Every finding on record at Joshua Tree Post Acute

Based on observation and interview, the facility failed to ensure the walk-in refrigerator and walk-in freezer were maintained. This failure had the potential for temperatures to fluctuate, putting an already vulnerable population at risk for foodborne illness. During a concurrent observation and interview on 9/15/25 at 8:05 AM, with the Maintenance Supervisor (MS) in the facility's kitchen, the gasket (an airtight seal around the door to keep cold air inside and warm, moist air out, maintaining consistent temperatures for food safety and energy efficiency) for the walk-in refrigerator was loose and held in place with tape. The walk-in freezer door was coated in a layer of ice. The MS stated the freezer door gasket did not create a tight seal which caused the door to shut improperly. The MS stated he needed to melt the ice with a blower every two to three weeks to remove the ice buildup. The MS stated both the walk-in refrigerator and walk-in freezer gaskets needed to be replaced. During a review of the facility's policy and procedure (P&P) titled, Physical Environment, dated 1/2025, the P&P indicated, It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that it remains in good working order for resident and staff safety.

Based on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive for four of 10 sampled residents (Residents 2, 5, 7, and 9). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. 1. A review of Resident 2's admission Record, (a document showing a summary of the resident's information) dated 9/17/25, indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's Advance Directives Checklist, dated 4/18/25, indicated Resident 2 did not possess an Advance Directive (a written document specifying an individual's end- of -life care). The section indicating I was offered and received referral tools to formulate Advance Directive was left blank. A review of Resident 2's History and Physical, dated 4/21/25, indicated Resident 2 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 9/16/25 at 3:24 PM with the Social Services Director (SSD), Resident 2's Advance Directive Checklist, dated 4/18/25 was reviewed. The SSD stated he documented in the Advance Directive Checklist, form to indicate if the resident or representative was informed of the right formulate an Advance Directive. When asked to show evidence Resident 2 or their representative were offered the right to formulate an Advance Directive, the SSD was unable to show any evidence information about Advance Directives were offered and verified the section was left blank. 2. A review of Resident 5's admission Record, dated 9/16/25, indicated Resident 5 was readmitted to the facility on [DATE]. A review of Resident 5's POLST, (Physician Orders for Life-Sustaining Treatment - form that documents an individual's preferences for end-of-life care) dated 10/13/24, indicated under Section D Information and Signatures, Resident 5 did not have an Advance Directive. A review of Resident 5's History and Physical, dated 8/22/25, indicated Resident 5 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 9/16/25 at 3:24 PM with the Social Services Director (SSD), Resident 5's clinical record was reviewed. The SSD stated he was responsible for ensuring the Advance Directives were available in the clinical record or offered to the residents. The SSD stated if the resident did not have an Advance Directive in place, he would follow up with the resident or the representative and offer to formulate one. The SSD stated he documented in the Advance Directive Checklist form to indicate if the resident or representative was informed of the right formulate an Advance Directive. When asked to show Resident 5's Advance Directive Checklist form, the SSD verified there was no documented evidence indicating Resident 5 or their representative was offered the right to formulate an Advance Directive and verified there was no Advance Directive Checklist form completed for Resident 5. 3. A review of Resident 7's admission Record, dated 9/16/25, indicated Resident 7 was first admitted to the facility 3/19/22. A review of Resident 7's POLST, dated 3/19/22, indicated under Section D Information and Signatures, Resident 7 did not have an Advance Directive. A review of Resident 7's History and Physical, dated 6/11/25, indicated Resident 7 did not have the capacity to understand and make decisions. Further review of Resident 7's clinical record indicated no documented evidence that the resident or the representative was provided with written information concerning the right to formulate an Advance Directive. During a concurrent interview and record review on 9/16/25 at 3:24 PM with the SSD, Resident 7's clinical record and POLST dated 3/19/22 were reviewed. The SSD stated that he was responsible for ensuring the Advance Directives were available in the clinical record or offered to the residents. If the resident did not have an Advance Directive in place, he would follow up with the resident or the representative and offer to formulate one. The SSD stated he documented in the Advance Directive Checklist form to indicate if the resident or representative was informed of the right formulate an Advance Directive. When asked to show Resident 7's Advance Directive Checklist form, the SSD verified there was no documented evidence indicating Resident 7 or her representative was offered the right to formulate an Advance Directive and verified there was no Advance Directive Checklist form completed for Resident 7. 4. A review of Resident 9's admission Record, dated 9/16/25, indicated Resident 9 was readmitted to the facility on [DATE]. A review of Resident 9's POLST, dated 7/6/24, indicated under Section D Information and Signatures, Resident 9 did not have an Advance Directive. A review of Resident 9's History and Physical, dated 11/26/24, indicated Resident 9 did not have the capacity to understand and make decisions. Further review of Resident 9's clinical record indicated no documented evidence that the resident or the representative was provided with written information concerning the right to formulate an Advance Directive. During a concurrent interview and record review on 9/16/25 at 3:24 PM with the SSD, Resident 9's clinical record and POLST dated 7/6/24 were reviewed. The SSD verified there was no documented evidence indicating Resident 9 or her representative was offered the right to formulate an Advance Directive. The SSD verified there was no Advance Directive Checklist form completed for Resident 9. The SSD stated the facility had a difficult time contacting the family and verified Resident 9 did not have an Advance Directive in place since admission. A review of the facility's policy and procedures titled Advance Directives, dated 1/25/25, indicated It is the policy of this facility that a resident's choice about advance directives will be recognized and respected. Further, it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment, and at the resident's option, formulate an advance directive.5. The care plan team will periodically, at least quarterly, annually, and on a change of condition, review the advance directive and/or preferences regarding treatment options with the resident or his/her representative his/her advance directives to ensure that they are still the wishes of the resident.

Based on observation, interview, and record review, the facility failed to ensure the lunch menu was followed when: The recipe was not followed during preparation of the pureed starch 2. The portion size for the ginger carrots was not followed during tray line These failures had the potential to put the residents at risk for choking hazards and malnutrition. 1. A review of the Fall Menus, dated 9/16/25, indicated that rice pilaf was on the menu for lunch. During a concurrent observation, interview, and record review on 9/16/25 at 11:01 AM, with the Cook, in the presence of the Registered Dietician (RD) and Dietary Services Supervisor (DSS), the [NAME] began to make the [NAME] Pilaf for 12 residents who were ordered a pureed diet. The [NAME] measured out 12 servings, placed them into the blender, and blended. The [NAME] then added approximately one cup of chicken stock and blended again until the right consistency was reached. The RD and DSS reviewed the facility's Recipe: Pureed (IDDSI Level #4) Starch (Rice, Pasta, Polenta, Potatoes, etc.), dated 2025, indicated, .1. Complete the regular recipe. Measure out the total number of portions .for pureed diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk . The RD and DSS verified the recipe required the use of warm milk, and not chicken stock. The [NAME] verified chicken stock was used instead of warm milk for the puree preparation for lunch. When asked if the nutritional value could be changed by not following the recipe, the RD stated, Yes. The RD and DSS stated the puree recipe should be followed. 2. A review of the facility's therapeutic spreadsheets titled, Fall Menus [NAME] Spreadsheet Week 3 Tuesday dated 9/16/25, indicated that ginger carrots were on the menu for lunch, and the regular serving size was one half cup. During an observation of tray line on 9/16/25 at 12:29 PM, the [NAME] was observed plating for Resident 23 in the presence of the RD and DSS. He placed one third cup scoop of carrots on the plate. At 12:51 PM, The [NAME] was observed plating for Resident 53 in the presence of the RD and DSS. He placed one third cup scoop of carrots on the plate. During a concurrent observation and interview on 9/16/25 at 1:15 PM, with the DSS, the DSS was asked how they determine serving sizes. The DSS stated they followed the therapeutic spreadsheet that listed the serving size. The DSS stated the serving size for the ginger carrots was one half cup and verified the [NAME] incorrectly served one third cup of the ginger carrots to Residents 23 and 53. The DSS stated Residents 23 and 53 should have received one half cup of the ginger carrots for lunch. During an interview with the RD on 9/16/25 at 1:16 PM, the RD stated staff should use the serving sizes listed on the therapeutic spreadsheet. The RD acknowledged using the wrong size scoop meant the residents received a smaller serving than they were supposed to get.

Based on observation and interview, the facility failed to clean and disinfect the shared toilet of two sampled residents (Resident 32 and Resident 53) after completing plumbing work.This failure violated the residents' right to a safe and sanitary living environment.During a concurrent observation and interview on 9/15/25, at 9:25 AM with Resident 53, in the resident's room, the door to the restroom had a red banner that read, Stop do not enter. Resident 53 stated the toilet was broken. During an interview on 9/15/25, at 4:19 PM with Resident 32, Resident 32 stated the toilet in their room was still broken and was not usable. During an observation on 9/15/25, at 11:13 AM in Residents 32 and 53 shared restroom, the top ring of the toilet bowl had multiple brown rings and stains. A review of the Maintenance Work Order Log, dated from 8/7/25 - 8/29/25 indicated an entry dated 8/16//25, that Resident's 32 and 53's shared toilet was clogged. During a concurrent observation and interview on 9/17/25 at 3:10 PM with the Director of Nursing (DON), in Residents 32 and 53's shared restroom, the DON confirmed the shared toilet was stained and unsanitary for resident use. During a concurrent interview and record review on 9/18/25 at 9:20 AM with DON, the facility's policy and procedure (P&P) titled, Housekeeping Services dated 1/2025 was reviewed. The P&P indicated, The policy of this facility is to promote a sanitary environment. The DON confirmed the toilet was left in an unsanitary condition and did not adhere to this housekeeping policy.

Based on interview and record review, the facility failed to ensure the medical record was accurate for one of 14 sampled residents (Resident 12) when the facility incorrectly assessed and documented Resident 12 as a good candidate for a bowel and bladder retraining program.This failure had the potential for Resident 12 to receive a delay in incontinence (involuntary loss and control of urine from the bladder and/or stool from the rectum) care, have an increased risk of skin breakdown and urinary tract infections (an infection in any part of the urinary system, such as the bladder, kidneys, or urethra).A review of Resident 12's admission Record, (a document showing a summary of the resident's information) dated 9/17/25, indicated Resident 12 was admitted to the facility on [DATE].During an interview on 9/17/25 at 2:39 PM with Resident 12, Resident 12 stated using a bedpan to urinate was difficult and preferred using incontinence briefs because of the loss of control of the bladder. Resident 12 also stated the use of the bedside commode and walking to the bathroom was not feasible because Resident 12 could not stand.During an interview on 9/17/25 at 2:41 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 required Hoyer lift (a mechanical device with a boom, mast, base, and a sling to lift and transfer individuals who are unable to move themselves) for transfers, was incontinent of urine, and CNA 1 provided urinary incontinence care after Resident 12 had an incontinence episode.During a concurrent interview and record review on 9/17/25 at 3:22 PM, with the Director of Nursing (DON), Resident 12's SSL-Bowel and Bladder Program Program Screener, dated 9/5/25, was reviewed. The SSL-Bowel and Bladder Program Screener under section A indicated Resident 12 voided appropriately without incontinence at least daily, and was alert and oriented. The DON reviewed Resident 12's Tasks - Bladder Continence dated 8/19/25 through 9/17/25, and verified Resident 12 had only one episode of bladder continence in the prior 30 days. The DON stated the SSL-Bowel and Bladder Program Screener was incorrect.

Based on interview and record review the facility failed to obtain informed consent (a process in which a healthcare professional educates a resident/patient about the risks, benefits, and alternatives of a given procedure or intervention so the resident/patient can make an educated decision) before administration of Ativan ([lorazepam] a psychotropic medication that affects a person's mental state and used to treat anxiety) for one of five sampled residents (Resident 1). This failure resulted in Resident 1 being administered Ativan without Resident 1 understanding or agreeing to the risks and benefits of the medication.A review of Resident 1's admission Record, (a document showing a summary of the resident's information) dated 9/18/25, indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety.A review of Resident 1's Order Summary Report, (a report that contains medication orders) dated 9/19/25 indicated Resident 1 had a physician's order dated 9/9/25 for Ativan Oral Tablet 0.5 mg (milligrams - unit of measurement) (Lorazepam) Give 1 tablet by mouth every 8 hours as need for Anxiety . During a concurrent interview and record review on 9/19/25 at 4:45 PM with the Director of Nursing (DON), the DON reviewed Resident 1's medical record and verified there was no documentation Resident 1 received informed consent prior to the administration of Ativan. The DON verified Resident 1 received Ativan without a signed informed consent. The DON reviewed the facility's policy and procedure (P&P) titled, Psychotropic Drug Use, dated 1/2025 which indicated, .6 .f. Informed consent was obtained prior to use . The DON verified the facility did not follow their policy for psychotropic drug use.

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (an advocate for residents in nursing homes) prior to the transfer or as soon as practicable when one of three sampled residents (Resident 3) was discharged to the hospital. This failure had the potential to leave Resident 3 unprotected from improper discharge and limit Resident 3's rights to advocacy and representation. 1. A review of Resident 3's admission Record, (a document showing a summary of the resident's information) dated 9/18/25, indicated Resident 3 was admitted to the facility on [DATE].A review of Resident 3's Order Details, dated 6/4/25, indicated a physician's order to transfer the resident to the hospital for a psychiatric evaluation.A review of Resident 3's eINTERACT Transfer Form V4.0, dated 6/4/25, indicated the resident had a planned transfer to the hospital on 6/4/25 due to behavioral symptoms.A review of Resident 3's Progress Notes, dated 6/27/25, indicated Resident 3 was readmitted to the facility.Further review of Resident 3's clinical record indicated no documented evidence that the Ombudsman was notified of Resident 3's discharge to the hospital. During a concurrent interview and record review on 9/17/25 at 3:39 PM with the Medical Records Director (MRD), Resident 3's clinical record was reviewed. The MRD stated part of her responsibilities was to fax a notification to the Ombudsman regarding resident transfers and discharges. The MRD explained she faxed the notification immediately and kept a copy of the fax transmittal. When asked to show the Ombudsman Notification regarding Resident 3's discharge to the hospital on 6/4/25, the MRD was unable to find the documentation. The MRD verified that the notification regarding Resident 3's discharge was overlooked and should have been sent to the Ombudsman.

Based on interview and record review, the facility failed to follow up on one of four residents (Resident 6) Level II (two) Preadmission Screening and Resident Review ([PASRR] a mandatory screening process to ensure that individuals with a serious mental illness or an intellectual disability are not improperly placed in a nursing home) to determine the resident's need for specialized services and appropriate placement. This failure placed Resident 6 at risk for unmet behavioral health needs and inappropriate care planning. A review of Resident 6's admission Record, (a document showing a summary of the resident's information), indicated Resident 6 was readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia (a severe brain disorder in which people interpret reality abnormally) and a mood disorder). A review of Resident 6's Preadmission Screening and Resident Review (PASSR) Level 1 Screening, dated 8/13/24, indicated a level one screening was completed following a change in condition. Further review indicated under Section III -Serious Mental Illness, Resident 6's PASSR Level 1 screening was marked Yes to a diagnosed serious mental illness and the specified diagnoses included schizoaffective disorder, depressive type, major depressive disorder. A review of Resident 6's Notice of Attempted Evaluation, dated 8/13/24, indicated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level one screening, therefore California Department of Health Care Services was unable to complete a level two evaluation for serious mental illness to determine if the individual could benefit from specialized services. During a concurrent interview and record review on 9/16/25 at 3:50 PM, with the Medical Records Director (MRD), Resident 6's clinical record was reviewed. The MRD reviewed Resident 6's Preadmission Screening and Resident Review PASSR - Level 1 Screening, dated 8/13/24, and Resident 6's Notice of Attempted Evaluation, dated 8/13/24. The MR stated she was responsible to complete and follow up the PASRR for the residents in the facility. The MRD stated the process of PASSR determines if residents require special services or if the residents are not appropriate to stay in the facility. The MRD was asked to provide documented evidence the facility followed up on the attempted PASSR Level II Screening. The MRD was unable to provide such evidence and stated it must have been missed. During a concurrent interview and record review on 9/17/25 at 3:18 PM, the facility's policy and procedure (P&P) titled PASSR Completion Policy, dated 1/25, was reviewed with the Administrator and the Administrator verified the PASSR Completion Policy, dated 1/25 indicated, The center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. 1. Center Administrator will designate the medical records to make sure that the PASRR and/or level of care (LOC) is done on all potential residents .4. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission. The Administrator stated he delegated the responsibility of the PASRR to Medical Records. The Administrator stated the completion and follow through of a resident's PASRR was important and necessary to ensure services and placement at the facility was appropriate for the resident.

Based on observation and interview, the facility failed to ensure that wound treatment supplies were maintained in a sanitary manner when a red-pink colored dried substance and an expired treatment wipe were found inside the facility's Wound Treatment Cart. This failure had the potential to result in unsafe or ineffective resident treatments. During a concurrent Wound Treatment Cart inspection and interview on [DATE], at 11:33 AM with Director of Nursing (DON), an expired (passed the use by date printed on the package and can no longer be clean or effective) SurePrep (skin protectant wipe that prevents irritation) and red-pink dried substance were found inside the treatment cart drawer. The DON verified that the SurePrep expired on [DATE] and that there was a red-pink colored dried substance in the top drawer of the treatment cart that had spilled onto other medications. During an interview on [DATE] at 11:10 AM with the Infection Preventionist (IP), the IP stated that there should not be expired supplies on the cart and spills are an infection control issue and should have been cleaned up immediately. During an interview on [DATE] at 11:20 AM with the DON, the DON stated, there should not be expired wipes on the cart and spills in the treatment cart should be cleaned up immediately.

Based on observation and interview, the facility failed to ensure the most recent survey results, and the corresponding plan of corrections were readily accessible to the residents, family, and visitors. This failure had the potential to limit the residents' and the public's ability to stay informed about the facility's quality of care and efforts to address the identified deficiencies.1. During an interview on 9/16/25 at 10:05 AM at the Resident Council meeting, the residents were asked if they were able to review the results of the state survey without having to ask a staff. All four residents (Residents 4, 35, 52, and 57) who attended the meeting stated they had not seen the survey results and did not know where they were located. During a concurrent observation and interview on 9/16/25 at 10:39 AM with the Administrator (ADM), the ADM was asked to locate the facility's survey binder (a binder containing the results of the most recent survey which includes the Statement of Deficiencies (Form CMS-2567) which contains any deficiencies resulting from a complaint investigation or recertification survey). The ADM then retrieved the survey binder from a locked room that cannot be accessed without a staff's assistance. When asked to show any facility signage indicating where the survey binder was kept, the ADM verified the facility did not have any signs posted. The ADM explained that the facility previously kept the survey binder in the lobby; however, it was often removed and misplaced, so it was relocated to a locked room. A review of the facility's policy and procedures titled Resident Rights, dated 1/25/25, indicated .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .w. examine survey results.

