Every finding on record at Hillcrest Nursing Home

Residents did not have a dignified experience when residents were sitting at a table and one resident was served lunch and the others had to wait 15 minutes for their lunch on September 29, 2025 Based on observation, interview, and record review, the facility failed to ensure residents who were sitting on the same table were served at the same time for three of five residents reviewed for dining observation (Residents 23, 29, and 36) when Residents 23, 29, and 36 receive their food 10 minutes after Residents 5 and 47 were served their lunch.This failure had the potential for Residents 29, 23, and 36 to feel less dignified and respected because they had to sit and watch other residents eat their lunch. Findings:During an observation on September 29, 2025, at 12:05 pm, in the north dining room, there were multiple dining tables pushed together to make one long table. Five residents were seated at this table (Residents 5, 23, 29, 36, and 47). Two (Residents 5 and 47) of the five residents were served their lunch. The remaining three residents (Residents 23, 29, and 36) were waiting for their food.During an interview with the Dietary Supervisor (DS), in the north dining room, on September 29, 2025, at 12:13 PM, the DS stated the food cart that transports the food from the kitchen to the dining room was limited on how many trays it held. The DS further stated Residents 23, 29, and 36's meals should be coming in the next cart.During further observation, in the north dining room, on September 29, 2025, at 12:15 PM, Residents 23, 29, and 36 received their food, while Residents 5 and 47, who received their food earlier, were finished with their meals.During an interview with the DS, on September 30, 2025, at 2:05 PM, the DS stated residents who were sitting at the table should be eating at the same time. The DS further stated one person should not be eating while the others were waiting for their food.During a review of the facility's policy and procedure titled, Meal Service, dated 2023, it indicated, 5. All residents at the same table should be served at the same time.

The facility did not implement antibiotic stewardship program according to facility policy.Based on interview and record review, the facility failed to implement its policy and procedure on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for two of six residents reviewed for antibiotic use (Residents 1 and 17) when Residents 1 and 17's Loeb's [a set of clinical guidelines for healthcare providers in long-term care facilities to help them decide when to start antibiotics for residents] Minimum Criteria for Initiating Antibiotic Therapy form were not filled out completely. This failure had the potential to place Residents 1 and 17 at risk for adverse events (undesirable physical side effects or harm resulting from medical treatment), including the development of antibiotic-resistant organisms (bacteria that are no longer killed by the antibiotics designed to destroy them), from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of Resident 1's face sheet, it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cystitis (condition when bladder gets swollen and sore) and paranoid schizophrenia (type of a serious brain illness that makes it hard for a person to tell the difference between what is real and what is not real).During a review on of Resident 1's physician's order, dated November 13, 2025, it indicated, Cephalexin [aka Keflex- antibiotic medication used to treat a wide range of bacterial infections in the body] Oral Tablet 500 MG [milligram - unit of measure]. Give 1 tablet by mouth three times a day for r/t [related to] skin tear with redness to (R) [right] hip for 7 Days. A review of Resident 1's Medication Administration Record (MAR) for the month of November 2025, indicated Resident 1 received the prescribed Cephalexin oral tablet from November 13, 2025, through November 17, 2025. During an interview and concurrent record review on November 17, 2025, at 3:45 PM, with the ICP nurse, the ICP nurse reviewed Resident 1's Loeb's [a set of clinical guidelines for healthcare providers in long-term care facilities to help them decide when to start antibiotics for residents] Minimum Criteria for Initiating Antibiotic Therapy form , dated November 10, 2025, which indicated Resident 1 had a suspected Skin and Soft Tissue Infection, and the criteria selected was new or increasing purulent drainage [the medical way of saying a wound is leaking thick, often yellowish, fluid from an infected cut or wound]. The portion of the form indicating whether SSTI was evaluated or whether the criteria were met was left blank. The ICP nurse confirmed the form was incomplete and stated that it should have been completed to indicate whether the initiation of antibiotics was appropriate for Resident 1. 2. During a review of Resident 17's face sheet, it indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia and hyperlipidemia (abnormally high level of fats in the blood),During a review of Resident 17's physician's order, dated November 10, 2025, it indicated, . Keflex Oral Capsule Give 500 mg by mouth three times a day for mole on forearm r/t redness and dry yellow drainage for 10 Days. A review of Resident 17's MAR for the month of November 2025, indicated Resident 1 received the prescribed Keflex oral capsule from November 10, 2025, through November 17, 2025. During an interview and concurrent record review on November 17, 2025, at 3:45 PM, with the ICP nurse, the ICP nurse reviewed Resident 17's Loeb's Minimum Criteria for Initiating Antibiotic Therapy form, dated November 10, 2025, which indicated Resident 17 had a suspected Skin and Soft Tissue Infection, and the criteria selected was new or increasing purulent drainage. The portion of the form indicating whether the information gathered, was evaluated or whether the criteria were met, was left blank. The ICP nurse confirmed the form was incomplete and stated that it should have been completed to indicate whether the initiation of antibiotics was appropriate for Resident 17. During a follow up interview on November 17, 2025, at 4:20 PM, with the ICP nurse, the ICP nurse stated The facility used the Loeb Criteria to help us decide if it's real infection or just symptoms that look like an infection. This process helps ensure that we administer antibiotics only when indicated by the criteria.During a concurrent interview and record review on November 17, 2025, at 4:30 PM, with the Director of Nursing (DON) and the ICP nurse, the DON and ICP nurse reviewed Residents 1 and 17's clinical records and were not able to locate any documentation showing any analysis (looking for trends, spikes, or unusual patterns in the data) to determine if infection was present before antibiotic were used. The ICP nurse stated that he should have been ensuring the completion Loeb Criteria and conducting an analysis to confirm the real infection, to support the appropriate use of antibiotic for Resident 1 and 17. During an interview and concurrent record review on November 17, 2025, at 4:35 PM, with the DON and ICP nurse, the DON and ICP nurse reviewed the facility's policy and procedure (P&P) titled, Antibiotic Stewardship [programs to ensure effective and safe use of antibiotics] - Review and Surveillance [process of continuously and systematically collecting, analyzing, and sharing data] of Antibiotic Use and Outcomes. The P&P indicated, Policy Statement. Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for-improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation. 1. As part of the facility antibiotic stewardship program, all clinical Infections treated with antibiotics will undergo review by the infection preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings . The DON stated the analysis should have been conducted to identify trends in antibiotics use, prevent unnecessary prescriptions, and reduce the spread of drug-resistant infections, but it was not. The DON further stated that the facility's P&P was not followed.During an interview and concurrent record review on November 17, 2025, at 4:45 PM with ICP nurse, the ICP nurse reviewed the facility's P&P titled, Infection Preventionist, dated 2001, which indicated, Policy statement. The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Policy Interpretation and Implementation. 5. The infection preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. The ICP nurse stated he was responsible for the oversight of the facility infection control program. The ICP nurse further stated that the facility's P&P was not followed.

