Every finding on record at San Francisco Health Care

Based on observation, interview and record review, the facility failed to ensure resident rights to privacy when Certified Nursing Assistant (CNA) 1 entered three resident rooms without knocking or announcing herself. These failures did not ensure residents' right to dignity and privacy.Findings: During an observation on 08/04/2026 from 11:23 AM to 11:29 AM, CNA 1 was seen entering three separate resident rooms (209, 211, and 213. All occupied) without knocking or announcing herself prior to entry. During an interview on 08/04/2026 at 11:32 AM with CNA 1, CNA 1 stated she had already introduced herself to the residents earlier in the morning and felt she did not need to knock or announce herself before entering resident rooms. During an interview on 08/05/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated her expectation was that all staff knock or announce themselves before entering a resident's room to ensure privacy and dignity. A review of the facility's policy titled Answering the Call Light, not dated, indicated staff are required to .knock before entrance into the .(resident's) room, identify yourself .

Based on observation, interview and record review, the facility failed to ensure Resident 1 received necessary care and services when Certified Nursing Assistant (CNA) 2 turned off Resident 1's shared call light three separate times without checking if Resident 1 required assistance. These failures did not ensure Resident 1's right to receive timely care, as Resident 1 stated she was in pain and wet from urine.Findings:Review of Resident 1's Minimum Data Set (MDS: a standardized resident assessment tool), dated 06/19/2026, indicated she had comprehension issues with communication and had long and short-term memory problems. Her preferred language was not English. She needed a translator to communicate with staff. Her vision was highly impaired. She was totally dependent on staff for toileting, toileting hygiene, and transfers. She was always incontinent of urine (lack of bladder control). She had multiple diagnoses including: kidney stones and left side flank pain (pain to the side of your lower back; area between the lower ribs and hip bone). During a concurrent observation and interview on 08/04/2026, between 10:44 AM to 10:50 AM, Resident 1 was in bed in her room with two family members present. A family member acted as a translator. Resident 1 stated she was in pain and wet. Permission was obtained from Resident 1 and her family member to activate her call light for assistance. CNA 2 came into the room. CNA 2 checked on Resident 1's roommate, turned off the shared call light (two call lights controlled by one switch) in Resident 1's room, did not interact with Resident 1 or her family, and left the room. Resident 1's call light was activated a second time with family's permission. CNA 2 came into the room a second time. CNA 2 checked on Resident 1's roommate, turned off the shared call light in Resident 1's room, did not interact with Resident 1 or her family, and left the room. Resident 1's call light was activated a third time. CNA 2 came into the room a third time and was checking on Resident 1's roommate. Resident 1's roommate was heard saying to CNA 2 she did not turn on the call light. On 08/04/2026 at 10:50 AM, CNA 2 was about to leave the room when she was stopped for an interview. CNA 2 was asked why she did not check on Resident 1 the last three times she was in the room. CNA 2 stated since Resident 1 had her family member and others in the room, she did not think Resident 1 needed assistance. CNA 2 was made aware Resident 1 stated she was in pain and needed assistance with toileting hygiene because she was wet. CNA 2 stated she will alert her nurse (Registered Nurse: RN 1). During an interview on 08/04/2026 at 10:52 AM with Registered Nurse (RN) 1, RN 1 stated Resident 1 had urinary issues and had a history of reporting pain to her pelvic area. RN 1 stated she just administered a pain medication to Resident 1 after being made aware that Resident 1 was in pain. During an interview on 08/04/2026 at 1:00 PM with the Administrator, the Administrator stated he was not aware some of his rooms had beds with shared call lights (two call lights controlled by one on/off switch). The Administrator stated he expected his staff to check both beds if they shared a call light switch. Review of a facility policy titled Answering the Call Light, not dated, indicated .Answer the resident call system at the earliest opportunity. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. There was no language within the policy directing staff to check residents with shared call light before turning of the call light.

Based on interview, and record review, the facility failed to ensure Resident 2 was free from physical restraints when Certified Nursing Assistant (CNA) 1 used a sheet to restrict Resident 2's movement. This failure had the likelihood to result in physical harm, pain, fear, and loss of autonomy for Resident 2. Additionally, this incident was not documented in Resident 2's electronic medical records. There was no documented evidence Resident 2's emergency contacts or her physician were notified of the incident. There was no documented evidence Resident was monitored and provided psychosocial care after the incident.Findings:During a review of Resident 2's medical records, dated 12/31/2025, Resident 2's Minimum Data Set (MDS= a standardized resident assessment tool) indicated Resident 2 was dependent on staff for toileting, required maximal assistance with personal hygiene, and required moderate assistance with transfers. Additionally Resident 2 was identified as having fallen since admission.During a review of Resident 2's medical records, dated 02/31/2026, Resident 2's Care Plan (care plan= a treatment plan to manage a resident's health) indicated Resident 2 was a fall risk and Resident 2 .needs 1:1 sitter.During a review of a facility document, dated 01/31/2026, titled REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE it indicated the Administrator .discovered that someone had used a folded sheet and wrapped it around the resident and through the back of the wheelchair. It was tied in a fashion around the back of the wheelchair to which the resident could not .(undo) or free herself from the chair.During an interview on 07/23/2026 at 3:32 PM with the Administrator, the Administrator stated the facility does not permit the use of bedsheets or other non approved materials to restrict a resident's movement. The Administrator stated CNA 1's action was not consistent with the facility's expectations or resident rights policies. The Administrator stated he substantiated the incident as abuse.During an interview on 07/29/2026 at 11:36 AM with CNA1's Supervisor, the Supervisor stated she interviewed CNA 1 after the incident. The Supervisor stated CNA 1 said it was a hard assignment and she could not keep an eye on Resident 2 while taking care of the other residents. The Supervisor stated CNA 1 said Resident 2 was very impulsive and wanted to self-transfer without assistance and the only way to keep her safe was to tie her up. During a concurrent interview and record review on 07/30/2026 at 11:00 AM with a Medical Record Staff (MRS), Resident 2's electronic medical records were reviewed for the restraint incident. After searching Resident 2's records, the MRS stated there was no evidence staff alerted the physician or Resident 2's emergency contacts regarding the incident. Additionally, there were no documentation from nursing services regarding the incident. There was no documented evidence the incident was addressed in Resident 2's care plans. During a review of the facility's policy titled ABUSE AND PREVENTION POLICIES & PROCEDURES, not dated, indicated . Residents must not be subjected to abuse by anyone, including but not limited to: facility staff. The Administrator is designated as the Abuse Prevention Coordinator for the facility. Such violations shall also be reported immediately to State agencies and other entities or individuals in accordance with or as may be required by existing State and Federal law.During an interview on 07/30/2026 at 11:40 AM the Director of Nursing was asked to provide the facility's policy regarding how nurses should monitor and document follow an unusual event such as an incident of abuse. The facility provided the following policy. The facility provided a policy titled Charting and Documentation, not dated, indicating . All incidents, accidents, or changes in the resident's condition must be recorded . shall include at a minimum: .The assessment; data and/or any unusual findings .Notification of family, physician. The policy failed to provide instructions on when and for how long a resident should be monitored after an unusual occurrence.

Based on interview and record review, the facility failed to re-admit Resident 1 after sending Resident 1 to a hospital for evaluation. This failure deprived Resident 1 of his right to return to the facility and resume necessary care and services identified in the resident's care plan.Findings:During a concurrent interview and record review on [DATE] at 11:30 AM with a Medical Record Staff (MRS), Resident 1's medical records were reviewed. Upon review, the MRS stated Resident was transferred to a hospital on [DATE] for evaluation due to a change in condition. The MRS stated Resident 1 was not re-admitted to the facility.During an interview on [DATE] at 12:49 PM with an admission Staff (AS), the AS stated Resident 1 was under hospice care prior to transfer to the hospital. When the hospital called to try to re-admit Resident 1, the AS said hospice would not take the resident back. The AS stated Resident 1 was a hospice patient and not a patient of the facility. Therefore, the facility did not re-admit Resident 1. The AS was asked to explain how Resident 1 converted to being a hospice patient and not a patient of the facility. The AS did not answer. The AS was asked if hospice was an ancillary service contracted and provided by the facility to residents under the facility's care and when under hospice, wasn't a hospice resident still contracted with the facility for 24- hour custodial care? The AS provided no explanation to indicate a hospice resident was no longer a resident of the facility. The AS provided no other explanation why Resident 1 was not re-admitted to the facility. The AS was asked if during the request for re-admission, were there appropriate beds available for Resident 1 and if there were none did the facility put Resident 1 on a wait list? The AS did not answer.During a review of Resident 1's medical record titled admission RECORD, RESIDENT INFORMATION, printed on [DATE], indicated there were three family members/emergency contacts for resident 1.During an interview on [DATE] at 3:55 PM with Resident 1's family member (FM 2), FM 1 stated the facility never contacted him regarding re-admission to the facility.During an interview on [DATE] at 3:59 PM with Resident 1's family member (FM 2), FM 2 stated the facility never contacted her regarding re-admission to the facility.During an interview on [DATE] at 4:01 PM with Resident 1's family member (FM 3), FM 3 stated the facility never contacted her regarding re-admission to the facility.Review of the facility's policy titled Bed-Holds and Returns, dated 2001, indicated .All residents/representatives are provided written information regarding the facility and state bed-hold policies, .residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source.Residents who seek to return to the facility within the bed-hold period defined in the state plan are allowed to return to their previous room, if available. Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room .

Based on observation, interview, and record review, the facility failed to inventory and secure personal properties for Residents 1, 2, 3, and 4. These failures resulted in missing properties for Residents 1 and 2 and inaccurate and/or missing inventory lists for Residents 3 and 4.Findings: During a concurrent inventory observation, interview, and record review with the Director of Nursing (DON) on 4/9/26 at 11:00 AM these issues were identified:The DON looked at Resident 3's medical records and stated Resident 3 was admitted on [DATE]. Observation/audit of Resident 3's inventory found one woman's housedress with a woman's name and room number on the inside of the dress under the collar.The DON looked at Resident 4's medical records and stated he was admitted on [DATE]. A search of Resident 4's electronic medical records found no inventory sheet and a search of his physical chart at the nursing station found no inventory sheet. Observation of Resident 4's room revealed he had: a long sleeve t-shirt, one sweatpants, one shirt, one pant, and one donated shirt labeled with Resident 4's room number.During the interview, the DON stated staff should inventory and document resident's belongings immediately upon admission and ensure items not belonging to residents be reported to facilitate return to original owner or donation. Review of Resident 1's medical records titled admission RECORD, printed on 4/10/26, indicated Resident 1 was admitted on [DATE] under hospice for comfort focused treatment (comfort care focused on quality of life rather than curing a terminal illness). Review of an Ambulance transport document (not titled), dated 10/7/25, indicated Resident 1 was transported with .belongings consisting of 1 bag with supplies, one cell phone, a wheelchair and one backpack. Review of Resident 1's medical records titled INVENTORY OF PERSONAL ITEMS, dated 10/7/25, indicated .No Belongings upon arrival I gave her clothes from donation. During an interview on 4/10/26 at 11:09 AM, Resident 1's responsible party (R1RP) stated she was in contact with the Administrator via phone and text regarding Resident 1's missing items such as cell phone, driver license, and debit card. R1RP stated she was quite alarmed regarding an abnormal financial issue going on while Resident 1 was staying at the facility. R1RP stated Resident 1 took $1,200 out of her account to give to a staff member to buy an airline ticket to Zimbabwe (a country in [NAME]). R1RP said Resident 1 has never been to [NAME] and does not know anyone in [NAME]. R1RP stated there were also abnormal issues going on after Resident 1 passed away on 12/17/25. Someone was making long distance calls from her cell phone after she passed away and there were withdrawals from her debit card after Resident 1 passed away. R1RP stated all this information was shared with the Administrator and she asked for help in investigating and retrieving Resident 1's cell phone, driver's license and debit card. R1RP stated to this day, the facility has not taken responsibility for safeguarding Resident 1's belongings. During an interview on 4/10/26 at 12:11PM, the Administrator stated he was aware of R1RP's requests and concerns. The Administrator stated he looked into the issue regarding Resident 1 transferring money to his Certified Nursing Assistant (CNA) 1 to purchase an airline ticket to Zimbabwe. The Administrator stated he has been an Administrator for 20-30 years and admitted these kind of interactions/relationships between resident and staff were highly unusual. The Administrator stated he looked into the matter, and found the money was refunded when Resident 1 was unable to take the trip. The Administrator stated he took no further action as there was nothing in the facility's handbook and/or policy specifically prohibiting this particular kind of interaction. The Administrator stated he was looking at revising policies after this incident. The Administrator stated the facility's admission inventory list for Resident 1 showed no belongings. The Administrator was made aware of ambulance transport documentation showing Resident 1 arrived with a cell phone and some belongings. The Administrator did not comment on this. The Administrator was made aware Resident 1's admission inventory documentation may not be accurate based on data gathered on the facility's current inventory system and safeguarding of belongings. The Administrator did not comment on this. The Administrator was asked if he expanded his sample to look at other residents under CNA 1's care? The Administrator stated No. The Administrator was asked if he documented all his investigation regarding R1RP's allegations? The Administrator stated some of the documentations were in emails but No he did not formally document the allegations and his investigation. Review of Resident 2's medical record titled MDS (Minimum Data Set, a standardized resident assessment tool), dated 1/4/26, indicated her BIMs (a 0-15 point test/assessment tool used to check a resident's memory and thinking abilities) score was 5 out of 15 (a score of 5 indicates severe problems with memory and thinking). Review of Resident 2's hospital discharge record titled D/C planning Ongoing Assessment, dated 9/27/24, indicated .Discharge To: Skilled nursing facility. (social worker) discussed with . (admission staff ) at San Francisco Health Care Center regarding .(Resident 2's) valuables. reported .(Resident 2) having $3600 in US dollars, a yellow necklace and bracelet, and two [NAME] pendants . (admission staff at San Francisco Health Care Center) documented and will put in safe place and return upon discharge. During an interview on 04/21/2026 at 1:55 PM, the Social Worker (SW) stated she was made aware of the missing money and jewelry by Resident 2's family member on March 17, 2026. The SW stated she started to investigate the case and based on Resident 2 arriving without any belongings from the hospital, the SW concluded the facility was not responsible for these missing items. The SW was asked if she was aware the hospital documented on 9/27/24 Resident 2 was to be discharged with $3,600 and jewelry. The hospital also documented they spoke with a facility admission staff (Admission) to lock these valuables for safe keeping. The SW said she interviewed the admission staff. The SW stated the admission staff said she did not remember the phone conversation with the hospital and does not remember if money and valuables were discussed with the hospital during Resident 2's discharge. The SW said during her investigation, the ombudsman translated for Resident 2 and Resident 2 stated upon arrival at the facility, she gave her money and jewelry to a Vietnamese man. The SW stated they did not have a Vietnamese man working at the facility during that time frame. The SW stated Resident 2 has never mentioned her money and jewelry since admission and this issue only came up when her family member asked about the money and jewelry. During an interview 4/9/26 at 3:30 PM with the Administrator, DON, and SW, issues with the facility's inventory system and safeguarding of resident's belongings were shared with the facility's management team. The following were discussed: There were issues identified with Residents 3 and 4 regarding their inventories (see above). This may indicate a recent problem or an ongoing systemic problem with the facility's inventory system and/or safeguarding of resident's belongingsThere was evidence CNA 1 was treating monetary transactions between him and Resident 1 as between two consenting adults. By bypassing management oversight, this creates an environment where the facility may not be able to safeguard belongings of vulnerable residents.There was an independent source (hospital staff) documenting Resident 2 was coming to the facility with money and jewelry. There was no documented evidence the facility followed up and investigated when Resident 2 arrived at the facility without her money and jewelry. The facility stated they were not aware of item 3 and will submit their investigation regarding item 3. The facility did not discuss or offered any new documentation regarding items 1 and 2. Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property. Providing measures to safeguard resident valuables from easy public access.Inventorying resident belongings upon admission .

Based on interview and record review, the facility failed to report allegations of misappropriation of personal properties for Residents 1 and 2 within 24 hours to the appropriate agencies. This failure did not ensure vulnerable residents were protected from misappropriation of personal properties. Findings: During an interview on 4/10/26 at 11:09 AM, Resident 1's responsible party (R1RP) stated she was in contact with the Administrator via phone and text regarding Resident 1's missing items such as cell phone, driver license, and debit card. R1RP sent evidence that she texted the Administrator on March 17, 2026 regarding these issues. During an interview on 4/10/26 at 12:11PM, the Administrator stated he was aware of R1RP's concerns thru phone calls and text messages but could not remember when he was first made aware of these allegations. When the Administrator was asked does March 17, 2026, sound about right? The Administrator answered sound about right. The Administrator was asked if he called this allegation in within 24 hours of learning about the allegation? The Administrator stated no. During an interview on 4/8/26 at 9:10 AM, the Complainant stated Resident 2 alleged she was missing approximately $3,000 and some jewelry. During an interview on 4/21/2026 at 1:55 PM, the Social Worker (SW) stated she was made aware of the missing money and jewelry by Resident 2's family member on March 17, 2026. Review of California Department of Public Health (CDPH) electronic data for facility reported incidents from March 17 to April 21 found no evidence the facility reported Resident 2's allegation to CDPH. Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property.Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incidents, as appropriate .