Based on observation, interview, and record review, the facility failed to provide assistance during mealtime as required by the care plan for 1 of 6 sampled residents (Resident 50) which resulted in Resident 50 being left with an uncovered and unattended breakfast tray which compromise the quality and temperature of the meal. This failure had the potential to lead to inadequate nutrition and placed Resident 50 at risk for malnutrition. Finding: A review of Resident 50 Admission Record (contains demographic and medical information) the admission record indicated Resident 50 was admitted to the facility on [DATE], with diagnosis of dementia (a condition that affects the brain and makes it harder for a person to think clearly, remember things, or make decisions) and hypertension (elevated blood pressure). During a review of Resident 50's Care Plan dated June 21, 2024, indicated, [AGE] years old female at risk for malnutrition r/t [related to] dementia ., Goal, maintain adequate nutrition & [and] hydration status , Interventions .set up meal tray, assist and give verbal cues . During an observation on September 18, 2024, at 7:45 AM in Resident 50's room, Resident 50 was lying in bed, facing the window, with her eyes closed and asleep. An unattended, uncovered and untouched breakfast tray was on the bedside table. The tray contained a bowl of soggy cereal, a plate with scrambled eggs and toast, an open 125 Milliliter (ml- a unit of measurement) carton of cranberry-raspberry juice, and an 8 ounce (oz- a unit of measure) open carton of milk. The food had been left uncovered and untouched by Resident 50 for over twelve minutes. During an interview on September 18, 2024, at 7:50 AM with the Procurement Director (PD- a person who is to ensure that the necessary supplies, equipment and services are available for the facility to operate), the PD observed Resident 50's uncovered and untouched breakfast tray and confirmed that it had been left unattended. The PD stated that she would look for a staff member to assist Resident 50. During an interview on [DATE], at 7:57 AM, with a Certified Nurse Assistant 1 (CNA 1), CNA 1 arrived and confirmed that Resident 50 requires assistance with eating. CNA 1 acknowledged that the tray had been left uncovered and unattended, causing the food to become cold. CNA 1 was not assigned to Resident 50, however CNA 1 offered to assist the resident with her meal. During an interview on September 19, 2024, at 10:32 AM with Certified Nurse Assistant 2 (CNA 2), CNA 2 admitted delivering the breakfast tray and leaving it uncovered and unattended. CNA 2 further acknowledged that Resident 50 requires assistance during meals but admitted that she forgot to return to assist th resident. During a concurrent interview, and record review on [DATE], at 9:51 AM with the Chief Nursing Officer (CNO) the facility's policy and procedure (P & P) titled, Activities of Daily Living (ADLs), supporting dated March 2024, was reviewed. The P&P indicated, Residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . The CNO confirmed the P&P was not followed by the staff.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 49 and 9) received treatment and care when the facility did not follow their policy and Procedures (P&P): 1. For Resident 49, the medication Linzess (a medication used to treat constipation) was not available from the pharmacy to be administered as ordered by the physician. This failure resulted in Resident 49 not receiving the medication and placing Resident 49's health and safety at risk. 2. For Resident 9, the treatment Administration Record (TAR) was not documented as being done on May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024 to Resident 9's right hip wound. This failure had the potential to result in worsening of skin condition placing Resident 9 at risk for further injuries. 3. For Resident 9, a Change in Condition Evaluation form (COC) and a SBAR (S-situation B-background A-assessment R-recommendation -A type of Communication Form) were not done for positive wound infection on April 17, 2024. This failure had the potential to result in an unidentified complications for Resident 9. Findings: 1. A review of Resident 49's Admission Record (contains medical and demographic information) dated June 5, 2024, the Admission Record indicated Resident 49 was admitted to the facility with the diagnoses of wedge compression fracture of T-11-T-12 vertebra (spinal break caused by too much pressure on the spine), diabetes mellitus type 2 (too much sugar in the blood), and hypertension (elevated blood pressure). During a concurrent observation and interview on September 16, 2024, at 9:49 AM, with Resident 49, in Resident 49's room, Resident 49 was dressed in casual clothing, laying on his bed, watching television. Resident 49 stated he has constipation (unable to poop). A review of Resident 49's physician orders dated September 14, 2024, the physician orders indicated, Give 72 mcg (microgram-a unit of measurement) by mouth one time a day for GI (gastrointestinal) until October 15, 2024, one capsule at least 30 minutes before the first meal of the day on an empty stomach once a day for 30 days. During a medication cart observation on September 18, 2024, at 1:40 PM, with Licensed Vocational Nurse 2 (LVN 2), the medication cart was opened and inspected. Resident 49's medication Linzess was unable to be found. During a concurrent interview and record review on September 18, 2024, at 1:45 PM, with LVN 2, Resident 49's MAR dated September 2024 was reviewed. The MAR indicated Linzess was given on September 17, 2024 and September 18, 2024 by LVN 2. LVN 2 stated she made a mistake and attempted to document that she could not give the medication as it had not yet been delivered by pharmacy. Resident 49 was not given the medication for 4 days as ordered by the physician. During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the CNO, the facility's P&P titled, Administration of Medications dated reviewed December 2023, was reviewed. The P&P indicated, . It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. 49001 2. A review of Resident 9's Admission Record (contains demographic and medical information) dated April 7, 2023, the Admission Record indicated Resident 9 was admitted to the facility with the diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, and reasoning), and adult failure to thrive (lack of interest). A review Resident 9's Physician's Order dated May 12, 2024, indicated Resident 9 was to receive the following treatment, Cleanse [clean] right hip pressure injury [localized damage to the skin and underlying soft tissue] with .25% strength Dakin's solution [diluted bleach solution], pat dry, pack undermining with 0.25% strength Dakin's solution, soaked gauze, cover wound bed with calcium alginate [wound dressings made from seaweed-derived], cover with bordered foam dressing twice daily x [times] 30 days every day and night shift for right hip pressure injury for 30 Days. A review of Resident 9's TAR for wound care from May 1, 2024, through May 31,2024, revealed staff did not documented wound care treatment as being done per physician's orders for two days for day shift, for May 27, 2024, and May 31, 2024. A review of Resident 9's Physician's Order dated July 15, 2024, indicated Resident 9 was to receive the following treatment: Cleanse right hip pressure injury with .25% strength Dakin's solution, pat dry, pack undermining with 0.25% strength Dakin's solution, cover wound bed with calcium alginate, cover with bordered foam dressing twice daily x 30 days every day and night shift for stage 3 [full thickness tissue loss] pressure injury to right trochanter [hip] for 30 Days. A review of Resident 9's TAR for wound care from August 1, 2024, through August 31,2024, revealed staff did not document wound care treatment as being done per physician's order for 2 days, for day shift on August 5, 2024, and August 10, 2024. During a concurrent interview and record review, on September 19, 2024, at 4:20 PM with Licensed Vocational Nurse Wound Care Certified (LVN WCC), reviewed Resident 9's TAR for May 1, 2024, through May 31, 2024, and August 1, 2024, through August 31, 2024. LVN WCC stated May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024, are missing check mark and nurse's initial in the box. LVN WCC stated, if treatment is done, nurses document on the TAR. LVN WCC stated, she is not sure why the documentation on the TAR for those days are missing. LVN WCC stated, she was not working at the facility at the time, but she believes, it was not being done. LVN WCC further stated, when she finished the wound care treatment, she document in the TAR by clicking the box for the treatment and documents in the progress note. During a concurrent interview and record review, on September 19, 2024, at 4:45 PM with the Chief Nursing Officer (CNO), reviewed Resident 9's TAR, for wound care from May 1, 2024, through May 31, 2024, and August 1, 2024, through August 31, 2024. The CNO acknowledged, May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024, Resident 9 had missing documentation for wound treatment for the day shifts as ordered by the physician. The CNO further stated, she expects the nurses to carry out the treatments and document. During a concurrent interview, and record review on September 20, 2024, at 9:00 AM with the CNO, reviewed the facility's policy and procedure (P&P) titled, Skin Assessment, with reviewed date 3/13/2024. The P&P indicated, Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's order . All wound or skin treatments should be documented in the resident's clinical record at the time they are administered . The CNO acknowledge the P&P and stated, the nurses should follow physician's orders and document. During a subsequent interview and record review, with the CNO, on September 20, 2024, at 9:52 AM, reviewed the facility's P&P titled, Documentation and Charting, with reviewed date of December 2023. The P& P indicated, A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner . The CNO stated, she would expect staff to follow physician's orders. 3. A review of Resident 9's clinical record titled, Progress Notes, Type: Nursing Note, dated April 17,2024. The Progress notes, Type: Nursing Note, indicated, resident cont [continue] to be monitor for Positive wound culture to rt [right] hip pt [patient] has started PO [oral] order of Bactrim DS [antibiotic] . A review of Resident 9's clinical record titled, eINTERACT Change in Condition Evaluation for the Month of April 2024. There is no documented evidence a change of condition evaluation was done for Resident 9's positive wound culture for April 17, 2024. A review of Resident 9's clinical record titled, SBAR [S-situation B-background A-assessment R-recommendation] Communication Form and Progress Note for RNs/LPN/LVNs for the Month of April 2024. There is no documented evidence a change of condition/SBAR was done for Resident 9's positive wound culture for April 17, 2024. During a concurrent interview and record review, on September 20, 2024, at 10:00 AM with the CNO, Resident 9's Progress Notes, Type: Nursing Note dated April 17, 2024, was reviewed. It indicated, resident cont to be monitor for Positive wound culture to rt hip pt has started PO order of Bactrim DS . The CNO acknowledge the progress note. The CNO further stated, it should have been a change of condition (COC) initiated for the wound infection. The CNO stated someone dropped the ball. The CNO expectation is for staff to initiate a COC for newly identified conditions. The CNO further stated, .no SBAR done. During a concurrent interview and record review on September 20, 2024, at 10:20 AM with the CNO, the facility's policy and procedure (P&P) titled, Change of Condition, with reviewed date December 2023, was reviewed. The P&P indicated, Document resident change of condition and response in SBAR UDA and update resident care plan, as indicated . The CNO acknowledged the P&P and stated, we did not do SBAR for positive wound infection.

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible for one of six sampled Residents (Resident 9) when Resident 9's call light was found on the floor. This failure had the potential to result in Resident 9 unable to use the call light system to call for any assistance Resident 9 may require. Finding: A review of Resident 9's Admission Record (contains demographic and medical information) dated April 7, 2023, the Admission Record indicated Resident 9 was admitted to the facility with the diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), dementia (loss of thinking, remembering, and reasoning), and gout (inflamed, painful joints). During a concurrent observation and interview on September 16, 2024, at 10:33 AM, with Resident 9, in Resident 9's room, the call light was observed on the floor adjacent to Resident 9's bed. Resident 9 stated he could not reach his call light. During a concurrent observation and interview on September 16, 2024, at 10:36 AM, with Resource Respiratory Therapist (RRT), in Resident 9's room, the RRT observed the call light on the floor. The RRT stated it should not be on the floor. During a concurrent interview and record review on September 20, 2024, at 9:30 AM, with the Chief Nursing Officer (CNO), the undated facility's policy and procedure (P&P) titled, Answering the Call Light, was reviewed. The P&P indicated, . 5. Ensure that the call light is accessible to the resident when in bed . The CNO stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure the dietary restrictions as indicated on the allergy diet card was followed for 1 of 6 sampled Residents (Resident 14) when Resident 14's diet card indicated Resident 14 had food allergies to cranberry. This failure had the potential for Resident 14 to develop serious and fatal allergic reactions. Finding: During a review of Resident 14's Admission Record (contains demographic and medical information) the admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses of paroxysmal atrial fibrillation (irregular heartbeat), asthma (a condition in which airways in the lungs become narrow, swollen, making hard to breath) and gastroesophageal reflux disease (GERD-a condition in which stomach acid frequently flows back into your esophagus). During an observation on September 18, 2024, at 8:01 AM, in Resident 14's room, Resident 14 was complaining about her breakfast tray to the staff, which had been served with two cartoons of cranberry juice of 125 ml, each, [ milliliters - unit of measurement of liquid volume], despite the documented allergy to cranberries on Resident 14's diet card. Further observation revealed the Medical Data Set Nurse (MDSN), was informed of Resident 14 compliant and promptly removed the two cartoons 125 ml each of cranberry juice from the room. MDSN confirmed with Resident 14 she had not consumed the juice and assure her that another type of juice would be provided. During a concurrent interview and record review on September 18, 2024, at 8:03 AM, with the MDSN the Diet Card dated September 18, 2024 was reviewed. It indicated, beverages: 8 oz Juice (NO CRANBERRY), further review revealed Allergies: CRANBERRY, WALNUTS. The MDSN confirmed Resident 14's allergies and stated she should not have been served cranberry juice and stated that it was an oversight. During an interview on September 18, 2024, at 8:48 AM with Resident 14, Resident 14 expressed concerns about the staff serving her cranberry juice, despite informing the facility of her allergies. Resident 14 stated, that if she consumed cranberries, her allergic reaction would cause her to develop hives on her tongue. Resident 14 further expressed frustration that the facility is not consistently adhering to her documented dietary restrictions. During a concurrent interview and record review on September 18, 2024, at 10:05 AM, with the Chief Nursing Officer (CNO) Resident 14's Diet Card dated September 18, 2024, was reviewed. The CNO acknowledged Resident 14 dietary restrictions were clearly stated on the card and confirmed that cranberry juice should not have been served. During an interview on September 18, 2024, at 11:02 AM, with License Vocational Nurse 2 (LVN 2), LVN 2 stated that she occasionally comes to help out at this facility and is familiar with Resident 14. However, when she delivered Resident 14's tray, she missed seeing the allergy information indicating Resident 14 is allergic to cranberries. LVN 2 expressed that this oversight was unintentional. During an interview on September 18, 2024, at 11:17 AM with Licensed Vocational Nurse 3/Wound care certified nurse (LVN 3, / WCC) stated that she was checking the breakfast trays with another nurse and missed the food allergy information for Resident 14. LVN 3/WCC explained that when checking the trays, they were focused on diet types and food textures, but overlooked the allergy information. LVN 3 / WCC acknowledged the importance of checking for food allergies, as residents could have serious allergic reactions, such as rashes or throat swelling if given food, they are allergic to. During a concurrent interview and record review on September 19, 2024, at 9:52 AM with the CNO, the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances dated March 2024 was reviewed. The P&P indicated, Residents with food allergies and / or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident to the allergen(s). Assessments and Interventions: 3. Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment . The CNO confirmed that staff did not follow their P&P.

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled Residents (Resident 48 and 49) when: 1. Resident 48 had missing interdisciplinary team (IDT- interdisciplinary team- a mix of different disciplines in medicine that meet to discuss patient's care) investigation and recommendation from a fall Resident 48 sustained on August 21, 2024. 2. Resident 49 had inaccurate documentation on the medication administration record for a medication documented as given but the medication had not arrived from pharmacy. These failures had the potential to place Resident 48 and 49 at risk for missed interventions being updated in the plan of care, inaccurate count of medications, further falls, and missed adverse side effects from medications. Findings: 1. A review of Resident 48's Admission Record (contains medical and demographic information) dated May 31, 2024, the Admission Record indicated Resident 48 was admitted to the facility with the diagnoses of dementia (loss of brain function-thinking, remembering, and reasoning), chronic pain syndrome (pain that lasts for longer than three months), and malignant neoplasm of brain (cancerous tumor in brain). A review of Resident 48's SBAR- Change of Condition Report (Situation, Background, Assessment, and Recommendation/Request - a structured communication framework used in medicine) dated August 21, 2024, the SBAR - Change of Condition Report indicated Resident 48 had a . witnessed fall and was seen hitting his head against the wooden railing. Resident 48 was sent to the hospital. A review of Resident 48's Care Plan - at risk for falls (document that outlines the type of care a patient needs and how to provide that care) dated June 4, 2024, the Care Plan - at risk for falls indicated it had not been updated since June 4, 2024. During a concurrent interview and record review on September 19, 2024, at 11:29 AM, with Minimum Data Set Nurse (MDSN), Resident 48's Assessments (list of different types of assessments used for residents) under IDT Meeting Note was reviewed. There were no IDT meeting notes for the fall Resident 48 sustained on August 21, 2024. MDSN stated there should have been an IDT meeting for Resident 48's fall. During a concurrent interview and record review on September 20, 2024, at 9:36 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Fall Prevention dated reviewed December 2023 was reviewed. The P&P indicated, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence .5. If there is an existing plan of care if the resident's medical record pertaining to falls it should be updated to reflect newly identified risk factors and approaches . the complete incident report, post fall evaluation, and incident investigation report will be reviewed by the facility Interdisciplinary Team. The CNO stated the P&P was not followed. During a concurrent interview and record review on September 20, 2024, at 9:36 AM, with the CNO, the facility's P&P titled, Fall Management System dated reviewed December 2023, was reviewed. The P&P indicated, .5. The investigation will be reviewed by the Interdisciplinary Team . a. a summary of the investigation and recommendations will be documented in the resident's clinical record . 6. Resident's care plan will be updated. The CNO stated the P&P was not followed. 2. A review of Resident 49's Admission Record (contains medical and demographic information) dated June 5, 2024, the Admission Record indicated Resident 49 was admitted to the facility with the diagnoses of wedge compression fracture of T-11-T-12 vertebra (spinal break caused by too much pressure on the spine), diabetes mellitus type 2 (too much sugar in the blood), and hypertension (elevated blood pressure). A review of Resident 49's Medication Administration Record (MAR) for the month of September 2024 was reviewed. The MAR indicated Linzess (medication for chronic constipation) Oral Capsule 75 MCG (microgram-unit of measurement) was administered on September 17th, 2024, and September 18, 2024. During a medication cart observation on September 18, 2024, at 1:40 PM, with Licensed Vocational Nurse 2 (LVN 2), the medication cart was opened and inspected. Resident 49's medication Linzess was unable to be found. During a concurrent interview and record review on September 18, 2024, at 1:45 PM, with LVN 2, Resident 49's MAR dated September 2024 was reviewed. The MAR indicated Linzess was given on September 17, 2024 and September 18, 2024 by LVN 2. LVN 2 stated she made a mistake and attempted to document that she could not give the medication as it had not yet been delivered by pharmacy. LVN 2 further stated the September 17, 2024 and September 18, 2024 documentation was not accurate. During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Documentation and Charting dated reviewed December 2023, was reviewed. The P&P indicated, It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner . 6. The elements of quality medical nursing care . The CNO stated the P&P was not followed. During a concurrent interview and record review on September 20, 2024, at 9:38 AM, with the CNO, the facility's P&P titled, Administration of Medications dated reviewed December 2023, was reviewed. The P&P indicated, . 9. Should a drug be withheld, refused, or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. The CNO stated the P&P was not followed.

