Every finding on record at Shafter Nursing Care

Based on observation, interview, and record review, the facility failed to follow its policy and procedure titled, Response to Falls for one of three sampled residents (Resident 1). This failure had the potential for staff not identifying Resident 1's decline in condition and potential for delay in care. Findings: During an observation on [DATE] at 9:48 a.m. in Resident 1's room, Resident 1 was lying in bed with a soft neck brace (soft foam collar to stabilize the neck). Resident 1 was not answering to questions, was unable to be interviewed. During a review of Resident 1's SBAR (situation, background, appearance, review and notify) Communication Form dated [DATE] at 2:16 p.m., the SBAR indicated Resident [1] fell in the dining area. Noted a bump to the right head and right forehead. Recommendations: orders received to monitor for 72 hours and initiate neurological [network made up of brain, spinal cord, and nerves] checks per facility protocol. During a review of Resident 1's Emergency Department Reports (EDR), dated [DATE], EDR indicated, This [Resident 1] is a [AGE] year old female history of hypertension [high blood pressure], dementia [memory loss] who presents with fall and head trauma [injury to scalp, skull or brain] today. She [Resident 1] fell three times last month and lives at the facility. They [facility staff] sent her [Resident 1] in because she hit her head today. During a review of Resident 1's Neurological Flow Sheet [NFS-assessment for level of consciousness, motor strength, and sensory function], dated [DATE], the NFS indicated the neurological assessment started at 4:15 p.m. (two hours after the fall incident) and ended 6:15 p.m. (two hours). Resident 1's NFS was not completed for 72 hours. During a review of Resident 1's Care Plan Report (CPR) dated [DATE], the CPR indicated, High risk for repeated falls due to history of falls, poor safety awareness, impulsive behavior. Interventions: Neuro checks [neurological assessment] per protocol. During a review of Resident 1's Nurses Note dated [DATE] at 1:41 p.m., the Nurses Notes indicated, Resident [1] returned from hospital. During a review of Resident 1's SBAR dated [DATE] at 9:22 p.m., the SBAR indicated, Resident [1] had unwitnessed fall hitting head. Small amount of bleeding was noted on right side/back of head. Recommendations: send to hospital. During a review of Resident 1's NFS dated [DATE] the NFS indicated only one assessment completed at 8:40 p.m. Resident 1's NFS was not completed for 72 hours. During a review of Resident 1's EDR dated [DATE], EDR indicated. Post [after] unwitnessed fall, likely chronic C2 fracture [broken bone in the neck], degenerative [condition or disease that gets progressively worse over time] changes C1-C2 [neck bone] , retrolisthesis [spinal condition where one of the bones in your backbone slips backward over the bone directly beneath it] mild C2 and C3 [neck bone].During a review of Resident 1's Nurses Notes dated [DATE] at 12:12 p.m. (approximately 16 hours after the fall incident), Resident [1] arrived to facility from hospital at approximately 12:07 p.m. Resident [1] returned to facility wearing the appropriate cervical collar [neck brace] as ordered.During a concurrent interview and record review on [DATE] at 10:20 a.m. with Director of Nursing (DON), DON reviewed the NFS dated [DATE] and [DATE]. DON stated the NFS were not completed. DON stated the neurological assessments were not completed for 72 hours.During a review of the facility's policy and procedure (P&P) titled, Response to Falls, dated [DATE], the P&P indicated, Post Fall Assessment and Monitoring: B. The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall or witnessed fall with known head injury for 72 hours following the fall.

Based on interview and record review, the facility failed to report an unusual occurrence with major injury for one of three sampled residents (Resident 1). This failure had the potential for negative consequences.Findings:During an interview on 5/26/26 at 1:52 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was sent to the hospital (unknown date) for falling out of bed. CNA 1 stated Resident 1 does not move at all and is not sure how she (Resident 1) was able to fall out of bed. CNA 1 stated Resident 1 is dependent (helper does all effort) on staff for all aspects of care including moving.During an interview on 5/26/26 at 3:01 p.m. with Director of Nursing (DON), DON stated on 5/21/26 Resident 1 had an unwitnessed fall from her bed. DON stated the unwitnessed fall was shocking to the facility as she has had no previous falls in the past. DON stated Resident 1 was sent to the acute hospital for treatment due to a large (no measurements given) laceration (a jagged or irregular tear or cut in your skin) on her head (not specific where). DON stated the facility did not report this unusual occurrence to the California Department of Public Health (CDPH) because the facility thought process was only major injuries should be reported.During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 5/29/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was NA (unable to assess).During a review of Resident 1's MDS Assessment, dated 5/28/26, under the section titled, GG, the GG section indicated Resident 1 was completely dependent on staff for all aspects of care.During a review of Resident 1's acute hospital, History and Physical (H&P), dated 5/21/26, the H&P indicated, This is a [AGE] year-old female (Resident 1) who is nonverbal (unable to speak), with developmental delay (a person continually behind in gaining the expected skills compared to others their same age) and lives at a nursing facility. She reported to the emergency department via ambulance as reported by facility staff that (Resident 1) had a fall from her bed . she had an unwitnessed fall and she had sustained a left periorbital (around or surrounding the eye) laceration with bleeding. CT (an advanced type of x-ray) . head shows Small bilateral (both sides) intraventricular (within the ventricles [a network of four connected, fluid-filled cavities located deep inside the brain]) hemorrhage (bleeding) is present and ventriculomegaly (ventricles are larger than normal due to a buildup of fluid). Emergency department physician contacted on-call neurosurgeon (specialized doctor of the brain). Assessment/Plan . Facial laceration . Above ground fall from a low-lying bed with . intracranial (inside the skull) hemorrhage .During a review of Resident 1's acute hospital Discharge Summary (DC), dated 5/27/26, the DC indicated, Discharge Diagnosis . Traumatic (sudden severe physical harm) bilateral intraventricular hemorrhage . Traumatic head trauma . Unwitnessed fall from bed . Left-sided facial bone fractures (break in bone). 5/22/26 . CT Head . Subtle (not obvious) fracture anterior wall (front portion) of the left maxillary sinus (a hollow space in the bones around the nose). Nondisplaced fracture (a break in bone that remains lined up) of the left orbital floor (bottom part of the eye socket).During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 11/1/17, the P&P indicated, Purpose . To ensure that timely reports are made to designated agencies as required by state and federal law . The Facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences. The Facility has a no-retaliation policy toward anyone who makes good faith reports to the Department of Public Health or for any other reporting required by law. The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies . Other occurrences that interfere with Facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.Findings:During a concurrent interview and record review on 4/7/26 at 11:52 a.m. with Director of Staff Development (DSD), facility's Nursing Staffing Assignment and Sign-In Sheet (NSASS), dated January 2026 was reviewed. The NSASS indicated, there was no RN available to work in a consecutive 8 hour shift on 1/17/26 and 1/24/26. DSD stated there was no RN present in the building for 8 hours a day on 1/17/26 and 1/24/26.During a concurrent interview and record review on 4/7/26 at 11:54 a.m. with DSD, facility's NSASS, dated December 2025 was reviewed. The NSASS indicated, there was no RN available to work in a consecutive 8 hours shift on 12/24/25. DSD stated there was no RN present in the building for 8 hours a day on 12/24/25.During a review of the facility's policy and procedure (P&P) titled, RN Staffing Coverage Policy, dated 8/9/2016, the P&P indicated, F727 requires that nursing homes have an RN onsite at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review, the facility failed to accurately complete the quarterly Minimum Data Set (MDS-part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. A comprehensive assessment of each resident's functional capabilities is completed) assessment for one of 44 sampled residents (Resident 10). This failure had the potential for Resident 10 to not receive the appropriate required services. Findings:During a review of Resident 10's MDS assessment, dated 3/9/26, the MDS indicated, Section I- Active diagnoses in the last 7 days included Depression (a common, serious medical illness that causes persistent sadness, loss of interest in activities, and a range of physical and emotional symptoms) and Schizophrenia (causing psychosis (hallucinations/delusions), disorganized thinking, and emotional disconnection from reality).During a review of Resident 10's Diagnosis Information (DI), dated 3/9/26, the DI indicated Resident 10 did not have documentation of a diagnosis of Depression or Schizophrenia.During a concurrent interview and record review on 4/9/26 at 9:35 a.m. with Minimum Data Set Coordinator (MDSC), Resident 10's MDS section I active diagnosis (MDS), assessment dated [DATE], was reviewed. The MDS indicated Resident 10 had an active diagnosis of Depression and Schizophrenia. MDSC stated Resident 10 does not have an active diagnosis of depression or Schizophrenia and Resident 10 is not taking medication for depression of schizophrenia. MDSC stated she did not complete the assessment accurately and she should have reviewed it before submitting. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated 2019, the P&P indicated, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interview, and record review, the facility failed to ensure meal preferences were honored for one of 25 sampled residents (Resident 82). This failure had the potential for nutritional needs not to be met for Resident 82. Findings:During a review of Resident 82's Meal Ticket (MT), dated 4/7/26, the MT indicated, Resident 82 dislikes Spinach.During a concurrent observation and interview on 4/7/26 at 11:22 a.m. with Dietary Aide (DA) 1, in the kitchen, DA 1 was checking Resident 82's lunch tray during tray line. Resident 82's lunch tray contained Meatballs and Gravy, Penne pasta with Garlic & Herbs, Zesty Spinach, Fresh [NAME] Salad, and Chocolate Cake. DA 1 stated Resident 82's tray was ready to be delivered to Resident 82. During a concurrent interview and record review on 4/7/26 at 11:23 a.m. with DA 1 in the kitchen, Resident's 82's MT dated 4/7/26 was reviewed. The MT indicated, Resident 82 dislikes Spinach. DA 1 stated she had not noticed the tray had Spinach on it. DA 1 stated she should have caught it and should have removed the spinach from the tray since the Resident 82 did not like it. During a review of the facility's policy and procedure (P&P) titled, Food Preferences, dated 2023, the P&P indicated, Resident's food preferences will be adhered to within reason. Substitutes for all food disliked will be given from the appropriate food group.

Based on observation, interview, and record review, the facility failed to implement effective infection control practices when:Hand hygiene was not provided for two of three sampled residents (Resident 19 and Resident 86) before residents were given their lunch tray. This failure had the potential to spread infection to residents.Dress Code policy was not followed by one of two sampled cooks (Cook 1) in the kitchen. This failure had the potential for food contamination.Findings: 1.During a review of Resident 19's BIMS (Brief Interview of Mental status), dated 1/17/26, the BIMS indicated Resident 19's score was 15 (cognitively intact). During a concurrent observation and interview with Resident 19 in Resident 19's room, Resident 19 was sitting up in bed eating his lunch. Resident 19 was asked if the Certified Nursing Assistant (CNA) had offered hand hygiene. Resident 19 stated he had not received hand hygiene and would like to have his hands cleaned. During an interview on 4/6/26 at 11:53 a.m. CNA 1 was asked if she had provided hand hygiene to Resident 19. CNA 1 stated she had not provided hand hygiene and stated she have offered. During a concurrent observation and interview on 4/6/26 at 11:58 a.m. in Resident 86's room, CNA 1 delivered Resident 86's lunch tray. CNA 1 was asked if she had provided hand hygiene to Resident 86 before giving him his lunch tray. CNA 1 stated she had not provided hand hygiene and stated she should have offered. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene During Mealtime, dated 2024, the P&P indicated, Hand hygiene is offered to all residents prior to meal tray service. Staff must ensure residents clean their hands before trays are passed or meals are served. 2. During a concurrent observation and interview on 4/7/26 at 11:17 a.m. in the kitchen with [NAME] 1, [NAME] 1 had a beard that was not covered with a beard restraint. [NAME] 1 was uncovering the food to check the temperature. [NAME] 1 stated he should have been wearing a beard restraint while he was in the kitchen. During an interview on 4/8/26 at 2:20 p.m. with Certified Dietary Manager (CDM), CDM stated the cook should have been wearing a beard restraint and stated it was her expectation for all staff that are in the kitchen to use a hair or beard restraint. During a review of the facility's policy and procedure (P&P) titled, DRESS CODE, dated 2023, the P&P indicated, If applicable, beards and mustaches (any facial hair) must wear beard restraint.

Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 1) Responsible Party (RP) a written notice of the Notice of Medicare Non-Coverage (NOMNC-a notification letter stating Medicare will no longer pay for services) and ensure NOMNC notice was understood by RP. This resulted in Resident 1 being discharged without being given the right to appeal the NOMNC decision.Findings:During an interview on 2/17/26 at 8:24 a.m. with Resident 1's RP, RP stated on 12/23/25 at approximately 4 p.m. she received a phone call from Social Service Designee (SSD) stating Resident 1 was being discharged to a room and board (housing arrangements for adults). RP stated she did not fully understand the NOMNC notice and was not given the option to appeal the NMNC decision. RP stated, She (Resident 1) was being discharged . I just did what they told me, I didn't know. I didn't know I had options.During a concurrent interview and record review on 2/23/26 at 1:03 p.m. with SSD, Resident 1's NOMNC letter was reviewed. The NOMNC letter indicated Please sign below to indicate you received and understood this notice. No RP signature was noted on Signature of Patient Representative line. SSD stated on 12/23/25, Resident 1's RP was notified by phone of Residents 1's NOMNC notice. SSD stated option to appeal was not provided to RP. SSD stated, (RP) was not opposed to discharge, so it (appeal option) was not discussed with her.During a review of Resident 1's clinical record, a facility form titled, Optional Form to Document Alternate Delivery Notice of Medicare Non-Coverage, indicated Resident 1's RP was notified by phone on12/23/25 at 4 p.m. regarding Resident 1's NOMNC notice. The form indicated, Document that representative verbalizes understanding of the information provided.During a concurrent interview and record review on 2/23/26 at 1:57 p.m. with SSD, SSD reviewed Resident 1's clinical record and was unable to provide documented evidence Resident 1's RP verbalized understanding of the NONMC notice.

