Every finding on record at Jewish Home & Rehab Center D/P SNF

Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 2 and 332) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1. For Resident 2, there was no specific target behavior monitoring for the use of Olanzapine (an antipsychotic medication).2. a. For Resident 332, the order for Lorazepam (medication used to treat anxiety) PRN (as needed) did not have a stop date, and b. Lorazepam PRN was administered without behavior exhibited.These deficient practices had the potential for Residents 2 and 332 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.1. Resident 2 was admitted on [DATE] with diagnoses that included vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) with psychotic disturbance [behavior that can include hallucinations (seeing, hearing, or feeling things that are not there) and delusions (persistently thinking things that are not true e.g. caregivers are stealing, intruders are in the house, or deceased loved ones are alive)].Review of Resident 2's Order Summary Report (OSR) for the month of February 2026 indicated, .Olanzapine Tablet 5 mg (milligram) Give 1 tablet by mouth at bedtime for psychotic symptoms.Order Start Date [DATE].Review of Resident 2's Medication Administration Record (MAR), dated [DATE] to [DATE] and [DATE] to [DATE] indicated, .Behavior Monitoring for Olanzapine: Episodes of verbalization of delusional thinking.Review of Resident 2's care plan indicated, .Focus: Resident 2 is at risk for altered thought processes and behavioral instability related to psychotic symptoms (delusional thinking) requiring antipsychotic (Olanzapine) therapy.Interventions.Monitor for changes in thought content, hallucinations, delusions.During a concurrent interview and record review on [DATE] at 11:17 AM with Licensed Vocational Nurse (LVN) 1 , Resident 2's OSR, MAR, and behavioral care plan were reviewed. LVN 1 acknowledged the clinical records did not indicate the specific target behavior symptoms to be monitored for the use of Olanzapine, and stated, It's general. It should be specific because there are different kinds of delusions and hallucinations.During an interview on [DATE] at 12:53 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 2's manifested behaviors were yelling, agitation, and shouting. CNA 1 said licensed nurses did not tell her what behavior to monitor for Resident 2. CNA 1 further stated, I'm not aware of her care plan. I don't know her care plan. Hallucination is like she's panicking. I don't know what delusion is.2.a. Resident 332 was admitted on [DATE] with diagnoses that included dementia (a progressive decline in mental ability including memory, thinking, and behavior severe enough to interfere with daily life) with agitation (manifests as restlessness, verbal/physical aggression, and emotional distress). Resident 332 was in hospice care.Review of Resident 332's OSR for the month of February 2026 indicated, A.Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for mild anxiety.Order Start Date [DATE]. The order did not have an end date. B.Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 2 tablets by mouth every 4 hours PRN for moderate anxiety.Order Start Date [DATE]. The order did not have an end date. C.Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 4 tablets by mouth every 4 hours PRN for severe anxiety/seizures.Order Start Date [DATE]. The order did not have an end date.Review of Resident 332's MAR dated [DATE] to [DATE] indicated, .Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for mild anxiety. was administered once on [DATE], [DATE], and [DATE].During an interview on [DATE] at 1:29 PM with Pharmacist 1, Pharmacist 1 said, MRR is completed monthly, and all medications are reviewed. Identified irregularities are communicated to the licensed nurses and the physician. For psychotropic medications, Pharmacist 1 stated, PRN medications are recommended for 14 days and should be renewed after. When queried if an order of PRN Lorazepam should have an end date, Pharmacist 1 stated, Yes, I agree, it should have a stop date.During a concurrent interview and record review on [DATE] at 2:14 PM with LVN 2, Resident 332's medication orders were reviewed. According to LVN 2, Resident 332 had PRN orders for Lorazepam according to resident's level of anxiety, all with start dates of [DATE]. LVN 2 confirmed there were no end dates to the PRN Lorazepam orders and stated, She's on hospice, receiving it (PRN Lorazepam) indefinitely.2.b. Review of Resident 332's OSR for the month of February 2026 indicated, .Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for mild anxiety.Review of Resident 332's MAR dated [DATE] to [DATE] indicated, .Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for mild anxiety. was administered once on [DATE], [DATE], and [DATE].During a concurrent interview and record review on [DATE] at 2:58 PM with Unit Supervisor (US) 1, Resident 332's MAR and licensed nurses' progress notes were reviewed. US 1 acknowledged that on [DATE], [DATE], and [DATE], Lorazepam 0.5 mg 1 tablet for mild anxiety was administered to Resident 332. US 1 said that when PRN Lorazepam is administered, there should be corresponding behavior observed. US 1 confirmed that there was no behavior exhibited when the medication was administered and stated, I can't see documentation saying she (Resident 332) had a behavior noted. I don't see anything. US 1 further stated, Don't give the medication unless a behavior was observed. That's why we have the behavior monitoring to see if medication is effective.Review of facility policy titled Use of Psychopharmacologic Medications, last revised on 2/26 indicated, .3. Monitoring - Monitoring of all psychopharmacologic medications will be done by Licensed Nurses for desired effectiveness.C. Coding of Target Behaviors.Using 0-8, based on an 8 hour shift (ex: Code 0 if target behavior not present, if present any time during the shift Code the number of hours in the shift the behavior occurred, not number of episodes.) D. Goals regarding target behaviors should be resident specific.G. PRN Psychopharmacologic Medication Monitoring .PRN orders for anxiolytics or hypnotics are limited to 14 days.A PRN order for anxiolytic or hypnotic cannot be renewed unless the attending physician/prescriber evaluates the resident to determine if it is appropriate to write a new order for the anxiolytic or hypnotic medication with a specified end date.The PRN medication may only be administered for the behavior identified.

Based on interview and record review, the facility did not send notification to Ombudsman when two of three residents (Resident 1 and Resident 2) were transferred out to acute.This failure has potential for residents not having the right to appeal when necessary.During a record review on 2/12/26 at 10 AM, Resident 12's admission Record dated 2/12/26, indicated, was admitted on [DATE] with diagnoses including: Retention of Urine (inability to fully empty the bladder), Benign Prostatic Hyperplasia(a non cancerous age related enlargement of the prostate), Infection and Inflammatory Reaction due to other Urinary catheter ( infection often stems from medical devices like the foley catheter.) During a review on 2/12/26 at 10AM, of nurses notes, dated 10/1/15 at 00:39, indicated, Resident 12 screamed for help, he transferred from bed to chair unassisted, with foley bag still hanging by his bedside, pulling the catheter midway had bleeding noted.patient confused and agitated. MD called and ordered to transfer to Emergency Room(ED) for active bleeding and for further evaluation. Resident was picked up by 911 and transported to ED and was admitted . During a review on 2/12/26 at 10 AM, of facility document, Notice of Transfer or Discharge, dated 9/30/25.Resident transferred to ED for reason: transfer is necessary for the resident's welfare and resident's needs cannot be met in this facility. No documentation that Notice of transfer was sent to Ombudsman.During a record review on 2/12/2 at 10 AM, Resident 15's admission Record dated 2/12/26, indicated was admitted on [DATE] with diagnoses including: Fracture of Left Femur( a severe injury causing immediate intense pain, not able to bear weigh on left leg) Repeated Falls( common among older adults), Dependence on Renal Dialysis ( occurs when kidneys unable to filter waste and fluid).During a review on 2/12/26 at 10 AM, of nurses notes, dated, 12/8/25, Post Fall Evaluation, indicated, resident had an unwitnessed fall on 12/8/25 at 12:46 PM in the resident's room .Reason for falling, trying to eat by sitting on side of bed without assistance. Resident had left hip pain and upper lip cut with bleeding. Resident was picked up by paramedics to acute. Resident is alert and oriented x 3.During a review on 2/12/26 at 10 AM, of facility document, Notice of Transfer or Discharge, dated 12/8/25, indicated, transfer was necessary for the resident's welfare and the resident's needs cannot be met in this facility. No notification of Ombudsman was found documented.During an interview and concurrent chart review on 2/12/26 at 11 AM with Director of Clinical Reimbursement (DCR), per DCR, different units have different system to notify the Ombudsman. For these two residents, looking at the Notice of Transfer, the Ombudsman was not notified for both patients. Per DCR, a notification should be sent to the Ombudsman's office for every resident who are transferred to acute for emergency. During a review of facility Policy and Procedure, Transfer and Discharge Policy, dated 5/25, indicated, 10. Emergency Transfers to Acute Care: a. The facility will obtain a physician's order for emergency transfer or discharge stating the reason the transfer or discharge is necessary on an emergency basis. G. Provide a notice of transfer and the facility's bedhold notice policy to the resident and representative as indicated. H. The Social Services or designee, will provide copies of notices for emergency transfers to the Ombudsman.

Based on interviews and record review, facility staff failed to provide pressure injury services for one of three sampled residents, Resident 1.The facility failed to:1. Accurately monitor and evaluate Resident's 1's pressure injuries. 2. Revise treatment plans to promote healing of pressure injuries (any lesion caused by unrelieved pressure that results in damage to the underlying skin- see full definition below). 3. Evaluate and monitor the impact of interventions to prevent new pressure injuries from developing. 4. Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. These failures resulted in Resident 1 developing new Moisture Associated Skin Damage (a type of skin irritation or damage caused by prolonged exposure to moisture) on Coccyx (small triangular bone at the base of the spinal column), a Stage II pressure injury on the Coccyx, new open lesions (tissue which has suffered damage through injury or disease,) on both rear (the back part of the thigh) thighs, and a Stage III pressure injury on the left heel. Definition of pressure injuriesStage I: Intact skin with a localized area of non- blanchable redness (non-blanchable: redness persist and does not fade or turn white after removal of fingertip pressure).Stage II: Partial thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible.Stage III: Full thickness loss of skin, in which the subcutaneous fat (a type of body fat that is stored just beneath the skin) may be visible. Slough (Yellow/white dead tissue) and/or eschar (black dead tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by location.Stage IV: Full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the wound.Unstageable pressure injury: Full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is obscured by slough or eschar.Deep Tissue Injury (DTI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of the underlying soft tissue. This injury results from intense prolonged pressure at the bone-muscle connection. The wound may evolve rapidly to reveal the actual extent of tissue injury.Diabetic (a person who has high blood sugar levels) Foot Ulcer: Open sores that develop on the feet of people with diabetes.During a review of Resident 1's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnosis including: Hemiplegia (loss of muscle function or weakness on one side of the body) and Hemiparesis (weakness affecting one side of the body) following Cerebral Infarction (a condition where blood flow to the brain is interrupted) affecting right dominant side, Monoplegia (a type of paralysis that affects only one limb) of upper limb following Cerebral Infarction affecting non dominant side, Dysarthria (a motor speech disorder that affects the muscles controlling speech), Type 2 Diabetes Mellitus (a chronic condition where the body does not use insulin effectively ) with diabetic peripheral angiopathy (a complication of diabetes that damages the blood vessels in the legs, feet, and arms) without gangrene (a condition where tissue dies due to a lack of blood supply), muscle weakness, peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain), muscle spasms (sudden, involuntary contractions of muscles), and difficulty walking.A review of Resident 1's Minimum Data Set (MDS: a standardized resident assessment tool), dated 08/12/2025, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 1 scored 15 out of 15, this indicated Resident 1 had intact memory/reasoning. Resident 1's MDS also indicated limitations in range of motion (the extent of movement possible at a joint) that included impairments on one side of her upper extremities (shoulder, elbow, wrist, hand), impairments on both sides of her lower extremities (hip, knee, ankle, foot), and was completely dependent (staff does all of the effort) for toilet hygiene (the ability to maintain perineal [the area of skin located between the anus and the genitals] hygiene, adjust clothes before and after urinating or having a bowel movement), Shower/bathing, and both upper and lower dressing. During a record review on 9/16/2025 at 11:23 AM with Medical Records (MR) 1, Resident 1's Skin Check- V12 dated 11/25/2024 was reviewed. The Skin Check- V12 indicated, Resident 1 was admitted with these skin injuries:Right dorsum (back or top) 2nd digit (second toe) amputation (the surgical removal of a body part) site.Right Diabetic Foot Ulcer, size= (initial measurement not documented).Right Heel Diabetic Foot Ulcer, size = (initial measurement not documented).Left transmetatarsal (long bones in the foot located between the ankle) amputation site.Left Diabetic Foot Ulcer, size= (initial measurement not documented).A review of Resident 1's Care Plan Report initiated on 11/26/2024 revised on 4/18/2025 was reviewed. The Care Plan Report indicated, Resident 1 was at risk for impaired skin integrity (the overall health and condition of the skin) due to fragile skin.dry scaley skin on both lower legs.Type 2 Diabetes Mellitus.incontinence (involuntary loss of urine or stool) of bladder and bowel functions. During a review of Resident 1's History and Physical (H&P: a comprehensive assessment by a healthcare provider) dated 11/26/2024, the H&P indicated her Primary Care Physician evaluated Resident 1, and determined she had high risk for skin breakdown and faculty staff were to continue wound care recommendations and follow non weight bearing (supporting a load or your own body weight) on right lower extremity (leg) and follow up care with a local hospital Orthopedics department (a medical division specializing in the diagnosis, treatment, and prevention of diseases, injuries, and conditions affecting the musculoskeletal [bones, muscles, tendons, ligaments, and joints that provides support and movement] system).During a concurrent interview and record review on 9/18/2025 at 10:48 AM with Registered Nurse (RN) 1, RN 1 stated she has worked as a RN at the facility for five years and now functions as a Point Click Care (an electronic medical record system) super user. Resident 1's Skin Issue- V8 evaluation, dated 4/18/2025 was reviewed. The Skin issue evaluation indicated, Resident 1 developed new Moisture Associated Skin Damage (MASD) on the Coccyx which measured 1.5cm by 0.5cm developed in-house (while she was a resident of the facility) with new onset (first-time appearance of a medical condition) RN 1 defined MASD as A wound that is blanchable (blanchable: redness that fades or turn white after removal of fingertip pressure), little excoriation (superficial abrasion of the skin's surface layer) but not open. That is why there is no depth in the measurement.During a review of Skin Issue- V8 evaluation dated 04/27/2025, the Skin Issue evaluation indicated Resident 1 developed a new Stage II pressure ulcer/injury on the Coccyx which measured 2cm by 0.5cm by 0.1cm, developed in-house with new onset.During a review of Skin Issue- V12 evaluation dated 08/16/2025, the Skin Issue evaluation indicated Resident 1 developed a new open lesion on the right rear thigh which measured 7cm by 0.8cm by 0cm AND a new open lesion on the left rear thigh which measured 1.5cm by 0.3cm by 0cm both developed in-house with new onset. Additional location information stated skin lesions appear to be from MASD.During a review of Skin Issue- V13 evaluation dated 08/28/2025, the Skin Issue evaluation indicated Resident 1 developed a new Stage III pressure ulcer/injury on the left heel which measured 2.4cm by 3.1cm by 0.1cm, developed in-house with new onset. During concurrent interview and record review on 9/18/2025 at 11:03 AM with RN 1, Resident 1's Skin Check- V15 evaluation dated 08/25/2025 was reviewed. The Skin Check evaluation indicated, Resident 1's Coccyx Stage II pressure injury increased in size from 0.2cm by 0.2cm by 0cm on 8/4/2025 to 0.3cm by 0.3cm by 0cm on 8/25/2025. RN 1 stated all wounds are to be measured weekly to assess progress or decline of wounds and update treatment interventions. During an interview on 9/19/2025 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated resident's wounds are monitored weekly and documented on the Skin Check form and new skin issues are documented on the Skin Issue forms as needed. LVN 1 stated wound measurements are to be documented on each form completed. When asked what staff are responsible completing wound care for residents, LVN 1 stated the facility had a designated wound nurse (a licensed nurse specializing in treating complex wounds) that would assess wounds weekly and document wound progress or wound decline. LVN 1 stated the facility's wound nurse stopped working at the facility Sometime in 2024 and the floor nurses were completing wound care, weekly skin check evaluations, and notify Primary Care Providers (PCPs) if a wound consult is needed. When asked how are wound treatment orders re-evaluated or assessed, LVN 1 stated I think it is up to the Medical Doctor (MD) or the Physician Assistant (PA) to reassess and change treatment orders based on the information from the weekly skin evaluation forms. LVN 1 stated he was not aware of any routine scheduled days when the MDs or PAs reviewed weekly skin check or skin issue evaluations. When asked how the impact of wound care treatments or pressure injury prevention measures were evaluated by MD/PA's, LVN 1 stated It would just be if the PCP's would happen to be here, then they would take a look for themselves whenever they could. LVN1 reported new wound care team, which includes a MD and PA began working at the facility approximately One month ago. LVN 1 added, When we didn't have anyone (wound care nurse), I think it did affect our wound progress. The new wound PA's wound assessments and care has improved. When asked if LVN 1 participated in interdisciplinary team (IDT: a healthcare team made up of staff from various departments such as nurses, physical therapy, registered dietitian, social worker etc.) meetings to discuss resident care needs or care refusals, LVN 1 stated Floor nurses are not involved with that process. We do not sit in on those meetings.During a phone interview on 9/19/2025 at 11:45 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she has worked at the facility for 11 years and was familiar with Resident 1's care, when asked what tasks were included in caring for Resident 1, CNA 1 stated Make sure she is always dry, make sure she gets repositioned every two hours, that's all. CNA 1 stated on approximately three (3) separate outings Resident 1 returned to the facility from the outing with family Soaking wet. CNA 1 stated the Licensed Nurse (LN) was made aware after each outing and the LN evaluated Resident 1's skin after each notification. When asked if any new interventions or changes in Resident 1's care was made after the three reports of Resident 1 returning to the facility soaking wet, CNA 1 replied, No. The same thing. Clean her and put her back to bed.During a phone interview on 9/19/2025 at 12:20 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she has worked at the facility for over 15 years, and We (LNs) monitor (wounds) every two weeks, then inform the PCP. Every time I do the weekly skin check I see if the treatment is effective. When asked if there was documentation of PCP notification when wounds were evaluated, LVN 2 stated Honestly no. LVN 2 stated also Resident 1 had MASD On and off while a resident at the facility. When asked if pressure injury prevention interventions were impactful in reducing new pressure injuries, LVN 2 stated They are effective if we put barrier cream on after every pericare (the act of cleaning the genital and anal areas). When asked if she applied barrier cream on Resident 1 to prevent further skin breakdown, LVN 2 stated, The CNAs are the ones putting the barrier cream, so I am not sure if it was applied every time. LVN 2 verified Resident 1 was incontinent of her bowels and bladder and dependent on staff for all repositioning and personal hygiene needs. When asked what she believed were possible contributing factors that could have increased Resident 1's skin injuries, LVN 2 stated, Her family would take her out for multiple hours without pericare When asked if LVN 2 made her Nursing Supervisor aware of concerns, LVN 2 stated, Honestly no. When asked if Resident 1 was provided barrier cream or extra continence supplies while out of the facility, LVN 2 stated No. When asked if she was aware if Resident 1 or (family) were given any training or education on perineal care, LVN 2 stated No, only at the time of discharge. When asked if LVN 2 recalled participating in any care conferences or IDT meetings with Resident 1 or family, LVN 2 stated No we (licensed nurses) do not participate in IDT meetings. During a review of the facility's policy and procedure titled, Wound and Skin Management dated 11/2005 last revised on 07/2025, indicated, .Procedure A. Assessments: .3. IDT and Licensed nurse will assure that treatment plan and progress notes reflect patient's current status and appropriate interventions. The treatment plan will have an interdisciplinary approach.6. Licensed nurse will refer newly identified pressure ulcers to IDT for further assessment and treatment planning.During a concurrent interview and record review on 9/30/2025 at 3:16 PM with Nursing Supervisor (NSP) 2, Resident 1's Wound Consult Referral dated 4/28/2025 was reviewed. The Wound Consult Referral indicated Resident 1's PCP placed an order for a wound consult referral for Wound consult with Skilled Care Surgical Group until wounds resolve.coccyx bed sore (skin damage that occurs when pressure is applied to the same area of the body for an extended period). NSP 2 verified no follow up wound consult or updated treatment orders were documented. A review of Medical Staff- Podiatry (a medical specialty that diagnoses and treats conditions of the foot, ankle, and lower leg) Note dated 6/18/2025, indicated no updates were made to current treatment orders for multiple skin injuries. A review of Progress Notes- Medical staff Consultation dated 7/15/2025 indicated PLAN/RECOMMENDATIONS: Continue present care. A review of Progress Notes- Medical staff Consultation dated 7/22/2025 indicated PLAN/RECOMMENDATIONS: Continue current dressing and keep wounds moist.Coccyx wound- continue current dressing changes. During an interview on 9/30/2025 at 3:16 PM with NSP 2, NSP 2 verified the facility currently has a new wound care group assessing and treating residents with wounds. NSP 2 stated the new wound care group began approximately July 2025 and prior to the new wound care group there was a gap when licensed nurses were responsible for completing all wound care. NSP 2 stated, the new wound care group now provides consults for wounds that were identified on newly admitted residents and monitors the progression of wounds for residents with complicated wounds.During an interview on 9/29/2025 at 5:02 PM with Resident 1's Emergency Contact (EM) 1, when asked if the facility staff provided any wound care training or education about pressure injury development or increased risks factors, EM 1 stated No. The only thing they told us was it (pressure injuries) was because she peed a lot. We asked for more frequent diaper changes and no improvements (were made). When asked if Resident 1 and/or emergency contacts were involved in reviewing Resident 1's wound care interventions or participated in updates to plans of care, EM 1 stated, No. When asked if Resident 1's wounds caused a change in her mood/behavior or ability to function, EM 1 stated, It kept her uncomfortable most of the time she was there.During a review of IDT Meeting Note dated 5/30/2025, the IDT meeting note indicated The family and the resident.also report that she (Resident 1) is unable to stand up due to foot ulcer and the resident reports that her left leg pain and pain on (her) coccyx due to pressure ulcer prevent her from standing up and spending more than five minutes in the w/c (wheelchair).During a concurrent interview and record review on 9/30/2025 at 12:57 PM with the Nursing Supervisor (NSP) 1, Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. NSP 1 verified, Resident 1's Coccyx pressure injury was reopened on 4/18/2025 and stated This wound (pressure injury) was on and off. When asked if there were any updates to the interventions for the focus/goals, NSP 1 stated, No. There were no updated interventions for this reported wound (pressure injury), but the old interventions were resumed.During a concurrent interview and record review on 9/30/2025 at 1:10 PM with the Director of Long Term Care/Quality Assurance (DLTC/QA), Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. DLTC/QA verified interventions were resumed from 11/26/24, with no additional revisions made for the pressure injury on Resident 1's Coccyx. DLTC/QA agreed interventions should have been revised. A review of Resident 1's care plan titled SKIN ISSUES initiated on 04/18/2025 last revised on 8/17/2025 AND Resident 1's care plan titled Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025, DLTC/QA and NSP 1 agreed the Risk and Skin Issue care plans are two separate documents and have two different focus and goal outcomes. DLTC/QA agreed the goals identified in the Risk care plan focused on addressing risk factors with interventions to reduce risk of future ongoing pressure injuries, while the Skin Issue care plan and interventions focus on healing/treating the identified skin issues. DLTC/QA agreed that interventions for risk care plan should have been updated at least with every new inhouse pressure injury and more frequently throughout resident's stay.During a review of Resident 1's IDT meeting note(s) throughout her stay, dated 12/8/2024, 5/30/2025, 6/10/2025, 7/29/2025, 7/31/2025, 8/17/2025, and 8/19/2025, no indication of updated treatment orders, review of impact of current wound treatment orders, or collaboration with Resident 1 and/or family for new interventions to reduce risk for continued impaired skin integrity were discussed.

