2025 indicated, Resident 1 received medication quetiapine 100 MG at 9:00 p.m. everyday. Further review of Resident 1's clinical documentation indicated, there was no documented evidence of facility attempted non-drug approaches before administered this antipsychotic medication to Resident 1.During a concurrent record review of Resident 1's order summary report and EMAR for medication quetiapine and interview with facility's director of nursing (DON) on 12/29/2025 at 3:45 p.m., DON confirmed quetiapine order and administration during above three months for Resident 1. DON also confirmed there was no documented evidence of non-drug interventions attempted before administered this antipsychotic medication to Resident 1. DON stated license staff should have attempted non-drug approaches before given quetiapine to minimize the need or allow the lowest possible dose for this resident.Review of Resident 2's FS indicated Resident 2 was admitted to facility on 7/11/2024 and was discharged from facility on 11/25/2025.Review of Resident 2's diagnoses included dementia (condition that interfere with daily living, memory, thinking, problem solving and language abilities), depression (mood disorder with persistent feelings of sadness, hopelessness, and loss of interest in active daily living situations), and adjustment disorder (a mental health condition that causes struggle to cope with changes in daily life).Review of Resident 2's order summary report indicated, an order for quetiapine 75 MG at bed time, dated 8/22/2025.Review of Resident 2's EMAR for September 2025, October 2025, and November 2025 indicated Resident 2 received medication quetiapine 75 MG at 9:00 p.m. everyday. Further review of Resident 2's clinical documentation indicated, there was no documented evidence of facility attempted non-drug approaches before administered this antipsychotic medication to Resident 2.During a concurrent record review of Resident 2's order summary report and EMAR for medication quetiapine and interview with facility's director of nursing (DON) on 12/29/2025 at 3:45 p.m., DON confirmed quetiapine order and administration for above three months for Resident 2. DON also confirmed there was no documented evidence of non-drug interventions attempted before administered this antipsychotic medication to Resident 2. DON stated license staff should have attempted non-drug approaches before given quetiapine to minimize the need or allow the lowest possible dose for this resident.Review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised July 2022, the P&P indicated, Pertinent non-pharmacological interventions must be attempted. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: not sufficiently relieved by non-pharmacological interventions;

Based on observation, interview and record review the facility failed to prevent one of 17 sampled residents (Resident 82) from multiple falls from August 2024 to May 2025 when:1. Resident 82 had a total of nine fall incidents as follows: a. Unwitnessed fall on 8/20/24 at 10:00 a.m. with no injuryb. Unwitnessed fall on 11/11/24 at 1:34 p.m. resulting to injury (abrasion-a superficial scrape or wound to the skin or other body tissue, caused by rubbing or friction against the surface) to right knee.c. Unwitnessed fall on 12/5/24 at around 11:00 a.m. with no injuryd. Unwitnessed fall on 4/12/25 at 12:30 a.m., with low spine back pain and swelling on the [NAME]. Two unwitnessed falls on 4/24/25 at 7:30 a.m. and 3:30 p.m. with no injuries notedf. Unwitnessed fall on 5/1/25 at 12:59 p.m. with major injury resulting to a compression fracture (type of bone fracture that occurs when a vertebra (bone in the spine) is crushed or compressed) of the first lumbar vertebra (L1, a bone in the lower back) requiring hospitalization on 5/3/25.g. Unwitnessed fall on 5/6/25 at 12:15 p.m., with no injury.h. Unwitnessed fall on 5/9/25 at 6:42 a.m., with no injury.2. The facility did not develop Resident 82's resident-centered care plan (short term care plan, an individualized care document created to focus on the unique needs specific to the resident's fall incident situation) on 8/11/24, 11/11/24; and did not update Resident 82's comprehensive care plan (long-term care plan, a detailed document that outlines a resident's healthcare goals, interventions, and expected outcomes that serves as a roadmap for coordinating and managing resident's care across various healthcare settings and providers) when Resident 82 had fall incidents on 8/11/24, 11/11/24, 4/12/25, 5/1/25, 5/6/25 and 5/9/25 fall incidents.3. The facility did not implement the post-fall rehabilitation assessment recommendations dated 4/14/25 to perform Physical therapy (PT, healthcare practice that uses physical interventions to improve mobility, reduce pain and restore function after an injury or illness) evaluation, and ST (speech therapy, healthcare profession that focuses on evaluating and treating disorders related to speech, language and communication) evaluation, and the Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) recommendations on 4/13/25 for physical therapy and referral to social services for psychological support for behavior management after an unwitnessed fall incident that occurred on 4/12/25 that resulted to low back pain with swelling.4. The facility did not implement the Fall Risk Evaluation- Actioned/Clinical Suggestions dated 4/12/25 to provide rubber-soled shoes (footwear where the bottom part (the sole) is made from rubber, a flexible and durable material that provides excellent traction, cushioning, and water resistance) or non-skid slippers (footwear designed to prevent or reduce slips, trips, and falls), for ambulation and utilize personal/pressure sensor alarms (a safety device that creates a loud sound or sends an alert to staff when resident gets out of bed).5. Resident 82's Fall Risk Evaluation and Post Fall Evaluation dated 5/1/25, and the Post Fall Evaluation on 5/6/25 were incomplete and inaccurate.6. There was no IDT conference record - Fall Management Follow - up or IDT conference notes meeting after two episodes of unwitnessed fall incidents on 4/24/25 (one fall happened at 7:30 a.m. and another at 3:30 p.m.).7. The IDT did not identify the specific risk/causative factors that may have contributed to each of Resident 82's fall incidents, and to monitor whether the interventions were effective to prevent falls from recurring.These failures placed Resident 82 at continued risk for falls, resulting to nine fall incidents, from August 2024 to May 2025. Resident 82 had a unwitnessed fall on 5/1/25 with a compression fracture (type of bone fracture that occurs when a vertebra (bone in the spine) is crushed or compressed) of the first lumbar vertebra (L1, a bone in the lower back) requiring hospitalization on 5/3/25.Findings: A review of Resident 82's Face Sheet (summary page of a patient's important information), he was admitted to the facility on [DATE] and re- admitted on [DATE] with diagnoses including Dementia (a progressive state of decline in mental abilities), Schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), anxiety disorder (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem), lack of coordination, abnormalities of gait (a person's manner of walking) and mobility.Review of Resident 82's MDS since admission on [DATE], and prior to his fall on 4/12/25, indicated he had a Brief Interview for Mental Status (BIMS, an assessment tool for cognition) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact).Review of Resident 82's Quarterly MDS, Section GG (function and mobility assessment) dated 2/28/25, indicated Resident 82 had weakness in both lower extremities (legs, ankles, feet). He required partial/moderate assistance with sit-to-stand and bed-to-chair transfers, substantial/maximal assistance (requires staff to provide more than half the effort) with tub/shower transfer and walking 10 feet was not attempted due to medical or safety concerns. The MDS further indicated he was independent in propelling his wheelchair at least 50 feet with two turns, and 150 feet in a corridor. Review of Resident 82's Comprehensive Fall Risk Care Plan (CP) initiated on 12/5/24 indicated Resident 82 was at high risk for falls due to: confusion, gait/balance problems, lower extremity weakness, impaired communication, dementia, schizoaffective disorder, psychoactive medications (drug that alter brain function and produces changes in mood, perception, behavior, or consciousness) and abnormal mobility. 1.a Review of Resident 82's Post fall Evaluation, dated 8/20/24, indicated resident was found at 10:00 a.m. lying on his left side. 1.b Review of Resident 82's Post Fall Evaluation dated 11/11/24, indicated he had an unwitnessed fall on 11/11/24 at 1:34 p.m. at the courtyard resulting to injury (abrasion-a superficial scrape or wound to the skin or other body tissue, caused by rubbing or friction against a surface) to right knee.1. c Review of Resident 82's SBAR dated 12/5/24 indicated around 11:00 a.m., Certified nursing assistant (CNA) reported to licensed nurse that Resident 82 was found sitting on the floor next to his wheelchair in the hallway and he stated that he slides from his wheelchair.1. d Review of Resident 82's Change of Condition (COC) dated 4/12/25 indicated, @ [at] 12:30 a.m., the patient had an unwitnessed fall near his bedside. He explained he fell because he tried to walk. When CNA came into his room, he was found in the prone position with his head and neck rising above the floor. He c/o [complained of] back pain in the lower back near the spine with the pain level 8 out 10 [pain level of 7-10 indicates severe pain] . 1. e Review of Resident 82's Rehab (Rehabilitation) Post-Fall/Incident Assessment, dated 4/28/25, indicated that Resident 82 had two unwitnessed falls on 4/24/25 at 7:30 a.m. and 3:30 p.m. Both falls occurred next to Resident 82's wheelchair when he tried to get up and walk.1. f Review of Resident 82's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem), dated 5/01/25 indicated, Resident 82 was found sitting on the floor, trying to stand up and he slid on the floor and was assisted back to his wheelchair by one CNA after licensed nurse did the head - to-toe assessment.During a concurrent interview and record review on 8/25/25 at 4:36 p.m., with the Director of Nursing (DON), the DON reviewed Resident 82's SBAR and verified Resident 82 had a fall on 5/1/25, was sent out to acute hospital on 5/3/25 due to increased lower back pain. Resident 82's acute hospital CT (Computed tomography, a detailed x-ray of bones) done on 5/3/25 indicated, Acute fracture of the L1 superior endplate (top surface of L1 vertebra) with 20% loss of height and 2 mm (millimeter, unit of measurement) retropulsion (a bone fragment has pushed backward).Review of Resident 82 Discharge Summary from the acute hospital, dated 5/3/25, indicated that Resident 82 had CT scan (Computed tomography, a detailed x-ray of bones, soft tissues, organs and blood vessels). The CT scan indicated an acute fracture of the L1 superior endplate (top surface of L1 vertebra) with approximately 20% loss of height and 2 millimeters of retropulsion (a bone fragment has pushed backward).Review of the Minimum Data Set (MDS, a standardized assessment tool), Significant Change in Status assessment dated [DATE], indicated Resident 82 now needed supervision or touching assistance to propel his wheelchair 50 feet with two turns, and 150 feet in a corridor.Review of Resident 82's Provider Follow up Note progress notes, dated 8/14/25, indicated that Resident 82 had mobility and daily activity impairments after the lumbar fracture from previous falls. Resident 82 now has gait impairment, deconditioning (a state of reduced physical fitness and functional capacity that occurs as a result of prolonged inactivity or disuse and generalized weakness. 1. g Review of Resident 82's SBAR progress notes, dated 5/6/25, indicated Resident 82 was found lying on the floor in the facility's lobby. Resident 82 denied the pain or hitting his head, and no injuries were noted.1. h Review of Resident 82's SBAR progress notes, dated 5/9/25, indicated Resident 82 had another unwitnessed fall in his room while attempting to self-transfer from bed to wheelchair without calling for help. No injuries were noted.During a concurrent interview and record review on 8/25/25 at 2:30 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 82's clinical records and confirmed that Resident 82 had multiple falls on 8/20/24, 11/11/24, 12/5/24, 4/12/25, 4/24/25 (two falls), 5/1/25, 5/6/25, and 5/9/25.2. During a concurrent interview and record review with the ADON on 8/25/25 at 3:51 p.m., the ADON acknowledged there was no short-term care plan developed after the fall on 8/20/24 and 11/11/24. The ADON stated, the charge nurses are responsible for creating the actual fall care plan or short-term care plan after each episode of fall. The ADON upon further review of Resident 82's care plans, she confirmed the comprehensive care plan was not updated when Resident 82 fell on 8/20/24,11/11/24, 4/12/25, 5/1/25, 5/6/25 and 5/9/25. The ADON stated, the IDT were responsible for updating the comprehensive care plan and add new interventions after each episode of fall. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the facility's revised policy dated 3/2022, titled Care Planning-Interdisciplinary Team, indicated the interdisciplinary team is responsible for the development of the resident care plans. The comprehensive person-centered care plans are based on resident assessments and developed by an Interdisciplinary Team (IDT).3. Review of Resident 82's Change of Condition (COC) dated 4/12/25 indicated, @ [at] 12:30 a.m., the patient had an unwitnessed fall near his bedside. He explained he fell because he tried to walk. When CNA came into his room, he was found in the prone position with his head and neck rising above the floor. He c/o [complained of] back pain in the lower back near the spine with the pain level 8 out 10 [pain level of 7-10 indicates severe pain] . During a concurrent interview and record review on 8/25/25 at 3:45 p.m., with the ADON, she reviewed Resident 82's Post fall evaluation dated 4/12/25 and indicated Resident 82 had unwitnessed fall with injury - had pain in the lower back over the spine with swelling in his back measuring 2 centimeters (cm, unit of length) in length by 1 cm. width by 0.2 cm depth and the location of fall was in his room because he wanted to get up to walk.During an interview and concurrent record review with the director of nursing (DON) on 8/25/25 at 5:20 p.m., the DON confirmed Resident 82 had an unwitnessed fall on 4/12/25. The DON reviewed the IDT Conference Record dated 4/13/25, it indicated interventions to include Physical Therapy (PT) and referral to social services for psychosocial support for behavior management. The DON confirmed the PT was not done and it was ordered on 5/9/25. Review of Resident 82's Rehabilitation Post - Fall /Incident Assessment, done on 4/14/25, it indicated the following: Resident 82 had an unwitnessed fall that occurred in the resident's room and attempting to get up and walk. Injury details: lower back pain with swelling. Resident 82 could not recall details of the incident, bed mobility level of assistance is limited, does not demonstrate proper safety techniques during transferring task, could not demonstrate proper safety techniques during task, could not use call light properly, could not recall and demonstrate the proper use of call light after one hour, does not have a proper safe sitting/standing balance, does not demonstrate sufficient strength and correct posture while setting, preferred to ambulate using his own wheelchair against the therapist recommendations, using wheelchair for ambulation and transfers. The assessment also included, Recommendations: PT evaluation and ST evaluation. During a phone interview on 8/25/25 at 5:27 p.m., with the Regional Director of Rehabilitation (RDR), the RDR stated, Physical Therapy could only do PT evaluation and treatment if we received an order from the attending physician for Physical therapy treatment and evaluation. The RDR also stated she was not aware of an order for PT and ST evaluation after Resident 82 had a fall on 4/12/25. She also stated, Nursing staff did not communicate to her that PT and ST evaluation should be done. The RDR further stated PT staff cannot evaluate or treat Resident 82 without an order for PT evaluation.During a concurrent interview and record review on 8/25/25 at 5:41p.m., with the Social Service Director (SSD) she reviewed Resident 82's IDT Conference Record Fall Management Follow-Up notes, dated 4/13/25 that indicated Resident 82 had a fall on 4/12/25. One of the interventions included Referral to social service for psychosocial support for behavior management and recommendations included Social Service Consult. The SSD stated she was not present during the IDT conference on 4/13/25, and no one informed her about the interventions and recommendations for social referral and social service consultation. Review of the facility's policy dated 3/2018, titled Falls and Fall Risk, Managing, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and cause to try to prevent the resident from falling and try to minimize complications from falling.The staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors (s) of falls for each resident at risk or with a history of falls. 4. Review of Resident 82's Fall Risk Evaluation, dated 4/12/25, he had a balance problem while walking, decreases muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, requires use of assistive device (walker, wheelchair), balance problem while standing and fall risk score was 14 (high risk of falling). The fall risk evaluation included Clinical Suggestions such as: Utilize personal/pressure sensor alarms and rubber soled or non-skid slippers.During an observation on 8/18/25 at 9:28 a.m., Resident 82 was in his room, lying in bed watching TV and verbally responsive. Resident 82 stated he's okay. Noted with landing pad at the left side of bed, and sitter at bedside. There were no personal/pressure sensor alarms seen attached to bed.During a concurrent interview and record review with the ADON on 8/25/25 at 3:24 p.m., the ADON stated, rubber-soled shoes or nonskid slippers worn for ambulation and utilize personal/pressure sensor alarms should have been included as interventions for fall prevention in the IDT and care plan. The ADON further stated, if the intervention was not placed in the care plan, it was not done.Review of the facility's policy dated 3/2018, titled Falls and Fall Risk, Managing, indicated, Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist staff in identifying patterns and routines of the resident.5. During a concurrent interview and record review with the ADON on 8/25/25 at 4:23 p.m., the ADON reviewed Resident 82's Post Fall Evaluation, dated 5/1/25. The ADON acknowledged this evaluation was incomplete and inaccurate. The ADON verified the missing entries about the location and reason for the fall including the pre (before) and post (after) Fall Risk Score. The ADON stated this evaluation should be complete with no entries left blank. The ADON also verified the Fall Risk Evaluation dated 5/1/25 was inaccurate with a Fall risk score of 9 (a score of 10 and above is high risk) instead of 15 because the question regarding the history of falls in the past three months- the response was b indicating 1-2 falls in past 3 months. The correct response should be c which is 3 or more falls in past 3 months. The assessment also inaccurately responded, No in the item: Change in Condition in the last 14 days. The ADON verified there was a change in condition when Resident 82 had a fall on 4/24/25 (about 7 days before this assessment/evaluation). The Fall Risk Evaluation also indicated, if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented in the care plan.Further review with the DON on 8/25/25 at 4:38 p.m., the Post Fall Evaluation, dated 5/6/25, the DON confirmed the date and time of fall, reason for the fall, and pre and post fall risk scores were left blank. The DON stated all the areas in this assessment for the Post fall Evaluation should have been completed. 6. Review of Resident 82's Rehab (Rehabilitation) Post-Fall/Incident Assessment, dated 4/28/25, indicated that Resident 82 had two unwitnessed falls on 4/24/25 at 7:30 a.m. and 3:30 p.m. Both falls occurred when resident was found next to his wheelchair when he tried to get up and walk.During a concurrent interview and record review with the ADON on 8/25/25 at 10:40 a.m., the ADON confirmed there was no IDT Conference Record/Fall Management Follow up conducted after Resident 82 fell twice on 4/24/25. The ADON stated after each fall the facility should conduct an IDT care conference/meeting to know what interventions the resident needs and IDT would do an investigation to find the root cause of the fall/s. She also stated the IDT care conference for fall management should have been done because this is part of our policy and procedure.7. During an interview with the ADON on 8/25/25 at 10:40 a.m., the ADON stated, every fall we conduct an IDT conference, to know what interventions the patient needs, we should do the IDT investigation to find the root cause. The ADON upon review of Resident 82's clinical records could not find any documented evidence that the causes or risk factors for Resident 82's falls were identified and discussed by the IDT to help prevent further fall episodes or injuries. The ADON further stated, the IDT are responsible for updating the comprehensive care plan, we should have added new interventions with each episode of fall and remove interventions if it did not work. Further review with the DON on 8/25/25 at 4:38 p.m., the Post Fall Evaluation, dated 5/6/25, the DON confirmed the date and time of fall, reason for the fall, and pre and post fall risk scores were left blank. The DON stated all the areas in this assessment for the Post fall Evaluation should have been completed. Review of the facility's policy dated 3/2018, titled Falls and Fall Risk, Managing, indicated Based on previous evaluations and current data. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

