Every finding on record at Samarkand Skilled Nursing Facility

Based on record review and interview the facility failed to implement its policy and procedure for the timely reporting of unusual occurrences to the State Agency, California Department of Public Health (CDPH), when one resident (Resident 1) experienced a fall with fracture on 2/28/26 and it was not reported to CDPH until 4/30/26.This failure had the potential to delay the investigation of the State Agency and affect the health, safety, or welfare of residents.During a review of the Face Sheet (FS) for Resident 1, undated, FS indicated Resident 1, a [AGE] year-old female, admitted on [DATE] with diagnosis including Dementia (a decline in mental ability affecting memory, communication, reasoning, and behavior), Osteoarthritis (a degenerative disease causing bones to wear away leading to pain, stiffness, and swelling), and unsteadiness on feet.During a review of the Resident Note Entry (RNE), dated 3/2/26, for Resident 1, the RNE indicated in part . reviewed and discussed fall on 2/28/26', and Resident had admitted and x-ray imaging result nondisplaced fracture of distal end of right femur.During a review of the facility's policy and procedure titled, Unusual Occurrence Reporting, revised December 2007, indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of our residents, employees or visitors. And, Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four hours of such incident or as otherwise required by federal law and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and or other appropriate agencies as required by law) within forty-eight hours of reporting the event or as required by federal and state regulations.During an interview on 5/7/26 at 1:04 PM with the facility administrator (Admin), Admin agreed Resident 1's fall on 2/28/26 resulting in a fracture should have been reported to CDPH following the facilities policy and procedure for unusual occurrence reporting and was not reported until 4/30/26.

Based on interview and record review, the facility failed to ensure ensure that the daily posted nurse staffing information accurately reflected the actual staff on duty.This failure had the potential to result in inaccurate information being available to residents and the public.During a concurrent observation and interview on 1/20/26 at 11:12 a.m., with the Director of Nursing (DON) and the Certified Nurse Assistant (CNA)/Scheduler Coordinator (CSC) [a CNA tasked with assisting in scheduling of licensed and non-licensed staff), the posted Direct Care Staff Report was observed and reviewed, the daily nurse staffing posted had inconsistencies/inaccuracies:11/22/25 missing date and census.11/23/25 missing date and census.12/20/25 census of 59, no RN was scheduled/assigned to work for 24 hours. Later review of the sign-in sheet dated 12/20/25, a different document from the posted daily staffing document, revealed RN coverage for only 4 hours instead of the required 8 hours.1/1/26 census missing.1/7/26 census missing.1/17/26 census missing.1/18/26 census missing.The DON and the CSC reviewed the documents and confirmed these entries. The CSC stated, I forgot to write down the dates and census.During an interview on 1/21/26 at 8:31 a.m. with the DON, the DON was asked about the importance and consequences of the inconsistencies on the posted daily nurse staffing, the DON stated this can be misleading and can cause confusion to residents and visitors. During a concurrent interview and record review on 1/22/26 at 10:33 a.m. with the Administrator and DON, the facility's Policy and Procedure (P&P) titled Charting and Documentation dated July 2017, indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. When asked if this P&P applied to all documentation in the facility, since the facility did not have a specific P&P on how the facility meets the Federal requirements on nurse (licensed and non-licensed) patient ratio responsible for direct resident care to be posted/displayed daily, including the posted daily nurse staffing and not only to medical records, the Administrator and DON stated, Yes, all or any kind of documents/documentation in the facility should be accurate and complete.

Based on interviews, and record review, the facility failed to ensure the Wander Guard bracelets (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) were maintained in safe operating condition for two of three sampled residents (Resident 1 and Resident 2) when the Wander Guard's batteries were not checked nor the bracelets periodically cleaned and disinfected.This facility failure has the potential for the Wander Guards to malfunction resulting in resident elopement (leaving/departing without anyone knowing and unsupervised).During an interview on 9/08/25 at 6:43 p.m. with a licensed nurse (LN1), LN 1 stated she had training to check the placement of the wander guard every shift but was unaware of a process to check if the Wander Guards on the residents are working (are operational) batteries or cleaning.During an interview on 9/10/25 at 11:53 a.m. with the Director of Nursing (DON), the DON stated the facility does not have a process or documentation to verify that the Wander Guards worn by the residents are functioning appropriately, have sufficient battery life, or for operational integrity such as tampering or cleaning. During a review of the manufacturer's operational manual titled [NAME]-CARE700 Wander Management System, dated 5/2019, the manual indicated The SF705 tag [wander guard bracelet] does not have a visual LED indicator. It must have the battery tested weekly by the ID-TAD Tag activator/deactivator [a second-generation version of the secure tag activator/deactivator]. Like any piece of medical hardware, the tags should be periodically cleaned and disinfected. Tags should only be wiped down with a 3% hydrogen peroxide and water solution or isopropyl alcohol. Tags should be removed from the resident or asset prior to cleaning .Each facility should develop a tag sanitation and battery test regimen.The ID-TAD will show LB (low battery) next to the tag number. Replace the tag if the battery condition is low.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 3/2019, the P&P indicated, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety (is. Wander Guard, redirection).

***REPEAT Deficiency*** Based on record review and interview, the facility failed to ensure two of two sampled residents' (Resident 1 and Resident 2) assessments were performed by a registered nurse (RN) to meet professional standards of practice. This facility failure place residents at risk of not being assessed appropriately and potentially resulting in harm to residents. Finding: According to the Nursing Practice Act, Business & Professions Code, Chapter 6, Nursing Section 2725 indicates, .(b) The . RN is accountable for an ongoing comprehensive assessment that includes data collection (LVN data collection contribution), analysis, and drawing conclusions/making judgments in order to: formulate diagnoses and update diagnoses, formulate or change the plan of care, decide on specific activities to implement the plan of care, prioritize and coordinate delivery of care, delegate to nursing care competent staff to deliver required care . RN uses scientific knowledge and experience to make clinical judgments/assessments about observed abnormalities and changes based on a series of complex, independent and collaborative decision-making activities Set priorities for implementation of nursing care, priorities regarding urgency of patient concerns . LVN is not prepared by formal education to make RN level nursing judgments/assessments that include independent analysis, synthesis, and decision-making. RN is responsible for collecting (LVN data collection), analyzing, and collaborating with all information sources to ensure a comprehensive written plan of care that is based on current standards of safe practice. According to the Scope of Vocational Nursing Practice, section 518.5 indicates, The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. The data collection performed by the LVN is integrated into the data collection the RN collects to analyze, synthesize, and make decisions regarding patient/residents' care as outlined above. During a concurrent review of Resident 1's assessments and interview with the director of nursing (DON) and administrator (Admin) on 4/17/25 at 1:16 p.m., the document titled SBAR Communication Form . which consist of resident's evaluation of ten body systems was reviewed. The Admin was asked under which category this document was located. The Admin stated The SBAR Communication form is located under the assessments category. On the front page of document indicated Before calling Physician/NP/PA/other healthcare professional: Evaluate the Resident: Complete relevant aspects of the SBAR form below . On the second page of document indicated Resident Evaluation .listed 10 body systems to be evaluated. The DON and Admin confirmed the SBAR form was an assessment of a resident. A review of the resident assessments indicated the following: SBAR Communication forms dated 4/8/25 at 12:05 p.m., and 3/8/25 at 6:00 a.m., were not signed by a nursing staff, the signature area was left blank. SBAR Communication forms, dated 3/31/25 at 11:25 p.m., and 2/26/25 at 12:23 a.m., were signed by an LVN and not an RN. During a concurrent interview and record review on 4/17/25 at 1:16 p.m. with director of nursing (DON) and administrator (Admin) Resident 2's assessments and SBAR (Situation, Background, Assessment, and Recommendation - a tool used to share information about a patient) Communication Form, dated 2/11/25 at 5:59 a.m. were reviewed. The assessment was not signed by a nursing staff, the signature area was left blank. The DON and Admin were informed that the residents' SBAR forms required a signature to indicate who is completing the assessment, and the assessments need to be completed by an RN. If an assessment is completed by a licensd vocational nurse (LVN) then an RN must validate the assessments and/or cosign the assessments. It is not within the LVN scope of practice (activities and duties a healthcare professional is allowed to do) to perform assessments independently. The Admin stated OK . The DON stated OK .

