Every finding on record at Majestic Mountain Care Center

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when facility staff did not provide supervision for Resident 1 when Resident 1 exited the facility through the back patio door, wandered off the facility perimeter that did not have a fence or barrier dividing the front and back of the facility and was located in a rough terrain area with tall grass, tall bushes, long tree branches, mud and a water hole. This failure had the potential to cause falls and injuries to Resident 1 and other Residents in the facility.Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for history of falling, muscle weakness, anxiety disorder (disorder causing excessive, persistent fear or worry that interferes with daily life), insomnia (sleep disorder characterized by difficulty falling or staying asleep), abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/29/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 5/6/26 at 10:13 a.m. with certified nursing assistant (CNA) 1, the back patio and trail leading to the front of the facility was observed. The back patio and trail were observed with no barrier or fence separating the front and back of the facility. CNA 1 stated that on 5/2/26, Resident 1 went outside to the back patio, walked around the trail leading to the front of the facility and walked outside the facility perimeter without supervision or staff knowledge that Resident 1 had left the facility grounds. CNA 1 stated the area where Resident 1 was found had rough terrain with tall grass, long bushes and tree branches and a water hole with a narrow trail. CNA 1 stated she was unsure if Resident 1 required supervision while being outside as he had been seen sitting alone outside in the past. During a telephone interview on 5/6/26 at 10:43 a.m. with licensed vocational nurse (LVN) 1, LVN 1 stated on 5/2/26, Resident 1 was observed by Activity Assistant (AA) 1 going outside alone without staff. LVN 1 stated she was alerted via staff communication that Resident 1 could not be found in the facility and immediately initiated a search. LVN 1 stated that Resident 1 was found lying outside the facility perimeter located between a wire fence, bushes, and tall grass. LVN 1 stated it was the facility process to monitor and supervise residents when they went outside for safety. During a telephone interview on 5/6/26 at 10:54 a.m. with AA 1, AA 1 stated that on 5/2/26, Resident 1 was observed walking outside to the back patio through the dining room door. AA 1 stated that Resident 1 had stated he would be going outside for fresh air and would be returning shortly. AA 1 stated Resident 1 walked outside with his walker alone. AA 1 stated Resident 1 was observed by the dining room window as AA 1 continued to assist other residents in the dining room activities. AA 1 stated, when she did not see Resident 1 from the window after approximately 10 minutes, she alerted a staff member to look for Resident 1 and the staff member discovered Resident 1 was not in the facility. AA 1 stated the facility process was for all residents to have supervision when going outside for safety. During a telephone interview on 5/6/26 at 11:22 a.m. with LVN 2, LVN 2 stated that on 5/2/26 Resident 1 had left the facility through the back door and was located outside the facility perimeter lying on the ground surrounded by thick bushes, tall grass, and a water hole. LVN 2 stated the facility process was for all residents in the facility to have been monitored when they were going outside to ensure safety and to know where residents were at all times. During a telephone interview on 5/6/26 at 11:30 a.m. with LVN 3, LVN 3 stated that on 5/2/26 Resident 1 had left the facility through the back door and was located outside the facility perimeter lying on the ground surrounded by thick bushes, tall grass, and a water hole. LVN 3 stated the facility process was for all residents to have been monitored by staff when going outside or going into the back patio. During a concurrent observation on 5/6/26 at 12:00 p.m. with the MDS nurse and the director of nursing (DON), the facility's video surveillance dated 5/2/26 was reviewed. The video surveillance showed Resident 1 walking outside with a walker to the back patio area through the dining room back door. Resident 1 was observed to be walking alone with no staff or other visitors or residents present. Resident 1 was observed walking with his walker to the end of the cemented pathway and onto the grass area leading to the front of the facility parking lot and driveway. Resident 1 was observed walking toward the driveway until the end of the wire fence was reached, then proceeded to walk into the tall grass area with heavy terrain and bushes outside the facility perimeter. During an interview on 5/6/26 12:10 p.m. with Registered Nurse (RN) 1, RN 1 stated the facility process was for staff to monitor all residents when they were outside. RN 1 stated the facility had a back patio area where residents sat for smoking breaks or outings when doing activities. RN 1 stated the lack of fencing to the back patio area could have been a safety concern due to residents' access to the parking lot and driveway. During an interview on 5/6/26 at 2:18 p.m. with the activities director (AD), the AD stated the facility process was for all residents to have supervision when going outside by themselves. The AD stated the AAs were trained to alert staff when a resident was requesting to go outside and when the AA was unable to assist with monitoring the resident. During an interview on 5/6/26 at 2:39 p.m. with CNA 2, CNA 2 stated the facility process was for the staff to monitor all residents including residents who were independent and ambulatory when they were in the facility or going outside. CNA 2 stated it was important to monitor residents to ensure they are safe from falls or injuries and to ensure the residents do not wander away from the facility. CNA 2 stated the lack of fencing and barriers causing an open landscape around the facility was not safe for the residents, especially the residents who wander around the facility. During an interview on 5/6/26 at 2:51 p.m. with social services (SSD). The SSD stated on 5/2/26, Resident 1 left the facility through the back door in the dining room and was located outside the facility perimeter. The SSD stated the facility process was for all residents to be monitored when the residents were able to go outside independently or required assistance. The SSD stated the assumption was that if a resident in the facility used a walker or wheelchair and they were able to go outside, the facility staff should have monitored the residents. During an interview on 5/6/26 at 3:28 p.m. with the MDS, the MDS stated that on 5/2/26, Resident 1 had exited the facility through the back patio and walked around to the front of the facility where he exited the facility perimeter into a rough terrain area where he was found. The MDS stated the facility's lack of fencing or barriers dividing the back patio from the parking lot and front of the facility driveway was unsafe for the residents. During an interview on 5/6/26 12:30 p.m. with the administrator (ADM), the ADM stated the facility expectation was to ensure resident safety within the facility. The ADM stated the back patio area was not enclosed, fenced or had a barrier dividing the back patio to the front of the facility driveway and parking lot. The ADM stated all residents in the facility should be supervised or monitored when going outside to ensure residents were safe and that they did not leave the facility without staff knowledge. During a record review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 2001, the P&P indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety addresses risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis. Our individualized resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The facility oriented and resident oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors and then adjust interventions accordingly. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when Resident 1, was left unattended in bed lying on his right side by Licensed Vocational Nurse (LVN) during wound-care treatment (specialized medical management of skin injuries to promote healing and prevent infection) on [DATE], while the right side of his bed had no bedrail in place.This failure resulted in Resident 1 falling from his bed onto the floor causing an avoidable left hip fracture (broken bone) and mild pain.During a concurrent observation and interview on [DATE] at 9:17 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 was covered with a blanket that notably outlined his bilateral (left and right) above the knee amputations (removal of limbs). Resident 1 stated he had a fall at the facility. Resident 1 stated on the day of the fall, he was receiving care from the LVN and a wound doctor, and during the care they left the room. Resident 1 stated he had fallen asleep, rolled on to his back and off the bed. Resident 1 stated staff had to get a machine to help get him back in bed. Resident 1 stated x-rays (medical test that produces pictures of the inside of the body) were taken and he was told he had a fracture.During an interview on [DATE] at 9:30 a.m. with Resident 2 (Resident 1's roommate), Resident 2 stated Resident 1 fell two weeks ago in their room. Resident 2 stated he did not witness the fall. Resident 2 stated on the day of the fall, a woman was with Resident 1 and then she left the room. Resident 2 stated he heard a shaking motion coming from Resident 1's bed and then Resident 1 fell onto the floor, on the right side of Resident 1's bed. Resident 2 stated four or five people came to help get Resident 1 off the floor and into bed. Resident 2 stated Resident 1 was bedridden because he had no legs.During an interview on [DATE] at 10:02 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on the day of Resident 1's fall, CNA 1 was caring for another resident who was across the hall from Resident 1's room. CNA 1 stated he heard a faint cry for help. CNA 1 stated he entered Resident 1's room and noticed Resident 1 was not in his bed. CNA 1 stated it was not normal for Resident 1 to be out of his bed due to his condition. CNA 1 stated he found Resident 1 on the floor. CNA 1 stated Resident 1 had no visible injuries and was not complaining of any pain. CNA 1 stated he called a Registered Nurse (RN) for help. CNA 1 stated a large team of staff needed to get Resident 1 into bed but could not recall who was specifically there. CNA 1 stated Resident 1 was a one-person assist prior to his fall at the facility.During an interview on [DATE] at 10:15 a.m. with the LVN, the LVN stated she was the wound treatment nurse caring for Resident 1 on the day of his fall. The LVN stated she and the wound doctor were performing wound care on Resident 1 when she noticed blood on Resident 1's brief (a single use absorbent garment like underwear). The LVN stated she asked a CNA to get her a new brief for Resident 1. The LVN stated she then left Resident 1's room with Resident 1 lying on his side without placing a new brief. The LVN stated she assumed a CNA would put a brief on Resident 1. The LVN stated she went into another resident's room and heard Resident 1 fell. The LVN stated she did not return to Resident 1's room after the fall but was made aware he sustained a left hip fracture. The LVN stated Resident 1 used Acetaminophen (medication used for mild pain) as needed for pain control after the fall. The LVN stated she should have made sure a brief was placed on Resident 1 before she left the room. The LVN stated she felt it was her fault that Resident 1 fell.During an interview on [DATE] at 10:30 a.m. with CNA 2, CNA 2 stated he did not witness Resident 1 fall, but he was at the facility at the time it happened. CNA 2 stated he was caring for another resident when CNA 1 asked him to help get Resident 1 back into bed. CNA 2 stated he grabbed a sling (hammock-like support system attaches to a mechanical lift) and the mechanical lift (a device used to transfer someone from one place to another) to lift Resident 1 back into bed. CNA 2 stated this was the first time Resident 1 had fallen at the facility.During an interview on [DATE] at 12:53 p.m. with CNA 3, CNA 3 stated CNA 1 informed her of Resident 1's fall. CNA 3 stated she asked Resident 1 what happened. CNA 3 stated Resident 1 reported he was waiting for the LVN who was doing his wound care to get a brief and he fell. CNA 3 stated Resident 1 complained of pain in his left hip. CNA 3 stated this was Resident 1's first fall in the facility. CNA 3 stated Resident 1 must have been left in a vulnerable position to have fallen.During an interview on [DATE] at 11:18 a.m. with the Director of Nursing (DON), the DON stated she was not familiar with Resident 1 because she had only been the DON at the facility for two weeks. The DON stated she heard of Resident 1's fall from the Assistant Director of Nursing (ADON). The DON stated Resident 1 had an unwitnessed fall off the right side of the bed. The DON stated prior to the fall Resident 1 had a side rail for mobility on the left side of his bed only. The DON stated Resident 1 initially did not complain of pain but later reported left side pain. The DON stated Resident 1 refused to be transferred to the hospital for further evaluation.During a concurrent interview and record review on [DATE] at 11:41 a.m. with the ADON, Resident 1's Care Plan Report (CPR) dated [DATE] was reviewed. The CPR indicated, prior to Resident 1's fall, Resident 1 .Requires Assist of 1-2 person Assist to Start and Complete Most ADL [activities of daily living - basic routine self-care tasks such as bathing, dressing, and eating] Task. The ADON stated she was familiar with Resident 1's recent fall. The ADON stated she had been informed Resident 1 had a fall, complained of left side pain but refused to go to the hospital. The ADON stated Resident 1 reported he was leaning on his right side waiting for help and it felt like gravity pulled him down. The ADON stated Resident 1 fell off the right side of his bed. The ADON stated Resident 1 was a two-person assist prior to fall. The ADON stated she was shocked to hear Resident 1 was a one-person assist. The ADON stated had two caregivers been present, the fall could have been avoided. The ADON stated the LVN should never had left Resident 1 in the middle of providing care. The ADON stated it was standard practice (written guidelines that define the minimum, acceptable level of performance, skill and care expected of a professional) to not leave any resident by themselves during care. The ADON stated if Resident 1 had his care completed before the LVN left the room, the fall could have been avoided.During an interview on [DATE] at 12:04 p.m. with the Administrator (ADM), the ADM stated he was not in the facility at the time of Resident 1's fall. The ADM stated he was not a part of the Interdisciplinary Team (IDT- a collaborative routine gathering of professionals from various specialties like nurses, doctors, therapists and social workers) for Resident 1's fall investigation. The ADM stated he was the Abuse Coordinator and should have probably been a part of the IDT investigation into Resident 1's fall. The ADM stated the results of the IDT investigation showed the LVN left Resident 1 unattended during wound care. The ADM stated during wound care two people should be present, the nurse and the wound care doctor. The ADM stated Resident 1's fall was potentially avoidable.During a record review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with the diagnosis of .Acquired Absence of Right Leg Above the Knee, Acquired Absence of Left Leg Above the Knee.During a record review of Resident 1's Order Summary Report (OSR) dated [DATE] the OSR indicated, Resident 1 had an order to assess for pain every shift and chart intensity of pain 0 equals no pain, 1-4 equals mild pain, 5-7 equals moderate pain, 8-10 equals severe to excruciating pain. The OSR indicated, he had an order for left side 1/4 rail for functional bed mobility assist. The OSR indicated, an order for .Acetaminophen Tablet 325 MG [milligrams- unit of measurement]. 2 tablet by mouth every 6 hours as needed for pain . The OSR indicated, an order for wound care to the left and right medial (middle) buttocks one time a day. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated [DATE], the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life, a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) score of 14. The MDS section GG Functional Abilities indicated, substantial/maximal assistance - helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort. During a review of Resident 1's Medication Administration Record (MAR) dated 4/26, the MAR indicated, Resident 1 was administered Acetaminophen Tablet 325 MG on [DATE] for pain rating of 2, on [DATE] for a pain rating of 4, and on [DATE] for a pain rating of 2.During a review of Resident 1's Progress Note (PR) dated [DATE], the PR entry titled FALL IDT REVIEW indicated, Resident 1 had .Risk Factors: BL [Bilateral - both] above the knee amputation, preference of having his bed at a high level.x-ray done of left hip.fracture of the left femoral trochanter [type of broken hip at the top of the thigh bone].TX [treatment] nurse stepped away from the room.resident was left on his right side while awaiting the nurse's return.she never showed up.During a review of Resident 1's Radiology Results Report (RRR) dated [DATE], the RRR indicated, Resident 1 x-ray findings of .Fracture involving the left femoral trochanters.During a review of Resident 2's MDS dated [DATE], the MDS indicated, a BIMS score of 7.During a review of the facility's policy and procedure (P&P) titled Provision of Quality Care dated [DATE], the P&P indicated, .the facility will ensure that residents receive treatment and care.in accordance with professional standards of practice.

Based on observation, interview and record review the facility failed to follow its policy and procedure (P&P) titled Abuse Prevention and Response Policy to ensure residents were free from abuse and neglect for two of six sampled residents (Resident 1 and Resident 3) when:1.Social services was made aware of Resident 1's allegation of sexual abuse and did not investigate or document the incident.This failure placed Resident 1 at risk for further abuse, neglect and emotional harm.2. Licensed Vocational Nurse (LVN) 3 left Resident 3 unsupervised outside the facility front door for 15-20 minutes and Resident 3 left the facility.This failure placed Resident 3 at risk for harm due to the facility being located on a busy highway, at risk for falls and injury.Findings:1. During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE].During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/26/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.During a telephone interview on 3/24/26 at 8:50 a.m. with the administrator (ADM), the ADM stated that on 3/12/26, he was informed by facility staff that Resident 1 had reported an incident involving Resident 2 inappropriately touching Resident 1's breast. The ADM stated that on 3/12/26, an investigation was initiated to gather more information regarding the incident. The ADM stated that during the investigation Resident 1 had requested the incident not be reported to any authorities. The ADM stated that based on Resident 1's request the incident was not reported per facility policy and instead was only reported to law enforcement.During a review of Resident 2's admission Record, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis for Alzheimer's disease.During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 4 out of 15, which indicated Resident 2 had severe cognitive impairment.During an interview on 3/24/26 at 11:20 a.m. with CNA 1, CNA 1 stated it was the facility process to report and investigate sexual abuse or any forms of abuse allegation immediately to ensure all residents were safe. CNA 1 stated Resident 1 had reported feeling uncomfortable with Resident 2 and Resident 1 would request staff keep her away from Resident 2. CNA 1 stated it was important to report and investigate sexual abuse allegations to prevent further abuse and to protect Resident 1 from any distress.During a concurrent observation and interview on 3/2/26 at 11:41 a.m. with Resident 2 in Resident 2's room, Resident 2 was observed sitting on his wheelchair not moving right hand, arm and right leg. Resident 2 denied any incident involving any residents in the facility. Resident 2 stated he did not recall any inappropriate touching toward another resident in the facility.During a concurrent interview and record review on 3/24/26 at 12:13 p.m. with LVN 1, Resident 1's Electronic Medical Record (EMR) were reviewed. The LVN 1 stated, no documentation or investigation was found for Resident 1's report of sexual abuse incident on 3/12/26 in Resident 1's EMR. Resident 2's document titled, Inappropriate Behavior- Care Plan (CP), dated 9/1/2025, was reviewed. The CP indicated, . Inappropriate behavior towards a female resident. Was witnessed grabbing a female resident's breast in the social dining room. Goal: my behavior will stop with staff interventions. Interventions: 15 minute checks. offer me something I like as a diversion. Resident to be monitored during mealtimes at the social dining room to ensure he is not to be by female residents. LVN 1 stated Resident 1 had reported, that during a mutual hug with Resident 2, Resident 2 touched both of Resident 1's breast without consent. Resident 1's report of alleged sexual abuse should have been reported immediately to ensure Resident 1 was separated from Resident 2 and safe from any potential abuse. LVN 1 stated Resident 2 should have been kept away or separated from female residents. During an interview on 3/24/26 at 12:55 p.m. with Resident 1, Resident 1 stated she recalled an incident that involved Resident 2 inappropriately touching both her breast. Resident 1 stated she could not recall the date of the incident but did recall Resident 2 requesting a hug from Resident 1 as she was attempting to walk away in the hallway. Resident continued to state, Resident 2 would not allow her to walk through the hallway therefore Resident 1 agreed to give Resident 2 a hug. Resident 1 stated that as she pulled away from Resident 2, Resident 2 slid his hand over both of Resident 1's breast. Resident 1 stated she immediately yelled at Resident 2 and informed him that the action was inappropriate. Resident 1 stated she felt violated as the action from Resident 2 touching her breast felt intentional. Resident 1 stated she felt safe in the facility only after she informed the staff herself of the situation.During an interview on 3/24/26 at 1:22 p.m. with social services (SS), the SS stated that on 3/12/26 Resident 1 reported that Resident 2 had been harassing and following Resident 1 in the facility. SS stated Resident 1 reported that there was an incident in which Resident 2 had inappropriately touched her breast while engaging in a mutual hug. SS stated the incident was not reported per Resident 1's request to not report it. SS stated there was nothing that was done for the allegation other than a call to local law enforcement, who had concluded there was nothing they could do. SS stated following the local law enforcement visit, no further interventions were made from the facility. SS stated the facility process was to conduct an investigation, ensure resident safety and implement new interventions to ensure the incident would not happen again. SS stated the process was to monitor Resident 1 for psychosocial harm or changes in behavior. SS stated since the incident was reported there were no SS visits with Resident 1 due to a lot going on and forgot to do it. SS stated Resident 1 was kept safe and interventions were initiated but could not answer how facility staff was made aware of the allegation or where the allegation was documented.During an interview on 3/24/26 at 1:37 p.m. with the clinical coach (CC), the CC stated the facility had made her aware of the allegation on 3/24/26. The CC stated the facility process for an allegation of abuse was for staff to ensure safety, separate the residents, and report it immediately. The CC stated it was important to report and document allegations of abuse to ensure the residents were safe and to prevent further abuse. During a concurrent interview and record reviewed on 3/24/26 at 2:05 p.m. with LVN 2, Resident 1's EMR were reviewed. The LVN 2 stated, no documentation or investigation was found for Resident 1's report of sexual abuse incident on 3/12/26 in Resident 1's EMR. LVN 2 stated she was made aware of Resident 1's allegation toward Resident 2, when Resident allegedly touched Resident 1's breast. LVN 2 stated Resident 2 had a history of inappropriate behavior toward female residents and staff. LVN 2 stated she was unaware of new interventions for Resident 1 following the incident. LVN 2 stated all staff would monitor Resident 2 when he was up in the wheelchair due to the past inappropriate behaviors. LVN 2 stated the facility process was to ensure resident safety following an allegation of abuse, documenting the incident, ensuring all residents involved were closely monitored for behavioral changes and implementing new interventions. LVN 2 stated the facility process was to report and document the allegations to ensure the incident was investigated and to monitor Resident 1 for emotional distress, withdrawing from normal activities or feeling scared. The LVN stated, no documentation or investigation was found for Resident 1's report of sexual abuse incident on 3/12/26 in Resident 1's EMR. 2. During a review of Resident 3's admission Record, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis for Dementia, Schizophrenia, muscle weakness.During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated, Resident 3's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15, which indicated Resident 2 cognitively intact.During an interview on 3/24/26 at 11:48 a.m. with Resident 3, Resident 3 stated he had left the facility through the front door during a smoke break. Resident 3 stated he had hitchhiked a ride to an unfamiliar female's home where Resident 3 was given money to travel. Resident 3 stated the unfamiliar female drove Resident 3 to a local casino 12.4 miles away from the facility where Resident 3 remained until local law enforcement arrived. Resident 3 stated he felt safe in the facility but when Resident 3 was given an opportunity to leave the facility, Resident 3 would leave again.During a concurrent interview and record review on 3/24/26 at 11:55 a.m. with the activities director (AD), the facility's Elopement Binder, undated, was reviewed. The AD stated the elopement binder was used to identify the residents who were at risk for elopement. The AD stated Resident 3 was listed on the Elopement binder as at risk with a total elopement assessment score of 20. The AD stated a score of 10 or above represented a high risk for elopement. The AD stated the purpose of identifying the residents at risk for elopement was to ensure all facility staff were closely monitoring the residents identified to prevent residents from eloping.During a review of Resident 3's, Elopement Risk, dated 1/10/2026, the document indicated Resident 3 had a score of 20 indicating a total score 10 or above represented high risk.During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, the facility's Elopement Binder, undated, was reviewed. The Elopement binder indicated Resident 3 had an elopement risk score of 20. LVN 1 stated the elopement binder was the first tool used by the facility staff to identify the residents at risk for elopement. LVN 1 stated the elopement binder consisted of the residents' admission record, elopement risk assessment, elopement care plan and the residents physician orders. LVN 1 stated that Resident 3 had left the faciity on 3/21/26 when Resident 3 was left outside by LVN 3 during a smoking break without staff supervision. LVN 1 stated the facility process was for all residents to have staff supervision when going outside, especially residents who were at risk for elopement. LVN 1 stated the facility process was to monitor residents who were outside to avoid falls, injuries and elopement.During a review of Resident 3's Progress Note, dated 3/21/26 at 6:30 p.m., the note indicated, .Nurse on shift heard front door alarm going off and approached to turn off alarm and found [Resident 3] sitting on bench outside of front door smoking a cigarette. Alarm on door was shut off and staff reminded [Resident 3] to come inside building once done smoking, resident agreed. [LVN 3] went back to north hall to finish completing admission. after approximately 10-15 minutes [LVN 3] went to check on [Resident 3] in front sitting area and [Resident 3] was not there. [LVN 3] walked out to front parking lot with certified nursing assistant (CNA) and saw nothing signaling [Resident 3] was outside. [LVN 3] and CNA returned into the building and checked [Resident 3] room and bathroom. When [Resident 3] was not found in room/bathroom CNA and [LVN 3] alerted staff to start searching building for client. Parking lot around building, inside building searched and [Resident 3] was not found.During an interview on 3/24/26 at 1:09 p.m. with social services (SS), SS stated that on 3/21/26, Resident 3 had eloped from the facility. SS stated that Resident 1 was left alone and unsupervised during a smoke break by LVN 3. SS stated the facility process was for the assigned staff to remain outside with residents during an outing or during smoke breaks. SS stated the residents should not be left alone when being outside. SS stated Resident 3 should not have been left outside unsupervised due to the potential for elopement that could have led to injury or accidents.During an interview on 3/34/26 at 1:37 p.m. with the Clinical Coach (CC) the CC stated Resident 3 had eloped from the facility on 3/21/26. The CC stated Resident 3 was left outside without supervision during a smoke break. The CC stated that according to the facility's investigation, Resident 3 was left outside without supervision for approximately 10-15 minutes. The CC stated the facility process was for the staff to monitor and remain with residents when residents were outside, especially during smoking breaks to ensure resident safety.During an interview on 3/24/26 at 1:51 p.m. with the AD, the AD stated it was the facility process for all residents to be monitored during outings and smoking breaks. The AD stated on 3/21/26, Resident 3 was left outside by LVN 3 unsupervised during a smoking break. The AD stated Resident 3 should not have been left outside unsupervised due to the high risk for elopement and for safety. The AD stated the facility had a designated smoking area with designated smoking times that should have been followed on 3/21/26. The AD stated the front of the facility where Resident 3 was left was not a designated smoking area. The AD stated it was important to follow the facility's process to ensure all residents were safe and monitored.During an interview on 3/24/26 at 2:05 p.m. with LVN 2, LVN 2 stated that on 3/21/26, Resident 3 was left unsupervised outside the front door by LVN 3 during a smoking break. LVN 2 stated the front door area was not a designated smoking area and Resident 3 should have been redirected by LVN 3. LVN 2 stated the facility staff should monitor all residents that were outside especially the residents who were a high risk for falls an elopement. LVN 2 stated residents should not have been left unattended and unsupervised at any moment during an outing or smoking break. LVN 2 stated there was a safety concern for residents left unattended due to the potential for falls, injury or elopement.During an interview on 3/24/26 at 2:50 p.m. with the administrator (ADM), the ADM stated the expectation was for the facility staff to follow all policy and procedures which included monitoring of residents during smoke breaks. The ADM stated that no residents should have been left alone during smoking breaks due to the safety concerns. During an attempted telephone interview on 3/24/26 at 4:30 p.m. with LVN 3, LVN 3 was called with several attempts for interview, messages were left requesting call back but were unsuccessful.During a record review of the facility's policy and procedure (P&P) titled, .Abuse Prevention and Response Policy, undated, the P&P indicated, Purpose: To ensure the safety, dignity, and well-being of all residents by preventing, identifying, reporting, and responding to all forms of abuse, neglect, mistreatment, and exploitation within the facility. Policy Statement: This facility maintains a zero-tolerance policy for abuse, neglect, exploitation, or mistreatment of residents. All staff, contractors, volunteers, and visitors are required to uphold this policy and report any suspected or alleged incidents immediately. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress. Reporting Requirements. staff must not delay reporting to conduct their own investigation. Response and Investigation, Ensure immediate protection of the resident, including medical care if needed. All allegations, observations, and actions taken must be documented promptly and accurately. Records must include dates, times, individuals involved, and actions taken. Residents have the right to be free from abuse, neglect, exploitation, and mistreatment. Residents and families will be informed of these rights upon admission and throughout their stay.

Based on interview and record review, the facility failed to ensure violations involving abuse were reported for one of three sampled residents (Resident 1) when facility staff did not report an allegation of abuse for Resident 1's report of sexual abuse involving Resident 2 touching her breast without consent.This failure placed Resident 1 safety at risk and there was potential for further abuse.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE].During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/26/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE].During a review of Resident 2's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/5/26, the MDS indicated, Resident 2's Brief Interview for Mental Status score was 4 out of 15 which indicated Resident 2. During a telephone interview on 3/24/26 at 8:50 a.m. with the administrator (ADM), the ADM stated that on 3/12/26, he was informed by facility staff that Resident 1 had reported an incident involving Resident 2 inappropriately touching Resident 1's breast. The ADM stated that on 3/12/26, an investigation was initiated to gather more information regarding the incident. The ADM stated that during the investigation Resident 1 had requested the incident not be reported to any authorities. The ADM stated that based on Resident 1's request the incident was not reported to state agency and instead was only reported to law enforcement.During an interview on 3/24/26 at 11:20 a.m. with CNA 1, CNA 1 stated it was the facility process to report and investigate sexual abuse or any forms of abuse allegation immediately to ensure all residents were safe. CNA 1 stated it was important to report and investigate sexual abuse allegations to prevent further abuse and to protect Resident 1 from any distress.During a concurrent interview and record review on 3/24/26 at 12:13 p.m. with licensed vocational nurse (LVN) 1, the facility document titled, Report of Suspected Dependent Adult/Elder Abuse, undated, was reviewed. The facility document indicated, . This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. Abuse means any treatment with resulting physical harm, pain, or mental suffering or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering. Any mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting abuse or neglect, or reasonably suspects that abuse or neglect has occurred, shall complete this form for each report of known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult immediately or as soon as practicably possible. LVN 1 stated the facility process for an allegation of abuse was for the allegation to have been reported immediately using the Report of Suspected Dependent Adult/Elder Abuse document. LVN 1 stated Resident 1 had reported that during a mutual hug with Resident 2, Resident 2 touched both of Resident 1's breast without consent. Resident 1's report of alleged sexual abuse should have been reported immediately to ensure Resident 1 was separated from Resident 2 and safe from any potential abuse.During an interview on 3/24/26 at 12:55 p.m. with Resident 1, Resident 1 stated she recalled an incident that involved Resident 2 inappropriately touching both her breast. Resident 1 stated she could not recall the date of the incident but did recall Resident 2 requesting a hug from Resident 1 as she was attempting to walk away. Resident continued to state, Resident 2 would not allow her to walk through the hallway therefore Resident 1 agreed to give Resident 2 a hug. Resident 1 stated that as she pulled away from Resident 2, Resident 2 slid his hand over both of Resident 1's breast. Resident 1 stated she immediately yelled at Resident 2 and informed him that the action was inappropriate. Resident 1 stated she felt violated as the action from Resident 2 touching her breast felt intentional. Resident 1 stated she felt safe in the facility only after she informed the staff herself of the situation.During an interview on 3/24/26 at 1:22 p.m. with the social services director (SSD) the SSD stated that on 3/12/26, Resident 1 reported that Resident 2 had touched her breast without consent. The SSD stated that Resident 1 requested the SSD to not report the incident outside of the facility. The SSD stated the incident was not reported as per facility policy. The SSD stated all staff in the facility were mandated reporters and the allegation of sexual abuse that Resident 1 had reported should have been reported immediately.During an interview on 3/24/26 at 1:37 p.m. with the clinical coach (CC), the CC stated the facility process for an allegation of abuse was for staff to ensure safety, separate the residents, and report it immediately. The CC stated it was important to report allegations of abuse to ensure the residents were safe and to prevent further abuse.During an interview on 3/24/26 at 2:50 p.m. with the ADM, the ADM stated the facility process was for an abuse allegation included reporting the incident immediately. The ADM stated the expectation was for staff to follow all policies.During a record review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, . Our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Our facility will report the following events to appropriate agencies. allegations of abuse, neglect. unusual occurrences shall be reported via telephone to appropriate agencies as required as required.

