Every finding on record at Pacific Heights Transitional Care Center

Based on interview and record review, the facility failed to ensure three out of three sampled staff employee files, (Unlicensed Staff A, Unlicensed Staff B and Unlicensed Staff C) had annual performance reviews or evaluations (systemic [entire organization], periodic process that assesses an employee's job performance, skills, and accomplishments against established company goals) performed for the year(s) 2025 and 2026.These failures had the likelihood for missed opportunities to provide specific education-based training for unlicensed staff members to capture potential safety concerns and improve outcomes like improving resident care concerns.During an interview on 3/12/26 at 2:29 PM with Director of Staff Development (DSD), DSD stated they had been in the position with the facility for approximately two years and had the responsibility of managing all of the unlicensed staff at the facility who provide care to the residents within the facility. During a concurrent interview and record review on 3/12/26 at 2:55 PM with DSD, the employee file of Unlicensed Staff A (USA) was reviewed. DSD stated USA had been hired in the month of July and the annual performance review or evaluation would not be completed until July of 2026 and it was March, sot it had not been done. Surveyor requested the annual performance review or evaluation for 2025, and DSD stated, they do not do performance reviews but presented a document, Annual Clinical Care Training Checklist dated 7/21/25 was reviewed. The checklist indicated to be comprised of skills which the employee and DSD initialed and there was no indication how the skills were assessed, for example by return demonstration or verbalizing to the DSD how the employee might perform the skill. DSD was asked if the form would capture, for example; an incident where Unlicensed Staff A had an allegation with a resident which had been unsubstantiated, but further training might have been helpful and DSD stated no, the form would not capture those types of instances. DSD looked down and stated, I work very hard and try my best. Surveyor asked for clarification if anyone else in the building was conducting performance reviews or evaluations and DSD stated no one would because they were in charge of all unlicensed staff and it was their responsibility to do anything related to these staff members. During an interview on 3/12/26 at 3:58 PM with Administrator (ADM), ADM was asked who performed the annual performance evaluations for unlicensed staff in the facility and ADM stated it was the DSD. Surveyor asked ADM what would be considered a performance evaluation and ADM presented a copy, titled, Performance Evaluation, reviewed 9/13/2023. Surveyor presented ADM with a copy of Annual Clinical Care Training Checklist and asked if this would be considered a performance evaluation and ADM stated no, the form presented and titled performance evaluation was the approved form. ADM stated the form (Annual Clinical Care Training Checklist) indicated to be a skills type of check list and actually that was why the facility chose the performance evaluations as part of the quality improvement for the year (2026). Surveyor asked why it was chosen and ADM stated because it was identified that it was not being completed with the unlicensed staff. Surveyor asked who the DSD reported to and ADM stated it was the Director of Nursing and the Director of Nursing reported to ADM. ADM stated ultimately, it's their responsibility that the performance evaluations were not getting done, since their were in charge of the building. During a concurrent interview and record review on 3/12/26 at 4:23 PM with DSD, the employee file of Unlicensed Staff B (USB) was reviewed. Surveyor presented the performance evaluation form obtained from Admin to DSD who stated, Yes, I was supposed to complete all of the unlicensed staff by April 1, 2026, but I have not completed any of them yet. Employee file review for USB was reviewed and DSD presented, Annual Clinical Care Training form dated 1/6/26. Surveyor clarified with DSD regarding the performance evaluation for USB and if there was one for 2025 or 2026 and DSD stated no. During a concurrent interview and record review on 3/12/26 at 4:55 PM with DSD, the employee file for Unlicensed Staff C (USC) was reviewed. DSD stated USC had been hired in January of 2025. Surveyor clarified with DSD if USC had a performance evaluation due in January of 2026 and had one completed to date, DSD stated no. During a review of the facility's, Employee Handbook titled, Performance Evaluations, dated 2023, indicated, Performance feedback should be on-going between supervisors and employees. However, we established annual, documented reviews as a standard to formalize an interactive conversation about what is going well, where there could be improvements, goals for career growth and to set objectives to work towards.You (employee) will be critiqued on the quality and quantity of the work you perform: job knowledge, customer service, professional behavior, attitude and treatment of others, . Included was a copy of the Performance Evaluation, revised 2/4/2026 (5 pages total).

Based on observation, interview, and record review, facility staff failed to ensure their walk-in freezer and walk-in refrigerator were maintained in a sanitary manner and a container of thickening powder was dated and labelled. These failures had the potential for food to be stored in an unsanitary manner and for residents to be exposed to expired food products.Findings:During a concurrent kitchen observation and interview with the Nutritional Service Supervisor (NSS) on 3/9/26 at 9:17 AM, these observations were made with the NSS:A clear plastic container, 1/2 full of a white powder was stored on a shelf next to the cook top. The container had no label and there was no opened date nor expiration date on the container.two blue berries, a clear plastic lid for a disposable cup, a can of ginger ale (8 fluid ounce, fluid ounce is a unit of liquid measurement), and a container of Ensure plus (dietary supplement, 8 fluid ounce) were found on the floor of the walk-in refrigerators (under the shelves).A handful of frozen peas and diced carrots, and four small frozen doughs were found on the floor of the walk-in freezer (under the shelves).During the interview, the NSS stated the white powder was a fluid thickening agent and should have been labelled and dated for a used by date. An observation was made that the walk-in refrigerator was dimly lit and the NSS confirmed this observation. The NSS stated this may have prevented staff from cleaning the area properly and may impede supervisory staff from checking to see if the area was clean in a proper manner.Review of the facility's policy titled GENERAL APPEARANCE OF FOOD & NUTRITION DEPARTMENT, dated 2018, indicated .Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition.1. Floors must be mopped at least once per day. 2. Sweep the floor, pushing all debris forward. Use a dust pan to remove and dispose of debris as it accumulates.Review of the facility's policy titled DRY STORAGE QUICK REFERENCE GUIDE, dated January 2026, indicated .Thickener . Recommended storage time .18-24 months. No other policy was provided by the facility regarding labeling and dating of food items.

Based on interview and record review, three issues were identified regarding dialysis communication books for Resident 7 and 27, two out of four resident receiving outpatient dialysis.1. Resident 7's dialysis communication book was missing important information. 2. Two medications were administered by dialysis staff to Resident 7. One was not clarified and both were not communicated to the physician and/or dietitian.3. Residents 27's dialysis communication book was left at the dialysis center and information regarding the latest dialysis session was not charted in the nursing notes.These failures had the potential to negatively impact continuity of care for Residents 7 and 27.Findings:Review of Resident 7's medical records titled dialysis communication book on 3/11/26 at 1:29 PM indicated documentations regarding post dialysis pain assessments were left blank on these dialysis dates: 3/10/26, 3/7/26, 3/5/26, 3/3/26, 2/28/26, 2/26/26, 2/24/26, 2/21/26, 2/19/26, 2/17/26, 2/14/26, 2/12/26, 2/10/26, 2/7/26, 2/5/26, and 2/3/26. Additionally, on 3/10/26, dialysis staff documented in the dialysis communication book they administered two medications to Resident 7 during his dialysis session. One medication was calcitriol (a medication that helps with calcium absorption), and the other medication was written in an illegible manner.During a concurrent interview and record review on 3/11/26 at 1:33 PM, the missing pain assessments and the illegible medication within Resident 7's dialysis communication book were reviewed with the Unit Manager. The Unit Manager looked at the medications administered by the dialysis staff on 3/10/26 and stated calcitriol was administered and she was unable to identify the second medication because it was written in an illegible manner. The Unit Manager was asked to search Resident 7's medical records for documentation that:staff clarify what medications were administered by dialysis staff and/or communicated to physicians and/or Registered Dietitian which medications were administered during dialysis.Staff documented they assessed Resident 7 for pain after returning from dialysis (from March to February 2026).The Unit Manager searched Resident 7's medical records and stated she could not find these documentations. During a concurrent interview and record review with the Nurse Manager on 3/11/26 at 1:51 PM, the Nurse Manager stated Resident 27's dialysis communication book was left at the dialysis center. The Unit Manager was asked to search for documentation regarding the missing dialysis communication book and data collected by the dialysis staff such as pre and post dialysis weights, medications administered, and/or other complications during Resident 27's last dialysis session. After searching Resident 27's records, the Unit Manager stated she was unable to find documentation regarding the missing dialysis communication book nor information regarding the last dialysis session. Additionally, the Unit Manager confirmed staff failed to document post dialysis assessments for vital signs, pain assessment and dialysis site condition after Resident 27's last dialysis session.Review of the facility's policy titled Hemodialysis Care and Coordination (hemodialysis = a process to help diseased kidney filter wastes and fluid), revised on October 2025, indicated .The facility shall assure that each resident receives care and services for the provision of . dialysis consistent with professional standards of practice. This shall include: Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on interviews, and record reviews, the facility failed to ensure the accountability of controlled medications (medication with high potential for abuse and addiction) when the Controlled Drug Record (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for one of six sampled residents (Resident 66) did not reconcile with the Medication Administration Record (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. Review of Resident 66's Physician's Order, dated 1/20/26, indicated oxycodone (a controlled narcotic medication for pain) 5 mg (milligram, unit of measurement), Give 1 tablet (5 mg) by mouth every 6 hours as needed for breakthrough pain (moderate pain 4-7 [pain scale]). and Give 2 (10 mg) tablet by mouth every 6 hours as needed for breakthrough pain (severe pain 8-10). During a concurrent interview and record review on 3/11/26 at 2:40 PM with License Vocational Nurse (LVN) 2 and Nurse Manager (NM) 2, Resident 66's CDR and MAR were reviewed. The MAR indicated two tablets of oxycodone 5 mg were administered on 1/22/26 at 9:08 AM. However, the CDR did not indicate the medications were signed out on that date and time. LVN2 and NM2 verified the two tablets of Resident 66's oxycodone 5 mg were documented as administered on the MAR on 1/22/26 at 9:08 AM but not signed out of the CDR. During an interview on 3/12/26 at 3:33 PM, the Director of Nursing (DON) stated, she was aware of the concern with the narcotic accountability for Resident 66. The DON stated it is important to ensure medications are properly accounted for to prevent missing medications and possible medication diversion by staff. During a concurrent interview and record review on 3/12/26 at 3:38 PM with the DON. The facility's policy and procedure (P&P) titled, PREPARATION AND GENERAL GUIDELINES, dated in April 2008 was reviewed. The P&P indicated, . Controlled Medications.When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration .Amount administered .Signature of the nurse administering the dose . The DON stated the information in the CDR and MAR should match.

Based on observation, interview, and record review, the facility failed to ensure a bed / bedroom was accessible to one of three sampled residents (Resident 1) when Resident 1 did not have a bed to sleep on for the night. The facility failure resulted to Resident 1 sitting up on the wheelchair in the facility lobby for over thirteen (13) hours during the night until the next day. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including diabetes (abnormally high blood sugar level) and obesity (having too much body fat). A review of Minimum `Data Set (MDS, a standardized assessment tool) dated 11/22/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning such as orientation, attention and recall ability) score of 15 indicated Resident 1 was cognitively intact. Functional status indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to supervision (helper provides verbal cues and contact guard assistance) with transfer, independent with bed mobility, and was able to ambulate (walk) in short distances. Resident 1 is continent of bladder (aware of need to pass urine) and is frequently incontinent of bowels (2 or more episode of involuntary bowel movement). During an interview on 1/27/ 25, at 2:30 PM, Resident 1 stated that on 11/2/24, at around 10:00 AM, while waiting for the staff to take him back to the 5th floor, he was informed that the elevator had stopped working. The repairman came but was unable to fix the elevator. Resident 1 stated the staff told him that he was too heavy to be carried back to the 5th floor and no one was able to assist him back to his bedroom. Resident 1 further stated he was not able to sleep during the night and had pain to his back and legs from sitting up the whole night. A review of the untitled document dated 11/3/24, provided by the Nurse Manager (NM) 1, indicated, the elevator broke down the second time that day. The documentation further indicated the elevator technician was not able to fix the problem, and the elevator remained down and inoperable. A review of the untitled document dated 11/3/24, provided by NM 1 indicated, . at 9:10 AM, elevator technician came, and reset the whole system and the elevator worked . (Resident 1) was able to come back up to his room at 9:20 AM with assistance of a Certified Nurse Assistant. (Resident 1) was then transferred back to bed . A review of the untitled document dated 11/3/24, provided by NM 1 indicated, Resident complained of sore body and pain. A review of the untitled document dated 11/4/24, provided by NM 1 indicated, Resident 1 was very tired during the stay in the lobby, and the staff tried some ways to bring him up, but no one could. During an interview on 1/29/24, at 11:57 AM, NM 1 stated that Resident 1 was over 300 pounds, and the staff said that they don ' t want to risk their back. During an interview on 1/29/24 at 12 PM, the Maintenance Supervisor (MS) stated there was work order on 11/7/24, that the yellow chair lift was not working. MS further stated that the yellow stair lift chair had a faulty battery. MS acknowledged there was no evidence of maintenance performed to the stair lift chair before and after the incident involving Resident 1 when the elevator stopped working on 11/2/24. The MS and DSD acknowledged there was no facility policy and procedure for the use and maintenance of the stair lift chair. During an interview on 1/29/25, at 2:20 PM, the DSD stated there was no staff in-service provided regarding the use of the stair lift chair. A review of the facility Elevator Malfunctioning Maintenance dated 4/26/10, indicated, Rationale: Center staff, residents, and families/responsible partied have alternative arrangements in case of elevator malfunction, repairs, and/or maintenance that inhibit transportation between floors. Loss of Elevator Contingency Plan Development .1. c. Alternative arrangements for visitors and/or residents who may not be able to climb or descent the stairs .h. education of residents, family, responsible partied and /or appropriate significant others regarding contingency plan in case of elevator malfunction, repairs, and/or parts replacement by communicating via resident council, family council, mailings . Performance Improvement. Evaluate Loss of Elevator Contingency Plan for issues and/or concerns that may have taken place during the time frames that eh elevator(s) was unavailable for use. Develop an action plan, if necessary to address issues/concerns. Update the Loss of Elevator contingency Plan, as needed. A review of the product information for Genesis Mobile Stairlift chair provided by the DSD, indicated, .The Food and Drug Administration approved Genesis Mobile Stairlift is your go to solution for safe and efficient stair navigation. This stairlift chair makes it easy to transport individuals up to 120 flights of stairs on a single charge, handling up to 400 pounds while weighing just 62 pounds. It is the perfect combination of power and versatility, making it dependable and easy to use and store . A review of the Quality Assurance and Performance Improvement (QAPI) for months of 11/2024, 12/2024 and 1/2025, did not address the facility Elevator Malfunction /Restoration Contingency Plan/ Loss of elevator Contingency Plan. The facility was not able to provide, Alternative Arrangement for visitors and /or residents who may not be able to climb or descend the stairs, as indicated in the facility Loss of Elevator Contingency Plan.

