Every finding on record at Huntington Healthcare Center

Based on observation, interview and record review, the facility failed to remove contaminated (dirty) gloves (a disposable personal protective equipment used as a barrier to stop the spread of germs, bacteria, and fluids between patients and health workers) after removing dirty wound dressing, and failed to put on new pair of gloves, prior to providing wound care, for one of three residents, (Resident 2).This deficient practice had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and cause infection to the resident's wound.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of right buttocks and type 2 diabetes mellitus (abnormal blood sugar in the body).During a review of Resident 2's Care Plan titled Impaired skin integrity related to pressure ulcer to the sacral (tailbone) area., dated 4/18/2026, one of the interventions included to perform wound treatment using appropriate infection-control and clean/aseptic technique according to facility policy and current standards of practice.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/22/2026, the MDS indicated Resident 2 was usually able to understand and be understood by others. The MDS indicated Resident 2 dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene. Resident 2 was dependent with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to standing, chair/bed to chair transfer, and tub/shower transfer. Resident 2 had one unhealed stage 3 pressure ulcer (a deep, open wound where the skin is completely lost and the underlying layer of body fat is visible, but muscle, tendon, and bone are not exposed). During a review of Resident 2's History and Physical (H&P) dated 6/23/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Order Summary Report dated 8/17/2026, the order dated 7/2/2026 indicated to cleanse the sacrum pressure injury (damage to the skin and underlying tissues caused by prolonged pressure, often over bony areas, which can range from mild redness to deep tissue necrosis) with normal saline (NS- a cleansing solution) or wound wash, pat dry, gently pack with a Dakin's solution (weak bleach mixture used on the skin to clean wounds and kill bacteria [1/2-half strength solution]) by a damped 4 by 4 gauze, cover with a dry 4 by 4 gauze, then cover with a boarder form (typo the word should be foam) dressing. During a concurrent observation and interview on 8/17/2026 at 1:30 p.m., with Registered Nurse (RN 1), RN 1 was observed sanitizing hands, put on gloves, removed the wound dressing off the sacral wound and cleansed the sacral wound with NS- soaked gauzed, pat dried and placed Dakin's solution on the sacral wound. RN 1 was not observed removing the contaminated gloves, performing hand hygiene and putting on new pair of gloves, prior to cleaning and dressing the wound. RN 1 stated she did not remove the dirty gloves and sanitized hands after removing Resident 2's dirty dressing. RN 1 stated that after cleansing Resident 2's sacral wound, she did not remove the dirty gloves and sanitized hands. RN 1 stated it was important to change gloves and sanitize hands after removing the resident's dirty dressing, after cleansing and putting on treatment to prevent cross contamination and infection. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Treatments, dated 1/29/2026, the P&P indicated to use standard precautions when indicated and maintain clean or aseptic (free from disease-causing germs, bacteria, or viruses) technique appropriate to the procedure. The P&P indicated to perform hand hygiene before and after treatment and after removal of gloves.

Based on observation, interview and record review, the facility failed to ensure the right measuring device and the right ingredients were used in preparing the Consistent Carbohydrate Diet (CCHO, meal plan designed to manage blood sugar, especially for diabetes) and the low sodium (salt) food. This deficient practice had the potential to affect all the residents receiving CCHO and low sodium diets. This had the potential to result in elevated blood sugar levels for diabetic residents and fluid overload (clinical condition where excess fluid builds up in the body), edema (swelling), heart failure (chronic condition where heart muscle becomes weak or stiff to pump blood efficiently to meet the body's needs for oxygen), for residents with kidney diseases.Findings: During a concurrent observation on 4/15/2026 at 11:50 a.m., with the Dietary Supervisor (DS), the DS observed and verified the kitchen staff used scooper #8 (kitchen utensil used to provide 4 ounces [oz, unit of measurement] or half [1/2] cup portions) to serve mashed potatoes. During a concurrent record review and interview on 4/15/2026 at 1:35 p.m. with the Dietary Supervisor (DS), the Cooks Spreadsheet titled Spring 2026 Menus, dated week three, 4/15/2026, was reviewed. The DS stated the menu indicated to use #16 scoop (kitchen utensil used to provide 2 oz. or 1/4 [quarter] cup portions) when serving CCHO diet with small and regular servings of mashed potatoes. The DS stated using #8 scoop for serving mashed potatoes resulted in doubled portion of carbohydrates which could lead to an increase in blood sugar levels in residents receiving CCHO diets. During a concurrent observation, interview and record review on 4/16/2026 at 12:00 p.m., with the Cook, DS and Lead Assistant, the menu titled, The Good for You Health, dated 4/16/2026, indicating Szechuan pork and fried rice will be served for lunch, was reviewed. The Recipe Healthcare Menus Direct, LLC. 2026-week 3 Thursday, indicated to use low sodium chicken broth, soy sauce and hoisin sauce (a type of sauce) for the Szechuan pork sauce and to use low sodium soy sauce for the fried rice. The kitchen was observed and had no low sodium soy sauce, chicken broth and hoisin sauce. During a food test tray on 4/16/2026 at 12:26 p.m., the pork sauce and fried rice tasted were salty. During an interview on 4/16/2026 at 12:34 p.m., with the Cook, the [NAME] stated that she always followed the recipe but if the right ingredients were not available, she would use whatever was available. On the morning of 4/16/2026 (no time indicated), she checked the ingredients to be used for Szechuan pork and fried rice and there was no low salt soy sauce, hoisin sauce and chicken broth. The [NAME] stated she used the regular (salted) ingredients. The cook stated the regular chicken bouillon contained 620 milligrams (mg, a unit of measurement) salt per (/) three-fourth (3/4) of a teaspoon. The regular Chicken broth contained 700 mg of salt/cup, and the low salt chicken broth contained 140 mg/cup. The regular hoisin sauce contained 200 mg of salt/ tablespoon. The regular soy sauce had 900 mg/tablespoon, and the low soy sauce had 540 mg/tablespoon of salt. The cook stated the difference of salt was so much. During a phone interview on 4/21/2026 at 4:11 p.m., with the Registered Dietitian (RD), the RD stated, for example in renal diets, the amount of sodium ordered should be followed. RD stated that high sodium diets could lead to hypertension, fluid overload and edema. RD stated having too many carbohydrates could lead to elevated blood sugar levels. During a review of the facility's P&P titled, Diet / Special Diets I Therapeutic Diets, dated 12/8/2025, the P&P indicated the facility should provide resident's assessed needs, physician/practitioner orders. The P&P indicated diets should be served as ordered.

Based on interview and record review, the facility failed to ensure dental services were scheduled so that one of three sampled residents (Residents 1), was seen by a dentist (a health care professional who specializes in teeth, gums, and mouth).This deficient practice had the potential to result in the worsening condition of the resident's teeth, leading to tooth infection, to suffer toothache, affecting the resident's inability to eat. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels) and end-stage renal disease (ESRD, kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for eating and dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete activity) for oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was dependent with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, tub/shower transfer, and car transfer. During an interview on 4/15/2026 at 2:58 p.m., Resident 1 stated he had not seen a dentist since he was admitted to the facility (12/16/2025), and his teeth were in bad condition (unspecified). During a concurrent observation and interview on 4/15/2026 at 3:48 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had come to the facility with decomposed (deteriorated or broken) teeth, bad breath and did not know if Resident 1 was seen by a dentist since he was admitted . During a phone interview on 4/16/2026 at 8:57 a.m., with Renal Registered Dietitian (RD 2), RD 2 stated when Resident 1 was at the hemodialysis (HD, a medical treatment that filters waste, toxins, and excess water from the blood when kidneys cannot function effectively) center, she (RD 2) observed Resident 1 with rotten lower teeth and foul breath. RD 2 stated Resident 1 informed her that he had not seen a dentist since he was admitted to the facility. During a phone interview on 4/27/2026 at 4:06 p.m., with the Social Services Director (SSD), the SSD stated the dentist could not see Resident 1 whenever the dentist comes to the facility because Resident 1 was out for HD. The SSD stated she should have scheduled the dentist's visit on a day Resident 1 did not have HD to ensure he was seen. The SSD stated Resident 1's tooth decays could worsen and infected, affecting the resident's inability to eat and the resident could suffer tooth pain. During a review of the facility's P&P titled, Dental Services, dated 12/1/2025, the P&P indicated the facility will ensure every resident at the facility, receives or refuses, with full informed choice, the dental services necessary to maintain or improve oral health, including routine, preventive, restorative, and emergency dental care. The P&P indicated the facility will assist residents in obtaining routine dental care from a licensed dentist.

Based on observation, interview and record review, the facility failed to ensure the food was palatable (tasty) for one of three sampled residents (Residents 1). This deficient practice had the potential for resident's poor meal intake and weight loss.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels) and end-stage renal disease (ESRD, kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for eating and dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete activity) for oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was dependent with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, sitting to stand, chair/bed to chair transfer, tub/shower transfer, and car transfer. During an interview on 4/15/2026 at 2:58 p.m., with Resident 1, Resident 1 stated the food was very salty and sometimes it was difficult for him to eat. During a concurrent observation, interview and record review on 4/16/2026 at 12:00 p.m., with the Cook, DS and Lead Assistant, the menu titled, The Good for You Health, dated 4/16/2026, indicating Szechuan pork and fried rice will be served for lunch, was reviewed. The Recipe Healthcare Menus Direct, LLC. 2026-week 3 Thursday, indicated to use low sodium chicken broth, soy sauce and hoisin sauce (a type of sauce) for the Szechuan pork sauce and to use low sodium soy sauce for the fried rice. The kitchen was observed and had no low sodium soy sauce, chicken broth and hoisin sauce. During a food test tray on 4/16/2026 at 12:26 p.m., the pork sauce and fried rice tasted were salty. During an interview on 4/16/2026 at 12:34 p.m., with the Cook, the [NAME] stated that she always followed the recipe but if the right ingredients were not available, she would use whatever was available. On the morning of 4/16/2026 (no time indicated), she checked for the ingredients to be used and there was no low salt soy sauce, hoisin sauce and chicken broth. The [NAME] stated she used the regularly salted ingredients. The cook stated the regular chicken bouillon contained 620 milligrams (mg, a unit of measurement) salt per (/) three-fourth (3/4) of a teaspoon. The regular Chicken broth contained 700 mg of salt/cup- the low salt chicken broth contained 140 mg/cup. The regular hoisin sauce contained 200 mg of salt/ tablespoon. The regular soy sauce had 900 mg/tablespoon, and the low soy sauce had 540 mg/tablespoon of salt. The cook stated the difference of salt was so much. The [NAME] stated if food served were too salty, the residents won't enjoy it and might lose weight. During a review of the facility's policy and procedure (P&P) titled, Menu Planning & Implementation, dated 12/8/2025, the P&P indicated the facility would provide nutritionally adequate, palatable, and well-balanced meals that meet the daily nutritional and special dietary needs of each resident in accordance with physician orders, resident preferences, and current standards of practice.

Based on observation, interview and record review, the facility failed to provide a therapeutic diet (meal plan prescribed by a healthcare professional [physician or dietitian] that modifies a regular diet to manage a specific medical condition, treat an illness, or improve overall health) as ordered by the physician for one of three sample residents (Resident 1). This deficient practice resulted in high blood sugar readings for Resident 1 and had the potential to cause complications such as diabetic coma (life-threatening, state of unconsciousness caused by extreme blood sugar levels). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end-stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Care Plan titled, Risk for unstable blood glucose due to diagnosis of DM type II dated 12/30/2025, the Care plan interventions indicated to administer diet as ordered: Consistent Carbohydrate Diet (CCHO-meal plan designed to manage blood sugar, especially for DM, by eating roughly the same amount of carbohydrates at the same time each day), soft and bite sized texture, regular/thin liquid consistency During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) for eating and was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete activity) for bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), transfers, oral hygiene, toileting hygiene, showering/bathing self and dressing. During a review of Resident 1's Order Summary dated 1/16/2026, the Order Summary indicated to provide Resident 1 with a renal diet (kidney-friendly eating plan designed to reduce waste in the blood and protect kidney function), soft and bite sized texture, regular/thin liquid consistency, CCHO, and no salt placed on tray (NSPOT). The Order did not indicate to provide double portions (twice the standard amount of food for specific items on a resident's meal tray) to Resident 1. During a concurrent observation and interview on 4/15/2026 at 11:50 a.m., with the Dietary Supervisor (DS), the DS stated Resident 1 was served double portions of garden-fresh meat loaf, double portion of rice and a single portion of green beans. During meal service, the kitchen staff used #8 scoop, which provided 4 ounces (oz- measuring unit) or (1/2 cup) of rice, 3 oz. (3/8 cup) ladle for garden-fresh meat loaf, and 4 oz. ladle for green beans. During an observation on 4/15/2026 at 12:38 p.m., in Resident 1's room, Resident 1's lunch meal ticket indicated Resident 1 received a CCHO, NSPOT renal diet, soft and bite size double portions. Resident 1 had double portions of rice and meat, a single portion of green beans, and one 4 oz. carton of apple juice. During a subsequent, concurrent interview and record review on 4/15/2026 at 1:35 p.m., with the DS, Resident 1's meal ticket provided on 4/15/2026 and Physician's order dated 1/16/2026 were reviewed. The DS stated Resident 1 did not have an order for double portions of food. The DS stated Resident 1 had requested double portions and that was the reason the kitchen gave two 3 oz ladles of meatloaf to two #8 scoops of rice. The DS stated giving double portions of rice to Resident 1 could lead to high blood sugars. During a concurrent interview and record review on 4/16/2026 at 2:38 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 was being monitored for blood sugars and his blood sugars ranged from 177 milligram/deciliter (mg/dL- unit of measure) to 343 mg/dL for the month of 4/2026 before dinner. LVN 2 stated normal ranges for blood sugars were 70 to 99 mg/dL. LVN 2 stated he did not know Resident 1 was getting double portions. Double portions could lead to elevated blood sugar levels and if not managed properly could cause diabetic coma. During a review of the facility's P&P titled, Diet / Special Diets / Therapeutic Diets dated 12/8/2025, the P&P indicated the facility will provide diets consistent with each resident's assessed needs and physician/practitioner orders. The P&P indicated diets should be served as ordered and monitored for tolerance, adequacy, acceptance and effectiveness.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. This deficient practice had the potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 94 of 94 residents who received food from the kitchen. Findings:During an observation on 12/1/2025 at 8:15 a.m., in the kitchen, in the presence of the Dietary Supervisor (DS), the following findings were observed:a. The handwashing sink did not have hot water.b. The handwashing sink was clogged. c. The surface of the can opener was blackened and covered with black stains and dried residue.d. The area surrounding the can opener blade and gear were stained with dark, hardened food debris. e. The air-drying area for the food services equipment such as water pinchers, plates, cutting boards, cups and spoons was dusty and unsanitary. f. A large piece of raw beef was not fully frozen and was leaking blood onto a box stored directly underneath it in the freezer. During a subsequent interview on 12/1/2025 at 8:20 a.m., with the DS, the DS stated the handwashing sink did not have hot water and was clogged which prevented staff from performing proper hand hygiene and increased the risk of food contamination. The DS stated unclean kitchen equipment and food service equipment kept under unsanitary conditions created a risk of re-contamination. The DS stated it was important for the kitchen sink to be operational and the food contact surfaces to remain clean and sanitary. The DS stated the raw beef should have been stored separately, and fully frozen to prevent leakage and contamination of other food items or food contact surfaces. The DS stated these failures had the potential of increased risk of foodborne illness due to cross-contamination and improper hand hygiene. During a concurrent observation and interview on 12/2/2025 at 11:55 a.m., in the kitchen, during a tray line observation, with the DS, multiple meal service plates were observed to have brownish-yellowish dried food particles. The plates were still wet. The DS stated unclean and wet plates indicated they had not been properly washed, rinsed, or air-dried prior to being stored for use. The DS stated staff are expected to follow proper dishwashing procedures, including complete removal of the food debris and allowing the items to air-dry thoroughly to prevent bacterial growth, The DS stated improper cleaning and sanitizing of the food service plates had a serious risk of foodborne illness. During a review of the facility's policy and procedure (P&P) titled Infection Control in Dietary and Kitchen Areas, revised 9/20/2025, the P&P indicated the facility was committed to maintaining strict infection prevention and control practices in all dietary and kitchen operations to minimize the risk of foodborne illness, cross-contamination, and the spread of infectious diseases within the facility. The P&P indicated the facility was to ensure a safe, sanitary environment for food preparation, handling, storage and services. During a review of the facility's P&P titled Food storage and Safety, revised 9/29/2025, the P&P indicated the facility was to store all food in a safe, sanitary, and temperature- controlled environment to prevent contamination, and foodborne illness. The P&P indicated raw meats must be stored on the lower shelf to prevent cross-contamination. During a review of the facility's P&P titled Kitchen Equipment Use, Cleaning, and Maintenance, revised 9/29/2025, the P&P indicated the facility was to ensure all kitchen equipment was cleaned and sanitized daily, or after each use.