Based on observation, interview, and record review, the facility failed to: 1. Ensure food was dated and stored under sanitary conditions. 2. Ensure food was maintained at safe temperatures. These failures had the potential to result in residents getting food borne illnesses. Findings: 1. During a concurrent observation and interview on 12/16/24 at 9:15 a.m. with Dietary Supervisor (DS) in the kitchen, a container labeled peas was on the top shelf of Refrigerator #3 with an cracked/unsealed lid. DS stated the container of peas should have been sealed. During a concurrent observation and interview on 12/16/24 at 9:19 a.m. with DS at Refrigerator #5, an egg tray containing approximately two dozen eggs was open, uncovered, and undated. A carton of Liquid Pasteurized eggs was opened but without an open date. DS stated the egg tray should have been left in the original container and there was no way to determine the expiration date of the eggs. DS stated the carton of Liquid Pasteurized eggs was good for 7 days from the date it was opened but there was no open date. During a concurrent observation and interview on 12/16/24 at 9:20 a.m. with DS at Refrigerator #5, three trays of corn salad in small bowls were stacked on top each other. No date was observed on the trays or on the individual salad bowls. DS stated the corn salad bowls should have been dated. During a concurrent observation and interview on 12/16/24 at 9:22 a.m. with DS at Freezer #8, frozen broccoli was not sealed in the plastic bag. DS stated the broccoli should have been sealed. During a concurrent observation and interview on 12/16/24 at 9:24 a.m. with the DS in the dry storage room, a plastic bag containing elbow macaroni was not labeled or dated, and a container of nonfat dry milk was not sealed. DS stated they should have been dated and sealed. During a review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, the P&P indicated, 9. Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date and used by date. 2. During an observation on 12/17/24 at 9:53 a.m. in the kitchen, three large metal trays covered with foil containing already baked lasagna were sitting on a shelf above the steam table. During an interview on 12/17/24 at 9:59 a.m. with [NAME] 1, [NAME] 1 stated the lasagna trays had come out of the oven approximately twenty minutes ago and were placed on the shelf above the steam table. During a concurrent observation and interview on 12/17/24 at 10 a.m. with Certified Dietary Manager (CDM) at the kitchen's steam table, the temperature of the lasagna in the three trays was taken by [NAME] 2. Lasagna Tray 1's food temperature was 127 degrees Fahrenheit (F-measurement of temperature), Lasagna Tray 2's food temperature was 143 degrees F, and Lasagna Tray 3's food temperature was 141 degrees F. CDM stated the food in Lasagna Tray 1 was not in the safe temperature range (140 F to 70 F). CDM stated the lasagna trays should not have been left on a shelf to cool off. During a concurrent observation and interview on 12/17/24 at 12:05 p.m. with DS, in the kitchen, peas were added to a resident's lunch plate during tray line. The temperature of the peas was not taken prior to plating and placing the plate in the dining cart. DS stated the temperature should have been taken prior to plating the food. During a review of the facility's P&P titled, COOLING AND REHEATING OF POTENTIALLY HAZARDOUS OR TIME/ TEMPERATURE CONTROL FOR SAFETY FOOD, dated 2023, the P&P indicated, POLICY: Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. PHF or TCS food include: . garlic . meat . pasta. PROCEDURE: When cooked PHF or TCS food will not be served right away it must be cooled as quickly as possible. The method is: THE TWO-STAGE METHOD Cool cooked food from 140 F to 70 F within two hours. 1) Previously cooked PHF or TCS food that will be hot-held should be rapidly reheated to an internal temperature of 165 F within two hours.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Informed Consent for eight of eight sampled residents (Resident 31, Resident 38, Resident 44, Resident 46, Resident 49, Resident 75, Resident 76, and Resident 286) receiving psychotherapeutic (affect thought, mood, perception, or behavior) drugs when the resident or resident's representative did not sign the VERIFICATION OF RESIDENT INFORMED CONSENT FOR PSYCHOTHERAPEUTIC DRUGS (California) (VRIC) form. This failure had the potential to result in questions regarding if informed consent had been obtained. Findings: During a review of Resident 31's VRICs, the VRICs for the following psychotherapeutic medications were found not to contain the resident or resident representative's signature: Clonazepam for anxiety (excessive feelings of worry, fear, or unease), dated 11/9/23; Seroquel for schizophrenia (chronic mental illness causing altered thought processes, perceptions, emotions, and social interactions), dated 9/5/24; Cymbalta for neuropathic (nerve) pain, dated 9/11/24; and Venlafaxine for major depressive disorder (persistent sadness), dated 4/1/24. During a review of Resident 44's VRICs, the VRICs for the following psychotherapeutic medications were found not to contain the resident or resident representative's signature: Duloxetine for major depressive disorder, dated 10/9/24; and Seroquel for Schizoaffective Disorder, dated 2/19/24. During a review of Resident 49's VRICs, the VRICs for the following psychotherapeutic medications were found not to contain the resident or resident representative's signature: Seroquel for Bipolar Disorder, dated 4/1/24; Depakote for Bipolar Disorder, dated 9/11/24; and Paxil for Major Depressive Disorder, dated 7/1/24. During a review of Resident 76's VRICs, the VRICs for the following psychotropic medications were found not to contain the resident or resident representative's signature: Prozac for Depression, dated 9/11/24; Remeron for Depression, dated 9/11/24; and Cymbalta for Depression, dated 9/11/24. During a review of Resident 286's VRICs, the VRICs for the following psychotropic medications were found not to contain the resident or resident representative's signature: Depakote for Bipolar Disorder, dated 12/16/24; Trazadone for Major Depressive Disorder, dated 11/19/24; Olanzapine for Schizoaffective Disorder, dated 11/19/24; Buspirone for Anxiety Disorder, dated 11/19/24; and Venlafaxine for Major Depressive Disorder, dated 11/20/24. During a concurrent interview and record review on 12/17/24 at 4:06 p.m. with Director of Nursing (DON), Resident 46's VRICs were reviewed. The VRIC's for the following psychotropic medications were reviewed and found not to contain the resident's signature: Temazepam for insomnia (inability to sleep), dated 11/14/24; Lexapro for Major Depressive Disorder, dated 9/9/24; and Wellbutrin for Major Depressive Disorder, dated 9/11/24. DON stated the facility does not have the resident sign the VRIC forms. During a concurrent interview and record review on 12/18/24 at 10:21 a.m. with Minimum Data Set Nurse (MDSN), Resident 75's VRICs were reviewed. The VRICs for the following psychotherapeutic medications were found not to contain the resident or resident representative's signature: Buspirone for Anxiety, dated 3/15/24; Xanax 1 mg for Anxiety, dated 7/2/24; and Xanax 0.25 mg (milligram) for Anxiety, dated 9/27/24. MDSN stated there was no place on the VRIC form for the resident or their representative to sign and there was no place for a nurse to witness a resident signature. During a concurrent interview and record review on 12/18/24 at 10:40 a.m. with MDSN, Resident 38's VRICs were reviewed. The VRICs for the following psychotherapeutic medications were found not to contain the resident or resident representative's signature: Buspirone for anxiety, dated 11/13/24; Depakote for Schizoaffective Disorder, Bipolar (extreme mood swings with changes in mood, behavior, ability to think, inability to sleep) type, dated 11/13/24; and Ziprasidone for Schizophrenia, Dated 11/13/24. MDSN stated the VRICs did not contain the resident or resident family member's signatures for consent. During a concurrent interview and record review on 12/18/24 at 2:09 p.m. with Administrator, the facility's policy and procedure (P&P) titled, Informed Consent, dated 11/30/2020, was reviewed. The P&P indicated, III. Obtaining Informed Consent A.i. An informed consent is required but not limited to, the administration of psychotherapeutic drugs . B. The resident or representative must sign an informed consent prior to administration of treatment/procedure. Administrator stated the facility was not following their P&P.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review on 12/17/24 at 11:05 a.m. with Director of Staff Development (DSD), the Nursing Staffing Assignment and Sign-in Sheet dated July 2024 were reviewed. The staff schedule indicated, there was no RN for 8 hours a day on 7/3/24, 7/4/24, 7/5/24, 7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/14/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/23/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24. DSD stated there was no RN present in the building for 8 hours a day on those days. During a concurrent interview and record review on 12/17/24 at 11:33 a.m. with DSD, the Nursing Staffing Assignment and Sign-in Sheet dated August 2024 was reviewed. The staff schedule indicated, there was no RN for 8 hours a day on 8/1/24, 8/6/24, 8/7/24, 8/8/24, 8/9/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24. DSD stated there was no RN present in the building for 8 hours a day on those days. During a concurrent interview and record review on 12/17/24 at 11:48 a.m. with DSD, the Nursing Staffing Assignment and Sign-in Sheet dated September 2024 was reviewed. The staff schedule indicated, there was no RN for 8 hours a day on 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, 9/30/24. DSD stated there was no RN present in the building for 8 hours a day on those days. During a concurrent interview and record review on 12/17/24 at 3:35 p.m. with DSD, the facility's policy and procedure (P&P) titled, RN Staffing Coverage Policy, dated 8/9/16 was reviewed. The P&P indicated, nursing homes have an RN onsite at least 8 consecutive hours per day, 7 days per week. DSD stated We don't meet the requirement for RN onsite at least 8 consecutive hours a day, 7 days a week. During a concurrent interview and record review on 12/18/24 at 7:38 a.m. with DSD, the Nursing Staffing Assignment and Sign-in Sheet dated October 2024 was reviewed. The staff schedule indicated, there was no RN for 8 hours a day on 10/1/24, 10/2/24, 10/3/24, 10/8/24, 10/9/24, 10/10/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/16/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/25/24, 10/29/24, 10/30/24, 10/31/24. DSD stated there was no RN present in the building for 8 hours a day on these days. During a concurrent interview and record review on 12/18/24 at 9:07 a.m. with DSD, the Nursing Staffing Assignment and Sign-in Sheet dated November 2024 was reviewed. The staff schedule indicated, there was no RN for 8 hours a day on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/5/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/11/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, 11/16/24, 11/18/24, 11/19/24, 11/21/24, 11/26/24, 11/27/24. DSD stated there was no RN present in the building for 8 hours a day on those days. During a concurrent interview and record review on 12/18/24 at 2:06 p.m. with DSD, facility's staff schedule dated December 2024 was reviewed. The staff scheduled indicated, there was no RN for 8 hours a day 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/8/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/13/24, 12/14/24, 12/15/24 . DSD stated there was no RN present in the building for 8 hours a day on those days. During a review of the facility's P&P titled, RN Staffing Coverage Policy, dated 8/9/16, the P&P indicated, nursing homes have an RN onsite at least 8 consecutive hours per day, 7 days per week.

Based on interview and record review, the facility failed to ensure Performance Evaluation (PE-a process to give employees feedback on their job performance) for two of eight sampled employees (Certified Nursing Assistance [CNA] 3, CNA 4), were completed. This failure had the potential for the staff not be aware of their need for improvement in certain areas, which could affect patient care. Findings: During a concurrent interview and record review on 12/18/24 at 8:33 a.m. with Director of Staff Development (DSD), CNA 3's PE was reviewed. The PE indicated, CNA 3 was hired on 3/28/23 and there was no PE found in their employee file. DSD stated CNA 3's annual PE had not been completed. During a concurrent interview and record review on 12/18/24 at 8:55 a.m. with DSD, CNA 4's PE was reviewed. The PE indicated, CNA 4 was hired on 11/1/21 and there was no PE found in their employee file. DSD stated CNA 4's annual PE had not been completed. During a review of the facility's policy and procedure titled, Employee Performance Evaluation, (undated), the P&P indicated, To provide employees with the necessary feedback about job performance, employees will receive performance evaluations.Performance evaluations will be kept in the employee's personnel file.

Based on interview, and record review, the facility failed to ensure MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessment was completed for one of 16 sampled residents (Resident 77). This failure had the potential for the delay in development and implementation of Resident 77's individualized care plan. Findings: During an interview on 12/19/24 at 11:45 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated MDS assessments need to be completed on admission, quarterly, annually and at discharge. MDSN stated MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD-the specific end point of look-back periods in the MDS assessment process). During a concurrent interview and record review on 12/19/24 at 11:53 a.m. with MDSN, Resident 77's clinical record (CR), (undated) was reviewed. The CR indicated, Resident 77's admission MDS was completed on 7/30/24. MDSN stated Resident 77's quarterly MDS assessment had not been completed and was overdue. MDSN stated Resident 77's quarterly MDS should have been completed in October 2024. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated November 2019, the P&P indicated, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements.(2) Quarterly Assessments- Conduct not less frequently than (3) three months following the most recent.assessment of any type.2. A comprehensive assessment includes: a. completion of the Minimum Data Set (MDS).12. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessment are used to develop, review and revise the residents comprehensive care plan.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Pre-Admission Screening and Resident Review (PASRR) for two of two sampled residents (Resident 66 and Resident 38) with identified serious mental illness diagnoses when an updated PASRR Level 1 was not submitted. This failure had the potential for residents not to receive the specialized mental health services to meet their needs. Findings: During a review of Resident 66's History and Physical Reports (H&P) from General Acute Care Hospital (GACH), dated 1/22/24, the H&P indicated, Resident 66 had a history of Schizoaffective Disorder (a serious mental health condition with symptoms of hallucinations [seeing or hearing things that are not there]), delusion (false belief that is held even when presented with evidence that it is not true), depression (persistent sadness), and mania (abnormally elevated mood, energy, or activity), Anxiety (excessive feelings of worry, fear, or unease), and Suicidal behavior (threatening to harm or kill oneself). During a review of Resident 66's PASRR Level 1 screening from GACH, dated 1/23/24, the PASRR indicated, the screening was negative and indicated No to the question Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis [mental health condition with loss of contact with reality], Delusions, and/or Mood Disturbance? During a concurrent interview and record review with Minimum Data Set (MDS- comprehensive standardized assessment of resident's functional capabilities and health needs) Nurse (MDSN), Resident 66's Diagnosis Report (DR), dated 12/17/24, and MDS Section I- Active Diagnoses, dated 11/19/24, were reviewed. The DR indicated Resident 66 had diagnoses of Schizophrenia (chronic mental illness causing altered thought processes, perceptions, emotions, and social interactions), Anxiety Disorder, and depression. The MDS indicated, Resident 66 had active diagnoses of Anxiety Disorder, Depression, and Schizophrenia. MDSN stated Resident 66's admitted was 1/24/24. MDSN stated when a new resident is admitted , she checks the PASRR Level 1 screening. MDSN stated she inputs the diagnoses into the MDS, but she does not have a process for checking the PASRR against the resident's diagnoses for accuracy. MDSN stated based on Resident 66's admitting diagnoses, she should have submitted a new PASRR Level 1 screening. 46958 During a review of Resident 38's Admission Record (AR), (undated), Resident 38 had a diagnosis of Schizophrenia (a mental illness that affects a person's thoughts, feelings and behaviors), Major Depressive disorder, Anxiety, Schizoaffective Disorder, Bipolar Type (mental health condition that causes extreme mood swings). During a review of Resident 38's PASRR Level I Screening from GACH, dated 11/13/24, the PASRR indicated the screening was negative and indicated No to the question Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis [mental health condition with loss of contact with reality], Delusions, and/or Mood Disturbance? During a concurrent interview and record review on 12/18/24 at 3:38 p.m. with Director of Nursing (DON), Resident 38's PASRR, dated 11/13/24 was reviewed. DON stated Resident 38 was readmitted to facility from hospital and had new diagnosis on 11/13/24 for Schizoaffective Disorder, Bipolar Type. DON stated PASRR Level I screening was completed by the GACH and had been filled out wrong. DON stated it is ultimately the facility's responsibility to make sure the PASRR is completed correctly with all current diagnosis. During a review of the facility's policy and procedure (P&P) titled, Pre-Admission Screening and Resident Review (PASRR), dated 7/1/23, the P&P indicated, Procedure.III.If the MDS does not match the PASRR Level 1 from the GACH or there is a significant change in the resident's mental or physical condition, the Facility is responsible for completing and new PASRR Level 1.