Based on interview and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when an Activities Staff (AS) person grabbed Resident 1 ' s right arm and yanked Resident 1 down onto her bed. This failure caused Resident 1 to suffer fear and abuse. Findings: An unannounced visit was made to the facility on [DATE], at 10:32 AM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 1 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning). During an interview with a Certified Nursing Assistant (CNA 1) on July 17, 2024, at 11:43 AM, CNA 1 stated she came into the room with Resident 1 ' s roommate (Resident 2) because Resident 2 had complained of pain and wanted to go back to her bed. CNA 1 stated she began to help Resident 2 to bed when she saw Resident 1 stand up from her bed and begin walking to the door and she was not supposed to walk without assistance, but Resident 1 was a Spanish speaker and CNA 1 stated did not speak Spanish. CNA 1 stated she knew Spanish for sit down and pointed to Resident 1's bed. Resident 1 walked a few paces towards the door. CNA 1 stated an AS walked into the room with her handbag still on her shoulder and a big cup in her right hand. CNA 1 stated the AS grabbed Resident 1's right arm and pulled her roughly towards her bed and then yanked Resident 1 down towards her bed. CNA 1 stated Resident 1 stumbled onto her bed. CNA 1 stated she finished transferring Resident 2 to her bed and went immediately to Resident 1's bedside and lifted her legs onto the bed. CNA 1 stated Resident 1 made an attempt to hit the AS but missed and the AS immediately left the room making comments in Spanish and was met by a Housekeeper (HS 1) just outside the door. CNA 1 stated she heard HS 1 state Who are you taking to like that. The AS stated, That f**king old lady tried to hit me, dumb a** b*tch! Then the AS walked off. CNA 1 stated she stayed with Resident 1 because Resident 1 was crying and upset, and she knew Resident 1 would not stay in bed. CNA 1 stated she transferred Resident 1 to her wheelchair and positioned her at the nursing station to be monitored while she went to report the incident. During an interview with the Director of Staff Development (DSD) on July 17, 2024, at 12:15 PM, the DSD stated he had a conversation with the AS and the AS denied that she abused anyone and did not opt to provide a statement. The DSD stated the AS left the building on July 3, 2024, and never returned. The DSD stated the AS resigned her position via a text message. The DSD stated HS 1 was not currently on shift and he could not reach HS 1 by phone. The AS was unavailable for interview. HS 1 was unavailable for interview. During an interview with the Director of Nursing (DON) on July 17, 2024, at 12:03 PM, The DON stated the facility confirmed the AS acted abusively towards Resident 1. The DON stated the facility failed to protect Resident 1 from abuse. A review of the facility ' s policy and procedure titled, Abuse: Prevention of and Prohibition Against, dated January 2024, indicated, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and record review, the facility failed to ensure their fall prevention policies and procedures were implemented for one of three sampled residents (Resident 1). This failure resulted in Resident 1 to fall on March 27, 2024, sustained an injury (subdural hematoma-occurs after a head injury such as a fall) necessitating admission to the acute hospital to intensive Care Unit (ICU) trauma for a higher level of care. Findings: During a review of Resident 1 ' s Admission Record (a document that contains resident ' s information that includes admitted , demographic information, and medical history) dated April 3, 2024, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses which included dementia ( a condition was a person experiences a decline in their memory, thinking and reasoning skills), lack of coordination (difficulty on maintaining balance), and muscle weakness (lack of muscle strength). During a review of Resident 1 ' s Minimum Data Set (MDS) Under Section C- Cognitive Patterns (section used to determine a resident cognitive functioning status), dated February 20, 2024, indicated Resident 1 had a Brief Interview for Mental Status (BIMS a score 0-15 used to determine cognitive functioning) score of 99 (99 indicate the resident was unable to complete the interview. During a review of Resident 1 ' s Minimum Data Set (MDS) under Section GG - Functional Abilities and Goals (Section used to indicate the level of assistance), dated February 20, 2024, it indicated Resident 1 needed substantial or maximal assistance (Helper does more than half the effort) during sit to stand. During a review of Resident History and Physical (H&P) dated March 18, 2024, it indicated Resident 1 does not have the capacity to understand and made decisions. During a review of Resident 1 ' s Fall Risk assessment dated [DATE], at 5:50 PM, indicated Resident had a score of 18 (If the total score 10 or greater, the resident is on a high risk for potential falls). During a review of Resident 1 ' s SBAR - Change of Condition Report (Situation, Background, Assessment and Recommendation is a communication tool used in healthcare settings) dated, March 27, 2024, at 6:03 PM, it indicated 7. Behavior resident is not compliant with it comes to calling for help and tries to get out of bed and wheelchair on his own. During a review of Resident 1 ' s IDT Post Fall Review (IDT-team composed of staff from various disciplines) dated March 28, 2024, at 7:19 AM, in indicated . Per LVN (License Vocational Nurse) report, resident was found on the floor by nursing staff in common area (outside of room [ROOM NUMBER]), left side lying in front of wheelchair with both wheelchair locks in the unlocked position. Resident was observed with eyes open and full movement of upper extremities attempting to get themselves up from off the floor .Interventions: resident was sent to ER (emergency room ) for further evaluation . During a review of Resident 1 ' s undated care plan for falls (an individualize plan of care) indicated, resident is capable of unlocking w/c (wheelchair) and propels self through hallway. Goal, resident will remain free from falls r/t (related to) independently propelling self through facility, interventions .maintain visual checks for resident safety . During a review of Resident 1 ' s care Plan for falls (an individualize plan of care) undated, indicated Resident 1 is at risk for falls/injury related to: difficulty walking, gen (general) weakness, history of falls, impaired cognition, poor balance, poor safety awareness .interventions visibly observe resident frequently . During a review of Resident 1 ' s care plan for high risk for falls r/t (related to) confusion dated March 12, 2024, indicated Unaware of safety needs .Goal, Resident 1 will be free for falls .Interventions .follow facility fall protocol, [NAME] and [NAME] for Fall Prevention . During a review of Resident 1 ' s Admission H & P EMR (admission history and physical of emergency medical record) dated March 27, 2024, at 9:58 PM, it indicated, M (male) BIBA ([NAME] by ambulance) as transfer from (acute hospital name) for ground level fall .Workup at outside of facility subdural hematoma with midline shift (a condition where blood accumulate and put pressure on the brain) . During a review of Resident 1 ' s Nursing Note dated March 30, 2024, at 2:01 PM, it indicated Resident [Resident 1] is admitted to ICU (intensive care unit) trauma. Resident is s/p (status post) neurosurgery / craniotomy (surgery in the skull) for removal of subdural hematoma after recent fall . During a telephone interview on April 3, 2024, at 4:15 PM with the Administrator (Admin), the Admin stated leaving Resident 1, who has cognitive impairment and high risk for falls, without supervision was not a safe practice. During a telephone interview on April 3, 2024, at 6:41 PM with Certified Nurse Assistant, (CNA 1), CNA 1 stated that prior to the start of the shift on the day of Resident 1 ' s fall incident, they did not have a huddle. CNA 1 further stated there was a lack of communication between license nurses and CNA ' s. During an interview on April 8, 2024, at 10:06 AM, with CNA 2, CNA2, indicated that no huddle had occurred on that day or on any other day. CNA 2 expressed concerns regarding lack of communication between licensed nurses and CNAs regarding resident care. During an interview on April 8, 2024, at 11:05 AM with CNA 3, CNA 3, stated on March 27, 2024, they did not have a huddle the day when Resident 1 fell . During a review of the facility ' s policy and procedure titled [NAME] and [NAME] - Fall Prevention Program dated 2015, indicated, 2. Any resident who fell withing the 3-month period would be given yellow bands until they graduate off the [NAME] and [NAME] Program. 5. Management will identify a [NAME] and [NAME] Champion per shift for continuous re-education to staff on the floor. High fall risk residents should be mentioned every huddle for reinforcement . During a review of the facility ' s policy and procedure (P&P) titled Safety and Supervision of Residents undated, indicated Facility - Oriented Approach to Safety 1. Our resident-oriented approach to safety address risk identified based on assessments .Individualized, Resident -Centered Approach to Safety .10. Implementing interventions to reduce accidents risk and hazards shall include the following: a. Communication specific interventions to all relevant staff .c. Ensuring that interventions are implemented; and d. Documenting interventions . During a review of the facility ' s policy and procedure (P&P) titled Falls - Clinical Protocol undated indicated Treatment / Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of clinically significant consequences of falling .2. If the underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessments of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .Monitor and Follow -Up .2. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling.

Based on observation, interview, and record review, the facility failed to ensure two of 25 rooms were clean, sanitary, and homelike when damage was observed on walls and ceiling of rooms [ROOM NUMBERS]. These failures created an environment that was not clean, sanitary, and homelike for residents who reside in room [ROOM NUMBER] and 107. Finding: During an observation on March 25,2024, at 4:10 PM, in resident's room [ROOM NUMBER], an entire section of wooden trim was observed to be missing along the back wall and the headboard wall creating an open area of exposed unpainted dry wall along the length of the room. During an observation on March 25, 2024, at 4:15 PM, in resident's room [ROOM NUMBER], an approximate 2 foot by 4-foot section of wall and ceiling and windowsill was found to be unpainted with exposed drywall and chipping paint. During a concurrent observation, and interview, on March 25, 2024, at 4:30 PM, with the facility Infection Control Practitioner 1 (ICP1), in room [ROOM NUMBER], the damaged section of wall, ceiling and windowsill were observed. ICP 1 stated, the room is not in good repair, she states she would not find this acceptable if this was my home. ICP 1 further stated she was aware of the damage in room [ROOM NUMBER] as well and had put in a work order in today to have it fixed properly. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated March 13, 2024, the P&P indicated, The facility staff and management maximizes to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to provide proper treatment and assistive devices to maintain hearing ability for one of 12 Sampled Residents (Resident 10). This failure resulted in Resident 10 not being assessed for hearing ability and unable to appropriately express his needs. Finding: During a review of Resident 10's Admission Record (A document with basic information about the resident), the Admission Record indicated, Resident 10 was admitted to the facility on [DATE], with diagnosis which include Alzheimer's disease (a progressive disease the destroys memory and other important mental functions.), Dementia (Loss of cognitive functioning, thinking, remember and reasoning), and Unspecified hearing loss. During a concurrent observation, and interview, on March 25, 2024, at 11:37 AM, with Resident 10, in room [ROOM NUMBER], Resident 10 was observed in bed without hearing aids. Resident 10 stated, I am unable to hear very well. The following conversation had to be spelled out 1 letter at a time after multiple prompts stating he was unable to hear me. During a review of Resident 10's Minimum Data Set (MDS) (a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated March 15, 2024, the MDS indicated Under section B, Hearing, speech and vision, Resident 10 has Moderate hearing difficulty and No hearing aid. During a review of Resident 10's Care Plan, dated April 7, 2023, indicated, Resident has a communication problem related to Hearing deficit. Intervention: Monitor/ document/ report to Medical Doctor (MD) as needed, changes in ability to communicate, potential contributing factors for communication problems potential for improvement. Refer to audiology for hearing consult as ordered. During a concurrent interview, and record review, on March 27, 2024, at 1:00 PM, with Licensed Vocational Nurse 3 (LVN 3) Resident 10's Physician Orders were reviewed. The physician's orders indicated, no order was ever placed for an audiology or hearing consult. LVN 3 stated, I don't see any orders ever placed for this, LVN 3 further stated resident 10 did have hearing difficulties that appear to have gotten worse. During an interview on March 28, 2024, at 3:00 PM with Medical Records Director (MRD), MRD stated No order was placed for an auditory consult prior to today, we should have gotten an order for this prior.

Based on observation, interview, and record review, the facility failed to ensure the blood glucose monitor's (a device used to test a person's blood sugar level) control solutions (a pair of sugar solution, each set with a specific amount of sugar, used to ensure the glucometer and strips are accurate) were dated with an open date. This failure had the potential for the glucometer control testing to be inaccurate and potential for residents that require blood sugar monitoring to have inaccurate results. Findings: During a concurrent observation, and interview, on [DATE], at 06:00 AM, at medication cart #2, (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment), with Licensed Vocational Nurse 1 (LVN1), it was observed that medication cart 2's glucometer controls had been opened and used, but did not have an open date written on the bottles or the box. LVN 1 stated, the glucometer controls were opened about a week ago and should have been dated with the open date, but were not. LVN 1 went on to say that registry personal and other staff would not be able to identify when these controls were opened, LVN 1 further stated the control solution would be thrown away after 90 days of opening. During a concurrent interview, and record review, on [DATE], at 10:00 AM, with Director of Nursing 2 (DON 2), The [name of brand] Glucose Monitoring System User's Guide was reviewed. The [name of brand] Glucose Monitoring System User's Guide page 24 indicated, Meter set up: Control Solution Testing Note: Use only [name of brand] Glucose Control Solutions with [name of brand] Blood Glucose Test Strips .Always check the expiration date of the control solution . DO NOT use expired control solution. Record the date on the bottle when opening a new bottle of control solution. Discard any unused control solution three months after the opening date. Control solutions are good for three months after opening or until the expiration date on the bottle, whichever comes first . DON 2 stated, the glucose controls are only good for three months after opening. The bottles should be labeled with date opened and date expired. Expired controls could lead to inaccurate blood glucose results.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 21) received care and treatment for Resident 21's left contracted foot (preventing proper expansion of the foot parts producing pressure on the soft structures), when Resident 21 was found to have multiple skin tissue injuries to her contracted left foot which was not identified by the facility. This failure resulted in a delay in the treatment for skin injuries to Resident 21's contracted left foot. Findings: During a review of Resident 21's Admission Record (contains demographic and medical information) dated, October 4, 2023, indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included: gangrene (Dead tissue caused by an infection or lack of blood flow), Methicillin Resistance Staphylococcus Aureus Infection (an infection that is difficult to treat because of resistance to antibiotics), hemiplegia (A condition which causes weakness to one side of the body) and hemiparesis (paralysis of partial or total body function on one side of the body). During a review of Resident 21's, Braden Scale - For Predicting pressure sore Risk, dated, August 30, 2023, the Braden Scale indicated Resident 21 was at high risk for pressure sore development with score of 8 out of 23 score. (A low score indicates increased risk for pressure sore development). During a review of Resident 21's, care plan, dated, August 1, 2022, Resident 21's care plan indicated, Risk for developing pressure sore, and other types of skin breakdown related to: Aging Process, fragile skin, hx [history of] skin alteration, immobility, impaired cognition, incontinence of (bowel, bladder) .Goal: Minimize the risk for breakdown / pressure sore daily .Interventions .Provide good skin care q shift [every shift] Assess skin integrity during care .Notify MD of any changes . During a concurrent observation and interview on October 3, 2023, at 9:01 AM, with Licensed Vocational Nurse 3 (LVN 3) Resident 21 was observed lying on her back while in bed. Resident 21 was wearing a left heel boot. Upon removal of the left heel boot by LVN 3 the following was noted on Resident 21's contracted left foot: A. The lateral (outer side) area of the left foot, distal from the 5th toe, noted with purple color blister characterized by skin elevation, (1.5 cm x 1.5 cm). B. The left 5th toe pressure tissue injury with partial thickness loss of dermis (thickest layer of the skin) and red/pink wound bed. (approx. 2.0 cm length) C. The 4th left foot toe had circular, dry and cracked skin (approx. 2 cm length) D. The 3rd left foot had circular dark cracked skin. E. The Left great toe had a circular area (approx. 1 cm x 1 cm) on the bottom of the toe which was dark in color. F. Between the great toe and 3rd toe of the left foot, there was dark colored skin tissue and dryness. LVN 3 stated Resident 21 did not have any treatment for Resident 21's skin tissue injuries to the contracted left foot. During an interview on October 4, 2023, at 12:21 PM, with the Director of Nursing (DON), the DON stated she was not aware Resident 21 had multiple skin tissue injuries to her contracted left foot. During a review of Resident 21's physician's orders for the month of September 2023, there were no orders for the treatment of any skin injuries to Resident 21's contracted left foot. During a review of Resident 21's physician's orders for the month of October 2023, there were no orders for the treatment of any skin injuries to Resident 21's contracted left foot. During a review of Resident 21's physician's orders, dated August 25, 2023, indicated, left foot heel protector (boot like device which us used to help prevent the development of pressure injuries on the foot) while in bed and wheelchair for skin integrity. Every 12 hours for wound prevention. During a review of Resident 21's Treatment Administration Record, (TAR- document used to record treatments administered to the resident), dated September 1, 2023, through October 5, 2023, the documents indicated there were 9 days (September 22, 25, 28, and 29 and October 1, 2, 3, 4, and 5) without documented evidence that the heel protector was applied as specified by the physician's orders. During a review of Resident 21's Skin & Wound-Total Body Skin assessment dated [DATE], at 10:12 PM, indicated, 1. Skin Assessment, 1. Turgor [skin elasticity] poor elasticity, [skin ability to stretch] ., Enter the #[number] of new wounds [injury to the tissue] 0 [no indication of new wounds was noted] During a review of Resident 21's Skin & Wound-Total Body Skin assessment dated [DATE], at 10:52 PM, indicated, 1. Turgor, 2. Poor Elasticity ., Enter the # [number] of New Wounds, 6. New Wounds 0 [No indication of new wounds was noted] During a review of Resident 21's Weekly Summary V2.1 dated September 17, 2023, at 10:49 PM, indicated, Mobility / Ambulation, 2. How much assistance is required 5. Total Dependence [needs maximum of assistance] ., I, Skin Condition, 1. Is the resident free of any open areas? A. Yes .4. Are other skin condition (s) present? b. No, 5. Additional documentation (treatments, pressure reducing devices etc.) [no documentation noted] During a review of Resident 21's Weekly Summary V2.1 dated September 24, 2023, at 11:48 PM, indicated, I. Skin Condition, 1. Is the resident free of any open areas? a. Yes, 5. Additional documentation (treatments, pressure reducing devices, etc.) [No documentation noted] During a review of Resident 21, Weekly Summary V2.1 dated October 1, 2023, at 11:22 PM indicated I. Skin Condition, 1. Is the resident free of any open areas? a. Yes ., 5. Additional documentation (treatments, pressure reducing devices, etc.) NA [NA-meaning not applicable] During a review of the facility's policy and procedure titled, Pressure Injury Risk assessment dated [DATE], indicated, the purpose of this procedure is to provide guidelines for the structured assessment and identification of resident at risk of developing a new pressure or worsening of existing pressure injuries (PIs) The purpose of pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addresses .h. Impaired perfusion, oxygenation or circulation deficit .or lower extremity arterial insufficiency; .4. Conduct a comprehensive skin assessment with every risk assessment. B. Once inspection of skin is completed document the findings on a facility- approve skin assessment tool., c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin .Documentation .1. The type of assessment (s) conducted. 2. The date and time and type of skin care provided, if appropriate .,4. Any change in the resident's condition, if identified ., 12. Documentation in medical record addressing MD notification if new skin alteration noted .