Based on observation, interview and record review, the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents for two days (8/16/25-8/17/25) in the main entrance of the facility by the receptionist area and in each three halls of the facility. This failure resulted in residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled.During an initial tour of the facility on 8/18/25 at 8:40 a.m., observed there were no posting of direct care staffing numbers, and nursing staff responsible for direct care to residents in the main entrance of the facility for 3 days 8/16/25, 8/17/25 and 8/18/25. Last date posted was 8/15/25.During an observation on 8/18/25 at 8:45 a.m., in Hall BB. No staff schedule or direct patient care hours were seen posted.During an observation on 8/18/25 at 8:50 a.m., in Hall CC. No staff schedule or direct patient care hours were seen posted.During an observation on 8/18/24 at 9:00 a.m., in Hall AA. No staff schedule or direct patient care hours were seen posted.During a concurrent observation and interview on 8/18/25, at 9:05 a.m., with ACR he confirmed that the staff schedule or direct patient care hours last date posted was 8/15/25 and there were no postings for 8/16/25, 8/17/25 and for today 8/18/25 they will post it in the main entrance of the facility and three halls of the facility.During a concurrent observation and interview on 8/15/24, at 9:05 a.m., with the Assistant Director of Nursing (ADON), at the receptionist area in the main entrance of the facility and confirmed that there was no staffing schedule, or direct patient care hours were posted for 8/16/25, 8/17/25 even today's date 8/18/25 and the last date posted was 8/15/25. The ADON stated that the Director of Staff Development (DSD) is responsible for posting it in all three hallways and in the main entrance of the facility by the receptionist. ADON further stated that the information is supposed to be posted.During a concurrent interview and record review with the DSD on 8/22/25, at 11:38 a.m., the DDS acknowledged the above observations and stated that direct care staffing numbers, and nursing staff responsible for direct care to residents should have been posted in the three halls of the facility and main entrance of the facility by the receptionist area daily for seven days.During a review of the facility's Policy & Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 2022, the P&P indicated, Direct care daily staffing number (the number of nursing personnel responsible for providing direct patient care to residents) are posted in the facility to every shift.

Based on observation, interview and record review, the facility failed to maintain a clean home-like environment, placing residents at risk for low self-esteem and living in an unkempt environment when: 1.Toilet room next to Resident 74 's Room, smelled feces and has feces on top of the toilet seat with smeared brownish substance around the toilet seat, toilet paper on top of the toilet seat and scattered small pieces of toilet paper on the toilet floor; and 2. Resident 73,74 and 76's window blinds were broken. Findings:1.During an initial tour of the facility on 8/18/25 at 9:25 a.m., toilet room next to Resident 74 's room observed with feces top of the toilet seat approximately 9 centimeters (cm, unit of measurement) and has smeared brownish substance around the toilet seat, and one piece of toilet paper was on top of the toilet seat and scattered small pieces of toilet paper on the toilet floor .During a concurrent observation and interview on 8/18/25 at 9:30 a.m., with the Activity Director (ACTD), she confirmed the above observation and stated that housekeeper and nursing staff were responsible for cleaning the toilet.During interview on 8/21/25 at 11:26 a.m., with the Environmental Services/Account manager (ESAM), he acknowledged the above observation and stated that the toilet seat cover should have been cleaned by the facility staff, should be free from feces odor, feces or other dirty substances. The ESAM further stated that the facility should provide a homelike environment to the residents in the facility.2. During an initial tour of the facility on 8/18/25 at 9:22 a.m., observed Resident 73,74 and 76's window blinds were broken.During a concurrent observation and interview on 8/20/25 at 10:36 a.m., with the Director of Maintenance (DOM), he acknowledged the above observation and stated Resident 73,74 and 76's window blinds need to be replaced.Review of the facility's Policy & Procedure (P&P) titled, Homelike Environment, dated February 2021, the P&P indicated, Resident are provided with a safe, clean comfortable and homelike Environment .The facility staff and management maximizes, to the extent possible , the characteristics of the facility that reflect a personalized homelike setting that includes Clean, sanitary and orderly Environment ,personalized furniture and room arrangement .