Based on observation, interview, and record review, the facility failed to implement one of six sampled residents' (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) when the facility did not ensure Resident 1's room was well-lit and Resident 1 was wearing footwear (item of clothing that covers and protects the foot, including the soles of the feet) when walking. These failures resulted in Resident 1 sustaining a nondisplaced fracture (broken bone that did not move out of alignment) of the neck of the right femur (thigh bone) requiring open reduction and internal fixation (surgical procedure that treats severe bone fracture or dislocation by realigning the bones and stabilizing them with internal hardware [tools or devices used in medical procedures]). Findings: During a review of Resident 1's Admission Record (AR), dated 11/15/24, the AR indicated, Diagnosis. Spondylosis (age-related breakdown in the spine [backbone]) . Muscle Weakness (Generalized). Anemia (condition in which the body does not have enough healthy red blood cells that provide oxygen throughout the body) . Unsteadiness on Feet (difficulty walking or maintaining balance). During a review of Resident 1's Admission Minimum Data Set (MDS - an assessment tool), dated 9/24/24, the MDS indicated under Section GG (Functional Abilities and Goals) Resident 1's admission performance required substantial or maximal assistance (helper does more than half the effort) with putting on or taking off footwear. The MDS indicated walking was not attempted due to safety concerns (Resident 1 was not walking at the time of assessment). During a review of Resident 1's Care Plan (CP), dated 9/23/24, the CP indicated, (Resident 1) is high risk for falls related to generalized weakness, balance problems, decreased strength. Interventions. Footwear to prevent slipping when ambulating (walking). Keep environment well-lit. During a review of Resident 1's Clinical Health Status with Baseline Care Plan (CHSBCP), dated 9/23/24, the CHSBCP indicated Resident 1 had a score of 13 indicating he was high risk for falls. During a review of Resident 1's SBAR (Situation Background Appearance Review), dated 11/3/24, the SBAR indicated, Res (Resident 1) had a witnessed fall (someone had seen the fall) when attempting to sit on the edge of his bed; abrasion (scrape) to top of head, skin tear (cut) to R (right) elbow, and c/o (complained of) pain with AROM (assisted range of motion - assistance provided to move a part of the body through its full range of movement) to RLE (right lower extremity). During a review of Resident 1's Medication Administration Record (MAR), dated November 2024, the MAR indicated Resident 1 had a pain level of 3/10 (mild pain) on 11/3/24 at 3:05 a.m. (time of fall). During a review of Resident 1's RISK MANAGEMENT IDT (Interdisciplinary Team - group of professionals who assess, coordinate, and manage each resident's comprehensive needs [RMI]), dated 11/3/24, the RMI indicated, (Resident 1) is high risk for falls. He is alert and able to make needs known. Resident interviewed and stated, I (Resident 1) was getting out of the restroom and when I got out, I turned around (to sit on his bed) and my feet slipped. Xray (medical imaging technique that uses radiation to create a picture of the inside of the body) was completed. MD (Medical Director) orders to send out to ER (emergency room ) for further eval (evaluation) and tx (treatment). During a review of Resident 1's Core Analytics Lab & Radiology Patient Report (CALRPR), dated 11/3/24, the CALRPR indicated, There appears to be an acute (severe and sudden in onset) nondisplaced right femoral (part of the thigh bone) neck fracture. During a review of Resident 1's SBAR Post Fall (SBARPF), dated 11/3/24, the SBARPF indicated, Prior to fall resident was: a. Ambulating (walking). Bare Feet. Environment. Dim lighting. Injury. Skin tear. VISION STATUS. Poor (with or without glasses) During a review of Resident 1's Nurses Note (NN), dated 11/6/24, the NN indicated, Recently sent out to (acute hospital) due to hip fracture to right side with admitting diagnosis of fracture of femoral neck (right), s/p (status post [condition after]) open reduction internal fixation. During a review of Resident 1's Documentation Survey Report (DSR - activities of daily living [basic personal tasks that people perform in their everyday lives] flowsheet), dated November 2024, the DSR indicated on 11/3/24 night shift, CNA 1 provided Resident 1 partial or moderate assist (helper does less than half the effort) with putting on or taking off footwear. During a concurrent observation and interview on 11/15/24 at 12:56 p.m. with Resident 1 in Resident 1's room, Resident 1 was not wearing footwear. Resident 1 stated he needed assistance when getting up and walking. Resident 1 stated, I couldn't do (walking) it myself. I'm scared of falling again. Resident 1 stated, I don't think I was (wearing footwear at the time of fall). During an interview on 11/18/24 at 4:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 11/3/24 she was guiding Resident 1 to the restroom at 2:40 in the morning. CNA 1 stated Resident 1 slipped and fell when she was assisting him back to bed. CNA 1 stated every time a staff would assist a resident to walk, the staff must make sure the resident wears a nonskid (designed to prevent slipping or skidding) footwear for safety. During an interview on 11/19/14 at 10:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, He (Resident 1) told me (11/3/24) when he was about to sit on the bed, when he turned, his legs flew under him. He was barefoot. LVN 1 stated it was dim in Resident 1's room and the overhead light was the only light on. LVN 1 stated Resident 1 was supposed to wear nonskid footwear whenever walking to prevent slipping. LVN 1 stated CNA 1 could not find Resident 1's nonskid footwear when Resident 1 was going to the restroom, but LVN 1 found Resident 1's nonskid footwear in Resident 1's room after the fall on 11/3/24. During an interview on 11/19/24 at 2:07 p.m. with Physical Therapy Assistant Rehabilitation Coordinator (PTARC - treats residents through exercise, massage, gait and balance training, and coordinates rehabilitation services for residents), PTARC stated Resident 1 was supposed to wear nonskid socks or nonskid footwear when walking to prevent slipping. During an interview on 11/19/24 at 2:33 p.m. with Director of Nursing (DON), DON stated Resident 1's cause of fall on 11/3/24 was Resident 1's feet slipped. DON stated Resident 1 was barefoot when he fell . During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, Purpose To ensure that a comprehensive person-center Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) discharge care plans were developed. This failure had the potential for Resident 2 and Resident 3 to have unmet care needs upon discharge. Findings: During a review of Resident 2's Admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE] and discharged on [DATE]. During a review of Resident 2's Multidisciplinary Care Conference, (MCC) dated 9/9/24, MCC indicated, (Resident 2) wishes to return to room and board when discharge is appropriate. During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted on [DATE] and discharged on [DATE]. During a review of Resident 3's MCC, dated 6/12/24, the MCC indicated, (Resident 3) wishes to ALF (assisted living facility) when discharge is appropriate. During a concurrent interview and record review on 10/2/24 at 12:34 p.m. with the Director of Nursing (DON), DON stated Discharges are a team effort, planning start on admission, each resident should have a care plan indicating the reason why they are here and how long they are going to stay, short or long term. Resident 2 ' s care plans were reviewed. DON confirmed Resident 2 did not have a discharge care plan. Resident 3 ' s care plans were reviewed. DON confirmed Resident 3 did not have a discharge care plan. DON stated she expects a discharge care plan to be completed once the MCC is completed. During a review of the facility ' s policy and procedure (P&P) titled, Care Planning, revised 11/1/17, the P&P indicated, Purpose To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. II. The Care Plan serves as a course of action where the resident (resident ' s family and/or guardian or legally authorized representative), resident ' s Attending Physician, and IDT (Intradisciplinary Team) work to help the resident move toward resident-specific goals that address the resident ' s medical, nursing, mental and psychosocial needs. II. Each resident ' s Care Plan will describe the following: . E. Discharge plans as appropriate . III. The resident ' s preference and potential for future discharge.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from financial abuse when: 1. The facility did not have a policy & procedure in place to protect vulnerable residents who do not have the mental capacity to manage their own financial matters. 2. The Social Services Director (SSD), as the perpetrator (culprit/wrongdoer), used Resident 1 ' s credit card (a plastic card you can use to buy goods and services and pay for them later) and debit card (a payment card that can be used in place of cash to make purchases or withdraw cash) without Resident 1 ' s consent when more than $6,500 in unauthorized purchases were made by her (SSD). These failures resulted in Resident 1 being a victim of financial abuse and resulting in over $6,500 in financial loss for Resident 1. Findings: 1. During a concurrent interview and observation on 9/17/24 at 11:48 a.m. with Resident 1, Resident 1 was sitting in a chair at the dining room table, with large white purse closed and hanging on a chair. Resident 1 stated she has been in the facility for two years and does not really ask anyone to help her call her bank (sic). Resident 1 stated she does not go out with her friends. Resident 1 stated she would give her (credit) card to someone (staff) if they needed it (sic). Resident 1 stated she is unaware of any issues regarding her credit card or debit card. During a review of Resident 1 ' s Minimum Data Set (MDS-assessment tool), dated 6/7/24, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status-assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6 (score of 0-7 means severe cognitive impairment). The MDS indicated Resident 1 required supervision (needs touch assistance and verbal cues) with activities of daily living. During a review of Resident 1 ' s Inventory List (list of items resident possess), dated 2/28/23 (admitted ), the Inventory List indicated Resident 1 had a Visa (credit/debit card), Mastercard (credit card), Costco card (membership card) and $30 cash. During a review of Resident 1 ' s Admission Record (AR), dated 9/17/24, the AR indicated Resident 1 is a [AGE] year-old female resident. Resident 1 had diagnoses of Dementia (memory loss), Psychotic Disturbance (a severe mental disorder that causes people to lose touch with reality and experience abnormal thinking and perceptions), Mood Disturbance (a change in a person's emotional state that can involve feelings of distress, sadness, depression, or anxiety), Cognitive Communication Deficit (communication issues), Bipolar Disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). During an interview on 9/17/24, at 11:08 a.m. with Business Office Manager (BOM), BOM stated, Resident ' s [1] BIMS is a 6, in my personal opinion, she [Resident 1] does not have [mental] capacity. BOM stated the facility do not have a policy on financial protection for vulnerable residents having no capacity to manage their finances. 2. During an interview on 9/12/24 at 9:53 a.m. with Complainant, Complainant stated he is from the fraud (wrongful or criminal deception intended to result in financial gain) department at a bank. Complainant stated, A woman named [SSD] that works at [the facility] has been calling in and impersonating [pretending to be] [Resident 1] to gain access to her [Resident 1 ' s] accounts. Complainant stated, Reviewing all recorded phone calls in the past, [SSD] has called in with [Resident 1] present and has identified herself as the Social Services, a facility representative, however now, she is not, she is changing her voice and calling in stating her name is [Resident 1 ' s name]. Complainant stated, We locked resident ' s [1] debit card, however her credit card was not locked and has concerning charges such as from gas stations, shoe store with $200 charges, clothing store with $300 charges. There are several gas station charges. During an interview on 9/17/24 at 11:18 a.m. with SSD, SSD stated she did call the bank and stated her (SSD) name was Resident 1 ' s name because she (SSD) was trying to help her (Resident 1) get access to her (Resident 1) pin number because Resident 1 was asking for assistance to get a new pin number. SSD stated, [Resident 1] goes out shopping on the weekends with friends. During an interview 9/17/24 at 11:48 a.m. with Resident 1, Resident 1 stated she does not really ask anyone to help her call her bank, and she stated she does not go out with her friends. Resident 1 stated she would give her (credit) card to someone (staff) if they needed it [sic]. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 4/3/24-5/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated a charge on 4/11/24 at a grocery store for $132.13. During a review of the facility ' s Resident Sign in and out Sheets (record of residents going out of the facility), dated April 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility in April 2024 to go to a grocery store to make purchases. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 5/3/24-6/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 5/3/24, there was a charge at a gas station for $114.99. b) On 5/8/24, there was a charge at a grocery store for $225.30 and a grocery store for $37.38. c) On 5/22/24, there was a charge at a pizza place for $10.70. d) On 5/23/24, there was a charge at a gas station for $202.00. The total charges for May 2024 were $590.37. During a review of Resident 1 ' s Inventory List (list of items resident possess), dated 2/28/23, the Inventory List indicated Resident 1 did not have a vehicle to get gas at a gas station. During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 5/3/24, 5/8/24, 5/22/24, and 5/23/24 to make the purchases indicated in the above credit card statement. During a review of Resident 1 ' s (Name of Bank) Credit Card statement, dated 6/3/24-7/2/24, the (Name of Bank) Credit Card statement, indicated on 6/3/24 there was a charge at a dollar store for $40.86, another dollar store for $43.62, and a gas station for $303.00. During a review of the facility ' s Resident Sign in and out Sheets, dated June 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 to go to a dollar store and to the gas station. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking (debit card), dated 6/17/24-7/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated a cash back (a debit card transaction in which cardholders receive cash when they make a purchase) withdrawal on 7/16/24 of $35.00 at a dollar store. During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 and 7/16/24 to go to the dollar store and a gas station. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 7/3/24-8/2/24 the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 7/5/24, there was a charge at a dollar store for $ 59.19, another dollar store for $32.49, and a gas station for $422.59. b) On 7/13/24, there was a charge at a dollar store for $137.47, pharmacy for $37.53, and a gas station for $1,035.57. c) On 7/15/24, there was a charge at a dollar store for $57.86 and a gas station for $1,048.97. d) On 7/26/24, there was a charge at a dollar store for $ 151.99, dollar store for $55.33, and a gas station for $65.00. e) On 7/27/24, there was a charge at a grocery store for $12.56. f) On 7/29/24, there was a charge at a gas station for $69.78 and gas station for $1.99. g) On 7/30/24, there was a charge at a dollar store for $150.80. h) On 7/31/24, there was a charge at a gas station for $76.79, gas station for $29.85 and fast food for $42.19. The total charges for July 2024 were $3,487.95. During a review of the facility Resident Sign in and out Sheets, dated July 2024, the Resident Sign in and out Sheet indicated Resident [1] left the faciity on [DATE] for facility activity outing to a cinema. There was no documentation of Resident 1 going to a dollar store, grocery store, or a gas station in July 2024. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 7/17/24-8/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated: a) On 8/5/24, there were cash back withdrawals and charges of $315.64 at a grocery store, $58.77 at a gas station, $284.00 at a clothing store, and $194.79 at a shoe store. b) On 8/6/24, there was a charge of $72.05 at a gas station During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 8/3/24-9/2/24, the (Name of Bank) Credit Card Statement, indicated the following charges: a) On 8/1/24, there was a charge at a gas station for $78.78 and clothing store for $179.54. b) On 8/2/24, there was a charge at a grocery store for $128.15 and a makeup store for $314.80. c) On 8/6/24, there was a charge at a dollar store for $91.99. d) On 8/11/24, there was a charge at a gas station for $70.00. e) On 8/14/24, there was a charge at a grocery store for $10.65. f) On 8/15/24, there was a charge at a gas station for $151.52, shoe store for $406.90, and shoe store for $200.25. g) On 8/17/24, there was a charge at gas station for $60.00. h) On 8/21/24, there was a charge at a Dollar store for $79.63 and dollar store for $182.32 and gas station for $74.74. The total charges for August 2024 were $2,029.27. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 8/17/24-9/16/24, the Statement of Accounts (Name of Bank) Member Advantage Checking, indicated on 8/19/24, there was a withdrawal $6,287.99 to transfer (payment) to Resident 1 ' s credit card. During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated there were no outings in August due to the facility vehicle being broken down. During a review of the facility Resident Sign in and out Sheets, dated August 2024, the Resident Sign in and out Sheets indicated there were no documentation of Resident [1] left the facility in August 2024. During an interview on 9/17/24 at 12:23 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she works on the weekends on a rotating schedule and has not seen Resident 1 go out of the facility with anyone during her (day) shifts. During an interview on 9/17/24 at 12:27 p.m. with CNA 2, CNA 2 stated she has not seen Resident 1 go out of facility on the weekends or with anyone during her shifts. During a concurrent interview and record review on 9/17/24 at 12:45 p.m. with SSD, Resident 1 ' s Inventory List dated February 2023 was reviewed. The Inventory List indicated there was no documentation of additional items purchased since admission. SSD stated, The inventory list is supposed to be updated frequently anytime a resident gets something new, the item should be labeled with resident ' s name also. During an interview on 9/18/24 at 10:33 a.m. with Family Member (FM) 1, FM 1 stated, I received a call yesterday from [SSD] at 2:22 p.m., she [SSD] said there was an ongoing investigation regarding financial abuse, the cops came in, [SSD] was very defensive in our conversation, and it did not sit right. [SSD] also stated, ' your mother [Resident 1] likes to go shopping a lot and go out. ' That statement didn ' t sit right with me because I know my mother [Resident 1] and she [Resident 1] does not in fact like to go shopping, every time I talk with her [Resident 1] she asks me to send her [Resident 1] clothes and toiletries. So, I was thinking why she [Resident 1] is asking for these things if she [Resident 1] is going out all the time. FM 1 stated, My mother [Resident 1] does not know anyone at all in that area [facility location]. My brother and I live out of state we know no one there, and her [Resident 1] friends from [out of state] do not go down there to see her. I became suspicious a few months ago when I started getting alerts about her [Resident 1] credit card bill not being paid and her [Resident 1] regular recurrent charges for other bills not being paid and the balance jumping to $4,655. I tried to call the bank, but I was not a user anymore, but somehow, I still got the alerts. I was trying to get Power of Attorney [POA-a legal document that gives someone permission to act on behalf of another person] and had a conversation with [SSD] where she told me I could not get POA while my mom was at nursing home, so I stopped that process but I am really concerned and have a lot of red flags [something that indicates or draws attention to a problem, danger, or irregularity]. I have reached out to an attorney to assist. During an interview on 9/18/24 at 10:59 a.m. with Complainant, Complainant stated, I can verbally give you a list of transactions that stand out to me that are recent. Going back to April 2024 there is a [grocery store] for $132, May 2024 a [gas station] charge one transaction for $105 another for $202. A [grocery store] for over $300, June 4 2024 a [gas station] for $300, July 5 2024 a [dollar store], a [gas station] again for $422, July 13 2024 a [gas station] for $1035, July 13 2024 a [dollar store] for $113, August 1 2024 a [gas station], [clothing store] on August 2 2024 and [Makeup store] $315, August 6 2024 [dollar store], August 11 2024 [gas station], August 14 2024 [grocery store], August 15 2024 a [gas station] $151. There are more charges I can continue to compile a list. During an interview on 9/18/24 at 2:27 p.m. with SSD, SSD stated Resident 1 goes out shopping with her [SSD] and Activities Director (AD). SSD stated she got confused about Resident 1 going out on weekends, and SSD and AD take her shopping [clothing stores], [dollar store], [grocery store] and there is a shopping center with clothes and a couple shoe stores. SSD stated, I spoke with the daughter about the financial abuse allegation on Monday and yesterday morning before you guys [California Department of Public Health surveyors] got here. SSD stated she does not sign Resident [1] in and out even though she was supposed to. SSD stated Resident 1 did not give her the receipts (proof of purchase from the shopping expenses). During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated she does take Resident 1 out on activity outings but there were no outings in August due to facility vehicle being broken down. AD stated she did not start signing Resident [1] in and out on the log until July (2024) when it was enforced. Resident [1] did attend outing in February to Walmart, May to Picnic in the park, June to Dewars [NAME] store and July to Cinema. AD stated she reported using personal vehicle one time with SSD to take Resident 1 to a dollar store. AD stated she does not recall the date when it took place, but it was a couple months ago, and she stated she did not obtain a receipt as the business office was not handling Resident 1 ' s funds. AD stated she has never taken Resident 1 to a gas station, and the only place outside of town they go to is Walmart in [out of town], she has never taken Resident 1 anywhere in [out of town] besides an approved activity outing. During an interview on 9/26/24 at 4:11 p.m. with Administrator, Administrator stated he was able to obtain bank records from Resident 1 ' s daughter and compare the records against Resident 1 ' s sign in and out logs which indicated Resident [1] had not been leaving the facility when the credit card was being used, and notified Police Department (PD) when they did not match and gave the PD the records. Administrator stated he suspended the SSD, visited local gas stations where the Resident 1 ' s credit card was used with photo of the SSD. Administrator stated he notified the PD on 9/19/24 or 9/20/24 who have begun an investigation. During an interview on 9/30/24 at 9:40 a.m. with Administrator, Administrator stated SSD was suspended on 9/18/24. Administrator stated they reviewed Resident 1 ' s inventory sheet from admission and looked at Resident [1 ' s] belongings she has in her room. Administrator stated Resident [1] does have a few clothing items but nothing they can identify with the amount of purchases on her credit card statements. Administrator stated they reviewed the statements and there are several concerning charges they cannot confirm Resident [1] authorized. Administrator stated they re-interviewed Resident 1 and Resident 1 does not recall going shopping or giving her credit card or debit card to anyone. Administrator stated Resident 1 ' s memory varies from day to day; Resident 1 cannot recall what she did the previous days. During an interview on 10/1/24, at 2:10 p.m. with Administrator in Training (AIT), AIT stated, We actually terminated [SSD] last Friday, 9/27/2024. Based on the evidence we collected and our investigation on our end we are confident that she was in fact the perpetrator based on the bank records of where the credit card was being used, there could have been no one else. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 2020, the P&P indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and or misappropriation of resident property. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. During a review of the facility ' s Job Description-Social Services (JDSS), dated 2/21/22, the JDSS indicated, Essential Job Duties: Understand, comply with and promote all rules regarding resident rights, promote positive relationships with residents, visitors and regulators.