Based on interview and record review, the facility failed to investigate allegations of misappropriation of personal properties for Residents 1 and 2. This failure did not ensure the facility could uncover weaknesses within their system to safeguard personal properties or implement effective measures to prevent misappropriation of personal properties. Findings: Review of Resident 1's medical records titled admission RECORD, printed on 4/10/26, indicated Resident 1 was admitted on [DATE] under hospice for comfort focused treatment (comfort care focused on quality of life rather than curing a terminal illness). Review of an Ambulance transport document (not titled), dated 10/7/25, indicated Resident 1 was transported with .belongings consisting of 1 bag with supplies, one cell phone, a wheelchair and one backpack. Review of Resident 1's medical records titled INVENTORY OF PERSONAL ITEMS, dated 10/7/25, indicated .No Belongings upon arrival I gave her clothes from donation. During an interview on 4/10/26 at 11:09 AM, Resident 1's responsible party (R1RP) stated she was in contact with the Administrator via phone and text regarding Resident 1's missing items such as cell phone, driver license, and debit card. R1RP stated she was quite alarmed regarding an abnormal financial issue going on while Resident 1 was staying at the facility. R1RP stated Resident 1 took $1,200 out of her account to give to a staff member to buy an airline ticket to Zimbabwe (a country in [NAME]). R1RP said Resident 1 has never been to [NAME] and does not know anyone in [NAME]. R1RP stated there were also abnormal issues going on after Resident 1 passed away on 12/17/25. Someone was making long distance calls from her cell phone after she passed away and there were withdrawals from her debit card after Resident 1 passed away. R1RP stated all this information was shared with the Administrator and she asked for help in investigating and retrieving Resident 1's cell phone, driver's license and debit card. R1RP stated to this day, the facility has not taken responsibility for safeguarding Resident 1's belongings. During an interview on 4/10/26 at 12:11PM, the Administrator stated he was aware of R1RP's requests and concerns. The Administrator stated he looked into the issue regarding Resident 1 transferring money to his Certified Nursing Assistant (CNA) 1 to purchase an airline ticket to Zimbabwe. The Administrator stated he has been an Administrator for 20-30 years and admitted this kind of interaction/relationship between resident and staff was highly unusual. The Administrator stated he looked into the matter, and found the money was refunded when Resident 1 was unable to take the trip. The Administrator stated he took no further action as there was nothing in the facility's handbook and/or policy specifically prohibiting this particular kind of interaction. The Administrator stated he was looking at revising policies after this incident. The Administrator stated the facility's admission inventory list for Resident 1 showed no belongings. The Administrator was made aware of ambulance transport documentation showing Resident 1 arrived with a cell phone and some belongings. The Administrator did not comment on this. The Administrator was made aware Resident 1's admission inventory documentation may not be accurate based on data gathered on the facility's current inventory system and safeguarding of belongings. The Administrator did not comment on this. The Administrator was asked if he followed this precise sequence of action upon learning of this allegation. 1. Suspend CNA 1; 2. Report the allegation to the appropriate agencies; 3. Conduct and document a thorough investigation. The Administrator stated No. The Administrator stated he investigated immediately, found no merit to the allegations and closed the case. The Administrator was asked if he expanded his sample to look at other residents under CNA 1's care? The Administrator stated No. The Administrator was asked if he documented all his investigation regarding R1RP's allegations? The Administrator stated some of the documentations were in emails but No he did not formally document the allegations and his investigation. Review of Resident 2's medical record titled MDS (Minimum Data Set, a standardized resident assessment tool), dated 1/4/26, indicated her BIMs (a 0-15 point test/assessment tool used to check a resident's memory and thinking abilities) score was 5 out of 15 (a score of 5 indicates severe problems with memory and thinking). Review of Resident 2's hospital discharge record titled D/C planning Ongoing Assessment, dated 9/27/24, indicated .Discharge To: Skilled nursing facility. (social worker) discussed with . (admission staff ) at San Francisco Health Care Center regarding .(Resident 2's) valuables. reported .(Resident 2) having $3600 in US dollars, a yellow necklace and bracelet, and two [NAME] pendants . (admission staff at San Francisco Health Care Center) documented and will put in safe place and return upon discharge. During an interview on 04/21/2026 at 1:55 PM, the Social Worker (SW) stated she was made aware of the missing money and jewelry by Resident 2's family member on March 17, 2026. The SW stated she started to investigate the case and based on Resident 2 arriving without any belongings from the hospital, the SW concluded the facility was not responsible for these missing items. The SW was asked if she was aware the hospital documented on 9/27/24 Resident 2 was to be discharged with $3,600 and jewelry. The hospital also documented they spoke with a facility admission staff (Admission) to lock these valuables for safe keeping. The SW said she interviewed the admission staff. The SW stated the admission staff said she did not remember the phone conversation with the hospital and does not remember if money and valuables were discussed with the hospital during Resident 2's discharge. The SW said during her investigation, the ombudsman translated for Resident 2 and Resident 2 stated upon arrival at the facility, she gave her money and jewelry to a Vietnamese man. The SW stated they did not have a Vietnamese man working at the facility during that time frame. The SW stated Resident 2 has never mentioned her money and jewelry since admission and this issue only came up when her family member asked about the money and jewelry. During an interview 4/9/26 at 3:30 PM with the Administrator, DON, and SW, issues with the facility's inventory system and safeguarding of resident's belongings were shared with the facility's management team. The following were discussed: There was evidence CNA 1 was treating monetary transactions between him and Resident 1 as between two consenting adults. There was no documentation the investigation expanded the sample to look at residents under CNA 1's care. There was no documented evidence the investigation looked into what type of relationship CNA 1 had with Resident 1.There was an independent source (hospital staff) documenting Resident 2 was coming to the facility with money and jewelry. There was no documented evidence the facility followed up and investigated when Resident 2 arrived at the facility without her money and jewelry. After discussing these issues, the facility offered no other documents regarding these issues. Except to say they will be submitting their investigation and conclusion regarding Resident 2's issues. On 4/22/26, at 10:03 AM, the SW was asked to submit all raw data and her investigations and conclusions regarding Resident 2's allegations. Review of the untitled and undated documents sent by SW regarding Resident 2's allegations found these issues:There was no attempt to contact the transporting company regarding what item(s) Resident 2 brought from the hospital.The facility's conclusion was weighted heavily on Resident 2's statement she handed over her money and jewelry to a Vietnamese man upon admission. The investigator accepted this statement was from a resident with an assessed severe memory problem. Expansion of the sample may be necessary in this case instead of concluding all elements of Resident 2's statements were false. There was no evidence the facility expanded their sample to look at other residents' belongings surrounding the admission staff identified in Resident 2's allegation. Review of a facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, revise April 2017, indicated .Residents have the right to be free from theft and/or misappropriation of personal property. Providing measures to safeguard resident valuables from easy public access. The investigation shall consist of at least the following:An interview with any witnesses that may have knowledge of the missing items . interviews with staff members (on all shifts) having contact with the resident during the past 48 hours.interview with the resident's roommate, family members, and visitors.

Based on observation, interview, and record review, the facility failed to identify environmental hazards, implement interventions, and maintain assistive device (refers to any item including wheelchair and walker, that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety) in good working condition for two of 22 sampled residents (Resident 25 and Resident 73) when: 1. A fall mat was placed on the floor between Resident 25 in bed A and his roommate in bed B obstructing the path and safe passage. As a result, Resident 25 tripped, fell on to the floor and sustained a right hip fracture requiring surgical repair. Resident 25 was readmitted to the facility status post (s/p-a medical or clinical shorthand that refers to a state after an intervention) right hip hemiarthroplasty (a surgical procedure that replaces the femoral head (ball) of the right hip joint with an artificial implant). 2. A missing arm rest padding on Resident 73's wheelchair was not reported and replaced to ensure safe use. As a result, Resident 73 slid her right arm on the metal part of the wheelchair, hit her head on the window and sustained a large hematoma (a closed wound where blood collects and fills a space inside your body) on the forehead requiring two hospital transfers on two different occasions. Findings: 1. During the initial tour on 2/24/25 at 7:10 AM in resident's room, Resident 25 was sleeping in bed. A blue fall mat was observed on the floor, situated between the beds of Resident 25 (bed A) and his roommate (bed B). Review of Resident 25's admission record indicated, was readmitted to the facility on [DATE] with diagnosis including fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of right artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the right hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), difficulty walking, and unspecified fall. During an interview on 2/24/25 at 10:51 AM Resident 25 stated, he was recently hospitalized due to a fall that required him to undergo hip surgery. Resident 25 stated, he tripped on the [pointing to] fall mat between him and his roommate, fell and hit his right hip onto the floor. Resident 25 stated he's on non-weight bearing (NWB-a person should not put any weight on a specific limb, usually after an injury or surgery) on his lower extremities and has not been out of bed since he came back to the facility. Additionally, Resident stated he was not evaluated by a physical therapist (PT) and occupational therapist. Review of Resident 25's undated care plan titled, The resident is on high risk of fall and risk for the further multiple injuries related to following factors: Decline in functional status, Incontinence, Pacemakers (a small implantable device used to control an irregular heart rhythm), Unsteady Gait, Use cardiovascular meds/diuretics, Use of cane/walker/crutch, indicated interventions including Assess cause, pattern of falls, and activities .Keep environment free from obstruction . Review of Resident 25's 3-Morse Fall Scale (a tool used to assess a patient's risk of falling), dated 1/12/25, indicated, Resident 25 had a high risk for falls. Review of Resident 25's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment, dated 1/19/25, indicated, no cognitive impairment. Under the functional abilities and goals of MDS assessment indicated, Resident 25 required supervision with transfer and moderate assistance with ambulation using a walker. Review of Resident 25's Change in Condition Evaluation, dated 2/15/25, indicated, CNA (Certified Nursing Assistant) .finding resident on floor of resident room on bottom. Resident alert and oriented x4 (refers to someone who is alert and oriented to person, place, time and event). Resident verbalized he landed on his right hip, did not head strike .bruise forming on right hip . Resident feels soreness on right hip. When getting resident back to bed, his legs buckled and was unable to walk. MDs (Medical Doctor) notified .Waiting for order from MD for x-ray for hip. Review of Resident 25's Licensed Nurse's Notes, dated 2/15/25, indicated, .Resident endorses 10/10 pain (a pain scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable) when moving, 4/10 still. Pain, sharp localized to hip, bruise is forming. MDs notified . Sending to [Name of acute hospital] to rule out fracture . Review of Resident 25's Plan of Care Note, dated 2/15/2025, indicated, Late Entry Note Text: Contact by our team regarding a recent fall, landed on right hip now having severe pain over right hip. Unable to move extremity . Orders placed to send out for further trauma evaluation and hip fx. (fracture) . # Mechanical ground level fall .we will start PT (physical therapy) / OT (occupational therapy) . Review of Resident 25's Post Fall Assessment, dated 2/15/25, indicated, Resident 25 was getting out of bed and tripping under his feet. Review of Resident 25's General Acute Care Hospital (GACH) Discharge Summary, dated 2/19/25, indicated, Resident 25 was brought in for right hip pain with obvious deformity s/p GLF (ground level fall) and was taken to the operating room on 2/16/25 for right hip hemiarthroplasty. The Discharge Summary indicated, a discharge diagnosis of femoral neck fracture (a break in the bone [femur] that connects the hip joint [acetabulum] to the upper thigh [femoral head]) and requires SNF (skilled nursing facility) for rehab . Further review of the Discharge Summary dated 2/19/25, indicated, .#R FNF (right femoral neck fracture) s/p R hemi .WBAT (weight bearing as tolerated) RLE (right lower extremity), posterior hip precautions .discharge back to SNF for PT . Review of Resident 25's Plan of Care Note, dated 2/19/2025, indicated, Late Entry Note Text: Patient is back from the hospital status post arthroplasty for right femoral neck . # Mechanical ground level fall .-we will start PT/OT . During a concurrent interview and record review on 2/26/25 at 10:02 AM with Registered Nurse Supervisor (RNS), Resident 25's Order Summary Report was reviewed. The Order Summary Report did not indicate Resident 25 has an order for WBAT and PT referral. The RNS stated there was no documentation that an order was carried for WBAT and PT referral. Furthermore, RNS was unable to find documentation that an IDT (interdisciplinary team) meeting occurred to discuss and assess the cause of the fall and update Resident 25's plan of care related to the recent fall and right femoral fracture. RNS stated, I could not see a care plan for fracture. Additionally, RNS stated that Resident 25 had been in bed since readmitted to the facility. 2. Review of Resident 73's admission record indicated, was admitted to the facility on [DATE] with diagnosis including COVID-19 (Coronavirus disease 2019-is an infectious disease caused by the SARS-CoV-2 virus), Parkinson's disease (a progressive movement disorder of the nervous system) without dyskinesia (involuntary and uncontrolled movements, is a common side effect of Parkinson's medications), dementia (a progressive state of decline in mental abilities) without behavioral disturbance, and muscle weakness. Review of Resident 73's MDS assessment dated [DATE], under staff assessment for mental status indicated, memory problem and severely impaired cognitive skills for daily decision making. Under the functional abilities and goals of the MDS assessment indicated, Resident 73 has impaired upper and lower extremities, a manual wheelchair, and is totally dependent to staff with activities of daily living (ADL-routine tasks/activities), and wheelchair for mobility. During the initial tour on 2/24/25 at 6:54 AM, in Resident 73's room, Resident 73 was in bed asleep. Observed a fading yellow/green discoloration on Resident 73's right eye and side of the forehead. During a phone interview on 02/25/25 at 11:10 AM, Family Member 1 stated, he was notified on 1/5/25 that Resident 73 fell and hit her head on the windowsill. The son stated, Resident 73 had a bruise and swelling on the right side of the forehead. The son also stated that the swelling subsided, but the bruising is still present. Furthermore, the son stated Resident 73 might have slipped from the arm rest of her wheelchair that had a missing padding. Review of Resident 73's Change in Condition Evaluation, dated 1/5/25, indicated, At 11:50 AM, the CNA reported a forehead bruise on the patient. The nurse assessed a hematoma, redness, and scratches on both hands, with no other injuries or signs of shock . Physician ordered ice packs and ED (emergency department) transfer. Family was notified, and [Name] Ambulance transported the patient at 12:40 PM. At 6:20 PM, the patient returned after a CT scan (A computed tomography scan, formerly called computed axial tomography scan, is a medical imaging technique used to obtain detailed internal images of the body) (results pending). The hematoma had enlarged, partially covering the right eye . During a concurrent interview and record review on 2/27/25 at 2:09 PM with Licensed Vocational Nurse (LVN) 1, Resident 73's clinical record was reviewed. The clinical record did not indicate Resident 73 had a fall on 1/5/25. LVN 1 stated, No fall incident this year. Change in Condition on 1/5/25 did not indicate fall incident. Review of Resident 73's fall assessment dated [DATE], indicated, high risk for fall. LVN reviewed all change in condition and progress notes including IDT meeting notes and was not able to find any documentation pertaining to a fall incident. LVN 1 stated, No notes regarding fall. I don't see it in the progress note. During an interview on 2/27/25 at 2:27 PM, Certified Nursing Assistant (CNA) 1 stated, Resident 73 did not have a fall on 1/5/25. CNA 1 stated, he left Resident 73, who was sitting on her wheelchair by the window, to get her lunch tray that was just outside the resident's room. But when CNA 1 came back with the lunch tray, he found Resident 73 leaning on her right side to the wall by the window. CNA 1 stated, he noticed there was no padding on the right arm rest of the wheelchair exposing the metal part. CNA 1 stated, Resident 73 slid her arm on the metal part of the right arm rest. CNA 1 further stated, he did not notice there was no padding on the arm rest when he transferred Resident 73 to the wheelchair. During further interview, CNA 1 stated, Resident 73 had a bump and red discoloration on the forehead and was transferred to the hospital via 911 for further evaluation and treatment. CNA 1 stated, Resident 73 came back in the evening with bluish/blackish discoloration on the forehead. Review of Resident 73's CT scan result dated 1/5/25, indicated, .fall with hematoma right eyebrow, r/o (rule out) ICH (intracerebral hemorrhage) . Impression: Large right periorbital soft tissue hematoma. No intraorbital (situated or occurring within the orbit, the bony cavity that contains the eyeball) hematoma, underlying fracture, or acute intracranial abnormality . Review of Resident 73's Plan of Care Note, dated 1/6/25, indicated, Patient is seen and examined, discussed in IDT meeting. Patient had a recent fall with headstrike, evaluated by [VDA-Vascular Disrupting Agents] and cleared from trauma standpoint. We will order labs in 2 to 3 days to monitor patient's duration status . Review of Resident 73's Licensed Nurse's Notes, dated 1/6/25, indicated, COC (change of condition) 1/3 R (right) side of head hit the edge of the window and sustained hematoma, swelling on the R side of forehead and around the R eye . Review of Resident 73's IDT Post Fall Notes, dated 1/12/25, indicated, Noted Text: **IDT Note for unwitnessed Fall on 1/5/2025 .At approximately 11:50 AM, the assigned CNA reported to the on-duty nurse that the patient had a bruise on the forehead while seated in a wheelchair. the on-duty nurse promptly assessed the patient and noted a large hematoma and bruise on the right side of the forehead, minor redness and scratches on the back of both hands, but no other injuries .Noted some forehead frowning upon touching the hematoma with no verbalization of pain. The nurse notified the physician, who ordered intermittent application of ice packs to the forehead and recommended transferring the patient to ED for further evaluation . Ambulance arrived at around 12:40 pm and transferred out to [Name of GACH]. At 6:20 PM, the patient returned after a CT scan with hematoma had enlarged, partially covering the right eye . RECOMMENDATION/IDT .a safety plan was established, including placing bilateral mattress next to the bed .low bed is positioned. Closed monitoring of the forehead hematoma for healing and possible complications . documenting all actions, and communications in the resident's medical record. Updating the care plan to incorporate enhanced fall precautions . Review of Resident 73's Change in Condition Evaluation, dated 1/22/25, indicated, Np. (Nurse Practitioner) [Name] and this writer noticed that pt's hematoma on right periorbital (area around the eye socket) is boggy (efers to abnormal texture of tissues characterized by sponginess, usually because of high fluid content), darker purple color and more swollen compared to last week. Informed MD with results of CT scan at [Name of GACH] on 1/5/25. MD said monitor for now .Skin changes: skin scratches and hematoma with bruise . Review of Resident 73's Transfer to Hospital Summary, dated 1/22/25, indicated, Resident has been experiencing a hematoma on right lateral forehead since 1/5. NP [Name] was seen resident today and noted hematoma was previously though to be resolving, but then the sudden increase in swelling and color change is concerning for a potential deeper issue, such as clotting or bleeding. The resident exhibited facial grimacing when the hematoma was touched, indicating discomfort or pain .As per MD's orders, the resident was sent to [Name of GACH] .for further evaluation . Review of Resident 73's undated care plan titled, Altered skin integrity RT patient accidently head trauma while sitting on wheelchair as evidenced by Skin hematoma and bruise noted on the right forehead, minor skin scratches on the back of both hands on [1/5/25]. hematoma on her right periorbital is boggy, darker purple color and more swollen compared to last week on 1/22/25, indicated the following interventions: - Patient will be sent out to the hospital for further evaluation and treatment. - Skin hematoma will be free from s/s of pain, swelling, and skin breakdown thru next review. - Gentle handling during ADL care. - Have resident wear long sleeves clothes as the weather permits. - Head to toe assessment, neurological and pain assessment with no concerning manifestations. - Ice pads applied intermittently on forehead. - Inform responsible party (son) for presence of skin hematoma. - Notify MD for presence of skin hematoma. - Observe skin hematoma for s/s of pain, swelling, and skin breakdown. - Pt returned back form hospital at 18.20 pm with pending result for CT scan. - Safety measures are rendered including lower bed level, floor [NAME] next to the bed to safeguard against any further inadvertent injury. - Transfer out to Ed for further evaluation per MD order. - Use palm of the hand when holding and turning resident during care. - Use two-person assist for transfers and positioning as indicated. During an interview on 2/28/25 at 8:49 AM, RNS stated, she never heard or not aware of the missing arm rest padding for Resident 73. RNS stated, anything broken should be taken out immediately from the floor and should not be used. RNS also stated that it should be reported to the maintenance and have it fixed or replaced. Review of the facility's Daily Maintenance Request Log, dated 12/9/24 through 2/25/25, indicated, no documentation of Resident 73's missing arm rest padding was reported. During an interview on 2/28/25, at 1:05 PM, Nursing Home Administrator (NHA) stated, they reviewed the Daily Maintenance Request Log and could not find any reports or documentation regarding the broken wheelchair that caused Resident 73's injury. Review of the facility's policy and procedure titled, [Name of Facility] Falls - Clinical Protocol, revised 7/9/19, indicated, Assessment and Recognition - 1. As part of the initial assessment, Interdisciplinary Team and the physician will help identify individuals with a history of falls and risk factors for subsequent falling . 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk . Cause Identification - 1. For an individual who has fallen, staff will attempt to define possible causes within 24 to 48 hours of the fall . c. When necessary, Licensed Staff or Interdisciplinary Team (IDT) will refer the resident to other disciplines such Rehabilitation Department .to rule out possible causes of fall . 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified . Treatment/Management - 1. Based on the preceding assessment, the staff or IDT and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . Review of the facility's policy and procedure titled, Work Orders, Maintenance, revised April 2010, indicated, Maintenance work orders shall be completed in order to establish a priority of maintenance service . 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the maintenance director.