Based on observation, interview, and record review, the facility failed to develop an individualized resident centered care plan for six of 18 sampled residents (Resident 91, Resident 20, Resident 42, Resident 55, Resident 61, and Resident 70) when: 1. Staff failed to develop a care plan addressing Residents 91 and 20's hearing impairment.2. Staff failed to develop a care plan addressing Resident 42 and 55's diagnosis of dementia (a progressive state of decline in mental abilities). 3. Staff failed to develop a care plan addressing Resident 61 and 70's missing natural teeth. These deficient practices had the potential for Residents 91, 20, 42, 55, 61, and 70 to not receive required appropriate care.Findings: 1. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE]. Resident 91's diagnoses included history of falling, functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and hypertensive heart disease (high blood pressure). During a review of Resident 91's Minimum Data Set (MDS, a resident assessment tool) dated 11/26/2025, the MDS indicated Resident 91's hearing and vision were adequate. The MDS indicated Resident 91's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 91 required supervision or touching assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 91's Social Services Quarterly Note, dated 11/21/2025, the note indicated Resident 91 was hard of hearing, which affected her ability to engage in communication. During an interview on 12/1/2025 at 8:00 a.m. with Resident 91, in Resident 91's room, Resident 91 stated she could not hear because her ears did not work well. Resident 91 asked to speak louder into her right ear. During a concurrent observation and interview on 12/2/2025 at 2:45 p.m. with Certified Nursing Assistant (CNA) 2, Resident 91 was observed in the hallway. CNA 2 approached Resident 91's right side, leaned close to the resident's ear and asked Resident 91 if she had any hearing aids. Resident 91 did not respond. CNA 2 repeated the question a second time. Resident 91 did not respond to verbal cues when CNA 2 spoke to the left side. CNA 2 stated Resident 91 was hard of hearing. During an interview on 12/2/2025 at 3:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 91 had hearing impairments. During a concurrent interview and record review on 12/3/2025 at 2:40 p.m. with LVN 1, all of Resident 91's Care Plans, dated in 2025, were reviewed. There were no care plans addressing Resident 91's hearing impairment or loss. LVN 1 stated it was important that Resident 91 had a care plan for her hearing loss so that staff would know how to care for and perform ALDs with Resident 91. 2. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included unspecified hearing loss to the left and right ear (loss of hearing in both ears), dementia (a progressive state of decline in mental abilities), quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), and encephalopathy (any disease, damage, or disorder that affects the brain's function). During a review of Resident 20's History and Physical (H&P), dated 6/3/2025, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognition was moderately impaired. The MDS indicated Resident 20 required supervision (helper provides verbal cues and/or touching/steadying as the resident completes activity) for eating and moderate assistance (helper does less than half the effort) with toileting, bathing, oral, and personal hygiene. The MDS indicated Resident 20 required a wheelchair for mobility. During a review of Resident 20's Order Summary Report, dated 12/4/2025, the Order Summary Report indicated Resident 20 had an active order dated 6/5/2024 for an ear, nose, and throat consultation (ENT – an evaluation of the ears, nose, or throat by a specialist) as needed. During a review of Resident 20's medical record, the medical record indicated there was no care plan initiated for addressing Resident 20's hearing impairment. During a concurrent observation and interview on 12/3/2025, at 1:58 p.m., with Certified Nursing Assistant (CNA) 3 and Resident 20, observed Resident 20 seated on a wheelchair while CNA 3 assisted her with dressing. Resident 20 was called by name. The resident did not respond. CNA 3 stated Resident 20 was hard of hearing and would not be able to hear anyone unless the person was positioned very close to her ear. During a concurrent interview and record review on 12/3/2025, at 2:34 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 20's care plans were reviewed. LVN 2 stated he knew Resident 20 well and he was aware of Resident 20's hearing impairment. LVN 2 stated the MDS nurse (MDSN) was responsible for initiating care plans upon admission. LVN 2 stated LVNs could also initiate, and revise care plans as needed. LVN 2 stated Resident 20 did not have a care plan addressing her hearing impairment. LVN 2 stated the staff knew when speaking to Resident 20 they must get close to her ear for her to hear what was being said. LVN 2 stated a care plan should have been initiated for Resident 20's hearing loss once it was determined she had a hearing impairment. LVN 2 stated the care plan guided the resident's care in the best way. LVN 2 stated a care plan for Resident 20's hearing impairment would have provided interventions on how to appropriately approach and communicate with the resident. LVN 2 stated not having a care plan for Resident 20's hearing impairment could affect the resident's communication and quality of life. During an interview on 12/4/2025, at 1:36 p.m., with the Director of Nursing (DON), the DON stated if Resident 20 had a diagnosis of hearing loss and staff stated the resident could not hear, then a care plan should have been initiated. The DON stated moving forward the nursing staff should initiate a care plan for anyone with potential hearing loss, especially older residents. The DON stated the nursing staff were relying too much on the consultant to do the care plans. The DON stated the nursing staff should be responsible for the care plans. The DON stated the licensed nursing staff needed more training in initiating care plans because she had been doing the care plans to make it easier on the nursing staff. The DON admitted she was helping the nurses so much they did not know how to use the care plans. The DON stated this created a problem because she could not be there all the time to see changes in the residents, and changes in the residents' condition could get missed because she did not provide direct care. The DON stated not having a care plan made it more difficult to know the needs of the residents and holistically provide the resident care. 3. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42's diagnoses included dementia, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 42's H&P dated 3/1/2025, the H&P indicated Resident 42 did not have the capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42's cognition was impaired. The MDS indicated Resident 42 required supervision assistance from staff for ADL's. During a concurrent interview and record review on 12/3/2025 at 8:06 a, m., with the MDS Nurse (MDSN), Resident 42's medical record was reviewed. The medical record indicated there was no care plan developed addressing Resident 42's diagnosis of dementia. The MDSN stated Residents 42 should have a care plan for dementia with interventions to ensure the continuity of care and to guide nurses on how to provide proper care for Residents 42 to improve outcome. 4. During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE]. Resident 55's diagnoses included dementia. During a review of Resident 55's H&P dated 3/1/2025, the H&P indicated Resident 55 did not have the capacity to understand and make decisions. During a review of Resident 55's MDS, dated [DATE], the MDS indicated Resident 55's cognition was impaired. The MDS indicated Resident 55 required supervision assistance from staff for ADLs. During a concurrent interview and record review on 12/3/2025 at 8:06 a, m., with the MDS Nurse (MDSN), Resident 55's medical record was reviewed. The medical record indicated there was no care plan developed addressing Resident 55's diagnosis of dementia. The MDSN stated Resident 55 should have a care plan for dementia with interventions to ensure the continuity of care and guide nurses on how to provide proper care for Resident 55 to improve outcome. 5. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included dysphagia (difficulty swallowing), dementia, and major depression disorder. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61's cognition was severely impaired. The MDS indicated Resident 61 required supervision assistance from staff for ADLs. During a concurrent observation and interview on 12/1/2025 at 8:01 a.m., in Resident 61's room, observed Resident 61 eating breakfast. Resident 61 stated it was hard to chew the food because he did not have teeth. During a concurrent interview and record review on 12/3/2025 at 8:30 a.m., with the MDSN, Resident 61's current care plans were reviewed. There was no care plan addressing Resident 61's missing teeth. The MDSN stated a care plan was a tool to communicate and summarize the problem, the goal, and interventions to ensure the residents would receive proper care. 6. During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 70's diagnoses included dysphagia, dementia, and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 60's cognition was impaired. The MDS indicated Resident 70 required supervision assistance from staff for ADLs. During a concurrent observation and interview on 12/3/2025 at 8:20 a.m., in Resident 70's room, with the MDSN, Resident 70 was observed sitting on the chair. The MDSN stated Resident 70 did not have her upper and bottom teeth. The MDSN stated Resident 70 did not have her natural teeth. During a concurrent interview and record review on 12/3/2025 at 8:30 a.m., with the MDSN, Resident 70's current care plans were reviewed. There was no care plan addressing Resident 70's missing teeth. The MDSN stated a care plan was a tool to communicate and summarize the problem, the goal, and interventions to ensure the residents would receive proper care. During a review of the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care Planning, dated 9/29/2025, the P&P indicated the facility would develop and implement a comprehensive, person-centered care plan for each resident based on and interdisciplinary assessment of physical, mental, and psychological needs. The P&P indicated the care plan will include measurable objectives, timeframes, specific interventions.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled resident (Resident 72) after a change in condition. This failure resulted in incomplete and missing documentation regarding Resident 72's clinical status and had the potential to affect the resident's continuity of care.Findings:During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (loss of memory, thinking, reasoning, and judgment), tachycardia (fast heart rate), hypertension (HTN - high blood pressure), pneumonia (infection in the lungs), hyperlipidemia (high fat levels in the blood), age-related physical disability (physical limitations related to aging), unspecified fall (a fall with no specific cause documented), and gastric ulcer (an open sore on the lining of the stomach). During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 72's cognitive skills for daily decision making were moderately impaired (ability to think and reason). The MDS indicated Resident 72 had short term memory problems. The MDS indicated Resident 72 was dependent (helper does all the effort) on staff for eating, toileting, bathing, dressing, oral and personal hygiene. During a review of Resident 72's History and Physical (H&P), dated 11/20/2025, the H&P indicated Resident 72 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 72 developed a fever (an abnormally high body temperature), increased agitation (restlessness or irritability), and aggressive behavior (actions such as resisting care) after a fall at the facility. The H&P indicated Resident 72's mental status deteriorated. The H&P indicated Resident 72 was transferred to a general acute care hospital (GACH) for further evaluation and was discharged back to the facility on [DATE]. During an observation on 12/1/2025 at 9:56 a.m., in Resident 72's room, observed Resident 72 lying in bed. Oxygen was infusing via a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 4 liters per minute (lpm). Resident 72 was lethargic (very tired, slow to respond, or difficult to wake up) and had shallow breathing. During a review of Resident 72's Nursing Progress Notes, dated 9/13/2025 through 11/12/2025, the progress notes indicated Resident 72 was being monitored for a fall. The progress notes did not indicate the date of the fall, the circumstances of the fall, or the resident's assessment immediately following the fall. During a review of Resident 72's Nursing Progress Notes, dated 11/18/2025 through 11/30/2025, the progress notes indicated licensed nurses documented Resident 72's antibiotic administration, monitoring, and the resident's condition. The Nursing Progress Notes did not indicate documentation regarding Resident 72's change in condition or any clinical concerns. During a review of the Nursing Progress Note dated 12/1/2025 at 6:10 p.m., the progress note indicated staff from a hospice (care focused on comfort for residents who are nearing the end of life) evaluated Resident 72 for hospice services. The progress notes did not indicate the reason the hospice referral was made and did not indicate the resident's condition leading to the hospice evaluation. During a review of Resident 72's Nursing Progress Note dated 12/2/2025 at 9 p.m., the progress note indicated Resident 72 was transitioning and had irregular breathing. The progress note did not indicate the resident's decline prior to the transition, did not indicate what assessments were completed, and did not indicate communication with the physician regarding the resident's worsening condition. During a review of Resident 72's Nursing Progress Note dated 12/3/2025 at 3:06 a.m., the progress note indicated Resident 72 was observed with irregular breathing throughout the night and was confirmed deceased by the Registered Nurse (RN) at 2 a.m. The progress notes further indicated the physician was notified. The progress note did not indicate Resident 72's condition leading up to her death and did not indicate what assessments were completed. The progress note did indicate any clinical concerns or changes before the resident was confirmed deceased . During an interview on 12/3/2025 at 8:18 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated on 12/3/2025, Resident 72 did not eat breakfast. CNA 4 stated Resident 72 was placed on hospice and was now NPO (no food or drink by mouth). During a concurrent interview and record review on 12/4/2025 at 8:29 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 72's medical record, including Nursing Progress Notes dated 11/8/2025 through 12/3/2025 and Situation, Background, Assessment, Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among residents) dated 11/8/2025 was reviewed. LVN 3 stated he was unable to locate documentation in the nursing progress notes reflecting Resident 72's fall on 11/8/2025. LVN 3 stated the circumstances of the fall or the resident's status following the fall were not included in the progress notes. LVN 3 stated there were several entries but those entries did not indicate details of Resident 72's fall, the completed assessment, or any physician communication. LVN 3 stated the SBAR indicated Resident 72's physician and family were notified however, the SBAR was marked in progress and unsigned which prevented it from being viewed during the record review. LVN 3 stated he was unable to determine from the progress notes how Resident 72 progressed from the fall on 11/8/2025 to the hospital transfer on 11/12/2025 or why the hospitalization occurred four days after the fall. LVN 3 stated there was no documentation describing how Resident 72 declined following her return to the facility. LVN 3 stated he could not locate documentation reflecting communication with Resident 72's physician regarding the resident's decline, the rationale for the hospice referral, or the resident's condition prior to death. LVN 3 acknowledged the nursing progress notes were not complete. During a concurrent interview and record review on 12/4/2025 at 11:04 a.m., with the Assistant Director of Nursing (ADON), Resident 72's Nursing Progress Notes dated 11/8/2025 through 12/3/2025, SBAR Communication Form dated 11/8/2025, and the Fall Incident Report dated 11/8/2025 were reviewed. The ADON stated Resident 72 fell on [DATE] when she slipped down from her wheelchair. The ADON stated she was responsible for completing the resident's assessment and the incident report after the fall. The ADON stated she completed the body assessment, pain assessment, post-fall assessment, physician notification, family notification, and the investigation. The ADON stated all related documentation, including the fall details, the investigation, witness statements, the SBAR communication form, and the IDT documentation, were kept in the incident report binder in the Director of Nursing's (DON) office and were not placed in the nursing progress notes or elsewhere in the medical record. The ADON stated Resident 72 was transferred to a GACH on 11/12/2025 and returned on 11/18/2025 with pneumonia. The ADON stated she initiated antibiotic therapy and documented the resident's monitoring during and after the antibiotic course, which reflected the resident was stable. The ADON stated she did not document any assessments or change of condition after the antibiotic monitoring ended. The ADON stated she spoke with the family regarding the resident's decline and the plan for hospice but did not chart the resident's decline or the hospice discussion. The ADON acknowledged she did not document communication with the physician or the resident's worsening condition. The ADON stated, Legally, I do not have to document the resident's decline. I don't have to document anything after the antibiotic monitoring. The ADON stated, I do admit, I did not document on the resident for four days. During an interview and record review on 12/4/2025 at 12:00 p.m. with the Medical Records Director (MRD), Resident 72's SBAR Communication Forms dated 11/8/2025, 12/2/2025 and 12/3/2025 were reviewed. The MRD stated the SBAR Communication Forms in the electronic health record (EHR) were marked in progress and were not signed. The MRD stated the SBAR Communication Forms should have been completed and signed. The MRD acknowledged the incomplete status prevented the forms from being viewable in the EHR. During a concurrent interview and record review on 12/4/2025 at 1:36 p.m. with the DON, Resident 72's SBAR Communication Forms dated 11/8/2025, 12/2/2025 and 12/3/2025 were reviewed. The SBAR communication forms were marked in progress and unsigned in the system. The DON stated Resident 72 was transferred to the GACH after the resident's family reported the resident was in pain. The DON stated the facility notified Resident 72's physician based on the family's concern. The DON stated the resident declined while at the hospital and returned to the facility with additional issues and continued to decline after readmission. The DON stated staff had been communicating with Resident 72's family regarding the resident's decline and stated the resident was being monitored. The DON stated nurses should have documented what was occurring with Resident 72 and stated documentation was important because staff performed the work and it should have been recorded. The DON stated documentation helped address issues affecting the resident and stated if staff did not document or address what was occurring, the resident would not receive the care they needed. The DON also reviewed Resident 72's EHR as displayed during the interview and stated she could see why it appeared the facility was withholding documentation. During a review of the facility's policy and procedure (P&P) titled Nursing Documentation, last updated 9/29/2025, the P&P indicated nursing documentation was required to be accurate, timely, complete, and legally compliant. The P&P indicated documentation must reflect assessments, interventions, resident responses, and clinical decision-making. The P&P indicated staff were required to document in real time or as soon as possible after care was provided and ensure entries were clear, concise, and legible. The P&P indicated incident and change-of-condition documentation was required to include the event, the resident's response, the assessment performed, physician notification, family notification, interventions, and the outcome, and indicated corresponding forms such as incident reports and post-fall evaluations must be completed as required.

