Every finding on record at Orchards at Tulare

Based on interview and record review, the facility failed to ensure Stop and Watch(tool use to notify nurse of a change in condition) form was filled for one of three sampled residents (Resident 1) when a change in condition was identified. This failure had the potential to result in a delay of care. Findings:During an interview on 8/17/26 at 12:14 p.m. with Certified Nurse Assistant (CNA 1), CNA 1 stated she was assigned to Resident 1 on 7/5/26. CNA stated when she arrived to work on 7/5/26 at 2:30 p.m., she noticed Resident 1 looked different, wasn't talking, was asleep more, his face looked sad.looked sick. CNA 1 stated it was the facility practice to fill out the form titled Stop and Watch when residents are acting and looking differently. CNA stated she did not fill out the Stop and Watch form. CNA stated she should have. During an interview on 8/18/26 at 10:21 a.m. with Director of Staff Development (DSD), DSD stated, staff are expected to fill out Stop and Watch form when staff notices a change in resident condition.During an interview on 8/18/26 at 10:24 a.m. with DON, DON stated she did not receive a Stop and Watch form on 7/5/26 for Resident 1. DON stated Stop and Watch form should have filled out when CNA 1 identified Resident 1 with change in condition. During a review of the facility's form titled, Stop and Watch (undated), the Stop and Watch form indicated, If you have identified a change while caring for or observing a resident please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Seems different than usual, Talks or communicates less, Overall needs more help, Pain- new or worsening; Participated less in activities, Ate less, No Bowel movement in 3 days; or diarrhea, Drank Less, Weight change, Agitated or nervous more than usual, Tired weak confused or drowsy, Change in skin color or condition, Helping with walking transferring toileting more than usual.

Based on observation, interview, and record review, the facility failed to ensure three of three residents' rooms were free of cracked flooring, damaged door jambs, and chipping and bubbling wall plaster. This failure had the potential to result in an increased risk of Resident 1 and Resident 2 being exposed to accidental lacerations (cuts) and contaminants which can contribute to respiratory illness.Findings:During a concurrent observation and interview on 7/6/26 at 1:39 p.m. with Maintenance Lead (ML), in room [ROOM NUMBER], the wall plaster above the baseboard underneath the window was damaged and cracked with gaps. ML stated there was damage on the wall and something like that would be high priority to be worked on.During a concurrent observation and interview on 7/6/26 at 1:52 p.m. with ML, in room eight, the floor molding along the base of the door jamb was rusted and cracking, the wall across from the toilet had chipped paint, and the molding underneath the sink was pulling away from the wall. ML stated it looked like deterioration and paint was chipping on the wall.During a concurrent observation and interview on 7/6/26 at 1:58 p.m. with ML, in room five, the wall underneath the windowsill and the plaster along the windowsill were chipping and bubbling. In the restroom, the base of the door jamb was rusted and flaking off. In the restroom, the flooring behind the toilet and across from the toilet was cracked. ML stated that was deterioration and needed replacing. During an interview on 7/6/26 at 2:04p.m. with Housekeeping (HSK), HSK stated staff should be reporting any issues in the rooms.During an interview on 7/6/26 at 2:40p.m. with the Administrator, the Administrator stated managers should be reporting any issues in the rooms.During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, dated 2001, the P&P indicated, Policy Interpretation and Implementation, 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards.

Based on interview and record review, the facility failed to ensure the physician was made aware of one of three sampled residents (Resident 4)'s request to be sent to the hospital. This failure resulted in Resident 4's rights being violated.Findings:During a review of the text messages between Licensed Vocational Nurse (LVN) 2 nurse and the physician, dated 5/18/26 at 9:52 p.m., the text message indicated, Patient (Resident 4's name) is 94% (oxygen) SAT (saturation) room air, he is complaining of vomiting but he barley [sic] threw up on my shift regular clear w (with) some food chunk he's just gagging a lot. He's saying his testicle hurt very bad and is having chest pain. He is stating he can't swallow pills right now because he throw the [sic] up. His VS (vital signs) when last checked were 152/80 (blood pressure-the force of blood pushing against the walls of your arteries as your heart pumps it though your body. Pulse 82 (heart rate).(Physician response).zofran (medication used to treat nausea) 4 mg (milligrams) TID (three times a day) PRN (as needed) x (times) 3 days.Is he still having chest pain?During a review of the text messages between LVN 2 and the physician, dated 5/18/26 at 10:11 p.m., the text message indicated, Hes [sic] just saying everything hurts now but we got the order for Zofran He's stating he can't swallow pills because he's gonna throw them up so he's denying it at thistime [sic].(Physician response.sublingual (administered under the tongue) Zofran?During a review of Resident 4's text messages between LVN 3 and the physician, dated 5/18/26 at 10:39 p.m., the text message indicated, Sending out pt (Resident 4) attempted all other methods requested to be sent out per pt request.During a review of Resident 4's Progress Notes (PN) (documented by LVN 2) dated 5/18/26 at 10:21 p.m., the PN indicated, Resident has been wanting to be sent out (to the hospital) since start of shift for pain and vomiting. Resident NOC (night) and AM (morning) nurse denied emesis (vomiting) being coffee ground like and stated he barley [sic] threw up. During my shift he barley [sic] had any throw up in his bag during the whole 8 hours. Resident is having pain to his testicle area which is very swollen, but due to his liver failure no pain medications have been prescribed. Notified (physician) of this and he ordered zofran sublingual due to resident stating that he can swallow pills or he will throw them up. Resident is now stating his chest is hurting MD notified as well. Resident VS are 158/80 P (pulse) 82 at SAT 94% room air resident already has a PRN for 3L (liters) of oxygen as needed.During a review of Resident 4's PN (documented by LVN 3) dated 5/18/26 at 10:42 p.m., the PN indicated, Upon arrival to shift, resident stating being unable to breath and having chest pain checked O2 (oxygen) levels resident was at 97% on room air, at approx 10:43 p.m. resident had emesis x (times) 1 but is refusing zofran states not wanting to throw up again and requesting to besent (be sent) out MD (Doctor of medicine) notified RP (responsible party) notified. Attempted to get order for nitroglycerin (medication used to treat chest pain) for chest pain resident is stating not wanting and wanting to be sent out of facility. ADON (Assistant Director of Nursing) notified and approved send out.During an interview on 6/4/26 at 3 p.m. with LVN 2, LVN 2 stated she was assigned to Resident 4 on 5/18/26, LVN 2 stated during the shift Resident 4 was complaining of pain and was requesting to be sent to the hospital. LVN 2 stated she did not notify the physician of Resident 4's request to be sent to the hospital and she should have. LVN 2 stated Resident 4 was sent to the hospital by the next shift. During an interview on 6/4/26 at 3:34 p.m. with Director of Nursing (DON), DON stated when Resident 4 was requesting to go to the hospital at the beginning of the shift, the physician should have been notified right away.During an interview on 6/4/26 at 4:07 p.m. with Resident 4, Resident 4 stated on 5/19/26 he was feeling miserable and experiencing chest pain and vomiting. Resident 4 stated it took about 12 hours for the facility to send him to the hospital after he requested to be sent.During a review of the facility's policy and procedure (P&P) titled, Resident Rights undated, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be informed of, and participate in, his or her care planning and treatment.choose an attending physician and participate in decision-making regarding his or her care.

Based on interview and record review, the facility failed to ensure physician orders were followed for one of three sampled residents (Resident 4) when eye drops were not initiated. This failure had the potential for Resident 4 to experience discomfort.Findings:During a review of Resident 4's Ophthalmology Notes (ON) dated 11/24/25, the ON indicated, Care Plan.Add Cosopt (eye drop medication used to lower eye pressure) bid (twice a day) OU (both eyes) for comfort.During a concurrent interview and record review on 6/25/26 at 10:49 a.m. with Director of Nursing (DON), DON reviewed Resident 4's clinical record. DON stated the Cosopt eye drops were never implemented for Resident 4.During a review of the facility's policy and procedure (P&P) titled Consulting Physician/Practitioner Orders dated 5/20/26, the P&P indicated, Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician.who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's.specialist such as.ophthalmologist.for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will.call the attending physician to verify the order.document the verification order by entering the order and the time, date.follow facility procedures for verbal or telephone orders including.noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on interview and record review, the facility failed to ensure supervision was provided when 15 minutes checks were not completed for one of three sampled residents (Resident 1) with a history of elopement. This failure resulted in Resident 1 eloping through his bedroom window, found approximately two blocks away and potential for harm.Findings:During a review of Resident 1's admission Record (AR) undated, the AR indicated Resident 1 was a [AGE] year-old male with diagnoses that included unspecified dementia (a decline in mental abilities severe enough to interfere with memory, thinking, language, reasoning and behavior), severe, with mood disturbance.major depressive disorder.anxiety disorder.During a review of Resident 1's Elopement Evaluation (EE) dated 2/13/26, the EE indicated, Does the resident have a history of or attempted leaving the facility without informing staff.yes.Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door.yes.Does the resident wander.yes.Is the wandering behavior a pattern, goal-directed.yes.During a review of Resident 1's Cognitive Patterns (CG) dated 4/15/26, the CG indicated, BIMS (Brief Interview for Mental Status) Summary Score 00 (indicating severe cognitive impairment) .During a review of the document titled List of Resident's on Q Monitor Checks (LRQMC) dated 4/27/26, the LRQMC indicated, (Resident 1 and room number) Q (every) 15 mins checks for elopement.During a review of Resident 1's Change in Condition (COC) dated 5/29/26 at 8:36 a.m., the COC indicated, Elopement.5/29/26.Review & Notify.Writer came back from lunch approx. (approximately) 2:34 a.m. Around 2:40 a.m. CNA (Certified Nursing Assistant) notified writer that resident was missing and his room's window screen was broken or cut. Immediate search of facility and surrounding grounds initiated per DON (Director of Nursing) made (aware) approx. 2:50 a.m., ADON (Assistant Director of Nursing) made aware, MD (Doctor of Medicine) made aware.Tulare Police department made aware.Resident came back to facility approx. 5:30 a.m. Head to toe assessment done, no physical injuries noted.During a review of Resident 1's Progress Notes (PN) dated 6/1/26 at 7:25 a.m., the PN indicated, Nurse came back from lunch approx. 2:34 a.m. Around 2:40 a.m. CNA notified nurse that resident was missing and his room's window screen was cut open. Immediate search of facility and surrounding grounds initiated, resident was not in facility or on facility grounds. Per CNA's monitoring resident was last visualized at approximately 2:00 a.m., and at the time CNA had gone to relieve a sitter in the hall for their lunch. Tulare PD (police department) was contacted and was located and returned to facility at approximately 5:30 a.m.Root cause.Resident is on monitoring for exit-seeking behaviors and wandering. Resident does wear a wander guard and has a history of prior elopement attempts. Nurses do door alarm checks Q (every) shift to ensure all doors are locked and armed for our dementia and elopement risks residents. Resident however did not utilize a door during his elopement. Resident is believed to have eloped through his bedroom window as evidenced by the screen in the window beingcut [sic] out, at this time making his wander guard ineffective as resident did not elope through the facility's doors.During a review of Resident 1's Noc (night) Q 15 min monitoring check (NQMMC) dated 5/28/26 (includes 5/29/26), the NQMMC indicated, Time. (5/29/26) 2:15 a.m.-5:15 a.m. (three hours) were blank (indicating no monitoring was completed).During a review of Resident 1's PN dated 5/29/26 at 6:02 a.m., the PN indicated, Received a call from Tulare PD approx. 5:25 a.m., that they found resident. Resident came back to facility approx . 5:30 a.m.During an interview on 6/4/26 at 1:30 p.m. with DON, DON stated on 5/29/26 at the time of the elopement, Resident 1 was on Q15 minute checks due to being an elopement risk. DON stated CNA 1 was assigned to Resident 1 and was responsible for the Q 15 minute checks. DON stated CNA 1 checked on Resident 1 at 2 a.m. and then relieved another staff for lunch. DON stated when CNA 1 returned she checked on Resident 1 between 2:30-2:45 a.m. (approximately 30-45 minutes later) and Resident 1 was not in his bed. DON stated when CNA 2 went to relieve staff for lunch she should have passed on the Q 15 minute checks to CNA 1 and she did not do that.During an interview on 6/17/26 at 1:29 p.m. with CNA 2, CNA 2 stated on 5/29/26 she was hall partners with CNA 1. CNA 2 stated CNA 1 went to lunch at 1:30 a.m. and she (CNA 2) was responsible to do Q 15 minute checks on Resident 1. CNA 2 stated she last seen Resident 1 at approximately 1:41 a.m. and when CNA 1 returned from her lunch at 2 a.m. she (CNA 2) went to relieve other staff for lunch breaks. CNA 1 stated there was a form that was completed when the 15 minute checks were done and she last documented at 1:45 a.m.During an interview on 6/24/26 at 4:15 p.m. with CNA 1, CNA 1 stated on 5/29/26 she was assigned to Resident 1 at the time of the elopement. CNA 1 stated she went to lunch at 1:30 a.m. and returned at 2 a.m. she checked on Resident 1 and then relieved another staff for their lunch break. CNA 1 stated she returned at approximately 2:30 a.m. and when she checked on Resident 1 she realized he wasn't in bed and the bathroom door was open. CNA 1 stated when she got closer to the window, she could see the screen was broken. CNA 1 stated she notified the nurse and went to search for Resident 1 but he was not on the facility grounds. CNA 1 stated when she relieved staff for lunch she should have given the Q 15 minute form to CNA 2 so she knew she was responsible for the Q 15 minute checks.During a concurrent interview and record review on 6/24/26 at 4:40 p.m. with DON, Resident 1's Care Plan was reviewed, the CP indicated, Resident is a high elopement risk and is a wanderer that is currently being monitored for exit seeking behaviors.date initiated 2/9/26.Goal.resident will be free from injury while monitoring for elopement is in place through review date.Interventions.Monitor resident q30 minutes for elopement and exit seeking behaviors.Date initiated.2/9/26. DON stated the care plan was incorrect and should have indicated Q15 minute monitoring.During a review of the facility's policy and procedure (P&P) titled Wandering and Elopement undated, the P&P indicated, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.During a review of the facility's policy and procedure (P&P) titled, Accidents and Supervision undated, the P&P indicated, Each resident will receive adequate supervision.this includes.identifying hazard(s) and risk(s).implementing interventions to reduce hazard(s) and risk(s).Implementation of interventions-using specific interventions to try to reduce a resident's risks form hazards in the environment. The process includes.communicating the interventions to all relevant staff.assigning responsibility.documenting interventions.ensuring the interventions are put into action.supervision.supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision.defined by type and frequency.based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on interview and record review, the facility failed to follow its own policy and procedure (P&P) for one of two sampled residents (Resident 1) when written request for Resident 1's clinical records was not provided in a timely manner. This failure resulted in violation of Resident 1's rights and not providing Resident 1's clinical records approximately 14 days after the request date.Findings:During a concurrent interview and record review on 3/9/26 at 10:34 a.m. with Administrator and Medical Records Personnel (MRP), MRP stated on 2/17/26 a written request for Resident 1's clinical record was received. MRP stated Resident 1's clinical record was not released until 3/9/26 (approximately 14 days after the request date). Administrator reviewed the facility's P&P titled, Release of Medical Records. Administrator confirmed the facility P&P was not followed when written request for Resident 1's clinical record was not released within 2 working days.During a review of facility's P&P titled, Release of Medical Records, dated 2025, the P&P indicated, Access Rights to Medical Information are as Follows: 1.The resident of his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made.

Based on observations, interviews, and record review, the facility failed to ensure the ceiling vents (outlets that allow conditioned air to flow into a room) were clean and sanitary for ten of ten sampled residents' rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). This failure had the potential to result in the spread of respiratory illnesses to residents, staff, and visitors.Findings:During an observation on 3/3/26 at 10:14 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an observation on 3/3/26 at 10:17 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris.During a concurrent observation and interview on 3/3/26 at 10:20 a.m. with Housekeeping (HSK) in room [ROOM NUMBER], HSK stated, The ceiling vents need to be cleaned, the vent has dirt on it, vents need to be cleaned, if not, it [dirt] falls on residents.During an observation on 3/3/26 at 10:30 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During an observation on 3/3/26 at 10:41a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an observation on 3/3/26 at 10:42 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During a concurrent observation and interview on 3/3/26 at 10:45 a.m. with Housekeeping Supervisor (HSKS) in room [ROOM NUMBER], HSKS stated, Maintenance and myself are in charge of cleaning the vent, that vent hasn't been cleaned in days. We are supposed to clean, its dirty. All the stuff on the vents gets into their (residents) lungs if we don't clean them During an observation on 3/3/26 at 10:48 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During an observation on 3/3/26 at 10:58 a.m. in room [ROOM NUMBER], there was one ceiling vent with black mold like debris. During an observation on 3/3/26 at 11:03 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an interview on 3/3/26 at 11:12 a.m. with Resident 1, Resident 1 stated, I have not seen housekeeping cleaning my room.During an observation on 3/3/26 at 11:17 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris.During an interview on 3/3/26 at 11:18 a.m. with HSKS in room [ROOM NUMBER], HSKS stated they missed to clean the ceiling vents it shouldn't have been built up like that.During an interview on 3/3/26 at 11:25 a.m. with Maintenance Lead (MTL), MTL stated he doesn't do much cleaning, it's more of housekeeping and he doesn't clean them (ceiling vents) unless he's told to.During an interview on 3/3/26 at 11:40 a.m. with Infection Prevention (IP), IP stated she has not noticed issues with dust and has monthly meetings with housekeeping to maintain oversight. IP stated, It would be a respiratory concern with moldy or dusty vents. I have not implemented anything other than a deep cleaning schedule. During a review of the facility's Deep Clean Schedule (DCS), undated, the DCS indicated there were no instructions for cleaning ceiling vents.During a review of the facility's Room Rounds, Area of Observation (RRAO), undated, RRAO indicated there were no instructions for cleaning ceiling vents During a review of the facility's policy and procedure (P&P) titled, Routine Cleaning and Disinfection dated 2025, the P&P indicated Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaced will be performed in common areas, resident rooms, and at the time of discharge. 3.c. Clean from top to bottom (bring dirt from high levels down to floor levels). 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces.

Based on interview and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1) with impaired cognition (problem in ability to think, learn, remember, make decisions). This failure resulted in Resident 1 eloping (leaving facility unsupervised and without prior authorization) from the facility without staff being aware and had the potential for harm. Findings:During an interview on 2/26/26 at 12:06 p.m. with Registered Nurse (RN), RN stated on 2/7/26 at 10:38 a.m., she was made aware Resident 1 was outside the facility without supervision. RN stated Resident 1 was found in the parking lot across the street from the facility. RN stated Resident 1 was alert with impaired cognition, did not have an order to leave the facility, and was not safe to go outside the facility without supervision.During an interview on 2/26/26 at 12:19 p.m. with Infection Control Preventionist (ICP), ICP reviewed Resident 1's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/16/26, the MDS indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 (score range from 0-7 severe impairment.During an interview on 2/26/26 at 12:35 p.m. with Certified Nursing Assistant (CNA), CNA stated on 2/7/26 at approximately 10:30 a.m., he had opened the facility door for visitors to exit. CNA stated he did not recognize Resident 1 was standing among the visitors and had exited the facility when the door was open. CNA stated Resident 1 exited the facility without supervision. During a review of the facility 5-Day Follow-Up Report, the report indicated, On February 7, 2026, at approximately 10:38 AM, staff were notified that a male resident (Resident 1) was observed outside the facility in the hospital parking lot across the street. The resident had exited through the front entrance after a newly hired CNA opened the secured door for visitors and did not recognize the resident as a non-visitor.During a review of the facility's policy and procedures (P&P) titled, Elopements and Wandering Residents, undated, the P&P indicated, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.During a review of the facility's policy and procedures (P&P) titled, Accidents and Supervision, undated, the P&P indicated, 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. A glucometer (used to take residents blood sugar) was not sanitized after use for one of three sampled residents (Resident 1);2. Personal Protective Equipment (PPE-gown, gloves, mask, eye protection) was not worn when entering a droplet precaution (used to prevent the spread of germs transmitted through large respiratory droplets from coughing, sneezing, or talking) isolation room.These failures had the potential for spread and risk of infections to residents, visitors, and staff.Findings:1. During a concurrent observation and interview, on 11/24/25 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, LVN 1 placed a glucometer test strip in the glucometer, cleaned Resident 1's finger with alcohol, poked Resident 1's finger with the lancet (small, disposable, sterile needle used to prick the skin), placed a drop of blood on the test strip, reviewed the result, removed the test strip from the glucometer and placed the glucometer back in the medication cart. The glucometer was not sanitized prior to placing it in the medication cart. LVN 1 stated she forgot to sanitize the glucometer, and it should have been done after using the glucometer.During an interview on 11/24/25 at 1:53 p.m. with Infection Preventionist (IP), IP stated the glucometers were to be sanitized after each use.During a review of the facility's policy and procedure (P&P) titled Glucometer Disinfection dated 2025, the P&P indicated The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use.2. During a concurrent observation and interview on 11/24/25 at 12:49 p.m. outside Resident 2's door, there was a sign on the door that indicated Droplet Precautions. Certified Nursing Assistant (CNA) 2 entered the room and picked up a food tray without putting PPE on. CNA 2 stated he was unaware of the type of precautions required when entering Resident 2's room.During an interview on 11/24/25 at 12:50 p.m. with Director of Staff Development (DSD), DSD stated Resident 2 was in droplet precautions and the staff should be wearing PPE when entering the room.During an interview on 11/24/25 at 12:54 p.m. with CNA 2, CNA 2 stated when he entered Resident 2's room, he should have had full PPE on including an N95 (a type of respirator that filters at least 95% of air particles), gown, gloves and eye protection.During an interview on 11/24/25 at 1:53 p.m. with IP, IP stated Resident 2 was on droplet precautions and when staff entered the room, they should be wearing a N95, gown, gloves and eye protection.During a review of the facility policy and procedure (P&P) titled, Transmission-Based (Isolation) Precautions dated 2025, the P&P indicated, Droplet Precautions.Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying or respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn.

Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen when: 1. A brown colored substance and a dead bug were observed between a reach-in freezer and reach-in refrigerator. 2. The ice machine was not sanitized in accordance with manufacturers' guidelines. 3. Baseboards were observed to be peeling away from the wall under a sink leaving a potential entry for pests. These failures placed the residents at an increased risk for foodborne illness. Findings: 1. During a concurrent observation and interview on 05/05/25 at 10:04 a.m. with Dietary Supervisor (DS) in the kitchen, a brown colored substance on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer was observed. DS was asked what the brown colored debris/substance was, and DS stated, I don't know. DS stated the floor between the freezer and refrigerator was dirty with debris and the external side stainless steel walls of both units that faced each other had a buildup of dust. During an interview on 05/05/25 at 10:04 a.m. with DS, DS stated she had not seen any pests in the kitchen. During a concurrent observation and interview on 05/05/25 at 10:29 a.m. with Maintenance Supervisor (MS) in the kitchen, MS observed the round brown colored item on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer. MS stated that was a bug, and it looked like a water bug which he stated was a type of cockroach. MS stated the floor between the two units was dirty with debris and a dead waterbug/cockroach, as well as a buildup of dust alongside the external surfaces of the two units that faced each other. MS observed behind the two units in which there was another white pest control trap and dirty flooring. MS stated the white pest control traps were placed there by outside pest control company. During a review of the FDA Food Code (FDAFC), dated 2022, FDAFC indicated, Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of FDAFCA, dated 2022, FDAFCA indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic [capable of causing disease] microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 2. During an interview on 05/05/25 at 10:13 a.m. with MS, MS stated he was responsible for cleaning the ice machine. MS stated the facility did not have an outside vendor to clean the ice machine. MS stated once a month he deep cleaned the ice machine located in the kitchen, which was the facility's only ice machine. MS stated the only product that was circulated through the ice machine was Nickel Safe Ice Machine Cleaner (NSIMC) and he showed the bottle of NSIMC. MS was asked how he sanitized the ice-machine and MS stated with Nickel Safe Ice Machine Cleaner, it does both. During a review of the manufacturer's guidelines (MGs) for the Koolaire Ice Machine located in the kitchen, the MGs indicated, Cleaning/Sanitizing Procedure: This procedure must be performed at a minimum of once every six months.Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime.Wait until the trough refills, then add the proper amount of Manitowoc Ice Machine Sanitizer to the water trough. During a review of the facility's policy & procedure (P&P) titled Ice Machine Cleaning Procedures (IMCP), dated 2023, the IMCP indicated, The ice machine needs to be cleaned and sanitized monthly. Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and/or in the directional panel on the inside of the machine. 3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. 3. During a concurrent observation and interview on 05/05/25 at 10:08 a.m. with DS in the kitchen, the baseboards underneath the sink were separating from the floor showing an open crevice. DS stated the open crevice between the floor and baseboard was identified via audit of the kitchen by the Registered Dietitian and MS was aware. DS did not know when the repair was to be made. During a concurrent observation and interview on 05/05/25 at 10:32 a.m. with MS in the kitchen, MS observed the baseboard separating from the floor alongside the wall in which the dirty side of the dish machine was located. MS stated that it could be an entry for pests and stated he was aware. MS stated the facility started talking about the need to fix that and had been talking about replacing the flooring. MS was asked if there were any action plans put into place that he could provide for review, and MS stated no. During a review of Food & Nutrition-Monthly Inspection Checklist (FNMIC), dated 03/25/25, the FNMIC indicated old tile needs repair and also baseboards. During a review of FNMIC, dated 04/15/25, the FNMIC indicated old tile, baseboards repair. During a review of the facility's P&P titled Sanitation Inspection, the P&P indicated it is the policy of this facility as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. According to the FDA (Food and Drug Administration) Food Code 2013, Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. (Cleanability 6-201.11 Floors, Walls, and Ceilings. 6-201.12 Floors, Walls, and Ceilings, Utility Lines)