Based on observation, interview, and record review, for Residents 3, one of two residents with weight loss out of a total sample of 22 residents, the facility did not: 1. Provide 1:1 assistance/support during meals as ordered by the physician. 2. Monitor percentage of supplement eaten. 3. Offered alternatives/other interventions during poor meal intake. 4. Implement a meal monitoring system that could distinguish between 0-25% intake for residents at risk for poor intake. 5. Use meal intake data to investigate refusals, assess food preferences, and/or identify other issues. 6. Assess for food preferences. This resulted in a 24.4% weight loss for Resident 3 within a six months period. Findings: Review of Resident 3's medical record titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 02/07/2025, indicated she sometimes understood others and had long and short-term memory problems. Her MDS indicated there were no rejection of care. Review of Resident 3's records titled Progress Notes, dated 02/18/2025, indicated . (responsible party) .re-confirmed .NO ARTIFICIAL MEANS OF NUTRITION, INCLUDING FEEDING TUBES. Review of Resident 3's MDS, dated [DATE] indicated her weight was 98 pounds. Review of Resident 3's MDS, dated [DATE] indicated her weight was 74 pounds. This was a 24 pounds weight loss or a 24.4 % weight loss. Review of Resident 3's records titled Nutrition Therapy (initial Assessment), dated 07/23/2024, indicated .Presents with severe .(weight) loss of 32 .(pounds) 24.6% x 3 months. BMI (Body mass index: used to determine a healthy body weight in relation to a specific height) at underweight status . protein . malnutrition . Remains on (nutritional) shake . Will follow .(plan of care) and monitor closely .Goal: maintain or gradual .(weight) gain, . (increase intake to greater than) 75%. Review of Resident 3's records titled Order Summary Report (physician orders), printed on 02/25/2025, indicated Resident 3 was to have Ensure Clear (a fat-free, fruit-flavored nutrition drink containing high-quality protein and essential nutrients ) two times a day for weight loss. During a concurrent interview and electronic record review with the RD (Registered Dietitian) on 02/25/2025 at 12:23 PM, the RD was asked to show how supplement intakes were documented in Resident 3's electronic records. The RD navigated to the supplement section in Resident 3's records. On the screen, there were check marks indicating when supplements were provided. The RD was asked if there were documentation of percentage of supplement consumed by Resident 3. The RD said she was not sure. The RD said she will look through Resident 3's records and provide the information if it was available. The RD agreed it would be difficult to objectively evaluate effective nutritional interventions if percentage supplement intakes were not documented. An email was sent on 02/25/2025 at 1:42 PM to the RD, DON (Director of Nursing) and MDS Coordinator requesting percentage of supplement consumed by Resident 3 in the last 30 days. As of exit on 02/28/2025, the requested document was not provided. Review of Resident 3's records titled Order Summary Report (physician orders), printed on 02/25/2025, indicated Resident 3 was to have Feeding Assistance: 1:1 with meals for assist with eating/feeding. During lunch observation on 02/24/2025 at 11:50 AM, a staff member brought Resident 3's lunch tray into her room and set up her tray for her. At 12:15 PM, Resident 3's lunch tray was removed and placed in a metal tray container. During an interview with Certified Nursing Assistant (CNA) 1on 02/24/2025 at 12:30 PM, he stated Resident 3 has a poor appetite and usually only eat around 20% of her meals. CNA 1 stated he provided set up only and did not assist Resident 3 with her meals because she could feed herself. During lunch observation on 02/26/2025 at 11:48 AM, a staff member brought Resident 3's lunch tray into her room and set up her tray for her. During intermittent observations at 12:05 PM and at 12:08 PM, no staff went into Resident 3's room to check in on her or to assist her. At 12:14 PM, Resident 3's tray was taken away and placed in a metal tray container. During an interview on 02/26/2025 at 12:19 PM CNA 1 stated he was the one who removed Resident 3's tray and he stated she ate her usual amount of 20%. CNA 1 was asked if he attempted to offer her any alternatives or assistance/support to increase her intake. CNA 1 stated no and added Unfortunately, I cannot communicate with her. She's Chinese speaking. Review of the facility's policy titled Offering Alternatives and Encouraging Intake Meals Policy, dated July 1, 2024, indicated .If a patient consumes less than 25% of their meal, nursing and dietary staff must intervene by offering nutritional alternatives, providing additional support, and encouraging intake to prevent malnutrition and weight loss. Review of Resident 3's records titled What percentage of the meal was eaten?, dated 01/27/2025 to 02/25/2025, indicated there were four main columns for staff to assess percentage of meal eaten: 0-25%, 26-50%, 51-75%, 76-100%. During an interview on 02/28/2025 at 9:37 AM, the Director of Nursing (DON) agreed their current method of meal percentage monitoring was not able to determine if a resident ate 0% or 20% or 25%. The DON agreed the ability to distinguish between these low intakes was critical to determine if staff should intervene and offer alternatives and/or assistance/support. The DON stated she expected her staff to intervene if a resident was experiencing inadequate intake during meals. The DON agreed . It makes sense to intervene even if a resident was on comfort measures or requested no aggressive nutritional interventions because residents are not static medically/psychologically and may change their mind at any time. There was no documented evidence the facility was using the meal percent monitoring as a tool to assess food preferences. For example, review of Resident 3's records titled What percentage of the meal was eaten?, dated 01/27/2025 to 02/25/2025, indicated she ate 51-100% of her food for 21 out of 87 meals (24%). For these meals there were no documented evidence staff analyzed if her higher intakes were correlated to specific food preferences. Additionally, review of the same document indicated for 41 out of 87 meals (47.1%), Resident 3 ate between 0-25%. There was no documented evidence these meals were assessed to see if they were related to things the kitchen could control (menu items, temperature, timing etc.) or related to other issues. During an interview on 02/25/2025 at 12:30 PM, the Registered Dietitian (RD) was asked to provide documented evidence the facility assessed Resident 3 for food preferences. The RD stated Resident 3 was unable to respond due to impaired thinking/reasoning and memory problems. The RD was asked to provide documented evidence the facility reached out to Resident 3's responsible parties and/or family members prior to 02/25/2025 to help with food preference assessment. The facility was unable to provide the requested documents. Review of Resident 3's records titled Care Plan Report, printed on 02/26/2025, indicated staff should .ENCOURAGE (Resident 3) TO EAT AT LEAST 75% OF MEALS.OFFER SUBSTITUTES FOR REFUSED FOODS/FLUID .Promote good .intake (eating by mouth).

Medication Error rate- 25.9% Based on observation, interviews and record review, the facility had a medication error rate of 25.9% when seven medication errors occurred out of 27 opportunities during the medication administration for four of seven residents (Residents 256, 72, 63 and 17). The failure had the potential to result in residents not receiving full therapeutic effects or causing side effects for the residents. FINDINGS: 1. During the medication administration observation on 2/24/25 at 8:03 AM, for Resident 17, Registered Nurse (RN) 3 was observed preparing and administering four oral medications. RN 3 crushed all 4 tablets, poured them in a medication cup, mixed with applesauce and administered to patient. Patient took the medication with applesauce. Per RN 3, patient takes medications with no problem. Review of Resident 17's Admission Record, admitted 0n 3/15/24 with diagnoses including: Dementia (memory loss) and Failure to Thrive (a decline characterized by weight loss, decreased appetite, poor nutrition, and inactivity). Review of Order Summary Report, dated 2/27/25, indicated, May crush medications or open capsules as indicated per pharmacy protocol. 2. Review of Resident 256's Admission Record, admitted on [DATE] with diagnoses including: Cerebral Infarction (a condition where blood flow to the brain is interrupted causing brain tissue to die), Dysphagia( difficulty swallowing), Gastrostomy Status( where a thin flexible tube is inserted through the abdominal wall and into the stomach for feeding). Review of Order Summary Report for Resident 256, dated 2/28/25, indicated, Enteral Feed order every shift Diabetic Source feeding @ 90 ml/hr start at 1 pm stop at 9 am. May crush medications and open capsules as indicated per pharmacy protocol to give via GT. During the medication administration observation on 2/24/25 at 8:30 AM, for Resident 256, RN 3 was observed preparing 6 tablets for Gastrostomy administration. RN 3 crushed all 6 tablets and poured them into a cup of water. After GT placement check, RN 3, poured the mixed tablets with water into the syringe. RN 3 then flushed the tube with a cup of water. RN3 proceeded with giving a liquid antibiotic per GT. RN3 stated it takes a while to dilute the tablets, needs a little push at times. 3. During the medication administration observation on 2/25/25 at 11:30 AM for Resident 63, RN 3 stated, the PCC (Point Click Care - an electronic health record program ) is down but I know his medication, will check the MAR(medication administration record) later. RN 3 was observed getting the eyedrop, Artificial Tears and 2 tissues, prepared and explained to the patient, dropped one dop to right eye, then wiped with tissue. Then dropped one drop to left eye and wiped the left eye. Review of Order Summary Report for Resident 63, dated 2/28/25, indicated, Artificial Tears, Instill 2 drops to left eye every 4 hours for dry eyes. Review of facility Policy and Procedure, Medication Administration-Preparation and General Guidelines, dated 6/15, indicated, B. Administration, 2. Medications are administered in accordance with written orders of the prescriber. A. Preparation, 5. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medications, the medication and dosage schedule on the resident's MAR are compared with the medication label. 4. A review of Resident 72's Admission Record, indicated, admitted on [DATE] with diagnoses including: Organ-Limited Amyloidosis (abnormal protein deposits that can build up in organs and tissues causing damage and disease), Paroxysmal Atrial Fibrillation ( a kind of irregular heartbeat that occurs intermittently and stops on its own.) During a concurrent observation and interview on 2/24/25 at 9:00 AM, with RN 3, for medication administration for resident 72, RN 3 stated, Resident 72 has an order for Vyndaquel (a medication to delay nerve damage caused by abnormal protein deposits in organs and tissues) 20 mg 4 capsules every day. RN 3 pulled out the box and stated, medication is not available, has been reordered. Last given on 2/19/25. This medication is not available in our Automatic Dispensing Unit (ADU - a computerized system used in healthcare settings to store, dispense, and track medications). During an initial interview on 2/24/25 at 7:00 AM, with Resident 72, Resident 72 stated he has not been given his cardiac medication, Vyndaquel 20 mg since last week. During an interview on 2/24/25 at 9:00 AM, with RN 3, RN 3 stated the medication was reordered; the pharmacy was notified but needed the Attending physician to order. MD gave order and was faxed to pharmacy but the pharmacy stated [the medication was] not available. No progress notes found on this issue. Review of Order Summary Report dated, 2/26/25, indicated, Tafamidis Meglumine (Cardiac - a medication used to treat cardiac amyloidosis - a rare condition caused by abnormal protein deposits in the heart) oral capsule 20 mg. Give 4 capsules by mouth one time a day for cardiac amyloidosis, start date 1/7/25. Review of MAR for February 2025, indicated, Tafamidis Meglumine Cardiac, on 2/20/25 to 2/25/25, code 9 = Other/see progress notes initialed by nurses. A review of progress notes did not indicated what code 9 meant. On 2/25/25, indicated Tamafidis is not available . Review of facility progress notes, by MD, dated 2/17/25,Follow ups: if additional 30 days supply of Tafamidis not delivered on 1/8/25, call [Hospital] Specialty Pharmacy at XXX-XXX-XXXX. Review of facility Policy and Procedure, medication Administration- General Guidelines, dated 6/15, indicates: D. Documentation (including electronic) 6.If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on reverse side of record. If a vital medication is not available, the physician is notified. Nursing documents the notification and physician response.

Based on observation, interview and record review the facility failed to prepare, store, and serve food in a sanitary manner when these were observed in the kitchen and other areas: 1. One of the icemaker's dispensing spouts was dripping water. 2. The ice maker had two water filters and one of the water filters was not replaced. 3. The bottom of the kitchen hood was covered in a film of a greasy-looking substance. These failures had the potential to result in putting residents at risk for food borne illnesses. Findings: During initial kitchen observation on 02/24/2025 at 6:21 AM with Dietary Aide (DA), the following were observed and confirmed with the DA: 1. One of the icemaker's dispensing spouts was dripping water. 2. The icemaker had two water filters and one of the water filters was not replaced. 3. The bottom of the kitchen hood was covered in a film of a greasy-looking substance. The film was heavy enough there were at least 30+ spots on the hood where the substance were lumped into early droplets and ready to drip down. During an interview on 02/26/2025 at 9:52 AM with the Maintenance Manager (MM). the MM stated he changed both water filters for the kitchen's icemaker back in December 2024. Since there were no dates on the water filters, the facility was asked to provide documented evidence the water filters were changed back in December 2024. A review of the facility records titled Details for Order ., dated 12/11/2024, indicated one water filter was purchased for the icemaker. There was no evidence the second water filter was purchased and/or replaced back in December 2024. On 02/24/2025 at 10:58 AM, the Administrator (NHA) , the Director of Nursing (DON) and the Registered Dietitian (RD) were asked to provide their policies regarding icemaker water filter replacement, and maintenance of the icemaker regarding drips. On 02/26/2025 at 10:15 AM, the RD stated the facility do not have the requested policies. A review of the facility's policy titled HOODS, FILTERS, AND VENTS, dated 2023, indicated .Hoods must be cleaned every two weeks and must be free of dust and grease.

Based on observation, interview and record review the facility failed to dispose of kitchen refuse properly when two garbage containers within the kitchen did not have lids. This failure had the potential to result in flying insects contaminating food items, food prep areas and utensils. Findings: During initial kitchen observation on 02/24/2025 at 6:21 AM with Dietary Aide (DA), two garbage containers without lids were found in the kitchen and these observations confirmed with the DA. During an interview on 02/24/2025 at 10:57AM with the Registered Dietacian (RD), the RD agreed that there should be lids on all garbage containers in the kitchen. Review of the facility's policy titled MISCELLANEOUS AREAS GARBAGE AND TRASH, dated 2023, indicted .Adequate, clean, . areas must be provided for storage of garbage .All food wasted must be placed in a sealed leak-proof, non-absorbent, tightly closed containers .

Based on observation, interview, and record review, the facility failed to implement its infection control program when enhanced barrier precautions (EBP) was not followed for four of 11 residents (Resident 62, Resident 204, Resident 25, Resident 256) with indwelling medical devices. This failure has the potential to result in cross contamination of infection which may jeopardize the health and safety of the residents and staff. Definition: Enhanced Barrier Precautions (EBP) - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Indwelling medical devices - refers to a device that is inserted into the body and remains there for a period of time, such as central lines, urinary catheters, and feeding tubes. Additionally, there was no signage posted and personal protective equipment (PPE) cart set up by the resident's care area. Findings: 1. Review of Resident 62's admission record indicated, Resident 62 was admitted on [DATE] with diagnoses including stroke, heart failure, diabetes mellitus (high blood sugar), and gastrostomy status (presence of an artificial opening in the stomach (gastrostomy) used for nutritional support or gastric decompression - removing gas and fluid from the stomach), During an observation on 2/24/25 at 6:56 AM in Resident 62's room, Resident 62 was in bed asleep and was receiving enteral (a thin flexible tube inserted through the gastrointestinal tract for nutrition) feeding via an automated feeding pump. During further observation, an opened, unlabeled, and undated irrigation syringe (a medical device used to flush fluids or medications into specific areas of the body) inside its plastic packaging was hanging on the feeding pump pole. During an interview on 2/24/25 at 7:03 AM with Registered Nurse (RN) 2, RN 2 stated, the irrigation syringe should be dated and labeled with resident's name once opened. During further interview, RN 2 stated, Resident 62 is not on any precautions. Review of Resident 62's undated care plan indicated, infection control precaution was not addressed in the care plan. 2. Review of Resident 25's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of right artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the right hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), and neuromuscular dysfunction of bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). During an observation on 2/24/25 at 7:10 AM in resident's room, Resident 25 was in bed asleep. A partially filled urinary catheter drainage bag was observed hanging on the lowered partial side rail by the left side of the foot of the bed exposing its contents. The urinary catheter drainage bag had no cover and a reddish-brown discoloration on the front of the bag was observed. The drainage bag was unlabeled and undated. A reddish-brown fluid was also observed in the tube attached to the urinary catheter drainage bag. During a concurrent observation and interview on 2/24/27 at 7:18 AM with Certified Nursing Assistant (CNA) 3, CNA 3 acknowledged Resident 25's urinary catheter drainage bag was uncovered, undated, and unlabeled. CNA 3 stated, there was no date on the drainage bag and should have been placed inside a dignity bag. During an interview on 2/26/25 at 1:43 PM, RN 1 stated she follows contact precaution (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) when changing the dressing for Resident 25's suprapubic catheter (a medical device that drains urine from the bladder directly through the abdominal wall). Review of Resident 25's undated care plan titled, Resident has an suprapubic catheter DUE TO: Overactive urinary bladder/spasms. At risk for UTI Bleeding due to trauma to perennial area Urinary meatus or other parts of the genital area, indicated, infection control precaution was not addressed in the care plan. 3. Review of Resident 204's admission record indicated, was admitted on [DATE] with diagnoses including heart failure, acquired absence of left leg below knee, kidney disease, and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so). During an observation and interview on 2/24/25 at 7:41 AM in resident's room, with Resident 204, Resident 204 was awake, still lying in bed. Resident 204 stated he has a catheter on his right upper chest used for dialysis. During an interview on 2/24/25 at 8:42 AM, Registered Nurse Supervisor (RNS) stated, Resident 204 has a central venous catheter (CVC - a tube inserted into a major vein in the chest, neck, or groin for emergency dialysis or temporary access) on his right upper chest for his dialysis. RNS also stated that no special precautions are followed for Resident 204's care. Review of Resident 204's Order Summary Report indicated, an order date of 2/22/25 for Daily Dialysis access site care: The patient has -CVA (Central Venous Access)- Assess for bleeding or infection every shift. Review of Resident 204's undated care plans indicated, CVA site care and infection control precautions were not addressed in the care plan. During the initial tour on 2/24/25 at 6:30 AM to 7:41 AM, there were no residents observed to be on EBP. Additionally, there were no signs posted and PPE cart set up near the resident care area or outside the resident's room. During an interview on 2/26/25 at 2:13 PM with the Infection Preventionist (IP), the IP stated all catheters, nasal cannulas, O2 tubing had to be changed and labeled. The IP also stated, residents with catheters, tube feedings, and wounds should be placed on EBP. Additionally, the IP stated a sign on the resident's door is posted with instructions on what PPE's to wear and a PPE cart is set up outside the resident's room. During further interview, the IP acknowledged that there was no signage for EBP posted and PPE cart set up for residents with catheters and tube feedings including Resident 62, Resident 204, Resident 25, Resident 256. 43913 4. During a concurrent observation and interview on 2/24/25 at 6:30 AM, Resident 256 was up in wheelchair, observed holding his Gastrostomy tube (GT) tubing, resident stated, don't worry about it when asked what he was doing. Resident stated they showed me how to do it, then disconnected his GT feeding himself, leaving the end of the feeding tube on his bed. During a concurrent observation and interview on 2/24/25 at 6:35 AM, with CNA 5, no sign or posting for EBP was observed on Resident 256's room. CNA 5 stated the posting was for residents with tube feeding and oxygen, when asked about a sign posted on another room. During and observation for medication pass 2/24/25 at 8:30 AM , with RN 3, RN 3 observed giving the GT medication using gloves only. Review of Resident 256's Admission Record, admitted on [DATE] with diagnoses including: Cerebral Infarction (a condition where blood flow to the brain is interrupted causing brain tissue to die), Dysphagia( difficulty swallowing), Gastrostomy Status( where a thin flexible tube is inserted through the abdominal wall and into the stomach for feeding). During an interview on 2/25/25 at 11 AM, with RNS, RNS stated residents with any tubing should have a signage for EBP (Enhanced Barrier Precaution) on the door.

Based on observation, interview and record review the facility failed to maintain an effective pest control program, when flying insects were seen in the facility. This failure had the potential to result in exposing residents to pest borne illnesses. Findings: During a concurrent observation and interview on 02/24/2025 at 1:00 PM, in Resident 93's room, with Resident 93's family member, Resident 93's family member stated you can see these insects here and pointed to a little flying insect resting on the wall approximately 8 feet above the floor. During a concurrent observation and interview on 02/25/2025 2:07 PM, with Kitchen Supervisor (KS) a flying insect was observed flying in the room while interviewing Resident 82. KS confirmed he saw the flying insect. During an interview on 02/26/2025 at 9:52 AM, the Maintenance Manager (MM) stated the facility was subcontracted with a pest control company as part of their pest management program. Review of the facility's policy titled Pest Control, revised on May 2008, indicated .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was covered with a privacy bag for one of 6 residents with indwelling catheters (Resident 25). This failure had the potential to affect Resident 25's psychosocial (mental, emotional, social, and spiritual effects) well-being. Findings: During the initial tour on 2/24/25 at 7:10 AM in resident's room, Resident 25 was sleeping in bed. A partially filled urinary catheter drainage bag was observed hanging on the side rail by the left side of the foot of the bed exposing its contents. The urinary catheter drainage bag had no cover and a reddish-brown discoloration on the front of the bag was observed. The drainage bag was unlabeled and undated. A reddish-brown fluid was also observed in the tube attached to the urinary catheter drainage bag. During a concurrent observation and interview on 2/24/27 at 7:18 AM with Certified Nursing Assistant (CNA) 3, Resident 25's urinary catheter drainage bag was uncovered, undated, and unlabeled. CNA 3 acknowledged and stated, there was no date on the drainage bag and should have been placed inside a dignity bag. During an interview on 2/26/25 at 1:43 PM, Registered Nurse (RN) 1 stated, resident's urinary catheter drainage bag needs to have a cover for privacy.

