Every finding on record at Monrovia Post Acute

Based on interview and record review, the facility failed to provide requested food preference for one of three sampled residents (Resident 1) when Resident 1 was not served ice cream as requested. This failure resulted in Resident 1 not receiving requested food preferences and had the potential to result in decreased meal intake leading to weight loss and further malnutrition (deficiency or imbalance of nutrients). Cross reference: F656Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/18/2026 with diagnoses including severe protein-calorie malnutrition (insufficient intake of protein and calories that the body needs) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). During a review of Resident 1's History and Physical (H&P) dated 6/19/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and personal hygiene, partial moderate assistance (helper does less than half the effort) with oral hygiene, setup or clean up assistance with eating, and was dependent (helper does all of the effort) with lower body dressing, bathing, and toileting hygiene. During a review of Resident 1's Food and Nutrition Progress Note (FNPN) dated 7/22/2026 at 12:40 PM, signed by the Registered Dietician (RD), the FNPN indicated, Visit [Resident 1] at bedside regarding meal concerns. [Resident 1] reports occasionally receiving the wrong liquid consistency and not always receiving dessert with dinner. (Dietary Manager-DM] to follow up with kitchen staff to ensure [Resident 1's] food preferences.are followed consistently during meal service. During a review of Resident 1's Nursing Progress Note (NPN) dated 7/23/2026 at 8:33 AM, signed by Licensed Vocational Nurse (LVN) 1, the NPN indicated, Spoke with MD regarding the [RD's] recommendation to add ice cream to dinner.per resident request. Order received, noted, and carried out. During a review of Resident 1's Order Summary Report (OSR), dated 8/4/2026, the OSR indicated Resident 1 had the following active orders:No added salt (NAS) diet pureed level 4 texture (smooth, moist foods that require no biting or chewing), thin level liquids (liquids that flow freely) with a start date of 7/2/2026Ice cream with dinner in the evening with a start date of 7/23/2026 During an interview on 8/4/2026 at 11AM with Resident 1, Resident 1 stated Resident 1 liked ice cream and had requested ice cream as a food preference several weeks ago (date unknown). Resident 1 stated Resident 1 only received the requested ice cream three times. Resident 1 stated Resident 1 was frustrated because the facility was not honoring Resident 1's food preferences. During an interview and record review on 8/4/2026 at 1 PM and 1:54 PM with the Dietary Manager (DM), Resident 1's Noon Meal Ticket (MT) dated 8/4/2026 and Resident 1's physician's orders were reviewed. The DM stated on 7/23/2026 Menu2U (a computer software system used for menu planning and food service management) did not allow the DM to order ice cream for Resident 1 since Resident 1 was on a pureed diet. The DM stated the DM spoke to Resident 1 on 7/23/2026 and notified Resident 1 that Resident 1 could have pudding instead of ice cream. The DM reviewed Resident 1's diet order and stated that since Resident 1 was allowed to have thin liquids as indicated in the diet order dated 7/2/2026 then Resident 1 could have ice cream. The DM stated residents' (in general) food likes and dislikes were documented on the meal ticket to ensure the dietary staff were aware of the residents' food preference. The DM stated Resident 1's MT did not indicate Resident 1 had a food preference for ice cream. The DM stated it was important to honor Resident 1's food preference because it was Resident 1's right. During an interview on 8/4/2026 at 1:13 PM with the Registered Dietician (RD), the RD stated it was Resident 1's food preference to have ice cream. The RD stated it was important to honor Resident 1's food preference since it would lead to meal satisfaction. During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Preferences, revised July 2017, the P&P's policy statement indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's' consent. The P&P's policy interpretation and implementation indicated, upon the resident's admission.the dietitian/dietary manager or nursing staff will identify a resident's food preferences. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes.

Based on interview and record review, the facility failed to develop a comprehensive care plan (CP, a person-centered plan that outlines a resident's specific health needs, goals, and tailored interventions required to achieve their highest level of physical, mental, and psychosocial well-being) for one of three sampled residents (Resident 1) when Resident 1's care plan did not indicate Resident 1's food preference for ice cream. This failure had the potential to result in unmet individualized needs for Resident 1 and had the potential to affect the resident's physical and psychosocial well-being. Cross reference: F806Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/18/2026 with diagnoses including severe protein-calorie malnutrition (insufficient intake of protein and calories that the body needs) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). During a review of Resident 1's History and Physical (H&P) dated 6/19/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and personal hygiene, partial moderate assistance (helper does less than half the effort) with oral hygiene, setup or clean up assistance with eating, and was dependent (helper does all of the effort) with lower body dressing, bathing, and toileting hygiene. During a review of Resident 1's Food and Nutrition Progress Note (FNPN) dated 7/22/2026 at 12:40 PM, signed by the Registered Dietician (RD), the FNPN indicated, Visit [Resident 1] at bedside regarding meal concerns. [Resident 1] reports occasionally receiving the wrong liquid consistency and not always receiving dessert with dinner. (Dietary Manager-DM] to follow up with kitchen staff to ensure [Resident 1's] food preferences.are followed consistently during meal service. During a review of Resident 1's Nursing Progress Note (NPN) dated 7/23/2026 at 8:33 AM, signed by Licensed Vocational Nurse (LVN) 1, the NPN indicated, Spoke with MD regarding the [RD's] recommendation to add ice cream to dinner.per resident request. Order received, noted, and carried out. During a review of Resident 1's Order Summary Report (OSR) dated 8/4/2026, the OSR indicated Resident 1 had an order for ice cream with dinner in the evening with a start date of 7/23/2026. During an interview on 8/4/2026 at 11AM with Resident 1, Resident 1 stated Resident 1 liked ice cream and had requested ice cream as a food preference several weeks ago (date unknown). Resident 1 stated Resident 1 only received the requested ice cream three times. Resident 1 stated Resident 1 was frustrated because the facility was not honoring Resident 1's food preferences. During an interview on 8/4/2026 at 1:13 PM with the RD, the RD stated it was Resident 1's food preference to have ice cream. During a concurrent interview and record review on 8/4/2026 at 2:15 PM with the Director of Nursing (DON), Resident 1's CPs were reviewed. The DON stated Resident 1's CPs did not address Resident 1's preference for ice cream. The DON stated it was important to address Resident 1's food preferences in the CP because the facility should individualize the CPs for each resident. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P's policy statement indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled, Resident Food Preferences, revised July 2017, the P&P's policy interpretation and implementation indicated, Nursing staff will document the resident's food and eating preferences in the care plan.

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices for four of eight sampled residents (Residents 1, 5, 6, and 7) by failing to:Ensure Resident 1's bedside dresser was clean.Ensure Residents 1, 5, 6, and 7's shared bathroom closet area was clean.These failures had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to Residents 1, 5, 6, and 7.A&B. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 12/19/2025 with diagnoses including fracture of upper and lower end of right fibula (a break in the lower leg bone), subsequent encounter for closed fracture with routine healing (a follow up visit indicating the break is healing normally), and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H&P), dated 12/21/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 required setup or clean- up assistance with eating, oral hygiene, and bathing and was independent with toileting, dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 5's AR, the AR indicated the facility originally admitted Resident 5 on 6/6/2024 and was readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) with diabetic chronic kidney disease (long-term kidney damage caused by diabetes) and hypertensive heart disease with heart failure (a condition where the heart is unable to pump blood effectively).During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making were severely impaired (never/rarely makes decisions). The MDS indicated Resident 5 required setup or clean-up assistance with eating, partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, and personal hygiene, and substantial/maximal assistance (helper does more than half the effort) with toileting, bathing, and lower body dressing.During a review of Resident 6's AR, the AR indicated the facility originally admitted Resident 6 on 1/28/2025 and was readmitted on [DATE] with diagnoses including rhabdomyolysis (a medical condition where muscle tissue breaks down, releasing harmful substances in the bloodstream) and sciatica (nerve pain).During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making were intact. The MDS indicated Resident 6 required setup or clean-up assistance with eating and oral hygiene, supervision or touching assistance with toileting and personal hygiene, and partial/moderate assistance with bathing, dressing, and putting on/taking off footwear.During a review of Resident 7's AR, the AR indicated the facility originally admitted Resident 7 on 4/11/2025 and was readmitted on [DATE] with diagnoses including disorders of digestive system (health problems that occur in the digestive tract) and hypertensive heart disease with heart failure.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 7 required setup or clean-up assistance with eating, oral hygiene, dressing, and personal hygiene, required supervision or touching assistance with toileting, and partial/moderate assistance with bathing.During a concurrent observation and interview on 7/15/2026 at 11 AM with Resident 1 in Resident 1's room, a white hard substance was observed under the metal edge of Resident 1's bedside dresser. Resident 1 stated the white hard substance looked like old gum and had been on Resident 1's bedside dresser since Resident 1 was admitted to the facility. During the same observation in Residents 1, 5, 6, and 7's shared bathroom closet area a dried brown substance was observed on a cupboard door. During a concurrent observation and interview on 7/16/2026 at 6 AM with the Certified Nursing Assistant (CNA), in Resident 1's room a white hard substance was observed under the metal edge of Resident 1's bedside dresser. The CNA stated the white substance on Resident 1's bedside dresser looked like old tape and should not be on the dresser. The CNA stated the CNA would not want to touch the white substance since it might be old gum or tape from a wound. During the same observation in Residents 1, 5, 6, and 7's shared bathroom closet area a dried brown substance was observed on a cupboard door. The CNA stated the brown substance should not be there.During a concurrent observation and interview on 7/16/2026 at 6:05 AM with the Infection Prevention Nurse (IPN), in Resident 1's room a white hard substance was observed under the metal edge of Resident 1's bedside dresser. The IPN stated the white substance looked like old gum. During the same observation in Residents 1, 5, 6, and 7's shared bathroom closet area a dried brown substance was observed on a cupboard door. The IPN stated the brown substance looked like feces. The IPN stated Resident 1's bedside dresser and Resident 1's shared bathroom closet space should be clean to prevent cross contamination and infection to the residents (in general).During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control, revised December 2025, the P&P's policy statement indicated, The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P's policy interpretation and implementation indicated, The objectives of the infection prevention and control policies and procedures are to: monitor, prevent, detect, investigate, and control infection in the facility; maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public [.]During a review of the facility's P&P titled, Cleaning and Disinfecting Residents' Rooms, revised February 2026, the P&P's purpose indicated, The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. The P&P's general guidelines indicated, Resident rooms are cleaned regularly and as needed by housekeeping/environmental services. Walls, blinds, and window curtains in resident rooms are cleaned when visibly contaminated or soiled.