Based on observation, interview, and record review, the facility failed to ensure no portable space heaters were placed in sleeping areas of residents to prevent a hazardous accident from occurring as follows: 1. room [ROOM NUMBER], with 2 Residents (Resident 1 and Resident 2) residing in the room, had a portable space heater plugged in an outlet in the room and turned on. 2. room [ROOM NUMBER], with 2 Residents (Resident 3 and Resident 4) residing in the room, had a portable heater space plugged in an outlet in the room and turned on. 3. room [ROOM NUMBER], with 1 Resident (Resident 5) residing in the room, had a portable space heater plugged in an outlet in the room and turned on. 4. room [ROOM NUMBER], with 3 Residents (Resident 6, 7, and 8) residing in the room, had a portable space heater plugged in an outlet in the room and turned on. 5. room [ROOM NUMBER], with 4 Residents (Resident 9, 10, 11, and 12) residing in the room, had a portable space heater plugged in an outlet in the room and turned on. 6. room [ROOM NUMBER], with 1 Resident (Resident 13) residing in the room, had a portable space heater plugged in an outlet in the room and turned on. This failure had the potential to [MEDICAL CONDITION] or fires affecting the health and well-being of 13 Residents residing in these rooms and a census of 51residents. An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under 4[AGE].25(d), Accidents on December 23, 2019 at 4:30 PM, in the presence of the Administrator, Administrative Assistant (AA), and the Director of Nurses (DON). Findings: During an observation on December 2, 2019, at 1:10 PM, of resident rooms (Rooms 100, 102, 103, 112, 116, and 122) affecting Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 with portable space heaters plugged into outlets in their rooms and no documented monitoring completed to prevent accidents from occurring. During an interview on December 5, 2019, at 1:00 PM, with the Administrator (ADM), the ADM confirmed the facility has been having problems with its heating unit. The ADM stated the facility bought portable space heaters for six of 25 Resident rooms (100, 102, 103, 112, 116, and 122) that no longer have heat. He said the space heaters are plugged into outlets in each of those rooms 24 hours, seven days a week. During an observation and concurrent interview with DEVS 1, on December 5, 2019, at 1:50 PM, DEVS 1 confirmed the resident rooms affected with portable space heaters in use in the rooms as follows: 1. room [ROOM NUMBER], with 2 Residents residing in the room (Resident 1 and 2). 2. room [ROOM NUMBER], with 2 Residents (Resident 3 and Resident 4) residing in the room. 3. room [ROOM NUMBER], with 1 Resident (Resident 5) residing in the room. 4. room [ROOM NUMBER], with 3 Residents (Resident 6, 7, and 8) residing in the room. 5. room [ROOM NUMBER], with 4 Residents (Resident 9, 10, 11, and 12) residing in the room. 6. room [ROOM NUMBER], with 1 Resident (Resident 13) residing in the room. During an interview on December 5, 2019, at 2:30 PM, with DEVS 1, DEVS 1 confirmed he was aware there was a problem with the heat in the facility. The DEVS 1 stated they have six Resident rooms that are not getting heat so they bought portable heaters to temporarily provide heat until we can get the heat fixed. When asked how do you ensure the safety of the residents with these portable heaters in their sleeping areas, DEVS 1 stated, The residents have not touched them. A review of the, Heating & Air Conditioning Log, dated August 25, 2019 through November 27, 2019, indicated all good except on October 31, 2019 (No heat in the back hall). During an observation and concurrent interview on [DATE], at 5:50 AM, confirmed by Certified Nurse's Aide (CNA 1) of resident rooms with portable space heaters plugged in an electric outlet and turned on as follows: 1. room [ROOM NUMBER], with a portable space heater plugged into an outlet and turned on. 2. room [ROOM NUMBER], with a portable space heater plugged into an outlet and turned on. 3. room [ROOM NUMBER], with a portable space heater plugged into an outlet and turned on. During an interview on [DATE] at 6:00 AM, with CNA 1, CNA 1 stated residents have complained about it being cold in their rooms at night. During an observation and concurrent interview on [DATE], at 6:15 AM, confirmed by Licensed Vocational Nurse/Charge Nurse (LVN 1 /CHN) of resident rooms with portable space heaters plugged in an electric outlet and turned on as follows: 4. room [ROOM NUMBER], with portable space heater plugged into an outlet, turned on. 5. room [ROOM NUMBER], with portable space heater plugged into an outlet, turned on. 6. room [ROOM NUMBER], with a portable space heater plugged into an outlet, turned on. During an observation on [DATE], at 6:20 AM of the activities room, the temperature was 57 degrees F and was confirmed by CNA 1. The large Dining room temperature was 67 degrees F and was confirmed by CNA 1. CNA 1 states it is always cold in those common rooms. A review of the Manual for the portable space heaters titled, (Name of company), dated April 2019, was provided by the DEVS 1. The following was indicated: Warning-Extreme caution is necessary when any heater is used by or near children or invalids. The heater should not be left operating unattended. Never leave children unattended when the heater is on or plugged in. Maintenance: Vacuum intake grills every two weeks, this will help to maintain the optimum heater performance. Caution: The heater is hot when in use: To avoid burns, do not let bare skin touch hot surfaces. During an observation and concurrent interview on December 22, 2019, at 11:57 AM, confirmed by DEVS 1 of the affected resident rooms with portable space heaters placed in the rooms and in use as follows: 1. room [ROOM NUMBER], with Resident 1 and Resident 2 residing in the room. 2. room [ROOM NUMBER], with Resident 3 and Resident 4 residing in the room. 3. room [ROOM NUMBER], with Resident 5 residing in the room. 4. room [ROOM NUMBER], with Resident 6, 7 and 8 residing in the room. 5. room [ROOM NUMBER], with Residents 9, 10, 11 and 12 residing in the room. 6. room [ROOM NUMBER], with Resident 13 residing in the room. During an observation and concurrent interview on December 23, 2019, at 11:57 AM, confirmed by DEVS 1 of the affected resident rooms with portable space heaters placed in the room and in use as follows: 1. room [ROOM NUMBER], with Residents 1 and 2 residing in the room. 2. room [ROOM NUMBER], with Residents 3 and 4 residing in the room. 3. room [ROOM NUMBER], with Resident 5 residing in the room. 4. room [ROOM NUMBER], with Residents 6, 7 and 8 residing in the room. 5. room [ROOM NUMBER], with Residents 9, 10, 11 and 12 residing in the room. 6. room [ROOM NUMBER], with Resident 13 residing in the room. During an interview on December 23, 2019, at 2:00 PM, with the ADM, the ADM confirmed the facility has been motoring the heating situation closely. The ADM stated he has been in-touch with DEVS 1 and are coming up with a plan to get the heating unit fixed. When asked if the portable heating units in the residents' rooms are safe, the ADM stated, They are not ideal but, that is all we have right now. During an observation on December 23, 2019, at 3:48 PM, of the affected resident rooms with portable space heaters placed as follows: 1. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. 2. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. 3. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. 4. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. 5. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. 6. room [ROOM NUMBER] - Heater placed against the wall by the dresser with cord plugged into an outlet and turned on. A review of the facility's policy and procedure titled, Quality of Life-Homelike Environment, Revised May 2017, indicated . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Comfortable and safe temperatures (71 degrees F- 81 degrees F). A review of the facility's policy and procedure titled, Maintenance undated, indicated . Heating, Cooling, Air Conditioning, and Ventilation Systems: Clean non-disposable filters according to the manufactures instructions. Record inspection, cleaning and/or replacement, and the date in the maintenance log and air filter record. General Maintenance Procedures for Heating and Cooling Systems: Do not attempt to repair the system if they break down unless you are qualified to do so. Major system problems may require a heating and air conditioning specialist. Repair immediately or call service company immediately. An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under 4[AGE].25(d), Accidents on December 23, 2019 at 4:30 PM, in the presence of the Administrator, Administrative Assistant (AA), and the Director of Nurses (DON). The IJ was called and the Administrator, Administrative Assistant (AA), and the DON were made aware that 6 of 25 Resident rooms affecting 13 Residents were being provided portable space heaters in sleeping areas without supervision to protect Residents from possible hazardous accidents. An IJ removal corrective plan was requested and accepted on December 23, 2019, at 7:30 PM The plan included - To ensure all residents are in appropriately heated rooms, (Name of the Facility) QAPI Committee team will execute the following plan: 1. Remove all portable heaters from resident sleeping areas. 2. Vacate residents from affected rooms (Rooms 100, 102, 103, 112, 116, and 122). 3. Due to a lack of beds at (Name of the Facility) to accommodate, DON Social Services (SSD), ADM, Director of Staff Development (DSD) have determined a list of nine residents who will, with Medical Doctor (MD) and Responsible Party (RP's) approvals, transfer temporarily to (Name of the Facility). Nursing has notified and received permission from Resident's MD's. SSD also coordinated transportation and communicated to (Name of Facility). 4. Nursing and SSD will follow proper room change protocol and ensure residents who changed rooms at (Name of the Facility) and receive [AGE]-hour charting and monitoring. 5. All residents were transferred to (Name of the Facility). DSD and Director of Environmental Services (DEVS 1) provided staff training on appropriate way to check temperatures with Laser gun, what the safe range should be, and what to do if the temperature falls below a safe range. Once the heating system has been completed, and temperatures were monitored and maintained at safe range, the residents will be safely moved back. The IJ was lifted on December 30, 2019 at 3:17 PM, in the presence of the Administrator after on-site verification that the corrective action plan was implemented.

Based on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure the Dietary Manager was competent and qualified to run the day to day operations of the food service department for 53 of 53 residents when: 1. The Dietary Manager did not possess the qualifications necessary to serve as the Director of Food and Nutrition Services. 2. The Dietary Manager was not knowledgeable about safe and sanitary food storage, handling and distribution. (Cross reference F 812) 3. The Dietary Manager did not provide a palatable meal for puree diets or follow the menu appropriately for puree, fortified, finger foods, large portions or thickened liquids. (Cross reference F 804, F 803) 4. The Dietary Manger did not ensure equipment used for food storage and production was clean and in working order. (Cross reference F 908) These failures put all 53 residents receiving food prepared in the kitchen at risk for food- borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites due to how food is prepared or cooked) for 23 residents receiving puree diets, six residents receiving thicken liquids, five residents receiving finger foods and one resident receiving large portions at risk for compromised nutritional status. Findings: During a review of the FDA (Federal Food and Drug Administration) Food Safety.gov, last reviewed (MONTH) 14, 2019, the document indicated, Good food safety practices are vital in long term care facilities, as seniors are at an increased risk for hospitalization and death from foodborne illnesses. Seniors living in nursing homes face 10 times the risk of dying from bacterial gastroenteritis (an infection or inflammation in the stomach and intestine) than people in the community. The gastrointestinal tract (mouth, esophagus, stomach and intestines) holds onto food for a longer period of time, allowing bacteria to grow. The liver and kidneys may not properly rid the body of foreign bacteria and toxins. The stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Underlying chronic conditions, such as diabetes [MEDICAL CONDITION], may also increase a person's risk of foodborne illness. During a review of (Sura et.al., 2012 -US National Library of Medicine). The article indicated the following: Ensuring meals are delivered in accordance with physicians' orders are crucial in maintaining patient safety. Dysphagia (a swallowing disorder) is a common difficulty among aging adults. Increasing age facilitates changes in swallow function and age-related diseases are significant factors in the presence and severity of dysphagia. Among the elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. Dysphagia is associated with nutritional deficits and increased risk of pneumonia. Review of the California Code of Regulations, Health and Safety Code, Section 1265.4, added 1973, requires that the full time staff, designated as the Director of Food Services, meet specific requirements at time of appointment to the position. These requirements include but are not limited to graduation from an approved dietary services training program. According to the Risk Management Handbook for Healthcare Organizations, published (MONTH) 2010, indicated due to the higher incidence of chronic illness and disability, long term care organizations encounter some unique risks. Employee competency assessment and education are significant strategies that long term care facilities may utilize to ensure employees possess the required skill set in accordance with position responsibilities. Elements of competency assessments may include verification of an employee's training, education and experience; position orientation; a system to determine and document successful completion of required skill set as well as documentation of areas which may require additional skill development. 1. On (MONTH) 27, 2019 at 10:54 AM, an interview was conducted with the Dietary Manager (DM) regarding his qualifications to run the food and nutrition department. The DM stated he was currently in school to obtain his Food Manager Safety certificate. He provided the website information for the surveyor. Review of the provided information revealed the program did not meet regulatory requirements. He stated he was a cook at the facility for six years and was promoted to the DM position when the previous DM left approximately seven months ago. On (MONTH) 27, 2019 at 4:00 PM, a follow up interview was conducted with the DM. The surveyor asked the DM how he selected the program he was enrolled in. The DM stated he looked online on www.you-tube for information. On (MONTH) 27, 2019 at 4:17 PM, a phone interview was conducted with the Registered Dietitian (RD) 2. When asked about the DM's qualifications to run the food and nutrition department, the RD 2 stated she assumed the DM was qualified. The RD 2 stated she had not done a competency evaluation on the DM. On (MONTH) 27, 2019 at 4:43 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated the DM was promoted in March, 2019. The ADM was aware the DM was not qualified to run the day to day operations of the Food and Nutrition, but stated he thought the DM could operate under the RD's license. When asked how the ADM deemed the DM competent he stated the DM had been trained by the previous DM. The ADM further stated the DM had been a cook for several years and knew the staff plus the ADM preferred to promote from within the facility. When asked if the ADM knew the program the DM was enrolled in did not meet regulatory requirements, the ADM stated he had not verified the program. Review of the facility's job description for the Director of Food and Nutrition Services dated (MONTH) (YEAR), showed the primary purpose of the Director of Food and Nutrition Services position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food and Nutrition services Department in accordance with current federal .regulations and to assure that quality nutritional services are provided on a daily basis and the Food and Nutrition Services Department is maintained in a clean, safe and sanitary manner. Under Duties and Responsibilities, the Director of Food and Nutrition Services is responsible to ensure kitchen work area, food preparation areas and food storage areas are maintained in a clean and sanitary manner. The Director of Food and Nutrition Services is responsible for periodic rounds to check equipment and to assure that necessary equipment is working properly. The job description did not list the necessary minimum education requirements. Review of the Dietary Manager's file showed a performance review dated (MONTH) 12, (YEAR), for the position of a cook. There was no documentation in the Dietary Manager's file to indicate he was promoted to the position of Director of Food and Nutrition Services. 2. During the survey from (MONTH) 26, 2019 through (MONTH) 28, 2019, the following practices were identified that were not consistent with safe food handling standards of practice, which are the responsibility of the DM to identify and correct: a. On (MONTH) 26, 2019 at 11:50 AM, an observation of the ice machine and interview was conducted with the Maintenance Director. The ice chute (area where the ice is dispensed) had a large amount of a brown slimy substance that was easily removed with a white paper towel. The Maintenance Director confirmed the ice chute was not clean and the ice should not be used. There was no indication the DM independently evaluated ice machine cleanliness. b. On (MONTH) 26, 2019 at 11:10 AM, and on (MONTH) 27, 2019 at 8:49 AM, during handwashing observations, Cook 1 and Diet Aide (DA) 1 touched soiled surfaces and returned to food preparation and equipment sanitation without handwashing. According the USDA Food Code (YEAR), Section ,[DATE].14,Food employees shall clean their hands and exposed portions of their arms .after handling soiled equipment or utensils. Review of the facility document titled, Consultation Dietitian Report Card, an audit of the Food and Nutrition Services Department performed by the Registered Dietitian (RD), dated (MONTH) and (MONTH) 2019, showed employees thoroughly wash their hands and exposed arms before starting work and as often as necessary. Despite this, staff were not observed [MEDICATION NAME] appropriate hand washing. c. During the initial tour of the kitchen and concurrent interview with the DM on (MONTH) 26, 2019 at 10:50 AM, a thawed pork loin dated (MONTH) 19, 2019 was observed in the walk-in refrigerator. The DM stated the pork loin was pulled from the freezer on (MONTH) 19, 2019. The DM stated the pork loin was for the lunch meal on (MONTH) 27, 2019, which would equate to a total of 8 days. According to the United States department of Agriculture (USDA) guidelines for cold storage, dated (YEAR), for thawed ground meats, ground poultry and fish are ,[DATE] days under refrigeration. Whole cuts of meat and poultry are ,[DATE] days under refrigeration. d. During an observation on (MONTH) 27, 2019 at 9:45 AM, there was a box of opened thickened apple juice in the nursing unit refrigerator with an open date of (MONTH) 4, 2019. There was also an eight-ounce chocolate shake carton, undated. On (MONTH) 27, 2019 at 11:00 AM, an interview was conducted with the DM, he stated opened thickened juice is only good for one day. The DM did not know how long the chocolate shake was good for. Review of the thickened juice label from the manufacturer showed thickened juice should be used within seven days after opening. According to manufactures guidance the juice should have been discarded on (MONTH) 10, 2019. Review of the Review of the facility P&P titled, Labeling/Date Marking and Safe Storage of Refrigerated & Frozen Foods, dated (YEAR), showed food produced in the community should be dated with day one as the day made and discarded on or before the seventh day. Health shakes have a 14-day refrigerated shelf life once thawed. They must be individually labeled or kept together in a box or container that has a date mark for use by date. e. During a dishwashing observation on (MONTH) 27, 2019 at 8:49 AM, two staff were observed with uncovered facial hair. In a concurrent interview the DM acknowledged facial hair should be covered. According the USDA Food Code (YEAR), Section ,[DATE].11, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and Linens; and unwrapped single-service and single-use articles. Review of the facility document titled, Consultant Dietitian Report Card, dated (MONTH) and (MONTH) 2019, showed, kitchen staff do not wear beard coverings appropriately. f. On (MONTH) 26, 2019 at 10:45 AM, during the initial tour of the kitchen with the DM, two food bins containing flour and sugar were observed with plastic bags lining the bin. The surveyor asked the DM what type of bags were used to line the food bins. The DM stated the plastic bags labeled can liners were used to line the food bins. The DM confirmed the can liners were garbage can liners and should not be used to store food. According to the United States Department of Agriculture (USDA), the use of plastic trash bags is not recommended for food storage or cooking .because they are not food grade plastic and chemicals from them may leach into the food. www.fsis.usda.gov/oa/pubs/meatpack.htm g. On (MONTH) 26, 2019 between the hours of 10:50 AM and 1:35 PM, there were multiple pieces of equipment and areas that were not clean. An interview was conducted with the DM on (MONTH) 27, 2019 at 9:35 AM. The DM confirmed the equipment in the kitchen was not clean and that all equipment in the kitchen should be kept clean. According to the USDA Food Code (YEAR) Section ,[DATE].11, Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of facility documents titled, Director of Food and Nutrition services (DFNS), dated 2001, indicated under Safety and Sanitation the DFNS is responsible to ensure that all Food and Nutrition Services service personnel follow established departmental policies and procedures. Under Personnel Functions, the DFNS is responsible to Review and check competence of Food and Nutrition Services personnel and make necessary adjustments/corrections as required or that may become necessary and Make daily rounds to assure that Food and Nutrition Services personnel are performing required duties and to assure that appropriate Food and Nutrition Services procedures are being rendered to meet the needs of the facility. Under Administrative Functions the DFNS should inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control. 3. During the survey from (MONTH) 26, 2019 through (MONTH) 28, 2019, there were multiple observations where meals were not prepared in accordance to the physician ordered diet or standardized recipes: a. On (MONTH) 27, 2019 at 11:30 AM, an observation of the puree preparation with the Dietary Manager was conducted. The DM stated he was making 23 puree portions. The DM put an unmeasured quantity of cooked pork loin that had been previously prepared with seasoning, three and a half cups of hot water, an unmeasured quantity of onion powder, pepper and garlic, a #24 scoop (2 ,[DATE] Tablespoons) of chicken base in a food processor, a device used to puree food. The mixture was blended then an unmeasured quantity of instant mashed potatoes and water were added to the meat mixture two more times and blended. The meat mixture began to overflow from the food processor. When asked what quantity of the ingredients were needed, the DM stated he goes by the line on the food processor to determine the quantity. On (MONTH) 27, 2019 at 3:32 PM, an interview was conducted with the DM, he confirmed he did not follow a recipe. Review of the facility document titled, Pork Cutlet (ground meats), dated (MONTH) 15, (YEAR), showed for puree diets, place portions needed of prepared product in food processor. Add one tablespoon broth, gravy or sauce for each portion. Blend until smooth, add additional liquid one tablespoon at a time as needed until pudding-like consistency is reached. b. On (MONTH) 27, 2019 at 11:25 AM, gelatin was served to five residents with physician ordered thickened liquid diets. On (MONTH) 27, 2019 at 3:30 PM, an interview was conducted with the DM. The DM confirmed gelatin was not a thick liquid and not safe to serve to residents on a thick liquid diet. Additionally, one resident was not given finger foods in accordance with the menu and diet order and 23 residents did not receive their physician ordered fortified diet. During a review of facility documents titled, Director of Food and Nutrition Services (DFNS), dated 2001, indicates under Administrative Functions the DFNS is responsible for review(ing) therapeutic and regular diet plans and menus to assure they are in compliance with the physicians' order. 4. The Dietary Manger did not ensure equipment used for food storage and production was clean and in working order when: a. The walk-in freezer door had ice build-up preventing the door from properly closing. The DM and Maintenance Director were aware of the ice build-up and stated the unit had been serviced by an outside vendor, however the facility was unable to validate the vendors' visit. b. The bottom shelf of the walk-in freezer was observed in disrepair. The maintenance Director was aware of the faulty shelf but had not remedied the problem. c. There was a pipe leading from the walk-in refrigerator/freezer located in the storeroom which was leaking fluid onto the shelves. The Maintenance Director was aware of the leaking pipe but had not remedied the problem. d. Behind the walk-in refrigerator there was a wall constructed of wood with six inches of wet wood along the top portion of the wall. The Maintenance Director was aware of the wet wood but had not remedied the problem. e. In the kitchen there was a food preparation sink that was clogged and being used for food production activities. f. Review of ice machine sanitation on (MONTH) 26, 2019 at 11:50 AM revealed the Maintenance Director failed to use the proper chemicals as required by the manufacturer. During a review of facility documents titled, Director of Food and Nutrition Services (DFNS), dated 2001, indicates under Administrative Functions, the DFNS is responsible for Assume(ing) administrative authority, responsibility and accountability of supervising the Food and Nutrition Services Department and under Equipment and Supply Functions the DFNS is responsible for Make(ing) periodic rounds to check equipment and to assure that necessary equipment is available and working properly An Immediate Jeopardy situation (a situation in which the facility's non-compliance has placed the health and safety of residents at risk for harm) was called on (MONTH) 27, 2019 at 5:24 PM, in the presence of the Administrator, Director of Nursing, Dietary Manager, and Admissions Coordinator due to the facility's failure to ensure the Dietary Manager possessed the qualifications and competency to run the day to day operations of the food service department in a safe and sanitary manner. On (MONTH) 29, 2019 at 3:39 PM, the IJ was lifted in the presence of the Administrator (ADM), Director of Nursing and Registered Dietitian (RD) 1 after an acceptable Corrective Action Plan was provided by the ADM. The corrective action plan included the following: a contract was signed which provided a full time RD (RD 1) to oversee the daily operations of the dietary services until a qualified Certified Dietary Manager or qualified Dietary Service Supervisor is hired; the full time RD 1 qualifications and competency for running the daily operations of the dietary services were verified; the Dietary Manager Job Description was signed by RD 1; sufficient recruitment efforts for a Certified Dietary Manager or qualified Dietary Service Supervisor were initiated. In addition, on site verification of implementation of the corrective action plan was confirmed.