Based on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for one of 22 sampled residents (Resident 204). This failure had the potential to result in inadequate care and services rendered to the residents. Findings: Review of Resident 204's admission record indicated, was admitted on [DATE] with diagnoses including heart failure, acquired absence of left leg below knee, kidney disease, and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so). During an interview on 2/24/25 at 7:41 AM with Resident 204, Resident 204 stated he has a catheter on his right upper chest used for dialysis. Resident 204 stated that he was not able to go to dialysis on Saturday (2/22/25) because transportation needed to be arranged. During an interview on 2/24/25 at 8:42 AM, Registered Nurse Supervisor (RNS) stated, Resident 204 has a central venous catheter (CVC - a tube inserted into a major vein in the chest, neck, or groin for emergency dialysis or temporary access) on his right upper chest for his dialysis. RNS also stated that no special precautions are followed for Resident 204's care. During a concurrent interview and record review on 2/25/25 at 2:26 PM, with Licensed Vocational Nurse (LVN) 1, Resident 204's care plan was reviewed and was unable to find a care plan addressing Resident 204's dialysis and CVC care. LVN 1 also reviewed Resident 204's baseline care plan and stated, not completed yet. LVN 1 added that the baseline care plan is completed 3 days on admission. During an interview on 2/25/25 at 2:44 PM, RNS stated, No dialysis care plan right now. Nursing section is not complete yet. RNS also stated, there is no deadline for the baseline care plan to be completed and that it depends on family or resident preferences.

Based on observation, interview, and record review, the facility failed to develop a plan of care for one of 22 sampled residents (Resident 25) who fell and fractured his hip. This failure resulted in Resident 25 not receiving the necessary care and treatment such as physical and occupational therapy. Additionally, this resulted in miscommunication between the staff and Resident 25 regarding aftercare and weight bearing activities. Findings: During an observation on 2/24/25 at 7:10 AM in resident's room, Resident 25 was sleeping in bed. A blue fall mat was observed on the floor, situated between the beds of Resident 25 (bed A) and his roommate (bed B). Review of Resident 25's admission record indicated, Resident 25 was readmitted to the facility on [DATE] with diagnosis including fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of right artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the right hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), difficulty walking, and unspecified fall. During an interview on 2/24/25 at 10:51 AM with Resident 25, Resident 25 stated, he was recently hospitalized due to a fall that required him to undergo hip surgery. Resident 25 stated, he tripped on the [pointing to] fall mat between him and his roommate, fell and hit his right hip onto the floor. Resident 25 stated he's on non-weight bearing on his lower extremities and has not been out of bed since he came back to the facility. Additionally, Resident stated he was not evaluated by a physical therapist (PT) and occupational therapist. Review of Resident 25's Change in Condition Evaluation, dated 2/15/25, indicated, CNA (Certified Nursing Assistant) . finding resident on floor of resident room on bottom. Resident alert and oriented x4. Resident verbalized he landed on his right hip, did not head strike .bruise forming on right hip . Resident feels soreness on right hip. When getting resident back to bed, his legs buckled and was unable to walk. MDs (Medical Doctor) notified .Waiting for order from MD for x-ray for hip. Review of Resident 25's Licensed Nurse's Notes, dated 2/15/25, indicated, .Resident endorses 10/10 pain when moving, 4/10 still. Pain, sharp localized to hip, bruise is forming. MDs notified . Sending to [Name of acute hospital] to rule out fracture . Review of Resident 25's undated care plan titled, The resident is on high risk of fall and risk for the further multiple injuries related to following factors: Decline in functional status, Incontinence (loss of bladder control), Pacemakers (an electronic device to regulate the heart's rhythm), Unsteady Gait, Use cardiovascular meds/diuretics, Use of cane/walker/crutch, indicated interventions including Assess cause, pattern of falls, and activities .Keep environment free from obstruction . Review of Resident 25's Post Fall Assessment, dated 2/15/25, indicated, Resident 25 was getting out of bed and tripping under his feet. Review of Resident 25's General Acute Care Hospital (GACH) Discharge Summary, dated 2/19/25, indicated, a discharge diagnosis of femoral neck fracture (a break in the bone [femur] that connects the hip joint [acetabulum] to the upper thigh [femoral head]) and requires SNF (skilled nursing facility) for rehab . The Discharge Summary indicated, .#R FNF (right femoral neck fracture) s/p R hemi .WBAT (weight bearing as tolerated) RLE (right lower extremity), posterior hip precautions .discharge back to SNF for PT . Review of Resident 25's Plan of Care Note, dated 2/19/2025, indicated, Late Entry Note Text: Patient is back from the hospital status post arthroplasty for right femoral neck . # Mechanical ground level fall .-we will start PT/OT (physical therapy/occupational therapy) . During a concurrent interview and record review on 2/26/25 at 10:02 AM with Registered Nurse Supervisor (RNS), Resident 25's Order Summary Report was reviewed. The Order Summary Report did not indicate Resident 25 has an order for WBAT and PT referral. The RNS stated there was no documentation that an order was carried for WBAT and PT referral. Furthermore, RNS was unable to find documentation that an IDT (interdisciplinary team - team of individuals with different areas of expertise) meeting occurred to discuss and assess the cause of the fall and update Resident 25's plan of care related to the recent fall and right femoral fracture. RNS stated, I could not see a care plan for fracture. Additionally, RNS stated that Resident 25 had been in bed since readmitted to the facility. During a follow-up interview on 2/27/25 at 9:37 AM, Resident 25 stated, PT/OT were not aware he had a fall and fractured his right hip that is why he was not seen since he was readmitted on [DATE]. During an interview on 2/27/25 at 1:05 PM, Physical Therapist (PT) stated, Resident 25 had history of falls but was not aware of the recent fall with fracture until 2/26/25.

Based on observation, interview and record review, the facility failed to develop a coordinated plan of care and communication process with the Hospice agency, when there was no care plan to address what services Hospice will provide and for facility when to notify Hospice for one (Resident 61) of two sampled residents. This failure had the potential to result in hospice residents being at risk for gaps in their hospice services. Findings: Review of Resident 61's Admission record dated 6/15/21, indicated admitted to SNF under Hospice Services on 1/31/25 with End Stage diagnosis of Dementia (decline in cognition including memory). Review of Order Summary Report, dated 2/27/25, indicated, Admit to facility under Hospice Service for comfortable care. DNR, Comfortable-Focus Treatment. No artificial nutrition. During an interview on 2/24/25 at 11:30 AM, with MDS Coordinator (MDSC, MDS - minimum data set, a standardized tool used to plan resident care) , MDSC stated the Hospice residents each have a binder which contains the name of hospice agency and their plan of care, names of hospice staff who will visit and notes of their visits. MDSC also stated the facility has their own care plan for each Hospice resident. During a concurrent interview and record review on 2/25/25 at 12:00 PM, with Director of Social Service (DSS), DSS stated the Hospice agency makes their care plan in their binder. Review of chart, care plan indicated, Comfort Altered Pain Related to Dementia: no mention of Hospice, no interventions as to communication between Hospice and facility. DSS acknowledged, Moving forward, will document in care plan what Hospice will do and how facility will coordinate with Hospice for the care management and comfort of the hospice patients. During an Interview on 2/25/25 at 3:00 PM, with Director of Nursing (DON), DON stated Hospice communicates with facility staff. The hospice nurse, whoever comes, will talk to the nurse on duty of any changes for plan of care or any new orders. During an interview on 2/26/25 at 9:30 AM, with Registered Nurse (RN) 4, RN 4 stated when there is change in the needs of the patient, such as medication, the facility calls the Hospice nurse and Hospice nurse will order medication and have it delivered to facility. If the Hospice nurse is visiting and there is a change of medication, Hospice nurse will inform [the facility staff] and document in their binder. Review of facility Policy and Procedure Policy on Collaboration with Hospice Providers, (undated), indicates: Conclusion . The facility will . Participate in regular interdisciplinary team meetings with hospice providers, Document all collaboration efforts, including meeting records and care plan updates, Ensure clear communication between facility staff and hospice providers.

Based on observation, interview, and record review, the facility failed to provide specialized rehabilitative services (includes but is not limited to physical therapy, speech-language pathology, occupational therapy, or respiratory therapy and are provided or arranged for by the nursing home) for one of 22 sampled residents (Resident 25) that required physical therapy (PT-treatment that helps you improve how your body performs physical movements) and occupational therapy (OT-a healthcare profession that focuses on helping individuals improve their ability to perform everyday activities) status post (s/p-a medical or clinical shorthand that refers to a state after an intervention) right hip hemiarthroplasty (a surgical procedure that replaces the femoral head (ball) of the right hip joint with an artificial implant). This failure may result in further decline in condition for Resident 73 and the potential to negatively affect the ability to attain and maintain his highest practicable level of physical, mental, functional and psycho-social well-being. Findings: During the initial tour on 2/24/25 at 7:10 AM in resident's room, Resident 25 was sleeping in bed. A blue fall mat was observed on the floor, situated between the beds of Resident 25 (bed A) and his roommate (bed B). Review of Resident 25's admission record indicated, was readmitted to the facility on [DATE] with diagnosis including fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of right artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the right hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), difficulty walking, and unspecified fall. During an interview on 2/24/25 at 10:51 AM Resident 25 stated, he was recently hospitalized due to a fall that required him to undergo hip surgery. Resident 25 stated, he tripped on the [pointing to] fall mat between him and his roommate, fell and hit his right hip onto the floor. Resident 25 stated he's on non-weight bearing (cannot put any weight) on his lower extremities and has not been out of bed since he came back to the facility. Additionally, Resident stated he was not evaluated by a physical therapist (PT) and occupational therapist. Review of Resident 25's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment, dated 1/19/25, indicated, no cognitive impairment. Under the functional abilities and goals of MDS assessment indicated, Resident 25 required supervision with transfer and moderate assistance with ambulation using a walker. Review of Resident 25's Plan of Care Note, dated 2/15/2025, indicated, Late Entry Note Text: Contact by our team regarding a recent fall, landed on right hip now having severe pain over right hip. Unable to move extremity . Orders placed to send out for further trauma evaluation and hip fx. (fracture) . # Mechanical ground level fall .we will start PT/OT (Occupational Therapy, a treatment to help develop, recover, improve, and maintain skills needed for daily living and work) . Review of Resident 25's General Acute Care Hospital (GACH) Discharge Summary, dated 2/19/25, indicated, a discharge diagnosis of femoral neck fracture (a break in the bone [femur] that connects the hip joint [acetabulum] to the upper thigh [femoral head]) and requires SNF (skilled nursing facility) for rehab . Further review of the Discharge Summary indicated, .#R FNF (right femoral neck fracture) s/p R hemi .WBAT (weight bearing as tolerated) RLE (right lower extremity), posterior hip precautions .discharge back to SNF for PT . Review of Resident 25's Plan of Care Note, dated 2/19/2025, indicated, Late Entry Note Text: Patient is back from the hospital status post arthroplasty for right femoral neck . # Mechanical ground level fall .-we will start PT/OT . During a concurrent interview and record review on 2/26/25 at 10:02 AM with Registered Nurse Supervisor (RNS), Resident 25's Order Summary Report was reviewed. The Order Summary Report did not indicate Resident 25 has an order for WBAT and PT referral. The RNS stated there was no documentation that an order was carried for WBAT and PT referral. Furthermore, RNS was unable to find documentation that an IDT (interdisciplinary team) meeting occurred to discuss and assess the cause of the fall and update Resident 25's plan of care related to the recent fall and right femoral fracture. RNS stated, I could not see a care plan for fracture. Additionally, RNS stated that Resident 25 had been in bed since readmitted to the facility. During a follow-up interview on 2/27/25 at 9:37 AM, Resident 25 stated, PT/OT were not aware he had a fall and fractured his right hip that is why he was not seen since he was readmitted on [DATE]. During an interview on 2/27/25 at 1:05 PM, Physical Therapist (PT) stated, Resident 25 had history of falls but was not aware of the recent fall with fracture until 2/26/25. Review of the facility's policy and procedure titled, [Name of Facility] Falls - Clinical Protocol, revised 7/9/19, indicated, Assessment and Recognition - 1. As part of the initial assessment, Interdisciplinary Team and the physician will help identify individuals with a history of falls and risk factors for subsequent falling . 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk . Cause Identification - 1. For an individual who has fallen, staff will attempt to define possible causes within 24 to 48 hours of the fall . c. When necessary, Licensed Staff or Interdisciplinary Team (IDT) will refer the resident to other disciplines such Rehabilitation Department .to rule out possible causes of fall . 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified . Treatment/Management - 1. Based on the preceding assessment, the staff or IDT and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .

Based on interview and record review, the facility failed to ensure appropriate discharge for one of 3 sampled residents (Resident 1) when there was no evidence of discharge basis and discharge summary for Resident 1 regarding his discharge on 7/17/24. This failure could result in an inappropriate discharge that may disrupt the provision of care for Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including cachexia (a condition that causes significant weight loss and muscle loss), severe protein-calorie malnutrition (the state of severely inadequate intake of food), iron deficiency (a condition that your body does not have enough iron), and unsteadiness (inability to stand firmly) on feet. Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/19/24, indicated, his memory was moderately impaired. Review of Resident 1's doctor's order, dated 7/16/24, indicated, May discharge to Home on 7/17/2024 with HH (Home health, a nursing specialty in which nurses provide multidimensional home care to patients of all ages) (PT [physical therapy, a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities]/OT [occupational therapist, a healthcare provider who helps patients improve their ability to perform daily tasks]/RN [registered nurse]) and incontinent supplies (products designed to help manage urine or stool) Review of Resident 1's Licensed Nurse's Notes, dated 7/17/24 indicated, . Patient is discharged , left the facility at around 1400 (2 PM) with social worker on a wheelchair . During an interview on 8/1/24 at 11:11 AM with Director of Social Worker (DoSW), DoSW stated, . Of course! The doctor should have a discharge note for him . I don't see it here (in Resident 1's medical record) . when asked about the basis of discharge of Resident 1. DoSW stated, . I cannot see . when asked about Resident 1's basis of discharge again. She stated, there should be a reason for discharge to be documented by the doctor when asked. She stated, Definitely! when asked if there should be the basis of discharge. During an interview on 8/1/24 at 3:18 PM with DoSW, DoSW verified, there was no discharge summary from the doctor for Resident 1 when asked. Review of the facility's policy and procedure (P&P) titled, Discharging the Resident revised in December 2014 indicated, . review the reason for the discharge . State Operations Manual titled, Appendix PP, dated 2/3/23 indicated, . F622 . When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record . Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section .