Based on observation, interview and record review, the facility failed to follow professional food standards for food safety , when facility : 1. Failed to label food items as to date prepared and expiry date 2. Failed to provide adequate concentration of sanitizing solution in red buckets These failures has the potential for food borne illnesses to the residents. Findings : 1.During an observation on [DATE] at 9:50 AM at the kitchen, the following food items were beyond the expiry date: One (1) pack of Ground Beef with a discard date of [DATE]; six (6) bags of potato wedges with expired date of [DATE]; One (1) bag of hamburger buns with expiry date of [DATE]; One (1) bag of diner rolls, unlabeled and undated. During an interview on [DATE] at 9:50 AM with Dietary Manager (DM) validates the findings that the identified food were expired. During an observation on [DATE] at 10: 36 AM at the kitchen, 4 bags of grapes brought in from the independent living kitchen had no labels with one of the four bags having mold. During an interview on [DATE] at 10:36 AM with DM, DM validates the findings that the identified food are expired. 2. During an observation on [DATE] at 2:16 PM at the kitchen, two (2) red buckets were tested . Dietary Aide (DA1) tested the solutions and the result with the comparator chart with both buckets having a result of 170 ppm (parts per million / a unit of measure). During a concurrent interview with DA on and review of the comparator chart on [DATE] at 2:16 PM, the recommended concentration of the sanitizing solution is ,d+[DATE] ppm. During an interview on [DATE] at 2:16 PM with DM, DM validates the findings and verbalized that a consult on how to adjust the concentration of the sanitizing solution and the solution is not as effective based on concentration. During a review of Policies and Procedures (P&P) titled Sanitation and Infection Control: Sanitation Buckets, the Sanitation and Infection Control indicates in part: d. Test sanitizer solution when buckets are filled and ensure that the concentration is ,d+[DATE] parts per million (ppm). e. Sanitizer solution in the buckets should be changed at minimum of 4 hours or more as needed to keep the water clean and maintain effectiveness of the sanitizer.

Based on record review, observation, and interview, the facility failed to provide privacy and confidentiality of resident's electronic health record (name, diagnosis, medication list and other personal information) for two unsampled residents (Resident 13 and 40). Residents 13 and 40's electronic health records were exposed to the public when staff left the facility's computer on. This failure violated Resident 13 and 40's right to privacy. Findings: During an observation on 12/17/24, at 10:10 a.m., the Registered Nurse (LN4) left the medication cart at the Garden Court station with an open computer exposing the Resident 13 and 40's electronic health record. Further observation, two individuals passed by the medication cart while the electronic record were exposed out in public's view. During an interview on 12/17/24, at 10:25 a.m., with the LN 4, LN4 acknowledged Resident 13 and 40's electronic record were left exposed to the public when the computer was left open. LN4 further acknowledged after using residents' electronic medical record, it must be closed at all times. During a review of the facility's policy and procedure titled, Confidential Information, undated, the P&P indicated, Knowledge of confidential information is a trust to be honored. It is critical that all team members respect the resident's right to confidentiality .All team members should respect the confidentiality of residents' and co-workers' protected health information (PHI). In order to maintain the privacy of residents and ensure compliance with HIPAA (Health Insurance Portability Accountability Act - a federal law that protects sensitive health information from being disclosed without a patient's consent) regulations, team members are not to post electronic information about residents and/or family members. During a review of the P&P titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .18. Resident's health information needs to remain private. The pages of the MAR (Medication Administration Record) notebook containing resident health information must remain closed or covered when in not in direct use. During a review of the P&P titled, Resident's Rights, dated 02/2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to privacy and confidentiality. During an interview on 12/19/24 at 3:28 p.m. with the Director of Nursing (DON), the DON acknowledged that residents' rights on privacy and confidentiality of medical records must be followed and respected and for this incident it was not.

Based on interview and record review, the facility failed to ensure two of two unsampled residents (Resident 31 and 37), had their Minimum Data Set (MDS - a core set of screening, clinical, and functional status data elements) records transmitted to Centers for Medicare & Medicaid (CMS) Internet Quality Improvement and Evaluation System (iQIES) within the required timeframes. These failures resulted in delayed validation of the assessment by iQIES and had the potential to result in errors in billing to CMS or payment to the facility and quality ratings of the facility. Findings: During a review of the facility's Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated ,d+[DATE], the RAI indicated, Timeliness Criteria . Completion Timing . must be no later than 14 days after the Assessment Reference Date . Encoding Data . For a quarterly . encoding must occur within 7 days after the MDS Completion Date . Assessment Transmission . All other MDS assessments must be submitted within 14 days of the MDS Completion Date . Tracking Information Transmission . Death in the facility tracking records, information must be transmitted within 14 days of the Event Date. During a review of Resident 31's Face Sheet (FS), printed [DATE], the FS indicated, Resident 31 was discharged [DATE]. During an interview and record review on [DATE] at 11:02 a.m. with a licensed nurse (LN1), Resident 31's discharge assessment MDS transmission date was not available because it had not been transmitted. LN1 further stated it should have been transmitted within 14 days of their discharge date on [DATE]. During a review of Resident 37's FS, printed [DATE], the FS indicated, Resident 37 was admitted to the facility on [DATE] and discharged from the facility on [DATE] when Resident 37 expired. During a concurrent interview and record review on [DATE] at 11:02 a.m. with LN1, Resident 37's untitled record of transmitted MDS assessments (MDS record), was reviewed. The MDS record indicated: 1) MDS quarterly assessment reference date (ARD - the specific end date of the resident observation period) [DATE] that was transmitted [DATE], 39 days after the ARD date. 2) MDS quarterly assessment ARD [DATE] that was transmitted [DATE], 28 days after the ARD date. LN1 stated LN1 does not recall why they were late. During a concurrent interview and record on [DATE] at 9:40 a.m. with LN1, Resident 37's MDS, dated [DATE] was reviewed. The MDS indicated, Resident 37 was discharged [DATE] with a discharge status of deceased . LN1 stated this MDS should have been submitted within 14 days of the death in the facility and it wasn't.

Based on observation, interview, and record review, the facility failed to develop a care plan for urinary catheter (foley catheter flexible rubberized tube inserted into the urinary tract to drain the urine out) care in one of two sampled residents (Resident 36). This failure has the potential for Resident 36's to have the urinary catheter in place with no follow up or plan of care resulting to urianry tract infections (UTI), dislodgement and other bladder issues. Findings: During an observation on 12/16/24 at 10:45 a.m., Resident 36 was observed in bed with a urinary catheter connected to a urine bag. During a concurrent interview and record review of Resident 36's clinical record, on 12/19/24 at 07:30 a.m., with Licensed Nurse (LN2), the face sheet indicated an admitted [DATE], and a condition of urinary indwelling catheter for obstructive and reflex uropathy ( inability to completely drain urine out of the urinary tract). The Progress notes indicated Resident 36 was hospitalized for UTI on 10/31/24 and readmitted back to the facility on [DATE], on antibiotic treatment, which resolved the UTI . Further review of the clincial record for Resident 36 indicated no careplan for the urinary catheter was developed for the care. LN2 acknowledged no careplan was in place for the urinary catheter. During a review of facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated March 2022, P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident, which describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility to failed to review and update the plan of care (CP) after a fall for one of 16 sampled residents (Resident 18). This failure placed Resident 18 at a higher risk for recurring falls secondary to no updated plan in place for staff to follow and implement for prevention. Findings: During an interview on 12/16/24, at 12:15 p.m. with Resident 18, Resident 18 verbalized having a fall two weeks prior; which resulted to a week stay in the hospital . The resident further verbalized while at the hospital an antibiotic treatment was started due to an infection. During a review of Resident 18's hospital discharge summary, dated 11/19/24, the discharge summary indicated, Resident 18 was admitted to the hospital after a ground level fall and a diagnosis of septic joint (infection of the joint). Resident was discharged with an intravenous antibiotic administered through the vein) treatment. During a concurrent record review and interview on 12/18/24, 12:05 p.m. with the Director of Nursing (DON). The interdisciplinary ( IDT) notes and CP for fall, dated 11/14/24 were reviewed. The IDT notes indicated Resident 18 had a fall incident and CP will be updated upon return to the facility to include resident teaching on using call button for assistance. Upon review of the fall CP, the last updated date was 10/20/24, no update was entered when resident returned to the facility on [DATE]. The DON acknowledged the care plan for fall was not updated when the resident returned to the facility from the hospital on 11/19/24. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2011, the P&P indicated, 1. The interdisciplinary team (IDT - group of people with different areas of expertise to solve a problem or care for a patient) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

Based on observation, interview and record review, the facility failed to provide an eye drop medication for glaucoma ( degenerating of eye condition leading to vision loss or blindness) as ordered by the physician when supply runned out for one of 16 sampled residents (Resident 12). This failure resulted to Resident 12, not receiving the eye medication as ordered with the potential and risk for rapid vision loss /blindness. Findings: During the medication pass observation on 12/18/24, at 9:00 a.m. with the Registered Nurse (LN5), LN5 indicated Resident 12's eye drop medication for glaucoma will not be adminsitered as ordered as currently the medication is being reordered. During a review of physician's order (PO), dated 7/10/24, the PO indicated, Resident 12 is to receive Timolol Maleate 0.5% (percent) eye drops to both eyes for glaucoma daily. During a concurrent record review and interview on 12/19/24, at 2:15 p.m. with the Minimum Data Set Coordinator (LN1). Resident 12's current Medication Administration Record (MAR) was reviewed and indicated the eye medication Timolol Maleate 0.5% (percent) was not administered 12/17 and 12/18/2024. LN1 acknowledged the non administration of the eye medication on Resident 12 on 12/17 and 12/18/24. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .c. Certain products or package types such as multi-dose vials and ophthalmic (eye) drops have specific shortened end-of-use dating, once opened, to ensure medication purity and potency .Position statements from American Society of Ophthalmic Registered Nurses and American Society of Cataract & Refractory Surgery (ASCRS) state that the multi-use eye drops and ointments should be disposed of 28 days after initial use. During a review of the pharmacist recommendation titled, Executive Summary of Consultant Pharmacist's Medication Regimen Review (MMR), dated 6/29/24, pharmacist notes indicated, Per P&P, most eye drops should be discarded after 2 months from the open date for infection control, regardless of the manufacturer expiration date. During a concurrent record review and interview on 12/19/24, at 3:33 p.m. with the Director of Nursing (DON). The pharmacist MMR recommendation and the facility's P&P, both provided by the DON were reviewed. The DON was unaware of the pharmacist MMR recommendation for the eye drop medication. The DON acknowledged, the conflicting information on eye drops medication administration from the pharmacist and the facility's policy. The DON further acknowledged, that as a result Resident 12 did not receive the medication for two days.