Based on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. The pureed (smooth, thick liquid or paste made by crushing or grinding solid foods and often made using a food processor and has a consistency that's thicker than juice) and regular (no modifications to food texture or consistency) green beans tasted bland; and2. They cooked the yellow corn in the stove for an extended period (approximately 2 hours).These failures of decreased food palatability could lead to decrease in food consumed by residents, and the food cooked in the stove for extended period could lose nutritive value, that could lead to decreased nutrient intake for the ninety-four facility residents receiving food from the kitchen.Findings: 1.During the test tray tasting on 8/21/25 at 1:05 p.m., two surveyors tasted the pureed green beans and it tasted bland. During the concurrent pureed tasting and interview with kitchen supervisor (KS) on 8/21/25 at 1:06 p.m., KS tasted the pureed green beans, and he acknowledged that it tasted bland and would check on it. During the continued test tray tasting on 8/21/25 at 1:10 p.m., tasted the regular green beans and it also tasted bland. During the concurrent food tasting and interview with KS on 8/21/25 at 1:11 p.m., KS tasted the regular green beans, and he verified that it tasted bland and would also check on it. During the interview with the registered dietitian (RD) on 8/22/25 at 2:41 p.m., RD verified that foods from the facility kitchen should not taste bland and would follow up on it. 2. During the concurrent initial kitchen tour observation and interview with KS on 8/18/25 at 9:25 a.m., they were already cooking the yellow corn in the heated stove, for lunch. KS verified that they should have started cooking the yellow corn near the tray line (a healthcare food service method where workers assemble food trays for residents on a moving assemble line) preparation for lunch which would start at 11:30 a.m. and they started cooking the yellow corn too early and for an extended period. KS further verified that he would follow up on this concern. During the interview with RD on 8/22/25 at 2:41 p.m., RD verified that the yellow corn was cooked too early, and it should have been cooked near the tray line preparation and not for an extended period to preserve the nutritive value and would check on it. During the interview with the director of nursing (DON), on 8/25/25 at 10:27 a.m., DON verified the above concerns and would follow up on them. Review of the facility's policy and procedure titled, Food and Nutrition Services, revised October 2017 indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections when:1.The Housekeeping (HK) J was wearing a pair of gloves and was holding a wet floor mop in the hallway Infront of the opened food cart with lunch trays for the residents eating in the dining room;2. A licensed Nurse entered a contact precaution room without wearing gloves to administer medications;3. There was one fly flying around the dining area near the table of Residents 105 and 32 and 4a. Laundry staff R (LS R) did not perform hand hygiene (the process of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) between handling soiled and clean laundry. b. Certified nursing assistant K (CNA K) did not perform hand hygiene between resident care tasks. c. Facility staff did not properly store respiratory (the process of breathing) equipment. These deficient practices had the potential to result in cross-contamination and the spread of infection and had the potential for residents to be at increased risk of healthcare-associated infections. Findings: 1.During a dining observation on 8/18/25 at 12:13 p.m., HK J was wearing a pair of gloves and was holding a wet floor mop in the hallway Infront of the opened food cart with lunch trays for the residents eating in the dining room. During a concurrent observation and interview on 8/18/25 at 12:14 p.m., with the HK J together with an interpreter certified nursing assistant K (CNA K) , HK J acknowledged the above observation and stated that she needs to mop the floor Infront of the food cart that was opened because the floor was dirty and she was waiting for the CNA's to finish the lunch trays distribution for the Residents in the dining area in order for her to start mopping the floor. HK J further stated that she should not be wearing gloves, hold the floor mop and clean the floor during lunch tray distribution due to infection control issue. A review of Resident 54's clinical record indicated the following physician orders: a. Contact/Isolation Precautions: Every shift for C. difficile, start date 8/18/2025. b. Vancomycin oral capsule 125 mg (milligram, a unit of measurement for weight in the metric system): Give one capsule by mouth every 6 hours for C. difficile for 10 days, start date 8/19/2025. During an observation on 8/19/2025 at 5:39 p.m., Licensed Vocational Nurse (LVN) D was preparing medications for Resident 54 in the hallway. LVN D entered Resident 54's room, which was under contact precautions, wearing a gown but without gloves, and administered vancomycin 125 mg one capsule with her other medications. During an interview with LVN D on 8/19/2025 at 5:53 p.m., LVN D acknowledged that she should have worn gloves when entering a room under contact precautions to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 8/25/2025 at 1:27 p.m., the DON stated that nurses entering rooms under contact precautions are required to wear full personal protective equipment (PPE), including gowns and gloves, to prevent the spread of infection. A review of the facility's policy and procedure titled Isolation-Categories of Transmission-Based Precautions revised September 2022, indicated .contact precautions are implemented for residents known or suspended to be infected with microorganisms that can be transmitted by direct contact with environmental surfaces or resident-care items in the resident's environment. staff and visitors wear gloves (clean, non-sterile) when entering the room. During lunch observation in the dining area on 8/18/25 at 12:20 p.m., there was one fly flying around near the meal trays of Residents 105 and 32. Resident 105 was sitting at the table eating her lunch. Resident 105 was frightened when the fly flying around the table, got near her meal tray but did not say anything. Resident 32 was in her wheelchair, also eating lunch, beside Resident 105, totally fed by certified nursing assistant L (CNA L). Resident 32 was confused and could not verbalize. The fly also went near her tray. During the concurrent lunch observation in the dining area and interview with CNA L on 8/18/25 at 12:20 p.m., CNA L was sitting between Residents 105 and 32. She was feeding Resident 32 for her lunch. CNA L verified that there was a fly flying around the dining area and it should not be there. She further verified that she would tell the nurse about it. Review of Resident 105's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 105 was admitted to the facility on [DATE] with the primary diagnosis of unspecified encephalopathy (brain disease that alters brain function or structure that maybe caused by infection, tumor, and stroke). Review of Resident 32's admission record indicated, Resident 32 was readmitted to the facility on [DATE] with the primary diagnosis of metabolic encephalopathy (condition where the brain does not function properly due to underlying metabolic disturbances). During the interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., the DON acknowledged that there should be no insects or flies flying around the dining area and would follow up on it. Review of the facility's policy and procedure titled, Pest Control, revised May 2008 indicated, Our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects. 4a. During an observation on 08/18/2025 at 9:05 a.m., while in the facility hallway, observed laundry staff (LS) pushing a laundry cart while wearing gloves. LS transferred dirty laundry items into a bin. LS returned to the laundry area, still wearing the same gloves, and opened the dryer containing clean clothes. LS was about to touch the clean laundry with the same gloved hands, the surveyor intervened. During a concurrent interview, the LS stated he was supposed to wash his hands and change gloves after handling dirty items. LS pointed to a nearby sink used for handwashing. 4b. During an observation of 8/18/25 at 12:54 p.m., observed Certified Nursing Assistant K (CNA K) delivering meal trays. CNA K entered Resident 2's room, placed Resident 2's meal tray on the bedside table, touched the bed control to raise the bed, applied a towel for Resident 2. CNA K then entered Resident 54's room. Resident 54 was sitting in the wheelchair, CNA K applied Resident 54's nasal cannula (a thin, flexible tube that is inserted into the nostrils to deliver oxygen to a patient), and served Resident 54's meal tray. CNA K did not perform hand hygiene (the process of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) between tasks. During a concurrent interview, CNA K acknowledged that she should have performed hand hygiene in between tasks and before providing care to another resident. 4c. During an observation on 8/18/25 at 2:00 p.m., observed Resident 33 lying in bed. A nasal cannula was found stored inside the bedside cabinet drawer, not stored properly. In the same room, Resident 38 was observed lying in bed, asleep. There was a suction machine at the bedside, and the attached suction tubing was lying on the floor. During an interview with the Infection Preventionist (IP) on 8/25/25 at 5:00 p.m., the IP was made aware of the above observations. IP stated that facility staff are expected to perform hand hygiene between resident care tasks, after handling soiled laundry, and before touching clean laundry. The IP acknowledged Resident 33's nasal cannulas and Resident 38's suction tubing were not stored properly. IP stated it should be stored in a protective bag to prevent contamination. Review of facility's policy, Handwashing/Hand Hygiene dated 8/2019, indicated .All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . According to the Centers for Disease Control and Prevention (CDC) Guidelines indicated respiratory equipment such as nasal cannulas and suction tubing must be cleaned, dried and and stored in a closed or protected environment to prevent contamination (Source: CDC Guidelines).

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for four out of twenty-five sampled residents, (Residents 12, 36, 72, 73 and 76), when:1. For Resident 12, there was no care plan developed for her use of antibiotic;2. For Resident 36, Fall comprehensive care plan was not developed, and the short-term care plan was not person- centered;3. For Resident 72, the comprehensive Smoking Care plan was not initiated on time and was not person- centered;4. For Resident 73, the Fall comprehensive care plan was not initiated on time and the short-term care plan was not person centered; and 5. For resident 76, there was no pain care plan developed for her Lidocaine External patch 5 % patch (used to provide targeted pain relief by numbing the area where they are applied, medication, a local anesthetic, works by blocking nerve signals from reaching the brain).These failures had the potential to result in residents not receiving the interventions and monitoring necessary to maintain their highest level of well-being and failures to develop and/or follow care plans had the potential of not meeting the care needs of the residents. Findings: 1.During the observation of Resident 12 on 8/21/25 at 1:05 p.m., Resident 12 was sitting in her wheelchair outside in the smoking area, alert, comfortable and verbally responsive. Review of Resident 12's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 12 was readmitted to the facility on [DATE] with diagnoses including unspecified schizophrenia (serious mental health condition that affects how people think, feel and behave), unspecified bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs, called mania and lows, known as depression) and adult failure to thrive (condition characterized by significant unintentional weight loss, muscle wasting and decreased activity levels in older adults). Review of Resident 12's order summary report dated 8/12/25 indicated, Resident 12 had an order Rifaximin (Xifaxan, antibiotic used to treat specific conditions of the digestive system) 550 milligrams (mg, unit of weight) oral tablet, give one tablet by mouth two times a day for liver disease (also known as hepatic disease is any of many diseases of the liver often manifested by swelling of the abdomen and legs and bruising easily), ordered and started on 3/17/25. Review of Resident 12's care plans indicated, she did not have a care plan for her use of Rifaximin for liver disease. During the concurrent review of Resident 12's care plans and interview with the minimum data set coordinator H (MDSC H, specially trained nurse who works primarily in long-term care facilities, assessing residents' needs, developing care plans and collaborating with a team of healthcare professionals to ensure comprehensive care) on 8/21/25 at 2:50 p.m., MDSC H verified that Resident 12 did not have a comprehensive, person-centered care plan for her use of the antibiotic for liver disease, and she should have one. MDSC H further verified that she would check on this concern. During the interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., the DON verified that Resident 12 should have a comprehensive, person-centered care plan for her use of antibiotic and would follow up on it. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2.During an initial tour of the facility on 8/18/25 at 9:26 a.m., Resident 36 was sitting in his wheelchair, and was screaming inside his room. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 8/21/25 at 9:00 a.m., the ADON reviewed Resident 36's clinical records, and she stated Resident 36 was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), adjustment disorder with anxiety (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem) and Type 2 diabetes mellitus (high blood sugar). ADON reviewed the Comprehensive Care plans (CP) ADON confirmed that there was no Fall comprehensive care plan initiated on 2/7/25 when Resident 36 was admitted but fall risk short term care plan was initiated on 6/20/25 and was not person- centered. The ADON further stated that a comprehensive, person-centered care plan for fall should have been initiated due to Resident 36's history of multiple falls. 3. Review of Resident 72's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder, Bipolar type, muscle weakness, Chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and other symptoms and signs involving cognitive functions and awareness. Resident 72's minimum data set (MDS, an assessment tool) dated 6/18/25 indicated her cognition (ability to remember, judge and use reason) with a brief interview for mental status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 moderately impaired cognition. During a concurrent interview and record review on 8/20/25 at 11:55 a.m., with the ADON, the ADON reviewed the Comprehensive Care plans and confirmed that there was no smoking comprehensive care plan initiated when Resident 72 was admitted on [DATE], the smoking CP was initiated on 11/04/24 and not a person-centered CP. The ADON further stated Resident 72 should have a comprehensive, person-centered care plan initiated for smoking for Resident 72's safety when smoking. 4. Review of Resident 73's clinical record indicated he was admitted to the facility on [DATE] with diagnosis of Multiple sclerosis (a disease affecting the brain and spinal cord that disrupts the communication of the brain and the rest of the body), lack of coordination, depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and abnormalities of gait and mobility. Resident 73's MDS dated [DATE] indicated her cognition with a BIMS (brief interview for mental status, an assessment for cognition) score of 9 was moderately impaired cognition. During a concurrent interview and record review with the ADON on 8/21/25 at 1:29 p.m., the ADON reviewed resident 73's fall comprehensive care plan and she confirmed there was no comprehensive CP initiated when Resident 73 was admitted on [DATE], it was initiated on 2/13/25 due to history of falls in the facility and has short term fall care plan initiated on 8/4/25 after an unwitnessed fall. During a concurrent interview and record review with the Regional Quality Assurance and the MDS Consultant (RQA/MDSC), both staff reviewed Resident 73's fall care plan dated 8/4/25 and confirmed that Fall care plan was not person-centered care planning. The RQA/MDSC stated Resident 73 had unwitnessed fall on 8/4/25, after each fall, the licensed nurses need to reassess or do a fall risk evaluation, care plan for fall dated formulation or care planning interventions relevant to fall management must be conducted once a resident has been identified as at risk for fall, or immediately following a fall occurrence. He further stated that Resident 73's reassessment for fall was done on 8/4/25 with the score of 17 (score of 10 and greater is high risk for fall) and there were no new interventions indicated in the fall intervention Care plan dated 8/4/25. He stated there should have been a person-centered fall care plan for Resident 73 based on fall risk assessment clinical suggestions dated 8/4/25. 5. During an observation on 8/18/25at 9:31 a.m., Resident 76 was sitting in her wheelchair in the hallway and her back was halfway exposed from the tail bone up to the upper part of her back and exposed to public view in the hallway during patch administration by the Licensed Vocational Nurse L (LVN L). During a concurrent interview and record review on 8/21/25 at 9:34 a.m., with the ADON, she reviewed Resident 76's clinical records and stated that the physician order dated 4/2/25 indicated Lidocaine (used to provide targeted pain relief by numbing the area where they are applied, medication, a local anesthetic, works by blocking nerve signals from reaching the brain) External patch 5 % apply to lower back topically one time a day for lower back pain 12 hours on and 12 hours off and remove per schedule. The ADON further stated that Resident 76's had diagnosis of lower back pain, sciatica (pain or other symptoms—like numbness, tingling, or weakness—that occur when pressure is applied to or irritation affects one or more of the five nerve roots that form the sciatic nerve (sciatic nerve is the largest nerve in the body, extending from the lower back down to the foot) . During a concurrent interview and record review with the ADON, on 8/21/25 at 10:32 a.m., the ADON reviewed Resident 76's Care Plans (CP) and stated there was no care plan for pain that was initiated when the physician ordered the Lidocaine patch 5% on 4/2/25 up to this date 8/21/25. The ADON further stated that the pain care plan should have been initiated to address the pain issue of Resident 76. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interviews, and record review, the facility failed to ensure that 3 of 6 sampled residents (Residents 1, 15 and 37) were free from unnecessary medications, when:1. Resident 1 and Resident 15 were prescribed the psychotropic medication (medications that affect the mind, emotions, and behavior) Lorazepam without an end date; and2. Resident 37 was prescribed Haldol (antipsychotic medication, used to treat nervous, emotional, and mental conditions), but did not have the specific indication or behavioral manifestation for its use.These failures resulted in residents receiving unnecessary medications and had the potential to affect their clinical conditions negatively. Findings: A review of Resident 1's medical record indicated that he was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM, a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to maintain normal blood sugar levels), schizophrenia (a brain disorder that affects how a person thinks, feels, and behaves), schizoaffective disorder (a mental health condition that includes symptoms of both schizophrenia and a mood disorder), and dementia (a decline in memory, thinking, and reasoning severe enough to interfere with daily life) with psychotic disturbance. A review of Resident 1's physician orders dated 8/21/25 indicated that lorazepam oral tablet 0.5 mg (milligram, a unit of measurement for weight in the metric system) — administer one tablet by mouth every 4 hours as needed for anxiety manifested by agitation/restlessness; no end date due to end-of-life care; start date 8/21/2025. A review of Resident 15's medical record indicated he was admitted to the facility in 4/5/2024 with diagnoses including type 2 DM, schizoaffective disorder (bipolar type), major depressive disorder, and generalized anxiety disorder. A review of Resident 15's physician orders dated 2/10/25 indicated that Lorazepam oral concentrate 2 mg/mL (milligram/milliliter)— administer 0.5 mL by mouth every 4 hours as needed (PRN) for inability to relax, agitation, or anxiety; no end date due to end-of-life care; start date 2/10/2025. During a concurrent interview and record review with the Director of Nursing (DON) on 8/25/2025 at 1:29 p.m., the DON reviewed the Medical records for both Residents 1 and 15. She stated that PRN psychotropic medications, such as Lorazepam, should be limited to 14 days. During a phone interview with the facility consultant pharmacist (CP) on 8/25/2025 at 1:55 p.m., the CP stated that PRN psychotropic medications, including Lorazepam, need to include an end date, usually within 14 days, unless the prescribing physician justifies an extended duration. A review of the facility's Psychotronic Medication Use, revised July 2022, indicated psychotropic medications are not prescribed or given on a PRN basis unless that the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN order for psychotropic medications are limited to 14 days. Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). Review of Resident 37's Physician's Order, dated 7/24/25, indicated Haloperidol (Haldol) 20 milligrams (mg, unit of weight), give 1 tablet by mouth two times a day for Schizophrenia. During a concurrent interview on 8/21/25 at 4:05 p.m., the Assistant Director of Nursing (ADON) stated that psychotropic medication orders should include the indication for use, including the target behavior or symptom. The ADON stated that Resident 37's order should include the specific behavior or symptom for the use of Haldol.

