Every finding on record at Humboldt County Memorial Hospital

Based on record review, staff and resident interview, the facility failed to ensure a resident's call light was in reach for 1 of 13 resident's reviewed (Resident #7). The facility reported a census of 25 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident depended on staff for toileting hygiene, rolling left and right, and transfers. The resident's diagnoses included chronic kidney disease, diabetes, and coronary artery disease.The Care Plan revised 9/7/21 identified Resident #7 at risk for falls. Interventions included the resident used the call light, and the resident needed a safe environment with a working and reachable call light.On 2/4/26 at 11:05 a.m. Resident #7 stated staff did not give him his call light last night, and when he needed help, he had to yell out help until someone heard him. He said he was in bed and the call light on his walker. He said that upset him.On 2/4/26 at 3:25 p.m. Staff A Licensed Practical Nurse (LPN) verified she worked the previous night shift. She said sometime around 10:30 p.m. she thought she heard someone calling out. She did some checking and Resident #7 did not have his call light. She gave it to him and apologized. She planned to talk to the staff who put him to bed about this. They should have made sure he could reach his call light.On 2/5/26 at 12:29 p.m. the Assistant Director of Nursing (ADON) stated staff should ensure residents have the call light within reach. She said a resident should not have to yell out to get help.The facility's, Resident's [NAME] of Rights, modified 3/2/17 included the residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on clinical record review, staff interviews and policy review, the facility failed to notify the Physician and family/resident representative of a condition change for 1 of 13 residents reviewed (Resident #26). The facility reported a census of 25 residents.Findings include: The Minimum Data Set (MDS) for Resident #26 dated 11/3/25 assessment identified a Brief Interview for Mental Status (BIMS) score was a 5, indicating severe cognitive impairment. Resident #26's MDS included diagnoses of Alzheimer's, Non-Alzheimer's disease, gastroesophageal reflux disease, anxiety, and depression.The Care Plan revised on 8/8/25 documented staff to monitor, document, and report as needed any signs and symptoms of dysphagia (difficulty swallowing) which included pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and concerns during meals. The Progress Note dated 12/9/25 at 12:15 PM documented Resident #26 was in the dining room eating lunch. The note documented Resident #26 was drinking and eating then started to cough. A tablemate alerted staff that Resident #26 appeared to have choked and the nurse was summoned to the table. Resident #26 was able to cough, talk and reported drink went down the wrong pipe. Review of the Clinical Record lacked documentation Resident #26's Physician or family/resident representative was notified of the incident on 12/9/25. On 2/5/26 at 2:43 AM, Staff C, Quality of Assurance Nurse reported she could not locate family and Physician notifications for 12/9/25 and verified the notifications should have been completed. The facility policy titled Change in Resident's Condition or Status dated 7/14/25 documented nursing services to notify the resident's attending Physician and representative of changes in the resident's condition and/or status.

Based on clinical record reviews and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 1 residents reviewed (Resident #19) for falls. The facility reported a census of 25 residents. Citation considered past noncompliance as the facility completed the following interventions prior to the surveyor entering the facility on February 4, 2026:Staff education provided on always utilizing the gait belt with resident transfers on 10/22/25.Staff education provided to Staff D, Certified Nursing Assistant, on the importance of utilizing a gait belt with the resident transfers on 10/23/25. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS identified Resident #19 required substantial/maximum assistance for all transfers. The MDS included diagnoses of heart failure, anemia and cancer. The Care Plan with a start date of 11/21/25 revealed Resident #19 had impaired cognitive/functional status and required assistance of two staff members for all transfers. The Incident Report (IR) dated 10/22/25 at 6:43 a.m. documented Resident #19 had a fall in his room with no apparent injuries. According to the IR, Staff D, Certified Nursing Assistant (CNA) reported Resident #19 slipped and landed on his right hip. The IR documented the gait belt was not used at the time of the fall. On 2/5/25 at 1:37 p.m. with Staff D, CNA, stated that she was getting Resident #19 ready for the day. Staff D stated his usual routine would be to stand up from the bed and utilize the urinal and then sit back down and then staff would get him ready for the day. Staff D stated he slept with a brief only. Staff D stated she did not utilize a gait belt during this transfer. Staff D stated Resident #19 got weak and his legs gave out and he was lowered to the floor. Staff D stated that she was educated regarding utilizing the gait belt. The facility policy titled Fall Prevention dated 9/29/2016 revealed the purpose it to outline the process to identify residents that are at risk for falls and those at risk for injuries related to falls. The Care Team will identify these residents on admission, quarterly with their MDS assessment, and as needed. The Care Team will then plan interventions and implement measures to decrease the incidence of falls and injury related to falls. The policy states the residents will be free from falls and injuries related to the falls. The policy states to utilize the gait belt while assisting residents with transfers and ambulation. On 2/9/26 with Staff E, Registered Nurse, stated the expectation of the staff is to utilize the gait belt when assisting the resident with transfers/ambulation, unless otherwise care planned.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed (Resident #37) with an indwelling catheter. The facility reported a census of 25 residents.Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS identified Resident #3 required partial/moderate assistance with toileting hygiene. Resident #3's MDS included diagnoses of benign prostatic hyperplasia (BPH), neoplasm (tumor) of the bladder and overactive bladder. The MDS documented Resident #3 had an indwelling catheter. On 2/5/26 at 10:46 AM, Staff B, Certified Nursing Assistant (CNA), put on a gown and pair of gloves prior to entering Resident #3's room. Staff B carried a box of gloves into the room and sat the box of gloves on the floor without a barrier next to a towel on the floor that had a graduate and alcohol swabs on it. Staff B removed her gloves and applied a pair of gloves from the box of gloves sitting on the floor without completing hand hygiene. She then proceeded to cleanse the leg bag spout with an alcohol swab, empty the urine into the graduate and then cleanse the spout with a different alcohol swab. Staff B then took off her gloves and put on a pair of gloves from the box of gloves sitting on the floor without completing hand hygiene. Staff B pulled Resident #3's pant leg down and then went to the restroom to empty the graduate and rinse it out. Staff B acknowledged she put the box of gloves on the floor and did not do hand hygiene when changing gloves. On 2/5/26 at 1:19 PM, Staff C, Quality Assurance Nurse reported supplies should not be put on the floor without a barrier and hand hygiene should be completed when gloves are changed.A facility policy titled Hand Hygiene dated 4/23/25 documented the purpose of the policy was to establish guidelines for proper hand hygiene practices among patients, visitors and staff to prevent the spread of infections and ensure safety, following the Centers for Disease Control and Prevention (CDC) guidelines. The policy directed hand hygiene to be performed after removing sterile or non-sterile gloves.