Based on observations, interviews, record review, and facility policy review, the facility failed to implement measures to prevent Resident #76 from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This failure affected 1 (Resident #76) of 5 total residents identified by the facility as smokers. The facility allowed Resident #76 to have unsupervised visits with Visitor #28, who repeatedly provided the resident with smoking materials despite having been educated on the facility's smoking policies multiple times. After the facility had educated both Resident #76 and Visitor #28 on the facility's smoking policies, the resident and visitor continued to be noncompliant. The facility had assessed Resident #76 as requiring supervision while smoking and the facility was required to store all of the resident's smoking materials due to non-compliance with the facility's smoking policy, including a history of smoking inside the facility and in non-designated smoking areas. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J. The IJ began on 01/02/2024 at 11:16 AM when Resident # 76 was observed in the hallway of the facility with smoking materials, including cigarettes and a lighter, in their possession. The Administrator and Director of Nursing (DON) were notified of the IJ on 01/21/2024 at 10:55 AM and provided a copy of the IJ template on 01/21/2024 at 11:18 AM. A removal plan was requested. The removal plan was accepted by the State Survey Agency on 01/22/2024 at 10:05 AM. The IJ was removed on 01/22/2024 at 4:44 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings included: A review of a facility policy titled Smoking Policy - Residents, revised in August 2022, revealed, This facility has established and maintains safe resident smoking practices. The policy further indicated, 2. Smoking is only permitted in designated resident smoking areas which are located outside of the building, 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, or concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues, and 14. Residents without independent smoking privileges, may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. The policy specified, This facility maintains the right to confiscate smoking items found in violation of our smoking policies. A review of Resident #76's Admission Record revealed the facility admitted the resident on 11/19/2021. According to the Admission Record, the resident had a medical history that included diagnoses of tobacco use, senile degeneration of the brain, delirium due to known physiological condition, and muscle wasting and atrophy. A review of Resident #76's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2023, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #76's comprehensive care plan revealed a Focus area, initiated on 11/20/2021 and revised on 09/01/2023, that indicated the resident was a smoker and does not follow the scheduled smoking times. Very impulsive and screaming at staff to take [him/her] to smoke. The Goals were that Resident #76 would not suffer injury from unsafe smoking practices and Resident #76 would smoke at the designated area through the next review date of 03/13/2024. Resident #76's smoking care plan included the following active interventions created on 12/10/2021: - Complete smoking assessment. Reassess resident quarterly, annually, and with change of condition, - Educate resident and family about the facility policy on smoking: locations, times, and safety concerns, - Monitor resident's safety during smoking, - Notify charge nurse immediately if it is suspected resident has violated facility smoking policy, - The resident requires SUPERVISION while smoking, and - The resident's smoking supplies should not be stored at bedside. A review of Resident #76's quarterly Smoking - Safety Screen, dated 03/12/2023, revealed the resident could light their own cigarettes and was safe to smoke without supervision in designated areas. The Smoking - Safety Screen indicated the resident had prior episodes of smoking inside the facility, and the facility was to store the resident's cigarettes and lighter in the nurses' cart. A review of Resident #76's quarterly Smoking - Safety Screen, dated 05/30/2023, revealed Resident #76 could light their own cigarette but needed supervision and one-on-one assistance. According to the Smoking - Safety Screen, the resident was not safe to smoke without supervision, and the resident had a history of noncompliance with the designated smoking area and smoking inside the facility. The facility was to store the resident's cigarettes and lighter in the nurses' cart. A review of Resident #76's medical record revealed a Smoking - Safety Screen had not been completed since 05/30/2023. A review of Resident #76's Progress Notes revealed the following entries: - A COMMUNICATION - with Resident note, dated 04/01/2022 and documented by the Social Services Director (SSD), that indicated the SSD spoke with the resident to remind them of the facility's smoking policy after a nurse found a cigarette in the resident's possession. According to the note, the SSD discussed the following information with the resident: 1) [Resident #76] can't keep a cigarette and a lighter on [sic] [Resident #76's] possession. It must be kept by the charge nurse and will only be given to [Resident# 76] before smoking. 2) There is only one designated smoking area- outside by the end of the driveway/ left end side of the building. 3) [Resident #76] will be escorted by the staff for safety monitoring. The note indicated the resident understood, denied ever smoking inside the building, and said the cigarette that was found was an extra from the previous smoke break. - A COMMUNICATION - with Resident note, dated 07/01/2022 and documented by the SSD, which indicated the SSD spoke with and counseled the resident regarding an incident earlier in the morning on the same day in which the resident lit and smoked inside the facility. The SSD informed the resident the incident was a major fire safety concern and that their actions could endanger the resident, as well as everyone else in the facility. According to the note, the resident was again reminded of the facility's smoking policy, specifically, 1) Smoking in any part of the building is strictly prohibited. 2) Smoking should only be in the designated area - outside the building by the parking garage 3) Smoking is limited to 3x [times] per day/ one time every shift and [he/she] should be escorted depending on the availability of the staff while smoking. 4) [His/her] cigarette and lighter should be kept at the nurses' cart and will only be given to [him/her] during smoking schedules. 5) Violation of the Smoking Policies will result in the cancellation of [Resident #76's] smoking rights. The note indicated the resident understood and agreed. - A CARE CONFERENCE OR IDT [interdisciplinary team] NOTES entry, dated 09/28/2022 and documented by the SSD, that indicated the SSD facilitated a care conference on 09/27/2022 with Resident #76 in the presence of Visitor #28, the Ombudsman, and the Registered Nurse (RN) Supervisor (currently Assistant Director of Nursing (ADON)/Infection Preventionist (IP) #23) and discussed the resident's plan of care, and the resident's violation of facility house rules. According to the note, they also discussed that the resident was verbally aggressive and non-compliant with care, and the resident was continuously violating the house rules as far as smoking cigarettes and street drugs (marijuana). The note revealed the resident was again reminded of the facility's smoking policy, including that their cigarettes and lighter would be kept by the nurse, and the resident would have access only during scheduled smoking times to prevent the resident from lighting cigarettes in non-designated smoking areas. The note indicated, This restriction was violated by the resident several times despite frequent counseling and reminder. They also reminded Visitor #28 that all personal items brought to the facility should be endorsed by facility staff for inventory purposes and would allow cigarettes to be supervised and accounted for. The note also indicated the Ombudsman informed Resident #76 and Visitor #28 that federal law prohibited organizations such as nursing facilities from allowing the use of street/prohibited drugs on their premises. The note revealed the Ombudsman informed the resident that this violation was grounds for eviction from the nursing home, and that while smoking was a resident's right, the nursing home had the right to make their own rules to accommodate the right to smoke. The note also indicated Resident #76 and Visitor #28 were advised to look for alternative placement as soon as possible because the resident's physical and medical condition were stable and did not require the services provided at the nursing home. - A CARE CONFERENCE OR IDT NOTES entry, dated 12/21/2023 and documented by the SSD, that indicated the Nursing QA Director, RN Supervisor, SSD, Ombudsman, and Abuse Coordinator met with Resident #76 and Visitor #28 to discuss the resident's plan of care and other concerns related to violation of the facility's house rules. According to the note, the SSD informed the resident and Visitor #28 that during the deep cleaning of the resident's room over the weekend, a significant amount of marijuana cigarettes were found on top of [his/her] bedside table and bed by maintenance staff, and the RN Supervisor was informed and confiscated the items. The note revealed Resident #76 and Visitor #28 were reminded of the prior meeting on 09/28/2022 in which it was discussed that street/illegal drugs were not permitted on the premises of the facility per federal law and were grounds for eviction. The note revealed the RN Supervisor also reminded Visitor #28 that they had previously discussed that marijuana use could increase the resident's heart rate and blood pressure and lead to an increased risk of stroke, heart disease, and other vascular diseases, and combined with the resident's ongoing cardiovascular and coagulation issues, could lead to death. According to the note, Resident #76 admitted they used marijuana, promised not to do it again, and said they would not light and smoke cigarettes inside the building. On 01/02/2024 at 11:16 AM, Resident #76 was observed in the hallway waiting on the elevator. The surveyor rode the elevator to the first floor with the resident, and the resident then wheeled themself to the back door with their cigarettes and lighter in their pocket. No staff members were present, and Resident #76 said they could go out to smoke on their own and did not need any help. At 11:21 AM, the Chief Executive Officer (CEO) was entering the facility through the back door and stopped the resident from going outside. She instructed RN #1 to go with Resident #76 outside because the resident needed someone to be always with them while smoking. Once outside, Resident #76 pulled their cigarettes and a lighter out of their pocket and lit a cigarette. When Resident #76 finished smoking, Resident #76 put their cigarette out on their wheelchair tire and threw the cigarette butt onto the ground. RN #1 assisted Resident #76 back into the facility. During a subsequent interview with Resident #76, on 01/02/2024 at 11:38 AM, the resident's cigarettes and lighter were observed on the resident's bedside table. During the interview, the resident stopped a staff member and asked for a cup of hot water to make coffee. The staff member returned with the hot water, and the resident made a cup of coffee using instant coffee from their drawer and stirred it with the end of their cigarette lighter. On 01/05/2024 at approximately 2:10 PM, Resident #76 was observed sitting outside in their wheelchair next to the gate to the parking lot, not in the designated smoking area, and no staff members were present while the resident was smoking. Continued review of Resident #76's Progress Notes revealed the following entries: - A CARE CONFERENCE OR IDT NOTES entry, dated 01/10/2024, that indicated the IDT, including the Medical Director (MD), Administrator, DON, ADON #6, ADON/IP #23, SSD, Activity Director, and Director of Staff Development (DSD), met to discuss issues and concerns involving Resident #76. The note reflected the following, ISSUES AND CONCERNS: Resident is a cigarette smoker. [He/she] has also had episodes of smoking illicitdrug [sic] (marijuana). [He/she] was assessed and determined to be unsafe to smoke independently, the facility imposed smoking restrictions on [him/her] that [he/she] cannot smoke without support and supervision of visitors, family or staff and cannot keep smoking items (cigarette, tobacco, lighter or other smoking paraphernalia). Despite the restrictions, resident secretly, continuously and intentionally possessing cigarette, illicit drug and lighter to have easy access when needed. On several occasions, resident was reminded and counseled about the House Rules particularly Smoking (cigarette and illicit drugs) and Alcohol Consumption. Care conferences were conducted several times in the presence of [his/her] friend [Visitor #28], Ombudsman and IDT. Resident admitted and acknowledged [his/her] violation of House Rules specifically: 1) The use and possession of illicit frug (Marijuana) 2) Smoking inside the building (in bed, inside the bedroom, 2nd floor hallway and ground floor hallway) 3) Consumption of alcohol. The note revealed During those care conferences and counseling during actual incidents, resident apologized and promised that [he/she] will not do it again. However, those promises had never been fulfilled and there was no indication of following the facility House Rules. With these serious violations of the facility House Rules, the resident was putting [his/her] self and other residents to a [sic] significant danger by causing a potential fire in the building. This note reflected the following RECOMMENDATIONS from the IDT: To offer accommodation to escort and supervise the resident to the smoking area based on smoking schedules two to three times a day, not allow the resident to have possession of cigarettes, illicit drugs, lighter, or any other smoking materials, cigarettes and lighter will be under the safekeeping in a medication cart and will only be given to the resident during the agreed smoking schedules, the resident's room would be checked regularly to ensure that they did not have possession of any cigarette, lighter, and other smoking materials, and a 30-day discharge notice would be issued if the resident repeatedly violated the smoking policy. - A Licensed Nurse's Notes entry and a Psychosocial Note dated 01/13/2024 that indicated Resident #76 reported to a nurse that their roommate (Resident #404) threatened to hit them. According to the note, the nurse went to speak with Resident #404, who reported Resident #76 asked them to buy the resident cigarettes, and Resident #404 denied the request. Further, the SSD (via phone) and RN #27 spoke with the roommate, and the roommate denied having made such a threat but said Resident #76 kept asking the roommate for cigarettes, even at night, and Resident #76 got upset when they did not get one. - A Plan of Care Note documented by a physician for a date of service of 01/16/2024 that indicated the nurses reported Resident #76 was smoking cigarettes and marijuana outside and inside their room. The note revealed nursing staff reported to the physician that there had been a past incident of the resident smoking in their room, and they had already had a meeting with the resident, in which the resident admitted they violated the facility's policy. The note revealed the nursing staff told the physician that Resident #76 needed to be discharged or transferred to another facility. - A CARE CONFERENCE OR IDT NOTES entry, dated 01/18/2024, that indicated the Administrator, SSD, and RN# 27 met with Resident # 76 and Visitor #28 to discuss the resident's continued non-compliance with the facility's smoking policy and procedure. The note indicated, The resident has been witnessed smoking inside the facility, against the facility's policy, jeopardizing the health and safety of other residents. The resident was educated several times before and continues to be non-compliant. The facility expressed concerns regarding the resident's safety and the health of other residents. The resident agreed to 4 times daily smoking schedule with direct supervision of staff. The resident was offered a smoking cessation program and refused. The Resident also agreed not to keep any smoking materials on [his/her] person or in [his/her] room. - A COMMUNICATION - with Resident note documented by the Administrator and a Licensed Nurse's Notes entry, dated 01/19/2024, that indicated the Administrator witnessed the resident smoking inside the facility in the waiting area on the second floor. The note revealed the resident was immediately stopped, smoking materials were confiscated from the resident, and the resident gave verbal consent for their room to be searched. Per the note, a room search was conducted by RN# 27 and the Administrator, and no additional smoking materials were found. - A COMMUNICATION - with Resident note dated 01/20/2024 and documented by the Administrator revealed that the Administrator observed Resident #76 holding a cigarette lighter returning from the smoking area at approximately 4:45 PM. According to the note, the resident was out on pass and went to the smoking area with Visitor #28. The note indicated the Administrator reminded the resident they could not have any smoking materials, and the resident agreed to hand over a lighter. During an interview on 01/19/2024 at 4:02 PM, Resident #404, Resident #76's roommate, stated they had been at the facility for about two weeks, and Resident #76 did not follow the rules when it came to smoking. Resident #404 said Resident #76 had smoked in their room and had smoking materials in their room. Resident #404 further stated staff seemed to allow Resident #76 to do anything the resident liked. During an interview on 01/05/2024 at 9:33 AM, Certified Nurse Aide (CNA) #5 said she knew how much assistance a resident needed when smoking from the machine on the wall (kiosk), and the resident could usually tell her. CNA #5 stated she had not seen Resident #76 smoking independently because she was a new employee and took the resident to the smoking area herself when she was assigned to them. During an interview on 01/05/2024 at 9:41 AM, CNA #4 stated she stayed with smoking residents the whole time they were outside smoking. CNA #4 said she had never seen Resident #76 smoking independently and stated residents were not supposed to keep their cigarettes and lighters in their rooms, but some try to sneak them. CNA #4 could not recall the date of her last staff training on smoking safety. During an interview on 01/05/2024 at 1:14 PM, the DON stated it was her expectation that residents be assessed for their smoking capabilities upon admission, with any significant change, and quarterly. She stated if the assessments were not done or were not done accurately, residents could be at risk for injury while smoking. The DON said residents were educated about smoking safety and the facility's smoking rules upon admission. She further stated she thought all residents' lighters and cigarettes were kept at the nurses' station and staff members were responsible for returning the smoking materials back to the nurses' station after smoke breaks, but she was not sure and indicated ADON #6, the previous DON, would be able to clarify. During an interview on 01/05/2024 at 1:43 PM, ADON #6 stated residents were assessed for smoking safety upon admission and then reassessed quarterly, usually around the time of the MDS assessments, because they could have had a change in their ability to safely smoke. ADON #6 said two of the three smokers in the facility, including Resident #76, were required to have their smoking materials stored at the nurses' station, and the other one was independent and could keep their own smoking materials. ADON #6 said for the residents whose smoking materials were stored at the nurses' station, they provided them to the residents when requested and sent a staff member with them while the residents smoked. ADON #6 said the staff member was responsible for returning the smoking materials to the nurses' station so they could be locked up until the next smoke break because if they left it up to the residents, they would sneak and keep them. During an interview on 01/19/2024 at 4:30 PM, RN #27 stated smoking assessments were completed quarterly, during admission, and after significant changes. RN #27 revealed Resident #76 had smoked inside the facility, and the facility confiscated the resident's smoking materials. During a follow-up interview on 01/20/2024 at 1:46 PM, RN #27 stated she completed smoking assessments and confirmed Resident #76 had not been assessed for smoking since May 2023. During an interview on 01/19/2024 at 5:43 PM, RN #2 stated she had worked at the facility for six months. She stated that cigarettes and lighters were kept with the nurses, locked in a cart. She stated that when they went outside to smoke, they gave the residents the cigarettes and lighters and retrieved them when they were finished due to safety concerns. During an interview on 01/20/2024 at 9:48 AM, CNA #31 stated she had worked at the facility for three months and was not aware of any residents smoking in the facility. She stated that Resident #76 was allowed to smoke alone and that their family took them. She stated she had seen Resident #76 smoke alone about three months ago. During an interview on 01/22/2024 at 11:39 AM, CNA #5 stated that she was not sure if Resident #76 was allowed to have the smoking items. She stated she had seen the resident smoke in the facility's lobby once. During an interview on 01/20/2024 at 10:28 AM, RN #3 stated that she had worked at the facility since October 2023. She stated that she was not aware of Resident #76 smoking in the facility. She stated that the resident had to be taken down to the smoking area, then she would leave the resident and come back and get the resident. She stated she was not sure if the resident was safe alone. RN #3 stated she had not received training regarding smoking. She stated she last took Resident #76 to smoke last Saturday. RN #3 stated she left the resident and told the resident she would be back in 15 minutes. During an interview on 1/20/2024 at 10:59 AM, ADON/IP #23 stated that the resident had only been observed smoking in the facility once. During an interview on 01/20/2024 at 2:56 PM, the Administrator stated Resident #76 could not smoke inside and stated that the resident had to be supervised when they smoked. He stated the resident could not keep smoking materials their self. He stated that when he caught the resident smoking, the resident stated they received the smoking materials from Visitor #28. The Administrator stated that Visitor #28 came on 12/21/2023 and was formally informed not to bring the resident smoking materials. He said he had spoken with Visitor #28 at least three times about not allowing the resident to smoke unsupervised and having smoking materials. He stated that a family member gave the resident cigarettes today. The Administrator stated that he expected facility staff to make sure the resident got to the smoking area, ensure the resident was being safe, and ensure the cigarettes were placed in the receptacle. He stated that the staff were lighting the cigarettes and that the smoking materials were in the staff's possession. The Administrator stated that even after meeting with the resident and family member, the resident continued to be noncompliant. On 01/22/2024 at 10:05 AM, a removal plan was submitted by the facility and accepted by the State Survey Agency. It read as follows: Plan of Removal F689 - Free of Accident / Hazards 1. How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1.1 Resident #76 still resides in the facility. 1.2 Resident #76's ability to smoke independently was reassessed on 01/19/2024. The resident requires direct supervision to smoke. Resident #76's plan of care was updated to include the need for direct supervision during smoking activity as determined and assigned by the smoking schedule. 1.4 A smoking schedule was implemented on 01/18/2024 for resident #76 by the interdisciplinary team and agreed upon by the resident and friend. Long-Term Care Ombudsman was informed. 1.5 The facility issued resident #76 a 30-day discharge notice on 01/21/2024 for non compliance with the facility's policy and procedure for smoking. 1.6 The facility implemented new measures for visitation, including requiring direct supervision of each visit with Resident #76 by management staff and/or nursing staff. 1.7 Resident #76's attending physician was notified of the resident's non-compliance with the smoking policy. 1.8 The facility implemented new measures for out-on-pass, which include searching the resident upon return to the facility for any smoking material in his possession with consent. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; 2.1 The facility audited all five residents who smoke and reassessed their ability to smoke independently. 2.2 The facility updated the plan of care to include each resident's ability to smoke independently and safely. 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; 3.1 The Director of Staff Development and Assistant Director of Nursing provided in-service re-education to environmental, dietary, nursing, activities, and management staff on 1/20/24 and 1/21 /24 regarding the facility's policy and procedure titled 'Smoking Policy - Residents' with an emphasis on Resident #76's smoking schedule and interventions due to history of non-compliance. For staff who are not included in the initial training, the facility will provide in-service re-education on an ongoing basis. The facility will compare the in-service documentation with the staff roster to ensure all appropriate staff receive the training. Staff who fail to attend the in-service will be removed from the schedule until completion of the in-service training. 4. How the facility plans to monitor its performance to make sure that solutions are sustained; 4.1 Effective 01/21/2024, the Director of Nursing and/or Designee will complete monthly audits of residents who smoke to ensure the Smoking Assessment and care plans are accurate. Any concerns identified will be addressed immediately. 4.2 Effective 01/21/2024, the Smoking Monitors, as outlined in the resident's smoking schedule, and/or Designee will complete a daily visual audit four times daily to ensure the resident complies with the facility's smoking policy. Documentation of this audit will be maintained in a binder. Any concerns identified will be addressed immediately. 4.3 The Director of Nursing and/or Designee will report significant trends identified in the monthly smoking audit to the QAPI/QAA [quality assurance and performance improvement/ quality assessment and assurance] Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or, for the purpose of terminating this plan of correction when substantial compliance has been achieved. 4.4 The Administrator and/or Designee will report significant trends identified in the daily visual audit to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction or for the purpose of terminating this plan of correction when substantial compliance has been achieved. 4.5 Substantial compliance shall be indicated by three consecutive reviews during the QAPI/QAA Committee analysis without findings. 4.6 Allegation of compliance date: 01/21/2024. Onsite Verification: The IJ was removed on 01/22/2024 at 4:44 PM after the survey team verified the implementation of the facility's removal plan as follows: 1.2 Assessment documented Resident #76's need for supervision during smoking. Verified in chart 01/22/2024 at 10:11 AM. Verified through interview with the DON and Administrator on 01/22/2024 at 11:34 AM. 1.3 The care plan documented Resident #76's need for supervision during smoking. Verified in the chart on 01/22/2024 at 10:11 AM. Verified through interview with the DON and Administrator 01/22/2024 at 11:34 AM. 1.4 Reviewed the smoking schedule provided by the facility; the meeting was documented in progress notes and saved by the surveyor. Verified through a telephone interview with Visitor #28 on 01/22/2024 at 10:36 AM. Visitor #28 stated the facility had provided education regarding bringing smoking materials into the facility for Resident #76. The facility had placed Resident #76 on a smoking schedule, allowing the resident to smoke four times each day. The facility explained to Visitor #28 that Resident #76 was not allowed to smoke without being supervised. Resident #76 was not allowed to smoke in any areas within the facility. Verified through telephone interview on 01/22/2024 at 1:58 PM with the Ombudsman, who indicated being made aware of the meeting on 01/18/2024 but was unable to attend. The Ombudsman stated they attended a care plan meeting last month when the resident's smoking issues were discussed and was aware of the resident's behaviors in the facility regarding smoking. 1.5 Review of discharge notice provided to Resident #76 on 01/21/2024 was verified on 01/22/2024 at 11:54 AM. Verified through interview with the Administrator 01/22/2024 at 11:54 AM. He stated the discharge notice had been provided to the resident, but they refused to sign. The discharge notice was signed by two witnessing facility staff. 1.6 Reviewed progress notes and social service notes detailing the visitation guidelines and her discussion with the resident's friend and their family member. Note dated 01/21/2024. Verified through interview with the DON and Administrator 01/22/2024 at 11:34 AM. The Administrator stated the new measures for visitation included the activities department will schedule visits and have specific times for visitation. He stated the facility staff will directly supervise the resident outside smoking with family to ensure no smoking materials are given to the resident. 1.7 The Medical Director was notified on 01/21/2024 at 11:26 AM per a nursing note. Verified on 01/22/2024 at 10:18 AM. Verified through in[TRUNCATED]