Based on interview, and record review, the facility failed to report an allegation of financial abuse for one of three sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH) and complete a thorough investigation within five business days. This failure had the potential for Resident 1 experiencing continued financial abuse. Findings: During an interview on 9/17/24 at 11:18 a.m. with Social Services Director (SSD), SSD stated she called Resident 1 ' s bank and stated she pretended to be Resident 1 in order to reset (change) her pin number. SSD stated, Police Department [PD] came in last week or so, they pretty much just questioned who SSD and Administrator were. SSD stated on the weekends she [Resident 1] goes out with friends [unidentified] shopping. During an interview on 9/17/24 at 11:33 a.m. with Director of Nursing (DON), DON stated, PD came in last week, they spoke to resident [1] first then spoke to SSD, it was in regard to credit card fraud [wrongful or criminal deception intended to result in financial or personal gain]. During an interview on 9/17/24 at 1:09 p.m. with SSD, SSD stated she did not report the allegation of financial abuse to the CDPH. During an interview on 9/17/24 at 1:15 p.m. with DON, DON stated she did not report the allegation of financial abuse to the CDPH. During an interview on 9/17/24 at 1:22 p.m. with Administrator, Administrator stated he assisted Resident 1 in contacting her bank to reset her pin number on a video chat, then he heard there was some abuse going on and he spoke to everyone involved, SSD was working with Resident 1 prior to him assisting her (Resident 1). Administrator stated he was in the building when PD arrived but left and was interviewed by PD over the phone. Administrator stated he did not report the allegation of abuse to the CDPH. Administrator stated he did not check her (Resident 1) financial statements or any personal information. Administrator stated he was made aware of the financial abuse allegation when PD arrived in the building on 9/11/24. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017 the P&P indicated, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated. Findings of abuse investigations will also be reported. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than b. twenty four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

During an interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Abuse Prevention for two of 15 sampled employees (Licensed Vocational Nurse- LVN 2 and Certified Nursing Assistant- CNA 5) when reference checks were not completed prior to the date of hire. This failure had the potential to place residents at risk for abuse. Findings: During a concurrent interview and record review on 5/22/24 at 11:49 a.m. with Director of Staff Development (DSD), LVN 2's References for Potential Hires Candidate Employer/Reference Check [RPHCERC], dated 1/25/24 was reviewed. The RPHCERC indicated, Recruiter/Hiring Manager Role: The Recruiter or Hiring Manager will ensure that all employment references are completed prior to the new hire starting work. There was no documented evidence of reference checks. DSD stated LVN 2 employee file was incomplete. DSD stated employee files need to be complete to ensure the staff member is safe to work with the residents. During a concurrent interview and record review on 6/13/24 at 4:11 p.m. with DSD, CNA 5's employee file was reviewed. CNA 5's employee file indicated date of hire was 2/8/24. There was no documented evidence of reference checks. The DSD stated CNA 5 reference check was not followed up. During a review of the facility's P&P titled, Abuse Prevention, dated 5/18/20, the P&P indicated, Policy: It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations ), are reported immediately to the Executive Director of the center/location.Application: All Employees working in California.Procedure: The center/location shall take the following steps to prevent, detect and report abuse.Screening: All applicants for employment in the Company shall, at a minimum, have the following screening checks conducted: 1. Reference checks with the current and/or past employer.

Based on interview and record review, the facility failed to ensure ordered medication for one of three sampled residents (Resident 1) was administered within the ordered time frame. This had the potential for adverse side effects for Resident 1. Findings: During an interview on 3/6/24, at 2:53 p.m., with Resident 1, Resident 1 stated her Percocet (pain medication) was supposed to be administered at 12 pm today and she did not receive it until approximately 2:30 p.m. During an interview on 3/6/24, at 4 p.m., with Director of Nursing (DON), DON stated Resident 1's Percocet was scheduled to be administered at 12:00 p.m. DON stated the medication was considered timely if it was administered one hour before or one hour after the scheduled time frame. During a concurrent interview and record review on 4/5/24, at 2:52 p.m., with DON, Resident 1's Med [medication] Admin [administration] Audit Report (MAAR), dated 3/6/24 was reviewed. The MAAR indicated, Percocet Oral Tablet.give 1 tablet by mouth every 6 hours.3/6/24 12:00 (scheduled time to be given) .3/6/24 13:59 (indicating medication was administered at 1:59 p.m. (59 minutes out of the allowed parameter for administration) . DON stated the Percocet should have been administered and documented by 1 p.m. During a review of the facility's policy and procedure (P&P) titled, Medication Administration & Documentation Procedures dated 8/2014, the P&P indicated, To administer oral medications in a safe, accurate, and effective manner.Chart medication administration on Medication Administration Record (MAR) immediately following each resident's medication administration.

Based on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from staff verbal abuse. This resulted in staff verbally abused Resident 1 and had the potential to result in psychosocial harm for Resident 1. Findings: During an interview on 2/22/24 at 11:41 a.m. with Interim Administrator (IA), IA stated Certified Nursing Assistant (CNA 1), was witnessed by another staff member verbally abusing Resident 1 on 2/12/24. During an interview on 2/22/24 at 11:47 a.m. with Director of Staff Development (DSD), DSD stated CNA 1 was heard calling Resident 1 you old hag. DSD stated, calling resident you old hag is verbal abuse. During an interview on 2/22/24 at 12:01 p.m. with Housekeeper, Housekeeper stated he was in dining room cleaning when he heard CNA 1 telling Resident 1 in Spanish to shut up in a deep tone, like angry tone. Housekeeper stated when he stepped out to get a closer look as to what was happening, Housekeeper stated Resident 1 became aggravated when CNA 1 continued to tell Resident 1 in Spanish to shut up. Housekeeper stated Resident 1 had diagnosis of Dementia (condition that affect the brain's ability to think, remember and function normally) and had behaviors of repeating wanting to go home and looking for her sister. During a concurrent observation and interview on 2/22/24 at 12:17 p.m. with Resident 1, Resident 1 was observed walking in the hallway. Resident 1 is Spanish speaking, stated she was looking for her sister. During an interview on 2/22/24 at 2:17 p.m. with CNA 2, CNA 2 stated on 2/12/24 she had went to the Dementia unit. CNA 2 stated she heard CNA 1 in a really rude, aggressive, serious voice calling Resident 1 a stubborn old hag. CNA 2 stated CNA 1 repeatedly called Resident 1 a stubborn old hag. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 had a diagnosis of Alzheimer (type of dementia that damages the brain and affects memory, thinking, and behavior) and Dementia. Resident 1's annual Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 12/13/24, indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 3 (score range from 0 - 7 severe impairment). During a review of the facility's policy and procedure (P&P), titled Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation, the P&P indicated, Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.

Based on interview and record review, the facility failed to ensure the nutritional needs for eight of 12 sampled residents (Resident 1, Resident 7, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15) were met when the facility failed to: 1a. Complete a Nutritional Assessment by a Registered Dietician (RD) and develop a care plan for weight loss for one of 12 sampled residents (Resident 1). 1b. Complete a Nutritional Assessment by a RD and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Complete Nutritional assessments by a RD for six of 12 sampled residents (Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, and Resident 15). These failures resulted in Resident 1 and Resident 7 experiencing unplanned weight loss and the potential for all sampled residents to have unplanned weight loss. Findings: 1a. During a review of Resident 1's Monthly Weight Report (MWR), dated 1/11/22, the MWR indicated, Aug [August] 260.0 Lbs [pounds]. Sep [September] 257.0 Lbs (3 lb weight loss). Oct [October] 253.0 Lbs (4 lb weight loss). Nov [November] 246.0 Lbs (7 lb weight loss). Dec [December] 246.0 Lbs. Jan [January] 238.0 Lbs. From August 2021 to January 2022, Resident 1 had an unplanned weight loss of 22 lbs (8.46%) within five months. During a review of Resident 1's Minimum Data Set (MDS-clinical assessment tool) dated 9/6/21, 9/12/21, 9/22/21, 12/7/21, and 12/29/21, the MDS indicated, Resident 1 was not on a planned weight loss regimen. During a concurrent interview and record review, on 12/16/21, at 3:47 PM, with Registered Nurse (RN), RN reviewed Resident 1's medical record. RN was unable to find a completed Nutritional Assessment by a RD. RN stated, Resident 1 received enteral feedings (feeding through a tube) since admit to the facility and a Nutritional Assessment was never completed. RN stated, there should have been a Nutritional Assessment completed by a RD within 72 hours of admit to ensure Resident 1 was receiving proper nutrition. RN stated, currently the facility did not have a RD. During a concurrent interview and record review on 12/16/21, at 4:45 PM, with Certified Dietary Manager (CDM), CDM reviewed Resident 1's medical record. CDM was unable to find a Nutritional Assessment in the resident's medical record. CDM confirmed the finding and stated a Nutritional Assessment should have been completed upon admit. During a concurrent interview and record review, on 1/5/22, at 1:27 PM, with Director of Nursing (DON), DON reviewed Resident 1's medical record. There was no nutritional care plan. DON confirmed no care plan was developed for Resident 1's weight loss and the resident should have had a nutrition care plan developed. During a review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention dated 9/08, the P&P indicated, Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes or weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. 1b. During a review of Resident 7's SBAR-Change of Condition dated 12/16/21, at 9:35 AM, the SBAR indicated, Situation.difficulty with chewing regular food. Which started on 12/16/2021 in the morning.Response.Reported to primary care clinician.Recommendation's downgrade diet to mech [mechanical soft] ST Eval [Speech Therapy Evaluation] . During a review of Resident 7's OSR dated 12/31/21, the OSR indicated, ST Eval and Tx [treatment] as indicated.order date.12/16/21. During a review of Resident 7's Weight and Vital Summary (WVS) dated 1/6/22, the WVS indicated, 1/5/22.115 LBS.Warnings.-7.5 % change [Comparison weight 10/1/21, 125 Lbs.]. During a concurrent interview and record review on 1/5/22, at 3:22 PM, with Rehabilitation Coordinator (RC), Resident 7's POC [Point of Care] Response History (POCRH - electronic documentation completed by the Certified Nursing Assistants [CNAs] which includes meal percentage documentation) was reviewed. The POCRH from 12/28/21 to current indicated Resident 7 had a decrease in her meal intake. RC confirmed the findings and stated, she was aware Resident 7 had difficulty with chewing her food and the physician had downgraded Resident 7's diet and ordered a ST Eval and Tx. RC stated, the IDT [Interdisciplinary team- an approach to healthcare that integrates multiple disciplines through collaboration] had discussed Resident 7's ST Eval and Tx order and determined the ST Eval and Tx was no longer needed because staff were not reporting any further concerns with Resident 7 after the diet was changed. RC stated, she did not review Resident 7's meal intake documentation or the resident's weights. RC was unable to provide documentation the physician was notified of the IDT's decision to not carry out the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/5/22 at 3:34 PM, with Resident 7, Resident 7 stated, she was not eating very good and was having trouble with eating and swallowing. During an interview on 1/6/22 at 9:48 AM, with Registered Nurse (RN), RN stated, Resident 7 was having trouble chewing and the physician downgraded Resident 7's diet and ordered an ST Eval and Tx. During an interview on 1/6/22, at 10:07 AM, with CDM, CDM stated, when there was a significant change in a resident's weight the electronic medical record alerts staff. When a resident has a significant weight change the RD is notified and the RD completes a Nutritional Assessment and makes recommendations. CDM stated, the facility did not have a RD and Resident 7's weight loss was not assessed by a RD. No Nutritional Assessment was completed by the RD. 2. During a review of Resident 10's Admission Record (AR), the AR indicated, Resident 10 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During a review of Resident 11's AR, the (AR) indicated, Resident 11 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During a review of Resident 12's AR, the (AR) indicated, Resident 12 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During a review of 13's AR, the AR indicated, Resident 13 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During a review Resident 14's AR indicated, Resident 14 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During a review Resident 15's AR indicated, Resident 15 was admitted on [DATE]. There was no Nutritional Assessment completed by the RD. During an interview on 1/5/22, at 1:27 PM, with DON, DON confirmed the above findings and stated, the Nutritional Assessments for Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, and Resident 15 were not completed because the facility did not have a RD. During a review of the facility's policy and procedure (P&P) titled Dietician [sic] Services dated 2/17/16, the P&P indicated, A qualified dietitian provides regularly scheduled visits to review services; annually at minimum and within 72 hours upon admission. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention dated 9/08, the P&P indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe.Analysis.2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.b. chewing or swallowing abnormalities.Interventions.chewing and swallowing abnormalities and the need for diet modifications.