Based on observation, interview, and record review, the facility failed to ensure good grooming and personal hygiene for two of six sampled residents (Resident 61 and Resident 5) by failing to provide routine fingernail and toenail care. This failure had the potential to result in a negative impact on Residents 61 and 5's quality of life and self-esteem and had the potential for the development of infections. Findings:a. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 6/28/2025, the MDS indicated Resident 61's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 61 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 12/1/2025 at 10:00 a.m., in Resident 61's room, observed Resident 61's fingernails and toenails. Resident 61's fingernails had black substance underneath all ten fingernails. Resident 61's toenails were long, irregular in shape, and curled over the tip of the toes. During a concurrent observation and interview on 12/1/2025 at 10:03 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 61's room, observed Resident 61 with a black substance underneath his fingernails. CNA 1 stated Resident 61's nails were dirty and required cleaning and trimming. CNA 1 stated nail care was one of the CNA's duties. CNA 1 stated the CNAs were responsible for clipping, trimming, and cleaning the resident's nails. CNA 1 stated residents' nails should be monitored daily to ensure the nails are clean and neat. CNA 1 stated that sometimes the residents scratch their skin and if they scratch themselves hard enough, they could create an open wound. CNA 1 stated if a resident had dirty fingernails and scratched themselves, that increased their risk of infection. CNA 1 stated having dirty fingernails was not sanitary because the resident will use their hands to hold their utensils when eating and any bacteria could transfer into their body. CNA 1 stated having dirty fingernails was not sanitary to other residents because if Resident 61 were to touch objects that other residents also touched, the bacteria under the Resident 61's fingernails could transfer to the object and then to the other residents. b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included cellulitis (a skin infection that causes swelling and redness), major depression disorder, and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognition was intact. The MDS indicated Resident 5 required supervision from staff for ADLs. During a concurrent observation and interview on 12/1/2025 at 10:16 a.m., with Resident 5, in Resident 5's room, observed Resident 5 with black substance undeath all ten fingernails. Resident 5 stated, No one has helped me clean or cut my nails yet.During an interview on 12/2/2025 at 10:10 a.m., with the Infection Preventionist (IP), the IP stated nail care should be assessed daily. The IP stated residents who required assistance with cleaning or trimming their nails should be assisted by the CNAs or licensed nurses. The IP stated fingernails were a source of bacteria, and that dirty or untrimmed nails could contribute to the spread of infection, especially among residents who may not be able to maintain their own hygiene. The IP stated routine nail care was an essential part of both personal hygiene and infection control. During a review of the facility's policy and procedure (P&P) titled Nail Care- Fingernails and Toenails, revised 9/29/2025, the P&P indicated the facility staff would perform fingernail and toenail care, such as cleaning and trimming as part of residents' daily grooming. The P&P indicated nail care will be performed by staff to promote resident hygiene, comfort, and dignity while preventing potential complications such as infections, skin breakdown, and pain related to poor nail care.

Based on observation, interview, and record review, the facility failed to ensure a resident's personal inventory list was completed when staff did not obtain the resident's signature and did not document a valid reason for the missing signature for one of six sampled residents (Resident 3). This resulted in an incomplete inventory record and had the potential to affect the facility's ability to account for Resident 3's belongings.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), hypertension (high blood pressure), and diabetes (poor blood sugar control). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 3 required supervision or touching assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 3's History and Physical (H&P), dated 8/18/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a concurrent observation and interview on 12/3/2025 at 9:00 a.m., in the hallway, observed Resident 3 yell at staff and accuse the staff of lying and stealing her belongings. Resident 3 stated she was missing three purses and several pairs of underwear. During a concurrent interview and record review on 12/3/2025 at 9:50 a.m. with the Assistant Director of Nursing (ADON), Resident 3's Inventory Sheet, dated 8/18/2025, was reviewed. The Inventory Sheet was signed by a Certified Nursing Assistant (CNA) and the ADON. The space designated for Resident 3's signature was blank. The space for the reason the resident was unable to sign was blank. There was no other supplemental documentation that indicated the reason why Resident 3 did not sign the inventory sheet. The ADON stated the process to complete a resident's personal inventory documentation was to have the CNA itemize each item with the resident, have the resident or the representative party (RP) sign the form to confirm each item, and have the registered nurse sign the sheet as confirmation of its completion. The ADON stated the form lacked Resident 3's signature and the reason why Resident 3 did not sign the form. During an interview on 12/3/2025 at 11:00 a.m. with the Social Services Director (SSD), the SSD stated the normal process for completing the inventory sheet was to have the CNA or the admitting nurse confirm each personal item with the resident. The SSD stated it was the nursing staff's responsibility to obtain the signature of the resident or the RP to confirm that each item was accurately listed. The SSD stated that if the nursing staff were unable to obtain the resident's or the RP's signature, it was the responsibility of the nursing staff to make her aware so that she could follow up. The SSD stated the Inventory Sheet was incomplete because it lacked Resident 3's signature. The SSD stated she was not made aware that the form was incomplete. The SSD stated it was important the Inventory Sheet was completed to ensure each item was accounted for, especially upon discharge, and to protect the resident's right to possess personal belongings within the facility. During a review of the facility's Policy and Procedure (P&P) titled, Inventory-Resident Belonging, revised 9/29/2025, the P&P indicated the facility was to maintain complete and current inventory of each resident's personal items from admission through discharge. The P&P indicated the designated nursing staff would perform an inventory with the resident or RP.

Based on observation, interview, and record review, the facility failed to complete accurate Minimum Data Set (MDS) assessments for four of 21 sampled residents (Residents 91, 61, 70 and 20) when failing to: 1. Ensure an accurate assessment of Resident 91's hearing and vision impairments.2. Ensure an accurate assessment of Resident 61 and 70's oral/dental status.3. Ensure an accurate assessment of Resident 20's hearing impairment. This failure had the potential to delay the development or the revision of care plan interventions for communication and sensory deficits for Resident 91 and 20, and dental status for Residents 61 and 70.Findings: 1. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE]. Resident 91's diagnoses included history of falling, functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and hypertensive heart disease (high blood pressure). During a review of Resident 91's Minimum Data Set (MDS, a resident assessment tool), dated 8/26/2025, and 11/26/2025, the MDS indicated Resident 91's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 91 required supervision or touching assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 91's hearing was adequate (no difficulty in normal conversation, social interaction, listening to the television). The MDS indicated Resident 91's vision was adequate (sees fine detail, such as regular print in newspapers or books). During a review of Resident 91's Baseline Care plan, dated 3/29/2025, the Care Plan indicated Resident 91 had visual deficits. During a review of Resident 91's Eye Exam, dated 10/22/2025, the Eye Exam indicated Resident 91 had a history of decreased vision, difficulty watching television, eating and recognition. The Eye Exam also indicted Resident 91 was diagnosed with dense cataracts (an eye disorder that forms when the lens of the eye becomes cloudy due to age-related changes that can cause blurry vision, difficulty seeing in low light, and double vision), optic pallor (whitening of the optic disc and indicates reduced blood flow or nerve fiber loss, signaling potential damage to this critical visual pathway) and glaucoma suspect (high pressure inside the eye that damages the optic nerve and can result in permanent vision loss). During a review of Resident 91's Social Services Quarterly Note, dated 11/21/2025, the note indicated Resident 91 was hard of hearing and had decreased vision that affected her ability to engage in communication and ability to recognize staff. During a concurrent observation and interview on 12/1/2025 at 8:00 a.m. with Resident 91, in Resident 91's room, observed Resident 91 with an opaque, white film over both eyes. Resident 91 stared at the wall and failed to make direct eye contact. Resident 91 stated she could not hear because her ears did not work well and to speak louder into her right ear. During a concurrent observation and interview on 12/2/2025 at 2:45 p.m. with Certified Nursing Assistant (CNA) 2, Resident 91 was observed in the hallway. CNA 2 approached Resident 91's right side, leaned close to the resident's ear and asked Resident 91 if she had hearing aids. Resident 91 did not respond. CNA 2 repeated the question a second time. Resident 91 did not respond to verbal cues when CNA 2 spoke to the resident's left side. CNA 2 stated Resident 91 was hard of hearing and had poor vision. CNA 2 stated Resident 91 could identify an individual's location based on their silhouette or by determining where she heard the individual's voice. During an interview on 12/2/2025 at 3:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated for six months, she had known Resident 91 to have visual and moderate hearing impairments. During a concurrent interview and record review on 12/2/2025 at 4:11p.m. with the MDS Nurse (MDSN), the MDS RAI (Resident Assessment Instrument Manual) Version 3.0 (a manual that helps nursing home staff in gathering definitive information on a resident's strengths and needs, used in care plan development), dated 10/2025, was reviewed. The Manual indicated the MDSN was to observe the resident during verbal interactions throughout the day, consult direct care staff, and review the medical record to assess hearing. The Manual also indicated the MDSN was to ask caregivers and, or direct-care staff over all shifts about usual vision patterns. The Manual also indicated to ask the resident to look at regular-size print in a book or newspaper, and ask the resident to read aloud, starting with larger headlines and ending with the finest, smallest print to assess vision. The MDSN stated she assessed Resident 91's hearing, by asking Resident 91 one question and waiting for an appropriate response. The MDSN stated she did not observe Resident 91's verbal interactions throughout the day, nor consult other direct care staff. The MDSN stated if she had observed different observations and interviewed the staff, she would have been able to perform a more accurate assessment of Resident 91's hearing and the latest MDS submission was not accurate. The MDSN stated she assessed Resident 91's vision by asking Resident 91 whether she could read MDSN's name badge. The MDSN stated she was issued a standardized vision testing tool but did not use the tool at the time of the assessment. The MDSN stated there were different classifications of regular, fine and large print and a standardized vision tool would have enabled her to conduct a more accurate assessment of Resident 91's vision and the latest MDS submission was not accurate. The MDSN stated the inaccurate assessments led to an inaccurate clinical assessment of Resident 91 submitted to Centers for Medicare & Medicaid Services (CMS) and placed Resident 91 at risk for delayed implementation of care plan interventions. 2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61's cognition was severely impaired. The MDS indicated Resident 61 required supervision assistance from staff for ADLs. The MDS indicated Resident 61 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 12/1/2025 at 8:01 a.m., in Resident 61's room, observed Resident 61 eating breakfast. Resident 61 stated it was hard to chew the food because he did not have his teeth. 3. During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 70's diagnoses included dysphagia, dementia, and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70's cognition was impaired. The MDS indicated Resident 70 required supervision assistance from staff for ADLs. The MDS indicated Resident 70 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 12/3/2025 at 8:20 a.m., with the MDSN, in Resident 70's room, Resident 70 was observed sitting on a chair. The MDSN stated Resident 70 did not have her upper and bottom teeth. The MDSN stated Resident 70 did not have her natural teeth. The MDSN stated Resident 70 did not have her natural teeth and the MDS assessment should be coded correctly to reflect Resident 70's dental status. During a concurrent interview and record review on 12/3/2025 at 8:35 a.m., with the MDSN, Resident 61's MDS, dated [DATE] and Resident 70's MDS, dated [DATE], section oral/dental status were reviewed. The MDS indicated Residents 61 and 70 were assessed as not having any oral and/or dental issues. The MDSN stated Resident 60's and 70's MDS oral/dental status assessment was coded incorrectly as it did not reflect the residents' actual oral and/or dental status. The MDSN stated that because Resident 60 and 70 did not have their natural teeth, the MDS should have been coded to reflect that both residents were edentulous (toothless). The MDSN stated accuracy of the MDS assessment was important not only for outcome measures and quality indicators, but also for developing and individualizing the care plan based on the resident's actual needs. The MDSN stated inaccuracy of the MDS assessment had the potential to negatively impact the care provided, lead to inappropriate care planning, and not meeting the residents' needs and services. 4. During a review of Resident 20's admission Record, dated 12/4/2025, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included unspecified hearing loss to the left and right ear (loss of hearing in both ears), dementia (a progressive state of decline in mental abilities), quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury), and encephalopathy (any disease, damage, or disorder that affects the brain's function). During a review of Resident 20's History and Physical (H&P), dated 6/3/2025, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognition was moderately impaired. The MDS indicated Resident 20 had adequate hearing. The MDS indicated Resident 20 required supervision (helper provides verbal cues and/or touching/steadying as the resident completes activity) for eating and moderate assistance (helper does less than half the effort) with toileting, bathing, oral, and personal hygiene. The MDS indicated Resident 20 required a wheelchair for mobility. During a concurrent observation and interview on 12/3/2025, at 1:58 p.m., with CNA 3 and Resident 20, observed Resident 20 seated on a wheelchair while CNA 3 assisted the resident with dressing. Resident 20 was called by name. The resident did not respond. CNA 3 stated Resident 20 was hard of hearing and would not be able to hear anyone unless the person was positioned very close to her ear. During a concurrent interview and record review on 12/3/2025, at 2:34 p.m., with LVN 2, Resident 20's MDS dated [DATE] was reviewed. The MDS indicated Resident 20's hearing was adequate. LVN 2 stated he was aware of Resident 20's hearing impairment. LVN 2 stated the MDSN was responsible for the MDS coding. LVN 2 stated the MDS was incorrect because Resident 20 had a hearing impairment and staff had to speak very close to the resident's ear for her to hear what was being said. During an interview on 12/4/2025, at 1:36 p.m., with the Director of Nursing (DON), the DON stated if Resident 20 had a diagnosis of hearing impairment, then the MDS should have reflected the hearing loss. The DON stated the nursing staff did not know the MDS process and required additional education. The DON stated that the nursing staff's lack of understanding of the MDS process made it more difficult to know the needs of the residents and holistically provide the resident care. During a review of the facility's Policy and Procedure (P&P) titled, MDS Assessment and Submission, revised 9/29/2025, the P&P indicated the facility was to ensure timely, accurate, and comprehensive completion and submission of the Minimum Data Set (MDS) assessments in compliance with Centers for Medicare & Medicaid Services (CMS) regulations, including the RAI User's Manual and 42 CFR 483.20.

Based on observation, interview and record review, the facility failed to ensure the surgical face mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) of one of 4 staffs, was worn correctly while in a resident-care area, as indicated in the facility's policy and procedure (P&P) titled, Personal Protective Equipment-Using Face Masks.This failure had the potential to increase the spread of Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection) virus to other residents, staff, and visitors in the facility, resulting in respiratory infections, hospitalizations and death.Findings:During a concurrent observation and interview on 8/18/2025 at 10:30 a.m. with Restorative Nurse Assistant (RNA 1) in Resident 2's room, RNA 1 was observed wearing surgical face mask below her nose with both nares (nasal openings) exposed. RNA 1 acknowledged the surgical face mask was applied incorrectly. RNA 1 stated putting on a surgical face mask incorrectly increased the potential to spread the COVID-19 virus to the residents.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE]and re-admitted on [DATE] with diagnoses including cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), cellulitis (a bacterial infection of your skin and the tissue beneath your skin) and hypertension (high blood pressure).During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 3 had clear speech, was able to express needs and wants and understands. The MDs indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting and personal hygiene.During an interview on 8/18/2025 at 10:45 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated all staff should wear their surgical face mask correctly when inside the facility by covering the nose and mouth. The IPN stated not wearing the surgical face mask correctly had the potential to increase the risk in spreading COVID-19 virus and other germs to the other residents, staff and visitors in the facility.During a review of the facility's P&P titled Personal Protective Equipment-Using Face Masks, dated 9/2010, the P&P indicated staff should ensure face mask covers the nose and mouth while performing treatment or services.