Based on observation, interview, and record review, the facility failed to ensure a Hoyer lift sling (a supportive fabric device that cradles an individual used with a Hoyer lift [a patient lift, a mechanical device with lifting mechanism] to safely transfer individuals with limited mobility between a bed, wheelchair, or toilet) was maintained in a safe and functional condition prior to a transfer for one of two sampled residents (Resident 2). As a result, on 6/4/2026, the Hoyer lift sling ripped while Resident 2 was lifted off the bed, suspending Resident 2 in the air. Resident 2 fell from the Hoyer lift to the floor. Resident 2 sustained a Lumbar 2 (L2, lower back) wedge compression fracture (a break or collapse in the front portion of the second lower back vertebra [spine bone] causing a wedge shape), and moderate sharp pain (typically sudden, intense, and acts as a warning signal from the body. It is most commonly caused by a recent injury) to Resident 2's lower back. The facility transferred Resident 2 to a General Acute Care Hospital (GACH 1) for further evaluation and treatment.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility 8/28/2025 with multiple diagnoses including hemiplegia (a form of paralysis [complete or partial loss of muscle function in a part of the body] that affects one entire side of the body) and hemiparesis (muscle weakness or partial paralysis affecting only one side of the body) following cerebral infarction (commonly known as a stroke), affecting the left non-dominant side (the left half of the body for a right-handed person).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 2 had intact cognition (ability to understand and process information) and was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on bed to chair transfers and lying to sitting on the side of the bed.During a review of Resident 2's Change in Condition Evaluation (COC, an alteration in a resident's physical health that differs from his/her previous baseline), dated 6/4/2026, timed at 10 AM, the COC indicated Resident 2 had an assisted fall (an unintentional descent to the floor where a caregiver is present to physically guide the resident to the floor) to the floor with two staff members (Certified Nursing Assistant [CNA] 5 and CNA 6] present during a transfer due to a malfunction of the Hoyer lift sling. The COC indicated the Medical Doctor (MD, Resident 2's physician) was notified of the fall and the MD ordered a stat (immediately or without delay) X-ray (medical imaging that uses radiation to take pictures of bones and organs inside the body) of the left lower extremity (leg) and an X-ray of bilateral (two sides) hips. During a review of Resident 2's X-ray report on the lumbar spine dated 6/4/2026, the X-ray report indicated mild L2 anterior (situated toward or at the front of the body) wedge compression fracture.During a review of the Order Summary Report (OSR), dated 6/4/2026, the OSR indicated an order to transfer Resident 2 to GACH 1 due to L2 anterior wedge compression fracture.During a review of Resident 2's Progress Notes (PN), dated 6/4/2026, timed at 7:20 PM, the PN indicated Resident 2 complained of generalized body pain and had 5 out of 10 pain (on a pain scale from 0 to 10, 0 represents no pain, 4 to 5 represents moderate pain, and 10 represents worst pain imaginable) to the lower back (on 6/4/2026) at 5:17 PM. The PN indicated Resident 2 was given pain medication (pain reliever, Acetaminophen/Tylenol). The PN indicated Resident 2's lumbar spine X-ray indicated a mild L2 compression fracture. The PN indicated the MD ordered to transfer Resident 2 to GACH 1 for further evaluation and treatment. The PN indicated Resident 2 was taken to GACH 1 via ambulance [on 6/4/2026] at 7:20 PM. During a review of Resident 2's GACH 1 Patient Results (PR), dated 6/4/2026, the PR indicated Resident 2's computed tomography (CT -advanced X-ray that takes multiple pictures of bones, organs, and soft tissues from different angles) scan of the lumbar spine without contrast (a specialized substance used during imaging tests to highlight specific organs, blood vessels, or tissues) indicated acute transverse comminuted fracture of L2 superior vertebral endplate (a sudden horizontal break located at the top flat surface of the second lumbar spine bone) with less than 10% reduction in height (a vertebral bone in the spine has collapsed slightly and lost up to 10% of its original vertical size). During a review of Resident 2's GACH 1 Discharge Instructions (DI), signed 6/5/2026, the DI indicated Resident 2 was seen in the emergency room (ER) after sustaining a fall at the facility. The DI indicated the CT imaging demonstrated a fracture in the lumbar spine at L2. The DI indicated Resident 2 would benefit from a Thoracolumbosacral Orthosis (TLSO, rigid medical-grade back brace designed to immobilize and support the middle, lower, and sacral regions of the spine, used to relieve pain, promote healing, and stabilize fractures) brace to resume normal activity. During a review of Resident 2's PN, dated 6/5/2026, timed at 11:34 AM, the PN indicated Resident 2 returned (readmitted ) to the facility from GACH 1. The PN indicated Resident 2 reported 4/10 lower back pain (moderate pain) during transfers from the bed to the wheelchair and when staff repositioning Resident 2.During a concurrent observation of Resident 2 in Resident 2's bed and interview on 6/9/2026 at 11:05 AM with Resident 2, Resident 2 was lying in bed on Resident 2's back. Resident 2 held the left side of Resident 2's bed rail with Resident 2's right hand and grimaced as Resident 2 showed the pain felt while Resident 2 moved. Resident 2 stated facility nurses (in general) used the Hoyer lift [with a Hoyer lift sling] every day to assist Resident 2's transfer from the bed to a wheelchair due to weakness on Resident 2's left side from a prior stroke. Resident 2 stated [on 6/4/2026] two CNAs (CNA 5 and CNA 6) attempted to transfer Resident 2 from Resident 2's bed to a wheelchair as part of Resident 2's normal routine to go to activities. Resident 2 stated, I saw the Hoyer lift sling before it snapped. Resident 2 stated the Hoyer lift sling looked old and worn and had threads coming out. Resident 2 stated Resident 2 was placed on the Hoyer lift sling and was lifted off the bed to the level of the doorknob. Resident 2 stated during the lateral move from the bed to the wheelchair, the Hoyer lift sling strap supporting Resident 2's legs tore and Resident 2 remained suspended on the Hoyer lift sling for a brief moment before falling onto the ground and landing on Resident 2's buttocks and lower back. Resident 2 stated Resident 2 started to feel moderate sharp pain on Resident 2's lower back when Resident 2 was lifted from the floor by facility employees (CNA 5, CNA 6, Licensed Vocational Nurse [LVN] 2, and Registered Nurse [RN] 3) with a bedsheet. Resident 2 stated Resident 2 also experienced (moderate) sharp pain on Resident 2's lower back when Resident 2 was turned side to side by staff during pericare (process of gently washing a person's private parts, performed daily).During a concurrent interview and a review on 6/9/2026 at 2:25 PM, the facility's In-service (staff training) Meeting Minutes (ISMM), titled Safety, dated 12/29/2025, were reviewed with the Director of Staff Development (DSD), the ISMM's brief summary of lecture indicated Before the transfer of a resident, inspect the Hoyer lift and Hoyer lift sling for damage. The DSD stated the facility's latest in-service, dated 12/29/2025, on the use of Hoyer lifts indicated to check the Hoyer lift slings for any indication that the Hoyer lift sling was not safe to use such as having signs of wear and tear.During an interview on 6/9/2026 at 2:47 PM with LVN 2, LVN 2 stated [on 6/4/2026] two CNAs [CNA 5 and CNA 6] were transferring Resident 2 from Resident 2's bed to the wheelchair when the Hoyer lift Hoyer lift sling's black strap located near Resident 2's legs ripped. LVN 2 stated CNA 5 attempted to hold Resident 2 up, but Resident 2 slid off the Hoyer lift sling onto the ground. LVN 2 stated, prior to Resident 2's assisted fall, no staff had reported signs of wear and tear on the Hoyer lift slings. LVN 2 stated the Hoyer lift slings were not assigned to specific residents and staff (in general) were supposed to inspect the Hoyer lift slings for damage prior to their use. LVN 2 stated after staff assisted Resident 2 back to bed, LVN 2 showed the ripped black Hoyer lift sling strap to the Director of Maintenance (DM), the Administrator (ADM), and the DON.During a concurrent interview and a review of the facility's Resident Lifts Inspect Mobile Lifts and an interview on 6/9/2026 at 3:33 PM with the DM, the facility's Resident Lifts Inspect Mobile Lifts checklist completed by the DM, dated 5/26/2026, indicated to remind nursing staff to inspect all Hoyer lift slings and lifting straps for wear. The checklist indicated items identified as poor condition should be removed from service. The DM stated the DM replaced a damaged Hoyer lift sling in March 2026 but had not seen any more Hoyer lift slings with signs of wear and tear until Resident 2 fell on 6/4/2026. The DM stated, when completing the checklist, the DM did not know which Hoyer lift sling was inspected and could not differentiate between Hoyer lift slings.During an interview on 6/10/2026 at 12 PM with CNA 5, CNA 5 stated every day, CNA 5 assisted Resident 2 out of bed to participate in activities. CNA 5 stated in the morning of 6/4/2026, CNA 5 called CNA 6 to Resident 2's room to assist with Resident 2's transfer. CNA 5 stated Resident 2 always required the use of a Hoyer lift to transfer Resident 2 from the bed to the wheelchair. CNA 5 stated CNA 5 was familiar with how to use the Hoyer lift and Hoyer lift sling. CNA 5 stated the selected Hoyer lift sling used on Resident 2 looked worn in some areas, but CNA 5 did not think the Hoyer lift sling was so worn that the Hoyer lift sling would break or tear. CNA 5 stated the Hoyer lift sling ripped and CNA 5 tried to hold Resident 2, but Resident 2 was too heavy (233 pounds, unit of weight) and fell. CNA 5 stated CNA 5 had received in-services in the past (12/29/2025) and was instructed not to use Hoyer lift slings that looked worn. During an interview on 6/10/2026 at 1:11 PM with the Director of Rehabilitation (DOR), the DOR stated Resident 2 stayed in bed from 6/4/2026 to 6/10/2026 while waiting to receive a lumbar brace (TLSO) and Resident 2 had not been assisted out of bed. The DOR stated, after Resident 2's fall, Resident 2 experienced moderate pain in the lower part of the back. During an interview on 6/10/2026 at 4:50 PM with the ADM and the DON, the ADM stated the Hoyer lift slings were replaced on an as-needed basis and the facility did not have a system in place other than visual inspections [to ensure the Hoyer lift slings were not worn and torn]. The DON stated ultimately the final inspection needed to be done by the person using the sling to determine if the sling was in a [good] working condition. The DON stated the DON did not know the condition of the sling [used on Resident 2 on 6/4/2026] prior to being used. During a review of the facility's undated Instruction Manual for Full Body Sling (IMFBS), the IMFBS's warning indicated to carefully inspect the sling before each use and after each laundering for wear and damage to seams, fabric, straps, and strap loops. The IMFBS indicated torn, cut, frayed or broken slings could fail, resulting in serious personal injury to the user or caregiver. The IMFBS indicated use only slings that are in good condition. The IMFBS indicated to discard and destroy old, unusable slings. During a review of the facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, dated 7/2017, the P&P's steps in the procedure indicated to make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. The P&P indicated before resident is lifted, double check the security of the sling attachment. The P&P indicated check the stability of the straps, lift the resident two (2) inches from the surface to check the stability of the attachments, and the fit of the sling and weight distribution.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 3 and 14) received nursing care and services in accordance with professional standards of practice.For Resident 3 the facility failed to ensure the physician notification was completed and act upon a change in condition (CIC) when Resident 3 experienced the following: On 4/2/2026 Resident 3's sodium level (Normal sodium levels = 135 to 145 milliequivalent per liter (meq/L)) was 131 meq/L (low).Resident 3's level of consciousness was altered and Resident 3 was lethargic (consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep). This deficient practice led to a delay in Resident 3's care and treatment for the low sodium and Resident 3's change in the level of consciousness and the potential to result in a physical decline to Resident 3. For Resident 14, Licensed Vocational Nurse (LVN) 6 failed to ensure a physician's order was followed for the administration of Milk of Magnesium (medication used to relieve constipation) 2400 milligram (mg, unit of measurement)/10 milliliter (mL-a metric unit of volume) to give 30 mL by mouth one time a day for bowel management (structured program designed to help individuals control their bowels, achieve daily bowel movements, and prevents long standing constipation).This deficient practice had the potential to result in medication underdosing leading to constipation affecting Resident 14's physical well-being.Findings:A. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 5/8/2024 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and chronic kidney disease (condition characterized by a gradual loss of kidney function over time).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 3 had severe cognitive (ability to think and make decisions) deficit and Resident 3 was dependent with all activities of daily living.1. During an interview on 4/21/2026 at 12:08 PM, Resident 3's Family Member 2 (FM 2) stated Resident 3 had been sleeping a lot for 3 weeks. FM 2 stated Resident 3 was probably tired because Resident 3 was [AGE] years of age. During a review of Resident 3's Lab Results Report, dated 3/26/2026, the result indicated Resident 3's sodium level was 126 meq/L.During a review of Resident 3's CIC Evaluation dated 3/26/2026, the CIC indicated a low sodium level of 126 with clinician recommendation to administer sodium chloride via gastrostomy tube (GT - a feeding tube inserted through the abdomen directly into the stomach), for 5 days and to repeat Basic Metabolic Panel (BMP, blood test) on 4/2/2026.During a review of Resident 3's Lab Results Report, dated 4/2/2026, the result indicated a sodium level of 131 meq/L.During a review of Resident 3's CICs and Nurse's Progress Notes, dated April 2026, there was no documented evidence indicating Resident 3's physician (Medical Doctor, MD 1) was notified of the laboratory result dated 4/2/2026.During a concurrent record review and interview on 4/23/2026 at 10:45 AM with the Assistant Director of Nursing (ADON), Resident 3's sodium level lab result, dated 4/2/2026, Resident 3's CICs and Progress Notes dated April 2026 were reviewed. The ADON stated the timeframe for notifying a physician of a CIC was immediately or within the shift [of the CIC]. The ADON stated a low sodium level could lead to dizziness, mentation changes, and tiredness. The ADON stated there was no CIC evaluation on 4/2/2026 and the Progress Notes dated 4/8/2026 indicated MD 1 was notified of Registered Dietitian's recommendation for water flush due to low sodium. The ADON stated a sodium level of 131 meq/L was low and MD 1 needed to be notified immediately or within the same day of the laboratory test result. The ADON stated the ADON stated if a CIC evaluation was initiated on 4/2/2026, the evaluation would ensure monitoring of Resident 3's change in condition.2. During an observation on 4/23/2026, Resident 3 was sleeping during the following times: at 8:45 AM, at 11 AM, and at 1:10 PM.During an interview on 4/23/2026 at 2:53 PM, Certified Nursing Assistant (CNA) 3 stated Resident 3 was able to eat, walk, talk, and yell often. CNA 3 stated Resident 3 was now mostly sleeping starting on Monday 4/20/2026. CNA 3 stated Resident 3 would open Resident 3's eyes when being repositioned and today Resident 3 asked for water but coughed when drinking. CNA 3 stated CNA 3 reported to Licensed Vocational Nurse (LVN) 1 that Resident 3 was sleeping a lot.During an interview on 4/23/2026 at 2:57 PM with LVN 1, LVN 1 stated Resident 3 had been sleepy for a few days but Resident 3 woke up when someone talked to the resident. LVN 1 stated LVN 1 did not complete a change in condition because Resident 3 could be awakened.During an interview on 4/23/2026 at 3:17 PM, LVN 2 stated lethargy meant the resident (in general) would be unable to wake up right away, unable to answer right away, and waking up the resident would take time. LVN 2 stated Resident 3 was usually sleeping when LVN 2 started LVN 2's shift but Resident 3 usually opened Resident 3's eyes when LVN 2 talked to Resident 3. LVN 2 stated Resident 3's level of consciousness before was Resident 3 was awake and alert and yelled almost every minute.During an observation on 4/23/2026 at 3:25 PM, Restorative Nursing Assistant (RNA, specialized rehabilitative care provided by nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living) 1 attempted to wake up Resident 3 by calling resident's name three times, Resident 3 remained asleep with eyes closed. RNA 1 shook Resident 3's bilateral shoulder once, then twice and Resident 3 opened resident's eyes on the third try. RNA 1 informed Resident 3 the RNA 1 would be providing exercises, then Resident 3 closed Resident 3's eyes and fell back asleep. During this observation, Registered Nurse Supervisor 1 (RNS 1) was present at Resident 3's bedside.During an interview on 4/23/2026 at 3:44 PM, RNS 1 stated RNS 1 assessed Resident 3 when staff reported any changes to RNS 1. RNS 1 stated when a resident (in general) had increased sleepiness and was hard to wake up, RNS 1 checked for infections, aspiration pneumonia, or urinary tract infections (UTI - an infection in the bladder/urinary tract), and notified the physician to get physician orders for the resident. RNS 1 stated RNS 1 did not receive a report from any staff regarding any incidents for Resident 3. RNS 1 stated FM 2 was always present at Resident 3's bedside and did not report any changes to RNS 1. RNS 1 answered yes when asked are the licensed nurses and certified nursing assistants responsible for identifying changes in condition.During an interview on 4/23/2026 at 4:30PM, the Director of Nursing (DON) stated when determining a change in condition related to increased sleepiness, the DON investigated first why the resident (in general) was sleeping during the day and find out if the resident was awake during the night, find out if there was any medication changes, and look into the resident's co-morbidities. The DON stated if these were not the reasons [root cause], the DON notified the physician for the resident to be assessed and the facility receive physician orders for laboratory work-up to find the source of a possible infection or abnormal laboratory results.During an observation on 4/24/2026 Resident 3 was asleep during the following times: at 8:45 AM, at 9:55 AM, and at 11:27 AM.During an interview on 4/24/2026 at 11 AM, Resident 3's roommate stated Resident 3 used to scream day and night but Resident 3 sleeps all the time now for the past 3-4 months. During a review of Resident 3's Care Plan (CP) titled Episode of Hyponatremia initiated on 3/26/2026, the CP's interventions indicated to monitor for signs and symptoms such as confusion, lethargy, headache, nausea and vomiting.During a review of Resident 3's CP titled Potential for Complications, signs and symptoms related to Chronic Kidney Disease the CP's interventions indicated to monitor and report changes in mental status such as lethargy, tiredness, fatigue, tremors, and seizures.During a review of an undated article from the National Library of Medicine, National Institutes of health (NIH), titled Level of Consciousness-Clinical Methods, the article indicated the normal state of consciousness comprises either the state of wakefulness, awareness, or alertness in which most human beings function while not asleep or one of the recognized stages of normal sleep from which the person can be readily awakened. The article indicated the different altered states of consciousness are: clouding of consciousness, confusional state, delirium, lethargy, obtundation, stupor, dementia, hypersomnia, vegetative state, akinetic mutism, locked-in syndrome, coma, and brain death. The article indicated the following definition;Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.Coma is a state of unarousable unresponsiveness.During a review of the facility's Policy and Procedure (P&P) titled Acute Condition Changes - Clinical Protocol, dated March 2018, the P&P indicated direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. Nursing Assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the Nurse. The P&P indicated the nurse shall assess and document/report the following baseline information such as. level of consciousness, onset, duration, severity, recent labs.B. During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 7/26/2020 and re-admitted the resident on 9/6/2025, with diagnoses including Gastro-Esophageal Reflux Disease (GERD-when stomach acid flow back into the esophagus [the tube from the mouth to the stomach], causing burning in the chest and irritation), irritable bowel syndrome (IBS-a condition where the intestines are overly sensitive and don't move normally, causing abdominal pain, bloating, and changes in bowel habits [diarrhea, constipation, or both] without visible damage to the digestive tract), dysphagia (difficulty swallowing), and ileus (a condition where the intestines temporarily stop moving, so food and gas can't pass normally).During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 14 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and mobility was not attempted due to medical condition or safety concerns.During a review of Resident 14's Order Summary (OS), dated 3/18/2026, the (OS) indicated:Milk of Magnesium 2400 mg/10 mL, give 30 mL by mouth one time a day for bowel management.During a review of Resident 14's Medication Administration Record (MAR), dated 4/2026, the MAR indicated to administer the following medications at 9 AM:Milk of Magnesium 2400 mg/10 mL give 30 mL by mouth one time a day.Risperidone (used to treat mood or behavior conditions such as agitation or psychosis (mental health symptom characterized by disconnection from reality) 0.5 mg, give 1 tablet by mouth two times a day.Oxybutynin Chloride (used to treat overactive bladder [hollow muscular organ at the base of the pelvis [basin-shaped bony structure located at the base of the spine] acts as a reservoir for urine] by reducing urinary urgency and frequency) 5 mg, 1 tablet by mouth three times a day.Dicyclomine Hydrochloride (used to relieve stomach cramps and bowel spasms) 10 mg, 1 capsule by mouth three times a day.Sertraline (used to treat depression and anxiety) 50 mg, give 1 tablet by mouth every day.During a medication pass observation on 4/23/2025 at 8:36 AM, Licensed Vocational Nurse (LVN) 6 prepared the following medications for Resident 14: Risperidone, Oxybutynin Chloride, Dicyclomine Hydrochloride, Sertraline, and Milk of Magnesium. LVN 6 obtained the stock bottle of Milk of Magnesium with a concentration of 1200 mg/15 mL and poured 30 mL into a medication cup. LVN 6 stated she was done preparing the medication and was ready to administer it to Resident 14.During an interview and concurrent record review on 4/23/2026 at 8:45 AM with LVN 6, LVN 6 stated the physician's order indicated Milk of Magnesium 2400 mg/10 mL, give 30 mL, which equalled a total dose of 7,200 mg. LVN 6 stated the stock bottle available for Milk of Magnesium had a concentration of 1200 mg/15 mL, and administering 30 mL from that concentration provided [Resident 14] a total dose of 2,400 mg. LVN 6 stated LVN 6 prepared to administer 30 mL of Milk of Magnesium based solely on the volume listed in physician's order [30 mL], without accounting for the difference in concentration [in the bottle], resulting in a significantly lower dose than prescribed. LVN 6 further stated that she should have verified that the concentration of the medication matched the physician's order to ensure the correct dose was administered. LVN 6 stated that failing to verify the correct concentration could have resulted in underdosing Resident 14, leading to ineffective treatment, unresolved constipation, and result in complications or discomfort to Resident 14.During an interview and concurrent record review on 4/23/2026 at 10:38 AM, with the Assistant Director of Nursing (ADON), the ADON stated nurses are expected to cross-check each medication order against the medication label and concentration prior to administration. The ADON stated if anything appeared incorrect or unclear, the nurse should stop and verify the order with the physician and/or contact the pharmacy to obtain the correct concentration or clarify the order. The ADON stated in this situation, the nurse should have recognized the concentration discrepancy and either requested a corrected order or obtained the appropriate formulation. The ADON further stated that these practices are essential to ensure resident safety and ensure medications are administered accurately according to the physician's order.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated: Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment when:a. There was black substance on the caulk (a flexible sealing material used to fill gaps, cracks, and joints to prevent air, water, dust, and contaminants from passing through) in two of two showers (Shower 1 and Shower 2) located inside one of two facility shower rooms.b. The cove base (a type of vinyl and or rubber trim that's applied to the edges of a floor to help create a smooth transition between the floor and the wall) in the shared bathrooms of three of three sampled resident rooms (Rooms 1, 31 and 35) and the wall close to the bathroom door inside room [ROOM NUMBER] was loose and had a gap from the wall. Additionally, there was an insect found in the gap between the cove base and the wall close to the bathroom door inside room [ROOM NUMBER].c. The door trim, located outside the bathroom door in one of one sampled room (Resident 36, Resident 75, and Resident 12's room), was loose and had a gap from the door frame.d. A foul odor was detected in one of one multi-resident room (Resident 54, Resident 48, and Resident 7's room). These failures had the potential for residents and employees to be exposed to dirt, mold, drywall dust, and disease-carrying insects which could lead to a decline in residents' health. These failures also had the potential for residents and employees to sustain an injury from tripping on loose cove base and had the potential to cause discomfort among all residents inside the room and affect the residents' physical and psychosocial wellbeing.Findings: a. During a concurrent observation and interview on 4/23/2026 at 8:46 AM with the Maintenance Director, there was black substance on the silicone caulk on two corners of Shower 2. Maintenance Director (MD) was able to scrape off the black substance using the tip of the flathead screwdriver. When asked if the back substance was mold, the MD did not answer. The MD stated mold could be black, beige and brown in color. The MD answered yes when asked if mold could grow in a moist environment. During a concurrent observation and interview on 4/23/2026 at 8:50 AM, there was black substance on the silicone caulk on one corner of Shower 1. The MD attempted to scrape off the black substance, and some of the black substance came off. The MD stated the black substance that did not come off would be (caulking) glue. b. During an observation with the Director of Staff Development (DSD) on 4/23/2026 at 8:28 AM, approximately 3 inches of the cove base inside the shared bathroom in room [ROOM NUMBER] (shared with room [ROOM NUMBER]) was loose and had a gap off from the wall. During an interview on 4/23/2026 at 8:30 AM, the DSD stated we need to repair any areas that are broken or loose to provide a safe and homelike environment for all residents at the facility. During an observation on 4/23/2026 at 8:31 AM with the DSD, the cove base inside the shared bathroom in room [ROOM NUMBER] (shared with room [ROOM NUMBER]) was loose and had a gap from the wall. During an observation and interview on 4/23/2026 8:54 AM with the MD, the cove base on the wall close to the bathroom door inside room [ROOM NUMBER] was loose and had a gap. There were chunks of drywall in between the gaps. There was a light colored, shrimplike small insect approximately 0.5 centimeters in length found inside the gap. The MD stated the insect looked like a cricket. The MD answered yes when asked if insects, like cockroaches could hide behind the gaps. The MD stated MD would close the gaps with glue. c. During a concurrent observation and interview on 04/23/2026 at 8:38 AM with the MD, approximately 7 inches of the door trim leading to the shared bathroom in Resident 36, Resident 75, and Resident 12's room was loose and had a gap from the door frame. The MD answered yes when asked if the loose trim would put the residents and staff at risk for tripping on the loose door trim. d. During a review of Resident 54's admission Record (AR), the AR indicated the facility originally admitted Resident 54 on 3/10/2026 with diagnoses including unilateral primary osteoarthritis of the right hip (a progressive disorder of the joints, caused by a gradual loss of cartilage, that primarily affects one side of the body, often involving a single joint) and spinal stenosis (narrowing of the spinal canal), lumbar region (lower back) without neurogenic claudication (compression of the nerves in the lower spine leading to leg pain). During a review of Resident 54's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/11/2026, the H&P indicated Resident 54 had the capacity to understand and make decisions. During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 54's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 54 required supervision or touching assistance with eating, oral hygiene, and upper body dressing and required partial/moderate assistance with toileting, showering, lower body dressing and personal hygiene. During a concurrent observation and interview on 4/21/2026 at 11:20 AM with Resident 54 in Resident 54, Resident 48, and Resident 7's room, a foul odor was detected. Resident 54 stated there had been a foul odor in Resident 54's room for a week. Resident 54 stated Resident 54 had notified staff many times about the foul odor. During a concurrent observation and interview on 4/23/2026 at 12:09 PM in Resident 54, 48, and 7's room with Certified Nursing Assistant (CNA) 1, CNA 1 stated there was a foul smell detected in Resident 54, 48, and 7's room. CNA 1 stated the odor smelled like body odor. During a concurrent observation and interview on 4/23/2026 at 3:40 PM in Resident 54, 48, and 7's room with CNA 2, CNA 2 stated there was a foul smell which smelt like feces coming from Resident 54, 48, and 7's room. CNA 2 stated Resident 54 had complained to CNA 2 many times about a foul odor in Resident 54, 48, and 7's room. During an interview on 4/24/2026 at 11:26 AM with Registered Nurse (RN) 1, RN 1 stated there should not be a foul odor in the residents' rooms (in general). RN 1 stated it was the policy of the facility to ensure the residents' rooms (in general) were clean and did not have a foul odor. During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P's policy statement indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P's policy interpretation and implementation indicated, Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment; pleasant, neutral scents.