Based on interview and record review, the facility failed to follow its' policy and procedure in providing adequate nutrition for one of three sampled residents (Resident 1) when: 1. Weekly weights recommended by Certified Dietary Manager (CDM) were not implemented. 2. Weight loss of 20 pounds (lbs-unit of measurement)/-11.8% in one month was not reported to the Primary Care Physician (PCP) and to the Responsible Party (RP). 3. Fortified Diet (FD) recommended by Registered Dietitian (RD)was not followed through. 4. Nutrition assessment was not conducted by RD for the month of July, 2020 when Resident 1 started to have a weight loss of 20 lbs/-11.8 % in one month. These failure resulted in Resident 1's unplanned total weight loss of 30 lbs (-17.65%) in 45 days. Findings: 1. During a review of Resident 1's Admission Record (AR), undated, the AR indicated Resident 1 was admitted in the facility on 5/24/2020 and was transferred to the hospital on [DATE] related to altered mental status. She returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. During a review of Resident 1's Weights and Vitals Summary (WVS), the WVS documented weights were as follows: 5/26/2020: 170 pounds (lbs-unit of measurement) 5/29/2020: 170 lbs 6/1/2020: 170 lbs 7/1/2020: 150 lbs (weight loss of 20 lbs/ -11.8% in one month) 7/8/2020: 143 lbs (weight loss of 7 lbs/-4.7% in one week) 7/15/2020: 140 lbs (weight loss of 30 lbs/-17.65% from 6/1/2020 to 7/15/2020 During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with Director of Nursing (DON), Resident 1's Weights and Vitals Summary (WVS) and Progress Notes (PN), dated 7/10/20 were reviewed. The WVS indicated, Resident 1 had a significant weight loss of 30 lbs (-17.65%) from 6/1/20 to 7/15/20. Resident 1's PN, dated 7/10/20, indicated, Recommendations: 2.) Weekly weight monitoring. DON confirmed the findings and stated, (Resident 1) should have been weighed weekly (week 3 (6/9/2020) none and week 4 (6/16/2020) none). During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with DON, Resident 1's physician's orders [REDACTED]. The DON was unable to find documented evidence of weekly weights order as recommended by the Certified Dietary Manager (CDM). DON stated, They (the nurses) should have called the doctor to get an order. During a concurrent interview and record review on 10/20/2020, at 4:14 PM, with Minimum Data Set Coordinator (MDSC - a nurse that oversees and facilitate the completion of resident assessments and plan of care), Resident 1's care plan (CP) titled Involuntary Weight Loss, dated 6/1/2020 to 7/15/2020 was reviewed. The MDSC was unable to find documented evidence of weekly weights intervention in Patient 1's CP. MDSC stated, We're all responsible for updating the care plan. The Primary Care Physician (PCP) should have been notified of the recommendation and updated in the care plan. During an interview on 10/20/2020, at 10:33 AM, with Registered Dietitian (RD), RD stated, Residents are weighed on admission and then weekly for about four weeks if the weight is stable. RD confirmed weights were taken on the following weeks: 5/26/2020 to 7/29/2020: Week 1: 5/26/2020 - 170 lbs (admission weight) Week 2: 6/2/2020 - 170 lbs (taken 6/1/2020) Week 3: 6/9/2020 - None Week 4: 6/16/2020 - None RD also stated Resident 1 was weighed on admission. No weights were completed for the remaining two consecutive weeks (week 3 and week 4). During a review of the facility's policy and procedure (P&P) titled, RD's For Healthcare, Inc. Weight Change Protocol, dated 2018, the P&P indicated, Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes. 2. During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with Director of Nursing (DON), Resident 1's Progress Notes (PN) dated 7/1/2020 to 7/8/2020 were reviewed. The DON was unable to find documented evidence the Primary Care Physician (PCP) was notified of the 20 lbs weight loss (6/1/2020 to 7/1/2020) of Resident 1. DON stated, It looks like we did not communicate it with (PCP). During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with DON, Resident 1's Meal Percentage Intake (MPI), dated 7/9/2020 to 7/27/2020 were reviewed. The MPI indicated, Resident 1 refused meals or snacks on the following days: 7/9/2020 Dinner once 7/10/2020 Dinner two times 7/12/2020 Dinner once 7/13/2020 Lunch once, Dinner two times 7/14/2020 Lunch once, Dinner two times 7/15/2020 Lunch once 7/17/2020 Breakfast once 7/18/2020 Breakfast once, Lunch once, Snack once 7/19/2020 Lunch once 7/20/2020 Dinner once 7/21/2020 Dinner once 7/22/2020 Dinner once 7/23/2020 Lunch once, Dinner once 7/24/2020 Refused all meals and snacks for 24 hours 7/25/2020 No documented meal or snack percentage 7/26/2020 Lunch two times, Dinner once DON confirmed the findings and was unable to find documented evidence an alternate meal was offered to Resident 1. DON stated, (Resident 1's) average meal intake is about 0-25% according to the (MPI). During a concurrent interview and record review on 8/5/2020, at 1:55 PM, with Administrator, Resident 1's PN dated 7/1/2020 was reviewed. The Administrator was unable to find documented evidence the Responsible Party (RP) was notified of Resident 1's weight loss. The Administrator stated, We should have notified family with the significant change of weight loss. I guess we missed it. During an interview on 8/6/2020, at 5 PM, with RP, RP stated, The facility staff never called me or informed my mom that she was losing that much weight. We talk to the nurses all the time and they never told us anything. If we knew then, we could have talked to her (Resident 1) about it. During a review of Resident 1's care plan (CP) titled, Chewing Difficulty, dated 6/4/2020, the CP indicated, Notify physician and family/responsible party of weight change. During a review of the facility's policy and procedure (P&P) titled, Notification of Change in Resident Health Status, undated, the P&P indicated, The center will consult the resident's physician, nurse practitioner, or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: A. Acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification: Depending on the nursing evaluation appropriate notification may be immediate to 48 hours. 3. During a review of Resident 1's Nutrition Assessment (NA), dated 6/15/2020, the NA indicated, RD recommends: 1) MVM (multi-vitamin with minerals) PO QD (by mouth daily) as a supplement 2) Fortified foods (foods that have extra nutrients added to it to aide in proper nutrition). During an interview on 10/20/2020, at 4:10 PM, with Certified Dietary Manager (CDM), CDM stated, I don't believe Resident 1 was on a Fortified Diet (FD). She was initially on mechanical soft diet (foods that are soft and easy to chew) on admission, 5/24/2020 then it was changed to pureed (a diet that is soft, moist, and smooth for people who have trouble chewing or swallowing) on 6/25/2020 by the (Speech Therapist) (ST) recommendation. We do not normally put them on a FD. For weight loss, we try to give house supplements twice a day and weigh them weekly. During an interview on 11/17/2020, at 8:07 AM, with Registered Dietitian (RD), RD stated the ST can make recommendations of changing the texture of the diet, but does not recommend Fortified Diet (FD). Unless the physician changes the order, the FD should have been continued. During a review of the facility's policy and procedure (P&P) titled, RD's (Registered Dietician) For Healthcare, Inc. Weight Change Protocol, dated 2018, the P&P indicated, .The RD will assess nutritionally diagnosis, suggest interventions, monitor and evaluate the success of the interventions.INTERVENTIONS: Suggest interventions to correct the identified problems such as.Diet Fortification (Preferred before supplements). 4. During a review of Resident 1's Weights and Vitals Summary (WVS), the WVS documented weights were as follows: 5/26/2020: 170 pounds (lbs-unit of measurement) 5/29/2020: 170 lbs 6/1/2020: 170 lbs 7/1/2020: 150 lbs (weight loss of 20 lbs/ -11.8% in one month) 7/8/2020: 143 lbs (weight loss of 7 lbs/-4.7% in one week) 7/15/2020: 140 lbs (weight loss of 30 lbs/-17.65% from 6/1/2020 to 7/15/2020) During a concurrent interview and record review on 10/20/2020, at 10:33 AM, with Registered Dietitian (RD), Resident 1's Nutrition Assessment (NA), dated 6/15/2020 was reviewed. It was noted there was no other documented evidence of an assessment was done for Resident 1. RD stated, I do my initial assessment within 14 days of admission. I come in every month for assessment or evaluation on residents with a 3% weight change in a week which is about a 5 lbs weight loss or weight gain, or if there is a trend and just based on clinical judgement. RD confirmed no assessment was done for the month of July 2020. During a review of the facility's P&P titled, RD's For Healthcare, Inc. Weight Change Protocol, 2018, the P&P indicated, Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. Evaluation: The Evaluation process is done again if there is a significant weight change.

Based on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from unwanted intimate touching by another resident (Resident 2), who was known for having repetitive inappropriate sexual advances towards facility staff. Resident 2 was witnessed in Resident 1's room with his pants down, one hand on his groin area and one hand on Resident 1's right breast. This failure had caused Resident 1 to feel shameful and contributed to her fear of being subjected to additional non-consensual sexual contact. Findings: During an interview with Resident 1, on 12/19/18, at 12:35 PM, she stated on 12/9/18, around 8 PM, Resident 2 was in her room, uninvited, and had scared her. Resident 1 stated Resident 2 pulled his pants down and began to touch her right breast against her will. Resident 1 stated she screamed and staff ran to the room and removed Resident 2. Resident 1 stated Resident 2 continually tried to approach her and speak with her after the incident. Resident 1 stated He (Resident 2) keeps on bothering me. I'm not comfortable. I just stay in my room. During an interview with Resident 2, on 12/19/18, at 12:59 PM, he stated he remembered the incident on 12/9/18. Resident 2 confirmed he went to Resident 1's room uninvited. Resident 2 stated he wanted to touch Resident 1 despite knowing it was not right. Resident 2 stated, You know how us men are with our words and our actions. We do what we got to do. During an interview with Certified Nursing Assistant 1 (CNA 1), on 12/19/18, at 1:07 PM, she stated she currently was assigned to watch Resident 2 on one-to-one basis (continuous monitoring of a resident to ensure safety). CNA 1 stated Resident 2 had a history of [REDACTED]. CNA 1 stated Resident 2 verbalized Resident 1, Wanted it (to be touched). CNA 1 stated Resident 2 tried to go to Resident 1's room after the incident several times but was redirected by moving his wheelchair in the opposite direction back toward his room or to the activity room. During a review of Resident 1's Progress Notes, The SSD (Social Services Designee) documented, on 12/11/18, at 5:09 PM, This a.m. (morning) resident and sons came into SSD's office regarding occurrence on 12/9/18. Discussed families concerns of (Resident 1's) mental and physical well-being. Resident (1) stated fell ing ashamed and that 'I can't stay here with him (Resident 2) here (sic).' During an interview with Licensed Vocational Nurse 1 (LVN 1), on 12/19/18, at 2:10 PM, she stated she was the charge nurse on duty the evening of 12/9/18. LVN 1 stated CNA 2 heard Resident 1's scream and found Resident 2 in Resident 1's room with his pants down. LVN 1 stated she escorted Resident 2 out of Resident 1's room. LVN 1 stated Resident 1 was visibly shaken, scared, and asked if she could stay at the nurses' station with staff because she feared Resident 2 would come after her again. LVN 1 stated, at the nurses' station, Resident 1 broke down and cried. LVN 1 stated Resident 1 reported to her when she saw Resident 2 in her room, she told Resident 2 to leave the room; but he shushed her and then grabbed her right breast while grabbing his groin area. LVN 1 stated when she interviewed Resident 2 the same evening about the inappropriate touching of Resident 1, he smirked. LVN 1 confirmed Resident 2 was not on one-to-one or close monitoring at the time of the incident. During an interview with CNA 2, on 12/21/18, at 11:24 AM, she stated she responded to a scream on 12/9/18, around 8 PM from Resident 1's room. CNA 2 stated when she entered the room she saw Resident 2 with his pants and brief down to his knees and his right hand on his groin. CNA 2 stated Resident 1 repeatedly said she was scared. CNA 2 stated Resident 2 was not on one-to-one or close monitoring. During a review of the clinical record for Resident 2, the Progress Notes dated 8/31/17, at 11:16 AM, indicated Secondary Care Conference with (Resident 2's family) held . to discuss current and on-going behaviors and their inappropriateness, potential interventions, one-on-one care, psychiatric evaluation, and the possibility of room change. During a review of the clinical record for Resident 2, the Progress Notes dated 9/7/17, at 1:58 PM, indicated Resident continues 1:1 (one-to-one or close monitoring) care with diminished episodes of inappropriate behavior since Ombudsman and family care conference. However, has had several episodes of making angry and displeased comments at 1:1 staff, nursing, and to general occupants of the lobby. IDT (interdisciplinary team - a team of various professionals) recommends continued 1:1 care until resident is more stable in behaviors and mood. Psych evaluation yielded the following results: signs of depression, recommended continued medication regimen, keep on 1:1 . During a review of the clinical record for Resident 2, the Psychotherapy Progress Note, dated 8/31/18, at 1:20 PM, indicated: (Resident 2) continues to display inappropriate behavior with touching female staff. Appeared childish today with justification of touching female staff inappropriately. Unable to accept responsibility for his actions. Resistant to therapeutic intervention. During a review of the clinical record for Resident 2, the Psychotherapy Progress Note dated 10/5/18, at 1:24 PM, indicated Social Services reported that (Resident 2) is still trying to touch female staff in an inappropriate manner. He is in denial about his staff-grabbing (behavior). During a review of the clinical record for Resident 2, the Progress Note dated 10/27/18, by a nurse practitioner, indicated Per staff (Resident 2) presents angry outburst, refuses care, features sexually inappropriate behavior. All information is obtained from the discussion with the nursing staff . Plan .Monitor, record behaviors and refer accordingly. During a review of the clinical record for Resident 2, the Progress Note dated 11/17/18, by a nurse practitioner, indicated: Per staff (Resident 2) presents angry outburst, non (sic) compliant, refuses care, features sexually inappropriate behavior .Plan .Monitor, record behaviors and refer accordingly. During an interview with the Ombudsman, on 1/4/19, at 10:10 AM, she stated she had attended an interdisciplinary team meeting and understood Resident 2 was to be on one-to-one monitoring continuously. During a concurrent interview with the Assistant Director of Nursing (ADON), on 1/22/19, at 4:20 PM and review of the clinical record for Resident 2, the Medication Administration Record [REDACTED]. In (MONTH) (YEAR) he had 21 episodes of, inappropriate sexual advances reported by staff. After (MONTH) however Resident 2 was no longer monitored for inappropriate sexual advances. The ADON stated the monitoring should have continued but was not. The ADON could not explain why the monitoring was not continued. The ADON could not clarify whether the 21 behavior episodes of inappropriate sexual advances were towards staff or other residents. The ADON was not able to indicate what new interventions were implemented after Resident 2 had 21 episodes of inappropriate sexual advances. During a review of the facility policy and procedure titled Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation dated 2/12/16, indicated It is the policy of this center to take appropriate steps to prevent the occurrence of. Abuse. Sexual abuse includes, but is not limited to: sexual harassment. Sexual coercion (forced sexual action against one's will) . sexual assault. The center makes reasonable efforts to determine the cause of the alleged violation and takes corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The (Director of Nursing Services), or designee, initiates a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps are taken to prevent recurrence of the incident. The steps taken are documented.