Based on interview and record review the facility failed to: 1. Account for one dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 23, in one of two inspected medication carts (Medication Cart 1.) 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) on the Controlled Drug accountability logs for six of six sampled records awaiting disposal (removal, destroying) in the DON's office. 3. Include the witness signatures and quantity on the Medication Disposition log for 16 non-CMs disposed on 10/14/2024. As a result, control and accountability of the CS's did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) the risk that Residents 23 could have accidental overdose (administering more than the prescribed dose causing adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) and delayed treatment and continuity of care due to lack of availability of the CS negatively impacting Resident 23's health and well-being, and the potential for accidental exposure to harmful medications to all residents in the facility, possibly leading to physical and psychosocial harm and hospitalization . Findings: During a concurrent interview and record review on 10/15/2024 at 12:47 PM with the DON, in the DON's office, six (6) Controlled Drug accountability logs for CS's awaiting final disposition did not contain verifying signatures, and 16 non-CM disposals did not contain the witness signatures and quantities on the Medication Disposition log dated 10/14/2024. The DON stated the DON was unable to locate the verifying signatures of the LVN and Registered Nurse (RN) and/or DON on the six (6) Controlled Drug accountability logs. The DON stated the DON failed to sign the Controlled Drug accountability logs upon receipt of the CSs and the LVN's failed to sign upon handing the CSs to the DON. The DON stated she counts the CSs with the LVNs upon receipt of the accountability logs and knows who gave them to her, however there was no consistent process to sign & date the logs. The DON stated the DON understood the importance of CS accountability to ensure each CS dose was accounted for until disposed throughout the process of CS accountability. The DON stated it was important to verify and sign the logs to prevent medication diversions and accidental exposure of harmful substances to residents. The DON stated she was also unable to locate the witness signatures and quantity destroyed for non-CMs on the Medication Disposition logs dated 10/14/2024 for 16 non-CMs that were already disposed. The DON stated sometimes the DON disposes the non-CMs herself without a witness to help the LVNs and failed to include quantities destroyed. During an observation on 10/25/2024 at 1:57 PM, with LVN 3, in Medication Cart 2, there was a discrepancy in the count between the Controlled Drug accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following resident: 1. One dose of diazepam (a CS used for muscle spasm) 5 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug accountability log for Resident 23. The Controlled Drug accountability log for diazepam indicated the medication bubble pack should have contained a total of 29 diazepam 5 mg tablets, after the last administration of diazepam 5 mg tablet documented/signed-off on 10/15/2024 at 6 AM, however the medication bubble pack contained 28 diazepam 5 mg tablets and contained no other documentation of subsequent administrations. During a concurrent interview, LVN 3 stated LVN 2 administered diazepam 5 mg tablet to Resident 23 that afternoon (10/15/2024) at 1:45 PM and forgot to sign the Controlled Drug accountability log. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CS dose on the Controlled Drug accountability log after preparing the dose for the resident. LVN 3 stated LVN 3 understood it was important to sign each dose once administered to ensure accountability, prevent CS diversion and accidental overdose to Resident 23. During an interview on 10/15/2024 at 3:20 PM with the DON, the DON stated LVN 3 failed to follow facility policy of documenting the preparation of CS immediately on the Controlled Drug accountability log for Resident 23. The DON stated not documenting the Controlled Drug accountability log timely can lead to accountability failures, CS diversion and accidental overdose leading to adverse drug effects. During a review of Resident 23's Order Summary Report, dated 10/15/2024, the report indicated Resident 23 was admitted to the facility on [DATE] with a diagnosis including muscle spasm. The report also indicated Resident 23 was prescribed diazepam 5 mg to give 1 tablet by mouth every 8 hours for muscle spasm, starting 7/18/2023. During a review of Resident 23's Medication Administration Record ([MAR] - a record of mediations administered to residents), for October 2024, the MAR indicated Resident 23 was prescribed diazepam 5 mg to give 1 tablet by mouth every 8 hours for muscle spasm scheduled at 6 AM, 2 PM and 10 PM. During a review of the facility's policy and procedures (P&P), titled Controlled Substances, dated April 2019, the P&P indicated the facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of CM. The P&P indicated upon Administration the nurse administering the mediation is responsible for recording: (2) Name, strength, and dose of the medication. (3) Time of administration. (4) Method of administration. (5) Quantity of the medication remaining. (6) Signature of nurse administering medication. During a review of the P&P titled Discarding and Destroying Medications, dated April 2019, the P&P indicated Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and CS. The P&P indicated Non-controlled and Schedule V (non-hazardous) CS will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. The P&P indicated Schedule II, III, and IV (non-hazardous) CS will be disposed of in accordance with the state regulations and federal guidelines regarding disposition of non-hazardous CM. The P&P indicated the medication disposition record will contain the following information: b. Date medication disposed. e. The quantity disposed. h. Signature of witnesses.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices for 89 of 89 residents when: 1. The dietary staff failed to perform hand hygiene and change gloves when leaving and returning to the tray line to prepare food. 2. The dietary staff failed to wear a N-95 mask (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) appropriately while preparing food on the tray line. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses in all residents who received food from the kitchen. Findings: During an observation of the tray line service for lunch on 10/16/2024 at 11:44 a.m., Dietary Aide (DA) 1's N-95 face mask was not covering her nose and partially covering the mouth. During an observation of the tray line service for lunch on 10/16/2024 at 12:20 p.m. and 12:25 p.m., DA 1 left the tray line wearing gloves to retrieve supplies from the storage area. DA 1's gloves were not changed nor did DA 1 perform hand hygiene before she returned to the tray line. During an observation of the tray line service for lunch on 10/16/2024 at 12:28 p.m., DA 2 left the tray line wearing gloves to retrieve a pan from a cart located outside of the tray line area. DA 2 returned to the tray line wearing the same gloves and did not perform hand hygiene before she proceeded to serve trays on the tray line. During an interview on 10/16/2024 at 12:38 p.m., with DA 2, DA 2 stated she should have washed her hands and changed her gloves when leaving the tray line area and returning. During an interview on 10/16/2024 at 12:40 p.m., with DA 1, DA 1 stated the masks were worn while preparing food to prevent germs from getting in the food. DA 1 stated she should have worn her mask to cover her nose and mouth, changed her gloves and washed her hands when she returned to the tray line. DA 1 stated it was important to wash her hands and change gloves for infection control purposes because residents could get sick if the food was contaminated. During an interview on 10/16/2024 at 1:07 p.m., with the Dietary Supervisor (DS), the DS stated the facility required the kitchen staff to always wear N-95 masks while in the kitchen to prevent infection and protect the residents from illness. The DS stated N95s must cover the nose and mouth and must be worn correctly to be effective. The DS stated when staff leave the tray line, the staff should wash their hands and change their gloves. The DS stated improper hand hygiene could spread infection to residents who may already have other illnesses. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised August 2019, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. During a review of the facility's P&P titled, Food Handling, dated 2023, the P&P indicated, Food will be prepared and served in a safe and sanitary manner. The P&P indicated all food and nutrition services personnel will wash their hands prior to handling food. During a review of the facility's P&P titled, Nursing Home Dietary Tray Line Policy, dated 9/4/2024, the P&P indicated, the facility aims to maintain high standards of food hygiene, presentation and timely delivery to promote the health and well-being of all residents. The P&P indicated that dietary staff would maintain cleanliness and sanitation throughout the tray line process and all staff must wash hands and wear appropriate personal protective equipment such as gloves, aprons, and hairnets.

Based on interview and record review, the facility failed to revise the fall care plan for one of nineteen sampled residents (Resident 64), following Resident 64's fall with subsequent injury on 6/20/2024. This deficient practice increased the potential for staff to be unaware of the interventions required to prevent Resident 64 from suffering additional avoidable falls and potential subsequent injuries. Findings: During a review of Resident 64's Admission Record, the record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's admitting diagnoses included muscle wasting and atrophy (the loss of muscle tissue and strength), abnormalities of gait and mobility, weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 64's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 64 had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 64 required partial to moderate assistance from staff for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated Resident 64 required supervision or touch assistance from staff for mobility while in and out of bed. During a review of Resident 64's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Conference Record, dated 6/20/2024, the record indicated Resident 64 sustained a fall that resulted with a wound to the left upper eye. The record indicated Resident 64's physician orders and treatment record were reviewed. The record did not indicate that Resident 64's care plans were reviewed. During a review of Resident 64's Fall Risk Evaluation, dated 6/20/2024, the record indicated Resident 64 was at risk for falls. During a concurrent interview and record review, on 10/18/2024 at 11:23 AM, with Registered Nurse (RN) 2, Resident 64's IDT Conference Record, dated 6/20/2024, was reviewed. RN 2 stated the record did not indicate that Resident 64's care plans were reviewed following the fall he sustained on 6/20/2024. RN 2 stated the care plans were where staff would document interventions to prevent additional falls. During a concurrent interview and record review, on 10/18/2024 at 11:55 AM, with the Director of Nursing (DON), Resident 64's care plan titled Resident at risk for fall, revised 8/8/2024. The DON stated that after a fall, a resident was at risk for repeat falls, and stated that the care plan should have been updated. The DON stated Resident 64's care plan was not updated until 8/8/2024. During a review of the facility's policy and procedure (P&P) titled Fall Risk Assessment, revised 8/2018, the P&P indicated the staff and attending physician were supposed to collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated assessments of residents were ongoing and care plans were supposed to be revised as information about the residents and the residents' conditions change. The P&P further indicated the Interdisciplinary Team was supposed to review and update the care plan when there had been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 31) received appropriate treatment by applying a wrist hand finger orthosis ([WHFO] a device that provides support and help with joint stiffness and contractures [a condition of shortening and hardening of muscles, or other tissue, often leading to deformity and rigidity of joint]), and an elbow splint (a flexible device used to protect and immobilize a body part) as ordered by the physician. This deficient practice placed Resident 31 at increased risk of further decline to the right elbow and wrist contracture. Findings: During a concurrent observation and interview on 10/15/2024 at 10:05 AM, in Resident 31's room, with Resident 31, Resident 31's right arm elbow and wrist was observed without a splint and/or WHFO. Resident 31 stated he was not able to straighten his right arm and hand. Resident 31 stated he should have a splint on his right arm. During a review of Resident 31's Admission Record (Face Sheet), the Face Sheet indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 31's diagnoses included right-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (inability to move on one side of the body), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). During a review of Resident 31's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated Resident 31's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 31 required supervision (helper sets up or cleans up; resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 31's physician's order, dated 8/14/2024, the physician's order indicated Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function) for application of WHFO to the right upper extremity (RUE) five (5) times a week (5xWK) daily (QD) for four (4) to six (6) hours (4-6 hrs) as tolerated with skin check every one (1) to two (2) hours (1-2 hrs). The physicians' order indicated RNA for application of elbow splint to the RUE 5xWK QD for 4-6 hrs as tolerated with skin check every 1-2 hrs. During an observation on 10/15/2024 at 12:01 PM and 1:43 PM, in the activity room, Resident 31's right arm elbow and wrist was observed without a splint and/or WHFO. During an observation on 10/15/2024 at 2:34 PM, in Resident 31's room, Resident 31's right arm and wrist was observed without a splint and/or WHFO. During an observation on 10/16/2024 at 8:30 AM, in Resident 31's room, Resident 31's right arm and wrist was observed without a splint and/or WHFO. During an interview on 10/16/2024 at 3:00 PM with RNA 1, RNA 1 stated she applied Resident 31's right elbow splint and WHFO around 7:30 AM on 10/15/2024. RNA 1 stated she should have checked Resident 31's skin every 2 hrs per the physicians' order. RNA 1 stated she got busy with other residents' care and did not check Resident 31's skin or the splint and WHFO. RNA 1 she was not aware Resident 31 was not wearing the splint on 10/15/2024 from 10:05 AM until 2:34 PM. RNA 1 stated Resident 31 sometimes removed the splint. RNA 1 stated it was her responsibility to check Resident 31's splint and WHFO and reapply if removed. RNA 1 stated she would report to the rehabilitation (rehab) team when Resident 31 removed the splint and/or refused to wear the splint and WHFO. RNA 1 was not able to provide documentation when she reported to the therapy team of Resident 31's removal/refusal of the splint and WHFO. RNA 1 stated she verbally reported to the rehab team. During an interview on 10/16/2024 at 3:32 PM with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 stated the RNAs were to follow the physician's orders. COTA 1 stated Resident 31's right elbow splint and WHFO not applied as ordered placed Resident 31 at risk for a decline to the right arm and elbow mobility and increased contracture risk. During a concurrent interview and record review on 10/18/2024 at 11:29 AM with RNA 2, Resident 31's Restorative Nursing Weekly Summary ([RNWS]-RNA notes written summary), dated 9/7/2024 through 10/12/2024 was reviewed. RNA 2 stated the RNWS indicated Resident 31 was not refusing and/or taking off the right elbow splint and WHFO. RNA 2 stated the RNWS indicated Resident 31 was compliant with treatment and RNA 1 should have followed the physician's order. During a review of the facility's policy and procedure (P&P) titled Resident Mobility and Range of Motion,, revised 7/2017, the P&P indicated residents with limited mobility would receive appropriate services, equipment, and assistance to maintain or improve mobility. During a review of the facility's P&P titled, Quality of Care, revised 9/4/2024, the P&P indicated the facility was committed to providing exceptional care that met the physical needs of residents. During a review of the facility's P&P tilted Restorative Nursing Assistant (RNA) Job Description, undated, the P&P indicated RNAs responsibilities would perform tasks under required physician's orders and with supervision from nursing, and physical therapist or occupational therapist. The P&P indicated RNAs would assist with placement and use of splints and positioning devices and monitor resident for pressure areas.

Based on interview and record review, the facility failed to develop care plans for three of three sampled residents (Resident 72, 37, and 74) addressing the following: a. The hearing difficulties for Resident 72. b. The discomfort of dentures for Resident 37. c. The usage of dentures for Resident 74. These deficient practices placed Resident 72 at risk of an inability to be aware of the care being provided due to staff being unaware of Resident 72's hearing difficulty and need for staff to speak loudly or speak close to hear. These deficient practices also had the potential to delay necessary care, increase the risk of undesired weight loss, and increase the risk of pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Residents 37 and 74. Findings: a. During a review of Resident 72's Admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's admitting diagnoses included a history of falling, abnormalities of gait and mobility, dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affects brain function). During a review of Resident 72's History and Physical (H&P), dated 2/2/2024, the H&P indicated Resident 72 did not have the capacity to understand and/or make decisions. During a review of Resident 72's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/25/2024, the MDS indicated Resident 72 had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 72 required supervision or touch assistance from staff for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 72's Ear, Nose, and Throat (ENT) Progress Note, dated 10/10/2024, the progress note indicated Resident 72 had a diagnosis of hearing loss. During a review of Resident 72's Social Service quarterly assessment, dated 8/20/2024, the assessment indicated Resident 72 was hard of hearing and required staff to speak loudly to her. During an interview on 10/15/2024 at 10:22 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 72 was hard of hearing and did not use hearing aids. CNA 1 stated staff needed to speak to Resident 72 in a loud voice or speak closely to her for Resident 72 to hear what was being said. During a concurrent interview and record review, on 10/17/2024 at 12:46 PM, with Licensed Vocational Nurse (LVN) 1, Resident 72's active care plans were reviewed. LVN 1 stated Resident 72 did not have a care plan addressing her hearing loss. LVN 1 stated care plans could be developed, reviewed, and revised by any licensed nursing staff, and stated there should be a care plan addressing Resident 72's difficulty in hearing. LVN 1 stated the care plan would ensure all staff providing care to Resident 72 were aware of the resident's hearing difficulty, and the necessary interventions to provide quality care, including speaking loudly or closer to the resident. 49900 b. During a review of Resident 37's Admission Record, the admission record indicated Resident 37 was admitted to the facility on [DATE]. Resident 37's admitting diagnoses included weakness, anemia (a condition where the body did not have enough healthy red blood cells), diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia. During a review of Resident 37's H&P, dated 4/9/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37's cognitive for daily decisions making was moderately impaired. The MDS indicated Resident 37 receiving a mechanically altered diet (required change in texture of food or liquids) and at risk of developing a pressure ulcer/injury. During a review of Resident 37's physician orders, as of 10/17/2024, the orders indicated a mechanical soft texture diet was ordered on 4/8/2024. During an interview on 10/15/2024 at 2:06 PM with Resident 37, Resident 37 stated her dentures were hurting her and affecting her eating. Resident 37 stated she could not chew without her dentures. During a concurrent interview and record review on 10/17/2024 at 8:34 AM with the Director of Social Services (DSS), Resident 37's care plans as of 10/17/2024 were reviewed. The care plans indicated there was no documentation addressing Resident 37's discomfort with her dentures. The DSS stated there should have a care plan addressing Resident 37's discomfort with her dentures. The DSS stated the purpose of care plans were to correct a resident's problems, to know the resident's needs, and to see what specific staff could help with the resident's issue. The DSS stated the risk of not having a care plan addressing Resident 37's discomfort with her dentures was that staff would not know Resident 37 had a denture issue, and it could potentially delay necessary care. The DSS stated it could also possibly affect Resident 37's oral intake and cause undesired weight loss. The DSS stated a care plan should be done upon admission and when there was an issue. The DSS stated the nursing department was the one responsible for creating a care plan. c. During a review of Resident 74's Admission Record, the admission record indicated Resident 74 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 74's admitting diagnoses included weakness, anemia, failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity), and anxiety disorder (a mental health condition that involved excessive and persistent feelings of fear, dread, and uneasiness). During a review of Resident 74's H&P, dated 7/3/2024, the H&P indicated Resident 74 did not have the capacity to understand and make decisions. During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74's cognitive skills for daily decisions making was intact. The MDS indicated Resident 74 had no natural teeth or tooth fragments. The MDS indicated Resident 74 lost 10 percent (%) or more of her body weight in the last six months and was prescribed a mechanically altered diet. The MDS indicated Resident 74 was at risk of developing a pressure ulcer/injury. During a review of Resident 74's physician orders, as of 10/17/2024, the orders indicated a mechanical soft texture diet was ordered on 7/5/2024. During an interview on 10/15/2024 at10:59 AM with Resident 74, Resident 74 stated her dentures were missing and she had no grip in her mouth without the dentures. During a concurrent interview and record review on 10/17/2024 at 8:57 AM with the DSS, Resident 74's care plans as of 10/17/2024 were reviewed. There was no care plan addressing the usage of dentures. The DSS stated Resident 74 should have a care plan addressing the usage of dentures. The DSS stated she was aware of Resident 74's missing dentures, and Resident 74 was seen by dentist on 10/11/2024 for a denture try-in (a step in the denture fabrication process where a dentist placed a prototype of the final denture in the patient's mouth to evaluate its fit, function, and appearance). During an interview on 10/17/24 at 10:25 AM with LVN 3, LVN 3 stated residents who had dentures should have a care plan addressing the usage of the dentures. LVN 3 stated the purpose of the care plan was to ensure residents received the care they should. LVN 3 stated the licensed nurse was responsible for creating the care plans. LVN 3 stated it would be a potential delay to necessary care without a care plan addressing the usage of dentures. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 2016, the P&P indicated facility residents were supposed to have care plans that incorporated identified problem areas and included interventions that were targeted and meaningful to the resident. The P&P further indicated the care plan was supposed to describe the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to identify fire hazard risks for one of six sampled residents (Resident 23) by not knowing Resident 23 kept a lighter and cigarettes at the bedside. This deficient practice had a potential to increase the risk for injury for Resident 23. Findings: During a concurrent observation and interview on 10/15/2024 at 11:51 AM, in Resident 23's room, a pack of cigarettes and a lighter was observed on top of the nightstand in front of Resident 23's television. Resident 23 stated the lighter and cigarettes belonged to him. During a concurrent observation and interview on 10/16/2024 at 12:34 AM, in the hallway, Resident 23 was observed wheeling himself with a lighter and pack of cigarettes on his lap. Resident 23 stated he had been living in this facility for three and half years, and he kept his lighter and cigarettes with him all the time. Resident 23 stated no staff talked to him regarding the storage of the lighter or cigarettes. During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was originally admitted to facility on 3/26/2021 and readmitted on [DATE]. Resident 23's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness, schizophrenia (a mental illness that was characterized by disturbances in thought), anxiety (a feeling of fear, dread, or uneasiness), and nicotine dependence. During a review of Resident 23's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/6/2024, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 1 had impairment on the lower extremities and used a wheelchair for mobility. During a review of Resident 23's Smoking and Safety Assessment, dated 10/6/2024, the assessment indicated Resident 23 used tobacco products and followed the facility's policy on the location and time of smoking. The assessment indicated staff would continue to monitor smoking safety. During a review of Resident 23's care plan titled Resident is a smoker and is at risk for smoking-related injury or conditions, revised 10/13/2023, the care plan indicated the goal was for Resident 23 to smoke safely in accordance with the facility policy. The care plan indicated staff would observe Resident 23 for unsafe smoking behaviors or practices. During an interview on 10/17/2024 at 10:16 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated residents should not keep lighters at the bedside because it was a fire hazard and could possibly cause injury. LVN 3 stated he needed to confiscate the resident's lighter if found at the bedside. LVN 3 stated he was not aware Resident 23 kept a lighter and cigarettes at the bedside. LVN 3 stated all staff, particularly the nursing staff, were the ones responsible for ensuring the residents were free from hazards. During an interview on 10/17/2024 at 1:43 PM with the Director of Nursing (DON), the DON stated the purpose of facility's Memorandum posted on the door of the smoking patio was to inform residents, responsible parties, and families of the facility's smoking policy. The DON stated the residents should not keep cigarettes or lighters at the bedside because it was not safe. The DON stated staff should document if a resident refused to give up their cigarettes and lighters. During a concurrent interview and record review on 10/17/2024 at 1:52 PM with LVN 2, Resident 23's care plans, as of 10/17/2024, were reviewed. The care plans indicated there was no documentation regarding Resident 23's refusal to give up his lighter and cigarettes. LVN 2 stated they should have care plans if Resident 23 refused to give up his lighter and cigarettes. During a concurrent interview and record review on 10/17/2024 at 1:52 PM with LVN 2, Resident 23's Nurse's Notes for 2024 were reviewed. The notes indicated there was no documentation regarding Resident 23's refusal to give up his lighter and cigarettes. LVN 2 stated staff should document in the Nurse's Notes if Resident 23 refused to give up his lighter and cigarettes. During a review of the facility's Policy and Procedure (P&P) titled Smoking policy- residents, revised on 7/2017, the P&P indicated only disposable safety lighters were permitted and all other forms of lighters were prohibited. During a review of the facility's Memorandum dated 9/30/2022, the memorandum indicated Resident are not allowed to keep their cigarettes and lighters in their pockets, closets, bedside tables and room. All cigarettes and lighters should be given to the patio monitor to keep in the 'smoking cabin' for safe keeping . For the safety of all residents, lighters and cigarettes shall be confiscated and placed in a secured area under the resident's name for use as needed or according to the smoking schedule.