Based on interview, record review, and facility policy review, the facility failed to notify the physician when medications were not available for administration to 1 (Resident #38) of 1 resident reviewed for notification of change and 2 (Resident #308 and Resident #96) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Change in a Resident's Condition or Status, revised in 05/2017, specified, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): e. need to alter the resident's medical treatment significantly. 1. An Admission Record revealed the facility admitted Resident #38 on 07/18/2024. According to the Admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease with heart failure and hyperlipidemia (elevated cholesterol level). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #38 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #38's care plan included a focus area, initiated on 07/21/2024, that indicated the resident was at risk for cardiac distress related to atrial fibrillation, congestive heart failure, hyperlipidemia, and hypertension (high blood pressure). An intervention initiated on 07/21/2024 directed staff to administer prescribed medication. Resident #38's Order Summary Report for the timeframe from 07/18/2024 through 08/28/2024 contained a physician's order, dated 07/18/2024, for losartan potassium tablet 100 milligrams (mg), one time per day for hypertension. The Order Summary Report also contained an order, dated 07/18/2024, for atorvastatin calcium tablet 20 mg, one tablet in the evening for hyperlipidemia. Resident #38's August 2024 Medication Administration Record (MAR) revealed losartan potassium was scheduled to be administered daily at 9:00 AM. The MAR revealed Licensed Vocational Nurse (LVN) #1 documented 9, which indicated Other/See Progress Notes, for the scheduled doses on 08/11/2024, 08/19/2024, 08/20/2024, 08/21/2024, 08/26/2024, and 08/27/2024. The MAR also revealed that Registered Nurse (RN) #2 documented 9 for losartan potassium on 08/23/2024 and 08/24/2024. Resident #38's Progress Notes, dated 08/11/2024 at 11:18 AM, 08/19/2024 at 10:36 AM, 08/20/2024 at 11:51 AM, 08/21/2024 at 10:31 AM, and 08/26/2028 at 10:53 AM, revealed LVN #1 documented the resident's losartan was pending. Progress Notes dated 08/23/2024 at 9:11 AM and 08/24/2024 at 8:56 AM revealed RN #2 documented that losartan was on order. The Progress Notes revealed no documented evidence Resident #38's physician was notified that the resident's medication was not available and was not administered to the resident. Resident #38's August 2024 MAR revealed atorvastatin was scheduled to administered daily at 5:00 PM. The MAR revealed RN #4 documented 9 for the scheduled doses on 08/19/2024, 08/20/2024, 08/26/2024, and 08/27/2024. The MAR also revealed RN #3 documented 9 on 08/21/2024, 08/22/2024, 08/23/2024, and 08/24/2024. Resident #38's Progress Notes dated 08/19/2024 at 5:49 PM, 08/20/2024 at 5:21 PM, 08/21/2024 at 9:51 PM, 08/22/2024 at 10:10 PM, 08/23/2024 at 8:27 PM, 08/24/2024 at 7:02 PM, and 08/26/2024 at 5:23 PM, revealed staff documented Resident #38's atorvastatin medication was on order, pending pharmacy delivery, or waiting for delivery. During an observation of medication administration on 08/27/2024 at 8:57 AM, LVN #1 stated Resident #38's losartan was not available in the medication cart. During an interview on 08/28/2024 at 1:38 PM, LVN #1 stated chart code 9 Other/See Progress Notes documented on the MAR meant that the medication had not been administered and there was an associated progress note. LVN #1 stated pending in her progress notes meant they were waiting for a refill from the pharmacy. Per LVN #1, a chart code of 14 documented on the MAR indicated the physician was notified; however, LVN #1 stated she did not document code 14 for this resident. LVN #1 stated she should have notified the physician, and normally when a resident missed a dose, particularly for a blood pressure or heart medication, the physician should be notified. During an interview on 08/29/2024 at 1:35 PM, RN #3 stated she informed the physician the previous day about the missing atorvastatin. RN #3 stated she did not recall whether she called the physician on 08/21/2024, 08/22/2024, 08/23/2024, or 08/24/2024 when the medication was not available. She stated usually she documented if she called the physician. During an interview on 08/28/2024 at 1:48 PM, Unit Manager (UM) #6 stated if a resident's medications were not available, the nurses should notify the physician. She stated it was particularly important for residents to receive their blood pressure medication. UM #6 stated the nurse should document the situation and any calls to the physician in the progress notes. During an interview on 08/29/2024 at 1:46 PM, Physician #5 stated he expected a facility nurse to contact someone in the physician's group when a medication could not be given. He stated he was not aware Resident #38 had not received medications. Physician #5 stated generally that high blood pressure could lead to a stroke but stated Resident #38 was not at risk. During an interview on 08/29/2024 at 2:15 PM, the Director of Nursing Services (DNS) stated the nurses should always inform the physician if a medication was not available to administer. She stated a resident could have problems if their blood pressure was too high. She stated the physician should have been notified, and it should have been documented. During an interview on 08/29/2024 at 2:39 PM, the Administrator stated he expected the nurses to notify the physician when a medication was not available. 45555 2. An Admission Record indicated the facility admitted Resident #308 on 08/02/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with hyperglycemia (high blood sugar). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #308 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had received six insulin injections during the seven days prior to the assessment. The MDS revealed the physician had not changed the resident's insulin orders in the previous seven days. Resident #308's care plan included a focus area, initiated on 08/02/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar) and hyperglycemia. An intervention initiated on 08/02/2024 directed staff to administer prescribed insulin as ordered. Resident #308's Order Recap [recapitulation] Report for the timeframe from 08/02/2024 through 08/28/2024 revealed an order, started on 08/07/2024, for Ozempic (used to improve blood sugar levels) 2 milligrams (mg) per 3 milliliters (ml), with instructions to inject 0.25 mg subcutaneously, once every seven days for diabetes mellitus. Resident #308's August 2024 Medication Administration Record (MAR) revealed Registered Nurse (RN) #2 documented a code 9, indicating Other/See Progress Note, for the resident's Ozempic each week it was due to be administered, on 08/07/2024, 08/14/2024, and 08/21/2024. Resident #308's Progress Notes revealed Orders-Administration Notes, dated 08/07/2024, 08/14/2024, and 08/21/2024, that indicated the resident's Ozempic was on order. There was no documentation the physician was notified that the medication was not administered. During an interview on 08/29/2024 at 11:26 AM, RN #2 stated that the mangers entered physician's orders and put a medication list in the physician's binder. She stated once medications came from the pharmacy, she checked to make sure all the ordered medications were delivered. She stated if the facility did not receive all the resident's medications, she notified the physician to let them know a medication was not available. However, RN #2 stated when Resident #308's Ozempic was not available the first week, she notified the manager, and the manager called the pharmacy. She stated when it was not available the second week, she notified the manager and documented on the order form. According to RN #2, when Resident #38's Ozempic was not available again the next week, the manager requested a high-cost form and received the medication. During an interview on 08/29/2024 at 12:32 PM, RN #8, who was the nurse manager for the floor where Resident #308 resided, stated she admitted new residents and sent their medication list to the pharmacy. She stated the next morning the charge nurse should report any missing medication and notify the physician. During an interview on 08/29/2024 at 1:46 PM, Physician #5 stated there were three other doctors and a nurse practitioner with their group, and he expected the facility nurse to contact someone in their group if a medication could not be given. Physician #5 indicated he was not aware Resident #308 had missed their medications and stated their practice should have been aware. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated that when a medication was not available, the nurse should notify the physician that the medication was not available. During an interview on 08/29/2024 at 2:49 PM, the Administrator stated the physician should be notified if s medication was not available because the physician provided direction for resident care. 3. An Admission Record indicated the facility admitted Resident #96 on 07/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of acute on chronic diastolic congestive heart failure (CHF) and history of pulmonary embolism (blood clot in a lung). A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #96 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had taken an anticoagulant medication in the seven days prior to the assessment. Resident #96's Order Recap [recapitulation] Report for the timeframe from 07/05/2024 through 08/28/2024, contained an order, dated 08/08/2024, for Eliquis (an anticoagulant) 5 milligrams (mg) with instructions to administer two tablets twice a day for blood clotting prevention until 08/14/2024. Resident #96's August 2024 Medication Administration Record (MAR) for Eliquis revealed Registered Nurse (RN) #7 documented a code 9, which indicated Other/See Progress Note, for the resident's medication administration on 08/11/2024 at 9:00 PM and on 08/12/2024 at 9:00 AM. Resident #96's Progress Notes revealed an Orders-Administration Note dated 08/11/2024 and 08/12/2024 that indicated the resident's Eliquis was pending delivery. During an interview on 08/29/2024 at 10:53 AM, RN #7 stated if a medication was not available during medication pass, she notified the physician. RN #7 stated she did not recall specifics regarding Resident #96's Eliquis. During an interview on 08/29/2024 at 1:47 PM, Physician #5 stated he expected the facility nurse to notify someone in his group when a medication was not available to be administered. He could not recall any specific medications not being available. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated that when a medication was not available, the nurse should notify the physician that the medication was not available. During an interview on 08/29/2024 at 2:49 PM, the Administrator stated the physician should be notified if s medication was not available because the physician provided direction for resident care.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were received from the pharmacy in a timely manner for 3 (Resident #38, #96, and Resident #308) of 11 sampled residents reviewed for pharmacy services. Findings included: A facility policy titled, Medication Ordering and Receiving from Pharmacy, effective 01/2022, specified, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. 1. An Admission Record revealed the facility admitted Resident #38 on 07/18/2024. According to the Admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease with heart failure and hyperlipidemia (elevated cholesterol level). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #38 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #38's care plan included a focus area, initiated on 07/21/2024, that indicated the resident was at risk for cardiac distress related to atrial fibrillation, congestive heart failure, hyperlipidemia, and hypertension (high blood pressure). An intervention initiated on 07/21/2024 directed staff to administer prescribed medication. Resident #38's Order Summary Report for the timeframe from 07/18/2024 through 08/28/2024 contained a physician's order, dated 07/18/2024, for losartan potassium tablet 100 milligrams (mg), one time per day for hypertension. The Order Summary Report also contained an order, dated 07/18/2024, for atorvastatin calcium tablet 20 mg, one tablet in the evening for hyperlipidemia. Resident #38's August 2024 Medication Administration Record (MAR) revealed losartan potassium was scheduled to be administered daily at 9:00 AM. The MAR revealed Licensed Vocational Nurse (LVN) #1 documented 9, which indicated Other/See Progress Notes, for the scheduled doses on 08/11/2024, 08/19/2024, 08/20/2024, 08/21/2024, 08/26/2024, and 08/27/2024. The MAR also revealed that Registered Nurse (RN) #2 documented 9 for losartan potassium on 08/23/2024 and 08/24/2024. Resident #38's Progress Notes, dated 08/11/2024 at 11:18 AM, 08/19/2024 at 10:36 AM, 08/20/2024 at 11:51 AM, 08/21/2024 at 10:31 AM, and 08/26/2028 at 10:53 AM, revealed LVN #1 documented the resident's losartan was pending. Progress Notes dated 08/23/2024 at 9:11 AM and 08/24/2024 at 8:56 AM revealed RN #2 documented that losartan was on order. The Progress Notes revealed no documented evidence Resident #38's physician was notified that the resident's medication was not available and was not administered to the resident. Resident #38's August 2024 MAR revealed atorvastatin was scheduled to administered daily at 5:00 PM. The MAR revealed RN #4 documented 9 for the scheduled doses on 08/19/2024, 08/20/2024, 08/26/2024, and 08/27/2024. The MAR also revealed RN #3 documented 9 on 08/21/2024, 08/22/2024, 08/23/2024, and 08/24/2024. Resident #38's Progress Notes dated 08/19/2024 at 5:49 PM, 08/20/2024 at 5:21 PM, 08/21/2024 at 9:51 PM, 08/22/2024 at 10:10 PM, 08/23/2024 at 8:27 PM, 08/24/2024 at 7:02 PM, and 08/26/2024 at 5:23 PM, revealed staff documented Resident #38's atorvastatin medication was on order, pending pharmacy delivery, or waiting for delivery. During an observation of medication administration on 08/27/2024 at 8:57 AM, LVN #1 stated Resident #38's losartan was not available in the medication cart. During an interview on 08/27/2024 at 9:17 AM, LVN #1 stated she knew the losartan refill had been requested from the pharmacy. During a follow-up interview on 08/28/2024 at 1:38 PM, LVN #1 stated the MAR entry, 9 Other/See Progress Notes, meant the medication had not been administered, and there was an associated progress note. LVN #1 stated pending in her progress notes meant they were waiting for a refill from the pharmacy. LVN #1 stated she should have called the pharmacy again. During an interview on 08/28/2024 at 1:48 PM, Unit Manager (UM) #6 stated if a resident's medications were not available, the nurses should notify the pharmacy. UM #6 stated it was particularly important for residents to receive their blood pressure medication. UM #6 stated the nurses should document the situation and any calls to the pharmacy in the progress notes. UM #6 stated she expected the nurses to report to her if there was a missing medication that was not delivered, and she, or the evening supervisor, would follow up with the pharmacy. During an interview on 08/29/2024 at 1:35 PM, RN #3 stated she was unsure how the system worked and whether she should reorder medication. During an interview on 08/29/2024 at 12:23 PM, RN #2 stated the process for missing medication was to call the physician, notify the unit manager, and call the pharmacy. During an interview on 08/29/2024 at 1:46 PM, Physician #5 stated he was not aware of any missing medications but expected the nurse to notify someone in their clinic group if any medication was missing and could not be given. Physician #5 stated he had never heard of this type of delay in medication delivery. During an interview on 08/29/2024 at 2:15 PM, the Director of Nursing Services (DNS) stated the nurses should have followed up with the pharmacy because they were waiting for the refill. The DON stated, if medication was not available in the facility to give, the nurses should always inform the pharmacy and the physician and document it. The DON stated, if a resident did not receive medication, they could have problems if their blood pressure was too high. The DON stated the pharmacy and the physician should have been notified, and it should have been documented. During an interview on 08/29/2024 at 2:39 PM, the Administrator stated his expectation was for the pharmacy to deliver the medications that were ordered. The Administrator stated the residents needed the medications, and that was why they were ordered. The Administrator stated he expected the nurses to notify the pharmacy, notify the physician, monitor the resident's blood pressure, and document for any missing medication. 45555 2. An Admission Record indicated the facility admitted Resident #308 on 08/02/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with hyperglycemia (high blood sugar). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #308 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had received six insulin injections during the seven days prior to the assessment. The MDS revealed the physician had not changed the resident's insulin orders in the previous seven days. Resident #308's care plan included a focus area, initiated on 08/02/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar) and hyperglycemia. An intervention initiated on 08/02/2024 directed staff to administer prescribed insulin as ordered. Resident #308's Order Recap [recapitulation] Report for the timeframe from 08/02/2024 through 08/28/2024 revealed an order, started on 08/07/2024, for Ozempic (used to improve blood sugar levels) 2 milligrams (mg) per 3 milliliters (ml), with instructions to inject 0.25 mg subcutaneously, once every seven days for diabetes mellitus. Resident #308's August 2024 Medication Administration Record (MAR) revealed Registered Nurse (RN) #2 documented a code 9, indicating Other/See Progress Note, for the resident's Ozempic each week it was due to be administered, on 08/07/2024, 08/14/2024, and 08/21/2024. Resident #308's Progress Notes revealed Orders-Administration Notes, dated 08/07/2024, 08/14/2024, and 08/21/2024, that indicated the resident's Ozempic was on order. A Refills Orders Only form revealed Resident #308's Ozempic was ordered on 08/15/2024. There was a handwritten note on the side of the form to send the high-cost form, if needed. A Notice of Non-Covered/High-Cost Drug form revealed the authorization for the Ozempic was signed by the Director of Nursing Services (DNS) on 08/21/2024. A pharmacy delivery manifest indicated Resident #308's Ozempic was received by the facility on 08/22/2024 at 5:19 AM. During an interview on 08/28/2024 at 8:17 AM, Registered Nurse (RN) #8, the nurse manager for the 4th and 5th floors, stated Ozempic was a high-cost medication that had to have prior approval. RN #8 stated the pharmacy would usually let them know when they had a high-cost medication that needed authorization, but the facility did not receive the form, and the medication nurses did not know it was a high-cost medication. During an interview on 08/28/2024 at 3:35 PM, RN #8 stated they did not realize Resident #308's Ozempic was not in the facility until it was due to be administered on 08/07/2024. RN #8 stated the charge nurse called the pharmacy to find out where the medication was and reordered it. RN #8 stated, again, they did not realize that the medication was not in the facility until it was due to be given on 08/14/2024. RN #8 stated on 08/15/2024, the Ozempic was put on a refill order sheet that was sent to the pharmacy. RN #8 stated she followed up a few days later and found that the medication was not in the facility, so she resent the order sheet with a note that said to send the high-cost form, if it was needed. RN #8 stated the high-cost form was signed on 08/21/2024, and the medication was received at the facility on 08/22/2024. During an interview on 08/29/2024 at 10:29 AM, Case Manager (CM) #9 stated that when a resident was admitted to the facility all medications from their hospital discharge medication list were entered into the electronic charting system, and then the medication list was printed and faxed to the pharmacy with the resident's admission record, so that the pharmacy could deliver the medications. CM #9 stated the next morning, after a new admission, the nurse managers were supposed to review all the medications that were received and follow up on any that were not delivered. CM #9 stated she was not able to say why Resident #308's medications were not available. During an interview on 08/29/2024 at 10:53 AM, RN #7 stated every charge nurse was responsible for ensuring that all the medications were received from the pharmacy. RN #7 stated the nurse that was working the medication cart was the person responsible for following up if medications were not available. During an interview on 08/29/2024 at 11:26 AM, RN #2 stated that when Resident #308's Ozempic was not available the first week, she notified the manager, who called the pharmacy. RN #2 stated the next week, when the Ozempic was not available, she notified the manager and added the Ozempic to a pharmacy order form. RN #2 stated that when the Ozempic was not available again the next week, the manager wrote a note on the order form to send the high-cost form, and the facility received the Ozempic a few days later. RN #2 stated she should have reported the missing medication to the next shift to follow up on, and they should have done that every shift until the medication was received. During an interview on 08/29/2024 at 12:32 PM, RN #8 stated that if a medication was not available during medication pass, the nurse should call the pharmacy to expedite the delivery of the medication. RN #8 stated that if the medication was scheduled to be administered once a week, the nurse should follow up daily until the medication was received. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated that when a medication was not available, the nurse should follow up with the pharmacy. The DNS stated the nurse should ask the pharmacy when they should expect the delivery of the medication. The DNS stated they should continue to follow up on obtaining the medication until it was received. The DNS stated Resident #308's Ozempic should have been followed up on. During an interview on 08/29/2024 at 2:49 PM, the Administrator stated if they ordered medications from the pharmacy, the medications should be available in a timely manner. The Administrator further stated that if a medication was not available, the facility should be notified of when the medication was going to arrive. 3. An Admission Record indicated the facility admitted Resident #96 on 07/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of acute on chronic diastolic congestive heart failure (CHF) and history of pulmonary embolism (blood clot in a lung). A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #96 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had taken an anticoagulant medication in the seven days prior to the assessment. Resident #96's Order Recap [recapitulation] Report for the timeframe from 07/05/2024 through 08/28/2024, contained an order, dated 08/08/2024, for Eliquis (an anticoagulant) 5 milligrams (mg) with instructions to administer two tablets twice a day for blood clotting prevention until 08/14/2024. Resident #96's August 2024 Medication Administration Record (MAR) for Eliquis revealed Registered Nurse (RN) #7 documented a code 9, which indicated Other/See Progress Note, for the resident's medication administration on 08/11/2024 at 9:00 PM and on 08/12/2024 at 9:00 AM. Resident #96's Progress Notes revealed an Orders-Administration Note dated 08/11/2024 and 08/12/2024 that indicated the resident's Eliquis was pending delivery. During an interview on 08/29/2024 at 10:53 AM, RN #7 stated every charge nurse was responsible for ensuring that all the medications were received from the pharmacy. RN #7 stated the nurse that was working the medication cart was the person responsible for following up if medications were not available. During an interview on 08/29/2024 at 12:32 PM, RN #8 stated that if a medication was not available during medication pass, the nurse should call the pharmacy to expedite the delivery of the medication. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated that when a medication was not available, the nurse should follow up with the pharmacy. The DNS stated the nurse should ask the pharmacy when they should expect the delivery of the medication. The DNS stated they should continue to follow up on obtaining the medication until it was received. During an interview on 08/29/2024 at 2:49 PM, the Administrator stated if they ordered medications from the pharmacy, the medications should be available in a timely manner. The Administrator further stated that if a medication was not available, the facility should be notified of when the medication was going to arrive.