Based on observation, interview, and record review, the facility failed to provide two staff persons to physically assist one of one sampled resident (1) during toilet use and transfer. This failure resulted in Resident 1 falling and sustaining a fracture (broken bone) to his left hip. Findings: During a review of the clinical record for Resident 1, the nurses progress notes dated 5/26/16, at 6:25 AM, indicated This nurse (Licensed Vocational Nurse 1-LVN 1) went into rest room. Noticed resident (Resident 1) leaning with his back against the bathroom door and bil (bilateral-both legs) legs straight out on the floor with the cna (certified nursing assistant) C/O (complained of) pain/discomfort to left hip and left shoulder . Notified (physician), received orders to send to ER (emergency room ) for further eval (evaluation) and possible treat (treatment). The Minimum Data Set (MDS-a resident assessment tool) for Resident 1 dated 4/1/16, indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with two persons physical assist with transfers and toilet use. This MDS for Resident 1 indicated Resident 1's balance during moving on and off toilet was not steady and Resident 1 was only able to stabilize with staff assistance. During an interview with LVN 1, on 6/2/16, at 2:45 PM, she stated she heard someone calling her name from Resident 1's room. LVN 1 stated when she opened the bathroom door, she saw Resident 1 sitting on the floor and one CNA (CNA 1) was with him. During a concurrent interview with Registered Nurse (RN) 1 and review of the clinical record for Resident 1, on 6/2/16, at 2:55 PM, the care plan, date initiated 11/25/14, indicated Resident 1 was at risk for falls. This care plan indicated Resident 1 had mobility limitations in both his arms and left leg. The intervention, revised on 4/14/16, indicated Provide 2 person assist with bed mobility, transfers and toilet use. RN 1 verified Resident 1 should have been assisted by two people while he was in the bathroom. The risk for falls assessment dated [DATE], indicated Resident 1's total score was 11. A score of 10 or above indicated Resident 1 was at risk for falls. During a concurrent observation and interview with Resident 1 in his room on 6/2/16, at 3 PM, Resident 1's left leg had three surgical sites covered with bandages. Resident 1 stated his leg was painful. During an interview with CNA 1, on 6/7/16, at 9:08 AM, she stated she was assisting Resident 1 from the toilet to the wheelchair when his left side gave out. CNA 1 stated she was holding on to him and he hit the wall before falling to the floor. CNA 1 stated she could not lift Resident 1 off the floor so she called for help. CNA 1 verified Resident 1 was assisted by one person instead of two people on 5/26/16. During a review of the clinical record for Resident 1, the hospital History and Physical dated 5/26/16, indicated X-ray of the left hip shows that he (Resident 1) has fracture. (Physician's name) was consulted and the patient (Resident 1) will have surgical intervention (operation) soon. The hospital physician progress notes [REDACTED]. The facility policy and procedure titled Falls Management Guideline dated 10/21/15, indicated Residents at risk for falls are care planned with individualized interventions.

Based on interview and record review, the facility failed to: 1. Adequately supervise one sampled resident (1) while ambulating who was at high risk for falls. 2. Refer one sampled resident (1) for a rehabilitation screening when there was a decline in function. These failures resulted in Resident 1 falling and sustaining a fractured left fifth finger. Findings: 1. During a review of the clinical record for Resident 1, the "Admission Record," dated 3/4/14, included [DIAGNOSES REDACTED]. On 1/28/14, the optometrist (a doctor who treats and [DIAGNOSES REDACTED]. The care plan dated 11/13/13, indicated: "At risk for falls related to: use of medication antianxiety (medication that can relieve symptoms of anxiety), poor safety awareness secondary to Dx (diagnosis): Dementia, Wandering and poor eyesight, h/o (history of) fall..." Under the "Interventions" subheading it read, "...Direct resident as needed due to her poor eyesight. Assist to get to areas she needs to be in for programs, her room, bathroom, hallway..." The care plan dated 1/2/14, indicated, "Resident noted to have poor vision...Interventions...Monitor resident's movement while ambulating..." The Minimum Data Set (MDS, assessment tool) dated 3/4/14, was reviewed. The "Brief Interview for Mental Status (BIMS-a brief screener that aids in detecting cognitive impairment)" score was 3 out of 15 (severe cognitive impairment). The vision was coded as a 3 (highly impaired vision-object identification in question, but eyes appear to follow object). The active [DIAGNOSES REDACTED]. The 6/4/14, MDS assessment was reviewed. The BIMS score was 1 out of 15 (severe cognitive impairment) and the vision was coded as a 3. The document titled "Quarterly Interdisciplinary Resident Review...Section M...Risk for Falls" dated 6/4/14, indicated a total score of 11 (total score of 10 or above deems the resident is at risk for falls). The "Progress Notes" dated 7/14/14, at 9:22 PM, indicated in part, "...Resident (1) was pacing throughout ACU (Alzheimer's Care Unit); Seen resident bump head on corner of the door Room # (number) 8; staff attempted to help resident before resident fell on the floor and landed on left arm...Resident crying as usual behavior; Noted resident to be in distress with severe pain while resident holding onto left hand; swelling and purplish discoloration between pinky and ring finger; and between middle finger and index finger...Sent to ER (emergency room ) for treatment and evaluation..." The hospital "History and Physical", dated 7/14/14, indicated in part, "History of Present Illness...history of severe dementia...had an accidental fall, hit the corner of the wall and injured the right hip as well as the left forearm... She is not well ambulatory..." Under the Assessment subheading it read, "status [REDACTED]. During an interview with the Alzheimer's Unit Director (AUD), on 7/23/14, at 10:55 AM, she stated Resident 1 can only see shadows but is unable to see faces. AUD stated if Resident 1 would get upset, she would walk up and down the hall. When Resident 1 was unsteady on her feet, a staff would have to assist her getting to and from different locations in the ACU. AUD added Resident 1 would walk aimlessly. Some days she needed to be assisted (when walking and going to other areas of the ACU) when she was tired and upset. During an interview with Certified Nursing Assistant (CNA) 1, on 7/23/14, at 12:08 PM, she stated Resident 1's vision was impaired and she would bump into beds. CNA 1 stated Resident 1 was not steady on her feet when she walked and would lean forward. During an interview with CNA 2, on 7/23/14, at 4:10 PM, she stated while Resident 1 was walking (7/14/14), she saw Resident 1 fall. CNA 2 stated Resident 1 would walk straight without noticing something in front of her because she could not see very well, she was at risk of tripping. CNA 2 added, Resident 1 would not stay still, she would get up right away when she was asked to sit down or lay down on bed. CNA 2 stated Resident 1 had been crying more than usual on the day of fall and she was more anxious wanting to go home. During an interview with CNA 3, on 7/23/14, at 4:20 PM, CNA 3 stated Licensed Vocational Nurse (LVN) 1 told her she would watch the floor and she left Resident 1 being supervised by LVN 1. CNA 3 added Resident 1 needed to be watched constantly because she wandered into the other residents' rooms, walked up and down the hallway and would not stand still. During a subsequent interview with CNA 3, on 9/25/14, at 5:10 PM, she stated on the day of Resident 1's fall (7/14/14), LVN 1 was standing by the hallway outside the living room. CNA 3 stated Resident 1 walked down the hallway, ran into the door frame of Room 8, which "knocked" her off balance causing her fall to the floor. LVN 1 was not close enough to Resident 1 to catch her before she fell . She added, Resident 1 needed to be assisted when going to the bathroom, living room, dining room/kitchen and to other areas of the ACU. During an interview with LVN 1, on 7/23/14, at 3:51 PM, she stated Resident 1 was in the hallway walking near her room and she was crying. LVN 1 stated she noticed Resident 1 bumped her head at the corner of the door lost her balance causing her to fall to the floor. LVN 1 added Resident 1 would normally pace back and forth especially in the afternoons and cry for her family. During an interview with LVN 2, on 8/21/14, at 12:55 PM, she was asked how often Resident 1 was being monitored. LVN 2 stated when Resident 1 was up walking, she needed to be followed all the time. She stated Resident 1 is now on one to one (one caregiver supervising the resident at all times) supervision after the fall on 7/14/14. She added Resident 1 did not have one to one supervision before she fell . During a concurrent interview and review of the clinical record for Resident 1 with the Director of Nursing (DON), on 9/29/14, at 3:50 PM, the document titled, "Quarterly Interdisciplinary Resident Review" dated 6/4/14, was reviewed. The "Section M...Risk for Falls" indicated a total score of 11 (total score of 10 or above deems resident at risk for falls). This was validated with the DON. The facility policy and procedure titled "Falls Management Clinical Guidelines" revised 2013 indicated "...Residents at risk for falls are care planned with individualized interventions..." 2. During a concurrent interview and review of the clinical record for Resident 1 with the AUD, on 7/23/14, at 1 PM, the MDS assessment dated [DATE] indicated, for moving on and off the toilet, Resident 1 was "Steady at all times." For surface-to-surface transfers, Resident 1 was "Steady at all times." For dressing, Resident 1 required "Limited assistance (resident is highly involved in activity; staff provide weight bearing support)." The MDS assessment dated [DATE], indicated for moving on and off toilet, the resident was "Not steady, only able to stabilize with staff assistance." For surface-to-surface transfer, the resident was "Not steady, only able to stabilize with staff assistance." For dressing, the resident required "Extensive assistance (resident involved in activity, staff provide weight bearing support)..." This was verified with the AUD. During an interview with the MDS Nurse (MDSN), on 8/21/14, at 2:05 PM, she confirmed there was a significant change in status assessment done on 3/4/14, due to a decline in function. The MDSN stated, residents were referred to rehabilitation services if there was a noted decline in function, to determine if the resident could benefit from rehabilitation services. She was unable to provide documentation that Resident 1 was referred to rehabilitation services when Resident 1 had a decline in function on 3/4/14. No further information was provided. The facility policy and procedure titled "Falls Management Clinical Guidelines," revised 2013, read: "...The interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls... This evaluation may include a screening by a rehabilitation services representative..."

Based on interview and record review, the facility failed to stop range of motion treatment to one resident's (1) left upper extremity after staff noted redness and swelling to the left elbow. This resulted in the resident experiencing increased pain and sustain further complications from a fractured left elbow. Findings: During a review of the clinical record for Resident 1, the physician's orders [REDACTED]. The Occupational Therapist Progress and Discharge Summary dated 10/04/12 noted, "The patient demonstrates limited PROM on both shoulder flexion and left elbow flexion, FMP (functional maintenance program) done and RNA education completed..." The FMP for the RNA noted "Precautions: Limited left upper extremity passive range of motion." The Restorative Record sheet for October 2012 indicated Resident 1 received PROM from the RNA on October 4, 5, 6, 7, 8, 9, 11, 12, 13, and the 14, 2012. The "Restorative Nursing Program Weekly Summary" dated 10/12/12 indicated the following, "Follows Direction: No; Communication: Poor; Resident Response: Resistive and Refused." The nursing notes were reviewed and read as follows: "10/11/12 at 11:59 AM Resident noted to have swelling, tenderness and pain upon movement to left elbow. No bruising and redness to affected area noted. MD (physician) informed with new orders.... [MEDICATION NAME] 250 mg three times a day for 3 days. 10/11/12 at 1:15 PM MD said no to X-ray to affected site. Said it's possible gout, no labs ordered. 10/11/12 Noted to have left elbow swelling, pain, meds given. 10/12/12 at 6:19 PM seen by MD suggested for a x-ray...MD said not at this time...continue to monitor. 10/13/12 at 11:32 AM ...left elbow swelling noted to have purple bruising to site...tenderness noted when left arm if moved. 10/14/12 at 11:03 reported ... resident noted with swollen elbow and multiple bruises on her left arm to to her left elbow...MD made aware...x-ray ordered..." The x-ray report dated 10/14/12 indicated "Acute left forearm fracture." The care plan dated 10/11/12 noted "swelling, tenderness and c/o (complaints of) pain to left elbow, nursing to assess for pain such as grimacing..." The care plan dated 10/12/12 was noted for "altered skin integrity....skin tear on left forearm, nurses to provide skin care..monitor for signs of infection..." The care plan dated 10/14/12 was noted for "altered skin integrity...swollen left elbow with multiple bruises on her left forearm up to her left elbow, with plan for x-ray and apply ace wrap..." During an interview with the RNA on 10/29/12 at 8:55 AM, she described Resident 1 as having contractures to her upper extremities. "We just move them to keep loosen and I never pull on her arms." The RNA stated Resident 1 would become "stiff" when she provided the PROM but never combative. RNA stated she provided treatment to Resident 1 at 5:30 AM each day when she first came in. During an interview with Registered Nurse (RN) 1 on 10/29/12 at 10:30 AM she stated, the skin tear was first noted on 10/12/13 and treatment was ordered by MD. RN 1 stated the physician did not order x-rays. RN 1 described Resident 1 as sometimes she would move her arm back from touch and could be resistive to care. During an interview with the Director of Nursing (DON) on 11/20/12 at 9:40 AM, she was asked why the RNA continued treatment after the nursing staff noted the swelling and bruising of Resident 1's arm? The DON replied, "All the nursing staff were thinking about was trying to get an x-ray ordered and they did not think about stopping the RNA treatment. The RNA staff told us the resident was always resistive to care, so it didn't occur it could have been something else." When the DON was asked if the nursing staff could have asked the Medical Director to intervene, the DON replied, "The physician was our Medical Director." The resident was not interviewable due to her dementia.

