Every finding on record at Northvine Postacute Care

Based on interview and record review, the facility failed to ensure rehabilitative services were provided for one of four sampled residents (Resident 1) when Physical Therapy (PT) was not provided according to the plan of care and physician orders.This failure had the potential to result in the resident failing to attain her highest practicable level of physical and functional well-being.During an interview with the Administrator on 1/27/26 at 10:10 a.m., the Administrator stated that the facility was transitioning to having in-house rehab staff rather than staff from an outside rehab provider. The facility ended the contract with the outside rehab providers at the start of the year. The Administrator stated he hired one Occupational Therapist (OT) from the outside rehab providers to continue to work for this facility. She became the facilities employee on the day the outside rehab providers contract ended. The Administrator stated that the facility had a Physical Therapist Assistant (PTA), to start work next week and to serve as the Director of Rehab. The Facility had several positions advertised as available for PT, OT, and Speech Language Pathology (SLT.) The facility planned to utilize telehealth services to provide PT, OT and SLT services and have PT Aides and OT aides at the facility.During an interview with the OT on 1/27/26 at 10:30 a.m., the OT stated the transition happened on 1/5/26. The last day of the contract with the outside rehab providers was 1/4/26. They had not sent any PT, OT, or SLT to the facility since 1/4/26. The OT stated she has been able to provide the OT services ordered by physicians. The OT stated she did not think any Residents had needed PT or SLT services over the last month. The OT stated the facility could only provide OT services at this time. During an interview on 1/27/26 at 12:20 p.m., in Resident 1's room, Resident 1 stated I need to get walking and to get PT. I would like to be able to walk so I can go to another facility like a shelter. Resident 1 stated she maybe saw a therapist once and was promised therapy would start soon. Resident 1 stated, I have not had any PT appointments.A review of Resident 1's admission record indicated she was admitted [DATE] with the diagnosis Acute and Chronic respiratory failure, recent pulmonary emboli (blood clot to the lung,) muscle weakness and need for assistance with personal care.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/6/26, indicated she had no memory impairment.A review of Resident 1's Order Summary Report, dated 12/30/25 indicated the following physician's (MD) orders for PT: skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. (Physical therapy for 5 times a week for 4 weeks. PT may include Therapeutic exercises, Therapeutic activities, help Resident regain normal movement and to gain a safe ability to ambulate.)A review of Resident 1's Care Plan Report initiated 12/30/25 documented the Focus: Patient represents with generalized weakness, impaired functional mobility, balance deficit and increase need of assistance with caregivers. Interventions included skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. During an interview with the Director of Nursing (DON) and concurrent record review on 1/27/26 at 12:35 p.m., the DON opened the electronic record of Resident 1 and noted a Physician order dated 12/30/25 for Physical Therapy. The order read: skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. The DON stated that most of Resident 1's PT was due in Jan. 2026. The DON stated that was when they transitioned to an in-house therapy department rather than a contracted company to provide the PT.During an interview on 1/27/26 at 12:45 p.m., with the DON and RNA (Restorative Nursing Assistant) (trained certified nursing assistants who help residents maintain their functional level after therapy ends) Staff, the RNA staff stated that Resident 1 was not on her resident list. RNA stated that PT staff did not discharge Resident 1 to RNA services. During an interview on 1/27/28 at 12:50 p.m., the OT stated that the contracted company to provide therapy services has not sent any Physical Therapists, Occupation Therapists or other staff to the facility since 1/4/26. OT stated she provided the services ordered for OT for Resident 1. OT stated the facility did not have a PT so Resident 1 did not get the ordered service.During a review of the facility's policy titled, Scheduling Therapy Services, dated Jan. 2018, the policy stipulated Therapy services shall be scheduled in accordance with the resident's treatment plan.

Based on interview and record review, the facility failed to meet professional standards of nursing care when one resident (Resident 1) of three sampled residents did not have documented weekly skin assessments in their medical chart and wound care treatments were not implemented to Resident 1's right great toe.This failure resulted in the development of infection and maggots in Resident 1's right great toe, which required hospitalization and subsequent amputation to his right great toe. Cross reference F925.A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (a condition characterized by paralysis of one side of the body), and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of a Nursing admission Assessment, dated [DATE], indicated Resident 1's skin assessment was documented as Right Toe-Bruising. A review of Resident 1's Right Great Toe Ulcer Care Plan, dated [DATE], indicated Resident 1 had developed an ulcer (an open wound that fails to heal properly) with redness and swelling to his right great toe. Interventions included: monitor and document wound; to monitor, document and report any signs of infection; weekly documentation of wound which will include measurement of skin breakdown's width, length, depth, type of tissue and exudate (fluid seeping from wound). A review of Resident 1's Order Summary Report dated [DATE] indicated the following orders were written by Medical Doctor 1 (MD 1):[DATE]: Cleanse right great toe with normal saline (a solution of salt and water used in medicine to clean wounds), pat dry, apply small amount of triple antibiotic cream (a topical medication used to prevent infections in minor cuts) and cover with dry dressing. Every day shift for wound to right great toe. Start [DATE].[DATE]: Cleanse right great toe with normal saline, pat dry, apply small amount of betadine [antiseptic used to treat skin infections] and leave open to air every day shift for wound to right great toe. Start [DATE]. A review of a Treatment Administration Record (TAR) dated [DATE] indicated Resident 1 did not receive treatment for his right great toe as ordered on [DATE] and [DATE] for a total of 2 missed treatments. A review of Resident 1's Progress Notes dated [DATE] at 10:52 p.m., indicated, CNA [Certified Nursing Assistant] noticed [Resident 1's] right toe tip bleeding.minimal blood.small drainage . A review of Resident 1's Order Summary Report, dated [DATE], indicated a wound care order written by MD 1 for Resident 1's right great toe expired on [DATE]. There was no documented evidence that new orders were obtained after the expiration date. Due to this Resident 1 did not receive wound care treatment from [DATE] to [DATE] for a total of six missed treatments. A review of Resident 1's Order Summary Report dated [DATE], indicated a wound care order written by MD 1 for Resident 1's right great toe expired on [DATE]. There was no documented evidence that new orders were obtained after the expiration date. Due to this Resident 1 did not receive wound care treatment from [DATE] to [DATE] for a total of three missed treatments. A review of a document titled Skin Weekly Assessment dated [DATE], indicated a skin and wound assessment was performed on Resident 1. There was no further documented evidence of weekly skin assessments prior to or after [DATE] for a total of eight missed weekly skin assessments. A review of Resident 1's Progress Notes dated [DATE] at 1:49 p.m., indicated, While in the process of cleaning [Resident 1's] wound to better view base and surrounding area.observed.lifting of the skin. Upon further assessment.there was movement at the lifted spot. When.[Licensed Nurse 1 (LN 1)] wiped the area.saw a small white larvae [sic] looking bug coming up from the tip of the wound.Repetitive motion of cleaning the wound with warm water caused several more small ones to appear. A review of Resident 1's Progress Notes, dated [DATE], at 3:51 p.m., indicated Resident 1 was transferred to the hospital for evaluation of right great toe wound. A review of the hospital document titled Emergency Department [ED] Provider Note dated [DATE], indicated Resident 1 was evaluated and admitted to the hospital for Maggots on right first toe, open chronic wound and necrosis [dead or dying tissue]. A review of Resident 1's hospital document titled Computed Tomography [CT scan-medical imaging procedure using Xray and computers to obtain detailed cross-sectional images of the body] Foot Right with contrast [a substance used to make images clearer and more detailed] dated [DATE] indicated, Findings are concerning for septic arthritis [serious joint infection caused by bacteria] and gangrenous osteomyelitis [tissue death from a severe infection of the bone]. Soft tissue swelling of the great toe. A review of a hospital document titled Surgery Information dated [DATE] at 1:25 p.m., indicated Resident 1 had surgery for Partial First Ray Resection Right Foot [a surgical procedure when part of the first metatarsal [a group of five long bones in the midfoot] and the big toe are removed due to infection or gangrene [dead tissue]. During an interview on [DATE] at 10:44 a.m., LN 2 stated she remembered Resident 1 received wound care with betadine (a topical antiseptic used to prevent and treat minor skin infections). LN 2 stated, For some reason, [Resident 1] was removed from [the Wound Consultant's (WC- a healthcare professional who specializes in the assessment, treatment, and management of acute and chronic wounds)] service, but I don't know why. His [Resident 1] wound was still bad. During a concurrent interview and record review on [DATE] at 12:50 p.m., the Wound Nurse (WN) confirmed there was one weekly skin assessment documented on [DATE] and that it should have been completed and documented every week. She stated she collaborated with the WC during weekly rounds and remembered seeing Resident 1 twice before he was discharged from the WC's service, though the wound was still present. In a further interview at 2:09 p.m., the WN confirmed there were gaps in obtaining doctor orders when the wound treatment orders expired which left Resident 1's wound untreated on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. During an interview on [DATE] at 2:11 p.m., the Director of Nursing (DON) stated the weekly skin assessments should be completed by the WN for any resident with skin issues or wounds. The DON confirmed one weekly skin assessment was completed during Resident 1's entire stay at the facility and stated, It should have been done weekly. During an interview on [DATE] at 1:59 p.m., MD 1 stated, Missed wound treatments would affect wound healing and may attract more flies as compared to a clean wound. During an interview on [DATE] at 3:09 p.m., the DON stated nursing staff must call the doctor about physician orders that cannot be followed, implemented, or need renewal. The DON stated, The ball was dropped by the WN. It [Resident 1's recent maggot infestation] was heartbreaking and hope it never happens again. A review of the facility's document titled Physician Orders dated [DATE] indicated, Physician orders are obtained to provide a clear direction in the care of the resident. A review of The American Nurse's Association's website emphasized the critical role nurses play in implementing.physician orders.while ensuring orders are carried out safely and effectively. https://www.nursingworld.org/A review of the American Medical Directors Association (AMDA) article titled Pressure Ulcers in the Long-Term Care Setting published in 2008 indicated, .Inspect the patient's skin at least once weekly.Assessment by members of the interdisciplinary team [a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care] can help to distinguish ulcers that are caused by pressure, diabetes, ischemia [reduced blood flow], or venous disease [a condition which causes pooling of blood in the legs], each of which is evaluated and managed differently.weekly reassessment and documentation of ulcer characteristics is recommended. More frequent reassessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment.

A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (a condition characterized by paralysis of one side of the body), expressive language disorder (a communication disorder impacting a person's ability to communicate their thoughts), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's History and Physical, dated 11/1/24, indicated Medical Doctor 1 (MD 1) planned for a wound care consult, currently foam dressing to right dorsal [top of foot] foot ulcer every Monday, Wednesday, Friday. MD 1 noted the wound measurement taken on 10/4/24 was, 1 centimeter [cm-a unit of measure] x 1cm x 0.2cm. A review of the Physician's Progress Notes dated 5/16/25, indicated Resident 1 had an infection in his right great toe and was ordered antibiotics, warm compresses as needed and to cleanse the area with normal saline (a solution of salt and water used in medicine to clean wounds), apply betadine (antiseptic used to treat skin infections) and leave wound open to air. A review of a wound consultant document titled Preliminary Wound Report, dated 6/2/25 indicated Resident 1 had, necrotic [tissue that is dead or dying] right great toe with intact black eschar [a thick crust like area of dead tissue that forms on the skin].peripheral pulses [the beats of the heart felt in the extremities when touched ] non-palpable [pulse cannot be felt]. Extremities cold to touch. Great toe nail [sic] is almost detaching. Referral to podiatrist [a doctor specializing in treatment of the foot]. A review of Resident 1's Order Summary Report, dated 6/6/25, indicated a podiatry consult was ordered. A review of a wound consultant document titled Preliminary Wound Report, dated 6/9/25 indicated, Black eschar stable and dry. Paint wound with betadine and leave open to air. Follow up with Podiatrist.to [discharge from services] today. A review of Resident 1's Progress Notes dated 6/13/25 at 11:09 p.m., indicated Resident 1's right great toenail came off. A review of Resident 1's Progress Notes dated 6/14/25 at 10:05 p.m., indicated, Wound to [Resident 1's] right great toe is worsening.Will notify [Wound Consultant ((WC) a healthcare professional who specializes in the assessment, treatment, and management of acute and chronic wounds)] with further information. A review of Resident 1's Progress Notes, dated 7/21/25, at 1:49 p.m., indicated, While in the process of cleaning [Resident 1's] wound to better view base and surrounding area.observed.lifting of the skin. Upon further assessment.there was movement at the lifted spot. When.[Licensed Nurse 1-LN 1] wiped the area.saw a small white larvae [sic] looking bug coming up from the tip of the wound.Repetitive motion of cleaning the wound with warm water caused several more small ones to appear. A review of Resident 1's Progress Notes, dated 7/21/25 at 3:51 p.m., indicated Resident 1 was transferred to the hospital for evaluation of right great toe wound. A review of the hospital document titled Emergency Department (ED) Provider Note dated 7/21/25, indicated Resident 1 was evaluated and admitted to the hospital for, Maggots on right first toe, open chronic wound and necrosis [death of cells and living tissue]. A review of hospital document titled Computed Tomography [CT scan-medical imaging procedure using Xray and computers to obtain detailed cross-sectional images of the body] Foot Right with contrast [a substance used to make images clearer and more detailed], dated 7/21/25, indicated, Findings are concerning for septic arthritis [serious joint infection caused by bacteria] and gangrenous osteomyelitis [tissue death from a severe infection of the bone]. Soft tissue swelling of the great toe. A review of a hospital picture of Resident 1's right great toe wound, taken on 7/22/25, at 9:43 a.m., depicted Resident 1's right great toe with approximately 3.5 cm of black eschar. A small amount of light-yellow discharge was seen oozing from the center of the wound. Resident 1's toenails to healthy digits were yellowed, stained and long. A review of a hospital document titled Surgery Information, dated 7/25/25 at 1:25 p.m., indicated Resident 1 had surgery for, Partial First Ray Resection Right Foot [a surgical procedure when part of the first metatarsal (a group of five long bones in the midfoot)] and the big toe are removed due to infection or gangrene [dead tissue]. During an interview on 7/28/25 at 10:15 a.m., the Wound Nurse (WN) remembered the last orders placed for Resident 1's wound care was to, wash with soap and water then leave open to air. During an interview on 7/28/25 at 10:44 a.m., LN 2 stated she remembered Resident 1 had initially received wound care with betadine, then it was changed to soap and water. LN 2 stated, For some reason, Resident 1 was removed from [WC's] service, but I don't know why. [Resident 1's] wound was still bad. During an interview on 7/28/25 at 2:11 p.m., the Director of Nursing (DON) stated the WN should complete the weekly skin assessments for any residents with skin issues or wounds. The DON stated if assessments were completed weekly, the deterioration of the wound might have been caught and addressed. During an interview on 7/30/25 at 1:59 p.m., MD 1 stated he was worried about bacteria forming in Resident 1's wound when it was covered, so he ordered a different treatment with instructions to leave the wound open to air. MD 1 decided to change the treatment to soap and water on 7/3/25 and continue to leave the wound open to air. MD 1 stated he wanted the wound dry, thinking it would heal better. MD 1 stated he wrote two orders for a podiatry consult for Resident 1, as wound care was not his area of expertise. MD 1 also stated he had concerns about the wound healing knowing Resident 1 had poor circulation, which was another indication for a podiatry consult. MD 1 further stated Resident 1's insurance plan required a primary physician change to the same county to facilitate a podiatry consult for Resident 1's toe. MD 1 asked for assistance from the DON and the Social Services Director (SSD) to complete this task, but they were unsuccessful in doing so. MD 1 stated, There are always flies [in the facility], but I can't send every resident out who has a wound because of the flies. During an interview on 7/30/25 at 2:47 p.m., the SSD stated she became aware of the order to obtain a podiatry consult for Resident 1's right foot in early June. The SSD stated Resident 1's primary physician through his insurance provider was in a different county. The SSD stated Resident 1's insurance provider wanted Resident 1 to call them to change his primary physician to a local physician where he currently resided to facilitate a podiatry consult. The SSD stated she tried to call, but the insurance provider wanted to speak to Resident 1. The SSD stated Resident 1 then asked Family Member 1 (FM 1) to try and call him, but FM 1 reported she was told the same thing. The SSD stated Resident 1 refused to call the insurance provider himself because he was planning on returning to his residence up north. The SSD confirmed she did not inform MD 1 of Resident 1's refusal to call and she did not document this in Resident 1's medical record. During an interview on 7/31/25 at 9:18 a.m., MD 1 stated he became aware of the insurance barrier which prevented a podiatry consult on 7/11/25. MD 1 stated he spoke with Resident 1 and urged him to call the insurance provider to make the necessary changes. MD 1 stated Resident 1 agreed to call. During an interview on 7/31/25 at 1:54 p.m., FM 1 stated the facility notified FM 1 a change needed to be made with Resident 1's insurance provider at approximately the beginning of June 2025. FM 1 stated when FM 1 called the insurance provider, FM 1 was told there was no need to change physicians. FM 1 stated the insurance provider notified FM 1 that a bill for consulting services could be sent to Resident 1's documented county of residence. FM 1 denied the insurance provider told her they needed to speak with Resident 1. FM 1 then stated FM 1 called the SSD to inform her of this information, and the SSD became argumentative and told FM 1 this was incorrect. FM 1 stated FM 1 was unsure what happened after that and was distressed the podiatry consult never happened. FM 1 stated, Because of this lack of attention, six weeks later [Resident 1] had a toe amputation. During an interview on 7/31/25 at 2:31p.m., the Wound Consultant (WC) stated each resident in her service was endorsed to the WN, who rounded with the WC during her weekly treatment visits. After each visit, a treatment summary note is sent to the facility. The WC acknowledged she saw Resident 1 twice. The first visit was on 6/2/25 and a second time on 6/9/25, at which point Resident 1 was discharged from her services. The WC stated there was no need for her to continue following as the wound was stable as long as the wound was monitored closely and the eschar remained dry. The WC stated, If the wound gets wet or moist, the eschar would soak up the fluid, open up and cause an infection. My recommendation upon discharge from my service was to paint the wound with betadine and leave it open to air. Betadine has antiseptic properties and adds an additional layer of protection to wounds. During a concurrent interview and record review on 8/1/25, at 10:13 a.m., the DON stated the Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive and coordinated care to residents) meetings for skin occurred on a weekly basis. Residents discussed at the IDT meetings are brought forth by the WN who assessed all residents with skin issues in the facility. The DON confirmed the first documented skin meeting to discuss Resident 1's great right toe was on 6/11/25. The recommendations from this meeting indicated, .continue with treatment per MD order, continue with weekly wound visit, RD [Registered Dietitian] consult and recommendation, monitor for signs/symptoms of infection and notify MD if any noted. The recommendations for the week of 6/18/25 were identical to the previous week. The DON acknowledged there was no evidence of an IDT meeting documented for 6/25/25. The DON further acknowledged the IDT meetings dated 7/3/25, 7/10/25 and 7/17/25 all indicated a treatment of soap and water to the wound to be continued in addition to the previously documented recommendations. The DON confirmed there was no documented evidence of Resident 1's wound worsening, and no documented evidence of a podiatry consult in the IDT skin meetings. On 8/1/25 a request for the facility's policy and procedure regarding IDT meetings was submitted to the DON. The DON stated there was no existing policy on IDT function.A review of a facility document titled Facility Assessment, undated, indicated the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the resident require. The document further indicated wound care and wound care dressings are competency practices the facility offered.A review of recommendations titled Diabetic Wound Care from the American Podiatric Medical Association (APMA) dated 2025 indicated, Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States.Foot ulceration precedes 85 percent of diabetes-related amputations.Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated to reduce the risk of infection and amputation, improve function and quality of life, and reduce health-care costs.The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.To keep an ulcer from becoming infected, it is important to.keep the ulcer clean and bandaged.cleanse the wound daily, using a wound dressing or bandage.The old thought of ‘let the air get at it' is now known to be harmful to healing.The use of full-strength betadine.and soaking are not recommended, as these practices could lead to further complications.