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained and food items were stored and prepared in accordance with professional standards for food safety when: 1. The outside of the ice machine had white deposits on the sides,2. The temperature log of the refrigerator and freezer were not filled out properly and3. The kitchen staff did not wear his face mask properly while helping with the tray line (a healthcare food service method where workers assemble food trays for residents on a moving assemble line) preparation. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contamination (transfer of harmful bacteria, viruses, allergens, or other contaminants unintentionally, from one person, object, or place to another, with harmful effect) of food, for the ninety-four residents who received foods from the facility kitchen.Findings: 1.During the an initial kitchen tour observation and concurrent interview with the kitchen supervisor (KS) on 8/18/25 at 9:22 a.m., observed white deposits were found outside the ice machine, on the sides. The KS verified that there should be no white deposits in there and would have the maintenance clean the ice machine and would follow up on it.Review of the facility's policy titled, Ice Machines and Ice Storage Chests, revised January 2012 indicated, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice.2. During the initial kitchen tour observation and concurrent interview with cook I (COOK I) on 8/18/25 at 9:16 a.m., observed that there were already temperature logs for the afternoon shift of today's refrigerator and freezer temperature logs. COOK I verified that they should not log the temperatures ahead of time and should have monitored them properly. He further verified that they should not log the temperatures of the refrigerator and freezer ahead for the afternoon shift in the morning. During the interview with the KS on 8/18/25 at 9:17 a.m., the KS verified that the kitchen staff was not properly logging in today's temperatures of the refrigerator and freezer for the afternoon shift because it was done ahead of time since it's still morning shift. The KS further verified that he would follow up on it since the staff was not doing it right.Review of the facility's policy and procedure titled, Refrigerators and Freezers, revised November 2022 indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation.Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 3. During the concurrent tray line preparation observation and interview with cook G (COOK G) on 8/21/25 at 11:50 a.m., observed that COOK G was not wearing his face mask properly. His face mask was not covering his nose and only covering his mouth. COOK G verified that he was not wearing his face mask properly and corrected it right away. During the interview with the registered dietitian (RD) on 8/22/25 at 2:41 p.m., the RD verified all the above concerns and would follow up on them. During the interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., the DON verified the above concerns and would check on these concerns. Review of the Santa [NAME] County Public Health Orders titled, General Recommendations for Wearing a Mask, updated 10/21/24 indicated, .The mask should completely cover your nose and mouth and fit snugly against the sides of your face, leaving no gaps.

Based on observation, interview, and record review, the facility failed to ensure a care plan (CP) was revised based on preferences and needs of the residents for two of 25 sampled residents (Resident 72 and 73.This failure had the potential for Resident 72 and 73 not to receive the necessary care and services to achieve the highest practicable well-being and communicate necessary interventions to the staff. Findings:1. Review of Resident 72's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder, Bipolar type, muscle weakness, Chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and other symptoms and signs involving cognitive functions and awareness.Resident 72's minimum data set (MDS, an assessment tool) dated 6/18/25 indicated her cognition (ability to remember, judge and use reason) with a brief interview for mental status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 moderately impaired cognition.During a concurrent interview and record review on 8/20/25 at 11:55 a.m., with ADON, She reviewed Resident 72's smoking CP dated 11/04/24 and could not provide any documentation to indicate that smoking care plan was revised or reviewed every three months or quarterly. ADON further stated it should have been revised every quarter.2. Review of Resident 73's clinical record indicated he was admitted to the facility on [DATE] with diagnosis of Multiple sclerosis (a disease affecting the brain and spinal cord that disrupts the communication of the brain and the rest of the body), lack of coordination, depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and abnormalities of gait and mobility. Resident 73's MDS dated [DATE] indicated her cognition with a BIMS score of 9 was moderately impaired cognition.During a concurrent interview and record review with ADON on 8/21/25 at 1:29 p.m., ADON reviewed resident 73's fall comprehensive care plan which was initiated on 2/13/25 due to the history of falls in the facility and could not provide any documentation that Fall comprehensive care was revised or reviewed every three months and should have been revised or reviewed. A review of facility policy, Care Plans, Comprehensive Person -Centered Revised date March /2020, indicated A comprehensive , person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team reviews and updates the care plan when the desired outcome is not met, at least quarterly, in conjunction the required quarterly MDS assessment, when there has been a significant change in the resident's condition and when resident has been readmitted to the facility from a hospital stay.

Based on interview and record review, the facility failed to ensure that the resident with Level 1 (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was coded accurately and those with positive Level 1 PASARR were evaluated for Level 2, for three of twenty-five sampled residents, (Residents 22, 92 and 72) when:1.For Residents 22 and 92, there were no documentations that Level 2 PASARR screening (comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disorder, intellectual disability or related condition, determines the appropriate setting for the individual and recommends specialized services and/or rehabilitative services the individual needs) were done after positive Level 1 evaluation; and 2. For Resident 72, Level 1 PASARR was not coded correctly. These failures had the potential for the residents, not being comprehensively evaluated, which could result in not receiving the care and services in the most appropriate setting, necessary for their optimal health and well-being.Findings:1.Review of Resident 22's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (mental disorder characterized by persistently low or depressed mood or decreased interest in pleasurable activities), chronic post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it) and unspecified epilepsy (brain condition that causes recurring seizures), not intractable, with status epilepticus (serious neurological emergency that occurs when seizures last a long time or happen in close succession without recovery in between).Review of Resident 22's Level 1 PASARR screening indicated that she was positive for serious mental illness and Level 2 screening was recommended. Review of Resident 22's clinical records indicated, there was no documentation that Resident 22 was evaluated for level 2 PASARR. During the concurrent review of Resident 22's clinical records and interview with minimum data set coordinator H (MDSC H, specially trained nurse who works primarily in long-term care facilities, assessing residents' needs, developing care plans and collaborating with a team of healthcare professionals to ensure comprehensive care) on 8/21/25 at 2:13 p.m., MDSC H verified that Resident 22 had Level 1 PASARR screening which showed that she was positive for serious mental illness and Level 2 screening was recommended. MDSC H further verified that there was no documentation that she was screened for Level 2 PASARR. During the interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., the DON verified that Resident 22 should have been screened for Level 2 PASARR as recommended by her Level 1 screening but there was no documentation that she was evaluated for Level 2 and would follow up on it.1b. Review of Resident 92's admission record indicated, Resident 92 was readmitted to the facility on [DATE], with diagnoses including unspecified dementia (loss of memory), moderate, with psychotic disturbance (severe mental disorder that cause abnormal thinking and perceptions), paranoid schizophrenia (type of mental health disorder characterized by persistent delusions and hallucinations) and major depressive disorder, single episode, severe with psychotic features (loss of touch with reality). Review of Resident 92's Level 1 PASARR screening indicated that she was positive for suspected mental illness and Level 2 screening was needed. Review of Resident 92's clinical records indicated, there was no documentation that Resident 92 was evaluated for Level 2 PASARR.During the concurrent review of Resident 92's clinical records and interview with MDSC H on 8/22/25 at 12:13 p.m., MDSC H verified that Resident 92 had Level 1 PASARR screening which showed that she was positive for suspected mental illness and Level 2 screening was required. MDSC H further verified that there was no documentation that she was screened for level 2 PASARR. During the interview with the DON on 8/25/25 at 10:27 a.m., the DON verified that Resident 92 should have been referred and screened for Level 2 PASARR since her Level 1 screening indicated that she was positive for suspected mental illness and she would follow up on it. 2. Review of Resident 72's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs),psychotic disorder with delusion (a mental health condition characterized by a loss of contact with reality, involving symptoms like hallucinations (seeing, hearing, or feeling things that aren't there), delusions (false, fixed beliefs), disorganized thinking, and disorganized or abnormal behavior) and other symptoms and signs involving cognitive functions and awareness.During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 8 /20/2025 at 01:27 p.m., ADON reviewed Resident 72's diagnoses and Level I PASARR, dated 03/17/2021, and stated the resident had Diagnoses of Schizoaffective disorder, Bipolar type, psychotic disorder with delusion and other symptoms and signs involving cognitive functions and awareness. ADON further stated, the resident 72's Level I PASARR should have been resubmitted because it was not accurate and the importance of Level I PASARRs was to determine if residents required a Level II Evaluation. Review of a facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASARR), dated December 2017 indicated, All residents will be screened on admission and annually thereafter. To ensure that all facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated.A positive level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR level 2, which must be conducted prior to admission to a nursing facility.