Based on observation, interview and record review, the facility failed to ensure thawed bacon inside one of two refrigerators (Refrigerator 2) was labeled with a thaw date for dietary staff to follow recommended maximum storage period. This deficient practice had the potential to cause food borne illness that could potentially affect the residents at the facility.Findings:During an observation on 4/21/2026 at 9:10 AM, there were two refrigerators. The second refrigerator had 1 opened box of bacon with a full bag of thawed bacon inside the box. The box had the following information written outside the box: Received date: 4/2/2026, use by date: 7/1/2026, and opened date: 4/6/2026. There was no thawed date indicated or written on the box. During a review of the facility's guidelines posted inside the kitchen and a concurrent interview on 4/21/2026 at 9:16 AM, the posted guidelines indicated thawed bacon had a maximum storage period of one to two weeks. The Dietary Supervisor (DS) stated the kitchen staff would not know if the bacon would meet the recommended maximum storage period of 1-2 weeks since there was no information when the bacon was thawed. The DS stated the importance of following recommended storage guidelines would be to prevent foodborne illness to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage, dated November 2022. The P&P indicated foods shall be received and stored in a manner that complies with safe food handling practices. The P&P indicated Critical Control Point means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating foods.The P&P indicated refrigerated foods are labeled, dated and monitored so they are used by their use-by' date, frozen or discarded.

Based on observation, interview and record review, the facility failed to ensure two of four kitchen staff (Dietary Supervisor and [NAME] 1) follow the International Dysphagia Diet Standardization Initiative (IDDSI - developed a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties. To accompany this standard, IDDSI has also developed testing methods to determine if any food or drink conforms to the requirements of the IDDSI Standard) to test pureed food (A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon intact. The food is more easily swallowed and prevents aspiration) for 6 residents with orders for pureed - level 4 diet. This deficient practice had the potential for facility to serve pureed food that did not meet the standard characteristics which could potentially put the residents with dysphagia (difficulty swallowing) at risk for choking.Findings:During an observation on 4/23/2026 at 11:35 AM, [NAME] 1 was adding thickener to pureed rice pilaf and performed the spoon test. [NAME] 1 placed less than a spoonful of pureed rice pilaf on to the spoon. when the spoon was tilted, the pureed rice pilaf fell off the spoon right away. During an observation on 4/23/2026 at 11:48 AM, the Kitchen Staff (KS) added pureed food into the blender and blended the pureed pork. [NAME] 1 stated just to make sure there's no lumps on the puree. The KS removed the pureed pork from the blender and [NAME] 1 added the thickener while mixing the pureed food. The Dietary Supervisor performed the spoon test. The DS placed less than a spoonful of pureed pork on the spoon. When the spoon was tilted, the pureed pork easily fell onto the plate below. During an interview on 4/23/2027 at 12:57 PM, [NAME] 1 stated to test pureed food, we would do the spoon test. [NAME] 1 stated, we would check to make sure there were no lumps in the food. [NAME] 1 stated when performing the spoon test, we would tilt the spoon and food should fall off/down. The spoon test would measure the consistency of the pureed food. During a review of the posted IDDSI guidelines for testing Level 4 - Pureed Food and a concurrent interview on 4/23/2026 at 2:46 PM, the guidelines indicated Pureed critical test included two test; Fork Drip Test and the Spoon Tilt Test. The posted guidelines indicated at the bottom Must meet all critical test standards for 30 minutes after serving. The DS stated the [NAME] 1 and the DS only used the Spoon Tilt Test to test pureed food, but they used the Fork Drip Test yesterday. The DS stated the DS was not aware they needed to use both Fork Drip Test and Spoon Tilt Test to test pureed food. The DS checked the posted IDDSI guidelines and verified that the posted IDDSI guidelines indicated food must meet all critical test standards. During a review of the facility's Diet Type Report dated 4/23/2026, the report indicated there were six of 74 residents with orders for Pureed - Level 4 diet. During a review of the IDDSI Framework Testing Methods, the framework indicated it is safest to test pureed food using the IDDSI Fork Drip Test and the IDDSI Spoon Tilt Test. The IDDSI Fork Drip Test indicated the liquid does not dollop or drip continuously through the fork prongs, a small amount may flow through and form a tail below the fork. The IDDSI Spoon Tilt Test indicated sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. The sample should not be firm or sticky. During a review of the facility's Policy and Procedure (P&P) titled, Dysphagia Textures - Puree IDDSI Level 4, the P&P indicated puree items may or may not need any thickening agent depending on the food processing tool used and the water content of the food item. Gel or cornstarch or thickeners may be used to reach the required pureed texture. The HPSI recipes primarily incorporate the cornstarch-based thickener products. Follow the IDDSI Framework and suggested testing methods prior to service of pureed products to ensure the pureed products meet the IDDSl standards for pureed foods. The P&P indicated all prepared pureed recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines. They should pass the Fork Drip Test and the Spoon Tilt Test. The P&P indicated We recommend using water in the preparation of puree recipes as utilizing water will not alter the nutritional composition. However, broth, milk or juice may also be used.

Based on interview and record review, the facility did not provide needed dental services for one of one sampled resident (Resident 46) when the Social Service Director (SSD) did not follow up with Resident 46's denture needs.This failure resulted in Resident 46 having feelings of abandonment and had the potential to result in Resident 46 experiencing nutritional deficits and psychosocial decline.Findings:During a review of Resident 46's admission Record (AR), the AR indicated the facility originally admitted Resident 46 on 3/15/2026 with diagnoses including urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureters, bladder, and urethra) and sepsis (the body's extreme, life threatening response to an infection that can lead to organ damage or failure).During a review of Resident 46''s Nursing Progress Note, dated 3/15/2026, the progress note indicated, per [RP] [Resident 46] has loose fitting dentures on the bottom and missing teeth to the top dentures that prevents [Resident 46] from being able to chew effectively.During a review of Resident 46's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 46 had the capacity to understand and make decisions.During a review of Resident 46's Minimum Data Set (MDS- a resident assessment tool), dated 3/22/2026, the MDS indicated Resident 46's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 46 required partial to moderate assistance with eating, oral and personal hygiene, and upper body dressing, required substantial to maximal assistance with toileting, and lower body dressing and was dependent on showering.During an interview on 4/21/2026 at 11:06 AM with Resident 46, Resident 46 stated Resident 46 had not had dentures for one month and one week. Resident 46 stated someone from the Dental Office (DO) had told Resident 46 that Resident 46 needed new dentures.During an interview on 4/23/2026 at 9:45 AM with Resident 46, Resident 46 stated Resident 46 felt abandoned because Resident 46 has been waiting for the dentures to be fixed. Additionally, Resident 46 stated Resident 46 would like to be able to chew food but could not without dentures.During a concurrent record review and telephone interview on 4/23/2026 at 10:06 AM with the Scheduling Coordinator (SC) for the DO, Resident 46's Dental Notes, dated 3/17/2026, 3/25/2026, and 3/31/2026 were reviewed. The SC stated Resident 46's dental notes indicated recommendations were made to follow up with Resident 46 every 3 months, but no recommendations were made regarding dentures.During an interview on 4/23/2026 at 1:41 PM with the Social Services Director (SSD), the SSD stated there was no documentation in Resident 46's medical record regarding the delay of dentures. Additionally, the SSD stated the SSD did not follow up with the DO regarding Resident 46's dentures.During a review of Resident 46's Order Summary Report (OSR), dated 4/24/2026, the OSR indicated Resident 46 could have a dental consultation for evaluation of dentures with an order date of 3/16/2026.During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, revised December 2026, the P&P's policy statement indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The P&P's policy interpretation and implementation indicated, If dentures are damaged or lost, residents will be referred for dental services within 7 days. If the referral is not made within 7 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay.During a review of the facility's P&P titled, Resident Rights Policy, revised 4/15/2026, the P&P's policy statement indicated, The facility is committed to promoting and protecting the rights of each resident. All residents shall be treated with dignity, respect, and equality, and shall be free from abuse, neglect, exploitation, discrimination, and unnecessary restraint. The P&P's purpose indicated, To ensure compliance with federal and state regulations and to establish clear expectations for safeguarding resident rights in all aspects of care and services. The P&P's policy guidelines indicated, Residents have the right to receive care in a manner that enhances quality of life.