Based on observation and interview, the facility failed to maintain an effective pest control program when flies were observed in common hallways and three resident rooms and four resident rooms had torn window screens.This failure decreased the facility's potential to prevent vector (an insect or rodent that transmits bacteria and viruses) borne illnesses for a census of 54 residents.During a concurrent observation and interview on 7/28/25 at 10:30 a.m., Resident 3 was lying in bed. Upon observation a half full and open urinal and partially eaten personal food items had been placed on Resident 3's bedside table. In addition, a strip of fly paper with 3 dead flies attached and a live fly was seen on Resident 3's curtain Resident 3 stated he had seen flies in his room, all the time. Upon inspection, Resident 3's window screen was torn.During a concurrent observation and interview on 7/28/25 at 10:51 a.m., Resident 4 was sitting on the edge of his bed. Resident 4 stated flies had randomly been entering his room throughout the day and made him annoyed. Resident 4 stated, They land on your head and buzz around. A dead fly was observed on his windowsill.During an observation on 7/28/25 at 10:55 a.m., a torn window screen was found in resident room [ROOM NUMBER].During an observation on 7/28/25, at 10:56 a.m., a fly was seen flying around in resident room [ROOM NUMBER].During a concurrent observation and interview on 7/28/25 at 10:58 a.m., in Resident 5's room, holes were observed in the window screen. Resident 5 stated, Flies come in here all the time. I told them about this.During an observation on 7/28/25 at 11:02 a.m., a torn window screen was found in resident room [ROOM NUMBER].During an interview on 7/28/25 at 1:30 p.m., the Maintenance Worker (MW) reviewed the maintenance binder and could not locate a work order to repair any window screens. The MW confirmed he did not proactively work on pest prevention.During an observation on 7/28/25 at 1:40 p.m., at the nurse's station, a fly was persistently buzzing around this surveyor.During an interview on 7/28/25 at 2:51 p.m., the Administrator (ADM) stated he was not aware of a fly problem in the facility. The ADM stated flies in the facility, pose a significant problem.A review of the facility's policy titled Pest Control, dated 1/18, indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects.

Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment when three chairs available for resident use were worn out and tattered in one hallway of the facility.This failure decreased the facility's potential to provide a clean and comfortable environment for residents and their guests.During an observation of the facility's Garden Hall on 7/14/25 at 11:36 a.m., three wooden chairs with seats and arm rests made of pleather (a synthetic material made to look and feel like leather) were cracked, flaky, and worn-out which exposed light brown, discolored, and coarse fabric fibers. These chairs were available for residents and guests to use. One chair was removed by a guest and brought into a resident room. Thereafter, a resident sat in one of the other chairs. During a concurrent interview and observation on 7/14/25 at 1:12 p.m. with the Infection Preventionist (IP), the IP confirmed the three chairs in the Garden Hall were all torn with worn-out cushions. The IP stated the chairs were an infection control concern and stated she reported it to the previous facility Administrator but nothing was done with the chairs. The IP stated the three chairs could not be disinfected properly due to their condition. The IP confirmed the chairs were used by residents and stated, If a resident sits there and they [the residents] are wet, it's going to seep through the cushion and there is no way to clean and disinfect that. The IP further stated, I would not sit in those chairs.A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environment Surfaces, dated 2018 indicated, Environmental surfaces will be disinfected (or cleaned) on a regular basis.A review of the facility's P&P titled, Infection Prevention and Control Program, dated 2018 indicated, Prevention of infection.instituting measures to avoid complications or dissemination.

Based on observation, interview, and record review, the facility failed to protect residents from Resident 1's aggressive behavior when facility staff were not able to verbalize Resident 1's care plan for aggression. This failure resulted in Resident 1 becoming physically aggressive with two residents. Finding: On 5/20/25, the Department received a report from the facility that Resident 1 had hit Resident 2 when their wheelchairs became stuck together while in the hallway. During an observation on 5/27/25 at 9:44 a.m., Resident 1 was in her wheelchair holding a teddy bear and a piece of paper in the room where three male residents resided at the end of a hallway. Immediately outside the door to this room Licensed Nurse A was standing at the treatment cart. Across the hall, a housekeeping cart was in front of the doorway to a resident room. Resident 3, in her wheelchair, approached Licensed Nurse A and asked him to move the housekeeping cart so she could enter her room to use the bathroom. Resident 1 came to the doorway of the room she was in, and Licensed Nurse A asked Certified Nursing Assistant (CNA) B to move Resident 1 so the housekeeping cart could be moved. A second CNA (CNA C) came to help, and Licensed Nurse A told her Resident 3 was waiting to get into her room to use the bathroom. As CNA B pushed Resident 1 past the housekeeping cart, Resident 1 grabbed onto the handle of the cart and would not let go. Licensed Nurse A, CNA B, and CNA C all tried to get Resident 1 to release her grip on the cart. Resident 1 finally let go of the housekeeping cart and as CNA B pushed Resident 1 past CNA C, Resident 1 kicked repeatedly at CNA C's shins. Then, as CNA B pushed Resident 1 past Resident 3, Resident 1 attempted to kick Resident 3. On 5/27/25, the Department received a report from the facility that Resident 1 had struck Resident 3 with a piece of paper as she was passing her in the hallway. During a record review on 5/27/25 at 1:36 p.m., Resident 1's facesheet indicated an admission date of 11/13/24 and multiple diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions; memory loss and confusion are the main symptoms) and dementia with behavioral disturbance (changes in behavior and mood that can manifest as various symptoms, including agitation, aggression, anxiety, depression, and psychosis), among others. Review of Resident 1's care plan revealed a focus area, dated 12/27/24, The resident is experiencing increase in behavior problem manifested by, striking, spitting, grabbing out at others, refusing [medications], [treatment], care, throwing inanimate objects, cups of water, intrusiveness, persistent wandering, behaviors are difficult to redirect. Behaviors tend to escalate in the late afternoon and early evening hours. Further review of this focus area revealed an intervention, dated 3/6/25, Remove from area of increased stimulation/congestion to minimize agitation. Continuing the record review on 5/27/25 at 1:36 p.m., review of Resident 1's nurse progress notes revealed a note dated 5/27/25 at 10:50 a.m., [Resident 1] was in the process of being assited to activity room and passed [Resident 3] outside of her unit. [Resident 1] was holding on to a stuffed animal and a single piece of copy paper. As the 2 got closer to each other [Resident 1] leaned over and struct [sic] [Resident 3] with the piece of paper making contact on her upper arm. During an interview on 5/27/25 at 2 p.m., CNA B stated she was the CNA for Resident 1 today. CNA B stated her resident assignment changed every day. CNA B stated Resident 1 had a behavior of hitting all of the sudden. CNA B stated she did not know of anything that triggered Resident 1 to hit. CNA B stated there was nothing that could prevent Resident 1 from hitting, she just had to keep a close eye on her. During an interview on 5/27/25 at 2:10 p.m., Licensed Nurse A stated he had been working at the facility since April 2025 and was not familiar with Resident 1. Licensed Nurse A stated they managed Resident 1's aggressive behavior by keeping a close eye on her. Licensed Nurse A stated it did not take much to trigger Resident 1's aggressive behavior. Licensed Nurse A stated her aggression could be triggered by moving her, transfers, working with her, and doing activities of daily living (eating, dressing, bathing, etc). During an interview on 5/27/25 at 3:38 p.m., Licensed Nurse D stated she was Resident 1's nurse. Licensed Nurse D stated Resident 1 liked to hit. Licensed Nurse D stated Resident 1 could hit at any time, she did not have any triggers for hitting. Licensed Nurse D stated to prevent Resident 1 from hitting, they had medication they could give her and kept her distracted when she seemed agitated. During an interview on 6/3/25 at 2:02 p.m., Social Services Director verified that Resident 1's behavior had been discussed by the facility leadership in their morning meeting after the two reported incidents but could not recall what the plan was to manage her aggression towards other residents. During a record review and concurrent interview on 6/3/25 at 2:32 p.m., MDS Nurse verified Resident 1's care plan for her aggressive behavior included the intervention added 3/6/25 to remove Resident 1 from increased stimulation/congestion to minimize agitation. MDS Nurse stated that on the morning of 5/27/25 when Resident 1 struck Resident 3 with the piece of paper Resident 1 was in an area that was too congested. Review of facility policy, Abuse and Neglect Prohibition Policy, last revised 6/30/2020, revealed, The facility's abuse and neglect training program will be provided to all employees, through orientation and on-going sessions related to abuse prohibition practices at a minimum of annually and will include review of: . Appropriate interventions to deal with aggressive . reactions of residents. Review of policy section titled Prevention of Occurrences revealed, The following actions to prevent abuse . will include: . Identifying, correcting, and intervening in situations in which abuse . is more likely to occur. This includes analysis of: . The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs.