Based on interview and record review the facility failed to meet professional standards of practice and follow the policy and procedure titled, Nursing Assessment and Management of Residents Following a Fall, for one of three sampled residents (Resident 1), when LVN 1, CNA 1 and CNA 2 observed Resident 1 on 1/16/26 exhibit restless and anxious behavior, exit seeking behavior and wheeling herself into other resident rooms trying to get into their beds. LVN 1 did not assess the situation, did not assess Resident 1 at the time of the behaviors and did not notify the physician to provide instructions on how to address Resident 1. Instead, LVN 1 instructed CNA 1 and CNA 2 to put Resident 1 to bed and Resident 1 was found on the hallway floor outside her room [ROOM NUMBER] minutes later. LVN 1 did not assess Resident 1 following the unwitnessed fall on 1/16/26 and instead instructed CNA 1 and CNA 2 to transfer Resident 1 back to bed. Once Resident 1 was in bed, LVN 1 did not complete a full head to toe assessment following the fall. These failures resulted in not recognizing and acting appropriately on a change of condition, not taking the opportunity to conduct a physical assessment of Resident 1, not obtaining physician input on how to address the change of condition. These failures led to Resident 1 falling from her bed, a delay in assessing possible injuries from the fall. On 1/17/26 X-rays of the hand indicated there was a fracture to the left 5th metacarpal bone (the long bone in the hand located on the pinky finger side, forming part of the palm and connecting the wrist). Subsequently, Resident 1 was transported to the acute care hospital.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for history of falling Anxiety Disorder, Dementia (a condition with persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), cognitive communication deficit (an impairment in communication).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/18/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 5 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During an interview on 1/28/26 at 11:38 a.m. with CNA 1, CNA 1 stated that on 1/16/26, she was assigned to care for Resident 1. CNA 1 stated Resident 1 was observed restless and anxious wheeling herself in her wheelchair around the facility, which had been out of her normal behavior. CNA 1 stated LVN 1 requested Resident 1 be taken to Resident 1's room and assisted to bed. CNA 1 stated she felt it was unsafe to lay Resident 1 on her bed due to the anxious and restless behavior that could have caused Resident 1 to fall. CNA 1 stated Resident 1 was assisted back to bed where she remained awake and observed fidgeting with the bed remote and call light. CNA 1 stated that Resident 1 was found sitting on the hallway floor outside her room between fifteen to twenty minutes after she had been assisted back to bed. CNA 1 stated LVN 1 instructed CNA 1 and CNA 2 to transfer Resident 1 from the hallway floor to the bed prior to LVN 1 completing an initial assessment of Resident 1 following her fall. CNA 1 stated the facility process was for the nurse to assess and check residents for any injuries prior to residents being moved or transferred.During an interview on 1/28/26 at 11:54 a.m. with CNA 2, CNA 2 stated that on 1/16/26, Resident 1 was observed restless and anxious, which had been out of her normal behavior. CNA 2 stated LVN 1 told CNA 1 to assist Resident 1 to bed even though she was restless. CNA 2 stated she had informed LVN 1 that Resident 1 had the potential to fall if she was assisted back to bed. CNA 2 stated LVN 1 had insisted CNA 1 and CNA 2 assist Resident 1 to bed. CNA 2 stated CNA 1 assisted Resident 1 back to bed as requested by LVN 1. CNA 2 stated she assisted CNA 1 with another resident for approximately 20 to 30 minutes before both CNA 1 and CNA 2 found Resident 1 sitting on the floor in the hallway outside Resident 1's room. CNA 2 stated LVN 1 was standing in the hallway and ordered CNA 1 and CNA 2 to pick up Resident 1 from the floor and assist her to bed. CNA 2 stated LVN 1 did not assess Resident 1 prior to Resident 1 being moved and assisted back to bed following the fall. CNA 2 stated that once Resident 1 was in bed, LVN 1 went into the room and assessed Resident 1 for a few seconds then left the room. CNA 2 stated the facility process when there was a resident fall was to report the incident immediately to the nurse, then the nurse was supposed to assess the resident. Then the LVN would instruct the CNA's present when to move and transfer the resident safely. CNA 2 stated there was a risk for injury or further injury when Resident 1 was moved without LVN 1's assessment following the incident on 1/16/26.During a review of Resident 1's document titled, Progress Note, dated 1/16/26, the progress note indicated, . At 4:30 p.m. writer was notified that resident was on the ground in resident's room. Upon entering resident's room, resident was observed to be sitting upright on her bottom near the foot of her bed. Resident noted to be self-propelling through halls during the day and was attempting to lay in residents' beds that were not her own. Resident was laid down in her own bed approximately 30 minutes prior to being observed on the ground. The progress note indicated Resident 1 was exhibiting unsafe behaviors while attempting to self-transfer to other resident's beds. During a review of Resident 1's, Cognitive Impairment Care Plan, the care plan indicated, [Resident 1] exhibits cognitive impairments as evidenced by periods of poor recall. Goal. [Resident 1] will be able to be redirected/reoriented to situation daily. Interventions. Explain cares to [Resident 1] before and during, involve family as needed, keep daily routine as consistent as possible, reassure [Resident 1] as needed if confused, reorient [Resident 1] to situation as needed.During a review of Resident 1's document titled, Situation, Background, Assessment & Review/Recommendation (SBAR), dated 1/16/26, the SBAR indicated, . The change in condition reported on this change in condition evaluation are/were: falls. outcomes of physical assessment. mental status evaluation, no changes observed. skin status evaluation, no changes observed. nursing observations, evaluation, and recommendations are, Resident had unwitnessed fall in room, no injuries noted. Bed was in lowest position; resident was displaying anxious behaviors throughout shift and redirected multiple times. The SBAR indicated Resident 1 was exhibiting anxious behaviors that required staff interventions and redirection throughout the day on 1/16/26.During a review of Resident 1's document titled, SBAR Post Fall, dated 1/16/26 6:58 p.m., the SBAR indicated, . Situation, I am contacting you [Physician]about a fall the above resident experienced. Prior to fall resident was, Attempt to self-transfer. Fall risk factors: Impaired safety awareness/judgment. Risk for falls. total score greater than 10 resident is considered at risk for falls: 10, at risk for falls: Yes. The SBAR indicated, LVN 1 had notified the physician of the fall that occurred on 1/16/26, when Resident 1 was observed sitting in the hallway outside of her room. The SBAR indicated, Resident 1 was exhibiting behaviors of self-transferring self and was at risk for falls.During an interview on 1/28/26 at 12:15 p.m. director of staff development (DSD), the DSD stated the facility expectation when there was a fall or incident was for the nurse to assess the resident for injury prior to the CNAs moving or transferring the resident. The DSD stated it was important for the nurse to complete a thorough assessment of the residents immediately following a fall to identify any injuries and prevent further injury.During a telephone interview on 2/3/26 at 3:30 p.m. with LVN 1, LVN 1 stated that on 1/16/26, she was assigned to Resident 1. LVN 1 stated Resident 1 was found sitting on the hallway floor outside Resident 1's room on 1/16/26. LVN 1 stated that on this day, Resident 1 was observed with restless behaviors and appeared anxious as Resident 1 was exit seeking, propelling self, down the hallways in her wheelchair and not wanting to lie down as she normally would do after meals. LVN 1 stated Resident was also seen going into other resident rooms and attempting to self-transfer onto other resident beds. LVN 1 stated she asked CNA 1 and CNA 2 to assist Resident 1 back to bed as LVN 1 assumed Resident 1 was tired when she was attempting to self-transfer. LVN 1 stated Resident 1's behavior was different on 1/16/26, but no assessment was completed to attempt to identify cause. LVN 1 stated that approximately 20 to 30 minutes after LVN 1 had requested CNA 1 and CNA 2 assist Resident 1 back to bed, CNA 1 and CNA 2 were walking down the hall when they informed LVN 1 that Resident 1 was sitting on the hallway floor. LVN 1 stated when she arrived in Resident 1's room, CNA 1 and CNA 2 had transferred Resident 1 from the hallway floor to bed. LVN 1 stated due to CNA 1 and CNA 2 transferring Resident 1 back to bed following the fall, LVN 1 did not complete an assessment of Resident 1 or assessed Resident 1 for injuries. LVN 1 stated, once Resident 1 was assisted back to bed, LVN 1 completed a quick objective assessment that included visible skin, vitals and observation of Resident 1 moving extremities. LVN 1 stated a thorough complete assessment was not completed following the fall because LVN 1 had to attend to other obligations. LVN 1 stated she should have completed the assessment immediately after Resident 1 was observed on the hallway floor, but felt from what was observed, Resident 1 did not have any changes. LVN 1 stated the assessment was quick and was in and out of Resident 1's room. LVN 1 stated the facility process was for the nurse to assess the resident first before the resident was moved or transferred and to complete an accurate assessment of Resident 1 to ensure no injuries were missed. LVN 1 stated her lack of assessment to identify the changes in behavior could have contributed to Resident 1's fall on 1/16/26. LVN 1 stated it was important to follow the facility process because there was a potential for injury or further injury to Resident 1.During a review of Resident 1's document titled, Progress Note, dated 1/17/26 at 6:37 a.m., the progress note indicated, . Resident is up in wheelchair and sitting in lobby, writer notices bruise to top of left outer palm and top of left hand. Resident able to move all digits of left hand without grimacing or stating pain. The Progress note indicated that Resident 1 had an injury to the left hand that was not identified by LVN 1 on 1/16/26.During a review of Resident 1's document titled, Progress Note, dated 1/17/26 at 11:11 a.m., the progress note indicated, . [Physician] notified, order received for x-ray to left hand and wrist.During a review of Resident 1's document titled, Order Summary Report, dated 1/17/26, the order summary indicated, . May have x-ray to left hand and wrist related to unwitnessed fall.During a review of Resident 1's document titled, Radiology Report, dated 1/17/26, the report indicated, . Hand two views, left, Results: there is a fracture involving the 5th metacarpal shaft with minimal displacement. There is associated soft tissue swelling. Wrist two view left. Conclusion: no fracture seen. The progress note indicated that Resident 1 had a fracture/injury to the left hand that was not identified on the day of the fall on 1/16/26.During a review of Resident 1's document titled, SBAR, dated 1/17/26, the SBAR indicated, . The change in condition reported on this change in condition evaluation are/were: other changes in condition. nursing observations, evaluation, and recommendations are [Radiology company name] reported fracture to left wrist, resident had unwitnessed fall on 1/16/26 delayed injury noted to left wrist. Writer notified [Physician], [Physician] gave an order to send resident out to acute care for further evaluation and left-hand fracture. The SBAR indicated that Resident 1's physician was notified of Resident 1's injury to the left hand and the physician gave new order to transfer Resident 1 to the acute hospital for further evaluation.During a review of Resident 1's hospital record titled, Emergency Department (ED) Notes, dated 1/17/26, the record indicated, . [Resident 1] with bruising with purple discoloration to left hand, per staff, patient had ground level fall yesterday without complaint (around noon yesterday), but today she had discoloration, [physician] for facility called for x-ray and per staff, x-ray showed a broken hand.During an interview on 2/4/26 at 8:57 a.m. with the director of nursing (DON), the DON stated the facility expectation was for the nurse to assess residents when there was a change in behavior or a fall. The DON stated LVN 1 should have assessed Resident 1 prior to the fall when Resident 1 was exhibiting changes in behaviors. The DON stated LVN 1 should have been more aggressive with the assessment process and should have assessed Resident 1 before the fall and immediately following the incident on 1/16/26. The DON stated LVN 1 should have identified Resident 1's change in behavior, should have called the physician and put interventions in place according to the assessment findings to keep Resident 1safe. The DON stated LVN 1 should have assessed Resident 1 while Resident 1 was still on the floor prior to being transferred by CNA 1 and CNA 2 back to bed following the fall, but LVN 1 did not.During a record review of the facility's policy and procedure (P&P) titled, Nursing Assessment and Management of Residents Following a Fall, undated, the P&P indicated, . Purpose: To ensure timely, thorough, and consistent nursing assessment and intervention following a resident fall in the Skilled Nursing Facility (SNF) to identify injuries, prevent complications, and maintain resident safety. This policy applies to all licensed nursing staff providing direct resident care within the Skilled Nursing Facility. Fall: An unplanned descent to the floor, ground, or extension of the floor, with or without injury. Post-Fall Assessment: A systematic nursing evaluation performed immediately after a fall to identify actual or potential injury and contributing factors. All resident falls, whether witnessed or unwitnessed and whether or not injury is apparent, require an immediate nursing assessment. The nurse is responsible for completing a comprehensive post-fall assessment, initiating appropriate interventions. Immediate Response, Ensure the resident's safety and do not move the resident until assessed, unless remaining in place presents immediate risk. Initial Nursing Assessment. Head-to-toe physical assessment with focus on: Head, neck, and spine, Extremities for deformity, swelling, bruising, or limited range of motion, Neurological assessment, including: Level of consciousness, Orientation, Speech, Pupil size and reactivity, Motor strength and sensation, Skin assessment for lacerations, abrasions, bruising, or pressure injuries. Documentation. The nurse shall document in the medical record. Resident response to interventions and ongoing monitoring. Nursing Staff: Perform assessments, initiate interventions, communicate changes in condition, and document care. Charge Nurse/Designee: Ensure appropriate follow-up and monitoring.During a review of a professional reference (PR) titled, National Library of Medicine-Nursing Process, dated 2024, the PR indicated,. The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care. the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. Assessment, The Assessment Standard of Practice is defined as, The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.10 A registered nurse uses a systematic method to collect and analyze client data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. Licensed practical/vocational nurses (LPN/VNs) assist with gathering data. Subjective data is information obtained from the client and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a client, it should be in quotation marks. Objective data is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the client. There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results. A physical examination is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a client's anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid or air are present. After nurses collect assessment data from a client, they use their nursing knowledge to analyze that data to determine if it is expected or unexpected or normal or abnormal for that client according to their age, development, and baseline status. From there, nurses determine what data is clinically relevant as they prioritize their nursing care.

Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to notify the Resident 1 of the transfer or discharge, the reasons for the move in writing and in a language and manner they understand, develop and implement an effective discharge planning process that focuses on the resident's discharge goals and after the hospitalization, the facility refused to re-admit Resident 1 in accordance with court order. This failure placed Resident 1 at risk for loss of safety, homelessness, and delay in care.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of document titled, Department of Health Care Services Office of Administrative Hearings and Appeals, dated 11/7/25, the document indicated, . The appeal is granted [Facility Name] has not met the legal requirements to involuntary discharge [Resident 1]. Therefore, facility must follow the required procedures to appropriately discharge Resident. Resident was transferred to hospital and facility refused to readmit Resident. Facility is not excused from complying with the discharge requirements. before discharging a resident, a long term care facility must provide proper notice, identify and establish a legally permissible reason for the discharge, adequately document the reasons for the discharge in the medical record, and provide sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. in this case, facility transferred Resident to hospital and has not actually discharged Resident to a location that can meet his needs. Facility must readmit Resident and find a suitable discharge location or coordinate a discharge to another location that can meet his needs. Therefore, coordinating a safe discharge does not stop in this case even though Resident is not in Facility. During a review of Resident 1's hospital note titled, Case Management Note, dated 11/10/25, the note indicated, . Social worker consulted with [Registered Nurse] and escalated barriers for discharge to [skilled nursing facilities-SNF] to Leadership team. Statewide search for long term care placement at a SNF has been sent out and there are no acceptance. [Patient] came from home with daughter and per patient, is refusing to return due to not having support. During an interview on 12/2/25 at 10:49 a.m. with the administrator (ADM), the ADM stated Resident 1 was not readmitted into the facility since the court order to readmit Resident 1 was ordered on 11/7/25. The ADM stated the facility was informed by the acute care hospital (ACH), where Resident 1 was staying, that Resident 1 would be admitted to another facility. During an interview on 12/2/25 at 12:00 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process for an unplanned discharge was for the facility to involve the assistance of the social services director (SSD). LVN 1 stated it was the SSD who would arrange to call resident or resident representative to follow up on the unplanned discharge. During an interview on 12/2/25 at 12:38 p.m. with the SSD, the SSD stated the facility had informed him of the granted appeal that ordered the facility to readmit Resident 1. The SSD stated the facility initiated a plan to readmit Resident 1 by ensuring there was a room and bed available. The SSD stated there were multiple concerns regarding Resident 1 being readmitted to the facility. The SSD stated he was informed by the ADM that Resident 1 was being transferred to another facility. During an interview on 12/2/25 at 12:58 p.m. with the ADM, the ADM stated the facility was preparing to readmit Resident 1 when the court order was received. The ADM stated there were concerns with Resident 1's return to the facility due to Resident 1's history of behaviors. The ADM stated the SSD was assisting the ACH for an alternate placement for Resident 1. The ADM stated the facility was prepared to readmit Resident 1 ensuring there was a room available within the facility and initiated in-services for all staff on caring for residents with behaviors. The ADM stated the decision to not readmit Resident 1 was decided after concerns were raised with Resident 1's behavior. The ADM stated Resident 1 was not readmitted into the facility following the court order on 11/7/25. During a phone interview on 12/3/25 at 3:11 p.m. with Resident 1, Resident 1 stated he had been discharged from the ACH and was residing with a family member. Resident 1 stated he was informed that the facility was refusing to readmit him. Resident 1 stated his preference was to return to the facility as soon as possible. Resident 1 stated he was informed by the facility that they would not be re-admitting him following the court order on 11/7/25. During a review of Resident 1's hospital note titled, Emergency Department Note- Social worker Note, dated 11/17/25, the note indicated, . Patient accepted at [Facility Name] for long term care. family unable to care for patient. [Social worker] spoke with [Family Member] patient needs to be at a care facility, family unable to care for him. [Social worker] made patient aware that he has accepting placement, at first patient was upset, because he does not want to be at a care center, stated he would rather be on the street. Patient is bed bound, unable to ambulate due to functional status. Patient made aware being on the streets in his condition would be unsafe. Patient recently was home with [family member] and [family member] was unable to care for him. The Note indicated Resident 1 was discharged from the ACH to a skilled nursing facility on 11/17/25. During a review of document tilted, Notice of Transfer Discharge, dated 11/25/25, the document indicated, . [Resident 1] being discharged because the facility cannot safely or adequately meet your clinical, psychiatric, and behavioral health needs. On November 17, 2025, you were transferred from [ACH name] to your new residence, [Facility Name & Address] . During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 12/19/22, the P&P indicated, . It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.The facility's transfer discharge notice will be provided to the resident and the resident's representative in a language and manner they can understand. the notice must be provided at least 30 days prior to a facility initiated transfer or discharge of the resident. Exceptions to the 30-day requirement. the health and safety of individuals in the facility would be endangered due to clinical or behavioral status of the resident. in these exceptional cases, the notice must be provided to the resident. and long term care Ombudsman as soon as practicable before the transfer or discharge. emergency transfers/discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. the resident will be permitted to return to the facility upon discharge from the acute care setting. in situations where the facility has decided to discharge the resident while resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to increase range of motion (the full movement potential of a joint to flex and extend in any direction) to prevent further decrease in range of motion for one of four sampled residents (Resident 1) when Resident 1 had left knee surgery on [DATE] and a knee brace (a medical device worn on the knee to support, correct, or protect the joint for functional improvement) was left on Resident 1's left leg continuously until [DATE]. The facility failed to obtain a physician order for the use of the knee brace, develop an individualized care plan for the use of the knee brace, and did not schedule a follow up orthopedic (a branch of medicine that specializes in the diagnosis, treatment, and prevention of disorders and injuries of the musculoskeletal system) appointment for Resident 1 until [DATE]. This failure resulted in the development of an equinus contracture (a condition where the ankle is stuck in a pointed-down position, limiting the ability to lift the foot upward) to Resident 1's left ankle and decreased ability to Resident 1's left knee leaving Resident 1 immobile (unable to walk) and in pain.Findings: During an observation and interview on [DATE] at 12:57 p.m. in Resident 1's room, Resident 1 was in bed having lunch. Resident 1's feet were elevated on a pillow with heel protectors (a device used to prevent skin breakdown by cushioning and offloading pressure from the heel) on both feet. Resident 1 stated she was unable to move her left leg. Resident 1 stated she had 10/10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable) pain to her left leg with motion. Resident 1 stated she fell at home and broke her left leg. Resident 1 stated she had surgery at the hospital and was getting physical therapy (a healthcare profession that aims to improve and restore physical function, reduce pain, and prevent future injuries) at the facility. During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 had a history of fracture (broken) shaft of left tibia (lower leg bone), muscle weakness, history of falling, abnormal gait (walking) and mobility, muscle wasting and atrophy (the shrinking or wasting away of an organ, tissue, or muscle), and encounter for other orthopedic aftercare. During a review of Resident 1's admission Initial Evaluation (AIE), dated [DATE], the AIE indicated, Resident 1 was admitted on [DATE] at 6:00 p.m. from [name of rehabilitation facility - a specialized institution that provides therapies and services to help individuals recover from illness, injury, or disability to regain independence and improve their quality of life]. Resident 1 had Brace to left lower leg. Resident 1 rated her pain level 8/10 to the left leg. During a review of Resident 1's Orthopedic Trauma Surgery Progress Note (OTSPN), dated [DATE], the OTSPN indicated, .Patient is now s/p (status post) left Tibia IM (intramedullary - the canal of the tibia; a surgical procedure to fix a fracture which involves inserting a metal rod or nail into the hollow center of the tibia) performed by [name of orthopedic physician] on [DATE]. Plan: Weightbearing as tolerated to the left lower extremity. Physical Therapy to assist with ambulation (walking) and use of assistive devices. All splints (knee brace) must stay on until first post-op (postoperative - after a surgical procedure) appointmentFollow-up in [name of Orthopedic Physician] office in three weeks for wound check, suture/staple removal, and x-rays (medical imaging to create detailed images of bones, joints, and internal organs) of the operative extremity. During a review of Resident 1's Orthopedic Institute Progress Notes (OIPN), dated [DATE], the OIPN indicated, . Patient was lost to follow-up (did not see the Orthopedic Physician after the surgery) and had issues getting here from the skilled nursing facility (a healthcare center providing short-term rehabilitation or long-term care for individuals who need medical supervision and assistance with daily activities). Assessment/Plan: [name of Resident 1] with a history of a mechanical level fall (a fall caused by external forces, such as tripping over an obstacle, slipping on a wet surface, or stumbling) sustaining a left proximal third tibia fracture (a break in the upper portion of the left shinbone) post intramedullary nail on [DATE] lost to follow-up. patient has developed an equinus contracture as well as decreased ability to move her knee. Patient needs aggressive physical therapy as well as her range of motion. Knee immobilizer (a brace used to keep the knee joint stable and prevent movement after an injury or surgery) is discontinued. During a review of Resident 1's [name of rehabilitation facility] History and Physical (H&P), dated [DATE], the H&P indicated, .Impression: Weight-bear as tolerated left lower extremity, immobilizer at all times. During a concurrent interview and record review of Resident 1's [name of rehabilitation facility] Patient Transfer and Referral Record (PTRR), dated [DATE], with the Director of Nursing, the PTRR indicated, . Primary diagnosis (onset): GLF (ground level fall) L (left) tibial shaft fx (fracture) s/p IM nailing on [DATE]. The Medical Orders for Continued Care: was blank. The DON stated there were no instructions on the PTRR for The Medical Orders for Continued Care. During a concurrent interview and record review of Resident 1's Care Plan Reports (CPR), undated, with the DON, the CPR indicated there was no care plan to address Resident 1's knee brace and no orthopedic post-op follow up appointment was scheduled. The DON stated there were no care plans to address Resident 1's use of the knee brace and there was no orthopedic post-op appointment made for Resident 1. During a concurrent interview and record review on [DATE] at 1:16 p.m. with the Director of Rehabilitation Services (DOR), Resident 1's Physical Therapy Evaluation (PTE), dated [DATE] was reviewed. The PTE indicated, physical therapy (PT) was recommended 5 times a week for four weeks. The DOR stated during the course of Resident 1's physical therapy treatment, weight bearing was tolerated, standing balance was poor, and there was no progress. The DOR stated Resident 1 was self-limiting meaning that Resident 1 refused many of the therapy sessions, did not fully participate during the sessions due to pain and there was no progress. The DOR stated another PTE was completed on [DATE] and PT was recommended 5 times a week for four weeks. The DOR stated Resident 1's progress was slow and was not at her prior level of functioning. The DOR stated Resident 1 was wearing the knee brace during all the PT treatment sessions. The DOR stated there was no physician order to remove the knee brace and there should have been one. The DOR stated the PTE evaluations were based on the information provided from the previous rehabilitation facility during admission. During a concurrent interview and record review on [DATE] at 9:39 p.m. with Registered Nurse (RN) 1, Resident 1's AIE, dated [DATE] was reviewed. The AIE indicated, Resident 1 was admitted on [DATE] at 6:00 p.m. from [name of rehabilitation facility]. Resident 1 had Brace to left lower leg. RN 1 stated she admitted Resident 1 on [DATE] and recalled Resident 1 had a knee brace on her left leg. RN 1 stated during the admission assessment, an admission care plan was completed but a care plan for Resident 1's knee brace was not created or implemented. RN 1 stated she should have developed a care plan for the knee brace to provide the care that was required. RN 1 stated she should have clarified the order for the knee brace with the physician for the use and frequency of the knee brace. RN 1 stated the knee brace was to immobilize the knee and to keep the knee aligned. RN 1 stated if the knee brace was on too long it can cause stiffness to a joint. RN 1 stated she was unaware Resident 1 was only supposed to keep the knee brace on for three weeks and should have seen the orthopedic specialist during this time. During an interview on [DATE] at 10:21 a.m. with [name of rehabilitation facility] Case Manager (CM), CM stated Resident 1 was admitted on [DATE] from [name of hospital] and discharged on [DATE] to the skilled nursing facility. CM stated the hospital's discharge instruction indicated Resident 1 was to wear the knee brace until the first post-op orthopedic appointment in 3 weeks and the patient or family was supposed to make the appointment. CM stated the rehabilitation facility did not ensure the follow up orthopedic appointment was made because Resident 1 was discharged before the three weeks. During an interview on [DATE] at 9:04 a.m. with the Attending Physician (AP) of the skilled nursing facility, the AP stated he saw Resident 1 on [DATE] during the admission assessment but was unable to recall a knee immobilizer on Resident 1. The AP stated the purpose of the knee brace was to prevent injuries to the knee and to keep the knee in alignment. The AP stated the long-term effect for continued use of the knee brace can cause stiffness to the knee, scar tissue to develop in the joint, and the injury will not heal. The AP stated staff need to obtain particular instructions from the transferring facility to provide the required care Resident 1 needed. The AP stated facilities need to communicate the progress of Resident 1's physical therapy and have a plan to provide the care. The AP stated staff should have contacted him to obtain instructions on use of the knee brace. The AP stated he would have instructed staff to contact the orthopedic specialist for those instructions. The AP stated it was standard of practice to follow the specialist's recommendation after an orthopedic procedure. During an interview on [DATE] at 10:04 a.m. with the DOR, The DOR stated the rehabilitation department did not require or request additional information from the transferring facility because it was a nursing responsibility. The DOR stated there was enough information to evaluate Resident 1 and to recommend a PT plan. The DOR stated range of motion exercises was provided during the therapy sessions, but Resident 1 was self-limiting which did not advance her ability. The DOR stated the purpose of the knee brace was to remind staff and the patient not to move the knee and provide stability to the knee. The DOR stated long term use of the knee brace can have negative effects on the knee causing joint stiffness. During an interview on [DATE] at 11:25 a.m. with the Director of Nursing (DON), the DON stated the purpose of the knee brace was to provide stability after surgery and long-term effects of keeping the brace on which can cause stiffness to the joint. The DON stated it was standard of practice to contact the physician for the use of the knee brace to develop a resident centered care plan to provide the range of motion service Resident 1 required. The DON stated the miscommunication of important information between the hospital, the rehabilitation facility and the skilled nursing facility contributed to the failure to address the use of Resident 1's knee brace and failure to schedule a three-week post-op appointment for Resident 1 was unacceptable. During an interview on [DATE] at 12:14 p.m. with the Administrator (ADM), ADM stated the rehabilitation department assessed Resident 1 during the admission process, evaluated and recommended PT treatment. The ADM stated the discharge packet from the transferring rehabilitation facility did not address the use of the knee brace. The ADM stated it was nursing's responsibility to contact the physician, care plan the use of the knee brace, and share the information with the Interdisciplinary Team (IDT - a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of the resident). The ADM stated each department had a scope of practice, PT determines immobilization, nursing coordinates all care areas as an IDT and develop care plans, and the physician oversees the care of residents and write orders. The ADM stated the miscommunication of important information between the hospital, the rehabilitation facility and the skilled nursing facility contributed to the failure to address the use of Resident 1's knee brace and failure to schedule a three-week post-op appointment for Resident 1 was unacceptable. During an interview on [DATE] at 5:44 p.m. with the Orthopedic Physician (OP), the OP stated she did not see Resident 1 until [DATE]. The OP stated a general two-to-three-week post-op appointment was required to assess the wound and to remove the knee brace or immobilizer at the first appointment. The OP stated there was a break at the top of Resident 1's knee joint and an incision was made around knee joint to insert a rod to stabilize the tibia. The OP stated the purpose of the knee brace was to help with the acute swelling phase (the initial stage of the body's response to an injury or infection, typically lasting two to four days), to prevent bending of the joints, and should be removed two to three weeks post-op and start physical therapy with range of motion exercises. The OP stated when she saw Resident 1 on [DATE] Resident 1 had developed significant scar tissues to the left ankle called an equinus contracture to where Resident 1 would not allow the OP to touch because of the pain. The OP stated the transferring facility and receiving facility missed opportunities to communicate important information for the care of Resident 1. The OP stated the receiving physical therapy department could have reached out and update the OP of the progress of Resident 1. The OP stated she would have brought Resident 1 in sooner to assess and make recommendations. The OP stated it was not acceptable to leave the knee brace on for two and a half months without orthopedic follow up. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated [DATE], the P&P indicated, .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. During a professional reference review retrieved from https://newwestsportsmedicine.com/wp-content/uploads/2023/07/tibial-nail-surgery-rehab-protocol.pdf titled, Tibial Nail Surgery Rehab Protocol, retrieved on [DATE], the professional reference indicated, 0 2 weeks: Non weightbearing or toe touch weightbearing (a partial weight-bearing restriction where only the toes of the injured or operated leg can lightly touch the ground for balance, while the majority of the body's weight is supported by an assistive device like crutches) on operative leg. Postop splint (knee brace) in place. Encourage knee and hip ROM (range of motion). 2 4 weeks: Non weightbearing or toe touch weightbearing on operative leg. CAM boot (Controlled Ankle Motion - a type of walking boot or orthopedic boot used to immobilize and protect the foot and ankle after an injury or surgery) to be worn except with exercises or showering. ROM home exercises. 4 6 weeks: Non weightbearing on operative leg. CAM boot to be worn except with exercises or showering. Ankle and knee ROM encouraged. Gentle non weightbearing strengthening exercises may start at 4 weeks if ROM regained. PT starts 2 3/week for 6 8 weeks. 6 12 Weeks: WBAT (weight bearing as tolerated) in CAM boot starting at 6 weeks for most fractures. Strengthening, proprioception (the body's ability to sense its position, movement, and orientation in space through stimuli originating from within the body itself), quadriceps (large front thigh muscle) strengthening. Continue PT 2 3/weeks. 12+ Weeks: Typically wean out of CAM boot. Continue strengthening exercises as needed. Formal PT depends on patient progress.