Based on observation, interview, and record review, the facility failed to implement adequate accident prevention interventions for one (1) of (2) sampled residents (Resident 71) by failing to:A. Ensure Resident 71's bed alarm was properly functioning at the time of the fall on [DATE].B. Ensure adequate supervision was provided at the time of Resident 71's fall on [DATE].These deficient practices resulted in Resident 71 sustaining a fall, placing the Resident 71 at increased risk for injury, including potential fractures, head injury, and decline in overall condition. Findings: During a review of Resident 71's admission Record (AR), the AR indicated the facility admitted Resident 71 on [DATE], and readmitted the resident on [DATE], with diagnoses including history of falling, need for assistance with personal care, and dementia (a progressive state of decline in mental abilities). During a review of Resident 71's Care Plan Report (CPR), initiated on [DATE] and revised on [DATE], the care plan indicated the resident may utilize a bed sensor pad alarm due to a history of repeated falls. The care plan directed staff to monitor the bed alarm for proper functioning and placement every shift. Interventions included:Bed alarm and machine will be checked every shift to ensure proper function. Charge nurse will keep bed alarm monitor machine in hand at all times to properly monitor resident outside visual checks. During a review of Resident 71's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 71's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 71 required substantial/maximum assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximum assistance with mobility. During a review of Resident 71's Fall Risk Evaluation (FRE), dated [DATE], the FRE indicated that Resident 71 was assessed as a high fall risk. During a review of Resident 71's Change in Condition Evaluation (COCE) for Resident 71, dated [DATE] at 7:20 PM, the COCE indicated Resident 71 had a status post unwitnessed fall and was found seated on the left side of the bed facing the door. The evaluation indicated no change in mental status, no discoloration or bruising, no skin changes, and no change in range of motion of the upper and lower extremities. The resident reported attempting to go to the bathroom independently, losing balance, and falling. The evaluation indicated the resident was educated to request assistance when needed, and Spanish-speaking staff assisted with translation. During a review of the facility's Employee Timecard Report (ETR), dated [DATE], the ETR indicated that Licensed Vocational Nurse 3 (LVN 3) and LVN 4 were both off the unit for a meal break from 7:05 PM to 7:35 PM, as evidenced by their recorded punch-out time of 7:05 PM and punch-in time of 7:35 PM on the ETR. During a review of the facility's Nursing Staff Assignment and Sign-In Sheet (NSASS), dated [DATE], the NSASS indicated that LVN 3 had an assigned scheduled meal break from 7 PM to 7:30 PM, and LVN 4 had an assigned scheduled meal break from 7:30 PM to 8 PM, as documented on the NSASS. During an interview on [DATE] at 4:20 PM, Certified Nursing Assistant 4 (CNA 4) stated that the typical mid-shift staffing assignment consisted of two charge nurses (LVNs) at station 2 and two licensed nurses at station 1 (one Registered Nurse (RN) and one LVN). CNA 4 stated that due to the unit layout, station 1 did not have visibility of all residents' rooms, and certain areas, including the hallway connecting station 2 to the activities room, as well as Resident 71's room (room [ROOM NUMBER]). CNA 4 stated that these areas could only be monitored from station 2. CNA 4 stated that licensed nurses were expected to coordinate meal breaks (beginning approximately around 7 PM through 8 PM) to ensure coverage of at least one licensed nurse at each station. CNA 4 stated that on [DATE] between 07:15 PM and 07:30 PM, while retrieving ice near station 2, the Dietary Aide (DA) alerted her that Resident 71 had fallen in Resident 71's room and Resident 71 was sitting on the floor. CNA 4 stated that no licensed nurse was present at station 2. Upon entering the room, CNA 4 states she observed Resident 71 seated on the floor next to the bed and stated that the bed alarm did not activate. CNA 4 stated she directed CNA 5 to notify RN 1 and stated that both LVN 3 and LVN 4 were on their lunch break together at the time. CNA 4 stated this had occurred on prior occasions despite discussions, with both nurses leaving the unit together for extended periods without ensuring coverage. CNA 4 stated that the absence of a licensed nurse at station 2 created a risk for delayed response and compromised resident safety. During an interview on [DATE] at 4:50 PM, with LVN 5, LVN 5 stated that the unit staffing assignment consisted of two licensed nurses at station 1 (one RN and one LVN) and two charge nurses (LVNs) at station 2 this ensured resident safety and timely response to emergencies, with an expectation of continuous coverage at both stations. LVN 5 stated that at least one licensed nurse should always be physically present at each station to respond to emergencies, including contacting physicians and administering medications. LVN 5 acknowledged that LVN 3 and LVN 4 occasionally took their meal breaks together while assigned to station 2 and stated that although in-services had been conducted regarding this expectation, the practice continued to occur. LVN 5 further stated that failure to maintain a licensed nurse at station 2 made it difficult for licensed staff at station 1 to provide adequate coverage due to unit layout and visibility limitations, and that licensed nurses were expected to coordinate meal breaks to ensure continuous coverage at each station. During an interview on [DATE] at 3:37 PM, with RN 1, RN 1 stated that licensed nurses were expected to stagger meal breaks to ensure at least one licensed nurse remained at each station at all times for resident safety, medication administration, and emergency response. RN 1 stated that these measures were in place to prevent incidents such as resident falls and could have prevented the fall involving Resident 71. RN 1 stated that he served as the RN Supervisor on [DATE] from 3 PM to 11 PM and was notified by staff that Resident 71 had fallen. RN 1 stated that upon arrival, LVN 4 was already present, and the resident was found sitting on the floor next to her bed. RN 1 confirmed the resident had a high fall risk and had attempted to ambulate without assistance. RN 1 stated that it was not appropriate for both LVNs assigned to station 2 to take their meal breaks at the same time and confirmed that one licensed nurse should have physically remained at the station. RN 1 stated he was not aware that both LVN 3 and LVN 4 had gone to lunch together, and although LVN 4 reported notifying him of her break, he was not informed both nurses would be off the unit simultaneously. RN 1 stated that the absence of both licensed nurses from station 2 created a safety concern and limited the ability to monitor residents and respond timely, particularly as CNAs may be occupied with resident care. RN 1 further stated that although the bed alarm was reportedly in place, it would have been difficult to respond without a licensed nurse physically present at the station. During an interview on [DATE] at 4:07 PM, with LVN 3, LVN 3 stated that she worked on [DATE] from 3 PM to 11 PM and was assigned to Cart 2 at Station 2 as the charge nurse, alongside LVN 4, who was assigned to Cart 3 at station 2. LVN 3 confirmed that Resident 71 sustained a fall and stated the resident was a high fall risk, known to be forgetful, and attempted activities without assistance. LVN 3 stated that although Resident 71 was not her specifically assigned resident, she remained responsible for overall supervision of station 2. LVN 3 stated that licensed nurses were expected to coordinate meal breaks to ensure continuous coverage and were responsible for checking bed alarms each shift. LVN 3 acknowledged that on [DATE], she and LVN 4 took their meal break together and did not notify the RN supervisor prior to leaving the station. LVN 3 stated they were notified of the fall by CNA 5 while on break and that LVN 4 responded immediately. LVN 3 stated she was informed the bed alarm did not activate, possibly due to low batteries, and acknowledged that because both LVNs were on break, even if the alarm had activated, it would not have been identified. LVN 3 stated that a licensed nurse should be physically present at the station at all times to ensure resident safety. LVN 3 acknowledged that she did not ensure licensed nurse coverage at station 2 prior to leaving for her meal break with LVN 4. During a telephone interview on [DATE] at 12:16 PM, with LVN 4, LVN 4 stated that she worked on [DATE] from 3 PM to 11PM and confirmed that she took her meal break at the same time as LVN 3. LVN 4 stated that although she reported notifying the RN Supervisor prior to going on break, she did not ensure that a licensed nurse was physically present to cover station 2 during their absence. LVN 4 acknowledged that the absence of licensed nurse coverage at station 2 created a safety concern, as it limited the ability of licensed nurses at station 1 to adequately monitor both stations, particularly during overlapping meal breaks. LVN 4 stated she was notified by staff that Resident 71 had fallen and responded to assess the resident. LVN 4 stated that the resident did not sustain any injuries, a Change in Condition evaluation was completed, the physician was notified, and new orders were obtained to continue monitoring, including neurological checks. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated that the 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. The P&P indicated: The facility 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. 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 appropriate treatment and services were provided to or one (1) of one (1) sampled resident (Resident 44) who was at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent worsening skin integrity by failing to ensure the low Air Loss Mattress's (LALM- an air-filled mattress used to relieve pressure) setting was set according to Resident 44's weight.This failure had the potential to compromise pressure redistribution and increase the risk for skin breakdown and pressure injury development for Resident 44.Findings:During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted Resident 44 on [DATE], and readmitted the resident on [DATE], with diagnoses including muscle wasting and atrophy (shrinking and wasting away of a part of the body, usually a muscle or organ) multiple sites, contracture (when a muscle or joint tightens and gets stuck, limiting movement), and epilepsy (a condition where someone has recurring seizures due to abnormal brain activity).During a review of Resident 44's Care Plan Report (CPR), initiated on [DATE] and revised on [DATE] with a target date of [DATE], the CPR indicated that Resident 44 had a Low Air Loss Mattress (LALM- an air-filled mattress used to relieve pressure) care plan for skin integrity and prevention pressure injury. The CPR interventions indicated:Low air loss set according to residents' weight, comfort, and manufacture settings.Monitor the air pressure settings and functionality of the mattress.During a review of Resident 44's Order Summary Report (OSR), dated [DATE], the OSR indicated Resident 44 had an active order for a LALM every shift for wound management and prevention and to monitor placement and functioning.During a review of Resident 44's Weights and Vitals Summary (WVS), dated [DATE], the WVS indicated Resident 44's most recent weight was 135 lbs. (lbs.-a unit of mass).During a review of Resident 44's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 44's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 44 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and mobility was not attempted due to medical conditions or safety concerns.During a review of Resident 44's Braden Scale for Predicting Pressure Sore Risk (BSPPSR-a tool used to assess the likelihood of developing bed sores), dated [DATE], the BSPPSR indicated that Resident 44 was at a very high risk for pressure sore development. During an observation on [DATE] at 09:58 AM, Resident 44's LALM was noted to be set at 350 lbs. the maximum setting, as indicated on the mattress control panel.During a concurrent interview and record review on [DATE] at 10:55 AM, Resident 44's WVS and CPR were reviewed with the Treatment Nurse (TN), The TN stated that Resident 44's LALM was set at the maximum setting of 350 lbs., which was not appropriate for the resident's current weight of 135 lbs. The TN explained that the LALM was intended to prevent and treat pressure ulcers by redistributing pressure and promoting skin integrity; however, when set too high, it reduced the mattress's ability to provide adequate pressure redistribution, airflow, and moisture control, which were essential in the prevention of skin breakdown and pressure injuries. The TN further stated that excessively high setting could have had the opposite effect, and potentially increased pressure could have contributed to skin breakdown damage rather than protection.During a review of the facility's Policy and Procedure (P&P) titled, Prevention of Pressure Ulcers/Injuries, revision dated 7/2017, the P&P indicated to select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors.During a review of the manufacturer's operation manual titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System, revision dated [DATE], the manufacturer's operation manual indicated to determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on interview and record review, the facility failed to develop a specific and individualized smoking care plan for one of six sampled residents (Resident 73) to address safe storage and safety when Resident 73 kept their own smoking supplies. This deficient practice had the potential for unsafe smoking practices at the facility.During a review of Resident 73's admission Record (AR), the AR indicated the facility admitted Resident 73 on 5/20/2022, with diagnoses that included hemiplegia and hemiparesis (one-sided weakness and paralysis) affecting the left dominant side and depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of 73's Annual Exam (Amended) History (H&P), dated 11/2/2025, the H&P indicated Resident 73 had the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/24/2026, the MDS indicated Resident 73 had intact cognition. The MDS indicated Resident 73 required setup or clean-up assistance (helper sets up or cleans up, resident completes the activity. Helper assists only prior to or following the activity) with eating and the resident was independent with oral hygiene, rolling left and right. During an interview on 4/22/2026 at 3:31 PM, the Director of Staff Development (DSD) stated the facility would complete a smoking assessment and a smoking care plan for smokers. The DSD stated the facility would keep the smoking paraphernalia (refers to any equipment and smoking materials) and for those residents who would want to keep their own smoking paraphernalia, there would be an interdisciplinary meeting to assess and discuss safety and to educate the resident. During an interview on 4/22/2026 at 3:44 PM, the Activity Director (AD) stated the Activities Department would provide supervision to smokers because the smoking area was next to the Activity Room. The AD stated Resident 73 was independent and could keep smoking paraphernalia with the resident. The AD stated the AD and activities staff would be able to see any changes in Resident 73's status and would immediately notify the licensed nurses if there would be any change in physical status that would compromise safety. During a concurrent observation and interview on 4/22/2026 at 4:00 PM, there was no cigarette or lighter on the bed or on the table. Resident 73 stated the resident kept own cigarettes and lighter and would store the items inside the drawer. Resident 73 stated the resident was provided education regarding safety including not smoking inside the room or inside the facility and to store the cigarettes and lighter properly and not lying around. During an interview on 4/22/2026 at 4:12 PM, the Director of Nursing (DON) stated Resident 73 was alert and oriented, and the resident was assessed as able to handle smoking materials and could store smoking paraphernalia. During a review of Resident 73's Smoking Risk Evaluation (SRE), dated 4/17/2026, the SRE indicated Resident 73 was a safe smoker, and was capable of smoking without physical assistance but must be supervised per facility policy. During a review of Resident 73's Care Plan, initiated on 1/15/2026, and titled [Resident 73] is a supervised smoker. [Resident 73] is noncompliance in following the smoking schedule, refuses to wear a smoking apron while smoking, and prefers to keep smoking supplies, the Interventions did not indicate the safe storage of smoking paraphernalia and how to monitor for safety when Resident 73 would keep own smoking supplies. During a concurrent review of Resident 73's care plan titled The resident is a supervised smoker and an interview on 4/22/2026 at 4:15 PM, the DON stated that the care plan did not specify the storage of smoking supplies. The DON answered No when asked if the care plan addressed how to ensure safety when residents store their own smoking supplies. During a review of the facility's Policy and Procedure (P&P), titled Care Plans, Comprehensive, dated March 2022, the P&P indicated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on interview and record review, the facility failed to ensure an accurate comprehensive assessment for one of one sampled resident (Resident 46) when Resident 46's Minimum Data Set (MDS - a resident assessment tool) did not indicate Resident 46 had loosely fitting dentures. This failure had the potential to result in Resident 46's individualized needs not being met and had the potential to result in an increased risk of weight loss or malnutrition.Findings:During a review of Resident 46's admission Record (AR), the AR indicated the facility originally admitted Resident 46 on 3/15/2026 with diagnoses including urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureters, bladder, and urethra) and sepsis (the body's extreme, life threatening response to an infection that can lead to organ damage or failure).During a review of Resident 46''s Nursing Progress Note, dated 3/15/2026, the progress note indicated, per [Emergency Contact (EC)] [Resident 46] has loose fitting dentures on the bottom and missing teeth to the top dentures that prevents [Resident 46] from being able to chew effectively.During a review of Resident 46's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 46 had the capacity to understand and make decisions.During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 46 required partial to moderate assistance with eating, oral and personal hygiene, and upper body dressing, required substantial to maximal assistance with toileting, and lower body dressing and was dependent on showering.During an interview on 4/21/2026 at 11:06 AM with Resident 46, Resident 46 stated Resident 46 had not had dentures for one month and one week. Resident 46 stated the Dentist had told Resident 46 that Resident 46 needed new dentures.During an interview on 4/22/2026 at 1:57 PM with the Social Service Director (SSD), the SSD stated Resident 46 had dentures but they did not fit Resident 46.During a concurrent interview and record review on 4/23/2026 at 11:01 AM with the Minimum Data Set Nurse (MDSN), Resident 46's MDS, dated [DATE] was reviewed. The MDS indicated Resident 46 did not have any broken or loosely fitting full or partial denture. The MDSN stated Resident 46's MDS was incorrect. The MDSN stated it was important to have the correct information in the MDS to ensure the facility could identify Resident 46's needs.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Assessments, revised October 2023, the P&P's policy statement indicated, Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The P&P's policy interpretation and implementation indicated, The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge for one of one sampled resident (Resident 80) who discharged against medical advice (AMA- when a resident chooses to leave the facility before the physician recommends discharge).This failure had the potential to result in Resident 80 being discharged without necessary instructions, services, or follow-up care, placing the resident at risk for adverse health outcomes, including worsening conditions, medication mismanagement, or rehospitalization.Findings:During a review of Resident 80's admission Record (AR), the AR indicated the facility originally admitted Resident 80 on 2/2/2026 and readmitted the resident on 2/17/2026 with diagnoses including fusion of spine (a surgery where doctors permanently join two or more bones in the spine so they heal into one solid piece) lumbar region (the lower part of the back, just above the hips and below the ribs), need for assistance with personal care, and repeated falls.During a review of Resident 80's Discharge Planning Review (DPR), dated 2/3/2026, the DPR record indicated Resident 80 was expected to be discharged to the community and discharge was determined to be feasible. The DPR indicated the Social Services Director (SSD) would assist Resident 80 with placement and Resident 80 would go to an assisted living facility if willing. The DPR's care plan interventions indicated establishing a pre-discharge plan, arranging community resources, and providing written instructions to ensure continuity of care post-discharge. During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 80's cognition (the ability to think and process information) was intact. The MDS indicated Resident 80 required setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL, term used in healthcare that refers to self-care activities).During a review of the Physician's Discharge Summary (PDS), discharge date [DATE], the PDS indicated Resident 80 was discharged AMA.During a review of the Release of Responsibility for Discharge Against Medical Advice (RRDAMA), dated 2/23/2026, the RRDAMA indicated Resident 80 acknowledged being informed of the advisability of risk, inherent in and the probable consequences of leaving the facility against medical advice and/or without a physician's discharge order. The RRDAMA indicated Resident 80 assumed all responsibility for the care and custody of himself or of the risks of leaving prior to physician-recommended discharge and assumed responsibility for the decision to leave. During an interview and concurrent record review on 4/23/2026 at 2:22 PM with the Assistant Director of Nursing (ADON), Resident 80's Progress Note (PN)- Discharge summary, dated [DATE], were reviewed with the ADON, the PN indicated Resident 80 was informed of the risks and benefits of leaving the facility, with emphasis on the need for continued care related to Resident 80's recent cervical (neck) and lumbar spine fusion. The PN indicated accommodations such as transportation and medications would not be allowed. The PN indicated Resident 80 verbalized understanding. The ADON stated there was no documented evidence in Resident 80's medical record indicating the facility offered, attempted, or provided discharge planning instructions, education, or coordination of care prior to the AMA discharge. The ADON stated discharge planning was necessary to ensure Resident 80 received instructions, services, and follow-up care upon leaving the facility. The ADON stated without this, Resident 80 was at risk for worsening conditions, lack of services, medication mismanagement, and potential rehospitalization. The ADON stated that if the facility had offered, attempted, and documented discharge planning and coordination in good faith, it would have demonstrated efforts were made. The ADON acknowledged that while the resident may have refused, the attempt should have been [made and] documented in the medical record.During a review of the facility's Policy and Procedure (P&P) titled, Discharging a Resident Against Medical Advice, revision dated 7/2025, the P&P indicated residents are discharged in the safest and most appropriate manner possible. The P&P indicated prior to discharge, the following information is clearly documented in the resident's medical record:a.Facility staff, providers, and physician attempts to address or correct factors that have led to the request for discharge (e.g., dissatisfaction with care, financial concerns, dependent care, etc.)b.All information provided to the resident or representative regarding the clinical risks of discontinuing care at the facility, and why it is in the best interest of the resident to stay at the facility and complete the plan of care.c.Any information provided by the resident or representative regarding the setting and care-giving arrangements made for the resident after discharge.The P&P indicated if a resident or representative requests to be discharged to a setting that does not appear to meet the resident's post-discharge needs, or appears unsafe, the staff and physician will:1.Discuss with the resident and/or representative (and document) the implications and/or risks of being discharged to a location not equipped to meet the resident's needs and attempt to ascertain why the resident or representative is choosing that location.2.Discuss with the resident and/or representative (and document) other, more suitable locations equipped to meet the needs of the resident.3.Document if, despite being offered other options that could meet the resident's needs, the resident and/or representative refused the more appropriate settings.The P&P indicated otherwise, the facility will provide a Notice of Discharge, discharge orientation, and a detailed Discharge Summary (including referrals for continued care) .before the resident leaves the facility.