Based on interview and record review, facility failed to ensure residents were free of unnecessary medications for two sampled residents (Resident 54 and 57) when: 1. A. Resident 54 was not properly assessed and provided with the correct medication per physician's order. B. Resident 54's blood pressure parameter per physician order was not followed. 2. Resident 57's pain level was not assessed and the pain level parameter per physician order was not followed. These failures resulted in Resident 57 and 54 to receive unnecessary medication and not in accordance with what the physician had ordered. Findings: 1. A. During a review of Resident 54's physician's visit notes (PVN), dated 8/28/24, the PVN indicated, Resident 54 is an 82-years old with the diagnosis of hypertension (high blood pressure), Stroke (brain attack), and left femur (thigh bone) fracture, and thoracic vertebral compression fracture (a break in a bone in the spine where bone collapses). During a review of Resident 54's physician's order (PO), dated 12/24, the PO indicated, Resident 54 is to receive an Acetaminophen 325 mg (milligram - unit of measurement) tablet, two tablets orally (by mouth) as needed every four hours for mild pain and Tramadol 25 mg orally for moderate to severe pain. During a review of the document titled, Universal Pain Assessment Tool (UPAT), undated, the UPAT indicated, pain scale 0 = no pain, 1-2 = mild pain, 3-5 = moderate pain, 6-8 severe pain, and 9-10 = worst pain. During a review of Resident 54's Medication Administration Record (MAR) dated, 12/2, 12/5, and 12/18, Resident 54 had a pain scale of seven out of 10, and six out of 10 on 12/9 and 12/10. Resident 54 was administered Acetaminophen 325 mg (milligram - unit of measurement) tablet, two tablets orally (by mouth) as needed every four hours for mild pain for a pain scale of seven, instead of Tramadol 25 mg orally for moderate to severe pain on 12/2,/12/5,12/18, and 12/9,and 12/10/24 for a pain scale of six . During a concurrent record review and interview on 12/19/24, at 11:15 a.m. with Minimum Data Set Coordinator (LN1), LN1 confirmed that an Acetaminophen was given when Resident 54 was assessed to have seven out of 10 pain on 12/2, 12/5, and 12/18, and six out of 10 pain on 12/9 and 12/10. During an interview on 12/19/24, at 3:50 p.m. with the Director of Nursing (DON). The DON acknowledged that the physician's order was not followed on the administration of Resident 54's pain medication. The DON was unable to provide additional proof of documentation that support why the pain medication was administered to the resident without following the physician's order and if the physician had been notified. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .1. Medications are administered in accordance with written orders of the prescriber. If dose seems excessive .or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate .3. Medication administration timing parameters include the following: e. Any additional facility specific policies and procedures. B. During a review of Resident 54's PVN, dated 8/28/24, the PVN indicated, Resident 54 is an [AGE] years old with the diagnosis of hypertension (high blood pressure (BP)), Stroke (brain attack), and left femur (thigh bone) fracture, and thoracic vertebral compression fracture (a break in a bone in the spine where bone collapses). During a review of Resident 54's physician's order (PO), dated 12/2024, the PO indicated, Resident 54 is to receive Irbesartan 300 mg, one tablet orally at hour of sleep and to hold the medication if the SBP (systolic blood pressure - the pressure in the arteries when the heart beats) is less than 110. During a review of the Medication Administration Record (MAR), dated 12/13 and 12/17, Resident 54's SBP was recorded as 109 and 99. During a concurrent record review and interview on 12/19/24, at 11:15 a.m. with LN1, LN1 confirmed that BP medication was administered to Resident 54 despite of the SBP was below the parameters the physician had ordered. During an interview on 12/19/24, at 3:50 p.m. with the DON. The DON acknowledged that the physician's order was not followed for BP medication. The DON was unable to provide additional proof of documentation that support why the BP medication was administered to the Resident 54 below the parameters as instructed on the physician's order and if the physician had been notified. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .1. Medications are administered in accordance with written orders of the prescriber. 48668 2. During a review of Resident 57's Medication orders, dated 8/10/24, order indicated, Oxycodone 5 mg tablet (1 tablet) as needed for mild (pain level 1-3) or shortness of breath (SOB). Oxycodone 5 mg tablet (2 tablets) as needed for moderate (pain level 4-6) to severe (pain level 7-10) or shortness of breath (SOB). During an interview on 12/19/24 at 11:15 a.m. with Licensed Nurse (LN3), she stated that there was no pain evaluation or assessment prior to administering Oycodone 1 tablet for mild pain (pain level 1-3) per physician order. During the record review of Resident 57's Medication Administration Record (MAR) dated 12/9, 12/11, and 12/16/24, record indicated Oxycodone were administered without pain assessments on these dates and results were marked effective. During a review of facility's policy and procedure (P&P), titled Medication Management dated 2007, P&P indicated in part There are various opportunities during the care process to evaluate the effects of medications on a resident's physical, mental and psychosocial well-being, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified, opportunities include during the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications. and each resident's drug regimen is reviewed to ensure it is free from unnecessary medication that includes any drug without adequate monitoring.

Based on interview and records review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for two of seven sampled residents (Resident 57 and 12) when 1. There was no justification from the physician for continued use beyond 14 days of the drug Ativan and/or Lorazepam (a medication used to help control anxiety) for Resident 57. 2. No monitoring for side effects and hours of sleep was done for trazodone (an antidepressant medication used to treat depression, anxiety [feelings of tension, worried thoughts, and physical changes like increased blood pressure], and insomnia [trouble sleeping]) for Resident 12. These failures had the potential to result in use of unnecessary psychotropic drugs and the potential to develop unrecognized side effects due to the inadequate monitoring of efficacy of the medication. Findings: 1.During a review of physician order for Resident 57, the order indicated medication orders of: a. Ativan 0.5 mg tablet (1 tablet) as needed every four hours for anxiety and shortness of breath (SOB) starting 7/18/24 with no STOP date. b. Lorazepam 0.5 mg tablet (2 tablets) as needed every four hours for moderate anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. c. Lorazepam 0.5 mg tablet (4 tablets) as needed every four hours for severe anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. d. Lorazepam 2 mg/ml oral concentrate (0.25 ml) as needed every four hours for mild anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. e. Lorazepam 2 mg/ml oral concentrate (0.5 ml) as needed every four hours for moderate anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. f. Lorazepam 2 mg/ml oral concentrate (1 ml) as needed every four hours for severe anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. During the interview on 12/19/24 at 1:30 p.m. with the Director of Nursing (DON), DON acknowledged there was no Stop date nor physician's justification for continued use beyond 14 days of Ativan and/or Lorazepam. During a review of facility's policy and procedure (P&P) titled Medication Monitoring, Medication Management, dated 1/24, P&P indicated, Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order and attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. 50707 2. During a review of Resident 12's Clinical Record (CR), dated 12/19/24, the CR indicated Resident 12 has a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 12's Physician Order Sheet (POS) for December 2024, dated 12/19/24, the POS indicated an order for trazodone 100 mg (milligram) tablet as needed for sleep for 90 days was renewed on 12/4/24. Current order was compared to previous order that had monitoring for hours of sleep and side effects. There was no order to monitor side effects or hours of sleep. During a review of Resident 12's Care plan (CP), undated status active (current), the CP indicated, Monitor for side effects of medication (constipation [condition in which stool becomes hard, dry, and difficult to pass], dry mouth, anxiety, agitation, headache, falls). During a concurrent interview and record review on 12/19/24 at 6:07 p.m., with the Director of Nursing (DON), the Medication Administration Record (MAR) for December 2024 was reviewed for Resident 12. The last dose of trazodone administered was on 12/6/24 at 1:16 a.m. The DON stated hours of sleep and side effects monitoring are documented when Trazodone is administered. No documented evidence of hours of sleep or side effect monitoring on 12/6/24 was found. The DON stated, it was missed. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated July 2022, the P&P indicated, Psychotropic medication management includes: .d. adequate monitoring for efficacy and adverse consequences .