Based on observation, interview, and record review, the facility failed to ensure the environmrnt of one of one sampled resident (Resident 1) was free of potential accident hazards (falls and injuries from a lift) when they transferred Resident 1 in a lift to a commode and left her hanging a foot above the commode for several hours several times per day rather than lowering her to the toilet seat of the commode as instructed in the manual from the manufacturer (Invacare). Although Resident 1 chose this procedure and staff came to check on her while she was hanging from the lift, this does not prevent: the lift from failing; Resident 1 from falling; Resident 1 from injury; the facility from responsibility for Resident 1's safety. Findings: In an interview and record review with SN 1 on 8/8/25 at 10:45 a.m., SN 1 stated Resident 1 was admitted to the facility (over 10 years ago). SN 1 said Resident 1 was dependent on staff to turn and reposition her in bed, transfer her to a commode or wheelchair, and feed her. In an interview with SN 2 on 8/8/25 at 11:41 a.m., SN 2 said Resident 1 takes a shower in a chair with a seat like a commode and can sit in the shower chair for 30 minutes. SN 2 stated Resident 1 likes to hang over the commode in the sling of the lift for one to one and a half hours three times a day at 7 a.m., 10 a.m., and 7 p.m. In an interview with SN 3 on 8/8/25 at 11:35 a.m., SN 3 stated Resident 1 is fully dependent on staff and two people transfer her in the lift from her from her bed to the commode. SN 3 stated she hangs in the air sitting in the sling about one foot above the seat of the commode. SN 3 stated she hangs in the sling several times a day for up to one hour. Her preferred times to do this are at 7 a.m., 11 a.m. and 3:30 p.m. SN 3 said staff check on her and she lets them know when she is ready to go back to bed with a voice activated call light. In an interview with SN 2 and SN 4 on 8/8/25 at 2:33 p.m. SN 4 said Resident 1 called 911 last week because she said she was hanging in the sling too long. SN 4 said the police explained why she should not call them for this. SN 2 stated Resident 1 calls a family member who then calls SN 2 to complain that Resident 1 is hanging over the commode for too long a period. SN 2 said often Resident 1 does not have a bowel movement each time she hangs in the sling over the commode. In a discussion with SN 2 and SN 4 regarding the safety and responsibility issues of using a lift that was not designed to dangle a resident 12 inches above the seat of a commode for one to two hours three times a day, they said they understood these issues. In an observation and interview with Resident 1 on 8/8/25 at 4:30 p.m., there was a lift against the wall on the left at the entrance to the dark room. Resident 1 was in bed covered neatly with blankets. Only her face from her forehead to her lower lip could be seen. She talked about her concerns and mentioned dangling in the lift over the commode. When told by the surveyor that it was a safety issue, she said she was not concerned. She stated she was concerned staff broke her phone four times. In an interview with SN 5 on 8/8/25 at 3:03 p.m. regarding the safety and facility responsibility issues discussed above with SN 2 and SN 4, SN 5 was asked to provide documents that the manufacturer of the lift approves the manner in which they are using it for Resident 1. SN 5 stated the paperwork would be provided by the end of the day. On Friday, 8/8/25 at 5:03 p.m., three paper documents were received. The first was a 2/11/24 (revised 6/1/24) Care Plan Report that indicated under Interventions/Tasks, Per (Resident 1's) preference, she can be left while up on hoyer lift and toileting over a commode. Checked regularly by staff. (Resident 1) will give CNA time when to be back. The second document received was a 7/23/24 Nurse Note that indicated Resident 1 requested to be up in commode at (2:30 p.m.), she usually prefers to stay in hoyer lift for an hour. The third document received was a 10/18/24 Nurse Note that indicated at (10 a.m.) to request to be put to commode and hang via hoyer lift. There were no documents from the manufacturer of the lift as requested. At 5:05 p.m. on 8/8/25, SN 2 and Staff 1 were told (as SN 4 and SN 5 had left for the day) that unless the facility can provide documentation from the manufacturer that the lift can be used the way it is used by Resident 1 they would be cited. Staff 1 stated correspondence would be sent via email on Monday morning, 8/11/25. On 8/13/25 at 10:59 a.m., an email was sent to SN 4 and SN 5 regarding information from the manufacturer. A response was received from them at 11:33 on 8/14/25 that included a copy of the manual for the Invacare lift. A review of this manual, the Invacare/Reliant 450/600 Battery Powered Patient Lift User Manual (copyright 2022) indicated on page 40, 8.1.1, Transferring to a Commode Chair, 2. Lift the patient from the bed . 3. Note the patient should be elevated high enough to clear the commode chair arms and have his/her weight supported by the patient lift. 4. With the help of both assistants, guide the patient onto the commode chair. 5. Lower the patient onto the commode chair, and leave the sling attached to the hanger bar hooks. 6. When complete, recheck for correct attachments and then raise the patient off the commode chair. On 8/25/25 at 11:18 a.m., an email was received from SN 4 indicating the manufacturer of the lift, Invacare, could not provide guidance on using the lift to suspend a resident above a toilet or commode or confirm whether this was safe. In this email, SN 4 indicated the manufacturer stated Their recommendation is to place the resident directly onto the toilet or commode.

Based on observation, interview and record review, the facility failed to report three of 11 allegations of abuse within two hours, to the California Department of Public Health (the Department).This failure had the potential to leave residents vulnerable to further abuse. 1.Two intakes of the same allegation, sent 2 different dates. Cross reference to Incident 2303945 (CA0092790) and 2303946 (CA00928621) A review of Form SOC 341 Report of Suspected Dependent Adult/Elder Abuse with completed date 10/31/24, indicated, Resident 1 alleged that two Certified Nursing Assistants (CNAs) were handling him roughly while changing his bedsheets on 10/29/24 .nurse conducted skin and pain assessment .denied any pain and no noted skin injury .Both CNAs were immediately suspended pending investigation. DPOA, MD, CDPH ,Ombudsman, SFPD were notified of incident .facility conducting investigation of this incident.A review of admission Record, dated 7/23/25, indicated, admitted on [DATE] with diagnoses including: Traumatic Subdural Hematoma (a bleeding caused by head trauma), Diabetes Mellitus( high blood sugar), Cognitive Communication Deficit, Spinal Stenosis( narrowing of spine causing pressure on the nerve.Patient discharged to home on [DATE]. Not able to interview the patient, has been discharged [DATE].During an interview on 7/23/25 at 12:33 PM, with RN Unit Supervisor, per Unit supervisor, the TCC (Transitional Care Coordinator) reported to Unit Supervisor and DON that resident and wife, present for a care conference, reported that he was rough handled by 2 CNAs on 10/29/24 at 6 PM. SOC was completed by TCC. Per Unit Supervisor, she notified CDPH and Ombudsman by phone at 1:20 PM. Both CNAs were asked to come to sign administrative leave pending investigation. They were not scheduled until cleared to work. Abuse training is done annually and alleged abuser will be trained by Dept of Education 1:1 before they are reinstated to work. Abuse training is also done as per needed basis.Reporting is done immediately and within 2 hours to report alleged abuse.Review with Unit Supervisor of SOC and Investigation Summary dates, RN confirmed the dates are off and late for the 10/30/24 allegation of abuse. During an interview on 7/23/25 at 1:29 PM ,with Transitional Care Coordinator (TCC), per TCC wife present during the care conference on 10/30/24, and brought up the allegation of 2 CNAs rough handling on 10/29/24 at 6 PM. Then TCC reported this to Unit Supervisor and DON , as he was new at that time.Per TCC, he started work 9/7/24, orientation included Abuse training within 2 weeks, does not remember the date.Per TCC he completed the SOC, first time to complete the form and knows reporting in 2 hours. TCC confirmed the SOC 341 for this resident is not within 2 hours of reporting protocol. Review of the transmission page of SOC 341, indicated, date : Fri 11/1/24 at 7:17 AM. Confirmed with CDPH office, regarding phone message notification, per office staff, no phone message left on 10/30/24. A form 802 is generated when voice message reports are retrieved. No form 802 found. During an interview on 7/23/25 at 10:00 AM, with Director of Education (DOE), per DOE, during orientation, Abuse reporting, prevention, Identification is given 2 times a year. During incidents of Abuse, the alleged staff is given Focus Inservice on the abuse - 1:1 inservice. Online classes for training, as everyone is mandated reporter. Stressed to then Abuse is a crime. Our Policy and Procedure on reporting timeframe is within 2 hours to report and complete the SOC 341. The staff involved are put on administrative leave pending investigation. The investigation is started by the reporter, supervisor or DON and Abuse Coordinator is notified. Anyone can file an SOC. The Social Workers check in on patients providing psychosocial support. Nursing monitoring the patient for emotional distress. The summary of investigation is completed by Supervisors or managers and reviewed by Abuse Coordinator. Human Resources is aware of suspension for staff involved in the abuse incident. Police is notified and they come to investigate and a nurse supervisor comes with the Officer to take the report from them. We have 5 business days to send to CDPH the summary of investigation. Review of employee file for CNA 1, CNA certificate number CNA00458104, expires 4/10/2026, active.Employee acknowledgement of Elder Abuse /Reporting - 2/28/22, Abuse, Neglect and Exploitation in the Elder Care 6/24/24. 1:1 Focused Inservice 10/31/2024. on 1/2/15 - Abuse prevention and reporting inservice. Review of employee CNA 2, CNA certificate no. 01240332 expires 5/30/27, active. Abuse Prevention and Reporting -10/2/2024, 1:1 Focused service on Elder Abuse Prevention and Reporting -10/31/24, on 1/28/25 Mandatory Abuse Prevention and Reporting.Not able to interview the 2 staff, not working that time of investigation. 2. Review of SOC , Report of Suspected Dependent Adult/Elder Abuse, date completed 11/8/24, allegation from Resident 2 on November 8, 2024, that a staff member was verbally rude to her on November 6, 2024. Patient denies any physical contact with the staff member. SOC form did not indicate written report mailed or faxed to state agencies.Review of faxed transmission to CDPH, indicate, 11/9/24 at 8:16 AM. Review of admission record, indicated, resident admitted on [DATE] with diagnoses including: Adjustment Disorder with Anxiety and Depressed Mood, Mild Cognitive Impairment, Difficulty in Walking. Review of progress notes, nurses notes dated 11/6/24 at 16:22 PM, indicated, received endorsement from AM sitter that patient expressed that she does not want yesterday's PM sitter (11/5/24) to return d/t being aggressive. Per patient report, 11/5/24 PM sitter said things like, get up by yourself, walk by yourself and reportedly took her bags and left the patient's room. AM sitter endorsed to this to nursing supervisor who gave sitter instructions to report to this RN. Endorsed to PM and AM CN. Continuing plan of care. During an observation on 7/22/25 at 12 noon, Resident 2 up on a chair, volunteer came and left to give me time to talk to resident. I was introduced by her CNA, needs to call her Mademoiselle.Resident wanted to know why I am here. Told her about the incident last year, staff being verbally rude. Per resident, that's been a long time ago, In don't remember. I'm watching a movie right now, if I can do it? I am okay here, don't come again. During an interview on 7/22/25 at 12:14 PM, with CNA, per CNA resident is very particular with ADLs, activities and belongings. She attends almost all activities, she is a speaker for one of those activities which she enjoys. Per CNA she knows the incident last year and the CNA involved is never assigned to her again. she has no complaints with any CNA after that. Interview on 7/23/25 at 11:11 AM with RN 1, per RN1, that sitter reported to her at the end of her shift that resident 2 does not want the NOC shift sitter to come back and supervisor is aware. Per RN she went ahead and documented it, let the AM and PM charge nurses know about the report. per RN, later on (does not remember the date), she was reprimanded for not reporting appropriately.RN started her employment on 4/2024, does not remember if she got the abuse training when I got hired to report in 24 hours. Has not had any training on abuse after that. Review of SOC 341, completed by DON on 11/8/24.indicated, no dates when faxed to mandated agencies. no dates when telephone report made to mandated agencies. Reviewed and confirmed with Unit Supervisor, per Unit supervisor, abuse should be reported within 2 hours, and this one is not done on time per RN. Review of CNA alleged abuser 's Abuse training, indicated training for Identifying and Addressing Older and Dependent Abuse on 10/9/2024.Review of RN 1's license, license expires 8/31/2025. no disciplinary actions against the licensee. During an interview on 7/23/25 at 3:50 PM, with Administrator, per Administrator she is the Abuse Coordinator. Reviews for correct allegations. Notified of all abuse incidents. make sure that the reports are sent to agencies as required. Anybody can fill out the SOC as everyone is a mandated reporter. Investigation summary is a collaborated effort from IDT(Interdisciplinary team) and Administrator summarizes the investigation and have it faxed to agencies within 5 business days. Review of facility Policy and Procedure, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, dated 8/24, indicated, Purpose: The purpose of this policy is to describe the measures the Jewish Home and Rehab Center takes to prevent residents from abuse, neglect, mistreatment, exploitation, and misappropriation of property through screening, training and education, supervision, assessment, investigation and reporting. POLICY: It is the policy of Jewish Home .to ensure that each resident will be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property . In any allegation of abuse the Administrator, Director of Nursing and Clinical Operations, nurse manager, nursing supervisor or any mandated reporter will notify the California Department Of Public Health, the Ombudsman and San Francisco Police Department immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on interview and record review, the facility failed to report the result of investigations to the State Survey Agency (SSA) within 5 working days of the incident for four (4) of 12 residents' (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) abuse allegations .Resident 1 alleged 2 CNAs rough handling during change of bedsheet on 10/29/24Resident 2 alleged 1 CNA on 11/5/24 was aggressive and said get up by yourself, walk by yourselfResident 3 alleged a nurse on the night of 8/27/24 was rude, harsh, and hit her. Resident 5 went to Resident 4's room, grabbed his face and pushed it back.This failure may cause delay in taking all necessary actions to protect the residents and prevent further occurrences.1. Review of Resident 1's document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 10/31/24, indicated, an allegation of staff to resident abuse was reported to law enforcement on 10/30/24, to Ombudsman on 10/30/24, California Department of Public Health on 10/31/24. The SOC 341 indicated, staff reports alleged patient abuse reported on 10/30/24 from patient's wife that 2 CNAs were handling him roughly while changing his bedsheets on 10/29/24. Review of the facility's Fax Cover sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 day Follow -Up (result of investigation) to CDPH on 11/9/2024 at 8:20 AM. 2. Review of Resident 2's document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 11/08/24, indicated, an allegation of staff to resident abuse, no indication of reported to : law enforcement, Ombudsman, California Department of Public Health. The SOC 341 indicated, on 11/8/24 Resident 2 alleging that a staff member was verbally rude to her on 11/6/24. Review of the facility's Fax Cover sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 day Follow -Up (result of investigation) to CDPH on 11/9/2024 at 11:27 AM. 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 8/28/24, indicated, an allegation of staff to resident abuse was reported to the law enforcement, California Department of Public Health (CDPH), and Ombudsman on 8/28/24. The SOC 341 indicated, on 8/27/24, a night nurse was rude, harsh and hit Resident 3. Review of the facility's Fax Cover Sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 Day Follow-Up (result of investigation) to CDPH on 9/6/24 at 10:56 AM. 4. Review of the Resident 4 and Resident 5's SOC 341 report, with a completed date of 9/9/24, indicated, an allegation of resident to resident altercation was reported to the law enforcement, CDPH, and Ombudsman on 9/9/24. The SOC 341 indicated, on 9/9/24 at 1:20 PM, Resident 5 went to Resident 4's room, grabbed his face and pushed it back. Review of the facility's Fax Cover Sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 Day Follow-Up to CDPH on 9/17/24 at 9:53 AM. During an interview on 7/23/25 at 3:50 PM, the Administrator stated the 5-Day Follow-Up (result of investigation) should be reported to the state agency within five working days of the incident. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, revised 08/2024, indicated, .Compliance: . 7. Reporting/Response: It is the policy of the [SNF Name] to report all abuse allegations to the administrator/designee, California Department of Public Health, San Francisco Police Department if appropriate, Ombudsman, and any other required agencies . f. The administrator will follow up with government agencies to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident as required by state agencies .