Based on observation, interview, and facility policy review, the facility failed to follow procedures to prevent potential infections and cross-contamination during medication administration for 2 (Resident #305 and Resident #56) of 7 residents observed during medication administration. Findings included: A facility policy titled, Medication Administration (General), dated 08/18/2022, specified, 25. Staff shall follow established facility infection control procedures (e.g. [exempli gratia, for example], handwashing, antiseptic technique, gloves, isolation precautions, etc. [et cetera]) for the administration of medications, as applicable. During an observation of medication administration on 08/28/2024 at 8:36 AM, Registered Nurse (RN) #2 placed Resident #305's medications in a medication cup. RN #2's placed her bare hand around the lip-surface of a cup of water provided to the resident to use while taking their medications. At 8:40 AM, Resident #305 took their medications and drank from the cup of water. During an observation of medication administration on 08/28/2024 at 8:44 AM, RN #2 sanitized her hands and prepared Resident #56's medications. RN #2 placed her bare hand around the lip-surface of a cup of water provided to the resident to use while taking their medications. During an interview on 08/28/2024 at 8:47 AM, RN #2 stated she should not have touched the lip-surface of the water cups while passing medications, because it could result in possible cross-contamination and risk of infection. During an interview on 08/28/2024 at 3:34 PM, RN #8 stated she was a nurse manager. RN #8 stated nurses should not touch the lip-surface of water cups with bare hands because touching the cups contaminated them. During an interview on 08/28/2024 at 3:19 PM, the Infection Preventionist (IP) stated RN #2 should not have touched the lip-surface of the water cups. She stated that although RN #2 sanitized her hands, their hands would not be considered clean. The IP stated she expected nurses to use a tray to deliver medications and not place their hands on the lip-surface of cups, where a resident would place their mouth, because it could cause a risk of infection. During an interview on 08/29/2024 at 2:03 PM, the Director of Nursing Services (DNS) stated the nurse should not have touched the lip-surface of the water cups. During an interview on 08/29/2024 at 2:37 PM, the Administrator stated he expected nurses to hold water cups lower on the cup, below the lip-surface, because of infection control concerns.

Based on interview, record review, and facility policy review, facility failed to obtain laboratory testing as ordered by the physician for 1 (Resident #308) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Request for Diagnostic Services, revised in 04/2007, indicated, 3. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. An Admission Record indicated the facility admitted Resident #308 on 08/02/2024. According to the Admission Record, the resident had a medical history that included diagnoses of malignant neoplasm (cancer) of the anal canal, secondary malignant neoplasm of the bladder, type two diabetes mellitus with hyperglycemia, essential hypertension, iron deficiency anemia, and hyperlipidemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #308 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #308's care plan included a focus area, initiated on 08/02/2024, that indicated the resident had a potential for complications such as infections and physical decline. An intervention initiated on 08/02/2024 directed staff to follow up on laboratory testing as ordered and report abnormal findings to the physician. Resident #308's Order Recap [recapitulation] Report, for the timeframe from 08/02/2024 through 08/28/2024, contained an order, dated 08/15/2024, to obtain a complete blood count (CBC) and basic metabolic panel (BMP) weekly. The order included a note for the night nurse to print a requisition form. Resident #308's August 2024 Medication Administration Record (MAR) revealed Registered Nurse (RN) #7 signed the MAR indicating the CBC and BMP were completed on 08/23/2024. Resident #308's electronic health record and paper record revealed no documented evidence the facility completed a CBC and BMP for Resident #308 on 08/23/2024. During an interview on 08/29/2024 at 10:53 AM, RN #7 stated that when a resident had an order for routine laboratory testing, staff entered the order into the laboratory's online platform, printed off a laboratory requisition form, and placed the requisition form into a laboratory binder. She stated the nighttime nurse filled out the requisition form, and the floor nurse was responsible for ensuring the laboratory specimen was obtained and signed off on the MAR when it was obtained. RN #7 stated she was responsible on 08/23/2024 for ensuring Resident #308's laboratory testing was done. She stated she saw the laboratory staff in the facility and assumed they completed Resident #308's laboratory tests, but she did not verify that a laboratory requisition was completed or that a blood specimen was collected for testing. During an interview on 08/29/2024 at 11:26 AM, RN #2 stated if a routine laboratory test was due for collection, it showed up on the resident's MAR for the night shift to print the laboratory requisition from. She stated that when she came to work in the morning, she checked the laboratory binder and printed off laboratory requisitions, if needed. RN #2 stated the nurse was responsible for ensuring the laboratory specimens were collected and for following up on laboratory results. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated that in the past, if a routine laboratory test was due, the lab would automatically complete the testing; however, currently, the facility had to print a requisition form and place it in the laboratory binder. The DON stated the laboratory staff only completed laboratory testing for the requisitions in the binder. She stated the nurse manager for the unit should ensure that a requisition was in place and was also responsible for ensuring laboratory testing was obtained and that staff followed up with the provider. She stated she was not sure why Resident #308's laboratory testing was missed. During an interview on 08/29/2024 at 2:49 PM, the Administrator stated staff should be following physician's orders and scheduled laboratory tests should be obtained.