Based on observation, interview and record review, the facility to failed to remove: 1. Expired medical supplies in the medication storage room. 2. Expired unopen box of medication. These failures had the potential for the residents to receive expired, and ineffective medications and medical supplies. Findings: 1. During An observation on [DATE] 10:15 a.m. the Garden Court station medication room, the following medical supplies were found inside the intravenous (IV - a medical procedure involving inserting a needle through a vein) starter bin: - One expired medical supply: [NAME] IV start kit, expiration date: [DATE]. - One filter needle 19-gauge (unit of measurement), expiration date: ,d+[DATE]. - One opened box of bio patch disc (a medical supply that is applied to the IV catheter insertion site on the skin), expiration date: [DATE]. 2. One box, unopened, anti-diarrheal (loose, watery, bowel movements) medication, expiration date: ,d+[DATE] located in the garden court station medication cart. During an interview on [DATE], 10:45 a.m. with the Registered Nurse (LN4), the LN4 verified the expired medication and medical supplies. During an interview on [DATE] 3:40 p.m. with the Director of Nursing (DON). The DON acknowledged the expired medication and medical supplies. The DON further acknowledged, that expired items must be removed and discarded. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated ,d+[DATE], the P&P indicated in part, .Medications are administered in a safe and timely manner and as prescribed .12. The expiration/beyond use date on the medication label is checked prior to administering. During a review of the P&P titled, Medication Storage, dated 2007, the P&P indicated in part, .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on record review and interview, the facility failed to ensure Resident 1's post fall assessment and other assessments were performed by a registered nurse (RN) to meet professional standards of practice. The facility's failure place residents at risk of not being assessed appropriately and potentially resulting in harm to residents. Finding: According to the Nursing Practice Act, Business & Professions Code, Chapter 6, Nursing Section 2725 indicates, .(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill . RN is accountable for an ongoing comprehensive assessment that includes data collection (LVN data collection contribution), analysis, and drawing conclusions/making judgments in order to: formulate diagnoses and update diagnoses, formulate or change the plan of care, decide on specific activities to implement the plan of care, prioritize and coordinate delivery of care, delegate to nursing care competent staff to deliver required care . RN uses scientific knowledge and experience to make clinical judgments/assessments about observed abnormalities and changes based on a series of complex, independent and collaborative decision-making activities Set priorities for implementation of nursing care, priorities regarding urgency of patient concerns . LVN is not prepared by formal education to make RN level nursing judgments/assessments that include independent analysis, synthesis, and decision-making. RN is responsible for collecting (LVN data collection), analyzing, and collaborating with all information sources to ensure a comprehensive written plan of care that is based on current standards of safe practice. According to the Scope of Vocational Nursing Practice, section 518.5 indicates, The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. The data collection performed by the LVN is integrated to the data collection the RN collects to analyzed, synthesized, and make decisions regarding patient/residents' care as outlined above. During a concurrent review of Resident 1's SBAR Communication Form . dated 04/11/24 and interview with the interim assistant director of nursing (IADON) on 4/18/24 at 1:25 p.m., the IADON was asked if this SBAR communication form on 4/11/24 at 4:43 a.m., was the nursing assessment the patient received prior to being sent to the hospital emergency department ED, were there any other nursing assessments documented elsewhere in the record. The IADON confirmed the SBAR Communication form was an assessment and was created by a licensed vocational nurse (LVN). The IADON stated This SBAR form is the nursing assessment done before patient left to the ED. This is the only one (assessment). The SBAR document consisted of resident's assessment of all the body systems. A review of Resident 1's Daily Skilled Progress Note , dated 4/10/24 at 12:37 p.m., was conducted on 4/18/24. This progress note also consisted of the evaluation/assessment of the resident body systems. This assessment was also created by an LVN. During an interview with the IADON and administrator (ADMIN) on 4/18/24 at 2:05 p.m., the ADMIN and IADON were explained Resident 1's assessment dated [DATE] and 4/10/24 were conducted by an LVN without having an RN validate the assessments and/or cosign the assessments. It is not within the LVN scope of practice to perform assessments independently. The ADMIN acknowledged this and stated, I understand we need to look into this and change our practice.

Based on observation, interview and record review, the facility failed to ensure the Director of Food and Nutrition Services (Dietary Manager) met the state's education qualification requirements, as required per federal regulation, to be the Dietary Manager to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full-time Clinical Dietitian provided frequently scheduled consultation to the Dietary Manager to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with safe food handling and sanitation (Cross Reference F812), meal distribution accuracy (Cross Reference F803, F805) and puree meal preparation (Cross Reference F804), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day to day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DM by the RD, when the RD was the full-time Clinical Dietitian. There was a total of 53 residents receiving meals from the main kitchen and main dining room. Findings: During a concurrent observation and interview on 02/06/23, at 9:45 a.m., with Lead Cook (LC), in the walk-in refrigerator in the main kitchen, LC observed a large pan of cooked pasta labeled as 2-6-23 9:45 a.m. LC stated, he cooked the pasta that morning and it was for macaroni and cheese for the residents lunch today. During a concurrent observation and interview on 02/06/23, at 10:02 AM, with Registered Dietitian (RD), in the main kitchen, a scoop was observed touching uncooked rice inside a dry storage ingredient bin. The RD verified the scoop should not have been stored touching the rice as it was a source for potential cross contamination. The RD was asked where the dietary staff were supposed to store the scoop, and RD stated, she did not know but the Dietary Manager (DM) would know. The DM was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 10:03 a.m., in the presence of the RD, LC was asked for the cool down log. LC stated, We don't have a cool down log. Concurrently, the RD verified pasta is a TCS food, and RD stated, she did not know if the staff had a cool down log. The RD stated the DM would know as she was the clinical Dietitian. During an interview on 02/06/23, at 12:35 p.m., with RD, RD stated, she wasn't aware what portion sizes were planned today but she can get a copy of the menu extension. RD stated, she was not aware dietary staff serving meals in the dining room did not have the menu extension posted that contained direction on the portion sizes to serve. RD stated, Dietary Manager would know. The RD stated she was the clinical Dietitian. The DM was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 12:39 p.m., with RD, in the main dining room, the RD compared the portion sizes being served by DA 1 for the regular diet to the menu extension. The RD stated 2 oz. of mac & cheese was served and it should have been 4 oz. The RD stated 2 oz. of soup was served and it should have been 8 oz The RD stated, DA 1 was not serving 4 oz. of broccoli and should have used a measured scoop to ensure 4 oz. of broccoli was served. During an interview on 02/08/23, at 10:37 a.m., with DM, DM stated he was responsible for running the day-to-day food service operations for the skilled nursing facility. The DM stated he was not a Certified Dietary Manager and his credentials are ServSafe, and restaurant experience. During an interview on 02/08/23, at 10:45 a.m., with DM, in the presence of the Administrator (Admin), the DM reviewed the state's qualifying pathways that meet a DM's state education qualifications as listed in the Health and Safety Code 1265.4 (H & SC 1265.4). DM stated, he had not met any of the qualifying pathways to be a dietary manager (interchangeable with the state's terminology for a dietary services supervisor) as listed in H &SC 1265.4. The following state Title 22 requirement was shared with the DM and Admin; Title 22, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. During an interview on 02/08/23, at 10:45 a.m., with DM, in the presence of the Administrator (Admin), the DM verified that he was in charge of the day to day food service operation for the skilled nursing facility residents. The DM verified the RD was the Clinical Dietitian. The deficiencies that occurred during the survey related to food and nutrition services had not had the benefit of the RD expertise to have an opportunity to assist the facility to self-identify and self- resolve the food safety and food distribution concerns to ensure resident health and safety, as evidenced by interviews with the RD. The RD had not had a sufficient role to provide frequently scheduled consultation to the DM related to safety and sanitation of the food service department. The Admin stated, the DM and RD speak all the time. The Admin was unable to provide written consultation reports by the RD related to food safety, food preparation, food storage or sanitation of the food service operation. The Admin stated, Oh, so you are saying it needs to be in writing?. During an interview on 02/08/23, at 10:50 a.m., with RD, RD stated, she was unaware the facility's Dietary Manager was not a Certified Dietary Manager. The RD stated she works for an outside contract and was contractually hired to be the facility's full time Clinical Dietitian. The RD stated, she does not have a role or any tasks related to overseeing food safety and sanitation to include food preparation, monitoring meal tray line service and food storage. The RD verified the responsibility of the day to day food service operation was the Dietary Manager's position. The RD stated she does not perform any type of food safety and sanitation audits or monitoring over the food service operation. The RD stated her interactions that pertained to the dietary staff were limited to instructing on the diet manual, periodically reviews accuracy of residents meal tray tickets (the paper tickets that include diet orders and resident specific instruction regarding meal service) but does not include overseeing, or monitoring tray line meal service, and she used a form to complete with residents regarding their experience with their meals. RD stated, she had worked at the facility for approximately 2 1/2 years. During a review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), the SOM defined the word Consultants as the following; means an individual who gives professional advice or services. They are generally not direct employees of the facility and may work either full or part-time. During a review of the RD's job description (JD), the JD indicated, Clinical Dietitian; Position Summary: Responsible for providing comprehensive nutrition assessments and care planning for patients and residents with special needs. Implements business practices in order to uphold Company mission and values. Contributes to account revenues and operating profit contribution through the implementation of services ., Duties: Directs dietary care of patients and residents with special needs including screening, assessment, intervention, care and discharge planning to ensure patient nutrition needs and customer satisfaction levels are met. Educates medical staff and counsels patients/residents and their families on proper nutritional care. Manages and promotes food and nutrition programs according to [name of contracted company] standards and policy. Collaborates and communicates with culinary and clinical departments on established processes, special diets, and menu requests. Stays current with most recent nutrition-related trends, research, policy, certifications, and standards of practice. Probes potential problems and apprises manager of status on resolution of problems or issues using appropriate [name of outside company] resource when necessary. Ensures compliance with all federal, state and local regulations as well as [name of outside company]/client policies and procedures .Establishes operating standards, implements quality improvements and communicates them to other departments. During an interview on 02/08/23, at 12:07 p.m., 6/3/18, with Director of Dining (DOD), the DOD stated, the DM was hired to be the Dietary Manager to run the day to day food service operations for the skilled nursing facility residents. The DOD verified the RD was hired to be the Clinical Dietitian. The DOD described her position as an Administration function dealing with fiscal. The DOD stated she was not involved in the day to day food service operation of the main kitchen for the skilled nursing facility, and stated she had not met any of the educational pathways to be a Dietary Manager as listed in the H & SC 1265.4. During a review of the DOD's job description (JD) titled GM 4, Food, that was provided by the DOD, the JD indicated, Position Summary: Provides local leadership and strategic direction to build client relationships and new business opportunities to enhance profitability for the Company. Directs business practices in order to uphold Company mission and values. Develops new and emerging business solutions for sustained growth and effective day-to-day operations ., Duties: .Supervises day-to-day work activities by delegating authority, assigning and prioritizing activities, and monitoring operating standards ., Creates and manages the budget by increasing revenue and controlling unit expenditures to ensure accuracy of operating and administrative budget ., Directs daily food service operations, including: menu evaluation and planning, purchasing, inventory, receiving, food preparation and storage. Maintains kitchen and storage facilities to meet/exceed sanitary conditions, monitors internal quality assurance and food safety audit process (including HACCP [Hazard Analysis Critical Control Point] record keeping). During a review of the DM's job description (JD) titled Health Care Dietary Manager, the JD indicated, Purpose of Position: This position is responsible for all aspects of supervision and administration of the day to day nutritional care and food service operations for the Skilled Nursing at the [name of the Skilled Nursing Facility] ., reports to Director of Dining Services [DOD]. 46948