Based on observations and staff interviews the facility failed to cover food items when transported. The facility identified a census of 26 residents. Findings include: On 1/3/24 during the noon meal service, observed 5 room trays leave the serving kitchen after Staff A, Cook and Staff B, Dietary Aide assembled each tray. The following items were not covered on each room tray: 1. Resident #9- garden salad and pineapple upside down cake 2. Resident #12- garden salad and pineapple upside down cake 3. Resident #13- garden salad 4. Resident #5- garden salad and pineapple upside down cake 5. Resident #6- pineapple upside down cake. On 1/3/24 at 1:00 PM, Staff A, Cook acknowledged and verified all items on a room tray should be covered. On 1/3/24 at 1:02 PM, Staff B, Dietary Aide reported she does not usually cover the salads or anything like that. Staff B stated she was not told to do that. On 1/3/24 at 1:30 PM, Staff C, Dietary Supervisor stated he thought every item on a room tray needed to be covered but would need to look at a policy. On 1/3/24 at 2:30 PM, Staff C, Dietary Supervisor reported the facility did not have a policy that addressed room trays and covering food items. On 1/3/24 at 4:40 PM, The Director of Nursing (DON) reported she could not locate a policy regarding room trays. The DON stated her expectations were all food items to be covered on the room trays during transport. The DON stated the dietary staff are responsible for covering the items before leaving the serving kitchen and her staff delivers the room tray. On 1/4/24 at 8:50 AM, Staff D, Dietary Manager stated she expected all items on the room tray to be covered when transported.

Based on observations, staff interviews, and policy review, the facility failed to prepare pureed food items with the most nutritional content, provide a full serving of pureed meat and failed to hold hot food at appropriate temperatures. The facility reported a census of 26 residents. Findings include: On 1/3/23 at 11:30 PM, observed the puree food process with Staff A, Cook. Staff A reported there were two residents that received puree food (Resident #4 and #10). Staff A reported she would need to puree 6 items (two servings of green beans, two servings of rice, one serving of salmon and one serving of barbeque (BBQ) ribs). Observations revealed the following: A. Staff A took two servings of rice from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the rice and added some thickener. Staff A split the pureed rice into two servings and scooped it into two bowls. Staff A placed a plastic lid on each bowl and placed it in the steam table without labeling or taking a food temperature. B. Staff A took two servings of green bean from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the greens beans and added some thickener. Staff A split the pureed green beans into two servings and scooped it into two bowls. Staff A placed a plastic lid on each bowl and placed it in the steam table without labeling it or taking a food temperature. The green beans appeared very runny in consistency. C. Staff A took one serving of salmon from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the Salmon, then added more water and some thickener to the mixture and blended it again. Staff A put the pureed salmon into a bowl. Staff A did not scrape out the blender to ensure the entire meat serving was obtained. Staff A placed a plastic lid on the bowl and placed it in the steam table without labeling the container or taking a food temperature. D. Staff A took one serving of BBQ ribs from the steam table, placed it in the blender and added tap water directly from the sink faucet. Staff A blended the BBQ ribs and added some thickener. Staff A placed the pureed BBQ ribs in a bowl filled to the top. Staff A took the blender to the sink and discarded the remainder of the pureed BBQ ribs. Staff A acknowledged and verified that she had discarded the remainders of the BBQ. Staff A placed a plastic lid on the bowl and placed it in the steam table without labeling the container or taking a temperature of the pureed BBQ ribs before placing it back in the steam table. E. Observed Staff A use cold tap water and hot tap water from the sink when adding the water to the blender. Staff A did not check the water temperature before adding it to the blender. On 1/3/24 at 12:00 PM, surveyor requested Staff A, Cook to take food temperatures on the pureed food items in the steam cart in the serving kitchen prior to serving. The food temperatures for the pureed food revealed the following temperatures: a. Green Beans- 111.5 degrees Fahrenheit b. Rice- 114.6 degrees Fahrenheit c. Salmon- 106.9 degrees Fahrenheit d. BBQ ribs- 104.8 degrees Fahrenheit On 1/3/24 at 12:10 PM, Staff A, Cook reported she was not sure what to do about the pureed food temperatures. Staff A stated she would call her Supervisor for direction. Staff A reported Staff C, Dietary Supervisor told her to reheat the pureed food items in the microwave before serving. Staff A reported she had taken food temperatures prior to leaving the main kitchen. Staff A stated that the food must have lost temperature on the way down from the main kitchen to the serving kitchen. On 1/3/23 at 2:30 PM, Staff C, Dietary Supervisor reported they had been having some issue with the steam table in the serving kitchen and had plans to replace it. Staff A reported when she arrived to the serving kitchen the steam table wells were out of water so she had to add water to each well before placing the food in the steam table. She stated the food sat on the cart for a little bit before going into the steam table. On 1/4/24 at 8:50 AM, Staff D, Dietary Manager reported she would expect staff to blend the food in the blender first before adding any liquids to see if the liquids were needed. Staff D stated she expected gravy or sauces to be used for meat and to use the green bean juice for the green beans. Staff D reported her expectations are for staff not to take water directly out of the tap. She stated if cold water was taken out of the tap, she would expect staff to take a food temperature before putting the food back into the steam table. Staff D stated if the sauces, gravy or juice were used from the steam table then a temperature would not need to be taken. Staff D stated she expected the staff to use a rubber spatula to get all the pureed food out of the blender. Staff D stated any measurable amount of food needs to be removed from the blender and offered to the resident to ensure a full serving was given. Staff D stated Staff A was a newer cook and would be provided education and training regarding the puree process. A facility policy titled Food Production- Puree food policy reviewed 11/07/22 documented the following: 1. The pureed foods will be prepared using the serving in/serving out method. 2. The standardized recipe will be followed to puree the food to the appropriate consistency. -The employee will add the desired amount of servings of the food needing to be pureed into the blender. Liquids and/or thickener will be added per the recipe. -After the product has reached the appropriate texture and consistency per IDDS guidelines, the employee will divide the pureed product evenly to equal the total amount of servings that were originally added to the blender. -If extra serving were prepared, these will be discarded for quality and infection control. The policy did not address taking temperature prior to placing the pureed food items back into the steam table. The policy did not address what type of liquids to be used during the puree process. A facility policy titled Food Production-Proper food preparation and handling revised 7/13/2015 documented hot foods shall be held and served at 140 degrees Fahrenheit.