Based on interview and record review, the facility failed to notify the responsible party (RP) of a change in condition for one of 19 sampled residents (Resident 79), in the RP's preferred language of Korean (language spoken in the country of Korea). This deficient practice delayed Resident 79's RP's ability to be informed and aware of Resident 79's plan of care, including changes in Resident 79's condition, hospitalization s, and readmissions. Findings: During a review of Resident 79's Admission Record, the record indicated Resident 79 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 79's admitting diagnoses included major depressive disorder (a serious mood disorder that affects how a person feels, thinks, and behaves), anxiety disorder (a mental health condition that involves excessive feelings of fear, dread, and uneasiness), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 79's History and Physical (H&P), dated 10/15/2024, the H&P indicated Resident 79 did not have the capacity to understand or make decisions. During a review of Resident 79's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/5/2024, the MDS indicated Resident 79 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and required supervision or touching assistance for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 79's Change of Condition (COC) assessment, dated 10/4/2024, the assessment indicated Resident 79 was displaying a change in behavior and indicated Licensed Vocational Nurse (LVN) 1 notified Resident 79's RP of the change of condition. During a telephone interview on 10/17/2024 at 12:00 PM, with Resident 79's RP, using a translator, Resident 79's RP stated her preferred language was Korean, and stated she could not speak or understand English well. Resident 79's RP stated that on 10/4/2024 the facility left her a voice message in English, and stated she did not understand what the message said. Resident 79's RP further stated she received an email from the Director of Social Services (DSS) on 10/17/2024 and stated the email was in English. Resident 79's RP stated that she was not aware Resident 79 had a change in condition on 10/4/2024, or that Resident 79 was transferred to the hospital on 10/5/2024. During an interview on 10/17/2024 at 1:48 PM, with the Director of Nursing (DON), the DON stated if a resident has a RP, the RP was supposed to be notified of any changes in the plan of care, including changes of condition, hospitalization s, and readmissions. The DON stated the RP should be notified immediately. During an interview on 10/18/2024 at 10:26 AM with LVN 1, LVN 1 stated she notified Resident 79's RP of Resident 79's change of condition on 10/4/2024. LVN 1 stated she notified Resident 79's RP by phone, and stated she left a voice message for Resident 79's RP in English. LVN 1 stated there was no language translator used. An attempt was made to contact RN 1 by telephone, but no answer was received. During an interview on 10/17/2024 at 2:06 PM, with RN 2, RN 2 stated she spoke Korean and assisted staff with translation, but she did not work every day, and her responsibilities as an RN meant she was not always available to translate for staff. RN 2 stated that when she was not available, staff notified Resident 79's RP in English, and Resident 79's RP would call the facility when RN 2 was available to translate. RN 2 stated it was important that the facility residents' RPs received information and updates in their preferred language. During an interview on 10/18/2024, at 12:13 PM, with the DON, the DON stated updates to the plan of care, or change in a resident's condition, should be provided in the preferred language of the RP as the RP was an extension of the resident. The DON stated it was the resident's right to provide this information in a language the resident and/or RP could understand. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised December 2016, the P&P indicated it was the resident's right to be notified of their medical condition and of any changes in their condition. The P&P further indicated it was the resident's right to be informed of the care planning and treatment received. During a review of the facility's P&P titled Accommodation of Needs, revised January 2020, the P&P indicated the resident's needs and preferences were supposed to be accommodated to the extent possible if it would not endanger the health and safety of others. The P&P further indicated staff were supposed to provide care in a manner that accommodated sensory limitations, promoted communication, and maintained dignity. During a review of the facility's P&P titled Communication Policy: Translation and/or Interpretation, revised April 2020, the P&P indicated that if there were no staff or family members available to assist with translation, facility staff were supposed to utilize the facility's contracted interpretation services.

Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 64) received a meal tray as prescribed by the physician. This deficient practice created the potential for Resident 64 to suffer from repeat weight loss and malnutrition resulting from not receiving his prescribed and expected number of calories and nutritive value. Findings: During a review of Resident 64's Admission Record, the record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's admitting diagnoses included failure to thrive (a syndrome that describes a general decline in health that can include weight loss, poor nutrition, and inactivity), muscle wasting and atrophy (the loss of muscle tissue and strength), dehydration, and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 64's History and Physical (H&P), dated 4/11/2024, the H&P indicated Resident 64 did not have the capacity to understand or make decisions. During a review of Resident 64's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 64 had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 64 required partial to moderate assistance from staff for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 64's active physician orders dated 6/12/2024, the orders indicated Resident 64 was to receive a fortified diet (a diet that includes foods with added nutrients, such as protein, carbohydrates, or fats, to increase their nutritional value). During an observation on 10/16/2024 at 12:55 PM, at Resident 64's bedside, Resident 64 was observed eating his lunch tray. Resident 64's meal tray ticket, (a piece of paper that displays exactly what that resident will be receiving based on the resident's prescribed diet order), dated 10/16/2024, indicated Resident 64 did not receive a fortified tray. A photo was taken of Resident 64's meal tray ticket. During a concurrent interview and record review, on 10/17/2024 at 10:28 AM, with the Dietary Supervisor (DS), the DS reviewed Resident 64's active diet order and meal tray ticket from 10/16/2024. The DS stated Resident 64's orders indicated he was supposed to receive a fortified tray and stated the meal tray ticket indicated Resident 64 did not receive a fortified tray on 10/16/2024 for lunch. The DS stated a fortified tray meant more calories were added to the tray to assist in weight gain. The DS stated Resident 64 had a history of severe weight loss and stated Resident 64 not receiving the ordered number of calories placed the resident at risk for not meeting his nutritional requirements and experiencing repeated weight loss. During a concurrent interview and record review, on 10/18/2024 at 1:46 PM, with Licensed Vocational Nurse (LVN) 2, Resident 64's active diet order dated 6/12/2024 was reviewed. LVN 2 stated Resident 64 was supposed to receive a fortified tray. LVN 2 stated that before meal trays were delivered to the residents, the staff were to check the meal tray ticket against the physician orders to ensure they matched, and the residents were receiving the correct tray. LVN 2 stated that a fortified diet was for residents with weight loss. LVN 2 stated Resident 64 needed to have the correct tray as ordered to receive the correct number of calories. LVN 2 stated that not receiving the tray as ordered placed Resident 64 at risk for weight loss. During a review of the facility's policy and procedure (P&P) titled Therapeutic Diets, revised 10/2017, the P&P indicated therapeutic diets were prescribed by the physician to support the resident's treatment and plan of care and in accordance with the resident's goals and preferences. During a review of the facility's P&P titled Nursing Home Dietary Tray Line Policy, revised 9/2024, the P&P indicated facility nursing staff or dietary staff were supposed to confirm that the correct meal was delivered.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of COVID-19 (COVID-19 is a disease caused by a virus called [CONDITION(S)]-CoV-2, a coronavirus) virus throughout the facility for 98 of 98 residents. The facility failed to: 1. Ensure a Certified Nurse Assistant (CNN 4) and the Registered nurse (RN 1) wore the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards) while transporting Resident 3, 4, and 5, who were potentially exposed to COVID-19. 2. Ensure CNA 1 and RN 2 wore the appropriate PPE while providing care to Resident 6 and Resident 7, who were in the yellow zone (a zone where residents reside if they are potentially COVID-19 positive), and to ensure the PPE cart was set up directly outside of the dining room converted to a yellow zone for staff use. 3. Ensure CNA 1, CNA 4, and RN 2 were fit tested for an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles, including those from [CONDITION(S)]-CoV-2) respirator. The facility's census was 93 residents. This deficient practice placed 93 residents (14 residents in the yellow zone and 79 residents in the green zone (a zone where residents reside if they do not have COVID-19), 120 staff, and the community at risk for the transmission and spread of COVID-19 virus. On [DATE], an unannounced visit was made to the facility to investigate a complaint regarding resident neglect. On [DATE] at 3:41 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified due to facility ' s failure to fit test staff (CNA 1, CAN 4, and RN 2 [who were assigned to the yellow zone]), for N95 respirator in accordance with the National Institute for Occupational Safety and Health (NIOSH, the agency that regulates N95 respirators) approved N95 respirator, and ensure the staff (CNA 4 and RN 1) wore proper PPE while transporting and caring for residents, who were potentially exposed to COVID-19. The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON), and the Infection Preventionist (IP). On [DATE] at 5:49 p.m., the ADMIN submitted an acceptable Plan of Action (POA, a plan that documents the immediate action an entity will take to prevent serious harm from occurring or recurring.). The IJ was lifted on [DATE], at 7:48 p.m., after POA implementation was verified onsite through observations, interviews, and record review. Findings: 1. A review of Resident 2's admission record dated [DATE], indicated the resident was admitted to the facility on [DATE] from a General Acute Care Hospital (GACH) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's admission assessment, dated [DATE], indicated the resident was alert with periods of confusion, had a clear speech, and was able to follow simple commands. A review of Resident 3's admission record dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 3 had the ability to make herself understood and understood others, and required supervision from staff for bed mobility, transfer, walking, and locomotion (moving from place to place), and extensive assistance with personal hygiene, and bathing. A review of Resident 4 ' s admission record, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, dated [DATE], indicated the resident had ability to make herself understood and understood others, and required limited assistance from staff with bed mobility, and extensive assistance from staff for transfer, walking, locomotion, personal hygiene, and bathing. During a review of Resident 5's admission record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident had the ability to make herself understood and understood others, and required limited assistance from staff for bed mobility, and extensive assistance form staff for and transfer, walking inside and outside the room, locomotion, personal hygiene, and bathing. During an observation on [DATE], at 9:50 a.m., CNA 4 and RN 1 were observed wheeling Resident 3 in her bed from Resident 3's room (in the green zone) to the dining room (converted to a yellow zone). During the transfer, CNA 4 and RN 1 were observed to have a close contact with Resident 3 (within 6 feet). CNA 4 was observed not wearing N95 respirator, a gown, and gloves. RN 1 was observed wearing two masks, one on top of the other. During an observation on [DATE], at 9:55 a.m., CNA 4 was observed wheeling Resident 4 in her bed from Resident 4's room (in the green zone) to the dining room (converted to a yellow zone). During the transfer, CNA 4 was observed to have a close contact with Resident 4 (within 6 feet) without wearing an N95 respirator, a gown, and gloves. During an observation on [DATE], at 9:59 a.m., CNA 4 was observed wheeling Resident 5 in her bed from Resident 5's room (in the green zone) to the dining room (converted to a yellow zone). During the transfer, CNA 4 was observed to have a close contact with Resident 5 (within 6 feet) without wearing an N95 respirator, a gown, and gloves. A review of the census dated [DATE], indicated Resident 2, 3 and 4, shared a room and Resident 5 was in the adjacent room to Resident 2, 3, and 4. Resident 2, 3, and 4's room and Resident 5's room shared a bathroom. During a concurrent interview and record review on [DATE], at 10:00 a.m., with IP, the census, dated [DATE], was reviewed. IP confirmed by highlighting the census, dated [DATE], that Residents 3, 4, and 5 were residing in the dining (yellow zone). During an interview on [DATE], at 10:05 a.m., CNA 4 stated when she was transporting Resident 3, 4, and 5 from their room in the green zone to the yellow zone, she was only wearing a surgical mask and eye protection. CNA 4 stated she was transporting Resident 3, 4, and 5 from the green zone to the yellow zone because they were exposed to Resident 2, who was confirmed positive for COVID-19 on [DATE] (from the GACH). CNA 4 stated that she was in close contact with Resident 3, 4, and 5 (within 6 feet). CNA 4 could not verbalize whether an N95 respirator, gown, and gloves were necessary when transporting and coming into close contact with a resident (Residents 3, 4, and 5) who was potentially exposed to COVID-19. During an interview on [DATE], at 10:30 a.m., IP stated Resident 2, 3 and 4, shared a room in the green zone before Resident 2 was transferred to the GACH on [DATE]. IP stated Resident 5 was considered exposed to COVID-19 because she shared a bathroom with Resident 2, 3, and 4. IP stated the GACH had reported to the facility that Resident 2 had tested positive for COVID-19 on [DATE]. IP stated the GACH did not provide a documented confirmation of Resident 2 ' s positive COVID-19 test, but the facility was verbally notified over the phone. IP stated that the facility was moving Resident 3, 4, and 5 from the green zone to the yellow zone because they were exposed to Resident 2, who was confirmed COVID-19 positive. IP stated when staff provide care or are in close contact to residents (within 6 feet) who were potentially exposed (like Resident 3, 4, and 5), they must wear eye protection, a gown, an N95 respirator, and gloves. IP stated if CNA 4 and RN 1 were not wearing eye protection, a gown, an N95 respirator, and gloves while transporting Resident 3, 4, and 5 from the green to the yellow zone, they can potentially spread COVID-19 to all other residents, staff, and visitors. During an interview on [DATE], at 12:11 p.m., RN 1 stated on [DATE], at around 10:00 a.m., she helped CNA 4 transfer Resident 3 from the green zone to the yellow zone wearing only a mask, but not goggles (or any other eye protection), gloves, nor a gown. RN 1 stated that the mask she was wearing was a KN95 respirator (a respirator not approved by NIOSH) under a surgical mask for double protection. RN 1 could not verbalize if the KN95 respirator she wore was NIOSH-approved nor whether the facility approved its use. RN 1 stated that she was not fit tested for the KN95 she wore while transporting Resident 3. RN 1 stated she did not know whether all respirators worn by staff must be NIOSH-approved or fit tested prior to its use. RN 1 stated she did not know whether double masking was appropriate and within the current COVID-19 PPE guidelines. RN 1 stated that the guidelines [COVID-19] keep changing, so I do not know what [PPE] to wear. 2. During a review of Resident 6's admission record, the admission record indicated Resident 6 was admitted to the facility the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had the ability to make himself understood and understood others and required a limited to extensive assistance from staff for transfer, locomotion, toilet use, personal hygiene, and bathing. During a review of Resident 7's undated admission record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had the ability to make himself understood and understood others and required a limited assistance from staff with bed mobility, and extensive assistance from staff members for transfer, locomotion, toilet use, personal hygiene, and bathing. During a concurrent interview and record review on [DATE], at 10:00 a.m., with I/P, the census, dated [DATE], was reviewed. The I/P stated and confirmed by highlighting the census, dated [DATE], that Residents 6 and 7 were residing in the dining room (yellow zone). During an observation on [DATE], at 10:10 a.m., CNA 1 and RN 2 were observed not wearing N95 respirators, gown, and gloves while providing care in the dining room converted to a yellow zone. CNA 1 was observed tucking Resident 6's sheets into the resident's bed while being within six feet of Resident 6. RN 2 was observed giving Resident 7 medications while being within 6 feet of the resident. During an interview on [DATE], at 10:12 a.m., CNA 1 confirmed she was in close contact with Resident 6 when she was tucking the resident's bed sheets CNA 1 confirmed she was only wearing a surgical face mask and a face shield. CNA 1 stated he should have worn an N95 respirator, a gown, and gloves. CNA 1 stated he did not wear a N95, a gown, and gloves because the PPE cart containing all required PPE was not set up outside of the room the dining room. CNA 1 stated he could spread COVID-19 because he did not wear all PPE as required when providing care to a resident in the yellow zone, which included an N95 respirator, gown, eye protection, and gloves. During an interview on [DATE], at 10:15 a.m., with RN 2, RN 2 stated she was passing medications to Resident 7 around 10:00 a.m. on [DATE]. RN 2 stated she came into close contact with Resident 7, within 6 feet. RN 2 confirmed she was only wearing a surgical face mask and a face shield when passed medications to Resident 7. RN 2 stated she should have worn full PPE, which included an N95 respirator, a gown, gloves, and eye protection because Resident 7 was in the yellow zone. RN 2 stated she did not wear full PPE because the PPE cart was not set up directly outside of the room in the yellow zone. RN 2 stated she should be wearing full PPE in the yellow zone and when providing resident care to prevent the spread of COVID-19. A review of the facility's census dated [DATE], indicated there were 14 residents residing in the yellow zone and 79 residents were in the green zone. A review of the facility's COVID-19 Vaccination Daily Tracking Log for Healthcare Personnel (HCP) indicated the facility had a total of 120 HCP staff. During an interview on [DATE], at 1:30 p.m., DON confirmed that the facility had 14 residents in the yellow zone and 79 in the green zone. The DON stated when staff provide residents ' care and come into close contact with residents, within 6 feet or closer, they must wear a full PPE, which includes eye protection, an N95 respirator, a gown, and gloves. The DON stated if the staff do not wear required PPE when providing residents ' care or coming into close contact with residents, they can potentially spread COVID-19 virus to other residents throughout the facility, staff, visitors, and the community. DON confirmed there was no PPE cart set up outside of the dining room converted to a yellow zone, because they were barely setting up the converted dining room to a yellow zone room. 3. During an interview on [DATE], at 10:05 a.m., CNA 4 stated she could not remember if she was fit tested for an N95 respirator. CNA 4 could not verbalize if N95 respirators must be fit tested prior to its use with residents who were potentially exposed to COVID-19. During an interview on [DATE], at 10:12 a.m., CNA 1 stated he was never fit tested for an N95 respirator. During an interview on [DATE], at 10:15 a.m., RN 2 stated she was never fit tested for an N95 respirator. During a record review of the assignment and sign-in sheet dated [DATE], the assignment and sign-in sheet indicated CNA 1 and RN 2 were assigned to work in the yellow zone. During an interview on [DATE], at 2:45 p.m., the Director of Staff Development (DSD), stated there was no documented evidence CNA 4, CNA 1, and RN 2 were fit tested for an N95 respirator. The DSD stated since CNA 4, CNA1, and RN 2 came into close contact or were assigned to care for Resident 3.4, 5, 6, and 7 in the yellow zone, they should have worn NIOSH-approved N95 respirator. The DSD stated when CNA 4, CNA 1, and RN 2 were caring for the residents in the yellow zone, they also should have worn an eye protection, a gown, and gloves. The DSD stated that all N95s worn by staff in the facility must be NIOSH-approved. The DSD stated RN 1 should not have worn a KN95 during resident care because it was not approved by the NIOSH nor was it approved for use by the facility. The DSD stated it is important for N95 respirators to be fit tested to ensure the N95 does not have leaks that can leak COVID-19 particles through to the wearer. A review of the facility ' s Mitigation Plan (the facility ' s plan to mitigate COVID-19 from spreading within the facility), dated [DATE], indicated it was the policy of the facility to protect the residents, staff and others who may be in the facility from harm during emergency events. Necessary PPE will be made available directly outside of resident ' s rooms and other care areas in the red, yellow, and green zone in accordance with current Centers for Disease Control (CDC, protects people from health, safety, and security threats) guidance. The asymptomatic negative Covid-19 resident exposed to the positive Covid 19 resident will be moved to the designated yellow zone. All staff will wear recommended PPE while in the building per current CDC or CDPH PPE guidance. Place residents into three separate cohorts based on the test results, accordingly, and regardless of their vaccination status: negative results but exposed within the last 14 days (yellow-exposed area); in general, all residents on the unit or wing where a case was identified in a resident or HCP are considered exposed. According to the Los Angeles County Department of Public Health's Coronavirus Disease 2019 Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities at http://publichealth.lacounty.gov/[MEDICATION(S)]/ncorona2019/healthfacilities/snf/prevention/, indicated: In the Yellow and Red Cohorts, all staff regardless of vaccination status should wear N95 respirators when providing resident care (e.g., entering resident room and/or within 6 ft of resident). If there is a need to preserve supply, N95 respirators can be worn in extended use (same N95 for duration of the shift). N95 respirators should be worn for all aerosol generating procedures (suction, ventilation, CPR, nebulizer treatments, etc.) for all cohorts including the Green Cohort regardless of the staff's vaccination status if the facility has an active outbreak. NIOSH-approved N95 respirators with an exhalation valve can be used as protection (i.e., as PPE) and source control when there are no anticipated high velocity body fluids as per CDC, in which case either a surgical N95 respirator should be used, or a face shield can be worn without compromising the fit of the respirator. Initial and annual N95 respiratory fit testing is required for all staff per California Division of Occupational Safety and Health (Cal-OSHA, provides free safety and health assistance to employers). Cal-OSHA no longer allows for re-use (over multiple shifts) of N95 respirators or extended use (with multiple residents in the same shift) when used for respiratory protection for confirmed or suspected cases, (e.g., in Yellow and Red Cohorts). However, staff may wear N95 respirators in an extended fashion if they are not interacting with confirmed or suspect cases of COVID-19.