Based on observation, interview, and record review, the facility failed to provide the services necessary to maintain good grooming for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when all three had long, jagged (rough, uneven shape, with some sharp points), and dirty fingernails. This failure decreased the facility's potential to prevent skin infections if the residents' scratched their skin with dirty jagged nails. Findings: A review of Resident 1 ' s admission record indicated admission to the facility on [DATE] with diagnoses including generalized muscle weakness and the need for assistance with personal care. A review of Resident 2 ' s admission record indicated admission to the facility on [DATE] with diagnoses including generalized muscle weakness and the need for assistance with personal care. A review of Resident 3 ' s admission record indicated admission to the facility on [DATE] with diagnoses including generalized muscle weakness and the need for assistance with personal care. During a concurrent observation and interview on 5/19/25 at 4:32 p.m., Certified Nursing Assistant A (CNA A) confirmed Resident 1 had many scratches on her forearm caused by scratching herself. During a concurrent observation and interview on 5/21/25 at 1:37 p.m., the Director of Nursing (DON) confirmed Resident 1 needed nail care, and it was obvious she had not received nail care, as her fingernails were excessively long, dirty, and some were jagged. The DON called Licensed Nurse B (LN B) and CNA C into Resident 1 ' s room and told them staff were expected to conduct a bedside assessment of each resident and identify resident care needs. During an observation on 5/21/25 at 4:10 p.m., Resident 2 had long fingernails with some of them jagged and had brown debris underneath them. During an observation on 5/21/25 at 4:15 p.m., Resident 3 had long fingernails with some of them jagged and had brown debris underneath them. During a concurrent observation and interview on 5/21/25 at 4:52 p.m., CNA D confirmed Resident 3 ' s fingernails needed to be trimmed, cleaned, and smoothed with a nail file. During a concurrent observation and interview on 5/21/25 at 4:57 p.m., CNA D confirmed Resident 2 ' s fingernails were jagged and dirty, and some were long. CNA D stated nail care was hit and miss and when CNAs were busy it was not a priority. A record review of the facility ' s policy titled Fingernails/Toenails, Care of released January 2018 indicated, Nail care includes regular cleaning and regular trimming during showers and/or as needed .Proper nail care can aid in prevention of skin problems around the nail bed [and] trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and record review, the facility failed to initiate and implement resident-centered nursing care plans for one of three sampled residents, when: 1. A nursing care plan was not initiated when Resident 1 developed a urinary tract infection (UTI- when bacteria enter the urinary tract, which includes the kidneys, bladder, and urethra. Most UTIs are caused by bacteria from the bowel); and, 2. Nursing care plan interventions were not implemented when Resident 1 experienced constipation for three days These failures had the potential to worsen or delay improvement of Resident 1's medical conditions. Findings: A review of Resident 1's Admission Record, printed 4/10/25, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (hemiplegia is a severe condition involving paralysis on one side of the body, while hemiparesis is a milder form of weakness on one side) of the right dominant side, vascular dementia (a type of dementia caused by impaired blood flow to the brain, leading to damage and eventual loss of brain cells), anxiety, and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a standardized, comprehensive assessment tool used in long-term care facilities to evaluate residents' health status and functional capabilities), dated 1/14/25, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-a standardized cognitive assessment used in nursing homes and other long-term care facilities to quickly screen for cognitive impairment, particularly dementia) of four (4), indicating severe cognitive deficit. 1. A record review of Resident 1's Progress Notes, dated 4/2/25 at 15:01 p.m., indicated Resident 1 left the facility with her sister. A record review of Resident 1's Progress Notes, dated 4/2/25 at 20:12 p.m., indicated Resident 1's sister called the facility to tell them Resident 1 was at Santa [NAME] Memorial Hospital due to stomach pain. A record review of Resident 1's Providence After Visit Summary, dated 4/2/25, indicated Resident 1 received blood and urine testing, and a computed tomography scan (CT scan - a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) of the abdomen. Resident 1 was diagnosed with an acute (a condition or illness that has a sudden onset and relatively short duration) UTI with abdominal pain and was treated with intravenous (existing or taking place within, or administered into, a vein or veins) fluids, pain medications and an antibiotic (medications that specifically target and eliminate bacteria causing infections in humans and animals) injection. Resident 1 was then discharged back to the facility via ambulance at 12:45 a.m. on 4/3/25. A review of Resident 1's Order Summary Report, dated 4/10/25, indicated Resident 1 was prescribed the following: Cefpodoxime Proxetil (used to treat bacterial infections in many different parts of the body) Oral Tablet 200 mg (milligram-a unit of measure), give 1 tablet by mouth two times a day for UTI for 10 days. Order date 4/3/25, end date 4/13/25. During a concurrent interview and record review with the Director of Nursing (DON) on 4/10/25 at 2:51 p.m., the DON acknowledged nursing staff did not initiate a nursing care plan for Resident 1's UTI or for antibiotic treatment. The DON stated this slipped by because the condition was found by an outside hospital, and Resident 1 arrived back at the facility late at night. The DON also stated a UTI care plan was important because it directed nursing staff in appropriate interventions. During an interview on 4/10/25 at 3:35 p.m. with Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated Resident 1 was still on antibiotic treatment for UTI and was doing well. LVN 1 acknowledged there was no nursing care plan for Resident 1's UTI, and this was not facility policy. LVN 1 stated many nursing interventions, such as increased water intake and observing for signs of systemic (affecting the entire body) infection, were typical interventions in a UTI care plan, and nursing staff should have notified the DON that the care plan was missing. During a review of facility policy and procedure (P & P) titled, Urinary Tract Infections/Bacteriuria-Clinical Protocol, dated 1/2018, it indicated, empirical treatment should be based on documented description of an individual's symptoms and on consideration of relevant test results, co-existing conditions, and pertinent risk factors, and, .nursing staff will review the status of individuals who are being treated and adjust treatment accordingly. During a review of facility P & P titled, Care Plans - Comprehensive Person Centered, dated 1/2018, it indicated, the nurse and/or the interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition . 2. During a concurrent interview and record review on 4/10/25 at 3:15 p.m. with the DON, Resident 1's Progress Notes, dated 1/15/25, and the Medication Administration Report (MAR- keeps track of every dose that the individual takes or misses for whatever reason) for January 2025, were reviewed. The DON agreed Resident 1 did not have a bowel movement (BM) for three days on 1/15/25, but no bowel care medications were administered. The DON stated facility bowel protocol was to implement specific interventions if a resident did not have a BM in three days. During a record review of Resident 1's Care Plan Report, printed 4/10/25, it indicated interventions for constipation instructed, administer Dulcolax (rectally inserted medicine used to relieve constipation), Fleet's enema (liquid is inserted into the rectum and colon through the anus), and MOM (Milk of Magnesia- Magnesium hydroxide, used to orally treat occasional constipation in children and adults on a short-term basis) as ordered .Follow facility bowel protocol for bowel management. During a record review of Resident 1's Order Details, dated 7/10/24, it indicated the following, Milk of Magnesia (MOM) Suspension 1200 mg/ml (milliliter-a unit of measure) by mouth; give 30 ml by mouth as needed for bowel care management/bowel care; give 30 ml PO (by mouth) if no bowel movement in 3 days in the evening, and Dulcolax Suppository 10 mg rectally; insert 1 suppository rectally as needed for bowel care management/bowel care; give 1 suppository if no (sic) MOM is ineffective on NOC (night) shift. During an interview on 4/10/25 at 3:35 p.m. with LVN 1, LVN 1 stated bowel care, including suppository administration, was done and documented by Licensed Nursing staff, not Certified Nursing Assistants (CNAs), and bowel care intervention is triggered in the electronic medical record (EHR) if a resident has not had a BM in three days. During an interview on 4/10/25 at 3:15 p.m. with the DON, the DON stated she did not know if Resident 1 failed to receive bowel care management per the nursing care plan on 1/15/25, or if the nurse just failed to document it. A record review of facility P & P titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated 1/2018, indicated, treatment/management: the physician will identify and order cause-specific and symptomatic interventions; for example institute a regimen to prevent constipation.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 57 out of 59 residents who received food from the facility's kitchen, when:1. a grease trap (a plumbing device, type of drain, intended to capture fats, oils and grease from wastewater), located in the dishwashing area under the two-compartment sink, was not maintained in good repair and caused wastewater (includes substances such as food scraps, oils, soaps and chemicals) to back-up on to the kitchen floor. This occurred while a County Department of Health Services (CDHS) Inspector was present on 3/18/25.2. did not ensure that the facility identified and resolved the source of the wastewater backup into the kitchen, despite evidence that staff were aware of wastewater coming up from the grease trap and drain under the grease trap prior to the survey. And,3. did not implement code compliance corrective actions, related to the kitchen (the physical environment of dietetic services) and including the grease trap in disrepair, issued to the facility by the CDHS on 10/28/24.These failures resulted in the County suspending the facility's retail food permit which required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and remains in effect until the facility can meet CDHS requirements. The facility's kitchen closing resulted in the interruption of dietetic services and facility having to find a commissary kitchen (a rentable commercial kitchen), to prepare food for the residents.On 3/19/25 at 12:47 p.m., Administrative Staff A and Administrative Staff B were verbally notified of the Immediate Jeopardy (IJ- is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) of the facility's failure to maintain the grease trap in the dishwashing area causing wastewater back-up on to the kitchen floor while County Health Inspector C was present, and leading to suspension of the facility's Food Permit. The Health Facilities Evaluator Nurse (HFEN also referred to as Surveyor) informed Administrative Staff A and Administrative Staff B of the Surveyor's findings that the facility's food permit would remain suspended until: the grease trap and plumbing issues were addressed, and dietetic services was brought into compliance based on results of the CDHS routine inspection which occurred on 10/22/24 and summarized in County Site Review Inspection report dated 10/28/24. Suspension of the facility's Food Permit resulted in the inability of the facility to meet the nutritional needs of 57 residents from the onsite kitchen.On 3/21/24 at 2:35 p.m., the facility presented an approved Action Plan (an IJ removal plan documents the immediate action a facility will take to prevent serious harm from occurring or recurring), which included but not limited to: 1) Food for residents to be prepared by the dietary staff at a commissary kitchen, 2) Residents' prepared food to be transported to the facility via a rental van in insulated food containers designed to maintain food temperatures during food transport, 3) Conversion of the facility staff breakroom into the temporary dietetic service space (area where the food from the commissary kitchen would be transferred to and residents meal trays arranged per the resident's diet card, and 4) Facility will contact HCAI (Department of Healthcare Access and Information: insures healthcare institutions are safe) to work out the details of moving the grease trap and arrangements will be made for HCAI, the city and county to meet at the facility to assess and guide for further actions.Findings:During a phone interview on 3/18/25 at 1:04 p.m. County Health Inspector C, who was still at the facility, stated she was completing a routine inspection to see if the facility had completed the required kitchen repairs, including the grease trap, as advised from a notification on 10/28/24. County Health Inspector C stated she noticed water on the floor under the two compartment-sink (used for soaking and rinsing dirty dishware) where the grease trap was located. County Health Inspector C stated she heard the Dietary Manager tell the dietary aide running the dishwasher not to run the dishwasher at the same time as draining the two-compartment sink. County Health Inspector C stated wastewater was coming up from the grease trap and flooding the kitchen floor. County Health Inspector C stated because there was a wastewater back-up, the County was suspending the facility from preparing food or using the kitchen equipment. County Health Inspector C stated the facility had a plumber come out to the facility but the plumbers could not do a hydro jet procedure (uses high pressure-water to clear clogs and debris from pipes) because there was too much water in the grease trap. The facility also called the company who serviced the grease trap to remove the wastewater from the clogged grease trap so the plumbing company could attempt to unclog the grease trap. Once the wastewater was removed the plumbing company was to come back to the facility to try and unplug the grease trap. County Health Inspector C stated the Santa [NAME] City Department of Environmental Compliance came out to the facility to inspect the grease trap on 3/18/25 and indicated the facility was in violation because of lack of maintenance of the grease trap. Santa [NAME] City Department of Environmental Compliance had indicated the facility should have had the grease trap serviced every one to two weeks instead of monthly based on the amount of food served daily. In addition, the grease trap looked like it was an inadequate size for the number of meals being prepared. County Health Inspector C stated since the facility was under a new ownership, the facility had a Conditional Permit whereby they had a number of items in the kitchen to fix, including the grease trap, in order for the kitchen to be up to California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health), which the facility failed to do.During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap was in disrepair and the facility's kitchen was not in compliance with the Calcode. Administrative Staff B stated County Health Inspector C had visited the facility in the morning of 3/18/25 when water was overflowing on to the kitchen floor from the grease trap and suspended the facility's retail Food Permit and closed the facility's kitchen where they prepared resident foods. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired.During an interview on 3/18/25 at 3:53 p.m., in the facility's kitchen, the Dietary Manager (DM) stated there had been an issue with the grease trap and plumbing causing wastewater to flow on to the kitchen floor. The DM stated it was a big problem causing the kitchen to be closed completely by CDHS until resolved.During a concurrent observation and interview on 3/18/25 at 4:05 p.m., the plumbing company was at the facility. Three plumbers were working on grease trap and were about to try to hydro jet the grease trap. Administrative Staff B confirmed the kitchen would remain closed since CDHS would not let the kitchen operate while there was a plugged grease trap. Administrative Staff B stated the County had approved for the facility to use the Emergency food for dinner 3/18/25 and for 3/19/25 breakfast but the facility needed to have an alternative meal preparation by lunch time.During an interview on 3/18/25 at 4:10 p.m., with Unlicensed Staff E translating Spanish to English, Dietary Aide D stated she had noticed water coming up from the grease trap for the last two months when the dishwasher is running and when she drains the two-compartment sink at the same time. Dietary Aide D stated a lot of wastewater can come up from the grease trap when the dishwasher was running. Dietary Aide D stated she had been directed by the DM to not drain the two-compartment sink while the dishwasher was running. Dietary Aide D stated the kitchen staff was serving the Emergency Food on paper plates, with plastic utensils and disposable cups, and no coffee was being severed.During a concurrent observation and interview on 3/18/25 at 4:35 p.m., three plumbers were working on the grease trap. Plumber F stated the issue with the grease trap had been building up for years whereby the bottom of the grease trap had decayed (deteriorated over time, often due to corrosion, rust, or other forms of damage, making it unsafe or ineffective). Plumber F stated when they used the drain snake (a flexible, slender tool used to dislodge and remove clogs from drains and pipes), they were hitting dirt. Plumber F stated if they tried to hydro jet the clog, they would just be blowing dirt. The drain snake was being fed to clear a blockage but all they heard was a grinding noise, which meant they were hitting rock, clay and mud. Plumber F stated when he pulled the drain snake back rock, clay and dirt was on the drain snake which meant the exit line for the grease trap had disintegrated.During a concurrent observation and phone interview on 3/18/25 at 5:20 p.m., the County Director was on the phone with Administrative Staff B. The County Director explained to Administrative Staff B she would not let the kitchen operate with a sewage back-up and wanted to know how the facility planned to provide meals to the residents while the kitchen was closed. Administrative Staff B did not explain the facility's meal plan. Surveyor joined the phone call and explained the facility was using their emergency food supply, utilizing canned and non-perishable foods, based on the facility Emergency Menu for dinner on 3/18/25 and breakfast 3/19/25 but the facility would still need to arrange for meals to be catered until the facility could find another place to prepare the residents meals. The County Director was agreeable with the plan for the time being.During an interview on 3/19/25 at 8:06 a.m., County Health Inspector G was standing by the nurse's station, which was located to the right of the entrance to the kitchen. County Health Inspector G stated he was given the facility document titled, Emergency Disaster Procedure Surveyor explained to County Health Inspector G, Administrative Staff B was fully aware per her conversation with the County Director last evening, the facility had to have a meal plan in place by 3/19/25 12:30 p.m The plan needed to identify how the facility was going to provide the residents their physician ordered diets. County Health Inspector G stated because of the amount of repair work required, the kitchen would remain closed for all activities.During an interview on 3/19/25 at 8:30 a.m., the Maintenance Manager stated he would have to unplug the grease trap two to three times a year using a drain snake. The last time he unplugged the grease trap was in January 2025.During an interview on 3/19/25 at 8:55 a.m., Administrative Staff A stated County Health Inspector C had approved a commissary kitchen. The facility still had not submitted a meal plan for the resident's lunch, which was expected to be served at 12:30 p.m. Administrative Staff A stated the previous Administrator did receive the County Site Review Inspection report from the CDHS dated 10/28/24, which addressed multiple kitchen repairs, including the grease trap, that needed to take place, and the kitchen was operating under a conditional status until plans were submitted.During an interview on 3/19/25 at 2 p.m., Administrative Staff A stated Administrative Staff B had not relayed to her that the CDHS and the California Department of Public Health (The Department) expected the facility to have an alternate meal plan for the residents starting by 3/19/2 at 12:30 p.m Administrative Staff A stated Administrative Staff B had not relayed to her the conversation that took place with Administrative Staff B and the County Director last evening whereby the County Director wanted an alternate meal plan to put into place by lunchtime.During a concurrent record and review and interview on 3/19/25 at 2:16 p.m., the facility's Action Plan number one to remove the IJ was reviewed. The Department's Surveyor and Nutrition Consultant explained to Administrator Staff A the Action Plan could not be approved since the facility could not show a safe plan for delivery of the required food and nutrition services in the absence of a kitchen and equipment for dietetic services.During a concurrent record review and interview on 3/20/25 at 9:10 a.m., the facility's Action Plan number two was reviewed with Administrative Staff A and explained the Action Plan could not be approved since the facility could not show a safe plan for delivery of the required food and nutrition services in the absence of a kitchen and equipment for dietetic services.During a concurrent record review and interview on 3/20/25 at 4:30 p, m., the facility's Action Plan number three was reviewed with Administrative Staff A and explained why the Action Plan could not be approved. While the facility reached a verbal agreement with the owner of the commissary, the rental agreement was not signed by the owner. The contract also indicated there was no garbage removal at the commissary kitchen. The Plan of Action number three did not include evidence of garbage removal at the commissary kitchen, proof of when a dumpster would be delivered at the commissary kitchen, how often garbage service would occur, and how was the garbage going to be discarded over the weekend since the garbage dumpster was not going to arrive at the commissary kitchen until Monday, 3/24/25.During an interview on 3/21/25 at 10:25 a.m., Administrative Staff A stated she had found out the garbage company could not deliver the garbage dumpster to the commissary kitchen site until Monday, 3/24/25. Administrative Staff A stated she would have the commissary kitchen contract updated reflecting the owner of the commissary kitchen would remove the trash Saturday, 3/22/25 and 3/23/25.On 3/21/25 at 2:35 p.m., Administrator Staff A was notified Action Plan number three was accepted. The action plan indicated the facility secured a contract with an offsite kitchen that would be utilized for food production, in accordance with physician ordered diets, in a safe, effective and timely manner.During the initial tour of the commissary kitchen on 3/22/25 from 5:45 a.m. to 7:03 a.m., the following was observed: 1. Handwashing sink faucet was loose and hot water knob difficult to turn off, 2. Paper towel dispenser next to the handwashing sink was broken, 3. Two-compartment sink faucet leaking, and 4. wall soap dispenser not working.A review of County Health Inspector G's Permanent Food Inspection Report, dated 3/22/25, indicated an inspection of the commissary kitchen took place during the preparation of the residents' lunch on 3/22/25. County Health Inspector G observed the following: The handwash sink had water leaking onto the floor from the waste pipe, the paper towel dispenser was not working, the food preparation sink had cold and warm water, but was leaking at the base of the faucet, and the ware washing sink (sink used to wash dishware, cookware, glassware, and other items) lacked the right drainboard to properly airdry the dishes.A review of County Health Inspector G's Permanent Food Inspection Report, dated 3/23/25, indicated an inspection of the commissary kitchen occurred during the preparation of the residents' breakfast on 3/23/25. County Health Inspector G observed the paper towel dispenser was still broken.During an observation on 3/24/25 at 3:25 p.m., the room temperature of the commissary kitchen was 84 degrees Fahrenheit. It was also noted the front door to the kitchen was open to help with air circulation, however there was no screen door. The paper towel holder next to the handwashing sink was still broken.During a concurrent observation and review of the Storage Room Temperature Log on 3/24/25 at 4:20 p.m., the temperature of the commissary kitchen had reached 88 degrees Fahrenheit. The Storage Room Temperature Log indicated the Storage Room Temperature should range between 50 -85 degrees Fahrenheit.During a observation on 3/24/25 at 4:50 p.m., the thermometer on the wall right of the front door read 90 degrees Fahrenheit.As of 3/24/25 at 5:40 p.m., the time the surveyor left the facility, the facility was unable to demonstrate minimum compliance with regulatory requirements for food production activities as evidenced by the inability to ensure the daily nutritional needs in a safe and effective manner for 57 residents in a facility census of 59.During a concurrent observation and interview on 3/25/25 at 3:07 p.m., the DM was mopping the commissary kitchen floor. The DM stated the Dietary Aide had unplugged the three-compartment sink (used to wash, rinse, and sanitize dishes) drains all at the once. The floor drain located underneath the sink could not withstand the amount of water draining from the three sinks all at once causing the wastewater to backup on to the kitchen floor. The entire kitchen floor was wet including the food prep area and the cooking area. [NAME] M stated when the three- compartment sink drains were unplugged simultaneous, the drain underneath the sinks could not withstand the amount of water draining causing the water to flood the entire kitchen floor. Maintenance N was working on the three compartment sink pipes and drain to see if there was a clog.During an observation on 3/25/25 at 4:35 p.m., Maintenance N was still working on the three-compartment sink drain system. Maintenance N was using a drain snake to clear a blockage of the drainpipe.The facility P/P titled, Storage of Food and Supplies, dated 2023, indicated: Policy: Food and supplies will be stored properly and in a safe manner. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 F -85 F- if dry food storage goes over 85 F take corrective action (see Corrective Action policy, page 6. 7) . The Facility P/P titled, Sanitation, dated 2023, indicated: Policy: The Food and Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working repair . 6. Employees are to alert the FNS Director immediately to any equipment needing repair. 7. The FNS [Food and Nutrition Services] Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man. 8. The Maintenance Department will assist Food & Nutrition Services as necessary in maintaining equipment and in doing janitorial duties which the Food & Nutrition Services employees cannot do and maintain maintenance records on all equipment . 15. The Food & Nutrition Services Department shall be ventilated in such a manner as to prevent excessive condensation, to maintain comfortable working conditions, and to remove objectionable odors and fumes . The hand washing sink shall have running hot and cold water, soap, paper toweling, and appropriate receptacles for wastepaper . The facility P/P titled, General Cleaning of Food and Nutrition Services Department, dated 2023, indicated: . Drain: Floor drains must be scheduled for routine cleaning in order to be maintained in a functional condition. 1. FNS staff should remove large debris as it accumulates and are encouraged to clean drains weekly. 2. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features . The facility P/P titled, Shelves, Counter, and Oher Surfaces Including Sinks Surfaces Including Sinks (Handwashing, Food Preparation, etc.), dated 2023, included: Note that for sink drains, Food and Nutrition Services staff are encouraged to remove large debris as it accumulates and to clean drains weekly. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features .