Based on interview and record review, the facility failed to ensure three out of three sample residents (Residents 1, 2, and 3) were free from neglect. All three residents were dependent on staff for transfers and ADL (Activities of Daily Living) and all three residents reported their unit was short staffed, resulting in long wait for services. These episodes may have resulted in: 1. Resident 1 expressing feelings helplessness, frustration and discomfort when: Resident 1 waited for four hours in her wet briefs before staff cleaned her and changed the brief; was left on the commode for 1.5 hours; was not repositioning by staff in a timely manner which caused her discomfort; Resident 1 expressing feelings of frustrations, abandonment, and being suicidal. 2. Resident 2 saying she was in pain at night after staff did not put her to bed in a timely manner. Resident 2 expressed feelings of frustrations and worry because staffing issues were communicated to the facility without any substantive changes. 3. Resident 3 expressing feelings of anger, frustration, and neglect when: Resident 3 was almost always served cold meal due to short staffing; waiting an hour for staff to answer his call light. Findings: Review of Resident 1 ' s record titled ADMISSION RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia(partial or total loss of function in all four limbs and the torso), constipation (difficulty in emptying bowel, usually due to hardened feces), depression, muscle spasms, and limitation of activities due to disability. Review of Resident 1 ' s records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/26/2024, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicated no impairment in memory and reasoning). According to her MDS, she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine (a non-invasive device that collects urine from the body without being inserted internally) and was continent of bowel. During a concurrent observation and interview of Resident 1 on 12/06/2024 at 11:30 AM, Resident 1 was in bed and on her back. She was not able to move her arms or her legs. Resident 1 stated .I ' m totally dependent on staff. I can ' t scratch an itch. I can ' t turn and reposition my arms and legs and my body. I need someone to feed me and give me water. I need a staff to clean me up when I soil myself. I need a staff to position my (urinary) catheter correctly.(the facility was) Supposed to give me a sitter at least every day to help me with these things. Lately, they are short and now I sit and wait for them.You are calling for help and you don ' t know when someone is coming. Can you imagine how frustrating that makes me feel.They said that I ' m depressed or I have depression. Wouldn ' t you be depressed if you were subjected to this almost every day? With my condition, my body needs to be on a regular schedule. If I don ' t eat and don ' t drink on time. Things starts shutting down. I get constipated, I ' m supposed to go to the commode around 7:00 AM. They didn ' t help me to the commode until 10:00 AM. Another time it got so bad, I was screaming for help no one came and I had to get my brother to call a supervisor .because I was wet for 4 hours. Review of Resident 1 ' s medical records titled Progress Notes indicated entries regarding how staffing was affecting her mental health: 1. Authored by Social Worker (SW) 1, dated 10/29/2024, indicated .she has a sitter who told (Resident 1) .she could not feed or transfer her. (Resident 1) . then asked sitter to leave. SW is clarifying with .(Director of Nursing, Scheduler, Unit Manager) tasks of sitter. During two conversations with .(Resident 1), she speaks of abandonment issues, not doing well alone. 2. Authored by SW 2, dated 10/29/2024, indicated .Much of the time was spent with complaints and frustration over staffing. She reports that her planning each day depends on the knowledge of staffing (who will be available to assist her) 3. Authored by SW 2, dated 10/28/2024, indicated .(interdisciplinary team) met and discussed .(Resident 1) who expressed a desire to die, stating, I just want to die .(because) I don't have a sitter, and I can't manage everything on my own. I am not as important as everybody else. She was distressed, and tearful. 4. Authored by SW 2, dated 10/07/2024, indicated Resident 1 . continues to complain that her needs are not being met especially for toileting . because of staffing needs of .(other residents) . (Resident 1) has reported fears of abandonment and she keeps her door open because she is afraid of being forgotten/ignored.(Resident 1) reports to SW that her day consists of eating .(related to) toileting needs and clarifying scheduling of CNA and sitter to meet the toileting needs. 5. Authored by SW 2, dated 09/20/2024, indicated Resident 1 .continues to report the difficulty in getting timely help with commode, shower, transfer, changing undergarments. She speaks of a fear of abandonment and the effect that has on her . Review of Resident 2 ' s record titled ADMISSION RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia, muscle spasm, depression, insomnia (sleep disturbances), and dysphagia (difficulty swallowing foods or fluids). Review of Resident 2 ' s records titled MDS, dated [DATE], indicated her BIM score was 15 out of 15. According to her MDS, she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 2 ' s MDS, dated [DATE], she had a catheter to manage her urine and was always incontinent of bowel. During an interview with Resident 2 on 12/06/2024 at 12:14 PM , she stated Today everything was late. One person on vacation. My (CNA) . has no help. (she is) feeding everybody. It ' s emotionally taxing for me to see that and have to wait for help. Sometimes when they are short, they are not able to put me back to bed in time. I have to wait and if I wait too long, sometimes it affect my sleep. I remember one time they put me to bed late and I was in pain the whole night. Review of Resident 3 ' s record titled ADMISSION RECORD, printed on 01/03/2025, indicated he was admitted with multiple diagnosis including: muscular dystrophy (genetic diseases that cause muscles to weaken and degenerate over time), bipolar disorder (mental condition causing extreme mood swings. Periods of elations, irritability and periods of sad depressed moods), and constipation. Review of Resident 3 ' s records titled MDS, dated [DATE], indicated his BIM score was 15 out of 15. According to his MDS, he was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 3 ' s MDS, dated [DATE], he had a catheter to manage his urine and was always incontinent of bowel. During an interview with Resident 3 on 12/06/2024 at 12:36 PM , he stated .Call lights are a problem when they are short. You can wait 25 minutes to have a call light answered. The longest was one hour wait. I need help with meals. When they are short, I have to wait maybe more than 25 minutes for them to help me with my meals. By then, the food is almost always cold. During an interview on 12/20/24 at 12:20 PM, Charge Nurse (CN) 1 stated CNA staffing on her unit has gotten worse since July 2024. CN 1 stated on her unit on AM shift there used to be six CNA and CNA staffing was reduced to five CNAs and sometimes as low as four CNAs. CNA staffing was reduced with no reduction in resident census and/or change in resident acuity/level of care. CN 1 stated sometimes when she was working late to finish her charting, she could hear Resident 2 screaming for staff to come help her. During an interview on 12/23/2024 at 10:53 AM, Certified Nursing Assistant (CNA) 2 stated she usually worked AM shift and sometimes her unit is short. CNA 2 stated The residents (who are) alert are mad at us because they have to wait. While we attend to others. Sometimes . (Resident 1) has to wait at least 45 minutes. The residents who cannot talk are the ones who suffer. AM shift (used to have) six CNAs now it ' s down to five CNA. Even if we divide the time between these residents, it ' s not enough. During an interview on 01/18/2025 at 10:00 AM, CNA 1 stated she mostly worked on one unit in the AM shift. On that unit, they were normally staffed with six CNAs. Sometimes CNA staffing can be as low as four. When the unit is short, residents have to wait for services/care. CNA 1 stated .Resident have to wait yeah it depends. We are .(given) more .(residents) than usual.(longest wait was) 40 minutes to 1 hour wait. They needed to get changed. There are some patients that needs 2 people.some .are frustrated some are mad . I can understand .(Resident 1 ' s) frustration.she shows frustration thru shouting and crying. During an interview with the Unit Manager (UM) on 01/15/2025 at 11:55 AM, she stated the census on her unit has been very stable and the acuity/care requirement for each resident has been very stable. The UM admitted sometimes the unit was short staff with only four CNAs. The UM stated residents .are going have to wait when we are short. The UM stated the facility implemented safety monitors but the safety monitors cannot function as CNA. The UM stated the safety monitors are not allowed to do tasks involving direct patient care like feeding, giving water, repositioning, providing incontinent care etc. During an interview on 01/22/2025 at 11:05 AM, CNA 3 stated she worked AM shift. CNA 3 stated prior to July 2024, AM shift used to be staffed with six CNA after July, CNA staffing was cut to five and can be as low as four CNAs. CNA 3 stated unfortunately, residents have to wait, up to 30-45 minutes for care. CNA 3 confirmed that Residents 1, 2, 3 have complained about waiting when the unit was short staffed. CNA 3 stated these Residents 1, 2, and 3 were not happy, mad, frustrated, and accused staff of ignoring their needs. CNA 3 stated Resident 1 and 2 sometimes reported discomfort/pain when staff was not able to reposition them or put Resident 2 back to bed in a timely manner.

Based on interview and record review, the facility did not report allegations of neglect for Resident 1, one of three sample residents. Resident 1 sent four emails to the facility alleging sub-par quality of care issues such as: delayed response to request for care, no care, not getting enough food and water, and getting minimal care. This has the potential to place Resident 1 and other residents at risk for abuse/neglect. Findings: Review of Resident 1 ' s record titled ADMISSION RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia (partial or total loss of function in all four limbs and the torso), constipation (difficulty in emptying bowel, usually due to hardened feces), depression, muscle spasms, and limitation of activities due to disability. Review of Resident 1 ' s records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/26/2024, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicated no impairment in memory and reasoning). According to her MDS: she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine and was continent of bowel. Review of emails provided by Resident 1 indicated: 1. Resident 1 emailed the facility ' s grievance web portal, on 12/23/2024, and wrote .I was not put on the commode before dinner as I am scheduled to do every day. Toileting is the worst problem, but other needs are not being met as well. Some issues are manifesting as painful symptoms and a week-long admission to the hospital because of an internal infection. 2. Resident 1 emailed the Administrator, and the Unit Manager, on 12/6/2024. Resident 1 wrote .for commode/ bowel movement. Without a sitter, a second CNA for the two person assist . I suffer with cramps and chills because I cannot be put on the commode. The issues continue to be that almost all of those scheduled care times are delayed by hours or not done at all when the regular AM CNA is off. The other challenge has been getting enough food and water around commode times. Without a sitter most of it does not happen at all. 3. Resident 1 emailed the Director of Nursing (DON) and the Administrator on 12/03/2024. Resident 1 wrote .when the regular CNAs are off, everyone thinks I have a sitter and no one takes care of me! No one was assigned to feed me my usual yogurt that I am supposed to eat because of the antibiotics, and worse, no one was assigned to feed me dinner! I am supposed to go to the commode around 3:45 PM, and no one was available. I have had a Sitter since every CNA has been hired and for years, no one thought about me, answered call lights, or entered my room until it 8 PM when it is my scheduled time to go to the commode. in this environment that I don't eat and my body shuts down. I end up in the hospital, and then I am blamed for the extra effort required by the CNAs when I returned. Thank goodness I'm not sick today as I was yesterday. I can't even imagine being as sick as I was without a sitter here. With my sensitive stomach, perhaps it's better that I don't eat or drink. I don't know how else to stress the importance of having a sitter/aide. I cannot eat, drink, or get help by myself, yet I need all three every day. Please, I need help. 4. Resident 1 emailed the DON, the Administrator, and the Director of Social Services on 11/29/2024. Resident 1 wrote .If the regular CNA . is not here, I have no regular schedule. I don't drink water as there is no one to give me any, I may or may not eat dinner, and my commode times may or may not happen or be on schedule! I am barely getting minimum care here! . One or two sitters a week along with my private pay, still leaves days when my body either functions as it should but in pain without care, or shutting down until I end up in the hospital again. Review of the facility ' s policy titled Grievance/Complaint Process, Revised on 11/2017, indicated .The responsibility to review and resolve grievances has been delegate to the designated Grievance Official who is responsible for: .Ensuring the immediate reporting of all alleged violations involving neglect, abuse, .to all agencies required by law.This is a shared by all facility staff. The Administrator was made aware of these emails on 12/08/2025 at 3:19 PM and the facility was asked if: 1. Any contents within Resident 1 ' s emails were treated as grievances (documented and logged as grievances, investigated as grievances, changes presented to Resident 1 and implemented to address Resident 1 ' s grievance). 2. Any contents within Resident 1 ' s emails were treated as neglect allegations and were reported and investigated per State regulations. The facility was unable to provided documentations regarding items 1 or 2.

Based on interview and record review, the facility did not provide the necessary care to maintain the highest practicable mental and psychosocial wellbeing for Resident 1, one of three sample residents. Resident 1 was totally dependent on staff for Activities of Daily Living (ADL) and other care needs. Starting July 2024, the facility unilaterally reduced direct care giver hours by 41.67% to Resident 1. This resulted in Resident 1 expressing feelings of frustrations, abandonment, and suicidal ideation. Findings: Review of Resident 1 ' s record titled ADMISSION RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia (partial or total loss of function in all four limbs and the torso), constipation (difficulty in emptying bowel, usually due to hardened feces), depression, muscle spasms, and limitation of activities due to disability. Review of Resident 1 ' s records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/26/2024, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicated no impairment in memory and reasoning). According to her MDS: she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine and was continent of bowel. During a concurrent observation and interview of Resident 1 on 12/6/24 at 11:30 a.m., Resident 1 was in bed and on her back. She was not able to move her arms or her legs. Resident 1 stated .As you can see, I ' m totally dependent on staff. I can ' t scratch an itch. I can ' t turn and reposition my arms and legs and my body. I need someone to feed me and give me water. I need a staff to clean me up when I soil myself. I need a staff to position my (urinary) catheter correctly.(the facility was) Supposed to give me a sitter at least every day to help me with these things. Lately, they are short and now I sit and wait for them. You are calling for help and you don ' t know when someone is coming. Can you imagine how frustrating that makes me feel. Sometimes they don ' t have enough staff to put me on the commode. I ' m forced to hold my bowel or if I know they are short staffed, I either don ' t eat or don ' t eat as much. Because I don ' t know if there ' ll be enough staff to put me on the commode. Another thing they need to do is reposition me on a regular basis. It gets uncomfortable if they leave me in one position for a long time. If they are short, I wait .even if I ' m in pain, I have to wait. I have no other choice. They said that I ' m depressed or I have depression. Wouldn ' t you be depressed if you were subjected to this almost every day? During an interview on 01/15/2025 at 11:55 a.m., the Unit Manager (UM) stated Resident 1 care needs has not changed. Resident 1 was totally dependent on staff for ADLs and other care. The UM stated the facility implemented Safety Monitors (SM) but the SM cannot function as Certified Nursing Assistant (CNA). The UM stated the SM are not allowed to do tasks involving direct patient care like feeding, giving water, repositioning, providing incontinent care etc. During an email communication with Resident 1, dated 01/20/2025 at 5:31 a.m., Resident 1 wrote she enjoyed working with SM 1 because SM 1 was providing direct patient care. Resident 1 wrote SM 1 .was not a .(CNA. However,) she .feed, assisted with (mechanical lift for transfers) and help with some ADLs. During an interview on 01/23/2025 at 3:25 p.m., SM 1 provided information she was hired as a safety monitor but was functioning as a direct care giver. SM 1 stated .(Resident 1 was) still in the commode sometimes I help the CNA to . change the diaper. I feed her, and clean her. After feeding her .(dinner) I go on my break. During a concurrent interview and record review on 01/28/2025 at 11:01 a.m., with the UM, the UM was made aware the facility provided two documents titled June 2024 Sitter Schedule for .(Resident 1) and December 2024 Sitter Schedule for .(Resident 1). Both these documents were not dated. The June 2024 document indicated 216 hours of sitter were provided to Resident 1 and the December 2024 document indicated 216 hours of sitter were provided to Resident 1. The UM was made aware these total hours were in error because: 1. During the interview the UM defined safety monitors as staff who do not provide direct patient care such as feeding, providing water, cleaning residents after an incontinent episode, repositioning. 2. Safety monitors were counted as sitters/CNA (direct care givers) in error. 3. One safety monitor (SM 1) admitted she was functioning as a CNA and providing direct patient care. The UM was made aware after analysis, in June 2024, the facility provided 192 hours/month of sitter/CNA hours to Resident 1. In December, the facility provided 112 hours/month of sitter/CNA hours to Resident 1. This was a reduction of 41.67% in direct patient care hours to Resident 1. Additionally, the UM was made aware these reduction in direct patient care levels may have resulted in Social Services notes documenting Resident 1 reported feelings of frustrations, abandonment, wanting to keep her door open because she was fearful of being ignored/forgotten, and suicidal ideation. Review of Resident 1 ' s medical records titled Progress Notes indicated these entries: 1. Authored by Social Worker (SW) 1, dated 10/29/2024, indicated .(Resident 1) has a sitter who told .(Resident 1) she could not feed or transfer her.(Resident 1) then asked sitter to leave. SW is clarifying with .(Director of Nursing, Scheduler, Unit Manager) tasks of sitter. During two conversations with .(Resident 1), she speaks of abandonment issues, not doing well alone. 2. Authored by SW 2, dated 10/29/2024, indicated .Much of the time was spent with complaints and frustration over staffing. She reports that her planning each day depends on the knowledge of staffing (who will be available to assist her) 3. Authored by SW 2, dated 10/28/2024, indicated .(interdisciplinary team) met and discussed .(Resident 1) who expressed a desire to die, stating, I just want to die .(because) I don't have a sitter, and I can't manage everything on my own. I am not as important as everybody else. She was distressed, and tearful. 4. Authored by SW 2, dated 10/07/2024, indicated Resident 1 . continues to complain that her needs are not being met especially for toileting . because of staffing needs of .(other residents) . (Resident 1) has reported fears of abandonment and she keeps her door open because she is afraid of being forgotten/ignored.(Resident 1) reports to SW that her day consists of eating .(related to) toileting needs and clarifying scheduling of CNA and sitter to meet the toileting needs. 5. Authored by SW 2, dated 09/20/2024, indicated Resident 1 .continues to report the difficulty in getting timely help with commode, shower, transfer, changing undergarments. She speaks of a fear of abandonment and the effect that has on her . On 01/28/2025 at 2:09 p.m., the facility was asked to provide clinical rationale(s) regarding why there was a reduction in Resident 1 ' s direct patient care hours when Resident 1 ' s acuity level/care needs remained the same. The facility was unable not provide the requested documents.