Based on record review and staff and resident interview, the facility failed to assure residents were treated with dignity and respect for 3 of 5 residents reviewed (Resident #1, #4, and #5). The facility reported a census of 25 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, and toilet use, and limited assistance with personal hygiene. The resident had diagnoses including hemiplegia (paralysis of 1 side of the body). The Care Plan dated 2/28/23 included Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident had impaired cognition related to short term memory loss from a car accident and difficulty with speech at times. The interventions included communication: identifying self at each interaction, facing the resident when speaking to him and making eye contact, and reducing any distractions such as turning off the television and radio, and shutting the door. The resident understood consistent, simple, directive sentences. A statement written by Staff A Certified Nursing Assistant (CNA) documented on 10/3/23 Staff B CNA asked her to assist with Resident #1's transfer from the wheelchair to the recliner. Staff A noticed the resident must have had a nose bleed. Staff B stated it was off and on all day. Staff B said he had Kleenex and for him to clean up. She said it was just a nose bleed, nose bleeds happened, probably not his first nose bleed nor his last nose bleed, and she walked out of his room. Staff A was getting something to clean him when the Activity Director (AD) came in the room. She saw the resident had dried blood on his nose and shirt. The facility investigation included an interview by the Director of Nursing (DON) with Staff A on 10/5/23 at 2 p.m. Staff A stated she had reported a concern about how Staff B had interacted with the resident in his room when he had a bloody nose and in the hallway. The investigation further revealed on 10/4/23 the DON pulled Staff A in the office as she wanted to talk to her on 10/3/23 as she was leaving for the day. The DON told her she was running late to an obligation and asked if she could call her later or talk the following day. She said they could talk the following day. Staff A voiced concerns to the DON regarding an interaction on 10/3/23 when the resident had a nosebleed and thought that Staff B did not interact with the resident with compassion. She stated that Staff B told the resident everyone gets nose bleeds, get a Kleenex and clean it up. Staff and Resident interviews were completed on 10/5/23 and 10/6/23. During staff and resident interviews, vague concerns were voiced to the DON regarding Staff B. Reports of a snarky tone, bossy, working to fast, were voiced. Staff stated they did not feel this was intentional or malicious but did bring it up due to the nature of the conversation. Prior to staff and resident interviews, these concerns had not been reported previously to the DON, the nurses or any other employees. A statement written by Staff C Licensed Practical Nurse (LPN) documented Staff A told him that Staff B yelled at the Resident #1 about a nose bleed and making a mess. Staff A stated feeling bad for the resident and how awful we would feel if it was us or our family being treated that way. The resident confirmed the interaction. On 11/16/23 at 2:40 p.m. the resident stated Staff B was mad he had a bloody nose. He could not expand beyond she was just mad. On 11/20/23 at 10:02 a.m. Staff C stated he was the overnight nurse and the alleged incident occurred on the previous shift. He didn't witness anything himself. But the resident did say something happened. On 11/20/23 at 10:52 a.m. the AD stated when she entered the resident's room, he was in the room alone and she could see he had a bloody nose. Staff A came in also. She got him a wash cloth. The resident seemed embarrassed about the bloody nose. On 11/20/23 at 2:16 p.m. Staff B stated the day Resident #1 had the bloody nose she may have said there's a Kleenex and made a comment about cleaning it but she would have helped him. She did not recall any issue. She said she was not mad about anything. She said she didn't notice the bloody nose until after the transfer. On 11/20/23 at 5:10 p.m. the DON stated the resident said nothing happened when they asked him about the day in regards to his nose bleed. 2) According to the MDS assessment dated [DATE] Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, and personal hygiene. The resident had diagnoses including heart failure and pulmonary disease. The Care Plan initiated 6/28/22 included the focus the Resident #4 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. On 11/20/23 at 1:59 p.m. Staff D CNA stated she had a concern one day when Staff B had a tone with the Resident #4 and told the resident she knew what she was doing. On 11/20/23 at 2:12 p.m. Resident #4 stated she had issues with Staff B several times. She thought she could come in and start bossing her and other aides around. Staff B thought things would be done her way. The resident said that was not going to work. She said that happened a couple times and then Staff B left. 3) a) According to the MDS assessment dated [DATE] Resident #5 scored 3 on the BIMS indicating severe cognitive impairment. The resident required assistance for dressing, toileting and personal hygiene. The resident had diagnoses including anxiety disorder. The Care Plan initiated 10/9/23 included the focus Resident #5 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. b) According to the MDS assessment dated [DATE], Resident #2 scored 15 on the BIMS indicating no cognitive impairment. On 11/20/23 at 10:25 a.m. Resident #2 stated Staff B was never mean to him, but he had heard her be verbally mean to his roommate (Resident #5). He clarified it was just verbal. The facility policy, Dignity and Respect approved 7/14/15 documented it was the policy of the facility to treat all residents with kindness, dignity and respect. The facility promoted care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his/her individuality. Staff should display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on record review and staff interview, the facility failed to notify the physician of a significant weight loss (5%) for one of one resident reviewed, (Resident #20). The facility reported a census of 22 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] for Resident #20, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident was independent with eating after set up, and was extensive assistance of 2 staff for bed mobility, transfers, toileting, and dressing. The MDS documented the resident had a Brief Interview for Mental Status score of 14, indicating intact cognitive response. Record review showed on 10/01/2022, the resident weighed 160 pounds. On 11/01/2022, the resident weighed 151 pounds, which was a -5.63 % weight loss in one month. No documentation of physician notification was found in the record. Review of facility policy titled Weight Loss of Residents, modified 3/01/22, documented physician and family to be notified monthly, and as needed, of significant weight loss and current interventions. Policy also documented significant weight loss considered 5% for one month.