Based on observation, interview and record review, the facility failed to ensure two sampled residents (12 and 14) and four random residents (19, 20, 21, and 24) were free from verbal, mental and physical abuse by failing to: Protect Resident 12 from verbal and mental abuse, when Resident 15 entered Resident 12's room and pulled back her covers and verbally abused her. Protect Resident 14 and Resident 19 from mental and verbal abuse when Resident 15 entered their room and verbally abused them. Protect Residents 20, 21 and 24 from verbal and physical abuse when they verbalized concern over their safety in a group meeting. These failures placed residents at risk for physical, mental, and verbal abuse and were determined to constitute an Immediate Jeopardy. Findings: 1. During a Resident Family Interview with Resident 12's daughter, on February 8, 2011, at 11:15 AM, in the facility lobby, she stated "(Resident 15) has such a bad mouth, a week ago he came in to my mom's room, he scared her and the Recreation Service Director (RSD) took the report and never told you. He came in and pulled off her covers and cussed her out. The other day he cussed out this lady and she was so scared. My mom is scared of him." Resident 12's daughter did not know the identity of the lady Resident 15 "cussed out". During an interview with Resident 12, on February 8, 2011, at 1:45 PM, she stated "(Resident 15) came in my room. He pulled my covers and he said bad words, not in Spanish, I said no, then he said bad words and scared me". During an interview with the RSD, on February 9, 2011, at 2:15 PM, she stated, "Yes, (Resident 12's) daughter did come to me and complain about an abusive incident with (Resident 15), more than once. You're not going to quote me are you? No, it was not reported." During an interview with the Executive Director (ED), on February 9, 2011, at 2:30 PM, she stated, "No, the RSD has not reported any incidences of abuse regarding (Resident 15) and (Resident 12)." 2. During a concurrent interview with Resident 14 and Certified Nursing Assistant (CNA) 3 on February 9, 2011 at 2:30 PM, Resident 14 stated, "When (Resident 15) comes in the room, more than once in a while, I have to jump out of bed and get him out, before (Resident 19) goes to pieces. She gets so agitated, she shakes and shivers if she sees him. He almost got me the other day, but the housekeeper got between us. My grand-daughter is scared for me, she doesn't like to come in here. He calls me a God-damm [***] , almost every time he sees me, I guess he thinks I'm his wife." As CNA 3 was assisting another resident in the room, she stated, "(Resident 15) goes in rooms, (Resident 19) shakes, and the more alert residents get aggravated. They use the call light or scream when they see him coming. He was getting better, but once the one-to-one (supervision) stopped a few weeks ago, there he went again and started again." During an attempted interview with Resident 19 on February 9, 2011, at 2:30 PM, she was unable to reply to questions due to her impaired condition. The housekeeper was not identified by Resident 14, thus not interviewed. The clinical record for Resident 12 was reviewed on February 14, 2011, at 3 PM. The Progress Notes dated, February 10, 2011, at 6:22 PM, indicated "Resident stated it all happened a couple of weeks ago. Resident stated another male resident came into her room and just tried to take a blanket off a bed. The Social Services Director (SSD) asked resident (12) if the male resident was upset or cursing, she stated, no, he was not and did not curse until after I started to yell at him." 3. During a group interview on February 8, 2011, at 4 PM, in answer to questions regarding the residents' knowledge of instances in which a resident was abused, Resident 21 stated, "Yes, (Resident 15) hits residents, he's been on one-to-one for two weeks, he calms down when his wife comes in." Resident 24 stated, "I'm scared of one man that threatens us. Yes, (Resident 15)." Resident 14 stated, "I was almost hit by (Resident 15), he got so close, but a staff member (not identified) got in between us." Resident 20 stated, "When his wife is gone he is so wacky, he comes right up to me and cusses at me." When the group was asked if (Resident 15's) profanity bothered them, eight residents present at the meeting responded by either nodding their head yes or verbalizing yes. 4. During an observation on February 8, 2011, at 3 PM, in the facility, (not including the Alzheimer's unit), 11 of 28 rooms had netting gates secured with Velcro across the doorways with a stop sign in the middle of the netting. During an interview with CNA 4, on February 9, 2010 at 3 PM, she stated, "These stop signs are to keep intruders out, like (Resident 15), the residents were upset because he cusses at them. Everyone is upset about being cussed at." 5. The clinical record for Resident 15 was reviewed on February 8, 2011. Resident 15 was admitted to the facility on [DATE], with diagnoses, in part, of fracture acetabulum (hip), generalized pain, unspecified [MEDICAL CONDITIONS], senile dementia with delusional features and anxiety state, unspecified. The "Psychosocial Progress Note/Quarterly", dated December 5, 2010, indicated the resident was alert and verbally responsive with confusion. He had long and short term memory impairments and moderately impaired decision making abilities. He had clear speech and was able to hold a conversation, but did not remember the conversation due to his diagnoses. He was administered medication routinely ([MEDICATION NAME] 0.5 milligrams (mg), three times a day) for his anxiety manifested by foul language, and [MEDICATION NAME] Sprinkles 250 mg twice daily for physical aggressiveness manifested by striking out at others. The progress note indicated he had 22 episodes of foul language, four episodes of physical aggressive behavior in the past thirty days, and three altercations since the last review (quarterly, October 2010). The "Return Nursing Visit" document, dated February 7, 2011, indicated he was agitated, combative, yelling out and cursing. He was placed on a one-on-one supervision for care and redirection. The "Progress Notes" dated January 17, 2011, signed by nursing staff, indicated he had an altercation with another resident when he hit another resident in her left arm. His medications were adjusted and he was placed on one-on-one supervision. On January 19, 2011, a nursing progress note indicated he had an "...episode of aggressive behavior before lunch (and was) redirected...to activity." Resident 15's plan of care, initiated December 6, 2010, indicated he had behavior of foul language, striking out at others and yelling and hitting others. The interventions included, in part, medication as ordered, monitor for behavior/symptoms of aggressiveness and report changes to his physician. A Hospice plan of care, dated January 20, 2011, indicated the resident was "frequently agitated". The facility failed to keep other residents safe from Resident 15's verbal and physical aggressiveness. The facility policy and procedure titled "Preventing Resident Abuse", dated July 2002, indicated the facility "Encourages associates, families and residents to report incidents of suspected abuse.....without fear of reprisal" and "reviews alleged violations in Quality Assessment and Assurance committee meetings for detection of patterns and trends." It indicated the "DNS (Director of Nurses) or...designee shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident's safety can be protected." The facility placed "stop" signs at certain resident room doorways, which did not prevent Resident 15 from his aggressive behavior toward other residents. The facility failed to ensure the safety of residents from verbal and physical abuse from Resident 15. A condition of Immediate Jeopardy (IJ) was identified by the survey team for the facility's failure to keep residents free from verbal, physical and mental abuse, and failure to report alleged abuse when five residents expressed fear of verbal and physical abuse from a resident that entered their rooms uninvited and verbally and physically abused them in hallways and other parts of the facility. The IJ was called on February 9, 2011, at 10:20 AM with the facility Executive and Director of Operations. The surveyor(s) confirmed by observation, interview, and record review on February 10, 2011, that the facility implemented the following to remove the Immediate Jeopardy: 1. One case of alleged abuse was telephoned to the California Department of Public Health on February 9, 2011, at 8:21 PM; the identified aggressive resident was placed on one-on-one supervision until the facility's Interdisciplinary Team (IDT) determine one-on-one supervision is no longer necessary. 2. Residents with the potential to be affected by the identified aggressive resident were reassured of their safety through a group meeting and one-on-one verbal counseling by the Executive Director or Social Services. 3. An in-service (training class) was held with all on-duty staff on February 9, 2011, with remainder of staff to complete prior to their next scheduled shift, to review signs and symptoms of fearfulness, identification of residents who may express fearfulness toward aggressive residents, identification and reporting of abusive and intimidating behaviors by aggressive residents, facility Abuse Policy, facility Grievance Policy and Procedure, and the Report of Change of Condition. 4. An in-service for all Licensed Nurses by the Director of Nursing on February 9, 2011, for on-duty licensed nurses and remainder of licensed staff prior to performing patient care, to review identification of abusive and intimidating behaviors, determination of possible causative factors, implementation of interventions to redirect an aggressive resident's behavior and placement of one-on-one supervision for aggressive residents. 5. The identified aggressive resident was evaluated by the IDT on February 9, 2011, with the identification of long term goals. 6. Facility staff will monitor residents exhibiting/verbalizing fearfulness on an ongoing basis and through resident council, and if fearfulness is identified due to an aggressive resident, the aggressive resident will be placed on one-on-one supervision. 7. Trends will be reported to the Quality Assessment and Assurance (QA&A, a committee that identifies quality concerns and develops action plans, monitoring and revisions if needed). 8. Any aggressive resident will be evaluated by a licensed nurse to ensure other residents' safety, the IDT will evaluate any aggressive resident weekly and trends will be reported to the QA&A. The IJ was abated on February 10, 2011, at 4:46 PM with the facility Executive Director and Director of Operations.

Based on interview, and record review, the facility failed to report one allegation of resident (15) to resident (12) abuse to the Executive Director (ED) of the facility, and to the State Agency for one (12) of 18 sampled residents for more than two weeks following the incident, which created the potential for unmonitored and uncorrected situations of abuse. The facility failed to conduct a thorough investigation of the abuse allegation. These failures caused Resident 12 to be fearful for her safety, placed residents at risk for potential abuse and were determined to constitute an Immediate Jeopardy. See F223 for additional information regarding Resident 12 and 15. Findings: During a Resident Family Interview with Resident 12's daughter, on February 8, 2011, at 11:15 AM, in the facility lobby, she stated, "(Resident 15) has such a bad mouth, a week ago he came in to my mom's room, he scared her and the Recreation Services Director (RSD) took the report and never told you. He came in and pulled off her covers and cussed her out. The other day he cussed out this lady and she was so scared. My mom is scared of him." During an interview with Resident 12, on February 8, at 2011, at 1:45 PM she stated "(Resident 15) came in my room he pulled my covers and he said bad words, not in Spanish, I said no, then he said bad words and scared me". During an interview with the RSD on February 9, 2011, at 2:15 PM, she stated, "Yes, (Resident 12's) daughter did come to me and complain about an abusive incident with (Resident 15), more than once. Your not going to quote me are you? No, It was not reported." During an interview with the ED on February 9, 2011, at 2:30 PM, she stated, "No, the RSD has not reported any incidences of abuse regarding (Resident 15) and (Resident 12)." The facility policy and procedure titled "Preventing Resident Abuse", dated July 2002, indicated, "All health practitioners and all employees in a long term care facility are mandated reporters. Any mandated reporter that reasonably suspects abuse shall report suspected abuse. Any associate who suspects an alleged violation shall immediately notify the ED or her designee."

Based on observation and interview, the facility failed to care for one of 18 sampled resident's (2) in an individualized, person-centered manner that was welcoming, comforting, enhanced and humanized the resident's quality of life, when her living environment was not home-like, she was not provided positive stimulation or activities by staff and was not regularly provided activities she enjoyed. The facility also failed to respond to Residents 2's agitation. These failures contributed to the resident's agitation and psychosocial well being. See F248 and F279 for additional information about Resident 2. Findings: During the initial tour of the facility on February 7, 2011, at 11:35 AM, Resident 2 was observed lying in bed wearing a facility gown. The window curtains were closed in the three-bed room and the privacy curtains were drawn the full length of the beds, between each of the three beds. Resident 2 was in the first bed, approximately eight feet from the door. No lights were on. Resident 2 had three signs above her bed; a star, a heart with the initials "TLC" inside, and an apple. The resident was non-verbal and responded to a greeting by moaning. No personal items for the resident were observed in her living space. The over bed table was empty, the night stand beside the bed held a plastic water pitcher and a plastic glass, and the top of the two-drawer dresser across from the foot of her bed was empty. A facility bulletin board was hanging on the wall across from the foot of her bed with the facility activity calendar on it. No wall decorations or pictures were observed in Resident 2's living area. The resident's roommate in bed two had a television that was on with the volume high. During an interview with Certified Nursing Assistant (CNA) 1, on February 7, 2011, at 3:10 PM, she stated the star symbol above Resident 2's bed indicated she was a fall risk; the heart indicated she was to receive "care" (she did not know the meaning of the initials "TLC") and she was unaware of the meaning of the apple. At 3:20 PM, CNA 1 stated the apple symbol indicated turning and that she had not been employed at the facility "very long." During an observation on February 8, 2011, at 9 AM, Resident 2 was observed lying in bed on her left side, wearing a facility gown. The room was dark with the window curtains closed and the privacy curtains between the three beds drawn the full length of the beds. At 12:50 PM, the resident was observed lying in bed on her left side with her eyes open. Her right hand and arm were shaking and the resident was moaning and cursing, stating ".....I'm gonna knock the[***]outta you..." Facility staff were observed in the hallway outside the resident's room. There was no communication from the staff with Resident 2. At 1 PM, the resident continued to moan and shake her right arm yelling "...come and get me, I'm dying..." Staff did not respond to the resident's yelling. Her roommate in bed two, was cursing and had her television on high volume. The facility did not respond to the resident's agitation and did not provide "care". During an interview with CNA 6 on February 8, 2011, at 1:10 PM, she stated the room was dark with the curtains drawn because it was the preference of Resident 2's two roommates (bed two and bed three). When asked about Resident 2's preferences, CNA 6 stated, "She's (Resident 2) unaware." The facility did not consider Resident 2's preferences or the non-home-like environment. On February 9, 2011, at 12 PM, Resident 2 was observed in bed, dressed in clothing, and positioned on her right side. She was awake and moaning. The room was dark with window curtains closed and privacy curtains closed between all beds. During a concurrent attempted interview with Resident 2, she was unable to reply due to her impaired condition. On February 10, 2011, at 10:25 AM, Resident 2 was observed up in a wheelchair, dressed, well groomed and attending the activity "Church with the Ladies." The activity leader was playing piano and leading the group in singing. Resident 2 was awake and quiet. No moaning was heard. At 10:40 AM during an interview with the Recreation Services Director (RSD), she stated Resident 2 "enjoys music.....it calms her." She stated the resident attends music related activities occasionally, when a specific CNA is working and helps get reluctant residents to activities. The RSD indicated Resident 2 stayed in bed most of the time, as she did not like to get up. During an interview with the RSD on February 14, 2011, at 3 PM, she stated Resident 2 liked music, however the activity department had not played music for the resident in her room. She stated the facility had a compact disc (CD) player but did not have headphones. The facility just obtained headphones (but they are not being used). She stated the activity carts were used occasionally and that "...we've been lax....we haven't had the staff for much in-room activity." She stated they have "tubes" (a hollow tube that makes noise when tilted) they used for sensory stimulation (for residents like Resident 2), but she had not used them for her (Resident 2) "because her roommate's TV is so loud." The facility did not regularly provide the resident activities she enjoyed. The clinical record for Resident 2 was reviewed on February 7, 2011. The "Recreation Progress Notes" dated March 18, 2010 indicated Recreation Services would "assign room visits three times a week, engage her (Resident 2) in conversation, massage her hands with cream and pretty picture books." A Recreation Progress Note dated "10-20-20" (entered after the March 18, 2010 note), indicated Resident 2 declined all attempts to be involved in activities. "On going in room visits from act's (Activity's) staff. Bring music, stories and conversation." A quarterly progress note signed by the RSD, dated December 19, 2010 indicated "Resident (2) prefers to spend most of her time in bed. She will become upset if cna's try to get her out of bed.....she sleeps most of the day.....(she) cannot participate in conversation, she moans and groans most of the time during room visits....hand massage will continue." During an interview with CNA 1 on February 14, 2011, at 2:55 PM, she stated she had not seen any in-room activities for Resident 2. During an observation of Resident 2 on February 14, 2011, at 12:45 PM, she was lying in bed on her back, wearing a facility gown. She moaned in response to a greeting. The room was dark with the window curtains closed and privacy curtains drawn the full length of the bed between the three beds. No personal items or any items to provide individualization were observed in Resident 2's living environment. Her roommate's (bed two) television was on with the volume loud and the roommate was cursing and chanting loudly. The facility did not create a home-like environment for Resident 2. The clinical record for Resident 2 was reviewed on February 7, 2011. The record indicated she has resided in this facility since September 2008. The Minimum Data Set (MDS, an assessment tool) dated December 4, 2009, August 26, 2010, and November 25, 2010, indicated her ability for decision making was severely impaired. A Recreation Progress Note dated March 18, 2010, indicated she had no family or visitors and enjoyed music and church. A Recreation assessment dated [DATE] indicated she was alert, her vision and hearing were intact and she enjoyed "simple life's pleasure.....music."