Based on interview and record review, the facility failed to monitor for potential side effects or adverse drug reactions related to the use of an anticoagulant (blood thinner) for 1 (Resident #96) of 5 residents reviewed for unnecessary medications. Findings included: An Admission Record indicated the facility admitted Resident #96 on 07/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of acute on chronic diastolic (congestive) heart failure (CHF) and personal history of pulmonary embolism (a blood clot in a lung). A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was taking an anticoagulant medication. Resident #96's Order Recap [recapitulation] Report, reflecting orders for the timeframe from 07/05/2024 through 08/28/2024, contained an order, dated 08/08/2024, for Eliquis (an anticoagulant) 5 milligrams (mg) with instructions to administer two tablets twice a day. Per the report, this order was placed on hold on 08/22/2024 while the resident was hospitalized and discontinued on 08/25/2024. The Order Recap Report also contained an order, dated 08/25/2024, for Eliquis 5 mg with instructions to administer one tablet two times a day for blood clotting prevention. The Order Recap Report contained no orders to monitor for side effects or adverse drug reactions related to the resident's use of Eliquis. Resident #96's August 2024 Medication Administration Record (MAR) and August 2024 Treatment Administration Record (TAR) revealed documentation that indicated the resident's Eliquis was administered, but there was no documentation of monitoring for side effects or adverse drug reactions related to the resident's use of Eliquis. Resident #96's Progress Notes for the timeframe from 08/08/2024 through 08/28/2024 revealed no documentation of monitoring for side effects or adverse drug reactions related to the resident's use of Eliquis. During an interview on 08/29/2024 at 10:53 AM, Registered Nurse (RN) #7 stated residents on anticoagulants should be monitored for bleeding and bruising. She stated residents receiving an anticoagulant should have an order for monitoring entered into their electronic record and indicated the monitoring should be documented on the MAR. She confirmed that Resident #96 did not have an order to monitor for side effects related to the use of the Eliquis. During an interview on 08/29/2024 at 11:26 AM, RN #2 stated a residents on anticoagulant medications should be monitored for bleeding and bruising, and the monitoring should be documented on the MAR every shift. RN #2 confirmed monitoring for bleeding and bruising was not included on Resident #96's MAR but stated it should have been. During an interview on 08/29/2024 at 12:32 PM, RN #8 stated she was the Nurse Manager responsible for the 4th and 5th floors. She stated residents receiving an anticoagulant should have an order for monitoring and indicated the monitoring should be documented on the MAR. RN #8 stated the admitting nurse was responsible for ensuring the order to monitor was put in place. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated the nurses should be monitoring residents on anticoagulants for bleeding and bruising and documenting their findings on the MAR.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure urinary catheter care was completed in a sanitary manner to prevent possible infection for 1 (Resident #202) of 1 resident sampled for urinary catheter use. Findings included: A facility policy titled, Urinary Catheter Care, dated 03/2021, specified, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The section of the policy titled, Steps in the Procedure included 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry, 16. For a male resident male [sic]: Use a washcloth with warm water and soap to cleanse around the meatus [the opening at the tip of the penis where urine exits the body] . Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. An Admission Record revealed the facility admitted Resident #202 on 10/21/2021. According to the Admission Record, the resident had a medical history that included diagnoses of hydronephrosis (excess of fluid in a kidney due to a build-up of urine), tubulo-interstitial nephritis (swollen tubules in a kidney), benign prostatic hyperplasia (enlarged prostate), obstructive and reflux uropathy (obstructed urinary flow), and retention of urine. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2024, revealed Resident #202 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling urinary catheter and was dependent on staff for toileting hygiene. Resident #202's care plan included a focus area, initiated on 05/09/2024, that indicated the resident was at risk for complications, including a urinary tract infection, due to use of an indwelling urinary catheter. An intervention initiated on 05/09/2024 directed staff to provide indwelling catheter care daily and as needed. Resident #202's Order Summary Report, for the timeframe from 01/01/2024 through 08/28/2024, contained a physician's order, dated 06/06/2024, for catheter care to be provided every shift. The order indicated to cleanse the site with soap and warm water, rinse, and pat dry. During an observation of catheter care for Resident #202 on 08/28/2024 beginning at 2:30 PM, Certified Nursing Assistant (CNA) #12 washed the creases (sides) of the resident's pubic area with a soapy washcloth and then squeezed the excess soapy water from the washcloth over the resident's entire pubic area. The CNA then used the same washcloth to clean the resident's penis by wiping from the base towards the meatus of the penis. CNA #12 did not use a clean soapy washcloth to cleanse the penis from the meatus to the base and did not rinse the area before she dried the area. CNA #12 also did not clean the resident's catheter tubing. During an interview on 08/28/2024 at 2:34 PM, CNA #12 stated the resident would be receiving catheter care on the next shift, and indicated the soap would be rinsed off at that time. CNA #12 proceeded to rinse and re-dry the area at that time, again wiping from the base of the penis towards the meatus. During an interview on 08/28/2024 at 2:58 PM, CNA #12 stated that per procedure, she should have pulled the catheter tubing out a couple of inches from the resident's penis to clean it, but the resident was too sensitive to do it. During an interview on 08/28/2024 at 2:52 PM, CNA #13 stated staff should rinse soap off a resident's skin because it could leave a film and compromise the integrity of the skin by drying out the skin. She stated she was trained on catheter care to always clean from the tip of the penis towards the base. She stated to clean from the base of the penis to the tip (meatus) might cause infection by bacteria entering the opening of the penis. CNA #13 stated she was trained to hold the catheter tubing in place and clean the tubing down several inches, especially if the resident wore a brief, because feces could get on the tubing and could cause a urinary tract infection. During an interview on 08/28/2024 at 3:02 PM, the Director of Staff Development (DSD) stated she was a licensed vocational nurse (LVN) who assisted the charge nurse on the floor Resident #202 resided. She stated for a male resident during catheter care, staff should clean the penis from the tip down toward the body. She stated that after that, staff should hold the catheter tubing in place and wipe down the tubing at least two inches from the penis. The DSD stated that cleaning a male from the base of the penis to the tip increased the potential risk of a urinary tract infection by bacteria entering the opening of the penis. During an interview on 08/28/2024 at 3:24 PM, the Infection Preventionist (IP) stated the CNA should have cleaned the male resident during perineal and catheter care by cleaning from the tip of the penis down toward the body. She stated the CNA should have then held the catheter tubing and cleaned down the tubing a few inches. She stated the way CNA #12 performed catheter care increased the chance of bacteria entering the opening of the penis and causing a urinary tract infection. She stated the washed areas of skin should always be rinsed, because if soap were left on the skin, it could dry out and irritate the skin, especially in the perineal area. During an interview on 08/29/2024 at 2:06 PM, the Director of Nursing Services (DNS) stated catheter care should be performed by cleaning from the meatus towards the base of the penis. She stated that infection was more likely when cleaning from the base of the penis to the tip of the penis. The DNS stated the soap left on the resident was considered dirty and should have been rinsed off. During an interview on 08/29/2024 at 2:44 PM, the Administrator stated he thought that during catheter care, the penis should be cleaned from the tip of the penis down toward the body. He stated staff should follow infection control procedures when providing catheter care. The Administrator stated he expected soap to be rinsed off the resident for their comfort.

Based on interview, record review, and facility policy review, the facility failed to ensure the use of an anticoagulant medication was addressed in the comprehensive care plan for 1 (Resident #96) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy revealed, 8. The comprehensive, person-centered care plan will: included g. Incorporate identified problem areas; and h. Incorporate risk factors associated with identified problems. The policy revealed, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: including c. When the resident has been readmitted to the facility from a hospital stay. An Admission Record indicated the facility admitted Resident #96 on 07/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of acute on chronic diastolic (congestive) heart failure (CHF) and personal history of pulmonary embolism (a blood clot in an artery of a lung). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS revealed the resident was not taking an anticoagulant medication at the time of admission. Resident #96's Order Recap [recapitulation] Report, reflecting orders for the timeframe from 07/05/2024 through 08/28/2024, contained an order, dated 08/08/2024, for Eliquis (an anticoagulant) 5 milligrams (mg) with instructions to administer two tablets twice a day. Per the report, this order was placed on hold on 08/22/2024 while the resident was hospitalized and discontinued on 08/25/2024. The Order Recap Report also contained an order, dated 08/25/2024, for Eliquis 5 mg with instructions to administer one tablet two times a day for blood clotting prevention. Resident #96's Medication Administration Record (MAR), for the timeframe from 08/01/2024 through 08/31/2024, revealed staff documented the resident began receiving Eliquis on 08/08/2024. The MAR revealed staff documented that the resident did not receive their Eliquis from 08/21/2024 at 9:00 PM through 08/25/2024 at 9:00 AM due to a hospitalization . Per the MAR, the resident began receiving their Eliquis again on 08/25/2024 at 9:00 PM. Resident #96's care plan did not include a focus area related to the use of an anticoagulant medication. During an interview on 08/29/2024 at 10:53 AM, Registered Nurse (RN) #7 stated the use of anticoagulant medications should be included on a resident's care plan. During an interview on 08/29/2024 at 11:26 AM, RN #2 stated if a resident was using an anticoagulant medication, then it should be included on the resident's care plan. She stated the nurse managers developed the care plans, but the nurses working the floor could update them. During an interview on 08/29/2024 at 12:32 PM, RN #8 stated she was the nurse manager for the floor where Resident #96 resided. She stated the use of an anticoagulant medication should be included on a resident's care plan. During an interview on 08/29/2024 at 2:04 PM, the Director of Nursing Services (DNS) stated residents on anticoagulants should be monitored for bleeding and bruising, and it should be addressed on their care plan.

Based on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I PASRR was accurately completed for 1 (Resident #4) of 1 resident reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #4's Level I PASRR Screening reflected the presence of a serious diagnosed mental disorder. Findings included: A facility policy titled, Preadmission Screening & Resident Review (PASRR), dated 11/30/2023, revealed, 1. Initial admission from General Acute Care Hospital: a. General Acute Care Hospitals (GACHs) located in California are enrolled and utilizing the Department of Health Care Services' (DHCS') PASRR Online System to complete the PASRR process prior to discharging an individual to a SNF [skilled nursing facility], regardless of payer source. b. Facility will: i. Confirm that the PASRR process was completed by the Hospital (including admission from the Emergency Department) by accepting and reviewing the PASRR documentation submitted by the Hospital via the file exchange feature in the PASRR Online System. The California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If 'yes', there will be a text box question [to] provide the type of mental illness. The guide further specified, Question 12. Psychotropic Medication *If 'yes' a text box will appear to list all the names of psychotropic medications for mental illness. An Admission Record revealed the facility admitted Resident #4 on 06/15/2024. According to the Admission Record, Resident #4 had a medical history that included a diagnosis of bipolar disorder. Resident #4's hospital discharge records, dated 06/14/2024, revealed Resident #4 had a diagnosis of bipolar disorder. The records revealed the resident's medication orders included an order for mirtazapine (an antidepressant) 15 milligrams (mg) at bedtime, with a start date of 05/27/2024. Resident #4's Medication Review Report, listing orders on or after 06/15/2024, contained an order, dated 06/15/2024, for mirtazapine oral tablet 15 mg, one tablet at bedtime for depression. Resident #4's care plan included a focus area, initiated on 06/15/2024, that indicated the resident had an alteration in their behavior pattern related to bipolar disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. According to the MDS, at the time of the assessment, the resident had an active diagnosis of bipolar disorder and was taking an antidepressant medication. Resident #4's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/15/2024, completed by a hospital, revealed Section III- Serious Mental Illness Screen, question #10 was answered No and did not reflect the resident's diagnosis of bipolar disorder. The screening also did not reflect that the resident was prescribed psychotropic medications for mental illness. This resulted in a Negative Level I Screening, and a Level II evaluation was not required. During an interview on 08/27/2024 at 1:33 PM, the Long-Term Care (LTC) MDS Coordinator stated medical records staff were responsible for reviewing Level I screenings upon admission. She stated that if the screening was not correct, she was responsible for completing a new resident review. She stated that she was not aware of any residents having an inaccurate Level I screening. During an interview 08/29/2024 at 8:56 AM, the Medical Records Director revealed she received the Level I screenings from the hospital. She stated that if there were any issues, she informed the LTC MDS Coordinator. She stated Resident #4 had been taking psychotropic medication and had a diagnosis of bipolar disorder. During an interview on 08/29/2024 at 9:14 AM, the Director of Nursing Services (DNS) revealed the admission team reviewed all residents' Level I screenings upon admission. She stated that if there were any issues with the screening, the LTC MDS Coordinator would submit an updated Level I screening. During an interview on 08/29/2024 at 11:17 AM, the Administrator stated that the MDS Coordinator was responsible for overseeing the Level I screening for each resident. He stated there should have been another Level I screening submitted for Resident #4 and stated that the facility staff missed it.

Based on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #2) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to code Resident #2's MDS assessment to reflect the use of an anticoagulant. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, indicated, N0415E1. Anticoagulant (e.g. [exempli gratia, for example], warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days. N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). A facility policy titled, RESIDENT ASSESSMENT INSTRUMENT, dated 10/01/2023, indicated Section N Medications was to be completed by MDS staff. The policy revealed, Each discipline assigned to complete the designated section of the MDS assessment is responsible for the accuracy of the information following the RAI manual. An Admission Record indicated the facility admitted Resident #2 on 06/29/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of other pulmonary embolism (a blood clot in an artery of a lung). Resident #2's care plan revealed a focus area, initiated on 06/29/2024, that indicated Resident #2 was at high risk for signs and symptoms of bruising and bleeding due to being on anticoagulant therapy to prevent thrombosis or embolism. Resident #2's Order Summary Report, listing active orders as of 08/28/2024, contained an order, started on 06/30/2024, for apixaban (an anticoagulant) oral tablet 2.5 milligrams (mg), one tablet by mouth two times a day for blood thinner. Resident #2's Medication Administration Record, for the timeframe from 06/01/2024 through 06/30/2024, revealed staff documented that the resident received apixaban 2.5 mg two times on 06/30/2024. Resident #2's Medication Administration Record, for the timeframe from 07/01/2024 through 07/31/2024, revealed staff documented that the resident received apixaban 2.5 mg during five of six opportunities from 07/01/2024 through 07/03/2024. An admission MDS, with an Assessment Reference Date (ARD) of 07/03/2024, was not coded to reflect Resident #2 was taking an anticoagulant medication. During an interview on 08/29/2024 at 10:51 AM, the Long-Term Care (LTC) MDS Coordinator stated they had two MDS staff, one for short-term care residents and one for long-term care residents. She stated that when a resident was admitted , the facility staff received an email and information from the hospital. The LTC MDS Coordinator stated she completed Section N of the MDS assessments. Per the LTC MDS Coordinator, she used doctor's orders to complete Section N. She stated that the other MDS Coordinator completed Resident #2's MDS assessment. She stated Resident #2's MDS assessment was coded to indicate the resident was not on anticoagulant medication. The LTC MDS Coordinator reviewed the resident's MARs and stated the MDS should have been coded to indicate the resident was receiving an anticoagulant medication. She stated it was missed and coded incorrectly. During an interview on 08/29/2024 at 11:05 AM, the Director of Nursing Services (DNS) stated she was not very involved with the MDS process and did not do a final review of MDS assessments. She stated that she expected MDS assessments to be coded accurately, including medications. During an interview on 08/29/2024 at 11:24 AM, the Administrator stated he was not involved with the MDS process at all. He stated that he expected MDS assessments to be coded accurately.

Based on observation, interview, and facility document and policy review, the facility failed to ensure each resident was provided a homelike environment, which affected 1 (Resident #55) of 2 residents reviewed for environmental concerns. Specifically, the facility failed to provide a window curtain upon Resident #55's request. Findings included: A facility policy titled, Quality of Life- Homelike Environment, revised 05/2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The policy further revealed, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting. c. Inviting colors and decor. An Admission Record revealed the facility admitted Resident #55 on 05/27/2021. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During a concurrent interview and observation on 08/26/24 11:27 AM, Resident #55 stated they had requested for several months that the facility staff install an additional window curtain in their room. An observation revealed the resident's room had one curtain that did not fully cover the window. During an interview on 08/27/2024 at 9:29 AM, the Environmental Services (EVS) Manager stated each floor of the facility had a work order binder for work orders to go in, and the binders were checked twice per day. A Work Orders LOG, for the timeframe from 07/01/2024 through 07/31/2024, revealed a work order, dated 07/26/2024, requesting an additional curtain for the window in Resident #55's room. The log indicated that the priority was categorized as ASAP [as soon as possible]. The log did not reflect a completion date for the work order but had an undated note that indicated blinds were ordered. A Work Orders LOG, for the timeframe from 08/02/2024 through 08/28/2024, revealed no work orders for Resident #55's room. During an interview on 08/28/2024 at 10:13 AM, the EVS Manager stated there had been no replacement curtains or blinds ordered until 08/28/2024. During interview on 08/29/2024 at 11:12 AM, the Administrator said residents should be able to close their curtains fully.