Based on observation, interview, and record review, the facility failed to: 1. Ensure the Registered Dietitian (RD) accurately and comprehensively assessed nutritional status for one of one sampled resident (Resident 68) in accordance with standard of practice and facility policy and procedure (P&P) related to lack of re-assessing Resident 68's daily calorie, protein and fluid needs after a significant change in condition related to pressure injury and significant unplanned weight loss. 2. Effectively monitor nutrition interventions when facility did not document quantity consumed of oral nutrition supplement (ONS) provided on meal trays for one of one sampled resident (Resident 68) and did not convene a follow-up IDT (interdisciplinary team) weight variance meeting to evaluate effectiveness of a ONS that was provided to address Resident 68's significant unplanned weight loss until a month after the ONS was initiated, during which time Resident 68 continued to have further significant weight loss. In addition, in general, the facility was implementing HN (house nourishment) shake as an equivalent choice to Mightyshakes in which the calories provided were not nutritionally equivalent. Further, the facility lacked a variety of nutrition supplements to offer to residents, in general, who were assessed as needing additional calories and/or protein, or who may want to opt for a different ONS after prolonged use of the same one, including for Resident 68. (Cross Refer F842) 3. Effectively monitor, evaluate and identify, inadequate fluid intake during which time Resident 68 had increased fluid needs due to multiple pressure injuries, including Stage 4 (Full-thickness skin and tissue loss) and apply relevant approaches such as obtaining Resident 68's beverage preferences to help Resident 68 improve fluid intake. (Cross Refer F807) Facility failure to identify gaps in the systematic interdisciplinary process to include identifying, assessing and monitoring resident's food and fluid intake (hydration) in accordance with standard of practice and facility P&P had the potential to negatively contribute to a symptom, illness, or decline in nutrition and medical status for Resident 68. Findings: 1. During a concurrent observation and interview on 5/05/25 at 1:00 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 68's room, Resident 68 was sitting up in bed. CNA 2 was encouraging Resident 68 to eat. Resident 68 stated she received a supplemental shake (to increase calories and protein) but did not like it so she did not drink it. During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with RD, Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated, Relevant Diagnoses.moderate protein-calorie malnutrition, iron deficiency anemia, adult failure to thrive.esophageal reflux disease.urinary tract infection, pressure ulcer of sacral [bottom of the spine] region, unspecified stage. Labs from acute: (8/12) Hgb [hemoglobin; a red protein responsible for transporting oxygen] 8.4L [liter; a metric unit of capacity], Hct [hematocrit; the percentage of red blood cells in your blood] 26.8 L, Na [sodium] 4.1, Cr [Creatinine] 0.50 [a waste product produced from muscle metabolism], BUN [Blood Urea Nitrogen; a waste product produced in the liver when proteins are broken down] 7 [indicating healthy kidney function], diet order: Regular diet, Regular texture, Supplement Order: Ferrous Sulfate [a form of the mineral iron].Height: 59 [inches] Date: 8/23/24, Weight: 113 pounds (lbs) Date: 8/26/24, Appearance/Skin full thickness unstageable [covered full-thickness skin and tissue loss] to coccyx [tailbone], wound to R [right] lateral leg, appears hydrated, Nutrition Needs Estimate: Kcal: 1,541 kcal [calories] (30kcal/[per] kg [kilogram; A unit of mass in the metric system, equal to one thousand grams]), Protein [pro]: 77 gm [grams] (1.5 gm/kg), Fluids: 1,541 ml [milliliter; unit of capacity] (30 ml/kg), Intake: 50-100%, Adequacy of Intake: adequate,.UBW [usual body weight]: 113# [lbs].Discussed importance of meeting EEN [estimated energy needs] and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs r/t [related to] wound healing AEB [as exhibited by] full thickness unstageable to coccyx, wound to R lateral leg. RD recommends: 1) Vit C 500mg BID [two times a day] 2) Prostat [nutrition supplement to increase calories and protein] 30 ml BID 3) MVI [multivitamin] QD [every day] RD.Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s [signs/symptoms] of dehydration. RD stated her nutrition recommendations were ordered by the physician the following day. During a review of Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG), dated 2019, the CPG indicated, In healthy people, water/fluid intake should be approximately 30 mL/kg body weight/day or 1 mL/kcalorie/day. During a review of Resident 68's Progress Notes (PN), dated 9/8/24, 9/16/24, and 9/24/24, the PN indicated Resident 68 refused weekly weight measurements despite risks vs benefits of weight explained. During a review of Resident 68's History and Physical (H&P), dated 10/14/24, the H&P indicated, Resident 68 had the mental capacity to make medical decisions. During a concurrent interview and record review on 05/06/25 at 2:50 p.m. with RD, Resident 68's RD/IDT [interdisciplinary] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 10/3/24 was reviewed. The Wt Mtg indicated Resident 68 had a 7.7% (percent) loss of body weight in one month. RD stated Resident 68 was eating 76-100% of meals and there was a stage 4 to sacrum, unstageable to R leg. RD stated Resident 68 was placed on a fortified diet that provided an additional 500 calories a day and double protein diet, in addition to Prostat 30 ml BID she had been receiving. During an interview on 05/06/25 at 2:55 p.m. with RD, RD stated it was standard of practice to reassess daily calorie, protein and fluid needs after a significant change in condition, whether it was during this IDT weight meeting or any other nutrition assessment. RD stated she did not do that for Resident 68 after she had significant weight loss. Although there was documentation of food intake [76-100% of meals] there lacked an evaluation as to whether the food intake met Resident 68's caloric needs as there was no accurate, relevant nutrition assessment of her needs after a significant change of condition. Lack of a current nutrition assessment posed a barrier in determining whether Resident 68's nutrition plan of care needed to be updated and revised. The RD and/or RD/IDT Wt Mtg note lacked indication that Resident 68's Monitor Fluid Intake logs (CNA documentation of Resident 68's fluid intake from meal trays) were reviewed which may lead to early identification of insufficient fluid intake to help prevent and/or minimize complications. There lacked documentation to indicate a review and evaluation of potential sources of fluid loss to include review of IDT Weight/Nutrition/Skin Progress Note, dated 9/3/24, and 9/5/24 that noted moderate serous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) from the Stage 4 pressure wound to sacrum and light serous drainage from the R leg, if chronic and prolonged, may require re-assessing for an additional amount of fluid per kilogram of body weight for Resident 68. Without an accurate and comprehensive re-assessment of fluid needs after a significant change of condition, there was not a mechanism to evaluate fluid intake as compared to assessed needs in order to identify and communicate quantity of ml of fluids not being consumed by Resident 68 to bring to the attention of IDT and/or physician in a timely manner, so MD could determine whether additional tests or interventions may have been warranted. During a review of Advances in Skin & Wound Care (WC), dated 2020, the WC indicated those with draining wounds require additional fluids/water to replace lost fluid, and should be monitored as dehydration could be a factor in weight loss. During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian.upon significant change in condition.Components of the assessment may include, but are not limited to:.Food and fluid intake, Evidence of fluid loss.Evaluation/analysis: The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. During a review of Resident 68's PN, dated 10/7/24 and 10/14/24, the PN indicated Resident 68 refused weekly weight measurements despite risks vs benefits of weight explained. During a concurrent interview and record review on 05/06/25 at 3:00 p.m. with RD, Resident 68's Wt Mtg, dated 11/6/24, was reviewed. RD stated due to Resident 68's refusals to have her weight taken the facility did not become aware of her significant unplanned weight loss of 10.2% of body weight until she allowed her weight to be taken on 11/4/24 and she was 97 lbs. The Wt Mtg note, dated 11/6/24, indicated, Po intake: 51-75%, Diet: Fortified diet, Double Protein diet.Skin: stage 4 to sacrum, unstageable to R leg, Prior Interventions: fortified diet, double protein, wound supplements [Prostat 30 ml BID].RD has explained importance of meeting EEN for wound healing and preventing weight loss. Family brings resident outside favorite food. CDM [Certified Dietary Manager; Dietary Supervisor (DS)] updated food preferences. Resident in agreement to add HN [house nourishment] w [with]/meals and ice cream. IDT Recommendations: add HN [4 oz] w/meals and weekly weights. During a concurrent interview and record review on 05/06/25 at 3:05 p.m. with RD, Resident 68's Wt Mtg, dated 12/5/24, was reviewed. The Wt Mtg note indicated Resident 68 weighed 90 lbs which was 7.2% further unplanned significant weight loss in a month and was an 18 lb wt loss (16.7% loss of body weight) over 3 months, po intake was 51-75% overall of breakfast, lunch and dinner meals, and skin continued with stage 4 to sacrum, unstageable to R leg. The Wt Mtg indicated during the time since the previous Wt Mtg, Prostat had been increased from 30 ml BID to 60 ml BID and an antidepressant medication was started on 11/21/24. There was no documentation of reviewing Resident 68's fluid intake utilizing Resident 68's Monitor Fluid Intake logs to evaluate and compare to assessed fluid needs. The Wt Mtg indicated, Dietitian met with resident to educate resident on the importance of wt measurements, meeting EEN and hydration needs for wound healing and wt maintenance. Resident verbalized understanding and indicated she is eating more and drinking the protein shakes. No new food preferences at this time. IDT Recommendations: RNA [restorative nursing assistance] dining and continue with weekly weights. RD stated she did not re-assess Resident 68's daily calorie, protein and fluid needs after significant change of condition (further, continued significant wt. loss) even though that was an established standards of performance. The facility's P&P Nutritional Management, dated 1/2025, was not followed and implemented, as the P&P indicated a comprehensive nutrition assessment will be completed by a dietitian upon significant change of condition, and data gathered to assess fluid as required per the facility's P&P. During an interview on 5/6/25 at 3:10: p.m. with RD, RD stated she did not recommend any additional interventions to increase calories and protein after Resident 68 had lost 16.7% of her body weight over 3 months because we were already giving her fortified diet which adds 500 calories, double protein, HN 4 oz with meals, Prostat and ice cream and she was eating 51-75% of her meals. RD was asked how she determined the interventions were adequate when Resident 68 had 7 lbs further weight loss since her significant wt loss the month prior. RD repeated she was eating 51-75% of her meals. RD was asked if she evaluated whether Resident 68 was in a hypermetabolic (a condition where the body's metabolism is increased above normal levels) and/or hypercatabolic (an abnormally high rate of metabolic breakdown of substances within the body leading to tissue breakdown and weight loss) state using evidence based guidelines for stage 4 pressure injury with co-existing other wounds that could contribute to further increased protein/energy [calories]/fluids per kg of UBW (113 lbs) nutritional needs related to increased demand of nutrients to support wound healing, as evidenced by delayed wound healing of stage 4 pressure injury to coccyx (tailbone), and continued significant weight loss. RD stated she did not need to re-assess daily calorie, protein and fluid needs to find out if Resident 68 was not eating or drinking enough. Lack of sufficient monitoring and evaluation of effectiveness of interventions and lack of comprehensive re-assessment of nutritional needs after a significant change of condition taking into consideration potential changes to metabolic state, and/or discussing with the doctor, may impede identifying a need for alternate nutrition approaches and revision of the nutrition care plan versus continuation of the same nutrition plan of care with negative outcomes. During review of Resident 68's nutrition assessment, dated 8/27/2024, RD calculated daily calorie needs at 30kcal/kg of admission weight and had not re-evaluated and reassessed Resident 68's daily calorie, protein and fluid needs since admission, despite being admitted with diagnosis of moderate protein calorie malnutrition, multiple occasions of significant unintended weight loss and no improvement in wound healing. Further, RD had not monitored and documented fluid intake from meal trays and compared to assessed needs to bring the quantity of deficit of insufficient fluid intake to the attention of the doctor as required per the facility's P & P titled Nutritional Management, dated 1/2025. During a review of Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG), dated 2019, the CPG indicated, Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. In adults who are underweight or who have had significant unintended weight loss, additional energy intake may be required. 2. During a general dining observation on 5/5/25 from 12:30 p.m. to 12:55 p.m. in the dining room, HN shake was the only ONS observed to be in use for those residents with an order. During a concurrent observation and interview on 5/05/25 at 1:00 p.m. with CNA 2 in Resident 68's room, Resident 68 was sitting up in bed. CNA 2 was encouraging Resident 68 to eat. Resident 68 stated she received a supplemental shake [HN shake to increase calories and protein) but did not like it so she did not drink it. During an interview on 05/06/25 at 10:53 a.m. with CNA 1, CNA 1 stated CNAs document quantity consumed of HN (house nourishment shake) with the overall fluid intake from any of the fluids consumed located on the meal tray in which the total number of ml (milliliter) was typed into a box on the Activities for Daily Living (ADL) Flow Sheet (Monitor Fluid Intake/Document Fluid Intake Ml's logs). CNA 1 stated CNAs did not document the type of fluid by name, such as the name HN supplement or shake would not appear on the Document Fluid Intake Ml's flowsheet, therefore there would not be a mechanism for the RD or nursing leadership to provide oversight to ensure the HN supplement (shake or ONS) was being consistently provided as ordered, and would not be able to tell whether the HN ONS was being routinely consumed. During a concurrent observation and interview on 5/06/25 at 11:50 a.m. with Dietary Supervisor (DS) in the kitchen, 4 ounce (oz) sized cartons of strawberry flavored Mighty Shake were placed on meal trays for those residents who had an order for HN (house nourishment). DS stated we did not have Mightyshakes available yesterday so we made vanilla flavored HN shakes because they are equivalent. During review of the facility's recipe titled High Protein House Supplement Recipe (HN shake recipe), the HN shake recipe indicated a 4 oz portion provided 117 calories and 6 gm protein per serving. During a review of Nutrition Facts located on a 4 oz carton of Mightyshakes (MS), the MS provided 220 calories and 6 g of protein per serving, almost doubled the amount of calories provided versus the HN recipe. During a concurrent interview and record review on 05/06/25 at 3:00 p.m. with RD, Resident 68's Wt Mtg, dated 11/6/24, was reviewed. RD stated Resident 68 weighed 97 lbs on 11/4/24 which was a loss of 10.2% of body weight. RD stated IDT recommendations were to add HN 4 oz w/meals. During a concurrent interview and record review on 05/06/25 at 3:05 p.m. with RD, Resident 68's Wt Mtg, dated 12/5/24, was reviewed. The Wt Mtg note indicated Resident 68 weighed 90 lbs which was 7.2% further unplanned significant weight loss in a month and was an 18 lb wt loss (16.7% loss of body weight) over 3 months. The Wt Mtg indicated, Dietitian met with resident to educate resident on the importance of wt measurements, meeting EEN [estimated energy needs] and hydration needs for wound healing and wt maintenance. Resident verbalized understanding and indicated she is eating more and drinking the protein shakes. During an interview on 5/6/25 at 3:20 p.m. with RD, RD was asked how much of the 4 oz HN shake with meals Resident 68 consumed in the past month, after it was initiated a month prior as an intervention to prevent further weight loss. RD stated she would not be able to estimate how many calories and protein she consumed during the past month from the HN shake to determine whether the intervention was adequate to meet Resident 68's nutritional needs because the CNAs document the intake of the HN shake with the overall fluid intake of any beverages on the meal tray that was consumed. RD was asked if it was adequate to follow up on the effectiveness of the HN shake provided to address significant unintended weight loss a month later, during which time Resident 68 had lost 7 more lbs and may have benefited from an alternative ONS option to help minimize further weight loss earlier than waiting a month. RD stated following up a month later was not timely nutrition care. During a review of Resident 68's Wt Mtg, dated 12/31/24, Wt Mtg indicated, Wt: 85#. Wt Change: -23# (21.3%) x 3 months, po intake: 0-50%, Diet: fortified, double protein diet, Supplements: HN 4 oz with meals, ferrous sulfate, Vit C, Prostat, MVM, Skin: Stage 4 to sacrum, unstageable to R leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute (12/14) for syncope [fainting] and readmitted (12/16) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R [right] leg trauma wound. CDM [Certified Dietary Manager; Dietary Supervisor (DS)] met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN and instead add ice cream and chocolate pudding w [with]/L [lunch]&D[dinner]. Resident own RP [responsible party] and aware of increased risks for continued weight loss and skin deterioration with poor meal consumption and in agreement with below recommendations. IDT Recommendations: d/c [discontinue] HN, appetite stimulant, ST [speech therapist] eval. There was no documentation specifying alternative ONS were offered to Resident 68, if any. During an interview on 05/07/25 at 08:57 a.m. with LVN 3, it was shared with LVN 3 that there was no documentation that Resident 68 was offered an alternative ONS when she did not want HN shake and instead requested ice cream. LVN 3 stated she usually sees the facility using HN shake the majority of the time, and stated, why not Magic Cup instead of ice cream. During a review of Sysco 4 oz container of ice-cream the facility provided was 130 calories and 2 g protein, versus a 4 oz serving of Magic Cup (Frozen supplement that resembles ice-cream) would provide 290 calories and 9 g protein. During an interview on 05/07/25 at 09:07 a.m. with Resident 68's specialized MD in wounds, in the presence of LVN 3, MD stated he agreed, without adequate fluid intake and offering alternative nutrition interventions the facility did not do all they could to improve wound healing. (Cross Refer F807) During an interview on 05/08/25 at 09:16 a.m. with DS, DS stated the facility primarily used HN shake recipe for ONS. DS reviewed the food purchase/ONS purchases from January 2024 to present and stated it was very likely there were no further ONS purchases made by her or the RD, other than one food invoice for one case of 32 oz sized carton of Sysco Imperial Supplement MedPlus Vanilla (which would provide 240 kcal and 10 g pro per 4 oz serving), and Sysco supplemental shake, strawberry and vanilla flavor, which provided 200 kcal and 8 g pro per 4 oz with a delivery date of 5/4/24. DS stated Prostat that was ordered for Resident 68 was purchased and delivered from the facility's central supply and she did not know of any other routine ONS that would be available at the facility. DS stated there was a recall of Sysco health shakes, however, the recall of Sysco Imperial Supplement Shake did not occur until Februrary 2025. During a review of the U.S. Food and Drug Administration (FDA) website, FDA indicated, On February 22, 2025, [NAME] LLC recalled 4 oz. [NAME] ReadyCare and Sysco Imperial Frozen Supplemental Shakes. Frozen supplemental shakes under brands [NAME] ReadyCare and Sysco were the only shakes that were recalled starting in February 2025. https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-listeria-monocytogenes-frozen-supplemental-shakes-february-2025. Statement Regarding Recall of Nutritional Shakes - Prairie Farms Dairy, Inc. The Vital Cuisine Mightyshakes observed in use by the facility on 5/6/25 during lunch trayline were not recalled. During a review of Resident 68's Progress Notes, (PN) dated 1/16/25, the PN indicated, Met with resident to update food preferences. Resident would like to discontinue with house nourishments and receive ice cream with lunch and dinner instead. Nurse informed. Dietary supervisor available prn., signed by DS. During a review of Resident 68's PN, dated 1/30/25, the PN indicated, IDT-Skin Integrity Review Mtg: . Asked for ONS [HN shake] to be d/c despite risks vs benefits and high risk of continued weight loss explained. During review of Resident 68's Discontinue Order, (DO) dated 2/3/25, the DO indicated, House Supplement three times a day 4 oz HN with meals, preferences reviewed with resident and updated by kitchen director [DS]. During a review of Resident 68's Admission history and physical examination (H&P), dated 2/5/25 as Late Entry, the H&P indicated, Resident 68 weighed 86 lbs with poor nutrition and continue Ensure [an ONS], however, Resident 68 did not have an order for Ensure, and was not provided with Ensure. During review of multiple PN's, as indicated above, Resident 68 had been telling the facility since 12/31/24 that she did not like nor want the HN shake (it was recommended by IDT on 11/6/24). There were no documented ONS alternatives specifically listed as to what ONS, if any, were offered to Resident 68 who had documented increased nutritional needs. During a review of Resident 68's Order Summary Report (OSR), dated 5/8/25, the OSR indicated regular diet, mechanical soft texture, fortified ordered on 1/17/25 and Prostat BID 60ml [increased from 30 ml BID Resident 68 had since admission]. During a review of Resident 68's progress note, dated 2/6/25, she was eating 26-50% of her fortified diet (double protein was no longer documented). During a review of Resident 68's interdisciplinary nutrition Care Plan Report, with a target date of 5/26/25, Resident 68's nutrition interventions were fortified diet, ice cream with lunch and dinner, Prostat 60 ml BID, antidepressant medication and appetite stimulant medication, vitamins and/or minerals as ordered, ST eval was her nutritional care plan. During a review of Resident 68's Medication Administration Record (MAR), dated May 2025, the MAR indicated from 5/1/25 through 5/5/25 Resident consumed 50% of the ordered Prostat 8 out of 10 times the Prostat was provided to Resident 68. There was no documentation an alternative nutrition intervention, to promote variety and continued palatability, designed for wound healing was offered to Resident 68 who had been receiving the same Prostat for a prolonged period of time since admission, nine months earlier. During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change of condition.Components of the assessment may include, but are not limited to:.Food and fluid intake, Evidence of fluid loss.Evaluation/analysis: The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. Care plan implementation: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident.Monitoring/revision:.Evaluating the care plan to determine if current interventions are being implemented and are effective.The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. 3. During a review of Resident 68's Wt Mtg, dated 12/31/24, Wt Mtg indicated, Wt: 85#. Wt Change: -23# (21.3%) x 3 months, po intake: 0-50%, Diet: fortified, double protein diet, Supplements: HN 4 oz with meals, ferrous sulfate [form of iron], Vit C, Prostat, MVM [multivitamin with minerals], Skin: Stage 4 to sacrum, unstageable to R leg, trauma wound to R leg, skin tear to R forearm, resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted (12/16/2024) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound. CDM met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN and instead add ice cream and chocolate pudding w[with]/L[lunch]&D[dinner]. Resident own RP [responsible party] and aware of increased risks for continued weight loss and skin deterioration with poor meal consumption and in agreement with below recommendations. IDT Recommendations: d/c [discontinue] HN, appetite stimulant, ST [speech therapy] eval [evaluation]. During a concurrent interview and record review on 05/06/25 at 3:30 p.m. with RD, RD was asked if monitoring fluid intake to assess hydration was part of an RDs responsibility when conducting a nutrition assessment and/or follow up, and RD stated yes. RD was asked if she reviewed Resident 68's fluid intake from meals as documented by CNAs, and RD stated Resident 68 was not on I & O's [No order to require nursing to document all fluid intake and urine output]. RD was asked if a resident's fluid intake from meals was standards of practice to consider when evaluating whether a resident was consuming enough fluids to promote adequate hydration, and RD stated, yes. RD stated she had not been gathering data from resident's individualized Monitor Fluid Intake logs to evaluate fluid intake from meals and had not been documenting fluid intake to compare to a resident's assessed daily fluid needs to assess hydration status which was a component of nutrition assessment. During a concurrent interview and record review on 05/06/25 at 3:40 p.m. with RD, RD began reviewing Resident 68's Monitor Fluid Intake logs recorded from meals for the week prior to Resident 68's admit to the hospital on 12/14/24 when IV hydration was administered. RD stated, I don't know how accurate that is [the documentation by CNAs related to ml fluid intake from meal trays] which was why I have not been reviewing the fluid intake logs. RD was asked if she had brought her concern to Quality Assurance committee and participated in providing recommendations for performance improvement related to accurate monitoring, tracking and analyzing hydration status for residents to promote early identification of insufficient fluid intake prior to complications such as dehydration, and RD stated no. RD stated Resident 68 had inadequate fluid intake for the majority of the week based on the fluid monitoring logs from meal trays prior to being discharged to the hospital. RD stated she had not identified the insufficient fluid intake to communicate the concern to IDT and/or the physician as she had not been reviewing the fluid intake logs. RD stated she had not been documenting fluid intake to determine whether Resident 68's daily fluid needs were being met, or improving toward a goal as she had also not re-assessed Resident 68's daily fluid needs after Resident 68 had a significant change of condition. RD did not follow and implement the facility's P & P's titled Nutritional Management, dated 1/2025, Hydration, dated 2022, nor Weight Assessment and Intervention, dated 2011 in which all three P&P's required RD to assess Resident 68's individual fluid needs to establish a goal for fluid intake, including after a significant change of condition, evaluate fluid intake as to whether intake meets Resident 68's individualized hydration needs, and monitor intake and notify the physician responsible for care of Resident 68 if there was lack of improvement toward fluid goals. (Cross Refer F807) During an interview on 05/06/25 at 03:57 p.m. with Director of Nursing (DON), DON stated the CNAs see how much fluid residents are drinking and they chart that into PCC (software used for resident's electronic health record) so in IDT meetings ADON (Assistant Director of Nursing) should access those monitoring fluid intake logs and discuss with IDT. During an interview on 05/06/25 at 04:06 p.m. with ADON, ADON stated, yes, daily monitoring of the fluid intake from meals log to identify potential concerns before outcome becomes worse would be ideal, I do not routinely monitor the fluid intake documented by the CNAs. During a concurrent observation and interview on 5/7/25 at 11:58 a.m. with Resident 68 in Resident 68's room, Resident 68 was lying in bed, lips were observed to be cracked and dry, and eyes appeared to have dark circles around them. Resident 68 stated facility staff had not asked her what her beverage preferences were or beverages she would drink if she were home. During a review of Resident 68's Nutrition Status Care Plan Report (IDT nutrition care plan/IDTNCP), dated 5/6/2025, the IDTNCP indicated, Interventions, lacked notation to indicate Resident 68 had been ordered an HN shake 4 oz with meals [TRUNCATED]

Based on interview, and record review, the facility failed to follow its policy and procedure regarding Advance Directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 446) were informed about their right to complete and AD or had evidence of declining to complete an AD. This failure had the potential for responsible parties and/or medical professionals not to honor resident healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation. Findings: During a concurrent interview and record review on 5/7/25 at 8:35 a.m. of Resident 446 medical record with Business Office Manager (BOM). BOM reviewed the medical record for Resident 446 and was unable to provide evidence of Resident 446 and/or responsible party were offered an opportunity to formulate or decline an AD. During a review of the facility policy and procedure (P&P), titled Resident Rights Regarding Treatment and Advance Directive, dated 2025, indicated, Policy It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.

Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 73), personal belongings were replaced within a timely manner once the items were reported loss. These failures resulted in Resident 32 and Resident 73 lost items not being replaced During an interview on 5/6/25 at 10:33 a.m. with Resident 73, Resident 73 stated his watch had been missing since December 2024. Resident 73 stated he had reported his missing watch to the social worker. Resident 73 was told by the social worker that the facility will replace the missing watch. Resident 73 stated he was upset that his watch had been missing, and the facility had not replaced the watch. During a review of Resident 73's Admission Record, (AR) dated 5/7/25, the AR indicated Resident 73's admitted was 9/9/24. During a review of Resident 73's Minimum Data Set, (MDS - a federally mandated resident assessment tool) dated 3/14/25, the MDS indicated Resident 73 had a (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (score of 13-15 means cognitively intact). During a review of Resident 73's Inventory List, (IL) dated 9/9/24, the IL indicated jewelry, one watch. During an interview on 5/7/25 at 10:30 a.m. with Acting Activities Director (AAD), AAD stated when she receives a theft or loss report, she will go speak to the resident. AAD stated the facility will replace missing items within seven days. During an interview on 5/7/25 at 10:36 a.m. with Administrator, Administrator stated her expectation from staff on loss or theft are to report to AAD, fill out the theft/loss form, and replace Resident 73's missing item within seven days. 45654 During an interview on 5/7/25 at 11:18 a.m. with Resident 32, Resident 32 stated a month ago her grey sweatshirt went missing. Resident 32 stated it was her favorite her daughter had given it to her. Resident 32 stated she reported the missing sweatshirt to housekeeping. During an interview on 5/8/25 at 10:55 a.m. with Laundry, Laundry stated social services tells us to look for missing clothing items. Laundry stated I inform my boss of missing clothing now since there is no current social services staff. During a review of the facility's policy and procedure (P&P) titled, Resident Personal Belongings, Undated, the P&P indicated, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings .7. The facility will exercise reasonable care for the protection of the resident's property from loss or theft.

Based on interview and record review, the facility failed to ensure a Significant Change in Status MDS Assessment (MDS-a federally mandated resident assessment tool; SCSA- a comprehensive assessment completed within 14 days of the identification of a status change) was completed for one of one sampled resident (Resident 68) when Resident 68 had a major decline in two or more MDS areas as evidenced by unplanned significant weight loss and the development of a new wound. This failure had the potential for Resident 68 to have unmet care needs. Findings: During a concurrent interview and record review on 05/08/25 at 11:14 a.m. with MDS Coordinator (MDSC), MDSC reviewed Resident 68's electronic health record (EHR). MDSC stated she should have completed a significant change of status MDS at the same time she had completed a quarterly MDS on 2/26/25 as Resident 68 had major decline in two MDS care areas which were significant weight loss not on prescribed weight-loss regimen and a new wound that triggered on the quarterly MDS. During a review of Resident 68's quarterly MDS, dated [DATE], the quarterly MDS indicated, D 1. Number of Stage 4 pressure ulcers: 1, D 2. Number of these Stage 4 pressure ulcers that were present upon admission/reentry: 1. During a review of Resident 68's quarterly MDS, dated [DATE], the quarterly MDS indicated, D 1. Number of Stage 4 pressure ulcers: 3, D 2. Number of these Stage 4 pressure ulcers that were present upon admission/reentry: 2. During a review of Resident 68's RD [Registered Dietitian]/IDT [interdisciplinary team] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 12/31/24, the Wt Mtg indicated, Wt: 85# (pounds). Wt Change: -23# (21.3%[percent loss of body weight]) x [for] 3 months,.Prostat [supplement to increase protein and calories], MVM [multivitamin with minerals], Skin: Stage 4 [pressure injury with full-thickness skin and tissue loss] to sacrum [bone in the lower portion of the spine], unstageable [pressure injury with covered full-thickness skin and tissue loss] to R [right] leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted (12/16/2024) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound. During a review of Resident 68's Weights and Vitals Summary (WVS), the WVS indicated, on 08/23/2024, Resident 68 weighed 113 lbs. On 02/17/2025, Resident 68 weighed 87 pounds which is a -23.01 % Loss [of body weight] in last 6 months. During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with RD, Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated relevant diagnoses.moderate protein-calorie malnutrition, adult failure to thrive [a process of physical and psychological decline], pressure ulcer. Diet order: Regular diet, Regular texture, Height: 59 [inches] Date: 8/23/24, Weight: 113 pounds (lbs) Date: 8/26/24, Appearance/Skin full thickness unstageable (pressure injury covered full-thickness skin and tissue loss to coccyx [tailbone], wound to R lateral leg, Nutrition Needs Estimate: 1,541 calories daily, Protein (Pro): 77 grams (g) daily, Fluids: 1,541 ml (milliliter- measurement of capacity), Discussed importance of meeting EEN [estimated energy needs] and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs r/t [related to] wound healing, RD recommends: Prosat 30 ml BID [two times a day for increased calories of 200 and 30 g of pro]. Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s (signs/symptoms) of dehydration. During a review of Resident 68's RD/IDT Weight Variance Meeting (Wt Mtg), dated 2/6/25, the Wt Mtg indicated Resident 68 was on a fortified diet [added 500 calories], Prostat 60 ml BID [added 400 calories and 60 g pro], on appetite stimulant indicative of not being on a prescribed weight-loss regimen. During a review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion, dated 2022, the P&P indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: d. Significant change is a major decline or improvement in a resident's status that: (1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting, if a decline); 2) impacts more than one area of the resident's health status, and (3) requires interdisciplinary review and/or revision of the care plan. Quarterly Assessment - completed using an ARD [Assessment Reference Date] no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). The R.N. [Registered Nurse] Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI [Resident Assessment Instrument], once all disciplines have completed their sections. 51540

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Matrix was accurate and up to date for three of eight sampled residents (Resident 1, Resident 23 and Resident 68). This failure resulted in the documentation of an inaccurate assessment and an inaccurate quarterly MDS for Resident 68. Findings: During a review of the facility's Resident Matrix, (RM) dated 5/5/25, the RM indicated, Resident 1 listed anticoagulant (medication used to help prevent blood clots from forming or growing) and Resident 23 listed antibiotic. During an interview on 5/5/25 at 10:16 a.m. with Resident 1, Resident 1 stated he is not currently taking any anticoagulant medications. Resident 1 stated he stopped taking anticoagulant medications this past January. During a review of Resident 1's Admission Record (AR), dated 5/7/25, the AR indicated Resident 1's initial admitted was 11/22/24. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had a (Brief Interview for Mental Status [BIMS] -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (score of 13-15 means cognitively intact). During a concurrent interview and record review on 5/8/25 at 10:28 a.m. with Minimum Data Set Coordinator (MDSC), Resident 1's Discontinue Order, DO dated 12/6/24 was reviewed. The DO indicated, Order Summary: Eliquis Oral Tablet 5 MG [milligram] (Apixaban) Discontinue Dated: 12/6/2024 Reason for Discontinue: D/C [discontinue] per MD [Doctor of Medicine] orders. MDSC stated she had refreshed the matrix on 5/5/25. MDSC stated Resident 1 is currently not on an anticoagulant medication. During an interview on 5/5/25 at 10:31 a.m. with Resident 23, Resident 23 stated he is not currently taking antibiotics. During a review of Resident 23's AR, dated 5/7/25, the AR indicated Resident 23's initial admitted was 2/25/25. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had a BIMS score of 15. During a concurrent interview and record review on 5/8/25 at 10:36 a.m. with MDSC, Resident 23's DO dated 2/25/25 was reviewed. The DO indicated, Order Summary [OS]: ceftazidime [medication used to treat infections] Intravenous [IV-administered directly into a vein] Solution .Discontinue Date: 2/25/2025. MDSC stated Resident 23 was admitted in the facility with IV antibiotic therapy. MDSC stated Resident 23 was on ceftazadine and was discontinued on 3/18/25. During an interview on 5/8/25 at 10:39 a.m. with MDSC, MDSC stated she generally tried to keep the matrix up to date on Fridays. MDSC stated she can manually update the matrix. MDSC stated she didn't get a chance to update the Matrix and she should have updated the Matrix. During an interview on 5/8/25 at 10:43 a.m. with Administrator, Administrator stated her expectations for the MDSC is for the Matrix to be updated on Fridays. During a review of the facility's RAI Coordinator - Job Description, RAI Coordinator - Job Description dated 2020, the RAI Coordinator - Job Description indicated, Major Duties and Responsibilities: Accurate completion of all MDS assessments and any supporting assessments or clinical documentation. A policy was requested and none were provided. 27157 During a review of Resident 68's Resident Matrix (RM), dated 5/5/25, the RM was reviewed. The RM did not have a check mark in the box under Excessive Weight Loss Without Prescribed Weight Loss Program. During a concurrent interview and record review on 05/08/25 at 11:38 a.m. with MDS Coordinator (MDSC), Resident 68's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/26/25, was reviewed. The quarterly MDS, with Assessment Reference Date (ARD) dated 2/26/25 indicated, K0200 B. Weight (in pounds) - 87, section K0300. Weight Loss; Loss of 5% [percent] or more in the last month or loss of 10% or more in last 6 months was coded as 1. Yes, on prescribed weight-loss regimen. MDSC stated the section titled K0300. Weight Loss; Loss of 5% or more in the last month or loss of 10% or more in last 6 months was not coded accurately, as it should have been coded as 2. Yes, not on prescribed weight-loss regimen, as the facility was not intentionally trying to get Resident 68 to lose weight. During a review of Resident 68's Weights and Vitals Summary (WVS), the WVS indicated on 08/23/2024, Resident 68 weighed 113 pounds (lbs) On 02/17/2025, Resident 68 weighed 87 lbs which is a -23.01 % loss of body weight in last 6 months. During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with Registered Dietitian (RD), Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated relevant diagnoses.moderate protein-calorie malnutrition, adult failure to thrive (a process of physical and psychological decline), pressure ulcer. Diet order: Regular diet, Regular texture, Height: 59 [inches], dated 8/23/24 and weight of 113 lbs dated: 8/26/24. Appearance/skin full thickness unstageable (pressure injury covered full-thickness skin and tissue loss to coccyx (tailbone), wound to R (right) lateral leg, nutrition needs estimate: 1,541 calories daily, protein (pro): 77 grams (g) daily and fluids: 1,541 ml (milliliter-measurement of capacity). The NE indicated RD, Discussed importance of meeting EEN (estimated energy needs) and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs related to wound healing, RD recommends: Prosat [nutrition supplement; increase of 200 calories; 30 g of pro] 30 ml BID (two times a day). Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s [signs/symptoms] of dehydration. During a review of Resident 68's RD/IDT Weight Variance Meeting (Wt Mtg), dated 2/6/25, the Wt Mtg indicated Resident 68 was on a fortified diet [added 500 calories], Prostat 60 ml BID [added 400 calories and 60 g pro], on appetite stimulant indicative of not being on a prescribed weight-loss regimen. During a concurrent interview and record review on 05/08/25 at 11:45 a.m. with MDSC, Resident 68's RM, dated 5/5/25, was reviewed. MDSC stated Resident 68's RM was not accurate as it did not have a checkmark for Excessive Weight Loss Without Prescribed Weight Loss Program and should have. MDSC stated the error was made on Resident 68's RM because the quarterly MDS, dated [DATE], was not accurate. During a review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion, dated 2022, the P&P indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: Quarterly Assessment - completed using an ARD [Assessment Reference Date] no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). The R.N. [Registered Nurse] Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI [Resident Assessment Instrument], once all disciplines have completed their sections.

Based on observation, interview, and record review the facility failed to provide quality care to one of one sampled resident (Resident 25) when: 1. Resident 25 had a chocking episode that was not immediately identified and addressed by nursing staff who were present in the dining room at the time of occurance. 2. A comprehensive (complete) assessment was not completed for Resident 25 after a chocking episode and delegation (assigning a task) of monitoring Resident 25 for safety was given to nonnursing staff position titled Hospitality Aid (HA). 3. Education was not provided to a family member who routinely fed Resident 25 who was on aspiration precautions (preventive measures taken to reduce the risk of accidental inhalation of food, liquid, or other substances into the lungs) to ensure swallow strategies, as assessed by a Speech Therapist (ST), was implemented. 4. Resident 25's thickened liquids (to help individuals with swallowing difficulties based on individualized assessment) order was not followed. These failures resulted in Resident 25 having unidentified needs and improper assessment during an episode of chocking with potential for aspiration or death. Findings: 1. During a review of Resident 25's facesheet, the facesheet indicated Resident 25 was admitted to the facility on [DATE] with diagnosis of aphasia (a language disorder that impairs a person's ability to understand and verbalize) and Alzheimer's (a brain disorder that impairs thinking and memory skills) disease. During a review of Resident 25's Minimum Data Set (MDS), dated [DATE], the MDS indicated Section C: BIMS [Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] score 0 [indicates severe cognitive impairment]. During an observation on 05/05/25 at 1:04 p.m. in the dining room, Resident 25 took a bite of food and began coughing continuously and then vomited into plastic red plate cover. Family Member (FM) 1, who was sitting next to Resident 25, flagged a nurse to check on Resident 25 after she vomited. Director of Staff Development (DSD), who was present in the dining room while Resident 25 was coughing, responded to FM 1 by going over to Resident 25. FM 1 requested Resident 25 be taken back to Resident 25's room. As Resident 25 was being wheeled out of the dining room by DSD, Resident 25 was still coughing. During an interview on 05/05/25 at 1:19 p.m. with the Assistant Director of Nursing (ADON), ADON stated she was in the dining room sitting in front of Resident 25 but was assisting another resident with eating. ADON stated she saw Resident 25 being wheeled out of the dining room, but other than that she did not hear anything. ADON stated DSD told her Resident 25 had vomited and DSD assessed her. During an interview on 05/07/25 at 10:18 a.m. with ADON, ADON stated the facility assigned DSD and Licensed Vocational Nurse (LVN) 3 to provide general supervision of residents eating in the dining room for emergent (emergency) reasons. ADON stated DSD and LVN 3 were present in the dining room and should have immediately attended to Resident 25 when she was coughing and vomiting, and that did not happen. During an interview on 05/07/25 at 11:15 a.m. with DSD, DSD stated he was aware of his responsibility to supervise during mealtimes. During a review of American Heart Association Basic Life Support (BLS) training, the BLS training indicated, The AHA's BLS course trains participants to promptly recognize several life-threatening emergencies. During a review of DSD's employee training, DSD was issued Basic Life Support (BLS) on 3/20/24 with an expiration date of 03/2026. During a review of the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance, the P&P indicated .adequate supervision and assistance to prevent accidents. 2. a) During a concurrent observation and interview on 05/05/25 at 1:13 p.m. with DSD, Resident 25 was taken back to her room by DSD after coughing/choking and vomited while eating lunch in the dining room. DSD stated, FM 1 stated Resident 25 was vomiting which was why FM 1 called me over. DSD stated he took Resident 25 back to her room and performed an assessment, which consisted of palpating (examination by touch) Resident 25's stomach in which Resident 25 did not grimace (expression) in pain. DSD stated Resident 25 was left in her room sitting in her wheelchair. During an observation on 05/05/25 at 1:18 p.m. Resident 25 was sitting in her wheelchair in her room next to her bed. During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated an appropriate resident assessment for someone who was choking should be assessing how the resident looks, are there signs and symptoms of aspiration, assessment of the way a resident was breathing, any respiratory (lung) distress, and any abdominal (stomach) pain. ADON stated palpating the abdomen only was not an accurate assessment to have completed on Resident 25 after the coughing and vomiting episode. During an interview on 05/07/25 at 11:01 a.m. with Licensed Vocational Nuse (LVN) 2, LVN 2 stated DSD said Resident 25 was observed to have one episode of coughing and one episode of vomiting in the dining room. LVN 2 stated DSD, and I laid Resident 25 in her bed (bed was at a 30-degree angle), and completed an assessment. LVN 2 stated the assessment included an assessment of G-Tube (gastrostomy tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and residual (remaining or left over contents) and Resident 25's blood pressure was taken. During an interview on 05/07/25 at 11:26 a.m. with ADON, ADON stated LVN 2's assessment was not appropriate for Resident 25. ADON stated LVN 2 should have assessed respiratory distress (danger), signs and symptoms of continual coughing, obstruction (blockage) of airway, and completed an oral cavity (mouth) assessment. ADON stated the lack of proper assessment was not a safe practice, and the staff needed more education on focused assessments. ADON stated when a proper assessment was not completed there could be signs and symptoms that were missed, therefore potentially not addressed, which could cause the patient to have further distress. During a review of Resident 25's Change in Condition Evaluation (COC), dated 5/5/25, the COC indicated Resident 25, observed having x1 episode of vomiting and x1 episode of cough. Resident removed from dining and taken back to room, for further assessment. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. b) During an interview on 05/05/25 at 1:13 p.m. with DSD, DSD stated he communicated to the HA to watch Resident 25 due to coughing and vomiting. DSD stated he did not mention the incident to anyone other than HA. During an interview on 05/06/25 at 10:56 a.m. with DSD, DSD stated the Hospitality Aid duties are to stay inside the room for redirection (to direct to a different place or purpose) of residents. During an interview on 5/6/25 at 12:47 p.m. with HA, HA stated his job was to watch all three residents in the room because those residents were at a higher risk of falling. HA stated no credentials (qualifications) are required for this position. During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated the Hospitality Aid was not a licensed CNA (certified nursing assistant); therefore, they could only monitor for safety. ADON stated HAs cannot assist in feeding or providing care to residents. ADON stated DSD should have reported to Resident 25's primary nurse. ADON stated appropriate delegation to the HA was for risk of falls or in case Resident 25 was in severe distress, the HA could call for help; however, in this situation the seriousness was not falling, the seriousness of the event was the choking, therefore this was not an appropriate delegation. During a review of Job description for Hospitality Aide (JDHA), the JDHA indicated The primary purpose of your job position is the provision of services to the residents. At no time are you to provide direct care to the residents. 3. During an observation on 5/6/25 at 1:02 p.m. in the dining room, Resident 25 was sitting in a wheelchair at a dining table with Family Member (FM) 1 to the right. Resident 25 was served a lunch meal with pureed diet; red drink (appeared to be thin liquid). FM 1 started feeding Resident 25 large bites of pureed food on a spoon. Resident 25 took several sips of red colored drink after each bite. Resident 25 was still chewing when FM 1 gave Resident 25 another bite. During an interview on 5/6/25 at 1:13 p.m. with DSD, DSD stated the expectation was to educate and teach Resident 25's family member who routinely fed Resident 25 about her diet and feeding skills to maintain consistency (performing in a similar way) when family helps feed Resident 25. During a concurrent interview and record review on 05/07/25 at 10:18 a.m. with ADON, Resident 25's care plan titled Resident has declined in: swallowing function resulting to risk in aspiration, dated 1/2025 was reviewed. The care plan indicated interventions Aspiration precautions: slow rate, small bite size, chin tuck, double swallow, position upright as close to 90 degrees as possible. ADON stated she was aware Resident 25 needed to follow aspiration precautions listed on the care plan. ADON stated the only intervention she would not be able to visualize was double swallowing. ADON stated she could visualize position, chin tuck (ADON demonstrated chin tuck by moving her chin down to her chest), and small bites. ADON stated FM 1 does not have training regarding feeding precautions for Resident 25 and should have been trained. During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated the way FM 1 was feeding Resident 25 was not appropriate based on observation of FM 1 feeding Resident 25 on 05/06/25. ADON stated this meant [name of FM 1] was not educated or did not understand the education provided to properly feed Resident 25 per Resident 25's Care Plan and aspiration precautions. During an interview on 05/07/25 at 10:46 a.m. with Minimum data Set Coordinator (MDSC), the MDSC stated a BIMS (Brief Interview for Mental Status) of zero, as listed for Resident 25, meant resident could not respond to the questions asked. MDSC stated when I spoke with Resident 25, she could verbalize (express) some needs but, at the time of the interview Resident 25 did not give a response to the questions. MDSC stated Resident 25 was more verbal on some days and other days Resident 25 was non-verbal. During an interview on 5/7/25 at 11:01 a.m. with LVN 2, LVN 2 stated FM 1 feeds Resident 25 100% of the time. During a review of Resident 25's Order Details (OD), dated 1/14/25, the OD: indicated ST [speech therapy] eval [evaluation] and tx [treatment] as indicated. During a concurrent interview and record review on 05/07/25 at 04:11 p.m. with ST, Resident 25's Care plan titled Resident has declined in: swallowing function resulting to risk in aspiration, dated 1/2025 was reviewed. The care plan indicated interventions Aspirations precautions: slow rate, small bite size, chin tuck, double swallow, position upright close to 90 degrees as possible. ST 1 stated this care plan was created by me and the interventions are compensatory (making up for a loss), the chin tuck protects the airway. ST stated diet recommendation was puree at this time food trials were being completed for Resident 25. ST stated the care plan indicated what was provided during treatments which included honey-thick liquids. ST stated Resident 25 was discharged on [DATE] from speech therapy because Resident 25 was sent to the hospital for vomiting and G-Tube dislodgement. ST stated Resident 25 never came back to speech therapy after returning from the hospital. During a concurrent interview and record review on 05/07/25 at 04:11 p.m. with ST, Resident 25's Speech Therapy Note (STN) dated 1/21/25 was reviewed. The STN indicated PT (patient)/caregiver ed (educated) to ensure safety of intake and oral hygiene to reduce risks for bateria [sic] in the lungs and prevention of bacterial pneumonia. ST stated a caregiver was anyone who was caring for the resident, this included family and staff. ST stated I am not sure if her family member or Certified Nursing Assistant (CNA) was trained. ST stated for Resident 25 I educated Resident 25 to the best of her ability and understanding. ST stated because of Resident 25's diagnosis of aphasia ST had to model a lot of the education provided to Resident 25. ST stated if Resident 25 was still in speech therapy she would be responsible for training family on feeding Resident 25 appropriately. ST stated her expectations were the interventions should have continued for Resident 25's safety. 4. During an observation on 5/6/25 at 1:02 p.m. in the dining room, Resident 25 was served her lunch meal tray. Resident 25 was observed drinking a red colored liquid that appeared to be a thin liquid. During an interview on 5/6/25 at 1:15 p.m. with FM 1, FM 1 stated the red liquid was thin, not thick like the white drink she also was served. During an interview on 5/6/25 at 1:18 p.m. with Dietary Aide (DA), DA stated she prepared thickened punch and placed punch on meal trays. During a review of Resident 25's Order Summary (OS), dated 4/10/25, the OS indicated CCHO [diabetic diet]/NAS [no added salt] diet Puree texture, Nectar consistency, Dietary oral gratification PO [by mouth] diet small portion. During a review of Resident 25's Meal Ticket (MT), the MT indicated Resident 25 had nectar thickened liquids. During a review of the facility's policy and procedure (P&P) titled, Serving a Meal, the P&P indicated diets should be served in accordance with the physician orders. During a review of the facility's P&P titled, Therapeutic Diet Orders, the P&P indicated The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pain Management, for one of one sampled resident (Resident 77) when Resident 77's pain was not controlled consistently. This failure had the potential for Resident 77's pain not to be correctly managed. Findings: During an interview on 5/7/25 at 1:50 p.m. with Resident 77, Resident 77 stated two weeks ago the nurse told her she needed to take a different medication and not her regular pain medication. Resident 77 stated she felt horrible for hours going without her pain medication. During a review of Resident 77's Physician Order (PO) dated 4/21/25, the PO indicated, Oxycodone HCL [narcotic medication for acute pain 0- no pain, 1-3 mild pain, 4-6 moderate pain interfering with daily activities, 7-9 severe pain, difficult to tolerate or manage, 10 worst pain possible]oral tablet 5 mg [milligram], give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. During a review of Resident 77's PO, dated 4/21/25, the PO indicated, Acetaminophen Tablet 325 mg give 2 tablets by mouth every 4 hours as needed for Mild pain 1-3 Not to exceed 3 grams Acetaminophen in 24 hours. During a concurrent interview and record review on 5/8/25 at 10:25 a.m. with Assistant Director of Nursing (ADON), Resident 77's Medication Administration Record (MAR) dated April 2025 was reviewed. The MAR indicated the following: On 4/21/25 at 5:00 p.m. Oxycodone HCL 5 mg. On 4/21/25 at 10:54 p.m. Oxycodone HCL 5 mg. On 4/22/25 at 10:34 a.m. Oxycodone HCL 5 mg. On 4/22/25 at 4:16 p.m. Oxycodone HCL 5 mg. On 4/22/25 at 10:50 p.m. Oxycodone HCL 5 mg. On 4/23/25 at 6:17 a.m. Oxycodone HCL 5 mg. On 4/23/25 at 11:38 a.m. Oxycodone HCL 5 mg. On 4/23/25 at 4:48 p.m. Oxycodone HCL 5 mg. On 4/23/25 at 11:37 p.m. Oxycodone HCL 5 mg. On 4/24/25 at 10:00 a.m. Oxycodone HCL 5 mg. On 4/24/25 at 3: 00 p.m. Oxycodone HCL 5 mg. On 4/25/25 at 4:54 a.m. Oxycodone HCL 5 mg. On 4/25/25 at 11:00 a.m. Oxycodone HCL 5 mg. On 4/26/25 at 6:30 a.m. Oxycodone HCL 5 mg. On 4/27/25 at 5:13 p.m. Acetaminophen 325 mg. On 4/28/25 at 3:19 a.m. Acetaminophen 325 mg. On 4/26/25 at 11:16 a.m. Oxycodone HCL 5 mg. On 4/29/25 at 11:00 a.m. Oxycodone HCL 5 mg. On 4/29/25 at 9:30 a.m. Oxycodone HCL 5 mg. ADON stated Resident 77 was a chronic pain management resident. ADON did not provide an answer for Resident 77 receiving Acetaminophen medication on 4/27/25 and 4/28/25. During a review of the facility's P&P titled, Pain Management, dated 10/2022, the P&P indicated, Pain Management and Treatment, 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professional and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain at admission.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation and accountability for the destruction of controlled substances, the facility did not ensure controlled substances were destroyed in the presence of a licensed pharmacist, and destruction was appropriately documented with a nurse and a pharmacist signatures. This failure had the potential to result in diversion or mismanagement of controlled medications. Findings: During an observation on 5/7/25 at 8:38 a.m. in the Director of Nursing (DON) office, there was a locked cabinet used to store medications to be destroyed. During a concurrent interview and record review on 5/7/25 at 8:38 a.m. with the Assistant Director of Nursing (ADON), The facility Controlled Medication Destruction Log (MDL), dated 03/25 and 04/25 were reviewed. The MDL indicated, entries had not been dated and signed without a pharmacist involvement. ADON stated she was unable to clarify the following entries: had been dated and signed without pharmacist involvement. The MDL indicated the following: On 3/6/25 RX # R817831 Oxycodone [Oxycodone is a prescription opioid pain medication used to relieve moderate to severe pain (generally falls within a range of 5-10 on a 0-10 pain scale)]. 10 mg. On 3/7/25 RX # 752758 Lorazepam [providing short-term relief from anxiety symptoms and is often prescribed for various anxiety disorders, including generalized anxiety disorder and panic disorder]. 0.5 mg. On 3/7/25 RX # 752006 Morphine 15 mg. [pain medication used to relieve severe pain (generally falls within a range of 7-10 on a 0-10 pain scale)]. On 3/7/25 RX # 831375 Hydrocodone [a semi-synthetic opioid that is used to treat moderate to severe pain and as a cough suppressant (generally falls within a range of 5-6 on a 0-10 pain scale)]. 5-325 mg. On 3/7/25 RX # C8809092 Lorazepam 0.5 mg. On 3/7/25 RX # C0874708 Lorazepam 30 ml. On 3/7/25 RX # 824460 Morphine 15 mg. On 5/5/25 RX # 831375 Hydrocodone 10-325 mg. During an interview on 5/7/25 at 9:08 a.m. with Pharmacy Consultant (PC), PC stated she had not participated in the destruction of the medications in question. PC stated the nurse had incorrectly documented the destruction of narcotics without proper verification. PC stated no concurrent destruction had occurred for those entries and the documentation errors did not reflect actual disposal events. During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 4/2019, the P&P indicated, Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances .3b. the receiving pharmacist and a registered nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned .6c. Disposal of controlled subtances must take place immediately (no longer than three days) after discontinue of use by the resident .7d. Document the disposal on the medication disposition record. 7e. Include the signature(s) of at least two witnesses .11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. the name and strength of the medication; d. The name of the dispensing pharmacy; e. the quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses.