Based on observation, interview and record review, the facility's staff failed to follow its policy and procedures (p/p) titled, Safety and Supervision of Residents, to supervise residents with escalating aggressive behavior, identify residents who had suicidal thoughts (to kill oneself) tendencies and illicit (forbidden by law) drug use to prevent accidents and injuries for five of seven sampled residents (Residents 1, 2, 3, 6 and 7) crossed referenced to F600. a. Resident 1, who had a history of [REDACTED]. Resident 1 was found on 8/20/19 sedated (sleepy) and diaphoretic (sweating heavily) in a wheelchair inside the resident's bathroom complaining of drug overdose and on 9/7/19 at 8:10 a.m., Resident 1 was found unresponsive (lack of the ability to notice or respond to stimuli in the environment) in a wheelchair inside the restroom with a metal spoon containing an unknown substance on top of the bathroom sink. b. Resident 2 sustained a scratch to the right lower eye after being struck on the face by Resident 3, while unsupervised. c. Resident 7 hit Resident 6 two times in the back of the head while in the dining room unsupervised waiting for breakfast. These deficient practices resulted in Resident 1 requiring [MEDICATION NAME] medication (given to reverse narcotic overdose in an emergency) and a transferred to the general acute care hospital (GACH) after overdosing on two separate occasions while on the facility. Residents 2 and 6 being physically injured. Findings: a. A review of Resident 1's GACH history and physical (H/P) record dated 8/11/19 indicated Resident 1 had attempted to commit suicide prior to admission to the GACH. The report indicated Resident 1 admitted to using heroin (highly addictive [MEDICATION NAME] drug derived from [MEDICATION NAME]) and [MEDICATION NAME] (synthetic, addictive, mood-altering drug, used illegally as a stimulant). A review of Resident 1's GACH discharge note, dated 8/14/19 indicated for Resident 1 to follow-up with a psychiatrist (medical practitioner specializing in the [DIAGNOSES REDACTED]. A review of Resident 1's Ambulance Service transportation sheet, dated 8/14/19, indicated Resident was transfer from GACH 1 to the facility after being discharged with [DIAGNOSES REDACTED]. The report indicated the facility was made aware of Resident 1's required care to supervise to prevent overdose. A review of Resident 1's skill nursing facility (SNF) Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/21/19 indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required an extensive assistance of a one-person physical assistance for ambulating in/off unit and was dependent on a wheelchair for mobility. The MDS indicated Resident 1 had no behaviors. A review of all Resident 1's care plans indicated there was no baseline Person-center care plan to indicate the facility staffs' interventions and supervision to prevent Resident 1 to commit suicide and drug use. A review of Resident 1's care plan titled, Antidepressant, dated 8/14/19 indicated the staffs to monitor and document the number of depression behaviors every shift and monitor Resident 1's whereabouts frequently. A review of Resident 1's GACH's Prehospital Care Report Summary, dated 8/20/19 indicated Resident 1 was seen for altered level of consciousness ((ALOC) abnormal measurement of a resident's awakening and responsiveness to stimuli) and drug overdose. The Prehospital Care Report indicated the facility's staff reported Resident 1 obtained illegal drugs an hour prior to the paramedic's arrival. A review of Resident 1's physician telephone order, dated 8/20/19, and timed at 12:20 p.m., indicated to transfer Resident 1 to the GACH via 911 (emergency services) for evaluation. A review of Resident 1's Nurses Progress Note, dated 8/20/19 and timed at 12:20 p.m., indicated Resident 1 was transferred to GACH 2 for altered mental status ((AMS) abnormal measurement of a resident's mental status). A review of Resident 1's GACH's laboratory results, dated 8/20/19 and timed at 12:42 p.m., indicated the resident's urine tested positive for [MEDICATION NAME], benzodiazepines (a class of psychoactive drugs, used to treat anxiety and other conditions) and opioids (highly addictive pain relief drugs). A review of Resident 1's Nurse's Progress Note, dated 9/3/19 and timed at 1:20 a.m., indicated Resident 1 was readmitted to the facility 14 days from GACH in stable condition. A review of Resident 1's Licensed Nurse Progress note, dated 9/7/19 and timed at 8:40 a.m., indicating Resident 1 was found unresponsive in the bathroom, skin noted flushed (red and hot) and perspired (sweat). The Nurses' note indicated a spoon with an unknown substance was found on the bathroom's sink and a syringe found on the floor. The note indicated Resident 1 was placed on a non-rebreather mask (nose/mouth mask that allows delivery of high oxygen concentrations delivery) with 15 liters of oxygen via the mask given. A review of Resident 1's physician telephone order, dated 9/7/19 and timed at 8:40 a.m., indicated to transfer Resident 1 to GACH 3 via 911 for evaluation related to drug use. A review of Resident 1's Situation, Background, Assessment, and Re-evaluation ((SBAR) internal communication document) dated 9/7/19 and timed at 8:44 a.m., indicated Resident 1 was found unresponsive sitting in his wheelchair inside the bathroom. The SBAR indicated an unknown substance was found on a spoon and a syringe was on the floor near Resident 1. The SBAR indicated Resident 1 was placed on a non-rebreather and 911 was called. A review of Resident 1's Prehospital Care Report Summary, dated 9/7/19 indicated Resident 1 was noted somnolent (drowsy/sleepy), with decreased respirations of 8 breath per minute ((bpm) normal reference range (NRR) 16-20 bpm) low oxygen saturation of 86 percent (%) (NRR 94-100% on room air) and an overdose of heroin. The report indicated a dose of [MEDICATION NAME] nasal spray was administered on 9/7/19 at 8:36 a.m., with positive effect. A review of Resident 1's GACH H/P, dated 9/7/19 indicated Resident 1 arrived to the GACH for shortness of breath (SOB) and a heroin overdose Resident 1 was admitted for monitoring of heroin overdose and rapid heart rate. A review of the facility's investigation report, dated 9/7/19 and timed at 8:10 a.m., indicated a certified nurse assistant1 (CNA 1) found Resident 1 in the bathroom unresponsive with an unknown substance on a metal spoon on top of the sink. The facility's investigation indicated Resident 1 received drugs from a friend in the facility's smoking patio. On 9/16/19 at 10:50 a.m., during an interview, Resident 1 stated he did overdose twice while in the facility. Resident 1 stated he injected heroin while in the facility's restroom on 8/20/19 and then again on 9/7/19. Resident 1 stated a friend brought him the heroin to the facility's parking lot. Resident 1 stated on 8/20/19 he was out of it after consuming the heroin, but the second time he was found unconscious. Resident 1 stated he was supposed to be monitored by facility's staff because of his drug abuse, but he was always left by himself. Resident 1 stated he was trying to commit suicide by overdosing and needed help. Resident 1 stated the facility's staff was aware of his drug addiction and of the two times he overdosed. On 9/16/19 at 11:10 a.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/7/19 at approximately 8-8:30 a.m., she was called by CNAs 1 and 2 to come to Resident 1's room. RN 1 stated she walked into the bathroom and Resident 1 was in his wheelchair facing the sink, his face was red in color and was down between his legs. RN 1 stated it was the second incident of Resident 1 overdosing. On 9/16/19 at 11:45 a.m., during an interview and a concurrent review of Resident 1's care plans, admission chart, and GACH's laboratory results, the Director of Nursing (DON) stated she was not aware of Resident 1's drug overdose incident that occurred on 8/20/19. The DON stated and confirmed Resident 1 was admitted to the facility on [DATE] with a history of suicidal attempt by drug overdose and there was no care plan created. The DON stated there was no close monitoring or supervision of Resident 1 implemented. The DON stated the staff should had evaluated Resident 1's chart prior to readmission and created a care plan to closely monitor Resident 1 to prevent any suicide of use of illicit drugs while in the facility. On 11/25/19 at 4:39 p.m., during an interview with CNAs 1 and 2, CNA 1 stated Resident 1 had been found unresponsive from drug overdose twice in the bathroom but could not recall the date or time. CNA 1 stated RN 1 found Resident 1 in the bathroom unresponsive and immediately called him (CNA 1) and CNA 2 to bring the crash cart and oxygen. CNA 2 stated Resident 1 had overdosed twice while in the facility and all the staff was aware Resident 1 needed to be monitored at all times. CNA 2 stated the DON and the ADM were aware Resident 1 used drugs. b1. A review of Resident 2's Face Sheet (Admission Record) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P) dated 8/5/19 indicated Resident 2 had periods of confusion and did not have the capacity to understand or make herself understood. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 8/11/19 indicated Resident 2 was unsteady on her feet and required an extensive assistance of a one-person physical assist for weight-bearing (amount of weight placed on an individual's leg) support. A review of a SBAR, dated 9/10/19 indicated Resident 2 had a scratch to her right lower eye. A review of Resident 2's Physician Orders, dated 9/10/19 indicated there was a right lower eye linear (straight line) scratch to Resident 2's eye and the order indicated to cleanse with normal saline (salt water), pat dry, apply triple antibiotic ointment every day for 30 days until 10/10/19. b2. A review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's H/P, dated 6/4/19 indicated Resident 3 did not have the capacity (ability) to understand and make decisions. A review of Resident 3's care plan titled, Potential for Emotional Distress Related to Resident to Resident Altercation, dated 6/8/19 indicated Resident 3 would not have episodes of distress. A review of Resident 3's Physician Orders, dated 9/10/19 indicated to transfer Resident 3 to a general acute care hospital (GACH) for further evaluation for aggressive behaviors. A review of Resident 3's physician's orders [REDACTED]. On 9/16/19 at 8 a.m., during an interview, Resident 4 stated her roommate Residents 3 was transferred to the GACH two days prior because of her aggressive behaviors. Resident 4 stated, Resident 2 would sneak into Resident 3's room as they were friends and lay on Resident 3's bed. Resident 4 stated Resident 3 was very aggressive towards everyone in the facility and all staff were aware of Resident 3's behavior. Resident 4 stated she informed the Administrator (ADM) Resident 3 would, steal our personal belongings and would try to hit us all the time. Resident 4 stated she was old and should not be hit by other residents. Resident 4 stated Residents 2 and 3 were fighting in the room over Resident 2 talking to a female staff. Resident 4 stated Residents 2 and 3 began to punch each other leaving Resident 2 with a scratch to the left side of her face. Resident 4 stated, It's scary to have both of the residents here because we don't know if they would come and attack us. On 11/25/19 at 4:17 p.m., during an interview, Certified Nurse Assistant 6 (CNA 6) stated hearing Resident 3 yelling from the hallway. CNA 6 stated upon entering Resident 2's room, Residents 2 and 3 were observed arguing about clothing. CNA 6 stated, I told them to move apart and asked Resident 3 to leave the room, before Resident 3 left the room, she reached out to Resident 2 and scratched her on the face. CNA 6 stated Residents 2 and 3 had altercations in the past. c1. A review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's H/P, dated 7/3/18 indicated Resident 6 did not have the capacity to understand and make decisions. A review of Resident 6's MDS, dated [DATE] indicated Resident 6 was able to make herself understood and understand others. The MDS indicated Resident 6 required supervision of a one-person physical assist ambulation in the facility and had no behavioral issues. A review of Resident 6's care plan titled, Impulse Control, evaluated 7/2019 indicated the goal was for Resident 6's behaviors to decrease within nine months. The staffs' interventions included to monitor Resident 6's mood state, behavior in private/public and report to physician. On 11/25/19 at 4:27 a.m., during an interview, LVN 3 stated on 9/16/19 at approximately 6:30 a.m., she was informed Resident 6 was in the dining room unsupervised and crying. LVN 3 stated there was no CNA present in the dining room monitoring the residents. LVN 3 stated a staff member should be in the dining room at-all-times monitoring the residents. LVN 3 stated Resident 6 was very aggressive and had episodes of hitting other residents and should not be left unsupervised c2. A review of Resident 7's Face Sheet indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's MDS, dated [DATE] indicated Resident 7 was able to make himself understood and understand others. The MDS indicated Resident 7 had behavioral symptoms of hitting, pushing, scratching, screaming, threatening, and cursing towards others and required limited assistance of one-person physical assist for locomotion (how resident moves between location) on/off unit. A review of Resident 7's care plan titled, Behavioral Patterns, dated 8/3/19 indicated the goal was for Resident 7 to not have more than three (3) episodes. The staffs' interventions included to monitor Resident 7's whereabouts frequently, keep away from other residents, monitor and document number of episodes, evaluate effectiveness and notify physician. A review of Resident 7's Physician Order, dated 8/19/19 indicated Resident 7 was receiving [MEDICATION NAME] (antipsychotic medication) 50 milligrams ((mg), unit of measure) by mouth (PO) twice a day (BID) for [MEDICAL CONDITION] manifested by ((m/b), symptoms of) delusion (belief that is not true) and verbalizing people are against him. On 9/16/19 at 9:40 a.m., during an interview, Resident 7 was noted confused stating he was going home to twenty-nine palms (military base) with his stepfather. Resident 7 stated hitting Resident 6 on her head twice because she hit him twice in the back of the head on 9/16/19 early morning. Resident 7 stated he did not tolerate others hitting him. On 9/16/19 at 9:45 a.m., during an interview, the facility's Housekeeper (HK) stated on 9/16/19 at approximately 6:40 a.m., Residents 6 and 7 were in the dining room getting ready for breakfast. The HK stated Resident 7 was sitting behind Resident 6 when studently Resident 7 hit Resident 6 twice in the head. The HK stated Resident 6 started crying and turned around and punched Resident 7 twice in the face. The HK stated she informed Licensed Vocational Nurse 4 (LVN 4) immediately but LVN 4 was not able to separate the residents. The HK stated 15 minutes after the first incident with Residents 6 and 7, she went to call LVN 4 again because Resident 7 threw a cup of water at Resident 6 and attempted to hit her again. The HK stated LVN 4 did not show up the first time she reported the incident. The HK stated then LVN 3 and both Residents 6 and 7 were separated immediately. The HK stated Resident 7 also attempted to hit LVN 3. The HK stated Resident 7 was aggressive towards others. The HK stated several residents were left in the dining room with no staff members present to supervised them. On 9/16/19 at 10:18 a.m., during an interview, LVN 2 stated LVN 4 informed him of the altercation between Residents 6 and 7. LVN 2 stated he was unaware there had been two separate incidents between the two residents that day. On 9/16/19 at 10:22 a.m., during an interview, CNA 5 stated Resident 7 was very aggressive and would yelled at the nurses and residents all the time. CNA 5 stated Resident 7 discriminated (treated someone unfairly) against certain ethnic groups and needed to be monitored all day, but the nurses were afraid to monitor Resident 7 because of his aggressive behaviors. A review of the facility's policy and procedures titled, Safety and Supervision of Residents, revised 7/2017 indicated resident supervision was a core component of the system approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessment and identified hazards in the environment. The policy indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. A review of the facility's undated policy and procedures titled, Resident to Resident Abuse, indicated the facility staff would monitor residents for aggressive/inappropriate behavior towards other residents or staff. The policy indicated the staff would remove the aggressor from the situation and temporarily separate the resident form the others to help lower agitation. The staff would evaluate the circumstances that lead to the incident and report to the physician. A review of the facility's undated policy and procedures titled, Care Plan, indicated the residents care plan should reflect the needs, strengths, and preferences of the residents and oriented to prevent of avoidable declines in functioning levels.