Based on interview and record review, the facility failed to ensure an accurate smoking assessment and complete smoking assessment were done every three months for two of 19 sampled residents who smoke (Residents 37 and 72).These failures had potential to cause accident/harm to these residents and potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.Findings: 1.Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During an observation on 8/21/25 at 1:00 p.m., Resident 37 was observed smoking outside while wearing a protective apron and under staff supervision. Review of Resident 37's Smoking Assessments, dated 1/18/25 and 4/18/25, but indicated no quarterly smoking assessment was completed for July 2025. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 8/21/25 at 2:58 p.m., the ADON stated smoking assessments are completed at admission and quarterly. The ADON acknowledged Resident 37's quarterly smoking assessment for July 2025 was missed and should be completed. Review of the facility's policy and procedure titled, Smoking Policy- Residents, revised August 2022 indicated, Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes Current level of tobacco consumptions, ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation . A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. Any smoking – related privileges, restrictions and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 2.Review of Resident 72's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnosis of Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs),psychotic disorder with delusion (a mental health condition characterized by a loss of contact with reality, involving symptoms like hallucinations (seeing, hearing, or feeling things that aren't there), delusions (false, fixed beliefs), disorganized thinking, and disorganized or abnormal behavior) and other symptoms and signs involving cognitive functions and awareness, muscle weakness, reduced mobility and obesity. Resident 72's minimum data set (MDS, an assessment tool) dated 6/18/25 indicated her cognition (ability to remember, judge and use reason) with a brief interview for mental status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 moderately impaired cognition. During a concurrent interview and record review on 8/20/25 at 12:22 p.m., with the Assistant Director of Nursing (ADON), She reviewed Resident 72's smoking and safety assessment evaluation dated 6/17/25 and stated that smoking care planning section, clinical suggestions and smoking safety notes were blank. ADON further stated it should have been completed and accurately assessed. During a concurrent interview and record review with Minimum Data Set Coordinator Q (MDSC Q) on 8/20/25 at 12:54 p.m., MDSC Q reviewed Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) smoking assessment conference dated 6/2/25 indicated Resident 72 is an independent smoker and is safe to smoke independently based on smoking assessment, smoking assessment is completed and up to date and reviewed by IDT per risk assessment , for the section smoking care planning indicated continued non-compliance may lead to unexpected burn related fire property or possibly death and for additional interventions indicated Resident 72 has history of non- compliance with smoking schedule and IDT will continue to re -evaluate resident and monitor any changes. MDSC Q stated that Resident 72 needed one person supervision during smoking for safety and he confirmed that the IDT assessment was inaccurate for Resident 72's smoking and safety assessment evaluation dated 6/17/25 was inaccurate also.

Based on interview and record review, the facility failed to ensure, the resident's discharge minimum data set (MDS, a standardized assessment and care screening tool) assessment was transmitted within 14 days after the assessment reference date (ARD, the specific end point of look-back periods in the MDS assessment process) for one (Resident 43), out of twenty-five sampled residents.This deficient practice had the potential to result in delayed services for the resident.Findings: Review of Resident 43's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 43 was initially admitted to the facility on [DATE] and was discharged on 5/23/25. Resident 43 was then readmitted on [DATE]. Review of the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services that administers the Medicare program) submission report indicated that the Assessment Completed Date for section Z0500B (assessment completion date) for Resident 43's MDS was more than 14 days after A2300 (assessment reference date). During the concurrent review of Resident 43's clinical records and interview with minimum data set coordinator H (MDSC H, specially trained nurse who works primarily in long-term care facilities, assessing residents' needs, developing care plans and collaborating with a team of healthcare professionals to ensure comprehensive care) on 8/22/25 at 9:46 a.m., MDSC H verified the late submission of the discharge MDS assessment, and she further verified of receiving the CMS final validation report warning for late completion of the assessment, more than 14 days after the assessment reference date.During the interview with the director of nursing (DON), on 8/25/25 at 10:27 a.m., DON acknowledged the above concern and would check on it.A review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual indicated, the MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically, no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days).

Based on interview and record review, the facility failed to report allegations of abuse to the appropriate agencies, including the California Department of Public Health (CDPH), within the required timeframe involving two of six sampled residents (Residents 37 and 91). This failure to report allegations of abuse placed Residents 37 and 91 at risk of potential abuse.Findings: Review of Resident 37's Face Sheet (summary page of a patient's important information) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including Schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors), Anxiety Disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness), Depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). Review of Resident 37's Minimum Data Set (MDS, a standardized assessment tool), dated 7/25/25, indicated Resident 37 had a Brief Interview for Mental Status (BIMS, an assessment tool for cognition) score of 10, indicating Resident 37 had a moderate cognitive impairment (decline in one or more cognitive abilities, such as memory, attention, language, reasoning, and problem-solving.) Review of Resident 91's Face Sheet indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Unspecified Severity, with Agitation (form of dementia that cannot be specified by its type or cause, has not been classified by severity and involves agitated behaviors such as restlessness, shouting, aggression, or physical violence), Cognitive Communication Deficit (a group of impairments that affect a person's ability to communicate effectively due to underlying cognitive difficulties). Review of Resident 91's MDS dated [DATE], indicated Resident 91 had a BIMS score of 5, indicating Resident 91 had a severe cognitive impairment (significant decline in cognitive abilities that interferes with daily functioning and independence.) During an observation and interview on 8/18/25 at 2:06 p.m., in resident's room. Resident 37 was sitting in the wheelchair. Resident 37 stated his roommate had tried to hit him during the night. Resident 37 reported he told the staff at the time of the incident, and staff offered him a room change, which he declined. Resident 37 became agitated when asked further questions. During an interview with Licensed Vocational Nurse P (LVN P) on 8/21/25 at 12;18 p.m., LVN P stated Resident 37 had told her a couple of weeks ago that his roommate wanted to hit him. LVN P stated she did not document the allegation because nothing happened. LVN P stated she did not notify the Director of Nursing (DON) or the Administrator (ADM), but reported it to the Social Service Director (SSD). LVN P stated a room change was offered, but Resident 37 declined. During a concurrent interview and record review with the SSD on 8/22/25 at 11:00 a.m., the SSD stated she was not made aware of Resident 37's allegation until 8/18/25. The SSD provided a Behavior Note Progress Note, dated 8/15/25 at 20:03, which indicated: Resident 37 insisting his roommate hit him while he was taking a nap just now .If his roommate does it again, he is going to punch him in the face. The SSD stated the note showed an abuse allegation and confirmed it should have been reported immediately to the ADM, CDPH, police, and Ombudsman (a neutral advocate for residents of long-term care facilities, acting independently to protect their health, safety, welfare, and rights). During a concurrent interview and record review with the DON on 8/22/25 at 3:50 p.m., the DON stated she was not aware of Resident 37's allegation regarding his roommate until 8/18/25. The DON reviewed the 8/15/25 Behavior Note, the DON confirmed the Behavior Note was an abuse allegation that should have been reported immediately to CDPH, the police, and Ombudsman. During a concurrent interview and record review with the ADM on 8/25/25 at 3:18 p.m., the ADM stated he was not aware of Resident 37's allegation until 8/18/25. The ADM confirmed the allegation should have been reported immediately as per the facility's abuse policy. Review of the facility's policy, titled Abuse Reporting and Investigation, updated 5/2025, indicated The Facility staff will report ALL allegations of abuse .as required by law and regulations to the appropriate agencies within 2 hours .For incidents involving resident on resident abuse that did not result in bodily harm where the alleged abuser is a resident diagnosed with Dementia, the facility is required to notify the ombudsman and local law enforcement in writing within 24 hours. The facility must still report to appropriate agencies within 2 hours .

Based on observation, interview and record review, the facility failed to maintain resident's privacy or dignity for one of 25 sampled residents (Resident 76) when her back was halfway exposed from the Coccyx or tailbone (the last bone at the bottom (base) of the spine) up to the upper part of her back to public view in the hallway. This failure had the potential to affect Resident 76's self-esteem and self-worth. Findings:Review of Resident 76's clinical record indicated she had diagnosis of lower back pain, sciatica (pain or other symptoms-like numbness, tingling, or weakness-that occur when pressure is applied to or irritation affects one or more of the five nerve roots that form the sciatic nerve (sciatic nerve is the largest nerve in the body, extending from the lower back down to the foot) , Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), Bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The physician order dated 4/2/25 indicated Lidocaine (used to provide targeted pain relief by numbing the area where they are applied, medication, a local anesthetic, works by blocking nerve signals from reaching the brain) External patch 5 % apply to lower back topically one time a day for lower back pain 12 hours on and 12 hours off and remove per schedule.Resident 76's minimum data set (MDS, an assessment tool) dated 7/02/25 indicated her cognition (ability to remember, judge and use reason) with a brief interview for mental status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 was intact.During an observation on 8/18/25at 9:31 a.m., Resident 78 was sitting in her wheelchair in the hallway, her back was halfway exposed from the tail bone up to the upper part of her back to public view in the hallway during patch administration by licensed vocational nurse O (LVN O).During an interview on 8/18/25 at 9:43 a.m., with LVN O , she acknowledged the above observation and stated that she should have brought Resident 78 to her room to protect Resident 76's body parts exposure during medication administration.During an interview on 8/18/25 at 1:12 p.m., Resident 76 confirmed the above observation and stated that assigned Nurses in the facility was putting her patch on her back in the hallway, and was not offered by the nurse to go inside her room for privacy.Review of the facility's Policy & Procedure (P&P) titled, Dignity , dated February 2021, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always treated with dignity and respect.

Based on interview and record review, the facility failed to ensure that the preadmission screening and resident review (PASARR, federal requirement under the Medicaid program or public health insurance program that provides health care coverage to low-income individuals, families and people with disabilities, to screen all applicants and residents for serious mental illness, intellectual or developmental disabilities, and related conditions before they are admitted to the nursing facility) was done and accurately implemented to two of twenty-five sampled residents, (Residents 85 and 6) when: 1.For Resident 85, there was no level 1 PASARR screening (involves completion of an evaluation to determine if the individual has, or is suspected of having serious mental illness, intellectual disability, developmental disability or related condition) and 2. For Resident 6, the level 1 PASARR screening was not accurately done. These failures had the potential to cause the delay, in the care of the residents and not receiving the care and services in the most appropriate setting, necessary for their optimal health and well-being.Findings: 1.Review of Resident 85's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 85 was readmitted to the facility on [DATE], with diagnoses including schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), bipolar type (includes bouts of hypomania or mania or abnormally elevated energy level and sometimes major depression or feeling of sadness), unspecified dementia (loss of memory), unspecified severity with agitation (state of physical and psychological restlessness) and unspecified anxiety (feeling of fear, dread and uneasiness) disorder. Review of Resident 85's clinical records indicated that she had no level 1 PASARR screening. There was no documentation that Resident 85 was evaluated for her mental health condition. During the concurrent review of Resident 85's clinical records and interview with minimum data set coordinator H (MDSC H, specially trained nurse who works primarily in long-term care facilities, assessing residents' needs, developing care plans and collaborating with a team of healthcare professionals to ensure comprehensive care) on 8/22/25 at 11:43 a.m., MDSC H verified the above diagnoses of Resident 85 and further verified that there was no documentation that she was screened for level 1 PASARR. During the interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., DON verified that Resident 85 should have been screened for level 1 PASRR but there was no documentation of the screening and would follow up on it. 2. Review of Resident 6's admission record indicated, Resident 6 was admitted on [DATE] with diagnoses including Dementia (loss of memory), Schizophrenia (a serious mental health condition that affects how people think, feel and behave), Anxiety (feeling of fear, dread and uneasiness). Review of Resident 6's PASARR level 1 dated 2/14/25, indicated negative for Serious Mental Illness (SMI). The form indicated No under the section asking about diagnosed mental disorders such depressive disorder, anxiety, schizophrenia. During a concurrent interview and record review on 8/21/25 at 4:10 p.m., the Assistant Director of Nursing (ADON) confirmed the PASSR Level 1 was inaccurate because Resident 6 was admitted with diagnosis of Schizophrenia. The ADON stated the PASSR Level 1 was completed at the hospital. The ADON stated nursing staff should have reviewed the PASRR Level 1 upon admission for accuracy, but this was not done. Review of a facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASARR), dated December 2017 indicated, All residents will be screened on admission and annually thereafter. To ensure that all facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated.PASARR level 1 screening is to be completed before the individual is admitted to the facility. If it is not completed by the sending institution, it should be completed by nursing staff prior to admission.