Based on observation, record and policy review, and staff interview the facility failed to provide complete incontinence care for one of three residents reviewed, (Resident #14). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 7/8/22, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident needed extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. The MDS identified the resident was frequently incontinent of urine. The MDS documented a Brief Interview for Mental Status of 6, indicating major cognitive impairment. During an observation on 11/9/22 at 12:47 PM, with the Director of Nursing (DON) present, Staff A, Certified Nurse's Aide assisted the resident to the toilet with a walker. Staff A removed the resident's wet pull-up brief and pants. Staff A wiped between the resident's leg and groin on each side, using a new wipe for each side. Staff A did not cleanse the penis or scrotum. Staff A cleansed the buttocks and hips using a new wipe for each swipe. Staff A removed gloves, sanitized hands, and applied a new pull-up brief and clean pants. Staff A confirmed the old pull-up brief was wet with urine. Review of facility policy titled, Perineal Care , modified 5/18/21, documented: for male resident wash the penis from the urethral opening or tip of the penis and wash the scrotum, pay attention to skin folds, dry. Immediately following the observation on 11/9/22, the DON stated her expectation was to cleanse the penis and scrotum with cares.

Based on observation, clinical record review and staff interview the facility failed to ensure that staff had up to date information available to them regarding a resident's choice for code status/Do Not Resuscitate(DNR) for 1 of 16 residents reviewed, (Resident #14). The facility did not have a red dot on Resident #14's chart which indicated this resident wished to be a full code, meaning she wanted to have cardiopulmonary resuscitation (CPR) performed if her heart stopped beating and/or if she stopped breathing, which contradicted her most current wishes of DNR status indicated by the signed DNR/CPR Acknowledgement Form signed by the physician. The facility reported a census of 22. Findings include: The Minimum Data Set (MDS) assessment for Resident #14 with an Assessment Reference Date of [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview of Mental Status showed a score of 15 indicating resident's cognition was intact. A DNR/CPR Acknowledgement Form dated [DATE], documented Resident #14 wished to be a DNR and was signed by the Primary Care Provider as a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An Advance Directives -LTC (Long Term Care) policy dated [DATE], documented the facility will honor advance directives which are properly executed in accordance with state law. The policy defined advance directives included No CPR, which indicated in the case of respiratory or cardiac failure the resident or their representative directed that no CPR or other life saving methods are to be used. In an observation on [DATE] at 3:37 PM, it was noted that there was not a red dot on Resident #14's chart. In an interview on [DATE] at 11:01 AM, Staff H, Registered Nurse (RN), MDS nurse stated there was to be a red dot on each residents chart if that resident wished to have DNR as their code status and the residents code status will also be in the chart. The Director of Nursing (DON) was present during this interview and concurred. When asked about if staff would proceed to look into the chart if there is a dot or there isn't a red dot, Staff H stated they could and the DON added they could also look into PCC (the facilities electronic health record). Staff H pulled out Resident #14's chart and Staff H noted there was not a red dot on the outside bridge of the chart. Staff H opened the chart and saw that this resident was a DNR and stated there should have been a red dot on the chart. The DON concurred. They both said there isn't one specific person who places the red dot on the chart, whoever does the resident's admission usually does. Staff H grabbed a red dot and placed it on the outside of the chart. The facility failed to have a red dot on the bridge of Resident #14's chart which would have indicated her wishes for DNR status. By not having the dot on this resident's chart, it indicated that the resident wanted CPR which went against her wishes for code status and directed CPR qualified staff to initiate CPR in the event of respiratory or cardiac failure for Resident #14 occurred.

Based on observation, record review and staff interviews, the facility failed to provide services that met professional standards by not consistently documenting and completing the 15 minute resident check elopement prevention intervention for 1 out of 2 residents reviewed (Resident #17). The facility reported a census of 22 residents. Findings include: A Minimum Data Set with an Assessment Reference Date of 2/22/21 documented a Brief Interview of Mental Status score of 10. This indicated Resident #17's cognition was moderately imparied. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 4/6/21, identified Resident #17 required one person assist for ambulation in the facility and one person assist for ADLs (activities of daily living). A Care Plan focus area for Resident #17 identified the resident was an elopement risk/wanderer with interventions that included: a. Wander guard bracelet, resident has a history of cutting off wanderguard. b. Distract resident from wandering by offering pleasant diversions, structured activities. c. 1:1 given as needed. d. Redirect resident if able. e. Do 15 minute checks on location and safety. On /27/21 at 1:49 PM Resident #17 was reading a book in her room. She appeared very agitated as she explained she is supposed to go home every day after lunch. Resident #17 reported family normally provided her with a ride, then recited her home address. At the end of the visit, she demanded the situation be looked into. On 4/27/21 at 1:59 PM, interview was conducted with Staff I, Certified Nurse Aide (CNA). Staff I reported Resident #17 suffered from dementia and that she can be often fixated on going home. Her behavior was known to staff and family. Resident #17 often times resorted to reading to be comforted. A Progress Note dated 4/26/21, reflected a recent elopement attempt. Progress Note stated Resident #17 was demanding to go home and had tried to exit through doors. Staff had walked with this resident, offered her a snack, tried to get her to play games on the IPAD, and tried to get her to read her book prior to her attempt to exit through the doors. Resident #17 continued to try and leave. This resident became angry towards staff. An observation on 4/29/21 at 1:15 PM, revealed Resident #17 was assisted back to her room by Staff G, CNA. During continuous observation staff occasionally glanced toward Resident #17's room; however no one entered the room to check on the resident as required for 15 minute elopement interventions listed on the care plan. Observation ended at 1:37 PM. On 4/29/21 at 1:38 PM, Staff F, CNA, was asked for documentation related to 15 minute checks. Staff F first inspected the resident's room, next the nurse's station, then eventually questioned Staff G. Staff G did not think there was a form started for Resident #17. Staff G then retrieved a new form from a drawer located at the end of the nurse's station. On 4/29/21 at 1:43 PM, Staff F delivered a new 15 Minute Check form to the resident's room. Staff F was asked how she would know when the resident was last checked if there was not a form to refer to. Staff F answered she would not know how she would know. On 4/29/21 at 1:45 PM, Staff reported the 15 Minute Check form was in the break room. Upon entering the break room Staff G appeared to be writing on the form. Staff G did not turn around until after she placed her pen in the pocket of her scrub pants. Review of the form revealed the last 8 areas of the 15 minute checks were completed by Staff G and Staff F. Staff G and Staff F had already indicated they did not know if a form was started for that day. The form provided a place for documentation every 15 minutes starting at 12:00 AM to 11:45 PM daily. A 15 Minute Check form provided by the facility and dated 4/29/21, revealed this resident did not get checked on by staff during the following 15 minute check times: 12:15 AM, 12:30 AM, 12:45 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:15 AM, 3:30 AM, 3:45 AM, 4:15 AM, 4:30 AM, 4:45 AM, 5:15 AM, 5:30 AM, 5:45 AM, 10:45 AM, 11:15 AM and 11:45 AM. On 4/29/21 at 2:00 PM, the Director of Nursing (DON), delivered all 15 Minute Check forms since the onset of intervention on 4/20/21. She noted several missed checks and pointed out areas the night staff completed documentation every hour instead of every 15 minutes. The DON shrugged her shoulders and relayed Staff F did not sign her own initials on 4/29/21 at 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:30 PM or 1:45 PM. The DON voiced understanding of concerns and was going to look into the matter. On 4/29/21 at 2:17 PM, during interview Staff F denied writing her initials on that day's 15 Minute Check form. Her initials were written in 5 different areas. Review of the 15 Minute Check forms used as an intervention to prevent elopement revealed that 342 areas out of 884 areas were not signed. This indicated staff did not perform the 15 minute checks on Resident #17 342 times out of the 884 times they were to be done.