Based on observation, interview, and record review, the facility failed to ensure three of twenty eight opportunities for medication administration were performed without error, resulting in an 11% medication error rate. These failures had the potential for: 1. Resident 46, ineffective medication delivery. 2. Resident 46, omissions are inconsistent with manufacturer instructions for use. 3. Resident 34, to rotate injection sites as required. Findings: 1. During a review of the manufacturer's instructions for Combivent Respimat(inhaler for breathing difficulties) indicated, The patient should exhale fully, place lips around the mouthpiece, then inhale slowly and deeply while pressing the inhaler button. After inhalation, the patient should hold their breath for 10 seconds or as long as comfortable. During an observation on 5/6/25 at 9 a.m. in Resident 46's room during a medication pass, a Respiratory Therapist (RT) was observed administering Combivent Respimat to Resident 46. Resident 46 was not instructed to exhale fully prior to inhalation and hold their breath following the dose. During an interview on 5/6/25 at 9:15 a.m. with RT, RT stated, I just forgot to tell him to exhale and hold his breath. I know I'm supposed to, but I was moving quickly. 2. During a review of the manufacturer's instructions for Ellipta (inhaler for breathing difficulties) indicated: Instruct the patient to exhale fully before inhaling the dose. After inhaling, the patient should hold their breath for about 3-4 seconds, or as long as comfortably possible. During a cocurrent observation and interview on 5/6/25 at 9 a.m. in Resident 46's room, the RT was administering Ellipta to Resident 46. Resident 46 was not instructed to exhale prior to inhalation and was not told to hold their breath after receiving the dose. At 9:15 a.m., the RT stated, I just forgot to do it-I'll make sure to go slower next time. 3. During a review of the manufacturer's instructions for Humalog (used to treat low blood sugars) indicated, Injection sites should be rotated within the same region to reduce the risk of lipodystrophy [how the body breaks down fat]. During a concurrent observation and interview on 5/6/25 at 9:10 a.m. in Resident 34's room, Licensed Vocation Nurse (LVN) 2 was administering Humalog insulin to Resident 34 in the left lower abdomen. At 9:20 a.m., with LVN 2 stated, I gave it in the same spot as before because I forgot to rotate. I'll try to do better next time. During a review of Resident 34's Medication Administration Record, (MAR) dated 5/1/25, the MAR indicated, the left lower abdomen was also the last documented injection site.

51540 Based on observation, interview, and record review the facility failed to: 1. Follow the planned menu for finger foods diet for one of one sample resident (Resident 18) during lunch trayline (a system of food preparation). 2. Ensure the allotted fluid from dietary was followed as ordered pertaining to a fluid restriction for one of one sample resident (Resident 32). These failures had the potential for Resident 18 to have loss of independence and dignity, and Resident 32 to not have adequate hydration. Findings: 1. During an observation on 5/6/25 at 12:03 p.m. in the kitchen during lunch trayline observation, Resident 18's meal tray card indicated finger foods. A whole piece of chocolate cake was served onto Resident 18's lunch meal tray and placed on the meal delivery cart for distribution. Per the therapeutic diet spreadsheet Chocolate cake cut into smaller pieces was the planned menu for finger foods. During an interview on 05/06/25 at 12:03 p.m. with Registered Dietitian (RD), RD was asked to check if the planned menu for finger foods was followed. RD stated the cake was not cut into pieces as written on the therapeutic menu extension, it was just a smaller piece. During an observation on 5/6/25 at 12:09 p.m. in the kitchen, observed RD giving the chocolate cake to staff and asked them to cut into smaller pieces as indicated on Resident 18's meal tray ticket and on the menu. RD stated she did not like that because it might fall into pieces when picked up. During a review of Resident 18's Diet Order (DO), dated 5/1/23, the DO indicated, Regular diet: regular texture, thin liquids consistency, finger foods. During a review of Resident 18's Meal Tray Ticket (MTT), the MTT indicated, Resident 18 was on a finger food diet. During a review of Resident 18's Care plan-nutrition status (CP), dated 7/27/23, the CP indicated, Resident 18 is at risk for weight loss, dehydration, skin breakdown, and altered nutritional status.interventions: Diet as orders: finger food, fortified, regular diet. During an interview on 5/6/25 at 12:13 p.m. with RD in the kitchen, RD stated she approved the menus, including the planned menu for finger foods. RD stated she was aware it was the facility's RD responsibility to review and approve the menus and she had not identified concerns with the finger foods menu in advance in order to provide instruction to dietary staff on modification to the menu to address concerns that it may impede a resident's dignity while eating amongst others, or potential with difficulty getting the food into the mouth, if the food might be falling between the fingers. During an interview on 05/08/25 at 10:18 a.m. with the Dietary Supervisor (DS), DS stated the RD did sign the current menu cycle that included cutting up the cake into smaller pieces for the finger foods planned menu. DS stated she expects the dietary aid (DA) who prepared and placed the whole cake onto Resident 18's lunch meal tray to have had the skill set to follow the planned menu as indicated on the therapeutic spreadsheet for finger foods. During a review of the facility's job description (JD) titled Dietitian, dated 2023, the JD indicated, Major Duties and Responsibilities: Reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines. Updates diet orders and menu changes as required. Conducts audits of relevant nutritional care on a routine basis. During a review of the facility's policy and procedure (P&P) titled Menus and Adequate Nutrition, dated 2/2025, the P&P indicated, The facility's dietician or other clinically qualified nutrition professionals will review all menus for nutritional adequacy and approve the menus. During a review of the facility's diet manual (DM), dated 2023, the DM indicated, Regular Diet-Finger Foods (RDFF), dated 2023, the RDFF indicated the finger foods diet is a regular diet that provides food in appropriate size and shape to be eaten without utensils, but rather with fingers. This allows residents to maintain independence, dignity and quality of life.cut food to size per the diet order. If no size is indicated, cut food in bite-size pieces (approximately 1). During a review of the facility's P&P titled Tray Identification, dated 4/2007, the P&P indicated, Appropriate identification/coding shall be used to identify various diets. 1. To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification to identify the various diets. 2. The food service manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. During review of the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM defined finger foods as finger foods can be easily picked up with the hands without falling apart.Indication: Using fingers to pick up foods enables self-feeding, independence, and diet adequacy. 2. During a review of Resident 32's facesheet, the facesheet indicated Resident 32 was admitted on [DATE] with diagnosis of end stage renal disease. During a review of Resident 32's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/5/25, the MDS section C indicated Resident 32's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen an identify memory, orientation, and judgement status of the resident) was a score of 15 (able to understand and verbalize thoughts and needs). During a review of Resident 32's DO, dated 11/14/24, the DO indicated Resident 32 was on a fluid restriction. During a review of Resident 32's CP dated 8/29/23, the CP indicated Resident 32 is at risk for weight loss, dehydration, skin breakdown, and altered nutritional status r/t [related to] medical condition/dx [diagnosis] ESRD [end stage renal [kidney] disease] w/[with] dialysis tx [treatment]. Interventions: diet as ordered.Fluid restriction: 1500 ml [milliliters-a measurement of volume]/ [per] day; Dietary: 1080 ml; Nursing: 420 ml. During a review of Academy of Nutrition and Dietetics Nutrition Care Manual (NCM), dated 2025, the NCM indicated to determine how to distribute total fluids throughout the day. During a concurrent interview and record review on 05/08/25 at 10:13 a.m. with DS, Resident 32's meal tray card (MTC) indicated 1080 ml fluid restriction. DS reviewed Resident 32's MTC that listed the following: 4 fl oz [fluid ounces- a measurement of liquid] fruit juice and 8 fl oz Soy Milk. For lunch 8 fl oz Soy Milk and 4 fl oz Water. For dinner 4 fl oz of Soy Milk and 4 fl oz Water. DS stated, 4 oz is missing and she [Resident 32] has been stating she is thirsty too. DS stated the facility's expectation was for the total allotted amount of 1080 fl oz per 24 hours to be served by dietary, not more and not less. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, the P&P indicated The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 1) was free from physical abuse by facility staff (Certified Nursing Assistant-CNA 1). This failure resulted in Resident 1 sustaining discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization . 2. Ensure one of four sampled residents (Resident 3) was free from verbal abuse by facility staff (Licensed Vocational Nurse-LVN 3). This resulted in staff verbally abused Resident 3 and resulted in Resident 3 feeling angry and frustrated. Findings: 1. During a review of Resident 1's Admission Record (AR), dated 10/28/24, the AR indicated Resident 1's diagnoses included Alzheimer (a disease characterized by a progressive decline in mental abilities and Dementia (a progressive state of decline in mental abilities). Resident 1's annual Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/11/24, indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 (score range from 0-7 severe impairment). During a review of Resident 1's Progress Notes (PN), dated 10/21/24 at 9:21 p.m., the PN indicated, At Approx. (approximately) 1930 (7:30 p.m.) Resident (Resident 1) was sent to ER (emergency room ) for further eval (evaluation) per MD (Medical Doctor) orders.Heat [sic] to toe assessment performed. Discoloration noted to bilateral (right and left side) forearms. Discoloration to left eye. Redness noted to upper right eyebrow. Approx. Nickel size abrasion to left shin. During a review of the facility's Investigation Report (IR), dated 10/28/24, the IR indicated, This nurse immediately assessed (Resident 1) for reported skin changes at approximately 1730 (5:30 p.m.) and noted skin intact, with discoloration to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities, and to left posterior (back) thigh. (Resident 1) is unable to verbalize events surrounding discoloration due to cognition (process of knowing) impairment.During initial investigation (Resident 1) is noted to share roommate (Resident 2) with a BIMS of 14 (score range from 13-15 intact cognition), who (Resident 2) verbalizes that this morning (Resident 1) was being combative with the CNA (CNA 1) and was kicking and hitting the CNA, but the CNA was also hitting her back and had her against a corner holding her down. During an interview on 10/24/24 at 12:11 p.m. with Administrator in Training (AIT), AIT stated a facility investigation was completed regarding the allegation of staff to resident abuse reported on 10/21/24 at 5:30 p.m. AIT stated Resident 2 had witnessed CNA 1 cornering her (Resident 1), holding her down, pulling her hair. AIT stated Resident 1 sustained injuries which included, discoloration to left and right eye, discoloration to bilateral upper extremities, discoloration to the back of left thigh, a bald spot to the back of head. AIT stated based on Resident 2's witnessed statement and Resident 1 ' s injuries, lead us to believe it could be caused from (CNA 1) doing that. During a concurrent observation and interview on 10/24/24 at 12:20 p.m. with Resident 1, Resident 1 was in her room, sitting in a chair eating lunch. Resident 1's left outer eye was noted with red/purple/black discoloration measuring approximately 2.5 centimeters (cm) and left inner eye with red discoloration measuring approximately 1 cm. Resident 1 only smiled when spoken to. During an interview on 10/24/24 at 12:52 p.m. with Director of Nurses (DON), DON stated on 10/21/24 at approximately 5 p.m. Licensed Vocational Nurse (LVN 1) reported Resident 1 having a new discoloration to left and right eye. DON stated upon further assessment, Resident 1 also had discoloration to bilateral upper extremities and discoloration to the back of her left thigh. DON stated all injuries looked really fresh. DON stated Resident 1 had diagnosis of Alzheimer and Dementia and was not able to verbalize how she sustained her new injuries. DON stated Resident 2 witnessed CNA 1 putting Resident 1 against the wall, holding her down, and pulled her hair. DON stated Resident 2 is alert and oriented, and cognitively (process of knowing) intact. During a concurrent observation and interview on 10/24/24 at 1:26 p.m. with Resident 2, Resident 2 was in her room, sitting in her bed. Resident 2 stated on 10/21/24 at approximately 6 a.m. CNA 1 entered the room to provide care for Resident 1. Resident 2 stated the privacy curtain between the beds was halfway open and saw Resident 1 with eyes closed, when CNA 1 pulled her clothes down and attempted to change Resident 1. Resident 2 stated Resident 1 allowed CNA 1 to remove and change her top shirt but became combative. Resident 1 was kicking CNA 1 and refusing to change her pants. Resident 2 stated CNA 1 held Resident 1 with one hand and managed to pull Resident 1's pants off. Resident 2 stated she saw CNA 1 holding Resident 1 on the bed, pulled her hands by the wrist, got her up, placed her in the corner of the room, and pulled Resident 1 by the hair. Resident 2 stated Resident 1 continued to fight to be released. During an interview on 10/30/24 at 11:32 a.m. with CNA 2, CNA 2 stated on 10/21/24 at 6:30 in the morning, she saw Resident 1 walking in the hallway with discoloration to her left eye. CNA 2 stated while changing Resident 1 with CNA 3, they noticed discoloration to bilateral upper extremities extending from wrist all the way up below the elbow. CNA 2 stated Resident 1's discoloration to left and right eye, discoloration to her bilateral upper extremities found on 10/21/24 were not there on 10/20/24. CNA 2 stated Resident 1's discoloration to her left eye looked like someone punched her in the eye and the discoloration on bilateral upper extremities could be caused from being held too tight or pressing on her like in a forceful way. During an interview on 10/30/24 at 11:48 a.m. with LVN 1, LVN 1 stated on 10/21/24 a full body assessment on Resident 1 was completed. LVN 1 stated Resident 1 had left and right eye discoloration and discoloration to bilateral upper extremities. LVN 1 stated the discoloration on both upper extremities would not have been caused by bumping into something. LVN 1 stated Resident 1's left and right eye discoloration and discoloration to her bilateral upper extremities found on 10/21/24, were not there on 10/20/24. LVN 1 stated Resident 1 was transferred to the acute hospital for further evaluation. During an interview on 10/30/24 at 12:01 p.m. with CNA 3, CNA 3 stated on 10/21/24, during breakfast, he noticed Resident 1's left eye and right with red discoloration. CNA 3 stated while changing Resident 1 with CNA 2, they noticed discoloration to bilateral upper extremities. CNA 3 stated, Really bad discoloration, like purple from wrist to below elbow. CNA 3 stated while combing Resident 1's hair, he noticed bald spot in the back of her (Resident 1) head that had not been there before. During a review of Resident 1's Emergency Documentation (ED-acute hospital), dated 10/21/24 at 9:12 p.m. the ED indicated Resident 1 had left periorbital (tissues around the eye) ecchymosis (bruise, discoloration) and bilateral forearm bruising. 2. During an interview on 10/30/24 at 10:20 a.m. with DON, DON stated on 10/24/24, Resident 3 sent her a text message alleging LVN 3 of calling Resident 3 names including drug addict. During a review of Resident 3's Admission Record (AR), dated 10/31/24, the AR indicated Resident 3's diagnoses included Schizoaffective disorder (a mental health condition with symptoms including hallucination [false perception of an object or event that involves one of the senses, such as sight, sound, smell, touch or taste] and mania [period of extreme mood swings, high energy]) Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission MDS dated [DATE], indicated under BIMS a score of 15 (cognitively intact). During a concurrent observation and interview on 10/30/24 at 10:53 a.m. with Resident 4, Resident 4 was in his room sitting in a wheelchair. Resident 4 stated on 10/24/24, he was headed to the day room to watch Thursday night football with Resident 3 when LVN 3 went behind Resident 3, started pulling on his wheelchair, and telling Resident 3 he was not allowed to go into the day room. Resident 4 stated Resident 3 became upset at LVN 3. Resident 4 stated LVN 3 was doing most of the yelling calling Resident 3 a drug addict, pill seeker. During a review of Resident 4 quarterly MDS dated [DATE], the MDS indicated under BIMS a score of 15 (cognitively intact). During a concurrent observation and interview on 10/30/24 at 11:03 a.m. with Resident 3, Resident 3 was in the activity room, sitting in a wheelchair. Resident 3 stated on 10/24/24, he was entering the day room to watch Thursday night football with Resident 4 when LVN 3 told him he was not allowed to go in the day room. Resident 3 stated LVN 3 then began calling him a drug addict, pill seeker, just calling me names. Resident 3 stated he felt angry and frustrated. Resident 3 stated, I ' m here to get better, I ' m not here to be called names. During an interview on 10/30/24 at 4:25 p.m. with LVN 4, LVN 4 stated she was at the nurse station when she saw LVN 3 grabbed Resident 3 ' s wheelchair away from the day room, saying he was not allowed to go in the day room. LVN 4 stated she heard LVN 3 calling Resident 3 a drug addict, a pill seeker. LVN 4 stated calling Resident 3 names was not appropriate and should not be done. During an interview on 10/31/24 at 9 a.m. with Director of Staff Development (DSD), DSD stated calling resident names including drug addict, pill seeker is not appropriate and a form of verbal abuse. During a review of the facility IR dated 10/28/24, the IR indicated, At approx. [sic] 20:26 (8:26 p.m.) (Resident 3) made an allegation .that she (LVN 3) .pulled me away from the day room, calling me a drug addict. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not acquired to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff;

