Every finding on record at The Ridge Post Acute

Based on observation, interview and record review, the facility failed to ensure dignity for one of three sampled residents (Resident 1) when Resident 1 was called hardheaded or stubborn by a facility staff during ADL (Activities of daily living, are the fundamental self-care tasks individuals must perform daily to live independently and maintain their well-being) care. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 1.Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including altered mental status, unspecified and heart failure (progressive condition where the heart muscle weakens or stiffens, preventing it from pumping enough oxygen-rich blood to meet the body's needs), unspecified. Review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 4/6/2026, indicated Resident 1's brief interview for mental status score was 12 (BIMS, an assessment to test a person's cognitive level, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 cognitively intact). During an interview on 5/22/26 at 2:51 p.m., in Resident 1's room, Resident 1 stated there was one staff member that she doesn't like, she stated she made a complaint about the staff. Resident 1 stated Certified Nursing Assistant A (CNA) A, was helping her by changing briefs. Resident 1 stated it takes her some time to turn to her left because of her right shoulder, instead of supporting her right shoulder CNA A called her a name which is not good to her, in English it means hardheaded. Resident 1 stated she is not a kid, she is 95 y/o. During an interview on 5/22/26 at 2:51 p.m., with Certified Nursing Assistant A (CNA) A stated she was doing the regular rounds, helping Resident 1 change the briefs, she stated Resident 1 is like covering herself and she called her Nanay (means mother, in Tagalog) and talked to resident in Tagalog, in a nice way like please. She stated she didn't know the meaning in English is stubborn, she stated Resident 1 got mad at her. CNA A stated she called the Nurse on duty immediately and she did not come back inside Resident 1's room. CNA A further stated she didn't know that Resident 1 would get mad. During a phone interview on 6/8/26 at 3:45 p.m., with the Director of Staff Development (DSD), the DSD stated the staff called resident by their first name or last name, the DSD was asked if facility staff can call residents hardheaded or stubborn, the DSD stated it's not allowed. During a review of facility's policy and procedure (P&P) titled, Dignity Revised February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times.2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on observation, interview, and record review, the facility failed to ensure staff were trained and competent in the use of Wander Management Transmitters (wander guard, a device placed on a resident's wrist, ankle, or wheelchair that alarms to notify the staff if a resident tries to leave the facility) used for two of two residents (Residents 7 and 35). This failure had the potential to result in transmitter equipment failure or system failure and resident elopement (to leave a health facility without notification or permission).Findings: Review of Resident 7's face sheet indicated she was admitted to the facility with diagnoses including dementia (decline in mental capacity affecting daily function) and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar). Review of Resident 7's elopement care plan, dated 12/26/25 indicated the resident exhibited wandering behavior and was at risk for elopement. Review of Resident 7's Order Listing Report, dated 1/9/26 indicated she had a physician order to apply wander guard to right ankle and check placement and functioning every shift as a monitoring device due to episodes of going out of the facility unassisted. Review of Resident 35's face sheet indicated she was admitted to the facility with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and schizophrenia (a mental illness that is characterized by disturbances in thought). Review of Resident 35's elopement care plan, dated 5/21/25 indicated the resident is at risk for elopement and had episodes of going out of the facility unassisted. Review of Resident 35's Order Listing Report, dated 1/9/26 indicated he had a physician order to apply wander guard to right ankle and check placement and functioning every shift as a monitoring device due to episodes of going out of the facility unassisted. During an observation and interview on 1/8/26 at 10:50 a.m., licensed vocational nurse C (LVN C) stated the door will alarm when the resident gets close to the door. LVN C stated the nurses should check that wander guard is intact. LVN C went Resident 7's room to check whether Resident 7 had her wander guard in place. Resident 7 was asleep in bed with a blanket covering her body. LVN C was not able to check whether the wander guard was in place and stated she would try again later. During an observation and interview on 1/8/26 at 11:02 a.m., licensed vocational nurse D (LVN D) stated he is pretty sure there is a way to check whether the wander guard is functioning. LVN D checked whether Resident 35's wander guard had a light and confirmed there was no light on his wander guard. LVN D stated he will ask the director of nursing (DON). During an interview on 1/8/26 at 11:05 a.m. the DON stated there is a device that lights up that is used as a tester to test whether the wander guard is functioning. The DON stated the nurses should know. She stated she will check where the tester was. During an interview on 1/8/26 at 11:05 a.m., the director of staff development (DSD) stated will look for documentation of a training or inservice related to the use of the wander guard During an interview on 1/9/26 at 4 p.m., the DON stated maintenance has the testing device that tests the functionality of the wander guard. The manufacturer's user manual for the wander guard was requested. During an interview on 1/12/26 at 9:51 a.m., the DSD stated she was not able to find an inservice on the wander guard. The DSD stated they started training nurses regarding the use of the wander guard on 1/9/26. During an observation and concurrent interview on 1/12/26 at 2:30 p.m., the administrator (ADM) stated the testing