Based on observation, interview, and facility document and policy review, the facility failed to ensure nurse staffing data was posted on a daily basis at the beginning of each shift, and failed to ensure the posting was in a prominent place readily accessible to residents. This deficiency had the potential to affect all residents residing in the facility. Findings included: A facility policy titled, Posting Direct Care Daily Staffing Numbers, revised in 07/2016, revealed, Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The policy revealed, 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs [registered nurses], LPNs [licensed practical nurses], and LVNs [licensed vocational nurses]) and the number of unlicensed nursing personnel (CNAs [certified nursing assistants]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The facility's floor plan revealed residents' rooms were located on the second, third, fourth, and fifth floors; there were no resident rooms located on the first floor. An observation on 08/26/2024 at 12:42 PM revealed a California Department of Public Health (CDPH) Census and Direct Care Service Hours Per Patient Day (DHPPD) document, dated 08/22/2024, was posted in the first-floor lobby area. An observation on 08/27/2024 at 8:36 AM revealed the same CDPH Census and Direct Care Service Hours Per Patient Day (DHPPD) document, dated 08/22/2024, was posted in the first-floor lobby area. Observations on 08/27/2024 from 8:38 AM to 8:49 AM revealed no daily staffing data was posted on the second, third, fourth, or fifth floors. Observations on 08/28/2024 beginning at 10:30 AM revealed no daily staffing data was posted on the second, third, fourth, or fifth floors. During an interview on 08/28/2024 at 9:48 AM, the Staffing Coordinator revealed the CDPH staffing data form was posted in the lobby. She stated that the residents could not see the postings unless they went downstairs to the lobby. The Staffing Coordinator stated the daily staffing data should be posted daily, before each shift, but indicated she was on vacation from 08/23/2024 through 08/27/2024. The Staffing Coordinator confirmed that when she returned to work, she noticed the daily staffing data posting was dated 08/22/2024. She stated that, in her absence, the Director of Nursing Services (DNS) or a morning nurse manager was responsible for posting the daily staffing data in the lobby. During an interview on 08/28/2024 at 11:20 AM, RN #8 said she was the nurse manager for the morning shift on 08/26/2024. She stated she counted the nurses and aides on shift and reported the information to the DNS. Per RN #8, the DNS was responsible for posting the staffing data information when the Staffing Coordinator was not working. During an interview on 08/29/2024 at 9:14 AM, the DNS stated she or the nurse managers completed the staffing data postings when the Staffing Coordinator was not working and confirmed that she had not completed the staff postings. The DNS further stated the staffing data was posted in the lobby; the DNS stated this location was not accessible to the residents. During an interview on 08/29/2024 at 11:08 AM, the Administrator stated the daily staffing data was only posted in the lobby and should be posted by 9:00 AM each day.

Based on observation, interview and record review, the facility failed to maintain a pest free environment and an effective pest control program when cockroaches were noted on 2/14/23 in residents' room. This failure can result to infection control problems. Findings: During a record review on 9/12/23 at 3:00 PM, of Ecolab Service report dated 2/14/23, indicated, Pest Activity found during service: Patient/Guest rooms- Interior- Cockroaches noted during service especially Room- XXX. I will return for a follow up service on next week. This area was inspected and serviced. During an interview and concurrent observation of the room on 9/12/23 at 12:20 PM, with Nurse Manager (NM), NM stated, In January of 2023, this was all male patients in this room. We had a patient here that was very non-compliant, leaves food in the room, does not want to take a shower, combative. Housekeeper will go and mop the floor even if it was difficult. NM further stated I did not see roaches in this room. During an interview on 9/12/23 at 12:25 PM with Housekeeper (HK), HK stated, worked here over a year, I clean that room, there is patient mad when I clean. He is messy, got mad and yell when I go clean. I clean and mop the floor everyday even when he yells. No roaches there. During an interview on 9/12/23 at 3:30 PM, with Maintenance Director(MD), MD stated, Ecolab does what they are supposed to do. They give a copy of their report. He further stated, they did not talk about the result. On the follow up service indicated in the report, MD stated, I did not see a follow up service to specific room XXX. I should have followed up and requested for report. Next time I see the importance of making my own documentation. During a review of facility Policy document, Pest Control dated 5/2008, indicated, Policy statement, Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to maintain effective infection prevention and control program when there were seven basins, one bedpan, one measuring hat and one urinal in residents' bathroom A (Resident 1, Resident 2, and Resident 3) and bathroom B (Resident 4, Resident 5, and Resident 6), without name tags or labels, for six of 106 census. This failure had the potential to spread infection to residents, staff, and visitors. Findings: During an observation on 7/20/23 at 1:09 p.m., in bathroom A and B, there were seven basins, one bedpan, one measuring hat and one urinal on top of the toilet without name tags or labels. During a concurrent observation and interview on 7/20/23 at 1:14 p.m., with certified nursing assistant (CNA) 1 in the shared bathroom A and B, CNA 1 had seen the items (seven basins, one bedpan, one measuring hat and one urinal) on top of the toilet without name tags or labels. CNA 1 stated, The items should be disposed because none of them belong to anybody. They should label the personal items with the resident's room number. During a concurrent observation and interview on 7/20/23 at 1:20 p.m. with licensed vocational nurse (LVN) 1 in the shared bathroom A and B, LVN 1 also observed the items (seven basins, one bedpan, one measuring hat and one urinal) on top of the toilet without name tags or labels. LVN 1 stated, The items should be thrown away. There should be labels on them. I will throw them away. It's not sanitary when asked about the items, then he threw the items away. He stated, the items were all stacked up without labels, so staff don't know who has which item. He stated, It's considered dirty when asked. During interview on 7/20/23 at 1:58 p.m., with infection preventionist (IP), IP stated, They should put on labels and initials on the items when asked how to handle the items. Review of the facility's policy and procedure (P&P) titled, ADL Personal Equipment: Urinals, Bedpans, Basins, and Emesis Basins, dated 4/2020 indicated, . 2. The urinal and/or bedpan, basin, and emesis basin will only be used by the resident assigned to it. 3. Personal equipment will be labeled with initials/ room no. 4. After each use, the bedpan, basin, and emesis basin will be rinsed out with water and stored in the nightstand at the bedside . Review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program revised in 6/2021 indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .

Based on interviews and record review, the facility failed to maintain an effective pest control program. An Ombudsman and a pest control technician all reported an ongoing problem with cockroaches. Failure to maintain an effective pest control program subjected residents to an unsanitary environment and placed residents at risk for pest borne diseases. Findings: During an interview on 03/29/2022 at 1:00 PM, Ombudsman A stated he .witnessed cockroaches in .(a) resident's room . I advised facility staff to perform deep cleaning of room on multiple occasions, . During an interview on 07/05/2023 at 12:20 PM, the Environmental Services Director (ESD) stated the facility hires an outside pest company for regular . monthly service. We also ask for extra services for cockroaches flies and other pest control.(when) Our housekeepers they report to me they saw cockroaches a few months ago . The ESD stated staff could also enter service requests on a maintenance logbook if they see pests in the building. During an interview on 07/05/2023 at 12:31 PM, a contracted Pest Control Technician stated .we ' ve been having issue with the .(resident) rooms with cockroaches.(the facility) wanted me to go in and treat the .(resident) rooms .I believe (the residents complained about the roaches) .(Unfortunately,) with healthcare facilities the . (residents) keep food in nightstands . and (the roach problem was) getting out of hand . Yes .(I saw roaches during the initial treatment). (also) back in 2021 and 2022 .(it was the same) issue we do the same process . The infestation was even at the nurse station I believe. Review of the facility ' s policy titled Plant Review Maintenance Request Log Sheet indicated there was an entry on 03/07/22 .Resident complained there was cockroaches in her room . During an interview on 07/06/2023 at 11:06 AM, The Director of Nursing (DON) was asked about the presence of cockroach in the building. The DON stated I remember the previous owner this was also a (cockroach) problem. It ' s an old building that ' s why we have maintenance and do fumigation. The facility policy and procedure titled Pest Control, revised on May 2008, indicated .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review the facility failed to develop a person-centered (focuses on the resident as the center of control, and supports each resident in making his or her own choices.), culturally competent, and trauma-informed (is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) Care Plan (a road map for the care of a patient and a necessary tool in following the nursing process) for one (1) of three (3) sampled residents (Resident 1) when, the Care Plan had interventions that were not specific to address the resident ' s inability to get a sleep due to roommate who screams and howl and howl. This deficient practice had resulted in Resident 1 feeling it was affecting her mental and physical health and her ability to do her therapy (physical and occupational therapy) in the morning, I can ' t ' take it anymore. Findings: Review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and the diagnoses included, chronic pain, anxiety disorder (type of mental health condition), adjustment disorder (stress-related conditions where you feel overwhelmed and have a hard time adjusting to a stressful event or change), insomnia due to medical condition, and polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body). In an observation and interview on 6/1/23, at 12:05 PM, Resident 1 was awake, alert, seating up in bed. The resident ' s room has three occupants, Resident 1 was by the door, Resident 2 was in middle of the room, and Resident 3 was by the window. Resident 1 stated, the resident next to her bed (Resident 2) screams, howl and howl, and because of that she could not get a sleep, and could not progress with her physical therapy, if she did not sleep. Resident 1 further stated, she would get only three (3) hours of sleep at night, maybe an hour of sleep in the afternoon, can ' t take it anymore, it was affecting her mental and physical health and her ability to do her therapy (physical and occupational therapy) in the morning. Resident 1 stated, she had been in that room,she should not be the one to move out, and the facility moved the resident (Resident 2) next to her bed, was told she was quite as a mouse, she howls and howls. Resident 1 was getting loud, stated, she did not have rights in the facility and should have an equal right with other residents. In an interview on 6/1/23 at 11:38 AM, with the CNAs in the presence of the Nurse Manager (NM) and the Infection Control Nurse (ICN), CNAs stated, Resident 1 told her about the resident in the next bed (Resident 2) who screamed at five (5:00 am) this morning and she could not sleep and she don ' t get a sleep. In an interview on 6/1/23, at 11:40 AM, with the NM and the ICN, NM stated, Resident 1 decline the offer to move out to another room and the family of Resident 2 had declined to move the resident out to another room. NM stated, she had called to adjust the Tylenol (pain medication) or Resident 2 to help with the ADL (Activities of Daily living). ICN stated, Resident 1 was very disrespectful and abusive towards her roommates. In phone interview on 6/7/23, at 10:06 AM, with the Social Worker Assistant (SWA), SWA stated, Resident 1 alleged her roommate was howling and prevented her from getting a sleep. Resident 1 was offered another room to move, was offered, ear plug to use, and was offered to see another room, if she liked she could move in. Review of the Care Plan (CP) with the last revised date of 2/22/23 indicated, Alteration in Psychosocial well-being related to: constant chronic complaint, negative behavior towards others, _____ (blank) Cultural Differences, Manipulative behavior, and Personality Conflict as evidence by: Conflict with staff, Conflict with roommate and other residents. The Goal was, Resident will demonstrate effective coping behavior, Resident will verbalize alternative positive behavior, and Resident will demonstrate reduced manipulative behavior. The Interventions /Task were, allow residents to talk about feelings, explain procedures, set limits on manipulative behaviors, distract resident with activities. The interventions reported by the staff to address the issue of a roommate who screams and howl and howl such as, offered to move to another room, offered ear plugs, adjusting the pain medications of the resident in the next bed, and offered to see another room were not mentioned in the CP. In an interview on 6/1/23, at 10:46 AM, with the facility Administrator (FA) and the Director of Nursing (DON), DON stated, Resident 1 was alert, oriented, and makes her own decision and had complained about her roommates, the faclity kept changing her roommates, tried three to four times in the past, and the residewnt was not happy with her roommates. FA stated, the roommate issue was a lower concern regarding the so many concerns that the resident had presented, the resident was manipulative. DON asked to provide the Care Plan that address issue on the howling roommate. Review of the facility ' s Care Plan (CP) with the last revised date of 4/25/23 indicated, The resident has a behavior problem, . The Goal was, The resident will have no evidence of behavior problems . The interventions /Tasks were discuss behavior, explain/reinforce why behavior is unacceptable, administer medications, . assists resident to develop more appropriate methods of coping and interacting, . Educate the resident/family . In a phone interview on 6/22/23, at 10:37 AM, DON stated, the interventions done to address the howling roommate issue were, offered the resident to move to another room, res refused, ear plugs were offered but decline, offered the roommate to change room, family refused initially but recently had agreed. The roommate (Resident 2 was moved out on 6/6/23. The DON verified the interventions mentioned were not listed in the CP interventions, it ' s not here. Review of the facility ' s Policy and Procedure titled, Care Planning Interdisciplinary Team with the last revised date of 9/13 indicated, Policy Statement. Our facility ' s Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plans for each resident. Based on observation, interview, and record review the facility failed to develop a person-centered (focuses on the resident as the center of control, and supports each resident in making his or her own choices.), culturally competent, and trauma-informed (is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) Care Plan (a road map for the care of a patient and a necessary tool in following the nursing process) for one (1) of three (3) sampled residents (Resident 1) when, the Care Plan had interventions that were not specific to address the resident's inability to get a sleep due to roommate who screams and howl and howl . This deficient practice had resulted in Resident 1 feeling it was affecting her mental and physical health and her ability to do her therapy (physical and occupational therapy) in the morning, I can't' take it anymore . Findings: Review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and the diagnoses included, chronic pain, anxiety disorder (type of mental health condition), adjustment disorder (stress-related conditions where you feel overwhelmed and have a hard time adjusting to a stressful event or change), insomnia due to medical condition, and polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body). In an observation and interview on 6/1/23, at 12:05 PM, Resident 1 was awake, alert, seating up in bed. The resident's room has three occupants, Resident 1 was by the door, Resident 2 was in middle of the room, and Resident 3 was by the window. Resident 1 stated, the resident next to her bed (Resident 2) screams , howl and howl , and because of that she could not get a sleep, and could not progress with her physical therapy, if she did not sleep. Resident 1 further stated, she would get only three (3) hours of sleep at night, maybe an hour of sleep in the afternoon, can't take it anymore , it was affecting her mental and physical health and her ability to do her therapy (physical and occupational therapy) in the morning. Resident 1 stated, she had been in that room, should not be the one to move out, and the facility moved the resident (Resident 2) next to her bed, was told she was quite as a mouse , she howls and howls. Resident 1 was getting loud, stated, she did not have rights in the facility and should have an equal right with other residents. In an interview on 6/1/23 at 11:38 AM, with the CNAs in the presence of the Nurse Manager (NM) and the Infection Control Nurse (ICN), CNAs stated, Resident 1 told her about the resident in the next bed (Resident 2) who screamed at five (5:00 am) this morning and she could not sleep and she don't get a sleep. In an interview on 6/1/23, at 11:40 AM, with the NM and the ICN, NM stated, Resident 1 decline the offer to move out to another room and the family of Resident 2 had declined to move the resident out to another room. NM stated, she had called to adjust the Tylenol (pain medication) or Resident 2 to help with the ADL (ACTIVITEIS OF Daily Living) . ICN stated, Resident1 was Resident 1 was very disrespectful and abusive towards her roommates. In phone interview on 6/7/23, at 10:06 AM, with the Social Worker Assistant (SWA 1) , SWA 1 stated, Resident 1 alleged her roommate was howling and prevented her from getting a sleep. Resident 1 was offered another room to move, was offered, ear plug to use, and was offered to see another room and if she liked, she could move in. Review of the Care Plan (CP) with the last revised date of 2/22/23 indicated, Alteration in Psychosocial well-being related to: constant chronic complaint, negative behavior towards others, _____ (blank) Cultural Differences, Manipulative behavior, and Personality Conflict as evidence by: Conflict with staff, Conflict with roommate and other residents . The Goal was, Resident will demonstrate effective coping behavior , Resident will verbalize alternative positive behavior , and Resident will demonstrate reduced manipulative behavior . The Interventions /Task were, allow residents to talk about feelings, explain procedures, set limits on manipulative behaviors , distract resident with activities. The interventions reported by the staff to address the issue of a roommate who screams and howl and howl such as, offered to move to another room, offered ear plugs, adjusting the pain medications of the resident in the next bed, and offered to see another room were not mentioned in the CP. In an interview on 6/1/23, at 10:46 AM, with the Facility Administrator (FA) and the Director of Nursing (DON), DON stated, Resident 1 was alert, oriented, and makes her own decision and had complained about her roommates, kept changing her roommates, tried three to four times in the past, not happy with roommates. FA stated, roommate issue was lower concern regarding the so many concerns she presented, resident was manipulative. DON was asked to provide the Care Plan that address issue on the howling roommate. Review of the facility's Care Plan (CP) with the last revised date of 4/25/23 indicated, The resident has a behavior problem, . The Goal was, The resident will have no evidence of behavior problems . The interventions /Tasks were discuss behavior, explain/reinforce why behavior is unacceptable, administer medications, . assists resident to develop more appropriate methods of coping and interacting, educated the resident/family . In a phone interview on 6/22/23, at 10:37 AM, DON stated, the interventions done to address the howling roommate issue were, offered the resident to move to another room, res refused, ear plugs were offered but decline, offered the roommate to change room, family refused initially but recently had agreed. The roommate (Resident 2 was moved out on 6/6/23. The DON verified the interventions mentioned were not listed in the CP interventions, it's not here. Review of the facility's Policy and Procedure titled, Care Planning Interdisciplinary Team with the last revised date of 9/13 indicated, Policy Statement. Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plans for each resident.