Based on observation, interview, and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when: 1) Tuna and chicken salad sandwiches did not reach a safe internal serving temperature, 2) [NAME] and dishwasher were not wearing an apron 3) Absence of a touch free garbage can by hand washing sink, 4) Internal food temperatures were not monitored prior to transporting residents' meals to the facility, 5) Pots and pans were not air dried, 6) Three-compartment sink manual dishwashing process was not done correctly, 7) Temperature monitoring for the walk-in refrigerator, freezer and commissary kitchen (a rentable commercial kitchen), were not completed, and 8) Dietary Aide used the food production two-compartment sink to rinse out a dirty pan. These failure placed, 57 out of 59 residents who received facility prepared foods, at risk for foodborne illness (any illness resulting from eating contaminated/spoiled foods). Findings: 1. During an observation on 3/24/25 at 3:25 p.m., [NAME] K was preparing tuna salad sandwiches for the resident's dinner. [NAME] K stated chicken salad sandwiches had already been made and were in the refrigerator. During an observation on 3/24/25 at 4:20 p.m., the thermometer on the commissary kitchen wall read 88 F. During a concurrent observation on 3/24/25 at 4:30 p.m., [NAME] K measured the internal temperatures of the prepared foods. The tuna salad sandwiches were at 63.7 degrees-Fahrenheit (F, a unit of measure for temperature), and the pureed tuna salad was at 53 F. During an interview on 3/24/25 at 4:40 p.m., [NAME] K stated she made the chicken and tuna salad at 1:30 p.m. During an observation on 3/24/25 starting at 4:50 p.m., the kitchen thermometer near the kitchen entrance read 90 F. At 4:55 p.m. the pureed tuna salad's internal temperature was 51 F. During an observation on 3/24/25 at 5 p.m., the RD L was helping [NAME] K try to get the internal temperatures of the tuna and chicken salad sandwiches to cool down to 41 degrees or below. RD L moved all the sandwiches to cookie sheets, placed the sandwiches in a single layer, then put the cookie sheets in the freezer. By 5:13 p.m. the internal temperature of the chicken salad sandwiches read 49 F and by 5:15 p.m., the tuna salad sandwiches internal temperature read 54 F. RD L continued to try to get the tuna and chicken salad sandwiches to cool down to 41 F. At 5:30 p.m. the internal temperature of the tuna salad was 54 F, chicken salad sandwiches 49 F, and the pureed chicken salad sandwiches 46 F. The facility P/P titled, Cooling and Reheating of Potentially Hazardous or Time/ Temperature Control for Safety Food: Policy: Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety . Ambient Temperature Food: PHF or TCS food shall be cooled within 4 hours to 41 degrees Fahrenheit or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned tuna. Use the Cool Down Log/or Ambient Temperature Food . 2. During a tour of the facility's commissary kitchen, on 3/22/25 at 5:45 a.m., with the Dietary Manager (DM), [NAME] K was preparing food but was not wearing an apron. The DM stated cooks were supposed to wear an apron. During an observation on 3/23/25 at 9:49 a.m., Dietary Aide Q was not wearing an apron when washing the dishes. The DM stated there were disposable aprons, which the dietary aide should wear and change if they are going from washing dishes to handling and/or preparing food. During an interview on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated cooks should wear a black cloth apron while prepping food and cooking and the dishwasher should wear a plastic apron to prevent cross contamination of the residents' food. 3. During a tour of the facility's commissary kitchen, on 3/22/25 at 5:45 a.m., noted the absence of a touch free garbage can next to the handwashing sink. There was only a garbage can with a lid for the food prep area. This led to dietary staff having to lift the garbage can lid with their clean hands leading to the dietary staff's hands becoming contaminated. The facility's Policy and Procedure (P/P) titled, Sanitation, dated 2023, indicated, Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food . All Food & Nutrition Services staff shall know the proper hand washing technique .The hand washing sink shall have .appropriate receptacles for wastepaper . 4. During an observation on 3/22/25 at 7:03 a.m., the van driver arrived at the commissary kitchen to load the serving containers with the residents' breakfast into the van. [NAME] K was about to hand off the containers to the driver when [NAME] K had to be reminded to take the internal temperatures of the prepared hot food items and log the temps. The facility P/P titled, Meal Service, dated 2023, indicated: POLICY: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized . 5. The standard of practice requires that Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow (USDA Food Code 4-901.11). During an observation on 3/22/25 at 9:30 a.m., [NAME] M was stacking wet pots and pans, not allowing for the pots and pans to air-dry (lets the dishes dry naturally on a rack or dish drying mat, without touching one another). During an interview on 4/3/25 at 2 p.m., the DM stated it was important to air dry to prevent bacteria (germs) from growing. The facility's P/P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, POLICY: . dishwashing procedures Set up area for air drying . All items are air-dried, which means no water droplets are present 6. During an observation on 3/22/25 at 9:30 a.m., Dietary Aide Q was washing dirty pots and pans in the three-compartment sink (a manual ware washing system used in commercial kitchens, consisting of three separate compartments for washing, rinsing, and sanitizing dishes and utensils). Surveyor needed to remind Dietary Aide Q pots and pans needed to be fully submerged in the sanitizer solution for 30 seconds per the bleach container directions to be affective in killing bacteria. The facility P/P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated: POLICY: . manual dishwashing procedures . Step One: Clean and sanitize all work surfaces. Set up area for air drying. Step Two: Rinse, scrape, or soak all items before washing . Step Three: The first compartment is for washing. Step Four: The second compartment is for rinsing.Step Five: The third compartment is for sanitizing. Fill the third compartment with clean, clear water to the fill line L_ gallons .Then add .sanitizer. Immerse all washed items for ____ (note time). 7. During an observation on 3/24/25 at 4:20 p.m., the thermometer on the commissary kitchen wall read 88 F. During an observation on 3/24/25 starting at 4:50 p.m., the kitchen thermometer near the kitchen entrance read 90 F and bin containing bread was stored in the area. During a record review of facility logs titled, Cold Storage Temperature Logs and Storage Room (general commissary kitchen) Temperature Log on 3/25/25 at 3:07 p.m., both logs were not filled out for the 3/25/25 AM shift nor for the PM shift. During an observation on 3/25/25 at 3:40 p.m., the commissary kitchen thermometer read 86 F. During an interview on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated The DM stated the Cold Storage Temperature Logs for the walk-in refrigerator and freezer and the Storage Room (general commissary kitchen) Log should be recorded on during the AM and PM shifts. The DM stated you want to make sure food is being stored at safe temperatures to prevent spoilage of food, which could cause foodborne illnesses. The DM stated storage of pantry food items at a high room temperature could spoil the food items and bread could become moldy. The kitchen should be at a safe cool temperature for the can goods, baking items and for staff. The facility P/P titled, Storage of Food and Supplies, dated 2023, indicated, Policy: Food and supplies will be stored properly and in a safe manner. The storeroom should be . well-ventilated, cool . Thermometers should be placed in all storage areas and checked frequently . Recommended temperature is 50° F -85° F if dry food storage goes over 85°F take corrective action (see Corrective Action policy, page 6. 7) . 8. The standard of practice would be to ensure sanitation methods that ensure food debris on equipment and utensils are scraped over a waste disposal unit or garbage receptacle or shall be removed in a warewashing machine with a prewash cycle (USDA Food Code, 2022). During an observation and interview on 3/25/25 at 3:40 p.m., with RD L, Dietary Aide R was rinsing off a dirty pan in the food production sink. RD L directed Dietary Aide R to stop and scrap the food debris from the dirty pots and pans into the garbage can and then use the three-compartment sink to wash, rinse and sanitize the pots and pans. RD L stated the food production sink was used for food preparation and was considered a clean area not appropriate for dirty dishes. The facility Policy and Procedure (P/P) titled, Sanitation, dated 2023, indicated, Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for . disposal of waste . kitchen wases which are not disposed of by garbage disposal units shall be kept in leak-proof, non-absorbent and tightly closed containers .If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed .

Based on interview and record review, the facility's administration (the person/s responsible for the overall operation and management of a skilled nursing facility, ensuring the facility meets regulations and provides quality care for residents) failed to use their resources effectively and efficiently, when corrective actions were not completed following the issuance of the County's Department of Health Services (CDHS) Site Review Inspection Report in October 2024. This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit which required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908). Findings: During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap was in disrepair and the facility's kitchen was not in compliance with the California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health). Administrative Staff B stated County Health Inspector C had visited the facility in the morning of 3/18/25 when wastewater was overflowing on to the kitchen floor from the grease trap and suspended the facility's retail Food Permit and closed down the facility's kitchen were they prepared resident foods. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired. During an interview on 4/2/25 at 5:10 p.m., Administrative Staff J (ADM J) stated she did the handoff (process where the responsibility for a specific task transfers from one person to another) between the Administrator who left and ADM B who took over. ADM J stated the previous Administrator did not address the Site Review Inspection Report, received by the facility on10/28/24, detailing the items needing to be addressed in the kitchen. ADM J stated it was the responsibility of the Administrator to follow through with addressing the kitchen repairs needed in order to comply with current Calcode requirements. During a phone review on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated herself as well as the previous Administrator and the Maintenance Manager had received the Site Review Inspection Report on 10/28/24 via email. The DM stated during the facility's Stand-up meeting (morning meeting that includes all department heads) she brought up several kitchen issues, including the grease trap disrepair, that needed to be addressed per the Site Review Inspection Report. The DM stated despite bringing it up, and the Administrator acknowledging the kitchen repairs needed to be addressed, the Administrator did not follow up with the County's kitchen repair requirements. A review of the facility job description titled, Administrator, revised 10/16/15, indicated: Position Summary: The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated [promoted or make widely known] by government agencies to ensure proper health care services to residents . Superintends [be responsible for the management or arrangement] physical operations of the Center . implements corrective action and budgetary constraints as required .

Based on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, when the facility's QAPI program did not address code compliance corrective actions, related to the physical environment of dietetic services, issued to the facility by the County Department of Health Services (CDHS) on 10/28/24. This failure resulted in the interruption of food services for 57 out of 59 residents who received food from the facility's kitchen when CDHS suspended the facility's Retail Food Permit and required the facility to cease all food production operations effective 3/18/25 at 10:37 a.m. and to remain in effect until the facility can meet CDHS requirements (cross reference with F908). Findings: During a concurrent interview and record review on 3/18/25 at 4:34 p.m., with Administrative Staff B (ADM B), Site Review Inspection Report, dated 10/28/24, was reviewed. ADM B confirmed she received the report which indicated the grease trap (a plumbing device intended to capture fats, oils and grease from wastewater) was in disrepair and the facility's kitchen was not in compliance with the California Retail Food Code (Calcode- outlines structural, equipment, and operational requirements for all retail food facilities in California, ensuring food safety and sanitation, and is enforced by local environmental health agencies and the California Department of Public Health). Administrative Staff B stated an inspector from CDHS had visited the facility on the morning of 3/18/25, when wastewater (includes substances such as food scraps, oils, soaps and chemicals) was overflowing on to the kitchen floor from the grease trap. The ADM B confirmed the CDHS inspector subsequently suspended the facility's retail Food Permit and closed the facility's kitchen, where they prepared resident foods, until repairs could be completed. ADM B stated the facility's previous Administrator had resigned a couple of weeks prior to the 3/18/25 site visit and ADM B was taking over until a new administrator was hired. ADM B stated when taking over for the previous Administrator, there was no communication related to the County Site Review Inspection Report from 10/28/24 and the grease trap had not been repaired. During a phone review on 4/3/25 at 2 p.m., the Dietary Manager (DM) stated herself as well as the previous Administrator and the Maintenance Manager had received the Site Review Inspection Report on 10/28/24 via email. The DM stated the previous Administrator had a monthly QAPI meeting but never brought up the CDHS's County Site Review Inspection Report or kitchen repairs needing to be addressed. The DM stated the previous Administrator just ignored the CDHS report and requests for the various kitchen items to be repaired. During an interview on 4/3/25 at 5:40 p.m., Administrative Staff J stated she reviewed the QAPI program documentation and could not find any documentation indicating administration had ever addressed the CDHS inspection report, which was received on 10/28/24, detailing kitchen repairs that needed to be completed to follow Calcode requirements. A review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, released 1/2018, indicated, Policy: The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. 1.The administrator, whether a member of the QAPI committee or not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 2. The governing body is responsible for ensuring that the QAPI program: a. is implemented and maintained to address identified priorities; b. is sustained through transitions of leadership and staffing . focuses on problems and opportunities that reflect processes, functions and services provided to the residents . help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care . coordinates the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals . Special meetings may be called by the administrator as needed to present issues that need to be addressed before the next regularly scheduled meeting .

Based on observation, interview and record review, the facility failed to ensure an effective pest control program when: 1) Evidence of a rodent infestation was at the offsite commissary (a rentable commercial kitchen) and 2) A fly infestation was present in the designated dietetic service space (formerly the facility breakroom). These failures had the potential to cause foodborne illness (any illness resulting from eating contaminated/spoiled foods) for 57 of 59 residents who received food from the facility ' s kitchen. Findings: 1) During an interview at the facility on 3/28/25 at 3:37 p.m., the Dietary Manager stated all resident food was being prepared in their commissary kitchen due to remodeling of their onsite kitchen. During an interview on 3/28/25 at 4:05 p.m., [NAME] M stated she was working earlier in the day when a County Health Inspector (Inspector C) visited the commissary kitchen. [NAME] M stated Inspector C found bags of stuffing mix that had been chewed and subsequently discarded the bags. [NAME] M stated Inspector C found rat poop behind the stove and a hole in the ceiling. During a tour of the commissary kitchen and concurrent interview on 3/28/25 at 4:13 p.m., [NAME] M indicated the ceiling above a red refrigerator contained a hole. [NAME] M stated Inspector C told her rats could be entering the kitchen through the opening. A photo was taken of the area. During an observation and concurrent interview on 3/28/25 at 4:15 p.m., a plastic grocery bag was located inside a plastic basket next to the red refrigerator. [NAME] M opened the bag and revealed multiple dirty-looking rodent traps; the traps appeared to have been previously used. Photos were taken of the traps. During an observation and concurrent interview on 3/28/25 at 4:16 p.m., [NAME] M pulled the red refrigerator away from the wall. The floor contained the following: sawdust-like material, dirt, and multiple brown/black droppings resembling rodent feces. [NAME] M stated the droppings were rat poop. Photos were taken of the area. During an observation and concurrent interview on 3/28/25 at 4:18 p.m., the area next to the red refrigerator was cluttered with furniture. Droppings that looked like rodent feces were located behind a black armchair. Photos were taken of the material behind the chair. During an observation and concurrent interview on 3/28/25 at 4:25 p.m., [NAME] M pulled the stove away from the wall. The floor contained dirt, food particles, and multiple droppings resembling rat feces. [NAME] M stated the droppings were definitely rat poop. Photos were taken of the area behind/under the stove. During a telephone interview on 3/28/25 at 4:29 p.m., County Health Inspector O (Inspector O) stated he would inspect the commissary kitchen the following morning at 5 a.m., before food preparation began. He stated a pest control company would be onsite that night. Review of Company P's pest report, dated 3/28/2025, indicated, .rodent feces/activity was reported inside the kitchen . set 8 traps inside the kitchen . Review of Inspector O's report titled, Permanent Food Facility Inspection Report (dated 3/29/25) indicated, .Specialist observed the following: Large quantity of rodent dropping (approximately >50) on top of walk-in refrigeration unit along with chewed up insulation and boxes which appeared to be used as nesting material for rodents . Review of Company P's pest report, dated 3/29/2025, indicated, . I began to move some boxes on top of the freezer, and immediately found rat nesting material. Rats had chewed through boxes and pulled insulation from the attic in our nesting on top of the freezer . workers are going to do cleaning of this area. They are going to remove the rest of the boxes and remove the insulation and feces . During a telephone interview on 4/1/2025 at 1:58 p.m., Administrative Staff J stated the facility began using the commissary kitchen on 3/22/25 and they discovered rats in that kitchen on Friday, 3/28/25. When asked if the owner of the offsite kitchen had a pest mitigation program, Administrative Staff J stated she was not sure; she stated she had not discussed that with the owner. 2) During a concurrent observation and interview on 3/21/25 at 10:50 a.m., County Health Inspector C stated there were multiple flies in the temporary dietetic service space (Staff Breakroom). Surveyor entered the temporary dietetic service space and observed several small flies on the ceiling light fixture, ceiling walls, and windowsill. There were multiple chocolate mints on the windowsill and one dead ant. County Health Inspector C directed the housekeeping and kitchen staff to pull everything out of thetemporary dietetic service space, close the door, kill and get rid of the flies, then wash and sanitize everything from top to bottom. The dietary staff was reminded they needed to follow the same infection control protocols in the temporary dietetic service space as they would in the facility kitchen. The door to the temporary dietetic service space needed to be kept closed, the windowsill should not be used to store food, there should be a garbage can with a lid, which there was not, and the tables and counters should be washed and sanitized routinely to prevent flies and other insects. A review of County Health Inspector C ' s Permanent Food Inspection Report, dated 3/21/25, indicated: Several flies were observed throughout the temporary dietetic service space. Staff were instructed to remove all single-use items, food, and equipment, and to alleviate flies in the affected area. Staff were encouraged to maintain entrance door leading into the temporary dietetic service space closed to prevent entrance of flies and other insects. The screen on the window of the temporary dietetic service space was observed to be damaged. During a concurrent observation and interview on 3/24/25 at 3:25 p.m., upon arrival to the commissary kitchen, it was noted the kitchen door was wide open and there was no screen door. Dietary Staff D stated the RD had opened the door because it had gotten extremely warm in the kitchen. Review of County Health Inspector O's report titled, Permanent Food Facility Inspection Report (dated 3/31/25) indicated, . Side door next found to be unlocked and wind kept blowing it open during inspection. Operator was unable to lock it and placed a table in front of it in the meantime to prevent it from staying ajar. Ensure door is able to remain closed to prevent entrance of vermin/flies into the facility . During an interview on 4/3/25 at 2 p.m., when the DM was asked if the commissary kitchen door should be left open, the DM stated the kitchen door should be kept closed to prevent flies and other insects from entering. The DM stated the door to the commissary kitchen and the temporary dietetic service space should be kept closed. The DM stated the dietary staff should not store their personal food in the commissary kitchen and the temporary dietetic service areas in order to prevent the infestation of flies and other insects. Review of facility policy and procedure (P/P) titled, Pest Control, subtitled, Process (dated 1/2018) indicated, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . The facility P/P titled, Sanitation, dated 2023, indicated: . 10. On a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department. If at any time additional servicing is needed, the pest control company will be notified . The facility P/P titled, Miscellaneous Areas, dated 2023, indicated: .Fly and Vermin Control: Flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department. Suggestions for Fly and Vermin Control: 1. All doors and windows must be properly screened. 2. Food must be properly covered and stored. 3 The Food & Nutrition Services Department must be kept free of soil and clutter. 4. Arrangements should be made by the Administrator for pest control service on a routine basis.