Based on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Comprehensive Care Plan (a written plan developed by an interdisciplinary team [attending physician, registered nurse, dietician, etc.] and the resident, to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being) to prevent a fall incident when Resident 1 was left in the dining room without staff supervision. This failure resulted in Resident 1 falling and sustaining a right inferior orbital wall fracture (a break in the inner wall of the eye socket), requiring a transfer to an acute hospital. Findings: During a review of Resident 1's Admission Record (AR), dated 8/3/23, the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included Alzheimer's disease (type of dementia that damages the brain and affects memory, thinking, and behavior) and Dementia (condition that affect the brain's ability to think, remember and function normally). During a review of Resident 1's quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 5/12/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 0 (score range from 0 - 7 severe impairment). The MDS Section G 300 Balance During Transitions and Walking indicated, Resident 1 was Not steady, only able to stabilize with staff assistance when moving from seated to standing position and walking (with assistive device). During a review of the facility Investigation Report (IR), dated 7/26/23, the IR indicated, On July 22, 2023, at approximately 1630 [4:30 p.m.] hours, [Resident 1] was on a 2 to 1 [two residents to one staff direct supervision at all times] with a staff member [Certified Nursing Assistant 1] and stated she [CNA 1] was in the dining room with both residents [Resident 1 and Resident 2] when the other resident [Resident 2] needed to use the restroom; therefore, she [CNA 1] reported to a different CNA [CNA 3] who was also in the dining room that she was leaving to take the other resident [Resident 2] to the restroom. Minutes later [Resident 1] was found on the ground in the dining room. Later in the evening during rounds. [Resident 1] had bruising [discoloration] to the right cheek area and swelling. send [Resident 1] to the ER [emergency room ] for evaluation [7/22/23]. [Resident 1] returned [7/23/23] from the ER with diagnosis: . Non-displaced [bone cracks or breaks but retains its proper alignment] fracture of the right inferior orbital wall. During a review of Resident 1's Computed Tomography (CT - imaging technique used to obtain detailed internal images of the body) scan dated 7/23/23, the CT result indicated, fracture of the right inferior orbital wall. During an interview on 8/2/23 at 9:30 a.m. with Director of Nurses (DON), DON stated on 7/22/23 (at approximately 4:30 p.m.), Resident 1 and Resident 2 were in the dining room with their assigned 2 to 1 sitter (CNA 1) when Resident 2 wanted to get up. DON stated CNA 1 told another staff (CNA 3) who was in the dining room to keep an eye on Resident 1 while CNA 1 took Resident 2 for a walk. DON stated CNA 1 returned (no time given) in the dining room and found Resident 1 on the floor. DON stated Resident 1 was transferred to an acute hospital and sustained a right inferior orbital wall fracture. During an interview on 8/2/23 at 10 a.m. with CNA 1, CNA 1 stated on 7/22/23, she was assigned as 2 to 1 sitter for Resident 1 and Resident 2 during her p.m. (2 pm-10 pm) shift. CNA 1 stated at approximately 4 p.m. (7/22/23), she was in the dining room with Resident 1 and Resident 2 when Resident 2 needed to use the bathroom. CNA 1 stated before leaving the dining room, she told CNA 3 who was in the dining room passing out snacks, to keep an eye on Resident 1. CNA 1 stated she was not in the dining room when Resident 1 fell on the floor. CNA 1 stated Resident 1 was a fall risk and requiring 2 to 1 sitter at all times to prevent Resident 1 from falling. CNA 1 stated Resident 1's fall incident could have been prevented if someone was watching her [Resident 1]. During a concurrent observation and interview on 8/2/23 at 11:06 a.m. in Resident 1's room, Resident 1 was lying in bed. Resident 1 was observed spitting on the left side of the bed, she did not make an eye contact or respond when spoken to. During an interview on 8/2/23 at 6:53 p.m. with Licensed Vocational Nurse (LVN), LVN stated on 7/22/23, at approximately 4:30 p.m., CNA 2 found Resident 1 on the floor in the dining room, without staff present. LVN stated a few hours after the fall incident at approximately 8 p.m. Resident 1 started showing a bruise to her face area and was transferred to an acute hospital. LVN stated Resident 1 sustained a right inferior orbital wall fracture. LVN stated Resident 1 was a high risk for fall and was assigned a 2 to 1 sitter to prevent her [Resident 1] from falling. LVN stated the fall could have been prevented if the 2 to 1 sitter was there with her [Resident 1]. During an interview on 8/7/23 at 12:51 p.m. with CNA 3, CNA 3 stated on 7/22/23, she was in the dining room obtaining weights for the residents scheduled to be weigh and she was never asked by CNA 1 to keep an eye on Resident 1. CNA 3 stated there were approximately 15 residents in the dining room doing activities with the Activity Assistant (AS) including Resident 1. CNA 3 stated she was not in the dining room when Resident 1 fell on the floor. CNA 3 stated Resident 1's fall incident could have been prevented if the assigned 2 to 1 sitter was present. During an interview on 8/9/23 at 2:54 p.m. with AS, AS stated on 7/22/23, at approximately 4:15 p.m., she was in the dining room providing activities for approximately 15 residents including Resident 1. AS stated she noticed Resident 1 sitting in her wheelchair, before leaving the dining room for about 10 minutes for a bathroom break. AS stated nobody had asked her to keep an eye on Resident 1. AS stated she was not in the dining room when Resident 1 fell on the floor. During an interview on 8/10/23 at 9:30 a.m. with CNA 2, CNA 2 stated on 7/22/23, at approximately 4:30 p.m., she was in the hallway when she heard yelling coming from the dining room. CNA 2 stated she arrived in the dining room and found Resident 1 on the floor next to her wheelchair. CNA 2 stated No other staff were present, no sitter, no activity staff, no CNA's, no RNA's [Restorative Nursing Assistant], there was nobody. CNA 2 stated Resident 1 Had a history of falling and was assigned a 2 to 1 sitter to prevent Resident 1 from falling. CNA 2 stated Resident 1 should not have been left alone, she was screaming pretty loud. During a concurrent interview and record review on 8/15/23 at 10:52 a.m. with DON, Resident 1's Fall Risk Evaluation (FRE), dated 7/14/23, was reviewed. The FRE indicated, Resident 1 had a score of 11 (if the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls). DON stated [Resident 1] was high risk for fall, was impulsive [tendency to act without thinking], had poor safety awareness and required 2 to 1 sitter. During a concurrent interview and record review on 8/18/23 at 11:39 a.m. with DON, the facility's daily staff assignment, dated 7/22/23, was reviewed. The daily staff assignment for p.m. shift (2 pm-10 pm) indicated, CNA 1 was assigned as 2 to 1 sitter for Resident 1 and Resident 2. DON stated [Resident 1] should not have been in the dining room without her assigned 2 to 1 sitter. During a concurrent interview and record review on 9/6/23 at 12 p.m. with DON, DON stated Resident 1 had fall incidents on 5/27/23 and 7/14/23. Resident 1's Care Plan (CP), dated 5/30/23 was reviewed. The CP indicated, Resident 1 was At risk for unavoidable falls related to: Poor safety awareness, Unaware of physical limitations, Impulsiveness, Wanders into other residents room, At times unbalanced on feet. Intervention indicated, Resident 1 to have a 2 to 1 staff at all times. DON stated Resident 1's care plan dated 5/30/23, was not implemented. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 6/1/2022, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. During a review of the facility's Job Description for (Sitter), undated, the Job Description for sitter indicated, The primary purpose of your job position is to provide close observation of the resident you are assigned to. It is your responsibility to monitor the resident for safety issues and are to keep the resident within arm's length on your entire shift. During a review of the facility's P&P titled, Accidents and Supervision, dated 2022, the P&P indicated, 3. Implementation of Intervention-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: . e. Ensuring that the interventions are put into action. 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) when Resident 1 was not in staff's line of sight (where staff can observe at all times) while up in her wheelchair. This failure resulted in Resident 1 and Resident 2 having a resident-to-resident altercation and Resident 2 falling to the floor, sustaining a right hip fracture (broken bone) requiring hospitalization and the need for surgical intervention. Findings: During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341-form used to report suspected abuse) dated 6/8/23, completed by the facility, the SOC 341 indicated, Writer call to Resident [Resident 1] room by nursing staff, per CNA [certified nursing assistant], 'Walked in room [X], near doorway. [Resident 2] was sitting on floor. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them [Resident 1] stated, 'You better stop taking my things.' During a review of Resident 1's (aggressor) Progress Note (PN), dated, 5/8/23 (one month prior to current incident [6/8/23]), at 9:32 a.m., the PN indicated, IDT [Interdisciplinary Team-group of professionals who work together to discuss about resident care needs] .On 5/8/23 at approx. [approximately] 1:30 pm, staff member reported she witnessed [Resident 1] in dinning [sic] room in her w/c [wheelchair]. There was a female [Resident 4] standing beside [Resident 1], when [Resident 1] stood up from her w/c and reached over to the female resident and with a closed fistmade [sic] contact to the female residents left arm.[Resident 1] is very territorial (guard or defend belongings) with her space and does not like confused (mentally impaired) residents approaching her space.IDT REC [recommendation].keep in line of sight when up in w/c. During a review of Resident 1's Care plan (CP-specific care needs of resident), dated 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, [Resident 1] had a resident-to-resident incident where she made contact with another female [Resident 4] left arm.Interventions.continue to be in the line of sight of staff when up in wheelchair. During a review of Resident 1'sCare plan revised on 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, Behaviors: [NAME] others off [showing anger or frustration toward a person] at random.Cursing at others.H/O [history of] striking out at others.Unprovoked physical aggression [hostile]/striking out.likes her space and doesnt [sic] like others approaching her.interventions.Keep in line of sight when up in w/c. During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool), dated 4/21/23, the MDS indicated, BIMS [Brief Interview for Mental Status) Summary Score.4 (0-7 suggests severe impairment). During a review of Resident 1's Order Summary Report (OSR), dated 6/1/23, the OSR indicated, Resident 1 diagnoses included schizophrenia (a mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).unspecified dementia (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety (mental condition characterized by excessive apprehensiveness about real or perceived threats) and Resident 1 was being treated with bupropion (medication used to treat depression).buspirone (medication used to treat anxiety) for behaviors of unprovoked physical aggression. During a review of Resident 2's (victim) Progress Notes (PN), dated 6/8/23, at 7:30 a.m., the PN indicated, Writer call [sic] to resident room by nursing staff, per CNA, 'walked in room [X], near doorway. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them. 'Per CNA, '[Resident 1] stated, 'you better stop taking my things.' During a review of Resident 2's PN, dated 6/8/23, at 3 p.m., the PN indicated, Resident complain of pain to right hip area.received order for: X-ray to right hip. During a review of Resident 2's PN, dated, 6/8/23, at 4:56 p.m., Received order from [Physician] to send resident to ER [emergency room ] for evaluation due to increase c/o [complaint of] pain. During a review of Resident 2's Orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) Consultation (OC), from the acute hospital, dated 6/9/23, the CN indicated, .female who came to the hospital because of after a GLF [ground level fall] at [Facility Name].the patient had an altercation with another resident at [Facility Name] causing her to fall. Impression: Fracture of the right femoral neck (fracture of the right femur [thigh bone] within the hip joint). During a review of Resident 2's PN, from the acute hospital, dated 6/10/23, at 1:19 p.m., the PN indicated, Assessment/Plans.Fracture of femoral neck, right, closed.underwent right hip hemiarthroplasty [replacing half of the hip joint]. During a review of Resident 2's Order Summary Report (OSR), dated 6/1/23, the OSR indicated, Resident 2 diagnoses included psychotic disturbance (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and anxiety. During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS Summary Score.00 (0-7 suggests severe impairment). During an interview, on 6/12/23, at 11:14 a.m., with CNA 1, CNA 1 stated, on the day of the incident (6/8/23), it was Resident 1's first day of being off one-to-one (having a staff member always assigned only to the resident) supervision. CNA 1 stated, she and CNA 2 got Resident 1 up in her wheelchair prior to breakfast. CNA 1 stated, she and CNA 2 were passing breakfast trays and heard Resident 1 speaking loudly. CNA 1 stated, when she arrived in Resident 1's room, she noted Resident 1 sitting in her wheelchair and Resident 2 was sitting on the floor. CNA 1 stated, CNA 2 was in-between Resident 1 and Resident 2, and Resident 1 was swinging at Resident 2. CNA 1 stated, Resident 1 was saying curse words and Resident 2 was saying Resident 1 kicked her on the right side of the leg, and she could not walk anymore. CNA 1 stated, Resident 1 used to have one-to-one supervision due to her aggressive behavior like hitting. CNA 1 stated, she was unaware of any interventions being implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview, on 6/12/23, at 11:41 a.m., with Director of Nursing (DON), DON stated, when Resident 1 was asked regarding the resident-to-resident altercation happened on 6/8/23, Resident 1 verbalized Resident 2 was in my things. DON stated, Resident 1 had just been taken off one-to-one supervision the day (6/7/23) prior to the incident due to Resident 1 not having any resident-to-resident altercations. DON stated, Resident 1 was previously on one-to-one supervision due to incidents of resident-to-resident altercations with other residents. DON stated, Resident 1 had episodes of aggressive behaviors like hitting when someone was in her space. During an interview on 6/26/23, at 2:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was assigned to Resident 1 the day (6/8/23) of the resident-to-resident altercation between Resident 1 and Resident 2. LVN 1 stated, Resident 1 had been taken off one-to-one supervision the day (6/7/23) prior to the incident and there was no witness to the resident-to-resident altercation between Resident 1 and Resident 2, on 6/8/23. LVN 1 stated, Resident 1 was previously on one-to-one supervision due to her aggressive behaviors of hitting residents, but she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview on 6/26/23, at 2:24 p.m., with CNA 3, CNA 3 stated, Resident 1 would get physically and verbally aggressive with other residents and the facility would try to avoid resident-to-resident altercations by placing Resident 1 on one-to-one supervision. CNA 3 stated, she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview on 6/26/23, at 4:27 p.m., with Hospitality Aide (HA) 1 stated, she had been one-to-one supervision with Resident 1 in the past to prevent Resident 1 from getting into physical fights and arguments with other residents. During an interview on 6/26/23, at 4:41 p.m., with HA 2, HA 2 stated, Resident 1 had been one-to-one supervision because when other residents would go by or even look at Resident 1, Resident 1 would become verbally or physically aggressive. During an interview on 6/30/23, at 1:13 p.m., with CNA 2, CNA 2 stated, she was assigned to Resident 1 on the day of the resident-to- resident altercation (6/8/23) between Resident 1 and Resident 2. CNA 2 stated, Resident 1 was in her room, sitting in her wheelchair when CNA 2 went to go check on the breakfast trays. CNA 2 stated, she heard someone speaking loudly and went back to Resident 1's room. When she returned to Resident 1's room, Resident 2 was sitting on the floor and Resident 1 had Resident 2 by the hair and was shaking Resident 2's head. CNA 2 stated, when she was separating Resident 1 and Resident 2, Resident 1 kicked Resident 2 on the right side of the leg. CNA 2 stated, no one was watching Resident 1 at the time of the resident-to-resident altercation because Resident 1 was taken off (6/7/23) one-to-one supervision. CNA 2 stated, any small thing can trigger [Resident 1's behavior] her or if someone is in her way and she will start fighting. CNA 2 stated, she was unaware of any other interventions being implemented to prevent further resident-to-resident altercations. During an interview on 6/30/23, at 1:25 p.m., with DON, DON stated, no one witnessed the resident-to-resident altercation (6/8/23) between Resident 1 and Resident 2. DON stated, Resident 1 does not like to stay in her room when she is up in her wheelchair she should have been where staff could see her at all times according to the care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plan Revisions Upon Status Change dated 6/1/22, with the DON, on 7/26/23 at 11:37 a.m., the P&P indicated, The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.Upon identification of a change in status, the nurse will notify the MDS (minimum data set-resident assessment tool) Coordinator, the physician, and the resident representative.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The team meeting discussion will be documented in the nursing progress notes.The care plan will be updated with the new or modified interventions.Staff involved in the care of the resident will report resident responses to new or modified interventions. DON stated, staff should have been made aware of Resident 1's care plan interventions.

Based on observation, interview, and record review the facility failed to provide supervision for one of three sampled residents (Resident 1). This resulted in Resident 1 sustaining a right [CONDITION(S)] from an unwitnessed fall in the bathroom. Findings: During an interview on 11/17/21, at 10:15 AM, with Administrator and Director of Nurses (DON), Administrator stated Resident 1 had an unwitnessed fall on 11/8/21. X-ray to right knee and hip was obtained due to complaint of pain. X-ray to right knee and hip indicated no fracture. On 11/10/21, Resident 1 was transferred to the acute hospital due to uncontrolled pain. Administrator stated hospital Computed Tomography (CT) scan report indicated a fracture to Resident 1's right hip. During an interview on 11/17/21, at 10:47 AM, with Registered Nurse (RN), RN stated on 10/8/21 at approximately 4:30 PM, he was at the nurse station when he was alerted by Sitter (non-licensed staff), that Resident 1 had an unwitnessed fall in the bathroom. RN stated he was told by the Sitter, Resident 1 was left in the bathroom without supervision. During an interview on 11/17/21, at 3:20 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 10/8/21, she assisted Resident 1 to the bathroom, placed him on the toilet, and left Resident 1 on the toilet while she continued to pick-up the evening meal trays from other rooms. CNA 1 stated, He [Resident 1] said he needed to go number two [bowel movement], so I left him to give him privacy. CNA 1 stated Resident 1 was already on the bathroom floor being assessed by RN when she returned to check on Resident 1. CNA 1 stated I was told not to leave him [Resident 1] alone. He's a high fall risk. During a concurrent observation and interview on 12/1/21, at 9:58 AM, Resident 1 was in his room lying down with eyes closed. CNA 2 was at Resident 1's bedside. CNA 2 stated Resident 1 required assistance in transferring and walking, he's wobbly when walking or getting up. CNA 2 stated Resident 1 should never be left unsupervised when in the bathroom. During an interview on 12/1/21, at 10:03 AM, with CNA 3, CNA 3 stated Resident 1 didn't have a good balance and required assistance going to the bathroom. CNA 3 stated Resident 1 should not be left alone in the bathroom because he [Resident 1] tries getting up and he's unsteady, he can fall. He's a high risk for fall. During an interview on 12/1/21, at 10:10 AM, with Director of Staff Development (DSD), DSD stated Resident 1 was a high risk for fall, and should not have been left in the bathroom by himself. DSD stated, Staff are supposed to stay in the room with the bathroom door a little open just in case he gets up. His unsteady. During an interview on 12/1/21, at 12:05 PM, with Sitter, Sitter stated, he was assigned 1:1 (staff to resident direct observation) with Resident 2 when CNA 1 assisted Resident 1 to the bathroom and left the room with Resident 1 still in the bathroom. Sitter stated, She [CNA 1] didn't say anything to me she just left the room. Sitter stated approximately five minutes after CNA 1 left the room, he heard Resident 1 fall in the bathroom. Sitter stated Resident 1's fall could have been prevented if CNA 1 just stayed.[Resident 1] is unsteady, he will try to get up on his own but he needs help. During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 1 was cognitively impaired. The MDS, Section G (Functional Status) indicated Resident 1 required extensive assistance in toileting, was not steady, only able to stabilized with staff assistance when moving on and off toilet. During a review of Resident 1's Care Plan (CP), date initiated on 9/1/20, the CP indicated Resident 1 had a decreased in mobility. Intervention included Resident 1 requiring extensive assist with ADL [Activities of Daily Living] care . During a review of Resident 1's CT scan, dated 11/11/21, the CT indicated Resident 1 had sustain a Basicervical fracture of the right femoral neck [right [CONDITION(S)]]. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 2018, the P&P indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . c. Elimination (toileting). During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 2017, the P&P indicated, Individualized, Resident-Centered Approach to Safety .4. Implementing interventions to reduce accident risks and hazards shall include the following: . d. Ensuring that interventions are implemented; .5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P & P), Change in a Resident's Condition or Status when the facility failed to assess and notify Attending Physician (AP), for one of three sampled residents (Resident 1) that a bruise was identified on 10/19/21 to Resident 1's right hip. This resulted in a delay in treatment, right hip fracture, and potential for pain. Findings: During a concurrent interview and record review on 11/3/21, at 10:30 AM, with Director of Nursing (DON), DON reviewed Resident 1's medical records. DON stated on 10/21/21, a bruise on Resident 1's right hip was identified, an x-ray was obtained on 10/23/21 with a result of a right hip fracture. During a concurrent observation and interview, on 11/3/21, at 12:57 PM, with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed lying in bed with eyes closed. CNA 1 stated Resident 1 was non-verbal, can't walk, can't transfer herself, is dependent on staff with all ADLs. CNA 1 stated Resident 1 currently had a right hip fracture. During an interview on 11/3/21, at 1:05 PM, with CNA 2, CNA 2 stated she had noticed a bruise on Resident 1's right hip/leg area while giving Resident 1 a shower on 10/19/21 AM shift. CNA 2 stated she verbally informed the Licensed Vocational Nurse (LVN) on duty on 10/19/21 of Resident 1's bruise to right hip/leg area. During an interview on 11/3/21, at 1:30 PM, with CNA 3, CNA 3 stated on 10/20/21 PM shift, she had noticed Resident 1's right side hip area down to her leg had a dark purple bruise. CNA 3 stated the facility practice was to immediately notify the on duty LVN of any new skin issues identified. CNA 3 stated she did not report Resident 1's right hip bruise to the on duty LVN on 10/20/21 PM shift because LVN wasn't nice, was rude. not approachable. During an interview on 11/3/21, at 4:14 PM, with CNA 4, CNA 4 stated she first saw Resident 1's right hip bruise on 10/20/21 PM shift while providing continent care for Resident 1. CNA 4 stated, Resident 1 has a bruise to right leg hip. it was greenish bruise. CNA 4 stated she reported the bruise to the on duty LVN. During an interview on 11/17/21, at 8:43 PM, with LVN 1, LVN 1 stated it was the facility practice for CNAs to report all new skin issues to LVN's. LVN 1 stated LVN's were responsible for assessing new skin issues, assessing for pain, notifying AP, obtaining x-ray if needed, developing care plan, and monitoring the site for signs of worsening. During an interview on 11/18/21, at 7:44 PM, with LVN 2, LVN 2 stated on 10/21/21 NOC (night) shift CNA 5 was providing care to Resident 1 when CNA 5 noticed a purple bruise to her hip area. LVN 2 stated no other report was made to her prior to 10/21/21. LVN 2 stated, That was the first time I saw it [Resident 1's right hip bruise]. During a review of Resident 1's Nurses Notes (NN), dated 10/12/21 thru 10/21/21, the NN dated 10/21/21, at 9:30 PM, indicated, cna notified nurse of discoloration and swelling to right upper leg. upon check discoloration to cover [sic] upper leg light purple, slight greenish color, and swelling noted. res [Resident 1] had facial grimacing when leg was touched. There was no documented evidence Resident 1 was assessed and AP was notified when Resident 1's right hip/leg area bruise was first identified by CNA 1 on 10/19/21 AM shift. NN notes indicated Resident 1 was assessed and AP was notified of the right bruise two days after the bruise was first identified. During a review of Resident 1's Right Hip x-ray dated 10/23/21, the result indicated a right hip fracture. During a review of the facility Investigation Report on [Resident 1] undated, completed by Administrator, the report included a statement from staff member who provided Resident 1 care from 10/15/21 thru 10/21/21. The report indicated CNA 2 was interviewed and stated she provided Resident 1 care on 10/19/21 and saw a small bruise on her thigh. Charge nurse was aware and knew of the small bruise. CNA 3 was interviewed and stated she provided Resident 1 care on 10/20/21, did notice a bruise and reported the bruise to another CNA, does not remember if she let a LVN know, this was her first round before 6 pm. During an interview on 12/1/21, at 10:10 AM, with Director of Staff Development (DSD), DSD stated CNAs were responsible for immediately reporting to LVN's for any new skin issues, including skin tear, bruise, red areas, DSD stated, LVN's will then do their assessment, complete Change of Condition [COC] form, notify MD [Medical Doctor], monitor area. During an interview on 12/1/21, at 10:28 AM, with Administrator, DSD, and DON, DON stated CNAs were responsible to notify nurse for any skin issues including skin tear, bruising, redness. DON stated, LVN will then follow up, do assessment, document finding, fill out COC form, notify MD (Medical Doctor), RP [Responsible Party]. DON stated, LVN should have followed up when made aware of Resident 1's bruise to right hip on 10/19/21. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated, 1. The nurse will notify the resident's AP or Physician on call when there has been a(an): b. discovery of injuries of unknown source: d. significant change in the resident's physical/emotional/mental condition; 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.

Based on observation, interview, and record review, the facility failed to provide a safe environment when the bed was not in the locked position for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a nasal bone fracture (broken nose). Findings: During a review of Resident 1's Interdisciplinary Team (IDT, group of health care professionals with various areas of expertise who work together toward the goals of their clients) note, dated 9/8/21, at 8:55 AM, the IDT indicated, Early this morning Staff reported [Resident 1] was attempting to get out of bed, when one to one [staff to resident direct supervision] attempted to assist [Resident 1], she was standing at the edge of her bed, when the bed moved causing [Resident 1] to lose her balance, fall towards her left side landing on floor. [Resident 1] was bleeding from her nose, her nose was swollen with a laceration [cut] to the bridge [bony part] of her nose. During a concurrent observation and interview on 9/9/21, at 3:35 PM, in Resident 1's room, Resident 1 was lying in bed with closed eyes, a purplish discoloration was noted on Resident 1's nose and the left side of Resident 1's face. Certified Nursing Assistant (CNA) 1 was seated next to Resident 1's bed. CNA 1 stated, Resident 1's facial bruising was from a recent fall. CNA 1 stated, Resident 1 was very impulsive and unsteady. CNA 1 stated, she was told Resident 1 was trying to get out of bed when her bed moved. CNA 1 stated, Maybe someone unlocked it and forgot to lock the bed back. It [the bed] should always be locked. During an interview on 9/10/21, at 2:39 PM, with Activity Staff, Activity Staff stated, on 9/8/21, he was assigned as the one to one with Resident 1. Activity Staff stated, Resident 1 stood up from her bed and fell forward. Activity Staff stated, Yeah, the bed moved, it wasn't locked. I didn't know it wasn't locked. I was never taught how to lock the bed. During a concurrent observation and interview on 9/22/21, at 9:34 AM in Resident 1's room, Nurse Assistant (NA) stated, Resident 1 was unable to lock or unlocked her own bed. NA stated, Her [Resident 1] bed should always be locked, especially with her, because she's always trying to get up. During an interview on 9/22/21, at 9:45 AM, with Director of Nurses (DON), DON stated, CNAs sometimes move the beds for better access when providing care to residents, but they should always make sure the bed is locked. During an interview on 9/22/21, at 12:50 PM, with Licensed Vocational Nurse (LVN), LVN stated, on 9/8/21, Activity Staff told her the bed was not locked and when Resident 1 stood up, the bed moved back, Resident 1's shoulder hit the ground first then face planted to the ground. LVN stated, I know the bed was not locked because when I was assessing her [Resident 1] the bed rolled from me. LVN stated, Resident 1 was on one to one because she was a fall risk. LVN stated, Resident 1 was very impulsive and had a history of falls. LVN stated, the fall could have been prevented if the bed was in the locked position. LVN stated, All beds are supposed to be locked. During an interview on 10/18/21, at 4:50 PM, with the Administrator, Administrator was unable to provide a policy and procedure on Bed Safety. During a review of Resident 1's hospital computed tomography (CT) head scan, dated 9/8/21, the CT result indicated, a nasal bone fracture. During a review of the facility policy and procedure (P&P) titled, Safety and Supervision of Residents dated 2017, the P&P indicated, Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Bed Safety .