Three rooms have less than 80 square feet per resident in rooms [ROOM NUMBER].Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for three of 32 resident rooms (rooms [ROOM NUMBER]). This failure had the potential for the residents housed in rooms [ROOM NUMBER] to not have the ability to move about freely if the square footage limited their personal space. Findings:During a concurrent interview and record review, with the Administrator (Admin), on September 29, 2025, at 8:45 AM, the Admin reviewed the Entrance Conference Checklist and stated the facility had room waivers for rooms [ROOM NUMBER], which had less than the required square footage of livable space (less than 80 square feet). During an environmental tour with the Maintenance Supervisor (MS), on November 18, 2025, at 2:00 PM, rooms [ROOM NUMBER] were inspected and the residents' rooms and their measurements of livable space were noted as follows:1. room [ROOM NUMBER] (two beds) measured 151.66 sq. ft = 75.8 sq. ft. per resident2. room [ROOM NUMBER] (two beds) measured: 141.16 sq. ft = 70.6 sq. ft. per resident3. room [ROOM NUMBER] (two beds) measured: 141.67 sq. ft = 70.8 sq. ft. per resident During a follow-up interview with the Admin on November 18, 2025, at 2:15 PM, the Admin confirmed the measurements of the three resident rooms, and stated rooms [ROOM NUMBER] did not meet the 80 sq. ft per resident requirement. The Admin further stated the rooms were not crowded, did not impose any safety hazards to the residents and there were no complaints about space or room issues from the residents occupying these rooms.The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when: 1. Cut watermelon and butter were stored in refrigerator at a temperature of 60 degrees Fahrenheit (unit of measurement). 2. Two cracked and chipped spatulas were observed in the kitchen's utensils drawer. 3. The microwave's anti-splatter shield had a layer of food residue. These failures had the potential to cause foodborne illnesses to 51 residents who receive food served by the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS) in the kitchen, on July 22, 2024, at 8:31 AM, a tray with individual servings of cut watermelon and a tray containing several quarter-pound sticks of butter was inside the walk-in refrigerator. The temperature of the walk-in refrigerator was 60 degrees Fahrenheit. The DSS stated their walk-in refrigerator stopped functioning around 7:00 AM (One and half hour ago). The walk-in temperature was found to be 19 degrees Fahrenheit above the proper holding temperature of 41 degrees Fahrenheit (or lower). During an interview with the DSS, on July 25, 2024, at 10:39 AM, the DSS stated the cut watermelon and butter needed to be refrigerated at the proper holding temperature (41 degrees Fahrenheit or lower). The DSS further stated both food items were ultimately disposed of and reordered. During a review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, 1. Refrigerator - 41 F or lower Freezer 0 F or lower to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 F lower. For example, to hold chicken at 41 F, the air temperature must be 39 F . During a review of the 2022 Food Code by the U.S. FDA (United States Food and Drug Administration), dated 2022, the 2022 Food Code indicated, 3-202.11 Temperature (A) Except as specified in (B) of this section, refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be at a temperature of 5 C (41 F) or below when received. 2. During a tour of kitchen, with the DSS, on July 22, 2024, at 8:54 AM, an observation of the kitchen's utensils drawer was conducted. Two spatulas, which were inside the drawer, were inspected. Pieces of the rubber parts of the spatulas were missing and cracked, while one was also discolored. During an interview with the DSS, on July 25, 2024, at 10:43 AM, the DSS stated broken utensils are to be replaced upon discovery of damage. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas During a review of the 2022 Food Code by the United States (U.S.) Food and Drug Administration (FDA), dated 2022, the 2022 Food Code indicated 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. 3. During an observation of the kitchen, with the DSS, on July 22, 2024, at 8:51 AM, the facility's microwave was inspected. The microwave's anti-splatter shield, which was inside the microwave, had a layer of old and hardened brown food residue spanning the inner upmost portion of the shield. During an interview with the DSS, on July 25, 2024, at 10:41 AM, the DSS stated the anti-splatter shield should be cleaned after service prior to its next use. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . During a review of the 2022 Food Code by the U.S. FDA, dated 2022, the 2022 Food Code indicated . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .

Based on observation, interview, and record review, the facility failed to ensure menus were followed for 21 residents on a regular and Controlled Carbohydrate diet (CCHO- eating the same amount of carbohydrates every day, to help keep blood sugar, or glucose levels stable) during lunch on July 22, 2024. This failure had the potential for 21 residents on a regular and CCHO diet to have altered nutritional intake and weight loss. Findings: During a review of the Cooks spreadsheet, dated July 22, 2024, the lunch menu indicated the following serving sizes, Salisbury steak: 3 oz (small), 4 oz (regular), 4 oz (large). During an observation of the kitchen's meal preparation and tray line (system of food preparation where hot and/or cold foods are held and served) for lunch on July 22, 2024, at 11:40 AM, with the Dietary Services Supervisor (DSS) and cook, a prepared plate to represent residents on regular and CCHO diet was selected for weight validation. The Cook, along with assistance from the DSS, was asked to remove and weigh the Salisbury steak from the prepared plate using the kitchen food scale. The DSS placed the Salisbury steak on the scale and noted its weight at 3 oz, 1 oz below the menu's provision of 4 oz (for those on a Regular diet). During an interview on July 25, 2024, at 10:39 AM, with the Registered Dietician (RD) and DSS, the RD stated the facility never aims to serve less than what is specified on the menu, but to serve that amount as the minimum. During a review of the facility's policy and procedure (P&P) titled, Regular Diet, dated 2023, the P&P indicated, The regular diet is designed to meet the nutritional needs of residents who do not need dietary modifications or restrictions. Individual preferences or intolerances may necessitate the exclusion of certain food items.

Based on interview and record review, the facility failed to ensure the code status (emergent treatment options during a life-threatening event) and Advance Directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), were consistent and accurately documented for two of 12 residents reviewed for Advanced Directives (Residents 15 and 47). These failures had the potential to result in a delay of treatment for Residents 15 and 47 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: 1. During a review of Resident 15's Admission Record (contains demographic information), it indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), asthma (a condition that affects the lung airways), and schizoaffective disorder (a mental health condition that is a mixture of a person seeing things or hearing things that others do not observe as well as having periods of high and low sadness and happiness). During record review of Resident 15's Advance Directives, signed by Resident 15 on October 6, 2023, it indicated Do Not Resuscitate (DNR - tells the health care team that the resident does not want any lifesaving efforts performed). During a review of Resident 15's Code Status in her EHR (Electronic Health Record), it indicated a Full Code (tells the health care team to do any and everything to save your life if the person has no heartbeat and is not breathing). During a concurrent interview and record review with the Director of Nursing (DON), on July 26, 2024, at 10:15 AM, the DON reviewed Resident 15's Advance Directives and compared it with the Code Status on her EHR. The DON stated the Code Status on Resident 15's EHR did not reflect the accurate information of her signed Advance Directives. 2. During a review of Resident 47's Admission Record, it indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder and hypertension. During record review of Resident 47's Advance Directives, signed by Resident 47 on October 6, 2023, it indicated Full Code. During a review of Resident 47's Code Status in her EHR, it indicated Do Not Resuscitate. During a concurrent interview and record review with the DON, on July 26, 2024, at 10:16 AM, the DON reviewed Resident 47's Advance Directives and compared it with the Code Status on her EHR. The DON stated the Code Status on Resident 47's EHR did not reflect the accurate information of her signed Advance Directives. During a follow up interview and record review with the DON, on July 26, 2024, at 10:40 AM, the DON reviewed the facility's policy and procedure (P&P) titled, Advance Directives, revised on September 2022, which indicated Policy Statement: Advance directives are honored in accordance with state law and facility policy .If the Resident Has an Advance Directive .2. The director of nursing services (DNS) or designee notifies the attending physician of advance directive (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care .4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive. The DON stated the policy was not followed

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the physical restraint (any device or method used to limit a resident's movement) under Section P for one of six residents reviewed for MDS (Resident 43). This failure had the potential to cause inaccuracy in identifying Resident 43's care and support needs. Findings: During a review of Resident 43's Admission Record (a document that contains demographic and clinical data), it indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a serious mental illness) and major depressive disorder (a mental health condition where a person feels very sad or hopeless for a long time). During a review of Resident 43's MDS Quarterly Assessment (an assessment for a resident that must be completed every 3 months), dated July 1, 2024, under Section P0100 titled Physical Restraints, it indicated Resident 43 had physical restraints of bed rails, that were used in bed daily. During a concurrent interview and observation on July 22, 2024, at 9:46 AM, in Resident 43's room, Resident 43 was sitting on the edge of the bed without the full-size bed side rails (barriers attached to the sides of a bed considered a type of restraint if they are used to prevent a resident from getting out of bed, limit the resident's freedom and mobility). Resident 43 stated that she has never had full side rails to prevent her from getting out of bed. During an interview with the Director of Nursing (DON), on July 26, 2024, at 10:15 AM, the DON stated Resident 43 never had any order for restraints. During a concurrent interview and record review with the Administrator/Minimum Data Set Nurse (Admin/MDS Nurse) and DON, on July 26, 2024, at 10:21 AM, the Admin/MDS Nurse and DON reviewed Resident 43's clinical record which indicated Resident 43 did not have restraint order. Furthermore, the Admin/MDS Nurse and DON stated the bed rails as physical restraint should have not been coded. The Admin/MDS Nurse and DON further stated, it was coded in error. During a concurrent interview and record review with the Admin/MDS Nurse and DON, on July 26, 2024, at 10:40 AM, the Admin/MDS Nurse and DON reviewed the facility policy and procedures titled Certifying Accuracy of the Resident Assessment revised November 2019, indicated The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. The Admin/MDS Nurse and DON stated the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2019, it indicated .The RAI process .require that (1) the assessment accurately reflects the resident's status . When the use of physical restraints is considered, thorough assessment of problems to be addressed by restraint use is necessary to determine reversible causes and contributing factors and to identify alternative methods of treating non-reversible issues . Steps for Assessment 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period. 2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations. 3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident's normal function .