Based on observation, interview and record review, the facility failed to ensure resident environment remained free from accident hazards and that residents received assistance devices to prevent accidents for one of seven sampled residents (Resident 1) when nursing staff were aware Certified Nursing Assistant (CNA)s used a regular wheelchair to transport Resident 1 over an elevated threshold (a strip of wood, metal, or stone forming the bottom of a doorway) to the smoking area, CNA 5 wheeled Resident 1's wheelchair pulling him backwards in order to get Resident 1 over the threshold and tilted, causing Resident 1 to fall back. Nursing staff did not evaluate the hazardous nature of the path of travel or the unsafe technique to tilt the wheelchair. Nursing staff did not consider a physical therapy evaluation for a new wheelchair with anti-tilt bars.These failures resulted in the unsafe practice of transporting Resident 1 which caused an avoidable accident on 7/25/25, Resident 1 struck the back of his head onto the concrete floor, suffering avoidable pain and injury to his neck.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the fire escape door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated the wheelchair went backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture. Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident1's, Situation, Background, Assessment and Recommendation (SBAR) Post Fall, dated 7/25/25, the SBAR indicated, . Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The documentation indicated Resident 1 fell in the hallway, but findings indicated Resident 1 experienced a fall going through the fire escape door.During a review of Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals (indicators that reflect a person's basic body functions and overall health), just wanted smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 1's, SBAR Post Fall, dated 7/25/25, Progress Note (PN), dated 7/25/25 at 9:50 a.m., SBAR dated 7/25/25 and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, .Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The Radiology Result Report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. with LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in going through the fire escape door. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause of the fall and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain). The progress note indicated Resident 1 was reporting increased pain related to the fall on 7/25/25 and was not given the correct information regarding the x-ray results obtained.During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Progress Note, dated 7/25/25 at 9:50 a.m. and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . Prior to fall [Resident 1] was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology results report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be excluded until the x-ray results were obtained for Resident 1.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain was located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury to his neck and back due to a medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., the therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs .During a concurrent telephone interview and record review on 9/11/25 at 1:15 p.m. with the director of rehab (DOR), Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., was reviewed. The therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs . The DOR stated Resident 1's recommended wheelchair was supposed to be used by Resident 1 beginning 7/25/25, but another resident in the facility was mistakenly sat on the wheelchair and it needed to be washed. The DOR stated the recommendation was given due to Resident 1 requesting a better wheelchair. The DOR stated that based on her visual assessment she did not like the way the previous original wheelchair looked and agreed to recommend a better wheelchair. When asked to elaborate on what constituted she did not like how the wheelchair looked, the DOR stated she . Just didn't like the way it looked . The DOR stated Resident 1 was not under her services, but it was something she observed and recommended a new wheelchair.During an interview on 9/12/25 at 10:42 a.m. with the administrator (ADM), the ADM stated Resident 1 had a fall on 7/25/25 when CNA 5 was backing him out through the fire escape door by his room. The ADM stated the general practice in the facility was not to tilt the wheelchairs. The ADM stated he was unaware if Resident 1's path to go outside had not been assessed for safety.During an interview on 9/12/25 at 11:17 a.m. with the DOR, the DOR stated that Resident 1's path was not assessed prior to the fall on 7/25/25 because it was a supervised path with staff having to push Resident 1 outside. The DOR stated, it was Resident 1's preference to utilize the fire escape door to enter and exit the facility when attending his smoke breaks. The DOR stated it was the staff taking Resident 1 outside, decision to determine if the wheelchair needed to be tilted or if they needed to pull Resident 1 backwards to get through the door. The DOR stated the fire escape door that Resident 1 was using, was not meant for daily access therefore it was not equipped to get Resident 1 outside safely. The DOR stated that ultimately if the staff member determined the safest way to get Resident 1 outside was to pull him backwards and tilt the wheelchair to keep him from falling, then that was the best way.During an interview on 9/12/25 at 11:23 a.m. with LVN 2, LVN 2 stated Resident 1 was being assisted outside by the staff on 7/25/25. LVN 2 stated the CNA 5 was pulling Resident 1 backwards going outside, once the threshold was passed, the concrete was slanted down. LVN 2 stated Resident 1's wheelchair wasn't tilted by the CNA 5 at the time of fall but rather the wheelchair tilted backwards during the path outside. LVN 2 stated the CNAs, and all staff members knew not to pull any residents into the facility backwards as LVN 2 had repeatedly informed the facility staff regarding this practice. LVN 2 stated Resident 1 had used that door every time he went outside and was not informed by anyone in the facility that the fire escape door could not be used.During a concurrent observation and interview on 9/12/25 at 12:07 p.m. with Resident 1, Resident 1's wheelchair located in Resident 1's room was observed, the wheelchair appeared new with anti-tilt bars located on the back of the wheelchair next to the wheels. Resident 1 stated staff would use the fire escape door before and at the time of the fall to take him outside for smoking breaks because it was wider and could fit his wheelchair without risk of injury. Resident 1 stated he was not pulled backwards all the time it was certain staff that would do that. Resident 1 stated he had requested a new wheelchair because the wheelchair that was given to him was not safe and would sometimes tilt, which he informed the facility staff of the issues. Resident 1 stated since the wheelchair was already tilting on its own, when the staff member took him outside on 7/25/25, the concrete going downhill caused the wheelchair to completely hit the ground backwards. Resident 1 stated the motion of pulling the wheelchair backwards could have caused the wheelchair to tilt backwards.During an interview on 9/12/25 at 1:20 p.m. with the minimum data set nurse (MDS), the MDS nurse stated Resident 1 had used the fire escape door when he was given a bigger wheelchair. The MDS nurse stated the facility made an exception to allow Resident 1 to use the fire escape door because it was a wider door for the wheelchair being used at the time of admission. The MDS nurse stated after Resident 1 received a new manual wheelchair that would fit through the designated resident door leading outside, Resident 1 continued to use the fire escape door. The MDS nurse stated the path leading outside was never assessed for safety.During an interview on 9/16/25 at 1:32 p.m. with the DON, the DON stated on 7/25/25 Resident 1 was being wheeled out by CNA 5 when he fell. The DON stated CNA 5 lost control of the wheelchair causing Resident 1 to fall going through the fire escape door. The DON stated the wheelchair itself was safer going backwards due to the risk of Resident 1's wheelchair bumping the threshold that would have caused him to go forward. The DON stated it was safer to use the designated resident door that all residents in the facility used because it had rails and the concrete wasn't made to go downward.During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, undated, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. a fall is defined as unintentionally coming to rest on the ground, floor or other lower level.During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents for one of five sampled residents, (Resident 1), when Resident 1 suffered a head and neck injury on 7/25/25, nursing staff did not assess Resident 1's pain, administer medications to effectively address the pain in accordance with professional standards of practice and the facility's policy and procedure Pain Management. On 7/25/25, staff tilted Resident 1's wheelchair backward in order to transport Resident 1 to the smoking area and Resident 1 fell backward, striking his head onto the concrete ground. Afterwards, Resident 1 complained of head and neck pain that radiated to the right side and nurses did not effectively treat the pain.These failures resulted in Resident 1 feeling unheard of, experiencing avoidable uncontrolled and unmanaged pain due to delay in assessment and treatment following the fall on 7/25/25.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status [BIMS screening tool used to assess resident cognitive (understanding through thought, experience and senses) level] score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the back door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated he fell backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor and offered to transfer him to the acute care hospital, but Resident 1 stated he refused. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture (break in a bone). Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident 1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall Interdisciplinary team (IDT- consisting of nurses, physician, resident and other members of the health team to discuss and plan resident treatment plan), dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Order Summary Report, dated 7/26/25, the order summary indicated, Oxycodone-Acetaminophen/APAP (medication with high risk for addiction and dependence used to treat moderate to severe pain) tablet 10-325 mg . give 1 tablet every 8 hours as needed for pain for 30 days. discontinued date 8/11/25. The order summary indicated Resident 1 had an as needed pain medication available for 15 days following the fall on 7/25/25.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The note indicated Resident 1 had verbalized medication was not managing his pain effectively after the fall on 7/25/25.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a concurrent interview and record review on 8/29/25 at 10:33 a.m. with LVN 1, Resident 1's electronic medical record (EMR) for, Pain Levels, dated 7/26/25-8/25/25, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 1 stated the EMR for pain levels indicated Resident 1 complained of pain: 10/10 on 7/26/25 at 3:09 p.m. and 9/10 pain at 9:21 p.m. 9/10 p.m.7/28/25: 7:45 p.m. 10/10 pain, 7:45 p.m. 9/10 pain7/29/25: 1:31 p.m. & 9:06 p.m. 8/10 pain7/30/25: 12:45 a.m. 7/10 pain7/31/25: 9:57 a.m. & 3:00 p.m. 6/10 pain8/1/25: 2:22 p.m. 9/10 pain, 6:35 p.m. 10/10 pain8/4/25: 9:19 a.m. 9/10 pain8/7/25: 5:22 p.m. 9/10 pain8/8/25: 2:00 p.m. 9/10 pain, 5:31 p.m. 9/10 pain8/9/25: 11:55 a.m. 9/10 pain8/10/25: 11:03 p.m. 8/10 pain8/11/25: 6:05 p.m. 8/10 pain8/12/25: 9:54 a.m. 8/10 pain8/13/25: 3:36 a.m. 8/10 pain8/14/25: 9:13 a.m. & 3:00 p.m. 8/10 pain8/15/25: 10:19 a.m. & 2:32 p.m. 8/10 pain8/16/25: 10:01 a.m. & 4:15 p.m. 8/10 pain8/17/25: 10:12 p.m. 8/10 pain8/18/25: 10:57 p.m. 8/10 pain8/19/25: 8:28 a.m. & 12:54 p.m. & 5:05 p.m. & 11:15 p.m. 8/10 pain8/20/25: 8:02 a.m. & 4:03 p.m. 8/10 pain8/21/25: 12:42 p.m. & 4:43 p.m. 8/10 pain8/22/25: 6:05 a.m. 5/10 pain8/23/25: 4:08 p.m. 6/10 pain8/25/25: 12:05 a.m. 9/10 pain . LVN 1 stated Resident 1 pain levels averaged at an 8/10 pain based on the EMR pain levels reviewed. LVN 1 stated when Resident 1 complained of medication ineffectiveness and increased pain, it was the facility expectation that the nurse would complete an assessment to identify Resident 1's pain and severity, notify the physician and document. LVN 1 stated that based on the record review, Resident 1's pain was not effectively managed following the fall on 7/25/25.During a review of Resident 1's, Medication Administration Record (MAR), dated 7/2025 and 8/2025, the MAR indicated, . Oxycodone-Acetaminophen/APAP tablet 10-325 mg, administered:7/27/25: 3:47 p.m. Medication Effective No pain level.7/28/25: 7:45 p.m. Medication Ineffective pain level 9/10.7/29/25: 1:31 p.m. Medication Effective pain level 8/10.8/1/25: 2:22 p.m. Medication Effective pain level 9/10.8/2/25: 2:50 a.m. & 8:16 p.m. Medication Effective pain level 5/10.8/3/25: 12:10p.m. Medication Effective pain level 8/10.8/4/25: 1:19 a.m. Medication Effective pain level 7/10, 9:19 a.m. Effective pain level 9/10.8/5/25: 2:00 a.m. Medication Effective pain level 7/10.8/6/25: 5:59 a.m. Medication Effective pain level 7/10.8/7/25: 11:55 a.m. Medication Effective pain level 8/10.8/8/25: 8:43 a.m. Medication Effective pain level 9/10.8/9/25: 11:55 a.m. Medication Effective pain level 9/10.8/10/25: 9:57 p.m. Medication Effective pain level 7/10.8/11/25: 6:26 a.m. Medication Effective pain level 7/10, 3:20 p.m. Medication Unknown Effectiveness pain level 7/10. The MAR indicated Resident 1's pain medication was administered for pain and the follow up with the medication effectiveness was documented as medication was effective in managing Resident 1's pain even though Resident 1's pain levels reached 7/10-9/10.During a concurrent interview and record review on 8/29/25 at 11:12 a.m. with the DON, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The DON stated Resident 1's medication for pain was ineffective. The DON stated Resident 1's cervical x-ray had unknown results and therefore could not rule out an injury that could have caused Resident 1's increased pain. The DON stated the facility expectation was for the facility staff to inform the physician of findings regarding increased pain in order to achieve proper pain management for Resident 1 which was not done.During a concurrent interview and record review on 8/29/25 at 11:20 a.m. with LVN 2, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 2 stated, Resident had complained of 10/10 pain to his back during the day. LVN 2 stated Resident 1's pain levels ranged between 8-10/10 pain on a daily basis. LVN 2 stated the progress notes indicated Resident 1 was experiencing an increase in pain with unrelieved pain with medications ordered. LVN 2 stated the facility process was to complete an assessment of Resident 1, document in the EMR, and notify the physician of Resident 1's ineffective pain medication and increased pain. LVN 2 stated Resident 1's pain was not properly managed following the fall on 7/25/25.During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated, 9/2/22, the P&P indicated, . The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. the facility will Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon. a significant change in condition or status occurs. Manage or prevent pain, consistent with. current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident. Identifying key characteristics of the pain, Duration of pain, Frequency, Location, Timing, Pattern (e.g. constant or intermittent), Radiation of pain, Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms). The resident's goals for pain management and his/her satisfaction with the current level of pain control. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion .

Based on observation, interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of five sampled residents (Resident 1), when the facility staff did not complete documentation of Resident 1's fall or possible injuries and did not follow up with cervical (neck) x-ray results for three weeks following Resident 1's fall on 7/25/25.This failure resulted in delay in assessment and treatment for Resident 1 due to a potential injury following the fall on 7/25/25.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1, Resident 1 was observed sitting up in wheelchair and appeared to limit movements with arms and neck. Resident 1 stated that on 7/25/254, staff were wheeling him out to the courtyard using the backdoor. Resident 1 stated that for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated he fell backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor and offered to transfer him to the acute care hospital, but Resident 1 stated he refused. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture. Resident 1 stated the pain did not go away due to a previous medical procedure but stated the pain had been felt at all times since the fall.During a review of Resident1's, Situation, Background, Assessment and Recommendation (SBAR) Post Fall, dated 7/25/25, the SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations.During a review of Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated that after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in the hallway. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. The DON stated all nurses in the facility should have followed the process for documenting including the full completion of Resident 1's SBAR and progress note. The DON stated the nurses had been educated on the importance of complete and accurate documentation in the facility.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area, had now exacerbated since the fall. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated that prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated that his pain level decreased to 6/10 with pain medication since the fall. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request.During a review of Resident 1's, Order Summary Report, dated 8/15/25, the report indicated, . Oxycodone oral solution. give 15 ml (unit of measure) every 4 hours as needed for pain. During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary (IDT) team regarding the resident's condition and response to care. the following information is to be documented in the resident medical record, objective observations. treatments or services performed, changes in the residents condition, events, incidents or accidents involving the resident. documentation in the medical record will be objective, not opinionated or speculative, complete and accurate. documentation of procedures and treatments will include care-specific details, including, the date and time the procedure/treatment was provided. the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated.

Based on interview and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 19 sampled residents (Resident 41), when Resident 41 experienced an unplanned weight loss of six pounds (3.4%) in one month (2/1/25-3/1/25), nine pounds (5.3%) in one month (5/1/25-6/1/25), and 23 pounds (13.7%) in five months (2/1/25 - 7/7/25), and interventions to prevent weight loss were not recommended and implemented in a timely manner. In addition, nursing staff did not notify the physician, notify Resident 41's responsible party (RP), schedule an inter-disciplinary team (IDT-a group of professionals from different fields who collaborate to achieve a common goal) meeting to determine the cause of the weight loss in accordance with professional standards of practice and the facility's policy and procedure, Weight Management Policy .These failures had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), loss of independence, and decreased quality of life.Findings:During a review of Resident 41 s admission Record (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 41 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty in swallowing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety (a feeling of unease, worry or fear) and unspecific protein-caloric malnutrition ( a condition resulting from insufficient intake of protein and/or calories). During a review of Resident 41s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/7/25, the MDS, indicated Resident 41's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 41 was unable to complete the interview.During a review of Resident 41's MDS section GG (standardized functional assessment used in all post-acute care settings to measure self-care and mobility) dated 3/2/25, the MDS indicated Resident 41 required partial/moderate assistant (helper does less than 1/2 e) with eating.During a review of Resident 41's MDS section GG dated 5/29/25, the MDS indicated Resident 41 required substantial/maximum assistance with feeding (helper does more than 1/2 ) with eating.During a review of Resident 41's MDS dated 7/7/25, the MDS indicated Resident 41's weight was 153 pounds and was not on physician prescribed weight loss regimen. During a record review of Resident 41's Weights and Vitals Summary from 2/1/25 to 7/7/25, the following monthly weights for Resident 41 were shown:2/1/25: 176 lbs (pounds-unit of measurement):3/1/25: 170 lbs (3. 4%, -6 lbs weight loss in 30 days compared to previous month 176 lbs.).4/1/25: 171 lbs5/1/25: 169 lbs6/1/25: 160 lbs (5.3% , 9 lbs weight loss in 1 month compared to previous month 169 lbs)6/23/25: 156 lbs (2.5%, -4 lbs in 3 weeks compared to 160 lbs on 6/1/25)7/7/25: 153 lbs (13.7%, 23 lbs weight loss compared to 176 lbs on 2/1/25).7/14/25: 151 lbsDuring an observation on 07/21/2025 at 10:22 a.m. in Resident 41's room, Resident 41 was lying in her bed. Resident 41 was dressed in a gown. Resident 41 was not able to state her name and was not interviewable. During a concurrent interview and record review on 7/23/25 11:47 a.m., with License Vocational Nurse (LVN), Resident 41's RD's Progress Notes (PN) dated 7/15/25 was reviewed. The PN indicated, .Dietary: 7/7: 153lb, 3 lb weight loss x 2 weeks (6/26:156lb) and significant 14% 25 lb weight loss x 6 month (1/1/:178lb) .IDT recommendation: continue with plan of care and monitor weekly weight x 1 week. LVN 1 stated an IDT should have discussed Resident 41's weight loss. LVN 1 stated the IDT should have recommended any changes for the residents and the nurses should have followed the recommendations. LVN 1 stated she was not aware she had to notify the physician of Resident 41's weight loss on 6/1/25 and 7/7/25. During an interview and record review on 7/24/25 at 2:20 p.m. with the Registered Dietitian (RD), the RD stated Resident 41 had a six-pound weight loss in one month on 3/1/25. The RD stated the facility should have had an IDT meeting in the month of 3/1/25 and was not done. The RD stated she should have made recommendations for weekly weight check in 3/2025. The RD stated on 6/1/25 Resident 41 had a nine-pound weight loss. The RD stated on 6/12/25 there was an IDT meeting and Resident 41 was added to the weekly weight and weight variance program (system for monitoring and addressing significant weight changes in residents, especially weight loss, to ensure their health and well-being). The RD stated Resident weight was 160 lbs on 6/1/25 and on 6/23/25 her weight was 156 lb. The RD stated Resident 41 had four pounds weight loss in three weeks. The RD stated Resident 41 was started on Prostat (collagen protein medical food used to address increased protein needs in individuals with conditions like pressure injuries, wounds, and protein-energy malnutrition) for supplement on 7/21/25. The RD stated Resident 41 had a significant weight loss and should have additional supplement on 6/25. The RD stated the facility should have done a diabetic oral supplement to prevent weight loss. The RD stated she did not do all the interventions to prevent weight loss. The RD stated the physician should have been notified of the weight loss on 6/1/25. During an interview on 7/24/25 at 2:50 p.m. with the Speech Therapist (ST), the ST stated Resident 41 had a fall and was not eating after returning from the hospital . The ST stated she was asked to evaluate Resident 41 swallowing . The ST stated she recommended a downgrade to pureed diet. The ST stated Resident 41 had weight loss. During an interview on 7/24/25 at 4:16 p.m. with the Administered in Training (AIT), the AIT stated Resident 41's weight loss should have been discussed in the IDT meeting on 3/1/25. The AIT stated the RD should have implemented interventions to prevent further weight loss. The AIT stated he was not notified of the weight loss on 6/2025 and 7/2025. The AIT stated he was not part of the IDT meeting. The AIT stated the weight loss should have been discussed during stand up (a short, daily meeting where team members quickly update each other on their progress and any roadblocks they're facing). The AIT stated all team members including himself should have been notified of the weight loss. The AIT stated it was important to notify all team members so residents would not have further weight loss. The AIT stated the weight loss could have contributed to residents eating less, eventually declining and dying.During an interview on 7/24/25 at 5:30 p.m. with the Director of Nursing (DON) the DON stated she expected Resident 41's weight loss to be addressed. The DON stated the nurses should have contacted the physician[ and responsible party (R/P) right away about weight loss. The DON stated an IDT meeting with progress notes should have been done and there should have been documentation in the medical chart. The DON stated a change in condition (a noticeable alteration in a person's physical or mental state or in the circumstances surrounding a situation) should have been done. The DON stated the change of condition should be initiated on 3/1/25 with the first six pounds loss being identified. The DON stated the nurses should have documented the physician and R/P were notified on 6/1/25. The DON stated an IDT meeting should have been held on 3/2025 for the weight loss. The DON stated IDT should have been done weekly. The DON stated an IDT meeting was not done on time. The DON stated the IDT meeting should have been conducted on 6/14/25. The DON stated the physician should have been notified to recommend interventions to prevent further weight loss. The DON stated she should have monitored the intervention to see if it was effective. The DON stated the facility did not follow the weight management policy and procedure.During a review of Resident 41's Care plan Report undated, the Care Plan indicated, [box interventions/task] if weight decline persists, contact physician and dietician immediately.Determine percentage lost and follow facility protocol for weight loss.During a review of Resident 41's Skilled Nursing Nutrition Risk Review Form dated 3/5/25 the Skilled Nursing Nutrition Risk Review Form indicated, .admission weight185 lb.Most recent weight: 170 lb.Usual body weight (UBW): 172-187 lb. There were no supplement recommendations and no documentation showing the physician and responsible party notification. During a review of Resident 41's Progress Note (PN) dated 6/12/25, the PN indicated, .Dietary: 6/1:160 lb, 5.3% 9 lb weight loss x 1 month (5/1/:169lb) and 10.6% 19 lb weight loss x 6 months (12/1: 179lb) . There were no supplement recommendations and no documentation showing the physician and responsible party notification.During a review of Resident 41's Progress Note (PN) dated 7/15/25, the PN indicated, .Dietary: 7/14:151lb, 2 lb weight loss x1 week (7/7:153lb) and significant 10.7% 18 lb weight loss x 2 months (5/1:169lb) .IDT recommendation: continue with plan of care and monitor weekly weight x 1 week. Add prostate 30 ml bid [twice a day ] . There was no documentation indicating the physician was notified. During a review of Resident 41's Progress Note (PN) dated 7/21/25, the PN indicated, New order received from MD [Name of MD] for Prostat 30ml BID for supplement. Called R/P [name of R/P] son to notify him of new order.During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, .Weights are monitor monthly and more often as recommended by the interdisciplinary care team.Intervention.g. Use of supplementation.During a review of the facility's policy and procedure (P&P) titled, Weight Management Policy dated 12/19/2022, the P&P indicated, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight.6.Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days). B. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions.During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, the article indicated, .Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both.During a review of a professional references titled Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016 , the article indicated, .The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight.During a review of a professional references retrieved from the Academy of Nutrition and Dietetics titled What Resources Are Available to Assist in Assessing Body Weight in Older Adults dated 7/1/2025 the article indicated, .Usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in older adults.

Based on interview and document review, the facility failed to have qualified, full-time oversite of Food and Nutrition Services. This deficient practice could result in compromising the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 55 residents who received food from the kitchen out of a census of 56. Findings: Review of the California Code, Health and Safety Code - HSC S 1265.4, a licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The requirements of subdivision (b) includes:(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility.(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration.(3) A graduate of a dietetic assistant training program approved by the American Dietetic Association.(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.(5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.(6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision.(7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).During an interview with the Dietary Supervisor (DS) on 7/21/25, DS stated she was the supervisor of the kitchen and started going to school to become a Certified Dietary Manager (CDM) in January 2025. DS stated she became the supervisor of the kitchen in December of 2024. DS stated the Registered Dietitian was at the facility one to two days a week. During an interview with the Dietary Supervisor Mentor (DSM) on 7/21/25 at 2:56 p.m., DSM stated he was a CDM at another facility and mentored DS. DSM stated his mentoring was usually by phone, not on site at the facility. During an interview on 7/22/25 at 2:19 p.m., RD stated she usually worked at the facility on Thursdays only.During an interview on 7/23/25 at 4:30 p.m., the Administrator in Training (AIT) stated he reviewed the Health and Safety Code, and the plan was to have DS qualified by becoming a CDM, and she was currently the CDM training. AIT stated he realized it would take a while for DS to complete the CDM training and confirmed she was not currently qualified to be the full-time person to supervise Food and Nutrition Services. AIT also stated DS had a CDM mentor (DSM), and there was an RD, but confirmed DSM and the RD did not work full time at the facility. Review of the undated job description titled Manager of Dining Services, provided as the job description for DS, showed the general purpose of the position was to manage the operation of the Dietary Department to include staffing, food ordering and preparation, food delivery and clean-up in accordance with facility policies, physician orders, patient care plans, and appropriate regulations.

Based on observation, interview, and record review the facility failed to ensure kitchen staff had the appropriate competencies to carry out the functions of the food and nutrition service when: 1. [NAME] 2 was not competent in the use of the dish machine and testing the dish machine sanitizer strength. 2. [NAME] 1 was not competent preparing pureed food. 3. [NAME] 1 and the Dietary Supervisor (DS) were not competent in the use of the three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing). These failures had the potential to result in contamination of resident food and utensils used by residents leading to illness for 55 who received food from the kitchen; This failure also had the potential for residents receiving a pureed diet to consume less food due to decreased palatability and appearance resulting food related medical complications for 8 residents on a physician prescribed pureed diet out of a census of 56. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:13 p.m. with [NAME] 2 and the Dietary Supervisor Mentor (DSM) in the kitchen, [NAME] 2, stated he was an ex-kitchen employee and currently worked in housekeeping but was helping out in the kitchen. As [NAME] 2 washed kitchen utensils in the dish machine, the temperature gauge for the dish machine was noted to be 110 degrees Fahrenheit (F-unit of measurement) for the wash cycle and the sanitizing cycle. [NAME] 2 stated the dish machine was a low-temperature dish machine (dish machine that uses chemical sanitizers instead of high heat to sanitize dishes). [NAME] 2 was asked to demonstrate checking the sanitizer strength in the dish machine. [NAME] 2 reached for Quaternary ammonium (Quat) test strips (used to measure the concentration of quaternary ammonium compounds in sanitizing solutions) to test water in the dish machine after the sanitizer cycle completed. [NAME] 2 was about to test the sanitizer in the dish machine with the Quat test strip, when the DSM stated the Quaternary ammonium test strips should not be used to test the sanitizer in the dish machine since chlorine was used as the sanitizer. The DSM handed [NAME] 2 chlorine test strips (used to measure the concentration of chlorine in a solution by using a chemical reaction that causes a color change on the strip). [NAME] 2 dipped the chlorine test strip in the solution inside the dish machine after the sanitizer cycle completed. [NAME] 2 compared the chlorine test strip to the color chart on the chlorine test strip vial. The strip did not change color. When the test strip was compared to the color chart located on the chlorine test strip container, the strip indicated a low concentration of less than 10 parts per million. (PPM - a way to express very dilute concentrations of substances, indicating how many parts of a substance are present in a million parts of the solution or mixture) [NAME] 2 stated the sanitizer strength was acceptable. DSM confirmed the test strip indicated there was no sanitizer in the dish machine. According to the test strip color chart, when the sanitizer is 50 PPM, the chlorine test strip will turn a light purple color. [NAME] 2 stated he did not know if there was a log to record temperatures or sanitizer strength for the dish machine. The dish machine manufacturer label, attached to the dish machine was observed. The manufacturer label indicated, .Minimum wash temperature: 120 F . Minimum chlorine: 50 PPM .During an interview on 7/21/25 at 3:25 p.m. with the DS, the DS stated the sanitizer strength should be checked before use, three times a day, when items were washed from the breakfast, lunch and dinner meals. The DS also stated the temperature of the dish machine should be at 120 degrees F before use. The DS stated the dish machine needed to be run a few cycles before use to ensure the temperature reached 120 degrees F. DS also stated the dish machine log should be filled out for lunch before the dish machine was used at the lunch meal. During a review of the facility's document titled Dish machine Temperature Log (Low Temperature) dated July 2025, indicated boxes where staff documented wash temperatures, and rinse chlorine ppm on a daily basis for breakfast, lunch, and dinner. All fields were filled out from July 1 to July 20, but for July 21, the lunch wash temperature and rinse ppm was not documented. During a concurrent interview and record review on 7/22/25 at 4:45 p.m. with the DS, the Dish Machine In-service Training, dated 12/19/24, was reviewed. The Dish Machine In-service Training sign-in sheet indicated [NAME] 2 was not a participant in the training, and the DS confirmed [NAME] 2 was not a participant. The DS stated she was not able to provide dish machine in-service training for [NAME] 2. During a review of the facility's policy and procedure (P&P) titled, Dishwashing: Machine Operation, dated 2020, indicated, .All dishwashing machines should be operated according to manufacturer recommendations . If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function . If the machine is found to be out of the acceptable range for final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes . 2. During a concurrent observation and interview on 7/24/25 at 10:59 a.m. with [NAME] 1 in the kitchen, [NAME] 1 was observed pureeing chicken for residents who received a pureed diet. [NAME] 1 added a brown colored liquid to the pureed cooked chicken in a blender and blended the ingredients. [NAME] 1 stated the brown colored liquid was chicken broth. [NAME] 1 blended the broth and the chicken. The consistency appeared to be runny. [NAME] 1 stated she added a total of three-and-a-half cups of chicken broth to the chicken because that was what the recipe stated to add. [NAME] 1 stated she would add more chicken broth if needed but did not think more chicken broth would need to be added. [NAME] 1 stated the pureed chicken should have a pudding-like consistency. [NAME] 1 stated she would check the consistency of the pureed chicken by doing a spoon test (a method to assess the consistency of a food item, particularly when it's being cooked or thickened, involving the use of a spoon to scoop up a sample and observing how it behaves, such as how it drips off the spoon, or whether it holds its shape). [NAME] 1 stated the pureed chicken should hold shape and not drip over the spoon. [NAME] 1 stated the consistency of the pureed chicken she just made was runnier. [NAME] 1 added one teaspoon (tsp) of thickener (a substance added to a liquid to increase its density, making it thicker), blended the pureed chicken, and added another tsp of thickener. Then added another tsp of thickener and blended. As [NAME] 1 prepared the pureed chicken, she referred to the recipe for Pureed Fried Chicken and stated she was following the recipe. During a review of Pureed Fried Chicken recipe, dated 2025, the recipe indicated, .To prepare 3 1/2 cups of chicken broth and to gradually add the broth as needed to prepared chicken and blend until smooth.Any liquid specified in the recipe is a suggested amount of liquid (if needed) . If product needs thinning, gradually add an appropriate amount of liquid to achieve a smooth, pudding or soft mashed potato consistency. During an interview on 7/24/25 at 11:05 a.m., with RD, the RD stated, according to the pureed fried chicken recipe, [NAME] 1 should not have added the entire three-and-a-half cups of chicken broth in order to get the desired consistency. During an interview on 7/24/25 at 11:51 a.m. with the RD, the RD stated small amounts of liquid should be added to achieve the desired consistency when pureeing food. The RD stated pureed foods should be a formed consistency, like mashed potatoes. RD stated she just did an in-service about how to puree foods with [NAME] 1 on 7/21/25. During a review of In-service Signature Sheet, dated 7/21/25, The In-service Signature Sheet indicated, .Subject: Fortified Diets . In-serviced on . proper procedure to puree . The In-service Signature Sheet indicated [NAME] 1 was in attendance. 3. During a concurrent observation and interview on 7/21/25 at 3:01 p.m. with [NAME] 1 and the DS in the kitchen, the three-compartment sink was observed. [NAME] 1 stated the three-compartment sink was used to wash kitchen utensils and other kitchen equipment if the dish machine was not working. [NAME] 1 described how to clean dishes in the 3-compartment sink. She stated the first sink was for washing, the second sink was for rinsing, and the third sink was for sanitizing. [NAME] 1 stated the third sink would be filled with a sanitizer solution. [NAME] 1 stated she did not know how long items had to be submerged in the sanitizing solution. [NAME] 1 stated she had to ask someone and walked away. When [NAME] 1 returned, she stated items had to be submerged solution in the third compartment should be 110 degrees F. [NAME] 1 stated she did not know what the temperature of the water in the wash and rinse compartments should be. The DS stated the instructions for use of the 3-compartment sink were posted above the sink and should be followed. The instructions titled [Brand Name] Pot & Pan Wash Procedure indicated to submerge items being cleaned in the sanitizer solution for one minute. The DS stated the instructions did not provide exact temperatures for the water and to rinse using hot water. The DS stated she thought the water in the wash compartment should be 110 degrees F. During an interview on 7/22/25 at 4:45 p.m. with the DS, the DS stated she was not able to provide documentation for training on the use of the three-compartment sink for any staff. During a review of the facility's P&P titled, Emergency Dishwashing, dated 2020, indicated, .Staff will follow emergency procedures established for dishwashing to comply with sanitation regulation at all times . The three-step manual washing process is as follows: First sink: 120 degrees F water and adequate detergent. Second sink: 120 degrees F clean, clear water. Third sink: Chemical sanitizing solution .