Based on interview and record review, the facility failed to immediately report an influenza (the flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) outbreak (the occurrence of influenza cases greater than would normally be expected) to the Los Angeles County (LAC) Department of Public Health (DPH) when 3 of 6 sampled residents (Resident 1, Resident 2, and Resident 3) tested positive for influenza and as indicated in the Influenza and other Respiratory Virus Diseases Outbreak Toolkit.This deficiency had the potential to delay implementation of specific instructions from DPH to prevent the spread of influenza throughout the facility.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of base of the neck of the left femur (hip injury where the bone is broken and separated near the hip joint) and acute cholecystitis (inflammation of the gallbladder).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/24/2026, the MDS indicated Resident 1 had intact cognition (ability to understand and process information) and required partial or moderate assistance (helper does less than half the effort) for bathing and toileting hygiene.During an interview on 2/12/2026 at 10:09 AM with the Infection Preventionist (IP), the IP stated Resident 1 was the first resident to present with symptoms of influenza on 2/1/2026 and Resident 1 had a cough. The IP stated Resident 1 resulted positive for influenza on 2/7/2026.During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses including osteomyelitis (bone infection typically caused by bacteria) of the right ankle and foot and type 2 diabetes mellitus (a common form of diabetes in which the body cannot properly store or use sugar, the body's main source of energy) with foot ulcer (an open sore that occurs on the skin).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition and required partial or moderate assistance for bathing and toileting hygiene.During an interview on 2/12/2026 at 10:09 PM with the IP, the IP stated Resident 2 presented with cough and wheezing on 2/2/2026 and resulted positive for influenza on 2/5/2026.During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hemiplegia (severe or complete paralysis [loss of motor function] on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting the left non-dominant side and type 2 diabetes mellitus with diabetic neuropathy (complication of diabetes where chronic [long term] high blood sugar damages nerves throughout the body.)During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had impaired cognition and was dependent (helper does all of the effort) for activities of daily living.During an interview on 2/12/2026 at 10:09 AM with the IP, the IP stated Resident 3 started with symptoms of cough on 2/4/2026 and resulted positive for influenza on 2/7/2026.During an interview on 2/12/2026 at 2:42 PM with the IP, the IP stated the first positive test for influenza resulted on 2/5/2026 and two more positive tests resulted on Saturday, 2/7/2026. The IP stated the IP was not working over the weekend and did not report the influenza outbreak until the IP came back to work on Monday, 2/9/2026. The IP stated the Registered Nurse Supervisor (RNS, in general) worked on Saturday 2/7/2026 and the RNS had the information [how to report an outbreak] available to make the report but may not have known the criteria for reporting an outbreak. The IP stated per Los Angeles County DPH reporting guidelines found in the Influenza and other Respiratory Virus Diseases Outbreak Toolkit, (IRVDOT) dated 12/2025, indicated, a report of an influenza outbreak should be made after two or more residents have received lab confirmed positive tests. The IP stated the facility should have reported the influenza outbreak on Saturday 2/7/2026.During an interview on 2/12/2026 at 2:57 PM with RNS 1, RNS 1 stated the facility reports to DPH if there were two residents who tested positive for influenza. RNS 1 stated on 2/7/2026, the facility received results for two residents who tested positive for influenza and RNS 1 was aware of both resident's results. RNS 1 stated RNS 1 did not report to DPH. RNS 1 stated it was important to report [to DPH] so that facility received guidelines from DPH to help prevent the spread of infection.During a concurrent observation and interview on 2/12/2026 at 4:06 PM with RNS 2, the document titled, Reportable Diseases and Conditions, (RDC) dated 9/19/2025, by the LAC DPH, was reviewed. RNS 2 stated staff who received the [positive influenza] lab results reported to DPH and the information for reportable disease and contact information was posted at the nurse's station. The RDC indicated influenza, due to novel strains, human (pathogens [organism that causes disease], particularly viruses) is a reportable communicable disease and to report immediately by telephone for both confirmed and suspected cases.During a review of (IRVDOT), dated 12/2025, the IRVDOT indicated suspected outbreaks of respiratory illnesses other than COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) in LAC skilled nursing facilities must immediately be reported to LAC DPH. The IRVDOT further indicated when an outbreak is suspected, prompt and simultaneous implementation of all recommended interventions can minimize the size and scope of the outbreak and adverse impact on resident health.

Based on observation, interview and record review, the facility failed to ensure: 1. Certified Nursing Assistant (CNA) 3 changed gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. 2. CNA 1 and CNA 2 changed wash cloths and bath water prior to providing Resident 2 and Resident 3 perineal care on 2/5/2026. These deficient practices had the potential to spread bacteria that could lead to urinary tract infection.Findings: 1.During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 5/30/2025, with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked which causes the urine to back up and injure one or both kidneys), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 4 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation on 2/4/2026 at 1:44 PM to 1:56 PM, Certified Nursing Assistant (CNA) 3 and CNA 4 performed hand hygiene at the door and put gloves on prior to entering Resident 4's room. CNA 3 and CNA 4 transferred Resident 4 from the geriatric chair to the bed. CNA 3 took towels from the cabinet located at the foot of Resident 4's bed and went to the bathroom and placed the towels on top of the table on the left side of Resident 4's bed without changing gloves. CNA 3 checked Resident 4's diaper and then closed the sliding door, opened the top drawer of a cabinet located at the foot of Resident 4's roommate bed and took out a bottle of body wash from the top drawer. CNA 3, using the same gloves, squeezed body wash onto the wet towel, wiped the perineal area of Resident 4, turned Resident 4 to the left side and wiped the bottom then put on a new diaper on Resident 4. CNA 3, using the same gloves, opened the top drawer of the same cabinet located at the foot of Resident 4's roommate and took a sheet from inside the drawer and touched the items inside the drawer while pulling out a sheet used to cover Resident 4. During an interview on 2/4/2026 at 2:51 PM with CNA 3, CNA 3 agreed CNA 3 did not change gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. During a review of the facility's Policy and Procedure (P&P) titled Standard Precautions, dated September 2022, the P&P indicated, Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces. 2a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff with shower/bath, toileting and personal hygiene. 2b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/6/2025, with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions]) and a history of falling. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated was dependent on staff with shower/bath and toileting hygiene. During an observation on 2/5/2026 at 8:37 AM, CNA 1 donned PPE (gown and gloves) prior to entering Resident 2's room. CNA 1 brought one basin of water to the room, squeezed body wash to the water, removed the blanket, gown and diaper then started cleaning Resident 2 in this order: the face, chest, left armpit, left arm, neck, right armpit, right arm and the fingers rinsing the towel into the water before moving to other areas of the body. CNA 1, using the same water, washed the left leg, right leg, perineal area, the back and then the buttocks area. During an observation on 2/5/2026 at 9:33 AM, CNA 2 prepared the supplies then put gloves on, and brought a bucket of water into Resident 3's room. CNA 2 removed the blanket and gown covering Resident 3. CNA 2 used one small, wet towel to clean the face, right armpit, right arm, left armpit, left arm rinsing the towel into the water before moving to different areas of the body. CNA 2 used the same water to rinse the towel, squeezed body wash to the towel and cleaned the perineal area. CNA 2 poured water from the basin into the perineal area, then dry the area with a big towel. CNA 2 squeezed body wash to the towel and cleaned the buttocks area. During a review of the facility's P&P titled Bath Bed dated March 2021, the P&P indicated the steps in the procedure were to wash the face, ears and neck, the arms and hands, chest and abdomen, change the bathwater, wash the legs and feet, change the bathwater, wash the back and buttocks, change the bathwater before washing the perineal area using the following steps:Perineum:a. Wash, rinse well, and dry the genital and anal areas.b. Always wash the anal area last to avoid contaminating the urinary tract with fecal matter.c. If the resident can perform this task, he/she may do so. Allow for privacy at all times. During a review of an article taken from the National Institute of Health titled Assisting Patients with Personal Hygiene dated September 26, 2022, the articled indicated when cleaning the genital area of a patient, roll the patient onto their side. Make sure to use disposable wipes and wipe from front to back when cleaning the genitals. This process prevents urinary tract infections. Immediately dispose used wipes in the plastic waste bag. If disposable wipes are unavailable, use new cloths and fill the basin with clean water.

Based on observation, interview and record review, the facility failed to provide dignity and privacy for two of three sampled residents (Resident 2 and Resident 3).This deficient practice had the potential to affect Resident 2's and Resident 3's psychosocial wellbeing. a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff with shower/bath, toileting and personal hygiene. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/6/2025, with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions]) and a history of falling. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated was dependent on staff with shower/bath and toileting hygiene. During an observation on 2/5/2026 at 8:37 AM to 8:48 AM inside Resident 2's room, Certified Nursing Assistant 1 (CNA 1) prepared a basin with water, towels and soap. CNA 1 removed the blanket that was covering Resident 2, removed Resident 2's gown and then removed Resident 2's diaper. Resident 2's whole body was exposed as CNA 1 started to wipe Resident 2's face, chest, left arm, neck, right armpit, right arm and then the fingers. At 8:48 AM, while Resident 2 was uncovered, CNA 1 opened the privacy curtain surrounding Resident 2's bed and the door to Resident 2's room was wide open. With the curtain slightly open, Resident 2's exposed body could be seen through the open doorway. During an observation on 2/5/2026 at 9:33 AM to 9:50 AM, CNA 2 prepared supplies for a bed bath, closed the privacy curtain around Resident 3's bed, removed the blanket which covered Resident 3 then removed Resident 3's gown. CNA 2 cleaned Resident 3's face, right armpit, right arm, perineal area and cleaned Resident 3's buttocks. Resident 3's roommate opened the privacy curtain surrounding Resident 3's bed while Resident 3's whole body was exposed. CNA 2 did not cover Resident 3 and did not close Resident 3's privacy curtain after Resident 3's roommate opened the privacy curtain. CNA 2 continued to provide care to Resident 3, applied powder to Resident 3's groin area and fastened Resident 3's diaper. During a concurrent observation and interview on 2/5/2026 at 9:50 AM with Resident 3, Resident 3 stated Resident 3 felt upset since Resident 3 could not have privacy. Resident 3 asked CNA 2 to close the privacy curtain surrounding Resident 3's bed. During an interview on 2/6/2026 at 9:38 AM, CNA 1 stated staff (in general) must cover residents during a bed bath to provide privacy. CNA 1 stated CNA 1 forgot to cover Resident 2 when CNA 1 bathed Resident 2 in bed on 2/5/2026. During an interview on 2/16/2026 at 10:12 AM, CNA 2 stated residents (in general) must be covered during a bed bath so the resident's whole body would not get exposed and feel uncomfortable. During a review of the facility's Policy and Procedure (P&P) titled Bath, Bed, dated March 2021, the P&P indicated residents must not be exposed and must be covered with a bath blanket and kept covered as much as possible during the bed bath. During a review of the facility's P&P titled Resident Rights, dated December 2021, the P&P indicated all residents of the facility have the right to a dignified existence, to privacy and confidentiality.

Based on interview and record review, the facility failed to provide copies of requested medical records within two business days from written request as indicated by the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records for one of three sampled resident (Resident 1). This deficient practice violated Resident 1's right to obtain copies of resident's medical records in a timely manner and had the potential to affect Resident 1's psychosocial well-being. Findings: a) During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included obesity (an abnormal or excessive body fat accumulation), acute respiratory failure without hypoxia (an impairment in oxygenation), basal carcinoma (a type of skin cancer) of skin of right upper limb including shoulder, unilateral primary osteoarthritis (a joint disease where protective cartilage wears down, causing bones to rub, leading pain, stiffness, and swelling) of left hip, and muscle wasting and atrophy (a partial or complete wasting away of a part of the body). During a review of Resident 1's Initial History and Physical (H&P), dated 12/14/2025, the H&P indicated that Resident 1 has the capacity to understand and make decisions. During a review of the Authorization for Use or Disclosure of Protected Health Information form, dated 3/6/2025, the form indicated the facility received a request for release of Resident 1's medical records on 3/6/2025. During a review of the facility's email dated 3/26/2025, the email indicated that the requested medical records were sent to Resident 1 on 3/26/2025. During a review of the Authorization for Use or Disclosure of Protected Health Information form, dated 4/4/2025, the form indicated the facility received a request for release of Resident 1's medical records on 4/4/2025. During a review of the facility's email dated 4/14/2025, the email indicated that the requested medical records were sent to Resident 1 on 4/14/2025. During a review of the Outlook Medical Records Request email from Resident 1, dated 6/23/2025, the email indicated that Resident 1 sent the facility a request for release of medical records on 6/23/2025. The facility did not release Resident 1's medical records. During a review of the Authorization for Use or Disclosure of Protected Heath Information form, dated 7/1/2025, the form indicated the facility received a request for release of Resident 1's medical records on 7/1/2025 without resident's signature. During a review of the facility's email dated 11/12/2025, the email indicated the requested medical records were sent to Resident 1 on 11/12/2025. During a concurrent interview and record review on 1/2/2026 at 3:05 PM with the Administrator (ADM), Resident 1's Authorization for Use or Disclosure of Protected Health Information forms, dated 3/6/2025, 4/4/2025, and 7/1/2025, were reviewed. The ADM stated that on 3/6/2025 and 4/4/2025, Resident 1 requested a large volume of records, which could take several days to provide. The ADM stated that on 7/1/2025, Resident 1 refused to sign the form and the facility was only able to show the medical records but could not provide copies without a signature. The ADM stated that the requested medical records were provided to Resident 1 via email on 11/12/2025. During a concurrent interview and record review on 1/2/2026 at 3:05 PM with the ADM, the ADM stated, If the resident requests their medical records and it is something small, then it can be provided the same day, but if it is a lot, it can take several days to provide their records - it depends on the amount of records that are being requested. During an interview on 1/5/2026 at 10:00AM with the Director of Medical Records (DMR), the DMR stated medical records department visits the residents and guides them to fill out the consent to request medical records. The DMR stated that the resident signs as well as the employee who helped to fill out the form. The DMR stated that depending on the size of the record, it can be provided on the same day, but for the large volume of record request, it can take a few days. The DMR stated that residents are informed of how long it may take and are asked in what format they would like to receive the documents. During an interview on 1/5/2026 at 12:31 PM with Resident 1, Resident 1 stated that she had requested medical records in November with the Ombudsman (an independent government official to advocate for residents). Resident 1 stated she had previously requested the records via email and phone call without success. Resident 1 stated that she refused to sign the medical records release form because the form releases the facility from liability. During an interview on 1/5/2026 at 2:52 PM with the DMR, the DMR stated that the medical records does not document on the resident's record when they visit the resident to fill a Medical Records form. During an interview on 1/5/2026 at 3:03 PM with Resident 1, Resident 1 stated that the DMR was the only medical records employee she had ever spoken to and he never mentioned how long it would take to receive the records. During a concurrent interview and record review on 1/5/2025 at 4:20 PM with the ADM, the ADM stated that the 6/23/2025 medical record request was not honored for Resident 1. The ADM further stated that the medical records department may need more time to compile the records, and they will tell the residents that they need more than the two days, or 48 hours as indicated in the policy. The ADM stated medical records does not chart in the resident's record. During a review of the facility's P&P, titled Access to Personal and Medical Records, revised on May 2017, the P&P's Policy Statement section indicated that each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. The P&P's Policy Interpretation and Implementation section indicated:Access to the resident's personal and medical records will be provided to the resident within 24 hours (excluding weekends and holidays) of his or her request.The resident may obtain a copy of his or her personal and medical record within two business days of oral or written request.