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of twenty-five sampled residents, (Resident 22), when for Resident 22: 1.The care plan for the risk of elopement was not followed;2. There was MDS assessment inaccuracy; and3. The care plan was not person-centered.These failures caused the resident to have an episode of elopement and potentially, not attaining or maintaining the highest practicable physical, mental and psychosocial well-being.Findings: 1.During the concurrent lunch observation and interview of Resident 22 on 8/18/25 at 12:18 p.m., Resident 22 was sitting in the dining area table, eating her lunch. Resident 22 was alert, calm and verbally responsive and stated that she was fine.Review of Resident 22's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (mental disorder characterized by persistently low or depressed mood or decreased interest in pleasurable activities), chronic post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it) and unspecified epilepsy (brain condition that causes recurring seizures), not intractable, with status epilepticus (serious neurological emergency that occurs when seizures last a long time or happen in close succession without recovery in between). Resident 22 went to the hospital on 7/19/25 and came back on 7/23/25.Review of Resident 22's risk for elopement care plan indicated that the goal was for Resident 22, not to leave the facility unattended and it was not followed since resident went out of the facility unattended.Review of Resident 22's progress notes indicated, Resident 22 had an episode of elopement on 8/14/25. She went out of the facility by herself.During an interview with certified nursing assistant M (CNA M) on 8/22/25 at 4:01 p.m., CNA M verified that another staff should have watched Resident 22 when she was on lunch break at that time of elopement on 8/14/25, to avoid the incident to happen and further verified that the care plan was not followed. During an interview with licensed vocational nurse N (LVN N) on 8/14/25 at 3:36 p.m., LVN N verified the elopement of Resident 22 on 8/14/25. LVN N further verified that her care plan was not followed and would ensure Resident 22 would not be left unattended.During the concurrent review of Resident 22's care plans and interview with minimum data set coordinator H (MDSC H, specially trained nurse who works primarily in long-term care facilities, assessing residents' needs, developing care plans and collaborating with a team of healthcare professionals to ensure comprehensive care) on 8/21/25 at 1:58 p.m., MDSC H verified that the risk for elopement care plan of Resident 22 was not followed. 2. During the concurrent review of Resident 22's clinical records and interview with MDSC H on 8/22/25 at 8:57 a.m., MDSC H reviewed the minimum data set (MDS, a standardized assessment tool used to evaluate the health and functional capabilities of nursing home residents) assessments and other clinical records of Resident 22 and she verified that there was no significant change of condition MDS assessment for Resident 22 for the significant change in her health condition. MDSC H further verified that there was MDS inaccuracy because Resident 22 had a change of condition.Review of the facility's policy and procedure titled, Resident Assessments, revised March 2022 indicated, A comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget Reconciliation Act (OBRA of 1987, evaluations required to ensure quality care and protect the rights of nursing facility residents, particularly those with mental illness or developmental disabilities).OBRA required assessments - conducted for all residents in the facility:.Significant Change in Status Assessment (SCSA)(Comprehensive).3. During the concurrent review of Resident 22's care plans and interview with MDSC H on 8/22/25 at 8:57 a.m., MDSC H reviewed the care plans of Resident 22 and she verified that they were not person-centered and would update them.During an interview with the director of nursing (DON) on 8/25/25 at 10:27 a.m., the DON acknowledged the above concerns and would check on these issues. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review the facility failed to implement their discharge planning process in including residents for their preparation to effectively transition them to post-discharge care for two of three sampled residents (Residents 1 and 2). Resident 1 and 2's records did not contain discharge care plans, interdisciplinary team (IDT, members of healthcare team that meets to discuss and plan resident care) meeting note addressing discharge planning, and referrals being sent to and accepted from shelters (temporary housing) and home health agencies (organization that provides skilled nursing and other therapeutic services to individuals in their homes). This failure resulted in unsafe discharges and placed residents at health and safety risks. Resident 2 after discharge was found sleeping outside a liquor store and admitted to a hospital. Findings: Review of Resident 1's record indicated he had diagnoses including dementia (memory problem) with agitation, failure to thrive (progressive loss of physical and functional abilities, often accompanied by weight loss, poor appetite and inactivity) and anxiety (mental disorder). Review of Resident 1's hospital History and Physical Note, dated 9/21/24, indicated the resident was non-English speaking, had a history of behavior change, agitation and violent behavior against caregiver, had visual hallucinations (seeing images that are not actually present) and was highly suspicious for insidious progression of dementia. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/11/24, indicated his Brief Interview for Mental Status (BIMS) was 3, indicating he had severe cognitive impairment in daily decision-making skills. Resident 1's MDS, dated [DATE] and 1/23/25, indicated there were no active discharge plan for the resident to return to the community. Review of Resident 1's Psychosocial Note, dated 11/8/24 at 2:19 p.m., indicated Resident 1 was being taken care of by a longtime friend, became physically violent over the 10 years, hurt the friend/caregiver and the caregiver wanted no contact with Resident 1. Review of Resident 1's Psychosocial Note, dated 1/20/25 at 2:56 p.m., indicated the resident stated he would like to be back in his hometown community. Review of Resident 1's Psychosocial Note, dated 1/21/25 at 11:12 a.m., indicated the resident had stated he would like to be transferred to a lower level of care, had no income, no family involved in care, and referrals were to be made to a home health agency and case manager for housing. Review of Resident 1's record did not contain discharge care plan, IDT discharge planning notes, referrals with information indicating resident status and acceptance from the shelter and home health agency. During an interview on 1/29/25 at 4:15 p.m., the regional social services director (RSSD) stated Resident 1 was discharged to a homeless shelter and the IDT met weekly discussing resident discharges. The RSSD also stated when a resident was being discharged there should be progress notes addressing discharge planning. During an interview on 3/27/25 at 12:30 p.m., the social services director ( SSD) who documented Resident 1's Psychosocial Notes stated there should have been and were no discharge care plans, no IDT notes, no referrals and acceptances letter from shelters and home health agencies and no notes indicating resident participation in discharge planning. During a follow-up interview on 4/24/25 at 1:40 p.m., the RSSD stated as part of the discharge process the facility sends information such as resident history and physical, rehabilitation notes to shelters and home health agencies, and makes arrangements for sheltered individual as to where to meet for home services. When asked for supportive documentation the RSSD stated everything is done verbally over the phone. No discharge referral or documentation were provided. Resident 1's discharge documentation was requested from the assistant director of nurses (ADON) and/or SSD on 3/27/25, 4/24/25 and 5/15/25 and were not provided. Review of Resident 1's physician's order, dated 1/22/25, indicated the resident may be discharged to home with home health services. Resident 1 was discharged on 1/23/25 at 1:36 p.m. to a shelter. Review of Resident 1's face sheet (document that provides an overview of a residents' information and medical history) indicated the resident was readmitted to the facility on [DATE]. Review of Resident 1's Physician Note, dated 2/6/25 at 12:25 p.m., indicated Resident 1 was readmitted due to dementia and was unable to care for himself. During an interview on 1/30/25 at 11:50 a.m., a staff member (SM) A from Resident 1's shelter stated when residing in the shelter individuals needs to check in daily by 5 p.m. and leave the next day by 9 a.m. and if a person had problem behavior they may not have a bed to return to. The SM A also said the shelter rarely received referral or accepted admission of elderly skilled nursing residents, they are a red flag. 2. Review of Resident 2's record indicated he had diagnoses including alcohol-induced dementia and anxiety. Resident 2's MDS, dated [DATE] indicated his BIMs was 8, indicating he had moderate difficulty with daily decision-making skill. Resident 2's MDS, dated [DATE], indicated no to active discharge planning in returning to the community. Review of Resident 2's Psychosocial Note, dated 11/5/24 at 1145 a.m., indicated the SSD spoke to a Resident 2's family member who stated the family could not care for the resident at home and Resident 2 could not be in a facility that is not locked. Review of Resident 2's Psychosocial Note, dated 1/20/25 at 2:56 p.m., indicated the resident stated he would like to be back to his hometown community, his income was unknown, family uninvolved and the resident would be linked to county resources. Review of Resident 2's Psychosocial Note, dated 1/23/25 at 11:22 a.m., indicated the resident was informed he would be picked up at 9 a.m. (date not specified) for discharge. There was no documentation Resident 2 was informed in advance of where he was going, behavioral expectations of the shelter, and no documentation community resource information was provided. The record also did not contain a discussion indicating whether the resident could manage living in a community without income and social support and if he understood and would abide by the shelter's rules. Review of Resident 2's Psychosocial Note, dated 1/23/25 at 11:31 a.m., written by the RSSD, indicated a family member stated he did not want to be involved and to just call when the resident is dead. It also indicated the discharge plan was to educate Resident 2 upon discharge of resources in the community and to attend programs to help him find permanent housing and mental/behavioral help. There was no documentation Resident 2 was provided with community resource information besides the name and telephone number of the home health agency. Resident 2's record also lacked an assessment determining capability of obtaining assistance from community resources. Resident 2 was discharged from the facility to a shelter on 1/24/25 at 10 a.m. During an interview on 1/31/25 at 12:15 p.m., the regional clinical consultant (RCC) stated discharge planning began on admission, residents' capabilities, goals and interventions were to be identified and documented in progress or IDT notes. During an interview on 3/27/25 at 12:30 p.m., the SSD who documented Residents 2's Psychosocial notes except on the Psychosocial Note on 1/23/25 at 11:31 a.m., acknowledged there were no discharge care plans, IDT discharge planning notes, information of community resources provided, referrals and acceptances from shelters and home health agencies and no notes indicating resident participation in discharge planning. During an interview on 5/12/25 at 10:38 a.m., the administrator (ADM) stated the role of the ADM was to oversee residents' discharges were safe and to document ADM participation in resident progress and or IDT notes. The ADM stated he did not document discharge planning notes for Residents 1 and 2. During an interview on 5/14/25 at 2:30 p.m., the medical director (MD) stated did not know Resident 1 and 2 were discharged to shelters and given the residents' circumstances i.e., no income or family support the discharges may not have been safe. On 1/29/25, 4/24/25 and 5/15/25 the ADON and SSD were asked for discharge documentation i.e. faxed information to shelter and home health agency, community resources given to Resident 2 and were not provided. Review of Resident 2's Hospitalist Discharge summary, dated [DATE] at 11:42 a.m., indicated the resident was brought to the hospital after found sleeping outside a liquor store, he was gravely disabled (unable to obtain basic survival needs of food, clothing and shelter due to a mental health condition), he was currently homeless and complained about his living situation being out in cold weather and did not have any family or friends to turn to. Review of the Facility-Initiated Transfer or Discharge policy, dated October 2022, indicated a post-discharge plan was developed for each resident prior to his or her discharge. This plan was to be reviewed by a member of the interdisciplinary team with the resident at least 24 hours before discharge. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented discharge included explaining to the resident where he/she was going and why, taking steps to minimize anxiety or depression, and nursing notes were to include documentation of appropriate orientation and preparation prior to discharge. The policy also indicated information were to be communicated included the basis for discharge, all special instructions or precautions for ongoing care such as comprehensive care plan goals, resident status, diagnoses and allergies, medications. Review of the Comprehensive Person-Centered Care Plans policy, revised in March 2022, indicated each resident had the right to participate in the planning process and in establishing goals and outcomes of care.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was free from sexual abuse (sexual act that is committed or attempted by another person who is incapable of appraising the nature of the act or unable to give consent) when certified nursing assistant E (CNA E) did not separate female Resident 1 from male Resident 2. As a result of above failure, Resident 1's naked waist down body and Resident 1's private area were exposed to Resident 2. Findings: Review of Resident 1's undated face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 6/13/2023. Review of Resident 1's FS indicated diagnoses included schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods and behaviors), bipolar disorder (a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration),anxiety (persistent, excessive fear or worry for day to day situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily living), dementia (loss of thinking, memory, language and reasoning skills) and hospice care (a specialized care designed to provide comfort and support to individuals with terminal illness). Review of Resident 1's minimum data set (MDS: Resident's clinical and functional assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS) score of 8 of 15 which means 8-12 with moderately impaired cognition. Review of Resident 1's medical doctor (MD)'s progress notes dated 3/20/2025 indicated, orientation to person only, not to place or time. Review of Resident 1's document for change in condition (CIC: a document used to document and report a change in a resident's physical and mental health) evaluation dated 3/18/2025 indicated, Resident (Resident 1) was found in Unit 1 in one of the male resident's (Resident 2) bed laying down with no pants or brief on. The male resident was standing next to her. Review of Resident 2's FS indicated Resident 2 was admitted to facility on 1/30/2025 with diagnoses of dementia and anxiety. Review of Resident 2's MDS assessment dated [DATE] indicated, Resident 2's BIMS score of 12 of 15, which means 8-12 with moderately impaired cognition Review of Resident 2's document for CIC evaluation dated 3/18/2025 indicated, Resident (Resident 2) was seen with a female resident (Resident 1) in his bed. Resident (Resident 1) had no clothes waist down and laying down with Resident (Resident 2)'s bed while the male resident was standing up fully clothed, but belt buckle undone. During concurrent observation and interview with CNA B on 3/20/2025 at 11:30 a.m., noted CNA B was watching Resident 1 in Resident 1's room. CNA B stated she was monitoring Resident 1 one on one basis to prevent Resident 2 was not approaching Resident 1 to prevent further altercations. During an interview with LVN D on 3/20/2025 at 3:35 p.m., LVN D (licensed vocational nurse D) stated CNA E came to LVN D, (LVN D that time was in another unit adjacent to Resident 2's unit) CNA E reported saying that Resident 1 and Resident 2 were in Resident 2's room when CNA E tried to separate both, Resident 2 became aggressive and threatened to hit CNA E on 3/18/2025 around 4:30 p.m. LVN D stated CNA E did not separate both residents, left the Resident 2's room to report to LVN D. Few minutes later when LVN D walked into Resident 2's room, LVN D noted privacy curtain was around Resident 2's bed, Resident 1 was laying in Resident 2's bed with no clothes waist down, naked. LVN D also stated Resident 2 was standing at the foot of the bed with fully clothes on, belt buckle undone. LVN D further stated Resident 1's waist down naked body and Resident 1's private area were exposed to Resident 2. LVN D confirmed there were no staff in the room when he arrived at Resident 2's room. LVN D also stated he was able to get help from another staff, separated both residents, dressed Resident 1 and made her to leave the room. LVN D also stated CNA E should not have left both male and female residents together in room without staff's presence before left the room report to him. LVN D further stated CNA E should have stayed with both residents or separated both residents to prevent sexual abuse altercation (a dispute or conflict involving sexual activity or interactions including inappropriate looking) between Resident 1 and Resident 2. During an interview with CNA E on 3/20/2025 at 3:55 p.m., with the presence of facility's director of staff development (DSD), CNA E stated she noticed Resident 1 sitting on Resident 2's bed, fully clothed. When CNA E tried to separate both residents, Resident 2 became aggressive, threatened to hit CNA E with belt and asked CNA E to leave the room. CNA E got scared, called for help, no staff came. CNA E left the room and walked to another unit to report to charge nurse (charge nurse was in other unit that time). CNA E also stated she did not separate both residents before she left to report to charge nurse. CNA E also stated she should have waited for help to come or separated both residents before she left Resident 2's room to prevent sexual abuse altercation between Residents 1 and 2. During an interview with DSD on 3/20/2025 at 4:14 p.m., DSD stated CNA E should have not have left Resident 1 and 2 in a room for Resident 1's safety and prevent sexual altercation. DSD also stated this sexual abuse altercation could have been prevented if CNA E did not leave Resident 2's room or separated Resident1 from Resident 2. During an interview with facility's assistant director of nursing (ADON) on 3/20/2025 at 4:20 p.m., ADON stated CNA E should not have left both male and female residents in a room together alone to prevent sexual altercation and safety of the female resident. During an interview with facility's director of nursing (DON) on 4/18/2025 at 1:32 p.m., nursing staff should have separated both residents to prevent and residents were free from sexual abuse altercations. Review of facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised December 2016, the P&P indicated, Our Residents have the right to be free from abuse.