Based on observations, staff interviews, and policy review the facility failed to ensure the oxygen tubing was changed, the use of oxygen was documented, and the oxygen concentrator was turned off when resident was out of their room for three out of four residents (Residents #5, #6, and #22). The facility reported a census of 22. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the resident was totally dependent on staff for locomotion on the unit. The MDS showed she used oxygen (O2) therapy while a resident. An observation on 4/28/21 at 1:04 p.m., showed Resident #5's oxygen machine was running in the room while she was not in the room. 2. The MDS assessment dated [DATE] for Resident #6 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. The MDS showed she used oxygen therapy while a resident. During an observation on 4/26/21 at 12:17 p.m., noted oxygen tubing not labeled. A review of an order dated 12/19/19 at 9:51 a.m., revealed the order for oxygen tubing and nebulizer tubing every 2 weeks with no documentation required. A review of the Treatment Administration Record (TAR) for Resident #6 revealed no order for changing oxygen tubing every two weeks. During an observation on 4/28/21 at 12:56 p.m., noted the oxygen tubing was not labeled. During an observation on 4/29/21 08:30 a.m., noted the oxygen tubing was not labeled. During interview with the Director of Nursing (DON) on 4/29/21 at 10:05 a.m., she stated the nurses were to sign the TAR when they changed the tubing. The DON stated she didn't expect the nursing staff to label the oxygen tubing. An interview with Staff A on 4/29/21 at 10:10 a.m., revealed the night shift nursing staff changed the oxygen tubing on a certain day. Staff A stated that they do not label the oxygen tubing since the nursing staff sign it off on TAR. During an interview with the Assistant Director of Nursing (ADON) on 4/29/21 at 1:13 p.m., the ADON verified there was no order for changing the O2 tubing for Resident #6. A review of the policy titled Respiratory Care last modified 7/14/15 revealed oxygen tubing, cannula, and mask would be changed on a bi-weekly basis and as needed (PRN) as indicated on the resident's treatment record. 3. The MDS assessment completed for Resident #22 showed a BIMS score of 9, indicating moderate cognitive impairment. The resident used oxygen within fourteen days of the look back period. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/21 at 1:56 PM observed the resident wearing oxygen (O2) at 3 Liters (L) via (/) nasal cannula (NC) with the tubing not labeled. The 4/21 TAR showed an order dated 4/12/21 for O2 at 2 to (-) 3L/NC to keep oxygen saturations (sats.) greater than (>) 90 percent (%) as needed related to acute [CONDITION(S)] with [CONDITION(S)]. The 4/21 TAR lacked documentation to show the use of Oxygen for the resident. The Care Plan problem dated 4/26/21 showed the resident has oxygen therapy related to [CONDITION(S)]. The Care Plan included the following interventions dated 4/26/21: 1. Monitor for signs or symptoms of respiratory distress and report to the doctor as needed (PRN): respirations, pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. 2. Monitor lung sounds as needed. 3. O2 sats. as needed. 4. Oxygen settings: O2 at 2-3 L/NC 5. Oxygen tubing changed every two weeks. On 4/29/21 at 1:18 PM The Director of Nursing (DON) said there should be an order in the TAR to clean and change the oxygen tubing. The DON said she would review the oxygen and cleaning protocol for the resident.