Based on observation, interview, and record review, the facility failed to accommodate the needs four of four sampled residents (Residents 1, 2, 3, and 4 ) in accordance with the facility's Policy and Procedure (P&P) by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was functioning during the power outage for 11 hours from 10/16/2025 at 9:30 PM to 10/17/2025 at 8:30 AM.These deficient practices had the potential for Residents 1, 2, 3, and 4 who were assessed as high risk of falls to not be able to call the facility staff for help or assistance and placed the residents at risk for harm/injury.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/23/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, toileting hygiene and shower/bathing self. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1's Care Plan (CP) related to risk for falls revised 9/5/2025, the CP indicated facility staff should ensure Resident 1's call light was within reach and encourage the resident to use it for assistance as needed. During an interview on 10/22/2025 at 3:26 PM with Resident 1, Resident 1 stated the call light system was not working from 10/16/2025 after 9:30 PM to 10/17/2025 at 8:30 AM during the power outage in the facility. Resident 1 stated Resident 1 did not get any call bell to ring for help and had to yell for help when Resident 1 needed assistance. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to facility on 10/25/2024 with diagnoses including hemiplegia (partial or total paralysis on one side of body) and hemiparesis (weakness on one side of the body), left hip and knee osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and epilepsy (a long-term disease that causes repeated seizures). During a review of Resident 2's History and Physical (HP) dated 10/28/2024, the HP indicated Resident 2 was alert and oriented. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was dependent on (helper does all the effort) with toileting hygiene and shower/bathing self, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene. During a review of Resident 2's CP related to risk for falls, revised 8/14/2025, the CP indicated facility staff should ensure the call light was within reach and for Resident 2 to get prompt response to all requests for assistance. During an interview on 10/22/2025 at 3:15 PM with Resident 2, Resident 2 stated the call light system was not working during the night the power in the facility was off, Resident 2 stated Resident 2 did not receive any call bell or device to request assistance if needed. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), hypertension (high blood pressure), and epilepsy. During a review of Resident 3's CP related to risk for falls, revised 5/21/2025, the CP indicated facility staff should ensure Resident 3's call light was within reach and for Resident 3 to get prompt response to all requests for assistance. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills were intact. The MDS indicated Resident 3 was dependent on toileting hygiene and shower/bathe self and putting on/taking off footwear. The MDS indicated that Resident 3 required substantial/maximal assistance with personal hygiene and lower body dressing. During an interview on 10/22/2025 at 3:02 PM with Resident 3, Resident 3 stated the call light system was not working during the night the power was off for more than ten hours in the facility. Resident 3 stated Resident 3 did not receive any call bell or device to request assistance. 4. During a review of Resident 4's AR, the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs cannot supply enough oxygen to the blood), end stage renal disease (ESRD -irreversible kidney failure) and cerebral infarction (disrupted blood flow to the brain). During a review of Resident 4's HP dated 6/18/2025, the HP indicated Resident 4 had intact cognition including orientation, attention, and memory, and had normal insight and judgment. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 was dependent on toileting hygiene and shower/bathing self, and lower body dressing. The MDS indicated Resident 4 required substantial/maximal assistance with putting on/taking off footwear and upper body dressing. During a review of Resident 4's CP related to risk for falls, revised 1/31/2025, the CP indicated facility staff should ensure Resident 4's call light was within reach and for the resident to get prompt response to all requests for assistance. During an interview on 10/22/2025 at 2:34 PM with Resident 4, Resident 4 stated the call light system was not working during the night that the power was off in the facility. Resident 4 stated Resident 4 did not receive any call bell or device to request assistance. During an interview on 10/23/2025 at 9:51 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the call light system was not working when the facility had power outage. During a concurrent interview and record review on 10/23/2025 at 10:09 AM with the Maintenance Director (MD), the facility's Generator Weekly Run Report was reviewed. The MD stated the facility had a power outage on 10/16/2025 at 9:30 PM, and the power was back on 10/17/2025 at 8:30 AM. The MD stated the power outage lasted for 11 hours. During an interview on 10/23/2025 at 4:38 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the call light system was not working when the facility had power outage on the night of 10/16/205. During a concurrent observation and interview on 10/27/2025 at 9:28 AM with Registered Nurse 1 (RN 1) at Nurse Stations 1 and 2, there were 16 bells at Nurse Stations 1 and 2, totaling 32 bells. RN 1 stated the facility provided temporary bells for residents to ring for assistance when the facility had power outage. RN 1 states the facility did not have enough bells for every resident in the facility. During a review of the facility's undated P&P titled, Building Systems Electrical and Generator, the P&P indicated, Check and repair as necessary monthly to verify that all connections and mountings are secure and in good working order .electrical service system. During a review of the facility's P&P titled, Call System, Resident revised 9/2022, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting /bathing facilities and from the floor. The P&P indicated, The resident call system remains functional at all times. During a review of the facility's P&P titled, Maintenance Service, revised 12/2009, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P) titled Medication Orders and Receipt Record to ensure three of three sampled residents (Residents 1, 6 and 7)'s medication delivered by the pharmacy were checked, signed, dated and timed by licensed staff upon receiving. This failure had the potential for missing medication or residents receiving wrong medication.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/23/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, toileting hygiene and shower/bathing self. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1's Treatment Administration Record (TAR), dated 8/2025, 9/2025 and 10/2025, the TAR indicated Resident 1 had an order for Ketoconazole (is a drug used in the management and treatment of fungal infections) External Shampoo 2% Topical, apply to scalp topically every day shift every Monday, Thursday, Saturday for Seborrheic Dermatitis (skin disease that cause scaly, oily, and flaky patches, on the scalp, face, ears, and chest), leave in for 5 minutes then wash out. The medication order date was 7/25/2025. 2. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to facility on 2/14/2025 with diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs cannot supply enough oxygen to the blood), end stage renal disease (ESRD -irreversible kidney failure), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 6's History and Physical (HP), dated 2/17/2025, the HP indicated Resident 6 had full mental capacity to make own decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had intact cognition. The MDS indicated Resident 6 required substantial/maximal assistance with lower body dressing, putting on/taking off footwear and shower/bathing self. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 6's Order Listing Report (OLR) dated 7/2024, the OLR indicated Resident 6 had a medication order for Ipratropium-Albuterol (medication used to prevent difficulty breathing, chest tightness, and coughing in people with COPD) Inhalation Solution 0.5-2.5 milligram (MG, a unit of measurement)/3 milliliter (ML, a unit of measurement), one inhalation by mouth via nebulizer (a medical device that turns liquid medication into a fine mist for inhalation, making it easier to deliver medicine deep into the lungs) two times a day for COPD for 12 weeks. 3. During a review of Resident 7's AR, the AR indicated Resident 7 was originally admitted to facility on 5/8/2023 and readmitted on [DATE] with diagnoses including ESRD), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and major depressive disorder (a persistent feeling of sadness and loss of interest). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognitive skill was intact. The MDS indicated Resident 7 required partial/moderate assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 7 required supervision or touching assistance with upper body dressing and personal hygiene. During a review of Resident 7's OLR dated 7/2024, the OLR indicated Resident 7 had an order for Doxycycline Hyclate Oral Tablet 100 MG, one tablet by mouth two times a day for facial redness for 60 Days. The last medication ordered date was 7/17/2025. During a review of Resident 7's H&P dated 8/22/2025, the HP indicated Resident 7 had the capacity to understand and make own decisions. During an interview on 10/23/2025 at 10:59 AM with Treatment Nurse 2 (TN 2), TN2 stated every medication received from the pharmacy should have a receipt with signature, date, and time of pharmacy delivery. During a concurrent interview on 10/27/2025 at 3:32pm with Registered Nurse 3 (RN 3) and record review of the facility's Prescription Delivery Receipt (PDR) as of 7/14/25, RN 3 stated there was no date, time or signature of the licensed nurse who received the medications for Residents 1, 6 and 7. RN 3 stated the licensed nurse should sign, date and indicate the time on the receipt upon receiving the medications, and make a copy of the signed receipt as part of the residents' record. During a review of the facility's undated P&P titled, Medication Orders and Receipt Record, the P&P indicated, .The medication order/receipt record shall contain:g. The date and quantity received; andh. Name and title of the person receiving the order.

Based on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) as indicated in the facility's policies and procedures (P&P) titled, Safety and Supervision of Residents, and Falls and Fall Risk, Managing, by failing to: 1. Ensure Certified Nursing Assistant 1 and/or Licensed Vocational Nurse 1 provided supervision/monitoring when Resident 1, who was assessed as being high risk for falls, had increased agitation and confusion, repeated episodes of getting out of bed, and ambulating in Resident 1's room unassisted. 2. Ensure LVN 1 revised Resident 1's untitled care plan for falls and implemented new interventions after Resident 1 first fell on [DATE] at 1:20 AM to prevent Resident 1 from further falls and injuries. As a result, on 6/24/2024 at 2:15 AM, after the first fall at 1:20 AM, Resident 1 fell to the floor again. Resident 1 sustained a moderately displaced fracture (bone breaks into two or more pieces and move out of alignment) and mildly impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) at the neck of the left subcapital femur (neck of the thigh bone). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 2 on 6/24/2024 at 3:08 AM for further evaluation and had a left hip hemiarthroplasty (a type of partial hip replacement surgery that involved replacing half of the hip joint) on 7/1/2024. Cross Reference F657 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain due to injury) without loss of consciousness, Covid-19 (minor to severe respiratory illness caused by a virus and spread from person to person), fall (on)(from) other stairs and steps, and other abnormalities of gait (manner of walking or moving on foot) and mobility (ability to move). During a review of Resident 1's Fall Risk Evaluation, dated 6/7/2024, the Fall Risk Evaluation indicated, Resident 1 was at high risk for falls. During a review of Resident 1's History and Physical Examination (H&P), dated 6/8/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's untitled care plan (CP), initiated on 6/7/2024, and revised on 6/9/2024, the CP indicated, Resident 1 was at high risk for falls due to confusion, gait/balance problems, psychoactive drug (medication that affects behavior, mood, thoughts, or perception) use, unawareness of safety needs, and history of falls. The CP interventions included for staff to anticipate and meet Resident 1's needs, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter/remove any potential causes of falls if possible. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 6/11/2024, the MDS indicated, Resident 1 had severely impaired cognition (ability to think and process information). The MDS indicated, Resident 1 normally used a walker (a device that gives support to maintain balance or stability while walking) and wheelchair. The MDS indicated, Resident 1 required substantial/maximal assistance (helper did more than half the effort and lifted or held trunk or limbs) for toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated, Resident 1 required substantial/maximal assistance for rolling left and right on the bed, lying to sitting on side of the bed, sitting to standing, and walking 10 feet. The MDS indicated, Resident 1 had a fall in the last month prior to admission to the facility. During a review of Resident 1's Physical Therapy (PT- therapy used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) Discharge Summary (PTDS), dated 6/23/2024, the PTDS indicated, Resident 1 required minimal assistance (assisting person performed 25 percent (%) of the task) for transfers and ambulating 150 feet using a two-wheeled walker. During a review of Resident 1's Situation-Background-Assessment-Recommendation Summary for Providers (SBAR Summary), dated 6/24/2024, timed at 1:34 AM, the SBAR Summary indicated, on 6/24/2024, untimed, CNA 1 found Resident 1 sitting on the floor (in Resident 1's room) in an upright position with her back against the wall and her legs straight out. The SBAR Summary indicated, Resident 1 had no injuries and denied any pain. The SBAR Summary indicated, two staff members (unidentified) assisted Resident 1 back to bed. The SBAR Summary indicated, Resident 1's bed remained in the lowest position. The SBAR Summary indicated, Resident 1's primary care provider recommended neurological checks (assesses level of consciousness, movement, hand grasp, pupil [the black opening in the middle of the colored part of the eye) reaction, speech, and vital signs [measurements of the body's most basic functions]) and frequent visual checks. During a review of Resident 1's Nursing Progress Notes (NPN), dated 6/24/2024, timed at 2:43 AM, the NPN indicated, on 6/24/2024, at 1:20 AM, Resident 1 had an unwitnessed fall in Resident 1's room. The NPN indicated, CNA 1 found Resident 1 sitting on the floor in front of Resident 1's bed with Resident 1's back against the wall and near the window. The NPN indicated, Resident 1 could not say what happened. During a review of the same NPN, dated 6/24/2024, timed at 2:43 AM, the NPN indicated, on 6/24/2024, at 2:15 AM, Resident 1 had a second fall. The NPN indicated, Resident 1's roommate (Resident 3) was calling for help. The NPN indicated, CNA 1 found Resident 1 sitting on the floor in an upright position near Resident 3's bed. The NPN indicated, Resident 1 had laceration (a tear, cut, or gash) on the left part of Resident 1's head and blood on her arm and gown. The NPN indicated, Resident 1 stated Resident 1 fell on something but was unsure of what it was. The NPN indicated, Resident 1 did not complaint of any pain or discomfort. The NPN indicated, LVN 1 called for emergency transport due to head injury. During a review of Resident 1's GACH 2 Emergency Medicine Report (EMR), dated 6/24/2024, timed at 3:08 AM, the EMR indicated, Resident 1was brought in by ambulance for contusion (injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow) after falling out of the bed. The EMR indicated, Resident 1 complained of six out of 10 pain (0 = no pain and 10 = the worst pain) to her left hip. The EMR indicated, Resident 1 would be admitted to GACH 2 for further care and evaluation. During a review of Resident 1's GACH 2 Hip and Pelvis X-ray (pictures of the inside of the body) Report of Resident 1's left hip, dated 6/24/2024, timed at 4:15 AM, the X-ray Report indicated, Resident 1 had a moderately displaced left femoral subcapital neck fracture. During a review of Resident 1's GACH 2 Computed Tomography Scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) Report of Resident 2's left hip, dated 6/24/2024, timed at 8:47 AM, the CT scan Report indicated, Resident 1 had a moderately displaced fracture and mildly impacted fracture at the neck of the left subcapital femur. During a review of Resident 1's GACH 2 Discharge Summary (DS), dated 7/9/2024, the DS indicated, Resident 1 had a left hip hemiarthroplasty (a type of partial hip replacement surgery that involved replacing half of the hip joint) for femoral neck fracture on 7/1/2024. During an interview on 7/19/2024 at 12:15 PM with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was unsteady and used a walker for ambulation. The DOR stated Resident 1 required a lot of cueing (to provide a hint or prompt for an action), but able to follow directions. During a telephone interview on 7/19/2024 at 1:07 PM with CNA 1, CNA 1 stated on 6/23/2024, at 11 PM, Resident 1 was very confused and could not sleep. CNA 1 stated on 6/24/2024, unable to recall time, CNA 1 had to sit by Resident 1's room door because Resident 1 kept getting out of bed. CNA 1 stated on 6/24/2024, at around 1:30 AM, CNA 1 found Resident 1 sitting on Resident 1's buttocks on the floor, close to Resident 1's bed. CNA 1 stated on 6/24/2024, after the first fall that occurred at 1:20 AM, unable to recall exact time, CNA 1 was in another resident's room, opposite Resident 1's room, when Resident 1 had a second fall. CNA 1 stated CNA 1 heard a loud sound and before CNA 1 entered Resident 1's room, CNA 1 saw Resident 1 on the floor by Resident 1's room door. CNA 1 stated CNA 1 notified LVN 1. CNA 1 stated LVN 1 did not provide CNA 1 with any specific instructions to increase supervision/monitoring of Resident 1 after Resident 1's first fall (on 6/24/2024 at 1:20 AM). During a follow-up telephone interview on 7/22/2024 at 12:21 PM with CNA 1, CNA 1 stated on 6/23/2024, at 11 PM, CNA 1 found Resident 1 walking unassisted to Resident 1's bathroom. CNA 1 stated CNA 1 assisted Resident 1 to the bathroom then put Resident 1 back to bed. CNA 1 stated a few minutes after, CNA 1 heard Resident 1 getting up from Resident 1's bed. CNA 1 stated CNA 1 asked Resident 1 what Resident 1 needed but Resident 1 did not say anything. CNA 1 stated Resident 1 was confused and CNA 1 redirected Resident 1 back to Resident 1's bed. CNA 1 stated (on 6/24/2024, at 1:20 AM), Resident 1 got up from Resident 1's bed unassisted for the third time and fell . CNA 1 stated CNA 1 was sitting in the hallway monitoring the call lights when Resident 1 fell the first time on 6/24/2024 at 1:20 AM. CNA 1 stated CNA 1 could not see inside Resident 1's room from the hallway where CNA 1 was sitting. CNA 1 stated CNA 1 notified LVN 1 and LVN 1 gave medication to Resident 1. During a review of Resident 1's Medication Administration Record (MAR) for 6/2024, the MAR indicated, no documented evidence that LVN 1 administered medication to Resident 1 from 6/23/2024 to 6/24/2024 during the 11 PM to 7 AM shift. On 7/22/2024 at 10:55 AM and 11:31 AM, attempts were made to contact LVN 1, however LVN 1 did not answer or return the call. During an interview on 7/22/2024 at 2:07 PM with the Director of Nursing (DON), the DON stated (on 6/24/2024), Resident 1 was having increased confusion, agitation, and kept getting out of bed. The DON stated due to Resident 1's agitation and episodes of getting out of bed, the staff (CNA 1 and LVN 1) needed to increase supervision/monitoring of Resident 1 from every two hours to every hour, elevate to every 15 minutes, or have CNA 1 stay with Resident 1 as needed for Resident 1's safety. The DON stated LVN 1 needed to revise Resident 1's care plan and add new interventions after the first fall to help prevent the second fall and injuries. The DON stated CNA 1 needed to notify LVN 1 when CNA 1 had to help another resident so LVN 1 could have monitored Resident 1. On 7/30/2024 at 8:55 AM, an attempt was made to contact LVN 1, however LVN 1 did not answer or return the call. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated, resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The P&P indicated, the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The P&P indicated, the facility analyzed information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated, the care team targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated, implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring that interventions were implemented. The P&P indicated, monitoring the effectiveness of interventions shall include ensuring that interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. The P&P indicated, resident supervision was a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents. The P&P indicated, for example, resident supervision may need to be increased when there was a change in the resident's condition. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated, based on previous evaluations and current data, the staff identified 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. The P&P indicated, if the resident continued to fall, staff re-evaluated the situation and whether it was appropriate to continue or change current interventions. The P&P indicated, if falling recurred despite initial interventions, staff implemented additional or different interventions, or indicate why the current approach remained relevant.