Based on observation, interview, and record review, the facility failed to maintain infection control practices when a Certified Nursing Assistance (CNA 4) did not follow facility policy and procedure in handling soiled linen. This failure had the potential to cause and spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to 51 residents and staff in the facility. Findings: During a concurrent observation and interview with CNA 4, on July 22, 2024, at 9:21 AM, in Resident 23's room, CNA 4 was holding soiled linen against her body. The soiled linen was in contact with her uniform. CNA 4 stated, I should not be holding it to my uniform; it can cause cross-contamination (transfer of harmful bacteria from one person, object or place to another). During an interview with the Infection Preventionist (IP), on July 23, 2024, at 8:16 AM, the IP stated when holding dirty linen, it must be held away from the body. During a review of the facility's policy and procedure (P&P) titled Laundry and Bedding, Soiled, dated September 2022, it indicated, .5. Staff handled soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Transport. 1 contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport .

Based on observation, interview, and record review, the facility failed to ensure three out of thirty-one rooms (Rooms 29, 31 and 32) had the required 80 square feet of space for each resident when: 1. For room [ROOM NUMBER], the room measured 152.83 sq ft (square feet) = 76.41 sq.ft. each. 2. For room [ROOM NUMBER], the room measured 140 sq ft. =70 sq. ft each. 3. For room [ROOM NUMBER], the room measured 141.67 sq ft= 70.83 sq ft each. This failure has the potential to limit the freedom of movement for the residents that occupied the rooms, which could place them at risk for injury. Findings: 1. During a concurrent observation on July 25, 2024, at 3:20 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance of the room, occupied by Resident 39. Resident 39 was lying on his bed and had a walker (device to help residents walking independently) located next to his bed. b. Bed B was located against the wall near the window, occupied by Resident 48. Resident 48 was walking independently around the room. 2. During an observation on July 25, 2024, at 3:25 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance door, occupied by Resident 43. Resident 43 was lying in her bed and had a walker located next to her bed. b. Bed B was located against the wall near the window, occupied by Resident 40. Resident 40 was lying in her bed and had a wheelchair (mobility device designed to assist people who have difficulty walking or are unable to walk), placed at the end of the bed. 3. During an observation on July 25, 2024, at 3:35 PM, in room [ROOM NUMBER], the following were noted: a. Bed A was located against the wall near the entrance door, occupied by Resident 37. Resident 37 was lying in his bed and had a wheelchair, placed at the end of the bed. b. Bed B was located against the wall near the window, occupied by Resident 4. Resident 4 was lying in his bed and had a wheelchair, placed at the end of the bed. During an observation on July 25, 2024, at 3:45 PM, with the Maintenance Supervisor (MS), the room measurements were completed as follows: a. room [ROOM NUMBER] (2 beds): 10'11 x 14' = 152.83 square feet (76.4 square feet per resident) b. room [ROOM NUMBER] (2 beds): 10' x 14' = 140 square feet (70 square feet per resident) c. room [ROOM NUMBER] (2 beds): 10' x 14'2 = 141.67 square feet (70.8 square feet per resident) During a concurrent interview and record review with the Administrator (Admin), on July 25, 2024, at 3:55 PM, the Admin reviewed the facility's letter addressed to the California Department of Public Health Applications Unit, dated January 21, 2024, which indicated the facility requested a room waiver for rooms [ROOM NUMBER]. The Admin stated the annual room waiver request was submitted in January 2024. During the survey, the residents occupying Rooms 29, 31 and 32 were interviewed and had no complaints with regards to the size and the space of their rooms. During the survey, observations of rooms Rooms 29, 31 and 32 were conducted. The rooms were not crowded and did not impose any safety hazards to the residents that occupied the rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on interview and record review, the facility failed to notify the Responsible Person (RP) for one of three residents (Resident 1) of a change in medical condition when Resident 1 lost weight while in the facility. This failure resulted in Resident 1's RP being uninformed and unaware of Resident 1's significant weight loss. Findings An abbreviated survey was conducted on April 18, 2023, at 12:09 PM, to investigate a complaint related to Quality of Care During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Schizophrenia (interpret reality abnormally), Alzheimer ' s (gradual decline in memory), diabetes (high blood sugar). During a review of the Weight Summary (WS) for Resident 1, dated January 9, 2023, at 2:32 PM, the WS indicated: 1. On January 9, 2023, Resident 1 weighed 86.5 pounds (lb.). 2. On December 20, 2022, Resident 1 weighed 92 pounds which indicated a 5.5 lb. weight loss. (5.5%) 3. On July 4, 2022, Resident 1 weighed 98 pounds which indicated a 11.5 lb. weight loss (11.7%). Resident 1 ' s weight summary indicated Resident 1 had significant weight loss. During a concurrent interview and record review of Resident 1 ' s medical record with Licensed Vocational Nurse 1 (LVN 1), on April 18, 2023, at 2:02 PM, LVN 1 stated, There is nothing in Resident 1 ' s chart to say we notified the responsible person (RP) of the weight loss. We should have notified the RP as soon as the notification of weight loss was received. The facility could not provide documentation to indicate the RP was called regarding Resident 1 ' s continued weight loss. During an interview with the Administrator on April 18, 2023, at 2:35 PM, Administrator stated, When I spoke to the RP, I told her that she wasn ' t notified of the weight loss. The Administrator stated further, I reminded the Director of Nursing (DON) that the RP should have been told that Resident 1 was losing weight. I told the (DON) that we need to notify the family. The RP should have been notified of the weight changes. The facility could not provide documentation that the responsible person was notified of the weight loss. A review of the facility ' s policy and procedure (P&P) titled, Weight Assessment and Intervention dated September 2008 indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weight Assessment .6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant: greater than 5% is severe. B. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe. A review of the facility ' s policy and procedure (P&P) titled, Change in a Residents condition or status dated February 2021 indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, resident rights, etc.) .2. A significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical intervention .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage areas were maintained, as well as safe and sanitary practices were maintained in the kitchen when: 1. The ice machine was not kept in a clean and sanitary condition, which put 54 Residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. There were food crumbs and miscellaneous items in an enclosed area on a countertop that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 3. The floor under the deep fryer had food crumbs and trash that had the potential to attract microorganism carrying pests. 4. There was raw chicken that was thawing stored over previously cooked chicken, which had the potential to contaminate the cooked chicken and cause foodborne illness. The facility's failures to ensure a safe and sanitary food preparation and storage area resulted in the increased risk of resident harm related to disease causing microorganisms contaminating the residents' food which could cause food-borne illness to a population of 54 immuno-compromised (having an impaired ability to fight disease) residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Maintenance Supervisor (MS) and the Certified Dietary Manager (CDM), on February 28, 2022, at 8:45 AM, the top/ceiling of the ice machine chute were observed to have black, hard deposits. The back wall of the ice chute and the area where ice is formed within the machine had a black material build-up on the wall that could be wiped off with a paper towel. The Storage Bin Drain Tube, which is a clear tube that drains water from the ice bin, was observed to have a black material build-up within the inside of the tube . When the tube was removed, the noted black material had a slimy in consistency within the inside surface of the tube and this slime that adhered to the tube also extended to where it entered the ice bin. Additionally, the ice bin storage area, which is the area under the ice bin, had noodles noted littered on the bottom. The tray that collected the water that drained from the ice storage bin through the storage bin drain tube, had food crumbs and debris observed. The CDM stated that a company comes out to the facility two (2) times per year to clean the ice machine. The MS stated that he cleans the inside of the ice machine as well as where water drains, twice a month with hot water and a clean cloth . He stated, they rely on the contract company to do the deep cleaning. The last time he cleaned the ice machine was on February 25, 2022, three days prior to the observation and interview. During a follow up interview with the Certified Dietary Manager (CDM) on February 28, 2022, at 9:00 AM, she stated she has been working at the facility since January 2022. She stated that the ice machine cleaning schedule will need to be adjusted for more frequent cleanings and that she thought that the MS was using a sanitizer when cleaning the ice machine. She stated that ice is used for resident beverages and to keep food cold during meal service. She stated that she was not monitoring the cleanliness of the ice machine and was relying on the Maintenance Supervisor to do it. During an interview on February 28, 2022, at 2:30 PM, with the ice machine Service Technician (ST) from [Name of company that services the ice machine], the ST stated that the storage bin drain tube drains onto a tray, water that is from the melting ice drips down this tube and onto the tray, the tray collects the water, and it (the collected water) goes down to the floor drain. It is a small bit of water that drips out, but it gets dirty easily. He recommended that the facility replace all the clear rubber tubing on the ice machine regularly because they are hard to clean, and build-up happens quickly. During a follow-up interview with the MS on March 1, 2022, at 10:56 AM, the MS stated that he was not previously removing the ice bin drain tube to clean it. During a review of the FDA Federal Food Code 2017, it indicated that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During a record review of the Federal FDA 2017 Food Code 4-204.17, indicated The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form . are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferral of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses Recommendations for a regular program of maintenance and disinfection have been published Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. Record Review of the facility document titled, Diet Type Report, dated March 1, 2022, indicated there were 54 residents on PO (by mouth) diet. Record Review of the facility document titled, Ice Machine Cleaning Log, dated year 2022, indicated that the last time that the ice machine was cleaned was on February 25, 2022. Record Review of the facility document titled, [Name of manufacturer's] Instructional Manual, revised April 17, 2019, indicated Yearly: icemaker and dispenser unit/ice storage bin: clean and sanitize per the cleaning and sanitizing instructions provided in this manual. See III.B. Cleaning and Sanitizing Instructions. Yearly: Condenser: Inspect. Clean if necessary, by using a brush or vacuum cleaner. More frequent cleaning may be required depending on location. Yearly: water hoses: Inspect the water hoses and clean/replace if necessary. Cleaning and Sanitizing Instructions: The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions . 6. Remove the front insulation panel, then pour 10.4 fl. Oz. (fluid ounces) of [Name of Manufacturer's] Scale away (cleaning product to calcium scale deposits) into the water tank. Replace the front insulation panel . 12. Remove the front insulation panel, then pour 0.6 fl. Oz. (fluid ounces) of an 8.25% sodium hypochlorite solution (chlorine bleach) into the water tank. During a record review of the facility's policy and procedure titled, Ice Machine Cleaning Procedures, dated 2018, indicated, .3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. Add instructions to your policies or use manufacturer procedures to clean and sanitize the machine. During a record review of the facility's policy and procedure titled, Sanitation, dated 2018, indicated, Policy: All equipment shall be maintained as necessary and kept in working order .9. All utensils, counters, shelves, and equipment shall be kept in clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .12. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a concurrent observation and interview with the ST, on February 28, 2022, at 3:49 PM, the ST showed the new storage bin drain tube that he replaced and stated that it's micro bacterial coated. During an interview on March 1, 2022, at 10:56 AM, with the MS and CDM, in front of the ice machine, the MS stated that he will spray the areas where ice is made and where ice touches with a de-scaler and use a scrub brush to clean. He will then use a sanitizer and leave on for 1 minute, then rinse with water. He will remove the tubing and some plastic parts to clean and sanitize. The CDM stated that she will be monitoring cleanliness of the ice machine going forward and will be using the 3-compartment sink to clean the tubing and other plastic parts. During a review of facility's receipt [Name of] Refrigeration Supplies Distributor, dated February 28, 2022, at 3:39 PM, provided by the Administrator (Admin), indicated purchasing of 1 Gallon Ice Machine Cleaner and Ice Machine Sanitizer Concentrate. During a review of facility document titled, In-service on Ice Machine Cleaning and Maintenance, dated February 28, 2022, at 4:15 PM, indicated the Maintenance Supervisor and Certified Dietary Manager completed the competency training on February 28, 2022. 2. During a concurrent observation and interview on February 28, 2022, at 8:19 AM, with the CDM, a sink on the stainless steel counter in the kitchen, that was not being used, which had a stainless-steel cover, contained food crumbs, and miscellaneous items such as: staff lotion, tape, labels, a box alcohol wipes. The CDM stated that it should be kept clean and started discarding the items. During a record review of the facility's policy and procedure titled, Sanitation, dated 2018, indicated, Policy: All equipment shall be maintained as necessary and kept in working order .9. All utensils, counters, shelves, and equipment shall be kept in clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. During a concurrent observation and interview with the CDM, on February 28, 2022, at 8:35 AM, the floor under the deep fryer, had food crumbs and trash. The CDM stated that it should be swept, but was not sure if the fryer could be moved, but stated the staff could sweep under it. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the facility policy's titled Sanitation, dated 2018, indicated .9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over the stove, which will be cleaned by the maintenance staff. 4. During a concurrent observation and interview with the CDM, on February 28, 2022, at 8:25 AM, in the walk-in refrigerator raw chicken was thawing in a metal pan and was directly on top of cooked diced chicken that was thawing in a metal pan. The CDM stated that the raw chicken should be on a different shelf and not directly on top of the cooked chicken. During a record review of the FDA Federal Food Code 2017, it indicated, It is important to separate foods in a ready-to-eat form from raw animal foods during storage, preparation, holding and display to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods.