Based on observation, interview, and facility Policy and Procedure review, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner when: 1. The facility failed to ensure proper handwashing was used. 2. The facility failed to ensure expired food items in the walk-in refrigerator and nourishment refrigerator were discarded. 3. The facility failed to label and date food items. 4. The facility failed to ensure the temperature of the nourishment refrigerator used to store resident food was safe and monitored. 5. The facility failed to ensure proper facial hair covering was used. 6. The facility failed to ensure dry foods were stored off the floor. 7. The facility failed to ensure bags used to line dry food bins were appropriate for food use. 8. The facility failed to ensure the kitchen equipment was clean. . 9. The facility failed to ensure the ice machine was clean. 10. The facility failed to ensure proper back-flow prevention of one of three air gaps. 11. The facility failed to remove dented cans . These failures had the potential to cause food-borne illnesses in a medically vulnerable resident population of 53 Residents who consumed food prepared in the kitchen. Findings: Review of the CM'S 672 Resident Census and Conditions of Residents completed by the facility dated (MONTH) 26, 2019, showed 53 of 53 residents in the facility received food prepared in the kitchen. 1 a. According the USDA Food Code (YEAR), Section ,[DATE].14, Food employees shall clean their hands and exposed portions of their arms .after handling soiled equipment or utensils. Review of the facility document titled Consultation Dietitian Report Card, an audit of the Food and Nutrition Services Department performed by the Registered Dietitian (RD), dated (MONTH) and (MONTH) 2019, showed employees thoroughly wash their hands and exposed arms before starting work and as often as necessary. On (MONTH) 26, 2019 at 11:10 AM, an observation was conducted of Cook 1. Cook 1 touched the trash can with her bare hands then returned to food preparation without washing her hands. B. On (MONTH) 27, 2019 at 8:49 AM, an observation of the dishwashing with Cook 1 and Diet Aide (DA) 1 was conducted. Both Cook 1 and DA 1 were observed removing soiled resident dishes from the meal trays then touching clean dishes without washing their hands. On (MONTH) 27, 2019 at 09:45 AM, an interview was conducted with the Dietary Manager (DM). The DM confirmed employee hands should be washed after handling soiled items. 2 a. According to the United States department of Agriculture (USDA) guidelines storage time-frames for thawed ground meats, ground poultry and fish are ,[DATE] days under refrigeration. Whole cuts of meat and poultry are ,[DATE] days under refrigeration. During the initial tour of the kitchen on (MONTH) 26, 2019 at 10:50 AM, with the DM, a large piece of thawed pork loin dated (MONTH) 19, 2019 was observed in the walk-in refrigerator. In a concurrent interview the DM stated the pork loin was pulled from the freezer on (MONTH) 19, 2019. The surveyor asked the DM when the pork loin was to be used. The DM stated he was not sure. After reviewing the facility menu, the DM stated the pork loin was for the lunch meal on (MONTH) 27, 2019. The DM confirmed the pork loin would have been in the refrigerator for eight days and was not safe to use. B. On (MONTH) 27, 2019 at 9:45 AM, an observation of the nourishment refrigerator on the nursing unit used to store resident's food was conducted with the Director of Nurses (DON). A box of opened thickened apple juice was observed dated (MONTH) 4, 2019. The DON confirmed the date on the thickened apple juice box was the open date. The surveyor asked the DON how many days opened thickened apple juice is safe for consumption. The DON stated she was not sure. The DON discarded the opened box of thickened apple juice. On (MONTH) 27, 2019 at 11:00 AM, an interview was conducted with the DM. The surveyor asked the DM how long opened thickened juice can safely be stored in the refrigerator. The DM stated opened thickened juice is only good for one day. Review of the thickened juice label showed thickened juice should be used within seven days after opening. 3 a. Review of the facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated & Frozen Foods dated (YEAR), showed food produced in the community should be dated with day one as the day made and discarded on or before the seventh day. Health shakes have a 14-day refrigerated shelf life once thawed. They must be individually labeled or kept together in a box or container that has a date mark for use by date. During the initial tour of the kitchen on (MONTH) 26, 2019 at 10:50 AM with the DM, a quarter pan covered in foil, unlabeled and undated was observed in the walk -in refrigerator. The surveyor asked the DM what food was in the covered pan. The DM stated he did not know what food was in the pan and confirmed the covered pan should be labeled and dated. B. On (MONTH) 27, 2019 at 9:45 AM, an observation of the residents' nourishment refrigerator on the nursing unit was conducted with the Director of Nursing (DON). An eight-ounce chocolate shake carton was observed without a date. The surveyor asked the DON how long the chocolate shake could safely be stored in the refrigerator. The DON stated she did not know. The chocolate shake was discarded. On (MONTH) 27, 2019 at 11:00 AM, an interview was conducted with the DM. The surveyor asked the DM how long chocolate shakes can safely be stored in the refrigerator. The DM was unable to answer. 4. Review of the facility IP&IP titled Food Storage dated (YEAR), showed all readily perishable foods shall be maintained at a temperature of 41 degrees Fé or below . On (MONTH) 27, 2019 at 9:45 AM, an observation of the nourishment refrigerator on the nursing unit used to store resident's food was conducted with the DON. An internal thermometer of the nourishment refrigerator read 50 degrees Fahrenheit (Fé). The DON confirmed the temperature of the refrigerator was too high. When the surveyor asked how staff monitored the internal temperature of the nourishment refrigerator, the DON stated the temperature was recorded every shift however, the DON was not able produce a temperature log for the nourishment refrigerator. 5. According the USDA Food Code (YEAR), Section ,[DATE].11, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and Linens; and unwrapped single-service and single-use articles. Review of the facility document titled Consultant Dietitian Report Card dated (MONTH) and (MONTH) 2019 showed, kitchen staff do not wear beard coverings appropriately. On (MONTH) 27, 2019 at 8:49 AM, an observation of dishwashing was conducted with Cook 1, DA 1, and the DM. DA 1 and the DM were observed with uncovered facial hair. The surveyor asked the DM when facial hair should be covered. The DM stated if you can pull the facial hair it should be covered and confirmed both he and the DA 1 should wear appropriate hair restraints. 6. According to the USDA Food Code (YEAR), Section ,[DATE].11, Foods should be stored six inches above the floor. Review of the facility document titled Consultant Dietitian Report Card dated (MONTH) and (MONTH) 2019, showed food was stored six inches off the floor. On (MONTH) 26, 2019 at 10:45 AM, during the initial tour of the kitchen with the DM, a large opened bag of pancake mix was observed on the floor of the storeroom. The DM confirmed food should not be stored on the floor. 7. According to the United States Department of Agriculture (USDA), the use of plastic trash bags is not recommended for food storage or cooking .because they are not food grade plastic and chemicals from them may leach into the food.www/Loa/pubs/cheap[NAME] On (MONTH) 26, 2019 at 10:45 AM, during the initial tour of the kitchen with the DM, two food bins containing flour and sugar were observed with plastic bags lining the bin. The surveyor asked the DM what type of bags were used to line the food bins. The DM stated the plastic bags labeled can liners were used to line the food bins. The DM confirmed the can liners were garbage can liners and should not be used to store food. 8. According to the USDA Food Code (YEAR) Section ,[DATE].11, Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility document titled Cleaning Schedule dated (YEAR), showed the plate warmer, shelves and drawers of kitchen were to be cleaned once a week, work tables and racks were to be cleaned once a week. Review of the facility document titled Consultant Dietitian Report Card dated (MONTH) and (MONTH) 2019, showed the can opener, carts, floor drains and plate warmer were clean. On (MONTH) 26, 2019 between the hours of 10:50 AM and 1:35 PM, the following observations were made: -The can opener base had a black residue that was removable with a paper towel, -The sink in the rear food preparation area had a pink slimy substance in the drain, -Three of three floor drains were observed with a black substance inside the drains, -The sink in the rear of the front room had a black substance in the corners and bottom of the sink, -A food cart used to deliver resident meal trays was observed with food debris, dried yellow liquid on the inside and tape residue on the outside with a black sticky substance. On (MONTH) 27, 2019 between the hours of 8:49 AM and 11:25 AM the following observations were made: -The shelf under the tray line used to store clean pans had food crumbs and dust on it, -The plate warmer used to store clean plates had food crumbs on top and throughout the warmer, -A wood food preparation table had a black substance on the surface that could not be removed per the DM, -A bin used to store clean scoops had food crumbs and a dead insect in it, -The snack cart used to deliver residents beverages and snacks was dirty with food crumbs. An interview was conducted with the DM on (MONTH) 27, 2019 at 9:35 AM. The DM confirmed the equipment in the kitchen was not clean and that all equipment in the kitchen should be kept clean. 9. According to the USDA Food Code (YEAR) Section ,[DATE].11, Equipment and food-contact surfaces shall be clean to the sight and touch. Review of the facility IP&IP titled Ice Machines and Ice Storage Chest dated (MONTH) 2012, showed ice machines will be used and maintained to assure a safe and sanitary supply of ice. Review of the facility document titled Consultant Dietitian Report Card dated (MONTH) and (MONTH) 2019, showed the ice machine interior food contact surface was cleaned and sanitized and that the internal components were cleaned and sanitized every six months by maintenance. Review of the facility document titled Ice Machine Cleaning Log showed the ice machine had been de-scaled, the bin sanitized and the water filter changed on (MONTH) 16, 2019, and the bin sanitized on (MONTH) 18, 2019, (MONTH) 4, 2019, (MONTH) 1, 2019. Review of the ice machine manufacturer guidelines dated (MONTH) 22, (YEAR), showed to clean the ice dispenser unit and ice storage bin liner with a neutral cleaner. On (MONTH) 26, 2019 at 11:50 AM, an observation of the ice machine and interview was conducted with the Maintenance Director. The ice chute (area where the ice is dispensed) had a large amount of a brown slimy substance that was easily removed with a white paper towel. The Maintenance Director confirmed the ice chute was not clean and the ice should not be used. The surveyor asked when the Maintenance Director cleaned and sanitized the ice bin was the ice chute also cleaned. The Maintenance Director stated he follows the manufacturers guidelines. A follow up interview was conducted with the Administrator. On (MONTH) 28, 2019 at 11:21 AM, an interview was conducted with the ice machine manufacturer technician via the phone. The ice machine technician stated the ice chute should be cleaned with a neutral cleaner and followed with a sanitizer each time the ice bin is cleaned and sanitized. 10. According to the USDA Food Code (YEAR), Section ,[DATE].14, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On (MONTH) 26, 2019 at 10:50 AM during the initial tour of the kitchen with the DM, a pipe with thick brown reddish residue was observed attached to the drain from the walk-in refrigerator and freezer. The pipe was observed in a floor sink with black residue. When asked, the DM confirmed the pipe from the walk-in refrigerator and drain were not clean and did not have an adequate air gap. On (MONTH) 26, 2019 at 11:40 AM, an observation of the pipe attached to the walk-in drain and interview with the Maintenance Director was conducted. The Maintenance Director confirmed the pipe from the walk-in did not have an air gap. 11. Review of the facility policy and procedure titled Damaged Cans and Packages to be Returned to Vendor dated (YEAR), showed cans should be inspected for dents and placed in a specified area to be returned to the vendor. The location of this area is in the storeroom. On (MONTH) 26, 2019 at 10:50 AM during the initial tour of the kitchen with the DM, one can of sliced apples, one can of diced tomatoes, one can of three bean salad were observed in the store room with dents on the sides of the cans. The dented cans were commingled with the indented cans on the shelf. The DM confirmed dented cans should not be commingled with non-dented cans. Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants such as ,[MEDICAL CONDITION]. [DIAGNOSES REDACTED] may find their way into the food. In anaerobic conditions (lack of oxygen), [DIAGNOSES REDACTED] toxin may be formed (USDA Food Code (YEAR), Annex).