Based on interview and record review, the facility failed to monitor the whereabouts and implement fall care plan interventions for one of two residents (1) when Resident 1 fell while ambulating with no staff present at the time of the fall. These failures resulted in Resident 1 sustaining a proximal right humeral fracture (fracture at the top of the right arm bone). Findings: Review of Resident 1's Admission Record indicated she was admitted with [DIAGNOSES REDACTED]. Review of Resident 1's Morse Fall Scale (a method of assessing a resident's likelihood of falling), from 6/18/18 to 12/24/18, indicated she was moderate to high risk for falling. Review of Resident 1's Post Fall Incident Investigation, dated 7/11/18, indicated she fell in the courtyard and sustained front right knee redness. Review of Resident 1's fall care plan, initiated on 7/11/18 and revised on 11/19/18, indicated an intervention of visual check. Review of Resident 1's Fall Incident Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reports, dated 7/11/18, 11/11/18, and 12/10/18, indicated the intervention was to monitor Resident 1's whereabouts. Review of Resident 1's Post Fall Incident Investigations, from 10/10/18 to 12/10/18, indicated Resident 1 fell four times while ambulating with no staff present at the times of the falls: On 10/10/18 Resident 1 fell in the courtyard and sustained a bruise at the corner of the mouth and redness on the right cheek; On 10/14/18 Resident 1 fell in the courtyard with no injury; On 11/11/18 Resident 1 fell in another resident's room and sustained a skin tear on the bridge of her nose; and On 12/10/18 Resident 1 fell in the hallway with no injury. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 12/17/18, indicated her cognitive skills for daily decision making were severely impaired and Resident 1 needed supervision when she ambulated. The MDS under section G Walk in corridor, Locomotion on unit, and Locomotion off unit indicated Resident 1 needed supervision and with one-person physical assist. Review of Resident 1's Physical Therapist Progress notes, dated 12/20/18, indicated Resident 1 had standing balance and muscle strength deficits and required hand held assist with initiation cue, visual instruction/cues for safety when she ambulated on level surfaces. Review of Resident 1's Post Fall Incident Investigation, dated 1/2/19, indicated Resident 1 fell in the courtyard while ambulating and sustained a front right knee abrasion. No staff were present at the time of the fall. Resident 1 was sent to the hospital for complaint of pain on the right shoulder. Review of Resident 1's acute care emergency department provider notes, dated 1/2/19, indicated Resident 1 sustained a proximal right humeral fracture and final [DIAGNOSES REDACTED]. During an interview with restorative nursing assistant A (RNA A) on 1/8/19 at 10:45 a.m., she stated she was in the smoking area and heard a sound from the side of the building. She went over and saw Resident 1 lying on the ground. During an interview with certified nursing assistant B (CNA B) on 1/10/19 at 1:45 p.m., she stated there was no staff watching the residents while they ambulated in the courtyard. If she did not see her residents in the building, she would look for them in the courtyard. During an interview with CNA C on 1/10/19 at 2 p.m., she stated there was no staff watching the residents while they ambulated in the courtyard. If she did not see her residents in the building, she would look for them in the courtyard. During an interview with CNA D on 1/10/19 at 2:15 p.m., he stated the residents were not allowed to go to the courtyard because there was no staff watching them there. He monitored the residents, but sometimes he was busy and residents went outside. If he did not see his residents in the building, he would look for them in the courtyard. Review of the facility's undated policy, Fall Prevention Program Policies and Procedures, indicated The Registered Nurse Care Manager (RNCM) will complete an assessment of the resident's fall risk and a care plan will be implemented to reduce falls and prevent injury within State and Federal time frames beginning at admission.

Based on observation, interview, and record review, the facility failed to provide supervision and a safe environment for one of three residents (Resident 1) when staff did not supervise Resident 1 while she was sitting upright in a wheelchair without footrests. This resulted in a fall with injury (forehead lacerations and rib fractures). Findings: Review of Resident 1's admission record indicated Resident 1 was admitted with [DIAGNOSES REDACTED]. a clear cause), and anxiety disorders (restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping). Review of the Minimum Data Set (MDS, an assessment tool) dated 4/18/17 indicated Resident 1 was total dependent for all activities of daily living (ADL's). Review of Resident 1's Morse Fall Scale (a method of assessing a patient's likelihood of falling) dated 4/18/17 indicated she was a high risk for falls. During an interview with the director of nursing (DON) on 6/14/17 at 1:15 p.m., she stated Resident 1 was assessed by the occupational therapist (OT, a person who helps people to fully engage in their daily lives, from their work and recreation to activities of daily living like getting dressed, cooking, eating and driving) to have poor trunk control. The DON also stated, as per OT's assessment Resident 1 required a Tilt-in-Space wheelchair (a wheelchair that reduces the risk of slumping and sliding for people who are at risk of falling out of a wheelchair) for safety. During an interview with certified nursing assistant A (CNA A), on 6/26/17, at 10:20 a.m., she stated after lunch she prepared to transfer Resident 1 from wheelchair to bed. She set the wheelchair to upright position and removed the footrests. While waiting at the room door for CNA B to come and help her with the transfer, she saw CNA C helped a resident who almost fell . She then went to help CNA C. While helping CNA C, CNA B came and told her Resident 1 fell . She came to the room and saw Resident 1 with her face turned to her side and her head was lying on a bloody floor. During an interview with CNA B, on 6/14/17, at 2:10 p.m., she went in to Resident 1's room to help CNA A with the transfer and saw Resident 1 lying chest down on the floor. Her head turned to the side, and was lying on a bloody floor. CNA A was not in the room. During an interview with CNA C, on 6/14/17, at 4:20 p.m., she stated CNA A came to help her with a resident who almost fell from the hallway bathroom back to her room. While in the room she heard someone asked someone to call 911 for Resident 1. She came to Resident 1's room and saw her on the floor lying on her chest, her face turned to the side and her head lying on a bloody floor. Resident 1's wheelchair was in upright position and had no footrests on. During an observation on 6/14/17, at 1:45 p.m., Resident 1 was lying in bed with her eyes opened. There was 1.5 x 1.5 centimeters (cm. - unit of measurement) dry reddish brown scab on the right side of her forehead. The area was slightly swollen. Review of Resident 1's Interdisciplinary Meeting notes indicated Resident 1 sustained a laceration on right side of forehead and fractures on second to fourth ribs because of the fall. During an interview with licensed vocational nurse D (LVN D), on 6/16/17, at 3:45 p.m., she stated she had been working with Resident 1 since her admission. When Resident 1 was in the wheelchair, she needed to have the footrests and the wheelchair should be tilted back. Otherwise, she would fall because she had tendency to lean forward. During an interview with the director of staff development (DSD), on 6/22/17, at 11:55 a.m., she stated for Resident 1's safety she could not be left alone while she was in the wheelchair in upright position and the footrests were off. Even if the wheelchair was in the tilted back position and the footrests were on, Resident 1 could be left alone only for a short time. Review of Resident 1's OT Progress & Discharge Summary dated 4/24/13 indicated, The patient tolerates upright sitting in chair/wheelchair maintaining proper postural alignment for 1 minute. Patient demonstrates continuous non purposeful motor movements . The patient did not make significant progress toward goals. Standard manual wheelchair not appropriate for this patient due to motor movements. Requested Broda chair (tilt and recline positioning chair) from medical group . Precautions Fall risk . The facility policy and procedure titled Safe Lifting and Movement of Residents revision dated 12/2013, indicated In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.

Based on interview and record review, the facility failed to adequately supervise and prevent an accident and injuries for one of three sampled residents (Resident 1) who had a history of [REDACTED]. Findings: Resident 1's clinical record was reviewed and indicated he had [DIAGNOSES REDACTED]. to think and remember influencing their daily functioning). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/4/16, indicated Resident 1's cognition and vision were moderately impaired. It further indicated Resident 1 had impaired balance and required the assistance of one person for walking, standing, and transferring from one surface to another, with or without an assistive device (walker or wheelchair). A review of Resident 1's fall risk assessment dated [DATE], indicated Resident 1 had a fall risk score of 17 (score of 10 or above indicated high risk for falls). The nurses notes dated 4/16/16, at 3:30 p.m. indicated Resident 1 had an unwitnessed fall outside the building in the courtyard. The interdisciplinary team (IDT, team members from different departments involved in a resident's care) note dated 4/16/16, indicated staff would do stand-by assist when Resident 1 was walking and staff would monitor Resident 1's whereabouts. The nurses notes dated 4/23/16, at 4 p.m., stated Resident 1 had an unwitnessed fall in the courtyard with skin abrasions on his forehead and nose bridge. The IDT note dated 4/25/16, indicated staff would continue to monitor Resident 1's whereabouts because of his poor safety awareness. The care plan (CP), also dated 4/25/16 indicated staff should assist Resident 1 when he walked. The nurses note dated 5/9/16, at 9:55 p.m., stated Resident 1 had an unwitnessed fall in the dining room. The IDT note dated 5/10/16, indicated staff should remind Resident 1's family to notify them at the end of a visit. Nurses note dated 5/19/16 at 7:15 p.m., indicated Resident 1 had another unwitnessed fall outside of the building. During a telephone interview with the activity assistant (AA) on 6/14/16, at 2:35 p.m., she stated she heard a scream and found Resident 1 by himself, laying on the ground outside of the building, on 5/19/16 at around 7 p.m. The AA stated staff sent Resident 1 to the hospital that evening. A review of Resident 1's hospital discharge instructions dated 5/19/16 indicated Resident 1's hip X-ray was negative for fracture and Resident 1 was transported back to the facility with a [DIAGNOSES REDACTED]. A review of Resident 1's physician orders [REDACTED]. The PO dated 5/20/16, at 8:53 a.m. indicated medication orders to start Tramadol (a pain medication to treat moderate to severe pain) and Norco (a narcotic pain medication for severe pain). During an interview with registered nurse A (RN A) on 6/2/16, at 3:50 p.m., he stated staff should watch Resident 1 within a 20 foot viewing distance. During an interview with registered nurse B (RN B) on 6/20/16 at 11 a.m., she stated Resident 1 began taking Norco on 5/20/16. RN B stated Resident 1 refused to get out of bed, was able to sleep, but when he was turned for toileting he would cry out in pain. RN B stated Resident 1 did not improve and was sent to the hospital emergency department on 5/24/16 and had surgery to repair the hip fracture that evening. During an interview with the primary care physician (PCP), she stated on 5/24/16, Resident 1's family member left her a telephone message about Resident 1's continued pain. The PCP stated she then asked an orthopedic physician to review Resident 1's 5/19/16 hip X-ray and confirmed Resident 1 had a fracture in the left hip. The PCP then ordered Resident 1's return to the hospital for treatment. The hospital discharge summary, dated 5/27/16, at 2:17 p.m., indicated Resident 1 underwent an interval left femur fracture fixation (surgery to repair the fractured hip) on 5/24/16. During an interview with CNA B on 6/2/16, at 4:05 p.m., he stated he was responsible for Resident 1 on 5/19/16 but he was supervising residents on a smoke break at the time Resident 1 fell . CNA B stated he knew Resident 1 needed supervision. During an interview with the director of nursing (DON) on 6/2/16 at 4:45 p.m., she stated the staff were responsible for Resident 1 and should be held accountable for his whereabouts, especially because Resident 1 was ambulatory and had a high risk for falls. During an interview with the family member (FM) on 6/14/16, at 4:05 p.m., she stated Resident 1 was never supposed to walk alone. During an interview with the minimum data set coordinator (MDSC) on 6/15/16 at 9:10 a.m., she stated Resident 1 had to be supervised at all times. The MDSC stated Resident 1 had fluctuating cognition and was not safe by himself. The facility's 2001 policy, Falls and Fall Risk, Managing indicated if a resident had multiple falls, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. The facility's 2001 policy Safety and Supervision of Resident indicated the implementation of interventions to reduce accident risks and hazards should include communication of interventions to staff and assignment of responsibility to designated staff to carry out interventions. The policy indicated resident supervision should be a core component of the systems approach to safety: the type and frequency of resident supervision should be determined by the individual resident's assessed needs.