Based on interview and record review, the facility failed to ensure the Notice of Transfer/Discharge forms were complete for three of three sampled residents (Residents 41, 43 and 55). This failure led to incomplete discharge records for Residents 41, 43, and 55, who were discharged to a psychiatric hospital to be evaluated for depression, however, the Notice of Transfer/Discharge was not completed per the facility's policy and procedure. Findings: During a record review on March 3, 2022, at 1:30 PM, of the discharge record for Resident 41, the document title Notice of Transfer/Discharge, dated January 10, 2022, indicated, Resident 41 was sent to a psychiatric hospital for evaluation of increased depression, was incomplete. The following areas were not completed: 1. There was no date of Notification on the Notice of Transfer/Discharge form. 2. There were no boxes checked for the reason why the transfer/discharge was necessary. 3. There was no contact information for the resident on obtaining an appeal form and who to contact for hearing request. 4. There was no resident/representative signature. The client was self-responsible and should have signed the form. 5. There was no indication of a copy being sent to the State LTC (Long term care) Ombudsman Office and date. During a record review on March 3, 2022, at 2:30 PM, of the nurses' notes in the discharge record of Resident 41, the resident was agreeable to the transfer/discharge to [name of the psychiatric hospital]. The resident was transferred for an evaluation by psychiatry for having an increase in depression. During a record review on March 3, 2022, at 3:10 PM, of the discharge record for Resident 43, the document titled Notice of Transfer/Discharge, dated January 10, 2022, was incomplete. The following areas were not completed: 1. There were no boxes checked for the reason why the transfer/discharge was necessary. 2. There was no contact information for the resident on obtaining assistance (if needed) for obtaining and completing and submitting an appeal form and hearing request. 3. There was no contact information written for resident to contact the State LTC Ombudsman Office, the State Agency for the Developmentally Disabled, or the State Agency for the Mentally Ill. 4. There was no resident/representative signature. The client was self-responsible and should have signed the form. 5. There was no indication of a copy being sent to the State LTC Ombudsman Office and date. During a record review of the nurses' notes in the discharge record of Resident 43, the resident was agreeable to the transfer/discharge to [name of hospital] for evaluation of depression. During a record review on March 3, 2022, at 3:45 PM, of the discharge record for Resident 55, the document titled Notice of Transfer/Discharge Notice, dated December 21, 2021, was incomplete. The following areas were not completed: 1. There were no boxes checked for the reason why the transfer/discharge was necessary. 2. There was no contact information for the resident on obtaining assistance (if needed) for obtaining and completing and submitting an appeal form and hearing request. 3. There was no resident/representative signature. The resident is self-responsible and should have signed the form. 4. There was no indication of a copy being sent to the State LTC Ombudsman Office and date. During a record review of the nurses' notes in the discharge record of Resident 55, the resident was agreeable to the transfer/discharge to [name of psychiatric hospital]. During a concurrent interview and record review with the Director of Nurses (DON), on March 3, 2022, at 4:15 PM, of the Facility's Policy and Procedure (P&P), titled Transfer or Discharge Documentation, revised December 2016, was reviewed. The P&P indicated, .4. When a resident is transferred or discharge from the facility, the following information will be documented in the medical record: a. The basis for the transfer or discharge: (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met (b) this facility's attempt to meet these needs; and (c) the receiving facility's service(s) that are available to meet those needs. b. That an appropriate notice was provided to the resident and/or legal representative c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition. The DON stated that the Notice of Transfer/Discharge had not been completed for Residents 41, 43 and 55.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed when: 1. Thirty three out of fifty-four residents were on a regular, No Added Salt (NAS), and low-fat/ low cholesterol diet and received the incorrect dessert for lunch on February 28, 2022. 2. Nine out of fifty- four residents on a large portion diet received four ounces of milk instead of eight ounces of milk for lunch on February 28, 2022. These failures had the potential to decrease the nutritional intake and meal satisfaction for the 54 residents who are immuno-compromised. Findings: 1.During a concurrent observation and interview on February 28, 2022, at 11:32 AM, with a Dietary Aide (DA) in the kitchen during tray line, green Jell-o with whipped cream was served to all the residents. The DA stated that everyone gets the same dessert. During a follow-up interview with the Certified Dietary Manager (CDM), on February 28, 2022, at 3:39 PM, the CDM confirmed that all residents received the diet citrus chiffon delight/whipped gelatin with one tablespoon whipped topping. During a record review of the Winter Menus Week 1 Monday (WM), dated February 28, 2022, the WM indicated that the regular, NAS, and low fat/low cholesterol diets were to receive Citrus Chiffon Delight/ Whipped Gelatin with one tablespoon whipped topping. The residents on a CCHO (carbohydrate-controlled diet for residents with diabetes, a disease that affects how the body uses blood sugar) were to receive DIET Citrus Chiffon Delight/Whipped Gelatin with one tablespoon whipped topping. During a record review of the Recipe: Citrus Chiffon Delight, dated week 1 Monday, indicated May give to the following special diets: 2GM (gram) NA(sodium)/ Low salt, low fat/low cholesterol, mechanical soft (Prepared to require minimal chewing)/ pureed( Blended to pudding consistency)/ dysphagia(difficulty shallowing). During a record review of the facility document titled, Diet Type Report, dated March 1, 2022, thirty-three residents were on regular, NAS, low fat/ low cholesterol, and fortified diet. 2. During tray line observation on February 28, 2022, at 11:32 AM, four ounces of milk were given instead of eight ounces to residents on large portions. During a record review of the Cooks Spreadsheet: Winter Menus Week 1 Monday (WM), dated February 28, 2022, indicated that small and regular portions were to receive four ounces of milk, and large portions were to receive eight ounces of milk. During a record review of the facility document titled, Diet Type Report, dated March 1, 2022, indicated, nine residents were on large portions. During a record review of the facility's policy titled, Portion Sizes, dated 2018, indicated, Various portion sizes of the food will be available to better meet the needs of the residents .the small and large portion servings will be served as printed on the cook's spreadsheets for every meal.