Based on observation, interview and record review, the facility failed to protect two of three Residents, Resident A and Resident C , rights to be free from sexual abuse when Resident A was sexually assaulted in her room and Resident C was inappropriately touched in her private part along the hallway, both by Resident B. This deficient practice resulted in mental anguish to Resident A when she was saying Get off me now repeatedly . repeatedly yelling angrily to Licensed Nurse (LN) get off me .biting repeatedly on her teeth. This deficient practice also had the potential to result in mental anguish to Resident C. Findings: During the review of Resident A's clinical records, the Minimum Data Set (MDS, a resident assessment tool) dated 10/1/2019, indicated Resident A was originally admitted to the facility on [DATE] and readmitted on [DATE] with a Brief Interview for Mental Status (BI[CONDITION], tool used to screen for cognitive impairment) score of 00 (severe cognitive impairment). Her [DIAGNOSES REDACTED]. During the review of Resident B's clinical records, the MDS dated [DATE], indicated the resident was admitted in the facility on [DATE] with a BI[CONDITION] score of 14 (cognitively intact). His [DIAGNOSES REDACTED]. During the review of Resident C's clinical records, the MDS dated [DATE], indicated Resident C was originally admitted to the facility on [DATE] and readmitted on [DATE] with a BI[CONDITION] score of 06 (severe cognitive impairment). Her [DIAGNOSES REDACTED]. During observation and concurrent interview with Resident A on 11/6/19 at 10:05 am, regarding the alleged sexual assault, she looked well-kept but was confused and sleepy. She stated she couldn't remember anything and also stated she was exhausted. During an interview with the Assistant Director of Nursing (ADON), on 11/6/19 at 9:30 am, regarding the alleged sexual abuse incident in the facility, the ADON stated they have a video showing about 30 minutes' duration of when Resident B went into Resident A's room and when Resident B came out. The ADON described the incident as, at about 1 am on [DATE], Certified Nursing Assistant (CNA) 1 was walking by and heard unusual noise in Resident A's room. CNA 1 walked in and saw Resident B with his pants down and private part exposed. Resident A was not lying the normal way on her bed; Resident A was lying at the edge of the bed with her legs bent at the knees, her briefs were off with her private part exposed. The ADON stated that CNA 1 told Resident B to leave the room. The ADON stated that CNA 1 told CNA 2 to watch Resident B and make sure he doesn't leave the facility. CNA 1 then reported the incident to the Charge Nurse, Registered Nurse 1 (RN 1). The ADON further stated when CNA 1 asked Resident A what happened, Resident A's response was, he tried to [***] me. ADON stated Resident A's Physician ordered for her to be sent to the hospital for evaluation. ADON further stated Resident B has not gone to this extent before but he has touched a female resident inappropriately in the past. The ADON stated police came the day of the incident, [DATE], to interview Resident B but he had already left the facility Against Medical Advice (AMA). ADON further stated the police found Resident B on the street and sent him to a hospital emergency room . During an interview with the Administrator on 11/6/19 at 10:20 am, Administrator confirmed the incident on [DATE] happened. Administrator stated Resident B said he was going out of the country on 11/4/19 and Resident B left the facility AMA. Adminstrator also stated that on 10/20/19, Resident B was seen touching Resident C inappropriately in her private part along the hallway. Adminstrator stated Resident C had dementia and may not remember the incident. The Administrator further stated that they monitored Resident C for 3 days after the 10/20/19 incident. During an interview with the witness, CNA 1, on [DATE] at 3:26 pm, she stated she was checking on residents along Resident A's unit which also housed Resident B. CNA 1 stated she heard Resident A talking loud to herself. She stated she went in to stop her from speaking loud, then she saw Resident B naked by Resident A's bed. She stated Resident A was pulled down on her bed with her knees bent. CNA 1 stated Resident A told her, that man was trying to [***] me. During an interview with Resident A's family member on 12/6/19 at 3:25 pm, he sounded upset about the incident and stated, it is pretty alarming. Camera showed the guy (Resident B) was in my mom's room for 30 minutes with his pants down. When I saw my mother (Resident A), she was reserved. She couldn't tell me anything. My mother (Resident A) says something and forgets within 5 minutes due to aneurysm (an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall) she had [AGE] years ago and dementia. During a record review of the Facility's Resident Incident Investigation dated [DATE], CNA 1 wrote, I heard (name of resident) singing/talking loudly & (and) went to check on her when I opened her curtain (resident name) (Resident B) was at the edge of her bedside with her (Resident A) at the edge of the bed. He (Resident B) had his pants pulled down and his privates exposed. I told the resident (Resident B) to leave her alone, he left the room quietly and went to the men's shower room where another CNA (CNA 2) told him to return to his room. During the review of Resident A's Care Plan dated [DATE], it indicated, resident will not experience emotional distress from alleged sexual assault, resident will not experience negative physical outcome from the alleged sexual assault and resident will be free from psychosocial distress. During a record review of Reisdent A's Progress Notes dated 11/1/2019 at 09:58, it indicated Resident A was sent to a hospital on [DATE]. During a record review of Resident A's Assessment and Plan from the hospital dated [DATE], it indicated, [AGE] y. o (year old) female with dementia and [MEDICAL CONDITION] evaluated for possible sexual assault by male assailant. Forensics - SVU (Special Victim's Unit) at bedside with search warrant and affidavit for SAEK (Sexual Assault Examination Kit or Rape Kit) forensic exam . Upon arrival to ED (emergency department), the patient (RA) states she has some vaginal discomfort. Patient later denied pain anywhere in her body. SNF (Skilled Nursing Facility) reports pt (patient) had [MEDICAL CONDITION] years ago. During a review of the hospital's After Visit Summary dated [DATE] at 3:51 pm, it indicated, You have been evaluated for abuse and concern for assault. Based on your evaluation we performed a rape kit, and gave you [MEDICATION NAME] and [MEDICATION NAME]. We also called the police to go to the skilled nursing facility to arrest the individual who assaulted you. This is in efforts to maintain a safer living environment. During a record review of RA's Progress Notes dated [DATE] at 04:06 written by RN 2, it indicated, Resident A came back to the unit to the facility on this date. It also indicated, by end of shift resident (Resident A) refused blood sugar check told LN (Licensed Nurse) Get off me now repeatedly, and was combative during diaper change, repeatedly yelling angrily to LN get off me. Settled and kept quiet after care but noted to be biting repeatedly on her teeth. During a review of Resident A's progress notes indicated, .11/5/2019 0[AGE]0 . Transfer to Hospital Summary Note Text . The paper dropped by (Police officer's name, title and identification number) where (sic), a Your Rights, Your Rights as a Survivor of sexual assault brochure . During the review of Resident B's Care Plan under Discipline Codes Short Term Goals dated [DATE], it indicated, resident (Resident B) was seen with his pants down with a female resident (Resident A) who had her brief off with knees bent on her bed lying criss crossed in a sexual position. The resident (Resident A) is not able to consent for sexual action due to her mental status/dementia. During the review of Resident B's progress notes dated [DATE] at 15:37, written by the Director of Social Services (DSS), it indicated, DSS talked to resident (Resident B) regarding the reported incident happened early today around 2 am when he (Resident B) was found at the female's room (Resident's room number) (Resident A). That according to the staff who saw him (Resident B), he was by the bedside of resident (Resident A) at bed C with his pants down and exposed his private. DSS further informed resident (Resident B) that a police officer came past 3 am to talk to him (Resident B) but he was already sleeping at that time. He (Resident B) was reminded that they will come back again to conduct investigation. Resident (Resident B) didn't deny the reported incident - that he went to (Resident's room number) (Resident A's room) and exposed himself. But didn't give any reason why he (Resident B) did that. Resident (RB) preferred not to answer the question if he touched Resident (Resident's identification number) (Resident A) inappropriately. Further, resident (Resident B) was reminded that he had a series of sexual abuse incidents and he (Resident B) was informed of the consequences of his action. Resident (Resident B) told DSS that he will be leaving the facility for good today. During a review of the facility's Interdisciplinary Notes (IDT, a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient) dated 11/04/19, it indicated Resident B is alert, oriented and verbally responsive. Pleasant. Accommodating. Can make daily decision. Exhibited behavioral concern manifested by sexual preoccupation. Recently resident (Resident B) got involved in. sexual abuse involving other resident. On [DATE] at around 1:25 am, Certified Nurse Assistant (CNA 1) found (resident name) (Resident A) with her genital exposed and knees bent at the edge of the bed while male resident (resident name) (Resident B) standing by the bedside, pants down and exposed his private. During interview (resident name) (Resident A) stated that (resident name) (Resident B) tried to [***] her. (resident name) (Resident B) didn't deny but also didn't give the reason/s why he did it. IDT meeting notes also indicated, Reported incident was substantiated. Discharge of (resident name) (Resident B) was initiated. During observation and concurrent interview with Resident C on 11/6/19 at 10:33 am, Resident C looked well-kept but couldn't remember the alleged sexual abuse incident on 10/20/19 and continued talking about wars. During the review of Resident C's Care Plan under Discipline Codes Short Term Goals dated 10/20/19, it indicated, (resident's name) (Resident B) inappropriately touched pt (patient) (Resident C). Was seen rubbing her (Resident C) groin area. Short term goal, pt (patient) (Resident C) will not experience any distress regarding the incident. During a record review of Resident B's Care Plan dated 10/20/19, it indicated, monitor resident (Resident B) whereabouts Q 30 mins (every 30 minutes) for [AGE] hours. During the review of Resident C's IDT notes dated 10/21/19, it indicated, on 10/20/19 at about 8 pm, Care Manager (Staff name) saw Resident (Resident C) was touched inappropriately on her private parts by a male resident (Resident B). During investigation, perpetrator (resident name) (Resident B) denied the incident but upon reviewed video of the in-house camera along the hallway, it showed that reported incident was true .psychosocial monitoring for Resident C was ordered . reported incident was substantiated and verbal warning was given to (resident name) (Resident B). During a review of RB's Progress Notes dated 10/22/19 at 10:42, RN 2 wrote, resident (Resident B) was nowhere to be found in the unit since dinner time, did not sign out on the OOP book (Out On Pass). Came back in the unit at 2045 hrs. Resident (Resident B) reminded he need to inform staff if he is going out and sign the book, agreed .went to his room and ate dinner. During a review of the facility's Abuse Prevention Policies and Procedures dated 8/23/18, page 1 of the document indicated, It is the policy of (Facility's name) not to condone any form of abuse, mistreatment . it is also the facility's policy to take appropriate steps to prevent the occurrence and to ensure . sexual abuse . are reported .

Based on interview and record review, the facility failed to ensure one of one Residents (Resident 1) was free of significant medication error when two medications were not administered in accordance with the physician's orders [REDACTED].>1. [MEDICATION NAME] Solution 10 milligrams (mg) / (in) 5 milliliters (ml) 2.5 ml by mouth every 4 hours was ordered for Resident 1 but was given 7.5 ml (three times more than prescribed dose) on 10/7/18 at 9 am and 10/8/18 at 9 am; 2. an order for [REDACTED]. This failed practice led to a significant medication error that caused Resident 1 to be heavily sedated with decreased food and fluid intake and decreased O2 saturation (amount of oxygen in the blood). Findings: Review of Physician (MD) note titled Visit Type: Nursing Facility, Initial dated 9/28/18, at 4:40 pm indicated Resident 1 was admitted to the facility on [DATE] for comfort care (end of life care), with a [DIAGNOSES REDACTED]. A review of Lexicomp online undated, indicated [MEDICATION NAME] is An opioid [MEDICATION NAME] indicated for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate and has the potential for adverse reactions including serious, life-threatening or fatal respiratory depression (lack of oxygen and decreased breathing). Review of Physician order [REDACTED]. Review of Physician order [REDACTED]. Review of the document titled Controlled Substance Accountability Sheet for Resident 1 indicated [MEDICATION NAME] 15 mg ER was to be administered by mouth one tablet every 12 hours. It was documented as administered by LVN 1 on 10/8/18 at 9 pm and 10/9/18 at 9 am after being discontinued. Review of the Controlled Substance Accountability Sheet for Resident 1 indicated [MEDICATION NAME] 10 mg / 5 ml was to be administered at 2.5 ml by mouth. [MEDICATION NAME] Solution 7.5 ml was documented as administered by LVN 1 on 10/7/18 at 9 am and on 10/8/18 at 9 am. Review of the document titled Nursing Observation Notes for change of Condition Resident 1 indicated on 10/10/18 under Chief Complaint, Resident 1 had a change in level of consciousness and lethargy (drowsy / sleepy). Under Oral Assessment, Resident 1 was refusing to eat solids and had decreased fluid intake. Under Chest / Respiratory Assessment, Resident 1 was noted to have an episode of low O2 saturation on room air. During an interview on 10/19/18, at 2 pm, the Director of Nursing (DON) stated she identified a medication error on 10/9/18 while reviewing the controlled substance sheet. Resident 1 had an order to receive [MEDICATION NAME] Solution 10 mg / 5 ml (2.5 ml) every four hours for pain and tachypnea. A Licensed Vocational Nurse (LVN 1) mistakenly administered 7.5 ml [MEDICATION NAME] solution on 10/7/18 and 10/8/18 at 9 am. Resident 1 also had a medication order for [MEDICATION NAME] mg extended release tablets to be administered every 12 hours. The physician had an order to discontinue this medication on 10/8/18 at 10:35 am. A Nursing Supervisor (RN 1) failed to input the discontinued [MEDICATION NAME] into the Medication Administration Record [REDACTED]. Unaware of the new medication order, LVN 1 administered the discontinued medication on 10/8/18 at 9 pm and 10/9/18 at 9 am. During an interview on 11/16/18, at 9:43 am, the Medical Doctor (MD) of Resident 1 stated I found on 10/8/18, from the nurse, that the patient (Resident 1) was receiving the short-acting [MEDICATION NAME] instead of long-acting, which is not the way it was ordered. The patient's outcome was highly sedated after med error for about a week and was very distressing for the family. Review of the current Policy and Procedure titled Administering Medications dated (MONTH) 2012 indicated .Medications shall be administered in a safe and timely manner, and as prescribed.5. If a dosage is believe to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident . the person . administering the medication shall contact the resident's Attending Physician or the facilities Medical Director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to accurately assess two of 25 sampled residents' (Residents 4 and 9) pressure ulcers. Additionally, the facility failed to provide services to prevent the development of Resident 9's pressure ulcer and promote healing of Resident 9's pressure ulcer. 1. For Resident 4, his stage II pressure ulcer was assessed inaccurately. Failure to accurately assess Resident 4's pressure ulcer had the potential for inappropriate treatment and may negatively impact healing. 2. For Resident 9, the facility failed to: a. Accurately assess his pressure ulcer in order to provide appropriate treatment and appropriate dietary supplement for a stage III pressure ulcer. b. Consistently implement Resident 9's care plan interventions regarding repositioning. c. Revise Resident 9's care plan regarding preventative interventions when he was identified at high risk for developing a pressure ulcer on 1/18/16. For Resident 9, these deficient practices resulted in development of a stage II pressure ulcer. Additionally, due to inaccurate assessment, insufficient dietary supplement, and inconsistent repositioning, his stage II pressure ulcer deteriorated into a worsening pressure ulcer. His pressure ulcer degenerated into an unable to determine (UTD) pressure ulcer, which constituted harm. Definitions: A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage to the underlying tissue (s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. The definitions for the stages of pressure ulcers identified below are from the Long - Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0. Stage I - An observable, pressure - related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Slough tissue - non-viable yellow, tan, gray, green or brown tissue, usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Eschar tissue/Necrotic - dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. [MEDICATION NAME] tissue - new skin that is light pink and shiny (even in persons with darkly pigmented skin). In stage II pressure ulcer, [MEDICATION NAME] tissue is seen in the center and edges of the ulcer. In full thickness stage III and IV pressure ulcer, [MEDICATION NAME] tissue advances from the edges of the wound. Granulation tissue - red tissue with cobblestone or bumpy appearance, bleeds easily when injured. Undermining - the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. Findings: 1. Review of Resident 4's Minimum Data Set (MDS) assessment (a standardized resident assessment to facilitate care management), dated 8/2/16, indicated he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident 4's WOUND/SKIN HEALING RECORD, dated 7/22/16, indicated a . stage II (pressure ulcer on his) . right buttocks. Staff documented this stage II pressure ulcer had . Black/Brown (eschar) . The National Pressure Ulcer Advisory Panel's (NPUAP) website defines stage II pressure ulcers as partial-thickness loss of skin with exposed dermis (living tissue below the skin). The wound bed is viable, pink or red, moist . The website indicated eschar (dark scab) is found in unstageable pressure ulcers not on stage II pressure ulcers. During an interview on 8/24/16 at 10:00 AM with the Nursing Supervisor (NS), Resident 4's pressure ulcer assessments and the NPUAP information were shared with the NS. The NS stated, No it should not be like that (stage II pressure ulcers should not have eschars). 2. Review of Resident 9's face sheet indicated he was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. from interruption of its blood supply), and adult failure to thrive (describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Review of Resident 9's Minimum Data Set (MDS) assessment, dated 6/27/16, indicated he was totally dependent on one staff assistance for bed mobility and he was not resistant to care. a. Review of Resident 9's clinical records indicated incomplete and inaccurate pressure ulcer assessments. Resident 9's Wound/Skin Record, dated 4/26/16, indicated stage II with slough in wound bed. Another Progress Notes, dated 6/14/16, indicated . wound bed moist beefy with yellow slough surrounding area is dark brownish in color warm. Remain on stage 2 (II). Review of Resident 9's record, dated 7/14/16, indicated staff did not document the stage of Resident 9's pressure ulcer. Review of Resident 9's records, dated 7/26/16 and 8/2/16, indicated stage II with slough in wound bed. According to NPUAP, stage II pressure ulcers do not contain slough. During an interview on 8/29/16, at 9:58 AM, Licensed Vocational Nurse (LVN) 6 stated his assessment of Resident 9's pressure ulcer dated 5/10/16, 6/24/16, and 7/14/16 had incomplete information regarding odor, wound bed, surrounding skin color, and wound edges. LVN 6 stated his assessments regarding Resident 9's pressure ulcer dated 4/26/16, 7/26/16, and 8/2/16 were inaccurately assessed as stage II. The pressure ulcer should have been assessed as a stage III due to the presence of slough. During an interview on 8/25/16, at 11:09 AM, Registered Nurse (RN) 2 reviewed Resident 9's wound records and stated, When there's slough, it's stage III already. The staging is wrong. During an interview on 8/26/16, at 2:23 PM, the Director of Nursing (DON), stated, I know my treatment nurse (LVN 6) is a LVN. He's not certified to be a wound nurse. He report(s) to me every week. The DON stated, We did not train him. When he applied for the position, he mentioned and in his resume that he knows to perform the wound treatment for [REDACTED]. I trust his judgement. If he had questions, I assist him and I go with him to see the wound. There was no documented evidence LVN 6 was provided supervision regarding the inaccurate assessments and omissions found within Resident 9's pressure ulcer records. Review of the facility's job description for a treatment nurse, dated 4/11/16, indicated, . The primary purpose of your job position is to provide primary skin care to residents under the .supervision of .Director of Nursing Services .with an emphasis on treatment and therapy of skin disorders.Identify, manage, and treat specific skin disorders .such as .(pressure) ulcers . During an interview with the Certified Nursing Assistant (CNA) 8, direct care staff for Resident 9, on 8/23/16, at 8:15 AM, he stated Resident 9's pressure ulcer was healed. CNA 8 was unaware Resident 9's pressure ulcer had deteriorated into a stage III pressure ulcer. During an interview with the Director of Staff Development (DSD), on 8/22/16, at 2:45 PM, she stated, I didn't know he still .(has a) pressure ulcer. I thought it was healed. During an observation of Resident 9's pressure ulcer with the Nursing Supervisor (NS) on 8/24/16, at 10:30 AM, the NS stated Resident 9's pressure has deteriorated. The NS stated, It's stage III now. It has 30% (percent) slough, maceration in edges of the wound, blanchable (application of light pressure will whiten the skin and skin color should quickly turn pink as pressure is removed) and reddish in skin color. The NS stated, I will notify (the DON), continue turning the resident strictly every two hours, and I will update the care plan. The NS stated the assessment of the treatment nurse was not accurate and He needs education. During an interview, on 8/26/16, at 2:10 PM, RN 2 stated, Resident 9's . pressure ulcer is UTD (Unable to determine - unstageable/unclassified, full thickness skin or tissue loss - depth unknown). Almost 100% slough with undermining of 0.3 cm, 6 o'clock to 9 o'clock. RN 2 stated Resident 9's pressure ulcer was deteriorating. I recommend strict turning every two hours, make a log for turning schedule, and sufficient supplement of Vitamin C or multivitamins to promote wound healing. During an interview on 8/24/16, at 10:08 AM, the Nursing Supervisor (NS) reviewed Resident 9's record, titled Order Summary Report, dated 7/19/16. The report indicated staff were applying .hydrogel (a hydrating gel, for partial and full-thickness wounds), (wound dressings) Apply to .(tail bone area) topically one time a day for stage I pressure ulcer . The NS stated there was an error in the order, . (the order was not updated, the pressure ulcer was a) stage II not stage I. That's an error. Review of the facility's policy and procedure, titled Pressure Ulcer Treatment, revised on 7/21/16, indicated hydrogel was appropriate for .stage II (or) .stage III pressure ulcers. There was no documentation in the facility's policy directing staff to use hydrogel on stage I pressure ulcers with intact skin. During an interview with the Director of Dietary Services (DDS), on 8/24/16, at 3:05 PM, she stated Resident 9 .has stage II pressure ulcer on . (bottom of the spine) area. She stated she based her dietary recommendations by checking on the resident, talking to the treatment nurse, looking at the treatment record and progress notes. The DDS stated, I didn't add any multivitamins .(his pressure ulcer was) healing. The DDS' statement regarding Resident 9's healing pressure ulcer was inaccurate. Review of the clinical record for Resident 9's Wound/Skin Healing Record, dated, 7/7/16, indicated, it had deteriorated from a stage II into a stage III pressure ulcer. b. Review of Resident 9's Minimum Data Set (MDS) assessment, dated 6/27/16, indicated he was totally dependent on one staff assistance for bed mobility. Resident 9's MDS indicated he was not resistant to care. Review of Resident 9's pressure ulcer care plan, initiated 10/2/15, indicated staff were to Assist in turning and repositioning in bed every 2 hours and .(as needed). During an interview, on 8/25/16, at 9:45 AM, RN 2 stated, CNA's doesn't document the turning of the resident every 2 hours. RN 2 showed the turning and repositioning schedule attached to her ID (identification) badge. During an interview on 8/25/16, at 12:40 PM, CNA 9 stated, We have this turning schedule attached to my ID. CNA 9 stated, I missed (turning Resident 9 at) .9 o'clock. Review of the turning and repositioning schedule information attached next to a staff member's ID, indicated there were clearly defined body orientation every two hours for residents who required assistance with repositioning. For example, at 7:00 AM, the resident should be position on his back; at 9:00 AM, the resident should be facing the window. During an interview on 8/26/16, at 2:48 PM, the DON stated the turning and repositioning schedule attached to staff's ID was part of their policy. When asked if staff should follow the schedule, she stated, I think so. The facility policy and procedure titled Pressure Ulcer Treatment , revised date 7/21/16, indicated Purpose: .to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers.Stage I Pressure Ulcer Interventions/ Care Strategies: .4. Immobility: a. Turn Schedule; and b. Restorative Nursing (range of motion, walking, bed mobility). There were no turn schedule identified as treatment interventions in the facility's protocol for dependent residents with stage II, III, or IV pressure ulcers. The facility policy and procedure titled Pressure Ulcer Assessment and Risk Assessment, revised date 10/10, indicated .General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues.5. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin . According to NPUAP website, www.npuap.org, Pressure Ulcer Treatment, Quick Reference Guide, dated 2009, indicated .General Recommendations: .Positioning: .2. Continue to turn and reposition the individual regardless of the support surface in use. c. Review of Resident 9's Braden scale score (a tool to assess pressure ulcer risks. A score of less than 12 indicates high risk. A score of 13-14 indicates moderate risk), dated 10/2/15, indicated he scored 13. Review of Resident 9's Risk Pressure Ulcer Care Plan, dated 10/2/15 indicated he was at moderate risk for developing pressure ulcers. Review of Resident 9's Braden scale score, dated 1/18/16, indicated he scored 11. A Braden score of 11 indicated Resident 9 was now at high risk for the development of a pressure ulcer. Even though Resident 9 was identified at high risk for developing a pressure ulcer, there was no documented evidence new preventative measures were implemented from 1/18/16 to 3/20/16 to prevent the development of a pressure ulcer. Resident 9 developed a stage II pressure ulcer while at the facility on 3/21/16.