Based on interviews and record reviews, the facility failed to ensure an abuse allegation was reported to the appropriate agencies within 2 hours after an allegation was made for one out of two sampled residents (Resident 1). This failure could put the resident's safety at risk and potentially hinder the ability to properly investigate and protect the resident due to a lack of time to intervene effectively. Findings: A review of Resident 1's face sheet (demographics) indicated he was admitted to the facility on [DATE] with a diagnoses of Muscle Weakness and Anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 10/7/24 indicated Resident 1 had intact cognition (memory). Resident 1's MDS also indicated he was dependent on staff with his care except for eating and oral hygiene on which needed substantial assistance from staff. A review of the facility initial report dated 11/14/24 indicated this verbal abuse allegation occurred on 11/12/24. A review of Resident 1's Progress note dated 11/12/24 at 8:00 p.m. indicated Resident 1's brother-in-law approached Licensed Staff D to complain about Unlicensed Staff B working with Resident 1 of using vulgar words. During an interview on 12/4/24 at 11:15 a.m., Unlicensed Staff A stated, using vulgar words on residents or telling resident to f--- off or f--- you was a verbal abuse and should have been reported right away. Unlicensed Staff A stated all abuse allegations had to be reported within 2 hours after learning about the allegation. Unlicensed Staff A stated not reporting abuse allegations timely could put the resident's safety at risk. During an interview on 12/4/24 at 11:32 a.m., Licensed Nurse (LN) B stated using vulgar or swear words or telling a resident to f--- off or f---you were considered a verbal abuse and should be reported to the Ombudsman (assist in the resolution of problems and advocate for the rights of residents of long-term care facilities), the state and local police department (PD) within 2 hours after an allegation was made. LN B stated not reporting abuse allegation within 2 hours put residents' safety at risk. LN B stated not reporting an abuse allegation timely could also result to resident feeling nobody believed their complaint and could be distrustful to staff. LN B stated reporting the abuse allegation timely within 2 hours not only protect the resident involved but the rest of the facility's residents as well. During a concurrent interview and abuse policy and procedure record review on 12/4/24 at 12:15 p.m., the Administrator (ADM) stated when this allegation was reported to the nurse on 11/12/24, this allegation should have been reported to the state, ombudsman, and local PD within 2 hours. The ADM verified the facility did not report the abuse allegation to the state, local PD and the Ombudsman within 2 hours of Resident 1 making the allegation. The ADM stated not reporting abuse allegations within 2 hours after an abuse allegation was made, would be a possible safety risk for the residents. During a concurrent interview and abuse policy and procedure record review on 12/4/24 at 12:45 p.m., the Director of Nursing (DON) verified the facility's policy on abuse was not followed when the abuse allegation was not reported to the state, ombudsman and the local PD within 2 hours after an abuse allegation was made. The DON stated not reporting abuse allegation timely within 2 hours after an allegation was made would likely put the resident's safety at risk. A review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting , updated 2/2024, the P&P indicated, .an alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property will be reported to the proper agencies as guided per regulations

Based on interview and record review, the facility failed to protect the resident when a staff member (Unlicensed Staff C) was allowed to continue working on her shift while the investigation for the abuse allegation was in progress. This failure reduced the facility ' s potential to protect Resident 1 from further abuse while the alleged abuse investigation was in progress. Findings: A review of Resident 1 ' s face sheet (demographics) indicated he was admitted to the facility on [DATE] with a diagnoses of Muscle Weakness and Anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 10/7/24 indicated Resident 1 had intact cognition (memory). Resident 1 ' s MDS also indicated he was dependent on staff with his care except for eating and oral hygiene on which needed substantial assistance from staff. A review of the facility initial report dated 11/14/24 indicated this verbal abuse allegation occurred on 11/12/24. A review of Progress note dated 11/12/24 at 8:00 p.m. indicated the alleged staff (Unlicensed Staff C) working with Resident 1 during the incident was not suspended immediately after an abuse allegation was made against her and was only reassigned to another room. During a concurrent interview and abuse policy and procedure record review on 12/4/24 at 12:15 p.m., the Administrator (ADM) verified the facility did not suspend Unlicensed Staff C immediately after Resident 1 accused her of verbal abuse per facility policy. The ADM stated not putting the alleged staff on suspension immediately after an abuse allegation was made against her might taint the investigation and could influence staff or residents judgement so there could be a risk of not getting an impartial investigation. During a concurrent interview and abuse policy and procedure record review on 12/4/24 at 12:45 p.m., the Director of Nursing (DON) verified the alleged staff (Unlicensed Staff C) was not immediately suspended after Resident 1 made the abuse allegation against her per facility policy. The DON stated not suspending Unlicensed Staff C immediately after an abuse allegation was made against her could put residents safety at risk and could compromise the investigation. A review of the facility ' s policy and procedure (P&P) titled Abuse Investigation and Reporting, updated 2/2024, the P&P indicated, .the administrator will suspend immediately any employee who has been accused of resident abuse pending outcome of the investigation .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests when flies were seen flying throughout the facility. The facility did not adequately address the pest problem, leading to residents being bothered by flies in their room while trying to rest and eat their meal. Flies were seen flying in the kitchen, which could lead to contamination of food being prepared and the spread of disease. Findings: During a concurrent observation and interview on 10/21/24 at 10:08 a.m., a fly was flying around Resident 30's bed. Resident 30 stated he had been having a fly issue and pointed to a plug-in bug trap, which trapped flies, and a sticky fly paper trap hanging on the side of the curtain rod. There were multiple dead flies in the plug-in bug trap and a few dead flies on the sticky fly paper trap. Resident 30 stated the cartridge inside the plugin bug trap had not been changed for several weeks. Resident 30 had a portable fly fan on his overbed table too. Resident 30 stated he normally did not get up because of his right foot ulcer (wound in the skin that can get infected). During an observation on 10/21/24 at 10:28 a.m., Resident 13, was resting in bed and was wearing light washed jeans, when two black colored flies landed on his jeans. During a concurrent interview and observation on 10/21/24 at 11:05 a.m., flies were flying in Resident 108's room. Resident 108 stated he has been having an issue with flies and had asked his girlfriend to bring him a fly swatter. During an interview on 10/21/24 at 1:05 p.m., Resident 8 was sitting on the side of her bed having lunch. Resident 8 stated there has been a fly issue. Resident 8 stated she had her own fly swatter. During an interview on 10/21/24 at 1:17 p.m., Resident 108 stated he had just finished eating spaghetti, but two flies were flying around in his room while he was eating, so he went back to bed to cover himself up to avoid the flies. During an observation on 10/21/24 at 3:29 p.m., in the kitchen a fly was seen on a cart used to deliver food and drinks to the residents. The Certified Dietary Manager (CDM) killed the fly with a fly swatter and asked a Dietary Aide to disinfect the cart. During a kitchen observation on 10/22/24 at 3:30 p.m., two flies were flying around in the kitchen. One fly was flying around the dishwasher and the other fly was on the window in the dry goods pantry. During an interview on 10/22/24 04:10 p.m., the Administrator (ADM) stated there has been a fly problem this summer. The ADM stated the Pest Control Company thought the increase in flies was because of the compost (the natural process of recycling organic matter, such as leaves and food scraps, into a valuable fertilizer) on the outside near the Garden Hall. The surveyor pointed out to the ADM the surveyor assigned to rooms in the Garden Hall had not seen any flies. Mostly in rooms in the [NAME] Hall and in the kitchen. The ADM was asked about the fly issue in Resident 30's room who had a plug-in bug trap and a sticky fly paper trap with many fiels trapped. The ADM stated the Pest Control Company did not spray for flies, only for ants and spiders. During a medication pass observation on 10/23/24 at 8:51 a.m., Resident 19 asked Licensed Nurse D to open the curtain over her window. When Licensed Nurse D pulled back the curtain, a fly was noted to be crawling on the window. When Licensed Nurse D returned to the hall outside Resident 19's door, a fly was buzzing around the hall next to the medication cart. During an observation on 10/23/24 at 8:55 a.m., a fly that was crawling around on the floor in front of room [ROOM NUMBER] flew up and landed on the arm of the surveyor. During an observation on 10/23/24 at 4:04 p.m., a fly was buzzing around the hall outside room [ROOM NUMBER]. During an interview on 10/24/24 at 9:11 a.m., Certified Nursing Assistant (CNA) H started she has worked at the facility for about six months. CNA H stated, Yes there has been a fly issue. During an interview on 10/25/24 at 1:20 p.m., Licensed Nurse (LN) F stated she started working at the facility three weeks ago and there has been a fly issue in the [NAME] hallway, with multiple flies flying around. LN F stated the flies had been swarming all over her medication cart and throughout the hallway. During an interview on 10/25/24 at 1:34 p.m. CNA G confirmed a problem with flies in the facility. A review of a Pest Control Report, dated 10/10/24, indicated the Pest Control Company had recommended for a back door from being propped open to prevent flies from coming into the facility. The pest report indicated the service technician was targeting ants and rodents such as mice and rats. The facility policy/procedure titled, Pests Control, dated 4/2018, indicated: Policy: It is the policy of the facility to maintain an ongoing pest control program to ensure the building premises and its grounds are kept free of insects, rodents, and other pests. Purpose: To ensure that facility is free of insects, rodents and other pest that could compromise the health, safety and comfort of residents, staff and visitors. 38322 46132

Based on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for four of 18 sampled residents (Resident 45, 48, 54, and 108). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being. Findings: 1. A review of Resident 45's Admission Record, indicated Resident 45 was admitted to the facility on [DATE], with a diagnosis including Acute (short-term condition) and Chronic (ongoing condition) Respiratory (breathing) failure with Hypoxia (having to little oxygen), Morbid Obesity (excessive body fat), Chronic Congested Heart Failure (a weakened heart condition that occurs when the heart can't pump enough blood to the body), Atrial Fibrillation (irregular heart beat), Tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing), Stage 2 Pressure Ulcer (an open wound that has broken through the top layer of skin and part of the layer below) of Sacral Region (lower back), muscle weakness, amongst others. A review of Resident 45's Baseline Care Plan v1.1-V1, signed and dated by a Licensed Vocational Nurse (LVN) on 8/10/24, indicated Resident 45 was his own responsible party, initial admission goals was to promote his strength, initial discharge goals was to return to the community, Resident 45 was alert and oriented, needed two person physical assist with personal hygiene, toilet use, dressing and transferring, one person physical assists with bed mobility (positioning while in bed), used oxygen therapy (treatment that provides extra oxygen to people who have breathing problems or lung diseases), occasionally incontinent (lacking control) of bowel, a current medication list was provided to Resident 45 and Resident 45 reconciled the medication list (the process of comparing a patient's current medication orders to all the medications a patient has been taking), amongst other information and goals. Under Section: 5. Baseline Care Plan Summary and Signatures: B.: Signature of Resident and Representative, 1. Resident signature and date, was left blank. There was no indication Resident 45 received a copy of his Baseline Care Plan and a current list of his medications. During an interview on 10/24/24 at 11:44 a.m., Resident 45 stated he did not receive any paperwork. Resident 45 stated he did not sign his Baseline Care Plan and he never received a current list of medications. 2. A review of Resident 48's Admission Record, indicated Resident 48 was admitted to the facility on [DATE], with a diagnosis including Cerebrovascular Disease (stroke), Type Two Diabetes (high blood sugar), Major Depression, Urinary Tract Infection (bacteria infection of the urinary tract), Muscle Weakness, Hemiplegia (partial or complete paralysis of one side of the body), Alcohol Use, Dysphagia (partial loss of the ability to use or understand language), amongst others. A review of Resident 48's Baseline Care Plan v1.1-V1, signed and dated by the MDSC (Minimum Data Set Coordinator) on 6/25/24, indicated Resident 48 was his own responsible party but deferred to his daughter, needed an interpreter to communicate with a doctor or health care staff, family or significant other involved in his care discussion, initial admission goals was for resolution of sepsis (resolve a severe infection) and improvement in overall functioning with therapy treatment to facilitate return to home, discharge goal was to return to the community, left sided weakness because of a stroke, needed one person physical assist for eating, personal hygiene, toilet use, dressing and bathing, transferring and walking, used a wheelchair, alert but cognitively impaired (memory deficit), always incontinent of urine and bowel, had fallen at home within the last month and times one while at the hospital, and a current medication list was provided to Resident 48's representative, and the medication list was reconciled with Resident 48's representative, amongst other information and goals. Under Section: 5. Baseline Care Plan Summary and Signatures: B.: Signature of Resident and Representative, 1. Resident signature and date, was left blank and 2. Representative signature and date, indicated Resident 48 was his own responsible party, daughter very involved, but representative did not sign and date. There was no indication Resident 48 and/or Resident 48's responsible party received a copy of Resident 48's Baseline Care Plan and a current list of his medications. 3. A review of Resident 54's Admission Record, indicated Resident 54 was admitted to the facility on [DATE], with a diagnosis including Fracture of Right and Left Lower Legs, Muscle Weakness, Need for Assistance with Personal Care, amongst others. A review of Resident 54's Baseline Care Plan v1.1-V1, signed and dated by a RN (Registered Nurse) on 10/8/24, indicated Resident 54 was his own responsible party, initial discharge goals was to return to the community, needed one person physical assist with personal hygiene, toilet use, dressing, bathing, bed mobility (moving from one bed position to another) and transferring from the bed to wheelchair, cognitively intact, and Resident 54 was thrown from his motorcycle causing bilateral wrist and ankle fractures and was on non-weight bearing status and was going to have physical therapy (PT: treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), occupational therapy (OT: focuses on things you want and need to do in your daily life), amongst other information and goals. The question under Section 3. Health Conditions: D. Medications: 3. Current medication list provided to resident/representative was not marked Yes or No and D. 4. Indicated: Resident 54's medication list was not reconciled with Resident 54. Under Section: 5. Baseline Care Plan Summary and Signatures: B.: Signature of Resident and Representative, 1. Resident signature and date, Resident 54's name was typed in and no date. There was no indication Resident 54 received a copy of his Baseline Care Plan and a list of his current medications. During a concurrent observation and interview on 10/21/24 at 11:58 a.m., Resident 54 had casts on his right and left wrist and left ankle. Resident 54 stated he had been in a motorcycle accident. Resident 54 stated he did not receive a copy of his Baseline Care Plan and a list of his current medications. 4. A review of Resident 108's Admission Record, indicated Resident 108 was admitted to the facility on [DATE], with a diagnosis including concussion (brain injury), aphasia (loss of ability to understand or express speech) following a stroke, fracture of the pelvis, multiple ribs and fifth lumbar (lower back), colostomy (surgical procedure that bypasses part of the colon and redirects your poop to come out of a new hole in your abdomen, called a stoma), open wound left buttocks, muscle weakness, amongst others. A review of Resident 108's Baseline Care Plan v1.1-V1, signed and dated by a RN (Registered Nurse) on 10/8/24, indicated Resident 108 was his own responsible party, was to receive PT and OT, goal was to return to the community, needed one person physical assist with personal hygiene, toilet use, dressing and bathing, one person assist with bed mobility and transferring from the bed to wheelchair or walker, Resident 108 was cognitively intact, a current medication list was provided to Resident 108 and the medication list was reconciled with Resident 108, amongst other information and goals. Under Section: 5. Baseline Care Plan Summary and Signatures: B.: Signature of Resident and Representative, 1. Resident signature and date, Resident 108's name was typed in and no date. There was no indication Resident 108 received a copy of his Baseline Care Plan and a current list of his medications. During an interview on 10/24/24 at 10:16 a.m., the IDON (Interim Director of Nursing) stated the IDT (Interdisciplinary Team: a group of healthcare professionals who work together to plan and coordinate patient care.), which included the Minimum Data Set Coordinator (MDSC), Social Services, Activities, Dietary, amongst others, should complete their part of the Baseline Care Plan. The MDSC represented the nursing section of the Baseline Care Plan. The IDON stated, Yes, the resident was supposed to get a copy of the Baseline Care Plan and a list of their current medications, which the resident's nurse was supposed to go over with the resident. The IDON stated, Yes, the resident or the representative should sign and date the Baseline Care Plan, and the resident or their representative should receive a copy of the Baseline Care Plan and a current list of the medications. The IDON stated if the resident's name was just typed into the signature box, no one could not tell if the resident was given a copy of their Baseline Care Plan and a list of their current medications. The IDON stated the resident or their representative needed to sign and date the Baseline Care Plan. During an interview on 10/24/24 at 11:31 a.m. the MDSC stated normally social service would make a copy of the resident's Baseline Care Plan and medication list, have the resident sign and date their Baseline Care Pan indicating they received a copy, then the signature page would be uploaded into the resident's electronic medical record. The MDSC stated this has not been happening lately because there was no social service staff. During an interview on 10/24/24 at 12:05 p.m., Resident 108 stated he never received a copy of his Baseline Care Plan or a list of his current medications. The facility Policy/Procedure titled, Baseline (Initial) Plan of Care, dated 12/2016, indicated: Policy: It is the policy of this facility to provide each resident with an interim (initial) plan of care developed within 48 hours of admission that addresses identified risk areas and resident's initial individual needs . Responsible Discipline: The DON and/or its designee shall be responsible for the implementation of this policy .