Based on staff interviews and record reviews, the facility failed to ensure an annual (a comprehensive assessment for a resident that must be completed on an annual basis) Minimum Data Set (MDS- a computerized assessment tool) assessment for one of five residents (Resident 6) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 6. Findings: A review of the facility document titled, Admission Record (a document that contains demographic and clinical data), indicated, Resident 6 original admitted to the facility was on June 14, 2017. A review of the MDS assessments for Resident 6 revealed the last annual assessment was completed on January 28, 2021, followed with: a. Quarterly assessment April 30, 2021 b. Quarterly assessment July 23, 2021 c. Quarterly assessment October 23, 2021 No other MDS assessments had been completed since October 23, 2021 During a concurrent interview and record review on March 3, 2022, at 3:00 PM, with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health), the Administrator/MDS nurse confirmed that no other MDS assessments had been completed since October 23, 2021. The Administrator/MDS nurse further stated, she missed completing the annual assessment for Resident 6 and it should have been completed in January 2022. During record review on March 3, 2022, at 3:30 PM, of the facility policy and procedures (P&P) titled Resident Assessment, reviewed and updated on January 28, 2022, indicated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: . (4). Annual Assessment (Comprehensive) - Conducted not less than once every twelve (12) months; .

Based on record reviews and staff interviews, the facility failed to ensure a quarterly (a quarterly review for resident that must be completed every 3 months) Minimum Data Set (MDS- a computerized assessment tool) assessment for two of five residents (Resident 3 and Resident 4) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 3 and Resident 4. Findings: A review of the facility document titled, Admission Record (a document that contains demographic and clinical data), indicated, Resident 3 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident 3 revealed the last assessment completed was a quarterly assessment completed on September 20, 2021. No other MDS assessments had been completed since September 20, 2021. During a concurrent record review and interview on March 3, 2022, at 2:30 PM, with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health), the Administrator/MDS nurse confirmed that no other MDS assessments had been completed since September 20, 2021, and during interview she stated she missed completing the quarterly assessment for Resident 3 and it should have been completed in December 2021. A review of the facility document titled, Admission Record, the Admission Record indicated, Resident 4's original admitted to the facility was on February 20, 2019. A review of the MDS assessments for Resident 4 revealed the last assessment completed was a quarterly assessment completed on October 04, 2021. No other MDS assessments had been completed since October 04, 2021. During a concurrent record review and interview on March 3, 2022, at 2:50 PM, with the Administrator/MDS nurse, the Administrator/MDS nurse confirmed that no other Quarterly MDS assessments had been completed since October 04, 2021, and during interview she stated she missed completing the quarterly assessment for Resident 4 and it should have been completed in January 2022. During record review on March 3, 2022, at 3:20 PM, of the facility policy and procedures title Resident Assessment, reviewed and updated on January 28,2022 indicated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: . (2). Quarterly Assessment - Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed to accurately reflect the resident's status, care and services, in the area of active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure had the potential to cause inaccuracy in identifying resident 505's care and support needs. Findings: A review of the facility document titled, Admission Record (a document that contains demographic and clinical data), indicated, Resident 505 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on March 2, 2022, at 9:35 AM, of Resident 505's electronic clinical records, titled Progress Note-Monthly Medical-new admit, dated January 18, 2022, and interview with the Administrator/MDS nurse (minimum data set nurses = nurses assess, monitor, and document patients' health) confirmed record indicated Assessments .1. Alzheimer's disease with early onset . as one of the Resident 505's diagnosis. During a concurrent interview and record review on March 2, 2022, at 9:45 AM, with the Administrator/MDS nurse, Resident 505's electronic clinical records, titled Progress Note-Monthly Medical-progress notes dated September 01, 2021, were reviewed. The Administrator/MDS nurse confirmed record indicated Assessments .1. Alzheimer's disease with early onset . as one of the Resident 505's diagnosis. During a concurrent interview and record review on March 2, 2022, at 9:55 AM, with the Administrator/MDS nurse, Resident 505's electronic clinical records were reviewed. The Administrator/MDS nurse confirmed the Annual MDS assessment (a comprehensive assessment for a resident that must be completed on an annual basis) dated February 1, 2022, on active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator/MDS nurse stated, It should be marked as one of active diagnosis, I missed it and didn't mark it. During record review on March 2, 2022, at 2:20PM, of the facility policy and procedures titled Certifying Accuracy of the Resident Assessment reviewed and updated January 28, 2022, indicated, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

Based on interview and record review, the facility failed to ensure a Bowel and Bladder care plan was developed to meet and address the needs and goals for one out of five sampled residents (Resident 5). This failure has the potential to prevent Resident 5 from reaching his maximum functional capability and/or prevent any complications that may arise from bowel and bladder incontinence (the lack of voluntary control to hold bowel [stool] and bladder [urine].) Findings: During an interview on March 2, 2022, at 8:24 AM, with Certified Nurse Assistant 1 (CNA 1) identified Resident 5 as one of the residents assigned to her who was incontinent of bowel and bladder. CNA 1 stated that Resident 5 used the call light if he needed to be changed, but the resident was sometimes unaware if he was wet. During a concurrent interview and record review on March 2, 2022, at 8:50 AM, with the Director of Nursing (DON), the DON stated Resident 5 was incontinent of both bowel and bladder according to the Minimum Data Set (MDS-comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems). The same MDS shows that Resident 5 has a Brief Interview for Mental Status score of 00 (BIMS-used to assess cognitive status in elderly patients, wherein a score of 0-7 is severe cognitive impairment, 8-12 is moderate impairment and 13-15 is intact cognitive response). The DON stated, Resident 5 was dependent on staff for toileting needs. The DON stated a care plan should have been developed for Resident 5. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, was reviewed. The P&P indicated, .1. The Interdisciplinary Team (IDT- a group of clinical staff), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The DON stated that the facility did not follow their policy.