Based on observation, interview and record review the facility failed to maintain a sanitary kitchen when: 1. A rodent dropping was found under the cooking line (area in the kitchen where multiple pieces of cooking equipment are in a line), this area had a build-up of food, black grime and trash. 2. Multiple areas in the kitchen on the floor under equipment, there was old food, trash and black grime. 3. The ice machine had a black grime build-up on the area above the ice grates where water flows to fill up the grates. 4. Utensils were stored with a build-up of old food. 5. The refrigerator utilized to store food for activities was food crumbs and spills and expired foods. 6. Multiple floor drains in the kitchen had a build-up of old food and grime. 7. The dating system in the walk-in refrigerator was not accurate and readable. These failures had the potential to cause foodborne illness in 332 out of 338 medically compromised residents who receive food from the kitchen. Findings: 1. During an observation, on the meat preparation side of the kitchen, on [DATE], at 10:40 AM, on the floor under the tilting skillet (cooking equipment that allows the user to prepare a variety of foods in large batches), there was a build-up of food, trash and a rodent dropping was found. On the floor under the cooking line in this same area, there was a scattered build-up of old food, crumbs, grease and black grime. During an interview with the Technician 2 from [company name] pest control on [DATE], at 3:40 pm, he stated if food is left out, it can attract rodents. T2 verified that the rodent dropping found at 10:40am was mouse dropping. He stated that due to the size of the dropping (larger than usual) it was probably a breeder mouse. He stated that there is an exterior door that goes to the outside that is automatic and stays open for a certain amount of time and this could be how the mice are entering the kitchen. During an interview with the Infection Preventionist 1 (IP1), on [DATE], at 10:03 AM, IP1 agreed that salmonella is a concern because the mouse could contaminate the food. During an interview with the Registered Dietitian 1 (RD1) and the Director of Dining Services (DDS), on [DATE], at 12:31 pm. The DDS stated that the floors under the equipment should be maintained clean and there should not be any rodent droppings. During a review of the policy titled Sanitation and Infection Prevention/Control, dated [DATE], indicated, the Food and Nutrition Services department shall be free of all rodents and insects. During a review of the FDA Federal Food Code, dated 2022, ,d+[DATE].111 indicated, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B) Routinely inspecting the PREMISES for evidence of pests; . (D) Eliminating harborage conditions. In addition, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 2. During an observation in the kitchen, on [DATE], at 3:05pm, the floor underneath the coffee cart near the handwashing sink had black grime and trash. During an observation in the kitchen on [DATE], at 3:27 pm, there was a build-up of food under the tilting skillet and under the flat top grill and two ovens. During an observation in the kitchen, on [DATE], at 9:48 am, on the floor under the under the counter fridge #14 and #15, there was a build-up of food crumbs. During an observation in the kitchen, on [DATE], at 10:23 am, the floor under the stainless steel counters in the vegetable preparation area had a build-up of black grime and food crumbs. During an interview on [DATE], at 3:03 pm, with the Technician (T1) from [company name], T1 stated they come every 60 days to deep clean the cooking equipment. He stated that [DATE]th was the last time he was at the facility to do a deep clean. He stated they are not currently contracted to do deep cleaning of the floors. During an interview with the Director of Dining Services (DDS) on [DATE], at 3:22 pm, The DDS stated that she thought they were doing the deep cleaning of the floors, and she was not aware that they were not contracted to do regular deep cleaning of the floors under equipment. She stated that her staff cleans the floor daily but does not clean the floor under the equipment because its harder to clean. During an interview with the Director of Dining Services (DDS) on [DATE], at 12:33 pm, DDS stated that the floors under equipment should be kept clean and free of any debris. During a review of the facility policy titled Sanitation and Infection Prevention/Control, dated [DATE], indicated nonfood contact surfaces of utensils and equipment must be . maintain in good condition. In addition, nonfood contact surfaces of equipment . shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. During a review of the FDA Federal Food Code, dated 2022, ,d+[DATE].11 indicated (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 3. During an observation and concurrent interview with the Director of Dining Services (DDS) on [DATE], at 3:34 pm, the ice machine had a black grime build-up on the area above the ice grates where water flows to fill up the grates. The shield that covers the ice grates was covered in black grime. The top portion of the ice bin also had a build-up of black grime. DDS stated that they contract with a company to come every 6 months to clean the ice machine. She stated after finding this build-up she is going to need to do frequent checks of the internal cleanliness of the ice machine. During an observation on [DATE], at 3:36 pm, Director of Dining Services (DDS) stated that the ice machine is used for water pitchers and to keep food cold. During an interview with the Director of Dining Services (DDS) on [DATE], at 12:33 pm, FSD stated the interior part of the ice machine where the ice is made should be kept clean with no build-up of any kind. During a review of the FDA Federal Food Code, dated 2022, ,d+[DATE].11 indicated, ,d+[DATE].11 (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, . EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 4. During an observation in the kitchen and concurrent interview with the Director of Dining Services (DDS) on [DATE], at 10:23 am, there were two vegetable peelers stored ready for use in a drawer that were coated in food grime. Per the DDS, all the utensils should be stored clean and shouldn't have any build-up of old food. In another drawer there was a mandolin (utensil for slicing) and a vegetable slicer were crusted with old food and stored ready for use. During an interview with the DDS on [DATE], at 12:33 pm, the DDS stated utensils should be stored free of food debris. During a review of the FDA Federal Food Code, dated 2022, ,d+[DATE].11 indicated, (A) Equipment food-contact surfaces and utensils shall be cleaned: .(5) At any time during the operation when contamination may have occurred. In addition, Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 5. During an observation in the kitchen on [DATE], at 3:05 pm, the refrigerator next to the handwashing sink that was used to store food for activities had a half gallon of expired milk, puree challah with no date, and a block of yellow cheese that was expired. During an interview with the Director of Dining Services (DDS) on [DATE], at 12:33 pm, DDS stated, all expired foods should be discarded. During a review of the facility policy titled, Production, Purchasing, Storage, dated [DATE], indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. In addition, Use manufacturer's expiration date for products. 6. During an observation in the kitchen on [DATE], at 3:05 pm, the floor sink under the handwashing sink where water drains had a build-up of old food and black grime. During an observation on [DATE] at 3:23 pm, the floor sink on the dairy side of the kitchen had a build-up of food and black grime. During an interview with the Director of Nutrition Services (DNS) on [DATE], at 12:33 pm, DNS stated the floor drains should be maintained clean. During a review of the FDA Federal Food Code, dated 2022, ,d+[DATE].11 indicated (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 7. During an observation and concurrent interview with the Director of Dining Services (DDS) and the Registered Dietitian 1 (RD1) in the Walk-in refrigerator, on [DATE], at 10:04 am, there was a large bowl of salad dressing with no label or date. There was a fruit salad that was not dated, and a bag of shredded carrots with a use by date of [DATE]. RD 1 stated that even though the sticker on the carrots with the date says use by, it should have read opened on. The DDS stated that they would need to in-service staff on how to use the dating gun correctly. During an interview with the Director of Dining Services (DDS) on [DATE], at 12:33 pm, DDS stated anything that has been opened should have a use by date, or received by date and prepared foods should have a use by date or expiration date. During a review of the facility policy titled, Production, Purchasing, Storage, dated [DATE], indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. In addition, Use manufacturer's expiration date for products.

Based on interview and record review, the facility failed to implement their fall policy and procedure for three of 6 sampled residents (Resident 187, 327, and 356) when: 1. There was no evidence of post fall interdisciplinary team (IDT, a group of healthcare professionals from different fields who work together to provide the best care for a patient) meeting for Resident 187. 2. There were no consent for video monitoring and evidence of post fall IDT meeting for Resident 327. 3. There was no post fall assessment and completed IDT meeting note for Resident 356. These failures could potentially result in negative outcomes for Resident 187, 327, and 356. Findings: 1. Review of Resident 187's clinical record indicated, Resident 187 was admitted to the facility with diagnoses including dementia (memory loss), hypertension (high blood pressure), and atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke). Review of Resident 187's Minimum Data Set (MDS, resident assessment tool), dated 2/8/24 indicated, her memory was severely impaired. During an interview on 8/27/24 at 2:02 PM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, Resident 187 was confused due to dementia. Review of Resident 187's Nurse Note (NN), dated 2/15/24 indicated, . 02/15/2024 7:25 AM Fall was not witnessed. Fall occurred in the hallway . found lying on the floor . Possible missed the chair. [NAME] was in front of the res. (resident) . No injury noted . Review of Resident 187's NN, dated 3/23/24 indicated, At 0700 (7:00 AM), CNA (Certified Nursing Assistant) found resident sitting on floor in her room . No s/s (signs and symptoms, abnormalities that can indicate a medical condition) of head injury . During an observation on 8/27/24 at 2:03 PM in the activity room, Resident 187 did not have an injury. During a concurrent interview and record review on 8/27/24 at 2:17 PM with Registered Nurse (RN) 2, Resident 187's IDT Meeting Notes were reviewed. RN 2 stated, there was no evidence of IDT meeting after Resident 187's fall on 2/15/24, and 3/23/24 when asked. 2. Review of Resident 327's clinical record indicated, Resident 327 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a condition that causes excessive fear, worry, and uneasiness that can interfere with daily life), and urinary tract infection (UTI, a common infection that occurs when bacteria enter the urinary tract and cause inflammation). Review of Resident 327's Minimum Data Set (MDS, resident assessment tool) dated 4/17/24 indicated, . Cognitive Patterns (the mental processes that people use to perceive, interpret, and process information from their surroundings) . resident is rarely/never understood . During a concurrent interview and record review on 8/26/24 at 1:33 PM with RN 2, Resident 327's fall care plan, dated 6/21/24 was reviewed. The fall care plan indicated, . Video monitoring . RN 2 stated, I don't see anything related to the consent of video monitoring in the progress notes, as verbal consent from the family when asked about the consent. Review of Resident 327's Nurse Note (NN), dated 8/21/24 indicated, Resident had a witnessed fall @ (at) 8:15 AM . no injury noted . During an interview on 8/26/24 at 2:37 PM with Nurse Manager (NM) 1, NM 1 stated, There should be IDT meeting note for every fall when asked about IDT meeting after falls. During an interview on 8/27/24 at 9:10 AM with Director of Nursing (DON), DON stated, consent for video monitoring is needed per the facility's policy and procedure (P&P) of fall when asked. During a concurrent interview and record review on 8/27/24 at 1:35 PM with RN 2, RN 2 stated, the latest IDT meeting note regarding fall for Resident 327 was on 7/19/24 when asked about evidence of IDT meeting after Resident 327's fall on 8/21/24. RN 2 stated, For August, No IDT note unfortunately . when asked again. RN 2 stated, IDT meeting should be held after each fall when asked about the facility's P&P of fall. Record Review of P&P titled, Fall Prevention Policy revised in August 2024 indicated, . 4. Appropriate interventions . will be implemented for residents/patients at risk for falls as identified by Nursing, and the IDT 7. Video monitoring may be considered as an intervention for patients/residents at risk for falling. If video monitoring is determined appropriate for the patient/resident, obtain consent for the monitoring from the patient/resident or responsible party and note the consent in the clinical notes. a. Document consent for video monitoring in the clinical notes . 1. A resident/patient who triggers the fall assessment as high risk will be reviewed by the IDT . 3. Review by Shift IDT: a. Cause of fall is discussed b. Root cause is analyzed and documented c. Recommendations for interventions are documented d. Care plan updated and documented e. IDT Participants presence is documented . 49264 3. A review of Resident 356's face sheet (summary of resident's demographic and admitting information), dated 08/27/24, indicated that Resident 356 was admitted in 2024 with diagnoses including DISPLACED FRACTURE OF MEDIAL CONDYLE OF RIGHT FEMUR . (a break in the right upper leg bone) and HISTORY OF FALLING. A review of Resident 356's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) dated on 08/03/2024 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 out of 15 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). During an interview on 08/21/24 at 1:28 PM with Resident 356, Resident 356 stated that she fell in her room a few weeks ago while a Physical Therapist (PT) was assisting them from the edge of the bed to the wheelchair. Resident 356 further stated that it was a controlled fall . I landed on my back. During a concurrent interview and record review on 08/26/24 at 10:49 AM with Registered Nurse (RN) 3, Resident 356's electronic medical record was reviewed. RN 3 stated that she does not see a post-fall assessment for Resident 356. RN 3 stated she does not recall if Resident 356 has fallen at the facility but confirmed that if Resident 356 did fall in the facility, a post-fall assessment should be completed. RN 3 further stated that she only sees one fall assessment for Resident 356 that was completed as part of their admission. During an interview on 08/26/24 at 11:05 AM with PT 1, PT 1 stated she recalls helping Resident 356 during a therapy session on August 5th. PT 1 stated that during a transfer (physical move) from the edge of the bed to a wheelchair, Resident 356 had an assisted fall to the ground. During a concurrent interview and record review on 08/27/24 at 11:24 AM with Nurse Manager (NM) 2, Resident 356's electronic medical record was reviewed. NM 2 stated that she does not see a post-fall assessment done. During a concurrent interview and record review on 08/27/24 at 11:24 AM with Nurse Manager (NM) 2, Resident 356's Interdisciplinary Team Meeting (IDT, a collaborative group of people involved in a resident's care) note, dated 08/08/24 was reviewed. The IDT note indicated that after Resident 356's fall, Fall safety precautions at all times enforced all shift. Family and staff fully aware. NM 1 stated that this was the only documentation by the IDT of the fall on August 5th, 2024. During a concurrent interview and record review on 08/27/24 at 11:24 AM with Nurse Manager (NM) 2, facility Policy and Procedure (P & P) titled, Fall Prevention Policy, last revised August 2024 was reviewed. The P & P indicated that the IDT should ensure that Cause of fall is discussed . Root cause is analyzed and documented .recommendations for interventions are documented . Care plan updated and documented .IDT participants presence is documented. NM 2 stated that these details were not documented in the IDT note for Resident 356's fall on August 5th, 2024.

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 8/20/24 and 8/21/24, four medication errors were observed out of twenty-six opportunities for three out of six residents, resulting in an error rate of 15%. This failure had the potential to result in harm in the health and safety of residents. Findings: 1. A review of the manufacturer insert for Flovent indicated to properly administer the Flovent HFA 220 ug inhaler, it is essential to follow the manufacturer's instructions. Begin by shaking the inhaler vigorously for five seconds to ensure that the medication is well-mixed. Hold the inhaler with the mouthpiece facing downwards, and exhale deeply through the mouth to empty the lungs as much as possible. While inhaling deeply, press the top of the canister all the way down to release the medication. After inhaling, hold your breath for up to 10 seconds, or as long as you comfortably can, allowing the medication to settle in your lungs. Once you have held your breath, resume normal breathing to restore regular respiratory function. By carefully following these steps, you can ensure that the medication is administered effectively and reaches the lungs, providing the intended therapeutic effect. During an observation on 08/20/24 at 10:15 AM, LVN 1 administered the Flovent HFA 220 ug inhaler to Resident 102. However, the administration technique appeared to be inadequate as Resident 102 did not receive the full dose of the medication. The nurse neglected to shake the inhaler for five seconds before placing the mouthpiece into the resident's mouth, which is an essential step to ensure proper mixing of the medication. LVN 1 failed to instruct Resident 102 to inhale deeply and hold their breath while administering the medication. Consequently, most of the mist was observed coming out of the resident's mouth, indicating that the medication was not effectively delivered into their lungs. During an interview on 8/20/24 at 10:15 AM LVN 1 stated and acknowledged that Resident 102 did not receive the full dose of the administered medication, as a significant portion was visibly observed exiting the resident's mouth. Additionally, LVN 1 admitted to not shaking the inhaler before administration, which is an essential step in ensuring proper medication mixing and dosing. Although LVN 1 correctly placed the mouthpiece of the inhaler into Resident 102's mouth, LVN 1 failed to instruct Resident 102 to inhale deeply and hold their breath while administering the medication. Consequently, most of the mist was observed coming out of the resident's mouth, indicating that the medication was not effectively delivered into their lungs. Proper instruction and technique are crucial to ensure the effective administration of inhaled medications and should be emphasized in future administrations. 2. According to the hospital policy, Specific Medication Administration Procedures - Eyedrop Administration, Section 8.5, dated 06/2015, the purpose is to ensure the safe, accurate, and effective administration of ophthalmic solutions into the eye. To achieve this, the policy outlines specific steps for administration. Firstly, put on gloves and gently pull down the patient's lower eyelid with a gloved finger, creating a pouch. Instruct the resident to look upward, exposing the pouch for proper administration. Hold the inverted medication bottle securely between the thumb and index finger, taking care not to touch the dropper tip to maintain sterility of the eyedrop. Apply gentle pressure to dispense the prescribed number of drops into the pouch near the outer corner of the eye, ensuring the dropper does not touch the eye or any other surface. By adhering to this hospital policy, healthcare providers can administer ophthalmic solutions accurately and safely while minimizing the risk of adverse events or complications. During an observation on 08/20/24 at 10:15 AM, LVN 1 administered one drop of Systane in both eyes to Resident 102; however, while administering the eyedrops, the tip of the dropper came into contact with the eyelashes of both eyes. Systane is a brand of eye drops used to relieve dry, irritated eyes. It helps to keep the eyes moist, protect them from injury and infection, and reduce symptoms like burning, itching, and redness. This contact between the dropper and eyelashes deviates from the recommended technique for maintaining sterility during eyedrop administration. To ensure safety and minimize the risk of contamination, it is essential for healthcare providers to avoid touching the tip of the dropper to any surface, including eyelashes, when administering ophthalmic solutions. During an interview conducted on 08/20/24 at 10:15 AM, LVN 1 acknowledged that during the administration of Systane eyedrops to Resident 102, the tip of the eyedrop bottle had indeed made contact with the resident's eyelashes. This admission confirms the deviation from recommended practices for maintaining sterility during eyedrop administration, highlighting the importance of adhering to proper techniques to ensure the safe and effective delivery of ophthalmic solutions. 3. During an observation on 08/20/24 at 12:23 PM, LVN 2 administered one drop of Systane in both eyes of Resident 217. However, the LVN 2 did not wear gloves during the administration process, which raises concerns about maintaining appropriate infection control standards. Moreover, the tip of the dropper bottle touched the eyelashes of both eyes, which deviates from the recommended technique for ensuring sterility during eyedrop administration. To maintain safety and minimize the risk of contamination, healthcare providers should wear gloves and avoid contact between the dropper tip and any surface, including eyelashes, when administering ophthalmic solutions. During an interview on 8/20/24 at 12:30 PM, LVN 2 confirmed that she did not wear gloves while administering one drop of Systane in both eyes of Resident 217. She further acknowledged that she encountered difficulties during the process, which led to the tip of the eyedrop bottle touching the eyelashes of both eyes. LVN 2's statement corroborates the observed deviation from recommended practices for maintaining sterility during eyedrop administration. Healthcare providers should emphasize the importance of adhering to proper infection control standards, such as wearing gloves and avoiding contact between the dropper tip and any surface, including eyelashes, to ensure the safe and effective administration of ophthalmic solutions. 4. During an observation on 8/21/24, at 9:15 AM, Registered Nurse 2 administered Olopatadine 0.2% eyedrops to Resident 428. However, while administering the drops, the tip of the dropper bottle touched the patient's eyelashes and was placed very closely to the eye. This resulted in Resident 428 repeatedly blinking their eyes, and it was evident that their eyelashes made contact with the tip of the bottle. Maintaining proper technique during eyedrop administration is crucial to avoid potential contamination and ensure the safety of patients. In this case, the nurse should be reminded of the importance of adhering to recommended practices and taking necessary precautions to prevent contact between the dropper tip and the patient's eyelashes or any other surface. During an interview conducted on 8/21/24, at 9:20 AM, Registered Nurse 2 acknowledged that she had held the tip of the Olopatadine 0.2% eyedrop bottle too close to Resident 428's eyes during administration. RN 2 also admitted that she noticed Resident 428 was blinking excessively during the process. Recognizing these issues, RN 2 expressed her intention to improve her technique in the future to prevent similar incidents from occurring again, demonstrating a willingness to learn from her experience and prioritize patient safety.