Based on interviews and record review, the facility failed to provide a sitter (a caregiver assigned to only one resident or patient to ensure safety), create and revise a Care Plan (a plan with a goal and interventions to achieve a goal for a resident) to prevent falls, and failed to implement interventions to prevent falls for two out of three (Resident 1, and Resident 2) residents reviewed. The facility failed to Implement fall risk interventions for Resident 1 on the day of his admission resulting in two falls. For Resident 2 the facility failed to; I) Create a Care Plan to prevent falls after the 1/21/22,3/25/22, 4/18/22, 4/21/22 PM shift, 4/25/22, 4/29/22, 5/2/22, 5/3/22, 6/3/22, 6/9/22,6/10/22, 7/13/22, 8/5/22, 8/30/22 fall. II) Create a Morse Fall Assessment (an assessment to determine the likelihood of a resident falling and why) after the 1/21/22, 4/21/22 PM shift (PM shifts time duration is 3:00 PM to 11:30 PM), 4/25/22, 5/3/22, 8/5/22, 9/1/22 fall. III) Create a Post Fall Assessment (an assessment tool to help identify injury after a fall, factors that lead to a fall, and interventions placed to prevent future falls and injury) after the 1/21/22, 4/21/22 PM shift, 4/24/22, 5/3/22, 8/5/22, 9/1/22 fall. IV) Create an IDT Note (the interdisciplinary team or IDT consist of care provider and the Resident or Residents Responsible party. The care providers are Physicians, social workers, case managers, nurses, administration, pharmacist any other discipline involved in a resident's care. This team meets and evaluate goals and interventions specific to each resident.) after the fall on 5/3/22. V) Provide a sitter to prevent any of the 21 falls Resident 2 had in 2022. These failures resulted in the following; 1)Resident 1 having two unwitnessed falls at 2:40 PM, and 4:00 PM on 7/20/22. These falls resulted in Resident 1 sustaining a large bump and bleeding to the forehead. 2)Resident 2 falling 21 times in the year 2022. Resident 2's fall occurrences with injury are as follows; I)1/21/22 at 8:30 PM, resulted in Resident 2 obtaining a bump on his forehead after hitting his head on the bathroom sink. II) 04/29/22 at 1036 AM Resident 2 obtained bump on forehead after an unwitnessed fall. III) 06/09/22 Resident 2 obtained injury to head, required 20 stitches to left forehead, after an unwitnessed fall. IV) 07/13/22 at 7:10 PM Resident 2 obtained Right side forehead contusion(bruising) after an unwitnessed fall. V) 08/17/22 at 1:29PM. Resident 2 obtained a right knee abrasion and right hip pain after an unwitnessed fall. VI) 08/30/22 at 0400 am. Resident 2 obtained forehead bump and a cut to the left knee after an unwitnessed fall. VII) 09/02/22 at 1:30 PM. Resident 2 obtained swelling and discoloration to his forehead after falling from the wheelchair. Findings. 1. Review of the MDS (Minimum Data Set, tool used for a comprehensive Resident assessment) dated 7/20/22 indicated that Resident 1 was admitted with a lumbar fracture with a history of falls, bladder cancer, and Parkinson's disease (a disorder that includes nerve cell damage in the brain causing tremors and difficulty with movement). Review of Resident 1 Progress Note dated 07/20/22 at 6: 44 PM by Infection Prevention Nurse (IPN) 1 indicated that the Resident 1 arrived on 07/20/22 at 12:40 PM via ambulance. Resident 1 was confused, forgetful, and non-ambulatory (unable to walk) at the time of admission. Review of Resident 1 Progress Note dated 07/20/22 at 6:45 PM by IPN 1 stated that the code status was verified at 06:16 PM with the daughter and Resident 1 was a full code. During an interview with the Nurse Manager (NM)1 on 12/28/22 at 11:30 AM it was stated that on 7/20/22 before Resident 1 arrived to the facility, staff received report ( a comprehensive verbal sign off on information from one provider to another regarding a patient's condition) that Resident 1 was a high risk for fall, had previous falls, and would most likely require a sitter. NM1 stated that Resident 1 did not have a sitter at his stay at this facility. Review of Resident 1's Progress Note dated 07/20/22 at 10:10 PM by Registered Nurse (RN) 1 indicated that RN 1 received report on Resident 1 during shift change from Resident 1's day shift primary nurse. This note indicated that the day shift primary nurse gave report that Resident 1 was a hospice patient, and at 2:40 PM fell and hit his head on the nightstand. No further information was endorsed to RN 1. RN 1 then proceeded to confirm hospice status with the admit Nurse (IPN1) and the Charge Nurse. IPN 1 and the Charge Nurse informed RN 1 that Resident 1 is not on hospice and is a full code. RN 1 informed the physician of the fall and received an order to send Resident 1 to the emergency room for a hematoma (pooled blood that collects inside a tissue, organ, or in a body space) on the head. At 4:00PM RN 1 found Resident 1 on the floor, assessed Resident 1 for injuries, and sent Resident 1 to the emergency room . This Progress Note indicated that RN1 informed the family of the falls, and placed fall mats (mats that are placed on the floor to help reduce impact during a fall) on the floor for Resident 1. Review of Resident 1's Progress Note and Assessments indicates a physician notification, a Morse Fall Assessment , a Post Fall Assessment , and immediate interventions were not done to prevent further falls for the fall that occurred at 2:40 PM on 07/20/22m by the dayshift primary nurse. During an interview with NM1 on 12/28/22 at 11:40 AM it was confirmed that a Morse Fall Assessment , a Post Fall Assessment , and immediate interventions to prevent further falls were not created after Resident 1's fall on 7/20/22 at 2:40PM. During an interview with RN1 on 12/28/22 at 2:30 PM it was stated that when RN 1 receive report from the day shift primary nurse for Resident 1, it was confirmed by the day shift nurse that the physician and responsible party were not informed of the fall on 7/20/22 at 2:40 PM. 2. Review of Resident 2's MDS dated [DATE] indicated Resident 2 was admitted with diagnoses including Cerebral infarction (disrupted blood flow to the brain tissue), Aphasia (disorder that affects ability to communicate), and mobility abnormality (impaired ability to move around). Review of the MDS indicated Resident 2 had unclear speech, was sometimes understood by others, sometimes understood others, and his vision was highly impaired without the use of corrective lens. Resident 2 had a Brief interview of Mental status (BIMS, tool used to assess cognitive function. A score of 15 means the person assessed has the highest level of cognitive function and score of zero is no cognitive function) score of three. Review of the MDS indicated that Resident 1 required extensive assistance with transfers and mobility to get around in bed, in the room, in the corridors, and required a wheelchair. During an Interview on 12/09/22 at 12:25 PM with Certified Nurse's Assistant (CNA) 1, it was stated that CNA1 knew Resident 2 very well. Per CNA 1 Resident 2 would be sleeping and then would suddenly wake up and get out of bed without request for help. Resident 2 would sleep for 15 to 20 minutes then suddenly get up again and try to get out of bed. There was a mattress placed on the floor to help prevent falls and injury. Per CNA 1, Resident 2 would get up and start looking for something without warning or signs of Resident 2 needing help. Per CNA1, it was hard to communicate with Resident 2 because he did not speak. Resident 2 understood others at times, and would try to communicate via body language, squeezing hands, smiling, and showing objects. Per CNA 1 Resident 2 was very active and had lots of falls. Per CNA1 staff would try to get to Resident 2 before he could get out of bed and re-direct him or keep him in his wheelchair near the nurse's station to keep a closer eye on him. During an interview on 12/09/22 at 12:50 PM with IPN 1, IPN 1 stated that they knew Resident 2 well and that he had frequent falls and would try to get out of bed by himself a lot. Per IPN 1 some interventions the staff placed for him were to keep the bed in a low position, floor mats on both sides of the bed, keep Resident 2 in a wheelchair near the charge nurse, and keep curtains open when Resident 2 was in bed. The IPN 1 stated that due to Resident 2's diagnosis of cerebral infarction, he could not be educated to use the call light or ask for help verbally. IPN 1 stated that due to Resident 2's diagnosis of Cerebral infarction Resident 2 was very impulsive and would get up or out of bed without any warning or signs that he needed help. During interview with NM1 on 12/22/22 at 09:30 AM, NM1 stated that Resident 2 did not have a sitter during his stay at the long-term care facility. NM1 stated after a resident has a fall it is the facilities policy to complete a Morse Fall Assessment a Post Fall Assessment , a Pain assessment , a Change in Condition , and a Care Plan to prevent further falls and injury immediately after each fall. The IDT reviews the interventions daily after a fall (or the next business day), 72 hours after fall, and quarterly. During review of the Progress Note dated 1/21/22 at 9:40 PM, the Progress Note indicated that on 1/21/22 at 8:30 PM Resident 2 had an unwitnessed fall and acquired a bump on his forehead. The Progress Note indicated that the fall was most likely due to Resident 2 hitting his head on the bathroom sink, as he was found in the bathroom. This Progress Note indicated that the Physician (or Doctor of Medicine aka MD) was informed of the fall, although no documentation was found in the note that the Responsible Party (RP) was notified. During review of Resident 2's Care Plan a Care Plan was not found to be revised or made to prevent falls after the 1/21/22 fall. During review of Resident 2's Assessments no evidence was found that the Morse Fall Assessment , Post Fall Assessment , and IDT Note was completed after the fall on 1/21/22. During an interview with NM1 and the Director of Nursing (DON) on 12/28/22 at 11:30 AM, it was confirmed by NM1 that a Morse Fall Assessment , Post Fall Assessment , Care Plan , and IDT Note was not completed for the fall that occurred on 1/21/22 at 8:30 PM. During review of the nurse's Progress Note dated 03/25/22 at 2:15 PM it was indicated that Resident 2 was sitting in his wheelchair before he fell . Resident 2 stood up quickly from a sitting position and tried to walk and fell . In this note it was indicated that Resident 2 is unable to verbalize what he wants, and therefore staff is unable to determine the cause of the fall. Review of the Post Fall Assessment note dated 03/25/22 at 2:15 PM indicated that the interventions placed post fall were to involve Resident 2 in activities, place bilateral floor mats, keep Resident 2 closer to the nurse's station, and apply hip padding (to protect the resident from injury in case of future falls) for Resident 2. Review of the IDT Note dated 03/25/22 at 12:53 PM and review of the interventions from the Progress Note dated 3/15/22 at 2:15 PM indicated to continue to monitor Resident 2, and no new interventions were suggested. Review of Resident 2's Care Plan dated on 03/25/22 indicated a Care Plan was created so Resident 2 will not have an ill effect through the next review date , and a Care Plan for fall prevention was not created after the 3/25/22 fall. During an interview with the NM1 and the DON on 12/28/22 at 11:30 AM it was stated by the DON that the goal for Resident 2 was to minimize and prevent injury, not to prevent future falls. The DON and the NM indicated that to prevent falls for Resident 2 was impossible, as he required continuous monitoring and a sitter for safety. During this interview it was confirmed by NM1 and the DON that Resident 2 did not have a sitter during his stay at this facility. During this interview NM1 confirmed that a Care Plan to prevent falls was not created for Resident 1 after the 03/25/22 fall. During review of the nurse's Progress Note dated 4/18/22 at 02:27 AM it was indicated that Resident 2 had a witnessed fall on 04/18/22 at 12:50 AM. This Progress Note indicated that staff found Resident 2 out of bed, tried to assist Resident 2 to the bathroom, and Resident 2 tried to sit in the air and fell . In this note it was assessed that Resident 2 needed to go the bathroom as he had an episode of incontinence. In this Progress Note the new immediate interventions to be placed were hourly monitoring for safety and whereabouts. Review of the IDT Note on 4/18/22 at 10:45 AM added new interventions to always anticipate resident's needs, provide assistance when toileting, do not leave unattended while toileting, and confirmed hourly monitoring. Review of Resident 2's Care Plan showed no documentation of a Care Plan was created to prevent falls after the 4/18/22 fall. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan was not created to prevent falls after the fall on 4/18/22 at 12:50 AM. During review of the Progress Note dated 04/21/22 at 7:36 AM indicated that Resident 2 had an unwitnessed fall on 4/21/22 at 04:20 AM. This Progress Note indicated that the nurse attempted to determine the cause of the fall but Resident 2 was unable to verbalize or communicate his needs. Review if this Progress Note indicated that new immediate interventions placed after the fall were to implement a bowel and bladder program and use a wander guard (alarm sounds if a resident changes position or tries to get out of bed). No IDT Note was found for the fall on 04/21/22 at 04:30 am. Review of Residents 2 Care Plan on 04/21/22 for falls indicated the goal for Resident 2 was to not have ill effect due to the recent fall , not to prevent future falls. Review of Resident 2's Care Plan indicated that a Care Plan to prevent future falls was not created after the fall on 4/21/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan was not created to prevent falls after the fall on 4/21/22 at 4:20 AM. Review of Resident 2's Progress Note dated 4/21/22 at 10:23 PM indicated that Resident 2 had an unwitnessed fall sometime during the PM shift as Resident 2 was trying to get up on his own. Review of Resident 2's Progress Notes , Care plan , and Assessments indicated that a Morse Fall Assessment , a Post Fall Assessment , immediate interventions, a IDT Note , and a Care Plan was not created after the fall on 04/21/22 on the PM shift. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was stated by NM1 that a Care Plan to prevent falls, Morse Fall Assessment , Post Fall Assessment was not created after the fall on 4/21/22 on PM shift. During this interview NM1 stated that the fall on 4/21/22 at 04:20 AM was so close to the fall on 4/21/22 PM shift that the interventions from the previous IDT Note had not taken effect, and therefore a new one was not made. During Review of Resident 2's IDT Note dated 04/25/22 at 12:21 PM it was indicated that the Charge Nurse heard a loud sound and found Resident 2 laying on his right side on the floor. This note indicated that staff was unable to determine the cause of the fall because Resident 2 cannot verbalize his needs. Review of this IDT Note implemented new interventions of having things close by to prevent falls. Review of the Assessment and Care Plan indicated that a Morse Fall Assessment , Post Fall Assessment , and a Care Plan was not created to prevent further falls after the fall on 4/25/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan , Morse Fall Assessment , and a Post Fall Assessment was not created after the fall on 4/25/23 at 12:21 PM. During review of Resident 2's Progress Note on 4/29/22 at 10:36 AM it was indicated that Resident 2 fell while walking to the bathroom and sustained a bump on his right forehead. In this Progress Note it is indicated that the immediate intervention made to prevent falls was to place Resident 2 in a wheelchair near the Nurse's station. Review of resident 2's IDT Note on 4/29/22 at 2:30 PM indicated that staff is unable to educate Resident 2 to use the call light due to cognitive impairment. Review of Resident 2's Care Plan shows a Care Plan was not created to prevent future falls after the fall on 4/29/22 at 10:36AM. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan was not created to prevent falls after the fall on 4/29/22 at 11:30 AM. During review of Resident 2's IDT Note on 05/03/22 at 11:00 AM it was indicated that Resident 2 was found on the floor by the charge nurse, and unable to communicate his needs. In this IDT Note no new interventions were placed to prevent falls. Review of Resident 2's Assessments indicated that a Post Fall Assessment was done on 5/2/22 at 12: 52 AM, and a Morse Fall Assessment was created on 5/2/22 at 12:51 AM. Review of Resident 2's Care Plan indicated that a Care Plan was created on 5/2/22 for an unwitnessed fall on 5/2/22, with a goal that Resident 2 will not have an ill effect from the fall. A Care Plan for fall prevention was not indicated. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 a Care Plan was not created to prevent falls after the fall on 5/2/2 at an unknown time. Review of Resident 2 Progress Note on 05/03/22 at 11:01 PM indicated that Resident 2 was found on the floor at 5:30 PM. Review of Resident 2 Assessments indicate a Morse Fall Assessment and Post Fall Assessment was not created, review of Resident 2's Progress Notes indicate a IDT Note was not created, and review of Resident 2's Care Plan indicate a Care Plan to prevent further falls was not created after the fall on 5/3/22 at 5:30PM. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 a Care Plan , Morse Fall Assessment , Post Fall Assessment , and a IDT Note was not created after the fall on 5/03/22. During review of Resident 2's Progress Note dated 05/30/22 at 07:26 AM it was indicated that Resident 2 had an unwitnessed fall at an unknown time. This Progress Note indicated that Resident 2 needed toileting. Review of the Post Fall assessment dated [DATE] a new intervention implemented to prevent falls was to monitor Resident 2 every 30 minutes. During review of Resident 2's Progress Note dated 06/3/22 at 10:47 PM it was indicated that Resident 2 was seen standing on his own, staff was unable to catch him in time, and Resident 2 fell near the bed. Review of this Progress Note , and Post Fall assessment dated [DATE] at 11:35 PM indicated no new interventions to prevent falls were implemented. Review of Residents 2 Care Plan indicated a Care Plan to prevent further falls was not created after the fall on 6/3/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan to prevent falls was not created after the fall on 6/3/22. During review of Resident 2's IDT Note on 6/9/22 at 12:15 PM it was indicated that Resident 2 fell on his face and sustained a lump and bleeding to his left eyebrow, Resident 2 was sent to the emergency room and returned with 20 stitches. This IDT Note recommended staff to provide needs at all times for Resident 2. Review of Resident 2's Care Plan indicated a Care Plan was not created to prevent future falls after the 6/9/22 fall. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan to prevent future falls was not created after the 6/9/22 fall. During review of Resident 2's Progress Note on 6/10/22 at 3:15AM it was documented that Resident 2 had an unwitnessed fall on 6/10/22 at 12:30 AM. Resident 2 was found on his back, and no new interventions were implemented. Review of Resident 2's Care Plan indicated a Care Plan was not created to prevent further falls after the 6/10/22 fall. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan to prevent future falls was not created after the 6/10/22 fall. During review of Resident 2's Progress Note dated 6/17/22 at 1:45 PM indicated that Resident 2 was seen getting out of bed on his own and fell . Review of the IDT Note on 6/20/22 at 5:50PM indicated that Resident 2 exhibited behaviors of getting out of bed to ambulate on his own, and due to his cognitive impairment staff is unable to educate Resident 2 about safety and fall precautions. This note indicates that Resident 2 is unable to use the call light or ask for help. Review of this IDT Note indicated that Resident 2 required a 1-1 sitter to prevent falls. During review of the Progress Note dated 7/13/22 at 9:50 PM it was indicated that Resident 2 had an unwitnessed fall on 7/13/22 at 7:10 PM and sustained a bruise on the right side of his face above his eyebrows. Review of Resident 2's Care Plan indicate a Care Plan was not created after the fall on 7/13/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was stated by NM1 that a Care Plan to prevent future falls was not created after the 7/13/22 fall. During review of Resident 2's Summary for Providers Notes on 8/5/22 at 4:00 AM it was indicated that Resident 2 had an unwitnessed fall on 8/5/22 at 4:00 AM, and family was notified of the fall. During review of Resident 2's Progress Note on 8/5/22 at 10:14PM it was indicated that Resident 2 had an unwitnessed fall and hit his head. In this note it was indicated that MD was notified, but it was too late to call and notify the family and will do so in the morning. Review of Resident 2 Post Fall Assessment and Morse Fall assessment dated [DATE] indicate only one of each assessment was completed. Review of the Morse Fall Assessment and Post Fall Assessment was created on 9/01/22 and it is unclear which fall it is documented for. Review of Resident 2's Care Plan indicate a Care Plan was not created to prevent future falls after both falls on 8/5/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was confirmed by NM1 that a Care Plan was not created to prevent future falls after the 8/5/22 falls, and a Morse Fall Assessment and Post Fall Assessment was not created for one out of two falls that occurred on 8/5/22. During review of Resident 2's ' Change of Condition Notes on 8/17/22 at 1:33 PM it was indicated that Resident 2 had a unwitnessed fall on 8/17/22 at 1:29 PM and sustained a cut to his right knee and acquired pain in his right hip. This note indicated that the cause of the fall could not be determined as Resident 2 cannot verbalize his needs, and no new risk factors could not be identified. During review of Resident 2's Progress Note dated 8/30/22 at 8:31 AM it was indicated that Resident 2 had a unwitnessed fall on 8/30/22 at 4:00 AM, and Resident 2 sustained a bump on his left forehead and a cut on his right knee. In this note it was determined that Resident 2 needed to use the restroom because Resident 2 was also found wet with urine. Review of Resident 2 Care Plan reveals a Care Plan was not created to prevent falls after he fall on 8/30/22. During an interview with NM1 and the DON on 12/28/22 at 11:30 AM it was stated by NM1 that a Care Plan was not created to prevent future fall after the 8/30/22 fall. During review of Resident 2's Progress Note on 9/1/22 at 10:43 PM it was indicated that Resident 2 fell on [DATE] at 8:10 PM from his bed. This note does not clarify if the fall was witnessed or unwitnessed. A risk factor identified in this note was that Resident 2 does not use his call light. Review of Resident 2's Assessments does not show documentation of a Post Fall Assessment and Morse Fall Assessment for Resident 2 after the fall on 9/1/22. During an interview with NM1 and DON on 12/28/22 at 11:30AM it was stated by NM1 that a Morse Fall Assessment and a Post Fall Assessment was not completed after the fall on 9/1/22. During review of Resident 2's Progress note on 9/2/22 at 3:21 PM indicated Resident 2 fell from his wheelchair, Resident 2 needed constant safety monitoring, and that Resident 2 sustained swelling and discoloration on his forehead. During review of the facility policy titled Falls Management Program dated 01/2019, it was indicated that the purpose of the policy is to provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury . The procedures to prevent falls and post falls include: The Licensed nurse will observe the resident and review risk factors that may potentially contribute to the occurrence and reoccurrence of a fall on admission, quarterly thereafter, and following an incident of a fall, and when a significant change of condition is identified to determine if he/she is at risk for falls using the Morse Fall Scale in PointClickCare (electronic health care record). The Licensed Nurse will initiate a plan of care within 24 hours from admission and readmission on residents identified as high risk for fall. The plan of care will be updated by the Licensed Nurse and Interdisciplinary Team (IDT, team of physicians, nurses, therapist, family, and any other related service team member that effect a resident's care) as indicated. The Interdisciplinary Team will reassess the risk factors contributing to falls and interventions to minimize recurrence of falls and injury during the initial, quarterly, and annual assessment, post fall and when a significant change of condition is identified. After a fall incident, the Licensed Nurse will check the resident for a change in the level of consciousness, change in the range of motion, functional mobility, and ADL (Activities of living) function and for presence of visible injury. The Licensed Nurse will notify the Attending Physician and the resident's responsible party regarding the fall incident and the status of the resident. The Licensed Nurse will determine the cause of the fall and provide interventions to manage the fall's and then reduce the risk of additional falls and injury .