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) were transmitted timely, per regulation for four of eight residents sampled (Residents 57, 28, 9, and 54). This failure resulted in the facility's non-compliance with the regulatory requirements; and had the potential for not knowing resident's whereabouts and current conditions. Findings: During a review of the facility's provided CMS RAI (Resident Assessment Instrument) 3.0 Manual, dated October 2019, the manual indicated, .The Quarterly assessment must be transmitted no later than 14 calendar days after the MDS completion date. The Entry and Discharge tracking must be transmitted no later than 14 calendar days after the Entry and discharge date . During a concurrent record review and observation on 2/9/23, at 11:30 a.m., with the MDS coordinator (MDSC), the facility's MDS transmittal records (multiple dates) was reviewed. The records indicated: -Resident 57's quarterly assessment, with reference date of 12/29/22, remained open with no completion date. Resident 57 was discharged on [DATE], and the MDS assessment was completed on 1/6/23. -Resident 28's quarterly assessment, with reference date of 12/27/22, remained open without a completion date. -Resident 9's quarterly assessment, with reference date of 12/14/22, was completed on 1/9/23. -Resident 54 was discharged on [DATE], and the MDS assessment was completed on 9/25/22. On 2/9/23 all five assessments were found not transmitted to the federal database, and the 14 days requirement for submission was unmet. During an interview with the MDSC on 2/9/23, at 2:50 p.m., the MDSC acknowledged, the MDS transmittals for Residents 57, 28, 9, and 54 were not transmitted as stipulated in the regulation.

Based on observation, interview and record review, the facility failed to follow the menu as planned when: 1a. The portion size for the regular diet was not followed during the lunch tray line observation located in the main dining room. 1b. In addition, the portion size for soup was not followed during a lunch tray line observation located in the main kitchen. 2. A therapeutic diet order was not followed per the planned Heart Healthy menu for one of 19 sampled residents (Resident 100). The facility failure to ensure dietary staff followed the menu had the potential to not meet the residents' nutritional needs. There was a total of 53 residents receiving meals from the main kitchen and main dining room. Findings: 1a. During a concurrent observation and interview on 02/06/23, at 12:03 p.m., with Dietary Aide (DA) 1, in the main dining room, DA 1 was observed serving residents the lunch meal from a steam table. DA 1 pointed to the ladle that was located in the soup, and DA 1 stated, she was serving 2 ounces (oz.) of chowder soup for the regular diet orders. DA 1 showed the blue handled scoop she used for the macaroni and cheese (mac & cheese), and DA 1 stated, she was serving 2 oz. of the mac & cheese for the regular diet orders. DA 1 was observed using a slotted spoon to serve the broccoli for the regular diet orders, and DA 1 stated, the slotted spoon had not contained a measurement on the utensil. DA 1 stated she had been employed at the facility for approximately eight months. During a concurrent observation and interview on 02/06/23, at 12:06 p.m., with Director of Dining (DOD), in the main dining room, the DOD stated, DA 1 knew what portion sizes to use by training. DOD observed the portion sizes DA 1 was serving. DOD had not identified a concern with the portion sizes being served by DA 1 on the regular diet orders. During an interview on 02/06/23, at 12:35 p.m., with Registered Dietitian (RD), RD stated, she wasn't aware what portion sizes were planned today but she can get a copy of the menu extension. RD stated, she was not aware dietary staff serving meals in the dining room did not have the menu extension posted that contained direction on the portion sizes to serve. RD stated, Dietary Manager would know. The RD stated she was the clinical Dietitian. The Dietary Manager (DM) was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 12:39 p.m., with RD, in the main dining room, the RD compared the portion sizes being served by DA 1 for the regular diet to the menu extension. The RD stated 2 oz. of mac & cheese was served and it should have been 4 oz. The RD stated 2 oz. of soup was served and it should have been 8 oz The RD stated, DA 1 was not serving 4 oz. of broccoli and should have used a measured scoop to ensure 4 oz. of broccoli was served. During an interview on 02/08/23, at 10:07 a.m., with DM, DM stated, DA 1 should have had the menu extension readily available and should have followed the portion sizes listed on the menu extension. The DM was asked if there was a monitoring, or audit system in place to ensure dietary staff in the dining room followed the planned portion sizes. The DM stated, he did not know how long it had been that the menu extensions were not posted in the main dining room to be followed. DM stated, approximately 15 - 20 residents receive their lunch meal from the main dining room. During a review of the menu extension (ME), labeled as Spring Week 1 Monday, the ME indicated, Regular [diet], .Chowder Soup - 8 oz Ladle, Baked Mac & Cheese - 4 oz ladle, Broccoli 4 oz . 1.b During a concurrent observation and interview on 02/07/23, at 1:10 p.m., with Lead Cook (LC), in the main kitchen, LC was observed placing chicken noodle soup into a bowl using a ladle located in the soup in the steam table for regular diet orders. LC was observed using one ladle for the soup. LC observed the measurement listed on the ladle, and LC stated, It's 6 ounces (oz.). LC was asked if 6 oz was the correct portion size, and LC checked the menu extension that was posted behind him underneath other papers, and LC stated, 6 oz. was not correct, and he should have used an 8 oz. ladle. During a concurrent observation and interview on 02/07/23, at 1:13 p.m., with Lead Cook (LC), in the presence of dietary aide (DA) 2, in the main kitchen, Resident 47's meal tray was located on the meal delivery cart. Resident 47's meal tray ticket indicated fortified diet and to serve fortified soup. LC was asked the quantity of fortified soup that was served to Resident 47, and LC stated, 6 oz. LC verified the incorrect portion of fortified soup was served to Resident 47. During a review of the menu extension (ME), labeled as Spring Week 1 Tuesday, the ME indicated, Regular diet, chicken noodle soup - 8 oz. Ladle ., Fortified diet 8 oz. Fortified soup. During a review of Resident 47's Diet Order (DO), dated 10/18/2022, the DO indicated, Fortified diet and fortified soup for lunch and dinner. During a review of the facility's policy and procedure (P&P) titled, Every Bite Counts (fortified foods), undated, the P & P indicated, Purpose: Creation of an individualized high-calorie, high-protein food intervention for residents at nutritional risk. The Every Bite Counts (EBC program) increases the amount of calories and protein served to residents . During a review of the facility's policy and procedure (P&P) titled, Section 2: Diets & Menus Menu Extensions/Diet Spreadsheets, dated 1/2016, the P & P indicated, Policy: Menu extensions are to be available, referred to, and followed with each meal that is prepared and served. Therapeutic menus will be written for all diets served in the facility. Procedures: 1. Each employee is responsible for following the prepared menu extensions. 2. It is the management team's duty to ensure that the menu extensions are accurate and updated as needed. Management team will provide menu extensions for every serving area. 3. When serving, the employee refers to the menu extensions to ensure that the proper portion sizes and diet needs are being met . 2. During a concurrent observation and interview on 02/07/23, at 1:00 p.m., with dietary aide (DA) 2, in the main kitchen, Resident 100's lunch meal tray was observed on the meal delivery cart. Resident 100's meal tray ticket indicated Heart Healthy diet. A packet of salt was observed on Resident 100's meal tray. DA 2 was asked to remove Resident 100's meal tray from the meal delivery cart and check it for accuracy. DA 2 reviewed the lunch meal tray and had not identified any concerns. DA 2 was asked to review the menu extension that indicated cardiac/heart healthy: No salt packet ., and DA 2 stated, New to me. DA 2 verified that he had placed the salt packet on the meal tray and verified he was unaware that residents on a heart healthy diet should not be served a salt packet according to the menu. During an interview on 02/08/23, at 10:31 a.m., with Dietary Manager (DM), DM stated, a salt packet should not be on the meal tray with diet orders for heart healthy diet. DM verified the therapeutic heart healthy menu was not followed for Resident 100. During a review of Resident 100's Diet Order (DO), dated 1/17/2023, the DO indicated, Low fat/low chol [cholesterol], NAS [no added salt], regular texture thin liquids. During a review of the facility's policy and procedure (P&P) titled, Section 2: Diets & Menus Menu Extensions/Diet Spreadsheets, dated 1/2016, the P & P indicated, Policy: Menu extensions are to be available, referred to, and followed with each meal that is prepared and served. Therapeutic menus will be written for all diets served in the facility. Procedures: 1. Each employee is responsible for following the prepared menu extensions. 2. It is the management team's duty to ensure that the menu extensions are accurate and updated as needed. Management team will provide menu extensions for every serving area. 3. When serving, the employee refers to the menu extensions to ensure that the proper portion sizes and diet needs are being met . During a review of the facility's policy and procedure (P&P) titled, Section 8: Nutrition Care Diet Orders, undated, the P & P indicated, Policy: The Food & Nutrition Services Department will maintain a record of the current physician prescribed diet order for each resident to ensure resident meal services are provided in accordance with the current diet order. 46948