Based on observation, interview, and record review, the facility failed to maintain the weight of one of 25 sampled residents (Resident 1), when: a. Resident 1's lunch tray was served late; b. Resident 1 was not served her health shake for breakfast; c. two staff caring for Resident 1 was not aware she was still losing weight; d. documentation regarding offering of alternatives and percentage (%) consumption of health shakes for Resident 1 was not done. These failures resulted in Resident 1 experiencing a significant weight loss of 12 % or 12 pounds (lbs) over six months from 11/15 to 5/16; which constituted harm. Findings: Review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment to facilitate care management), dated 7/5/16, indicated she was admitted with multiple [DIAGNOSES REDACTED]. (a progressive disorder of the nervous system affecting movement), dehydration (lack of water), [MEDICAL CONDITION] (joint pain and stiffness), thin bones, and a history of falls. Resident 1's MDS indicated her cognition was severely impaired. She scored 0 out of 15 on her Brief Interview for Mental status (BIM is an assessment tool to evaluate cognition). Resident 1 required extensive assistance of one staff with transfers and was totally dependent on one staff during meals. Review of Resident 1's Medical Nutrition Therapy Quarterly note, dated 6/6/16, indicated her weight on 11/15 was 95 lbs and her weight on 4/16 was 83 lbs. This was a total weight . loss of . (12) lbs/12% x 6 months . continue diet and shake (three times a day) . Review of Resident 1's Monthly Weight, not dated), indicated for . August (2016, her weight was) 80 (lbs) . During observation on 8/22/16 at 12:15 PM, on the third floor dining room, four staff were passing out lunch trays to 11 residents in the dining room. Resident 1 was seated at a table with three other residents. Resident 1 did not receive her lunch tray. Resident 1 was left alone in her wheelchair while staff assisted Resident 1's table mates with lunch. Staff did not bring in Resident 1's lunch tray until 12:46 PM (31 minutes later). During an interview on 8/22/16 at 12:58 PM, Certified Nursing Assistant (CNA) 4 was assisting Resident 1 with her lunch. CNA 4 stated she was not aware Resident 1 was still losing weight. CNA 4 was unable to explain why staff waited 31 minutes before assisting Resident 1 with her lunch tray. During an interview on 8/22/16 at 2:50 PM, the Director of Staff Development (DSD) stated Resident 1 . (was) stable, no weight loss . After reviewing Resident 1's weight data, the DSD stated Resident 1 was declining and there . ( was a continual and) . gradual weight loss. The DSD stated given the continuing weight loss, Resident 1 should be a priority regarding assistance with meals. During observation on 8/23/16 at 8:05 AM, there was no shake on Resident 1's breakfast tray. During an interview on 8/23/16 at 8:30 AM, CNA 6 stated she served Resident 1 her carton of shake then threw . (the empty carton into) the garbage. During a concurrent observation into all the trash bins within Resident 1's room, CNA 6 stated there was no discarded carton of shake within these trash cans. CNA 6 was unable to provide evidence Resident 1 was served her shake during breakfast. During an interview on 8/23/16 at 8:45 AM, the Director of Dietary Services (DDS) stated Resident 1's shakes should be served with each meal three times a day. Review of Resident 1's Meal Intake Record for August 2016, indicated for 12 out of 63 meals (19.1%) she ate less than half of her meal. There were four refusals and two omissions in her August Meal Intake Record. There were no additional documentation in her Activity of Daily Living (ADL) records regarding these entries. Review of Resident 1's Meal Intake Record for July 2016, indicated for 31 out of 93 meals (33.3%) she ate less than half of her meal. There were two refusals and one omission in her Meal Intake Record. There were no additional documentation in her Activity of Daily Living (ADL) records regarding these entries. Review of the facility's document titled NUTRITIONAL CARE MANAGEMENT, Dated 1/06, indicated staff . will note any meals where resident consumes less than fifty percent (50%) and initiate the following actions: . The resident must be offered an alternative selection from the same food groups . Document in the . notes section on the back of the ADL Record a narrative note of resident's refusal, alternatives offered and resident's acceptance. Narrative note should be cosigned by the licensed charge nurse . During an interview on 8/25/16 at 1:00 PM, the Director of Nursing (DON) reviewed Resident 1's meal intake records and the DON stated her expectations were staff should be documenting if alternatives were offered if Resident 1 had a low intake and staff should be documenting amount of shake consumed on the ADL records.

Based on interview and record review, the facility failed to maintain proper hydration of one sampled resident (Resident 1) when the staff failed to do timely follow-up of abnormal laboratory results, implement care plan for hydration, and implement facility's hydration policy and procedure. These deficient practice resulted in Resident 1 requiring admission to the hospital for dehydration on 8/2/13. Findings: Resident 1 was admitted to the facility for rehabilitation on 6/29/13. His [DIAGNOSES REDACTED]. On 7/5/13, Resident 1 complained of shortness of breath, was transferred to the hospital with [DIAGNOSES REDACTED]. Resident 1 was readmitted to the facility on [DATE] for continued rehabilitation. Review of the 7/15/13 MDS (Minimum Data Sheet - an assessment tool) indicated Resident 1 had moderately impaired mental status and required extensive assistance in eating and drinking. Review of the 7/2013 Medication Record indicated Resident 1 was administered [MEDICATION NAME] (a medication used to reduce extra fluid in the body by increasing urine output) 20 mg. (milligrams) once a day for [MEDICAL CONDITION] from 7/9/13 to 7/30/13 (21 days). According to online.lexi.com (lexicomp - medication information website) adverse effects of [MEDICATION NAME] included fluid loss and electrolyte (minerals in the body like calcium, magnesium, sodium etc.) loss; and close medical supervision and dose evaluation are required. Review of the 7/10/13 Registered Dietitian notes indicated, Resident 1 was on a mechanical soft diet with estimated fluid needs of 1,800 milliliters per day (approximately 7 glasses). Review of the 24 hour fluid Intake and Output (I&O) Record from 7/27/13 to 8/2/13 (seven days prior to admission to the hospital) indicated the following: 7/27/13 - 460 ml. 7/28/13 - 1,300 ml. 7/29/13 - 340 ml. 7/30/13 - 900 ml. 7/31/13 - 1,200 ml. 8/1/13 - 1,020 ml. 8/2/13 - 720 ml. Review of the CNA (Certified Nursing Assistant) notes of meal percentages intake from 7/16/13 to 8/1/13 (17 days) indicated multiple blank sections that did not record if Resident 1 ate his meals or if he refused to eat. On the sections that were filled, it indicated Resident 1's meal intake were ranging from 10% to 50%. The section for Snacks/Nourishment from 7/16/13 to 8/1/13 (17 days) indicated Resident 1 did not have snacks or nourishment. Review of the laboratory tests on 7/20/13 indicated high urea nitrogen of 42 (normal 5-26) and high creatinine 2.29 (Normal 0.61-1.24). This result was faxed to the physician on the same day but there was no documentation on the medical record of follow-up if the physician reviewed the results. On 7/30/13, laboratory result indicated, high urea nitrogen of 53 and high creatinine of 2.10 which was faxed to the physician, but there was no documentation on the medical record of follow-up if the physician reviewed the results until the following day on 7/31/13. The 7/31/13 Nurse's Notes indicated, "at 2:30 PM, order (from physician) noted to do renal (kidney) ultrasound, refer to nephrologist (physician specializing in kidney disease), hold [MEDICATION NAME]" The lack of timely and appropriate follow-up of abnormal laboratory results put Resident 1 at risk of dehydration and other possible complications like kidney failure. According to National Kidney Foundation website (kidney.org), kidneys can become damaged if they are not getting good blood flow. This can happen if you become dehydrated or seriously ill. High creatinine (waste product that comes from the normal wear and tear on muscles of the body) level of greater than normal may be an early sign that the kidneys are not working properly. High blood urea nitrogen (urea nitrogen - waste that comes from the breakdown of protein in the foods we eat) level may be an early sign that kidney function decreases. Review of the Dehydration Potential Assessment of Resident 1 indicated on 6/29/13 (first admission) and 7/8/13 (second admission), indicated Resident 1 was assessed as "low risk for dehydration". The section "Predisposing factors: prior [DIAGNOSES REDACTED]. During an interview and concurrent record review on 4/25/14 at 10:30 AM, the Registered Dietitian (RD) stated she was not informed by the licensed staff or the CNAs that Resident 1's food intake was ranging from 10%-50% as indicated on the July 2013 meal percentage record sheet. She stated that she was not informed Resident 1's fluid intake was less than 1,800 ml. per day as indicated on the I&O sheet, that's why she did not reassessed Resident 1 until he came back from the hospital on [DATE] with [DIAGNOSES REDACTED]. During an interview with concurrent record review on 5/9/14 at 1:32 PM, CNA 1 stated she took care of Resident 1 on 7/28, 7/29 and 7/30/13 in the afternoon shift. CNA 1 stated Resident 1 was able to drink and eat by himself as long as the food was set up in front of him. CNA 1 stated Resident 1 was not able to pick up a heavy water pitcher to fill up a glass so she made sure there was always a glass of water in front of Resident 1. CNA 1 stated she documented on the meal percentage sheet that Resident 1 did not eat much at dinner time (25% to 40%) but did not report it to the licensed nurse. During an interview with concurrent record review on 5/9/14 at 2:16 PM, LVN (Licensed Vocational Nurse) 1 stated she took care of Resident 1 on 7/27/13 and 7/28/13 morning shift (6 days prior to Resident 1's admission to hospital). The meal percentage sheet was reviewed with LVN 1 and she acknowledged on 7/27 and 7/28, Resident 1 either refused or ate 20%-40% of the food. The I&O was reviewed and LVN 1 verified Resident 1 had 1,760 ml. (approximately 7 glasses) of fluids in total for two days. When asked if she was aware of Resident 1's fluid needs per day, she stated, "No." When asked if she assessed prior days of food and fluid intake to check if Resident 1 was eating and drinking well, LVN 1 stated, "There's no process that I'm supposed to check prior days of food and fluid intake." LVN 1 stated she did not assess Resident 1 for signs and symptoms of dehydration on 7/27/13 and 7/28/13. During an interview with concurrent record review on 5/9/14 at 2:54 PM, LVN 2 stated she took care of Resident 1 on 7/29/13 and 7/30/13 morning shift (3 days prior to Resident 1's admission to hospital). The meal percentage sheet was reviewed with LVN 2 and she acknowledged on 7/29/13 and 7/30/13, Resident 1 ate 10% to 40% of the food. The I&O sheet was reviewed with LVN 2 and she acknowledged Resident 1 had 1,240 ml. (approximately 5 glasses) of fluids in total for two days. When asked if she was aware of Resident 1's fluid needs per day, she stated, "No." When asked if she assessed prior days of food and fluid intake to check if Resident 1 was eating and drinking well, LVN 2 stated, "No." When asked if she assessed Resident 1 for signs and symptoms of dehydration on 7/29/13 and 7/30/13, she stated, "No, because Resident 1 was walking around the building and seemed to be okay." During an interview on 5/9/14 at 4:11 PM, Charge Nurse (CN)/Registered Nurse stated she does not usually review the meal percentages and I&O forms unless licensed staff would tell her there was a significant change on a resident, like if the resident was not eating or drinking well, or if there were signs and symptoms of dehydration. CN stated she was not told Resident 1's food intake was less than 75% and fluid intake was less than what the resident needed. CN stated she was informed Resident 1 went for an appointment but paramedics brought him to Emergency Department (ED) because of dehydration. Review of the care plan for Fluid Volume Deficit dated 7/8/13 indicated Resident 1 was at risk for fluid volume deficit (dehydration) related to use of diuretics ([MEDICATION NAME]). The interventions included were to assess mucous membranes, promote good oral intake, monitor side effects of diuretic, refer to dietitian as needed. Review of the care plan for Malnutrition and Dehydration, dated 7/8/13, indicated Resident 1 was at risk due to multiple factors including poor intake. The interventions included to encourage to eat 75% of meals and monitor for signs and symptoms of dehydration like poor skin turgor, dry mucous membrane, decrease urine output and abnormal laboratory results. Review of the Nurses Notes indicated on 8/2/13 at 9:15 AM, "Resident went out for cardiology (physician specializing in [MEDICAL CONDITION]) follow-up... at 11:55 AM, the nurse wrote, "Transport called that they were not able to bring resident back to facility cause he was admitted to the hospital." Review of the 8/2/13 ED (Emergency Department) Report indicated, " He (Resident 1) was sent in by Dr. 1 (cardiologist) for dehydration and abdominal pain...Diagnoses: [REDACTED]. 2. Dehydration." Review of the 8/2/13 hospital H&P indicated, "The patient (Resident 1) had follow-up blood labs (laboratory) done at his skilled nursing facility. He was noted to have worsening renal (kidney) function... He was seen earlier by Dr. 1... found to be altered with low blood pressure and clinically dehydrated." During an interview and concurrent medical record review on 5/19/14 at 4:00 PM, the Director of Nursing (DON) stated licensed nurses should review food and fluid intake, refer the resident to RD or physician if resident was not eating or drinking well and assess for signs and symptoms of dehydration. DON verified and acknowledged that the Registered Dietitian, Nursing and physician progress notes [REDACTED]. DON acknowledged there was no timely and appropriate follow-up of abnormal laboratory results and the hydration care plans were not implemented. During interview on 5/19/14 at 4:05 PM, the Administrator stated the facility had policy to assess the resident's food and fluid intake and inform the physician or the dietitian for change of condition. He acknowledged the facility's hydration P&P (Policies and Procedures) were not implemented by the facility staff. Review of Resident Nutrition Services P&P revised December 2007 indicated, "7. Nursing personnel should evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems. Nursing staff will assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition. 8. Significant variations from usual eating or intake patterns must be recorded in the resident's medical record. The Nurse Supervisor and/or Unit Manager shall evaluate the significance of such information and report it, as indicated, to the Attending Physician and Clinical Dietitian." Review of the Resident Hydration and Prevention of Dehydration policy and procedure (P&P) revised December 2011 indicated, "1. The Dietitian will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need. 6. Nursing will assess for signs and symptoms of dehydration during daily care. 10. The Dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medication that may exacerbate dehydration (e.g. diuretics) will be reviewed and held if medically appropriate. 11. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration."