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 11 (Resident 1) sampled residents who was assessed at risk for falls was supervised to prevent accidents and injury. This failure resulted in the resident sustaining a fractured left hip. 2. Implement the Fall Prevention Program for eight of 26 sampled residents assessed at high risk for falls (Residents 1, 3, 7, 8, 9, 17, 21, and 26). This failure had the potential for the residents to sustain injuries from falls. 3. Have a process in place to maintain and update each resident's fall risk status per the facility's Fall Prevention Program. This failure had the potential for staff to be unaware of the change in fall status for the residents which could result in residents falling and sustaining injuries. 4. Have a list of residents assessed at high risk for falls in the nursing station per the facility's policy and procedure. This had the potential for staff to be unaware of residents who were at risk for falls. 5. Ensure 12 of 12 sampled staff (Certified Nursing Assistant (CNA) 1, CNA 2, CNA 3, CNA 4, CNA 5, CNA 9, Licensed Vocational Nurse (LVN) 1, Director of Staff Development (DSD), Activity Assistants (AA) 1, AA 2, Laundry Staff (LS), and Housekeeper (HSK) 1, were adequately trained on the facility's Fall Prevention Program. These failures had the potential to contribute to the resident falls. A condition of Immediate Jeopardy (IJ) was identified for the facility's failure to implement their fall prevention policies. This failure resulted in 26 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26) assessed at high risk for falls to have fallen (between 12/30/19 and 1/29/20) with one of 26 sampled resident (Resident 1) sustaining a left [MEDICAL CONDITION] (break in bone). This failure also had the potential for the other 25 residents to sustain injuries secondary to falls. The IJ was called on 2/26/20 at 4:05 PM with the Administrator and Director of Nursing. The surveyors confirmed by observation, interview, and record review, on 2/27/20 that the facility had in-serviced their staff on their fall prevention policies and procedures, had developed a fall risk alert identifier, had reviewed all fall risk assessments and verified all resident care plans appropriately addressed fall interventions consistent with the facility's acceptable plan of correction. The IJ was removed on 2/27/20 at 3:58 PM with the Administrator, Director of Nursing, and Facility Consultant. Findings: 1. During a review of the clinical record for Resident 1, the Progress Notes dated 1/25/20, at 10:11 AM, indicated Res (resident) has a (sic) unwitnessed fall, res was in the day room sitting in a w/c (wheelchair). a family member came out and said 'that man (referring to Resident 1) fell '.res was (sic) c/o (complaining of) pain to his leg. The Progress Notes dated 1/25/20, at 3:03 PM, indicated res was found on the ground on the right side of body.he was c/o pain to left hip/femur (thigh bone). A physician's orders [REDACTED]. During an interview on 1/29/20, at 9:08 AM, with Director of Nursing (DON), DON stated Resident 1 had two fall incidents on 1/25/20. After the second fall he was sent out to the hospital where he was diagnosed with [REDACTED]. During an observation on 1/29/20, at 9:20 AM, in Resident 1's room, Resident 1's nameplate was noted with no yellow dot sticker on his name plate (yellow dot will be placed on the resident's nameplate outside the door for residents at risk for falls). During an interview on 1/29/20, at 9:40 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated on 1/25/20, Resident 1 was unable to walk or move about when staff tried to get him out of bed around 7 AM. CNA 2 stated Resident 1 was complaining of pain to his left knee and hip area. CNA 2 stated Resident 1 was placed in a wheelchair even though he did not use one prior to the incident. CNA 2 stated later that morning around 9:50 AM, Resident 1 fell out of the wheelchair. CNA 2 stated after the fall from the wheelchair, she was instructed by Licensed Vocational Nurse (LVN) 4, to place the resident in bed and to monitor the resident every 15 minutes. CNA 2 stated, in the afternoon she became busy with other residents and was unable to monitor Resident 1 every 15 minutes. CNA 2 stated when she saw Resident 1 at 12:30 PM, Resident 1 was on the floor and appeared to be in pain. CNA 2 stated, the knee didn't look right. CNA 2 stated Resident 1 was then sent out to the hospital and diagnosed with [REDACTED]. During an interview on 1/29/20, at 12:35 PM, with LVN 4, LVN 4 stated Resident 1 was walking independently prior to the morning of 1/25/20. LVN 4 stated on 1/25/20, around 7 AM Resident 1 complained of pain to his left leg and was unable to walk so she instructed the staff to place the resident in a wheelchair. LVN 4 stated Resident 1 had not used a wheelchair prior to 1/25/20. LVN 4 stated around 10 AM on 1/25/20, Resident 1 had an unwitnessed fall out of his wheelchair and complained of hip pain. After Resident 1 fell , LVN 4 instructed staff to place the resident in bed, instructed the resident to stay put and instructed CNA 2 to check on Resident 1 at least every 15 minutes. She stated she was also going to monitor the resident every 15 minutes. LVN 4 stated around 12:30 PM, Resident 1 had a second unwitnessed fall and was found on the floor by the second bed in the room (Resident 1's bed was the first bed in the room closest to the entryway). LVN 4 stated she last saw Resident 1 around 11:50 AM, and did not see him again until he fell around 12:30 PM. She became busy. LVN 4 was unaware CNA 2 was busy as well and unable to check on Resident 1 every 15 minutes. LVN 4 stated Resident 1 did not need one-on-one supervision (one staff assigned to monitor one resident) because she and CNA 2 were checking on the resident frequently. LVN 4 stated Resident 1's inability to walk should have been considered a change of condition and the doctor should have been notified. LVN 4 confirmed the doctor was not notified of the change in the resident's condition. During an interview on 1/29/20, at 1:05 PM, with Director of Nursing (DON), DON stated she was not aware Resident 1 was unable to walk the morning of 1/25/20 prior to his two falls later that day. DON stated if she was aware that Resident 1 was unable to walk and complaining of pain she would have sent him out to the hospital to be evaluated. During a concurrent observation and interview on 2/11/20, at 11:34 AM, with DON, outside Resident 1's room, Resident 1's nameplate did not have a yellow dot sticker . DON confirmed there was no yellow dot sticker on the resident's nameplate. During an interview on 2/11/20, at 12:15 PM, with DON, she stated, Resident 1 had fallen two more times on 2/5/20, while he was recovering from his surgically treated left [MEDICAL CONDITION]. DON stated Resident 1 had five fall incidents in less than a month. During a concurrent observation and interview on 2/26/20, at 11:31 AM, with DON, outside Resident 1's room, Resident 1's nameplate did not have a visible yellow dot sticker. DON confirmed there was no yellow dot sticker on the nameplate. During a review of the clinical record for Resident 1, [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized comprehensive assessment tool) dated 1/6/20, indicated the Brief Interview for Mental Status score (BIMS score - an assessment used to determine a resident's cognitive status) was three out of 15 (a score of three indicates the resident has severe cognitive impairment). The Activity of Daily Living (ADL) indicated Resident 1 is able to walk in his room and walk in the corridor with supervision and setup help only. The Care Plan titled At risk for falls related to: History of falls; poor safety awareness dated 11/26/19, indicated under Interventions/Tasks Q (every) 15 min. Checks. The SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Post Fall assessment dated [DATE], indicated a score of 10 (a score greater than 10 indicates the resident is considered at risk for falls). During a review of Resident 1's acute hospital record titled Operative/Procedures (OP), dated 1/27/20, the OP indicated, Resident 1 had a left [MEDICAL CONDITION] that required surgical intervention. During a review of the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, dated 12/15, the policy and procedure indicated, Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident. and how to communicate these changes to the Nurse . Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician.The Nurse and Physician will discuss and evaluate the situation. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. During a review of the facility's policy and procedure titled, Falls and Fall risk, Managing, dated 12/2007, the policy and procedure indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 2. During an interview on 1/29/20, at 10:12 AM, with Administrator, Administrator stated there were 26 residents (Resident 1 through Resident 26) whom he identified had fallen approximately 53 times in the past 30 days. Administrator reviewed the list of residents who had fallen in the past 30 days and confirmed all 26 residents were assessed at high risk for falls. Administrator stated since the 26 residents were assessed at high risk for falls, the facility's Yellow Dot Program Fall Prevention should have been implemented to include placing a yellow dot sticker on the nameplates of those residents. During observations on 1/29/20, the following was noted: a. At 9:20 AM, Resident 1's nameplate outside the door did not have a yellow dot sticker. b. At 10:25 AM, Resident 3's nameplate outside the door did not have a yellow dot sticker. c. At 10:27 AM, Resident 26's nameplate outside the door did not have a yellow dot sticker. d. At 10:37 AM, Resident 21's nameplate outside the door did not have a yellow dot sticker. e. At 10:39 AM, Resident 8's nameplate outside the door did not have a yellow dot sticker. f. At 10:40 AM, Resident 7's nameplate outside the door did not have a yellow dot sticker. g. At 10:41 AM, Resident 17's nameplate outside the door did not have a yellow dot sticker. h. At 10:48 AM, Resident 9's nameplate outside the door did not have a yellow dot sticker. During a review of the facility's policy and procedure titled, YELLOW DOT PROGRAM FALL PREVENTION PROGRAM undated, indicated, It is the policy of this facility to identify residents who are at high risk for falls . Under the Procedures subheading it indicates, 1. A yellow dot will be placed on the resident's nameplate outside the door 2. Nursing personnel will monitor residents periodically, Observe resident area for safe environment, Check call light placement, Check proper positioning, Check all assistive devices are in place and working properly. 3. During an interview on 1/29/20, at 11:50 AM, with Medical Records (MR), MR stated she was the staff member responsible for the facility's Yellow Dot Program which included placing a yellow dot sticker on the nameplates of residents who were identified at high risks for falls. MR would place yellow dot stickers on admission and quarterly thereafter of the residents who were identified as high risk for falls. She stated the facility had no process in place for residents, when there was a change in their fall risk status even if it occurred in between the time they were first admitted and quarterly. MR stated she is the only person who places the yellow dot stickers. MR stated, No one else helps me with it. During an interview on 2/26/20, at 10:30 AM, with MR, MR stated, the Yellow Dot Program Fall Prevention Program is the only indicator the facility uses to identify high fall risk residents. MR stated the yellow dot sticker are always visible and are not removed. MR stated, I have been here for ten years, that is unlikely to happen (stickers being not visible or removed by residents) because I make sure yellow dot stickers are visible and the stickers have never fallen off. During an interview on 2/26/20, at 11:25 AM, with Administrator, Administrator stated the facility conducts quarterly audits of the placement of the yellow dot stickers. Administrator could not explain how the Yellow Dot Program Fall Prevention Program would be implemented if there was a change in a residents risk for falls status in between quarters. 4. During a concurrent observation and interview on 1/29/20, at 11:08 AM, with LVN 3, in the nurses station, LVN 3 looked around the nursing station and stated the facility did not have a list of high fall risk residents. During an interview on 1/29/20, at 1:05 PM, with DON, DON stated the facility did not have a list of high fall risk residents at the nurses station. During a concurrent observation and interview on 2/26/20, at 9:43 AM, with Assistant Director of Nursing (ADON), at the nurses station, ADON confirmed a list of high fall risk residents was not available for staff to use. During an interview on 2/26/20, at 10:18 AM, with Administrator, Administrator stated a list of high fall risk residents was not in place for staff to see because staff, Should know (the) yellow dot program. During an interview on 2/26/20, at 10:30 AM, with MR, MR stated I have been here for ten years, no it (facility policy and procedure) doesn't say about having fall log or tracking in the nursing station. During an interview on 2/26/20, at 11:31 AM, with DON, DON stated the facility does not have a list of residents who the high risk are for falls but MR should know who are the high risk for fall residents. During a review of the facility's P&P titled, YELLOW DOT PROGRAM FALL PREVENTION PROGRAM. undated, the P&P indicated, It is the policy of this facility to identify residents who are at high risk for falls. A list of residents who are high risk for falls will also be kept at the Nursing Station. 5. During an interview on 1/29/20, at 9:25 AM, with CNA 1, CNA 1 stated she did not know the facility system to identify residents who were high risk for falls. CNA 1 stated, We (staff) just kind of know (which residents are high risk for falls). During an interview on 1/29/20, at 9:40 AM, with CNA 2, CNA 2 stated she was not sure if the facility had a system in place for staff to identify high fall risk residents. During an interview on 1/29/20, at 9:54 AM, with CNA 3, CNA 3 stated she knew how to identify residents that were high risk for falls, because they have mats or non-skid socks. CNA 3 stated there were no other systems in place to identify high risk fall residents. During an interview on 1/29/20, at 10 AM, with CNA 4, CNA 4 stated she was not sure what system the facility used by staff to identify residents who were high risk for falls. CNA 4 stated, Mostly we (staff) just know. During an interview on 1/29/20, at 10:06 AM, with CNA 5, CNA 5 stated she had no idea how staff identify which residents were high risk for falls. During an interview on 1/29/20, at 10:13 AM, with LVN 1, LVN 1 stated the facility used little stickers to identify which residents were at high risk for falls but was not sure what color the stickers were supposed to be. During an interview on 1/29/20, at 11:14 AM, with DSD, DSD stated, she was not sure what process was in place for the facility to identify high fall risk residents. During an interview on 2/26/20, at 9:32 AM, with LS, LS stated, high fall risk residents were identified by just knowing and watching how the residents walk. During an interview on 2/26/20, at 9:34 AM, with HSK 1, HSK 1 stated, high fall risk residents were identified in the facility by how they walk and by what the CNA would tell her. During an interview on 2/26/20, at 9:36 AM, with CNA 9, CNA 9 stated, she did not know how to identify high fall risk residents. CNA 9 stated she knew residents were a high fall risk if they had a fall mat by their bed. During an interview on 2/26/20, at 9:55 AM, with AA 1, AA 1 stated, high fall risk residents are identified by a green dot on the outside of their room door. During an interview on 2/26/20, at 9:57 AM, with AA 2, AA 2 stated, high fall risk residents by a blue dot on their name outside their room door. During an interview on 2/26/20, at 11:23 AM, with Director of Nursing (DON), DON stated, the facility had 40 resident falls as of this date in February, 46 falls in January, and over 60 falls in December. During a review of the facility document titled Falls for the last 30 days with injury (FWI), dated 12/31/19 to 1/25/20, the FWI indicated, Resident 1, Resident 4, Resident 5, Resident 10, Resident 18, Resident 20, Resident 63, Resident 82, Resident 103, and Resident 105 had fallen and sustained injuries. During a review of the facility's policy and procedure titled, YELLOW DOT PROGRAM FALL PREVENTIONPROGRAM (sic) undated, indicated, It is the policy of this facility to identify residents who are at high risk for falls . A yellow dot will be placed on the resident's nameplate outside the door. Nursing personnel will monitor all residents periodically . Ancillary staff will be aware of this program and report any problems to the Nursing Supervisor.

Based on observation, interview, and record review, the facility failed to prevent the transmission of the COVID-19 (mild to severe illness that is caused by a Coronavirus, is transmitted chiefly by contact with infectious material (such as respiratory droplet) and is characterized especially by fever, cough, and shortness of breath and may progress to pneumonia and [MEDICAL CONDITION]) virus when: 1. An Infection Preventionist (IP - experts on practical methods of preventing and controlling the spread of infectious diseases) was not available; 2. A system was not in place for extended use and storage of N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask; 3. Staff were not using proper Personal Protective Equipment (PPE-refers to equipment worn to minimize exposure to a variety of hazards); 4. Used gowns were not discarded appropriately; 5. Education was not provided for all staff on the use, disinfection, and storage of PPE; 6. Staff were not social distancing in the breakroom. These failures had the potential to spread the COVID-19 virus to all 76 of 76 residents residing in the facility, staff, and visitors. Findings: 1. During an interview on 7/17/20, at 11:38 AM, with Director of Nursing (DON), DON stated the facility's Infection Preventionist (IP) was currently not working, and had last worked when the facility had it's first COVID-19 outbreak on 7/8/20. DON stated the facility currently did not have an IP. During an interview on 7/21/20, at 10:23 AM, with IP/(Director of Staff Development Consultant) DSDC 1, she stated if a facility had no infection control outbreak the IP is to be in the facility for 24 hours per week, if there is an outbreak, the IP was to be in the facility for 40 hours per week. IP/DSDC 1 confirmed the facility had an outbreak and the facility should have an IP in the building 40 hours per week. IP/DSDC 1 could not recall the last the time she had been at the facility, she stated, I try to come here (facility) as often but I've been more in the other two buildings (indicating two other buildings owned by the company). During an interview on 7/21/20, at 10:49 AM, with IP/DSDC 2, she stated the designated IP role is to educate staff and monitor daily to ensure all aspects of infection control is being followed. IP/DSDC 2 stated she last visited the facility on 7/10/20 and no other visits thereafter. During an interview on 7/21/20, at 11:07 AM, with the Administrator, DON, and IP/DSDC 1, the Administrator stated the designated IP had last worked on 7/8/20 and confirmed the facility currently had no available IP. During an interview on 7/21/20, at 2:58 PM, with the Administrator, DON, IP/DSDC 1, and Quality Assurance Nurse Consultant (QANC), QANC stated an IP should be in the building eight hours daily. During a review of the facility's policy and procedure (P&P) titled, Isolation-Initiating Transmission-Based Precautions, dated 1/12, indicated In an emergency, the Infection Preventionist, Administrator and/or Medical Director shall have the administrative authority, accountability, and responsibility to: a. Institute all actions necessary to control or prevent infections within the facility. During a review of the facility's COVID-19 Mitigation Plan (MP), undated, the MP indicated, Facility will designate an Infection Preventionist (IP). Facility will ensure IP reviews guidance recommendations provided by CDC (Centers for Disease Control and Prevention), CDPH (California Department of Public Health) and/or LHD (Local Public Health) to maintain consistent situational awareness with highly evolving nature of COVID. IP will monitor and collect guidance from LHD, CDPH, and CDC and educate all staff on best practices to ensure consistent application of safe IP practices. During a review of the facility's Infection Control Coordinator job duties, undated, the Infection Control Coordinator job duties indicated in part, Plan, develop, organize, implement, evaluate, coordinate, and direct our infection control program in accordance with current rules, regulations, and guidelines that govern such requirements in the long-term care facility. Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control or universal precautions. Monitor infection control practices and procedures to ensure that all personnel are implementing our standard operating procedures for tasks involving exposure to blood/body fluids. Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of isolation precautions/practices. Meet with the staff in identifying and correcting problem areas, and/or the improvement of services, as necessary. 2. During a concurrent observation and interview on 7/17/20, at 11:20 AM, with the Administrator, in the designated donning/doffing area (a separate area designated for putting on/removal of PPE), there were multiple clam shells (used to store used face mask) with more than one face mask being stored in the container. A paper bag contained a face shield and a N95 facemask being stored together. The Administrator confirmed the findings. During a concurrent observation and interview on 7/17/20, at 11:38 AM, the dedicated donning/doffing area was observed with the DON. Several brown paper bags contained face shields and N95 mask. Several individual clam shell containers were noted with multiple mask inside. DON confirmed the face shields and N95 masks were used and stated each used item should be placed in a separate bag or clam shell container when not being used. DON stated she does daily monitoring to ensure proper PPE storage but had not had a chance to do it. DON stated she will provide in-service to all staff on proper PPE storage. During a concurrent observation and interview on 7/21/20, at 9:05 AM, with the Administrator, in the designated donning/doffing area, there was a N95 mask laying on a table next to the storage racks. There was no indication of who the mask belong to, or if it was unused. There were multiple clam shells on the storage racks that contained N95 masks. The clam shells were not dated with the day the masks were provided to the staff and how many times it had been worn. The Administrator confirmed the findings and stated she was unaware of how many times the mask had been used and would have to ask the staff their process of rotating the masks. During an observation on 7/21/20, at 9:13 AM, the dedicated donning and doffing area was observed with the Administrator and DON. Several brown bags contained used face shields, N95 mask, and surgical mask. Administrator and DON confirmed the findings. DON stated the facility process was to store each item in a separate bag to prevent contamination. During a concurrent observation and interview on 7/21/20, at 9:20 AM, with Activities Assistant (AA) 1, in the designated donning/doffing area, he was observed donning an N95 mask. AA 1 stated he was only given one N95 mask and had been using the same mask for three consecutive days. Pointing at both the Administrator and DON, AA 1 stated, They weren't here, someone gave me one mask. I don't know if I'm supposed to wear a different one everyday. I've just been doing what my co-workers are telling me. Nobody has ever told me anything else. I've used the same mask three days in a row. During a concurrent observation and interview on 7/21/20, at 9:40 AM, with Nursing Assistant (NA) 1, NA 1 was observed wearing two mask; a surgical mask and a N95. NA 1 stated the surgical mask helps me breath better. NA 1 stated she was given three mask but uses the same mask two days in a row before discarding. NA 1 stated, Me personally, I use the same mask two days in a row then toss it. NA 1 stated she was never told to rotate the three mask given to her. During a concurrent observation and interview on 7/21/20, at 10:20 AM, with Certified Nursing Assistant (CNA) 1, in the designated donning/doffing area, she stated she was given three masks and three clam shell containers for storage. CNA 1's clam shell containers were dated 7/10, 7/11, and 7/12, and there were no other markings noted to indicate how often the mask had been used. CNA 1 stated, They gave us three mask but they never told us exactly when to replace it. I've probably used mine three or four times already, I'm not sure. During an interview on 7/21/20, at 10:23 AM, with IP/DSDC 1, IP/DSDC 1 stated, Staff are given three N95 mask to cycle one, two, three. Monday wear 1st mask, Tuesday wear 2nd mask, Wednesday wear 3rd mask and cycle back to the 1st mask. Each mask can be worn a maximum of five times, then toss unless broken or soiled. They get a new one no matter if its brand new. IP/DSDC 1 stated face shield, N95 mask, and surgical mask should be stored separately. During an interview on 7/21/20, at 10:49 AM, with IP/DSDC 2, IP/DSDC 2 stated the facility were preserving the mask by giving staff three to four mask at a time. IP/DSDC 2 stated, They (staff) alternate the mask, each can be used up to three times then get a new one or if soiled then they get a new one. IP/DSDC 2 stated staff were to store the face shield in a big brown bag, surgical mask in a smaller brown bag, N95 mask in a clam shell container, They should all be stored separately. IP/DSDC 2 stated she had provided several in-service on 7/10/20 to staff who were at the facility scheduled to work. IP/DSDC 2 stated she did not provide in-service to all staff. During an interview on 7/21/20, at 11:07 AM, with the Administrator, DON, and IP/DSDC 1, the Administrator stated the facility currently had approximately 170 staff. Administrator confirmed not all staff had been in-serviced on proper use and storage of N95 mask. DON was unable to provide documentation of completed staff in-serviced on proper PPE storage and monitoring. During a review of the Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators updated on 4/2019, it indicated, Training on indications for use of N95 respirators-It is important that HCP (Health Care Personnel) be trained on indications for use of N95 respirators. The OSHA Respiratory Protection standard requires employers to provide respirator training to an employee prior to use in the workplace. Limited re-use of N95 respirators-One effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to COVID-19 patients a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and sore them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for [DIAGNOSES REDACTED]-CoV2 (virus that caused COVID-19). HCP should still treat the respirator as though it is still contaminated. 3. During an observation on 7/21/20, at 9:35 AM, outside of each resident's room door was yellow signage that indicated, Enhanced Droplet and Contact Precautions .Before Entry 1. Wash or sanitize hands 2. Put on gown 3. Put on respiratory protection. Staff: N95 4. Put on eye protection. Staff: face shield or goggles 5. Put on gloves. During a concurrent observation and interview on 7/21/20, at 9:40 AM, Licensed Vocational Nurse (LVN) 1 was sitting at the nurses station. LVN 1 had the bottom strap of her N95 hanging down under her chin. LVN 1 walked out of the nurses station down the hall and into a residents room. LVN 1 confirmed the finding and stated she was not wearing the N95 appropriately and should have the bottom strap around the top of her head. During a concurrent observation and interview on 7/21/20, at 9:47 AM, in the hallway, with Restorative Nursing Assistant (RNA) 1, RNA 1 was completing RNA exercises with a resident. RNA 1 was not wearing a gown when performing the RNA exercises. RNA 1 confirmed the finding. RNA 1 stated the education provided to the staff was all different and complex. RNA 1 stated there was a lot of unanswered questions and he was unsure if he was required to wear a gown when performing RNA exercises. During a concurrent observation and interview on 7/21/20, at 9:40 AM, with Nurse Assistant (NA) 1, NA 1 was observed wearing two mask. A surgical mask and N95. NA 1 stated the surgical mask helps me breath better. During a concurrent observation and interview on 7/21/20, at 9:58 AM, with Housekeeper (HSK) 1, HSK 1 was observed inside a resident room wearing an N95 mask, face shield and no gown. Both residents A and B were observed sitting on the edge of their beds while HSK 1 wiped down residents bed side table, call light, bed rails, and swept the floor. HSK 1 states she was never told to wear a gown when entering and cleaning residents rooms. HSK 1 verbally asked DON, standing in the hallway, whether she should be wearing a gown when entering and cleaning a resident room, DON stated HSK 1 did not need to wear a gown, They're not providing care, they don't get close to the residents. During an interview on 7/21/20, at 10:23 AM, with IP/DSDC 1, IP/DSDC 1 stated all staff including housekeepers should be wearing four point PPE when going into resident rooms which included N95 mask, faceshield, gowns, and gloves. During an interview on 7/21/20, at 10:49 AM, with IP/DSDC 2, IP/DSDC 2 stated, The facility is considered yellow, they have had exposure (exposure to an individual positive with COVID-19 virus), everyone should be wearing four point PPE, gown, gloves, N95 mask, faceshield. IP/DSDC 2 stated all staff including housekeepers was to wear four point PPE. During an interview on 7/21/20, at 11:07 AM, with the Administrator, DON, and IP/DSDC 1, the Administrator stated the use of four point PPE for all staff was implemented on 7/8/20 when the facility had their first confirmed resident positive for COVID-19. During an interview on 7/21/20, at 2:58 PM, with the Administrator, DON, IP/DSDC 1, and QNAC, the Administrator stated three residents were confirmed positive for COVID-19 on 7/8, one confirmed positive on 7/17, and one confirmed positive on 7/21, with a current total of five positive residents. The Administrator stated the facility has had a cumulative total of eight staff confirmed positive of the COVID-19 virus. During a review of the facility's policy and procedure (P&P) titled, Isolation-Notices of Transmission-Based Precautions, dated 5/10, the P&P indicated, When Transmission-Based Precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of Transmission-Based Precautions. During a review of the facilities Lesson Plan (LP) titled Infection Control: Transmission Based Precaution, dated 7/10/20, the LP indicated, Gowns-Wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces (such as siderails or bed linens of an infected resident) is anticipated. Remove gowns when the procedure is complete and prior to leaving the resident's room. During a review of the facility's COVID-19 Mitigation Plan, undated, the Mitigation Plan indicated, All staff will wear recommended PPE while in the building per current LHD and CDPH PPE guidance based on the zone in which they work. During a review of the Centers for Disease Control and Prevention (CDC) Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs) updated on 4/2019, it indicated, If COVID-19 is identified in the facility, restrict all residents to their rooms and have HCP wear all recommended PPE for care of all residents (regardless of symptoms) on the affected unit (or facility-wide depending on the situation). This includes: an N95. , eye protection, gloves, and gown. HCP should be trained on PPE use including putting it on and taking it off. This approach is recommended because of the high risk of unrecognized infection among residents. residents could have COVID-19 without reporting symptoms or before symptoms develop. 4. During a concurrent observation and interview on 7/17/20, at 12:30 PM, with the DON, there was an employee gown laying on top of a resident dresser in the resident's room. The DON confirmed the finding and stated hooks were to be placed in each room for staff to hang their gowns on prior to exiting the room. During a concurrent observation and interview on 7/21/20, at 10:10 AM, with CNA 2, in a residents room, a crumpled gown was noted on top of residents dresser drawer. CNA 2 stated, It looks used. It should have been tossed in the dirty laundry. During an interview on 7/21/20, at 10:49 AM, with IP/DSDC 2, she stated, All cloth gown used after entering resident rooms should be hung on a hook in residents room, if the hook was not available, staff should put on a fresh gown and toss in bin after each use. During a review of the facility's COVID-19 Mitigation Plan, undated, the Mitigation Plan indicated, Staff will be trained on proper donning (putting on) and doffing (taking off) procedures. All staff will wear recommended PPE while in the building per current LHD and CDPH PPE guidance based on the zone in which they work. 5. During a concurrent observation and interview on 7/21/20, at 9:30 AM, with NA 2, in the designated donning/doffing area, NA 2 removed her face mask and placed it in a paper bag. She did not clean and sanitize her face shield prior to placing it in the paper bag, and did not perform hand hygiene after removing the face shield. NA 2 confirmed the findings, and stated she had not received any training on the storage or proper donning/doffing of PPE. During a concurrent observation and interview on 7/21/20, at 10:04 AM, with RNA 1, in the staff break room, and there were three other staff present. Next to a staff eating lunch, there was a face shield laying on the table, with a black sweater on top of it, and a N95 mask on top of the sweater. RNA 1 confirmed the findings and stated he asked about the storage of PPE during the break but was not provided with education on how to store PPE while on break. During an interview on 7/21/20, at 10:23 AM, with the IP/DSDC 1, IP/DSDC 1 stated, PPE should be stored in a container while on break and should not be stored with staff's personal items. During a review of the facility's policy and procedure (P&P) titled, 4 POINT PPE ROOMS, undated, the P&P indicated, If going to restroom/break/lunch: . Proceed to designated Donning/Doffing area; Perform hand hygiene with hand sanitizer; Remove face shield, Disinfect, and then place in bag; Perform hand hygiene with Hand sanitizer; Remove face mask and place in bag; Perform hand hygiene with hand sanitizer; Apply surgical mask prior to entering hallway; wash hands at wash station. 6. During a concurrent observation and interview on 7/21/20, at 10:04 AM, with RNA 1, in the staff break room, there were three staff in the break room, one sitting alone at one table and two other staff sitting at another table less than 6 feet apart. Both tables were less than six feet apart from the other. RNA 1 confirmed the findings and stated if staff were not able to be six feet apart in the break room then the dining room was to be used as a second break room. During an interview on 7/21/20, at 10:23 AM, with the IP/DSDC 1, IP/DSDC 1 stated, when staff are in the break room, they should be social distancing and limiting the amount of people in the break room at one time. During an interview on 7/21/20, at 10:57 AM, with the IP/DSDC 2, IP/DSDC 2 stated, staff are expected to social distance while in the break room and the breaks should be staggered or taken elsewhere to allow for social distancing. During a review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes updated on 6/2020, it indicated, Implement Social Distancing Measures. Implement aggressive social distancing measures (remaining at least 6 feet apart from others). Remind HCP to practice social distancing and wear a facemask (for source control) when in break rooms or common areas.