Based on observations, interviews, and record review, the facility failed to provide the menus as planned based on the nutritional needs of 3 out of 3 residents who received a puree consistency diet by not providing the food planned by a dietitian along with the appropriate serving size per the menu approved by the dietitian. The facility offered a roll on the menu and it was not provided and served a lesser amount of the approved serving size of pureed salmon. The facility reported a census of 22 residents. Findings include: A LTC (Long Term Care) Diet/Snack And Nourishment Form dated 4/27/21, documented that 3 out of 22 residents received pureed foods. A Diet Extensions: Wednesday, Week 3, Facility Fall Winter 2020-2021 with service for 4/28/21 print out, documented 1 #10 sc.(scoop) P/PU4 of balsamic salmon was to be served for puree consistency diets. An undated Recipe-P/PU4 Salmon Balsamic Herb (P/PU4 Balsamic Salmon),directed the method for the recipe was puree. The recipe gave the following amounts ¼ cup of vegetable f/base and 3 ounces salmon balsamic herb. The direction steps included; Pour liquid in blender or food processor. Add prepared fish. Blend until consistency is reached. Add additional liquid as needed to achieve desired consistency. Discard unused product. May use alternate liquid as desired. The recipe defined Pureed (PU4) as a recipe appropriate for those on a level 4 pureed. A Diet Orders- LTC policy dated 9/2/20, directed that diet textures and thickened liquids will follow the International Dysphagia Diet Standardization initiative (IDDSI) framework which included level 4 pureed. On 4/28/21 at 11:15 AM, Staff K, evening cook, grabbed 3 bowls for 3 pureed salmon. Staff K grabbed 3 pieces of salmon and placed them into the robot coup (food processor). Staff K then poured vegetable broth that she had mixed up prior. Staff K stated the vegetable broth was on the recipe for what to puree with the salmon. Staff K poured the broth into a blender then added the ground salmon. Staff K added more broth and stirred the mixture up with a rubber spatula then started the blender again. She added more broth and blended again. Staff K then pushed down the mixture again with a rubber spatula and blended again. Staff K poked contents down in the blender and blended again. Staff K then used a #10 scoop to place 1 scoopful of the mixture into each of the 3 bowls. Staff K then covered the 3 bowls with foil. Staff K was asked to measure the mixture that was left over. Staff K used the #10 scoop to measure the salmon puree left in the blender. The #10 scoop was short of being full. Staff K stated if she would get the rest of the salmon out of blender, the scoop would be an even #10 scoop. Staff K reported that a #10 scoop is 3/8ths of a cup or 3-4 oz. Staff K added it was okay to have leftover salmon puree because you wouldn't want to put too much liquid in it. Staff K said the puree was supposed to be 3oz of salmon. Staff K pureed green beans but did not puree or slurry any rolls. On 4/29/21 at 9:38 AM, Staff J, Dietary Manager brought in the recipe for pureed salmon and pointed out that the salmon recipe directed staff to discard any left over food after scooping out with the #10 scoop one portion for each individual. Staff J felt the recipe was followed. Staff J stated the roll was part of the meal but the residents who received pureed diets did not want the roll and they would have circled it if they wanted it. When asked if the 3 residents who receive pureed food are able to choose if they wanted a roll she said one of the residents was. The other 2 have pureed meat with minced and moist other foods. The rolls would need to be slurried. When told no rolls went out on the trays at noon yesterday that were slurried or pureed, Staff J acknowledged. On 4/29/21 at 9:46 AM Staff L, Dietitian RDLD stated there was a concern that the left over salmon was not divided (and added) into the 3 portions. Staff L stated that no education had been provided to the dietary staff on this (not discarding the extra amount left over but instead dividing it equally among the servings). The amount left over equalling a #10 scoop should have been divided into the 3 servings and not discarded. Staff L stated that rolls are part of the 24 hour caloric and nutrient needs for the residents and that also is a concern. Staff L stated that Certified Nursing Aides are not able to determine whether or not a resident would need a roll. Staff L stated that the CNAs are looking at it from, whether or not the resident would eat it, point of view. The aides are not looking at the nutrient side of it when deciding if the other two residents (the two residents that could not choose for themselves) want a roll or not. Staff L stated dietary staff are trained to achieve the right consistency of purees. So they are trained to be sure they are reaching the right consistency according to IDDSI. A Diet Orders- LTC policy dated 9/2/20, directed that diet textures and thickened liquids will follow the International Dysphagia Diet Standardization initiative (IDDSI) framework which included level 4 pureed.