Based on observation, interview and record review, the facility failed to ensure five of 14 sampled residents (1, 2, 3, 10, and 13) were free from restraints. For Residents 1, 2, and 3 the facility failed to ensure they were not tied in a chair with a gait belt by certified nurse assistants. For Resident 10, the facility buckled the seat belt across the front of the resident when she sat in the dining room without a medical indication or physician's order. Resident 13 also had a lap tray across her wheelchair and full long side rails with no adequate medical indication. The facility also placed the long side rails without attempting appropriate lesser restrictive interventions. This failure restricted the resident's movement thereby confining the resident. Findings: 1. Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/9/12 indicated Resident 1 was severely impaired in cognitive skills for daily decision making, had physical and verbal behavioral symptoms directed toward others, ambulated with a front wheeled walker and a gait belt, and had an impairment in one leg. Resident 2's MDS dated [DATE] indicated Resident 2 was severely impaired in cognitive skills for daily decision making, had physical behavioral symptoms directed toward others and ambulated with a walker and a gait belt. Resident 3's MDS dated [DATE] indicated Resident 3 was severely impaired in cognitive skills for daily decision making, had short and long term memory problems and ambulated without assistance. During interview on 2/9/12 at different times, none of these residents were able to answer questions due to their cognitive status. Also, none of these residents had physician orders for restraints. During a telephone interview on 2/10/12 at 2:10 p.m., certified nurse assistant A (CNA A) stated that on 11/13/11, when she was assigned to assist residents with activities in the activity room, she noticed two CNAs (CNA B and CNA C) tied Residents 1, 2, and 3 in their wheelchairs with gait belts. CNA A stated when she noticed one of the residents "trying" to stand up, she released the belt for him. She stated during the same time, another CNA brought another resident tied in a wheelchair with a gait belt and positioned him next to the other residents who were tied in a chair. CNA A stated a licensed nurse administered medications to the residents while they were tied to the chair with gait belts. When further asked, she stated the licensed nurse made no comment so she (CNA A) assumed it was the evening shift routine to have residents in a wheelchair tied with a gait belt. During interview on 2/15/12 at 8:25 a.m., CNA B stated in the past, they had used lap trays across the Gerichair to enable the licensed nurses to administer medications to the residents. He stated when the Gerichairs got ruined, they started using gait belts across the wheelchairs to prevent residents from rising. CNA B stated Residents 1, 2, and 3 got agitated and forceful. CNA B stated two licensed nurses on evening shift had always requested them to put the residents in the chair with the gait belts tied across them. CNA B stated another certified nurse assistant (CNA E) also applied gait belts on the residents. He stated CNA E was the one who would always ask the licensed nurse what they wanted the CNAs to do with the resident during medication pass and they would say to the CNAs "Tie them down." CNA B stated, " We all have done it", referring to tying residents in the wheelchair with gait belts. During interview on 2/13/12 at 2:05 p.m., CNA C stated in the past, an evening shift licensed nurse (LN H) who no longer worked at the facility had asked him to place Resident 2 in the Gerichair with a gait belt so that she could administer medications. He stated he only used the gait belt on Resident 2 to prevent him from rising as instructed by the licensed nurse. During an interview with the administrator on 2/9/12 at 10:40 a.m., he stated he was aware of the allegation of abuse by using gait belts across the arms of chairs to restrain Residents 1, 2, and 3 in chairs. He stated he did not document the date in January when he was made aware of the allegation of staff using gait belts, but it was in the beginning of January 2012. During an interview with Resident 12 on 2/10/12 at 8:30 a.m., he stated he had seen residents in the large activity room with safety belts tied across the front of their chairs so they do not get out. He stated the belts were placed across the front of the chairs to keep the residents from getting up out of the chair and falling. He also stated it happened around December 2011. During an interview with the administrator on 2/10/12 at 8:45 a.m., he stated during his investigation of the incidents concerning the use of gait belts placed across the chair to restrain a resident, he was informed by licensed nurse G (LN G) she entered early one morning the large dining room and a gait belt was around the arms of a chair with a resident in the chair. During an interview with LN G on 2/10/12 at 11:25 a.m., she stated she remembered she came in early, entered the large dining room and saw a gait belt tied around the arms of Resident 2's chair. She stated she thought the incident occurred a couple of months ago. During an interview with CNA F on 2/14/12 at 9:20 a.m., she stated before Thanksgiving 2011 she came in early about 6:40 a.m. and she noticed Resident 2 sitting in a high back chair in the large dining room. She stated there was a gait belt tied across the front of the resident's chair. She stated there was no staff present in the room so she did not ask about the gait belt. She stated Resident 2 could not have placed the belt around the arms of the chair and then across the front of the chair. During interview on 2/9/12 at 11:22 a.m., Resident 11 stated he had noticed staff placed belts across the residents in the dining room to strap them down. He stated he noticed that a lot in the evenings. Resident 11 stated "They can't do that to me." During review of the personnel file of certified nurse assistant B (CNA B) on 2/14/12, an Employee Verbal Counseling Verification Form documented on the evening shift of 12/19 or 12/20/11 CNA B's resident was seen to have a gait belt over his knees while in the chair. The form indicated the employee was counseled regarding "bad practice" on 12/28/11. 2. A record review was done on 2/8/12. Resident 10 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS also indicated Resident 10 had no restraint. A review of the February , 2012 physician order indicated Resident 10 had no order for a restraint. During an initial tour observation on 2/8/11 at 8:10 a.m. and 9:25 a.m., Resident 10 sat in a wheelchair in the dining room with a buckled belt across her lap. During interview on the same date at 9:27 a.m., nursing supervisor 1 (NS 1) walked over to the dining room, saw the resident with a belt and stated there was no physician orders for the seat belt. NS 1 stated the belt should not be buckled. A 2/10/12 nurse's late entries note at 7 a.m. and 10 p.m., indicated on 2/9/12 Resident 10 was found seated in a wheelchair with a seat belt on. When asked on 2/14/12 at 10:08 a.m., CNA J stated the resident had always had on the belt. She stated licensed nurses had seen the belts buckled but they did not say anything, so she thought it was okay. During interview on the same date at 11:25 a.m., CNA K stated everyone in the unit knew Resident 10 always had on the belt. She stated the licensed nurse did not discourage them from using it so the CNAs thought the resident had a physician orders for it. On the same date at 11:40 a.m., NS 1 stated the belt was to prevent the resident from falling. She stated Resident 10 "Never" had an order for [REDACTED]. 3. Resident 13 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS section "P" was inaccurately coded for a trunk restraint, when none was used. There was also no marking in the appropriate space to indicate a lap tray was used. The MDS also indicated Resident 13 ambulated with one person assist. A 1/6/12 fall risk assessment indicated Resident 13 was at high risk for fall. A review of 1/12/12 care plan "Risk for fall" indicated Resident 13 fell in 5/09 and sustained a [MEDICAL CONDITION]. A lap tray assessment dated [DATE] indicated the reason for the lap tray included unable to follow instruction, poor safety awareness, unsteady gait and slides out of chair. A bedrail assessment dated [DATE] indicated the reasons for the bedrail use included to prevent fall, episodes of restlessness at night, resident attempts to get up and ambulate independently and unsteady gait and balance. A physician order read: 5/15/09 -"Both side rails up while on bed for safety and positioning" 9/8/10- "May use wheelchair with lap tray for safety due to poor safety awareness." The following observations were made on these dates: 2/8/12 from 9:15 a.m. to 1 p.m. -resident sat in the dining room with a lap tray across her lap 2/9/12- from 8:30 to 12 p.m. resident sat in the dining room with the lap tray on 2/10/12- 9:22 a.m. to 1:18 p.m. resident sat in the dining room with a lap tray on On 2/14/12 at 10:30 a.m., Resident in bed awake and alert, with bilateral long rails on. At 3:12 p.m. on the same date, Resident 13 sat outside in the patio with a family member. During observation on 2/14/12 at 2:50 p.m., a family member (FM) walked with the resident in the center patio. During interview on 2/14/12 at 3:12 p.m., the FM sat outside in the patio with the resident and stated he was concerned Resident 13 sat in the dining room all the time. When asked about the lap tray, FM stated the facility told him they placed the lap tray to prevent her from falling. FM stated the facility informed him about the lap tray after they had already placed it. FM stated Resident 13 liked to be outside. FM was concerned staff do not walk the resident around the facility. He stated, "She's always sitting there." During interview on 2/13/12 at 5:20 p.m., certified nurse assistant L (CNA L) stated Resident 13 had the lap tray to prevent her from falling. CNA L stated Resident 13 had a history of [REDACTED]. She stated FM walked around the patio with the resident every time he visited. She stated the bilateral long rails were to prevent her from getting up at night because of a previous fall. When asked on 2/15/12 at 12:10 p.m., nursing supervisor 1 (NS 1) stated Resident 13 stayed in the dining room most of the day and did not respond to redirection. She stated both the full long rails and the lap tray were placed to prevent the resident from further falls. She stated the most appropriate thing to do during the day would be to release the tray frequently and have a CNA walk the resident. When asked on 2/16/12 at 9:40 a.m., the director of nurses (DON) reviewed the records and stated the indications for both restraints did not include the medical indications for use. Regarding the lap tray DON stated staff should release the lap tray to allow the resident to ambulate as well as monitor and document the frequency of monitoring of the lap tray. As for the full rails she stated she could not find any documentation indicating the facility tried lesser restrictive interventions before placing full side rails. She stated having a history of falls was not an acceptable indication for placing full long bilateral siderails. The back of the facility's informed consent form for physical restraint indicated a chair belt could increase the risk for fall if a resident attempts to stand and may also give the resident a false sense of security and potential for injury. A chair with a tray, commonly called a Gerichair, can be considered a restraint. If the tray goes across the front of the patient and is not easily removed it may be difficult for them to stand up or get out of the chair without assistance. The trays may also cause falls if the patients tries to climb over them. Even without a tray a patient with limited mobility may have difficulty getting out of the chair. (http://www.ehow.com/about_ 84_types-nursing-home-restraints.html) Gait belts could be used when transferring residents who are partially dependent, have some weight-bearing capacity, and are cooperative. Also use during transfers such as bed to chair, chair to chair, or chair to car; when repositioning residents in chairs; supporting residents during ambulation; and in some cases when guiding and controlling falls.(en.wikipedia.org/wiki/Gait_belt) Restraining patients should only be done when absolutely necessary. Older restrained patients are eight times more likely to die than an unrestrained patient, according to Carol Taylor in "Fundamentals of Nursing." A patient should never be restrained as a matter of convenience and restraint should be used as a last resort. (http://www.ehow.com/about_ 84_types-nursing-home-restraints.html) The facility's policy and procedure, "Use of restraints" dated 7/09 indicated restraints should only be used to treat resident's medical symptoms and never for staff convenience or prevention of falls. The policy also indicated restraints should only be used with a written order from a physician. It further indicated the physician order should include the specific reason for the restraint, period of time for the use of restraint and how the restraint would benefit the resident's medical symptoms.