Based on observation, interview, and record review, the facility failed to protect one of three sample residents (Resident 1) from abuse when Resident 1 was physically attacked by Resident 2 and Resident 3 during three separate incidents. This failure resulted in Resident 1 sustaining scratches, several skin tears to the right forearm, eyebrows and the top of his head. The resident was subsequently transferred to the hospital after the 10/29/19 incident. Findings: During a review of Resident 1's Progress Notes (PN), dated 8/2/19, the PN indicated at 1:30 PM, . resident (Resident 1) told her that his roommate (Resident 3) hit him . Resident 1 had two scratches to right forearm with discoloration, redness to neck, and scratch to left side of head . Resident (Resident 1) c/o (complained of) left shoulder pain upon assessment. During a review of Resident 1's PN, dated 10/29/19, the PN indicated at 6:25 AM, Resident 2 was on top of Resident 1 straddling him with his right elbow on (Resident 1's) chest and hitting him with his other hand in the face . (Resident 1) was covered in blood and covering his face . I observed skin tears to his right forearm approx (sic) the size of a quarter, a skin tear to his right eyebrow as well as his left eyebrow and a skin tear to the top of his head; res (Resident 1) had excessive amounts of blood all over his right ear, his face and his hair; (Resident 1) whimpered every time I cleaned his skin-tears . he was shaking as I was cleaning him up despite my trying to comfort him . During an interview on 11/5/19, at 8:50 AM with the Administrator, Administrator stated on 10/29/19, the night staff heard noises coming from Resident 1's room and found Resident 2 on top of Resident 1. Administrator stated Resident 1 had received superficial scratches. During a concurrent observation and interview on 11/5/19, at 9:21 AM, with Resident 1, in Resident 1's room, Resident 1 was observed lying down in bed. Resident 1 stated he had been punched and hit but was unable to state who or name the place the incident occurred at. During a concurrent observation and interview on 11/5/19, at 9:55 AM, with Certified Nursing Assistant (CNA) 1 in the dining room activities, Resident 2 was observed sitting down. CNA 1 stated, Resident 2 had some anger problem. Yells at family, yells at staff. Usually has problems with male residents. During an interview on 11/5/19, at 10 AM, with Activity Staff (AS), AS stated on 10/29/19, at 5 AM, she observed Resident 2, walking in the hallway looking lost, and she took him back to his room and laid him down. AS stated, at approximately 6:15 AM, she heard yelling, then grunting. AS stated she looked inside Resident 1's room but the room was too dark, and the privacy curtain was pulled closed so she was unable to see anything. AS stated, I can't say how long (Resident 2) was in the room. During an interview on 11/5/19, at 10:45 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she had just started her shift on 10/29/19 and witnessed Resident 1 bleeding from his face, he had scratches on his head, and was taken to the hospital. LVN 1 stated Resident 1 had also been previously attacked by another resident (Resident 3). During an interview on 11/5/19, at 11:03 AM, with Assistant Director of Nursing (ADON), ADON stated, Resident 1 had been involved in previous altercations, maybe three or four. ADON stated, on 7/15/19 Resident 3 attacked Resident 1. ADON stated, on 8/2/19 Resident 3 attacked Resident 1. ADON stated, on 10/29/19 Resident 2 attacked Resident 1. During an interview on 11/6/19, at 8:38 AM, with CNA 2, CNA 2 stated, on 10/29/19 she was at the nurses' station when she heard yelling. CNA 2 stated, I saw (Resident 2) on top of resident (Resident 1). CNA 2 stated Resident 1 had sustained a cut, not sure how bad. CNA 2 stated Resident 2 has a habit of lashing out at other residents, that's why he's by himself. CNA 2 stated, there was no hall monitor. During an interview on 11/7/19, at 7:52 AM, with LVN 2, LVN 2 stated, on 10/29/19, at approximately 6:45 AM, she was at the nurses' station when she heard a hooting sound. LVN 2 stated she walked into Resident 1's room, and saw CNA 2 holding Resident 2 back from attacking Resident 1. LVN 2 stated, Resident 1 sustained a skin tear, busted lip, and skin tear to top of head. LVN 2 stated, Resident 2 was territorial, that's why he can't be roomed with any other Residents. During an interview with LVN 3, on 11/13/19, at 7:16 AM, she stated she was sitting at the nurses' station on 10/29/19 when she heard a hooting, cheering noise. LVN 3 stated she walked into Resident 1's room, and saw Resident 2 straddling Resident 1. Resident 2 was hitting Resident 1. During a review of Resident 1's Care Plan (CP), dated 8/2/19, the CP indicated, Resident 1 was involved in a resident to resident altercation; whereby, Resident 1 was the victim. The goals indicated Resident 1 will have no delayed episodes of emotional distress R/T (related to) incident through next review, target date 11/2/19. The interventions indicated, all staff to provide emotional support, notify physician and responsible party. Nursing/social service to monitor for delayed emotional distress, and wound healing. The CP did not indicate intervention(s) implemented to protect Resident 1 from further physical abuse. During a review of Resident 1's CP, dated 10/29/19, the CP indicated, Resident 1 was at risk for potential or actual abuse r/t his dementia and facility population. Resident was the victim of physical aggression. The goals indicated, Resident 1 will be safe and potential for abuse reduced. The updated interventions indicated, Eval (evaluation) at acute hospital, neuro checks, and provide wound care as ordered. The CP did not indicate intervention(s) implemented to protect Resident 1 from further physical abuse. During a review of the policy and procedure titled Abuse Prevention Program dated 2006, indicated Our facility is committed to protecting our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The implementation of changes to prevent future occurrences of abuse.

Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for six of 30 sampled residents (33, 79, 19, 85, 51, and 200) as evidenced by the facility's failure: 1. To have an effective system in place to prevent repeated falls and falls with injury to three of 30 cognitively impaired residents (33, 79, and 19). This systemic failure placed residents with fall risk at risk for harm, injury or death resulting in immediate jeopardy. 2. To protect four of 30 sampled residents (85, 51, 33 and 200) from being improperly transported in their wheelchairs for staff convenience, resulting in the residents' feet dragging on the floor. This failure resulted in Resident 85's fall with injury and had the potential for residents to fall and/or sustain serious harm or injuries from their feet dragging on the floor while being transported in their wheelchairs. This resulted in an immediate jeopardy situation. Findings: 1. a. During a review of the clinical record for Resident 33, the admission record dated 2/16/17, indicated Resident 33 had been admitted to the facility with multiple [DIAGNOSES REDACTED]. (most common form of dementia, characterized by loss of mental ability severe enough to interfere with normal activities of daily living), Anxiety disorder, Generalized Muscle Weakness, unspecified Lack of Coordination, other abnormalities of Gait and Mobility. The admission record indicated Resident 33 spoke Portuguese. Resident 33's Minimum Data Set (MDS, a clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 2/16/18, indicated Resident 33's Brief Interview for Mental Status (BIMS - assesses cognitive ability) indicated her cognition was severely impaired. The MDS assessment also indicated the resident had not been given any anti-psychotic, anti-anxiety, antidepressant or hypnotic medications during the seven day look-back period, and had two or more falls without injury and no falls with injury since the prior assessment period on 11/16/17. The Interdisciplinary Team (IDT - a group of healthcare professionals from different fields who work together to share expertise, knowledge and skills to impact patient care) meeting minutes dated 2/28/18 through 3/23/18, indicated four falls of the six falls were identified to have occurred when Resident 33 got up from her wheelchair. The IDT minutes dated 2/28/18, indicated Resident 33 had a witnessed, non-injury fall (Fall 1), on 2/21/18, (no time indicated). The IDT minutes indicated (Resident 33) was by the nurses' station when she stood up out of wheelchair and fell . The IDT minutes indicated Resident 33 had multiple falls and the care plan reviewed and changes made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) Nursing to monitor 2) Request Vit (vitamin) D levels. The Fall Care plan was updated, on 2/27/18, to include Toileting Program. The Fall Care plan was updated on 3/2/18, using the previously documented interventions from 6/2/17 of 1) Tabs alarm (device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or bed) in bed, 2) Bed Pad Alarm (Sensor pad is connected to an alarm, which is triggered to alert staff when resident is getting out of bed). The status [REDACTED]. Continue all current interventions, no skilled services needed at this time. Resident 33 had received PT (Physical Therapy) services 9/17 through 11/17. The IDT minutes dated 3/19/18, indicated Resident 33 had an unwitnessed, non-injury fall (Fall 2), on 3/17/18, at 7:30 AM. The IDT minutes indicated (Resident 33) was sitting next to hall monitor (name) (HM) when doorbell rang. The HM went to answer and when she returned, (Resident 33) was on the ground, on her (right) knee. She was next to the wheelchair. There was no indication if the tab alarm was on and working as indicated on the Fall Care Plan. The IDT minutes indicated this incident was reviewed as (Resident 33) trying to stand without assistance. The IDT minutes indicated Recommendations/Follow-Up 1) DON (director of nursing) to talk about pharmacy recommendations 2) psychologist consultation 3) Pending family care conference to discuss [MEDICATION NAME] (medication used as an anticonvulsant or mood stabilizer). The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/16/18, at 7:30 AM, indicated Resident 33 was found on right knee next to wheelchair. Will have no complications from the fall during the next seven days, and will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD (medical doctor). The IDT minutes, dated 3/19/18, indicated Resident 33 had a witnessed fall, with injury (Fall 3), on 3/17/18, at 8:20 AM. The IDT minutes indicated . saw (Resident 33) leave her chair, walking away from chair . (Resident 33) lost balance quickly. She fell to her left hip.hit (left) side of head on metal corner of chair. There was no indication if the tab alarm was on and working as indicated on the Fall Care Plan. The IDT minutes indicated the incident was reviewed as fall from resident to be impulsive to stand and walk without assistance and care plans reviewed and changes made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) psychologist consultation 2) DON to discuss pharmacy recommendations 3) Pending family care conference to discuss [MEDICATION NAME] (medication used as an anticonvulsant or mood stabilizer). The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/16/18, at 8:20 AM, indicated Resident 33 had a fall with injury. Resident 33 hit head and swelling to head. Will have no complications from fall during the next three days and will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD. The status [REDACTED]. Continue all current interventions. No skilled services needed at this time. The IDT minutes dated 3/20/18, indicated Resident 33 had a witnessed fall with injury (Fall 4), on 3/20/18, at 2:45 AM. The IDT minutes indicated witnessed (Resident 33) ambulating while pushing her wheelchair towards the bed (and) lost her balance and fell . (Resident 33) landed on (right) knee and bumped her head on the end of the bed.(Skin tear) was noted on (left forearm) measuring 3 centimeters (cm) X (by) 2 cm. There was no indication if the tab alarm was on and working or the bed sensor alarm was working as indicated on the Fall Care Plan. The IDT minutes indicated Recommendations/Follow-Up: 1) continue current interventions 2) family meeting scheduled for 3/22/18. The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/20/18, at 2:45 AM, indicated Resident 33 will have no complications from the fall during the next seven days, will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD, review and update care plan as needed and for injury see short term care plan skin tear to left forearm. The status [REDACTED]. The IDT minutes dated 3/23/18, indicated Resident 33 had a witnessed, non-injury fall (Fall 5), on 3/21/18, at 10:50 AM. The IDT minutes indicated 1:1 (when one staff is assigned to only supervise one resident) (staff member name) was helping with (Resident 33) with her ambulation. During their walk (Resident 33) attempted to sit in her personal wheelchair and began to slide down with (staff member) guiding her to floor without injury. The IDT minutes indicated Resident 33 currently takes [MEDICATION NAME] (antianxiety medication) at bedtime and [MEDICATION NAME] (antianxiety medication) every eight hours. The IDT minutes indicated Recommendations/Follow-Up 1) rehab post fall review 2) physical/occupational therapy evaluation secondary to numerous recent falls and 3) pharmacy medication review. The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan, dated 3/21/18, indicated Resident 33 had a witnessed non-injury fall. Will have no complications from the fall during the next seven days, will monitor for delayed pain, injury decrease in function and report to the MD and review and update care plan as needed. The IDT minutes dated 3/23/18, indicated Resident 33 had an unwitnessed, non-injury fall, (Fall 6), on 3/23/18, at 12:30 AM. The IDT minutes indicated Certified Nursing Assistant (CNA) responded to a noise coming from (Resident 33's) room, and found (Resident 33) on the floor in her doorway. The IDT minutes indicated R/R (responsible party) has agreed to try [MEDICATION NAME] to stabilize (Resident 33) Bx (behaviors).IDT recommends to continue pharmacy recommendation and to continue 1:1 and 15 min (minute) checks during noc (night) shift. The short-term Fall Care Plan dated 3/21/18, indicated Resident 33 had an unwitnessed non-injury fall. Will have no complications from the fall during the next seven days, will perform neurological checks, monitor for delayed pain, injury decrease in function and report to the MD and review and update care plan as needed. The IDT minutes, dated 1/29/18, and 2/5/18, both indicated Resident 33 received [MEDICATION NAME] every evening for anxiety M/B (manifested by) restlessness. Resident 33's Fall Care Plan dated 6/2/17, indicated she was at risk for falls secondary to 1) History of Falls within 30 days prior to admission, 2) Wandering, 3) Impaired Balance, 4) Poor Safety Awareness, 5) At Risk of Fall, and 6) Other: History of Falls, Walks to Point of Exhaustion. The Fall Care Plan indicated the following seven interventions were initiated on 6/2/17: 1) Assess resident's balance, 2) Involve in activities program, 3) Provide adequate lighting, 4) Answer call light in a timely manner, 5) Keep environment free of clutter and safety hazards, 6) Place items frequently used by resident within reach, and 7) Keep resident/family informed. On 6/14/17, the Fall Care Plan was updated to include: 1) Fall mat to right side (of bed), 2) Tabs alarm in bed and wheelchair, and 3) Bed pad alarm. The Fall Care Plan was updated on 2/27/18, to include Toileting Program. The Fall Care Plan was updated, on 3/2/18, using the previously documented interventions from 6/2/17 of 1) Tabs alarm in bed, 2) Bed Pad Alarm. The Fall Care Plan did not have the box checked indicating Resident 33 had anti-anxiety medications. 1. b. During a review of the clinical record for Resident 79, the admission record, dated 4/3/17, indicated Resident 79 had been admitted to the facility with multiple [DIAGNOSES REDACTED]. The admission record indicated Resident 79 spoke Portuguese. Resident 79's MDS, dated [DATE], indicated resident's BIMS indicated Severe Cognitive Impairment, had received antidepressant medications and had had a fall with Major Injury (i.e. bone fractures, joint dislocations, closed head injury) since the previous MDS Assessment on 10/6/17. Resident 79's Fall Care Plan dated 6/2/17, indicated Resident 79 was at risk for falls secondary to 1) Impaired Balance 2) Anti-depressant medication 3) Poor Safety Awareness, 4) At Risk of Fall, 5) Other (Specify) Dementia 6) Fall with Injury on 10/16/17, to left humeral neck (humerus fracture is a serious injury to the humerus bone in the shoulder joint). The Fall Care Plan indicated the following seven interventions were initiated on 6/2/17: 1) Assess resident's balance, 2) Involve in activities program, 3) Keep call lights and bed controls within easy reach, 4) Encourage to call for assistance, 5) Keep environment free of clutter and safety hazards, 6) Place items frequently used by resident within reach, and 7) Keep resident/family informed. The Care Plan was updated on 10/16/17, with the date by the box Other (specify) nothing was specified (it was left blank) responsible discipline was nursing and it was initialed by a staff member. The Care Plan was updated again on 11/27/17, Other (specify) a side rail while in bed. During a review of the IDT minutes, dated 2/26/18, through 3/16/18, for Resident 79 were reviewed. It was noted she had experienced four falls during that period. The IDT minutes dated 2/26/18, indicated Resident 79 had a witnessed, non-injury fall (Fall 1), on 2/23/18, at 4:10 PM. The IDT minutes indicated CNA 16 witnessed (Resident 79) during patient care, reach for door without assistance, (CNA 16) asked (Resident 79) to wait for her assistance - (Resident 79) proceeding not to wait and tripped over her own feet causing (Resident 79) to fall to her bottom. The IDT minutes indicated Resident 79 had refused all her medications, was impulsive, difficult to redirect at times, and the Care Plans were reviewed and changes had been made as appropriate. The IDT Minutes indicated Recommendations/Follow-up: 1) rehab post fall review 2) continue P[NAME] (plan of care)/interventions/approaches and 3) (name) referral secondary to recent antidepressant change with BX (arrow up) (increased behaviors). The nurse's notes, dated 2/25/18, at 10:10 AM, indicated Resident 79, was in her bed at the time of discovery, when bruising all around base of right thumb and her right pinky with swelling was noted. The physician order, dated 2/25/18, at 10:15 AM, indicated X-ray to right hand secondary to swelling and bruising; rule out fracture. The status [REDACTED]. The IDT minutes, dated 2/26/18, indicated Resident 79 had a second witnessed, non-injury fall (Fall 2), later that same day, at 4:45 PM. Resident 79 was observed to attempt to sit in her wheelchair, after ambulating with her front wheeled walker. The wheelchair rolled back slightly, with Resident 79 landing on her bottom. The IDT Minutes indicated Recommendations/Follow-up: 1) rehab post fall review 2) continue P[NAME] /interventions/approaches and 3) continue referral to (name) psychiatrist. The nurse's notes, dated 2/25/18, at 10:10 AM, indicated Resident 79, was in her bed at the time of discovery, when bruising all around base of right thumb and her right pinky with swelling was noted. The physician order, dated 2/25/18, at 10:15 AM, indicated X-ray to right hand secondary to swelling and bruising; rule out fracture. The status [REDACTED]. The IDT minutes, dated 2/28/18, indicated Resident 79 had an unwitnessed, non-injury fall, (Fall 3), on 2/27/18, at 1 PM. Resident 79 was found in her room, on the floor by her bed, crying. The IDT minutes indicated Resident 79 was just taken on a walk around the facility by Activities Director, Resident 79 toilets herself and the care plans were reviewed and changes made as appropriate. The IDT minutes indicated Recommendations: 1) Start scheduled toileting program. The status [REDACTED]. Continue all current interventions. No skilled services needed at this time. The IDT minutes dated 3/16/18, indicated Resident 79 had a witnessed, non-injury fall, (Fall 4), on 3/15/18, at 7 PM. The IDT minutes indicated Resident 79 was being redirected to her room, when she lost her footing and was lowered to the ground. The IDT minutes indicated Resident 79 had a history of [REDACTED]. The IDT minutes indicated upon investigation, it was confirmed Resident 79 was wearing nonskid socks, the room was well lit, and care plans reviewed and changes were made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) rehab post fall Review 2) Pharmacy med (medication) review 3) Continue with RNA (Restorative Nursing Assistant - interventions that promote the resident's ability to live as independently and safely as possible) program. The status [REDACTED]. Continue all current interventions. Resident 79 has some PLOF <CLOF (Prior level of function less than current level of function). During an interview with the Director of Staff Development (DSD), on 3/29/18, at 9:12 AM, she reviewed the clinical record for Resident 79 and confirmed the Fall Care Plan did not show any new interventions for the four recent falls. 1. c. During an observation and interview with Licensed Vocational Nurse (LVN) 10, on 3/29/18, at 10:30 AM, Resident 19 was sleeping in her bed. Resident 19 had a sling on her left arm; the left upper arm and shoulder were bigger than the right shoulder and arm. Resident 19 had a bruise around her right eye. LVN 10 stated, She had an unwitnessed fall last night after midnight and broke her arm. She was found on the floor and she didn't know what happened. Her left shoulder and arm are swollen. During an interview with the Administrator, on 3/29/18, at 11:05 PM, the fall trend report was requested. At 12:30 PM, the Administrator provided a written fall report which indicated between 1/25/18 and 1/31/18 there were six falls and two of the six falls had minimal injuries. During the month of 2/18, there were 34 falls; two of the 34 falls had major injuries. During the month of 3/18, there were 37 falls; six of the 37 falls had minimal injuries and two of the 37 falls had major injuries. During an interview with the Administrator, on 3/29/18, at 3:35 PM, he handed a typewritten Fall Report. The Fall Report, dated 2/18 and 3/18, indicated there were 34 falls during 2/18 and 44 falls during 3/18. Between 2/18 and 3/18, four of 16 sampled residents had multiple falls: Resident 33 had 10 falls, Resident 79 had five falls, Resident 63 had four falls, and Resident 43 had three falls. The facility policy and procedure titled Duties and Responsibilities undated, indicated Duties and responsibilities of the Care Planning/Interdisciplinary Team include, but are not limited to: 1). Developing a comprehensive care plan for each resident that includes measurable objectives and timetables. 2). Reviewing care plans to assure that: a. They reflect the resident's medical and nursing assessment b. They are oriented toward preventing declines in functioning and/or functional levels c. They attempt to manage risk factors d. They build on the resident's strengths. e. They reflect standards of current professional practice f. Treatment objectives have measurable outcomes. g. They reflect and (sic) interdisciplinary approach to maintain or improved functional abilities. The facility policy and procedure titled Fall Prevention Program undated, indicated It is the policy of this facility to have a fall prevention program to identify residents who may be at risk for falls and establish a plan of care with interventions to prevent fall(s) and/or injury. Procedure:.5. If a fall occurs, the IDT members will conduct an additional conference to review risk factors, cause factors and review the plan of care with revision of interventions to prevent future falls. 7. Quality Assurance review will be conducted under the direction of the Administrator of the facility and reviewed by the QAAC (Quality Assessment and Assurance Committee). 2. During a concurrent observation and interview with the Activity Director (AD), on 3/28/18, at 9 AM, Resident 85 and Resident 51 were observed in the hallway, by the nurses' station, sitting in the wheelchairs, wearing non-skid socks. The AD grabbed the left armrests of Resident 85 and Resident 51's wheelchairs and started pulling them through the hallway simultaneously to the dining room with their feet dragging on the floor. The AD stated she was taking the residents to the dining room for an activity. During a concurrent observation and interview with the AD, on 3/28/18, at 9:08 AM, the Social Services Director (SSD) was observed pushing Resident 200 in a wheelchair through the hallway to the dining room with her feet dragging on the floor and the AD was watching. Resident 200 was wearing rubberized footwear. The AD stated, Oh, I see what can happen without the foot rest and the resident wearing non-skid socks. The resident can fall forward with the wheelchair and break their feet. All our wheelchairs don't have the foot rests except those brought from home. During an interview with LVN 3, on 3/28/18, at 3:28 PM, LVN 3 reviewed the clinical record for Resident 85. The Interdisciplinary Team (IDT-a group of healthcare professionals from different fields who work together to share expertise, knowledge and skills to impact patient care) meeting dated 1/9/18, indicated a Certified Nursing Assistant (CNA) was wheeling Resident 85 down the hall with her feet dragging on the floor, which resulted in Resident 85 falling forward out of the wheelchair to the floor. Resident 85 sustained a laceration (a deep cut or tear) to left eyebrow. The IDT identified transporting Resident 85 in a wheelchair with her feet dragging on the floor was the cause of the fall with injury. The IDT recommendation was to provide staff education on proper wheelchair positioning. During an interview with LVN 3, on 3/28/18, at 10:30 AM, LVN 3 reviewed the clinical record for Resident 51. Resident 51's admitted was 5/9/17 with a primary [DIAGNOSES REDACTED]. This is a 2-part surgery. First, the broken bone is put back into place. Next, an internal fixation device is placed on the long, straight part of the thigh bone), dementia (usually progressive condition, affects a person's thinking, behavior, and memory), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (the body is unable to metabolize sugars and starch resulting in abnormal sugar levels in blood and urine), arthritis (inflammation of one or more joints) and high blood pressure. LVN 3 also stated Resident 51 was forgetful and totally dependent on staff for ADL (activities of daily living). During an observation on 3/29/18, at 10:28 AM, Medical Records Staff (MRS) pushed Resident 33 in her wheelchair. The MRS stopped at the nurses' station to answer a question. While she was stopped, the MRS let go of Resident 33's wheelchair. Resident 33 propelled herself forward using her feet. The MRS reached out, grabbed the wheelchair handles and pulled Resident 33 backwards towards her. As she was pulled backwards, Resident 33's feet dragged on the floor.

Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for six of 30 sampled residents (33, 79, 19, 85, 51, and 200) as evidenced by the facility's failure: 1. To have an effective system in place to prevent repeated falls and falls with injury to three of 30 cognitively impaired residents (33, 79, and 19). This systemic failure placed residents with fall risk at risk for harm, injury or death resulting in immediate jeopardy. 2. To protect four of 30 sampled residents (85, 51, 33 and 200) from being improperly transported in their wheelchairs for staff convenience, resulting in the residents' feet dragging on the floor. This failure resulted in Resident 85's fall with injury and had the potential for residents to fall and/or sustain serious harm or injuries from their feet dragging on the floor while being transported in their wheelchairs. This resulted in an immediate jeopardy situation. Findings: 1. a. During a review of the clinical record for Resident 33, the admission record dated 2/16/17, indicated Resident 33 had been admitted to the facility with multiple [DIAGNOSES REDACTED]. (most common form of dementia, characterized by loss of mental ability severe enough to interfere with normal activities of daily living), Anxiety disorder, Generalized Muscle Weakness, unspecified Lack of Coordination, other abnormalities of Gait and Mobility. The admission record indicated Resident 33 spoke Portuguese. Resident 33's Minimum Data Set (MDS, a clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 2/16/18, indicated Resident 33's Brief Interview for Mental Status (BIMS - assesses cognitive ability) indicated her cognition was severely impaired. The MDS assessment also indicated the resident had not been given any anti-psychotic, anti-anxiety, antidepressant or hypnotic medications during the seven day look-back period, and had two or more falls without injury and no falls with injury since the prior assessment period on 11/16/17. The Interdisciplinary Team (IDT - a group of healthcare professionals from different fields who work together to share expertise, knowledge and skills to impact patient care) meeting minutes dated 2/28/18 through 3/23/18, indicated four falls of the six falls were identified to have occurred when Resident 33 got up from her wheelchair. The IDT minutes dated 2/28/18, indicated Resident 33 had a witnessed, non-injury fall (Fall 1), on 2/21/18, (no time indicated). The IDT minutes indicated (Resident 33) was by the nurses' station when she stood up out of wheelchair and fell . The IDT minutes indicated Resident 33 had multiple falls and the care plan reviewed and changes made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) Nursing to monitor 2) Request Vit (vitamin) D levels. The Fall Care plan was updated, on 2/27/18, to include Toileting Program. The Fall Care plan was updated on 3/2/18, using the previously documented interventions from 6/2/17 of 1) Tabs alarm (device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or bed) in bed, 2) Bed Pad Alarm (Sensor pad is connected to an alarm, which is triggered to alert staff when resident is getting out of bed). The status [REDACTED]. Continue all current interventions, no skilled services needed at this time. Resident 33 had received PT (Physical Therapy) services 9/17 through 11/17. The IDT minutes dated 3/19/18, indicated Resident 33 had an unwitnessed, non-injury fall (Fall 2), on 3/17/18, at 7:30 AM. The IDT minutes indicated (Resident 33) was sitting next to hall monitor (name) (HM) when doorbell rang. The HM went to answer and when she returned, (Resident 33) was on the ground, on her (right) knee. She was next to the wheelchair. There was no indication if the tab alarm was on and working as indicated on the Fall Care Plan. The IDT minutes indicated this incident was reviewed as (Resident 33) trying to stand without assistance. The IDT minutes indicated Recommendations/Follow-Up 1) DON (director of nursing) to talk about pharmacy recommendations 2) psychologist consultation 3) Pending family care conference to discuss [MEDICATION NAME] (medication used as an anticonvulsant or mood stabilizer). The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/16/18, at 7:30 AM, indicated Resident 33 was found on right knee next to wheelchair. Will have no complications from the fall during the next seven days, and will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD (medical doctor). The IDT minutes, dated 3/19/18, indicated Resident 33 had a witnessed fall, with injury (Fall 3), on 3/17/18, at 8:20 AM. The IDT minutes indicated . saw (Resident 33) leave her chair, walking away from chair . (Resident 33) lost balance quickly. She fell to her left hip.hit (left) side of head on metal corner of chair. There was no indication if the tab alarm was on and working as indicated on the Fall Care Plan. The IDT minutes indicated the incident was reviewed as fall from resident to be impulsive to stand and walk without assistance and care plans reviewed and changes made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) psychologist consultation 2) DON to discuss pharmacy recommendations 3) Pending family care conference to discuss [MEDICATION NAME] (medication used as an anticonvulsant or mood stabilizer). The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/16/18, at 8:20 AM, indicated Resident 33 had a fall with injury. Resident 33 hit head and swelling to head. Will have no complications from fall during the next three days and will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD. The status [REDACTED]. Continue all current interventions. No skilled services needed at this time. The IDT minutes dated 3/20/18, indicated Resident 33 had a witnessed fall with injury (Fall 4), on 3/20/18, at 2:45 AM. The IDT minutes indicated witnessed (Resident 33) ambulating while pushing her wheelchair towards the bed (and) lost her balance and fell . (Resident 33) landed on (right) knee and bumped her head on the end of the bed.(Skin tear) was noted on (left forearm) measuring 3 centimeters (cm) X (by) 2 cm. There was no indication if the tab alarm was on and working or the bed sensor alarm was working as indicated on the Fall Care Plan. The IDT minutes indicated Recommendations/Follow-Up: 1) continue current interventions 2) family meeting scheduled for 3/22/18. The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan dated 3/20/18, at 2:45 AM, indicated Resident 33 will have no complications from the fall during the next seven days, will perform neurological checks and monitor for delayed pain, injury decrease in function and report to the MD, review and update care plan as needed and for injury see short term care plan skin tear to left forearm. The status [REDACTED]. The IDT minutes dated 3/23/18, indicated Resident 33 had a witnessed, non-injury fall (Fall 5), on 3/21/18, at 10:50 AM. The IDT minutes indicated 1:1 (when one staff is assigned to only supervise one resident) (staff member name) was helping with (Resident 33) with her ambulation. During their walk (Resident 33) attempted to sit in her personal wheelchair and began to slide down with (staff member) guiding her to floor without injury. The IDT minutes indicated Resident 33 currently takes [MEDICATION NAME] (antianxiety medication) at bedtime and [MEDICATION NAME] (antianxiety medication) every eight hours. The IDT minutes indicated Recommendations/Follow-Up 1) rehab post fall review 2) physical/occupational therapy evaluation secondary to numerous recent falls and 3) pharmacy medication review. The Fall Care Plan did not indicate any new interventions. The short-term Fall Care Plan, dated 3/21/18, indicated Resident 33 had a witnessed non-injury fall. Will have no complications from the fall during the next seven days, will monitor for delayed pain, injury decrease in function and report to the MD and review and update care plan as needed. The IDT minutes dated 3/23/18, indicated Resident 33 had an unwitnessed, non-injury fall, (Fall 6), on 3/23/18, at 12:30 AM. The IDT minutes indicated Certified Nursing Assistant (CNA) responded to a noise coming from (Resident 33's) room, and found (Resident 33) on the floor in her doorway. The IDT minutes indicated R/R (responsible party) has agreed to try [MEDICATION NAME] to stabilize (Resident 33) Bx (behaviors).IDT recommends to continue pharmacy recommendation and to continue 1:1 and 15 min (minute) checks during noc (night) shift. The short-term Fall Care Plan dated 3/21/18, indicated Resident 33 had an unwitnessed non-injury fall. Will have no complications from the fall during the next seven days, will perform neurological checks, monitor for delayed pain, injury decrease in function and report to the MD and review and update care plan as needed. The IDT minutes, dated 1/29/18, and 2/5/18, both indicated Resident 33 received [MEDICATION NAME] every evening for anxiety M/B (manifested by) restlessness. Resident 33's Fall Care Plan dated 6/2/17, indicated she was at risk for falls secondary to 1) History of Falls within 30 days prior to admission, 2) Wandering, 3) Impaired Balance, 4) Poor Safety Awareness, 5) At Risk of Fall, and 6) Other: History of Falls, Walks to Point of Exhaustion. The Fall Care Plan indicated the following seven interventions were initiated on 6/2/17: 1) Assess resident's balance, 2) Involve in activities program, 3) Provide adequate lighting, 4) Answer call light in a timely manner, 5) Keep environment free of clutter and safety hazards, 6) Place items frequently used by resident within reach, and 7) Keep resident/family informed. On 6/14/17, the Fall Care Plan was updated to include: 1) Fall mat to right side (of bed), 2) Tabs alarm in bed and wheelchair, and 3) Bed pad alarm. The Fall Care Plan was updated on 2/27/18, to include Toileting Program. The Fall Care Plan was updated, on 3/2/18, using the previously documented interventions from 6/2/17 of 1) Tabs alarm in bed, 2) Bed Pad Alarm. The Fall Care Plan did not have the box checked indicating Resident 33 had anti-anxiety medications. 1. b. During a review of the clinical record for Resident 79, the admission record, dated 4/3/17, indicated Resident 79 had been admitted to the facility with multiple [DIAGNOSES REDACTED]. The admission record indicated Resident 79 spoke Portuguese. Resident 79's MDS, dated [DATE], indicated resident's BIMS indicated Severe Cognitive Impairment, had received antidepressant medications and had had a fall with Major Injury (i.e. bone fractures, joint dislocations, closed head injury) since the previous MDS Assessment on 10/6/17. Resident 79's Fall Care Plan dated 6/2/17, indicated Resident 79 was at risk for falls secondary to 1) Impaired Balance 2) Anti-depressant medication 3) Poor Safety Awareness, 4) At Risk of Fall, 5) Other (Specify) Dementia 6) Fall with Injury on 10/16/17, to left humeral neck (humerus fracture is a serious injury to the humerus bone in the shoulder joint). The Fall Care Plan indicated the following seven interventions were initiated on 6/2/17: 1) Assess resident's balance, 2) Involve in activities program, 3) Keep call lights and bed controls within easy reach, 4) Encourage to call for assistance, 5) Keep environment free of clutter and safety hazards, 6) Place items frequently used by resident within reach, and 7) Keep resident/family informed. The Care Plan was updated on 10/16/17, with the date by the box Other (specify) nothing was specified (it was left blank) responsible discipline was nursing and it was initialed by a staff member. The Care Plan was updated again on 11/27/17, Other (specify) a side rail while in bed. During a review of the IDT minutes, dated 2/26/18, through 3/16/18, for Resident 79 were reviewed. It was noted she had experienced four falls during that period. The IDT minutes dated 2/26/18, indicated Resident 79 had a witnessed, non-injury fall (Fall 1), on 2/23/18, at 4:10 PM. The IDT minutes indicated CNA 16 witnessed (Resident 79) during patient care, reach for door without assistance, (CNA 16) asked (Resident 79) to wait for her assistance - (Resident 79) proceeding not to wait and tripped over her own feet causing (Resident 79) to fall to her bottom. The IDT minutes indicated Resident 79 had refused all her medications, was impulsive, difficult to redirect at times, and the Care Plans were reviewed and changes had been made as appropriate. The IDT Minutes indicated Recommendations/Follow-up: 1) rehab post fall review 2) continue P[NAME] (plan of care)/interventions/approaches and 3) (name) referral secondary to recent antidepressant change with BX (arrow up) (increased behaviors). The nurse's notes, dated 2/25/18, at 10:10 AM, indicated Resident 79, was in her bed at the time of discovery, when bruising all around base of right thumb and her right pinky with swelling was noted. The physician order, dated 2/25/18, at 10:15 AM, indicated X-ray to right hand secondary to swelling and bruising; rule out fracture. The status [REDACTED]. The IDT minutes, dated 2/26/18, indicated Resident 79 had a second witnessed, non-injury fall (Fall 2), later that same day, at 4:45 PM. Resident 79 was observed to attempt to sit in her wheelchair, after ambulating with her front wheeled walker. The wheelchair rolled back slightly, with Resident 79 landing on her bottom. The IDT Minutes indicated Recommendations/Follow-up: 1) rehab post fall review 2) continue P[NAME] /interventions/approaches and 3) continue referral to (name) psychiatrist. The nurse's notes, dated 2/25/18, at 10:10 AM, indicated Resident 79, was in her bed at the time of discovery, when bruising all around base of right thumb and her right pinky with swelling was noted. The physician order, dated 2/25/18, at 10:15 AM, indicated X-ray to right hand secondary to swelling and bruising; rule out fracture. The status [REDACTED]. The IDT minutes, dated 2/28/18, indicated Resident 79 had an unwitnessed, non-injury fall, (Fall 3), on 2/27/18, at 1 PM. Resident 79 was found in her room, on the floor by her bed, crying. The IDT minutes indicated Resident 79 was just taken on a walk around the facility by Activities Director, Resident 79 toilets herself and the care plans were reviewed and changes made as appropriate. The IDT minutes indicated Recommendations: 1) Start scheduled toileting program. The status [REDACTED]. Continue all current interventions. No skilled services needed at this time. The IDT minutes dated 3/16/18, indicated Resident 79 had a witnessed, non-injury fall, (Fall 4), on 3/15/18, at 7 PM. The IDT minutes indicated Resident 79 was being redirected to her room, when she lost her footing and was lowered to the ground. The IDT minutes indicated Resident 79 had a history of [REDACTED]. The IDT minutes indicated upon investigation, it was confirmed Resident 79 was wearing nonskid socks, the room was well lit, and care plans reviewed and changes were made as appropriate. The IDT minutes indicated Recommendations/Follow-Up: 1) rehab post fall Review 2) Pharmacy med (medication) review 3) Continue with RNA (Restorative Nursing Assistant - interventions that promote the resident's ability to live as independently and safely as possible) program. The status [REDACTED]. Continue all current interventions. Resident 79 has some PLOF <CLOF (Prior level of function less than current level of function). During an interview with the Director of Staff Development (DSD), on 3/29/18, at 9:12 AM, she reviewed the clinical record for Resident 79 and confirmed the Fall Care Plan did not show any new interventions for the four recent falls. 1. c. During an observation and interview with Licensed Vocational Nurse (LVN) 10, on 3/29/18, at 10:30 AM, Resident 19 was sleeping in her bed. Resident 19 had a sling on her left arm; the left upper arm and shoulder were bigger than the right shoulder and arm. Resident 19 had a bruise around her right eye. LVN 10 stated, She had an unwitnessed fall last night after midnight and broke her arm. She was found on the floor and she didn't know what happened. Her left shoulder and arm are swollen. During an interview with the Administrator, on 3/29/18, at 11:05 PM, the fall trend report was requested. At 12:30 PM, the Administrator provided a written fall report which indicated between 1/25/18 and 1/31/18 there were six falls and two of the six falls had minimal injuries. During the month of 2/18, there were 34 falls; two of the 34 falls had major injuries. During the month of 3/18, there were 37 falls; six of the 37 falls had minimal injuries and two of the 37 falls had major injuries. During an interview with the Administrator, on 3/29/18, at 3:35 PM, he handed a typewritten Fall Report. The Fall Report, dated 2/18 and 3/18, indicated there were 34 falls during 2/18 and 44 falls during 3/18. Between 2/18 and 3/18, four of 16 sampled residents had multiple falls: Resident 33 had 10 falls, Resident 79 had five falls, Resident 63 had four falls, and Resident 43 had three falls. The facility policy and procedure titled Duties and Responsibilities undated, indicated Duties and responsibilities of the Care Planning/Interdisciplinary Team include, but are not limited to: 1). Developing a comprehensive care plan for each resident that includes measurable objectives and timetables. 2). Reviewing care plans to assure that: a. They reflect the resident's medical and nursing assessment b. They are oriented toward preventing declines in functioning and/or functional levels c. They attempt to manage risk factors d. They build on the resident's strengths. e. They reflect standards of current professional practice f. Treatment objectives have measurable outcomes. g. They reflect and (sic) interdisciplinary approach to maintain or improved functional abilities. The facility policy and procedure titled Fall Prevention Program undated, indicated It is the policy of this facility to have a fall prevention program to identify residents who may be at risk for falls and establish a plan of care with interventions to prevent fall(s) and/or injury. Procedure:.5. If a fall occurs, the IDT members will conduct an additional conference to review risk factors, cause factors and review the plan of care with revision of interventions to prevent future falls. 7. Quality Assurance review will be conducted under the direction of the Administrator of the facility and reviewed by the QAAC (Quality Assessment and Assurance Committee). 2. During a concurrent observation and interview with the Activity Director (AD), on 3/28/18, at 9 AM, Resident 85 and Resident 51 were observed in the hallway, by the nurses' station, sitting in the wheelchairs, wearing non-skid socks. The AD grabbed the left armrests of Resident 85 and Resident 51's wheelchairs and started pulling them through the hallway simultaneously to the dining room with their feet dragging on the floor. The AD stated she was taking the residents to the dining room for an activity. During a concurrent observation and interview with the AD, on 3/28/18, at 9:08 AM, the Social Services Director (SSD) was observed pushing Resident 200 in a wheelchair through the hallway to the dining room with her feet dragging on the floor and the AD was watching. Resident 200 was wearing rubberized footwear. The AD stated, Oh, I see what can happen without the foot rest and the resident wearing non-skid socks. The resident can fall forward with the wheelchair and break their feet. All our wheelchairs don't have the foot rests except those brought from home. During an interview with LVN 3, on 3/28/18, at 3:28 PM, LVN 3 reviewed the clinical record for Resident 85. The Interdisciplinary Team (IDT-a group of healthcare professionals from different fields who work together to share expertise, knowledge and skills to impact patient care) meeting dated 1/9/18, indicated a Certified Nursing Assistant (CNA) was wheeling Resident 85 down the hall with her feet dragging on the floor, which resulted in Resident 85 falling forward out of the wheelchair to the floor. Resident 85 sustained a laceration (a deep cut or tear) to left eyebrow. The IDT identified transporting Resident 85 in a wheelchair with her feet dragging on the floor was the cause of the fall with injury. The IDT recommendation was to provide staff education on proper wheelchair positioning. During an interview with LVN 3, on 3/28/18, at 10:30 AM, LVN 3 reviewed the clinical record for Resident 51. Resident 51's admitted was 5/9/17 with a primary [DIAGNOSES REDACTED]. This is a 2-part surgery. First, the broken bone is put back into place. Next, an internal fixation device is placed on the long, straight part of the thigh bone), dementia (usually progressive condition, affects a person's thinking, behavior, and memory), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (the body is unable to metabolize sugars and starch resulting in abnormal sugar levels in blood and urine), arthritis (inflammation of one or more joints) and high blood pressure. LVN 3 also stated Resident 51 was forgetful and totally dependent on staff for ADL (activities of daily living). During an observation on 3/29/18, at 10:28 AM, Medical Records Staff (MRS) pushed Resident 33 in her wheelchair. The MRS stopped at the nurses' station to answer a question. While she was stopped, the MRS let go of Resident 33's wheelchair. Resident 33 propelled herself forward using her feet. The MRS reached out, grabbed the wheelchair handles and pulled Resident 33 backwards towards her. As she was pulled backwards, Resident 33's feet dragged on the floor.

Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (81) received proper treatment and care for Resident 81's toenails and feet. This failure resulted in Resident 81's pain, thick, distorted, discolored, and infected toenails. Findings: During a review of the Admissions Record, on 1/23/18, at 8:50 AM, Resident 81 was a [AGE] year old female, with [DIAGNOSES REDACTED]. sugar levels are too high). The Nurses Notes, dated 12/30/17, indicated Resident 81 spoke and understood both the English and Spanish language clearly and could verbalize her needs. During an observation, on 1/23/18, at 8:55 AM, Resident 81 was observed screaming in pain when Certified Nursing Assistant (CNA) 6 was putting Resident 81's socks on. CNA 6 removed the socks and Resident 81's big toenails on both feet were observed to be thick, pulled forward, and filled with blackened substance. The side of the right big toenail was swollen and very tender to touch. The rest of the toenails for both feet were black in color. The skin on both feet was dry, scaly, and discolored both on the top and the bottom of the feet. During an interview with Resident 81, on 1/23/18, at 9:05 AM, she stated, My toes and my feet hurt. They have not done anything about it here. The doctor said he will cut the toenails but he never did. During a concurrent interview with the Social Services Director (SSD) and review of the clinical record for Resident 81, on 1/23/18, at 10:15 AM, the SSD reviewed the clinical record and was unable to find documentation of a podiatry consultation. The SSD stated, I faxed her facesheet. The podiatrist was here on 1/5/18 but he did not see her. The SSD reviewed the nursing notes and did not find documentation about the condition of Resident 81's toenails. The SSD did not find documentation CNA 6 reported to the licensed nurse Resident 81's complaint of pain on her toenails and feet. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 1/24/18, at 8:35 AM, LVN 1 was at the bedside and described Resident 81's toenails as thick, hard, long, and filled with blackened substance. Her toenails were misshaped due to the thick filling inside the big toenails. Both feet were [MEDICAL CONDITION] (swollen), at least +1 pitting (a patient with a score of 1 has [MEDICAL CONDITION] that is slight (roughly 2 mm in depth and disappears rapidly) [MEDICAL CONDITION]. The bottom of her feet were discolored, dry, and scaly. During a review of the clinical record for Resident 81, the Physician order [REDACTED]. LVN 1 verified the findings. During a concurrent interview with LVN 1 and review of the clinical record for Resident 81, on 1/24/18, at 8:45 AM, LVN 1 was not able to find Podiatry Consultation. LVN 1 reviewed the nursing notes and she was not able to find documentation of the condition of Resident 81's toenails by any nurses. LVN 1 reviewed the weekly nursing progress records and she was not able to find documentation addressing the toenails. LVN 1 reviewed the Care Plan and she was not able to find documentation addressing the care for Resident 81's toenails and pain. LVN 1 reviewed the pain assessment and was not able to find documentation regarding toenail pain and the condition of her feet and toenails. During an interview with LVN 2 on 1/24/18, at 4:40 PM, LVN 2 described Resident 81's toenails and feet as follows The skin is scaling on the left foot. The toenails have fungus embedded in all five nails, both feet. The bottom of the right foot is dry, black and gray in color. During an observation on 1/24/18, at 4:45 PM, when LVN 2 touched Resident 81's feet, Resident 81 made facial grimaces because of the pain, especially when LVN 2 touched and felt the right big toe. Resident 81 stated, There is something wrong. Resident 81 verbalized pain scale of 8 (description of each point on the medical pain scale for pain levels between 0 (pain free) and 10 (severe pain). The Lippincott Manual of Nursing Practice 10th Edition Standards of Care Guidelines for Diabetes Mellitus indicate .Perform thorough skin and extremity assessment for [MEDICAL CONDITION] (disease affecting peripheral nerves, which often causes weakness, numbness and pain, usually in one's hands and feet or [MEDICAL CONDITION] (a circulation disorder that affects blood vessels that supply the arms and legs), and any injury to the feet or lower extremities. Immediately report to health care provider any signs of skin or soft tissue infection (redness, swelling, warmth, tenderness, drainage). The facility policies and procedures titled Licensed Nurses Notes dated 1/2004, indicated .2. Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observation, and assessments, and other appropriate entries .Weekly progress notes are to be written on each resident .any pertinent information to reflect an overall profile of the resident .Summary of the events or condition changes since the last weekly summary.

Based on observation, interview and record review, the facility nursing staff failed to assess and notify Resident 10's physician of a change in condition, when Resident 10 complained of leg pain, redness and swelling to her left lower leg. This failed practice resulted in a decline in mobility, and an increase in pain and discomfort. Findings: Resident 10's Minimum Data Set (nursing assessment) indicated she was cognitively impaired with a [DIAGNOSES REDACTED]. During an observation and interview on 3/11/13, at 11:35 AM, in the resident's lounge, Resident 10 was having lunch complaining of left leg pain. She frequently lifted up her left pant leg and pointed to her left lower leg which appeared reddened and swollen. Certified Nursing Assistant, (CNA) 2 was observed pulling down the wanderguard band (plastic band with an attached device use to alert staff if resident attempts to leave facility) which was on her left leg above the ankle. An indentation was observed on Resident 10's leg where the wanderguard was placed. CNA 2 stated she was unable to move the wanderguard to another site. During an observation on 3/11/13, at 3:40 PM, in the hallway by business office, Resident 10 was attempting to ambulate and was limping holding up her left pants leg, her left leg continued to appear red and swollen. She continued to pull up her pant leg and showed staff her left leg and resisted ambulating although numerous nursing staff members were encouraging her to ambulate throughout the facility. During and concurrent observation and interview with the Director of Nursing on 3/11/13, at 3:45 PM, in the hallway she observed Resident 10 having difficulty walking and encouraged Resident 10 to use a wheelchair. During an observation and concurrent interview with Licensed Nurse (LN) 2, on 3/11/13, at 4 PM, he stated he had assessed Resident 10's legs and "that is just how she is", when asked if he had assessed the left leg, he stated he had not looked at the left leg and walked away. During a review of the clinical record for Resident 10 with LN 2, the Nurses Notes dated 3/1/13, at 10:30 AM indicated Resident 10's left leg swelling with redness. A faxed report from the facility to the physician dated 3/1/13, indicated Resident 10's left leg is red and swollen. The physician order [REDACTED]. LN 2 was unable to find documentation the stockings were ever placed on Resident 10. The Minimum Data Set (MDS, a resident assessment and screening tool used to identify care problems that are addressed in an individualized care plan) dated 2/2013 indicated Resident 10 could ambulate without assist. The nurse's note, dated 3/12/13 at 4:50 PM, indicated Resident 10 was attempting to ambulate to the nurse's station and fell . During an observation on 3/12/13, at 7:45 AM, Resident 10 was in the resident lounge sitting on the sofa eating breakfast. Resident 10 continually pulled on her left pant leg, pulling on her wanderguard, her left lower leg and feet were swollen and red, and her shoes were untied. Resident 10 ambulated slowly holding on to furniture and grimaced while ambulating. During an observation on 3/13/13, at 8:15 AM, Resident 10 was sitting in a chair across from the nurses station wearing slippers, her left lower leg remained red and swollen and she was unable to ambulate. She was placed in a wheelchair to return her to her room. During an interview and clinical record review with LN 2, on 3/12/13, at 2:30 PM, she was unable to find documentation that Resident 10's physician had been notified on 3/11/13 and that Resident 10 was having pain, swelling, and difficulty walking. During an interview with the facility Medical Director on 3/12/13, at 4 PM, he stated Resident 10 was assessed her left lower leg is swollen and red ... "I'm going to start antibiotics for [MEDICAL CONDITION] (a spreading bacterial infection of the skin). I'm the Medical Director and I'm available to come in right away if they call me." The facility policy and procedure titled "Change in a Resident's Condition or Status" undated, indicated, "Our facility shall promptly notify the residents, his or her attending physician,... of changes in the resident's condition and/or status... the license nurse will record in the resident's medical record any changes in resident's medical condition or status."

Based on interview and record review, the facility nursing staff failed to do weekly skin assessments for one one of 22 sampled residents (9) as indicated in her plan of care. This failure led to the development of unidentified pressure ulcers (wounds caused by pressure). The unidentified pressures went un-noted until they had developed into an unstageable full tissue thickness loss in which the actual depth of the ulcer is completely covered to the right heel which was discovered on 8/31/12 and a Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer...) to sacrum which was discovered on 12/26/12. Findings: During a review of the clinical record for Resident 9, the admission records indicated she was a cognitively impaired with a [DIAGNOSES REDACTED]. The "Resident Data Collection (admission)" dated 8/14/12, at 11:44 AM indicated under skin condition "no pressure ulcers." The Minimum Data Set (MDS, a resident assessment and screening tool used to identify care problems that are addressed in an individualized care plan) dated 8/26/12, indicated Resident 9 required extensive assistance with bed mobility, dressing, personal hygiene... The care plan "Pressure Ulcer/Skin Integrity" dated 8/16/12, indicated under approach #3 staff were to observe for skin improvement/deterioration weekly.... The "Weekly Pressure Ulcer Record" dated 8/31/12, indicated unstageable full thickness tissue loss in which the actual depth of the ulcer is completely covered to Right Heel which developed 8/31/12 and Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer...) to sacrum which developed 12/26/12 and progressed to Stage 3 (Full thickness tissue loss) on 1/16/13. During an interview with Licensed Nurse 3 on 3/13/13, he reviewed the clinical record and stated Resident 9 developed the Unstageable pressure ulcer to the right heel on 8/31/13 and Stage 2 to sacrum on 12/26/12 that progressed to a Stage 3 on 1/16/13. During an interview with the Chief Clinical Officer (CCO), on 3/13/13, she reviewed the clinical record and was unable to provide documentation of a skin assessment or physician order [REDACTED]. Facility policy and procedure for pressure ulcer prevention was not provided after two requests to the CCO.