Based on observation, interview and record review, the facility failed to ensure foods were prepared by methods that conserve flavor, appearance, and at an appetizing temperature when: 1. The temperature of the ham, cauliflower, and sweet potato wedges served for the lunch meal was below 120 degrees Fahrenheit (F-unit of measurement) and barely felt warm in the mouth when sampled. 2. The pureed ham, cauliflower, and sweet potato wedges served for the lunch meal were a thin, runny consistency. 3. The pureed sweet potato wedges were bland. These failures had the potential to result in weight loss and/or further complicate medical status of residents for 55 residents who received food from the kitchen out of a census of 56. Findings:1.During a review of the facility's Diet Spreadsheet dated 2025, indicated, the lunch meals served on 7/21/25 included but was not limited to the following: Regular diet (a balanced, unrestricted meal plan that includes a variety of foods from all major food groups, suitable for individuals without specific dietary needs or restrictions): Honey Glazed Ham, Sweet Potato Wedges, Cauliflower; Pureed diet (a modified texture diet where food items are blended into a smooth, pudding-like consistency, eliminating any lumps): Pureed Honey Glazed Ham, Pureed Sweet Potato Wedges, Pureed Cauliflower. During a concurrent observation and interview on 7/21/25 at 12:46 p.m. with the Dietary Supervisor (DS) and the Registered Dietitian (RD), a regular diet and a pureed diet test tray (a method of evaluating the quality and safety of food served to residents) for lunch meal was observed. The temperature of the items on the regular diet test tray were measured with a calibrated thermometer and were as follows: ham: 109.3 degrees Fahrenheit (F); cauliflower: 108.4 degrees F; sweet potato wedges: 104.8 degrees F. The temperature of the items on the pureed test tray were ham: 100.6 degrees F; cauliflower: 101 degrees F; sweet potato wedges: 104 degrees F. The RD stated the temperature of the food when served to the residents should be at least 110 degrees F. The RD stated she did not conduct test trays and did not assess the food trays as they were delivered to residents. The RD stated she did not know the temperature of the food as it was delivered to residents. During a review of the Registered Dietician job description, dated 10/27/15, indicated, Evaluates . preparation of food service procedures . During a review of the facility's policy and procedure (P&P) titled, In-Room Dining, dated 2020, indicated, Meals served . may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot food on . trays at the point of service are preferred to be at 120 F or greater to promote palatability for the resident. 2. During an observation on 7/21/25 at 12:46 p.m. with the DS and the RD, a pureed diet test tray was observed. The pureed ham, cauliflower, and sweet potato wedges had a thin, runny consistency, and was spread out flat on the plate. During an interview on 7/24/25 at 11:51 a.m. with the RD, the RD stated the pureed food from the test tray was too thin. The RD stated the food should have been a mashed potato consistency. The RD stated if food was pureed too thin, residents could choke if they could not tolerate thinner liquids. The RD also stated if the pureed food was thin, it may not have an appealing feel/texture in the mouth and residents could be sensitive to mouth textures. The RD stated the liquid/thin appearance of the pureed food was not appealing and may cause residents to eat less. During a review of the facility's document Long Term Care Diet Manual dated 2022, indicated the pureed diet was for individuals who were not able to chew foods and/or have difficulty swallowing. The appropriate consistency included consistency such as puddings and smooth mashed potato. 3. During an observation on 7/21/25 at 12:46 p.m. with the RD, a Regular and Pureed diet test tray was observed. When the regular sweet potatoes were tasted, they were flavorful, but when the pureed sweet potatoes were tasted, the flavor was bland (with little flavor). The RD stated the pureed sweet potatoes tasted bland. During a concurrent interview and record review on 7/21/25 at 1:02 p.m. with [NAME] 1, [NAME] 1 stated she did not follow a recipe for sweet potatoes because the sweet potatoes came prepared in a box. [NAME] 1 stated she added milk and thickener (a substance added to a liquid to make it thicker and more resistant to flowing) but no extra seasoning when she pureed the sweet potato wedges for the lunch meal. Review of the Pureed Sweet Potato Wedges recipe dated 2025, indicated, . Add hot milk as needed when the product needs thinning to achieve the desired consistency. [NAME] 1 stated she did not taste the sweet potatoes before they were served to residents. During an interview on 7/22/25 at 11:51 a.m. with the RD, the RD stated cooks should be following recipes when meals were prepared for residents. The RD stated cooks should taste the food. The RD stated salt should not be added to recipes, but it was acceptable to add other seasonings/spices in order to increase flavor. During an interview on 7/24/25 at 3:30 p.m. with the RD, the RD stated the lack of flavor of the pureed food may result in residents eating less. During a review of Cook job description, dated 9/1/16, indicated, .Follow recipes and prepare foods that correspond to menu cycles . [NAME] or prepare palatable . meals . During a review of the facility's P&P titled, Pureed Food Preparation, dated 2020, the Pureed Food Preparation indicated, Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability . The recipes will be adjusted . indicating seasoning and technique to ensure the highest quality . the flavor of pureed foods will be assessed. The pureed food should have the same desirable flavor as the menu item.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The dish machine was used without reaching 120 Fahrenheit (F-Unit of measurement) and without sanitizer. 2. The ice machine was not clean and was not cleaned according to the manufacturer's instructions. 3. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation and was not clean. 4. Kitchen floors, ceiling panels, walls, doors, and screens were not maintained in good condition. 5. The area underneath the three-compartment sink was not clean. 6. A can-opener and serving trays were not clean. 7. Pastrami deli meat and canned mushrooms were not discarded by the used by date (indicating the last day the product is recommended for use). These failures had the potential to contaminate resident food sources that can cause foodborne illness in a vulnerable population, resulting in severe patient harm, and even death. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:13 p.m. with [NAME] 2 and the Dietary Supervisor Mentor (DSM) in the kitchen, [NAME] 2 was washing kitchen utensils in the dish machine. The temperature gauge for the dish machine was noted to be 110 degrees Fahrenheit (F) for the wash cycle and the sanitizing cycle, while the dish machine was operating. [NAME] 2 stated the dish machine was a low-temperature dish machine (dish machine that uses chemical sanitizers instead of high heat to sanitize dishes). [NAME] 2 stated the dish machine was used to clean utensils and other kitchen equipment. [NAME] 2 tested the sanitizer strength in the dish machine by dipping a chlorine test strip (used to measure the concentration of chlorine in a solution by using a chemical reaction that causes a color change on the strip) in the dish machine water after the cycle was completed. The chlorine test strip did not change color. The DSM, who was a mentor for the Dietary Supervisor (DS), dipped a new chlorine test strip in the water. The chlorine test strip did not change color. The DSM stated the tubing for the sanitizer that supplied the dish machine with sanitizer was pinched and confirmed the sanitizer was not reaching the dish machine while [NAME] 2 was using the machine to clean kitchen utensils. [NAME] 2 confirmed he did not check the sanitizer strength before he started using the dish machine. During an observation on 7/22/25 at 11:29 a.m. in the kitchen, the dish machine manufacturer label, attached to the dish machine, was observed. The manufacturer label indicated, Minimum wash temperature: 120 F . Minimum chlorine: 50 PPM (parts per million - measurement used to express very small concentrations of a substance within a larger mixture or solution). During an interview on 7/22/25 at 3:25 p.m. with the DS, the DS stated the sanitizer strength should be checked before use, three times a day, when items were washed from the breakfast, lunch and dinner meals. The DS also stated the temperature of the dish machine should be at 120 degrees F before use. The DS stated the dish machine needed to be run a few cycles before use to ensure the temperature reached 120 degrees F. During a review of the facility's P&P titled, Dishwashing: Machine Operation, dated 2020, indicated, .All dishwashing machines should be operated according to manufacturer recommendations . If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function . If the machine is found to be out of the acceptable range for wither final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes . 2. During a concurrent observation and interview on 7/22/25 at 11:40 a.m. with the Maintenance Supervisor (MS) in the kitchen, the MS opened the ice machine to observe the interior components. The ice machine had yellow residue along the length of the upper part of the plastic frame of the evaporator plate (the surface within an ice machine where water freezes into ice). A white napkin was used to wipe the yellow residue which came off on to the napkin. In addition, there was a rough texture along the upper part of the evaporator plate frame. The MS stated the ice machine was cleaned monthly. The MS stated he followed instructions for cleaning the ice machine from the manufacturer. During and concurrent observation and interview on 7/22/25 at 2:10 p.m. with the MS in the kitchen, the MS provided instructions for cleaning the ice machine from the manufacturer. The MS provided two bottles of chemicals which he stated he used to clean the ice machine. One bottle was a nickel-safe cleaner (a cleaning solution specifically designed to remove scale and mineral buildup in ice machines and other equipment that have nickel or tin-plated components, without damaging sensitive parts) and the other bottle was sanitizer. The MS stated he ran the nickel-safe cleaner through the ice machine first, then the interior of the ice machine is sprayed with the nickel-safe cleaner. The MS stated the sanitizer was run through the ice machine after the nickel-safe cleaner. The MS stated the last step was to spray the nickel-safe cleaner again on the inside of the ice-machine and wipe down with a rag. During a concurrent interview and record review on 7/22/25 at 2:15 p.m. with the MS, the Cleaning Instructions - [Ice machine brand and model number] User Manual, (undated) was reviewed. The User Manual indicated, the sanitization step is the last step of the cleaning process for the ice machine. The MS confirmed he sprayed the nickel safe cleaner as the last step when cleaning the ice machine. When the instructions were reviewed, MS confirmed sanitization was the last step of the cleaning process for the ice machine. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Surfaces of . equipment contacting food . such as . ice makers . must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Multiuse food-contact surfaces shall be smooth, and equipment food-contact surfaces are to be clean to sight and touch and shall be sanitized before use and after cleaning.During a review of the facility's P&P titled, Cleaning Instructions: Ice Machine and Equipment, dated 2020, indicated, Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures (if available) . 3. During a concurrent observation and interview on 7/21/25 at 10:08 a.m. with the DS and MS in the kitchen, the three-compartment sink was observed. Inside the third compartment of the three-compartment sink, there was pink residue around the rim of the drain opening. A white napkin was used to wipe the pink residue which came off on to the napkin and was slimy in texture. There was also a brownish-yellow film on the inside bottom and side surfaces of the sink. When wiped with a white napkin, the texture felt rough, and the brownish residue wiped off onto the napkin. In addition, there were what appeared to be gray colored (similar to the color of the metal sink), hard in texture patches, one inch in length, on an inside corner of the second and the third sink. These patches had rough edges and had brown and black residue on the surface. The MS stated the sink should be cleaned daily and should also be deep cleaned. During an interview on 7/21/25 at 2:56 p.m. with the DS, the DS stated that there was a cleaning schedule for the three-compartment sink. During an interview on 7/21/25 at 3:01 p.m. with [NAME] 1, [NAME] 1 confirmed she was responsible for cleaning the 3-comapartment sink and stated to clean the internal part of the three-compartment sink, she sprayed the inside of the sink down with water only and did not scrub the sink with a cleaner. During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated the three-compartment sink was used to wash produce. During a concurrent interview and record review on 7/23/25 at 9:25 a.m. with the DS, the Food and Nutrition: Cleaning Log . 3-compartment sink, dated 7/1/25 through 7/5/25 was reviewed. The DS stated according to the cleaning schedule, the three-compartment sink was cleaned twice a day, a.m. (morning) and p.m. (evening). The DS stated when [NAME] 1 was done with her shift, she cleaned the three-compartment sink. The DS said the evening shift should also be cleaning the three-compartment sink at the end of their shift. The DS stated if the three-compartment sink was being cleaned twice a day, there should be two staff signatures on the cleaning log corresponding with the 3-compartment sink. The DS stated she was responsible for reviewing the cleaning logs. The DS confirmed from July 1 to July 2025, the cleaning schedule did not show the cleaning for the 3-compartment sink was consistently completed twice a day. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .If a dish washing sink is used to wash produce, or thaw food, the sink shall be cleaned before and after each time it is used to wash produce or thaw food. Sinks used to wash or thaw food shall be sanitized before and after using the sink to wash produce or thaw food. During a review of the facility's P&P titled, Dishwashing: Manual, dated 2020, indicated, .Each compartment of the three-compartment pot and pan sink will be cleaned and sanitized before use. During a review of the Manager of Dining Services job description, (undated), the Manager of Dining Services job description indicated, .Ensure equipment and work areas are clean, safe and orderly . During a review of the facility's P&P titled, Sanitation of Dining and Food Service Areas, dated 2020, indicated, .The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department . All staff will be trained on the frequency of cleaning . A cleaning schedule will be posted for all cleaning tasks. Staff will initial the tasks as they are completed . Staff will be held responsible for all cleaning tasks. During a review of the facility's P&P titled, Sanitation, dated 2023, indicated, .The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . Each employee shall know how to . clean all equipment in his specific work area . The FNS Director will write the cleaning schedule in which he designates by job title and/ or the employee who is to do the cleaning task . the kitchen staff is responsible for all the cleaning . 4. During a concurrent observation and interview on 7/21/25 at 10:05 a.m. with the DS in the kitchen, the floor had cracks and broken tiles in areas throughout the kitchen. Also, areas where floor tiles were replaced there were gaps between the tiles with no grout which created an uneven surface. In addition, there were multiple areas throughout the kitchen where the baseboard or the transition strip between the baseboard and the wall was pulled away from the wall creating a gap. During an observation on 7/21/25 at 10:05 a.m. in the kitchen, gaps between the wall and drainpipes under the 3-comapartment sink and the dish washing sink were observed. During an observation on 7/21/25 at 12:16 p.m. in the kitchen, multiple ceiling panels throughout the kitchen were warped creating gaps in the ceiling cover. A ceiling panel containing a vent, located above the tray-line (food service assembly line where food items are placed on trays as they move along a conveyor or series of stations) area had black colored residue around the vent and around the perimeter of the panel. During a concurrent observation and interview on 7/22/25 at 11:42 a.m. with the MS in the kitchen, MS confirmed multiple ceiling panels were warped creating gaps. The MS stated the ceiling panel containing a vent had dust and debris. The MS stated the dust and debris on the ceiling panel was likely from the vent and was old debris. MS also confirmed there were multiple areas throughout the kitchen floor where there were cracked, broken, and uneven tiles, there were gaps in the baseboard and the wall, and there were gaps between the drainpipe sinks and the wall. During a concurrent observation and interview on 7/23/25 at 3:10 p.m. with the MS, a back door to the facility near the kitchen entrance was observed. The bottom portion of the door was cracked and had broken off chunks of wood. When the door was closed, the door did not fit snuggly so there were gaps between the door and the door frame. Toward the top of the door there was a partially attached metal strip that created a gap in the door where the strip was pulled away. The MS stated that the door had a gap and needed to be repaired. During a concurrent observation and interview on 7/23/25 at 3:15 p.m. the back door in the kitchen was open with only the screen door closed. The screen in the screen door had multiple tears creating holes around the perimeter of the screen. The MS stated the screen had tears and needed to be patched. During a review of the Maintenance Director job description, dated 2/24/14, the Maintenance Director job description indicated, .Supervise the facility's day-to-day functions as it relates to the facility's interior . Ensuring that all maintenance activities in a facility are appropriately carried out. During a review of the facility's P&P titled, Cleaning Instructions: Ceilings and Walls, dated 2020, indicated, Ceilings and walls will be cleaned on a regular basis . Ceilings are cleaned annually, or as needed. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Floors, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. In a food establishment in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed to no larger than 1 mm (millimeter). In addition, outer openings of a food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings. Doors are to be solid and tight fitting. If the doors are kept open for ventilation or other purposes, the openings shall be protected against the entry of insects and rodents by screens, properly designed and installed air curtains (a machine that blows a stream of air across and opening to create an air seal to the other side), or other effective means. 5. During a concurrent observation and interview on 7/21/15 at 10:08 a.m. with the DS in the kitchen, the floor under the three-compartment sink was observed to have yellow and brown residue on the surface, and there was a significant amount of gray-colored substance, resembling dust, on the surface of the pipes under the sink. In addition, an upright pipe under the sink was connected to the sink drainpipe and had a significant amount of thick yellowish build-up on the inner surface of the pipe. The DS stated the area under the three-compartment sink looked old. The DS stated there was residue on the floor under the three-compartment sink. The DS stated the debris hanging from the pipe was fuzzy stuff. The DS stated the floors were swept and mopped by staff twice a day, including under the three-compartment sink. During a concurrent observation and interview on 7/21/25 at 10:13 a.m. with the Maintenance Supervisor (MS) in the kitchen, the floor under the three-compartment sink was observed. The MS stated the floor under the three-compartment sink was dirty. MS also stated he thought the thick yellow build-up in the upright pipe was grease. The MS stated, The place has been a mess. According to the 2022 Federal Food Code, physical facilities shall be cleaned as often as necessary to keep them clean. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, the presence of food debris or dirt on nonfood contact surfaces can provide a harborage for insects and other pests. During a review of the facility's P&P titled, Cleaning Instructions: Floors, dated 2020, indicated, .Guideline: Floors will be kept clean and sanitary, washed daily or as needed. 6 a. During a concurrent observation and interview on 7/21/25 at 9:58 a.m. with the DS in the kitchen, an industrial can opener held in a base attached to a food preparation table was observed. The can opener blade was observed to have a sticky gray colored residue. The can opener base was observed to have brown and black colored residue on the surface and imbedded around the perimeter crevices where the base came into contact with the table. The DS stated the can opener blade had a sticky gray residue. The DS stated the base of the can opener was not clean. The DS stated the can opener should be cleaned by staff after each use. The DS stated the can opener was used to open cans containing food. During a review of the facility's P&P titled, Cleaning Instructions: Can Opener, dated 2020, indicated, .Protocol for counter-mounted can openers: Pay close attention to blade . Wash the base carefully with mild detergent and hot water; be sure to get rid of all food particles from the blade and base. During a review of the facility's P&P titled Sanitation dated 2023, showed .All . equipment shall be kept clean . 6 b. During a concurrent observation and interview on 7/21/25 at 11:47 a.m. with the Registered Dietitian (RD) in the kitchen, plastic serving trays used to carry such things as residents' meal plates, napkins, utensils, and drinks were observed. The plastic trays had black, pink, and brown discoloration on the surface. The RD stated the trays were not clean. During a review of the facility's P&P titled, Sanitation, dated 2023, indicated, .All . utensils and equipment shall be kept clean . Plastic ware . that becomes unsightly, unsanitary . shall be discarded. During a review of the facility's P&P titled, Storing Utensils, Tableware, and Equipment, dated 2020, indicated, .Clean and sanitize trays . used to carry clean tableware and utensils. Do this daily or as often as necessary. 7. During an observation on 7/21/25 at 9:30 a.m. in the walk-in refrigerator, a package of open deli meat in a metal container was observed. The package indicated, Contents: Sliced Pastrami; O (opened): 6/23/25; UB (use by): 7/16/25. During an observation on 7/21/25 at 9:30 a.m. in the walk-in refrigerator, mushrooms in a plastic, re-usable container were observed. The label on the plastic container indicated, Item: Mushrooms; Prep Date: 7/12/25; Use By: 7/18/25. During a concurrent observation and interview on 7/21/25 at 9:38 a.m. with the DS in the walk-in refrigerator, the deli meat and mushrooms were observed. The DS stated the deli meat was Pastrami deli meat. The DS stated the mushrooms in the plastic container were canned mushrooms. The DS stated food items stored in the walk-in refrigerator were dated after opening and discarded within three days. The DS stated there was a binder for staff to reference food discard dates. The DS stated all staff were responsible for discarding food items. The DS stated staff should be checking the use by dates on food items and discarding them as needed. The DS stated the deli meat and mushrooms should be discarded because they were past the use-by date. During a review of Cupboard Storage Chart, (undated), the Cupboard Storage Chart indicated, Cured and Smoked Meats: . lunch meats, opened . Refrigerator at 32 to 40 F (Fahrenheit) . 3 to 5 days. The Cupboard Storage Chart indicated, Canned and Dried Foods: . opened vegetables . Storage: 2 days. During a review of the facility's policy and procedure (P&P) titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, indicated, General storage guidelines to be followed . Discard food that has passed the expiration date .

Based on interview and record review the facility failed to ensure arbitration agreements were explained to residents in a manner they could understand for 57 of 57 residents when the Admissions Coordinator (AC) did not explain arbitration to newly admitted residents.This failure violated the rights of 57 of 57 residents residing in the facility to be properly informed of the arbitration process and agreement. During an interview on 7/23/25 at 10:54 a.m., with the AC, The AC stated she gave residents the arbitration agreement upon their admission to the facility. The AC stated she did not explain what arbitration was to any resident who were newly admitted . The AC stated she had residents review the agreement with the rest of the admission packet on their own time. The AC stated she did not know what arbitration was and therefore had never explained it to any resident.During an interview on 7/24/25 at 2:44 p.m. with the Administrator in Training (AIT), the AIT stated the AC needed to be familiar with what arbitration was and the facility's arbitration agreement. The AIT stated residents had the right to understand what arbitration was and to know their rights regarding the process. The AIT stated some residents may not want to sign the agreement if it was not thoroughly explained to them and it was also their right to be informed.During a review of the facility's policy and procedure (P&P) titled Arbitration, dated 12/19/22, the P&P indicated, .The facility asks residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility . When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care are, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including the language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement .

Based on interviews and record reviews, the facility failed to implement adequate measures and a comprehensive water management plan to minimize the risk of Legionella (a harmful bacterium that lives in water systems and areas that are continuously wet) and other pathogens in the building's water system.This failure had the potential to expose 57 of 57 residents to Legionnaires' disease (a disease caused by legionella which affects the lungs) or other opportunistic infections. Findings:During a concurrent interview and record review on 7/23/25 at 2:21 p.m., with the Maintenance Supervisor (MS) the Facilities, Water Management plan, undated, was reviewed. The Water Management plan's sections titled, Description of the Building Water System, Identification of Potential Growth Areas, and Control Measures and Monitoring, were all empty and incomplete. The MS stated no legionella testing was done in 2024, and the facility currently did not have its Water Management plan complete. The MS stated it was important to have a complete water management plan because proper measures and plans for legionella helped prevent residents from receiving harm if they were to be infected by the bacteria.During an interview on 7/23/25 at 4:08 p.m., with the Infection Preventionist (IP-healthcare professionals specializing in the surveillance, control, and prevention of infections), the IP stated the facility needed to have a complete legionella and water management plan in place. The IP stated Legionella was contagious and had the potential to infect everyone in the facility.During an interview on 7/24/25 at 2:44 p.m., with the Administrator in Training (AIT), the AIT stated the facility should have been aware the water management plan was incomplete. The AIT stated proper water management documentation should have been included in the Water Management binder.During an interview on 7/24/25 at 2:17 p.m., with the Director of Nursing (DON) the DON stated the facility's Water Management plan should have been complete. The DON stated it was important to have a complete the plan because it helped ensure legionella did not spread to the residents.During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, dated 7/2017, the P&P indicated . The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease. the water management program includes the following elements: . b. A detailed description and diagram of the water system in the facility. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . The identification of situations that can lead to Legionella growth . j. the documentation of the program .

Based on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when: 1. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation, did not drain, causing water and debris to back up into the sink. 2. The three-compartment sink was used as a food preparation sink and did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 3. The facility did not have drain plugs in order to plug the sinks of the three-compartment sink, so the sink could be used in the way it was intended for ware washing. These failures had the potential to contaminate food sources for 55 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death; this failure also had had the potential for inability to safely clean items such as food preparation equipment and food service utensils in the case the dish machine was not available for use for 55 residents who received food from the kitchen out of a census of 56. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:01 p.m. with [NAME] 1 and the Dietary Supervisor (DS) in the kitchen, the three-compartment sink was observed. [NAME] 1 stated the three-compartment sink was used to wash kitchen utensils and other kitchen equipment if the dish machine was not working. The DS stated the instructions for use of the 3-compartment sink were posted above the sink and should be followed. Review of the [Name Brand] Pot and Pan Wash Procedure dated 2011 posted on the wall above the three-compartment sink, showed procedures for use of the sink included: to fill the first sink (the wash sink) with water and solution, fill the second sink (the rinse sink) with hot water, and fill the third sink (sanitizer sink) with sanitizer solution. During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated in addition to having the sink available for washing dishes in an emergency, the three-compartment sink was used to wash produce. During a concurrent observation and interview on 7/24/25 at 3:30 p.m. with the Maintenance Supervisor (MS) in the kitchen, the first and third compartment of the three-compartment sink was filled with water. The second sink of the three-compartment sink was empty. The MS removed the drain plug from the first compartment and the water was slow to drain. The MS stated something was going on with the drains and the drains were bad. The MS removed the drain plug from the third compartment and water and black, and brown debris backed up into the second compartment. The MS stated the drain could not handle draining two compartments at the same time. The MS replaced the drain plug in the first compartment and left the third compartment unplugged to drain. The drain plug in the first compartment pooed out and water and debris backed up into the second and third compartment. According to the 2022 Federal Food Code, equipment shall be maintained in a state of repair, and a plumbing system shall be maintained in good repair. In addition, A plumbing system shall be installed to preclude backflow of . liquid . into the water supply system at each point of use . Improper plumbing installation or maintenance may result in potential health hazards such as . back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food contact surfaces. 2. During a concurrent observation and interview on 7/21/25 at 10:12 a.m. with the MS in the kitchen, the space under the three-compartment sink was observed. The drain leading from the three-compartment sink was plumbed directly into the wall and there was not an air gap in the drain. The MS confirmed there was no air gap under the three-compartment sink. During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated the three-compartment sink was used to wash produce as there was not a sink available for only food preparation. During a review of the Federal Food Code, dated 2022, the food code indicate, .A direct connection may not exist between the sewage system and a drain originating form equipment in which food, portable equipment, or utensils are placed. During a review of the facility's P&P titled, Accident Prevention - Safety Precautions, dated 2023, indicated, .Backflow Prevention/ Air Gaps: If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. An air gap is the most reliable backflow prevention device. It is the physical separation of the potable (drinking water) and non-potable (non-drinking water) water supply systems by an air space. All . food preparation sinks . shall be drained through and air gap into an open floor sink. 3. During an interview on 07/24/2025 11:05 a.m., with DS, DS was asked to fill the sink compartments of the three-compartment sink with water to demonstrate the use of the sinks. DS stated the facility did not have drain plugs to plug the sinks so they could be filled. During a review of the facility procedure titled Dishwashing: Machine Operation dated 2020, indicated, if the dish machine was not functioning and cannot be repaired in a timely manner, the facility will use the manual dishwashing procedure. During a review of the facility procedure titled Dishwashing: Manual dated 2020, indicated all pots and pans shall be cleaned by washing, rinsing, and sanitizing, according to the following guidelines. These guidelines included but were not limited to: pots and pans will be washed in a hot detergent solution in the first compartment, rinsed in clean warm water in the second compartment, and sanitized by either heat or chemicals in the third compartment. The water in the first, second, or third compartment will be drained when it becomes heavily soiled. The sink will be refilled accordingly.

Based on observation, interview, and record review the facility failed to provide a safe, comfortable, homelike environment for four of 19 sampled residents (Resident 12 , 16. 31 and 38) when:1. Resident 12 was not provided with a mattress that was comfortable for him.This failure caused Resident 12 to be uncomfortable and not receive restful sleep.2. Resident 31 and Resident 38's room had two white painted patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door leading to the corridor.This failure had the potential for Resident 31 and Resident 38 to feel depressed and was not homelike environment.3. Resident 31 and Resident 38 shared restroom that had brown like substance on the seat of the toilet, personal items on the floor and top of the toilet. This failure had the potential for Resident 31 and Resident 38 to have cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and a not homelike environment.4. Resident 16's bathroom, had strong smell of urine when entering the room and the bathroom had urine and trash on the floor around the toilet.This failure had the potential for Resident 16 to have cross-contamination and a not homelike environment.5. Resident 54 was observed laying directly on the mattress of her bed without a sheet.This failure had the potential to cause Resident 54 to feel uncomfortable and depressed by leaving her bed without bedding and not providing a homelike environment. Findings:1. During an interview on 7/21/25 at 10:55 a.m. with Resident 12, Resident 12 stated his mattress was too small for him. Resident 12 stated he was six feet and seven inches tall and weighed 350 pounds, so the mattress did not provide him with a comfortable night's rest. Resident 12 stated the mattress had worn down a lot in the middle and it caused him to feel all the springs and metal from the bed frame.During an interview on 7/24/25 at 10:03 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 12 was a larger person, and a larger bed should have been supplied to him. LVN 1 stated there were other large residents with bigger beds in the facility so Resident 12 should also have a larger bed. LVN 1 stated it was important to provide Resident 12 with a larger bed because it ensured he was provided with a comfortable resting environment.During an interview on 7/24/25 at 11:33 a.m. with the Maintenance Supervisor (MS), the MS stated Resident 12 should have had his bed replaced if he expressed discomfort with his current bed. The MS stated it was important to provide Resident 12 with a different bed because it ensured he was comfortable and well rested, and since he was a bigger person he needed a mattress that could better accommodate him.During an interview on 7/24/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 should have been provided a different bed if he needed it, he is a large person and would benefit from having a comfortable mattress.During an interview on 7/24/25 at 2:44 p.m. with the Administrator in Training (AIT), the AIT stated residents in the facility were entitled to a comfortable bed and a restful sleep, it was their right to have a comfortable homelike environment provided to them.During an interview on 7/24/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated Resident 12's bed was older, and it did not provide the support he required to be comfortable. The DON stated the mattresses for all the resident's needed to be in good working conditions.During a review of the facilities policy and procedure (P&P) titled, Homelike environment, dated 12/19/22, the P&P indicated. In accordance with resident's rights, the facility will provide a safe ,clean, comfortable and homelike environment . a determination of 'homelike' should include the residents opinion of the environment.2. During an interview on 7/21/25 at 10:34 a.m. in Resident 38's room, Resident 31's and Resident 38's room had two white paint patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door. Family Member (FM) 1 stated she had offered to paint the room. FM 1 stated she felt the room was depressing and did not look homelike.During an observation and interview on 7/23/25 at 12:19 p.m. with the Lead Certified Nursing Assistant (LCNA), the LCNA stated the walls in the room had two different tones of paint. The LCNA stated the room was tacky and unfinished. The LCNA stated the room could have caused residents to feel depressed. The LCNA stated the room should have been painted all one color.During an interview on 7/23/25 at 3:30 p.m., with the AIT, the AIT stated the room should have been painted. The AIT stated residents could have been unhappy about the room being unfinished. The AIT stated it could have caused residents to be upset. The AIT stated the room could have caused residents to be depressed and the facility should have made the room homelike. The AIT stated the white painted patches on the wall were not a homelike environment. During a review of Resident 31's admission Record (AR) (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), acute respiratory failure (life-threatening lung disease) and heart failure (a condition when the heart can't pump enough blood to meet the body's needs).During a review of Resident 31 Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/9/25, the MDS, indicated Resident 31's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 31 was severely cognitively impaired.During a review of Resident 38 s AR dated 7/24/25, indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness), lower back pain, dysphagia (difficulty swallowing), heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 38s MDS dated [DATE], the MDS, indicated Resident 38's had a BIMS score of 15 indicating Resident 38 was cognitively intact.During a review of the facility's P&P titled, Safe and Homelike Environment dated 12/19/2022, the P&P indicated, .In accordance with resident's rights, the facility will provide a safe, clean and comfortable and homelike environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. 3. During an interview on 7/21/25 at 10:34 a.m., with Family Member (FM) 1, FM 1 stated the restroom was dirty and unacceptable. FM 1 stated the restroom was shared with other Residents and was concerned about infection control. During a concurrent observation and interview on 7/21/25 at 11:46 a.m., in Resident 31 and Resident 38's restroom with the LCNA, a brown substance was observed on the toilet seat, a bag of adult brief, a urinal hat and a commode bucket was on the ground, two bags of wipes and a bottle of lotion was on the top of the toilet, and a trash bin did not contain a bag liner. The LCNA stated none of it should have been there. The LCNA stated bag of briefs and lotion should have been in the resident personal closet. The LCNA stated the commode bucket, urinal hat should have been put on the ground and should have been stored away. The LCNA stated trash cans should have a bag liner, and the toilet should be cleaned and not contain feces (brown like substance) on the seat. The LCNA stated CNAs should have cleaned and housekeeping should have disinfected the toilet. The LCNA stated residents were at risk for cross-contamination when they used the restroom. During an interview on 7/24/25 at 3:40 p.m., with the Infection Preventionist, (IP-healthcare professional specializing in the surveillance, control and prevention of infections), the IP was shown a photo of the restroom. The IP stated the briefs should have been in the resident closet and not on the floor. The IP stated, the commode should not have been on the toilet. The IP stated the lotion, urinal hat, wipes should not have been in the restroom. The IP stated the feces on the toilet were unsanitary and not a home-like environment. The IP stated residents who use the toilet were at risk for cross-contamination and could have been upset from the restroom being filthy. The IP stated it was the facility's responsibility to ensure the restroom was clean and homelike. During an interview on 7/24/25 at 3:47 p.m., with the DON, the DON stated the dirty restroom was not homelike. The DON stated the CNA should have cleaned it and organized it. The DON stated the dirty restroom was an infection control issue and there could have been cross-contamination. The DON stated residents should not have a dirty restroom. The DON stated the restroom should have been cleaned. The DON stated the dirty restroom was not a homelike environment. During a review of Resident 31 s AR dated 7/24/25, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia, acute respiratory failure, and heart failure.During a review of Resident 31 MDS dated [DATE], the MDS, indicated Resident 31's had a BIMS score of 4 indicating Resident 31 was severely cognitive impaired.During a review of Resident 38 s AR dated 7/24/25, indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of anxiety, lower back pain, dysphagia, heart failure, and anemia.During a review of Resident 38s MDS dated [DATE], the MDS, indicated Resident 41's had a BIMS score of 15 indicating Resident 38 was cognitively intact.During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment dated 12/19/2022, the P&P indicated, .In accordance with resident's rights, the facility will provide a safe, clean and comfortable and homelike environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. During a review of the facility's P&P titled, Policy and Procedure on Housekeeping and Facility Cleanliness undated, the P&P indicated, .Purpose: To ensure the cleanliness and safety of the facility by maintaining high standards of sanitation and hygiene in compliance with state regulations and infection control guidelines.This policy applies to all housekeeping staff, nursing staff and other personnel involved in cleaning and maintaining the facility environment.Bathrooms (Resident and Public): .clean and disinfect toilets. 4. During a concurrent observation and interview on 7/21/25 at 11:46 a.m., with resident 16 in Resident 16's bathroom, a strong odor of urine was noted as well as yellow liquid on the floor around the toilet, and trash was seen on the floor. Resident 16 stated, The bathroom has not been cleaned for a long time, and it has always smelled of urine, I have had to get used to the smell.During an interview on 7/21/25 at 12:10 p.m., with LVN 1, in Resident 16's room, LVN 1 stated she could smell urine in the room and the resident should not have to get used to the smell of urine. LVN 1 stated Resident 16 had the right to have a clean and odor-free bathroom. LVN 1 stated having a dirty bathroom could discourage residents from using the bathroom resulting in more bowl and bladder accidents and the possibility of skin breakdown.During an interview on 7/24/25 at 1:20 p.m., with the MS, the MS stated, the bathroom was not up to his expectation. The MS stated it was his expectation for the residents' bathrooms to be cleaned once per day and as needed. The MS stated the bathroom did not Provide Resident 16 with a homelike environment. During an interview on 7/24/25 at 3:00 p.m., with the AIT, the AIT stated, The bathroom did not look like it had been cleaned, it is the responsibility of housekeeping to clean the bathrooms and the whole staff to monitor the bathrooms and resident rooms to notify housekeeping when they need to be cleaned. The bathroom does not meet expectations.During a review of Resident 16's AR dated 7/24/25, indicated Resident 16 was admitted to the facility on [DATE] with the following diagnosis, alcohol induced dementia (ARBD- a form of brain damage caused by long-term heavy drinking), muscle weakness, COPD, and anxiety disorder.During a review of Resident 16's MDS section C, dated 7/01/25, the MDS, indicated Resident 16's had a BIMS score of 10 indicating Resident 16 had moderate cognitive impairment.During a review of the facility's P&P titled, Policy and Procedure on Housekeeping and Facility Cleanliness undated, the P&P indicated, .Purpose: To ensure the cleanliness and safety of the facility by maintaining high standards of sanitation.5. During a concurrent observation and interview on 7/21/25 at 11:53 a.m., with CNA 3, in Resident 54's room, Resident 54 was observed lying directly on the mattress of her bed without bed sheets, pillowcase, or blankets. CNA 3 stated the CNA that gave her report told her that the resident was pulling at the sheets and putting them over her face, therefore CNA removed the sheets from the bed. CNA 3 stated she did not put sheets on the bed because she was following the instruction of the previous nurse. During a concurrent observation and interview on 7/21/25 at 11:56 a.m. with Licensed Vocational Nurse (LVN)1, LVN1 stated, The sheets should not have been removed from Resident 54, Resident 54 should have been re directed, put in a wheelchair, or something other than removing her sheets.During an interview on 7/23/25 at 10:45 a.m. with the Director of Staff Development (DSD), the DSD stated, Resident 54 should not be left on the bed without sheets, it is violation of her rights, and comfort. CNA 3 should have discussed the situation with LVN 1 and found a solution that did not leave Resident 54 lying on the bare mattress. During an interview on 7/23/25 at 1:10 p.m., with the AIT, the AIT stated Leaving Resident 54 on the bare mattress is unacceptable and the staff should have found another way to work with Resident 54's behavior.During a review of Resident 54's AR dated 7/24/25, the AR indicated Resident 54 was admitted to the facility on [DATE] with the following diagnosis: Alzheimer's Disease (a brain disorder that causes a progressive decline in memory, thinking, and reasoning skills), Dementia (a decline in mental ability, severe enough to interfere with daily life), Major Depressive Disorder (a serious mental illness characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly interferes with daily life) and Osteoarthritis (a common joint condition where the protective cartilage between bones breaks down).During a review of Resident 54 MDS dated [DATE], the MDS, indicated Resident 54's had a BIMS score of 0 indicating Resident 54 had severe cognitive impairment.During a review of the facilities P&P titled, Homelike environment, dated 12/19/22, the P&P indicated. In accordance with resident's rights, the facility will provide a safe ,clean, comfortable and homelike environment . a determination of 'homelike' should include the residents opinion of the environment.