Based on observation, interview, and record review, the facility failed to ensure 2 of 34 sampled residents (Resident 37 and 25) maintained acceptable parameters of nutritional status when: 1. Resident 37 experienced a severe 15 lb. (pound) avoidable weight loss in one month from (MONTH) 2019 when he weighed 186 lbs. to (MONTH) 2019 when he weighed 171 lbs. which was not documented in the medical record or informed to the resident's physician and led to a decline in multiple activities of daily living. 2. Resident 25 experienced a 11 lb. weight loss, from (MONTH) 2019 when she weighed 168 lbs. to (MONTH) 2019 when she weighed 157 lbs., in one month and the facility failed to assess this weight loss and develop a care plan to prevent further decline in nutritional status. These failures resulted in a significant decline in function for Resident 37 and a significant or severe avoidable weight loss in both Residents 37 and 25. Findings: A review of the medical record for Resident 37 indicated the resident was admitted to the facility from a sister facility on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment instrument) dated (MONTH) 2, 2019, Resident 37's BIMS score was 10 out of 15 (the BIMS or Brief Interview for Mental Status is used to assess cognitive status in elderly patients where the closer the score is to 0, the greater the cognitive impact). During an observation and concurrent interview with Resident 37 on (MONTH) 29, 2019 at 12 PM, Resident 37 ate in his room after being set up and was on a regular diet (no restrictions). He stated his lunch was fine, and ate most of his lunch, 80-90% of his meal. A review of the Inquiry Record (preadmission screen) dated (MONTH) 19, 2019 completed by the Admission Coordinator, and concurrent interview with Registered Dietician 2 (RD 2), indicated Resident 37's weight at the sister facility prior to admission was 190 lbs. Review of Resident 37's Baseline Care Plan (initial admission care plan developed on admission prior to the nutrition risk assessment) dated (MONTH) 20, 2019, indicated the resident was on a Regular diet (no restrictions), was at risk for weight loss and was eating in the dining room. RD 2 confirmed there were no dietary goals indicated for Resident 37 to prevent a decline in his nutritional status. RD 2 stated that they were not instructed to do care plans for residents. Further review of Resident 37's medical record and concurrent interview with RD 2 indicated a Nutrition Risk Assessment Summary was completed on (MONTH) 28, 2019, by RD 1. The weight section of the assessment was blank. RD 1's note stated that Resident 37's weight was not available on (MONTH) 28, 2019, seven days after admission to the facility. The estimated nutrition needs for Resident 37 were calculated by RD 1 based on his Ideal Body Weight (IBW used as a measure of a healthy weight) of 172 lbs. The assessment of Resident 37's nutrition risk and estimated nutrition needs were based on a weight approximately 18 lbs. less than his last weight recorded from prior to admission. No [MEDICAL CONDITION] was noted on this assessment. There was no nutrition risk care plan written that indicated goals or interventions to prevent undesirable weight loss. RD 2 stated that they were not instructed to do care plans for residents. The facility used a hybrid of paper and electronic medical records. A review of Resident 37's documented weights in the electronic medical record indicated weights as follows: April 8, 2019 188 lbs. April 16, 2019 187 lbs. August 7, 2019 172 lbs. A review of Resident 37's paper medical record revealed no documented weights. During a concurrent interview with the Director of Nursing (DON) on (MONTH) 29, 2019 at 3 PM, the DON verified that there were no other weights documented in Resident 37's paper medical record. Per the DON some information is kept in the paper medical record and some is kept in the electronic medical record. The DON presented a weight log dated (MONTH) 2019 with documented weights for six months for each resident. The DON stated these weights should have been entered into the electronic medical record, but were not. She verified that the weight log was not a part of the paper medical record. A review of the weight log dated (MONTH) 2019 indicated weights for Resident 37 as follows: March 2019 190 lbs. May 2019 187 lbs. June 2019 186 lbs. July 2019 171 lbs. August 2019 170 lbs. The exact dates of these weights were not indicated on the log. A review of the facility policy titled, Weight Assessment and Intervention, (revised (MONTH) (YEAR)) indicated, The nursing staff will measure resident weight on admission, the next day and weekly for two weeks thereafter Weights will be recorded in each unit's Weight Record chart and in the individual's medical record. During an interview with RD 1 on (MONTH) 29, 2019 at 3:55 PM, RD 1 stated that the staff who weigh the residents are supposed to enter the weight in each resident's electronic medical record. She stated that the Dietary Manager (DM) entered the weight in the weight log monthly which is not a part of the medical record. The RDs then review the weight log and put any residents with unintentional weight changes on weekly weights. RD 1 verified that there were no weekly weights done for Resident 37, despite a 15 lb. weight loss in one month. During the same interview and record review with RD 1, a progress note by RD 2 dated (MONTH) 8, 2019, was reviewed. RD 1 verified that there was no other RD note in the medical record between the Nutrition Risk assessment dated (MONTH) 28, 2019 and this progress note despite a 15 lb. weight loss in (MONTH) 2019. The (MONTH) 8, 2019 progress note indicated Resident 37's current weight was 170 lbs. which was a 9.1% weight loss in 90 days. The note stated the weight loss was significant and undesirable Wt. (weight) loss possibly related to occasional decreased energy intakes. Intakes range from 26-100% of meals. RD 2's progress note indicates Recommendations: HPN x (high protein nourishment) 4 oz. (ounces) QD (daily) to aid in wt. (weight) stability . RD 1 stated that the RD recommendations were communicated to the physician via a Nutrition Recommendations form given to the DON who then assigns a nurse to call the physician to get an order for [REDACTED]. A review of the facility's policy titled, Weight Assessment and Intervention, revised (MONTH) (YEAR), indicated The Dietitian will respond within 24 hours of receipt of written notification. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold (or level) for significant unplanned and undesirable weight loss will be based on the following criteria 1 month - 5% weight loss is significant; greater than 5% is severe. During an interview and review of Resident 37's paper and electronic medical record, section titled Care Plans, undated, with the DON on (MONTH) 29, 2019 at 4:30 PM, the DON verified that there was no care plan in either the paper or the electronic medical record that addressed Resident 37's weight loss. The DON verified that a care plan should have been written. A review of the facility's policy titled, Weight Assessment and Intervention, revised (MONTH) (YEAR)), indicated Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist and the resident or resident's legal surrogate (responsible party). Individualized care plans shall address, to the extent possible: The identified causes of weight loss; Goals and benchmarks (standards) for improvement; and time frames and parameters for monitoring and reassessment. A review of the Nutrition Recommendations form dated (MONTH) 8, 2019 with the LVN 2 on (MONTH) 29, 2019 at 4:25 PM, indicated an entry for HPN x 4 oz. 1x/day (one time per day) for weight stability. LVN 2 reviewed Resident 37's physician orders from (MONTH) 8 through (MONTH) 29, 2019 and verified that there was no physician order for [REDACTED]. weight loss in one month. LVN 2 verified a physician note, titled Physician's Progress Note in the medical record dated (MONTH) 12, 2019 only indicated No change signed by the physician. There was no other documentation by the physician on that date to indicate he was aware of Resident 37's weight loss. This was verified by LVN 2. A review of the facility's policy titled, Communication Lines and Follow-up on RDN (Registered Dietitian Nutritionist) Recommendations (revised (MONTH) 1, (YEAR)), indicated .the RDN write recommendations on the Nutrition Recommendations form and nursing makes appropriate contacts with the physician within 3 days. Nursing then documents results of the contact in the resident's chart . During a review of the MDS dated (MONTH) 3, 2019 and concurrent interview with the MDS Coordinator on (MONTH) 30, 2019 at 9:15 AM, the MDS Coordinator stated that Resident 37's MDS dated (MONTH) 3, 2019 was a Significant Change in Status assessment. The MDS Coordinator stated Resident 37 declined in many of his activities of daily living and his in his weight between the (MONTH) 2 and (MONTH) 3, 2019 MDS assessments. Comparison of these two MDS assessments show a general decline in all activities of daily living including bed mobility, transfers (from bed to chair and back), walk in room, locomotion, dressing, toilet use and personal hygiene. Resident 37 had a decline in the ability to feed himself from just requiring supervision and set-up in (MONTH) 2019 to limited one person assist in (MONTH) 2019. Resident 37's weight on the (MONTH) 2 MDS assessment was 190 lbs. and was 171 lbs. on the (MONTH) 3, 2019 assessment. A review of the Care Plan Conference Summary form (summary of the topics discussed for resident 37's care), dated (MONTH) 18, 2019 and concurrent interview with the MDS coordinator on (MONTH) 30, 2019 at 9:15 AM was conducted. The MDS Coordinator stated that this was the quarterly interdisciplinary care conference documentation for Resident 37 for the significant change of status assessment. The form lists topics discussed with comments. There were no comments for weight loss. The MDS Coordinator stated that she conducted the care conference. She verified that the 15 lbs. weight loss that Resident 37 experienced was not addressed on this form. During an interview with Certified Nursing Assistant 3 (CNA 3) on (MONTH) 30, 2019 at 10 AM, CNA 3 stated she was the CNA for Resident 37 and had been his CNA for about four to five months. CNA 3 stated that the resident usually eats well but does not want to get out of bed anymore. She stated that he was doing better with getting up and out of bed before his room was changed on (MONTH) 18, 2019. CNA 3 stated that since his room change the Resident 37 has had a decline in his function. She stated that he used to feed himself and now he requires more assistance with eating. She stated that he lays in bed and feeds himself while his head of bed is lowered. CNA 3 stated the RNAs (Restorative Nursing Assistants) assist him with eating and might know more about his needs during eating. During a concurrent review of the Narrative Nursing Assistant notes and continued interview with CNA 3, Resident 37's meal intake documentation was reviewed. CNA 3 verified that this was the form that the CNA's were supposed to document the meal percentages that the residents eat. The forms have a section for documenting breakfast, lunch and dinner meal percentages daily for the whole month. The forms were dated (MONTH) 2019. Out of 90 opportunities for meal consumption documentation in the month, only 25 of Resident 37's meal percentages were documented. CNA 3 verified the incomplete forms and could not explain why the forms were incomplete. The failure to document accurately resident intake impedes the ability to assess nutritional status of the resident. Without this information, avoidable weight loss can occur due to an inability to complete an accurate assessment. A review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol (revised (MONTH) 2019), indicated Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Nursing staff is to notify resident physician The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. A review of Resident 37's Room Change Forms dated (MONTH) 18 and (MONTH) 20, 2019 indicated the resident's room was changed twice in 2 days. During an interview with the Social Services Designee (SSD) on (MONTH) 30, 2019 at 11 AM, the SSD stated that Resident 37 appeared to tolerate his room change without issues. The SSD stated that she was not aware of Resident 37's weight loss and how it coincided with the room changes. The SSD stated that she only recently (date not specified) started receiving the weight logs and did not note Resident 37's 15 lb. weight loss. The SSD did not recall the weight loss being discussed at the care plan conference. During an observation and interview with Resident 37 on (MONTH) 30, 2019 at 10:20 AM, the resident was a pleasant gentleman lying in bed in his dark room. Resident 37 stated that he likes the food served to him. He could not remember if there was a time when he did not like the food or he did not eat the food. Resident 37 had difficulty recalling anything about the food he has eaten or how he likes to be situated to eat his meals. Resident 37 was unable to recall his usual weight. During an interview with RNA 1 on (MONTH) 30, 2019 at 10:30 AM, RNA 1 stated that she routinely worked in the evening at dinner time. She stated that during dinner Resident 37 often would use his call light to request to be sat at the edge of the bed to eat his meals. RNA 1 stated that the resident refused to get out of bed. When asked if this was on the care plan so that other caregivers would try to sit him at the edge of the bed and she stated it was not. 2. During a review of Resident 25's clinical record, the Admission Record (contains demographic and medical information), dated (MONTH) 15, 2019, indicated the resident was admitted to the facility on (MONTH) 15, 2019, with a [DIAGNOSES REDACTED]. During a review of Resident 25's electronic clinical record, titled Weight and Vitals Summary, dated (MONTH) 22, 2019, it indicated resident weight was 157 pounds. On (MONTH) 22, 2019, the resident weighed 170 pounds. This is a 7% weight loss. During an interview and review of the monthly weight log with RD 1 on (MONTH) 29, 2019 at 3:55 PM, RD 1 stated that the staff who weigh the residents are supposed to enter the weight in each resident's electronic medical record. She stated that the Dietary Manager (DM) entered the weight in the weight log monthly which is not a part of the medical record. The RDs then review the weight log and put any residents with unintentional weight changes on weekly weights. The monthly weight log, undated, indicated that Resident 25 was 168 pounds in (MONTH) 2019 and 157 pounds in (MONTH) of 2019. During a review of Resident 25's electronic clinical record, titled Nutrition services Visit Note, dated (MONTH) 23, 2019, it recommended that the resident be ordered a small portions diet at dinner to assist with weight management. During an interview on (MONTH) 29, 2019, at 3:53 PM, RD 2 stated that Resident 25 had dementia and often ate a meal and then forgot she had eaten and would ask for another meal. RD 2 stated Resident 25 would snack constantly throughout the day. RD 2 stated that the resident was also obese according to her BMI (Body mass index, a ratio of height and weight) and so Registered Dietitian 1 (RD 1) who did the dietitian assessment on (MONTH) 23, 2019, recommended that Resident 25 be on small portions at dinner. During a review of the electronic medical record, titled Care Plans, undated, RD 2 confirmed that no care plan was done for Resident 25 for planned weight loss. RD 2 also confirmed that since RD 1's assessment and recommendation on (MONTH) 23, 2019, RD 1 had not done another assessment as of (MONTH) 29, 2019, despite continued weight loss. During a concurrent interview and review of the facility policy titled, Weight Assessment and Intervention revised (MONTH) (YEAR), was conducted with RD 2 on (MONTH) 29, 2019, at 4:21 PM. The facility's policy titled, Weight Assessment and Intervention revised (MONTH) (YEAR)), indicated The Dietitian will respond within 24 hours of receipt of written notification. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesirable weight loss will be based on the following criteria 1 month - 5% weight loss is significant; greater than 5% is severe. The policy identified under, Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist and the resident or resident's legal surrogate (responsibly party) Individualized care plans shall address, to the extent possible: The identified causes of weight loss; Goals and benchmarks (standards) for improvement; and time frames and parameters for monitoring and reassessment. RD 2 stated that the policy is that if there is a significant weight loss of 5 pounds or 5% or more in a month, the RD is required to do a nutrition assessment. RD 2 stated that previously she was not instructed to participate in creating care plans for residents.