Based on observation, interview, and record review, the facility failed to implement its infection control program when: 1. there was a cockroach infestation in multiple areas throughout the facility. Immediate Jeopardy (IJ is a situation in which the provider noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared on 2/21/17 at 4:15 PM. Cockroach infestation can transmit diseases that could significantly affect the health and well-being of the residents , staff, families, and visitors; 2. contact isolation precaution (procedures that reduce the risk of spread of infections by direct or indirect contact) for suspected clostridium difficile (C-diff, a bacteria found in feces)). was not timely implemented. 3. fresh oranges fruit covered with molds inside plastic container was found at bedside in one Resident Room. Failure to ensure sanitary environment, adhere to the implementation of infection prevention, and hygiene of resident care equipment may result in cross contamination of infection that could jeopardize the health of residents, staff, and visitors. Findings: 1. During an observation on 2/21/17 at 2:15 PM, at the third floor of the facility, multiple cockroaches were seen crawling on floor and walls outside room [ROOM NUMBER], 307, and 308. The cockroaches were moving about openly in a fully lighted area. During an interview on 2/21/17 at 2:21 PM, the Certified Nursing Assistant (CNA) 4 acknowledged presence of live cockroaches, and proceeded to put on gloves and kill cockroach on the wall. During an interview on 2/21/17 at 2:40 PM, the Registered Nurse (RN 3) stated that roaches are an on and off problem. An Immediate Jeopardy was declared on site on 2/21/17 at 4:15 PM with the Executive Director (ED), Housekeeping Supervisor (HS), and the Director of Nursing (DON) were notified that the presence of the live roaches was an Immediate Jeopardy (IJ) situation. The facility submitted a plan of correction as follows: a. On 2/21/17, Emergency abatement cockroach treatment was done to all resident rooms. b. Daily monitoring, if any new pest is found Pest Control Company (PCC) 1 will perform follow-up treatment to eradicate the roaches. c. Arranged for another Pest Control Company to re-evaluate the situation and current treatment plan. d. Staff in-service about reporting of pest was initiated. e. Pest Control Contract was revised to include a rotation of thorough pest control service to 10 rooms every month and staff in-service about pest control procedure. f. Families and responsible parties of residents were notified about limiting the food brought from home. Leftover food will be discarded at the end of the day. g. Housekeeping Services contractor company will increase the staffing and revise the cleaning and sanitation of the rooms. h. The ED or designee will audit Pest Control reports and include results in Safety Committee Meeting agenda and Quality Assurance Performance Improvement (QAPI) meeting. During an interview on 2/21/17 at 4:35 PM, the ED stated that the third floor area had been recently sprayed and the roach activity observed was from that spraying. During an interview and a concurrent observation on 2/21/17 at 5:33 PM, Resident 26 stated that he had seen roaches in his room on a regular basis, I am used to it, he said, I've seen 4-5 at a time, then up to a dozen by the end of the day. Resident 26 state that he has been complaining to facility staff about the roaches for the past 2 weeks, and the situation is still the same. It feels like a dirty place, very unsanitary, and it is getting worse and worse. During the interview with Resident 26, RN 3 was observed killing roaches behind the resident's bed, along the wall, above the door to his room; a live roach was also observed crawling across the Resident 26's laptop computer. On further observation of the room, live roaches were observed on all 4 walls of the room, and on top of and underneath the window sill. During an interview on 2/21/17 at 5:40 PM, a family member of Resident 1 stated that she had seen cockroaches in her father's room before, and had just killed one along wall behind his bed that same afternoon. She stated that she had observed live cockroaches on her father's food table, and on the wall behind the television. Additionally, she stated that when she had gone to the employee lunch room last week, she had seen live cockroaches there as well. During an interview on 2/22/17 at 2 PM, the ED stated that the staff from PCC 1 had come the night before to inspect all the rooms to identify the source of the infestation. Two areas were identified with live roaches: room [ROOM NUMBER], on the third floor of the building, and in the employee lunch room, on the first floor of the building. The ED stated that both areas had received a treatment from PCC 1 the night before, which included patching gaps in the baseboards of room [ROOM NUMBER], and fog-spraying of fumigant to both of the affected areas. According to the ED, the chemical used to treat the affected areas had a three day shelf life, so if any live roaches were observed after the treatment, the facility was to notify the PCC 1 for further treatment. The ED also reported that a separate pest control company had come to conduct an onsite inspection of the facility, and had concurred with the treatment plan proposed by the current PCC 1. On 2/22/17, a follow up treatment was done by PCC 1 at Rooms 205, 206, 303, 306, 307, 506, 508, break room and housekeeping office using gel bait; PCC 2 representative visited and re-evaluated the situation and recommended to continue Gel treatment. During an interview on 2/23/17 at 10 AM, the PCO stated that live roaches were observed after initial treatment, so the proposed follow up treatment would be to drill holes in walls of affected area, and release fumigant into the area behind the walls. The treated area would be expanded to include two additional rooms on either side of the affected area. During the environmental tour with the Maintenance Supervisor (MS) and Housekeeping Supervisor (HS) on 2/23/17 at 1:50 PM, there was a cockroach crawling on the door to the Salon and Spa on the fifth floor. There was also one crawling on the door to the medical records room, and a dead one on the floor in front of the environmental storage room on the fourth floor. During an interview on 2/23/17 at 4:30 PM, the ED stated that live roaches were still observed following the follow up treatment by the PCO, and that the treatment plan was to be expanded to include the entire building. On 2/23/17 , PCC 1 performed another treatment using in-wall Boractin (insect killer) powder (for cracks and crevices) and gel baits treatments. During observation and concurrent interview on 2/24/17 at 2:30 PM, a dead cockroach was observed on the floor on the right side of the bed between the bed and the wall. R18's family member stated that he just killed 6 cockroaches the night before. On 2/27/17 , efficacy of the in-wall treatment was validated using scoping camera. The Immediate Jeopardy was lifted on 2/28/17 at 3:00 PM in the presence of the ED and the DON. The survey team verified that the corrective actions have been implemented. Review of Centers for Disease Control and Prevention (CDC) article titled Healthy Housing Reference Manual Chapter 4: Disease Vectors and Pests (retrieved on 3/7/17 at https://www.cdc.gov/nceh/publications/books/housing/cha04.htm) indicated, .Cockroaches .The sight of cockroaches can cause considerable psychologic or emotional distress in some individuals. They do not bite, but they do have heavy leg spines that may scratch .Daytime sightings may indicate potentially heavy infestations. They tend to hide in cracks and crevices and can move freely from room to room or adjoining housing units via wall spaces, plumbing, and other utility installations .Four management strategies .The first is prevention. This strategy includes inspecting items being carried into the home and sealing cracks and crevices in kitchens, bathrooms, exterior doors, and windows .The second strategy is sanitation. This denies cockroaches food, water, and shelter .The third strategy is trapping. Commercially available cockroach traps can be used to capture roaches and serve as a monitoring device .The fourth strategy is chemical control. The use of chemicals typically indicates that the other three strategies have been applied incorrectly . 2. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. He was at room [ROOM NUMBER]B. During interview on 2/22/17 at 9:57 AM, Certified Nursing Assistant (CNA) 3 stated that Resident 1 was having watery stool. Review of physician's order dated 2/22/17 indicated, send stool to R/O (rule out, means dismiss from consideration)[DIAGNOSES REDACTED]. Review of Center for Disease Control and Prevention (CDC), (retrieved on 3/3/17 at https://www.cdc.gov/hai/organisms/cdiff/cdiff-patient.html) indicated, .Clostridium Difficile is a bacterium that causes inflammation of the colon, known as colitis .The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact . During observation on 2/23/17 at 9:48 AM, Resident 1 was not on contact isolation precaution. There was no personal protective equipment (PPE, an equipment used to protect a person from injury or infection) outside or inside room [ROOM NUMBER]. During interview on 2/23/17 at 9:49 AM, Registered Nurse (RN 3) acknowledged that isolation precaution for Resident 1 was not initiated. RN 3 stated, (Resident 1 was not on isolation because) we're still waiting for the result of the culture. During interview on 2/23/17 at 9:51 AM, Infection Control Nurse (ICN) stated, Isolation starts when it is confirmed (C-Diff). During observation on 2/24/17 at 12:20 PM, there was a yellow gown, gloves, mask, cleaning wipes, alcohol gel (also called as personal protective equipment - PPE) hanging by the door of room [ROOM NUMBER]. Review of Resident 1's Diagnostic Laboratories & Radiology received (on) 2/24/17 at 3:44 PM indicated, Positive (on) C.Diff. Review of the facility policy titled NCD (Nursing Care Division) Managing Patients With Clostridium Difficile Infection dated 9/30/16 indicated, .Components: .5. Appropriate Transmission-Based Precautions are implemented for confirmed or suspected CDI (clostridium dificille infection). 6. Appropriate personal protective equipment (PPE) and hand hygiene are utilized when providing care to the patient . 3. During observation and concurrent interview on 2/26/17 at 10:20 AM, there was a clear plastic container stored on the bedside table next to bed A in Resident room [ROOM NUMBER]. There were two unpeeled oranges in the container and one that was fully covered with fuzzy blackish greenish matter. The Executive Director (ED) acknowledged that the blackish greenish matter was mold. ED stated that the one covered with mold was a peeled orange.