Based on interview and record review the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sample staff Licensed Vocational Nurse (LVN 2), when LVN 2 did not had the annual nursing skills training competency completed according to facility's policy and procedure (P&P) Nursing Skills Training and Competency Policy. This failure had the potential for areas of improvement to be identified for LVN 2 which placed all residents at risk for their health and safety.Findings:During an interview and record review on 7/24/2025 at 10:28 a.m. with the Director of Staff Development (DSD), the DSD stated LVN 2 did not have her annual nursing skills training competency check-off list in her personal file. The DSD stated it should have been done annually. The DSD stated it should have been done in 5/2025 and was not sure why it was not done. The DSD stated the annual nursing training skills training competency check-off list was needed to make sure the nurses were competent to care for the residents. The DSD stated the facility was currently working on getting the nursing skills competency check-off list for LVN 2. During an interview on 7/24/25 at 3:32 p.m. with the Director of Nursing (DON), the DON stated LVN 2 should have the nursing skills competency check off list evaluation during the first 90 days and then annually. The DON stated LVN 2's lack of competency could not have been identified, and the facility could not helped her improve on areas of concern. The DON stated LVN 2 could have benefit from the nursing skills competency evaluation check-off list. The DON stated resident care could effect by lack of competency check. The DON stated, We did not follow our policy and procedure.During a review of the facility's P&P titled, Nursing Skills Training and Competency Policy undated the P&P indicated, .Purpose: to establish standards for nursing skills and procedures in accordance with federal regulations, California Title 22, and evidence-based practices, ensuring the delivery of safe and high-quality care in a skilled nursing facility.Procedures and Guidelines.1.Competency Assessment.All nursing staff must demonstrate competency in required nursing skills upon hire and annually thereafter.skills competency will be assessed through a combination of hands-on demonstration, written evaluations, and direct observation.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) to staff and residents. Specifically, the facility failed to: 1. Ensure timely COVID-19 testing of symptomatic staff and residents and the implementation of COVID-19 testing during an outbreak, 2. Ensure staff were wearing proper Personal Protective Equipment (PPE), 3. Ensure signage was posted of proper PPE for rooms with positive COVID-19 residents, and 4. Ensure staff were fit tested for N-95 respirator masks. The failed practices had the potential to affect all residents that resided in the facility. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 Infection Control at a scope and severity of L. The IJ began on [DATE] when the Maintenance Director worked in the facility with symptoms of COVID-19. The Maintenance Director was not immediately tested for COVID-19, but the next day, on [DATE], tested positive for COVID-19. At that time, COVID-19 outbreak testing was not initiated for facility residents and staff. On [DATE], while symptomatic, Nursing Assistant (NA) #1 was asked to continue working while waiting for additional staff. During this time, NA #1 cared for Resident #51. On [DATE] NA #1 tested herself at home for COVID-19, and the result was positive. On [DATE], Resident #51 was sent to the hospital due to COVID-19. As of [DATE], 32 residents and 12 staff members had tested positive for COVID-19. On [DATE] at 5:51 PM, the Administrator and Interim Director of Nursing (IDON) were notified of the IJ and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 5:05 PM. The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F880 remained at the lower scope and severity of widespread, with actual harm that was not immediate jeopardy for F880. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 (Resident #5, #9, and #60) of 3 residents reviewed for EBP. Findings included: 1. An undated facility policy titled, COVID-19, revealed the section titled 2. Monitoring Signs and Symptoms, indicated, b. These symptoms may appear ,d+[DATE] days after exposure (based on incubation period of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] virus): i. Fever ii. Cough iii. Shortness of breath or difficulty breathing iv. Myalgia v. Chills or repeated shaking with chills vi. Headache vii. Sore throat viii. Runny nose ix. Loss of taste or smell x. Nausea/vomiting xi. Diarrhea c. Emergency warning signs include: i. Trouble breathing ii. Persistent pain or pressure in the chest iii. New confusion or inability to arouse iv. Bluish lips or face. The policy revealed the section titled 3. Resident Assessment, indicated, a. Criteria to Guide Evaluation of Persons Under Investigation (PUI) for COVID-19. The policy revealed the section titled Clinical Criteria, indicated, At least one of the following symptoms: - cough - shortness of breath - difficulty breathing. The policy revealed the section titled 4. Staff and Visitor Screening if Community Wide COVID-19 Illness, indicated, b. If a staff member develops signs & [and] symptoms of a respiratory infection during work, the staff member needs to: i. immediately stop work & put on a facemask ii. Inform the Infection Preventionist of any individuals, equipment or locations the person came in contact 1. Contact & follow local health department recommendations for next steps (e.g. [exempli gratia; for example], testing, locations for treatment). An email from the Department of Public Health, dated [DATE], sent to the facility in response to the facility's report of COIVD-19 positive staff members revealed the following instructions, A single new case of SARS-CoV-2 infection in any HCP [health care provider] or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using broad-based approach regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed the Maintenance Director had symptoms starting on [DATE] including fever, myalgia, sore throat, upset stomach, and cramping. The list revealed the Maintenance Director tested positive for COVID-19 on [DATE]. On [DATE] at 1:07 PM, the Infection Preventionist (IP) stated the Maintenance Director became symptomatic during a shift, tested positive for COVID-19, and went home. The IP stated the Maintenance Director was at the facility for a few hours and due to him not feeling well he wore a mask while he was at the facility. The IP stated the Maintenance Director asked to be tested sometime into his shift, and he tested positive for COVID-19. The IP stated staff should stay home if they are not feeling well. The IP stated the Maintenance Director was at the facility before she came in to work, and the Maintenance Director should have requested a test earlier if he was not feeling well. On [DATE] at 2:52 PM, the IP stated the Maintenance Director had worked and fixed a window on [DATE]. On [DATE] at 3:57 PM, the Maintenance Director stated he worked at the facility every day. The Maintenance Director stated on [DATE] he had a sore throat, headache, low energy, and fever and sweats at night. The Maintenance Director stated on [DATE] he had started the day and did not feel well, and that morning he had done some general things inside and outside the building. The Maintenance Director stated he told his boss he was not feeling well, and the Infection Preventionist (IP) tested him. The Maintenance Director stated he tested positive, and he went home. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Nursing Assistant (NA) #1 had symptoms starting on [DATE] including cough, myalgia, chills, and headache. The list revealed NA #1 tested positive for COVID-19 on [DATE]. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated NA #1 tested positive for COVID-19 at home. On [DATE] at 1:07 PM, the IP stated NA #1 became symptomatic early in the morning, worked four hours, and was sent home. The IP stated NA #1 tested at home and sent a picture of the test from home. The IP stated she did not test NA #1 because NA #1 just said she was not feeling well. The IP stated it seemed like an isolated case, there were no other cases, and no one else had symptoms. On [DATE] at 9:17 AM, NA #1 stated she picked up a shift to work on [DATE]. NA #1 stated she started feeling weak with chills around 7:30 AM, and she told the scheduler. NA #1 stated the scheduler asked her to stay until 10:00 AM when other staff would be there. NA #1 stated she still felt bad on Saturday ([DATE]), so she tested herself and was positive. On [DATE] at 9:06 AM, NA #1 stated she had helped with Resident #51 on [DATE]. NA #1 stated Resident #51 was constantly trying to go out the doors, and the alarms would go off. NA #1 stated Resident #51 usually had one-to-one supervision. NA #1 stated no one was assigned to do one-to-one supervision with the resident that morning, so she was helping to keep Resident #51 from exiting. An Admission Record revealed the facility admitted Resident #51 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and Alzheimer's disease. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #51 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Resident #51 had symptoms on [DATE] including cough, myalgia, fatigue, and mucous. The list revealed Resident #51 tested positive for COVID-19 on [DATE]. A late entry nursing progress note, dated [DATE] at 10:00 AM, revealed Resident #51 had altered level of consciousness, weakness, cough, and behavioral symptoms. The note revealed Resident #51 was wandering throughout the building sneezing and coughing. The note revealed hospice recommended sending Resident #51 out for further evaluation. A nursing progress note, dated [DATE] at 11:38 AM, revealed Resident #51 tested positive for COVID-19 and was experiencing cough, congestion, blowing mucus in their hands, and spitting on the floor. The note revealed an ambulance was called to transport Resident #51 to a medical center. On [DATE] at 4:22 PM, the Infection Preventionist (IP) stated Resident #51 was not tested for COVID-19 on [DATE] because she thought it was just a cold. The IP stated Resident #51 was tested on [DATE]. On [DATE] at 1:43 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #51 wandered the halls. LVN #2 stated the morning Resident #51 was sent to the hospital the resident was coughing and sneezing phlegm. On [DATE] at 1:53 PM, LVN #3 stated on [DATE] Resident #51 slept most of the day. LVN #3 stated Resident #51 had days where the resident slept most of the day. LVN #3 stated the morning Resident #51 was sent out to the hospital the resident had nasal secretions, throat clearing, and was not their normal self. Registered Nurse (RN) #12, a hospice nurse, was interviewed on [DATE] at 8:36 AM about her visit with Resident #51 on [DATE]. RN #12 stated Resident #51 was lying down, seemed lethargic, and a family member was concerned Resident #51was not waking up. RN #12 stated Resident #51's roommate stated Resident #51 had been lying down since yesterday. RN #12 stated Resident #51 was coughing, but the cough was not a concerning cough for her. RN #12 stated Resident #51's lungs had rales (abnormal lung sounds). RN #12 stated she spoke to the nurse on the floor who stated Resident #51's usual behavior was sleep for long periods. RN #12 stated she told the floor nurse about the cough and rales for monitoring. RN #12 stated she was not aware Resident #51 was exposed to COVID-19 when a staff member tested positive, and that would have changed her decision to treat the resident. RN #12 stated she would have done a COVID-19 test and maybe even have started Resident #51 on an antibiotic, if the resident had tested COVID-19 positive. A handwritten COVID-19 testing log, dated [DATE], revealed staff and resident testing for COVID-19 began after Resident #51 tested positive for COVID-19. A handwritten COVID-19 testing log, dated [DATE], revealed 103 staff and residents were tested for COVID-19. A handwritten testing log, dated [DATE], revealed 92 staff and residents were tested for COVID-19. A handwritten testing log, dated [DATE], revealed four staff and residents were tested for COVID-19. On [DATE] at 8:30 AM, the IP stated COVID-19 started with the Maintenance Director being symptomatic on [DATE]. The IP stated that since there was only one staff member who tested positive, it was an isolated case, and she did not implement testing. The IP stated, on [DATE], another staff member tested positive, and she did not test any other staff or residents. The IP stated she did not start testing all staff and residents until Resident #51 tested positive on [DATE]. The IP stated two other residents tested positive on [DATE], and all staff and residents were tested . The IP stated all staff and residents were tested again on [DATE]. The IP stated on [DATE] she tested symptomatic staff and residents. On [DATE] at 11:51 AM, during a follow up interview, the IP stated she tested symptomatic residents and staff only on [DATE] due to testing supplies being expired. The IP stated she did not want to use outdated testing supplies. On [DATE] at 1:07 PM, the IP stated there were not many stores locally from which to get testing supplies. The IP stated with the amount they needed there was nowhere to get the supplies, and they would have emptied out the drug stores as there was only one big pharmacy in the area. The IP stated she started outbreak testing for COVID-19 if there were three or more cases as that was considered an outbreak. On [DATE] at 1:55 PM, the Interim Director of Nursing (IDON) stated outbreak investigation and testing would start with three or more staff or residents positive for COVID-19. The IDON stated if the facility was in outbreak, every resident and staff should be tested on day one, day three, and day five. The IDON stated the facility was currently in outbreak as there was one COVID-19 positive resident on each hall for a total of three residents. The IDON stated if staff were not feeling well prior to work they would stay outside and test prior to working. The IDON stated she was not aware there were no testing supplies for the fifth day of testing. The IDON stated she would have expected the IP nurse to contact her for guidance upon finding outdated testing supplies. The IDON stated she would have expected the IP to look up the information on the company website that supplied the equipment to find the true expiration date, and it had been her understanding that testing supplies could be used beyond the expiration date. On [DATE] at 2:21 PM, the Administrator stated testing should be done per CDPH's (California Department of Public Health) guidance. The Administrator stated an outbreak was considered three or more positives, and the testing schedule would be day one, day three, and day five during the outbreak. The Administrator stated all the residents and staff would be tested . The Administrator stated he was unaware there were no testing supplies available for the fifth day of testing, [DATE]. The Administrator stated there was a sister facility with which they could share supplies, and he was asked to bring testing supplies on [DATE]. On [DATE] at 5:16 PM, the IP stated she tested staff and residents if they showed enough symptoms of COVID-19 like a sore throat, fever, no taste, and diarrhea, for those symptoms that would signal COVID-19, or if someone told her they needed to be tested . The IP stated she would test if there were different signs than just a cold. On [DATE] at 11:40 AM, the IDON stated if someone had new signs or symptoms testing would be initiated immediately. 2. An undated facility policy titled, COVID-19, indicated, 7. PPE [personal protective equipment] a. Gloves i. Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. The policy revealed, b. Gowns i. Put on a clean isolation gown upon entry into the patient room or area. The policy revealed, c. Respiratory Protection i. Use respiratory protection (i.e. a respirator) that is at least as protective as a fit-tested NIOSH [National Institute for Occupational Safety and Health]-certified disposable N95 filtering facepiece respirator before entry into the patient room or care area. The policy revealed, d. Eye Protection i. put on eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. An Admission Record revealed the facility admitted Resident #21 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnosis of mild persistent asthma with acute exacerbation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A late entry nursing Progress Note, dated [DATE], indicated Resident #21 had a change of condition and tested positive for COVID-19 with signs and symptoms of being tired, weak, increased confusion, and drowsy. An Admission Record revealed the facility admitted Resident #22 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of encephalopathy and muscle weakness. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A nursing progress note, dated [DATE] at 5:52 PM, revealed Resident #22 tested positive for COVID-19 with signs and symptoms of feeling weak and a of temperature of 101.1 F (degrees Fahrenheit). An observation of Resident #21's and Resident #22's room, on [DATE] at 10:08 AM, revealed signage on the wall by the entry that indicated staff should wash their hands and make sure their eyes and nose were covered prior to entry. The observation revealed enhanced barrier precaution (EBP) signage on the door of the room requiring staff to wash their hands and wear gown and gloves. The observation revealed Housekeeper (HK) #4 inside the room replacing trash can liners, cleaning the bathroom, and mopping the floors. The observation revealed HK #4 had an N-95 mask and gloves on. During the observation HK #4 exited Resident #21's and Resident #22's room, without removing her gloves in the room, to get cleaning supplies from the housekeeping cart. The observation revealed HK #4 taking her gloves off and placing them in the trash can on her cleaning cart. At the time of the observation, HK #4 stated staff were required to wear a mask and gloves inside the room where Resident #21 and Resident #22 resided. HK #4 stated staff were only required to wear a gown if they were providing care to the resident. HK #4 stated PPE should be taken off once staff exited the room at the door and placed in a bag and taken to the storage room. During an observation and interview on [DATE] at 10:19 AM, HK #5 was observed to go into Resident #21's and Resident #22's room donning an N-95 mask. At the time of the observation, HK #5 stated the signage on the wall meant that staff were supposed to wear more PPE when inside the room. HK #5 stated, since the residents had COVID-19, staff should wear additional PPE including a facemask, gloves, and a gown when entering the room. HK #5 stated he should have had additional PPE on when entering the room. An observation and interview on [DATE] at 8:12 AM, revealed Licensed Vocational Nurse (LVN) #6 donning an N-95 mask and gloves in Resident #21's room while taking the resident's blood pressure reading. LVN #6 stated he should wear the mask and the gloves while in Resident #21's room, but he was not required to wear a face shield or a gown. After observing the signage at the door, LVN #6 stated he missed seeing the sign that said to cover the eyes, nose, and mouth. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated PPE required to enter an isolation room was a gown, gloves, goggles, and an N-95 mask. On [DATE] at 1:55 PM, the Interim Director of Nursing (IDON) stated staff going into COVID-19 positive rooms should don PPE prior to entering the room including a gown, gloves, an N-95 mask, and a face shield. On [DATE] at 2:21 PM, the Administrator stated staff should use the proper PPE including a gown, face shield, gloves, and a mask, and the N-95 mask was preferred. The Administrator stated staff should put PPE on at the entry of the room and should take the PPE off inside the room. 3. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Resident #21 tested positive for COVID-19 on [DATE], Resident #22 tested positive for COVID-19 on [DATE], Resident #24 tested positive for COVID-19 on [DATE], Resident #29 tested positive for COVID-19 on [DATE], Resident #47 tested positive for COVID-19 on [DATE], Resident #37 tested positive for COVID-19 on [DATE], and Resident #56 tested positive for COVID-19 on [DATE]. An observation on [DATE] at 9:12 AM of Resident #47's room revealed the room had no signage or personal protective equipment (PPE) bins outside the room. Resident #47's room should have had signage to ensure staff wore proper PPE inside the room of a resident with COVID-19. An observation on [DATE] at 10:08 AM of Resident #21's and Resident #22's room revealed signage on the door that indicated droplet precautions and to fully cover the eyes, nose, and mouth before room entry. The observation revealed enhanced barrier precaution (EBP) signage on the door that indicated staff must clean their hands and gown and glove only during certain care. An observation on [DATE] at 10:18 AM of Resident #37's and Resident #56's room revealed the room had signage indicating droplet precautions, but there was no signage to ensure staff wore a gown and gloves. An observation on [DATE] at 11:18 AM of Resident 24's room revealed the room had droplet precaution signage on the wall in the hallway by the door that indicated everyone must fully cover their eyes, nose, and mouth before room entry and to remove face protection before room exit. There was no signage observed to indicate staff should be in full PPE including a gown, gloves, an N-95 mask, and a face shield to enter the Resident #37's room. An observation on [DATE] at 11:25 AM of Resident #29's room revealed the door open and signage on the door requiring eyes and nose to be covered. There was no signage observed to indicate staff should be in full PPE including a gown, gloves, an N-95 mask, and a face shield prior to entering the room. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated COVID-19 positive residents were in isolation with signage outside their doors indicating proper PPE. The IP stated staff were required to wear proper PPE to enter an isolation room which was a gown, gloves, goggles, and an N-95 mask. On [DATE] at 11:02 AM, the Director of Staff Development (DSD) stated the proper signage for COVID-19 isolation rooms was droplet and contact precaution signs. 4. A facility policy titled, Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak), revised ,d+[DATE], revealed the section titled Objective indicated To prevent transmission of infectious agents through the inhalation of airborne particles or droplet nuclei. The policy revealed, 1. When N95 filtering facepiece respirators (FFR) are available and there is not an anticipated shortage, the facility operates under conventional capacity measures, including: The policy revealed, f. adopting just in time fit testing if feasible. On [DATE] at 8:12 AM, Licensed Vocational Nurse (LVN) #6 was observed donning an N-95 mask and gloves while taking a blood pressure reading for Resident #21 who was COVID-19 positive. LVN #6 stated he had not been fit tested for the N-95 mask. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated staff were required to wear a gown, gloves, goggles, and an N-95 mask inside rooms with positive COVID-19 residents. The IP stated not all staff had been fit tested for the N-95 masks. On [DATE] at 2:21 PM, the Administrator stated staff should use the proper PPE including gown, face shield, gloves, and a mask. The Administrator stated using an N-95 mask was preferable. The Administrator stated not all staff were fit tested for N-95 masks. On [DATE] at 5:06 PM, a Removal Plan was submitted by the facility and the accepted by the state survey agency. It read as follows: Magestic Mountain Care Center 1. How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; 4. How the facility plans to monitor its performance to make sure that solutions are sustained; Version 7, F880 01.1 Failed to Provide Testing Residents who were found to be COVID-19 Positive had their physician notified, obtained appropriate orders to treat their symptoms, and were placed on alert monitoring. On [DATE] the Infection Preventionist (IP) and designee initiated COVID-19 testing for all 53 Resident in house and staff members. 01.2 All Residents had the potential to be affected by the deficient finding. All Residents and staff will be tested on the first day, third day, and fifth day. If there are new cases, the testing will continue every three to seven days until there are no new cases for fourteen days. On [DATE], 3 new COVID-positive Residents were identified and placed on close monitoring by following COVID 19 protocol and monitoring for any change of condition pertaining to COVID 19. Resident identifier #215 Resident identifier #33 Resident identifier #53 On [DATE] one additional employee tested positive for COVID-19 and was removed from the schedule. 01.3 On [DATE] the Interim Director of Nursing (DON) reeducated the IP and staff with an in-service on the following: - COVID-19 testing guidelines and the importance of compliance with testing and ensuring adequate supplies of testing kits to prevent the spread of COVID 19. -Donning and doffing with proper personal protective equipment (PPE) - N-95 fit-testing protocols. Any staff not on duty at the time of the in-service will be educated by the IP or Designee prior to the start of their next shift. The IP/Designee will post a schedule of staff required to COVID 19 test at least one day prior to the testing date. The staff posting will be next to the time clock. This will also be followed up with a group text message. Any staff reporting back on duty will need to be tested for COVID-19 prior to the beginning of their next shift. On [DATE] the DON and designee educated the staff with an in-service about the signs and symptoms of COVID-19. If staff identifies any symptoms from residents or themselves, they must report it to the IP or designee as soon as possible. Any reported symptoms from residents or staff must result in the immediate administration of a COVID test. 01.4. The IP/Designee will report the COVID-19 testing results at the next daily stand-up meeting. They will then follow-up the announcement with the appropriate corrective action. The DON will audit the IP/Designee testing process on day one, day three, and day five to ensure that the residents and staff were tested for COVID-19. Any deficiencies will be corrected immediately, and the Administrator will be notified. The Administrator will review the plan of correction and submit all findings of non-compliance to the Quality Assessment and Assurance (QAA) committee. The QAA Committee shall review and monitor the effectiveness of this Plan of Correction monthly through [DATE]. The identified deficient practice was the IP's failure to adhere to the protocol of testing residents and staff on day one, day three, and day five. The deficient practice has been corrected subsequent to the findings. 2.1 Proper PPE On [DATE] an IP from one of our sister facilities provided an in-service training to 40 out of 84 active staff on the following: - The guidelines for COVID-19 testing and the importance of compliance, including ensuring the adequacy of testing kit supplies to prevent the spread of COVID-19. -Donning and doffing with proper PPEs -[DATE] the IP from sister facilities initiated the skills competency validation for staff, ensuring the proper donning and doffing of PPE. -N-95 fit testing protocols. Any staff out on leave of absence (LOA) will be educated by the IP or designee prior to the start of their next shift. The IP or designee will provide an in-service to the remaining staff that were not in-serviced on [DATE]. The Administrator/DON will verify that the remainder of the staff are educated with an in-service training. 2.2 All Residents had the potential to be affected by the found deficiencies. All Residents and staff will be tested on the first day, third day, and fifth day. If there are new cases, the testing will continue every three to seven days until there are no new cases for 14 days. The DON/Designee shall conduct random observations of at least three staff members each week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved. Annual competency-tests for doffing and donning are to be completed by all staff. On [DATE], three additional residents tested positive for COVID-19 and were placed on close monitoring for any change of condition. Resident identifier #215 Resident identifier #33 Resident identifier #53 On [DATE] one additional employee tested positive for COVID-19 and was removed from the schedule. On [DATE], the IP from our sister facility initiated the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE. On [DATE], the IP from our sister facility will complete the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE. 2.3 On [DATE] the DON in-serviced and reeducated the IP on the following: - COVID-19 testing guidelines, emphasizing the importance of compliance and ensuring adequate supplies of testing kits to prevent the spread of COVID-19. -Donning and doffing with proper PPEs -N-95 fit testing protocols. The IP/Designee will complete a skills competency validation for newly hired staff on the proper donning and doffing of appropriate PPE during orientation. On [DATE], the IP from our sister facility initiated skills competency validation for staff on the proper donning and doffing of PPE. 2.4 The DON/Designee will conduct random observations of at least three staff members per week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved. Any findings will be corrected immediately, and the administrator will be notified. The administrator will submit all non-compliance findings related to the plan of correction to the Quality Assessment and Assurance (QAA) Committee. The QAA Committee will review and monitor the effectiveness of this plan of correction monthly through [DATE]. 3.1 Proper Signage On [DATE], the IP updated the signage for the five rooms of residents with COVID-19. 3.2 All residents had the potential to be affected by the identified deficiency. On [DATE], three