Based on observation, resident and staff interviews, and review of clinical records and facility policies and procedures, and other facility documents, the facility failed to ensure its dietitian (District Dietician, DD) assumed the responsibilities developing and approving all menus, ensuring that substitutions were comparable to the menu that was being replaced and that recipes existed for all food items prepared. The DD also failed to provide services to meet the nutritional needs of one of 18 sampled residents (3) and one non-sampled resident (25) by failing to adequately assess and reassess their specific nutritional needs. The DD failed to supervise food preparation resulting in Resident 25 receiving food that is unpalatable, a soggy sandwich that was prepared two days before she would have consumed it. The DD failed to ensure policies and procedures were in place that governed timing and frequency of assessments and which assessments she was responsible for. The DD failed use of the information in the record to formulate an effective care plan. Her lack of assessment and failure to coordinate care with other health professionals (pharmacist and physician) or evaluation of medications necessary to keep nutrition related laboratory values within normal levels. These failures resulted in Resident 3 gaining 25 pounds in a year and requiring more insulin than when he weighed less and Resident 25 with high levels of phosphorous. (Refer to F325 and 281) Findings: 1. On February 8, 2011, Resident 3's physician's orders [REDACTED]. This was food cut into small sizes to help the resident chew or swallow with ease, and liquids that were the consistency of nectar to prevent choking that would result from drinking thin liquids. In addition, Resident 3 had a tube feeding order for Promote with fiber one liter to equal 1000 calories in 10 hours per a gastrostomy tube ([DEVICE], a tube inserted through abdominal wall to stomach for nutritional purpose) pump at 100 milliliters (ml) per hour, on at 6 PM and off at 4 AM. According to his Weight Record, Resident 3 weighed 126.8 pounds (lbs) in January 2010, and by January 2011 he had gained approximately 25.7 lbs weighing 152.5 lbs. According to the minimum data set (MDS, an assessment tool) dated January 11, 2011, Resident 3 triggered for nutritional concerns based on high Body Mass Index (BMI) of 26 and the use of a tube feeding among other problems. BMI is a measurement of body fat, BMI of greater than 25 is considered overweight. On the Care Area Assessment (CAA) of the MDS, the MDS nurse documented: "refer to RD (registered dietitian)." Although the resident's BMI was one point over the classification of "overweight", the weight was 113% of his usual body weight of 135 lbs. A high BMI or being overweight causes the body to work harder including maintaining blood glucose. In a person with diabetes, being overweight causes the body to use more insulin. Further review of Resident 3's clinical record showed that his blood sugars in the previous week (February 1 to 8, 2011) ranged from 192 to 343 at bedtime and 355 at 11 AM on February 9, 2011 (normal blood sugar ranges between 70 and 100). As a result of these high blood sugars, Resident 3 received insulin injection many times when his blood sugar was tested in the month of February. It was 22 times out of 34 times or 64% of the time in February. He received between 2 to 8 units of insulin with an occasional 10 units. This is higher when compared to his insulin use in May 2010 when his weight was 135 lbs. Resident 3 received insulin 69 out of possible 124 opportunities or 55% of the time. The amount was between 2 and 4 units and twice he received 8 units of insulin twice that month. In October 2010 when his weight was 147 lbs, slightly above his IBW of 117 to 143 lbs; he received slightly more insulin. He used it 73 out of a possible 124 times or 58% of the time with doses of between 2 to 4 units. His Hgb A1c has increased within the past year from 5.9 in July 2010 to 6.27 in October 2010. Hgb A1C (hemoglobin glycosylated) or diabetic control index measures how well the body is able to control blood sugars, normal value is 4.6 to 6.20, although for diabetics values of under 7.0 are considered acceptable, Resident 3's recent level of 6.8 on January 19, 2011 showed he was very close to the higher end of normal for diabetics. Further review of Resident 3's clinical record revealed the Dietary Manager (DM) had conducted an annual review of the resident on January 6, 2011 and developed nutrition related care plans on January 18, 2011. However, the care plans developed did not include the areas identified in the CAA, the high BMI. For example, the care plan developed on tube feeding included goals of maintaining nutritional status and body weight with interventions such as "monthly weights." It failed to specify goals for his accepted BMI and failed to have individualized interventions in place to limit or identify the cause of his high BMI. These care plans related to Resident 3's nutritional status were later signed by the MDS nurse on February 7, 2011, 20 days after it had been initiated and developed by the DM. The DD documented on January 31, 2011 that the resident's weight was stable and recommended "continue with present plan" despite documentation that the resident had gained 25 lbs in a year, 5.5 pounds in three months and a referral from the MDS Nurse. Her note further described the resident's intake "averaged >65%." According to the facility's diet manual, the regular diet provides approximately 2200 calories per day. If the resident consumed 65% of his meal it meant that he consumed approximately 1430 calories orally and 1000 calories via tube feeding for a total of 2430 calories. This was 730 calories more than the DD assessed his nutritional needs to be. The DD failed to adequately assess the nutritional needs of the resident. The DD failed to revise the care plan to prevent the unplanned weight gain. The DD was interviewed on February 10, 2011 at 9:40 AM and was given the opportunity to review Resident 3's clinical record. When she was interviewed on what the facility policy was regarding the frequency of nutritional assessments. She stated that the facility did not have a policy on that and there was no requirement of having such policy. She further stated that she followed "the requirements of F325." Review of the clinical records of the residents showed more participation and documentation from the DM who was not a registered dietitian and did not have the scope of practice to conduct nutritional assessments or develop care plans. Therefore, during this interview, the DM was asked her role in nutrition care about the fact that some of her documentation's were assessments, not screening as the DM stated she did. The DD stood up and said, "This conversation was over," and asked the DM to leave the interview. When concerns were raised on the fact that the DD had made no recommendations on Resident 3's diet intake and tube feeding may have impacted his high BMI and blood sugars. The DD did not consider changing the tube feeding to a diabetic formula and/or adjust his regular diet. The DD stated Resident 3's high blood sugars were attributable to infections. She stated, "We are not going to change (his diet) every time he has an infection and blood sugar goes up." When asked whether Resident 3 had an infection, the DD stated she did not know. The Director of Nursing (DON) was interviewed on February 10, 2011, at 11:25 AM whether Resident 3 currently had an infection. The DON stated Resident 3 had not had an infection since October 2010. The "District Dietician" job description dated June 2009 was reviewed on February 14, 2011. The District Dietician's (DD) responsibilities included "complete nutrition assessment/reassessment and care plans as necessary ... Coordinates nutritional care with nursing, medical and other professional staff." The DD failed to properly assess the nutrition needs, develop and or revise care plans for Resident 3 after referral by the MDS nurse. 2. During an interview with the Executive Director (ED) on February 8, 2011, at 8:55 AM, she indicated the facility's dietitian (DD) was an employee of the corporation and not a contracted dietitian. In response to the question regarding hours she provided to the facility, the ED stated the DD would provide hours as needed. She added that the DD's responsibilities included reviewing admissions, charts, weight variances, and referrals from nursing staff. No employee personnel record or consultant report was provided during the survey and therefore the extent of her participation in the oversight of food service operation and nutrition assessment of residents in this facility could not be determined. The job description dated 6/2009 for the District Dietitian was provided on February 14, 2011. Her responsibilities included document approval of all menus, therapeutic modifications, and substitutions used in the facility. There was no evidence the DD approved regular, therapeutic diets or substituted menus. On February 7, 2011, at 12 PM, the copy of the menu was reviewed with the DM. It had no signature to indicate approval. There was no documented evidence that the menu was approved by the DD. The DM was asked if there was a master copy of the menu by which the approval could be verified. The DM stated that there was no master copy that had the signature or documentation from the DD indicating approval of the menu. At 12:25 PM on February 7, 2011, a black lunch bag dated "2/7/11" was found stored inside the kitchen refrigerator unit 3. Inside the bag were a tuna sandwich, a 4-ounce container of yogurt, 2 packets of graham crackers and a can of lemon-lime soda. Closer examination revealed that the sandwich was compressed and soggy. It did not appear to have a lot of tuna to meet the amount that would have been served had the resident being served in the facility. The DM who was present during the observation stated it had been prepared the day before a resident (25) who was scheduled for [MEDICAL TREATMENT]. It was later determined that the resident did not go for [MEDICAL TREATMENT] until two days later; at which time the tuna sandwich would have become more soggy, making it unpalatable, as a result of preparation two days ahead. The recipe for the tuna salad was requested on February 7, 2011. The copy provided by the DM had the notation: "This recipe is for emergency use only." At 2:50 PM, during an interview, the DM stated she was not sure how the tuna was prepared. The items in the lunch bag were not a good substitute for the lunch that the resident would have received had she received lunch in the facility. There were no items in the fruits and vegetable category or desserts that other residents on regular diets would have received. There was no posted menu for sack lunches or written guidance on the regular menu as what staff was to provide to residents receiving sack lunches. Resident 25 complained in an interview on February 9, 2011, at 10:55 AM, that she received the same "soggy" tuna sandwich, yogurt, graham crackers, lemon and lime soda every time, three days a week she went to [MEDICAL TREATMENT]. The DD failed to supervise food preparation, ensure that recipes existed for all items prepared in the facility. The DD also failed to develop and approve an alternate menu for residents who receive sack lunches. Resident 25 did not receive a variety of food three days a week when she went to [MEDICAL TREATMENT]. The sandwich she received was not palatable. (Cross reference F364) 3. Resident 25 is a [AGE] year-old female with [DIAGNOSES REDACTED]. Her physician ordered a regular diet and [MEDICAL TREATMENT] treatment three times a week. Her laboratory results from the [MEDICAL TREATMENT] center revealed that the resident had high levels of phosphorous (normal 3.0 - 5.0). High levels of phosphorous in a patient with [MEDICAL CONDITION] causes bone problems. Her levels ranged from 6.5 to 9.2 from August to November 2010. Sources of phosphorous in the diet are dairy products like cheese, milk and non dairy sources such as quick breads, whole grains, beans, nuts. This was the same resident who was had yogurt packed for her lunch on days she goes to [MEDICAL TREATMENT]. According to her she received this every time she goes to [MEDICAL TREATMENT]. Review of clinical record on February 8, 2011 showed the resident was on one of the medications used to bind phosphorous in her diet. This medication, according to the physician orders, should be given with meals. According to the facility schedule meal times, meal times are 7 AM 12 noon and 5 PM. Review of the Medication Administration Record (MAR) showed that the medication was given at 8 AM, 12 noon and 4 PM. An interview with the DON on February 9, 2011, at 10:45 AM, on medication times revealed that the facility's practice was to give medications up to 1 hour before or after meals. This medication, [MEDICATION NAME], according to its manufacturer should be given at meal time or up to 30 minutes before. The failure to give the [MEDICATION NAME]-binder medication as directed could result in the high blood levels of phosphorous. When the high phosphorous levels of Resident 25 were discussed with the DD in an interview on February 8, 2011, at 3:30 PM, she stated, "you know that medication is the first line (of treatment)?" When the surveyor told her that she was aware and the improper timing of the medication could be contributory, she responded that it was the pharmacist's responsibility, not hers. She failed to coordinate with the pharmacist on nutrition related issue as a result of medication administration time. The DD failed to utilize her expertise in the identification of the nutrition related problems for residents. The facility's dietitian failed to plan menus for residents on [MEDICAL TREATMENT] and receiving sack lunches, developing policies and procedures, ensuring that recipes existed for menu items, approving menus, and supervising food preparation and service. 2. The clinical record for Resident 3 was reviewed on February 8, 2011. The physician's orders [REDACTED]. In addition, he had a tube feeding order for Promote with fiber, one liter to equal 1000 calories in 10 hours per a gastrostomy tube ([DEVICE], a tube inserted through abdominal wall to stomach for nutritional purpose) pump at 100 milliliters (ml) per hour, on at 6 PM and off at 4 AM. According to his Weight Record, Resident 3 weighed 132.4 pounds (lbs) in February 2010, and by February 2011 he had gained approximately 20 lbs, weighing 151.3 lbs, a 15 percent weight gain. According to the minimum data set (MDS, an assessment tool) dated January 11, 2011, Resident 3's high Body Mass Index (BMI) was 26. BMI is a measurement of body fat, and a BMI of greater than 25 is considered overweight. On the same MDS, the MDS nurse documented: "refer to RD (registered dietitian)." An elevated BMI or being overweight causes the body to work harder and maintain a stable blood glucose. In a diabetic, being overweight causes the body to use more insulin. Further review of Resident 3's clinical record showed that his blood sugars in the previous week (February 1 to 8, 2011) ranged from 192 to 343 at bedtime and 355 at 11:00 AM on February 9, 2011 (normal blood sugar ranges between 70 and 100). Resident 3 received insulin injections every time his blood sugar was tested and elevated in the month of February 2011, which was 22 out of a possible 34 times, or 64% of the time. Each time his blood sugar was elevated, he received between two to ten units of insulin. In October 2010, when his weight was 147 lbs, he received insulin for elevated blood sugars 58 % of the time, with dosages of two to four units of insulin. His insulin usage for high blood sugars (55% of the time) in May 2010 was lower when his weight was 135 lbs. Resident 3's hemoglobin glycosylated (Hgb A1c, diabetic control index measurement of how well the body is able to control blood sugars) had increased from 5.9 in July 2010 to 6.27 in October 2010 (normal value of Hgb A1c is 4.6 to 6.2, with less than 7.0 considered acceptable for diabetics). On January 19, 2011, his Hgb A1c level was 6.8, an increase indicative of poorly controlled diabetes. The DD was interviewed on February 10, 2011 at 9:40 AM and was given the opportunity to review Resident 3's clinical record. When she was interviewed on what the facility policy was regarding the frequency of nutritional assessments, she stated that the facility did not have a policy on that and there was no requirement for such policy. She further stated that she followed "the requirements of F325." At one point, during this interview, the DM was asked about the fact that some of her documentation's were assessments, not screenings. The DD stood up and said, "This conversation is over," and asked the DM to leave the interview. Concerns were raised regarding the DD's lack of recommendations on Resident 3's diet intake and tube feeding, which may have impacted his high BMI, weight gain, and high blood sugars. The DD did not consider changing the tube feeding to a diabetic formula, and/or adjusting his tube feeding amount, or changing his regular diet. The DD stated Resident 3's high blood sugars were attributable to infections. She stated, "We are not going to change (his diet) every time he has an infection and blood sugar goes up." When asked whether Resident 3 had an infection, the DD stated she did not know. In an interview with the MDS coordinator on February 10, 2011, at 11 AM, she stated she did not speak with the DD directly about the referral she made on January 19, 2011. She said the weight concerns had been discussed at the Weight Variance Committee. When asked if Resident 3's case was discussed she stated that she was not sure. She further stated that she believed the DM would have been made aware. The director of nursing (DON) was interviewed on February 10, 2011, at 11:25 AM, to determine if Resident 3 currently had an infection. The DON stated Resident 3 had not had an infection since October 2010. Further review of the Resident 3's clinical record revealed that nutrition related care plans had been developed on January 18, 2011, with the DM's signature. However, the care plans developed did not include the resident's high BMI, weight gain, or high blood sugars. For example, the care plan developed on tube feeding included goals of maintaining nutritional status and body weight with interventions such as "monthly weights." It failed to specify goals for the resident's acceptable BMI, weight gain, or blood sugars. It also failed to have individualized interventions in place to prevent the causes of his nutritional issues. These care plans related to Resident 3's nutritional status were signed by the MDS nurse on February 7, 2011, 20 days after it had been initiated and developed by the DM. The "District Dietician" job description was reviewed on February 14, 2011. The DD's responsibilities included, "complete nutrition assessment/reassessment and care plans as necessary ... Coordinates nutritional care with nursing, medical and other professional staff." The DD failed to develop care plans for Resident 3 and coordinate Resident 3's nutritional care when referred by the MDS nurse.