Based on observation, interview and record review, the facility failed to ensure that food is obtained for resident consumption from sources approved, or considered satisfactory by Federal, State, or local authorities. The facility also failed to follow safe sanitation, handling and transportation practices to prevent the outbreak of foodborne illness. This was evidenced by transporting potentially hazardous food (PHF) for resident consumption in vehicles that had no refrigeration to keep the PHF safe during transport. The facility failed to store adequate food supply to meet residents' food need in cases of emergency/disaster. The facility's noncompliance resulted in increased potential risk for widespread serious harm, i.e., food poisoning, that could adversely affect the health and safety of all residents of the facility, due to the outbreak of foodborne illness, such as E. coli, or Salmonella infections. Potentially Hazardous Food (PHF), or Time/Temperature Control for Safety (TCS) Food refer to food that requires time/temperature control for safety to limit the growth of pathogens, or toxin formation by pathogens. Foodborne illness refers to illness caused by ingestion of contaminated food or beverages. Pathogen refers to an organism that is capable of causing a disease (e.g., pathogenic bacteria, or virus). E. coli infection causes abdominal cramps and diarrhea, which is sometimes bloody. Salmonella infection causes fever, abdominal cramps and diarrhea beginning 12 hours to a week after consuming a contaminated food, or beverage. Toxin is a chemical compound, produced by bacteria capable of causing serious illness. The deficient practices identified by this violation had a reasonable degree of predictability of a similar situation occurring in the future. The deficient practices constituted a multi-system failure that had the potential to affect all residents of the facility. The survey team identified and called an Immediate Jeopardy (IJ) on on 10/6/10 at 3:30 PM, as a result of the above violations. The Administrator was present at the time the IJ was announced. The IJ was not removed at the time of exit on 10/6/10. The temporary plan of correction, written by the Administrator on 10/6/10 at 5:10 PM, was not accepted. Findings: During the tour of the facility kitchen on 10/5/10 at 11:15 AM, the dry storage area was observed to have low supply of staple food items. Canned foods were depleted. Two 68 oz. (oz, ounce, a measure of volume) cans of mushrooms were dented. The walk-in refrigerator contained four boxes of pasteurized eggs that were marked "for emergency use only." In an interview the RD (Registered Dietitian) on 10/5/10 at 3:15 PM said that she was responsible for completing the order list of food supplies that she gives to Mr. X every Tuesday and Friday. Food supplies were enough only for 3 or 4 days. The RD did not know where Mr. X bought the food supplies and that there was no regular date, or time, when, or if the delivery will arrive. The RD stated that it was difficult to maintain inventory, because the original orders were altered, changed, items not ordered as specified on the original order sheet. It was possible that vegetables were bought from Farmers' Market and this was not an approved source. Food items, like meat and dairy products that are considered potentially hazardous foods need to be delivered and stored under controlled temperatures (Reference: www.fsis.usda.gov/oa/topics/transportguide.pdf <http://www.fsis.usda.gov/oa/topics/transportguide.pdf). They were transported in different vehicles, driven by Mr. X. The RD stated that she does not know how long it has been in the van, or how long it had taken for Mr. X to transport the food supplies from the supplier to the facility. The RD also stated on 10/15/10 at 3:15 PM, that she often has to make substitutions on the planned weekly menus, because the items she ordered were not delivered. The facility's Weekly Seasonal Menu from 9/13/10 to 9/26/10 was reviewed with the RD. This menu showed the following hand written menu changes, due to undelivered supplies: On 9/14/10, Tuesday, the lunch entree called for garlic mashed potatoes and apricot vanilla dessert. The hand written notes stated "no garlic in the mashed potatoes" and "no pudding." On 9/15/10, Wednesday, the lunch entree showed fish with tartar sauce. This was crossed off and replaced with chicken. On 9/16/10, Thursday, the lunch entree showed green beans and cauliflower. The handwritten note stated "did not have it." Replaced with frozen, mixed vegetables. On 9/18/10, Saturday, the lunch entree showed veal patty with creamy sauce. The handwritten note stated "had only for 20 residents. The rest ate beef." On 9/20/10, Monday, the breakfast entree showed fried egg. This was crossed off and replaced with hardboiled egg. On 9/20/10, Monday, the lunch entree showed garden green peas. This was crossed off and replaced with corn. The Pineapple Kuchen for dessert was replaced with orange. On 9/21/10, the lunch entree showed golden squash. This was crossed off and replaced with mixed vegetables. The purple plum crisp for dessert was crossed off and replaced with canned pineapple tidbits. On 9/22/10, Wednesday, the breakfast centres showed muffin with margarine. The muffin was crossed off and replaced with toast and margarine. On 9/22/10, the dinner entree showed cheese fondue. This was crossed off and replaced with macaroni and cheese. On 9/23/10, the breakfast entree showed prune juice. This was crossed off and replaced with apple juice, or cranberry juice. The french toast was crossed off and replaced with waffle with margarine. On 9/23/10, the lunch entree showed zucchini squash with margarine, this was crossed off and replaced with corn. Mr. X was not available for interview, because he is neither a Helping Hands, nor a Grove Street Extended Care and Living Center employee. During an interview the director of nursing (DON) on 10/5/10 at 4:15 PM stated that there were no contracts with vendors to supply food to the facility. She said that, "I think food items were purchased from a large grocery store chain, an international chain of membership warehouses, or Smart and Final." During an interview the Administrator on 10/5/10 at 4:35 PM said that there were no written contracts with food suppliers to deliver food regularly. He acknowledged and confirmed that he was aware that Mr. X purchased the food supplies for the consumption of the residents. The food supplies were transported and delivered to the facility by Mr. X using vehicles with no refrigeration. The Administrator also acknowledged and confirmed that the delivery schedule was erratic since August, 2010; and that he did not know where Mr. X will purchase the food supplies that were on the order list. Review of a copy of the Order List showed the food items for the menu from Thursday to Tuesday, from Sept. 23 to Sept. 28, 2010. The type and the amount of items were checked indicating that the items were delivered. The following items were on the list, but were not checked, not delivered: Meat items: chicken thigh, boneless 40 lbs.(pounds); cheese enchilada 1 case; roast turkey 20 lbs.; roast pork 40 lbs.; diced beef 60 lbs.; ground beef 60 lbs.; ground pork 40 lbs.; diced pork 40 lbs.; pork sausage 1 case; peanut butter cookie dough 1 box; french toast 2 cases; pancake 2 cases; sliced potatoes 2 bags. Vegetables: cauliflower 12 bags; broccoli 12 bags; zucchini 12 bags; green beans 12 bags. Dry goods: sliced peaches 6 cans; rocky road pudding 6 cans; vanilla pudding 6 cans; tapioca pudding 6 cans; dinner roll 45 pieces; cheesecake 165 pieces; beef gravy 5 bags; orange sherbet ice cream 60 cups; tator tots 1 box (a type of French fries), black bean sauce 3 bottles and pasteurized liquid egg 20 boxes of 30 ounces each. Review of the receipts for the purchases made from September 2, 2010 to October 5, 2010 showed that some of the food items were bought in the following stores: Costco Wholesale, Smart & Final, Grocery Outlet Bargain Market, Safeway Store, Cash & Carry Smart Foodservice, Lucky Store, New May Wah Supermarket, Foods Co. and 99 Ranch Market. Review of the above purchase receipts did not clearly indicate the source of the weekly supply of fresh fruits and vegetables. According to www.FoodSafety.gov: "Bacteria may be present on products, when you purchase them. Plastic-wrapped boneless chicken breasts and ground meat, for example, were once part of live chickens, or cattle. Raw meat, poultry, seafood and eggs are not sterile. Neither is fresh produce, such as lettuce, tomatoes, sprouts and melons.Foods, including safely cooked, ready-to-eat foods, can become cross-contaminated with bacteria transferred from raw products, meat juices or other contaminated products, or from food handlers with poor personal hygiene. Bacteria multiply rapidly between 40 ?F and 140 ?F. To keep food out of this "Danger Zone...Store food in the refrigerator (40 ?F or below) or freezer (0 ?F or below)." According to www.fsis.usda.gov/oa/topics/transport guide.pdf , "Food safety protection can be improved by the control of hazards through the use of preventive methods, including good sanitation, manufacturing practices, and the Hazard Analysis and Critical Control Point (HACCP) system throughout the food production and distribution chain. Meat, poultry, and egg products must be refrigerated or frozen after processing and before shipment to inhibit spoilage and growth of pathogens. During transportation and storage, the challenge is to maintain proper refrigeration temperatures and to keep the "cold-chain" from breaking during steps such as palletization, staging, loading and unloading of containers, and in storage." The facility demonstrated a multi systems failure, by: Transporting PHF from stores at high temperatures, instead of refrigerated containers that inhibit bacterial growth; thus putting the residents at risk for foodborne illnesses. The facility had no system in place to ensure that the food supply of 168 residents is continuously maintained by an approved vendor. The facility had no system in place to ensure that the food supply is adequate to provide the food needs of 168 residents for seven days in case of an emergency/disaster. An immediate jeopardy (IJ) was identified and called on 10/6/10 at 3:30 PM, due to facility's failure to ensure that foods were procured for resident consumption from approved sources; and for the facility's failure to ensure the safe transport of the food under sanitary condition. The IJ was announced to the Administrator on 10/6/2010 at 3:30 PM. The facility submitted a plan of correction on 10/8/10, but the corrective measures did not remove the immediate jeopardy.

Based on observation, interview and record review, the facility failed to ensure that each resident receives the necessary care and services to obtain optimal improvement, to attain the highest practicable physical, mental and psychosocial well-being of Resident 1 and Resident 2. This was evidenced by failure to provide sequential compression device (SCD, a pneumatic compression device that intermittently applies pressure, in sequence, from the ankle area toward the knee to force blood flow to the heart, to reduce accumulation of blood in the legs.); failure to carry out physician's orders [REDACTED]. The cumulative effect of these failures was a deficiency that was likely to cause serious injury, i.e., [MEDICAL CONDITION] (development of blood clots in the leg veins), or death to the residents, and therefore constituted an immediate jeopardy (IJ). The deficient practice identified by this violation had a reasonable degree of predictability of a similar situation occurring in the future. The deficient practice was a systemic failure that had the potential to affect 2 out of 2 residents of the facility, who had a physician's orders [REDACTED]. The survey team identified and called an immediate jeopardy on 9/22/10 at 4:50 PM as a result of the above violations. The administrator and the director of nurses were present at the time the immediate jeopardy was announced. IJ was not removed prior to exit on 9/22/10. A temporary plan of correction (POC), written by the administrator on 9/22/10 at 6:00 PM was accepted. The IJ was lifted on 9/24/10. Findings: During an interview on 9/22/10 at 2:45 PM, the administrator reiterated the physician's orders [REDACTED]. The facility did not make lease payments to the vendor and the vendor re-possessed the SCDs on 9/16/10. During observation on 9/22/10 at 3:20 PM, Resident 1 was sitting in a wheelchair at bedside. Resident 1 had eye contact. Resident 1 had two plus (2+), on a scale of one to four, swelling in both lower extremities (legs). In an interview on 9/22/10 at 3:23 PM Resident 1 stated that there was pain on a scale of nine over ten (9/10) in both legs. During observation, on 9/22/10 at 3:30 PM, Resident 2 was lying on the back in bed with one plus (1+), on a scale of one to four, swelling on the left leg. There was no SCD observed for Residents 1 and 2. During an interview on 9/22/10 at 4:00 PM Physician 1 stated that he ordered SCD for Residents 1 and 2 and he did not order to discontinue SCD for them. Physician 1 also stated, Residents 1 and 2 needed SCD to reduce the risk for [MEDICAL CONDITION] ([MEDICAL CONDITION], formation of a blood clot in the leg veins). The clinical record for Residents 1 and 2 were reviewed on 9/22/10. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. For venous stasis. "Resident 1's care plan, dated 6/3/09, indicated, "Excess in fluid volume as evidenced by [MEDICAL CONDITION] on both lower extremities," and the care plan's approaches included, "Apply SCD on both lower extremities as ordered." Nurses Notes dated 9/16/10 indicated SCD was "taken out by the company." The facility failed to implement the physician's orders [REDACTED]. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Monitor hours of use every shift." Resident 2's care plan with a revised date of 8/3/10, indicated: "Risk for [MEDICAL CONDITION], elevated blood pressure (BP), hypotensive episodes (sudden decrease in blood pressure), headaches, and dizziness." The care plan's approaches included: "Apply sequential compression device to both lower extremities when in bed." Nurses Notes dated 9/17/10 indicated: "SCD D/C (discontinued)." The facility failed to implement the physician's orders [REDACTED]. Facility's "Policy & Procedures On Sequential Compression Device", not dated, (received from the director of nurses on 9/22/10) indicated that the policy was to "... ensure the safe and effective use of Sequential Compression Device." The purposes were: "To reduce the risk of [MEDICAL CONDITION]" ([MEDICAL CONDITION], a formation of blood clot(s) in the vein) and "To stimulate arterial blood flow." The procedures included: "Follow prescribed therapeutic pressure as per PT (Physical Therapy) or MD order" and "Document number of hours of use q (per) shift." The facility failed to follow its own P&P for SCD. The facility on 9/22/10 had a census of 163 residents. Two residents had a physician's orders [REDACTED]. The facility failed to acquire replacement SCDs from September 16, 2010 until September 24, 2010. The facility failed to provide any documented evidence to acquire the SCDs. The facility failed to prepare and failed to implement a care plan for Resident 1 and Resident 2 at the time, when the vendor repossessed the SCDs for lack of lease payments. The facility failed to provide alternative care plan for the two residents between September 16, 2010 and September 22, 2010 to reduce the risk of developing [MEDICAL CONDITION]. The facility physician was consulted on 9/22/10 at about 5:15--5:30 PM by facility staff to develop an alternative care plan for the two residents. The temporary Plan of Correction, dated 9/22/10 at 6:00 PM, states: "...application of TED hose, thigh high, lower extremity elevation, and C.N.A.'s to perform massage on the three residents at the following frequency and duration: 3 times per shift, for 5 minutes per leg." The deficient practice had the potential to cause serious injury, serious harm, serious impairment that could affect the whole body, i.e., [MEDICAL CONDITION] (development of blood clots in the leg veins), or death and there was a reasonable degree of predictability of a similar deficient practice occurring in the future. The deficient practice represented a systemic failure that had the potential to affect 2 out of 2 residents of the facility, who had a physician's orders [REDACTED]. The survey team identified and called an immediate jeopardy on 9/22/10 at 4:50 PM, as a result of the above violations. The administrator and the director of nurses were present at the time, when the immediate jeopardy was announced on 9/22/10 at 4:50 PM. The survey team accepted a written plan of correction (POC) for the immediate jeopardy, dated 9/22/10 at 6:00 PM, in the presence of the administrator and the director of nurses. The facility's corrective actions included ordering SCD on 9/22/10 and documenting the order. In the meantime, a physician was consulted on the actions to "mitigate the risk presented by---application of TED hose (elastic stockings), thigh high, lower extremity elevation, and CNA (certified nurse assistant) to perform massage---three times per shift for five minutes per leg. Those measures will be logged and documented by the staff performing them. Those orders will be carried out until the devices are ready to be put into service on these residents. At that time the physician will be notified for detailed orders regarding the parameters he wants for their use. The Department will be notified by phone and by fax when the ordered devices arrive."

The facility failed to: 1. Provide the prescribed diabetic supplements resulted to Resident A's continued weight loss and the development of an unstageable pressure sore in resident's sacral area. Resident A had a weight loss of 18 pounds ( 17.12% ) in 10 months. Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had a 06/01/09 physician order [REDACTED]. The Minimum Data Set (MDS-assessment), dated 05/11/10, indicated that Resident A had short term memory problem and modified independence in decision making ability. She required extensive assistance from staff with eating. Resident A was totally dependent on staff for her activities of daily living, i.e., bed mobility (turning in bed, sitting up in bed), transfer to and from wheel chair/bed, bathing, personal hygiene, locomotion, dressing. She speaks a foreign language. The resident had a weight loss of 5%, or more in the last 30 days, or 10% or more in the last 180 days. Resident A had no ulcers. The Care Plan, dated 05/08/09, indicated: "The problem/concern: At risk for [MEDICAL CONDITION] and dehydration due to dysphagia (difficulty of swallowing), diet, dementia, assisted to dependent with feeding, [MEDICATION NAME] intolerance and swallowing difficulty..usual body weight-130 pounds per family..referred to speech therapist for swallowing evaluation." The approaches were as follows: "Serve diet and fluids as ordered, assess for signs and symptoms (S/S) of acute illness and report to physician (MD), keep water pitcher within reach at bedside, offer substitutes for refused foods/fluids, monitor weight and report any significant weight loss to (MD) physician and family, monitor for (S/S) of dehydration, (i.e.. poor skin turgor, dry mucous membranes..), encourage to eat at least 75% of meals, monitor weight as indicated, Asian puree nectar thick liquids, no added salt, no concentrated sweets..jook with meals..soy milk at meals..family member visit and will do feeding too..dietary consult as needed." During an observation on 09/17/10 at 1:20 p.m., Resident A was lying in bed, awake. She looked thin, her skin was dry and her face unhappy. She had an open wound in the sacral area with a yellow and black tissue surrounding the wound. When asked the resident about her care, (with an interpreter) she did not answer the questions appropriately. Resident A's weight record, dated 10/10/09, showed the admission height was 4'8" and the weights were taken on the following dates: 10/10/09---- 105.10 pounds 11/10/09---- 105.12 pounds 12/01/09---- 100.20 pounds 12/12/09---- 102.0 pounds 01/07/10---- 100.08 pounds 01/14/10---- 98.12 pounds 02/03/10---- 98.04 pounds 03/02/10---- 98.02 pounds 04/07/10---- 94.12 pounds 05/14/10---- 93.0 pounds 06/09/10---- 92.12 pounds 07/07/10---- 88.12 pounds 08/09/10---- 87.0 pounds 09/08/10---- 87.12 pounds Based from the resident's weight record indicated that Resident A had a weight loss in 30 days-4 pounds=4.35%; in 90 days-6 pounds=6.39% and in 180 days-11 pounds=10.48% The Initial Nutritional Assessment, dated 05/28/09, showed that Resident A's daily fluid requirement was 1770 milliliters, Protein daily requirement was 47-59 grams and the Calorie daily requirement was 1630 calories. The (RD) Registered Dietitian's annual review, dated 07/29/10, indicated: "Diet-mechanical soft, ground,(NCS ) no concentrated sweets, ( NAS ) no added salt, thin liquid. No jook. Feed self ( w/ ) with (po) by mouth intake: (brkfst ) breakfast-61%, lunch-39% and dinner-59%. Resume oatmeal at (brkfst ) breakfast; (DM ) diabetes mellitus-2 (cal) calorie formula-60 (cc ) cubic centimeter at medication pass. Boost DM (BID ) two times a day. [MEDICATION NAME] with Vitamin D-500 mg ( TID ) three times a day.Multivitamin with minerals every afternoon and 4 (oz) ounces San Francisco house supplement (TID ) three times a day with medication. ( WT ) weight 88.12 pounds and (BMI) body mass index-19.8-acceptable. Had weight losses 30 day-4 pounds=4.35 % (percent), 90 days-6 pounds=6.39% and 180 days-10 pounds=10.3%. Alert and verbally responsive. Diet tolerated.." There was no ( RD ) Registered Dietitian's initial assessment and follow up assessment from 11/09 to 7/29/10 about the resident's weight loss of 105.12 to 88.12 pounds. In 6 months --from 04/07/10 to 09/08/10, 98.02 pounds to 87.12 pounds, the resident lost 11 pounds ( 11.2% ) and in 10 months from 01/07/10 to 09/08/10, 105.12 pounds to 87.12 pounds, the resident lost 18 pounds ( 17.12% ). There was no follow up assessment when supplements were not provided, and the amount of calorie and the protein requirement for wound healing for the resident's pressure ulcer in the sacral area.There was no additional intervention other than the previous supplements mentioned in the dietary assessment note. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was receiving the prescribed diabetic 2-calorie formula at 5:00 p.m. for 100 cc ( cubic centimeter ) from 9/01/10 to 9/10/10.Resident A did not receive the prescribed boost (DM) 240 milliliters orally two times a day on 09/11/10 through 09/15/10.The resident received boost ( DM ) for 100 cc from 9/01/10 to 9/10/10.Resident A did not received house supplements on 09/01/10 through 09/15/10. Based from the Manufacturer's Guidelines indicated that boost DM 2 cans (per 8 oz )-190 calories=380 calories and 16 grams of protein=32 grams of protein; diabetic 2 calorie would have 237 calorie per day and 10 grams of protein. To meet the increased protein and calorie needs, to stressed resident's protein intake for wound healing, Resident A's nutrition required 475 calories and 19.8 grams of protein. Reference: Pocket Resource for Nutrition 2009 Edition Dietetics in HealthCare Communities American Dietetics Association In an interview on 09/15/10 at 9:45 a.m., Dietary Assistant 1 stated, "I was instructed to make the sugar free supplements, but we could not determine, if it's sugar free...we are just guessing it. The delivery of the food and the sugar free supplements was cancelled since September 1,2010." During an interview on 09/15/10 at 11:30 a.m., the Registered Dietitian (RD) said, "This is my big problem, because the delivery of foods and sugar free supplements was cancelled since September 1, 2010. We are using the blender to do the sugar free and other house supplements. It's hard to determine, if it is really sugar free." When the Surveyor asked the RD if the resident's calorie requirement had met and the intervention to meet the protein need for the resident's wound healing, she had no idea. In an interview on 09/16/10 at 11:00 a.m., LVN 1 stated, "I can't give the prescribed dietary supplements, because it was not available. Sometimes I gave only one, because the other two prescribed supplements were not available." An interview on 09/16/10 at 11:20 a.m., the Director of Nursing ( DON ) did not respond when the Surveyor asked her on 09/16/10, about the RD's nutritional assessment and follow up asssessments for this resident.She could not provide to the Surveyor the nutritional initial and follow up assessments from 11/09 to 07/29/10. Finally, she faxed it to Daly City office the Registered Dietitian's ( RD ) initial nutritional assessment which was dated 05/28/09. In an interview on 09/17/10 at 11:30 a.m., Resident A's family member said, "I come here everyday, bring food from home and feed my mom. She doesn't want to eat, she has poor appetite. I feel sorry for my mom, because she continues to lose weight." Resident A's family member showed to this Surveyor and the Ombudsman a cup of rice..not fully cooked (it felt hard to touch) wrapped in aluminum foil..she said, the rice was served to her mom and she kept it, to show it to the Ombudsman during the meeting. An interview on 09/17/10 at 11:40 a.m., the Registered Dietitian ( RD ) said, " The reason why the rice was cooked that way, it's because we are using different brand of rice now. We use a better brand of rice before..it takes a while to get used to cooking this new brand of rice." The Nurse's Notes for 09/14/10 indicated, "Reported by staff, noted inflammation on sacral area, scab on the affected site...adheres wound bed brownish in color, negative drainage...obtained order from (MD) physician to discontinue previous order [MEDICATION NAME] (antibiotic) instead cover with [MEDICATION NAME] every 3 days..." Therefore, the facility's failure to provide the prescribed diabetic supplements resulted in Resident A's continued weight loss and the development of an unstageable pressure ulcer to resident's sacral area. Resident A had a weight loss of 18 pounds ( 17.12 % ) in 10 months. The above violations presented either imminent danger that death, or serious harm would result; or a substantial probability that death, or serious physical harm could result.