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents with pressure ulcers received treatment and services in accordance with professional standards of practice, to promote healing and prevent deterioration for 3 (Residents #15, #5, and #46) of 3 sampled residents reviewed for pressure ulcers. Specifically, the facility failed to: - Accurately and consistently assess and document the appearance, stage, and complete measurements of pressure ulcers at least weekly to facilitate the ability to promptly identify deterioration or track healing progress of pressure ulcers for Residents #15, #46, and #5. - Consult with the physician to obtain appropriate pressure ulcer treatment orders when nursing staff noted a decline or deterioration in Resident #15's pressure ulcers and when a new Stage III pressure ulcer was identified for Resident #15. - Obtain pressure ulcer treatment orders to cover all dates when pressure ulcer treatments were needed for Resident #5. - Ensure wound treatments were consistently provided and documented for Residents #15, #46, and #5. - Notify the Registered Dietitian (RD) to obtain nutritional recommendations to facilitate wound healing for Resident #15 and Resident #46. The failures resulted in delayed healing and deterioration of Resident #15's Stage III pressure ulcers to the right and left buttocks and had the likelihood to cause delayed healing, deterioration, or infection of pressure ulcers for Resident #46 and Resident #5. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 Pressure Ulcers at a scope and severity of K. The IJ began on 04/25/2024 when nursing staff noted a decline in the condition of Resident #15's pressure ulcers and failed to consistently assess the wounds, consult with the physician to obtain appropriate treatment orders, and consistently provide pressure ulcer treatments to promote wound healing. The Administrator and Interim Director of Nursing (IDON) were notified of the IJ on 08/03/2024 at 1:30 PM and were provided the IJ template at 1:43 PM. A removal plan was requested. The removal plan was accepted by the State Survey Agency (SSA) on 08/06/2024 at 3:50 PM. The IJ was removed on 08/06/2024 at 6:30 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of isolated harm that was not immediate jeopardy for F686. Findings included: A facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 04/2018, specified, Assessment and Recognition 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. The policy also indicated, Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc. [et cetera]), and application of topical agents. The policy indicated, Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. An Admission Record indicated the facility admitted Resident #15 on 07/28/2022. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, obesity, and bilateral above the knee amputations. The Admission Record revealed diagnoses of Stage III pressure ulcers to the left and right buttocks were added to the resident's list of diagnoses on 07/19/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had two Stage III pressure ulcers, one of which was present upon admission. The MDS also revealed Resident #15 had moisture-associated skin damage. Per the MDS, the resident had treatments for pressure ulcers that included a pressure reducing device for the bed, a nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care. Resident #15's care plan included a focus area revised 08/16/2023 that indicated the resident had a recurring Stage III pressure ulcer to the left buttock due to being bedfast, incontinent of bowel, obesity, edema, and a history of a previous ulcer. Interventions directed staff to provide nutritional and hydration support (initiated 02/01/2023); provide a pressure reduction/relieving mattress (initiated 02/01/2023); provide treatment as ordered (revised 05/01/2024); and turn and reposition the resident per schedule (revised 05/01/2024); however, the care plan revealed the resident was noncompliant with repositioning. Resident #15's care plan revealed no focus area for the Stage III pressure ulcer to the right buttock was added to the care plan until 08/03/2024 (during the survey). Interventions initiated 08/03/2024 directed staff to evaluate the need for a pain reliever prior to cleansing or dressing changes, provide treatment as ordered, and perform weekly wound assessments. Resident #15's care plan included a focus area, initiated 08/05/2022 and revised 07/31/2024, that indicated the resident was at risk for altered nutritional status and dehydration related to pressure injuries (ulcers). The care plan indicated on 08/05/2022, the dietitian documented a wound was present and nutritional estimates of protein, calories, and hydration had been made. An intervention initiated by the dietitian on 12/08/2022 directed staff to provide Prostat (protein supplement) daily. Resident #15's Progress Notes, dated 04/17/2024, revealed a Weight and Skin Review was documented by the RD. The notes revealed the RD reviewed Weekly Skin Reviews, dated 04/11/2024, that revealed the resident had a Stage III pressure ulcer to the left buttock that measured 6.3 centimeters (cm) in length by (x) 0.6 cm in width x 0.1 cm in depth and a Stage III pressure ulcer to the right buttock that measured 1.7 cm in length x 0.5 cm in width x 0.1 cm in depth. The notes revealed the resident was receiving ProMod (protein supplement) once per day and ascorbic acid (vitamin C supplement). Per the notes, the RD recommended adding zinc sulfate (zinc supplement) for 14 days to promote wound healing. The notes revealed the goal was for skin improvement by the next review. There was no documented evidence the RD assessed Resident #15's nutritional status again until 07/31/2024, after the survey was initiated. Resident #15's Order Recap Report, printed 08/02/2024, revealed physician orders were initiated on 03/28/2024 to clean the recurrent Stage III pressure ulcer to the left superior buttock and the recurring Stage III pressure ulcer to the right buttock with normal saline, pat the area dry, apply Calmoseptine (a moisture barrier/skin protectant) and Vaseline/A&D Ointment (treats and prevents skin irritation) to the wound bed, and cover the area with a non-adherent dressing every shift for 21 days. The report revealed that order's end date was 04/04/2024, after which the physician ordered the same treatment again, beginning on 04/04/2024 and ending on 04/11/2024. The same order was repeated beginning 04/11/2024 and ending 04/18/2024. The same treatment order was repeated beginning on 04/18/2024 and ending 04/25/2024. The same treatment order was repeated beginning 04/25/2024 and ending 05/16/2024. The Order Recap Report contained no evidence the resident had a physician's order to treat a pressure ulcer to the left inferior buttock. Weekly Wound Reviews completed in April 2024 for Resident #15's left buttock pressure ulcer revealed the following: - The Weekly Wound Review, dated 04/04/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound measuring 6.3 cm in length x 0.6 cm in width x 0.1 cm in depth. The review indicated the wound base was comprised of 90% epithelial tissue and 10% red granulation tissue. - The Weekly Wound Review, dated 04/18/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound. The length had decreased to 3.2 cm; however, the width had increased to 1.7 cm. The depth remained 0.1 cm. The review indicated the wound base was comprised of 50% pink epithelial tissue (decreased from 90%) and 50% red granulation tissue (increased from 10%). - The Weekly Wound Review dated 04/25/2024 indicated Resident #15's left buttock pressure ulcer was a Stage III wound that measured 3.0 cm in length. The width of the wound had increased to 2.4 cm. The depth remained 0.1 cm. The review revealed the wound base was comprised of 75% pink epithelial tissue and 25% red granulation tissue. The review indicated Calmoseptine cream was unavailable for three weeks and the pressure ulcer declined in that time. The section of the Weekly Wound Review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by Licensed Vocational Nurse (LVN) #17. The surveyor attempted to contact LVN #17 for a telephone interview on 08/03/2024 at 11:18 AM and 08/05/2024 at 3:21 PM and left two voice mail messages requesting a return call. LVN #17 did not return the surveyor's call as of the survey exit date (08/07/2024). Resident #15's April 2024 Treatment Administration Record (TAR) revealed no documented evidence the pressure ulcer treatment for the left buttock pressure ulcer was provided as scheduled on eight occasions during the month, on 04/03/2024 night (PM) shift, 04/04/2024 day (AM) shift, 04/05/2024 AM shift, 04/11/2024 AM shift, 04/18/2024 AM shift, 04/25/2024 AM shift, 04/29/2024 AM shift and 04/30/2024 PM shift. According to the TAR, staff documented the pressure ulcer treatment, which included Calmoseptine, was provided all other days as scheduled, and there was no indication the Calmoseptine was not available. Weekly Wound Reviews completed in April 2024 for Resident #15's right buttock pressure ulcer revealed the following: - The Weekly Wound Review dated 04/04/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 1.7 cm in length x 0.5 cm in width x 0.1 cm in depth. The review indicated the wound bed was comprised of 100% granulation tissue. - The Weekly Wound Review dated 04/25/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 6.1 cm in length x 2.5 cm in width x 0.2 cm in depth. The review revealed the wound base was comprised of 75% epithelial tissue and 25% granulation tissue. The review also indicated the Calmoseptine cream was unavailable for three weeks and that the pressure ulcer had declined in that time. The section of the review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by LVN #17. The surveyor attempted to contact LVN #17 for a telephone interview on 08/03/2024 at 11:18 AM and 08/05/2024 at 3:21 PM and left two voice mail messages requesting a return call. LVN #17 did not return the surveyor's call as of the survey exit date (08/07/2024). Resident #15's April 2024 TAR revealed no documented evidence the right buttock pressure ulcer treatment was provided as scheduled on eight occasions during the month, on 04/03/2024 night (PM) shift, 04/04/2024 day (AM) shift, 04/05/2024 AM shift, 04/11/2024 AM shift, 04/18/2024 AM shift, 04/25/2024 AM shift, 04/29/2024 AM shift and 04/30/2024 PM shift. According to the TAR, staff documented the treatment, which included Calmoseptine, was provided all other days and there was no indication Calmoseptine was not available. After the Weekly Wound Reviews dated 04/25/2024 for the left superior buttock and right buttock pressure ulcers, there was no further documentation of assessments of Resident #15's pressure ulcers until 05/23/2024, approximately one month without a documented assessment. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 indicated the following regarding a newly identified Stage III pressure ulcer to Resident #15's left inferior buttock area: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated Resident #15 had developed a new a Stage III pressure ulcer to the left inferior buttock that measured 1 cm in length x 1 cm in width. The depth measurement was left blank. The report revealed the wound had 100% epithelialization. The report indicated the treatment being provided was the same as the other pressure ulcers, which included cleaning the wound with normal saline, patting the area dry, applying Calmoseptine and Vaseline/A&D Ointment, and covering the area with a non-adherent dressing. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the facility notified the physician of a new pressure ulcer to the left inferior buttock. - According to a Weekly Pressure Injury/Ulcer Progress Report dated 05/30/2024, the Stage III pressure ulcer to the left inferior buttock measured 1.1 cm length by 1 cm width, with no depth documented. The report indicated the wound was red but provided no other information about the appearance of the wound. The report indicated the treatment with Calmoseptine /Vaseline continued. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 revealed the following regarding the Stage III pressure ulcer to Resident #15's left superior buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated the Stage III pressure ulcer to the left superior buttock measured 5.5 cm in length x 2.9 cm in width, with no depth measurement provided. The wound had increased in length and width since the most recent documented assessment on 04/25/2024, yet the report indicated the wound had 100% epithelialization. The treatment was to clean the wound with normal saline, pat dry, apply Calmoseptine/Vaseline, and cover with a non-adherent dressing. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the resident's physician was notified of the increase in size of the pressure ulcer to the left superior buttock. - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/30/2024, indicated the pressure ulcer to Resident #15's left superior buttock measured 5.5 cm in length x 2.7 cm in width, with no depth measurement recorded. The report indicated the wound was red and had no undermining/tunneling; however, there was no other documentation regarding the appearance or stage of the wound. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 revealed the following regarding the pressure ulcer to Resident #15's right buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated Resident #15 had a Stage III pressure ulcer to the right buttock that measured 3 cm in length x 0.5 cm in width, with no depth measurement provided. The report revealed the wound was pink and had 100% epithelialization with no drainage/odor or pain. The treatment was to clean the wound with normal saline, pat dry, apply Calmoseptine/Vaseline, and cover with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/30/2024, indicated Resident #15 had a Stage III pressure ulcer to the right buttock that measured 3.1 cm in length x 0.8 cm in width, with no depth measurement provided. The report indicated the wound was red but provided no other information about the appearance or stage of the wound. Resident #15's Order Recap Report revealed treatment orders to the left superior buttock and right buttock Stage III pressure ulcers with Calmoseptine and Vaseline/A&D ointment ended on 05/16/2024, and there were no further orders to treat the left superior and right buttock pressure ulcers until 05/20/2024 when an order was written to clean the pressure ulcers with warm water, dry the area, apply Calmoseptine and Vaseline ointment, and cover the area with a non-adherent dressing every (day and night shift). Resident #15's May 2024 TAR revealed no documented evidence treatment was provided to the pressure ulcer to the left inferior buttock in May 2024. The TAR revealed no documented evidence treatment was provided to the left superior or right buttock pressure ulcers on 05/04/2024 during the PM/night shift. Further review of the TAR revealed no treatment orders for the pressure ulcers to the right, left inferior, or left superior buttocks from the evening/night shift on 05/16/2024 until the evening/night shift on 05/20/2024. Consequently, there was no documented evidence a treatment was provided to the pressure ulcers on those dates. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding a newly identified pressure ulcer to Resident #15's left sub-inferior buttock: - A Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, indicated Resident #15 had developed a new pressure ulcer to the left sub-inferior buttock that measured 0.4 cm in length x 0.5 cm in width, with no depth measurement provided. The report indicated the wound was red, had no drainage/odor, no pain, and no tunneling/undermining. No further information was documented regarding the type of tissue present in the wound bed, the appearance, or the stage of the wound. The report revealed the treatment being provided was to clean the wound with normal saline, pat the area dry, apply Medi-honey (an agent used for healing and removal of dead tissue), and cover the area with a non-adherent dressing. The physician notification portion of the form was not completed, and Resident #15's health record revealed no documented evidence the resident's physician was notified the resident had developed a new pressure ulcer to the left sub-inferior buttock. - A Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, indicated the pressure ulcer to Resident #15's left sub-inferior buttock had increased in size to 1.1 cm in length x 0.5 cm in width, with no depth measurement provided. The treatment information on the report did not reference the prior instructions to apply Medi-Honey to the wound; instead, the report indicated the wound was being treated by cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's left superior buttock area: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024 revealed the left superior buttock pressure ulcer measured 4 cm in length x 2.4 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, with no drainage/odor, pain, or undermining. The report did not indicate the stage or any other description of the wound. The report indicated the treatment was to clean with normal saline, pat dry, apply Medi-Honey, and cover with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024 for the pressure ulcer to the left superior buttock, revealed the wound measured 3.5 cm in length x 2 cm in width, with no depth measurement provided. The report indicated the pressure ulcer tissue was red and necrotic, and the wound had no drainage/odor, no pain, and no tunneling/undermining. There was no other documentation regarding the appearance or stage of the wound. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's left inferior buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, revealed the pressure ulcer to the left inferior buttock measured 1.3 cm in length x 1 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report indicated the wound treatment consisted of cleaning with normal saline, patting dry, applying Medi-Honey, and covering with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, revealed the pressure ulcer to Resident #15's left inferior buttock measured 2 cm in length x 1 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's right buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, revealed the pressure ulcer to the right buttock measured 1.9 cm in length x 0.6 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report indicated the wound treatment consisted of cleaning with normal saline, applying Medi-Honey, and covering with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, revealed the pressure ulcer to the right buttock measured 1.3 cm in length x 0.4 cm in width, with no depth measurement provided. The report indicated the pressure ulcer tissue was red and necrotic, and the wound had no drainage/odor, no pain, and no tunneling/undermining. There was no further documentation regarding the appearance or stage of the wound. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Resident #15's Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, indicated the pressure ulcer to the left inferior buttock measured 2 cm in length x 1 cm in width, with no depth measurement given. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/20/2024, indicated Resident #15 had multiple wounds to the left buttock with a total measurement of 9.3 cm in length x 2.2 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wounds had no drainage/odor, no pain, and no tunneling/undermining. No other information was provided regarding the appearance or stage of the wound. The report revealed the pressure ulcers continued to be treated by cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering with a non-adherent dressing. The physician notification portion of the report was not completed, and there was no documented evidence the physician was notified that the left buttock now had multiple wounds with an overall increase in size. Weekly Pressure Injury/Ulcer Progress Reports, dated 06/20/2024, indicated Resident #15 had a pressure ulcer to the right outer buttock that measured 0.6 cm in length by 0.5 cm in width (no depth measurement provided) and a pressure ulcer to the right inner buttock that measured 1 cm in length x 0.4 cm in width (no depth measurement provided). The reports indicated both pressure ulcers were red and necrotic with no drainage/odor or tunnelling/undermining. The reports contained no other description of the appearance or stage of the wounds. The reports revealed both pressure ulcers were being treated by cleaning with normal saline, patting dry, applying Calmoseptine, and covering with a non-adherent dressing. The physician notification sections of the reports were not completed, and there was no documented evidence the physician was notified of the development of an additional pressure ulcer to the right buttock. Resident #15's Order Recap Report revealed an order started on 06/20/2024 to treat the recurring Stage III pressure injury to the right buttock. The order did not specify whether the treatment order was for the right inner or outer buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, indicated Resident #15 the multiple open areas to site on the left buttock. The report did not include individual measurements for each wound or open area and indicated an overall measurement of 10 cm length by 7 cm width, with no depth measurement provided. This indicated an increase in the length and width of the pressure ulcers. The report indicated the wound was red and necrotic, had no drainage/odor, no pain, and no tunneling/undermining, but provided no other information about the appearance or stage of the wounds. The report revealed the treatment to the pressure ulcer continued to be cleaning the area with normal saline, patting the area dry, and applying Calmoseptine. The report indicated the treatment now included applying a non-adherent foam dressing. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, indicated Resident #15 now had multiple wounds to the right buttock; however, the report did not include individual measurements for each wound. The report indicated a measurement of 2.5 cm length by 1.9 cm width, with no depth measurement provided. The report indicated the wound was red and necrotic, with no drainage or odor, no pain, and no tunneling, but no other information about the appearance of the wound, including the stage. The report revealed the treatment to the pressure ulcer to the right buttocks continued to be cleaning the area with normal saline, patting the area dry, and applying Calmoseptine. The report indicated the treatment now included applying a non-adherent foam dressing. Resident #15's June 2024 TAR revealed the following: - Treatment instructions for the left buttock healing STG [stage] 3 pressure ulcer to the left buttock (specific location on buttock not documented) indicated the wound was to be cleaned with warm water and dried, then Calmoseptine and Vaseline ointment were to be applied and the wound was to be covered with a non-adherent dressing every shift. The TAR indicated this treatment started on 06/01/2024 and continued through the day shift on 06/06/2024. No treatment was documented as having been provided on the night shift on 06/06/2024, and the next treatment protocol was not initiated for the left buttock until the night shift on 06/07/2024. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, the Medi-Honey and a non-adherent dressing were to be applied every day and night shift for 21 days. The TAR indicated this treatment was initiated on the night shift on 06/07/2024 and continued through the night shift on 06/12/2024. The treatment scheduled on the day shift on 06/13/2024 was not initialed by a nurse as having been provided. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent dressing were to be applied one time daily for 21 days. The TAR indicated this treatment started on 06/13/2024 and continued through 06/26/2024. There was no documentation any treatment was provided to the left buttock pressure ulcer on 06/27/2024, and the next treatment protocol was not initiated until 06/28/2024. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adhesive foam dressing were to be applied one time daily for 21 days. The TAR indicated this treatment started on 06/28/2024 and continued through the end of the month. - Treatment instructions for the right buttock healing STG [stage] 3 pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with warm water and dried, then Calmoseptine and Vaseline ointment were to be applied, and the wound was to be covered with a non-adherent dressing every day and night shift. The TAR indicated this treatment was provided twice daily beginning 06/01/2024 and continuing through the day shift on 06/06/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Medi-Honey and a non-adherent dressing were to be applied every day and night shift for 21 days. The TAR indicated this treatment was provided twice daily beginning with the night shift on 06/07/2024 and continuing through the evening shift on 06/12/2024. The scheduled treatment for the day shift on 06/13/2024 was not initialed by a nurse as having been provided, and a new treatment protocol was initiated for wound treatments once daily on 06/13/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent dressing were to be applied once daily. The TAR indicated this treatment was provided daily from 06/13/2024 through 06/26/2024. No treatment was initialed as provided on 06/27/2024, and the next treatment protocol was not initialed as having been initiated until 06/28/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent foam dressing were to be applied once daily for 21 days. The TAR indicated this treatment was provided daily beginning on 06/28/2024 and continued through the end of the month. The Order Recap Record revealed orders to treat the pressure ulcers daily with Calmoseptine were discontinued on 06/27/2024, and another order for treatment was dated as ordered 06/27/2024; however, the Order Recap Record indicated the new treatment was not started until 06/28/2024. After the Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, Resident #15's health record contained no documented evidence the facility assessed the resident's pressure ulcers again until 07/11/2024, which was a period of 14 days with no assessment documented. Weekly Pressure Injury/Ulcer Progress Reports for July 2024 revealed the following regarding the pressure ulcer to Resident #15's left buttock: - A Weekly Pressure Injury/Ulcer Progress Report, dated 07/11/2024, indicated the site of the pressure ulcer was L [left] buttock. No [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse (intentional bodily injury) for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 4 was witnessed by CNA 1, CNA 2, and Environmental Services Supervisor (EVS) to use physical contact to force Resident 1 to walk to the dining room to have lunch on 6/6/22. Resident 1 verbally told CNA 4 he did not want to go to the dining room. CNA 4 pushed Resident 1 from behind in an effort to force Resident 1 to walk to the dining room. These failures resulted in the physical abuse of Resident 1, Resident 1 falling onto his face and left shoulder in an avoidable fall caused by the physical abuse and fracture of the left humerus (a break of the upper part of the bone of the arm close to the shoulder joint) with avoidable pain and suffering and loss of mobility. Findings: During a concurrent observation and interview, on 6/22/22, at 10:41 a.m., Resident 1 was lying in bed with his left arm resting to his side. Resident 1 stated, he slid in the hall and hurt his left arm and wore a sling to his left arm. During a review of Resident 1's admission Record, dated 6/22/22 , the admission Record indicated, Resident 1 was admitted on [DATE] and had diagnoses including: Dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Cognitive Communication Deficit (condition that interferes with a person's ability to mentally process their communication with others), and Vitamin D Deficiency (not enough fat-soluble vitamin that plays an important role in maintenance and repair of bone tissue). During a review of Resident 1's 'Progress Notes (PN) dated 6/6/22, at 1:36 p.m., the PN indicated, .Event type: witnessed fall .Resident shoe stuck to the floor and res (Resident 1) went forward on to his knees and then to his left shoulder, in the double doors by the activity room, C/O (complain of) left shoulder pain .MD notification .rec (received) n/o (New orders) for left shoulder x-Ray (A specialized imaging study that can diagnose and view bones and other internal body structure) .would not move left arm or allow palpitation . During a review of the Resident 1's Radiology Results Report, dated 6/7/22, the Radiology Results Report indicated .SHOULDER COMPLETE, MIN (minimum)2V [Views] LEFT .Findings: There is an acute appearing mildly displaced fracture [the pieces of the bone moved so much that a gap formed around the fracture (broken bone)] of the proximal humerus neck (the portion near the arm's attachment to the body.) with associated involvement of the greater tuberosity (bony bump in the shoulder area) .CONCLUSION: Proximal humerus fractures described . During a review of Resident 1's 'PN dated 6/6/22, at 12:15 p.m., indicated, .Resident (Resident 1) will not move the left arm. Resident (1) is guarding and grimaces with any movement and touch .Resident (1) has blue discolored area on his inner deltoid . During a review of Resident 1's PN dated 6/7/22, at 9:41 a.m., indicated, .Full Range of Motion (the capability of a joint to go through its complete spectrum of movements) Assessment Findings .[NAME] [move all extremities (a limb of the body, such as the arm or leg) except is favoring left arm and will barely move it. Swelling noted to left shoulder .Pain level: 5-6 (pain scale 0-10-0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) . During an interview on 6/22/22, at 11:00 a.m., with CNA 2, CNA 2 spoke with tears in her eyes when she recalled Resident 1's fall. CNA 2 stated on 6/6/22, she saw CNA 4 walk into Resident 1's room from the dining room and overheard CNA 4 telling Resident 1 You are not a baby; you need to come with me to the dining room to eat lunch. CNA 2 stated she witnessed CNA 4 pushing Resident 1 from behind to speed him up. CNA 2 stated Resident 1 yelled out No, no, no! CNA 2 stated she saw CNA 4 fall on top of Resident 1. CNA 4 stated Resident 1 fell face forward on his knees. During an interview on 6/22/22, at 11:05 a.m., with EVSS, the EVSS stated Resident 1 wanted to eat lunch in his room on 6/6/22. EVSS was waiting for the trays to arrive and was talking with Resident 1. EVS stated Resident 1 was laughing when CNA 4 walked into Resident 1's room, grabbed Resident 1 by his feet, sat him up and pulled him up to a standing position. EVSS stated CNA 4 grabbed Resident 1's armpits to push him to walk. EVSS stated Resident 1 said no, no, no as he was being pushed down the hall EVSS told CNA 4 You need to stop what you're doing, [NAME]! EVSS stated CNA 4 paused for a second then continued to shove Resident 1 approximately twenty feet. EVSS stated Resident 1 fell to his knees and elbows, face down, and CNA 4 fell on top of Resident 1 with one knee on ground in between Resident 1's legs. The EVS stated, after he reported the incident to DON, he went to Resident 1's room. EVS stated, Resident 1 was in bed, and he was in pain. EVS stated after the incident he was using wheelchair and did not talk like Resident 1 use to talk before the accident. During a concurrent interview and record review on 6/22/22 at 11:45 a.m., with the Assistant Director of Nursing/Minimum Data Set Coordinator (ADON/MDSC) Resident 1's Minimum Data Set (MDS - a standardized assessment tool), dated 2/18/22 was reviewed, the MDS indicated, Resident 1 had severe memory and judgement impairments. The ADON/MDSC stated Resident 1 was able to walk and transfer with one person assistance before the fall. The ADON/MDSC stated Resident 1 walked with a shuffled gait. The MDSC stated CNA 1 came into her office and told the ADON/MDSC, CNA 4 rushed Resident 1 down the hall without patience and caused Resident 1 to lose his balance by pushing him. The MDSC stated the injury to Resident 1 was preventable. During a concurrent interview and record review on 6/22/22, at 2:50 p.m., with Director of Staff Development (DSD) 1, CNA 4's personnel file was reviewed. The personnel file indicated CNA 4 was initially suspended pending the findings of the investigation n regarding Resident's 1 fall occurred on 6/6/22. The DSD 1 stated CNA 4 was terminated because the investigation found CNA 4 pushed Resident 1 causing his fall and injury to his left arm. During a phone interview on 6/23/22, at 12:44 p.m., with CNA 4, CNA 4 stated he was working in the dining room and went to get Resident 1 to eat lunch. CNA 4 stated he guided Resident 1 towards the door of his room. CNA 4 stated Resident 1 held on to the doorway. CNA 4 stated when he took Resident 1's hand off the door, Resident 1 stumbled. CNA 4 stated Resident 1 fell on the ground and then he tripped and fell on top of Resident 1. CNA 4 stated, It was awful. CNA 4 stated Resident 1 fell on his left shoulder. During a phone interview on 6/28/22, at 10:01 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a fall on 6/6/22 in the hall. LVN 1 stated Resident 1 fell in front of her med (medication) cart near the double doors to the dining room. LVN 1 stated she witnessed the fall. LVN 1 stated Resident 1 fell forward on his knees and fell to his left side. LVN 1 stated CNA 4 fell on top of Resident 1. LVN 1 stated Resident 1 complained of pain to his left shoulder. LVN 1 stated Resident 1 was given [Acetaminophen (pain medication used to treat minor aches and pains, and reduces fever)], and ice was placed on Resident 1's left shoulder. LVN 1 stated Resident 1's physician also ordered an X ray for his left shoulder. LVN 1 stated Resident 1's X-ray result showed a left arm fracture. During a phone interview on 6/28/22, at 3:12 p.m., with the Administrator (ADM), the ADM stated Resident 1's fall investigation started on 6/6/22. The ADM stated she took over the investigation on 6/8/22 but had to start over because the DON left for vacation on 6/7/22. The ADM stated the DON did not give her any details about Resident 1's injury. ADM stated there was a lack of communication between her and the DON which delayed the reporting of Resident 1's injury and allegation of abuse to the local ombudsman program and Survey State Agency. The ADM stated she asked CNA 4 about the incident. The ADM stated CNA 4 thought Resident 1's injury was not a big deal. The ADM stated she thought Resident 1's injury was accidental at first. The ADM stated when the investigation was completed, CNA 4 was terminated because the witnesses (CNA 1, CNA 2 and EVS) saw CNA 4 push Resident 1 which caused Resident 1's fall and sustained a physical injury. During a phone interview on 11/16/22, at 2:00 p.m., with the DSD 2, the DSD 2 stated, the staff was trained, how to handle residents who were resistant and say no to a request for assistance during the Dementia and resident's rights training. DSD 2 stated, it was everyone's responsibility to ensure the residents were free from abuse. DSD 2 stated, CNA 4 should have respected the resident's preference to eat lunch in his room. During a phone interview on 11/16/22, at 3:45 p.m., with the ADM, the ADM stated, everyone was mandated reporter and should report abuse immediately. ADM stated the expectation for staff was to respect residents' rights and should have left Resident 1 in his room for lunch. ADM stated, Residents has freedom to do what they want. During a review of Resident 1 ' s PN, dated 6/21/22 at 11:26 a.m., the PN indicated, .Res (Resident 1) cont (continued) to c/o (Complain of) left shoulder pain s/p (is a term used in medicine to refer to a treatment (often a surgical procedure), diagnosis or just an event, that a patient has experienced previously) fall and FX (fracture) to left shoulder. Tyle #3 (Acetaminophen-Codeine #3 -pain medication for moderate/severe pain) given as needed . During a review of Resident 1 ' s PN, dated 6/22/22 at 5:43 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/24/22 at 10:30 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/25/22 at 8:22 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/26/22 at 8:59 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/28/22 at 9:44 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/1/22 at 10:01 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/2/22 at 9:31 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/4/22 at 2:03 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/6/22 at 3:11 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/7/22 at 9:46 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/8/22 at 10:07 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/10/22 at 10:16 a.m., the PN indicated, .Resident (Resident 1) has fracture left arm and need to wear sling [a device used to support and keep still (immobilize) an injured part of the body)] at all times . During a review of Resident 1 ' s PN, dated 7/12/22 at 12:31 a.m., the PN indicated, .Wear a sling to support and stabilize left shoulder at all times until further notice. Every shift for proximal humerus fracture . During a review of Resident 1 ' s Medication Review Report (MRR), dated 6/6/2022 to 7/6/2022, the MRR indicated, .Order summary .Wear sling to support and stabilize left shoulder at all times until further notice, every shift for proximal humerus fracture .order date .6/7/2022 During a review of Resident 1 ' s Medication Review Report (MRR), dated 6/6/2022 to 7/6/2022, the MRR indicated, .Order summary .Acetaminophen-Codeine #3 tablet give 1 tablet by mouth every 8 hours as needed for pain .order date .6/7/2022 . During a review of Resident 1 ' s Medication Administration Record (MAR) dated 6/1/22 to 6/30/22, the MAR indicated, Acetaminophen-codeine #3 was administered to Resident 1 from 6/6/22 to 6/18/22, 6/20/22 to 6/22/22, 6/26/22 to 6/28/22 and 6/30/22 for pain level from 3 to 9 [a scale (0-10) used to measure pain- 0-3 mild pain, 4-7 moderate pain and 8 to 10 severe pain). During a review of Resident 1 ' s Medication Administration Record (MAR) dated 7/1/2022 to 7/31/2022, the MAR indicated, Acetaminophen-codeine #3 was administered to Resident 1 from 7/1/22 to 7/3/22, 7/7/22 and 7/10/22 for pain level from 4 to 6. During review of facility' document titled Resident Rights Guidelines for All Procedures (RRGP), dated 2018, the RRGP indicated, .Purpose: To provide general guidelines for resident rights while caring for the resident .1.prior to having direct care responsibilities for residents, staff must have appropriate in -service training on resident rights including .a. preventing, recognizing and reporting abuse .b. resident dignity and respect .f. resident right of refusal .h. residents freedom of choice . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2018, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident's right to: a. dignified existence .c. be free from abuse neglect .Protect our residents from abuse by anyone including, but not necessarily limited to other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individual . During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 2018, the P&P indicated, .Protect our residents from abuse by anyone including, but not necessarily limited to: other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individual . During a professional reference review retrieved from https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html, titled, Preventing Elder Abuse, dated 7/2/21, the professional reference indicated, .Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age [AGE] or older. The abuse occurs at the hands of a caregiver or a person the elder trusts . Elder abuse can have several physical and emotional effects on an older adult. Victims are fearful and anxious. They may have problems with trust and be wary of others . Enter comment here