Based on interviews and record reviews, the facility failed to ensure: 1.the Restorative Nursing Assistant (RNA, a certified nursing assistant (CNA) who has specialized training in therapeutic rehabilitation) process was followed when one out of two sampled residents (Resident 6) did not have a weekly summary completed by the RNA and there were no monthly summary meetings in Resident 6's electronic medical chart 2. the RNA followed the splint (provide a slow force to stretch the contracture- tightening of muscles that causes the joints to shorten, and improve mobility) order for both hand flexion contracture (shortening and hardening of muscles, resulting to deformity) management for one out of two sampled resident (Resident 6). These failures placed Resident 6 at risk for further contracture, pain and development of wound. Findings: A review of Resident 6's face sheet (demographics) indicated Resident 6 was admitted on [DATE] with a diagnoses of Muscle Weakness, Chronic Pain Syndrome (CPS, pain that lasts over 3 months) and Spinal Cord Disease (SCD, nerve damage that cause permanent severe problems, such as paralysis (loss of the ability to move (and sometimes to feel anything) in part or most of the body) or impaired bladder and bowel control). Resident 6's Brief Interview for Mental Status (BIMS, mandatory tool used to screen and identify the cognition, the process of acquiring knowledge and understanding through thought, experience, and the senses of residents) dated 8/29/24 score was 15 out of 15 indicating intact cognition. Resident 6's MDS assessment dated [DATE] functional abilities indicated he was dependent on staff for provision of all care. A review of Resident 6 Physician Order Summary (POS, a table view of a patient's orders that includes information such as the order item, category, frequency, status, and when the order was entered) for 9/1/24 up to 10/31/24 indicated an order for RNA to don/doff splint to both hands for 2 to 4 hours or as tolerated daily for 90 days. During a concurrent observation and interview on 10/23/24 at 3:40 p.m., Resident 6 was noted with both of his hand flexed. Resident 6 stated he had contracture on both his hand and RNA was supposed to put on a splint on both of his hands daily, however RNA only put the splint on his hands for about 30 minutes daily. Resident 6 stated he knows for sure it should be more than that. Resident 6 stated he did not know why the RNA was in a rush to take the splint off. Resident 6 stated he wished the RNA would follow the doctor's order. Resident 6 stated he thought 30 minutes of using the splint on his hands were ineffective. Resident 6 thought felt like his contracture was getting worse and his hands were getting weaker. Resident 6 stated he could tolerate up to 2 hours of splint before but now he was not so sure. He stated maybe he could not anymore because the RNA would only put the splint on for 30 minutes. During a concurrent interview and record review of physician order on splint, dated 9/25/24, on 10/24/24 at 9:23 a.m., the Director of Rehabilitation (DOR) stated an RNA order needs a physician order and must be followed. The DOR clarified the splint order for 2 to 4 hours as tolerated meant if Resident 6 felt discomfort or pain before the prescribed time which is 2 to 4 hours, then the RNA may take off the splint. The DOR reiterated the minimum amount of time a splint should be used for Resident 6 was 2 hours. The DOR stated if Resident 6 was unable to tolerate 2 to 4 hours of splint, this should have been reported to her so an adjustment to the time or the splint would have to be made. The DOR stated that so far, there were no report from the RNA that Resident 6 was not tolerating the splint. The DOR stated Resident 6 receiving 30 to 40 minutes of splint treatment was a concern and should have been reported to her as soon as possible and would need to be addressed right away. The DOR stated in order for a splint to be effective the minimum amount of time it should be worn was 2 hours. The DOR stated not following the order for splinting for Resident 6 put him at risk for further contracture, pain and further decrease of hand mobility. The DOR stated the RNA process involved monthly meetings between RNA, the DOR and the Director of Staff Development and a weekly summary should also be completed by the RNA. The DOR was unable to provide documentation for 9/2024 and 10/2024 monthly RNA meeting for Resident 6. DOR stated monthly meeting was important because it tracked residents' progress or lack of progress, if an adjustment to treatment was needed and to evaluate if current treatment was still appropriate. The DOR stated the RNA process was not followed in Resident 6's case which could put him at risk for decreased quality of life. During an interview on 10/24/24 at 9:37 a.m., the Interim Director of Nursing (IDON) stated RNA order need to have a physicians order and needs to be followed. The IDON stated Resident 6 receiving 30 minutes of splint treatment on his hands did not meet the physicians order for 2 to 4 hours of splint as tolerated. The IDON stated Resident 6 wearing the splint for only 30 minutes was a concern because for the splint to be effective, the minimum amount of time it should be worn was 2 hours. The IDON stated not wearing the splint as prescribed put Resident 6 at risk for further contracture. During a concurrent interview and RNA documentations for 10/2024 record review on 10/24/24 at 9:55 a.m., Restorative Nursing Assistant (RNA) B stated Resident 6 was able to tolerate 2 to 4 hours of splint on both hands when he was released from skilled services and transitioned to RNA program. RNA B stated the splint was important to prevent contracture. RNA B stated that for a month now, Resident 6 was only able to tolerate 40 minutes of wearing splint on his hands. When asked if this was a change in Resident 6 status, she stated yes. When asked if this change was something she would report to the DOR she stated yes. RNA B stated she might have mentioned this to the DOR but it was not her focus. When asked what her focus was, RNA B did not respond. When asked if an RNA order needs a physician order, RNA B stated yes. RNA B also stated the RNA order must be followed. RNA B verified the order for splint was for RNA to don/ doff splint to both hands for 2 to 4 hours or as tolerated daily. When asked if the doctors' order was followed when Resident 6 was only getting 40 minutes of splint treatment, she stated no. RNA B stated splint was important to prevent contracture. RNA B stated the RNA process involved monthly meetings with the RNA, DOR, the DSD and completion of weekly summary. RNA B was not able to provide documentations RNA weekly summaries were completed for Resident 6. RNA B stated if weekly summaries or monthly meetings or summaries were not done, it could be a risk for residents' being in a program that does not work or was inappropriate for them. RNA B stated Resident 6 had been wearing splint for about 30 to 40 minutes as a treatment for his contracture for a month at least. A review of the form titled Restorative Care Process provided by the DOR on 10/24/24 at 9:23 a.m., it indicated the resident is identified for need or restorative range of motion program by physician order .if complication are present, a physician order should be obtained with clarification and approval before beginning the program .the physical or occupational therapist should serve as a consultant when question arise the monthly range of motion documentation is filed in the residents clinical record form. A review of the facility's policy and procedure (P&P) titled Standard for RNA Program, release date of 9/2019, the P&P indicated the RNA will be responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines .the RNA will report any change in a patient's status to the therapist, DON, Dietitian, etc., in a timely manner .Documentation: Daily and weekly documentation will be done on the RNA Flowsheet .if the treatment is refused or withheld, it will be documented, and licensed nurse will be made aware .the RNA will document: the treatment provided, the endurance and tolerance level .document how the resident is progressing towards his/her goal(s) and compare with the last week or month .document how the resident responds to the program in relation to behavior .

Based on observation, interviews and record reviews, the facility failed to provide the necessary behavioral health care and services (a range of treatments and services that address a person's mental and emotional health) for one out of two sampled residents (Resident 27). This failure put Resident 27 at risk for worsening of mental health symptoms, poor physical health, social isolation, and decreased quality of life. Findings: A review of Resident 27's face sheet (demographics) indicated Resident 27 was admitted on [DATE]. Resident 27's Minimum Data Set (MDS, a standardized process for evaluating a resident's health and functional abilities in a nursing home) assessment dated [DATE] indicated an active diagnoses of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily living) and Persistent Mood Disorder (a continuous, long-term form of depression, persistent feeling of low self-esteem, failure and hopelessness). Resident 27's Brief Interview for Mental Status (BIMS, mandatory tool used to screen and identify the cognition-the process of acquiring knowledge and understanding through thought, experience, and the senses of residents) dated 9/8/24 score was 7 out of 15 indicating severely impaired cognition. Resident 27's functional abilities indicated she was dependent on staff for provision of all care. A review of Resident 27's Physician Order Summary (POS, a table view of all a patient's orders, including the category, order item, frequency, status, and when the order was entered) indicated Resident 27 was receiving an Antipsychotic (AP, used to treat psychotic disorder, a mental disorder that causes a person to lose touch with reality) 7.5 milligram (mg, a unit of measure) at bedtime, and 2 Antidepressants (AD, drug used to treat depression) for depression and insomnia (difficulty falling/staying asleep). A review of Resident 27's electronic medication administration record (EMAR, digital version of the paper records used to document a patient's medications) for 8/2024, 9/2024 and 10/2024 indicated her behaviors included self isolation, withdrawal and hallucination. During an observation on 10/21/24 at 10:15 a.m., Resident 27 was up in wheelchair. Resident 27 was crying but denied pain or discomfort. Resident 27 was unable to verbalize why she was crying. During an observation on 10/21/24 at 10:21 a.m., Certified Nursing Assistant (CNA) K stated Resident 27 cried no matter what staff did. CNA K stated Resident 27 cried while she was in bed, when she wanted to transfer into wheelchair, but when Resident 27 was in her wheelchair, she would still cry. CNA K stated sometimes he thought Resident 27 would only stop crying when she got tired from crying. CNA K stated no one really knew why Resident 27 always cried. CNA K stated they try to cater to whatever she requested them to do whenever she cried. CNA K stated sometimes this helped, other times it did not. During a concurrent observation and interview on 10/23/24 at 10:28 a.m., Resident 27 was observed to be crying in bed. Resident 27 denied pain. Resident 27 stated she wanted to get up in bed. Licensed Nurse (LN) D was in the opposite room passing medication. The Infection Preventionist (IP) went inside Resident 27's room and told her someone would assist her shortly. Resident 27 continued to cry. During a concurrent observation and interview on 10/23/24 at 10:35 a.m., Resident 27 continued to cry. LN D stated crying was Resident 27's behavior. LN D stated Resident 27 did this all the time. LN D stated Resident 27 mostly did this in the morning but usually calmed down after lunch. LN D stated Resident 27 was anxious that was why she cried. LN D stated Resident 27 wanted to get up and transfer to her wheelchair but her aide was currently helping another resident. LN D stated they would attend to her shortly. During an interview on 10/24/24 at 3:36 p.m., when asked what were Resident 27's behavior, the Minimum Data Set Coordinator (MDSC) stated Resident 27's behavior included yelling, crying and hallucination. The MDSC stated she knew Resident 27 still cried and yelled a lot but was not sure if Resident 27 still exhibits hallucinations. When asked what could be causing Resident 27's behaviors, MDSC stated she wasn't sure but stated Resident 27 had a lot of issues. MDSC verified Resident 27 was not receiving behavioral health care services and treatment. MDSC stated Resident 27 was receiving an antipsychotic and an antidepressant and was showing behaviors so Resident 27 should be receiving behavioral health care services. MDSC stated Resident 27 had behavioral issues such as crying and yelling and these behaviors were still an ongoing issue. MDSC stated Resident 27 would benefit from receiving behavioral health care services and treatment because Resident 27 had a lot of issues. When asked why Resident 27 was not receiving behavioral health care services and treatment, the MDSC stated, Resident 27 fell through the crack and there was no one that came to the facility to provide the services. During an interview on 10/25/24 at 10:31 a.m., LN I stated Resident 27 did continue to exhibit behaviors of crying and yelling. When asked if he knew how often and what could be causing Resident 27's crying and yelling, LN I stated Resident 27 cried and yelled daily but was not sure what was the root cause of Resident 1's crying and yelling. LN I stated staff tried to address Resident 1's crying and yelling as it arose. LN I stated Resident 1 did not receive behavioral health care and services because it was not available in the facility. When asked why, LN I stated he did not know. LN I stated Resident 27 behavior of crying and yelling out might improve if she was receiving behavioral health care and services. LN I stated Resident 27 should be receiving behavioral health care and services to find out what might be causing Resident 1's behavior as it might help with behavior modification. During an interview on 10/25/24 at 10:40 a.m., the Interim Director of Nursing (IDON) stated Resident 27 needed behavioral health care and services to help determine the root cause of Resident 27's behavior and to possibly address Resident 27's behavior with behavior modification. The IDON stated Resident 27 was qualified to be seen by behavioral health care and services because she was on psychiatric medications and she was exhibiting negative behaviors such as crying and yelling which might cause her distress. The IDON verified Resident 27 did not receive behavioral health care and services at this time. The IDON stated she should be seen by behavioral health care and services to help address her behaviors. The IDON stated not receiving behavioral health care and services placed Resident 27b at risk for emotional distress and unmet needs. During an interview on 10/25/24 at 10:50 a.m., the MDSC stated Resident 27 should receive behavioral health care and services. The MDSC stated not receiving behavioral health care and services could put Resident 27 at risk for behavior to escalate, anxiety and poor quality of life. A review of the facility's policy and procedure (P&P) titled Behavioral Health Services , release date 1/2023, the P&P indicated the purpose of the behavioral health was the prevention and treatment of mental disorders .assisting residents to access counselling (individual or group counselling services) to the fullest degree possible .

Based on observation, interview, and record review the facility failed to: 1. Implement EBP (Enhanced Barrier Precautions: a set of infection control guidelines that use personal protection equipment [PPE: gown and gloves] to reduce the spread of multidrug-resistant organisms [MDROs: a bacteria that has become resistant to an antibiotic [medication that treats a bacterial infection]) for two of 18 sampled residents (Resident 30 and Resident 108) and five unsampled residents (Resident 8, Resident 9, Resident 212, Resident 213, and Resident 214), who had wounds and required dressing changes, and/or indwelling medical devices, such as a foley catheter (a flexible tube that is inserted into the bladder to drain urine or a gastrostomy tube (G-tube: is a tube that is surgically inserted through the abdominal wall and into the stomach to provide a way to deliver nutrition, fluids, and medications directly to the stomach.) and 2. Ensure a service technician wore a hairnet and beard covering when entering the kitchen to service a refrigerator. These failures had the potential for: 1. Residents with wounds or indwelling medical devices were at higher risk of acquiring an MDRO and/or could serve as sources of transmission within the facility. MDROs can cause serious infections that are hard to treat, which can lead to increased morbidity (disease and illness) and mortality (death) for residents and 2. Food becoming contaminated causing foodborne illnesses to spread in the facility. Findings: 1. During an interview on 10/22/24 at 9:05 a.m., Resident 30 stated he had a dressing on his right foot. Resident 30 stated the wound nurse, who came to the facility on ce per week, changed the dressing yesterday. During an interview on 10/24/24 at 10:44 a.m., the IDON (Interim Director of Nursing) stated Resident 30 was admitted to the facility with a right heel PU (pressure ulcer: wound in the skin and tissue caused by prolonged pressure on an area). The IDON stated Resident 30 was being seen by wound doctor. During an interview on 10/24/24 2:30 p.m., the IIP (Interim Infection Preventionist) stated he did not believe the facility had implemented EBP. The IIP stated any resident who had a history of MDRO or had active MDRO, needed wound care, and/or had an indwelling device such as a Foley catheter, IV (intravenous method of administering fluids within a vein), G-tube, amongst other internal devices, should be on EBP. The IIP stated EBP should have been started but because the IP quit, EBP never was implemented at this facility. The IIP stated implementing EBP was important to prevent the spread of infections, control the spread from staff to resident, resident to staff and/or resident to resident. The IIP stated EBP was very individualized. The IIP stated residents on EBP should have signage posted outside their room indicating they were on EBP and a PPE cart with gowns and disposable gloves outside the resident's room. The IIP stated the staff had not been trained on EBP. During an observation on 10/24/24 at 4 p.m. there was no signage for EBP noted on the outside of any resident's room nor PPE carts. During an interview on 10/25/24 at 9:26 a.m., LN (License Nurse) I stated the wound care NP (Nurse Practitioner) came every Monday and LN I rounded with the NP. LN I stated Resident 30 had a diabetic (high blood sugar) PU (pressure ulcer: chronic Wound in the skin and tissue of the foot caused by a number of factors related to diabetes) on his right heel. LN I was asked to give surveyor a list of residents on wound care to see, which residents should have been on EBP. A review of the Preliminary Wound Reports, dated 10/21/24, signed by a Family Nurse Practitioner (FNP), indicated, Resident 8, Resident 9, Resident 30, Resident 108, Resident 212, and Resident 214 were all receiving wound care by an FNP. Note: EBP had not been implemented for Resident 8, Resident 9, Resident 30, Resident 108, Resident 212, and Resident 214. A review of Resident 212's Admission Recorded indicated Resident 212 was admitted to the facility on [DATE], with a diagnosis including a Stage Four PU (Pressure Ulcer which deep, to the bone) located at the Sacral Region (lower back), Retention of Urine (unable to empty bladder), History of Urinary Tract Infections (infection occurs when bacteria enter the urinary tract) among others. A Review of Resident 212's Order Summary Report, dated 10/2024, indicated Resident 212 had an order for an Indwelling Catheter (tube that goes into the bladder) to bedside drainage because of urine retention, start date 9/24/24. Note: EBP had not been implemented for Resident 212, who had an indwelling device. A review of Resident 213's Admission Record indicated Resident 213 was admitted to the facility on [DATE], with a diagnosis including a stroke, dysphagia (difficulty swallowing), among others. A review of Resident 213's Order Summary Report, dated 10/2024, indicated Resident 213 had an order for Enteral Feed, every shift via G-Tube feeding (tube for feeding patient that goes into the stomach) dated 10/14/24. Note: EBP had not been implemented for Resident 213, who had an indwelling device. The facility policy/procedure titled, Enhanced Barrier Precautions, dated 6/2022, indicated: Policy: It is the policy of this facility to ensure that isolation procedure standard is based on the most up-to-date infection control practice. Purpose: The purpose of this policy is to establish and provide guidelines for isolation precautions as well as prevent transmission of infectious agents in the facility. Responsible Discipline: The Director of Nurses (DON) and/or its designee shall be responsible for implementation and enforcement of this policy. This responsibility maybe designated to the Facility's Infection Control Preventionist. Definitions: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Key Points: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care . 2. During an observation on 10/21/24 at 8:45 a.m., there was a black hair in the kitchen handwashing sink. When inspecting the inside of the refrigerator located in the food prep area, there was a blond hair hanging on the refrigerator rack. During an observation on 10/21/24 at 3:29 p.m., there was a piece of orange tape with a black hair located on top of the handwashing sink faucet. During an observation on 10/23/24 at 11:20 a.m., a service technician came into the kitchen to work on the refrigerator located in the food prep area wearing a baseball cap. The technician had a beard, which was not covered. The Certified Dietary Manager (CDM) was asked if the service technician's attire was appropriate. The CDM stated he had a baseball cap on. The CDM was asked if the service technician's baseball cap was covering his hair and if his beard was covered. The CDM told the service technician he needed to put on a hairnet and a beard cover. During an interview on 10/23/24 at 3:41 p.m., the CDM stated when a service technician came into the kitchen, the sevice technician needed to put on a hairnet and a beard cover before entering the kitchen and wash their hands before working on anything in the kitchen. The facility policy/procedure titled, Dressed Code, 2023, indicated: Purpose: Appropriate dress in the Food & Nutrition Services Department. Procedure: Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department . Proper Dress: . 6. Hat for hair, if hair is short, which completely covers the hair. 7. Hair net for hair, if hair is long (over the ears or longer). 8. If applicable, beards and mustaches (any facial hair) must wear beard restraint .