Based on observation, interview and record review, the facility failed to provide a safe, functional and sanitary environment, in a universe of 55 residents, when the following hazards were present: 1. An approximate five-foot by two-foot area of the ceiling leaked water over a steam table (a table used as a heating device for foods that are waiting to be served. The bottom of the table contains boiling or simmering water that produces steam to keep the food hot) in the facility's kitchen. 2. An approximate three-foot by three-foot area of the ceiling leaked water, dripping through an electrical fire alarm system, in the dry food storage room. 3. An approximate six-foot by six-foot area of the ceiling leaked water, in resident room [ROOM NUMBER]. 4. An approximate three-foot by three-foot area of the ceiling leaked water, in resident room [ROOM NUMBER]. 5. A soiled and non-functional bathroom in resident room [ROOM NUMBER]. This failure exposed residents to a hazardous environment within their room and a potential for contamination of food in the kitchen and electrical shortages. Findings: An unannounced visit was made to the facility on (MONTH) 17, 2019 at 8:55 AM, to investigate a facility reported incident in regards to a ceiling leak in a resident room. A facility tour with the Business Office Manager (BOM) on (MONTH) 17, 2019 at 9 AM, revealed by observation, the following ceiling leaks and environmental hazards: 1. An approximate five-foot by two-foot area of the ceiling leaked water over a steam table (a table used as a heating device for foods that are waiting to be served. The bottom of the table contains boiling or simmering water that produces steam to keep the food hot) in the facility's kitchen. 2. An approximate three-foot by three-foot area of the ceiling leaked water, dripping through an electrical fire alarm system, in the dry food storage room. 3. An approximate six-foot by six-foot area of the ceiling leaked water, in resident room [ROOM NUMBER]. 4. An approximate three-foot by three-foot area of the ceiling leaked water, in resident room [ROOM NUMBER]. 5. A soiled and non-functional bathroom in resident room [ROOM NUMBER]. 1. During an observation and concurrent interview with a Dietary Aide (DA 1) on (MONTH) 17, 2019 at 9 AM, the kitchen ceiling above the steam table was observed with a crack that ran through an approximate five-foot by two-foot swollen bulging ceiling area. Water dripped from the ceiling down onto the steam table. Pieces of ceiling had fallen onto the steam table and kitchen floor. DA 1 stated he had personally informed the facility's Administrator (Admin) of the leak on (MONTH) 16, 2019. During an interview with the Cook on (MONTH) 17, 2019 at 10:13 AM, the Cook stated he had informed the Maintenance Supervisor (MS) and Admin about the leak on (MONTH) 16, 2019. The Cook stated the MS and Admin came and looked at the leak but did not do anything and no direction was given. The Cook stated he used the steam table to store and serve the residents' breakfast on (MONTH) 17, 2019. The Cook stated he dished out the residents' food while the water dripped onto his head and ran down his neck and back. The Cook stated pieces of the ceiling came down along with the water and he did the best he could to keep it out of the residents' food. The failure of the Administrator to act created the potential for the resident's breakfast food on (MONTH) 17, 2019, to come in contact with contaminated water and contaminated pieces of ceiling material. During an interview with the MS on (MONTH) 17, 2019 at 11:49 AM, the MS stated he had been notified of the ceiling leak, over the steam table, in the kitchen on (MONTH) 15, 2019 at 9:30 AM. The MS stated he had intended to put something up on the ceiling to divert the water away from the steam table. During an interview with the Administrator (Admin) on (MONTH) 17, 2019 at 2:03 PM, the Admin stated he had been notified of the ceiling leak, over the steam table, in the kitchen on (MONTH) 16, 2019 at 3 PM. 2. During an observation and concurrent interview with a Dietary Aide (DA 1) on (MONTH) 17, 2019 at 9:05 AM, an approximate three-foot by three-foot ceiling area in the dry food storage room had a smoke alarm unit mounted in the middle of the area. An electrical line ran along the ceiling and connected to one side of the smoke alarm unit. Water dripped from the ceiling around the smoke alarm unit and water dripped from the smoke alarm unit itself. The water landed on the floor of the dry food storage room creating a three-foot by three-foot wet puddle-like area. DA 1 stated he had personally informed the facility's Administrator (Admin) of the leak on (MONTH) 16, 2019. The failure of the facility to maintain the facility's roof caused water to come in contact with the facility's electrical system which had the potential for electrical shortages causing residents to be without electrical power. During an interview with the Maintenance Supervisor (MS) on (MONTH) 17, 2019 at 11:49 AM, the MS stated he had been notified of the ceiling leak in the dry food storage area on (MONTH) 15, 2019 at 1:30 PM. During an interview with the Administrator (Admin) on (MONTH) 17, 2019 at 2:03 PM, the Admin stated he had been notified of the ceiling leak in the dry food storage area on (MONTH) 17, 2019 at 10:30 AM. 3. During an observation and concurrent interview with a Business Office Manager (BOM) on (MONTH) 17, 2019 at 9:10 AM, an approximate six-foot by six-foot ceiling area in room [ROOM NUMBER] was observed discolored and dripped water onto the floor creating an approximate six-foot by six-foot wet puddle-like area. Pieces of ceiling had fallen onto the floor. The BOM stated two residents had been moved from the room to another room. A review of a room change form dated (MONTH) 13, 2019, indicated two residents had been moved from room [ROOM NUMBER] to room [ROOM NUMBER] on (MONTH) 13, 2019. The failure of the facility to maintain the facility's roof caused two residents' in room [ROOM NUMBER] to be exposed to water leaking through their ceiling with pieces of the ceiling falling to the floor. This created the potential for a ceiling collapse and/or the residents to slip and fall. During an interview with the Maintenance Supervisor (MS) on (MONTH) 17, 2019 at 11:49 AM, the MS stated he had been notified of the ceiling leak in room [ROOM NUMBER] on (MONTH) 14, 2019 at 1:30 PM. During an interview with the Administrator (Admin) on (MONTH) 17, 2019 at 2:03 PM, the Admin stated he had been notified of the ceiling leak in room [ROOM NUMBER] on (MONTH) 14, 2019 at 10 AM. 4. During an observation and concurrent interview with a Business Office Manager (BOM) on (MONTH) 17, 2019 at 10:03 AM, an approximate three-foot by three-foot ceiling area in room [ROOM NUMBER] that had a light fixture mounted in the middle of the it dripped water from the ceiling into the light fixture and down to the floor, creating an approximate three-foot by three-foot wet puddle-like area. The BOM stated two residents had been moved from the room to another room. A review of a room change form dated (MONTH) 17, 2019, indicated one resident had been moved from room [ROOM NUMBER] to room [ROOM NUMBER] and a second resident had been moved from room [ROOM NUMBER] to room [ROOM NUMBER] on (MONTH) 17, 2019. The failure of the facility to maintain the facility's roof caused two residents' in room [ROOM NUMBER] to be exposed to water leaking through their ceiling with pieces of the ceiling falling to the floor. This created the potential for a ceiling collapse and/or the residents to slip and fall. During an interview with the Maintenance Supervisor (MS) on (MONTH) 17, 2019 at 11:49 AM, the MS stated he had been notified of the ceiling leak in room [ROOM NUMBER] on (MONTH) 16, 2019 at 9:30 AM. During an interview with the Administrator (Admin) on (MONTH) 17, 2019 at 2:03 PM, the Admin stated he had been notified of the ceiling leak in room [ROOM NUMBER] on (MONTH) 17, 2019 at 10:30 AM. 5. During an observation and concurrent interview with the Administrator (Admin), Maintenance Supervisor (MS) and Director of Nurses (DON) on (MONTH) 17, 2019 at 9:40 AM, room [ROOM NUMBER] was occupied by two residents and their private bathroom was found as follows: The shower stall contained leaf debris and dirt. A toilet plunger was laying on its side in the shower stall. There was a dirty shower chair in the shower stall. The ceiling in the bathroom appeared to have been patched over multiple times with some type of ceiling paste. The ceiling was discolored with brown and yellow ringed areas. The floor of the bathroom was dirty and had pieces of ceiling lying on the floor. The inside of the toilet bowl was stained brown. The MS stated that the toilet and shower had not been functional for some time. The MS could not state how long the bathroom had been nonfunctional. The DON stated that the two residents living in room [ROOM NUMBER] did not use the bathroom. The DON could not state how long the bathroom had been nonfunctional. The Admin stated it was not his expectation that a bathroom would be in this state in his facility. The Admin could not state how long the bathroom had been nonfunctional. This failure had to the potential to cause future residents of room [ROOM NUMBER] to be exposed to a unsanitary and nonfunctional bathroom. A review of the facility's policy and procedure titled, Hazardous Areas, Devices and Equipment, dated (MONTH) (YEAR), indicated the following: A hazard is defined as anything in the environment that has the potential to cause injury or illness. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Interventions will address the specific hazards identified, and may be facility-specific or resident-specific. Hazardous areas in the facility that cannot be eliminated, adapted or corrected will be marked clearly and identified on floor plans posted throughout the facility. The Safety Committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.) As part of an overall culture of safety, staff, residents and family will be encouraged to report anything that appears to be an environmental hazard or a safety concern. An Immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the residents) was called under 42 CFR 483.90(i) F 921 Other Environmental Conditions, on (MONTH) 17, 2019 at 2:13 PM, in the presence of the Administrator (Admin) and Director of Nursing (DON). The Administrator (Admin) and Director of Nursing (DON) were verbally notified of the IJ situation identified based on the facility's failure to provide a safe, functional and sanitary environment for residents. The facility submitted a corrective action plan which was reviewed and accepted on (MONTH) 18, 2019 at 12:49 PM, in the presence of the Administrator (Admin). The facility's corrective action plan indicated the following: We are working to ensure that all leaks in roof and damage to ceilings will be corrected before End of Business today, 1/18/2019 (January 18, 2019). room [ROOM NUMBER]: 10:15 AM 1/17/19 (January 17, 2019)-staff cleaned fallen drywall in bathroom and the shower 6:30 PM 1/17/19 (January 17, 2019)-Maintenance Supervisor (MS) removed fractured drywall and replaced it with a new patch of drywall ceiling 1:00 PM 1/18/19 (January 18, 2019)-MS and/or assistant will assess replaced patch and add another layer of drywall replacement room [ROOM NUMBER]: 1:45 PM 1/13/19 (January 13, 2019)-Nursing staff notified DON (Director of Nursing) of leak in room, immediately removed patients from room (no patients have entered room since) 8:30 AM 1/14/19 (January 14, 2019)-MS made small opening in affected paint to allow water to drain 1:00 PM 1/16/19 (January 16, 2019)-MS made small opening in affected paint to allow water to drain 8:00 AM 1/18/19 (January 18, 2019)-Professional Roofer (name of roofer) and his team determined where water from roof is leaking into room 9:00 AM 1/18/19 (January 18, 2019)-MS removed water on roof above leak 10:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team will seal the roof over the affected area to ensure no further leaks occur 11:00 AM 1/18/19 (January 18, 2019)-Remove all loose material in room ceiling. Use fans to expedite drying of affected ceiling area. Once dry, MS will apply new dry wall mud to patch area 123 leak: 10:00 AM 1/17/19 (January 17, 2019)-Nursing staff notified SSD (Social Services Director) of leak in room immediately removed patients from room (no patients have entered room since). MS also notified. Room is locked to prohibit patient entry. Patients were safely relocated to other rooms. 8:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team determined where water from roof is leaking into room 9:00 AM 1/18/19 (January 18, 2019)-MS removed water on roof above leak. 10:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team will seal the roof over the affected area to ensure no further leaks occur 12:00 PM 1/18/19 (January 18, 2019)-Remove all loose material in room ceiling. Use fans to expedite drying of affected ceiling area. Once dry, MS will apply new dry wall mud to patch area Kitchen Leak: 2:00 PM 1/16/19 (January 16, 2019)-Removed water on roof above leak 9:15 AM 1/17/19 (January 17, 2019)-Halted food production under affected area (tray line) (steam table) 10:00 AM 1/17/19 (January 17, 2019)-Maintenance Supervisor removed all flaking drywall 10:45 AM 1/17/19 (January 17, 2019)-Diverted water away from steam table and other food prep areas 8:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team determined where water from roof is leaking into kitchen 9:00 AM 1/18/19 (January 18, 2019)-MS removed water on roof above leak 11:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team are sealing the roof over the affected area to ensure no further leaks occur. Sealing will be done by 5 PM today (January 18, 2019) 2:00 PM 1/18/19 (January 18, 2019)-MS will remove all loose material in room ceiling. Use fans to expedite drying of affected ceiling area. Once dry, MS will apply new dry wall mud to patch area Kitchen Storage Leak: 8:30 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team determined where water from roof is leaking into room 9:30 AM 1/18/19 (January 18, 2019)-MS removed water on roof above leak 12:00 AM 1/18/19 (January 18, 2019)-(Name of roofer) and his team will seal the roof over affected area to ensure no further leaks occur. Sealing will be done by 5:00 PM today (January 18, 2019). 2:00 PM 1/18/19 (January 18, 2019)-Remove all lose material in room ceiling. Use fans to expedite drying of affected ceiling area. Once dry, MS will apply new dry wall mud to patch area Food Preparation Plan-created with support and approval from (Name of Registered Dietitian-RDN) RDN (to ensure patients are getting appropriate nutrition and a hot meal option every 24 hours) Affected surface of kitchen (tray line) (steam table) will not be used during IJ (started 9:15 AM 1/17/19-January 17, 2019) Hot food will be prepared on stove and transferred to Cafe (small dining room) where emergency/portable gas stoves, slow cooker, and chafing trays will be used to keep food temperature appropriate. Once the food is transported to the Cafe (about 15 feet from kitchen) kitchen staff are using this area to prepare trays. We will keep door shut to ensure no patients have access to the portable stoves, chafing trays, and prepared food. Additionally, we are utilizing chafing trays to keep food temperature within regulations. (Name of RDN) has been working with us to ensure food preparation is being done correctly and that food served is ensuring patient nutrition. Please see our attached updated menu for the weekend (currently working on Monday) in case roofers do not finish today (January 18, 2019) Cafe has not (and will not) be used by patients during this time. On (MONTH) 23, 2019 at 1:30 PM, a review of the facility's corrective action plan against each of the environmental hazards was conducted using observation, interview and record review as follows: 1. Kitchen leak over steam table: Observation-Ceiling patched. Interview-kitchen went through a terminal clean. Record Review: Roofer patched roof. 2. Dry storage room: Observation-Ceiling patched. Interview-dry storage room went through a terminal clean. Record Review: Roofer patched roof. 3. room [ROOM NUMBER]: Observation-Ceiling patched. Interview-room cleaned. Record Review: Roofer patched roof. 4. room [ROOM NUMBER]: Observation-Ceiling patched. Interview-room cleaned. Record Review: Roofer patched roof. 5. room [ROOM NUMBER]: Observation-Ceiling patched and bathroom cleaned. Interview-bathroom door will remain locked and the bathroom will not be available for use. After a review of the affected areas in the facility against the facility's corrective action plan, the IJ was lifted on (MONTH) 23, 2019 at 4:03 PM in the presence of the Administrator (Admin) and Director of Nursing (DON).

Based on interview and record review, the facility failed to prevent multiple falls with progressive injuries for one of three sampled residents (Resident A), when the facility did not adequately assess the reasons for the falls and revise the care plan based on the identified reasons for the falls. These failures caused Resident A to suffer life threatening injuries as evidenced by: bleeding in the brain, the need for a ventilator (a machine that breathes for the resident) and placement in the general acute care hospital's intensive care unit (ICU). Findings: An unannounced visit was made to the facility on (MONTH) 4, (YEAR) at 9:56 AM, to investigate a complaint in regards to a resident fall with injuries. Resident A's clinical record was reviewed on (MONTH) 4, (YEAR). Resident A's face sheet (a document that gives a resident's information at a quick glance and includes a resident's contact details, a brief medical history and the resident's level of functioning, along with resident preferences and wishes), undated, set forth that Resident A was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Resident A's fall assessment, dated (MONTH) 18, (YEAR), set forth Resident A's history of falls due to balance problems during transition (moving from one position to another) and as a result of side effects of medications. During an initial tour of the facility on (MONTH) 4, (YEAR) at 11:23 AM, with the Director of Nursing (DON), the DON stated that Resident A was in the intensive care unit at the hospital and had not regained her base line status (normal level of functioning) at that time. Resident A's nursing notes from (MONTH) 6, (YEAR) to (MONTH) 5, (YEAR), were reviewed. The nursing notes set forth Resident A had sustained five falls as follows: a. (Fall 1) On (MONTH) 22, (YEAR), Resident A fell from a wheelchair when trying to stand unassisted and the wheelchair rolled out from under her. Resident A complained of 6 out of 10 pain (a zero to 10 pain scale where zero equals no pain and 10 equals the worst pain) to her left lower leg. (16 days after admission). b. (Fall 2) On (MONTH) 17, (YEAR), Resident A fell from a bed and was found on the floor. (23 days after Fall 1). c. (Fall 3) On (MONTH) 25, (YEAR), Resident A fell while ambulating (walking) with a walker, striking her head on the walker (a frame used by disabled or infirm people for support while walking, typically made of metal tubing with small wheels or rubber-tipped feet). Resident A sustained a gash to her left eyebrow and a reddened area to her neck where she had been hit by the walker. (8 days after Fall 2). d. (Fall 4) On (MONTH) 1, (YEAR) at 6 AM, Resident A fell from a bed after a bed alarm did not alert staff. Resident A sustained a 5 cm (centimeter) x 4 cm bump to the back of the head. (37 days after Fall 3). e. (Fall 5) On (MONTH) 1, (YEAR) at 5:45 PM, while ambulating with a walker (11 hours and forty-five minutes after Fall 4), Resident A suddenly stiffened and fell directly backwards hitting the back of her head on the floor resulting in a [MEDICAL CONDITION] and the need for a ventilator. During an interview with a Physical Therapist (PT 1) on (MONTH) 27, (YEAR) at 10 AM, PT 1 stated he was responsible for evaluating residents after a fall. PT 1 stated he had a post-fall procedure he followed to determine interventions to reduce the risk of future falls. PT 1 stated he had not been informed about any of Resident A's five falls at the facility (Fall 1, 2, 3, 4 and 5). PT 1 stated he had not been invited to, nor attended, any of Resident A's Interdisciplinary Team Meetings (IDT- a group of health care professionals who work in a coordinated fashion toward a common goal for the resident) regarding Resident A's five falls (Falls 1, 2, 3, 4, and 5). PT 1 stated, I should have been notified a long time ago in regards to these falls. This is clearly a pattern and we should have been consulted to keep this resident safe. During an interview with a Certified Nursing Assistant (CNA 2) on (MONTH) 27, (YEAR) at 11:24 AM, CNA 2 stated she had witnessed Resident A's first fall. CNA 2 stated Resident A was in the dining room in her wheel chair and attempted to stand up on her own. CNA 2 stated Resident A changed her mind and tried to sit back down in the wheel chair when the wheel chair wheeled backwards and Resident A fell to the floor. CNA 2 stated that the wheelchair wheels should have been locked by staff but they were not. CNA 2 stated she was unable to reinforce teaching for Resident A to ask for assistance with standing because Resident A communicated in a language different from the language spoken by CNA 2. During an interview with a Licensed Vocational Nurse (LVN 1) on (MONTH) 27, (YEAR) at 2 PM, LVN 1 stated she had assisted Resident A after Fall 1 and had documented Fall 1 in the nursing notes. LVN 1 stated that Resident A would spontaneously stand up and then sit right back down again. LVN 1 stated, You just didn't know what would happen. LVN 1 stated that the staff should have locked Resident A's wheelchair wheels so it would not go out from underneath her. LVN 1 stated she had difficulty communicating with Resident A because Resident A would transition between speaking a language LVN 1 did not speak and the English language. LVN 1 stated the communication difficulties made it impossible for her to reinforce teaching with Resident A to stay in her wheel chair. A review of Resident A's Event Investigation Record, dated (MONTH) 23, (YEAR), for Fall 1 indicated, Conduct a ROOT CAUSE ANALYSIS (a systematic process for identifying root causes of problems or events and an approach for responding to them). What factor(s) caused or contributed to this incident/accident? Chooses independence over safety. A review of Resident A's Interdisciplinary Team Conference Record-Falls, dated (MONTH) 23, (YEAR), indicated, Other factors considered by team: Enc. (encourage) pt. (patient) to comply with plan of care, re-direct and assist as needed. A review of a nursing note dated (MONTH) 17, (YEAR) at 6:45 AM, by a Licensed Vocational Nurse (LVN 2), indicated, Res (resident) was found sitting directly next to her bed on her buttocks .When asked what occurred res stated, 'I don't know.' A review of Resident A's Event Investigation Record, dated (MONTH) 19, (YEAR), indicated, Date of the event: 3/17/18 (March 17, (YEAR)) Type of Event: unwitnessed fall. A review of Resident A's Event Investigation Record, dated (MONTH) 19, (YEAR), for Fall 2 indicated, Conduct a ROOT CAUSE ANALYSIS (a systematic process for identifying root causes of problems or events and an approach for responding to them). What factor(s) caused or contributed to this incident/accident? Poor safety awareness, dx (diagnosis) dementia, depression, Chooses independence over ad lib ( ad libitum-spontaneously without restraint)- amb. (ambulation-walking) Ad lib c (with) walker. A review of Resident A's Interdisciplinary Team Conference Record-Falls, dated (MONTH) 19, (YEAR), indicated, Other factors considered by team: Encourage res. (resident) to use call light. During an interview with a Certified Nursing Assistant (CNA 1) on (MONTH) 27, (YEAR) at 1:04 PM, CNA 1 stated she had witnessed Resident A's third fall (Fall 3). CNA 1 stated Resident A was standing at the nursing station and when she turned to the left with her walker to start down the hallway she fell over to her left. CNA 1 stated she had been behind the nursing station and could only see from the middle of Resident A's chest and up to her head. CNA 1 stated, I couldn't see what happened below that; she just fell over. CNA 1 stated Resident A would have benefitted from assistance by staff while she ambulated with her walker. CNA 1 stated, I never discussed with anyone that I thought the resident could use more assistance. During an interview with a Licensed Vocational Nurse (LVN 3) on (MONTH) 28, (YEAR) at 7:12 AM, LVN 3 stated she had witnessed Resident A's Fall 3 and had documented Fall 3 in the nursing notes. LVN 3 stated Resident A had come up to the counter to ask where to go for lunch and LVN 3 had pointed and instructed to her that it was upfront. LVN 3 stated Resident A had her walker in front of her and she mis-stepped, caught the walker with her foot and fell to the left onto the floor. LVN 3 stated Resident A's neck was hit by the walker and she had a gash to her left eyebrow. LVN 3 stated Resident A was transported to the hospital. LVN 3 stated Resident A would not use the walker consistently and the staff would have to remind her constantly to use the walker. LVN 3 stated Resident A would attempt to ambulate independently then grab for something nearby when she lost her balance. LVN 3 stated that Resident A did not have a tab alarm (an alarm clipped onto the resident's clothing with a string that was attached to a magnet on a device on the wheelchair. When a resident tried to stand the string would pull and set off an alarm) to alert staff that she was ambulating independently. A review of the hospital's CT (computed tomography) scan (an x-ray of the head and brain) report, dated (MONTH) 25, (YEAR), indicated, Acute (immediate) subdural (under a brain membrane) hemorrhage (bleeding) seen over the left frontal lobe (front, left side of the brain) measuring up to 4 mm (millimeters-a unit of measurement) .slight 2-3 mm left-to-right midline shift (the brain is pushed to the right due to the pressure from the bleeding) noted. Resident A returned to the facility on (MONTH) 26, (YEAR), with physician's instructions to monitor bruising to upper arms and left eyebrow, every shift for 14 days, then re-evaluate. A review of Resident A's physician's orders [REDACTED]. A review of Resident A's care plan, that was completed and in effect for Resident A beginning (MONTH) 6, (YEAR), did not demonstrate that facility staff made revisions nor added any preventative interventions for Resident A after Resident A sustained her second and third falls (Fall 2 and 3). A review of Resident A's Event Investigation Record, dated (MONTH) 26, (YEAR), for Fall 3 indicated, Conduct a ROOT CAUSE ANALYSIS (a systematic process for identifying root causes of problems or events and an approach for responding to them). What factor(s) caused or contributed to this incident/accident? Chooses independence over safety, thin fragile skin. A review of Resident A's Interdisciplinary Team Conference Record-Falls, dated (MONTH) 26, (YEAR), indicated, Reinforce importance of seeking assistance, incl. (include) activities, monitor closely. During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on (MONTH) 27, (YEAR) at 3:06 PM, the RNS stated that a root cause analysis was a process to understand why the resident fell so the IDT could review the reasons and come up with interventions to prevent future falls. The RNS stated the root-cause analysis did not document that Resident A's wheelchair wheels had not been locked nor the difficulties with communication. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated that the IDT did not address the unlocked wheelchair wheels or the communication difficulties. The RNS stated, PT should have been invited to the 'Fall' IDT. During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on (MONTH) 27, (YEAR) at 3:23 PM, the RNS stated she did not speak Resident A's language, so she did not talk to Resident A about the fall. RNS stated her root cause analysis investigation did not identify why Resident A fell from her bed. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated the IDT meeting determined one intervention which was to encourage use of call light. The RNS stated that the IDT did not take into consideration the communication problems. The RNS stated that there was no documentation to show the physical therapist had attended the IDT meetings. The RNS stated: The care plan should have been updated with teach and reinforce, teaching of call light use - which would have been difficult to do because of the language barrier and dementia. During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on (MONTH) 27, (YEAR) at 3:38 PM, the RNS stated the root-cause analysis conducted after the fall did not adequately identify reasons why Resident A fell as Resident A had been ambulating with her walker and was using her walker appropriately. The RNS stated the root cause analysis was not conducted in a way to be effective. The RNS stated it did not make sense to reinforce importance for seeking assistance, as recommended by the IDT, when Resident A used her walker and used it appropriately. The RNS stated that there was no documented evidence to show the physical therapist had attended the meeting and the care plan had not been updated with interventions to prevent future falls after Fall 3. The RNS stated that the order for RNA ambulation should have been discussed in the IDT meeting and included on Resident A's care plan and it was not. During an interview with a Certified Nursing Assistant (CNA 3) on (MONTH) 28, (YEAR) at 6:50 AM, CNA 3 stated he, a Licensed Vocational Nurse (LVN 4) and another CNA (CNA 3 did not remember the name) were walking in the hallway and saw Resident A on her back on the floor of her room. CNA 3 stated that they all assessed Resident A at the same time and found the bump on the back of her head. CNA 3 stated, I saw the bump on her head, it was pretty visible. CNA 3 stated it was apparent to him that Resident A had fallen and the resident was incoherent and not speaking much. CNA 3 stated, I don't remember her saying anything that made sense. CNA 3 stated that he had been very concerned that the facility decided not to send her to the hospital. During an interview with a Licensed Vocational Nurse (LVN 4) on (MONTH) 27, (YEAR) at 2 PM, LVN 4 stated she had assisted Resident A after Fall 4 and had documented Fall 4 in the nursing notes. LVN 4 stated she did not remember where she had assessed Resident A after the fall but there had been a very large bump to the back of Resident A's head. LVN 4 stated Resident A had told her she hit her head on her bed. LVN 4 stated she had been very concerned that the facility had decided not to send Resident A to the hospital when she had such a large bump on her head. LVN 4 stated she obtained a verbal order from the physician on (MONTH) 1, (YEAR) at 6:30 AM to monitor bruising every shift for 14 days. LVN 4 stated that she had not completed an incident report or updated the care plan for Fall 4 because it had happened at the change of shift. A review of Resident A's clinical record from (MONTH) 1, (YEAR) to (MONTH) 27, (YEAR) was conducted. There was no documentation by facility staff to show an incident report, a root cause analysis, an IDT meeting or an update to the plan of care was completed for Fall 4. During an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on (MONTH) 27, (YEAR) at 3:57 PM, the RNS stated that there was no incident report, root cause analysis, IDT meeting or update to the plan of care for Fall 4. The RNS stated, We should have done this and we did not. During an interview with a Licensed Vocational Nurse (LVN 1) on (MONTH) 27, (YEAR) at 2:21 PM, LVN 1 stated she had witnessed Resident A's Fall 5. LVN 1 stated she was down by the nurse's station and Resident A was down the hall by room [ROOM NUMBER] or 20. Resident A was walking away from LVN 1 with her walker and Resident A was using her walker appropriately. LVN 1 stated Resident A stopped walking suddenly and then went straight backwards still holding onto her walker. LVN 1 stated that there was no crumble to the floor it was just stiff and flat backwards. LVN 1 stated there was no attempt by Resident A to brace or catch her fall. LVN 1 stated she ran down to Resident A and took her walker off of her and waved her hand over Resident A's face. LVN 1 stated, Her eyes were open and there was no response, no blinking, she was breathing. LVN 1 stated she called 911 and then sat with Resident A until they arrived. LVN 1 stated she did not document any interventions to Resident A's care plan other than to send her to the hospital. A review of the general acute care hospital's, History and Physical, dated (MONTH) 1, (YEAR), indicated the following interventions were taken for Resident A: a. Intubation and mechanical ventilation (breathing tube in place and hooked up to a breathing machine), not following commands b. CT (computed tomography) scan (an x-ray of the head and brain), indicated the following: Acute (immediate) left subdural (under a brain membrane, left side) hemorrhage (bleeding) measuring 17 mm (millimeters-size of area filled with blood) thick. Acute parenchymal (functional brain tissue) hemorrhage bordering along the right aspect (side) corpus callosum (nerves joining the two sides of the brain) measuring 8.5 x 3.6 x 2.0 cm (centimeters-size or area filled with blood). Mild intraventricular (within the ventricles of the brain) hemorrhage. A 17 mm rightward midline shift. (the brain is pushed to the right due to the pressure from the bleeding). A review of Resident A's Event Investigation Record, dated (MONTH) 2, (YEAR), for Fall 5 indicated, Conduct a ROOT CAUSE ANALYSIS (a systematic process for identifying root causes of problems or events and an approach for responding to them). What factor(s) caused or contributed to this incident/accident? History of multiple falls, chronic microvascular ischemic disease (damage to the small blood vessels of the brain), [MEDICAL CONDITION] (clouding of the lenses of the eye), [MEDICAL CONDITION] (increased pressure within the eyeball), dementia, anterograde amnesia (inability to recall the recent past), chooses independence over safety, web toes bilateral feet. During an interview and concurrent record review with a Registered Nurse Supervisor (RNS) on (MONTH) 27, (YEAR) at 4:03 PM, the RNS stated that the root cause analysis was a process to understand why the resident fell so the IDT could review the reasons and come up with interventions to prevent future falls. The RNS stated the root cause analysis conducted after the fall did not adequately identify reasons why Resident A fell , as it did not take into account the fall the same day at 6:00 AM with a head injury or that the resident did not appear to trip or crumble to the ground. Resident A instead went stiff and fell straight backwards still clutching her walker. The RNS stated that choosing independence over safety does not fit this picture so, the root-cause analysis was not conducted in a way to be effective. A review of the facility's policy and procedure titled, Fall Management Program, dated 2013, indicated the following: Purpose: This policy is intended to: (1) Explain how the facility will assess residents for fall risk and intervene to reduce falls; and (2) Describe procedures in the event of a resident fall. Policy: .A proactive interdisciplinary team approach will be maintained in an effort to reduce the number and severity of falls .Residents will be assessed for fall risk factors after a fall occurs and at least quarterly. Individualized care plans will be developed and updated as needed to address risk factors for falls. The interdisciplinary team will review all fall reports and will recommend interventions to help reduce future falls. Procedure: The plan of care should provide individualized interventions specific to the resident's fall risk factors. Post-Fall Documentation: Update the care plan after each fall as needed. Interdisciplinary Fall Review: Members of the IDT will review fall reports, review contributing risk factors, and investigate as needed to assist in revising the plan of care to reduce the risk of future falls.