Based on observation, interview and record review, the facility failed to ensure a safe environment for one of three sampled residents (Resident 1) when the facility failed to assess Resident 1's height of the bed, ensure the bed was adequately functioning and the mechanism to lower or raise the bed functioned properly to prevent falls. This failure resulted in Resident 1's fall on 5/8/21, fractures of two toes on the left foot, pain and the potential for other falls with serious injury and or death. Findings: Resident 1's Admission Record indicated, admitted [DATE] . Diagnoses [included]; fracture of fifth lumbar vertebra (spinal bones in lower back), fracture of T11-T12 vertebra, ([MEDICATION(S)] -upper spondylolysis lumbar region (stress fracture of lower back), type 2 diabetes mellitus (high blood sugar), repeated falls, difficulty in walking, muscle weakness, cognitive communication deficit, and presence of cardiac pacemaker. Resident 1's Minimum Data Set (MDS - a comprehensive assessment for functional capability) assessment dated [DATE], the Brief Interview of Mental Status (BIMS - a cognitive assessment tool) indicated a score .5, (indicating severe cognitive impairment). Resident 1's MDS assessment for functional status dated 4/1/21 indicated, Self-performance .bed mobility .3. extensive assistance - resident involved in activity, staff provide weight- bearing support .Support .2. One person physical assist .Transfer .support .2. One person physical assist. During a concurrent interview and record review on 5/18/21, at 11:29 a.m., with Registered Nurse (RN) 1, Resident 1's Progress Notes dated 5/8/21 were reviewed. The Progress Notes indicated, .Resident was found sitting on his buttocks on the floor arms at side, and legs extended out towards the end of his bed .A head to toe assessment was done .Resident [has] some redness .and abrasions to bilateral knees. The middle 3 toes on the resident's right foot are painful to touch .X-ray of right foot ordered r/t [related to] c/o [complaints] in middle three toes . RN 1 stated she had called the physician and there were no new orders for pain medication. The Progress Notes also indicated, Bed was waist high (unable to lower bed-crank). RN 1 stated she was unable to move the bed up or down after the fall and she did not know where the crank (handle used to adjust foot, head, and height of bed in case of electrical failure) was located. RN 1 stated, All the other beds go up and down with the remote, but not that one [Resident 1's bed]. During a review of Physician orders for Resident 1, dated 5/2021, the Physician order indicated, Pain scale, 1-3 mild pain .pain level .3 documented for the first and second shift. During a concurrent observation and interview on 5/18/21, at 11:55 a.m., with RN 1 and the Maintenance Supervisor (MS) in Resident 1's room, RN 1 stated on 5/8/21 when Resident 1 fell the height of the bed was at her waist level. RN 1 used a tape measure and measured from her waist down to the floor. RN 1 stated her waist was 37 inches from the floor and the top of the mattress was 37 inches from the floor on 5/8/21. The MS attempted to adjust the height of the bed and the bed would not move up or down. The MS stated the bed was not in working condition on 5/18/21. The MS stated the normal height of the bed should be 25.5 inches from the floor for Resident 1. During an interview on 5/18/21 at 1:29 p.m., with the MS, the MS stated the Maintenance Log did not have entries from 5/8/21 to 5/18/21 to report Resident 1's bed needed to be repaired. During an interview on 5/18/21, at 1:38 p.m., with RN 1, RN 1 stated, I tried to put the bed down, but it did not work. RN 1 stated, [Resident 1] could get hurt like he is now or worse [if the bed did not work properly]. RN 1 stated Resident 1's bed was not in the normal low position of 25.5 inches at the time of the fall as it was on 5/18/21. RN1 stated she did not recall if she had reported the malfunction of the bed or recorded it in the Maintenance Log. During an interview on 5/18/21, at 2:10 p.m., with the Director of Nursing (DON), the DON stated if the bed remote wasn't working the CNA was responsible to report the problem to the nurse. The DON stated the nurse was then responsible to report the problem to maintenance by writing it in the Maintenance Log. During a telephone interview on 6/15/21, at 11:00 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she had cared for Resident 1 during the night shift prior to his fall. CNA 3 stated she did not know if Resident 1's bed functioned properly. CNA 3 stated, Sometimes the [beds] stop working. Sometimes motors go out or screws become loose. I have switched multiple beds. CNA 3 stated, If a bed goes out, there is an arm [crank] in the linen closet to attach and adjust the bed. CNA 3 stated, any of the staff can report the malfunctioning equipment. During a telephone interview on 6/15/21, at 11:15 a.m., with RN 1, RN 1 stated Resident 1's bed had been broken for about two weeks prior to the fall on 5/8/21. RN 1 stated the malfunction of the bed should've been written in the Maintenance Log for the MS to see. RN 1 stated there was a box on the MS's door to place maintenance paper slips into it, but the report should also be in the log. During a telephone interview on 6/15/21, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the staff is taught if resident's feet are dangling and not touching the floor, they would need to lower the bed. LVN 2 stated the low position for Resident 1 was when Resident 1 could sit and touch the floor with his feet. LVN 2 stated she did not know what position the bed was in at the time of the fall. During a telephone interview on 6/15/21, at 12:38 p.m., with the DON, the DON stated the facility staff would repair, replace, or rent another bed when a bed is not working. The DON stated a rented bed was delivered on 5/18/21 and replaced the malfunctioning bed. The DON stated, As soon as they [CNA] find it [not working], they [CNA] should report it to the nurse who will report it to maintenance in the log. We didn't know that bed [for Resident 1] was broken. During a telephone interview on 6/21/21, at 11:25 a.m., with the DON, the DON stated she was unaware of a policy for reporting beds that malfunctioned. During a telephone interview on 6/21/21, at 12:00 p.m., with the MS, the MS stated the CNAs and nurses should fill out a work order slip to repair equipment including beds. The MS stated he did not have a work order slip that notified him Resident 1's bed was not working. The MS stated all staff is trained on hire how to report malfunctioning items. The MS stated he handled bed repairs and he was not aware of a facility's policy and procedure for reporting malfunctioning items. During a concurrent telephone interview and record review on 6/21/21, at 2:59 p.m., with RN 2, the admission and baseline care plan for Resident 1, dated 3/26/21, was reviewed. RN 2 stated, [Resident 1] scored 19, a pretty high risk for falls. RN 2 reviewed the care plan dated 3/25/21, indicated, Resident is at risk for falls/injuries r/t cognitive impairment, diabetes, fall history, gait and balance, difficulty walking, physical limitation/LE (left extremity) weakness, urinary incontinence .Interventions .shoes or nonskid slippers .keep bed in low position . RN 2 stated the bed would need to be kept in a low position and should have been implemented by the staff. RN 2 reviewed the care plan dated 5/13/21 which indicated, bed pad pressure alarm for safety awareness. RN 2 stated the bed alarm was put in place after the fall on 5/8/21 and it should have been implemented at the time of admission on 3/25/21. RN 2 stated the alarm would not prevent a fall, but it was a safety measure to help prevent a fall. During a concurrent interview and record review on 6/24/21, at 12:25 p.m., with LVN 1, Resident 1's record was reviewed. The title of document indicated, Resident 1 was admitted to the facility on [DATE] for rehabilitation services (physical or occupation therapy). During an interview on 6/24/21, at 1:45 p.m., with the Physical Therapist (PT) 1, PT 1 stated he was familiar with Resident 1 and had worked with Resident 1 on previous admissions to the facility. PT 1 stated, During our visits he would be confused, depending on the day and [he] was impulsive. PT 1 stated Resident 1 required supervision or touch assistance for sit to stand and bed to chair transfers. During a telephone interview on 6/24/21, at 3:45 p.m., with the DON, the DON stated the Interdisciplinary team (IDT a team of staff members who coordinate care and document communication related to the Resident's plan of care and treatment goals) met on 5/8/21 after Resident 1's fall. The DON stated the IDT was not aware the bed was in a high position and the height of the bed was not called into question. The DON stated the root cause of the fall was that Resident 1 stood up, tried to get out of bed and lost his balance. During a telephone interview on 6/28/21, at 2:30 p.m., with RN 3, RN 3 stated she assessed Resident 1 after he returned from the Acute Care Hospital (ACH) on 5/11/21. RN 3 stated she looked at Resident 1's right foot because the Radiology report of 5/10/21 indicated an X-ray had been taken of the right foot. RN 3 stated Resident 1 said an X-ray had been taken of his left foot. RN 3 stated, [Resident 1's] two toes of left foot were taped, were a little discolored and a little bit swollen. He said he had no pain. During a record review of Resident 1's Progress Note, dated 5/11/21, at 3:49 a.m., the Progress note indicated, At 0250 resident returned from [ACH] eval/treatment due to X-ray positive for fracture of #3, #4 proximal phalanges (toes) of left foot .toes are taped together with paper/surgical tape . During a telephone interview on 6/28/21 at 1:25 p.m., with the Director of Staff Development (DSD), the DSD stated during orientation the newly hired staff were shown the binder to log in repairs. The DSD stated sometimes the MS will train the staff during a huddle. The DSD stated there is no documentation of training to report items that needed repair. The DSD stated she did not know about Resident 1's bed that needed repair. The DSD stated the process to report should be to log in the repair needed and put a tag on the item to prevent use of the item. During an interview on 7/12/21 at 12:17 p.m., with the MS, the MS stated, manufacturer's guidelines for the Hill-rom bed that malfunctioned was not available and no longer in print from the company. The MS stated the guidelines were not on file at the facility. During a review of Resident 1's Radiology Report , dated 5/10/21, the Radiology report indicated, Foot AP (anterior posterior - X-ray beams front to back) and LAT 2V, RIGHT (2 views of side of right foot) indicated, Results: Acute oblique fractures (a break that is curved or at an angle to the bone) of 3rd-4th proximal phalanges -broken toes) seen with mild displacement. No joint dislocation. The bones appear diffusely demineralized. During a review Resident 1's Physician Order (PO) , dated 5/10/21, the PO indicated, Send out to [Acute Care Hospital (ACH) ] for Tx [treatment] due to s/p (status post-after) fall with X-ray to left foot: acute oblique fractures of 3rd and 4th proximal phalanges (broken toes). During a review Resident 1's Emergency Department Provider Notes (EDPN), dated 5/10/21, the EDPN indicated, .chief complaint; patient presents with Pain foot left 3rd and 4th toe injury .bruising noted. XR [x-ray] Foot Left complete-5/10/21 23:52 .reason for exam: pain and discoloration on 3rd and 4th digits (toe) .findings: there is generalized osteopenia. Nondisplaced fractures are seen of the 3rd and 4th proximal phalanges (toes). During a review of Resident 1's clinic note (untitled) from the Specialty Provider, dated 5/21/21, the note indicated, WBAT (weight bearing as tolerated) LLE (left lower extremity) in supportive shoes (e.g. sneakers- SAS (a brand of supportive shoe) x [times] 3 more weeks then no activity restrictions. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk 7/2018, the P&P indicated, Environmental factors that contribute to the risk of falls .incorrect bed height or width . During a review of the facility's P&P titled, Maintenance Service, dated 12/2009), the P&P indicated, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. During a review of the article titled, Falls in the Nursing Home: Are they Preventable?, dated 4/2006, from the Journal of the American Medical Directors Association at https://www.researchgate.net/publication/ 46 Falls_in_the_Nursing_Home_Are_They_Preventable, the article indicated, .An effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification .

Based on interview and record review, the facility failed to evaluate and analyze one of three sampled residents (Resident 1's), need for footrest devices to address leaning forward and lunging forward in the wheelchair to prevent falls. This failure resulted in Resident 1 falling and sustaining an intraparenchymal hemorrhage of the brain (bleeding into the brain) which led to the resident's death. Findings: During a review of Resident 1's face sheet (a document containing resident profile information) dated 4/8/2020, the face sheet indicated the facility admitted Resident 1 on 4/1/19, with diagnoses that included Alzheimer's disease (type of dementia that affects memory, thinking and behavior); major depressive disorder (feeling of sadness and loss of interest that could interfere with normal day-to-day activities), anxiety (feeling of fear, dread, and uneasiness); and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS) assessment (comprehensive, standardized assessment of each resident's functional and health needs) dated 3/23/20, the MDS assessment indicated Resident 1 had long and short term memory impairment; inability to recall: season, room location, names and faces of staff, and current location in a nursing home; and severely impaired cognitive skills for daily decision-making. During a review of Resident 1's Resident Baseline Evaluation Fall Management Risk Evaluation, undated, the document indicated, .A. Level of Consciousness/mental status .forgetful .history of falls (Past 3 months) 3 or more falls in the past 3 months checked . A Total Score of 10 or above represents at risk. The Total score was 22. During a review of Resident 1's clinical records, the Post Fall Assessments indicated Resident 1 had falls on the following dates: 8/20/19, 10/16/19, 1019/19, 10/22/19, 10/25/19, 11/7/19, 11/2719, 1/8/20, 1/13/20, 1/15/20, 1/18/20, 2/23/20 and 4/1/20. During an interview on 4/8/20, at 3:53 p.m., with Licensed Nurse (LN) 1, LN 1 stated, she witnessed Resident 1's fall on 4/1/20. LN 1 stated, she saw Resident 1 sitting up in a wheelchair. LN 1 stated, she saw Resident 1's feet were doing a shuffling like movement while the wheelchair was moving forward. LN 1 stated, Resident 1 was sitting all the way in the back of the wheelchair, but Resident 1 was leaning forward. LN 1 stated, she saw Resident 1's left foot caught under the wheelchair wheels and Resident 1 lunged forward and fell on the floor face first. LN 1 stated, she performed a head to toe assessment on Resident 1 and there was a skin tear on the bridge of the nose with a small amount of bleeding. LN 1 stated Resident 1 complained of nose pain. LN 1 stated, there were no other injuries observed. During an interview on 4/8/2020, at 1 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, she cared for Resident 1 and was familiar with the care. CNA 3 stated, Resident 1 was unable to use a call light when needing assistance. CNA 3 stated, Resident 1 tended to lean forward when sitting up in the wheelchair and Resident 1 required repositioning to prevent her from falling forward. CNA 3 stated, the fall was avoidable. CNA 3 stated, the LN saw that Resident 1 needed repositioning and told a CNA to pull her up in the wheelchair, but the CNA ignored the LN. During an interview on 4/8/2020, at 1:41 p.m., with CNA 2, CNA 2 stated, Resident 1 would call out and if not answered within five minutes, then Resident 1 would sit on the edge of the bed and try to lunge forward to stand up and run. CNA 2 stated, when Resident 1 was up in a wheelchair, the resident would lean forward and lunge forward. Resident 1 would not sit all the way to the back of the wheelchair, but would try to scoot forward. Resident 1 did not like to sit up straight in the chair. During a concurrent interview and record review on 4/8/2020, at 2:21 p.m., with LN 2, LN 2 stated, she heard about the fall on 4/1/2020, the following day when she reported to work. LN 2 reviewed Resident 1's nurse's notes, dated 4/2/2020 at 1100.Blood Pressure (B/P- pressure of circulating blood on the walls of blood vessels) 84/51 .Resident is very lethargic at this time .Res not bearing weight well, very weak .will continue to monitor. LN 2 stated, I put very lethargic because that was her normal, not bearing weight well and B/P was not Resident 1's normal. LN 2 stated, she was the charge nurse on 4/5/2020, when Resident 1 transferred to the general acute care hospital (GACH). LN 2 stated, on 4/5/2020, on the morning shift, Resident 1 was crying more and did not want to get up for breakfast. LN 2 stated, Resident 1 was very sleepy but pupils were reacting to light so I let her sleep. LN 2 stated, at 10 a.m., she went back to check on Resident 1 and found Resident 1 weak to respond to physical stimuli and pupils were slow to react. LN 2 stated, she notified the medical doctor (MD) of her assessment and the MD gave the order to send Resident 1 to GACH. LN 2 stated she did not send out Resident 1 to GACH until lunchtime because the Responsible Party (R/P) wanted to wait. LN 2 stated, Resident 1's pupils were fixed and not reacting and the left arm was flaccid. During a phone interview on 4/10/2020, at 4:10 p.m., with CNA 1, CNA 1 stated, she was the CNA assigned to Resident 1 on 4/1/2020, when Resident 1 fell out of her wheelchair. CNA 1 stated, when she entered Resident 1's room, the resident was still in bed sleeping. CNA 1 woke Resident 1 and sat her on the edge of the bed while she put the resident's slippers on her [Resident 1]. CNA 1 stated, she transferred Resident 1 in to the wheelchair that was next to Resident 1's bed. CNA 1 stated, Resident 1 suddenly put her foot down on the floor, and flew out of the wheelchair, and landed on the floor face first and knees on the floor. CNA 1 stated, Resident 1 had blood on her face near the nose. CNA 1 stated, staff assisted Resident 1 back to the wheelchair after LN 1's assessment. CNA 1 stated Resident 1 was always leaning forward and not sitting all the way to the back when sitting up in her wheelchair. CNA 1 stated, the staff had to constantly reposition and pull Resident 1 back to prevent Resident 1 from falling forward from the wheelchair. CNA 1 stated, Resident 1 did not have foot rests on the wheelchair and did not remember the resident having them. CNA 1 stated, she realized she used the wrong wheelchair for Resident 1 when she returned the wheelchair to Resident 1's room. CNA 1 stated, the wheelchair Resident 1 was in the day of the incident was lower than Resident 1's own wheelchair. CNA 1 stated, she used a lower wheelchair than Resident 1's and using the wrong wheelchair may have contributed to the fall. CNA 1 stated she should have taken the time to make sure the right wheelchair was used for Resident 1. During an interview on 4/10/2020, at 12:50 p.m., with the physical therapist (PT), the PT stated, she only worked with Resident 1 when first admitted in the facility. PT stated, occupational therapist (OT) worked with Resident 1 for feeding goals and proper positioning in the wheelchair. PT stated, Resident 1 was always sitting leaning forward because of the kyphosis (excessive outward curvature of the spine) of the back and Resident's feet were not always touching the ground. PT stated, she did not know if Resident 1 needed a special wheelchair due to the kyphosis because she did not perform a wheelchair evaluation. PT stated, Resident 1 would probably benefit from using a footrest if her feet were not always touching the ground. PT stated, the use of footrests was not decided and there was no form indicating it [footrests] had to be used. There was no documented evidence PT and the facility staff discussed the potential benefit of using footrests. During an interview on 4/10/2020, at 1:35 p.m., with the occupational therapy assistant (OTA), the OTA stated, she worked with Resident 1 for feeding, . The OTA stated, Resident 1 worked with the occupational therapist (OT) to work on posture, trunk control and strengthening. The OTA stated, Resident 1 leaned forward and did not sit all the way to the back of the wheelchair. The OTA stated, the OT recommended the use of a leg/foot rest. Resident 1 had the leg rest/footrest when she worked with Resident 1 because it helped to straighten her posture. The OTA stated, without the leg rest, Resident 1 was able to touch the floor with her feet. The OTA stated, the risk of falling was higher for a resident not sitting all the way to the back of the wheelchair. There was no documented evidence the facility developed a plan to address Resident 1's leaning forward in the wheelchair and the recommended use of a leg/foot rest to prevent falling. During an interview on 4/10/20, at 2 p.m., with LN 3, LN 3 stated, she was unable to find a care plan for Resident 1 that addressed wheelchair repositioning and requiring constant repositioning because of leaning forward a lot. LN 3 stated, she did not remember if Resident 1 had a leg/foot rest on the wheelchair. During an interview on 4/10/2020, at 3:45 p.m., with the director of nursing (DON), the DON stated, her expectation was for the LN's to fill out a packet for each fall, including the incident reports. The DON stated, the interdisciplinary team (IDT-group of health care professionals who work in a coordinated fashion toward a common goal for the resident) consisted of the PT, RNA and DON, who met every week to discuss falls. The DON stated, there should be a new intervention added after each fall. The DON stated, she did not remember discussing the leg/foot rests to prevent falls during the IDT meetings for Resident 1. During a phone interview on 4/15/2020, at 12:18 p.m., with OT, the OT stated, he worked with Resident 1 for feeding, wheelchair propulsion and upper body exercises. The OT stated, Resident 1 used her hands to propel self not her feet because Resident 1 had a footrest on her wheelchair when OT worked with her. During a review of Resident 1's [Name of GACH] Physician Certification and Patient Consent Transfer, dated 4/5/2020, the document indicated, .The patient has an emergency medical condition, specifically: Intracranial hemorrhage .4. As a result of this condition, the treating physician, recommends immediate transfer by: Critical care transport to [Name of GACH] Fresno .6.b .This transfer is to the closest, appropriate and available facility where the patient can receive Neurology, neurosurgery services . During a review of Resident 1's [Name of GACH] History, dated 4/5/2020, the document indicated, . frontal parietal hemorrhage .CT Head: extremely large intralobar hematoma involving the right frontal and parietal lobes with small subarachnoid component. There is a 9 millimeter (MM- dry measurement) shift to the left and mass effect with parietal effacement of the right lateral ventricle. During a review of Resident 1's [Name of GACH] Final Diagnosis, dated 4/12/2020, the document indicated, Intraparenchymal hemorrhage of brain. Acute Respiratory failure .On 4/12/2020, at 3:24 a.m., patient was noted to be not breathing. During a review of Resident 1's Certificate of Death, dated 4/17/20, the document indicated, .Cause of Death .B. Intraparenchymal Hemorrhage of Brain C. Post Fall . During a review of the facility's policy and procedure titled, Fall Management Program revised 11/7/16, the policy and procedure indicated, .A. A resident who sustains multiple falls as defined as more than one fall in a day, week or month, will be considered a high risk to fall and as a result may sustain a major injury. B. These residents may: .iv.may require special equipment to promote independence such as a merry walker, walker, grab bars, trapeze, commode chair, raised toilet seat, etc .C. These interventions will be documented on the resident's plan of care and in the resident's clinical record. There was no documented evidence the facility evaluated and analyzed Resident 1's leaning forward in the wheelchair as a potential for falling. There was no documented evidence the facility planned and implemented the OT's recommendation to use foot rests on the resident's wheelchair to straighten Resident 1's posture to prevent falling.

Based on observation, resident and staff interview, clinical record and administrative document review, the facility failed to develop an individualized care plan based on the assessment of healthcare needs, physician ordered services, and behaviors exhibited for one of five sampled Residents (Residents 1) when Resident 1 did not have an individualized assessment, care plan or intervention plan to minimize the risk for injury based on patterns of behavior and [DIAGNOSES REDACTED]. As a result of this failure, the facility failed to recognize Resident 1's need for individualized interventions which lead to the development of complications with the right foot. Resident 1 suffered avoidable foot injuries including abraded areas to the toes of his right foot, the formation of a diabetic neuropathic foot ulcer (a type of wound formation seen in individuals with diabetes (a disorder that affects blood sugar levels)), and right foot [MEDICAL CONDITION] (skin infection) requiring hospitalization , antibiotics, and wound care. Findings: 1. Resident 1's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's clinical record titled, history and physical examination [REDACTED]. The facility document titled, Minimum Data Set (MDS) assessment, (an assessment used for screening, clinical and functional status and needs for nursing home residents) dated 5/2/16, indicated Resident 1 had moderately impaired cognitive function (pertaining to long and short term memory deficits). Resident 1 required supervision for bed mobility and transfers. The MDS assessment indicated Resident 1 required assistance for mobility in the wheelchair including limited (guided) assistance to extensive (weight bearing support) from facility staff. The MDS assessment indicated Resident 1 required extensive assistance with personal hygiene. Resident 1's summarized physician's orders [REDACTED]. On 7/29/16 at 1 p.m., during an observation and concurrent interview, Resident 1 propelled himself in his wheelchair by using his legs and bare feet. There were no foot rests on Resident 1's wheelchair. Resident 1 had long thick toenails which extended outward past the top of all five toes of his right foot. Resident 1 had no toes on his left foot due to previous amputation. Resident 1 had four abraded, freshly bleeding areas to the 2nd, and 3rd, 4th and 5th toes on his right foot. Resident 1 stated he had bad eye sight and poor sensation in the foot which affected his ability to see and to feel the abrasions on the top of the right foot. Resident 1 stated he had been a resident in the facility close to one year and had been a diabetic for almost all of his life. Resident 1 stated he had [MEDICAL CONDITION] to both feet. Resident 1 stated he preferred not to wear shoes. On 7/29/16 at 1:35 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 1 occasionally became confused requiring re-direction, cues and reminders from staff. CNA 1 stated Resident 1 had the ability to propel himself in his wheelchair by using his legs and feet and did not like to wear shoes. CNA 1 stated Resident 1 received a shower on 7/29/16 around 10:30 a.m., by CNA 2, who discovered the abrasion on Resident 1's foot and informed the licensed nurse (LN) and the LN responsible for performing the treatments ordered for residents. CNA 1 did not provide a response when asked if Resident 1's abrasion to the top of his foot was new or old. CNA 1 did not provide a response when asked if she routinely removed residents' socks to inspect their skin. CNA 1 stated Resident 1 liked going outside and sitting in the sun in his wheelchair, barefoot, on the cement patio. On 7/29/16 at 1:45 p.m., during an observation, the facility patio where Resident 1 enjoyed sitting barefoot, was comprised of cement and was exposed to the sun. Review of the website <https://weather.com/weather/monthly>, indicated temperatures in the area of the facility on 7/29/16 ranged from a low of 66 degrees Fahrenheit to a high of 100 degrees Fahrenheit. On 7/29/16 at 2 p.m., during an interview, the facility's Social Service Director (SSD) stated she was responsible for tracking podiatry services of the residents in the facility. The SSD stated Resident 1 was on a list she used for tracking. The SSD stated Resident 1 was not eligible for podiatry services due to a lack of payment for these services by his insurance provider. The SSD stated Resident 1 had not been seen by the Podiatrist (doctor specializing in treatment of [REDACTED]. The SSD stated she was unsure if Resident 1 had ever received services from the Podiatrist. The SSD stated she had previously spoken to the Podiatrist about providing services to those residents with non-eligible insurance. The SSD stated the facility was required to provide podiatry services as ordered and the facility was responsible for the payment of those services given to residents with non-eligible insurance. On 7/29/16 at 2:25 p.m., during an interview, the SSD stated she had not been told to implement a care plan for the ancillary (additional services offered by optometrist, dentist, hearing specialist and podiatrist) services provided to the residents of the facility. On 7/29/16 at 2:50 p.m., during an observation of Resident 1's foot abrasions and foot ulcer, LN 2 measured the abraded areas determining length by width by depth on Resident 1's toes and ball of on the right foot. These measurements were as follows: On the right foot: The second toe's abraded area measured 4.3 centimeters (cm)-(dry unit of measurement) by 1.8 cm. The third toe's abraded area measured 3 cm by 1.3 cm. The fourth toe's abraded area measured 3.4 cm by 1.9 cm. The fifth toe's abraded area measured 2.2 cm by 1.3 cm. Resident 1's area of eschar (a dry dark scab or falling away of dead skin, caused from injury to the skin) found on the ball of the right foot (below the toes), measured 4 cm by 5.7 cm; the area was dry, black, thick, and leathery with surrounding boggy (soft) edges that were lifting without drainage. There was mild redness throughout the edges of the eschar and throughout the abraded areas of the toes. On 7/29/16 at 3 p.m., during an interview with LN 2, LN 2 stated she was informed by CNA 2 of Resident 1's foot wounds. LN 2 stated Resident 1 had abraded areas to the top of his toes and eschar on the bottom of his right foot. LN 2 stated she did not know how Resident 1 obtained the abrasion to the top of his toes or the eschar formation to the bottom of his foot. LN 2 stated Resident 1 preferred not to wear shoes, and had no foot rest on his wheelchair. On 8/3/16 at 3:05 p.m., during a joint interview with the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), the DON stated Resident 1 had [DIAGNOSES REDACTED]. The QAN stated Resident 1 had a risk of injuring his lower extremities because of the lack of sensation to his feet. The DON stated Resident 1 did not like to wear shoes and stated there was no care plan or documentation of his preference not to wear shoes or that he enjoyed sitting outside in the sun, barefoot on the hot cement patio. On 8/3/16 at 4 p.m., during an interview the DON stated interventions should have included encouraging Resident 1 to stay off the hot patio, that he wore shoes to protect his feet; and to ensure the CNA's performed daily skin checks, and that licensed nurses performed their skin assessments during the completion of the weekly progress notes. The DON stated there was not enough documentation to identify the CNA's were doing skin checks on the residents and she could not say if the CNA's were providing the residents with routine foot hygiene. The facility policy and procedure titled, Care Planning dated 3/1/2014, indicated, To ensure that a comprehensive Care Plan is developed for each resident. It is the policy of this Facility to provide person-centered, comprehensive .care that reflects best practice standards for meeting health, safety .behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial wellbeing .a Care Plan may be initiated upon identification of a change of condition or any new needs .

Based on observation, resident and staff interview, clinical record, administrative document and professional reference review, the facility failed to provide the necessary services, assessment, and care planning to attain the highest practicable physical well-being for one of five sampled residents (Resident 1), when Resident 1 did not have an individualized assessment, care plan or planned interventions to minimize the risk for injury based on his pattern of behaviors and [DIAGNOSES REDACTED]. These failures resulted in Resident 1's development of avoidable foot injuries including abraded areas to the toes of his right foot, formation of a diabetic neuropathic foot ulcer (a type of wound formation seen in individuals with diabetes) (disorder that affects blood sugar levels) and right foot [MEDICAL CONDITION] (skin infection) requiring hospitalization , antibiotics and wound care. Findings: Resident 1's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's clinical record titled, history and physical examination [REDACTED]. The facility document titled, Minimum Data Set (MDS) assessment, (an assessment used for screening, clinical and functional status and needs for nursing home residents) dated 5/2/16, indicated Resident 1 had moderately impaired cognitive function (pertaining to long and short term memory deficits). Resident 1 required supervision for bed mobility and transfers. The MDS assessment indicated Resident 1 required assistance for mobility in the wheelchair including limited (guided) assistance to extensive (weight bearing support) from facility staff. The MDS assessment indicated Resident 1 required extensive assistance with personal hygiene. On 7/29/16 at 1 p.m., during an observation and concurrent interview, Resident 1 propelled himself in his wheelchair by using his legs and bare feet. There were no foot rests on Resident 1's wheelchair. Resident 1 had long thick toe nails which extended outward past the top of all five toes of his right foot. Resident 1 had no toes on his left foot due to previous amputation. Resident 1 had four abraded, freshly bleeding areas to the 2nd, and 3rd, 4th and 5th toes on his right foot. Resident 1 stated he had bad eye sight and poor sensation in the foot which affected his ability to see and to feel the abrasions on the top of the right foot. Resident 1 stated he had been a resident in the facility close to one year and had been a diabetic for almost all of his life. Resident 1 stated he had [MEDICAL CONDITION] to both feet. Resident 1 stated he preferred not to wear shoes. On 7/29/16 at 1:35 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 1 occasionally became confused requiring re-direction, cues and reminders from staff. CNA 1 stated Resident 1 had the ability to propel himself in his wheelchair by using his legs and feet and did not like to wear shoes. CNA 1 stated Resident 1 received a shower on 7/29/16 around 10:30 a.m., by CNA 2, who discovered the abrasion on Resident 1's foot and informed a licensed nurse (LN), and the LN responsible for performing the treatments ordered for residents. CNA 1 did not provide a response when asked if Resident 1's abrasion to the top of his foot was new or old. CNA 1 did not provide a response when asked if she routinely removed residents' socks to inspect their skin. CNA 1 stated Resident 1 liked going outside and sitting in the sun in his wheelchair, barefoot, on the cement patio. On 7/29/16 at 1:45 p.m., during an observation, the facility patio where Resident 1 enjoyed sitting barefoot, was comprised of cement and was exposed to the sun. Review of the website <https://weather.com/weather/monthly>, indicated temperatures in the area of the facility on 7/29/16 ranged from a low of 66 degrees Fahrenheit to a high of 100 degrees Fahrenheit. On 7/29/16 at 2 p.m., during an interview, the facility's Social Service Director (SSD) stated she was responsible for tracking podiatry services of the residents in the facility. The SSD stated Resident 1 was on a list she used for her tracking. The SSD stated Resident 1 was not eligible for podiatry services due to a lack of payment for these services by his insurance provider. The SSD stated Resident 1 had not been seen by the Podiatrist (doctor specializing in treatment of [REDACTED]. The SSD stated she was unsure if Resident 1 had ever received services from the Podiatrist. The SSD stated she had previously spoken to the Podiatrist about providing services to those residents with non-eligible insurance. The SSD stated the facility was required to provide podiatry services as ordered and the facility was responsible for the payment of those services given to residents with non-eligible insurance. Resident 1's clinical record titled, physician's orders [REDACTED]. Resident 1's clinical record titled, Podiatric Evaluation and Treatment dated 5/31/16, indicated under assessments, No Elig (not eligible). On 7/29/16 at 2:20 p.m., during an interview and concurrent record review, the SSD stated Resident 1's physician's orders [REDACTED]. Resident 1's care plan titled, Diabetes dated 7/22/15, indicated .Approach Plan .Podiatry Services as needed. On 7/29/16 at 2:50 p.m., during an observation of Resident 1's foot abrasions and foot ulcer, LN 2 measured the abraded areas determining length by width by depth on Resident 1's toes and ball of right foot. Measurements were as follows: The second toe's abraded area measured 4.3 centimeters (cm)-(dry unit of measurement) by 1.8 cm. The third toe's abraded area measured 3 cm by 1.3 cm. The fourth toe's abraded area measured 3.4 cm by 1.9 cm. The fifth toe's abraded area measured 2.2 cm by 1.3 cm. Resident 1's area of eschar (a dry dark scab or falling away of dead skin, caused from injury to the skin) found on the ball of the right foot (below the toes), measured 4 cm by 5.7 cm; the area was dry, black, thick, and leathery with surrounding boggy (soft) edges that were lifting without drainage. There was mild redness throughout the edges of the eschar and throughout the abraded areas of the toes. On 7/29/16 at 3 p.m., during an interview with LN 2, LN 2 stated she was informed by CNA 2 of Resident 1's foot wounds. LN 2 stated Resident 1 had abraded areas to the top of his toes and eschar on the bottom of his right foot. LN 2 stated she did not know how Resident 1 obtained the abrasion to the top of his toes or the eschar formation to the bottom of his foot. LN 2 stated Resident 1 preferred not to wear shoes, and had no foot rest on his wheelchair. On 8/3/16 at 3:05 p.m., during a joint interview with the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), the DON stated Resident 1 had [DIAGNOSES REDACTED]. The DON stated Resident 1 did not have a care plan to reflect Resident 1's [DIAGNOSES REDACTED]. The QAN stated Resident 1 had a risk of injuring his lower extremities because of the lack of sensation to his feet. The DON stated Resident 1 did not like to wear shoes and stated there was no care plan that addressed Resident 1's risk for injury from going barefoot. The DON stated the CNA's were supposed to do head to toe skin checks every shower day but didn't think this was being done. The DON stated Resident 1 should have had a skin assessment done by a LN on 7/25/16 and the assessment should have been documented in a weekly progress note. The DON stated there was no skin assessment or weekly progress note for 7/25/16 in Resident 1's clinical record. The DON stated she did not know how Resident 1 sustained the abrasions and ulcer to his right foot. The DON stated she had observed Resident 1 sitting barefoot on the outside cemented patio in his wheelchair a few days before his hospitalization on [DATE]. The DON stated she asked Resident 1 to return indoors when she saw him sitting outside. The DON stated when Resident 1 returned indoors she did not inspect his feet for injury after being outside with contact to the hot cement while barefoot. On 8/3/16 at 4 p.m., during an interview, the DON stated interventions should have included to keep Resident 1 indoors, ensure the CNA's performed daily skin checks, ensure licensed nurses performed their skin assessments during the completion of the weekly progress notes and ensure Resident 1 wore shoes to protect his feet. The DON was unable to produce documentation the CNA's had completed skin checks for Resident 1. The DON stated she could not say if the CNA's were providing the residents with routine foot hygiene. On 8/4/16 at 10:55 a.m., during a telephone interview, CNA 3 stated she was assigned to care for Resident 1 during the night shift. CNA 3 stated she had never inspected Resident 1's feet. CNA 3 stated she did not typically do this for any of her residents. On 8/4/16 at 11:30 a.m., during a telephone interview, CNA 4 stated she was familiar with Resident 1 and cared for Resident 1 during the evening shift. CNA 4 stated Resident 1 had times of refusing to shower or change clothes. CNA 4 stated if Resident 1 refused to shower she would provide him with a bed bath washing his chest and back, not his feet. CNA 4 stated she did not check Resident 1's feet and had not removed his socks to check his feet when she cared for Resident 1. CNA 4 stated CNA's were not allowed to provide any type of foot or nail care to Resident 1 because of the [DIAGNOSES REDACTED]. CNA 4 stated Resident 1 sat outside on the cement patio almost every day and sometimes wore socks, but no shoes. On 8/4/16 at 3 p.m., during a telephone interview, CNA 2 stated she was the CNA who had identified the wound during Resident 1's shower on 7/29/16. CNA 2 stated the last time she had given Resident 1 a shower was on 7/2/16. On 8/4/16 at 5:20 p.m., during a telephone interview, LN 3 stated Resident 1 had episodes of refusing care from the CNA's. LN 3 stated Resident 1 would refuse to shower or change his clothes, sometimes for two to three days. LN 3 stated Resident 1 enjoyed being outside, sitting in the sun on the cement patio during extreme heat. LN 3 stated she understood Resident 1 had diabetes and [MEDICAL CONDITION]. LN 3 stated she did not make an assertive effort to talk to Resident 1 about the potential complications of his [DIAGNOSES REDACTED]. LN 3 stated she did not refer Resident 1's noncompliance to the interdisciplinary team (the healthcare team that makes care planning decisions) and had not given Resident 1 an option to accept or decline the use of a foot rest, which would have prevented the resident from propelling the wheelchair with his bare feet. Resident 1's clinical document from the acute care hospital titled, Discharge Summary dated 8/2/16, indicated Resident 1 was admitted to the acute care hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident 1's clinical document from the acute care hospital titled, Patient Education dated 8/2/16, indicated, Diabetes and foot care. Diabetes may cause you to have a poor blood supply (circulation) to your legs and feet .you may not notice minor injuries to your feet that could lead to serious problems or infections .do not go barefoot. Bare feet are easily injured; check your feet daily for blisters, cuts and redness .wear shoes all the time . Resident 1's clinical record titled, Facility acquired .Ulcer Investigation Tool dated 8/4/16, indicated, Root cause identified for pressure ulcer development: Diabetic [MEDICAL CONDITION]; no sensation of pain, prefers not to wear shoes, noncompliance to diabetic diet, unable to check his own feet, [MEDICAL CONDITION], refusal of showers . Review of professional reference, Nerve Damage, Diabetic Neuropathies, 2013 <https://www.niddk.nih.gov/health-information/diabetes/preventing-diabetes-problems/nerve-damage-diabetic-neuropathies>, indicated .Foot Exams. Experts recommend .People diagnosed with [REDACTED]. A comprehensive foot exam assesses the skin, muscle, bones, circulation and sensation of the feet .Foot Care. People with [MEDICAL CONDITION] need to take special care of their feet. Loss of sensation in the feet mean that sores or injuries may not be noticed and may become ulcerated or infected .Careful foot care involves cleaning the feet daily .inspecting the feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Using a mirror-handheld or placed on the floor-may be helpful in checking the bottoms of the feet, or another person can help check the feet .filing corns and calluses gently with a pumice stone after a bath or shower .cutting toenails to the shape of the toes .always wearing shoes or slippers to protect feet from injuries. Wearing thick, soft, seamless socks can prevent skin irritation .wearing shoes that fit well and allow the toes to move. New shoes can be broken in gradually by first wearing them for only an hour at a time .People who need help taking care of their feet should consider making an appointment to see a foot doctor, also called a podiatrist. Review of American Diabetes Association article titled, Foot Care dated 10/10/14, indicated, Prevention: .Because people with diabetes are more prone to foot problems, a foot care specialist may be on your health care team .Caring for Your Feet: Check your feet every day .Wear shoes and socks at all times .Never walk barefoot .Protect your feet from hot and cold .Wear shoes at the beach or on hot pavement .You can burn your feet without realizing it . The facility policy and procedure titled, Care Planning dated 3/1/2014, indicated To ensure that a comprehensive Care Plan is developed for each resident. It is the policy of this Facility to provide person-centered, comprehensive .care that reflects best practice standards for meeting health, safety .behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial wellbeing .a Care Plan may be initiated upon identification of a change of condition or any new needs .