Based on observation, interview, and record review, the facility failed to maintain safe and sanitary food handling practices when: 1. Expired peeled, chopped garlic was available for use in the refrigerator. 2. TCS food (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) was not documented on the facility's cooling log to ensure food safety. 3. A scoop was stored directly on rice in an ingredient bin increasing the risk of cross contamination. 4. A dietary employee failed to identify the proper sanitizing chemical. 5. Food delivery boxes were stored directly on the floor and then placed in the refrigerator, freezer and/or dry food storage room. These failures had the potential to result in foodborne illnesses. Findings: 1. During a concurrent observation and interview on [DATE], at 9:45 a.m., with Lead Cook (LC), in the walk-in refrigerator in the main kitchen, LC observed a five pound container of peeled garlic labeled as prep [DATE], Discard by [DATE]. Another smaller container of chopped garlic was labeled as Opened [DATE] 1:34 p.m., Discard [DATE] 1:34 p.m. LC stated, the garlic was expired and should not be available for use. During a review of the facility's policy and procedure (P&P) titled, C-26 Date Marking Ready to Eat TCS .Foods, dated [DATE], the P&P indicated, Refrigerated, ready to eat, .food prepared and held in a food establishment must be clearly marked with a consume by/discard date . 2. During a concurrent observation and interview on [DATE], at 9:45 a.m., with Lead Cook (LC), in the walk-in refrigerator in the main kitchen, LC observed a large pan of cooked pasta labeled as [DATE] 9:45 a.m. LC stated, he cooked the pasta that morning and it was for macaroni and cheese for the residents lunch today. During a concurrent observation and interview on [DATE], at 10:03 a.m., in the presence of the Registered Dietitian (RD), LC was asked for the cool down log. LC stated, We don't have a cool down log. LC stated the three pounds of pasta was done cooking at 9 a.m. that morning. LC stated he put the pasta on ice and the pasta was less than 41 degrees F in ,d+[DATE] seconds. Concurrently, LC used a digital thermometer and inserted the thermometer in the pasta, and LC stated, It's 46.4 degrees F. LC verified he had not documented the cool down process on a cool down log. Concurrently, the RD verified pasta is a TCS food, and RD stated, she did not know if the staff had a cool down log. The RD stated the Dietary Manager (DM) would know as she was the clinical Dietitian. During an interview on [DATE], at 10 a.m., with DM, DM stated, the cook should have begun documenting the cool down process for the pasta on the cooling log. During a review of the facility's policy and procedure (P&P) titled, C-23 Cooling and Chilling, dated [DATE], the P&P indicated, Cooked TCS/PHF [potentially hazardous food] food shall be cooled: from 140 degrees F to 70 degrees F within 2 hours or less and then to 40 degrees F or below with an additional 4 hours (total maximum cooling time 6 hours) .Cooling and chilling temperatures must be taken with a calibrated thermometer and recorded on the HACCP [Hazard Analysis Critical Control Point] Cooling and Chilling log . 3. During a concurrent observation and interview on [DATE], at 10:02 AM, with Registered Dietitian (RD), in the main kitchen, a scoop was observed touching uncooked rice inside a dry storage ingredient bin. The RD verified the scoop should not have been stored touching the rice as it was a source for potential cross contamination. Concurrently, another ingredient bin was observed to have a sign posted on the lid of the bin that indicated, Do Not Leave Scoop In Bin. During an interview on [DATE], at 10:02 a.m., with DM, DM verified the scoop should not have been stored inside the dry ingredient bin touching the rice. 4. During a concurrent observation and interview on [DATE], at 09:39 a.m., with dish washer (DW) 1, in the main kitchen, DW 1 was observed using a red cloth and wiping down a utility cart. DW 1 then proceeded to load dishes into the dish machine. In the presence of a dietary aide (DA) 3 translating in Spanish for DW 1, DW 1 stated, he was not done cleaning the utility cart as he still needed to sanitize it. DW 1 held up a bottle titled Orange Oasis Cleaner and stated that is what he used to sanitize. The Dietary Manager (DM) was present for the above observation and interview. During an interview on [DATE], at 9:41 a.m., with DM, DM stated, the Orange Oasis 137 Orange Force was a multipurpose cleaner and not a sanitizer. DM verified it was DW 1's assigned task to clean and sanitize the utility carts. DM stated, DW 1 should have sanitized the utility cart after cleaning using a quat (quaternary ammonium compounds) 146 sanitizer that was available in the kitchen. The DM provided a Sanitizer Solution Log- U.S. that indicated, Required concentration for Oasis 146: must be set at ,d+[DATE] ppm [parts per million] for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths. During a review of the facility's policy and procedure (P&P) titled, C-8 Preventing Cross Contamination, dated [DATE], the P&P indicated, .Utensils and equipment used for both raw and ready to eat foods must be cleaned and sanitized between uses . 5. During a concurrent observation and interview on [DATE], at 09:30 a.m., with Dietary Aide (DA) 3, in the main kitchen, DA 3 was observed receiving a food delivery supply in which the boxes of food were placed directly on the kitchen floor. DA 3 verified the cardboard boxes of food would be placed directly on the shelves inside the refrigerator, freezer and dry food storage room, as applicable. One of the boxes of food stored directly on the floor was a cardboard box labeled as pasteurized shell eggs, and another cardboard box was labeled as [NAME] Sure Crisp (French fries). During an interview on [DATE], at 10:02 a.m., with DM, DM stated they did not have a policy that indicated the food delivery cannot be placed directly on the floor, in which that same cardboard box is then placed on the food storage shelves. During a review of the Food and Drug Administration (FDA) Food Code, dated 2022, the FDA Food Code included, Employees are verifying that foods delivered to the food establishment are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination . (FDA Food Code 2022, ,d+[DATE].11) During a review of the FDA Food Code Annex ,d+[DATE].11, the FDA Food Code Annex indicated, When food and other purchased goods are delivered and placed into designated locations within the food establishment .the Person in Charge must make sure food employees inspect such product and verify that it is from the appropriate supplier, is in the desired condition, and was delivered to a proper storage location. Distributors deliver and place food and other goods in refrigeration units, freezers, and dry storage areas for confirmation of receipt and inspection by employees immediately upon arrival to the food establishment ., Upon delivery, all food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 F or below. Likewise, if the food product is frozen, it must be placed into the freezer. 46948

Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 53), received reasonable accommodation on the use of a call bell. This failure had the potential to not meet the health care needs of the Resident 53. Findings: During a review of Resident 53's MDS (Minimum Data Set - a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) 3.0 Nursing Home Quarterly Assessment . Section C - Cognitive Patterns . BIMS (Brief Interview for Mental Status) Summary Score, dated 1/12/23, Resident 53's BIMS indicated, a score of 11. During a concurrent observation and interview, on 2/6/23 at 10:45 a.m., with Resident 53, Resident 53 was observed in bed, awake, alert, and verbally consented to an interview. A visual inspection of Resident 53's room revealed, a call light system wall receptacle was installed, but the actual call light device cord was missing. A metal, desk call bell was noted on top of the Resident 53's left bedside table. When asked how Resident 53 would alert the staff if Resident 53 needed help or assistance, Resident 53 stated, Resident 53 would yell, Help, help! Resident 53 was reminded there was a call bell on the bedside table. To demonstrate how accessible the call bell was for Resident 53, Resident 53 was asked to reach for it while in bed, but Resident 53 could not do it. During a concurrent observation and interview, on 2/8/23 at 2:57 p.m., with a licensed nurse (LN 1), inside Resident 53's room, Resident 53's living set up was observed. Resident 53's call bell was noted in the same location, on top of the left bedside table, far from the resident's reach. Resident 53 could not reach the call bell while in bed when requested to use it. LN 1 confirmed and acknowledged, the call bell was not accessible to Resident 53. LN 1 mentioned, staff conducted their rounds frequently to check on Resident 53, but could not specify the exact times, nor was able to provide documentation of those rounds. During a review of Resident 53's, Care Plan Report, undated, the Care Plan Report indicated, (Resident 53) does not use the call light for assistance. The call light is a hazard for the resident due to possible tripping or getting wrapped around it. Further review of the Care Plan Report indicated, the intervention, Place call bell accessible to the resident. The intervention was not followed as observed inside Resident 53's room. During a review of the facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated in part, Policy Interpretation and Implementation . 9) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan, 10) Identifying the problem areas and their causes, developing interventions that are targeted and meaningful to the resident The P&P also indicated, 11) Care interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making.

Based on observation and interview, the facility failed to ensure a list of the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman was posted in at least four specific locations, that are frequently visited and readily accessible to the residents. This failure had the potential for residents to not know how to contact the Ombudsman, to address their concerns. Findings: During the initial tour of the facility on 2/6/23, at 10:50 a.m., the Ombudsman's contact information was not posted in the facility's dining and activity rooms, that are frequently visited by the residents. There was only one poster with the Ombudsman's information located in the facility. During an observation on 2/6/23, at 11:30 a.m., with the Director of Nursing (DON), the DON acknowledged, there was only one Ombudsman poster in the facility. During a follow up interview with the DON on 2/9/23, at 11:16 a.m., the DON further acknowledged, the Ombudsman's information was not posted in a location frequently visited and accessible to the residents.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 1), received adequate supervision during a transfer which resulted in a fall with injury. Resident 1 was transferred using a Sara lift (equipment used to lift, transfer, reposition, and move residents) assisted by one person when the care plan and facility policy required two or more persons to assist with transferring. 2. To ensure a safe environment for one of three sampled residents (Resident 2), when a contaminated (dirty) syringe was left unattended in Resident 2's room, accessible to the resident and visitors. This failure placed residents and visitors at risk for injury from potential exposure to a contaminated syringe. 3. Follow their policy for training facility staff using equipment to lift, transfer, reposition, and move residents. This failure placed residents requiring a lift to transfer, at risk for falls and injury. Findings: 1. Review of Resident 1's comprehensive assessment, dated 12/15/13, indicated, Resident 1 was assessed as mentally intact and had [DIAGNOSES REDACTED]. Resident 1 was assessed as requiring extensive assistance with two or more persons for transferring. Review of the emergency room (ER) physician documentation titled, "Presenting Problem", dated 1/21/14 at 3:13 p.m., indicated, Resident 1 had a fall from a lift resulting in "Injury - Pain - Swelling, Laceration" and "Mechanism of Injury: Caught in lift." The ER physician note titled, "Discharge", on the same date at 7:11 p.m. indicated, "Finger Crush Injury." Review of Resident 1's, "Clinical Note Licensed Nursing Progress Note", dated 1/22/14 at 12:25 a.m., by licensed nurse (LN 5), indicated, Resident 1 slipped from the Sara Lift and was lowered to the floor during toileting while assisted by certified nursing assistant (CNA 3). The note indicated, Resident 1 received a laceration to right 5th finger during this incident. 911 was called and the resident was sent to the hospital for evaluation. LN 6's clinical note, dated 1/24/14 at 3:18 a.m., indicated, "Bruising from fall to left side upper flank area." LN 7's clinical note, dated 1/27/14 at 9:38 p.m., indicated, "lg (large) bruise on Resident 1 from fall last week." Review of Resident 1's plan of care titled, "ADL (activities of daily living) Plan of Care Transfers", dated 1/13/14 - 2/21/14, indicated, Resident 1 was to be transferred using the Sara standing lift and the "Level of support: Two or more person physical assist." During an interview with CNA 3 on 3/7/14 at 10:05 a.m., CNA 3 stated, she was assigned to Resident 1 on 1/21/14, the day of Resident 1's fall from the lift. CNA 3 confirmed she knew Resident 1 was to be transferred with two people using the Sara lift. CNA 3 confirmed she transferred Resident 1 from the bed to the bathroom around 2 p.m., using the Sara lift with one person, not two persons as indicated in Resident 1's plan of care. During an interview with CNA 3 on 3/7/14 at 10:05 a.m., CNA 3 stated, "trained on the Sara lift 2 years ago." During an interview with CNA 1 on 3/7/14 at 9:30 a.m., CNA 1 stated, she was called to assist Resident 1 back to bed after the fall on 1/21/14. CNA 1 said, Resident 1 was complaining of pain in her back and right little finger. CNA 1 said, Resident 1's finger was bleeding. The facility policy and procedure titled, "Safe Patient Handling", last revised 11/12, indicated, "Control of risks of injury through Care Planning and Evaluation...Resident specific interventions will be documented, including the type of transfer techniques, special precautions, and the number of staff to be involved in performing the lift/transfer." 2. During a review of Resident 2's clinical record, the comprehensive assessment dated [DATE], indicated Resident 2 was assessed as having a severe cognitive impairment. Resident 2's [DIAGNOSES REDACTED]. Resident 2 required staff assistance for walking, dressing, and bathing, however, was assessed as capable of increased independence. During an interview with Resident 2's family member (FM) on 2/28/14 at 11:30 a.m., the FM stated she entered the room and observed a syringe laying on top of an over bed table in Resident 2's room on 2/1/14 around 2:30 p.m. The FM said she notified the DON, the administrator, and security. The FM presented photographs of the syringe taken by the FM at the time the syringe was seen. The FM stated a concern that Resident 2 was possibly injected with a medication. The FM said a LN came into the room and took the syringe. During an interview with CNA 2 on 3/7/14 at 3:05 p.m., CNA 2 explained she had entered Resident 2's room on 2/1/14 in the afternoon and observed a syringe on an over bed table. CNA 2 was asked to look at the photograph taken by the FM. CNA 2 confirmed it was a photo of the same syringe she saw on 2/1/14. During an interview with LN 2 on 3/7/14 at 3:30 p.m., LN 2 stated she removed a syringe from the over bed table in Resident 2's room on 2/1/14 and said it was a "hazard in the room." LN 2 confirmed the syringe was labeled as Enoxaparin (medication to help prevent blood clots). During an interview with LN 4 on 2/28/14 at 1 p.m., LN 4 confirmed she was responsible for medications in Resident 2's area on 2/1/14. LN 4 stated she had given an injection of Enoxaparin to another resident at around 9 a.m. on the same day. LN 4 stated the syringes were not labeled with the intended Resident's name, therefore, it was unknown whose syringe it was or how long it had been in Resident 2's room. LN 4 confirmed that a syringe cannot be taken out of a designated sharps container. The facility policy and procedure titled, "Disposal of contaminated Sharps", revised 3/22/11, indicated, "The facility shall discard contaminated sharps into designated containers. Contaminated sharps shall be discarded immediately or as soon as feasible into designated containers." 3. The facility policy and procedure titled, "Safe Patient Handling", last revised 11/12 indicated, "Staff would complete and document training of safe handling equipment and techniques initially during orientation, annually and as required." During an interview with the DON on 3/21/14 at 10:30 a.m., the DON said the facility has three Sara lifts and three Maxi lifts (equipment used to lift, transfer, reposition, and move residents). During an interview with CNA 4 and CNA 5 on 3/21/14 at 1:55 p.m., CNA 4 said, "had never been trained on the Sara lift or the Maxi lift." CNA 5 stated, there had been training with an old supervisor on the Sara lift but was never trained on the Maxi lift. During an interview with LN 3 on 3/21/14 at 4:55 p.m., LN 3 stated, "never received Sara or Maxi lift training at this facility, however, uses both resident lifts." During an interview with LN 4 on 3/21/14 at 5 p.m., LN 4 stated, "never been trained on either resident lift." During an interview with the director of staff development (DSD) on 3/21/14 at 3:36 p.m., the DSD stated, the facility had never offered yearly lift training to the CNAs. The DSD stated, she has never trained the licensed nurses how to safely use the resident lifts. During an interview with the DON on 3/21/14 at 4 p.m., the DON confirmed there is no annual training for use of the facility resident lifts.