Based on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed multiple medication errors related to eye drops (See F759). Findings: The hospital policy, Specific Medication Administration Procedures - Eyedrop Administration, Section 8.5, aims to ensure the safe and accurate administration of ophthalmic solutions by outlining specific steps, such as wearing gloves, creating a pouch with the lower eyelid, and carefully dispensing drops without touching the dropper to any surface. However, during an observation on 08/20/24, Licensed Vocational Nurse (LVN) 1 administered Systane eye drops to Resident 102 but allowed the dropper tip to touch the resident's eyelashes, which is a deviation from the recommended sterile technique. Systane is used to relieve dry, irritated eyes, and maintaining dropper sterility is crucial to prevent contamination. LVN 1 later acknowledged the mistake during an interview, underscoring the importance of adhering to proper procedures to ensure the safe and effective administration of eye medications to residents like Resident 102. During an observation on 08/20/24 at 12:23 PM, Licensed Vocational Nurse (LVN) 2 administered Systane eye drops to Resident 217 without wearing gloves, raising concerns about infection control. Additionally, the dropper tip touched the resident's eyelashes, which deviates from the recommended sterile technique. In an interview at 12:30 PM, LVN 2 confirmed that she did not wear gloves and acknowledged that the dropper tip touched the eyelashes due to difficulties during the procedure. This incident highlights the importance of adhering to proper infection control standards, such as wearing gloves and avoiding contact between the dropper tip and any surface, including eyelashes, to ensure safe and effective administration of ophthalmic solutions for residents like Resident 217. During an observation on 8/21/24 at 9:15 AM, Registered Nurse (RN) 2 administered Olopatadine 0.2% eyedrops to Resident 428. During the procedure, the tip of the dropper bottle touched the resident's eyelashes and was placed very close to the eye, causing the resident to blink repeatedly. This contact between the dropper tip and the eyelashes raised concerns about potential contamination and improper technique. In an interview at 9:20 AM, RN 2 acknowledged that she had held the dropper too close to Resident 428's eyes and noticed the excessive blinking. She expressed her intention to improve her technique in the future, demonstrating a commitment to learning from the incident and prioritizing patient safety. During an interview on 8/21/24 at 3:30 PM an interview was conducted with two members of the Quality Committee: the Assistant Director of Nursing, the Director of Nursing, and the Administrator. During this interview, it was noted that they had not identified any issues related to medication pass observations. Furthermore, they did not have any ongoing performance improvement projects specifically aimed at addressing medication errors. However, the Quality Committee members acknowledged the need for improvements in the medication administration process. They expressed concern over the survey results, which indicated a medication error rate of 15%. This statistic underscores the urgency of their commitment to enhancing the current procedures.

Based interview and record review, the facility failed to provide two of three residents, Resident 177 and Resident 248, with SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice). FINDINGS: Review of Resident 177, resident was admitted on [DATE] for Part A services, with diagnosis of Chronic Inflammatory Demyelinating Polyneuritis (a disease of the nervous system with progressive weakness and loss of sense and function of the legs and arms). SNF Beneficiary Protection Notification Review for Resident 177, indicated, Medicare Part A Skilled Services Episodes Start date:2/28/24. Last Covered day of Part A Service: 5/1/24. NOMNC was given 4/28/24. No issues. SNF ABN form not provided to resident. Per facility, CMS-10055 not needed, Resident 177 was placed on Part A for daily skilled PT,OT and ST. Resident 177 is still in the facility for custodial care. Review of Resident 248, resident was admitted on [DATE] for Part A services, with diagnosis of Ileus (a condition when the bowel does not work correctly). SNF Beneficiary Protection Notification Review for Resident 248, indicated: Medicare Part A Skilled Services Episode Start date: 3/18/24. Last covered day of Part A Service: 4/23/24. NOMNC given 4/9/24. SNF ABN form not provided to resident. Per facility,CMS-10055 not needed, Resident 248 was placed on Part A for skilled rehab. Resident 248 is still in the facility for custodial care. During an interview on 8/29/24 at 9:40 AM, with UM (Utilization Manager), per UM, form SNF ABN is for non-covered services, 90 % of admitted residents are discharged . SNF ABN form is provided when residents are under Medicare B. During an interview on 8/29/24 at 10:40 AM, with MDS RN (Minimum Data Set), per MDS RN, form SNF ABN is given when 100 skilled days is exhausted or when resident is readmitted without skilled need. Review of facility Policy and Procedure, Advanced Beneficiary Notices Policy, undated, indicated, Policy Explanation and Compliance Guidelines: 4. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay before the facility provides: a. an item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary, or b. Custodial care. 5. The current CMS-approved version of the forms shall be used at the time of the issuance to the beneficiary .a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), Form CMS-10055.

Based on interview and record review the facility failed to recognize and report an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not reported to the facility administrator or other necessary agencies. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse. Findings: A review of facility policy and procedure (P & P), titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, last revised August 2024, defined verbal abuse as the use of oral, written or gestured communication that willfully includes disparaging and derogatory terms to resident or their families . The P & P further indicated that reports of alleged abuse .are promptly and thoroughly investigated, and report all abuse allegations to the administrator/designee, California Department of Public Health, San Francisco Police Department if appropriate, ombudsman, and any other required agencies .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. A review of Resident 372's face sheet (summary of resident's demographic and admitting information), dated 08/27/24, indicated that Resident 372 was admitted in 2024 with diagnoses including AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY and INJURY OF FEMORAL NERVE [part of the body that sends signals from the brain to the leg] . A review of Resident 372's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents), dated 08/02/2024, indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15 out of 15 (scores of 0-7 suggest severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). A review of a psychosocial note written by SW 1, dated 08/02/24, indicated that Resident 372 had strong communication and analytical skills. It further stated that Resident 372 ordered something online and was 'yelled at' by nursing that she was not allowed to have it. Resident 372 also reported that she was switched from her very good PT to [PT 1] . and she feels like it might be 'retaliation' and was allegedly told by PT 1 that she could be discharged any day because she is not making progress and that she should be 'thankful that you [Resident 372] have one good leg.' A review of a social services note by SW 2, dated 08/07/24, indicated that SW 2 discussed scheduling a care conference (a meeting involving resident's, family, and their care team to discuss how to meet a resident's needs) and that Resident 372 only wanted to meet with certain people due to issues arising with specific departments. During an interview on 08/21/24 at 10:40 AM with Resident 372, in their room, Resident 372 stated that PT 1 was verbally abusive to her and told her she should be very happy I'm only paralyzed in one leg. Resident 372 stated this occurred around 08/01/24 and she initially reported this to SW 1 on 08/02/24 but does not recall anything happening after that. During an interview on 08/26/24 at 2:27 PM with the Director of Social Services (DSS), the DSS stated that any abuse or allegation of abuse should be reported immediately to the police . the State [State Agencies], and Ombudsman [a person that advocates fair processes, provides advice/resources, and helps address complaints]. The DSS stated that it is important to report any allegation of abuse to keep the patient or resident safe in our community and outside . and ensure that it is properly investigated and resolved. During a telephone interview on 08/27/24 at 9:49 AM with SW 1, SW 1 stated that they recall that the Resident 372 was upset. SW 1 stated that they should report any kind of abuse anytime they suspect it. SW 1 stated they likely should have reported this as an allegation of abuse. During an interview on 08/27/24 at 3:06 PM with the Administrator. The Administrator stated they were not able to locate a report of alleged abuse or investigation of alleged abuse regarding Resident 372.

Based on interview and record review the facility failed to recognize and investigate an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not thoroughly investigated by the facility. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse. Findings: A review of facility policy and procedure (P & P), titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, last revised August 2024, defined verbal abuse as the use of oral, written or gestured communication that willfully includes disparaging and derogatory terms to resident or their families . The P & P further indicated that reports of alleged abuse .are promptly and thoroughly investigated, and report all abuse allegations to the administrator/designee, California Department of Public Health, San Francisco Police Department if appropriate, ombudsman, and any other required agencies .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. A review of Resident 372's face sheet (summary of resident's demographic and admitting information), dated 08/27/24, indicated that Resident 372 was admitted in 2024 with diagnoses including AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY and INJURY OF FEMORAL NERVE [part of the body that sends signals from the brain to the leg] . A review of Resident 372's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents), dated on 08/02/2024, indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15 out of 15 (scores of 0-7 suggest severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). A review of a psychosocial note written by SW 1, dated 08/02/24, indicated that Resident 372 had strong communication and analytical skills. It further stated that Resident 372 ordered something online and was 'yelled at' by nursing that she was not allowed to have it. Resident 372 also reported that she was switched from her very good PT to [PT 1] . and she feels like it might be 'retaliation' and was allegedly told by PT 1 that she could be discharged any day because she is not making progress and that she should be 'thankful that you [Resident 372] have one good leg.' A review of a social services note by SW 2, dated 08/07/24, indicated that SW 2 discussed scheduling a care conference (a meeting involving resident's, family, and their care team to discuss how to meet a resident's needs) and that Resident 372 only wanted to meet with certain people due to issues arising with specific departments. During an interview on 08/21/24 at 10:40 AM with Resident 372, in their room, Resident 372 stated that PT 1 was verbally abusive to her and told her she should be very happy I'm only paralyzed in one leg. Resident 372 stated this occurred around 08/01/24 and she initially reported this to SW 1 on 08/02/24 but does not recall anything happening after that. During an interview on 08/26/24 at 2:27 PM with the Director of Social Services (DSS), the DSS stated that any abuse or allegation of abuse should be reported immediately to the police . the State [State Agencies], and Ombudsman [a person that advocates fair processes, provides advice/resources, and helps address complaints]. The DSS stated that it is important to report any allegation of abuse to keep the patient or resident safe in our community and outside . and ensure that it is properly investigated and resolved. During a telephone interview on 08/27/24 at 9:49 AM with SW 1, SW 1 stated that they recall that the Resident 372 was upset. SW 1 stated that they should report any kind of abuse anytime they suspect it. SW 1 stated they likely should have reported this as an allegation of abuse. During an interview on 08/27/24 at 3:06 PM with the Administrator. The Administrator stated they were not able to locate a report of alleged abuse or investigation of alleged abuse regarding Resident 372.

Based on interview and record review, the facility failed to accurately assess hearing for one out of two sampled residents (Resident 356) when Resident 356 was assessed as not having hearing aids when they used hearing aids on admission to the facility. This failure has the potential for Resident 356's needs to not be met due to their communication and hearing needs not being accurately assessed. Findings: A review of Resident 356's face sheet (summary of resident's demographic and admitting information), dated 08/27/24, indicated that Resident 356 was admitted in 2024 with diagnoses including DISPLACED FRACTURE OF MEDIAL CONDYLE OF RIGHT FEMUR . (a break in the right upper leg bone). A review of Resident 356's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) dated on 08/03/2024 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 out of 15 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). A review of Resident 356's care plan, dated 07/29/24, indicated that a focus of The resident has a communication problem r/t [related to] Hearing deficit. The interventions to this focus problem area included Apply bilateral [both sides] hearing aid while awake for communication. During a concurrent observation and interview on 08/21/24 at 2:27 PM with Resident 356 in their room, Resident 356 was observed pointing to their left ear. Resident 356 stated that she could best hear in her left ear because her right-sided hearing aid was broken. Resident 356 stated she thinks someone jammed a battery accidentally when changing the batteries. She further stated it occurred about ten days prior. During a concurrent observation and interview on 08/26/24 at 11:01 AM with RN 3 in Resident 356's room, RN 3 was observed asking Resident 356 about their hearing aids. RN 3 stated that she was not aware that Resident 356 had only been wearing one hearing aid. During a concurrent interview and record review on 08/28/24 at 2:18 PM with MDS Nurse 1, Resident 356's MDS, dated [DATE], was reviewed. The MDS indicated that Resident 356's Ability to hear (with hearing aid or hearing appliances if normally used) was assessed as Adequate - no difficulty in normal conversation, social interaction . The MDS further indicated that Resident 356's Hearing aid or other hearing appliance used was assessed as No. MDS Nurse 1 stated that it should have been assessed as a yes if the resident does wear hearing aids. MDS Nurse 1 further stated that this is an inaccurate assessment of the Resident's hearing.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for 1 of 35 sampled residents (Resident 327) when: 1. Care plan was not developed to address urinary tract infection (UTI, a common infection that occurs when bacteria enter the urinary tract and cause inflammation). 2. Fall care plan interventions were not implemented. These failures had the potential for not meeting Resident 327's nursing needs and goals to attain the resident's highest practicable well-being. Findings: 1. Review of Resident 327's clinical record indicated, Resident 327 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a condition that causes excessive fear, worry, and uneasiness that can interfere with daily life), and urinary tract infection (UTI). Review of Resident 327's Minimum Data Set (MDS, resident assessment tool) dated 4/17/24 indicated, . Cognitive Patterns (the mental processes that people use to perceive, interpret, and process information from their surroundings) . resident is rarely/never understood . Review of Resident 327's order, dated 6/30/24 indicated, . Sulfamethoxazole-Trimethoprim (Antibiotic, a drug used to treat infections caused by bacteria and other microorganisms) Oral Tablet 800-160 MG (milligram) . Give 1 table by mouth every 12 hours for Bacterial Infection -UTI for 5 Days until finished . Review of Resident 327's Medication Administration Record (MAR) of June 2024 and July 2024 indicated, the resident had Sulfamethoxazole-Trimethoprim from 9 PM on 6/30/24 to 9 AM on 7/5/24. Review of Resident 327's Progress Notes dated 7/5/24 indicated, . Chief Complaint UTI . She was sent to ER (emergency room ) on 6/28/24 for report of facial droop (a loss of facial movement or muscle function on one or both sides of the face) slurred speech (a condition that makes it hard to speak due to issues with the muscles used for speech) . and found to have UTI . During a concurrent interview and record review on 8/23/24 at 2:19 PM with Registered Nurse (RN) 2, Resident 327's care plans were reviewed. RN 2 stated, I don't see it when asked if there was a care plan for Resident 327's UTI. During an interview on 8/23/24 at 2:20 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 verified, Resident 327 had UTI before. During an interview on 8/26/24 at 11:12 AM with RN 2, RN 2 stated, I do not see anything on the care plan when asked about care plan for Resident 327's UTI. RN 2 acknowledged, They should have had a care plan for UTI when asked. 2. During an observation on 8/26/24 at 9:43 AM in the activity room, Resident 327 did not have an injury. During an interview on 8/26/24 at 9:50 AM with LVN 3, LVN 3 stated, Resident 327 was confused due to dementia. LVN 3 verified, Resident 327 did not have injuries from the recent falls. During a concurrent interview and record review on 8/26/24 at 10:08 AM with Registered Nurse (RN) 2, Resident 327's fall score (a medical assessment that estimates a resident's risk of falling), dated 5/7/24 was reviewed. The fall score indicated, . Score: 14 Score 10 or higher indicated the resident is at high risk of fall. RN 2 verified, Resident 327's fall score was 14 on 5/7/24 and the score of 14 meant the resident was at high risk of fall. During a concurrent interview and record review on 8/26/24 at 11:45 AM with RN 2, Resident 327's fall care plan was reviewed. The fall care plan indicated, . Risk for Falls r/t (related to) 1. Poor balance, 2. poor safety awareness . dementia 3. Unsteady gait . Date Initiated: 05/07/2024 . Then, updated fall care plan, dated 7/10/24 indicated, . Interventions . Rounding every 2-hour . RN 2 stated, I do not see the specific 2-hour monitoring . when asked about the evidence of it. RN 2 verified, Resident 327 fell on [DATE], 6/13/24, 6/18/24, 6/21/24, 6/24/24, 6/30/24, and 8/21/24 when asked. During an interview on 8/26/24 at 1:28 PM with RN 2, RN 2 stated, I couldn't find the order, when asked about the evidence of fall care plan intervention regarding . Rounding every 2-hour . for Resident 327. RN 2 stated, It should be documented. But I couldn't find it when asked if every 2-hour rounding should have been documented per Resident 327's fall care plan. During a concurrent interview and record review on 8/26/24 at 1:55 PM with Licensed Vocational Nurse (LVN) 3, Resident 327's fall care plan, dated 6/21/24 was reviewed. The fall care plan indicated, . Interventions . Video monitoring . LVN 3 stated, No when asked if there was evidence of documentation regarding video monitoring. During an interview on 8/27/24 at 11:35 AM with RN 2, RN 2 verified, there was no evidence of documentation of video monitoring. Review of the facility's policy and procedure (P&P) titled, Fall Prevention Policy revised in August 2024 indicated, . 4. Appropriate interventions . will be implemented for residents/patients at risk for falls as identified by Nursing, and the IDT (interdisciplinary team, a group of healthcare professionals from different fields who work together to provide the best care for a patient) . 7. Video monitoring may be considered as an intervention for patients/residents at risk for falling . Review of the facility's P&P titled, Care Plan Policy revised in March 2024 indicated, . The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .

Based on observation, interview, and record review, the facility failed to update care plans for three of 35 sampled residents (Resident 327, 187, and 264) when: 1. Fall care plan was not updated for Resident 187 after her falls on 2/15/24, 3/23/24, and 8/2/24. 2. Fall care plan was not updated for Resident 327 after her falls on 6/30/24, and 8/21/24. 3. Care plan for pain was not updated for Resident 264. These failures had the potential to put the residents at risk of not receiving appropriate cares. Findings: 1. Review of Resident 187's clinical record indicated, Resident 187 was admitted to the facility with diagnoses including dementia (memory loss), hypertension (high blood pressure), and atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke). Review of Resident 187's Minimum Data Set (MDS, resident assessment tool), dated 2/8/24 indicated, her memory was severely impaired. During an interview on 8/27/24 at 2:02 PM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, Resident 187 was confused due to dementia. Review of Resident 187's Nurse Note (NN), dated 2/15/24 indicated, . 02/15/2024 7:25 AM Fall was not witnessed. Fall occurred in the hallway . found lying on the floor . Possible missed the chair. [NAME] was in front of the res. (resident) . No injury noted . Review of Resident 187's NN, dated 3/23/24 indicated, At 0700 (7:00 AM), CNA (Certified Nursing Assistant) found resident sitting on floor in her room . No s/s (signs and symptoms, abnormalities that can indicate a medical condition) of head injury . Review of Resident 187's IDT (interdisciplinary team, a group of healthcare professionals from different fields who work together to provide the best care for a patient) Meeting Note, dated 8/2/24 indicated, Resident sustained (maintained) a witnessed fall. Resident was sitting in wheelchair . Resident was kicking against legs of table hard enough to tip wheelchair back, resident fell backwards, remaining in seated position in the wheelchair . No sustained injuries . During an observation on 8/27/24 at 2:03 PM in the activity room, Resident 187 did not have an injury. During a concurrent interview and record review on 8/27/24 at 2:17 PM with Registered Nurse (RN) 2, Resident 187's fall care plan was reviewed. The fall care plan indicated, there was no updated fall care plan for Resident 187 after her falls on 2/15/24, 3/23/24, and 8/2/24. RN 2 stated, I don't see a specific care plan for fall . when asked. RN 2 stated, No. I don't see anything for this year . when asked again if there is evidence of updated fall care plan after Resident 187's actual falls on 2/15/24, 3/23/24, and 8/2/24. 2. Review of Resident 327's clinical record indicated, Resident 327 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a condition that causes excessive fear, worry, and uneasiness that can interfere with daily life), and urinary tract infection (UTI, a common infection that occurs when bacteria enter the urinary tract and cause inflammation). Review of Resident 327's Minimum Data Set (MDS, resident assessment tool) dated 4/17/24 indicated, . Cognitive Patterns (the mental processes that people use to perceive, interpret, and process information from their surroundings) . resident is rarely/never understood . Review of Resident 327's Nurse Note (NN), dated 6/30/24 indicated, @1830 (at 6:30 PM) . resident fell while trying to get from the bed . Resident had small bump at right back of her head . Review of Resident 327's NN, dated 8/21/24 indicated, Resident had a witnessed fall @ (at) 8:15 AM . no injury noted . During an observation on 8/26/24 at 9:43 AM in the activity room, Resident 327 did not have an injury. During an interview on 8/26/24 at 9:50 AM with LVN 3, LVN 3 stated, Resident 327 was confused due to dementia. LVN 3 verified, Resident 327 did not have injuries from the recent falls. During a concurrent interview and record review on 8/26/24 at 11:45 AM with Registered Nurse (RN) 2, Resident 327's electronic medical record was reviewed. RN 2 verified, Resident 327 fell on [DATE], 6/13/24, 6/18/24, 6/21/24, 6/30/24, and 8/21/24 when asked. During a concurrent interview and record review on 8/26/24 at 1:55 PM with Licensed Vocational Nurse (LVN) 3, Resident 327's fall care plan was reviewed. LVN 3 stated, It's concerning when asked how she would feel if her mother was a resident at the facility and had multiple falls like Resident 327 and if Resident 327's fall care plan was effective to prevent falls. LVN 3 stated, Video monitoring. q2hour (every 2 hour) rounding. One- to-one safety monitor when asked what the most effective intervention for Resident 327 would be to prevent falls. LVN 3 stated, Yes when asked if Resident 327 is needed for one-to-one safety monitoring since Resident 327 had falls multiple times. During a concurrent interview and record review on 8/26/24 at 2:05 PM with RN 2 and LVN 3, Resident 327's fall care plan was reviewed. RN 2 and LVN 3 stated, there was no evidence of updated fall care plan after Resident 327's falls on 6/30/24 and 8/21/24 when asked. Review of the facility's policy and procedure (P&P) titled, Fall Prevention Policy revised in August 2024 indicated, . The Jewish Home & Rehab Center ensures . that each patient/resident receives adequate supervision . All patients/residents shall be assessed for fall risk . change of condition, after a fall . All patients/residents identified as at risk for falls shall have an individual care plan that includes interventions to prevent falls from occurring and considers the individual's ADL (Activities of Daily Living, the self-care tasks that a person does daily to maintain independence and care for themselves) ability . Review of the facility's policy and procedure (P&P) titled, Care Plan Policy revised in March 2024 indicated, . 4. Comprehensive care plans. a. The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . 5. A comprehensive care plan must be . c. Reviewed and revised by the interdisciplinary team (IDT, a group of healthcare professionals from different fields who work together to provide the best care for a patient) after each assessment . 43913 3. Review of Resident 264, resident admitted [DATE], with a diagnosis of Diabetes Mellitus (high sugar level), Cancer of the Lung, Osteoporosis (a disease that weakens the bones that they break easily). Resident re- admitted on [DATE] with diagnosis of Fracture of right Femur(a break of the right hip) needing surgery. During an interview on 8/20/24 at 10AM, with CNA3, per CNA 3, resident is alert but sometimes refused to talk to people she does not know. She had a fall last week, just came back and she is getting therapy. She complains of pain of the right hip, nurse gives pain pill. She was independent with walking, so she feels sad now she is in a wheelchair. Family comes to visit. During a concurrent interview and chart review on 8/23/24 at 9:30AM, with RN2, per RN2, resident had a fall on 8/11/24, sustained right hip fracture, was transferred to acute and has surgery on 8/12/24. IDT(Interdisciplinary) meeting done. Per IDT notes on 8/16/24, the resident is referred to PT/OT, recommendations for Vitamin D+Calcuim . will be on 2- hour rounding, educate to use call light, care plan is updated. Continue with fall interventions. Review of Fall care plan updated and revised 8/16/24. Post fall evaluation done 8/15/24. Review of Pain Care plan initiated 5/23/24. No updated interventions and goals for the fall on 8/11/24. During an interview on 8/22/24 at 3PM, with PT (Physical Therapist), per PT 1, patient is walking about 15 ft with the walker. Able to tolerate 6/10 pain level. Patient will get back to baseline. During an interview on 8/27/24 at 10AM,with LVN4, per LVN 4, care plans are updated when there is a change of condition, assessments due, re- admissions and when there is a need. Updating a care plan is adding new interventions and change dates. During an interview on 8/27/24 at 10:45 AM, with NM 2(Nurse manager), per NM 2, the goal date is changed when indicated in the chart, due to renew 11/19/24. Confirmed that pain care plan is not due for update. Review of facility Policy and Procedure, Care Plan Policy, dated 3/24, indicated, 5.A comprehensive care plan must be .c. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview and record review, the facility failed to ensure that a resident's assistive hearing device was functioning in one of two sampled residents (Resident 356) when Resident 356 reported that their hearing aid had been broken for multiple days and clinical staff were not aware of it. This failure has the potential to result in the residents' needs not being met due to a reduction in their ability to hear and communicate. Findings: A review of Resident 356's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) dated on 08/03/2024 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 out of 15 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). During a concurrent observation and interview on 08/21/24 at 2:27 PM with Resident 356 in their room, Resident 356 was observed pointing to their left ear. Resident 356 stated that she could best hear in her left ear because her right-sided hearing aid was broken. Resident 356 stated she thinks someone jammed a battery accidentally when changing the batteries. She further stated it occurred about ten days prior. A review of Resident 356's care plan, dated 07/29/24, indicated a focus of The resident has a communication problem r/t [related to] Hearing deficit. The interventions to this focus problem area included Apply bilateral [both sides] hearing aid while awake for communication. During an interview on 08/26/24 at 10:38 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated that Resident 356 has a hearing aid . only in one ear, that they are aware of. During an interview on 08/26/24 at 10:44 AM with Registered Nurse (RN) 3, RN 3 stated that Resident 356 has bilateral hearing aids. RN 3 stated they will usually know that a hearing aid is broken when a resident tells them. During a concurrent observation and interview on 08/26/24 at 11:01 AM with RN 3 in Resident 356's room, RN 3 was observed asking Resident 356 about their hearing aids. RN 3 stated that she was not aware that Resident 356 had only been wearing one hearing aid. During an interview on 08/27/24 at 11:42 AM with Nurse Manager (NM) 2, NM 2 stated that she was recently made aware that one of Resident 356's hearing aids were broken. NM 2 stated she expects nursing staff to check hearing aid function daily for residents when they speak to residents and they may notice a problem hearing. A review of facility policy and procedure (P & P), titled Hearing Enhancement - Care of Hearing Aids, last revised August 2024, indicated that For Cognitively Able Residents staff should Perform daily cleaning and inspection of hearing aid .

Based on interview, observation, and record review, the facility failed to provide an environment free of accident hazards when Resident 1 (one sampled resident), spilled a cup of hot water onto her chest, left hand, and left thigh, and suffered 2nd degree burns from the hot water. The facility failed to provide adequate supervision to prevent an avoidable accident. Finding: Resident 1 was readmitted to the facility on [DATE] with diagnoses including history of falling, muscle weakness, heart failure, liver and kidney disease, gait and mobility abnormalities. Review of Resident 1's Minimum Data Set (MDS), an assessment tool, indicated no cognition difficulties (thinking), required partial assistance transferring from bed to chair and back, required assistance with meal set-up and clean-up. Resident 1 has left-handed weakness due to a stroke in 2021. During an observation and interview in Resident 1's room on 1/22/2024, at 10:45 AM, resident was reclining on bed holding a small wrapped bag of ice on her chest, she stated she spilled hot water on her chest, left hand, and left leg when two covered cups were left on the overbed table while she was in the bathroom. She said she did not know one was hot water. She said she had asked only for warm water. She removed the cover of one cup to see what it was and her left hand is weak and she spilled the hot water on herself. She said it was painful. She showed me her chest, hand and leg. They were reddened and swollen. She said the ice made it feel a little better. Review of Nurses Notes dated 1/22/2024 on 2:20 PM, indicated Resident 1 requested warm water. CNA gave a cup of hot water and a cup of warm water to resident while resident was in bath room. During an observation and interview in Resident 1's room on 1/23/2024, at 2:45 PM, resident stated her chest had a blister on it. She said the burned areas were still sore. Resident's left hand and leg were still red and swollen. Review of Doctors Orders for resident's burns dated 1/23/2024 indicated Resident 1 had Second Degree burns to chest wall with blister and blister and redness to left thigh. During an observation and interview in Resident 1's room on 1/24/2024, at 1:50 PM, resident stated her leg had a blister on it. Blisters looked the size of a nickel, and filled with fluid. Chest and leg still looked red, swollen and sore. During an interview in facility conference room on 1/24/2024, at 3:16 PM, Nurse Manager 1 with Assistant Director Of Nurses 1 present, stated (Resident 1) had burned herself when she spilled hot water on herself because her left arm is weak. She had a stroke in 2021. She had a 2nd degree burn from the water spill. The Certified Nurse Assistant (CNA) 1, (who left the hot water), needs supervision . During an interview in facility conference room on 1/24/2024, at 4:50 PM, Licensed Staff member 1 stated, After I left the room, I heard the resident scream and went back into the room. She had spilled a cup of hot water on herself. I helped her to change out of her pajamas into dry ones. I notified the doctor and he ordered bacitracin and lubricating gel. I applied it on her. Her skin was red on her chest, left hand and left thigh. The CNA brought the resident a cup of hot water and a cup of warm water, while the resident was in the bathroom. During an observation and interview in Resident 1's room on 1/25/2024, at 1:40 PM, with resident's daughter present, resident stated her chest and leg blisters had burst. The blisters looked flat, dark red, and covered with wrinkled skin. The resident still had pain. During a telephone interview on 2/1/2024, at 3 PM, CNA 1 stated she brought two cups of water to resident. One cup was filled with hot water from the coffee machine and the other cup was filled with warm water. She said she had a three hour training last week and knows she needs to supervise the resident when she brings hot water. During a telephone interview on 2/8/2024 at 10:15 AM, the Director of Nursing (DON) exec. assistant stated they did not have a policy on providing hot water to residents.

Based on interview and record review, the facility failed to keep one out of three sampled residents (Resident 1) free from confinement to his bed when a staff barricaded the right side of Resident 1's bed with two chairs and a side rail while the left side of his bed was against the wall. This failure resulted in Resident 1's family member expressing strong feelings about Resident 1 being confined and stated I saw him caged up like that with the chairs up against his bed .I took pictures and then I went to get the manager.it's not right caging someone up like that. Findings: Review of Resident 1's record titled Face Sheet, printed on 1/13/23, indicated he was admitted with multiple diagnoses including: Dementia (impaired brain function affecting memory, judgement, self-care, and behavior), kidney disease, falls, unsteadiness on feet, glaucoma (eye disease affecting vision), and hearing loss. Review of Resident 1's Minimum Data Set (MDS) assessment, dated 8/4/2022, indicated: 1. His Brief Interview for Mental Status (BIMS) assessment score was 0 out of 15. BIMS is an assessment tool to determine memory and reasoning ability. Scores between 0 and 7 indicate severe cognitive impact (hard time remembering things, making decisions, concentrating, or learning). 2. He sometimes understands simple direct communication. 3. He needed supervision with: bed mobility, transfers, and walking in room and corridor 4. He needed extensive assistance of one staff with: walking on the unit and toileting 5. He needed limited assistance of one staff: for dressing, and personal hygiene. 6. He was unsteady and only able to stabilize with staff assistance moving on and off toilet 7. He normally ambulates with a walker (a four-legged device helping a user with balance and support when walking) or a wheelchair. 8. He frequently had no voluntary control of his urine. 9. His bed rails were coded as not being used. Review of Resident 1's records titled Care Plan, printed on 1/13/23, indicated Resident 1 was . noted with increased confusion and restlessness, . (as exhibited by) episodes of walking in/out of the Room .disoriented .poor judgment and (poor) safety awareness .unable to call for assistance .noted with ongoing decline in his overall condition and functioning . (Resident 1) has .(a history) of behavioral disturbance exacerbated by dementia with agitation . (history of) physical aggressiveness and restlessness .combativeness and resistance to care .(possible triggers were) change of environment, isolation confusion secondary to dementia. (Resident 1) is at risk for falls . (as exhibited by) history of falls, .poor balance, non-compliant use of a walker . Review of Resident 1's records titled Clinical Notes Report, dated 10/14/2022, indicated Resident 1 .at this time estimates life expectancy of about two weeks, however, also explained that not possible to determine. He is in/out of somnolence/sleeping. (somnolence=state of drowsiness) .(doctor) had .(discontinued) unnecessary .(medications). The resident is currently under Palliative/comfort care . According to www.getpalliativecare.org, downloaded on 1/26/2023, Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family. Review of two photos sent by Resident 1's family member, on 1/11/2023, showed Resident 1 lying face up in bed. The left side of Resident 1's bed was against the wall. The right side of Resident 1's bed was blocked by two obstacles: 1. the back of two chairs were positioned on the right upper half of Resident 1's bed. 2.The right lower side rail of his bed was raised. During an interview on 01/11/2023 at 3:13 PM, Resident 1's family member stated .I was visiting him on 10/12/2022 around 1:30 PM, I saw him caged up like that with the chairs up against his bed .I took pictures and then I went to get the manager.it ' s not right caging someone up like that. During an interview on 01/12/2023 at 11:14 AM, Resident 1's regular nurse, LVN 1 (Licensed Vocational Nurse) was shown the two photos provided by Resident 1's family member. LVN 1 agreed that both photos showed Resident 1 in his room at the facility, resting in his bed. The photos showed the left side of Resident 1's bed was against the wall and there were two chairs blocking the right upper half of his bed and a right bottom side rail blocking the right bottom half of his bed. Review of an email sent by Resident 1's family member to facility staff, dated 10/13/2022 at 7:01 AM, indicated .on October 12, 2022 at approximately 1:30 PM, I entered .(Resident 1's) room, to find him caged up like an animal. This is textbook confinement. During an interview on 01/12/2023 at 11:25 AM, the Unit Manager was asked about Resident 1's confinement on 10/12/2022. The Unit Manager stated I found . (Resident 1 in) bed with the chairs like that because . (Resident 1's family member) was visiting and alerted me. You know . (the confinement) is unacceptable we do consider it a restraint, agency care giver was the one that started it. We do not do this in this facility ever. The Unit Manager was asked if restraints were a form of abuse and the Unit Manager replied Yes. Due to Resident 1's mental status and clinical condition, Resident 1 was unable to provide any feedback regarding his confinement incident. Resident 1's family member was interviewed on 01/12/2023 at 2:14 PM regarding this confinement incident. Resident 1's family member stated You must understand the context of this confinement. Our family came from the South, they were slaves and sharecroppers (sharecroppers=farmers living under lopsided tenant contracts that favors the landlord). There is a history of confinement in . (Resident 1's) background. (Resident 1) would not have tolerated this confinement. He would view it as an insult to his manhood and his worth as a human being. You have to understand that this is a dying man in his last days of life. The man is already confused, imagine putting obstacles in front of a confused man as he's trying to get out of bed .maybe he's trying to go pee. Imagine the rage and confusion when . (Resident 1) sees himself confined. He is going to spend his last ounce of energy trying to get rid of those chairs in front of him. That's not right to cage him in like an animal and you wouldn't want to be treated like that . confused or not, nobody should be treated like that. Review of the facility's policy titled Prevention of Patient/Resident Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 10/12/2022, indicated .It is the policy of the Jewish Home & Rehabilitation Center that each resident/patient will be free from abuse and neglect. This includes but is not limited to, physical, verbal, sexual, mental, or financial abuse, neglect, abandonment, isolation, false imprisonment, abduction, unreasonable physical restraint, corporal punishment, involuntary seclusion, misappropriation of resident property, and/or deprivation of goods or services that are necessary for a resident's physical, mental and psychosocial well- being.Physical Restraint is . any manual method, physical or mechanical device, equipment, or material that Is attached or adjacent to the resident ' s body; Cannot be removed easily by the resident/patient; and restricts the resident's/patient's freedom of movement or normal access to his/her body.Abuse is the willful infliction of . unreasonable confinement, . with resulting physical harm, pain or mental anguish.