46132 Based on observation interview and record review, the facility failed to: 1. Have a consistent leadership of an Administrator, DON (Director of Nursing), and DSD (Director of Staff Development), which led to the lack of training for the nursing staff for both the Licensed Nurses and the Certified Nursing Assistants (CNAs). These failures had the potential for the nursing staff's inability to provide accurate assessments and safe provisions of care to the residents to ensure residents received high quality of care and effective care was being delivered. 2. To assess and treat Resident 11, who had been complaining of his coccyx/buttocks (lower/backside/behind) region feeling chapped and hurting since 5/30/23, until the surveyor had two CNAs turn Resident 11 on his side, after they finished his care on 6/2/23 at 9:45 a.m. Resident 11 had three open areas, one located on his left coccyx, another on his left lower buttocks region and another open area on his right lower buttocks to thigh region. The surrounding area looked red and irritated. Resident 11's Licensed Nurse was not aware of Resident 11's coccyx/buttocks skin breakdown until the surveyor asked one of the CNAs to get Resident 11's nurse in order to assess Resident 11's coccyx/buttocks region. This failure led to Resident 11 being uncomfortable for three days, because the appropriate treatment was not provided, feeling neglected, and the possibility of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) developing if Resident 11's coccyx/buttocks had not been assessed and treatment had not been started. On 6/5/23 at 10:47 p.m., due to the facility's failure to provide documentation and proof that an Annual Skill Competency check for both the nurses and the certified nursing assistants (CNAs) were being done annually and the lack of consistent Administrator and DSD in the building, Administrator 1 and the Interim DON were officially notified of an Immediate Jeopardy (Immediate Jeopardy is a situation in which provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident [State Operations Manual, Appendix Q]). During a concurrent interview and Administrator Job Description record review on 6/6/23 at 10:23 a.m., Administrator 1 clarified the Administrator's job description. The Administrator stated the Administrator was expected to be in the facility, in person, 75 percent (%, fractions that are counted out of 100) of the time and 25% outside the facility, conducting marketing (any actions a company takes to attract an audience to the company's product or services). When asked if the Administrator was expected to be in the facility, the administrator stated, Yes. On 6/8/23, at 2:30 p.m., the facility's Immediate Jeopardy Removal Plan was received and included, but was not limited to: 1) The Director of Nursing and/or designee auditing the annual competency evaluations for Licensed Nurses and Certified Nursing Assistants over the past year and ensuring all active Licensed Nurses and CNA's competency evaluations were completed by 6/9/23. 2) The Director of Nursing and/or designee in-servicing Licensed Nurses and CNAs on the facility's policy for, wound care, with an emphasis on wound assessments, prevention, treatment, and reporting of pressure ulcers (PU's, an injury that breaks down the skin and underlying tissue, when an area of skin is placed under pressure). Also, with a focus on providing accurate assessments including skin assessments and safe provisions of care to the residents, which would be completed by 6/7/23. 3) The Interim DON or the designee will conduct a weekly audit of newly-hired nursing staff to ensure completion of initial competency evaluations. 4) On a monthly basis the Director of Nursing and/or designee will audit nursing staff to ensure the completion of annual competency evaluations. The Director of Nursing will report the audit findings to the Administrator in the morning stand-up meeting, weekly. 5) Monthly, the Director of Nursing and/or designee will report their audit findings to the QAPI committee for further review and follow-up. The QAPI committee will reassess the need for further monitoring quarterly. 6) A new Director of Staff Development (DSD) was on-boarded on 6/6/23, and a newly-hired local (existing in or belonging to the area where the facility was located) Administrator was scheduled to report for duty in the building on 6/21/23. 7) During the absence of a Director of Nursing, the facility will designate Licensed Staff N, a qualified Registered Nurse, as the interim Director of Nursing in the absence of the DON. On 6/9/23 at 9:28 a.m., the removal of Immediate Jeopardy occurred in the presence of the Interim DON, the Administrator and another Administrative Staff after interviews and observations confirmed the facility implemented the corrective plan of actions. Findings: 1. During an interview on 5/30/23 at 9:50 a.m., the supplies manager verified the DON, Administrator, Infection Preventionist (IP) Nurse, the Minimum Data Set (MDS) Coordinator and the Director of Staff Development (DSD) were not in the building. During an interview on 5/30/23 at 12:07 p.m., the Medical Records Director (MRD) stated the corporate (relating to large companies) Administrator, and the corporate DON were not yet in the building. The MRD stated the Administrator did not come in the facility in person but was available via phone if needed. When asked how long it had been since the facility had an Administrator who came in the facility, the MRD stated she was not sure of the date, but it would have been since early May. The Administrator arrived in the building on 5/30/23 at 1:12 p.m. During an interview on 6/01/23 at 1:35 p.m., Licensed Staff B who was a long time employee stated he could not recall when the last time was he had an annual competency check done by the DSD. During an interview on 6/01/23 at 1:40 p.m., Unlicensed Staff H, Unlicensed Staff F and Unlicensed Staff P stated they could not recall whether they had received the annual competency skill check this year or last year. Unlicensed Staff H, Unlicensed Staff F and Unlicensed Staff P stated they could not recall the last time they were evaluated by the DSD. During an interview on 6/1/23 at 5:47 p.m., the Interim DON stated the annual competency test for both Licensed Nurses and CNAs should have been done yearly, per facility policy. The Interim DON stated the last annual competency skill done for the Licensed Nurses and the CNAs was in 2021. The Interim DON stated there had been so many management and DON changes over the year and lack of communication between the outgoing and incoming DON. The Interim DON felt this was the reason the annual competency skill check fell through the cracks. The Interim DON stated the reason why an annual competency skill check was completed, was to ensure staff were caring for the resident's safely, to learn new things and keep up with nursing changes and updates. The Interim DON stated the annual competency skill checks were conducted to ensure staff were able to care for the residents safely. During an interview on 6/02/23 at 9:21 a.m., Licensed Staff J stated it was important to ensure staff had annual competency skills checks. Licensed Staff J stated the competency skills check was important for residents' safety. Licensed Staff J stated, not having the annual competency skill check done for CNA's and nurses could negatively impact the way staff took care of the residents. Licensed Staff J stated there could also be missed opportunity for staff to learn how to perform tasks safely and appropriately. During an interview on 6/2/23 at 9:49 a.m., Unlicensed Staff O stated she was not sure the last time she received an annual competency skill check. Unlicensed Staff O stated it was very important to receive annual skill competency training. Unlicensed Staff O stated the annual competency skill check was important as this would provide feedback that would ensure staff were providing safe care to the residents. Licensed Staff O stated, ensuring the annual competency skill check was done annually, consistently and as needed, would benefit the staff and the residents by ensuring staff was providing care to their residents safely. During an interview on 6/2/23 at 11:37 a.m., the Administrator stated the Co-Administrator was the acting Administrator in charge of the facility's overall compliance, the general operation of the facility and the department and dealt with any issues as they arose. The Administrator stated it would be beneficial if the facility had an Administrator who could oversee the facility's general operation to ensure the systems in place were working or updated if need be. The Administrator stated he expected the nursing staff to have annual competency skills check to ensure staff were providing safe care to the residents. The Administrator stated the lack of annual skills competency check for staff could cause harm to the residents. The Administrator stated it would benefit the residents to ensure staff had a competency skills check completed annually, and stated there was an issue with oversight of the facility operation and maintenance system. The Administrator stated there was a fault somewhere in the management in the facility, and stated it was the responsibility of the Administrator to ensure the facility's system was working. During a concurrent interview and annual competency skills check for both licensed nurses and CNAs record review on 6/2/23 at 12:08 p.m., the Interim DON stated she was the Interim DON at the facility from 4/1/23,until the facility finds a new DON. The Interim DON stated the previous DON vacated the position on 3/31/23, and another DON started the following week. The Interim DON stated this DON was trained and worked for the facility for one week but resigned the following week. The Interim DON stated the DSD was in charge of ensuring annual skill competency checks were done for both the nurses and the CNAs. The Interim DON verified the facility currently had no DSD in place. The Interim DON stated she currently oversaw the DSD program. The Interim DON stated Licensed Staff B was hired as a DSD before the previous Administrator left but had not started the training yet. The Interim DON was not sure of the exact date on when the Previous Administrator left the company, but stated it could be early 5/2023. The Interim DON confirmed nurses and CNAs lacked the annual competency skills check. The Interim DON stated she was cognizant there was a need to look at some of the facility's systems, like the annual competency skills check not being done for staff. The Interim DON stated the last time an annual competency skills check done for the nurses and CNAs was on 2021. The Interim DON stated the facility had no consistent DSD to train staff. The Interim DON stated she was not sure when last time the nurses were checked for competency in wound identification and assessment. During a concurrent interview and record review of the last 15 months of DON and DSD hired and term dates form, on 06/05/23 at 10:53 a.m., the Interim DON verified the facility had multiple turn over as far as the DON was concerned. The Interim DON verified the DON's hired between 2022 and 2023, only lasted between two to four months. The Interim DON stated the last DON, prior to her assuming the Interim DON position, lasted for about a week. When asked the reason for the high turnover, she stated, I don't know. During an interview on 6/6/23 at 4:30 p.m., Licensed Staff C stated the residents were not receiving the quality care they needed. Licensed Staff C stated she could not recall when the last time was she had an annual skill competency check. Licensed Staff C stated the lack of management to give directions and assist the staff on patient care issues was too much to bear. Licensed Staff C stated, due to lack of management oversight, she often wondered what could happen to her nursing license. Licensed Staff C stated it would be great for the residents if staff received annual competency skill checks from the DSD, but the facility did not have one [DSD] for a very long time. Licensed Staff C stated the facility had no consistent managers to guide the staff at all. During a review of the Facility Assessment, dated 3/29/23, under the responsibility tab, it indicated the Administrator would attend the daily morning meetings and conducted daily rounds in the facility. Under the responsibility tab of the Facility Assessment, it also stated the Administrator's goal was to ensure each Department Managers were performing essential duties to correctly operate their department and to ensure compliance with facility protocols and regulations. During a review of the Facility Assessment, dated 3/29/23,under the responsibility tab, it indicated the DON oversaw the overall management of the nursing department, including nursing personnel performances education, training and monitoring. During a review of the Facility Assessment, dated 3/29/23, under the responsibility tab, it indicated the DSD ensured there was staff education and training to ensure protocols and regulations were being followed. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 1/2018, the P&P indicated the job performance of each employee should be reviewed and evaluated at least annually. 2. A review of Resident 11's, Admission Record, indicated Resident 11 was admitted on [DATE], with diagnoses including disease of the spinal cord, Type Two Diabetes (a disease that occurs when one's blood sugar was too high), chronic pain syndrome, major depression, severe obesity, anxiety, amongst others. A review of Resident 11's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 3/6/23, indicated Resident 11 had a BIM (Brief Interview of Mental Status) score of 15, meaning cognitively intact, and he needed two-person physical assist with bed mobility (how a person moves to and from lying position, turns side-to-side and positions body while in bed). During an observation and interview on 5/30/23 at 4:45 p.m., 5 p.m. and 5:11 p.m., Resident 11 was positioned on his back. Resident 11 had an egg-crate mattress topper (has bumps, dips, and curves designed to contour the body, provide support and alleviate any pressure on muscles and joints, and helps prevent pressure sores) and an oversize bed. Resident 11 stated he had been positioned on his back all day. Resident said, Call light not answered. I will have to call out and staff ignore me. The staff sees my light and ignore it. CNAs only come in when they have to come in to talk to me. A review of Resident 11's care plan, initiated 10/24/22, indicated Resident 11 had a history of MASD (Moisture-Associated Skin Damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, and/or sweat). Resident 11's care plan for, High Risk for Skin Integrity Impairment, related to disease process, incontinent of bladder and bowel, included interventions/tasks such as cleanse and apply barrier cream after incontinent episodes, keep clean and dry, and turn and reposition every two hours and as needed and chooses to use a brief. Additional interventions included avoid friction when repositioning resident in bed or wheelchair, monitor skin daily with ADL (Activities of Daily Living: The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), and reeducate/encourage resident regarding repositioning as needed. A review of Resident 11's Nursing-Weekly Summary Notes -V3, dated 4/15/23, indicated Resident 11's skin was clean and intact and there was no new skin breakdown noted. This was the last, Nursing-Weekly Skin Assessment - V3, found in Resident 11's electronic medical record. A review of Resident 11's MAR (Medication Administration Record), dated 5/2023, indicated Resident 11 had an order to be repositioned every two hours, start date, 7/7/21, and based on nursing signatures, Resident 11 was being repositioned every two hours. During a concurrent observation and interview on 6/2/23 at 9:45 a.m., after Unlicensed Staff F and Unlicensed Staff Q completed cleaning Resident 11's backside and performing peri care (cleaning private area), the surveyor asked Unlicensed Staff F and Unlicensed Staff Q to ask Resident 11 if it would be okay to see his backside, which Resident 11 agreed to. Resident 11 turned well with assistance from Unlicensed Staff F and Unlicensed Staff Q. Three open areas were noted: Left coccyx region and lower buttocks and right lower buttocks to thigh region. The area looked red and raw. Unlicensed Staff F stated Resident 11's buttocks did not look like that last week when she cared for him. Resident 11 stated his coccyx/buttocks area was burning. Unlicensed Staff Q applied a cream to the areas, which looked clean. Resident 11 wore a brief and was positioned on his back most of the time per multiple observations in the past three days (5/30-6/1/23). Resident 11 stated the nurses had not been treating his coccyx/buttocks region. Licensed Staff B came into assess Resident 11's skin breakdown, looked at Resident 11's coccyx and buttocks region and stated he was not aware of the new skin breakdown. Licensed Staff B started measuring the areas and was going to notify Resident 11's physician. Licensed Staff B stated each scheduled nurse per shift did their own wound care for their assigned residents based on the physician's orders. Licensed Staff B stated the facility did not have a scheduled wound nurse. During a concurrent observation and interview on 6/2/23 at 10:10 a.m., Resident 11 was being turned by a CNA. Resident 11 stated 50% of the nurses and CNAs were qualified to care for him. Resident 11 stated he was changed no more than twice per shift. Resident 11 stated the staff did not want to work with him. During a concurrent observation and interview on 6/2/23 at 4:28 p.m., Resident 11 was positioned on his back. Resident 11 stated being positioned on his back was the most comfortable position. During a concurrent observation and interview on 6/5/23 at 11:45 a.m., with the approval of Resident 11 and with the assistance of CNAs, the surveyor looked at Resident 11's coccyx/buttocks with another surveyor. Resident 11 stated the coccyx/buttocks region hurt. The area had been covered up with cream. The area looked purple/maroon in color, breakdown was still present, which looked like Suspected Deep Tissue Injury (STDI: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Resident 11's egg-crate mattress had been replaced with a low air loss mattress (air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture). A review of Resident 11's electronic medical record on 6/5/23 at 11:22 a.m., there was no SBAR (Situation, Background, Assessment, Recommendation: Is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations) and no, Nurses Progress Notes, addressing Resident 11's new skin breakdown. There was a new order to apply barrier cream (prevent excess moisture) every shift and if needed during incontinent care, starting 6/2/23 at 11 p.m. During a concurrent observation and interview on 6/5/23 at 1:25 p.m., Physician 2 assessed Resident 11's coccyx/buttocks region. Physician 2 stated she felt the skin breakdown was MSAD caused from Resident 11 wearing a brief. Physician 2 stated the open area at the right lower buttocks to the thigh region was caused from shearing of Resident 11's brief. The Interim DON and Unlicensed Staff Q were present too. During an interview on 6/5/23 at 1:42 p.m., Physician 2 was shown pictures of Resident 11's backside region (coccyx and buttocks) taken by surveyor, dated 6/5/23 at 11:37 a.m. Physician 2 stated what she saw on the pictures was not what she assessed today. Physician 2 stated the breakdown looked like STDI. During a concurrent observation and interview on 6/5/23 at 2:03 p.m., Physician 2 assessed Resident 11's coccyx/buttocks region for the second time. Physician 2 stated the areas were blanchable, so to her the skin breakdown was MSAD, caused from wearing a brief. The right buttocks to thigh breakdown was because of the brief causing shearing. Physician 2 stated the discoloration located at the lower backside was permanent discoloration she saw a lot from a resident being on their backside. During an interview on 6/5/23 at 3:56 p.m., Resident 11 stated he received his low air loss mattress yesterday, 6/4/23. Resident 11 said, You are making a difference in the quality of my care. Thank You. During a concurrent interview and electronic record review on 6/6/23 at 9 a.m., Resident 11's SBAR, dated 6/2/23, for Resident 11's new skin breakdown (excoriation and redness, MSAD to right buttocks and left upper gluteal fold) first assessed/found on 6/2/23, by the surveyor, had not been signed by Licensed Staff B until 6/5/23 (verifying when the SBAR was completed). The Interim DON stated Resident 11 did not have any, New Progress Note, addressing the new skin breakdown, the SBAR was the new note. A review of Resident 11's, Physician Note, dated 6/6/23 at 2 p.m., and signed by Physician 1 on 6/5/22 at 11:10 p.m., indicated Resident 11's skin breakdown was conferred as MASD and Physician 2 had likewise evaluated as MASD. A review of Physician 2's, Surgical Consult, dated 6/6/23, indicated Physician 2 evaluated Resident 11's coccyx/buttocks area on 6/5/23 (Note: first found/assessed on 6/2/23 at 9:45 a.m. by surveyor). Physician 2 indicated: Location: Right Buttocks: MASD. Lesion Condition: erosion (breakdown of the outer layers of the skin). Lesion Description: Small area of epithelial (outer layer of skin) breakdown. Recommend application of triad cream (Infection Protection Ointment for bed sores, pressure sores, diabetic wounds, ulcers, cuts, scrapes, and burns) daily and as needed. Location: Left Infragluteal Fold (the crease right under the butt): Shear injury related to rubbing from brief. Dressing Used: Skin prep and foam dressing. Tissue Type: 30% Granulation (pink in color and is an indicator of healing) and 70% Epithelial. Length: 0.5 centimeters (cm: 0.4 inches) and Width: 0.5 cm. Patient has a wound at the left infragluteal fold. The patient is also at risk for developing a pressure ulcer given the following factors: Diabetes, Depression, and Limited Mobility. During a concurrent interview and record review, on 6/6/23 at 4:50 p.m., the Interim DON was asked if Resident 11's, Nursing-Weekly Summary Notes - V3, dated 4/15/23, which included a skin assessment, was the last one complete for Resident 11. The Interim DON stated there should be a, Nursing-Weekly Summary Report, for Resident 11, which included an assessment of his skin, done every week. The Interim DON looked in Resident 11's electronic medical record and the last, Nursing-Weekly Summary Notes - V3 the Interim DON could find was dated, 4/15/23. The Interim DON stated she did not know why Resident 11's, Nursing-Weekly Summary Notes - V3, has not been completed weekly, since there was enough staff. The Interim DON was asked how often a resident had a skin assessment. Resident 11's last assessment titled, Skin Evaluation, was dated 2/7/23. The Interim DON stated part of the resident's, Nursing-Weekly Summary Notes. included an assessment of the resident's skin, which was supposed to be completed weekly. On 6/5/23, there was 47 residents residing in the facility. Based on part of the facility IJ removal plan, all residents had a skin assessment completed on 6/5/23. Four other residents were identified with skin issues, Unsampled Resident 28 and Resident 208 and Sampled Resident 19 and Resident 47. A review of residents, Progress Notes, dated 6/5/23, indicated the following new skin findings: *Resident 28 had redness to left groin. *Resident 208 had redness to buttocks. *Resident 19 had a blister to his left heel measuring 2.5 x 2.5. Treatment ordered. Redness to buttocks. *Resident 47 had an open area 1 x 2. Treatment ordered. A review of Resident 47's, Admission Record, indicated Resident 47 was admitted on [DATE], with diagnoses including Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, lack of coordination, need for assistance with personal care, failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), cognitive communication deficit, amongst others. A review of Resident 47's, Hospice Election Statement, indicated Resident 47 was started on Hospice, 3/8/23. A review of Resident 47's, Significant Change of Condition MDS, dated [DATE], indicated Resident 47 had a BIMs of 3 (severely cognitively impaired) and needed one-person physical assist with bed mobility. A review of Resident 47's, Nursing-Weekly Summary Notes - V3, dated 5/21/23 and 5/28/23, indicated Resident 47's skin was clean and intact. Resident 47's Nursing-Weekly Summary Notes - V3, dated 5/21/23, indicated Resident 47 had a special mattress, but he did not. Resident 47's care plan: Open Area to Coccyx, initiated on 6/6/23, indicated Hospice to provide Resident 47 a low air loss mattress on 6/6/23, which occurred on 6/6/23. A review of Resident 47's, Risk for Skin Integrity Impairment, care plan, initiated 2/15/23, indicated: Give peri care frequently, monitor skin daily with ADLs, reposition every 2 hours and as needed, and weekly skin sheets for any pressure ulcers. A record review of Resident 47's weight indicated on 1/26/23, he weighed 121 pounds and on 5/4/23, Resident 47 weighed 98 pounds. Resident 47 lost 23 pounds in a little over three months (3 months/9 days). During multiple observations on 5/30/23, Resident 47 was on his backside without a low air loss mattress. On 5/30/23 at 11:21 a.m., and 5/30/23 at 4:03 p.m., Resident 47 was on his back. There was no observation of Resident 47 being turned since 11:21 a.m. On 5/30/23 at 5:21 p.m., Resident 47 was still upright in bed after dinner, positioned on his buttocks and slightly turned to his right. During an observation on 5/31/23 at 8:50 a.m., Resident 47 was on his back and turned slightly to his right side. Pillows were under his lower extremities (legs) to relieve pressure, but he was still positioned on his buttocks. During a concurrent observation and interview on 5/31/23 at 6:01 p.m., Resident 47, who was in bed, stated he would like to get up but had not been up all day. During an observation on 6/01/23 at 9:24 a.m., Resident 47 was upright in bed, in a hospital gown and positioned on his back. A review of Resident 47's SBAR, dated 6/5/23, indicated Resident 47 had a new facility-acquired (pressure injury that developed after admission to the facility) open area on his coccyx measuring 1 x 2 cm. A review of a, Hospice order, dated 6/7/23, indicated Resident 47's new facility-acquired wound was a Stage 2 pressure ulcer (PU: when the sore digs deeper below the surface of your skin). The Hospice nurse was to perform wound care one time per week and as needed, using wound cleanser and cover with a bordered foam dressing. The facility staff was to perform wound care two times per week and as needed. A review of Resident 19's, Admission Record, indicated Resident 19 was admitted on [DATE], with diagnoses including cellulitis of the right lower leg (serious bacterial skin infection), chronic total occlusion of the artery of the extremities (blockage of blood flow to the heart), stroke, muscle weakness, diabetes, amongst others. A review of Resident 19's Quarter MDS, dated [DATE], indicated Resident 19 had a BIMs of 5 (severely cognitive impaired), and he needed one-person bed mobility. A review of Resident 19's, Impaired Skin Integrity, care plan indicated Resident 19's admission assessment, dated 8/23/22, showed Resident 19 was admitted with cellulitis of the right lower limb and his left foot had a black blister on the planter area (sole of the foot), but care plan was not initiated until 9/29/22. Interventions included: The resident requires supplement protein, amino acids (building blocks for proteins), vitamins (a nutrient that the body needs in small amounts to function and stay healthy) and minerals (a nutrient that is needed in small amounts to keep the body healthy), as ordered, to promote wound healing, treat pain, as ordered, prior to treatment/turning to ensure resident's comfort, amongst others. A review of Resident 19's weight indicated on 3/6/23, Resident 19 weighed 144 pounds and on 6/8/23, Resident 19 weighted 134 pounds. Resident 19 had lost 10 pounds in three months. A review of Resident 19's, ADL care plan, initiated 9/29/22, included Bed Mobility interventions: The resident is totally dependent on one staff for repositioning and turning in bed ever two hours and as necessary, and Transfer: The resident is totally dependent on one staff for transferring. A review of Resident 19's, Nursing-Weekly Summary Notes - V3, dated 4/26/23 and 5/3/23, indicated Resident 19's skin was clean and intact. No skin issues were identified. The skin assessment indicated Resident 19 had a special mattress, but he did not. A review of Resident 19's, Nurse's Progress Note, dated 6/8/23, and physician's order dated 6/8/23 at 10:30 a.m., indicated Resident 19's physician ordered for Resident 19 to have a low air loss mattress on 6/8/23, which was carried out on 6/8/23, related to limited mobility. Resident 19's, Nursing-Weekly Summary Notes - V3, dated 5/10/23, 5/18/23, and 5/24/23, indicated Resident 19's skin was clean and intact. No skin issues identified. The, Nursing-Weekly Summary Notes - V3, dated 5/31/23, indicated Resident 19's skin was clean and intact. There was no mention of a blister on Resident 19's left heel. Resident 19's, SBAR, dated 5/30/23, indicated Resident 19 had a blister on his left heel measuring 2.5 x 2.5. A review of Resident 19's, Impaired Circulation, care plan, initiate 9/22/22, interventions included elevating legs when resting. During an observation on 5/30/23 at 11:48 a.m., Resident 19 was positioned on his back sound asleep. No special mattress was on his bed and there were no pillows positioned under his lower extremities, so his heels were floating (suspended in air) to relieve pressure on his heels. During a concurrent observation and interview on 5/31/23 at 5:53 p.m., Unlicensed Staff R stated staff tried getting Resident 19 up, but often after ten minutes he wanted back in bed. Resident 19 was positioned on his back, and his bed was lowered to 25 degrees after dinner. During an observation on 6/5/23 at 4:34 p.m., Resident 19's head was elevated 30 degrees, positioned to the right side, a pillow was under Resident 19's knees, and he had boots on. A review of Resident 19's SBAR, dated 6/6/23, indicated Resident 19's buttocks was red. A review of Physician 2's, Surgical Consult, dated 6/6/23, indicated Physician 2 evaluated Resident 19's left heel on 6/5/23. Physician 2 indicated there was a blister on Resident 19's left heel measuring: Length 2 cm and width 3.5 cm. Physician 2 indicated Resident 19 was at risk for developing a PU because he was diabetic. Resident 19's prognosis was [TRUNCATED]