Based on interview and record review the facility failed to ensure that one of five sampled residents (Resident 5) received adequate supervision and assistive devices to prevent accidents. Resident 5 was assessed upon admission as a high risk for falls, and a plan of care was developed. The facility failed to monitor and reevaluate the effectiveness of interventions and implement new interventions, consistent with the resident's needs, to protect the resident from harm and reduce hazards and risks of continued falls. In the past year (,[DATE]-,[DATE]) the resident fell eight times. On [DATE] Resident 5 fell in her room (fall #8) and sustained multiple injuries including; facial fractures, a subdural hematoma (an accumulation of blood beneath the dura, the outer membrane covering the brain) and a fractured spine. The resident expired on [DATE]. The physician's discharge [DIAGNOSES REDACTED]." Findings: Review of Resident 5's record, beginning on [DATE] at 10 a.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her medication regime included; Cymbalta (an antidepressant which can lower blood pressure), Digoxin (heart medication which can lower heart rate), Seroquel (an antipsychotic which can lower blood pressure or cause dizziness), and Ambien as needed (a sleeping aide which can cause drowsiness and ataxia- lack of muscle coordination). The most recent annual comprehensive nursing assessment, dated [DATE], identified the resident as having short term memory problems, requiring limited assistance of one staff member to transfer from bed to chair, walk in her room, dress, and use the toilet. During testing for balance, she was described as "needing partial support for balance" and "stands but does not follow directions for test." The resident used a walker for support while ambulating, was noted to have an unsteady gait, and had experienced one fall during the previous month. Her overall change in care needs compared to the previous 90 days was assessed as "Deteriorated - receives more support." A plan of care was developed upon admission (,[DATE]) for the resident's risk for falls. The resident's risk factors included a history of falls, declining mobility and balance, an unsteady gait, use of psychotropic medications, poor safety awareness, and the resident's behavior of not consistently requesting assistance as needed. Interventions included: instructing the resident to use hand rails and ambulatory assist devices to maintain balance, keep the area free of obstructions, monitor for fatigue and side effects of medications (drowsiness, loss of coordination, fatigue, mental slowness, confusion) and remind the resident to call for assistance before getting out of bed, before going to the toilet. A subsequent quarterly nursing assessment ((MDS) dated [DATE] identified the resident as independent, needing set up only to use the toilet, and the supervision of one staff to ambulate with a walker. Again, it was noted that the resident's balance was "not steady, but able to stabilize without human assistance." The plan of care, also dated ,[DATE], continued to identify the resident as a high risk for falls. The only additional intervention on the plan of care was "Assist to wear non-skid footwear that fits." A review of the facility's "Falls Protocol" on [DATE] revealed that a fall risk tool should be reviewed and updated quarterly, and when there has been a change (for example, when there has been a decline in ability or increased need for staff intervention), and after each fall. The "Protocol" further directs that the plan of care will be updated after each fall. According to Resident 5's record, and a list provided by the Administrator of the dates of falls, the resident experienced eight falls between [DATE] and [DATE]. 1. Resident 5 experienced a fall on [DATE]. There was no documentation to indicate a "Post Fall Assessment" was completed following the fall. A quarterly fall assessment done before the fall identified the resident as having "balance problem while standing and walking, and the resident's fall risk was scored at "10" identifying her as a high risk for falls. There was no documentation to indicate the plan of care for falls was reviewed, and the effectiveness of interventions evaluated, following the resident's fall. 2. Resident 5 experienced a second fall on [DATE]. There was no documentation to indicate a "Post Fall Assessment" was completed following the fall. A quarterly fall assessment of the resident was done on [DATE] after the resident's fall, but the assessment data was incomplete as there was no summary results (score of risk) documented. There was no documentation to indicate the resident's current plan of care for falls was modified or evaluated. There was no documentation to indicate the safety interventions in place were evaluated for effectiveness. 3. Resident 5 experienced a third fall on [DATE]. A "Post Fall Assessment" completed the same day stated that the resident fell in the hall while using her walker. This assessment identified the cause of the resident's fall as "Needed to void. Cognitive decline. Forgets to use call light." Under "changes/updates" the interventions that were already on the plan of care were listed, and added "Instruct to always call for assistance with transfer/ambulation (walking) esp. after resident took her sleeping pills for the night." However, these recommendations were not added to the resident's plan of care for implementation by staff, and there was no documentation to indicate an evaluation of the current safety interventions was completed, or that new interventions were developed. 4. Resident 5 experienced a fourth fall on [DATE]. A "Post Fall Assessment" dated the same date stated the resident fell "Ambulating while lifting her toilet seat." The fall assessment listed contributing factors as "Need to void. Rises unassisted. Increased agitation. Cognitive decline. Forgets to use call light. Misuse/lack of adaptive devise. Unsteady gait. Behavior symptoms." The area for Changes/Updates" was blank. There was no documentation to indicate the resident's current plan of care was evaluated or modified, or that new interventions were identified in an attempt to reduce the risk of harm and prevent the resident from additional falls. 5. Resident 5 fell two weeks later on [DATE]. There was no documentation to indicate a "Post Fall Assessment" was completed following the fall. A quarterly fall risk assessment dated [DATE] (two weeks after the fifth fall), scored the resident's fall risk as "18." (a score of 10 or more is assessed as a high risk). Documentation stated "Patient has been informed about fall risk assessment results and safety/prevention recommendations." Yet documentation under "notes" states "Very forgetful, need constant reminder to use walker in her room, she will walk around the room holding on to the furniture." On [DATE] the notation to "assist the resident to wear non-skid footwear that fits" was added to the plan of care. 6. Resident 5 experienced a sixth fall on [DATE]. A "Post Fall Assessment" dated the same date scored the resident's fall risk as "20." According to the nurses' note timed 6 a.m. the resident was found seated on the floor. She stated she was sitting on the edge of the bed and suddenly slid down to the floor. It was noted she was "Alert with periods of confusion and disorientation even prior to the fall." The documented contributing factors included "Need to void. Rises unassisted. Cognitive decline. Forgets to use call light." The recommended interventions included "Check positioning/seating. More frequent toileting. Put to bed." There was no documentation to indicate any changes were made to the resident's current plan of care following the fall, or that the current interventions were evaluated for effectiveness, as the resident continued to experience accidental falls. 7. On [DATE], approximately a month later Resident 5 fell again (#7). There was no documentation to indicate a "Post Fall Assessment" was completed. Documentation dated [DATE] on the plan of care stated "Assist to wear non-skid footwear that fits." Use of non skid footwear was an intervention that had been added to the plan of care three months earlier on [DATE]. There was no documentation in the record to indicate that the resident was assisted to obtain/ or provided with "non-skid footwear that fits." A fall risk assessment dated [DATE] indicated a score of "19", and it was noted that the "patient has been informed about fall risk assessment results and safety/fall prevention recommendations." A clinical (nursing) note dated [DATE] entered by the Director of Nursing (DON) at 2 p.m., stated "Resident called me in to discuss her problem regarding the floor being slippery and reason why she keeps on falling." The resident requested to have the room carpeted. The DON "did evaluate her shoes that need to have a non skid sole" and offered to look at a catalogue to see if there was anything the resident liked and that would fit her narrow foot. The DON gave her a pair of non-skid slippers, an intervention that was identified on the plan of care on [DATE], three and a half months earlier. 8. The following day ([DATE]) Resident 5 experienced her eight fall, and sustained significant injuries that required hospitalization . Nurses' notes dated [DATE] at 8:40 p.m. stated "Found resident at 15:20 (3:20 p.m.) on the floor outside the door bathroom half way sitting position with the face down, her eyeglasses on the floor with her lens broken, noted a hematoma (an accumulation of blood under the skin related to injury) lower right eyelid, laceration (cut) above right eyebrow, skin tear right shoulder, alert and able to verbalize. The resident was transferred to the acute hospital and treated for [REDACTED]. On [DATE] the resident was readmitted to the facility, with an order for [REDACTED]." The resident expired on [DATE], ten days after her fall. The physician's discharge summary dated [DATE] stated "Death secondary to fall with head injury." On [DATE] at 3:45 p.m. during an interview with the clinical coordinator, he stated, "She was independent. She used a walker and had unsteady gait." When asked if any alarm, such as tab alarm to alert staff when she got up from her chair or bed, was used, the coordinator stated, "No. Because she was so independent. Generally she was self sufficient. She was forgetful, but not total confusion. Most of the time she knew where she was." A concurrent review of the electronic and hard copy of the resident's record revealed no mention of a tab alarm or bed sensor alarm being used for the resident. The clinical coordinator added that the determination of the possible use of a tab alarm would be if the resident "had poor balance and was declining in condition. Or had a history of [REDACTED]. She did not, from what I found in the chart." When asked if the plan of care had been revised when current interventions were not effective in preventing additional falls, he said it had not been. He also added that she would have been a candidate for a tab and bed sensor alarm to alert staff when she got up and did not call for assistance. On [DATE] at 2 p.m., during an interview with the attending physician, he stated, " She had been declining over past two years. A big problem was with her balance. She had physical therapy to help with that. She had no acute change in her cognitive function in the month or so prior to the fall."