Based on observations, interviews and record review the facility failed to ensure the safe handling of food during one lunch service and mold was noted on a kitchen wall. The facility reported a census of 22. Findings include: In an observation on 4/27/21 at 11:10 AM, during the initial kitchen walk through with Staff J, Dietary Manager, mold was noted above the chemical connection on the wall behind dishwasher. In an observation on 4/28/21 at 11:33 AM, Staff K dumped the scoop used to measure thickener out on a tray from a plastic bag. She then used scoop to measure thickener and poured it into pureed green beans. Staff K placed the thickener scoop back down on the tray and then used it again to measure two more scoops of thickener and added it into the pureed green beans. Staff K then used a 10 ounce scoop and measured the green beans. Staff K laid the scoop on the stainless steel countertop after being put into the food and then used the scoop again to scoop out green beans. Staff K had pureed salmon prior and did not sanitize countertop. In an interview directly following this observation, Staff K stated she had cleaned the countertop prior to pureeing food. Staff K stated that the tray she dumped the thickener scoop on was cleaned weekly. Staff K agreed that placing the scoop into thickener and adding thickener to food was not a clean process after she had placed it on the tray. Staff K also agreed that lying used #10 scoop on countertop, picking it off the countertop and using it again was not a clean process. Staff K said she should not have done either. In an interview on 4/29/21 at 9:46 AM, Staff L, Dietitian RDLD, concurred the scoop used to measure thickener should not have touched other surfaces, including the tray that was washed once a week and should not have been placed back into the thickener which was poured into the food. Staff L stated the scoop used to measure the green beans should not have been laid down on the countertop that had not been disinfected after pureeing salmon and then reused to measure the green beans when more green beans were added. She stated the two scoops should not have touched other surfaces and then been placed into the food that was being served. In an interview on 5/4/21 at 8:13 AM, Staff M, Cook Supervisor, stated he understood the concerns with pureed food and infection control issues regarding thickener scoop being placed on tray and then into food as well as the #10 scoop being used for food then placed on a countertop used to puree other food without being sanitized afterward and then the scoop being used for food again. Staff M stated he also understood the concern regarding the mold on the wall in the kitchen behind the dishwasher. A Food Production-Sanitary Food Preparation policy datd 4/21/16, directed that all food, including nourishments, shall be prepaed and served in a sanitary manner. A Cleaning and Sanitation-cleaning of department policy dated 7/13/15, directed that walls shall be cleaned on a regular scheule to provide and maintain sanitary food production and service environment by the Nutritional Services department.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate infection control techniques while providing resident care for two of twelve residents observed (Residents #2 and #19). The facility reported a census of 22. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 1/25/21 showed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The resident required an extensive assist of two staff with transfers and toileting. The resident required an extensive assist of one staff for toileting. The resident had a urinary tract infection (UTI) within the last thirty days. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/21 at 2:39 PM Staff E, Registered Nurse (RN), said the resident was on contact precautions due to a UTI, has a history of a contagious infection in her urine, and they were awaiting her culture. During observation on 4/29/21 at 9:25 AM with Assistant Director of Nursing (ADON) observing, Staff D, Certified Nursing Assistant (CNA), prepared the standing mechanical lift, then put on the resident's sling. Staff B, CNA, sanitized her hands and put on gloves then attached the rope to the sling. Staff B pulled the resident's pants down and noted the resident was dry. Staff B asked the resident if she needed more time, and the resident said yes. Staff D locked the brakes of the mechanical standing lift, then closed the accordion door. The Staff exited the room and waited in hall for the resident. Then the staff went to do something else while they waited for the resident to be finished. The ADON waited outside the room while the resident finished. On 4/29/21 at 9:39 AM the ADON checked on the resident who said she needed to get off the toilet because her tailbone hurt. The ADON went to get the other aides. Staff B put dry wipes into the sink without a barrier, then ran water over them, and sprayed perineal spray on them. Staff B placed a wipe down on the shelf, then put the wet wipes on top of the dry wipe. Staff B completed one wipe to the right side, then one wipe to the left and one down middle, and then wiped backside. Staff B, then used the dry wipe to dry the resident. Staff B removed her gloves and then pulled up the resident's brief and pants. Staff D assisted to put the resident into the recliner, then Staff B sanitized her hands and got the resident a wet wash cloth to wash her hands. Staff D put the resident's feet up and positioned her tray table with the call light. Staff D gathered garbage then the left the room. The 4/21 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan problem dated 1/8/21 explained the resident had the potential for bowel and bladder incontinence related to confusion, a history of a UTI, and the aging process. The resident has a staghorn stone in right kidney, and a small cyst, 2 centimeter (cm) on her left kidney, per the urologist. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The intervention dated 9/15/15 showed to clean the resident's peri-area with each incontinence episode. On 4/29/21 at 1:18 PM the Director of Nursing (DON) said that the staff shouldn't place the wipes in the sink to get wet and shouldn't have used the barrier wipe to dry the resident. 2. The MDS assessment dated [DATE] for Resident #19 showed a BIMS score of 10, indicating moderate cognitive impairment. The resident required an extensive assist of one staff with transfers and limited assist of one staff with walking. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/29/21 at 9:34 AM the Restorative Nurse entered the resident's room got the walker and gait belt. As walking out of the resident's room, she pulled gait belt across the floor down the hall then picked it up. The Restorative Nurse finished walking to the resident, applied the gait belt on the resident, and assisted the resident to stand. The Restorative Nurse, then walked the resident down the hall a few feet before the resident requested to sit in her wheelchair. The ADON helped the Restorative Nurse to sit the resident in her wheelchair. Before leaving the room the ADON then put the gait belt on the hook to the north of the bathroom with the other gait belt. The ADON exited the room and sanitized her hands before checking on the resident's roommate. On 4/29/21 at 1:18 PM the DON said the staff shouldn't have let the gait belt drag across the floor and then put on the resident. After using the gait belt they should have cleaned it before placing on the hook as the facility's gait belts are able to be sanitized.

Based on employee file review, staff interviews, and policy review for dietary employees the facility failed to ensure all staff were compliant with the mandatory reporter dependent adult abuse training within 6 months of the hire date for 2 of 13 staff members reviewed. Findings include: Record review of Staff A, Dietary Aide, employee file, documented a hire date of 10/10/19. The file lacked a certificate of completion for the mandatory reporter dependent adult abuse training. Record review of Staff B, Dietary Aide, employee file, documented a hire date of 5/29/19. The file lacked a certificate of completion for the mandatory reporter dependent adult abuse training. Review of Staff A and Staff B's training for online in-services lacked completion of a 2-hour course for mandatory reporter dependent adult abuse training. An interview with Staff B on 6/30/20 at 12:15 PM, revealed she needed to get training completed. During an interview with the Dietary Manger on 7/1/20 at 9:12 AM, she confirmed two of her staff were not up-to-date on the requirement to complete the training within the 6 months of hire. The facility provided 11 of 13 dietary staff Mandatory Reporter Dependent Adult Abuse certificates to the surveyor on 7/1/20. Review of the facilities policy titled, Employment Condition - Employee Education Requirements, with a date of 2/18/20 approved, documented employees of long term care will be required to complete a two-hour Mandatory Reporter Training of Dependent Adult Abuse from the Department of Human Services. Starting July 1, 2019, the new requirements will be that a person will have to complete within the first 6 months of their employment.

Based on observation, policy review and staff interview the facility failed to store, prepare, distribute and serve food in accordance with food service safety. The facility reported a census of 28 residents. Findings include: Food for long term care residents was prepared in the hospital kitchen. Observation of the hospital kitchen on [DATE] at 10:20 AM revealed several undated, open food items; in the walk-in cooler, a bag of Cole Slaw, a bag of broccoli (which was turning brown in color), a box of prune juice, package of shaved almonds and an open container of honey. Two large bins, one containing flour and one sugar, were on the floor in the baking area with no documentation of dates that indicated when the flour and sugar was put in the containers. On [DATE] at 10:50 AM observation of the walk-in refrigerator found two containers of lunch meat, a container of lettuce and a container of carrots each covered with plastic wrap with no date of preparation indicated. Inspection of the milk refrigerator found 8 individual size yogurts with expiration date of [DATE]. The yogurts were still in the refrigerator on [DATE] at 10:00 am. At 11:50 AM on [DATE] an inspection of two refrigerators in the serving kitchen revealed an open container of milk undated, a small serving dish of what appeared to be pudding covered with plastic wrap undated and a open juice box undated. In the freezer was a opened, undated gallon container of vanilla ice cream approximately ,[DATE] gone with some yellowing around the edges of the ice cream, and two bags of frozen cookie dough undated. During dining area observation on ,[DATE] at 12:30 PM on three occasions Staff I, CNA handled drinking glasses around the top rim with no hand hygiene between serving different residents. With gloved hands, Staff B handled salt and pepper shakers, touching several surfaces of the dining table before handling bread and serving it to a resident. On ,[DATE] 8:30 AM, Staff C, Activity Director grabbed top of milk and juice glasses no less than 8 times. She was observed to serve 5 different residents with no hand hygiene in-between. With gloved hands, Staff A, CNA handled a package of oatmeal, jelly and butter, touched other surfaces of the table and buttered toast with the same gloved hands and served it to the resident. On [DATE] at 8:30 AM during breakfast meal, Staff B was observed to grab drinking glasses around the top rim two times, Staff H did the same two times and Staff I one time. On [DATE] at 10:55 AM, the Dietary Manager acknowledged open containers should always be dated as well as the bins containing flour and sugar. She stated that expired milk items (such as the yogurt) are picked up on Mondays and Thursdays by the vendor, until that time, it would be expected the staff would check the expiration date on yogurt before serving it to residents. The Dietary Manager stated the expectation for serving drinks is the rim of drinking glasses are not touched. She also stated they do not recommend the use of gloves while serving residents at the table, it is expected that tongs and other utensil be used for handling food. Review of the policy titled: Food Production-Labeling of food items in IPC and LTC, Department: Food Production, Nutritional Services approved on [DATE], revealed all foods will be labeled and dated for safe consumtion by patients and residents.