Based on interview and record review the facility failed to provide care and services to prevent weight loss in accordance with the plan of care and the facility's policy and procedure for one out of three sampled Resident (Resident 1) by failing to: 1. Assess, monitor, and record Resident 1's weekly weight for four weeks upon readmission to the facility from a General Acute Care Hospital (GACH). 2. Notify the primary physician of the Registered Dietician (RD - are the food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living) recommendations for nutritional supplement on 5/12/17. 3. Implement the RD's recommendation within five days. 4. Ensure that Resident 1 received the recommended nutritional supplement and monitor Resident 1's intake of the nutritional supplement. 5. Conduct a complete Interdisciplinary (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) weight management care plan. Resident 1, who was assessed as a high risk for weight loss, had a readmission weight of 99 pounds (lbs). The RD made dietary recommendations on 5/12/17 but the physician made an order to implement the RD recommendation on 5/22/17 because the licensed nurses failed to notify the physician. The facility did not monitor the resident's weight weekly in accordance with the facility's policy and procedure. On 6/17/17, Resident 1 lost 16 lbs from readmission. The physician ordered a dietary (RD) consult but the RD evaluated the resident on 7/7/17, 20 days after the physician order [REDACTED]. The IDT conducted a weight management care planning on 6/17/17 and 7/7/17 but the IDT did not develop interventions to prevent further weight loss and documentation of an effort to determine the cause of the weight loss. On 7/7/17, Resident 1 lost six more pounds. This deficient practice resulted in Resident 1's weight loss of 22 lbs. in 8 weeks from readmission. Findings: On 7/19/17 at 11 a.m., an unannounced visit was conducted to the facility to investigate an allegation of neglect regarding Resident 1's significant weight loss. On 7/19/17 at 11:25 a.m., during an observation, Resident 1 was in her bed sleeping. Resident 1 had a white bandage wrapped around her right foot. A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on [DATE] and was transferred to GACH on 5/4/17 due to tachypnea (rapid breathing) and [MEDICAL CONDITION](rapid heart beat). During the hospitalization , Resident 1's family wanted a do not resuscitate status (DNR) status and refused tube feeding for the resident, and was aware that the resident was at a high risk for recurrent dehydration with aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach). A review of Resident 1's Record of Admission indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to use blood sugar). Resident 1 was transferred to GACH on 7/9/17 for failure to thrive (declining weight). The physician's progress note, dated 7/18/17, indicated the resident returned from GACH after hydration and antibiotic (a medication for infection) therapy for urinary tract infection and dehydration. A review of Resident 1's Vital Sign Flow Sheet form indicated Resident 1's weight record as follows: - 97 lbs on 1/6/17 - 96 lbs on 2/25/17 and 3/11/17 - 93 lbs on 4/1/17 - 90 lbs on 5/2/17 A review of Resident 1's Admission Care Plan, dated 5/10/17, indicated to monitor the resident's weight weekly for four weeks. A review of Resident 1's Care Plan for Nutrition, dated 5/10/17, indicated that Resident 1 was at risk for nutritional needs. Resident 1's care plan goal indicated the resident would not have a weight loss of 5 lbs monthly. The interventions included Resident 1's weight would be monitored and recorded, and the physician would be notified. There was no revisions made on this care plan to include RD recommendations made after 5/10/17 for nutritional supplements. A review of Resident 1's Weekly Weight Monitoring form, initiated on 5/10/17, indicated the resident's readmission (on 5/10/17) weight was 99 lbs and the reason for the weekly weights was the readmission. The monitoring form indicated to obtain the resident's weight on 5/17/17 (the first week), 5/24/17 (the second week), 5/31/17 (the third week), and on 6/7/17 (the fourth week). A review of Resident 1's Vital Sign Flow Sheet form indicated the following weight record: - On 6/17/17, the resident's weight was 83 lbs, a decrease of 16 lbs five (5) weeks from readmission. - On 7/7/17, the resident's weight was 77 lbs, a decrease of six (6) lbs four weeks from 6/17/17. Resident 1 lost 22 lbs from readmission. A review of Resident 1's History and Physical form, dated 5/11/17, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Physician's Progress Notes form, dated 5/11/17, indicated Resident 1's insulin therapy (a medication to treat high blood sugar) would be adjusted due to Resident 1's oral intake was poor. A review of Resident 1's Nutritional Assessment (an evaluation tool to gather information to an individual's food and nutrient intake, lifestyle, and medical history) form, dated 5/12/17 and completed by the RD, indicated Resident 1 was a high risk for excessive weight loss. The form indicated the RD's plan to implement for Resident 1 was to receive fortified (to add extra nutrients) pureed diet, no concentrated sweets, Pro-Stat sugar free (a ready-to-drink medical food for wounds and protein energy malnutrition) three times a day, and health shakes 4 ounces (oz.) daily at 2 p.m. A review of Resident 1's Physician order [REDACTED]. of Resident 1's nutritional status. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's care plan for weight loss, dated 6/17/17, indicated the resident's current weight was 83 lbs. The goal was Resident 1's weight would be stable in 30 days. The interventions included Resident 1's food intake would be monitored and Resident 1 would receive an RD assessment and consult. A review of Resident 1's Interdisciplinary Weight Management Care Plan, dated 6/17/17, indicated Resident 1 had a weight loss of 16 lbs. in a month. The form included sections for IDT recommendations and determination if the weight loss was expected, planned, or unavoidable but these sections were blank. The IDT weight management care plan did not contain signatures of the facility staff who attended the meeting and if the family was notified of the scheduled IDT weight management care plan. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/5/17, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) from staff with bed mobility, transfer, toilet use and personal hygiene and limited assistance (resident highly involved with activity; staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with eating. A review of Resident 1's Nutritional progress notes by Registered Dietician form, dated 7/7/17, indicated Resident 1 had a significant weight loss in the last 30 days of 7.23 percent. The RD's recommendations included a speech therapist (ST) evaluation (to evaluate the resident for difficulty in swallowing) and treatment as needed. The form indicated that Resident 1 was evaluated by the RD 20 days after the resident's primary physician ordered the dietary (RD) consult due to weight loss on 6/17/17. A review of Resident 1's IDT's weight management care plan form, dated 7/7/17, included sections for IDT recommendations and determination if the weight loss was expected, planned, or unavoidable but these sections were blank. The IDT weight management care plan did not contain signatures of the facility staff who attended the meeting and if the family was notified of the weight management care plan. There was no documentation indicating Resident 1's family declined the treatment plan for the weight loss, and there was no evidence indicating Resident 1's family was invited to IDT meeting. On 9/14/17 at 3:40 p.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 was not assessed for one on one feeding assistance. RN 1 stated he does not know the reason Resident 1's weekly weight was not recorded. RN 1 stated he did not know about the RD recommendations. RN 1 stated he did not know why the IDT Weight Management Care was not complete. On 10/13/17 at 10:35 a.m., during an interview, the RD stated she could remember the date the facility notified her on Resident 1 weight loss of 16 lbs in 5 weeks and the physician order [REDACTED]. The RD stated she evaluated Resident 1 on readmission on 5/12/17. The RD stated Resident 1 was a high risk for weight loss and the recommendations should be relayed to the resident's primary physician and carried out within 5 days. The RD stated the dietary recommendations were started on 5/22/17. The RD stated 10 days (5/12/17 to 5/22/17) was a long period of wait to start the dietary recommendations of additional supplement for Resident 1 to benefit from. On 10/13/17 at 12:20 p.m., during an interview, the Dietary Services Supervisor (DSS) stated Resident 1 did not have a record of weekly weights from readmission to the facility. The DSS stated Resident 1 should be on weekly weights. The DSS stated Resident 1 was not on feeding assistance. The DSS stated Resident 1 weight was not monitored. The DSS stated the RD's recommendations on 5/12/17 were not followed until 5/22/17. The DSS stated there was lack of communication to follow up on the RD recommendations for nutritional supplements for Resident 1. On 10/13/17 at 3:40 p.m., during an interview, the director of nursing (DON) stated Resident 1's weekly weight should be monitored upon readmission to facility on 5/10/17. On 11/7/17 at 2:10 p.m., during a concurrent interview and record review with the DON, she stated it was important to monitor Resident 1's weight upon readmission to the facility on [DATE] to establish a baseline and then monitor the resident's weight weekly to ensure Resident 1's did not have weight loss. The DON stated Resident 1's weekly weight should be monitored to determine underlying cause of weight loss. The DON stated the facility should call and notify the primary physician timely of the RD's recommendations. The DON stated Resident 1's RD recommendations on 5/12/ 17 were relayed to primary physician on 5/22/17 and that there was a 10-day delay. The DON stated RD recommendations should be initiated within 5 days. During the interview, the DON stated the RD recommendations for health shakes and Pro-Stat could be beneficial to Resident 1 to prevent further progression of weight loss and development of pressure sore. The DON stated Resident 1's care plan was not revised and was not specific to Resident 1's needs. The DON stated Resident 1's care plan that was initiated on 6/17/17 should have been re-evaluated and revised as it was not effective. The DON stated Resident 1's care plan should be specific to Resident 1's care needs. During the interview on 6/17/17, the DON stated Resident 1's primary physician ordered dietary consult due to the resident's 16 lbs weight loss and the RD reevaluated Resident 1 on 7/7/17. The DON stated 3 weeks to be evaluated by the RD was too long. The DON stated she did not know if the RD was notified when Resident 1 had a 16 lbs. weight loss in 5 weeks (recorded on 6/17/17). A review of facility's undated policy and procedure titled, Policy and Procedure on Weights, indicated the facility must ensure that based on a resident's comprehensive assessment, acceptable parameters of a resident's nutritional status, such as body weight and protein level shall be maintained. Weight shall be monitored for four (4) weeks after resident's admission or readmission. The Dietician and/or Food Services Supervisor shall record outcome of assessment and recommendation for changes to plan of care. Licensed Nurse shall notify primary physician for orders or recommendations. A review of facility undated policy and procedure titled, Weight Management, indicated: All residents are monitored for weight changes on a regular basis, or at least monthly. Residents with known nutritional risk factors and problematic weight gain/loss potential are placed on a weight management system. Resident at high risk of weight loss should be monitored weekly. Weekly meetings with the Food Service Director/Consultant Dietician and nursing management personnel are scheduled to review interventions and progress towards measurable resident care goals. Care plan are revised as necessary to reflect the current resident status.