Based on observation, resident and staff interviews, clinical and administrative document review, the facility failed to implement and maintain a safe and sanitary environment to prevent transmission of resident infections when facility processes were not implemented for: 1) Hand hygiene for staff prior to and following resident care for residents on isolation and those who were not. 2) Effective staff education and training based upon professional standards of practice. 3) Environmental cleaning when staff did not consistently follow recommended guidelines. 4) Handling and processing of contaminated linens by laundry staff. 5) Staff sick leave and visitor guidelines when no evidence policies were established. This failure exposed residents and staff to infectious disease resulting in resident illness and harm to 7 residents (Residents 1, 2, 3, 4, 5, 6 & 7) and one staff member who was diagnosed with [REDACTED]. Findings: 1. On 4/26/13 at 1:45 p.m., during initial tour and concurrent interview, the Director of Nursing (DON) stated, "The staff wash hands in the resident's rooms." On 4/26/13 at 2:15 p.m., during a concurrent observation and interview at the nurses station, Registered Nurse (RN) 1 was observed leaning over a medication cart, dressed in casual street attire (blue jeans and a T shirt). RN 1 stated, "This is casual Friday in case you are wondering...We wash our hands in the utility room." On 4/26/13 at 2:16 p.m., during an observation, the utility room was observed locked, requiring key entry. The door key was observed on the wall adjacent to the utility room. No observations were made of staff washing hands in the utility room. On 4/26/13 at 2:17 p.m., during an observation, "Gel-San" (an alcohol based hand sanitizer) hand wipes and pump solution were noted on medication and treatment carts, and on the nurses station countertop. No gloves were observed on any carts. On 4/26/13 at 2:18 p.m., during an initial tour, Occupational Therapist, (OT) stated residents were being asked to use alcohol based sanitizer on their hands before entering the therapy room. On 4/26/13 at 3:00 p.m., during an interview, the Director of Staff Development (DSD) was asked how residents were being protected from healthcare associated infections and stated, "We keep hand sanitizer and gloves in all the rooms." On 4/26/13 at 3:02 p.m., during an interview regarding components of the facility infection control program, the DON stated, "I can't speak to that, you'd have to ask the DSD." On 4/26/13 at 3:05 p.m., during an interview regarding facility methods of monitoring for staff compliance with hand washing, the DSD paused and stated, "I can't really answer that." On 5/4/13 at 3:05 p.m., during an observation of Resident 4's care at the bedside, RN 2 used hand sanitizer prior to entering Resident 4's room. RN 2 donned (put on) exam gloves and a disposable yellow gown. RN 2 assisted Certified Nursing Assistant (CNA 1) with skin care for Resident 4. RN 2 then pulled out a second pair of exam gloves which she placed over the dirty pair of exam gloves on both hands. RN 2 removed the cap from Resident 4's Gastrostomy Tube (GT) (a tube inserted through the skin into the stomach to feed or deliver medications) and placed the cap on top of the bag holding the enteral feeding. On 5/4/13 at 3:15 p.m., RN 2 stated she had donned a second set of gloves over her first pair in order not to get bowel movement (BM) on the feeding tube. When asked what she might have done differently to maintain a sanitary environment for Resident 4, she stated she should have removed the first set of gloves, washed her hands, and put on a clean set of gloves prior to handling his GT. When asked if she had attended an in-service training in the area of infection control this week she stated she had, but, "They just didn't get into details like that. They just talked about hand washing, gowning and gloving in isolation." On 5/10/13 at 11:30 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated, "I have seen nurses and CNAs glove up (on entering a resident room), take the gloves off (after resident care), and leave the room and not wash hands. The only place I have seen staff washing their hands is in the break room." The facility policy and procedure titled, "Infection Control, Policy for Antibiotic Resistant Microorganisms (MDRO)," undated, indicated under A. Standard Precautions including Contact Precautions, "1. Handwashing-before and after resident contact, and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms, including...MDRO..." Review of "Clinical Practice Guidelines for Clostridium difficile Infection (CDI) in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America," Infection Control and Epidemiology, May 2010, indicated on p. 432, under Measures for Healthcare Workers, Patients, and Visitors, " 14. Emphasize compliance with the practice of hand hygiene...p. 441 indicated "Hand hygiene is considered to be the one of the cornerstones of prevention of... [DIAGNOSES REDACTED]icile.... in its spore form, is also known to be highly resistant to killing by alcohol.....healthcare workers who decontaminate their hands with alcohol-based products....could potentially increase the risk of transferring this organism to patients under their care." 2. On 4/26/13 at 2:25 p.m., during an interview, the Director of Staff Development (DSD) stated, "I do the (infection control) inservice with the staff and with housekeeping." On 4/26/13 at 4:20 p.m., during an interview, the DSD stated she had recently provided infection control training to facility staff on 4/23/13. Training documents received indicated infection control reference information was taken from http://en.wikipedia.org downloaded on 9/13/12 and 3/8/13, a general information internet website, not recognized as a standard resource for professional infection control practice. Review of facility documents titled, "Inservice Training Minutes," indicated the DSD provided infection control inservice on the following dates: 8/1/12, 8/30/12, 9/2/12, 9/14/12, 10/18/12, 11/28/12, 1/9/13, 1/31/13, 2/26/13, and 3/11/13. No documented evidence of evaluations, observations of staff performance, or return demonstrations was provided. On 4/26/13 at 2:25 p.m., during an interview, the Director of Nursing (DON) stated, "We have three residents (Residents 1, 2 and 3) who are positive for Clostridium difficile (C.difficile) (a contagious gastrointestinal bacteria resulting in diarrhea and severe gastrointestinal illness). The DON stated she was waiting on test results for Resident 5. On 4/26/13 at 3:00 p.m., during an interview, the Director of Staff Development (DSD) confirmed she was also the Infection Control Coordinator for the facility. The DSD stated Resident 1, 2 and 3 were diagnosed with [REDACTED]. On 5/4/13 at 3:05 p.m., during an observation of Resident 4's care at the bedside, RN 2 used hand sanitizer prior to entering Resident 4's room. RN 2 donned (put on) exam gloves and a disposable yellow gown. RN 2 assisted Certified Nursing Assistant (CNA) 1 with skin care for Resident 4. RN 2 then pulled out a second pair of exam gloves which she placed over the dirty pair of exam gloves on both hands. RN 2 removed the cap from Resident 4's Gastrostomy Tube (GT) (a tube inserted through the skin into the stomach to feed or deliver medications) and placed the cap on top of the bag holding the enteral feeding. On 5/4/13 at 3:15 p.m., RN 2 stated she had donned a second set of gloves over her first pair in order not to get bowel movement (BM) on the feeding tube. When asked what she might have done differently to maintain a sanitary environment for Resident 4, she stated she should have removed the first set of gloves, washed her hands, and put on a clean set of gloves prior to handling his GT. When asked if she had attended an in-service training in the area of infection control this week she stated she had, but, "They just didn't get into details like that. They just talked about hand washing, gowning and gloving in isolation." On 5/10/13 at 11:30 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated, "I have seen nurses and CNAs glove up (on entering a resident room), take the gloves off (after resident care), and leave the room and not wash hands. The only place I have seen staff washing their hands is in the breakroom." Review of "Clinical Practice Guidelines for Clostridium difficile Infection (CDI) in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America," Infection Control and Epidemiology, May 2010, indicated on p. 432, under Measures for Healthcare Workers, Patients, and Visitors, " 14. Emphasize compliance with the practice of hand hygiene...p. 441 indicated "Hand hygiene is considered to be the one of the cornerstones of prevention of... C.difficile.... in its spore form, is also known to be highly resistant to killing by alcohol.....healthcare workers who decontaminate their hands with alcohol-based products....could potentially increase the risk of transferring this organism to patients under their care." 3a. On 4/26/13 at 2:18 p.m., during an initial tour, the Occupational Therapist, (OT) stated "We wipe our equipment down first thing (in the morning) and then at the end of the day....each staff person is responsible for wiping down therapy mats after resident use." On 4/26/13 at 3:10 p.m., during an observation and concurrent interview, Housekeeper 1 (H1) was observed at the entry to a resident room with a cleaning cart. She produced a spray bottle from her cleaning cart and admitted she was unable to read measurement markings, stating, "I just put bleach to that line (pointing to the bottom rim of the bottle, approximately 2 ounce mark) and fill the rest with water." The spray bottle measurement indicated it was a 32 ounce spray container. H1 stated "For the floor (a 4 gallon container) I use two of these (producing a bleach container cap, approximately 1.5 Tablespoons - less than a 1:10 ratio) and then fill it with water. We use 10:1 ratio (10 parts water to 1 part bleach), that's what they said." Review of Centers for Disease Control and Prevention "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" indicated under 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities, "17. In units with high rates of ...Clostridium difficile infection or in an outbreak setting, use dilute solutions of 5.25%-6.15% sodium hypochlorite (e.g., 1:10 dilution of household bleach) for routine environmental cleaning." According to this ratio (1:10 dilution), a 4 gallon container of water would have required 6.64 cups of bleach to obtain a 1:10 ratio; (instead of the 1.5 Tablespoons used). On 4/26/13 at 3:40 p.m., during an interview regarding deep cleaning of the facility (as a result of [DIAGNOSES REDACTED]icile infections), the Director of Nursing (DON) was unable to state the date or time of a scheduled cleaning. On 4/27/13 at 3:45, during an interview, the DON and Interim Administrator (IA) were unable to state who was responsible for cleaning medical equipment used by multiple residents. The IA stated, "I'll need to call our maintenance supervisor to find that out." On 4/30/13 at 12:15 p.m., during an observation and concurrent interview, H1 was observed mopping the floor of Isolation room [ROOM NUMBER]. H1 stated she was mopping the floor with a bleach solution. H1 stated someone else had mixed the bleach water for her, and was unable to verify it was the correct concentration. On 4/30/13 at 1:15 p.m., during an interview, the IA was unable to provide a cleaning schedule for resident equipment, stating, "My maintenance supervisor cleans them every Friday with bleach. We don't have a schedule or a log." The facility policy and procedure titled, Infection Control, Policy for Antibiotic Resistant Microorganism (MDRO), undated, indicated under C. Environmental and Equipment Protection, "1. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member should be done in order to prevent the spread of ...MDRO and other pathogenic microorganisms." On 5/10/13 at 11:00 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated she had no documentation of observations, return demonstrations or other measures for validating staff competence in correctly mixing 1:10 (1 part bleach to 10 parts water) bleach solutions. The HLC stated housekeeping staff do not routinely clean patient equipment. The HLC stated housekeeping staff were not routinely informed of resident status and care changes requiring isolation or contact precautions. The HLC stated, "Usually I would hear about it by word of mouth from CNA staff...days have gone by before I knew someone had [DIAGNOSES REDACTED] or MRSA." On 5/10/13 at 11:45 a.m., during an interview, the HLC stated, "Some days I cannot finish my assignment because of interruptions and I get redirected to clean for (resident) room changes. There are a lot of room changes." Review of the facility documents titled, "Daily Census Report," (a report of daily resident admissions, discharges and bed changes), from January 2013 through April 2013, tracking room changes for residents with [DIAGNOSES REDACTED] infections indicated: Resident 1's room locations: 19B, 25A, 27B, 16B, 25B, 21B. Resident 2's room locations: 25B, 31C, 1B, 21B, 21C. Resident 3's room locations: 10A, 25B. Resident 5's room locations: 16A, 21A, 22A. Resident 6's room locations: 17A, 25A. Resident 7's room locations: 10A. "Making Health Care Safer, Stopping [DIAGNOSES REDACTED]icile Infections," Vital Signs, March 2012, Centers for Disease Control and Prevention, indicated, "Make sure cleaning staff follows CDC recommendations, using an EPA-approved, spore-killing disinfectant in rooms where [DIAGNOSES REDACTED]icile patients are treated." 3b. On 5/2/13 at 1 p.m., during an observation of Resident 3 and 6's room (both positive for [DIAGNOSES REDACTED]icile), room [ROOM NUMBER] had 8 - 10 inches of water, half an inch deep on the floor surrounding the base of the toilet bowl in the bathroom. Brown flecks were observed floating in the water on the floor, on the toilet seat, and in the toilet bowl. Resident 3 stated, "The toilet ran over in there about 10:30 this morning, the Maintenance Supervisor (MS) fixed it, but it hasn't been cleaned up yet. They told us they couldn't fix it until we were done eating." 4. On 4/26/13 at 1:45 p.m., during an initial tour of the facility laundry room, two open piles of resident laundry were observed lying on the floor adjacent to the washing machine. On 4/26/13 at 1:46 p.m., during an interview, the Director of Nursing (DON) stated, "I need to take care of that," and directed laundry staff to move the laundry to a covered laundry cart. On 5/10/13 at 11:40 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated there were no special handling procedures for resident laundry, including those on contact precautions, "We don't do that. We were told it wasn't necessary...we don't get consistent information and direction on how to handle laundry.'' On 5/15/13 at 4:30 p.m., during an interview, the Medical Director (MD) could not state the facility laundry procedures were in place for residents on contact precautions. The facility policy and procedure titled, "Infection Control," undated, indicated under Section D. Linens, "Contaminated linens should be handled appropriately whether their source was an isolation room or a non-isolation room. All linen should be handled as if it were highly infectious." 5. On 4/26/13 at 1:30 p.m., during entry to the facility, no visitor instruction or guidance was posted at the entrance to the facility. Three to four visitors were observed talking with residents seated adjacent to the nurse's station. On 4/26/13 at 5:45 p.m., during an interview, the Director of Staff Development (DSD) stated one staff person had been off work for several weeks, with a confirmed [DIAGNOSES REDACTED]icile infection. On 4/30/13 at 4:00 p.m., during an interview, the Interim Administrator (IA) was unable to produce a sick leave policy for facility staff, stating, "I'll have to look for it." The IA produced a new employee handbook, stating the policy was included in the handbook. On 5/2/13 at 1:45 p.m., during a subsequent interview, the Administrator Consultant (AC) confirmed the handbook information was the only facility policy regarding staff illness. Review of the facility document titled, "(Facility) Handbook" dated 12/12, contained no direction to ill employees regarding not exposing residents of the facility to their illness. Review of SHEA/APIC Guideline for Infection Prevention and Control in the Long Term Care Facility (LTCF), July 2008, indicated, "Initial assessment of employees and education in infection control are also important, as is a reasonable sick leave policy. Ill employees may cause significant outbreaks in the LTC....LTCFs are required to prohibit employees with communicable diseases...from direct contact with residents ..." The facility policy and procedure titled, "Infection Control, Policy For ARM/MDRO" undated, indicated under I. "Visitors: Instruct visitors to wash their hands prior to resident contact, following contact with body fluids, before and after feeding the resident and following contact with other residents." Review of Centers for Disease Control and Prevention "Guideline for infection control in healthcare personnel, 1998, indicated under D. Elements of a Personnel Health Service for Infection Control, "Certain elements are necessary to attain the infection control goals of a personnel health service....(e) management of job-related illnesses and exposures to infectious diseases, including policies for work restrictions for infected or exposed personnel, (f) counseling services for personnel on infection risks related to employment or special conditions..." As a result of the above failures 6 residents (Residents 1, 2, 3, 5, 6, & 7)and one staff member contracted[DIAGNOSES REDACTED]icile. On 4/26/13 at 5:45 p.m., during an interview, the DSD stated one facility staff person (HLC) had been absent from work for several weeks, with a confirmed [DIAGNOSES REDACTED]icile infection. On 5/10/13 at 11:00 a.m. during a telephone interview, HLC stated her date of onset for[DIAGNOSES REDACTED]icile was on 3/30/13 and her culture was positive for[DIAGNOSES REDACTED]icile on 4/17/13. Review of the administrative documents reported to Madera County Public Health Department titled, "Confidential Morbidity Report," dated 4/29/13, indicated the following dates of [DIAGNOSES REDACTED]icile symptom onset and dates of Diagnosis: [REDACTED]. Resident 1: onset 3/29/13, diagnosis 4/1/13. Resident 2: onset 3/31/13, diagnosis 4/1/13. Resident 3: onset 4/18/13, diagnosis 4/19/13 (based on hospital records). Resident 5: onset 4/4/13, diagnosis 4/5/13. Resident 6: onset 4/24/13, diagnosis 4/26/13. Resident 7: onset 5/1/13, diagnosis 5/6/13. Review of clinical laboratory record documents titled, "Diagnostic Laboratories and Radiology," dated 4/23/13, 4/1/13, 4/26/13, and 5/6/13 for Resident 1, 2, 5, and 7 respectively, all indicated "Toxigenic [DIAGNOSES REDACTED] Positive... The 027/NAP1/BI strain has a high risk of sporulation and toxin production, and has been associated with epidemics of [DIAGNOSES REDACTED]icile infection." The lab record results identified all 4 residents were infected with the same strain of[DIAGNOSES REDACTED]icile. On 4/26/13 at 5:45 p.m., Immediate Jeopardy was called with the Director of Nursing (DON), the Director of Staff Development (DSD) and the Minimum Data Set (MDS) Coordinator when there was an outbreak of Clostridium difficile (C. diff), there was no system in place, and staff were not knowledgeable of infection control practices to prevent the spread of[DIAGNOSES REDACTED]. Immediate Jeopardy was abated on 5/9/13 at 5:17 p.m. with the Interim Administrator and the DON, when the facility provided an acceptable Plan of Action to educate the licensed nurses, laundry, and housekeeping staff in Infection Control practices with training provided by an acceptable outside resource. The isolation rooms were provided dedicated equipment to prevent cross-contamination of residents and a dedicated Certified Nurse Assistant (CNA) for isolated residents. Multiple hand sanitizing stations were placed throughout the facility. The facility implemented routine standardized infection control precautions: caution signs to warn visitors, separation of infectious linens, and cohorting (housing residents with like disease processes) of residents.

Based on observation, staff interview, and clinical record review, the facility failed to implement appropriate infection control interventions based on professional standards of practice. This failure resulted in resident exposure to [DIAGNOSES REDACTED]icile, infection, and resident illness. Findings: On 4/26/13 at 2:25 p.m., during an interview, the Director of Staff Development (DSD) stated, "I do the (infection control) inservice with the staff and with housekeeping." On 4/26/13 at 4:20 p.m., during an interview, the DSD stated she had recently provided infection control training to facility staff on 4/23/13. Training documents received indicated infection control reference information was taken from http://en.wikipedia.org downloaded on 9/13/12 and 3/8/13, a general information internet website, not recognized as a standard resource for professional infection control practice. On 4/26/13 at 4:21 p.m., during an interview, the Minimum Data Set (MDS)Coordinator stated she acted as interim DON prior to the new DON beginning employment at the facility. During that period she denied conducting research or seeking consultation on infection control measures for [DIAGNOSES REDACTED]icile infections. The MDS Coordinator stated she had talked to the administrator about it, but didn't feel the situation met the criteria to seek consultation. The MDS Coordinator denied seeking consultation from Madera County Public Health Department, Centers for Disease Control and Prevention materials, or other professionally recognized infection control resources. On 4/26/13 at 4:22 p.m., during an interview, the DSD denied conducting research or seeking consultation on [DIAGNOSES REDACTED]icile infections from professionally recognized infection control resources, stating, "No, I didn't get in touch with anyone in particular...we talked about it, but no, we didn't." On 4/26/13 at 4:45 p.m., during an interview, the DON denied conducting research or seeking consultation with Madera County Public Health Department, Centers for Disease Control and Prevention, or other professionally recognized resources stating "It was on my list to do... I just haven't done it yet." On 4/26/13 at 4:46 p.m., during an interview, the DSD, DON, and MDS Coordinator all denied conducting surveillance activities of non infected residents for signs and symptoms of potential [DIAGNOSES REDACTED]icile infection. Centers for Disease Control and Prevention "Frequently Asked Questions about [MEDICAL CONDITION] for Healthcare Providers", indicated "Healthcare facilities should monitor the number of [DIAGNOSES REDACTED]icile infections, and especially if rates at the facility increase...additional help should be sought from local and state health departments and/or infection control experts." "Clinical Practice Guidelines for [MEDICAL CONDITION] Infection (CDI) in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)" indicated under Epidemiology, "2. At a minimum, conduct surveillance for HCF-(Healthcare Facilities) onset, HCF-associated CDI in all inpatient healthcare facilities, to detect outbreaks and monitor patient safety."

Based on staff interview, and administrative document review, the Medical Director failed to ensure the facility implemented infection control policies necessary to prevent and control healthcare associated infection. This failure resulted in resident exposure, infection, and illness. Findings: On 5/15/13 at 3:15 p.m., during an interview, the Medical Director (MD) stated he spends an average of three hours per month in service to the facility as MD inclusive of site visits, travel time, fax dispositions and phone calls. The MD stated facility infection control policies and procedures were approved and reviewed on January 22, 2013 and April 24, 2013 at the facility Quality Assurance meeting. On 5/15/13 at 3:30 p.m., during an interview, the MD stated his being notified by the Interim Administrator (IA) on 4/26/13 of the Immediate Jeopardy status of the facility and stated, "I encouraged them to read and follow their (infection control) policies and procedures, and to contact county public health and CDPH." On 5/15/13 at 3:45 p.m., during an interview, the Medical Director stated he conducted a site visit of the facility after being notified of the Immediate Jeopardy status of the facility and stated, "I did a walk through of the facility...I was disappointed...I did see potential for resident harm. There were knowledge issues and a lack of understanding (by facility staff) regarding infection control." He was unable to state the date and time of his walk through. On 5/15/13 at 4:15 p.m., during an interview, the Medical Director acknowledged the http://en.wikipedia.org resource utilized for staff inservice training was not appropriate, and had assumed staff was knowledgeable regarding appropriate infection control resources. On 5/15/13 at 4:30 p.m., during an interview, the MD could not confirm the facility laundry procedures were in place for residents on contact precautions.

Based on observation, staff interview, and administrative document review the facility failed to ensure the Quality Assurance (QA) Committee identified issues related to infection control and implement an appropriate plan of action to prevent resident infections. This failure resulted in residents and staff exposure to healthcare associated infection and resident/staff illness. Findings: On 4/26/13 at 1:27 p.m., during an observation of the facility entrance, no visitor instructions or notification signs were posted. On 4/26/13 at 2:17 p.m., during an observation, "Gel-San" (an alcohol based hand sanitizer) hand wipes and pump solution were noted on medication and treatment carts, and on the nurse's station countertop. No gloves were observed on any carts. On 4/26/13 at 2:18 p.m., during an initial tour, the Occupational Therapist, (OT) stated "We wipe our equipment down first thing (in the morning) and then at the end of the day....each staff person is responsible for wiping down therapy mats after resident use." On 5/10/13 at 11:00 a.m., during a telephone interview, the Housekeeping and Laundry Coordinator (HLC) confirmed she had no documentation of observations, return demonstrations or other measures for validating staff competence in correctly mixing 1:10 bleach solutions. The HLC stated she contracted[DIAGNOSES REDACTED] on 3/30/13 and her culture was positive for[DIAGNOSES REDACTED] on 4/17/13. On 5/10/13 at 11:30 a.m., during an interview, the HLC stated, "I have seen nurses and CNAs (Certified Nursing Assistants) glove up (on entering a resident room), take the gloves off (after resident care), and leave the room and not wash hands. The only place I have seen staff washing their hands is in the break room." On 5/10/13 at 11:40 a.m., during an interview, the HLC stated there were no special handling procedures for resident laundry, including those on contact precautions, "We don't do that. We were told it wasn't necessary...we don't get consistent information and direction on how to handle laundry.'' On 5/15/13 at 3:15 p.m., the Medical Director stated the Quality Assurance Committee (identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies) included the Department Heads (Dietary, Social Services Designee, Activities Coordinator, Housekeeping/Maintenance), Director of Staff Development, Director of Nursing, Medical Director and Administrator. On 5/15/13 at 3:15 p.m., during an interview, the MD stated facility infection control policies and procedures were approved and reviewed on January 22, 2013 and April 24, 2013 at the facility Quality Assurance meeting. The MD stated his role was to work closely with the DSD, DON and Administrator by advising and consulting but it did not include the implementation of "Infection Control" Policy and Procedures. The MD stated his role in the QA committee was that he "runs the meeting" and he depended on staff to report to him if their were any unusual circumstances. On 5/15/13 at 3:45 p.m., during an interview, the Medical Director stated he conducted a site visit of the facility after being notified of the Immediate Jeopardy status of the facility and stated, "I did a walk through of the facility...I was disappointed...I did see potential for resident harm. There were knowledge issues and a lack of understanding (by facility staff) regarding infection control." He was unable to state the date and time of his walk through. On 5/15/13 at 4:30 p.m., during an interview, the Medical Director (MD) could not confirm the facility laundry procedures were in place for residents on contact precautions. The facility policy and procedure titled, "Infection Control-Policies and Procedures" dated January 12, 2012, indicated under Procedure III, "The Quality Assessment and Assurance committee, through the Infection Control Committee oversees implementation of infection control policies and procedures, and helps department heads ensure that they are implemented and followed." As a result of the above failures 6 residents (Residents 1, 2, 3, 5, 6, & 7)and one staff member contracted[DIAGNOSES REDACTED]icile. Review of the administrative documents reported to Madera County Public Health Department titled, "Confidential Morbidity Report," dated 4/29/13, indicated the following dates of [DIAGNOSES REDACTED] symptom onset and dates of Diagnosis: [REDACTED]. Resident 1: onset 3/29/13, diagnosis 4/1/13. Resident 2: onset 3/31/13, diagnosis 4/1/13. Resident 3: onset 4/18/13, diagnosis 4/19/13 (based on hospital records). Resident 5: onset 4/4/13, diagnosis 4/5/13. Resident 6: onset 4/24/13, diagnosis 4/26/13 (based on hospital records). Resident 7: onset 5/1/13, diagnosis 5/6/13.

Based on observation, staff interview, clinical record review and National Kidney and Urologic Diseases Information Clearinghouse, the facility failed to ensure 1 of 15 sampled residents (Resident 13) demonstrated a clinical condition for an indwelling catheter (a sterile tube inserted into the bladder to drain urine) . Resident 13 was on antibiotics for Urinary Tract Infections (UTI's) 12 times, from 7/10/11 through 5/5/12. This placed the resident at risk for ongoing UTI's. Findings: On 6/6/12 at 12:45 p.m., during observation, Resident 13 had an indwelling catheter which drained amber colored urine with white chunks of sediment into a closed drainage bag. Resident 13's annual Minimum Data Set (MDS) assessment completed 12/16/12, indicated the resident had an indwelling catheter. The "CAT Worksheet" (assessment tool) dated 12/6/11, had the following information in Analysis of Findings: "urinary incontinence...complicated by UTI..." There was no documented evidence of an assessment which related to Resident 13's indwelling catheter and no documentation of a clinical condition which would justify the use of an indwelling catheter. The following Nurses' Notes indicated Resident 13's status following removal of the indwelling catheter: On 7/1/11 at 2330, " D/C Foley catheter..." On 7/2/11 at 2330, "... voided (urinated) 3 X tonight..." On 7/4/11 (no date), "Resident without (sic) bladder distention, S/P (status [REDACTED]. On 7/4/11 at 1700, " Resident with void X 3 today. No (sic) bladder distention..." On 7/5/11 at 0300, "...voiding no (sic) distention of bladder observed." On 7/5/11 at 1600, "...CNA (Certified Nursing Assistant) reports incontinence X's 3 on this shift..." There was no documented evidence during this time period Resident 13 experienced [MEDICAL CONDITION] (inability to urinate). Nurses' Notes dated 7/5/11 at 2200, indicated the physician was in and gave an order for [REDACTED]. Resident 13 had laboratory testing performed for urinalysis and culture and sensitivity with subsequent antibiotic therapy as followed for UTI's: 7/10/11 [MEDICATION NAME] 100 mg. every 12 hours for 14 days. 7/30/11 [MEDICATION NAME] 500 mg. every day for 10 days. 8/16/11 [MEDICATION NAME] 500 mg. every 8 hours for 7 days. 8/31/11 [MEDICATION NAME] 100 mg. every day for 3 months. (An antifungal medication often used to treat a yeast infection which can develop as a result of the consumption of antibiotics). 9/16/11 [MEDICATION NAME] 1 gm. IM every day for 7 days. 12/4/11 [MEDICATION NAME] 500 mg. every day for 10 days. 12/22/11 [MEDICATION NAME] 100 mg. every 12 hours for 2 weeks. 1/11/12 [MEDICATION NAME] 1 gm. IM every day for 7 days. 3/27/12 [MEDICATION NAME] 500 mg. every 8 hours for 10 days. 4/14/12 [MEDICATION NAME] 500 mg. every day for 14 days. 5/5/12 [MEDICATION NAME] 1 gm. every day for 7 days. 5/12/12 [MEDICATION NAME] 100 mg. every day for 30 days. A Physicians Telephone Order FAX dated 3/6/12, requested the physician to give a [DIAGNOSES REDACTED]. In response to the FAX, the physician hand wrote on a Physician's Telephone order: "Patient does not have catheter because of retention, it is because of incontinence." Resident 13's physician progress notes [REDACTED]. Risk factor: permanent bladder catheter..." On 6/7/12 at 1:20 p.m., during an interview, the Director of Nursing (DON) was asked what the process was for assessment of residents who had indwelling catheters. The DON stated there was no process. On 6/7/12 at 2:30 p.m., during an interview, Licensed Nurse (LN) 3 was asked about Resident 13's indwelling catheter and was there an assessment for the continued need for the catheter. LN 3 was unable to find documented evidence of an assessment or clinical condition that demonstrated the need for Resident 13 to have an indwelling urinary catheter. There was no documented evidence of a valid medical justification for the use of the indwelling catheter. The National Kidney and Urologic Diseases Information Clearinghouse contained the following information regarding Urinary tract infections. "...Another common source of infection is catheters, or tubes, placed in the urethra and bladder. Catheters interfere with the body's ability to clear microbes (tiny organisms) from the urinary tract. Bacteria travel through or around the catheter and establish a place where they can thrive within the bladder... The Infections Diseases Society of America recommends using catheters for the shortest time possible to reduce the risk of UTI (Urinary tract Infection)..."