Based on observation and staff interviews the facility failed to provide accurate menus and nutritional adequacy to meet the nutritional needs by serving the correct portion size for 2 of 3 residents on a pureed diet in accordance with established national guidelines. The facility reported a census of 28 residents. Findings include: The menu for Spring-Summer 2019: Week 2, Tuesday lists puree menu as the following: 1 serving #10scp P.Herbed Fish 1 serving #10scp P. Squash Medley 1 serving #10scp P. Rice Pilaf 1 serving #12scp P. Brownie During observation on 7/16/19 two of three residents received incorrect pureed portion sizes for their lunch meal. At 10:48 AM on 7/16/19 Staff G, dietary aide pureed three brownies adding approximately 1/2 carton of chocolate milk to the mixture. She poured the pureed substance into three small dishes without having measured the volume. At 10:55 AM on 7/16/19 using a 1/2-cup scoop, Staff D dietary cook, put three scoops of creamed peas in blender. After pureeing, peas were poured into the warming dish. The same process was used for zucchini squash. For fish preparation, she put three pieces of baked fish in the blender and added an unmeasured amount of liquid from the baking pan to the mixture. Staff D referred to the Spring-Summer cycle menu (approved by the registered dietician on 4/17/19) to reference serving scoop size to be used. She stated that a #10 scoop (3/8 cup) would be used for the fish, squash, rice and #12 scoop for brownie. Observation during serving of lunch from 12:00-12:55 PM reveled that a #8 (1/2 cup) scoop was used for serving the peas and rice. A #16 (1/4 cup) serving scoop was used for pureed fish. Staff D acknowledged she used scoop sizes that were not indicated for those food items on the menu. On 7/17/19 at 11:05 AM, the Dietary Manager acknowledged pureed food should be served according to the recommended scoop size recorded on the dietary menu prepared by the dietician. On 7/1/719 at 12:50 PM, the hospital Dietitian stated the kitchen uses specific recipes indicating serving size and the number of the serving scoop to be used to assure residents are getting adequate nutrition. She acknowledged the serving scoop sizes used for the lunch meal on 7/16 were incorrect.

Based on record review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 27 residents. Findings include: 1. Resident #1 had an admission Minimum Data Set (MDS) assessment with a reference date of 5/16/16. The MDS reflected the resident scored 5 out of 15 on a BIMS (Brief Interview of Mental Status). A score of 5 identified the resident with a severe cognitive impairment. The resident required extensive assistance of one staff for dressing, personal hygiene and limited assistance with bed mobility and ambulation. A balance during transitions and walking test identified the resident not steady but able to stabilize without staff assistance for walking, turning around, moving from seated to standing position, and surface to surface transfers. The MDS indicated the resident had a fall in the month prior to admission to the facility. The resident had [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 90 on the assessment scale. A score of 45 or above represented the resident at a high risk for falling. The Care Plan, dated 5/18/16, identified the resident at risk for falls related to [DIAGNOSES REDACTED]. A fall incident report dated 6/13/16 at 3:05 p.m. indicated the staff discovered Resident #1 on the floor on his/her right side. The incident report indicated the alarm was not on and did not sound. The nurse assessed the resident and identified the resident had pain to his/her right hip and noted a slight external rotation. The resident was transported to the emergency room . An x-ray report dated 6/13/16 identified compression fractures of his/her vertebrae. On 7/1/16 at 10:53 a.m. the Assistant Director of Nursing (ADON) was interviewed and stated her investigation revealed Staff A, certified nursing assistant (CNA), transferred Resident #1 to the sunroom. Resident #1 was to have an alarm while in the chair, however, she left Resident #1 in the chair without an alarm. The resident's walker was across the room. On 7/1/16 at 11:25 a.m. Staff A stated she transferred Resident #1 to the sunroom, then left the resident in the chair while she returned to his/her room to get the chair alarm. She was aware Resident #1 was to have an alarm when in a chair. While enroute to Resident #1's room, she stopped to answer a call light then left the facility. Staff A stated she forgot to return to the resident and apply the chair alarm.

Based on record review, staff interview and facility policy, the facility failed to report the loss of a resident's personal items to the State Agency for 1 of 10 residents reviewed. (Resident #10) The facility census was 25 residents. Findings include: According to the 1/10/16 Minimum Data Set assessment, Resident #10 scored 11 on the Brief Interview for Mental Status, indicating some memory impairment. Resident #10 Required extensive assistance for bed mobility, transfers, toilet use and required a wheelchair for mobility. The resident had functional limitations of lower extremities and unable to to move from seated to standing position without staff assistance. The resident had [DIAGNOSES REDACTED]. When interviewed on 2/29/16 at 2:44 p.m., the Director of Nursing reported Resident #10 had a jar of missing quarters which was reported by the family member when contacted about an unrelated incident in October, 2015. The family member related the jar of quarters missing since November, 2014. The DON verified the missing quarters not reported to the State Agency when reported