Based on observation, interview, and record review, the facility failed to ensure staff demonstrate the ability to carry out an activity that is within the scope of practice a staff is certified to perform when Certified Nurse Assistant 3 (CNA 3) gave Resident 5 a lunch tray that belonged to another resident. This failure to demonstrate competency had the potential for a diminished quality of service and care for one of five sampled residents (Resident 5). Findings: During an observation on February 28, 2022, at 11:55 AM, CNA 3 was observed distributing lunch meal trays for residents at the dining area. Resident 5 started eating after CNA 3 placed his lunch tray in front of the resident. The diet card (a card that has information on the type of diet that is specific for a resident) on Resident 5's tray indicated the meal he was eating belonged to another resident. During an interview on February 28, 2022, at 12:05 PM, with CNA 3, stated Resident 5 has the same first name as Resident 24, which caused her to distribute the meal tray by mistake. CNA 3 further stated, I should have double-checked the full name that was on the diet card. During a record review on March 3, 2022, at 4:00 PM, the diet order for Resident 5 indicated mechanical soft texture (food that is prepared in a way that makes it easy to eat without having to bite or chew a lot) and Resident 24 was on a regular diet (There is no restriction on type or texture of food.) Resident 5, who had the same first name as Resident 24, was provided with a regular diet tray instead of his mechanical soft diet tray. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, the facility's policy and procedure on the job description, titled, Hillcrest Nursing Home Certified Nurse Aide, revised April 11, 2007, indicated, Essential Duties: .19. Prepare residents for meals. Assist serving food trays or feeds as necessary . The DON stated the CNA 3 did not demonstrate competency when the wrong food tray was served to Resident 5.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures when: 1. A Certified Nurse Assistant (CNA 1) did not remove gloves and observe hand hygiene after handling soiled linens, and before placing clean new ones on resident's bed. This failure had the potential to spread contaminants present from the soiled linens onto the clean new ones, that could potentially harm one unsampled resident (Resident 19). 2. A Housekeeping Aide 1 (HA 1) placed an undisinfected container of sanitizing wipes on top of one dining table that was disinfected in preparation for the lunch meal. This had the potential to spread pathogens to residents who use the dining table for eating meals. Findings: 1. During a concurrent observation and interview on February 28, 2022, at 8:53 AM, CNA 1 was observed wearing gloves while removing the dirty linens from the bed of Resident 19 and placed the dirty linens inside the soiled linen barrel. CNA 1 then placed a new pillowcase using the same gloves she used to handle the dirty linen and the soiled linen barrel. CNA 1 stated, I should have removed the gloves and washed my hands or used sanitizer before touching the clean linens. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Bed, Making an Unoccupied, revised February 2018, was reviewed. The P&P indicated, .Steps in the Procedure: 1. Wash and dry your hands thoroughly. 2. Wear clean gloves . The same policy indicated, Removing Soiled Linen: .9. Remove gloves and discard into designated container. 10. Wash and dry your hands thoroughly. The DON further stated that hand hygiene should have been done before handling the clean linens to be used for resident's bed. 2. During an observation on February 28, 2022, at 11:20 AM, the HA 1 was observed to disinfect the dining tables located at the dining area. After wiping the tables with bleach germicidal wipes (ready to use cleaner disinfectant), the HA 1 was observed to place the container of the wipes on top of the table he just finished disinfecting. The bottom of the container was observed to be dirty and scratched, with more dirt settled in those scratch marks. The HA 1 stated that the container was not disinfected and should have not been placed on top of the dining table that was just disinfected. During a concurrent interview and record review on March 3, 2022, at 4:50 PM, with the DON, the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, was reviewed. The P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities . The DON stated while the dining tables were disinfected, the container of the wipes was considered dirty and should have not been placed on top of the table, which caused the dining table to be considered unsanitary again.

Based on observation, interview, and record review, the facility failed to ensure safety practices related to residents smoking for two of two residents (Resident 33 and 38), when Residents 33 and 38 were observed smoking without supervision. This failure has the potential to place Resident 33 and 38 at risk for [CONDITION(S)]. Findings: During a concurrent observation and interview on February 28, 2022, at 12:36 PM, in the smoking patio, Residents 33 and 38 were observed sitting on a chair, smoking, without staff supervision. Resident 33 stated she was aware she needs to smoke under supervision and the staff will come later to check on us. Resident 38 acknowledged he was smoking without supervision. During an interview on February 28, 2022, at 12:41 PM, with the Director of Nurses (DON), the DON verbalized that staff must supervise residents when they are smoking during the seven smoking breaks scheduled. During an interview on March 2, 2022, at 3:05 PM, with a Certified Nurse Assistant (CNA 2), the CNA 2 verbalized any resident who needs to smoke, shall always be supervised while smoking in the designated area. During an interview on March 3, 2022, at 8:07 AM, with a Certified Nurse Assistant (CNA 1), the CNA 1 verbalized that residents must be supervised during smoking to prevent injuries. During a review of Resident 33's Admission Record (clinical record with demographic information), dated March 3, 2022, the Admission Record indicated, Resident 33 was admitted into the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident's 33's Smoking-Safety Screen (screening), dated June 7, 2021, the screening indicated Resident 33 needed to smoke with supervision. During a review of Resident 38's Admission Record, dated March 3, 2022, the Admission Record indicated, Resident 38 was admitted into the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident's 38's Smoking-Safety Screen, dated December 27, 2021, the screening indicated Resident 38 needed to smoke with supervision. During a concurrent interview and record review on March 3, 2022, at 11:40 AM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Smoking Policy-Residents, revised July 2017, was reviewed. The P&P indicated, .11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The DON stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to administer medication as prescribed to two of four sampled residents (Resident 1 and Resident 2), when Resident 1 was given medications prescribed to Resident 2 and Resident 2 did not receive medications as prescribed by the physician. This failure resulted in Resident 2 not receiving medications as prescribed and Resident 1 experienced slurred speech, blurred vision and a pulse of 42. Resident 1 was sent to the hospital for evaluation and treatment. Findings: During a review of the clinical record for Resident 1, the Facesheet (admission record), dated February 14, 2017, indicated the resident had an allergy to [MEDICATION NAME] (an antipsychotic medication) and had a [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on [DATE] at 3:00 PM, he stated that Resident 1 was given the wrong medications on [DATE] at 9:00 AM. The medications included; 1. [MEDICATION NAME] (an antidepressant) 2. [MEDICATION NAME] (used to treat fluid retention in people with heart failure). 3. [MEDICATION NAME] (blood pressure medication). 4. [MEDICATION NAME] [MEDICATION]). 5. [MEDICATION NAME], (an antipsychotic medication). 6. [MEDICATION NAME] [MEDICATION]). 7. Klonopin (medication used to treat [MEDICAL CONDITION] and panic disorder). 8. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]; a psychological disorder). 9. [MEDICATION NAME] [MEDICATION]). 10. [MEDICATION NAME] (used to treat a neurological disorder with symptoms of uncontrollable laughing and crying, contraindicated for people with heart failure). 11. Dietary supplements; fish oil, [MEDICATION NAME] D, and Senna. In a review of the clinical record for Resident 1, the Licensed Nursing Notes, dated [DATE], indicated; .BP (blood pressure) ,[DATE], p (heart rate): 42 , R (respiration) 15 . Also noted was that the resident complained of slurred speech, and double vision. The physician was notified and orders were received to send the resident out to the acute care hospital. Review of the facility's investigation letter, dated [DATE], indicated that the Licensed Vocational Nurse (LVN 1) who gave the incorrect medications had asked a Certified Nursing Assistant (CNA) about the identity of Resident 2. The CNA pointed to Resident 1 and the LVN gave all the medications intended for Resident 2 to Resident 1. LVN 1 was terminated after the incident. During an observation and a concurrent interview with Resident 1 on [DATE] at 2:35 PM, she was in her room, sitting in her wheelchair. When asked how she was feeling, she stated, Much better. When asked about the incident of her receiving the wrong medication, she stated that she did not like going to the hospital, and said she was grateful to be back at the facility. Review of the clinical record for Resident 1, from the acute care hospital, titled Consultation, dated [DATE] at 4:51 PM, indicated the resident was, extremely somnolent (drowsy) and .in ER, ekg (electrocardiogram; a test which shows heart rhythm) showed sinus [MEDICAL CONDITION] (slow heart rhythm). Vital signs were noted as follows: .HR (heart rate) 38, RR (resting respiration): 13, BP: ,[DATE]. Review of the clinical record for Resident 1, from the acute care hospital, titled, History and Physical, dated [DATE], at 4:56 PM, indicated, .THE PATIENT IS ALLERGIC TO [MEDICATION NAME] AND APPARENTLY, SHE RECEIVED [MEDICATION NAME]. .She became lethargic (drowsy) with slurred speech and upon arrival to the Emergency Department, her vital signs showed [MEDICAL CONDITION]. .Assessment: 1. Polypharmacy (multiple medications) overdose. 2. Beta blocker (medication that reduces blood pressure) overdose. 3. Symptomatic [MEDICAL CONDITION]. Plan: At this time patient will be admitted to Intensive Care Unit.We might need to start Isuprel (medication to increase a slow heart rate) infusion to keep the heart rate more than 40. Review of the clinical record for Resident 1, from the acute care hospital, titled, Transfer of Care Summary, dated, [DATE], at 2:56 PM indicated; .Diagnosis: [REDACTED].Ingestion, drug, inadvertent or accidental; .Sinus [MEDICAL CONDITION]. During an interview with the DON on [DATE] at 9:55 AM, when asked what the facility's policy and procedure was on identifying residents when administering medications, he stated that they used photographs on the Medication Administration Record (MAR) and resident wristbands. The DON also stated that it is not the usual practice to ask another staff member to identify the residents when administering medications. During an interview with the DON, on [DATE] at 3:38 PM, he stated that Resident 2 was not given her usual morning medications as ordered because the window of time had expired when the medication error was discovered. The DON stated that Resident 2 has the same physician as Resident 1, and the physician was notified of the error in medication administration at the time it was discovered. Record review of the facility policy and procedure, titled Administering Medications, dated 2001, indicated; .5. The individual administering medications must verify the identity before giving the resident his/her medications. This is done by photo in the MAR and wristband.