Based on observation, interview, and record review, the facility failed to prevent further falls for one of three sampled residents (Resident 1), who had a prior fall on the same day, when the facility failed to implement the use of the pressure pad monitor (a personal alarm device that sounds an alarm by using pressure to alert staff when the resident moves) on the bed as ordered. This failure resulted in a fall with injuries requiring transfer to the general acute care hospital (GACH). Findings: An unannounced visit was made to the facility on [DATE] at 9:25 AM, to investigate an entity reported incident related to quality of care and treatment. During an interview with the Director of Nurses (DON) on October 2, 2014 at 9:35 AM, in the presence of the Administrator, the DON stated (Used Resident 1's name) was "acting confused" a day before the falls on August 2, 2014. She stated the Certified Nurse Assistant (CNA 1) failed to apply the "bed alarm" on Resident 1's bed, as ordered by the physician, resulting in a fall. CNA 1 no longer works for the facility. During a facility tour on October 2, 2014 at 10:28 AM, Resident 1 was observed in a wheelchair being wheeled by a staff member in the hallway. A lap buddy (a thick flat cushion that fits over a person's lap and under the armrests of a wheelchair to prevent unassisted rising) and an anti-tipper (small bent bars placed at the back of the wheelchair to prevent from tipping backwards) were noted on the wheelchair. Resident 1 was observed to be alert and verbally responsive. A review of the clinical record revealed, Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of a care plan initiated on December 9, 2013, revealed Resident 1 was at, "Risk for falls due to: confusion...Approaches/Action added on December 10, 2015 included:" personal alarm in bed (checked off)," and under the section for "Problem," was listed for December 10 2013, "bed pad monitor when in bed." A review of Resident 1's nurses progress notes dated August 2, 2014 was conducted. The nurses note revealed Resident 1 had two fall incidents that day as follows: a. First fall incident - On August 2, 2014 at 2:45 PM, Resident 1 was found on the floor in Room 102. Resident 1 was confused and was "making no sence (sense)" when asked what happened. After Resident 1 was assessed, the nurse helped her back to bed. A physician order [REDACTED]. A skull Xray (X-ray- a radiology procedure used to view the structures inside the skull) report signed by the physician dated August 2, 2014 at 4:37:25 PM PST, revealed, "CONCLUSION: Unremarkable skull (indicates no fracture or other injury)." b. Second fall incident - On August 2, 2014 at 8 PM, "Nurse notified by CNA that res. (resident) was laying on the floor with bleeding noted from forehead area. Upon nurse's arrival res. found laying on floor, next to bed, in supine position (laying with face up)...res noted to have increase to size of previous raised area to forehead, (resident) also has a small laceration to base of raised area. Res. has moderate amount of bleeding to base of laceration..." The nurse's note continued at 8:02 PM, and revealed the physician ordered for Resident 1 to be transferred to the general acute care hospital (GACH) emergency room via ambulance for evaluation. The facility's Resident Admission Form dated August 4, 2014 at 2:45 PM, when Resident 1 was readmitted revealed, "Pt (patient) (with) bruising to forehead, around eyes, cheeks and on L (left) side neck, also has S/T (skin tear) with raised hematoma(localized swelling filled with blood) to the center forehead from a fall on 8.2.14 (August 2, 2014)." A review of the physician's orders [REDACTED]." During an interview with the Director of Staff Development (DSD) on October 2, 2014 at 11:55 AM, she stated CNA 1 had confirmed, during her interview with CNA 1, that CNA 1 had made a mistake when the bed pad alarm was not put on Resident 1's bed, which resulted in the second fall incident. A concurrent review of a "CONCERN FORM" completed and signed by Licensed Vocational Nurse (LVN 1) dated August 2, 2014, revealed, "(Resident 1) had a fall (first fall incident) earlier today . She was already on neuro VS (neuro vital signs - assessment of the brain activity by checking pupil reaction, level of alertness and orientation and range of motion in extremities); Res. (resident) was sitting in a w/c (wheelchair) for safety, (CNA 1) placed (Resident 1) in bed, did not check res. Had no bed pad alarm on the bed. Res has an order for [REDACTED]. fell (second fall incident) and had to go to the emergency room ." During a phone interview with LVN 1 on October 2, 2014 at 12 PM, LVN 1 confirmed the information on the "CONCERN FORM" dated August 2, 2014, was accurate and said CNA 1 did not place a pressure pad alarm (bed pad alarm) on Resident 1's bed, which resulted in the second fall incident. During an interview with the DON on October 2, 2014 at 12:15 PM, and a concurrent review of the POC (Point of Care) communication book (contains resident-specific physician orders, communication, changes in orders, etc ... that the CNA staff would access) for August 2014, revealed a physician's orders [REDACTED]." The DON confirmed, on August 2, 2014, CNA 1 signed the form to acknowledge that she knew about the order, but "neglected to put the bed (pad)alarm on the resident." The DON confirmed CNA 1 did not follow the physician's orders [REDACTED]. When asked for a copy of the facility's policy and procedure on the use of the bed pad alarm, the DON stated there was no specific policy for it. A review of the facility's policy and procedure titled, "Communication Systems" VERSION: 07.2013, revealed under procedure, "Communication Book (Recommended)...10. All nursing staff should check the communication book on their shift (recommend to use at each change of shift report) for new information and to initial that they have read it..." During an interview on October 2, 2014 at 12:25 PM, with the DSD and a concurrent review of the in-service contents for March 7, 2014, regarding "Dignity/Res Rights Body alarms/tab alarms/(wheelchair) cleaning", the DSD confirmed there was no documented evidence of any reference material or resources used during the in-service; only "verbal instructions." The DSD confirmed CNA 1 did not attend the March 7, 2014 in-service.

Immediate Jeopardy (IJ) was called on 4/28/11 at 6:30 PM, in the presence of the Chief Operating Office (COO), Administrator, and the Director of Nursing due to the following: Based on interview and record review, the facility failed to ensure resident drug regimen was free from unnecessary drugs as evidenced by inadequate monitoring. The facility failed to provide adequate laboratory monitoring for [MEDICATION NAME] (also known as [MEDICATION NAME], an anticoagulant medication used to prevent clot formation) for one of 12 sampled residents (Resident 6), which resulted in a critically high lab value (related to anticoagulation) and risk for significant bleeding: Resident 6 required an antidote medication (vitamin K) and transfer to the emergency room to reverse the anticoagulation effects of the [MEDICATION NAME] where she received 2 units of fresh frozen plasma ( a blood product). Findings: On 4/27/11, Resident 6's clinical record was reviewed. Resident 6, age 86, was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident 6 was readmitted to the facility on [DATE] following a short stay at an acute care hospital where she was given the medication [MEDICATION NAME] (an anticoagulant medication used to help prevent clot formation) for a new [DIAGNOSES REDACTED]. On 3/12/11 when Resident 6 was readmitted to the facility, her physician wrote an order for [REDACTED]. INR is the International Normalized Ratio, which is used to monitor the effectiveness of blood thinning drugs (prolonged clotting time) such as [MEDICATION NAME] /[MEDICATION NAME]. The normal reference range for this PT/INR lab value for [MEDICAL CONDITION] is 2.0-3.0. (Source: American College of Chest Physicians, a nationally recognized medical society). To achieve therapeutic effect (prevent blood clot formation), and prevent toxicity (risk of bleeding) caused by excessive dosing, the INR should be closely monitored to evaluate and modify therapy as needed to stabilize the INR. Ongoing [MEDICATION NAME] therapy should be guided by continued INR monitoring. [MEDICATION NAME] has a "Black Box" Warning from the manufacturer (as mandated by the FDA, and represents the most serious type of medication adverse events). According to the package insert for the drug, the boxed warning indicates that, "[MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR)... Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy." Because of the increased risk of excessive bleeding, the manufacturer's recommendation (in the package insert) stipulates the following: "The PT should be determined daily after the administration of the initial dose until PT/INR results stabilize in the therapeutic range. Intervals between subsequent PT/INR determinations should be based upon the physician's judgment of the patient's reliability and response to [MEDICATION NAME] in order to maintain the individual within the therapeutic range. Acceptable intervals for PT/INR determinations are normally within the range of 1 to 4 weeks after a stable dosage has been determined. Resident 6 had a physician's orders [REDACTED]. The first blood draw was to have been on 3/14/11. On 3/15/11 Resident 6's blood was drawn and her PT/ INR was 1.17 per the diagnostic lab record. Per the physician's orders [REDACTED]. No evidence of these lab draws was available in Resident 6's clinical record. On 4/27/11 Resident 6's blood was drawn and the results were reported to the facility via facsimile transmission at approximately 11:44 AM. Resident 6's PT/ INR lab was at a critically high level of 12.31, (more than four times the recommended therapeutic lab value). This critically high lab value put Resident 6 at a significant risk for bleeding. The Boxed Warning for the use of [MEDICATION NAME] reads in part ... " Risk factors for bleeding include high intensity anticoagulation (INR >4, International Normalized Ratio, a way of standardizing the results of the clotting time test), age (>[AGE] years), history of gastrointestinal (stomach or intestinal) bleeding, hypertension (high blood pressure), [MEDICAL CONDITION] disease (stroke), serious [MEDICAL CONDITIONS] ( a condition in which the body does not have enough healthy red blood cells), malignancy ( the tendency of a medical condition to become progressively worse and to potentially result in death) trauma, and renal (kidney) insufficiency. Resident 6 was [AGE] years old and because of her age, she was at increased risk of bleeding. The package insert lists special considerations for elder patients: "Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]." On 4/27/11 at 12:00 PM RN 1 notified Resident 6's physician of the critical lab values and orders were received to hold the 2.5 milligram [MEDICATION NAME] dose, give Vitamin K (antidote for the anti-coagulation medication) 5 mg by mouth for three doses to reverse the anti-coagulation effects and also to recheck Resident 6's PT/INR lab values on 4/28/11. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These nurses provided the medication despite the absence of a [MEDICATION NAME] flow sheet in the Medication Administration Record, [REDACTED]'s PT/INR levels. On 4/28/11 at 11:00 AM RN 1 notified Resident 6's physician of the new PT/INR of 14.27 (which exceeded the previous day's lab value of 12.31). The physician's orders [REDACTED]. On 4/28/11 at 11:10 AM the DON spoke with Resident 6's physician and an order was received to transfer Resident 6 to the emergency room for treatment to reverse the anti-coagulation effects of the [MEDICATION NAME]. Resident 6 was transferred to the emergency roiagnom on [DATE] at approximately 11:45 AM. On 4/28/11 at 11:45 AM Resident 6's physician was interviewed. He stated that he was unsure why the facility had not followed his orders to check Resident 6's lab values every two weeks. He also stated it was his position that the three doses of Vitamin K ordered to be given to Resident 6 on 4/27/11 should have reversed the anti-coagulation effects of the [MEDICATION NAME]. He stated he was repeating the doses of Vitamin K on 4/28/11 with the intent to reverse the anti-coagulation effects of the [MEDICATION NAME]. On 4/28/11 at 11:55 AM during an interview with the DON, she was asked to provide copies of the lab reports showing the PT/INR values for the time between 3/15/11 and 4/27/11. The DON confirmed the requested lab work was not available in Resident 6's clinical record. She stated she would look for the requested documentation in the medical records office and provide it for review. On 4/28/11 at 1:00 PM during an interview with the Chief Operating Officer (COO) she stated the facility was unable to produce the requested lab reports, because the tests were not done as the physician had ordered. She also provided a copy of the facility's policy and procedure for the use of the medication [MEDICATION NAME] and a copy of the [MEDICATION NAME] Flow Sheet. She stated that the facility had not been using the flow sheet as directed by their policy which may have prevented the facility oversight regarding the missed lab draws. Per the facility policy titled [MEDICATION NAME] Management dated 9/14/09, "each resident receiving [MEDICATION NAME] therapy should have a [MEDICATION NAME] Flow Sheet for the purpose of monitoring PT/INR results, MD notification of lab results, dosage adjustments, and lab follow-up orders. The flow Sheet should be filed with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]". On 4/28/11 at approximately 11:30 PM Resident 6 was readmitted from the emergency room to the facility following receipt of 10 mg of Vitamin K (antidote medication for [MEDICATION NAME]) and two units of Fresh Frozen Plasma (a clotting factor for blood) to stabilize her blood clotting levels. At discharge from the emergency room , Resident 6's INR level was 2.5. The IJ was abated on 5/2/11 at 4:30 PM, in the presence of the Administrator, Chief Operating Office and the DON following receipt and verification of an acceptable plan of correction.