Based on interviews and record review, the facility failed to ensure Residents 1, 2, 3, and 4, four out of 10 sample residents, were protected from abuse/neglect. Resident 1 reported long wait for staff assistance with repositioning and incontinence care. Additionally, Resident 1 reported to the facility that CNA 1 was rough with him and caused him pain during repositioning. Resident 1 stated he did not want CNA 1 working with him. Resident 1 stated CNA 1 was still helping to care for him and he is fearful of CNA 1. Resident 2 reported a pattern of long wait for assistance with incontinence care. It made Resident 2 so emotionally distraught that she said she wanted to cry thinking about what happened. Resident 3 ' s family member reported witnessing long wait for assistance for incontinence care for Resident 3. Resident 3 stated he felt neglected, mad, unclean when made to lay in a soiled wet adult brief for 45 minutes to an hour. Resident 4 reported a chronic problem of long wait for assistance with repositioning and incontinent care. Resident 4 reported feelings of not being treated like a human being, and this overwhelming feelings of guilt when she needs to ask for assistance. The facility failed to protect Residents 1, 2, 3, and 4 from neglect, when a pattern of delayed response to requests for assistance resulted in Resident 1, 2, 3 and 4 reporting psychosocial harm. Additionally, Resident 1 expressed fear of working with CNA 1 because she caused him pain when repositioning him. Findings: Resident 1 Review of Resident 1 ' s facility document titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 03/16/2022, his BIM score was 12 out of 15 (Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 8-12 indicates moderate impairment in memory and reasoning). His MDS indicated he displayed no episodes of hallucination (seeing, hearing, or sensing things that is not based on reality) and displayed no episodes of delusion (believing in something that is not based on reality). His MDS indicated he had no verbal behavioral symptoms directed toward others (for example: threatening others, screaming at others, cursing at others). His MDS indicated he needed extensive assistance of two staff with moving around in bed and for toilet use. His MDS indicated he was totally dependent on two staff for transfers and for moving around to different areas of the unit. His MDS indicated he was always incontinent of bowel and bladder. His MDS indicated he displayed no episodes of hallucination, no delusion, and no rejection of care. Review of Resident 1 ' s facility document titled FACE SHEET, dated 08/02/2022, indicated he was admitted to the facility on [DATE] with multiple diagnose including: depression, [CONDITION(S)] (a disorder associated with episodes of mood swings ranging from depressive lows: low energy, loss of interest in daily activities, low motivation, to manic highs: high energy, reduce need for sleep, and losing touch with reality), left sided [CONDITION(S)] (weakness and loss of control to one side of the body), stroke (a loss of blood flow to part of the brain, which damages brain tissue), During an interview on 07/28/2022 at 11:49 AM, Resident 1 stated .I have to wait a long time for them to come. Sometimes an hour or more. I remember waiting and waiting for them to come change me. I got so tired of waiting that I used my cell phone to call the nursing station. Sometimes the phone would ring and ring and ring. No one would come. One time someone did answer and they hung up on me right away. I got so upset I had to call . (my friend). She had to call them to come take care of me. It ' s depressing, I get mad just thinking about this. Resident 1 stated he does not want CNA 1 (Certified Nursing Assistant) working with him. Resident 1 stated .I had a stroke. It hurts when they turn me it ' s causes me pain. There ' s a certain way to turn me so that I ' m not in pain. (I do not want CNA 1 working with me) .They still have . (CNA1 working) with me at night. I don ' t want .(CNA 1). She hurt me. There was one time she was helping me. I told her she was hurting me and she laughs and she pushed down harder on my leg. Resident 1 stated staff made him feel guilty like he was a burden to them and was giving them extra work. Resident 1 stated .(staff would say to me) I just cleaned you. Make me feel guilty that I ' m making him clean me again as if I ' m making extra work for them. I ' m a human being. They keep putting the condom catheter (a medical device that covers the outside of the penis to help manage urinary incontinent) and it comes off. And it ' s urine all over. I don ' t want to sit there smelling like urine all day. Review of emails sent by Resident 1 ' s friend to this Department (CDPH, California Department of Public Health), dated 07/07/2022 at 11:32 AM indicated Resident 1 ' s friend was communicating on a regular basis with Resident 1 and alerted facility staff regarding allegations of abuse/neglect on multiple occasions. Resident 1 ' s friend emailed the facility ' s SSD (Social Service Director) and Unit Manager on 05/06/2022 at 12:11 AM. The email indicated .(the problem) continues .(in) particular the early am .(CNA 1) hurts me .(when) cleaning .(me) I have told .(the Unit Manager) but nothing has . (improved. In) fact things are worse with the nurse (RN 1) on duty . insisting that I should let . (CNA 1) continue to clean me and I'm refusing I've said I don't want you want to touching me to . (CNA 1) and .(RN 1) threatens me by saying no one is going to take care of me now if I complain about .(CNA 1) and they both show up in the morning at 6 AM trying to force me to let .(CNA 1) clean me and it's been a struggle it's been really unpleasant every morning I don't even want . (CNA1) touching me because she .was deliberately hurting me she pressed on my leg once and when I complained about it she pressed harder she did not stop hurting me even more it seems like very deliberate trying to hurt me that's what it felt like and I told her I don't want me to touch me anymore I don't want her to touch me anymore but she continues to come in every morning trying to force me to go through with it and I'm refusing it's been unpleasant last week with . (RN 1) taking her side trying to force me also I would like for this to stop please I would like for this stuff to .(end now please) . During an interview on 07/07/2022 at 10:10 AM, Resident 1 ' s friend confirmed at times Resident 1 would call her when he was unable to get staff to respond to his call light.I was on the phone constantly and it was very hard to get someone to go help him. Review of four facility documents titled NURSING STAFF ASSIGNMENT AND SIGN-IN SHEET, dated 7/16/2022, 7/17/2022, and 7/26/2022, indicated CNA 1 was assigned to care for Resident 1, Resident 2 Review of Resident 2 ' s facility document titled Minimum Data Set (MDS), dated [DATE], indicated her BIM score was 13 out of 15 (A score of 13-15 indicates no impairment in memory and reasoning). According to her MDS, she required extensive assistance of two staff for toilet use and bed mobility. Her MDS indicated she was always incontinent of bowel and bladder. Her MDS indicated she displayed no episodes of hallucination, no delusion, and no rejection of care. During an interview on 07/28/2022 at 12:03 PM, Resident 2 stated .The only problem we have is under staff and the patient suffer because of it. (Resident 2 stated she knows there is problem with staffing because) Nurses tell me. I have to wait a long time at night sometimes for quite a while at night. Sometimes an hour sometimes 45 minutes. (Resident 2 stated she needed) to be change. Makes me cry sometimes I ' m so upset. I hate to tell you that. (Resident 2 stated she knew how long she had to wait because she) time it. (points to the wall clock.) Resident 3 Review of Resident 3 ' s facility document titled Minimum Data Set (MDS), dated [DATE], indicated his BIM score was 13 out of 15 (A score of 13-15 indicates no impairment in memory and reasoning). According to his MDS, he required extensive assistance of two staff for toilet use and bed mobility. According to his MDS, he was always incontinent of bowel and bladder. His MDS indicated he displayed no episodes of hallucination, no delusion, and no rejection of care. During an interview on 07/28/2022 at 11:29 AM, Resident 3 ' s family member stated I visit (the facility) twice a week. My wife visits twice a week. So we visit a total of 4 times a week. When (Resident 3) needs help, sometimes it takes 1/2 hour to 1 hour for staff to respond. (Resident 3 ' s family member stated) . he soiled himself with BM (bowel movement, that was why we call the staff to help). Sometimes they take so long that I have to go out there to find staff. Because they didn ' t answer the call light. (Resident 3 ' s family member stated this long wait for staff response) happens like 50 percent of the time. Resident 3 was asked how this made him feel waiting for staff to clean him up. Resident 3 ' s family member translated that he felt unclean, mad and neglect when made to lay on a soiled adult brief for 45 minutes to an hour. Resident 4 Review of Resident 4 ' s facility document titled Minimum Data Set (MDS), dated [DATE], indicated her BIM score was 15 out of 15 (A score of 13-15 indicates no impairment in memory and reasoning). According to her MDS, she was totally dependent on two staff for toilet use, personal hygiene (combing hair, brushing teeth, applying makeup etc.), transfers, dressing, and bed mobility. According to her MDS, she was frequently incontinent of urine. Her MDS indicated she displayed no episodes of hallucination, no delusion, and no rejection of care. Review of Resident 4 ' s facility document titled FACE SHEET, printed on 08/02/2022, indicated she had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MS is a disease in which the body ' s defense system attacks and eats away at the protective covering of nerve cells. MS has severely impaired Resident 4 ' s coordination and movement of her arms and legs. Resident 4 is totally dependent on staff for all activities of daily living (bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During an interview on 07/26/2022 at 3:14 PM, Resident 4 stated .I don ' t trust anybody here. It ' s very sad .(that) you can ' t trust the people and (you) depend on them for your care. They are not friendly. Well in my case I ' m only speaking to my experience. When people walk in, they don ' t say anything. Usually there ' s two (staff, the only thing they will say is) we ' ll change you now. It ' s like an order we are going change you now. Twice a day to change me. 8 hours shift twice a day. It ' s very short.[PJ2] I ' m a two person (assist, sometimes) there is another shift where (only) one (staff) is assigned. They are (also) assigned to other wing. Sometimes it could be hours before they show up. I feel it ' s not quite hostile. It ' s just that I ' m not treated like a human being.There is a certain amount of professionalism but I can tell they are pissed.Maybe I have a reputation that may or may not be deserved. They are so pissed off .I can tell by how they open my .(adult brief).we are talking about regular staff. The people who are extremely competent are the ones that don ' t greet you . They don ' t consider their attitude as part of .(their) job. (when I need assistance) I can press the call light (but) I ' ve been encouraged not to call them. I know when they are busy .you have to wait.we are dealing with people saying yes and not coming over. There ' s this overwhelming feeling of guilt when you ask for something.The staff(ing) is getting smaller and smaller we are getting less and less.(There is a constant) call light issue. It can be as long as an hour sometimes waiting for someone to come help me. I get the reputation that no one wants to come to my room (and) no one wants to talk to me (when they come into my room). Review of the facility ' s policy titled JEWISH HOME OF SAN FRANCISCO RESIDENT ABUSE POLICY (SNF), not dated, indicated .Jewish Home shall take action to prevent mistreatment, neglect, or abuse of residents of the Facility. Neglect-is the failure .(of) the facility, its employees or service provider goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review, the facility failed to provide stand by assist (the presence of another person within arm's reach) during the performance of one of the Activities of Daily Living (ADL, the basic self-care tasks an individual does on a day to day basis), call light was not within reach and had no floor pad at bedside for one of three sampled residents (Resident 1) to prevent fall. This failure had resulted in Resident 1's unwitnessed fall on 2/18/22, sustaining a right [CONDITION(S)] then hip surgery. Findings: Review of Resident 1's Face Sheet (FS), indicated Resident 1 was admitted on [DATE] with diagnosis of dementia (memory loss), reduced mobility (ability or capacity to move), abnormalities of gait (manner of walking) and mobility, muscle weakness, [CONDITION(S)] (a condition in which bones become weak and brittle). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 1/6/22 and 11/13/20, indicated, Resident 1 was severely cognitively impaired and required supervision (oversight/cueing) with set up help only for bed mobility, transfer, walking in room, and eating. Resident 1 also required extensive assist (resident is involved in activity; staff provide weight bearing support), with one person physical assist for dressing, toilet use and personal hygiene. Resident 1 is not steady for balance during transitions and walking, only able to stabilize with staff assistance in moving on and off toilet. MDS dated [DATE], indicated a decline in functional status, Resident 1 required extensive assistance with two person assist with bed mobility, dressing, eating, toilet use and personal hygiene, walk in the room and the corridor, and locomotion on and off unit activities did not occur . Review of Resident 1's Interdisciplinary (IDT) Meeting Note, dated 2/18/22, at 9:07 AM, indicated, Resident 1 was asymptomatic (absence of signs/symptoms) to being Covid positive and refusing to leave her room. Review of Resident 1's Nursing 24 Hour Report, dated 2/18/22, at 5:17 PM, entered by Licensed Vocational Nurse 1 (LVN), indicated, on 2/18/22, at 4:50 PM, Resident 1 was found lying on her right side on the floor supporting her head with right hand between the bedside drawers and bedside table. The commode was upside down, translator stated, Resident 1stated that she wanted to use commode and lost balance, gait unsteady, need extensive assist with transfer, Range of Motion (ROM) (the flexibility of motion around a joint) on right leg decreased and not tolerated, no bump, bruising or redness on the right side of her head, attending Certified Nursing Assistant (CNA) was in the next room with another resident when he heard the hard bump . Review of Resident 1's Post Fall Assessment Notes, dated 2/18/22, at 5:16 PM, entered by LVN 1, the Post Fall notes indicated, at 4:50 PM, had unwitnessed fall in her room from moving to/from bedside commode due to urgency to void, last documented toileting prior to fall was at 4:26 PM, wearing a yellow none skid socks, no floor pad, call light not within reach, with history of prior fall on 1/28/22. Review of Resident 1's Post Skin Assessment Status Post (after) Fall, dated 2/18/22, at 5:17 PM, entered by LVN 1 indicated, at 4:50 PM, CNA called LVN 1 attention, Resident 1 lying on the floor, on her right side, supporting head with her right hand between the bed side drawer and bed side table, commode flopped down by her side, translator stated, Resident 1 wants to use the commode to urinate but lost her balance. Need extensive assist with transfer, decreased and unable to tolerate ROM on right side, holding right side of head pointing pain from right side of head to the lower leg. CNA stated, he was next to her room attending the other resident when heard a hard bump, search and noted resident on the floor, with root cause analysis of poor safety awareness. Review of Resident 1's Morse Fall Risk Scale (MFRS), dated 2/18/22, at 5:17 PM, entered by LVN 1, indicated total score of 90, MFRS dated 2/11/22, at 12:48 AM, entered by LVN 1, indicated total score of 90 and MFRS dated 11/11/21, at 7:29 PM, entered by LVN 1, indicated, total score of 65. Fall risk score of above 50 indicated high risk for fall. During an interview with RN 1(Registered Nurse 1), the RN 1 stated, incident happened on 2/18/22, on PM shift, Resident 1 got up from bed unassisted to use the commode then, found lying on her right side on the floor between a bedside table and nightstand. Commode was found upside down. Review of Resident 1's Care Plan Report, dated 12/28/2018, entered by LVN 2, indicated, Resident 1 was at risk for falls related to unstable gait and history of falls with intervention to have landing mat in place, place call bell/light within easy reach and remind Resident 1 importance of using call light. Review of Resident 1's Care Plan Report, dated 2/18/22, indicated, Resident 1 had unwitnessed fall inside her room, goal to maintain current level of mobility with no increase in the incidence of falls/injuries, instruct Resident 1 safety measures to reduce risk of falls. Care Plan dated 3/10/22 indicated, Resident 1 had a fall on 3/10/22 with no injury noted, related to dizziness, found lying on the floor in supine position with no injury, goal to maintain current level of mobility with no increase in incidence of falls up to 5/18/22 with a video monitor for intervention. Review of Resident 1's Occupational Therapy Plan of Care, dated 3/7/22, at 9:29 AM, entered by OT 1, indicated, prior level on initial assessment, Resident 1 not using a mechanical lift, current level is using a mechanical lift. Prior level for everyday activities with indoor mobility (ambulation), stairs, and functional cognition, Resident 1 need partial assistance from another person to complete activities, current level Resident 1 is dependent (a helper completes the activities for the resident). Prior level for eating, set-up or clean up assistance, current level is dependent (a helper does all effort). Prior level for oral hygiene, toileting, showers, dressing, and putting on/taking off footwear, supervision to substantial/ maximal assistance, current level is dependent. Review of Resident 1's Speech Therapy Plan of Care, dated 3/8/22, at 10:05 AM, entered by ST 1, indicated, Resident 1 has a diagnosis of dysphagia (difficulty or discomfort in swallowing), prior diet was regular, currently on pureed (soft, pudding-like consistency) diet. Review of Resident 1's Physical Therapy Plan of Care, dated 3/8/22, entered by PT 1, indicated, Resident 1 had status post right hip hemiarthroplasty (hip repair) on 2/19/22, now severely deconditioned (having lost fitness or muscle tone) requiring total assistance, required mechanical ventilation during Intensive Care Unit hospital stay. Initial assessment indicated, on prior level, Resident 1 required supervision with verbal cueing but no physical assist for bed mobility and transfers, with current level requiring moderate to maximum assist, prior gait distance was 150 feet and currently unable to do it. Review of Resident 1's UCSF Medical Center Discharge Summary Notes (DSN), dated 3/6/22, at 2:46 PM, entered by MD 1, the DSN indicated, [CONDITION(S)], displaced (bones broken into two or more pieces) fracture of right femoral neck (injury is just below the ball of the ball- and- socket hip joint), ambulates (walk, to move from place to place) with walker and stand by assist on baseline (normal/ beginning level), underwent a right hip hemiarthroplasty on 2/19/22. Review of the policy titled Fall Prevention Program revised 10/2021, indicated, Policy: The Jewish Home and Rehab Center ensures that the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents and mitigate injuries from falls while improving mobility and maintaining or enhancing Quality of Life. Extensiveness of supervision needed will be considered.

Based on observation. interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) who had mobility impairment and a history of a fall. Resident 1 was left in the dining room unsupervised and had an unwitnessed fall on 12/16/18 . The deficient practice resulted in a fractured bone on the neck (Type II dens fracture), multiple facial fractures and a right eye globe rupture requiring surgery and hospitalization . His functional activities of daily status declined after the 12/16/18 fall. Findings: Review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated 11/13/18, indicated he was admitted to the facility on [DATE] with diagnosis including heart failure, high blood pressure, arthritis (inflammation of the joints) , Alzheimer's Disease, Dementia, and weakness. (Dementia: an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Alzheimer's Dementia: a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks). He had moderate difficulty hearing, clear speech, usually was able to express ideas and wants with difficulty communicating some words, sometimes understood/responded adequately to simple direct communication, had impaired vision, one sided upper extremity impairment, impairment on both sides of lower extremity. He needed one staff assistance with dressing, eating, toilet use and personal hygiene; two staff assistance with bed mobility and transfer; and required 100 percent support assistance with locomotion off unit (in areas set aside for dining) when in a wheelchair. Record review of Resident 1's November 2018 Physician Order Sheet indicated diagnoses included [CONDITION(S)] and [CONDITION(S)] (muscle weakness or [CONDITION(S)] on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke) affecting dominant right side. Record review of document, Fall Risk Assessment, dated 11/06/18, for Resident 1 indicated, Total Score: 16 . Total Score of 10 or greater represents HIGH RISK . Record review of Resident 1's Comprehensive Care Plan, dated 5/14/18, indicated, Functional ADL (activities of daily living), Goals . will be assisted as needed . During an observation on 1/2/19 at 2:06 PM, Resident 1 was in his room, in bed, on his right side, asleep. During an interview on 1/2/19 at 2:58 PM, Registered Nurse (RN ) 1 stated that Resident 1 had a history of a fall prior to the 12/16/18 fall incident. Residents are brought into the dining room around 7:30 AM to 8 AM. Breakfast is at 8 AM. During an observation on 1/2/19 at 3:45 PM, Resident 1's family member was at the bedside. Resident 1 was in his bed. During an observation on 1/2/19 at 3:50 PM, Resident 1 had a scab on his right arm, a scab on the right top part of his forehead, his right eye was red, and he had a bruise by his right ear. During a telephone interview on 2/6/19 at 3:02 PM, Licensed Nurse (LN) 2 stated she was the nurse in charge on 12/16/18 when Resident 1 fell . During an interview on 2/6/19 at 3:10 PM, LN 2 stated, I was passing medications. Breakfast starts at 8 AM in the dining room. If a resident is in the dining room the nurse in charge or a staff should be in the dining room. LN 2 stated that Certified Nurse Assistant (CNA) 2 was the staff assigned to work with Resident 1 on 12/16/18, day shift. CNA 2 was the one that should have gotten (Resident 1) from his bed to his wheelchair to the dining room for his breakfast. Around 7:50 AM (12/16/18), I was passing medications. As I was heading back to the medication cart from a patient's room, I suddenly heard a falling sound and one resident scream in the dining room. I rushed to the dining room and saw (Resident 1) on the floor, on his right side, his head was resting on the floor. I saw blood on the floor. When I checked on the resident (Resident 1), I saw a laceration on his right upper eyebrow. There was one other resident in the dining room when I found the resident (Resident 1) on the floor. On 2/6/19 at 3:17 PM, LN 2 stated that when she went in the dining room to check what happened there was no nursing staff in the dining room with the residents. Before 8 AM, during that time all staff are with residents preparing them for breakfast. On 2/6/19 at 3:30 PM, LN 2 stated, I was not informed there were residents in the dining room. LN 2 stated a nursing staff should have been in the dining room with the residents. During a telephone interview on 2/7/19 at 1:29 PM, CNA 2 stated, she brought Resident 1 from his room to the dining room for breakfast. I put him in front of the table and I locked the wheelchair. Then I left to get to the other resident to bring them to the dining room. On 2/7/19 at 1:42 PM, CNA 2 stated, I know for a fact that the nurse was there when I left the resident in the dining room. We don't necessarily tell the nurse everytime we bring the resident to the dining room. During an interview on 5/23/19 at 4:15 PM, LN 2 stated, that on 12/16/18, she saw CNA 2 bring Resident 1 from his room to the dining room by wheelchair as they passed her while she was passing medications at the hallway. LN 2 stated she could not see Resident 1 when he was in the dining room, and did not see CNA 2 leave Resident 1 in the dining room. Record review of LN 2's Clinical Notes Report, dated 12/16/18 at 10:43 AM, for Resident 1, indicated, At around 07:40 AM, LN (licensed nurse) noted assign CNA (certified nurse assistant) propelling resident and getting ready for breakfast. Around 07:50 AM, LN heard sound from dining room and immediately checked the situation. Noted resident had an unwitnessed fall inside the dining room. LN found resident R (right) side lying on the floor with injury/laceration on his R upper eyebrow . Noted 4 cm (centimeter) x (by) 2 cm x 1 cm laceration (a deep cut or tear in skin or flesh) on R upper eyebrow . alert oriented x (times) 2 . with history of dementia and fluctuating cognition . When asked what happened before the incident, resident answers, I am not well situated .On call MD (medical doctor) notified . order to send resident to the hospital for further management and treatment . At 0820 AM, resident left the unit via gurney and was headed to (acute care hospital) . Record review of RN 1's Clinical Notes Report, dated 12/16/18 at 6:43 PM, for Resident 1, indicated, IDT (interdisciplinary team) Meeting Note, Unwitnessed fall with injury . discussed the issue of the unwitnessed fall with injury. On December 16, 2018 at approximately 07:50 AM, CNA . wheeled the resident (Resident 1) to the dining room area for breakfast and 10 minutes after, he was found lying on his right side on the floor and noted to have skin laceration on his right upper eyebrow . The resident complaint of head pain (8/10) . When the resident was asked how he fell , he stated that, I am not well situated . alert oriented x 2 and verbally responsive, with BIMS (Brief Interview for Mental Status) Score of 03 at latest MDS per ARD 8/30/18 . The resident has previous medical diagnosis of Alzheimer's Disease, Dementia, Generalized muscle weakness, [CONDITION(S)] . which together, can be contributory to his fall . Record review of document, CNS (clinical nurse specialist)/RN (Registered Nurse) Note for General Acute Care Hospital, Inpatient, dated 12/17/18, 17:31 (5:31 PM), for Resident 1 indicated, admitted s/p (status post) mechanical fall out of a wheelchair w/(with) head strike, found to have dens fracture, multiple facial fx (fractures) and C1 bilateral lamina fx. s/p OR w/ ophthalmology for globe rupture repair . Record review of LN 1's Clinical Notes, Readmission, dated 12/24/18 at 4:14 PM, for Resident 1, indicated, Received from hospital via ambulance . with stage PU (pressure ulcer) on COCCYX( Coccyx: a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum.), BRUISING ON RIGHT EYE COMING DOWN TO RIGHT CHEEK. 4cm LACERATION RIGHT EYEBROW with absorbable sutures. Noted eye patch ([NAME] shield) ON RIGHT EYE. Resident with Aspen collar to remain on resident x 24 hours for life . received with type 2 dens fx (fracture) bilat(eral) C1 laminae non operable fx, s/p repair of right eye globe rupture . on ATB (antibiotic) until 12/28/18 . Record review of Resident 1's MDS, dated [DATE], for Significant Change under functional activities of daily status indicated Resident 1 currently required full staff performance with locomotion on unit, and at least 2 person- physical assist with dressing, toilet use, and personal hygiene. During an interview on 1/2/19 at 3:39 PM, LN 1 stated that Resident 1 used to feed himself before his fall (12/16/18). Now he needs to be fed. In addition, LN 1 stated Resident 1 wore his neck brace for one or two days, now refuses to wear his neck brace. Resident 1's family was notified regarding Resident 1's refusing to wear his neck brace. Record review of Policy and Procedure titled, Fall Prevention Program, revised 5/14, indicated, Policy . ensures that the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents and mitigate injuries from falls while improving mobility and maintaining or enhancing the residents Quality of Life . Purpose . Any Residents identified as at risk for falls shall have an individual care plan that includes interventions to prevent falls from occurring . Procedure 3. A care plan and approaches for risks for falls will be initiated upon admission and updated as needed . 4. Appropriate interventions will be implemented for residents at high risk as identified by nursing, IDT (InterDisciplinary Team), and other disciplines . 6. A resident who triggers the fall assessment as high risk will be reviewed by the IDT .