Based on observation, interview, and record review, the facility failed to provide the care and services to prevent falls for one of two sampled residents (Resident 1), who was assessed to have poor trunk control (the ability to control and hold up the body upright when sitting or moving) and the tendency to lean forward when on a sitting position, in accordance with assessments, care plans, and physician's orders [REDACTED]. 1. Recline the back of the reclining wheelchair to prevent Resident 1 from falling forward. 2. Provide a wedge seat cushion (a cushion used to help prevent wheelchair-bound individuals from sliding forward) in the reclining wheelchair to prevent Resident 1 from leaning forward. These deficient practices resulted in Resident 1 sustaining a fall with a right frontal scalp laceration (a deep cut or tear in skin) and was sent out to the hospital for sutures (stitches used by doctors and surgeons to hold the skin together) procedure of the laceration. Resident 1 was diagnosed to have subdural hemorrhage (bleeding under the skull and outside the brain that is caused by traumatic head injury). Findings: A review of Resident 1's record titled, Record of Admission, indicated Resident 1 was admitted to the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's record titled, SBAR ((Situation, Background, Assessment, and Request), a form of communication between healthcare members for changes in resident's conditions), dated 4/12/13, at 6:18 p.m., indicated Resident 1 slid down from her wheelchair and hit the left side of her forehead on the floor. The SBAR indicated Resident 1 complained of pain on the left side of her forehead above the eye and had skin discoloration and swelling on the left forehead area. A record review of Resident 1's record titled, Physician Orders, dated 3/17/15, at 5 p.m., indicated, May get up resident in reclining wheelchair every day (QD) as tolerated per family request for poor trunk control. A review of Resident 1's SBAR, dated 4/5/15, no time, indicated Resident 1 had a fall. The SBAR indicated Resident 1 slid down from her reclining wheelchair and hit her left forehead on the floor. The SBAR indicated Resident 1 had a laceration (a deep cut or tear in skin) on the left forehead with bleeding. The SBAR indicated a Certified Nurse Assistant (unidentified) stated, Resident slid down from chair and within blink of seconds, resident was on floor on left side. A review of Resident 1's Physician Orders, dated 4/5/15, at 4:20 p.m., indicated, Wedge cushion when on reclining wheelchair as tolerated for safety and positioning due to (D/T) poor trunk control. A review of Resident 1's record titled, Physical Therapy Evaluation and Discharge Status, indicated the following: 1. On 4/8/15, to improve safety and positioning in wheelchair, recline the wheelchair and use cushion (wedge). 2. On 4/28/15, poor balance for static sit (seating is rigid or not moving) and dynamic sit (seating allows or encourages the seated individual to move). Wheelchair management: Wheelchair with reclining back for positioning and pommel wedge cushion for safety and comfort. A record review of Resident 1's record titled, Interdisciplinary Team (a group of health care professionals from diverse fields who work toward a common goal for the resident)/Care Plan Meeting, dated 5/18/15, indicated Resident 1 was fall risk and fall precautions/interventions were to use a wedge cushion and reclining chair due to poor trunk control. A review of Resident 1's record titled, History and Physical (H&P), dated 9/19/16, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's record titled, Resident Care Plan, dated 1/25/17, indicated Resident 1 was at risk for fall due to history of fall with last fall on 4/5/15, impaired cognition (the ability to think and reason), and osteoporosis (a medical condition in which the bones become brittle and fragile). The Resident Care Plan indicated Resident 1 had the tendency to lean forward and had poor trunk control. The Resident Care Plan indicated to keep the wheelchair in tilt position (reclined) while in the wheelchair. The Resident Care Plan did not indicate the physician's orders [REDACTED]. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated 1/27/17, indicated Resident 1 had short- and long-term memory problems and had severe impairment in cognitive skills for daily decision-making. The MDS indicated Resident 1 was totally dependent requiring two-person physical assistance with transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position) and dressing (how resident puts on, fastens and takes off all items of clothing), and personal hygiene (how resident maintains personal hygiene including combing hair). The MDS indicated Resident 1 used a wheelchair as a mobility device. A review of Resident 1's record titled, Progress Notes, dated 3/18/17, the physician indicated Resident 1 was non-ambulatory and had partial contracture of joints in both hips and knees. A review of the facility's document titled, Incident Report, dated 4/15/17, Resident 1 had a witnessed fall and sustained a laceration to the right side of the forehead by the right eye. The incident report included a Certified Nursing Assistant's (CNA 1) written declaration that on 4/15/17, at 9:35 a.m., CNA 1 transferred Resident 1 from bed to the wheelchair. CNA 1's written declaration indicated as Resident 1 sat on the wheelchair, CNA 1 turned around to get a comb from Resident 1's drawer and not even 5 seconds, CNA 1 heard a drop and quickly I turned back and saw resident on the floor facing down, bleeding. CNA 1's written declaration indicated Resident 1 was face down on the floor and bleeding. CNA 1's written declaration did not indicate Resident 1's wheelchair was reclined and a wedge cushion was placed in the seat of the wheelchair. A review of Resident 1's untitled physician's orders [REDACTED]. A review of Resident 1's hospital record titled, Transmission Log, indicated Resident 1 was admitted to the hospital on [DATE], no time, with an admitting [DIAGNOSES REDACTED]. A review of Resident 1's untitled hospital record of the CT scan (computed tomography scan, a diagnostic tool that uses x-rays to make detailed pictures) of the head, dated 4/17/17, indicated, Stable 3 millimeter (mm) left inferior frontal (lower front) convexity (surface of the brain) extra-axial fluid suggestive of subacute hemorrhage. Stable 1-2 mm dural calcification (calcium depositing and accumulating in the soft tissue of the brain) versus acute subdural hemorrhage. A review of Resident 1's record titled, History and Physical (H&P), dated 4/21/17, indicated Resident 1 was admitted to the hospital from 4/15/17, until 4/28/17. Patient (Resident 1) admitted to the hospital secondary to a mechanical fall from the wheelchair. Patient has a large right frontal scalp laceration, status [REDACTED]. The H&P indicated Resident 1 was transferred to an acute long-term care hospital (a transitional care hospital that provides long-term acute care to medically complex patients who require an extended stay in a hospital setting) for continuation of treatment. During an interview on 5/17/17, at 12:45 p.m., CNA 2 stated whenever Resident 1 sits in the wheelchair, the seat of the wheelchair should be adjusted so that Resident 1 would lean back and would not be sitting up straight because Resident 1 was at risk for leaning forward and falling. During an interview on 5/17/17, at 1:20 p.m., the Restorative Nurse Assistant ((RNA 1), a CNA who received training for expanded role to restore and maintain resident's strength, coordination and ADL skills) stated Resident 1 was confused and quiet. RNA 1 stated Resident 1 was not one to resist care and did not have a behavior of attempting to get out of bed or wheelchair. RNA 1 stated Resident 1 had the tendency to lean forward in the wheelchair. During an interview on 5/17/17, at 2:30 p.m., the Licensed Vocational Nurse (LVN 1) stated she had been taking care of Resident 1 and that Resident 1 had the tendency to lean her body to one side or forward due to poor trunk control. During a telephone interview on 6/27/17, at 10:50 a.m., CNA 1 stated she had taken cared of Resident 1 for over a year and did not have behaviors of trying to get up from the bed or wheelchair on her own. CNA 1 stated Resident 1 had the tendency of leaning forward when in the wheelchair so she would place Resident 1 in front of a table. CNA 1 stated on 4/15/17, at 9 a.m., she transferred Resident 1 from the bed to a wheelchair by herself. CNA 1 stated in detail, step-by-step, the process of transferring Resident 1 from the bed to the wheelchair the day of 4/15/17, was as follows: 1. Placed Resident 1's wheelchair next to the bed and locked the wheelchair. 2. Transferred Resident 1 from the bed to the wheelchair and placed Resident 1's feet on the foot rest. 3. While Resident 1 was sitting in her wheelchair at the foot of the bed, CNA 1 went to get Resident 1's comb from the drawer located next to Resident 1's bed. 4. CNA 1 turned her back to Resident 1 then she heard a sound. 5. CNA 1 saw Resident 1 on the floor lying on her right side, had a cut that was bleeding from above her eyebrow. During an observation of a reclining wheelchair on 8/1/17, at 1:50 p.m., RNA 2 stated the reclining wheelchair was the same as Resident 1's reclining wheelchair. RNA 2 demonstrated and stated the reclining wheelchair could be adjusted from a 90 degree angle (resident sitting upright) to a flat position. RNA 2 stated staff could adjust the reclining wheelchair seat using the levers on each side of the wheelchair handle. During an observation of a reclining wheelchair on 8/2/17, at 9:20 a.m., CNA 1 stated Resident 1 used the same type of reclining wheelchair on 4/15/17. In the presence of the Director of Nursing (DON 2) and the Regional Operations (RO) staff, CNA 1 provided a return demonstration of how she transferred Resident 1 from the bed to the reclining wheelchair on 4/15/17, using RO to represent Resident 1. 1. RO was lying in bed. 2. CNA 1 moved the reclining wheelchair next to the foot of the bed. 3. CNA 1 moved RO's legs down from the bed then placed her hands at RO's back to pull RO up to a sitting position. 4. RO was sitting at the edge of bed and CNA 1 wrapped RO's arms around her (CNA 1) body. 5. CNA 1 assisted RO stand up from the bed and then transferred RO to the reclining wheelchair. 6. CNA 1 unlocked the reclining wheelchair. 7. CNA 1 placed RO's feet on the foot rest of the reclining wheelchair. 8. CNA 1 stated Resident 1 was leaning and resting her head and upper body on CNA 1's chest as CNA 1 was putting Resident 1's vest (an article of clothing). 9. CNA 1 positioned RO to sit back on the wheelchair positioned at 90 degrees. 10. CNA 1 turned around to get a comb from the drawer. 11. CNA 1 stated within 5 to 6 seconds, she heard a drop then saw Resident 1 face down forward on the floor. During an interview on 8/2/17, at 9:50 p.m., CNA 1 stated on 4/15/17, she should have reclined the wheelchair more to prevent Resident 1 from falling forward from the reclining wheelchair. During an interview on 8/2/17, at 1:03 p.m., and concurrent review of Resident 1's care plan, DON 2 stated Resident 1's care plan did not indicate the fall precautions/interventions of placing Resident 1 in front of a table to prevent from leaning forward and a wedge cushion in the reclining wheelchair for safety due to poor trunk control. DON 2 demonstrated and stated a wedge cushion was placed on the wheelchair, the straps of the wedge cushion would go around the reclining wheelchair and buckled together and straps were adjusted as needed. DON 2 demonstrated and stated it was difficult for her to slide off from the wedge cushion. During the same interview, DON 2 stated during CNA 1's return demonstration, CNA 1 did not verbalize or demonstrate that the reclining wheelchair was reclined and a wedge cushion was placed in the reclining wheelchair. DON 2 stated Resident 1's fall could have been prevented if CNA 1 reclined the reclining wheelchair and/or reclined the reclining wheelchair enough to prevent the fall and used a wedge cushion in the reclining wheelchair. A review of the facility's policy and procedures titled, Fall Prevention and Reduction, dated October 2010, indicated the facility was responsible to prevent falls to the extent possible and within the control of the facility.

Based on observation, interview, and record review, the facility failed to ensure two-person assistance when transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position) dressing (how resident puts on, fastens and takes off all items of clothing) and providing personal hygiene (how resident maintains personal hygiene, including combing hair) for one of two sampled residents (Resident 1) in accordance with the comprehensive assessments. This deficient practice resulted in Resident 1 sustaining a fall with a right frontal scalp laceration (a deep cut or tear in skin) and was sent out to the hospital for sutures (stitches used by doctors and surgeons to hold the skin together) procedure of the laceration. Resident 1 was diagnosed to have subdural hemorrhage (bleeding under the skull and outside the brain that is caused by traumatic head injury). (Cross reference to F323 and F279) Findings: A review of Resident 1's record titled, Record of Admission, indicated Resident 1 was admitted to the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's record titled, Physical Therapy Evaluation and Discharge Status, dated 4/28/15, indicated Resident 1 was dependent with two-person assist with transfers from bed to wheelchair and wheelchair to bed. Resident 1 had poor balance for static sit (seating is rigid or resident not moving) and dynamic sit (seating allows or encourages the seated individual to move). A review of Resident 1's record titled, History and Physical (H&P), dated 9/19/16, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's record titled, Resident Care Plan, dated 1/25/17, indicated Resident 1 was at risk for fall due to history of fall with last fall on 4/5/15, impaired cognition (the ability to think and reason), and [MEDICAL CONDITION] (a medical condition in which the bones become brittle and fragile). The Resident Care Plan indicated Resident 1 was totally dependent on staff with transfers, dressing, bathing, and personal hygiene. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated 1/27/17, indicated Resident 1 had short- and long-term memory problems and had severe impairment in cognitive skills for daily decision-making. The MDS indicated Resident 1 was totally dependent requiring two-person physical assistance with transfer, dressing, and personal hygiene. The MDS indicated Resident 1 used a wheelchair as a mobility device. A review of the facility's document titled, Incident Report, dated 4/15/17, Resident 1 had a witnessed fall and sustained a laceration to the right side of the forehead by the right eye. The incident report included a Certified Nursing Assistant's (CNA 1) written declaration that on 4/15/17, at 9:35 a.m., CNA 1 transferred Resident 1 from the bed to the wheelchair. CNA 1's written declaration indicated as Resident 1 sat on the wheelchair, CNA 1 turned around to get a comb from Resident 1's drawer and not even 5 seconds, CNA 1 heard a drop and quickly I turned back and saw resident on the floor facing down, bleeding. CNA 1's written declaration indicated Resident 1 was face down on the floor and bleeding. CNA 1's written declaration did not indicate that another staff was present during transfer. A review of Resident 1's untitled physician's orders [REDACTED]. A review of Resident 1's hospital record titled, Transmission Log, indicated Resident 1 was admitted to the hospital on [DATE], no time, with an admitting diagnois of head trauma with subacute (a condition that is not sudden (acute) or happened a long time (chronic)) versus chronic subdural hemorrhage (SDH). A review of Resident 1's untitled hospital record of the CT scan (computed tomography scan, a diagnostic tool that uses x-rays to make detailed pictures) of the head, dated 4/17/17, indicated, Stable 3 millimeter (mm) left inferior frontal (lower front) convexity (surface of the brain) extra-axial fluid suggestive of subacute hemorrhage. Stable 1-2 mm dural calcification (calcium depositing and accumulating in the soft tissue of the brain) versus acute subdural hemorrhage. A review of Resident 1's hospital record titled, History and Physical (H&P), dated 4/21/17, indicated Resident 1 was admitted to the hospital from 4/15/17, until 4/28/17. The H&P indicated, Patient (Resident 1) admitted to the hospital secondary to a mechanical fall from the wheelchair. Patient has a large right frontal scalp laceration, status [REDACTED]. The H&P indicated Resident 1 was transferred to an acute long-term care hospital (a transitional care hospital that provides long-term acute care to medically complex patients who require an extended stay in a hospital setting) for continuation of treatment. During an interview on 5/17/17, at 3 p.m., the Director of Nursing (DON 1) stated DON 1 stated Resident 1 was totally dependent on staff with care and there should be two staff assisting Resident 1. During a telephone interview on 6/27/17, at 10:50 a.m., CNA 1 stated she had taken cared of Resident 1 for over a year and did not have behaviors of trying to get up from the bed or wheelchair on her own. CNA 1 stated Resident 1 had the tendency of leaning forward when in the wheelchair so she would place Resident 1 in front of a table. CNA 1 stated on 4/15/17, at 9 a.m., she transferred Resident 1 from the bed to a wheelchair by herself. CNA 1 stated in detail, step-by-step, the process of transferring Resident 1 from the bed to the wheelchair the day of 4/15/17, was as follows: 1. Placed Resident 1's wheelchair next to the bed and locked the wheelchair. 2. Transferred Resident 1 from the bed to the wheelchair and placed Resident 1's feet on the foot rest. 3. While Resident 1 was sitting in her wheelchair at the foot of the bed, CNA 1 went to get Resident 1's comb from the drawer located next to Resident 1's bed. 4. CNA 1 turned her back to Resident 1 then she heard a sound. 5. CNA 1 saw Resident 1 on the floor lying on her right side, had a cut that was bleeding from above her eyebrow. During an interview on 6/27/17, at 2:39 p.m., the Registered Nurse Supervisor (RN 1) stated CNA 1 should have asked another staff to assist her in transferring Resident 1 from bed to the wheelchair. RN 1 stated if CNA 1 had another staff to assist her, then the additional staff could have monitored Resident 1 and prevented the fall as CNA 1 was getting Resident 1's comb. During an observation of a reclining wheelchair on 8/2/17, at 9:20 a.m., CNA 1 stated Resident 1 used the same type of reclining wheelchair on 4/15/17. In the presence of DON 2 and the Regional Operations (RO) staff, CNA 1 provided a return demonstration of how she transferred Resident 1 from the bed to the reclining wheelchair on 4/15/17, using RO to represent Resident 1. 1. RO was lying in bed. 2. CNA 1 moved the reclining wheelchair next to the foot of the bed. 3. CNA 1 moved RO's legs down from the bed then placed her hands at RO's back to pull RO up to a sitting position. 4. RO was sitting at the edge of bed and CNA 1 wrapped RO's arms around her (CNA 1) body. 5. CNA 1 assisted RO stand up from the bed and then transferred RO to the reclining wheelchair. 6. CNA 1 unlocked the reclining wheelchair. 7. CNA 1 placed RO's feet on the foot rest of the reclining wheelchair. 8. CNA 1 stated Resident 1 was leaning and resting her head and upper body on CNA 1's chest as CNA 1 was putting Resident 1's vest. 9. CNA 1 positioned RO to sit back on the wheelchair positioned at 90 degrees. 10. CNA 1 turned around to get a comb from the drawer. 11. CNA 1 stated within 5 to 6 seconds, she heard a drop then saw Resident 1 face down forward on the floor. During a review of Resident 1's MDS (1/27/17) and care plan, and concurrent interview on 8/2/17, at 11 a.m., the MDS Nurse stated Resident 1 was totally dependent on two- person assistance for activities of daily living that included transfers, dressing, bathing, and personal hygiene. The MDS Nurse stated Resident 1 required two- person assistance with these tasks because one staff needed to hold and support Resident 1's body while the second staff performed the task. The MDS Nurse stated the required two- person assistance for transfer, dressing, bathing, and personal hygiene was not indicated in Resident 1's care plan. A review of the facility's undated policy and procedures titled, Moving a Resident, Bed to Chair/Chair to Bed, indicated the facility was responsible for providing safe transferring of a resident and the transfer procedure may require two persons. A review of the facility's policy and procedures titled, Fall Prevention and Reduction, dated October 2010 indicated the facility was responsible to prevent falls to the extent possible and within the control of the facility.