Based on interview and record review, the facility failed to ensure three of four residents (Residents B, C, and D) were free from abuse when Resident A's physical aggression was not managed by the facility as evidenced by: 1. Resident A's care plans were not updated to reflect each physical altercation, 2. Resident A's care plans were not updated to reflect adjustments to medications, and 3. The facility did not employ new interventions despite Resident A's repeated behavioral episodes. This failure resulted in the physical abuse of Resident B, C, and D. Findings: During an interview with the Director of Nurses (DON) on [DATE] at 1:16 PM, he stated Resident B was in an unprovoked physical altercation with Resident A on [DATE]. The DON stated Resident A approached Resident B; scratched Resident B's arm and hit Resident B in the mouth. The DON stated Resident B sustained abrasions to her left arm and a bloodied lip. The DON further stated Resident A had been in three previous altercations this year. 1. During a review of Resident A's Licensed Nurses Progress Notes dated [DATE] at 11:50 AM, Resident A was involved in a physical altercation with Resident C. It was noted Resident A, was observed striking out on another resident in the hand and chin. A late entry dated [DATE] at 2:00 PM, indicated Resident A was in a physical altercation with resident D. It was noted Resident A, wandered into the room of 27A and pulled her hair . Another progress note dated [DATE] at 12:45 PM, indicated Resident A was involved in a physical altercation with Resident C. It was noted Resident A, struck another resident (Resident C) in the face and right arm. There was no documented evidence Resident A's care plans had been updated to reflect the physical altercations occurring on [DATE] or [DATE]. During an interview with the DON on [DATE] at 1:45 PM, he confirmed Resident A's care plans had not been updated to reflect the physical altercations occurring on [DATE] or [DATE]. During an interview with a Licensed Vocational Nurse (LVN 1) on [DATE] at 9:08 AM, she stated LVNs are responsible for completing short term care plans and Registered Nurses (RNs) are responsible for completing long term care plans. 2. During a review of Resident A's Licensed Nurses Progress Notes dated [DATE] at 2:00 PM, indicated Resident A's [MEDICATION NAME] (a medication used to treat anxiety) was adjusted by the physician. Another progress note dated [DATE] at 10:00 AM, indicated Resident A's [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) was adjusted by the physician. There was no documented evidence Resident A's care plans had been updated to reflect the changes for [MEDICATION NAME] or [MEDICATION NAME]. During an interview with the DON on [DATE] at 1:45 PM, he confirmed Resident A's care plans had not been updated to reflect changes in medication for [MEDICATION NAME] or [MEDICATION NAME]. During an interview with the Minimum Data Set (MDS, a patient assessment tool) Nurse (MDS) on [DATE] at 9:15 AM, he stated RNs and LVNs are responsible for updating and revising care plans. The MDS Nurse further stated that the medical records staff were responsible for ensuring care plans are in place and up-to-date. The MDS Nurse stated he, too, utilized assessment data from the MDS to complete and update care plans. A review of the facility policy and procedure titled, Resident Care Plans, undated, under section, Revisions and Updating of the Resident Care Plans, indicated, .The plans will be reviewed weekly when the nursing staff record their weekly summaries to determine if the problems are still exist and/or if all new problems have been recorded. 3. A review of Resident A's [MEDICAL CONDITION] (drugs affecting a person's mental state) Summary Sheet recording the number of behavioral episodes of striking out each month, indicated the following: For the month of [DATE], Resident A had a total of 52 episodes. For the month of [DATE], Resident A had a total of 60 episodes. For the month of February 2017, Resident A had a total of 14 episodes. For the month of [DATE], Resident A had a total of 55 episodes. For the month of [DATE], Resident A had no recorded episodes despite a documented physical altercation with Resident C. For the month of [DATE], Resident A had a total of 2 episodes. A review of the documented care plans for Resident A's physical aggression indicated she was to be monitored for aggression with other residents. No further evidence of interventions protecting other residents from physical aggression could be found. During an interview with the DON on [DATE] at 2:20 PM, he confirmed Resident A's care plans had not been updated to reflect interventions to protect other residents from Resident A's physical aggression. During an interview with LVN 1 on [DATE] at 9:08 AM, she stated Resident A is monitored for aggression by all staff members. LVN 1 stated a PRN (as needed) medication is utilized when Resident A exhibits aggressive behavior. She further stated the PRN medication is usually administered after an altercation and, therefore, does not prevent the physical aggression. LVN 1 further stated Resident A is monitored by a safety float staff member. LVN 1 stated this staff member monitors all residents for behaviors and intervenes when necessary. LVN 1 states the safety float staff member does not monitor residents on a one-to-one basis. During an interview with the Social Services Designee (SSD) on [DATE] at 9:28 AM, she stated Resident A exhibits territorial behavior. The SSD further stated Resident A is monitored for this territorial behavior and redirected by safety float personnel. The SSD confirmed safety float personnel monitor all residents at the same time and do not operate on a one-to-one basis. A review of the facility policy and procedure titled, Resident-to-Resident Altercations, revised [DATE], indicated, .d. Review the events with the Nursing Supervisor and Director of Nursing including interventions to try to prevent additional incidents . f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness .

Based on observation, interview, and record review, the facility failed to provide fire safety protection on the smoking patio for one sampled resident (Resident 2) and seven unsampled residents (Residents A, B, C, D, E , F, and G) who used the patio for smoking when: 1. The facility did not provide a fire extinguisher or fire blankets on the smoking patio. 2. The facility did not assess all residents who smoked for smoking safety or add fire safety interventions to the care plans. This failure had the potential to cause injury to the residents if a resident's clothing or surrounding area caught on fire and a fire extinguisher or fire blanket was not available to put the fire out quickly. On September 29, 2015 at 4:17 PM, an Immediate Jeopardy Situation was declared in the presence of the facility Administrator who was verbally notified of the facility's failure to install fire extinguishers or smoking blankets on the smoking patio to provide protection from fires and burns. This failure had the potential to affect the safety of eight Residents in a universe of eight Residents who smoke. On September 29, 2015 at 5:07 PM, the Immediate Jeopardy was lifted in the presence of the Administrator and Director of Nursing (DON) when the facility's corrective action plan approved after observation, interview, and record review confirmed the facility installed the fire extinguishers, ordered fire blankets and in-serviced staff on their availability and use. Findings: During an observation on September 29, 2015 at 12:30 PM, on the smoking patio with the Maintenance Supervisor (MS), no fire extinguisher or smoking blankets were present. During a concurrent interview, when asked why the smoking patio did not have a fire extinguisher or a smoking blankets, the MS stated residents are always supervised while smoking. During an interview with Certified Nurse's Assistant (CNA 1) and Activities Assistant (AA) on September 29, 2015 at 1:25 PM, on the smoking patio while supervising smoking residents, when asked what they would do if a resident's clothing caught on fire, CNA 1 stated, I don't know, I guess I would take their shirt off. The AA then stated,I guess stop, drop and roll. When asked if they had formal training on what to do if a resident's clothing caught on fire, both said they did not. When asked if there was a fire extinguisher or a smoking blanket on the patio, they stated no. During an interview with a Licensed Vocational Nurse (LVN 1) on September 29, 2015 at 1:30 PM, when asked about smoking aprons and smoking assessments, LVN 1 stated residents are informed of the availability of smoking aprons on admission. The smoking aprons are kept at the nurse's station. She stated she was not aware of smoking assessments being done. During an interview with the Director of Nursing (DON) on September 29, 2015 at 1:40 PM, when asked if all residents who smoked were required to have smoking assessments, she stated no, but smoking is always supervised on the smoking patio. During an observation on October 1, 2015 at 10:10 AM, on the smoking patio, LVN 3 was noted supervising eight residents who were smoking (Residents A, B, C, D, E, F, G and 2). Resident B was observed smoking while sitting in her wheelchair about 10 feet in front of LVN 3. Resident B was observed to close her eyes and drop her head forward while holding a lit cigarette in her right hand. The lit cigarette was observed dropping from her hand onto the wheelchair seat next to Resident B's leg. LVN 3 rushed to Resident B and brushed the cigarette and hot ashes from the wheelchair seat. A small melted cigarette burn was observed on the wheelchair seat. When asked if the cigarette burn on the wheelchair had just occurred, LVN 3 verified that it did just occur. When LVN 3 was asked if Resident B had been offered a smoking apron, LVN 3 stated that Resident B always refused it. When asked if Resident B had been offered one that day, LVN 3 stated no. During a concurrent interview with Resident B when asked how her day was, Resident B mumbled and did not appear to understand the question. When LVN 3 was asked if Resident B had the mental capacity to refuse a smoking apron, LVN 3 stated no, she probably should have been wearing one. During a review of the medical records for Residents A, B, C, D, E, F, G and 2, four of eight residents, Residents A, C, G and 2 had a smoking care plan, however, the care plans did not include a smoking apron as an intervention. During an observation on October 1, 2015 at 11:16 AM, three smoking aprons were available for use. One smoking apron was at the nurses' station, one was with the Restorative Nurses Assistant (RNA) and one was with the Activity Department. No smoking aprons were observed immediately available to residents on the smoking patio. During a review of the policy and procedure titled, Policy and Procedure on Smoking Apron, dated January 2015, indicated It is this facility's policy to provide additional protective barrier to incapable or incapacitated residents who are known to smoke .1. The Interdisciplinary team shall assess residents who smoke, for safety awareness and safe practices of smoking. Assessment of resident shall include: Medical conditions that would place limitations on resident's ability to smoke, e.g.Alzheimer's . Dementia .cognitive ability to retain information .Residents who are assessed or determined to have poor safety awareness and poor smoking practices shall be provided with additional protective barrier such as smoking apron .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when a certified nursing assistant (CNA 2) hit Resident 1 on the forehead. This failure resulted in Resident 1 sustaining a laceration (a deep cut) on the forehead. Finding: An unannounced visit was made to the facility on [DATE] at 11:05 AM, to investigate a complaint regarding quality of care for Resident 1. A review of Resident 1's clinical record documented Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the history and physical dated December 10, 2014, reflected Resident 1 has a fluctuating capacity to understand and make decision, but can make immediate needs known. During an interview with Resident 1 on April 17, 2015 at 1:45 PM, he stated, There were 3 girls and one of them hit me in the face, and cut me. During a concurrent observation, Resident 1 was observed to have a healed scab on the left side of his forehead. During an interview with CNA 1 on April 17, 2015 at 2:45 PM, she stated on April 3, 2015 between 9 AM and 10 AM she was asked by CNA 2 to help transfer Resident 1 from bed to a wheelchair. CNA 2 had keys attached to a lanyard (a cord or strap worn around the neck to carry items such as keys and identification cards). Resident 1 was in the wheelchair, combative and started hitting CNA 2. CNA 2 proceeded to wheel Resident 1 out of the room. Resident 1 was observed hit CNA 2 outside the room. CNA 1 stated CNA 2 brought Resident 1 back into the room. CNA 2 was observed by CNA 1 hitting Resident 1 with keys attached to a lanyard to Resident 1's forehead. Resident 1 sustained a cut and bleeding on his forehead. A review of CNA 2's employee file on April 17, 2015 at 4 PM, documented the date of hire was January 12, 2015. Documentation showed CNA 2 received abuse prevention training on January 12, 2015. CNA 2 was not available to be interviewed during the investigation. A review of the licensed nurse's progress notes for Resident 1, dated April 4, 2015 at 11 AM, documented Resident 1 had a 1 1/2 centimeter scabbed laceration to the left side of forehead caused by a CNA hitting Resident 1 with keys. During an interview with the Director of Staff Development (DSD) on April 17, 2015 at 1:20 PM, she stated CNA 2 should have never hit Resident 1. A review of the policy and procedure titled, Abuse Policy and Procedure, undated, indicates (the facility) will not permit residents to be subjected to abuse by anyone. Physical abuse is defined as hitting, slapping, pinching, kicking, etc.

Based on interview and record review the facility failed to ensure that 1 of 15 sampled resident (Resident 2) was free from accident hazards when Resident 2 fell from a standing position while having her diaper changed. This failure resulted in Resident 2 falling backwards and sustaining a laceration (a torn and ragged wound) to the back of the head. Findings: A review of the clinical record for Resident 2, indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the "Resident Care Plan Falls," dated July 25, 2013, indicated that Resident 2 was "at risk for repeat fall...or risk for repeat injury fall related to dementia and Alzheimer's (the most common form of dementia)." It also noted that the resident's fall risk was manifested by generalized weakness, and listed contributing factors of medical condition, medications and cognitive (thinking, reasoning, or remembering) status. The fall care plan further indicated to monitor the resident for dizziness (lightheadedness), vertigo (sensation of spinning), syncope (fainting or passing out), agitation, postural hypotension (a drop in blood pressure due to a change in body position), bowel bladder urgency (the sudden intense sensation of needing to go to the toilet), muscle rigidity (muscle stiffness), tremors (shaking) and decreased alertness. A review of the Activities of Daily Living (ADL)care plan, dated July 25, 2013, noted that Resident 2 required extensive assistance for dressing, personal hygiene and bathing. A review of the of care plans for "Cognitive Status," dated July 25, 2013, noted that Resident 2 had a severe cognitive deficit (impairment to cognitive performance or thought process). A review of the nursing progress notes, dated June 21, 2014 at 8:30 PM, indicated that Resident 2 fell backward from an unsupported standing position, hitting her head on the side of her roommates bed while certified nursing assistant (CNA 1) was pulling down her diaper during ADL care. Resident 2 sustained a 0.1 centimeter (cm) by 0.1 cm laceration to the back of the head. There was no documented evidence to show that Resident 2 could stand while having her diaper changed. During an interview with the licensed vocational nurse (LVN 1) on October 8, 2014 at 9:15 AM, when asked if Resident 2 could stand, he stated, "For a short time only." LVN 1 also stated that the resident could walk and stand, but would fall real fast if you're not right there to support her. There was also no documented evidence to show that there should have been to persons to assist Resident 2 during the diaper change. During an interview with the DON (Director of Nursing) on October 8, 2014 at 2:35 PM, she stated that she counseled CNA 1 after the resident fell . The DON stated that the CNAs were to use two persons during ADL care on all unsteady residents, "because CNAs can't predict what they (the residents) are going to do." The failure to adequately supervise the resident during ADL care resulted in a fall with an injury for Resident 15.