Based on interview and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1), who was assessed as a high risk for falls. Resident 1, who was moderately impaired to make decisions and required supervision during smoking, was left unattended while smoking outside at the facility's patio area. This deficient practice resulted in Resident 1 sustaining a fall on 9/20/19 at 1:30 a.m., causing severe pain on the resident's right leg and hip. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on the same day, where Resident 1 was identified to have sustained a right hip intertrochanteric fracture (a break in the bony protrusions of the thighbone) and had undergone an open reduction and internal fixation (surgical implementation of implants to repair severely broken bone). Findings: A review of Resident 1's Admission Record indicated the facility readmitted the resident on 11/6/17. Resident 1's [DIAGNOSES REDACTED]. (a slowly progressive disease of the brain characterized by symptoms like impairment of memory and disturbances in reasoning, planning, language, and perception), and [MEDICAL CONDITION] (lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult). A review of Resident 1's care plan for Resident at Risk for Injury Due to [MEDICAL CONDITION]/Alzheimer's, initiated 7/24/18, indicated Resident 1 is a smoker and non-compliant on the smoking schedule. Staff interventions were to explain to resident the risk of non-complying on scheduled smoking time, smoking hazards, facility's policy on smoking including locations, times, safety concerns, and notify Charge Nurse immediately if suspected resident has violated facility smoking policy. A review of Resident 1's care plan for Falls Related to Gait/Balance Problems, [MEDICAL CONDITION] Disorder, and history of falls with fracture, initiated on 4/9/19, indicated for staff to anticipate and meet the resident's needs to minimize the potential for falls and educate the resident about safety reminders. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/9/19, indicated Resident 1 had moderate impairment in cognition (ability to think and process information). The MDS indicated Resident 1 required supervision (oversight, encouragement or cueing) for bed mobility, transferring, walking, and locomotion (how resident moves between locations). A review of Resident 1's Smoking Assessment, dated 7/9/19, indicated the resident's [DIAGNOSES REDACTED]. The assessment indicated Resident 1 was not able to store smoking and lighting materials to prevent access by other residents. Resident 1 cannot light own cigarette. Resident 1 was determined as not cognitively alert and does not exhibit independent judgment to maintain own smoking and/or lighting materials. The assessment indicated Resident 1 required supervision while smoking/and or using lighting materials. A review of GACH 1's History and Physical, dated 9/20/19, indicated the resident was walking to the patio outside to smoke when he subsequently slipped, fell and landed on his right hip. Resident 1 was transferred to GACH 1's emergency unit for further medical condition. X-ray (photographic or digital image of the internal composition of something, especially a part of the body) showed right hip intertrochanteric fracture. A review of Resident 1's Situation-Background-Assessment-Request/Change of Condition (SBAR /COC, communication tool used in healthcare), dated 9/20/19, indicated at 1:30 a.m., the Charge Nurse (unidentified) was notified by Resident 2's visitor of a noise from the parking lot and a resident lying on the ground at the facility patio area. The assessment indicated the Charge Nurse found Resident 1 lying on his left side on the ground at the facility patio area. The Charge Nurse assessed Resident 1's range of motion (ROM) on the left lower extremities and bilateral upper extremities and found no impairment. The assessment indicated the Charge Nurse was not able to assess Resident 1's right lower extremity due to Resident 1 did not allow the Charge Nurse to touch the right leg due to severe pain. The Charge Nurse called emergency 911 (emergency phone number) at 1:40 a.m. and Resident 1 was transferred to GACH 1 via paramedics on 9/20/19 at 1:55 a.m. for further evaluation and treatment. A review of Resident 1's progress notes, dated 9/20/19, indicated Resident 1's fall was unwitnessed. A review of the GACH 1's Operative Report, dated 9/21/29, indicated Resident 1's preoperative and postoperative [DIAGNOSES REDACTED]. Resident 1 had undergone an open reduction and internal fixation. A review of the Significant Change in Status Assessment MDS, dated [DATE], indicated a decline in Resident 1's level of assistance required for activities of daily living (ADL). Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transferring, walking, locomotion, dressing, eating, toilet use, personal hygiene and total dependence on the staff for bathing. During a telephone interview on 3/27/20 at 3:43 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 needs assistance with activities of daily living (ADL), but since Resident 1 refuses to be assisted, staff only provides supervision. CNA 1 stated Resident 1 was at risk for fall due to his balance was not good. CNA 1 added Resident 1 frequently goes outside the patio area to smoke and does not like to follow the smoking schedule. CNA 1 stated smoking schedule was at 9 a.m., 6 p.m., 8 p.m. and the rest, she does not remember, but it was twice every shift. CNA 1 stated Resident 1 kept his cigarette and lighter in his room in a locked bedside drawer. Resident 1 lights his cigarette with his lighter. CNA 1 stated she had observed Resident 1 holding the cigarette with minimal hand shaking due to [MEDICAL CONDITION]. CNA 1 stated on 9/19/19, Resident 1 woke up at 9:45 p.m. and requested to go outside the facility patio area to smoke. CNA 1 stated she told Resident 1 not to do so, but Resident 1 did not listen and wheeled himself outside the facility patio area. CNA 1 stated she went out to check on Resident 1 after he wheeled himself outside and encouraged him to go back inside the facility because he was at risk for fall. CNA 1 stated she went back inside the facility to take care of other residents when Resident 1 declined to go inside the facility. CNA 1 stated she went back out at the patio area at 10:30 p.m. and observed Resident 1 smoking while sitting on his wheelchair. CNA 1 stated she went out two more times at 11:30 p.m. and 12:30 a.m. and observed Resident 1 was still smoking while sitting on the wheelchair. CNA 1 stated she was taking care of another resident inside the resident's room prior to going out to check on Resident 1 at 1:30 a.m. CNA 1 stated when she went back out at 1:30 a.m., she found the resident lying on the ground at the facility patio area with three (3) other staff. CNA 1 stated Resident 1 was still holding his cigarette while lying on the ground. CNA 1 stated Resident 1 said he lost his balance when he got up to check the time. Resident 1 complained of leg pain and the Charge Nurse called the paramedics. During a concurrent review of Resident 1's Smoking Assessment, dated 7/9/19 and telephone interview with Director of Nursing (DON), on 3/27/20 at 4:02 p.m., she stated the assessment indicated Resident 1 was not cognitively alert, oriented and does not exhibit independent judgment to maintain own smoking and/or lighting materials and requires supervision while smoking and/or using lighting materials. The DON stated due to Resident 1's risk factors, Resident 1 need to be supervised while smoking by the CNA assigned to him. The DON stated Resident 1 was unsupervised outside at the facility patio when the resident fell on [DATE]. The DON stated it was Resident 2's visitor who saw Resident 1 outside lying on the ground and notified staff. The DON stated according to Resident 1, he stood up and walked to look at the clock to check the time and fell . The DON stated Resident 1 needed to be supervised all the time while smoking. During a telephone interview, on 3/27/20 at 4:07 p.m., the DON stated during smoking schedule (9 a.m., 11 a.m., 1 p.m., 3 p.m., 6 p.m., and 8 p.m.), one activity staff and one CNA take turn to supervise the residents who smoke in the designated smoking area. The DON stated Resident 1 slept mostly during the day and smoked when he was awake at night. The DON stated Resident 1 was non-compliant to smoking schedule and would wheel himself to the patio. The DON stated staff would sometimes find Resident 1 sitting or smoking in the patio by himself. The DON stated Resident 1 was allowed to keep smoking paraphernalia (cigarette and lighter) locked in a bedside drawer inside the resident's room to respect Resident 1's preference and right. During a concurrent review of Resident 1's care plan and telephone interview with the DON on 3/27/20 at 4:10 p.m., she stated Resident 1's care plan intervention indicated for staff to notify the Charge Nurse immediately if resident has violated facility's smoking policy including locations, times, safety concerns. During a telephone interview on 3/27/20 at 5:30 p.m., Resident 1 stated he was outside sitting at the patio area early morning on 9/20/19 but was not smoking. Resident 1 stated he got up from his wheelchair to look at the clock and fell . During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 3/31/20 at 7:30 a.m., she stated on 9/20/19, Resident 2's visitor knocked on the facility's locked door and informed her of the noise she heard from the parking lot. LVN 1 stated Resident 2's visitor also reported someone was lying on the ground at the facility patio area. LVN 1 stated she called another staff to go with her to check the patio area and they found Resident 1 alone outside lying on the ground. LVN 1 stated Resident 1 said he got up, but lost his balance and fell when he peeked through the dining room sliding door to check the time. LVN 1 stated due to Resident 1's complain of left leg and left hip pain, paramedic was called and transferred resident to GACH for further evaluation and treatment. A review of the facility's policy and procedure, titled Residents Smoking Policy, revised on 7/2017, indicated the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). The policy indicated any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. The policy indicated the facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted.