Based on observation, interview, and record review, the facility failed to provide adequate preventive treatment and services to maintain and improve range of motion (ROM) for one of 21 sample residents (Resident 27) when: a. The frequency and duration of Restorative Nursing Program (RNP) was not implemented as recommended by Physical Therapist; b. The order for the use of [REDACTED] c. The care plan to maintain ROM did not include specific interventions and was not revised to address the decline of the Resident 27's ROM of lower extremities. The deficient practice resulted in reduction of Resident 27's ROM of lower extremities and contracture of right knee. According to a Medical Dictionary, retrieved from http://medical-dictionary.thefreedictionary.com/contracture on 5/4/17, . Contracture is the shortening of the muscle and joints which limits and interferes with daily functioning. The CMS (Center for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual dated October 2016, indicated, RNP refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and as safely as possible. Findings: Resident 27 was admitted on [DATE] with [DIAGNOSES REDACTED]. a. Review of the Minimum Data Set (MDS an assessment tool) dated 8/8/16, indicated, Resident 27 did not have an impairment on lower extremities, The MDS assessment dated [DATE], indicated, ROM on one side of lower extremities was impaired. The MDS assessment dated [DATE], indicated, ROM on both sides of the lower extremities were impaired. During an interview on 4/27/17 at 2:38 PM, Certified Nurse Assistant (CNA 3) stated, Resident 27's lower extremities are contracted and she was wheelchair bound. Review of Restorative Referral Form for Resident 27 dated 10/12/16, indicated an order for [REDACTED]. The order did not include duration for each intervention. Review of Resident 27's Restorative Nursing Program Daily Record indicated, On 10/1/16 to 10/7/16, RNP service was provided four (4) times; On 10/8/16 to 10/14/16, RNP service was provided three (3) times; On 10/15/16 to 10/21/16, RNP service was provided two (2) times; On 10/22/16 to 10/27/16, RNP service was provided one (1) time; On 10/28/16 to 11/3/16, RNP service was provided five (5) times; On 11/4/16 to 11/10/16, RNP service was provided five (5) times; On 11/11/16 to 11/17/16, RNP service was provided five (5) times; On 11/18/16 to 11/ 24/16, RNP service was provided four (4) times; On 11/25/16 to 11/31/16, RNP service was provided two (2) times; On 12/1/16 to 12/7/16, RNP service was provided four (4) times; On 12/8/16 to 12/14/16, RNP service was provided four (4) times; On 12/15/16 to 12/21/16, RNP service was provided four (4) times; On 12/22/16 to 12/28/16, RNP service was provided three (3) times; On 12/29/16 to 1/4/17, RNP service was provided two (2) times; On 1/5/17 to 1/11/17, RNP service was provided two (2) times; On 1/12/17 to 1/18/17, RNP service was provided one (1) time; On 1/19/17 to 1/25/17, RNP service was provided four (4) times; On 1/26/17 to 2/1/17, RNP service was provided two (2) times; On 2/2/17 to 2/8/17, RNP service was provided two (2) times; On 2/9/17 to 2/15/17, RNP service was provided four (4) times; On 2/16/17 to 2/22/17, RNP service was provided three (3) times; On 2/23/17 to 3/1/17, RNP service was provided three (3) times; During an interview on 4/28/17 at 9:25 AM, Restorative Nursing Assistant (RNA 1) acknowledged that the frequency of RNP service was not followed as ordered. The RNA 1 stated, PT (Physical Therapist) recommendation should be followed. There were days that she (Resident 27) was not seen (by the RNA). During an interview on 4/28/17 at 9:16 AM, Unit Manager (UM 2) stated, RNA's keep their binder (records). I read the recommendation and sign it (RNA record) at the end of the month. UM 2 denies documenting the audit and review of the RNA documentation and stated, No documentation of the review, I just do verbal endorsement to the staff. During an interview on 5/2/17 at 8:59 AM, RNA 1 stated, ROM should be done at least every 4 hours, in at least 20 minutes each time. The order should be written that way. Review of undated facility policy titled, Restorative Nursing Program indicated, .Referral Process . A referral to the restorative nursing program should be completed by therapy or nursing .The referring therapist or nurse in conjunction with the restorative nurse designee will develop the RNA treatment plan .General Procedure: .RNA order contains specific task . frequency, time-frame/stop date .Rehab/nursing reviews and audit RNA documentation at least monthly .Monthly Meeting - Unit Manager and RNA will review all residents who are participating in the program monthly. In this meeting, resident's progress, tolerance, attendance, and benefits will be re-evaluated and reviewed . According to a Medical Dictionary, retrieved from http://medical-dictionary.thefreedictionary.com/range+of+motion+exercise on 5/4/17, indicated, . Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part, such as a leg or arm, throughout the available range. Injury, surgery, or immobilization of a joint may affect the normal joint range of motion . b. During an observation on 4/28/17 at 9:10 AM, Resident 27 was up on the wheelchair being fed by the staff. Resident 27 was observed not wearing a knee brace or splint. Her right and left upper extremities bended on her chest area. During an observation on 5/1/17 at 9:39 AM, Resident 27 was sleeping in her wheelchair and was observed not wearing a knee brace or splint. Review of Resident 27's Physical Therapy Plan of Care dated 9/29/16 to 10/12/16 indicated, .Pt (patient) referred for PT evaluation and TX (treatment) for BLE ankle brace for foot drop .Goal: RNA/nursing will be independent with donning/doffing (application/removal) of ankle brace in order to improve/maintain functional alignment of the ankle . Review of Resident 27's Physical Therapy Plan of Care dated 11/9/16 to 11/28/16 indicated, .Pt (patient) referred to PT eval (evaluation) for R (right) knee contracture .Goal: (patient) will receive R (right) knee brace to address contracture, RNA/nursing will be independent with donning/doffing . Review of Resident 27's physician's orders (supplemental sheet) dated 10/26/16 indicated, OT (Occupational Therapy)/ PT for right leg contracture, to increase mobility and decrease contraction. Splint to decrease contraction . The order did not include duration or time-frame of wearing the splint. Review of Resident 27's physician's orders (supplemental sheet) dated 11/28/16 indicated, . RNA/ CNA/ Nursing education done for right knee brace donning/doffing to address limited ROM . The order did not include duration or time-frame of wearing the brace. Review of Resident 27's care plan for limited ROM of upper and lower extremities, under Approaches dated 11/28/16 indicated, BLE ROM strengthening with RNA; knee brace During an interview on 5/1/17 at 10:02 AM, Licensed Vocational Nurse Educator (LVN Educator) stated, RNA takes care of knee brace. During an interview on 5/1/17 at 10:02 AM, Licensed Vocational Nurse (LVN 1) stated, RNA puts the (knee) brace on, nurses removed it towards the end of the shift. When asked why resident was not wearing the knee brace, LVN 1 could not explain why. During an interview on 5/1/17 at 10:58 AM, CNA 3 stated, Resident 27 's leg are getting more contracted and crooked. They don't put it (knee brace) anymore. CNA 3 also stated, she cannot remember the last time she saw the Resident 27 wearing the knee brace. During an interview on 5/2/17 at 8:59 AM, RNA 1 stated, CNAs are the one responsible for putting the knee brace of Resident 27, I did not get the instruction for that. The Physical Therapist who ordered the donning of brace stated that she instructed the CNAs to do it. Review of an undated facility policy titled, Restorative Nursing Program indicated, . A Restorative Nursing Care Program requires the effort of the entire interdisciplinary team - not just one discipline. There should be strict Nursing and Rehab involvement . Role Definitions: Restorative nursing utilizes the skills and expertise of each discipline to plan, implement and facilitate all possible course of action for returning an individual to their highest, practicable, physical, mental and psychological functional level of well-being . c. Review of the Minimum Data Set (MDS an assessment tool) dated 8/8/16, indicated, Resident 27 did not have an impairment on lower extremities, The MDS assessment dated [DATE], indicated, ROM on one side of lower extremities was impaired, The MDS assessment dated [DATE], indicated, ROM on both side of lower extremities was already impaired. Review of Resident 27's care plan for Limited ROM of upper and lower extremities . indicated the following intervention, On 7/12/16, RNA for BUE ROM 3-5 times a week, department: RNA (department responsible to implement the intervention); On 8/24/16, PT eval and tx (treatment) as indicated, no department indicated; On 10/12/16, RNA program to maintain BUE and BLE ROM, department: RNA; On 11/28/16, BLE ROM strengthening with RNA; knee brace. department: RNA; On 1/4/17, Program for PROM 3-5 x/week, department: RNA. There was no specific time frame, duration, and approach indicated on each intervention. The intervention dated 7/12/16; 10/12/16; and 11/28/16 was highlighted in yellow. During an interview on 4/28/17 at 1:40 PM, UM 2 acknowledged that the care plan addressing Resident 27's ROM was not updated and stated, There's no other care plan, just RNA. We should have included the recommendation of the PT order in the care plan. During an interview on 5/1/17 at 9:45 AM, LVN Educator stated, if (the intervention) was highlighted that means it was changed and discontinued. The LVN Educator also stated, (the care plan) was not updated according to the change of her (Resident 27) condition. There should be a change in intervention whenever there's a change in condition. The LVN Educator also acknowledged that care plan intervention was specific and stated, there's no specific instruction on RNA and didn't mention if right or left knee (for the brace). Review of the facility policy titled Care Plan dated 4/27/17 indicated, Policy: Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs .G. Care plans of residents requiring specialized rehabilitation include: 1. The type of treatment ordered; 2. Objectives of the treatment; 3. Rehabilitation potential; 4. Precautions; 5. Type of therapy ordered; 6. Amount of therapy; 7. Frequency and duration of the treatment; and 8. Procedures and modalities to be applied .I. Care plans are revised as changes in the condition dictate .

Based on interview and document review, the facility failed to ensure that one of one sampled resident (Resident 1) did not develop an avoidable pressure sore and the facility failed to provide the necessary treatment to promote the healing of the pressure sore according to the plan of care when: 1. There was no documented evidence that the nursing intervention of turning and repositioning was consistently carried out as care planned to prevent her development and worsening of the pressure ulcer. 2. The facility failed to develop interventions that addressed the problem of a low [MEDICATION NAME] level for Resident 1 that was identified on 3/22/15. 3. There was no documented evidence that nutritional supplements were provided to Resident 1 according to physician's orders [REDACTED]. The deficient practice resulted to Resident 1's development of Stage IV pressure ulcer on the left hip. Resident 1 was transferred to an acute care hospital on [DATE] for deteriorating pressure ulcer and protein-calorie malnutrition. Definitions: Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. Avoidable/Unavoidable Pressure Ulcers Avoidable means that the resident developed a pressure ulcer & that the facility did not do one or more of the following: evaluate the resident's clinical condition & pressure ulcer risk factors; define & implement interventions that are consistent with resident needs, resident goals, & recognized standards of practice; monitor & evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition & pressure ulcer risk factors; defined & implemented interventions that are consistent with resident needs, goals, & recognized standards of practice; monitored & evaluated the impact of the interventions; & revised the approaches as appropriate. Stages of Pressure Ulcers - The staging system is one method of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. This is the system used within the RAI (Resident Assessment Instrument) Stage I pressure ulcers may be difficult to identify because they are not readily visible & they present with greater variability. Advanced technology (not commonly available in nursing homes) has shown that a Stage I pressure ulcer may have minimal to substantial tissue damage in layers beneath the skin's surface, even when there is no visible surface penetration. The Stage I indicators identified below will generally persist or be evident after the pressure on the area has been removed for 30-45 minutes. The definitions for the stages of pressure ulcers identified below are from the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0. Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage II - Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue). May also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (wider area of wounding that lies beneath the wound opening) or tunneling (narrow opening or passageway underneath the skin). Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Record review of Minimal Data Set (- a resident assessment tool), dated 4/3/15, indicated that Resident 1 did not have pressure ulcer. Record review of Minimal Data Set, dated 4/3/15, indicated that Resident 1 was at risk of developing pressure ulcers. Record review of Minimal Data Set, dated 4/3/15, indicated that Resident 1 required two persons' physical assist when repositioning. Review of Care Plan for Skin, dated 3/27/15, indicated interventions including Turning and repositioning in bed every 2 hours and PRN (as needed). Review of Care Plan for Skin, dated 6/24/15 and updated 7/20/15, indicated interventions including Turning and repositioning in bed every hour and PRN (as needed). During an interview on 10/12/15 at 2:40 pm, Certified Nursing Assistant 1 stated that Resident 1 would sit out in the chair for her. When I put her up in the chair with her pants up, she would not pick on the wound on her hips. This way she was not putting pressure on her hips and not worsening the pressure ulcer. Review of the facility's Skin and Wound Care Policy and Procedure, not dated, indicated that: Turning /repositioning schedules, weigh shift schedule/ standard is every 2 hours. Special, individualized interventions, especially for turning and repositioning programs and weight shift programs that are more frequent than the standard practice of every 2 hours, will be instituted as indicated per evaluation of the resident and recommendation of skin team RN (Registered Nurse). This individualized turning and repositioning and/or weight shift program will be communicated to all staff in the Care Plan, on CNA (Certified Nursing Assistant) Care Card, in verbal report, and will also be documented on a separated form for 'Individualized Turning / Repositioning Program, and kept in the resident's chart/medical record. During an interview and concurrent record review on 10/13/15 at 4:00 pm, Unit Manager (UM) 1 acknowledged that there was no documented evidence to indicate the two hourly or one hourly repositioning interventions for Resident 1 were carried out consistently. Review of the Weekly Multidisciplinary Pressure Ulcer Assessment, indicated that Resident 1 developed a stage 2 ulcer (Partial thickness loss of dermis) on her left hip/upper buttock on 6/29/15, the ulcer became unstageable (not able to determine stage) on 7/20/15. Record review of Interdisciplinary Meeting Note, dated 8/6/15, indicated that the pressure ulcer on Resident 1's left hip became stage 4 (full thickness tissue loss). During an interview on 8/10/15 at 11:40 am, the Wound Care Nurse stated that Resident 1 was transferred to an acute hospital on [DATE] for treatment of [REDACTED]. 2. Record review of the laboratory tests indicated that Resident 1's [MEDICATION NAME] levels (a test used to assess patient's liver function and nutritional status, normal range: 3.5-5.0 gm/dl ) were: 2.6 on 3/22/15, 2.1 on 7/24/15, 2.0 on 7/27/15, and 1.9 on 8/4/15. Document review of facility's Nutrition and Patient Service Policies and Procedures with revised date of 7/23/15 indicated that the estimated protein requirement was based on current [MEDICATION NAME] level assuming there is no underlying renal (kidney) disease. [MEDICATION NAME] level between 2.4 to 2.7 gm/dl indicates moderate visceral protein (a measure of proteins outside the skeletal muscle) deficits and moderate nutritional risk. A higher level of 1.3 -1.5 gm of protein/kg of body weight should be provided to resident. Record review of the Care Plan for Skin, dated 3/27/15, indicated that Resident 1 had added risk factor for pressure ulcer related to low serum [MEDICATION NAME], weight loss and poor oral intake. Review of the Nutrition White Paper (2009), by NPUAP (National Pressure Ulcer Advisory Panel) indicated that compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition, and dehydration deficits are known risk factors for pressure ulcer development. Review of the Prevention and treatment of [REDACTED].) indicated that 1.25 to 1.5 grams protein/kg body weight daily should be offered for adults at risk of a pressure ulcer who are assessed to be at risk of malnutrition when compatible with goals of care Record review of the Initial Nutritional Assessment on Resident 1 by Registered Dietitian (RD) 3, dated 3/29/15, indicated that the Estimated Nutritional Needs was based on 1.0-1.2 gm of protein/kg of body weight. Record review of the Nutritional Service Clinical Note Report by RD 3 , dated 5/11/15, indicated plan to monitor weight, PO (oral) intake, skin, lab (laboratory tests) and hydration. During an interview on 10/16/15 at 1:37 pm, RD 3 stated that when reviewing Resident 1's nutritional status, the laboratory result was not available. RD 3 was not aware of the low [MEDICATION NAME]. Record review of Quarterly Nutritional Re-Assessment on Resident 1 by RD 1, dated 7/2/15, indicated that the Estimated Nutritional Needs was based on 1.0-1.2 gm of protein/kg of body weight. During an interview on 10/12/15 at 2:54 pm, RD 1 acknowledged that the dietitians were not aware of the low [MEDICATION NAME] level until 7/24/15 when the facility ordered [MEDICATION NAME] level came back, which was 2.1gm/dl. Record review of the Nutritional Service Clinical Note Report by RD 2 , dated 6/10/15, indicated plan to monitor weight, PO (oral) intake, skin, lab and hydration. During an interview on 10/16/15 at 1:10 pm, RD 2 stated that when reviewing Resident 1's nutritional status, she did try to review the lab result. There were no labs available on 6/10/15. RD 2 said: I was not aware of the low [MEDICATION NAME]. 3. During an interview and concurrent record review on 10/12/15 at 2:54 pm, Registered Dietitian (RD) 1 acknowledged that there was a physician's orders [REDACTED]. The electronic copy of the Physician order [REDACTED]. The paper copy of the Physician order [REDACTED]. Record review of the Nutritional Service Notes by RD 2, dated 6/10/15, indicated there was no supplement planned for the month. During an interview on 10/16/15 at 1:10 pm, RD 2 stated that when reviewing Resident 1's nutritional status, she was not quite sure whether the order of Resource 2.0 quite made to the computer system yet. Consequently, she did not chart in the assessment and plan regarding the Resource 2.0. I normally would have charted the supplement Resource 2.0 in my assessment and plan of the care for resident who is on it. During an interview and concurrent record review on 10/12/15 at 2:00 pm, Unit Manager (UN) 1 stated that Resident 1 was transferred, within the facility, from short term care unit on 5/27/15 to long term care unit where electronic documentation were used. When the nurse transcribed the physician's orders [REDACTED]. Record review of the treatment for [REDACTED]. Review of research literature by Crowe T & Brockbank C, (May 2009 Nutrition therapy in the prevention and treatment of [REDACTED]. when compared to patients receiving standard care Record review of the weight monitoring indicated that Resident 1's weight reduced from 114.6 lbs. (pounds) on 3/27/15 when admitted to 103.5 lbs. on 8/5/15 before she was transferred to an acute hospital. Record review of the Physician 1's Clinical Notes Report, dated 8/5/15, indicated that Resident 1 would be transferred to an acute hospital for deteriorating pressure ulcer and protein malnutrition.