Based on observation, interviews, facility and acute care record reviews, the facility failed to ensure the proper use of assistive devices and follow resident care plans, when two residents (Resident 1 and Resident 2) of four sampled residents, between them, fell three times in one day. Resident 1's second fall resulted in a [MEDICAL CONDITION]. Resident 2's fall, which occurred from a lift, resulted in lacerations, abrasions and a skin tear. These failures resulted in: a. Resident 1's severe pain, requiring hospitalization and surgery for [REDACTED]. Resident 2 having pain and requiring treatment for [REDACTED]. Findings: On 3/18/19, the Department received a complaint alleging two residents had falls. One fall resulted in a [MEDICAL CONDITION], and another happened when staff transferred a resident using a lift with only one staff assistance, against the resident's care plan and standard of practice for lift use. During an interview on 3/29/19 at 10:48 a.m., Management Staff A, stated the facility was aware of the falls and was working on addressing the issues by educating staff on alarm use and proper lift use. Management Staff A was asked for documentation listing facility falls. Management Staff A provided a document, untitled and undated, which revealed Resident 1 fell on [DATE] at 04:49 (4:49 a.m.) and on 2/24/19 at 17:25 (5:25 p.m.). The document revealed Resident 2 fell on [DATE] at 11:21 (11:21 a.m.). a. Resident 1: A document titled, Admission Record, dated 3/29/19, revealed Resident 1 was admitted to the facility 4/27/05. Resident 1 was [AGE] years-old. Resident 1's [DIAGNOSES REDACTED]. During an interview on 3/29/19 at 11:35 a.m. Licensed Staff B stated Resident 1 had sustained two falls in one day, with the second fall resulting in a [MEDICAL CONDITION] which required Resident 1 to be hospitalized . During an observation and concurrent interview on 3/29/19 at 1:30 p.m., Resident 1 was sitting in her wheelchair in the hallway. Resident 1 did not respond to questions about her injury. First fall: A review of a document titled, Progress Notes, dated 2/24/19 0330 (3:30 a.m.), written by a licensed nurse, revealed, Nurse found resident on floor between roommate FWW (front wheel walker). Resident was unable to communicate well but said she did not hit her head . A review of a document titled, IDT (Interdisciplinary Team)-Post Event Note, dated 2/24/19 03:34 (3:34 a.m.), revealed, Interventions sensor alarm on at all times.' A review of a document titled, SBAR (Situation, Background, Assessment, Recommendation) -Actual/Suspected Fall, dated 2/24/19 0335 (3:35 a.m.), revealed Resident 1 had a fall at 3:30 a.m. The document listed, Additional Circumstances .5. Alarm sounding. The option was not checked. Second Fall: A review of a document titled, Progress Notes, dated 2/24/19 17:50 (5:50 p.m.), written by a licensed nurse, revealed, Approximately at 5 p.m. resident fell in activity room slid from her wheelchair to floor prior falling on her bottom resident also hit right side of her head (sic). Resident verbalizes severe pain to her Right side hip, no head trauma noted. Resident obtained skin tear (2x2 cm) . A review of a document titled, SBAR-Actual/Suspected Fall, dated 2/24/19 17:25 (5:25 p.m.), revealed a witnessed fall. The document revealed Resident 1 had a pain level of 7 (scale of 0-10; 0 no pain, 10 worst pain ever). The document listed, Additional Circumstances 5. Alarm sounding. The option was not checked. A review of a document titled, IDT Post Event note, dated 2/24/19 18:00 (6 p.m.), revealed, Resident slid from wheelchair to floor hit her head before landing on the floor on her bottom .skin tear obtained .Resident sent to ED for further eval. Alarm was not sounding. During an interview on 5/13/19 at 2:02 p.m., Unlicensed Staff H stated she had been present when Resident 1 fell in the activity room on 2/24/19. Unlicensed Staff H stated Resident 1 had been asleep and then, slid from the wheelchair. Unlicensed Staff H stated there had been no alarms sounding to alert staff Resident 1 was sliding in her wheelchair. A review of a facility document titled, Fall Risk Assessment, dated 6/29/18, revealed Resident 1 had a score of 26. The document revealed, A resident who scores a 10 or higher is at risk for falls . A review of a facility document, untitled, provided by the facility as Resident 1's plan of care, revealed, Self care deficit with History of recurrent falls with hematoma and concussion . The date initiated was 5/14/14, and revision date was 7/3/18. Interventions/Tasks, revealed Alarm in chair . The document revealed, the resident is at risk for falls r/t (related to) Gait/balance problems, incontinence, Psychoactive drug use, Unaware of safety needs. Interventions/Tasks, revealed, Alarm in Wheelchair Clip Alarm when up in wheelchair. A review of a facility document titled, Investigation fall--resident # ., undated, provided by Management Staff A on 3/29/19 at 11:11 a.m., revealed, root cause identified of failure to turn on fall prevention device on w/c (wheelchair)(sic). A review of an acute care document titled, History and Physical, dated 2/24/19 2032 (8:32 p.m.), revealed, .this is a patient who had a ground-level fall resulting in the right intertrochanteric fracture and now requires surgical treatment. The document revealed, This is the second admission to this facility in 3 years for this [AGE] year-old female who was admitted from a (type and name of facility) because of a . ground-level fall resulting in a right intertrochanteric fracture.patient has had a history of [REDACTED]. A review of a facility document titled, Safety and Supervision of Residents, dated revised (MONTH) (YEAR), revealed, Policy Statement . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. b. Resident 2: A review of a document titled, Admission Record, dated 3/29/19, revealed Resident 2 was admitted to the facility 1/12/15. Resident 2 was [AGE] years-old. Resident 2's [DIAGNOSES REDACTED]. During an interview on 3/29/19 at 11:35 a.m., Licensed Staff B stated the facility had seen a high number of falls. Licensed Staff B stated Resident 2 had fallen because she had been, dropped from a lift when, only one CNA had transferred her. Licensed Staff B stated lift transfers, always required two staff members. Resident 2 had sustained a skin tear and other injuries. During an observation and concurrent interview on 3/29/19 at 12:45 p.m., Resident 2 was in her bed. Resident 2 stated she did not recall the fall. During an interview on 3/29/19 at 1 p.m., Unlicensed Staff C stated every resident transfer with a Hoyer lift required at least two staff members to assist. During an interview on 5/9/19 at 10:20 a.m., Licensed Staff D stated there should always be at least two staff members present during a lift transfer. During an interview on 5/9/19 at 12:35 p.m., Unlicensed Staff [NAME] stated Resident 2 needed to be transferred using a Hoyer lift, because Resident 2 was non-weight bearing. Unlicensed Staff 2 stated, when using the Hoyer lift, at least two to three staff members needed to be present to assist. During an interview on 5/9/19 at 1:25 p.m., Management Staff A stated only one CNA had been present when Resident 2 had fallen. Management Staff A stated staff had been re-educated regarding lift use. During an interview on 5/9/19 at 1:55 p.m., Licensed Staff D stated she was aware of the fall that happened with Resident 2. Licensed Staff D stated, using at least two staff members for Hoyer lift transfers was the, industry standard. During an interview on 5/9/19 at 1:40 p.m., Management Staff F, Director of Rehabilitation, stated a Hoyer lift transfer, always required two people to assist. Management Staff F stated staff were to wait for a second person to assist and then start the transfer. During an interview on 5/9/19 at 4 p.m., Unlicensed Staff G stated he had attempted to transfer Resident 2 on 3/8/19. Unlicensed Staff G stated, during the transfer, Resident 2 had, slid from the sling that was attached to the lift. Unlicensed Staff G stated he had tried to hold on to Resident 2, but had not been able to. Unlicensed Staff G stated he had transferred Resident 2 by himself because he had called for assistance, but everyone had been busy. Unlicensed Staff G stated two staff were required for lift transfers, but he had done it by himself because everyone was busy. A review of a facility document titled, SBAR --Actual/Suspected Fall, dated 3/8/19 11:21 (11:21 a.m.), revealed, .causing her to roll over side of sling and strike head on floor. The document revealed Resident 2 sustained a, laceration to right scalp, skin tear to left knuckle. The document revealed Resident 2 complained of pain to her head after the fall. A review of a facility document titled, Progress Note, dated 3/9/19, revealed, Late Entry: .Resident noted to be on floor of room on her right side. Per CNA (Certified Nursing Assistant), after shower, resident was being transferred via lift .Resident did strike her head on the floor and is noted to have a small contusion and laceration on her right scalp. Resident also noted to have a skin tear to left knuckle and an abrasion on left thigh . A review of Resident 2's most recent MDS (Minimum Data Set) (an assessment tool) prior to her fall from the lift, dated 12/10/18, revealed in Section G-- Functional Status, Resident 2 required, two plus persons physical assistance, for transfers. A review of an untitled document, provided by the facility as Resident 2's plan of care, revealed, Focus, dated revised 2/6/15, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to Dementia, Fatigue, Limited Mobility, Confusion, Impaired Balance, fear of falling having experienced same prior to admission . Interventions/Tasks, revealed, Hoyer lift with 2 person assist for transfers. The document revealed, The resident is at risk for falls r/t paralysis . A review of a facility document titled, Safe Lifting Movement, dated (MONTH) (YEAR), revealed, In order to protect the safety and well-being of staff and patients, and to promote quality care, this facility uses appropriate techniques and devices to lift and move patients . Staff will document patient transferring and lifting needs in the care plan . During an interview on 5/9/19 at 11:50 a.m., Management Staff I stated the facility used (Name) Hoyer lifts. The, Owner's Manual, for (Name) Hoyer lifts revealed, (Name) recommends that two assistants be used for all lifting preparation and transferring to/from procedures .