Based on observation, interview and document review, the facility failed to ensure one of one sampled Patient, Patient 1's feet were off the floor while wheeling him on a wheel chair without using foot rests. This deficient practice has resulted in Patient1's right foot being caught on the floor, and consequently, fracture of the distal femur (broken leg bone) on the right side. Findings: Patient was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (a Patient assessment tool), dated 11/15/15, indicated Patient 1: 1) had unimpaired cognitive function; 2) required extensive assistance to change position in bed and used wheelchair for ambulation. Document review of the Progress Note by Registered Nurse 1, dated 1/30/16, indicated: At 3:15 pm (1/29/16) Resident (Patient 1) completed therapy session going out the gym prefers not to use her foot rest while wheeled by the therapist she caught her right foot on the floor while the wheelchair still moving. Resident (Patient 1) felt right knee was overextended and complains of severe pain . 7:30 PM Resident (Patient 1) transferred to (Hospital 1) emergency for treatment and evaluation. 2:20AM Came back from hospital with [DIAGNOSES REDACTED]. Modified splint on right knee . Document review of the Hospital 1's After Care Instructions, dated 1/29/16, indicated Patient1 had a [DIAGNOSES REDACTED]. Document review of the Progress Note by Registered Nurse (RN) 2, dated 1/30/16, indicated: (Patient 1) Came back from hospital, with modified splint (pillows and tape) on RLE (right lower extremity) fractured distal femur . With swelling on RLE, limited motion. Complained of 10/10 (10 out of 10 - worst possible) pain on RLE when moving/turning . Document review of the Progress Note by RN 2, dated 1/31/16, indicated: Given Norco (a pain medication) for 9/10 (9 out of 10) pain on RLE, . During an interview on 2/9/16 at 11:35 am, Patient1 stated: On 1/29/16, at around 3 pm, the Physical Therapist (1) pushed me (with my wheel chair) out of the therapy room. She did not know my foot caught on the floor, . I screamed the house down . I was in agony . It still hurts like a hell, whenever I move (my right leg) . During a concurrent observation on 2/9/16 at 11:35 am Patient1 was observed to have her right leg immobilized with pillows and tape. During an interview on 2/18/16 at 1:50 pm, Physical Therapist (PT) 1 stated that after a routine physical therapy session on 1/29/16 at around 3pm, she pushed Patient 1's wheel chair to get her back to her room as she was tired. She was a large lady, I was not able to see her feet while pushing the wheel chair . I did not know that her right foot got caught on the floor until she screamed . On the hind sight, I should have used footrests to prevent this from happening. During an interview and concurrent observation on 11/28/16 at 12:05 pm, PT 1 stated the footrests were not used during the 1/29/16 incident because we were trying to build her leg muscles to tap on the floor to help to propel the wheel chair as she had weak arms due to rheumatoid arthritis. PT 1 showed the surveyor the white metal threshold under the safety door where Patient1's right foot got caught on 1/29/16. It has a rise of approximately 0.5 to 1 cm from the floor surface. Document review of facility policy titled Wheelchair Transport, with a reviewed date of 10/31/08, indicated The Patientwho requires assistance with wheelchair transportation is treated in a manner that preserves the resident's dignity and provides for their safety. Before wheeling the resident, the transporter should ensure that the footrests are lowered, and the resident's feet are firmly on the footrests . The facility failed to ensure Patient 1's feet were off the floor while wheeling him on a wheel chair without using foot rests. The violation had a direct relationship to the health, safety, or security of patients.

Based on observation, interview and record review, the facility failed to ensure Resident 1 received adequate supervision and assistance to prevent falls when her toileting schedule was not followed by the facility staff. Resident 1 stood up to go the bathroom, had a fall and sustained fracture of the left hip and left wrist. Findings: Review of the clinical record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. functioning) and history of falls. Review of Resident 1's multi-disciplinary quarterly electronic MDS 3.0 (Minimum Data Set - a standardized assessment tool for nursing home residents) dated 3/23/16, indicated Resident 1 had impaired vision and Brief Interview for Mental Status (BIMS) indicated a score of 2, meaning Resident 1 was severely cognitively impaired. The assessment further indicated Resident 1 used a walker but only able to stabilize with staff assistance and required one-person extensive assistance to use the toilet. Review of Resident 1 ' s Fall Risk Assessment Tool, dated 4/21/16 indicated a score of 7 meaning she was considered at risk of falling. Review of Resident 1 ' s Fall care plan initiated on 12/20/15, indicated she was at risk for falls or injury related to history of falls, impaired cognition, impaired functional mobility and incontinence. The interventions included were to anticipate and meet Resident 1 ' s needs and review toileting schedule with CNA (Certified Nursing Assistant). Review of Resident 1 ' s May 2016 Flowsheets indicated she was on a scheduled toileting at 1 AM, 6 AM, 9 AM, 1 PM, 4 PM and 9 PM. On 5/9/16, the 1 AM and 6 AM were signed by CNA 1 that Resident 1 was toileted. Review of Resident 1 ' s Progress Notes indicated, 5/9/16 0744 (7:44 AM) At around 5:30 AM, resident (Resident 1) had an unwitnessed fall. Found lying on her left side next to bathroom door. Asked resident what happen, resident stated she wanted to use the bathroom . resident complained of left hip pain 7/10 (score of 7 out of 10, meaning severe pain). And sustained skin discoloration and bump on the left upper eyelid. Resident had difficulty moving left lower extremities . Review of Resident 1 ' s 5/9/16 hospital record indicated, Patient (Resident 1) was brought to ER (emergency room ), where she was noted to have severe left hip pain .Wrist x-ray show a nondisplaced dorsal buckle fracture of the radial distal metaphysis (wrist bone fracture). Resident 1 had a hip surgery on 5/9/16. During an interview on 6/2/16 at 3:00 PM, the Director of Nursing (DON) stated Resident 1 was on a toileting schedule at night and supposed to be toileted at 1 AM and 6 AM. DON stated on 5/9/16, CNA 1 asked Resident 1 to be toileted at 1:00 AM, however, Resident 1 just opened her eyes and did't say anything and closed her eyes again. DON stated CNA 1 assumed Resident 1 did not want to use the bathroom at 1:00 AM and did not ask Resident 1 again. The next toileting schedule was at 6 AM but it was too late for toileting because Resident 1 was found on the floor at 5:30 AM on 5/9/16. During an observation and interview on 6/2/16 at 3:30 PM, Resident 1 was on bed and she had a soft cast on her left arm. When asked what happened to her arm, Resident 1 stated she had a fall. When asked how did she fall, Resident 1 stated she wanted to use the bathroom and got up on her own. Resident 1 was in a room shared with another resident and there was an adjacent bathroom. When asked if she used the call light to call for help, Resident 1 stated she could not remember. During an interview on 6/2/16 at 3:40 PM, the Administrator stated CNA 1 should have followed the toileting schedule for Resident 1 and if the resident refused, CNA 1 should go back after few minutes and not wait until the next toileting schedule or offer a bedpan. Review of the facility ' s Accidents and Supervision to Prevent Accidents policy and procedure, dated 4/28/11 indicated, 8. Both the center-focused and patient-directed approaches include evaluating the hazard and accident risk data, analyzing potential causes of the hazard and accident risk, and identifying and designing interventions (including care plan interventions) based on the severity of the hazards and immediacy of risk. Evaluations should also look at trends such as time of day, location, etc. Interventions for the center-focused approach might include educating the staff .A patient-directed approach might include implementing the care plan interventions, supervising staff and patients, etc.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 25 sampled residents (Residents 13) when: Resident 13 who needed 2 person assistance with transfers was assisted from bed to shower chair by one facility staff (CNA 1) on 2/5/14. Resident 13 ' s leg was caught under the shower chair during the transfer. The deficient practice caused the resident pain. She sustained a [MEDICAL CONDITION] tibia and fibula (left lower leg bones). She was transferred to an acute hospital for closed reduction of the left leg fracture and required application of a left long leg cast. Findings: Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 13's MDS (Minimum Data Set) an assessment tool, dated 2/27/14 for significant change of condition indicated BIMS -Section C0500 Summary Score (Brief Interview for Mental Status) a score of 15 indicating intact cognition. Resident 13 required extensive assistance for transfer to and from bed, chair, wheelchair and standing position. She needed physical help in part of bathing activity. Review of Resident 13's Care Plan initiated on 11/14/13 indicated the following under "Problem, Need, Strength, Potential Concern:" Impaired functional mobility as evidenced by: Requires mostly cueing, supervision to extensive assist with ADL (Activities of Daily Living) tasks. The goal of care included, "Functional mobility, positioning and transfers will be achieved daily with or without staff assistance; Resident will be safe and free from injury..." The approaches indicated on the care plan included: "...ADL support: bed mobility-extensive; Transfer: extensive to total;... Bathing: extensive; 2 Staff assist during transfer..." Review of "Resident Progress Notes" dated 2/5/14 under "Condition Change Form" indicated, "After shower at 10:45 AM CNA (Certified Nursing Assistant) noted redness on resident's L (Circled to indicate left) lower leg above ankle... Around 11:30 AM, charge nurse and supervisor approached resident, noted redness with bluish skin discoloration and slight swelling on left lower leg above ankle... Unable to measure discoloration D/T (due to) non-compliant.. She (Resident 13) said she has pain 4/10 on L (left) lower leg above ankle...Notified MD c (with) new order to X-ray to left ankle complete and left fibula today... At 3:45 pm, ...X-ray result received c (with) conclusion of [MEDICAL CONDITION] tibia and fibula c (with) demineralization present...Per MD order, transfer to GACH (General Acute Care Hospital) for further evaluation and treatment." Review of another Condition Change Form dated 2/18/14 at 4:30 pm, indicated, " At 4:30 pm, resident (Resident 13) arrived in unit via gurney c (with) 2 ambulance crew from the GACH ... closed reduction left tibia fibula under MAC (Monitored Anesthesia Care) anesthesia. Cast on L (left) leg intact..." In an observation and interview on 12/8/14 during the initial tour, Resident 13 was in bed with both lower extremities protected covered by a blanket over a foot cradle. Resident 13 stated she was in pain and was waiting for her nurse to bring her medication. In an interview on 12/9/14 at 12:15 PM Certified Nursing Assistant 1 (CNA1) stated, "It was shower day. He was helping Resident 13 to transfer from bed to shower chair. Her (Resident 13) right lower leg was strong but her left lower leg was not. Her (non-weight bearing) left leg was caught under the shower chair and got twisted. She yelled ouch! I went ahead and showered her then I placed her back to bed. I noted the redness on her left lower leg. I reported it to the nurse - LVN1".