Based on observation, interview, and record review, the facility failed to establish an Infection Control Program under which it: 1. Investigated the clinical signs and symptoms of Resident 5's skin condition and failed to identify Resident 5's scabies infestation. 2. Failed to control Resident 5's scabies infestation. The facility failed to treat Resident 5's scabies infestation in accordance with the physician's orders [REDACTED]. 3. Failed to place Resident 5 in isolation when Resident 5 was treated for [REDACTED]. 4. Failed to maintain a record of incidents and corrective actions taken related to Resident 5's rash or any resident rashes in the facility. 5. Failed to report Resident 5's scabies infestation to the Department of Public Health. This failure resulted in Resident 5 to have severe skin irritation causing the resident to uncontrollably scratch the infested skin areas. This prevented the resident from sleeping. The delay in identifying and treating Resident 5's scabies had the potential to spread the scabies infestation to all residents, staff and visitors in the facility. Findings: A review of the admission record indicated that Resident 5 was admitted to the facility on originally admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment tool, dated 8/10/16, Resident 5 had the ability to make self-understood and had the ability to understand others. The MDS functional status (activities of daily living), under Section G indicated Resident 5 required supervision for dressing, personal hygiene, bathing, and walking. On 11/2/16, at 9:15 a.m., Resident 5 was observed being wheeled by certified nurse assistant (CNA) 2 in the corridor after his shower. The bottom of Resident 5's feet were observed to be covered with a heavy white scaly crusted substance. During an interview, Resident 5 stated, I'm itching again. I had these rashes for about three months now. I can't sleep at night. They give me the cream but it does not help me. They itch so bad, I can't sleep at night. I felt like there bugs are inside my skin. Resident 5 added that the itching gets so bad that he felt like pulling out his shunt (access site into the resident's circulatory system for dialysis machine which filters the blood of waste due to the resident's kidneys not functioning)(Pulling out the shunt would lead to massive bleeding from the site.). On 11/2/16, at 10:30 a.m., with Resident 5's permission an observation of the resident skin condition was done with licensed vocational nurse (LVN) 4 and another Surveyor. The following was observed: 1. Resident 5's chest, abdomen, back, arms, and legs, were covered with raised red papules with tracking (blisters and bumps caused by the bites and burrows from the mite) indicative of scabies. 2. Between Resident 5's fingers were observed to be dry and scaly. 3. Resident 5's feet were observed with a heavy white scaly crusted substance. On 11/2/16, at 10 a.m., an interview was conducted with the facility's infection control coordinator. The Surveyor requested for a surveillance record of residents who were receiving skin treatment. According to the infection control coordinator there was no documentation of any surveillance and tracking of any resident's suspicious rashes. He further stated that the facility did not further investigate any rashes in the facility including Resident 5's. On 11/2/16, at 12:25 p.m., during an interview with LVN 4, she stated Resident 5 had been treated with [MEDICATION NAME] (anti-parasitic topical medication used to treat scabies) two times as ordered by the dermatologist (physician who specializes in skin conditions.) LVN 4 also stated that skin scrapings (test used to detect the presence of scabies) were done on 9/22/16, and the result was negative for scabies. LVN 4 added that there was no isolation precaution (precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases) was provided because Resident 5 did not have scabies. A review of the treatment record and concurrent interview with the Director of Nursing (DON) and LVN 4 on 11/2/16, at 2 p.m., indicated that skin scrapings were done after the [MEDICATION NAME] treatments. The treatment record indicated that the [MEDICATION NAME] treatments were done on two consecutive days. LVN 4 stated she applied the [MEDICATION NAME] on two consecutive days 9/21/16 and 9/22/16, and then had the laboratory perform the skin scraping. The DON stated she was aware that Resident 5 had rashes but did not know the extent of the rashes and was not aware that the skin scrapings were done after [MEDICATION NAME] treatments. Both the DON and LVN 4 did not know how Resident 5's feet looked like. In addition they both stated that they did not know what a scabies infestation looked like. A review of the facility's P/P (policy and procedures) on Scabies, Procedure Guidelines, revised 8/2002 indicated: 1. Implement Contact isolation (form of isolation in which anyone entering the resident's room and having direct contact with the patient wears gloves and a gown); 4. Should scrapings be ordered, contact the lab; . 8. Begin treatment: a. Day 1 -apply [MEDICATION NAME] or other prescribed medication from scalp down. Leave on twelve (12) hours, and then wash off; b. Day 2-6- Apply Eurax (used to treat scabies and to reduce itching associated with certain conditions) after morning bath; c. Day 7 - apply [MEDICATION NAME] from scalp down. Leave on twelve (12) hours, and then wash off; 9. Bathe resident daily for seven (7) days; 11. Continue Contact Isolation until twenty four (24) hours after last [MEDICATION NAME] treatment. On 11/2/16, at 2 p.m., during a telephone interview with the dermatologist, she stated that Resident 5 did not have scabies because the skin scraping results were negative. She stated that she diagnosed Resident 5 with end stage renal disease with pruritus (itching) and non-specific dermatitis (skin infection). The dermatologist also stated that she was at the facility on 11/1/16 to follow-up on Resident 5's rash but did not see Resident 5's feet. The dermatologist also stated that she was not aware that skin scrapings were performed after the [MEDICATION NAME] treatments were done. She stated that was, probably why the result was negative. On 11/2/16, at approximately at 3:45 p.m., the dermatologist arrived at the facility to reassess Resident 5. Upon completion of her reassessment, the dermatologist stated that Resident 5 had classic signs of Norwegian scabies (crusted scabies which is a severe form of scabies that can occur in some persons who are immunocompromised (have a weak immune system), elderly, disabled, or debilitated. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. Persons with crusted scabies are very contagious to other persons and can spread the infestation easily both by direct skin-to-skin contact and by contamination- Centers for Disease Control and Prevention). The dermatologist then performed skin scrapings on multiple sites on feet, hands and shoulders. On 11/2/16, the dermatologist ordered new treatments that included isolation precaution, oral medications, Ivermectrin (used to treat certain worm infections) 9 milligrams (mg) by mouth every week for five (5) weeks, [MEDICATION NAME] (an anti- itch drug) ten (10) mg every eight (8) hours for three (3) week, referrals to the Resident 5's renal (kidney) specialist, [MEDICATION NAME] treatments two (2) times- apply tonight from head to toe then wash after twelve hours (12), repeat in seven (7) days, [MEDICATION NAME] wash daily for 2 weeks and follow up visit in 5 days. According to Prevention and Control of Scabies in California Long-Term Care Facilities California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification, March 2008, Confirmation of Symptomatic Case(s): The [DIAGNOSES REDACTED]. Their skin is generally dry and scaly and there may be pre-existing, chronic dermatological conditions for which oral or topical steroids have been prescribed. Usually, the first indication that a scabies infestation is evolving is complaints of itching and new onset of a rash by one or more residents within a period of 5-12 days. Exposed health care workers, volunteers and frequent visitors may also complain of itching and rash at about the same time. Skin scrapings, when performed properly, will almost always be positive in persons suspected of having atypical or crusted scabies. However, newly infested persons are more likely to have typical scabies and skin scrapings, even when repeated several time at different sites, may be negative. The facility failed to establish an Infection Control Program under which it: 1. Investigated the clinical signs and symptoms of Resident 5's skin condition and failed to identify Resident 5's scabies infestation. 2. Failed to control Resident 5's scabies infestation. The facility failed to treat Resident 5's scabies infestation in accordance with the physician's orders [REDACTED]. 3. Failed to place Resident 5 in isolation when Resident 5 was treated for [REDACTED]. 4. Failed to maintain a record of incidents and corrective actions taken related to Resident 5's rash. 5. Failed to report Resident 5's scabies infestation to the Department of Public Health. This failure resulted in Resident 5 to have severe skin irritation causing the resident to uncontrollably scratch the infested skin areas. This prevented the resident from sleeping. The delay in identifying and treating Resident 5's scabies had the potential to spread the scabies infestation to all residents, staff and visitors in the facility.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to one of 15 sample residents (Resident 5). The facility staff failed to: 1. Follow the physician's orders [REDACTED]. 2. Follow the facility's scabies policy and procedures for the application of the [MEDICATION NAME] cream. 3. Perform continuous full body assessments on Resident 5 and inform the physician of Resident 5's status. This failure resulted in prolonging Resident 5's scabies infestation causing Resident 5 to continue to uncontrollably scratch the scabies infested skin areas and prevented him from sleeping. Findings: A review of the admission record indicated that Resident 5 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment tool, dated 8/10/16, Resident 5 had the ability to make self-understood and had the ability to understand others. The MDS functional status (activities of daily living), under Section G indicated Resident 5 required supervision for dressing, personal hygiene, bathing, and walking. A review of the nurse's admission assessment dated [DATE] indicated Resident 5 had rashes to both feet and had a physician's orders [REDACTED]. On 8/19/16, the licensed nurse's notes indicated: Resident noted with red rashes on abdomen area. Skin intact, no open sores, no bleeding, no signs and symptoms of infection. Physician had been informed with new orders noted and carried out. A review of the physician's orders [REDACTED]. On 11/2/16, at 9:15 a.m., Resident 5 was observed being wheeled by certified nurse assistant (CNA) 2 in the corridor after his shower. The bottom of Resident 5's feet were observed to be covered with a heavy white scaly crusted substance. During an interview, Resident 5 stated, I'm itching again. I had these rashes for about three months now. I can't sleep at night. They give me the cream but it does not help me. They itch so bad, I can't sleep at night. I feel like there are bugs inside my skin. Resident 5 added that the itching gets so bad that he felt like pulling out his shunt (access site into the resident's circulatory system for [MEDICAL TREATMENT] machine which filters the blood of waste due to the resident's kidneys not functioning)(Pulling out the shunt would lead to massive bleeding from the site.). On 11/2/16, at 10:30 a.m., with Resident 5's permission, an observation of the resident skin condition was done with LVN 4 and another Surveyor. The following was observed: 1. Resident 5's chest, abdomen, back, arms, and legs, were covered with raised red papules with tracking (blisters and bumps caused by the bites and burrows from the mite) indicative of scabies. 2. Between Resident 5's fingers were observed to be dry and scaly. 3. Resident 5's feet were observed with a heavy white scaly crusted substance. On 11/2/16, at 12:25 p.m., during an interview with LVN 4, she stated Resident 5 had been treated with [MEDICATION NAME] (anti-parasitic topical medication used to treat scabies) two times as ordered by the dermatologist (physician who specializes in skin conditions.) LVN 4 also stated that skin scrapings were done on 9/22/16, and the result was negative for scabies. LVN 4 added that there was no isolation precaution (precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases) was provided because Resident 5 did not have scabies. The dermatologist's note dated, 8/30/16, indicated Resident 5's chief complaint was body rash, dry and pruritus (itching.) Her [DIAGNOSES REDACTED]. The physician's assessment did not indicate to rule out scabies instead she ordered new treatments, with a follow up after seven days. A review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] (a type of skin cleanser used to kill germs) wash daily for 10 days for rash. 2. [MEDICATION NAME] lotion (moisturizes dry skin) to body twice a day for six weeks. Westcort 0.2% cream (reduces skin itching and redness) to back and abdominal rash twice a day for four weeks. 3. [MEDICATION NAME] II cream was discontinued for the abdominal rash. [MEDICATION NAME] II was ordered to be applied twice a day to both feet for four weeks for rash. 4. Penlac 8% solution (antifungal medication) applied to toenails three times a week for six weeks. 5. Skin scraping body rashes on 9/22/16. On 9/6/16, the dermatologist notes indicated, Rash slowly better including pruritus, continue current treatment, follow up in seven days. On 9/20/16, the dermatologist came to the facility. A review of Resident 5's clinical record no documentation was found that the dermatologist had followed up Resident 5 seven days after the last visit on 9/6/16. There no documentation of any assessment of Resident 5's skin condition since 9/6/16. On 9/20/16, the dermatologist ordered: 1. Perform skin scrapping. 2. Then apply [MEDICATION NAME] times two. 3. Bathe resident with [MEDICATION NAME] (a type of skin cleanser used to kill germs) wash daily for 10 days, 4. Apply [MEDICATION NAME] (used to relief skin inflammation and itching) 0.05 % ointment two times a day for four weeks for rash, 5. Administer [MEDICATION NAME] (medication used for itching) 10 milligrams (mg) daily for three weeks. 6. Follow up in 7 days. A review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] II cream twice a day for 21 days for generalized body rash. 2. [MEDICATION NAME] lotion to body twice a day for skin maintenance. 3. [MEDICATION NAME] wash daily for 21 days. In an interview with LVN 4 on 11/2/16, at 1 p.m., she stated that she was the one who applied the [MEDICATION NAME] cream to Resident 5 on 9/21/16 and 9/22/16. LVN 4 stated that the skin scrapings were done on 9/22/16. LVN 4 stated on 9/23/16 the skin scraping results were negative for scabies. A review of the treatment record and concurrent interview with the Director of Nursing (DON) and LVN 4 on 11/2/16, at 2 p.m., indicated that skin scrapings were done after the [MEDICATION NAME] treatments. The treatment record indicated that the [MEDICATION NAME] treatments were done on two consecutive days. LVN 4 stated she applied the [MEDICATION NAME] on two consecutive days 9/21/16 and 9/22/16, and then had the laboratory perform the skin scraping. The DON stated that she was not aware that the skin scrapings were done after the treatments. Both the DON and LVN 4 did not know how Resident 5's feet looked like. In addition they both stated that they did not know what a scabies infestation looked like. On 11/2/16, at 2 p.m., during a telephone interview with the dermatologist, she stated that Resident 5 did not have scabies because the skin scraping results were negative. She stated that she diagnosed Resident 5 with end stage [MEDICAL CONDITION] with pruritus (itching) and non-specific [MEDICAL CONDITION] (skin infection). The dermatologist also stated that she was at the facility on 11/1/16 to follow-up on Resident 5's rash but did not see Resident 5's feet. The dermatologist also stated that she was not aware that skin scrapings were performed after the [MEDICATION NAME] treatments were done. She stated that was, probably why the result was negative. On 11/2/16, at approximately 3:45 p.m., the dermatologist arrived at the facility to reassess Resident 5. Upon completion of her reassessment, the dermatologist stated that Resident 5 had classic signs of Norwegian scabies (crusted scabies which is a severe form of scabies that can occur in some persons who are immunocompromised (have a weak immune system), elderly, disabled, or debilitated. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. Persons with crusted scabies are very contagious to other persons and can spread the infestation easily both by direct skin-to-skin contact and by contamination- Centers for Disease Control and Prevention). The dermatologist then performed skin scrapings on multiple sites on feet, hands and shoulders. On 11/2/16, the dermatologist ordered new treatments that included: 1. Isolation precaution. 2. Ivermectrin (used to treat certain worm infections) 9 milligrams (mg) by mouth every week for five (5) weeks. 3. [MEDICATION NAME] (an anti- itch drug) ten (10) mg every eight (8) hours for three (3) week. 4. Referrals to the Resident 5's renal (kidney) specialist. 6. [MEDICATION NAME] treatments two (2) times- apply tonight from head to toe then wash after twelve hours (12), repeat in seven (7) days. 7. [MEDICATION NAME] wash daily for 2 weeks. 8. Follow up visit in 5 days. A review of the facility's P/P (policy and procedures) on Scabies, Procedure Guidelines, revised 8/02 indicated: 1. Implement Contact isolation (form of isolation in which anyone entering the resident's room and having direct contact with the patient wears gloves and a gown); 4. Should scrapings be ordered, contact the lab; . 8. Begin treatment: a. Day 1 -apply [MEDICATION NAME] or other prescribed medication from scalp down. Leave on twelve (12) hours, and then wash off; b. Day 2-6- Apply Eurax (used to treat scabies and to reduce itching associated with certain conditions) after morning bath; c. Day 7 - apply [MEDICATION NAME] from scalp down. Leave on twelve (12) hours, and then wash off; 9. Bathe resident daily for seven (7) days; 11. Continue Contact Isolation until twenty four (24) hours after last [MEDICATION NAME] treatment. A review of the facility's policy and procedure (P/P) revised on 8/02 titled,Scabies, indicated, scabies is an itching skin irritation caused by microscopic human itch mite. The mite burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and allergic rash Symptoms sometimes include severe itching, which worsens at night. Common locations of scabies: a. Anterior auxiliary (arm pits) region or under breast; b. Around the waist; c. Between the fingers and palm of hand; d. Anterior surfaces of wrists and elbows; e. On body parts which may come in contact with contaminated linens, beddings, or clothing; f. Upper backs of nursing home residents and; g. On the hands of employees. According to Prevention and Control of Scabies in California Long-Term Care Facilities California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification, March 2008, Confirmation of Symptomatic Case(s): The [DIAGNOSES REDACTED]. Their skin is generally dry and scaly and there may be pre-existing, chronic dermatological conditions for which oral or topical steroids have been prescribed. Usually, the first indication that a scabies infestation is evolving is complaints of itching and new onset of a rash by one or more residents within a period of 5-12 days. Exposed health care workers, volunteers and frequent visitors may also complain of itching and rash at about the same time. Skin scrapings, when performed properly, will almost always be positive in persons suspected of having atypical or crusted scabies. However, newly infested persons are more likely to have typical scabies and skin scrapings, even when repeated several time at different sites, may be negative. The facility staff failed to: 1. Follow the physician's orders [REDACTED]. 2. Follow the facility's scabies policy and procedures for the application of the [MEDICATION NAME] cream. 3. Perform continuous full body assessments on Resident 5 and inform the physician of Resident 5's status. This failure resulted in prolonging Resident 5's scabies infestation causing Resident 5 to continue to uncontrollably scratch the scabies infested skin areas and prevented him from sleeping.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for one of four sample residents (Resident 1), who was assessed with [REDACTED]. 1. Implement its policy and procedures regarding the use of shower chairs. 2. Implement the plan of care that Resident 1 was at risk for falls and injury, therefore needing to be assisted with bathing, showering, and shampoo with at least one staff. CNA 1 left Resident 1 unattended in the shower. Resident 1 fell while attempting to turn off the shower. The deficient practices resulted in Resident 1 sustaining left hip fracture (broken bone). Resident 1 underwent a surgical procedure, an open reduction and internal fixation of the left hip (surgical incision is made to expose the bone which is then realigned and held in position with metal rods and screws), and was hospitalized for [REDACTED]. Findings: A review of Resident 1's clinical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was transferred to the acute hospital via ambulance on 8/31/2016 due to a change in condition and re-admitted to the facility on [DATE]. A review of Resident 1's Fall Risk Assessment, dated 8/04/2016 indicated Resident 1 had a fall risk total score of 10. A total score of 10 represents a high risk for falls. A review of Resident 1's care plans included the following: a. At risk for falls and injury, dated 8/4/2016, approaches included: Anticipate resident needs and monitor resident for pattern of risk factors or tendency to fall. b. Requires assistance with activities of daily living, dated 8/4/2016, approaches included: Assist in bathing, showering and shampoo with at least one staff. A review of Resident 1's annual Minimum Data Set (MDS-an assessment and care planning tool) dated 8/05/2016, indicated Resident 1 had a total Brief Interview for Mental Status (BIMS) score of 12 indicating Resident 1 is cognitively intact. Resident 1 required one-person physical assist for bathing and transferring. Resident 1's balance for moving from a seated to standing position, walking, and surface-to-surface transfer was indicated to be not steady, only able to stabilize with staff assistance. A review of Resident 1's Licensed Personnel Progress Notes dated 8/31/2016 at 9:45 a.m., indicated Resident 1 was found lying on the shower room floor in supine (lying face forward) position. Resident 1 complained of severe left hip pain and was unable to move both lower extremities. Resident 1 stated she slid off the shower chair onto the floor, while trying to turn the water off. On 9/13/2016 at 1:35 pm, during an interview with Certified Nurse Assistant 1 (CNA 1), she stated she gave Resident 1 a shower at 10:00 am on 8/31/2016. CNA 1 stated she put Resident 1 into a shower chair and wheeled Resident 1 to Shower Room 2 (SR 2). CNA 1 stated when she was about to finish Resident 1's shower, Resident 1 told CNA 1 that she still felt soap on her body. CNA 1 stated she realized she forgot to bring in a towel and extra sheets to dry and cover Resident 1. CNA 1 stated she told Resident 1 to stay put in the shower chair and handed the resident the movable shower head so that the resident could rinse herself while CNA 1 got the towel and the sheet in Station 2 linen closet. CNA 1 stated Resident 1 was alert and understood her completely because both of them spoke and understood Spanish. CNA 1 stated she left SR 2 and proceeded to get the towel and sheet leaving Resident 1 unsupervised for two (2) minutes. CNA 1 stated she heard somebody yelling for help and saw CNA 2 and Licensed Vocational Nurse 2 (LVN 2) standing in front of SR 2 door. CNA 1 stated she had a hard time opening SR 2 door because Resident 1 was lying down on the shower room floor with her legs and feet pointing towards the shower room door. The shower chair flipped forward and was next to Resident 1. CNA 1 stated she observed Resident 1 awake and verbally responsive stating, I did not hit my head and only my left leg is painful. CNA 1 stated she forgot to use the call light and ask someone to bring towels and linen, and should not have left Resident 1 unattended while in the shower room. During an observation and interview on 9/13/2016 at 1:45 pm, CNA 1 demonstrated there were forty (40) steps from SR 2 to Station 2 linen closet. SR 2 call light was in good working condition at the time of visit. During an interview on 9/13/2016 at 2:40 pm, LVN 1 stated she was in charge of Resident 1 when the fall incident happened. LVN 1 stated Resident 1 required one (1) person assist. On 9/14/2016 at 11:50 am, an interview with CNA 3 was conducted. CNA 3 confirmed Resident 1 was in SR 2 unsupervised and was found lying down on the floor awake and verbally responsive. On 9/14/2016 at 12:30 pm, an interview with LVN 2 was conducted. LVN 2 stated she saw Resident 1 lying down on the SR 2 floor awake, both legs and feet pointing towards the shower door. LVN 2 also stated Resident 1 verbalized pain on the left leg. LVN 2 stated that the shower chair flipped forward beside Resident 1 A review of Resident 1's general acute care hospital (GACH), Discharge Summary dated 9/4/2016, indicated Resident 1 discharge [DIAGNOSES REDACTED]. While in the GACH Resident 1 underwent a surgical procedure, an open reduction and internal fixation of the left hip (surgical incision is made to expose the bone which is then realigned and held in position with metal rods and screws). Resident 1 remained in the GACH for five days. A review of undated facility Policy and Procedure on use of Shower Chairs indicated: A resident using a shower chair should be supervised at all times and provided with appropriate assistance as determined by the nursing assessment.