device tested the function of the door alarm. The ADM stated there was nothing to test the wander guard's functioning. The testing device had no label or instructions for use. The ADM was not able to provide the manufacturer's user manual for the wander guard transmitter. Review of the facility's policy, Wandering and Elopements, dated 3/2019 indicated, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the Secure Care Products, LLC's Transmitter User Guide, dated 12/11/17 indicated the following:This Product must be installed, set-up, tested, supported, operated, maintained, repaired and used only in accordance with all manuals and instructions (including the user, installation, technical and other manuals) issued by Secure Care (the Product Manuals).It is also your responsibility to assure that any person who might be operating or using this Product knows the contents of and has access to the Product Manuals and has successfully completed Secure Care in-service training.Testing the Transmitter Using the 707 Tester1. Turn the switch to TRANSMITTER TEST.2. Press and release the RESET button.3. Bring the Transmitter in front of the Tester. The yellow RECEIVED SIGNAL (LED) should [NAME] and the green TRANSMITTER OK light should come on. The 707 Tester is receiving transmitter signal.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for four out of fifteen sampled residents (Residents 12, 5, 8 and 31): 1. For Resident 12, there was no comprehensive, person-centered care plan for his side rail or bed rail (bars attached to the side of the bed for safety and mobility aids);2. For Resident 5, she had no bed rail care plan; 3. For Resident 8, staff did not implement a care plan intervention of monitoring oxygen saturation (measurement of how much oxygen is in the blood) every shift. 4. For Resident 31, she had no activity care plan. These failures had the potential to result in the residents, not receiving the intervention and monitoring necessary to maintain their highest level of well-being. Findings: 1.During the initial observation of Resident 12 on 1/6/26 at 12:40 p.m., Resident 12 was laying in his bed. Resident 12 was calm, comfortable, confused and could not answer questions. He had 1/3 left side rail or bed rail up. Review of Resident 12's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) dated 1/8/26 indicated, Resident 12 was readmitted to the facility on [DATE] with the primary diagnosis of catatonic schizophrenia (subtype of schizophrenia characterized by significant disruptions in motor behavior and extreme psychological disturbances). Review of Resident 12's order listing report dated 1/9/26 indicated, Resident 12 had an order to put 1/3 left bed rail up when in bed, to assist resident in bed mobility and/or transfers, last ordered on 1/4/26. Review of Resident 12's care plans indicated, Resident 12 did not have a comprehensive, person-centered care plan for his bed rail. During the concurrent review of Resident 12's care plans and interview with assistant director of nursing/infection preventionist (ADON/IP) on 1/9/26 at 10:20 a.m., ADON/IP acknowledged that Resident 12 had 1/3 left bed rail up when in bed but did not have a comprehensive, person-centered care plan for his 1/3 left bed rail and would have it updated. During the interview with director of nursing (DON) on 1/9/26 at 2:13 p.m., DON verified that the care plan for the bed rail should be comprehensive and person-centered and would follow up on it. 2. Review of Resident 5's admission record dated 1/8/26 indicated, Resident 5 was admitted to the facility on [DATE] with the primary diagnosis of hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage), unspecified affecting left dominant side (preference to use this side of the body over the other). Review of Resident 5's order listing report dated 1/9/26 indicated, Resident 5 had an order to put 1/5 bilateral bed rails up when in bed, to assist resident in bed mobility and/or transfers every shift. Resident 5 was discharged to home, 12/23/25 with medications, discharge instructions and home health was set-up. Review of Resident 5's care plans indicated, Resident 5 did not have a comprehensive, person-centered care plan for her bed rails. During the concurrent review of Resident 5's care plans and interview with ADON/IP on 1/9/26 at 11:40 a.m., ADON/IP acknowledged that Resident 5 had 1/5 bilateral bed rails but did not have a comprehensive, person-centered care plan for her bed rails. During the interview with director of nursing (DON) on 1/9/26 at 2:13 p.m., DON verified that the care plan for the bed rails should be comprehensive and person-centered and would follow up on it. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. During an observation on 1/6/26 at 10:28 a.m. Resident 8 was in bed and was on oxygen at 2 liters per minute (L/min, unit of flow rate). Review of Resident 8's clinical record indicated she was under hospice care and depended on supplemental oxygen. Review of Resident 8's physician orders indicated the resident had an order for oxygen at 2 L/min via nasal cannula for shortness of breath and comfort. Review of Resident 8's care plan for oxygen therapy, dated 6/3/25 indicated an intervention, Monitor and record O2 saturation QS [every shift]. There was no documentation that indicated Resident 8's oxygen saturation was monitored and recorded every shift. During an interview on 1/09/26 at 10:11 a.m., the Director of Nursing (DON) confirmed Resident 8 was on oxygen and her oxygen saturation should be taken every shift. The DON stated there was no order for Resident 8's oxygen saturation to be taken every shift. Review of the facility's policy, Oxygen Administration, revised 10/2010 indicated while the resident is receiving oxygen therapy, assess for vital signs, lunch sounds, and oxygen saturation. 4. Review of Resident 31's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident 31's activity care plan indicated a created date of 1/6/26. There was no documentation Resident 31 had an activity care plan after her 11/18/25 admission. During an interview on 1/12/26 at 1:42 p.m. the DON stated Resident 31 only had one activity care plan and confirmed it was created on 1/6/26. Review of the facility's policy, Activity Evaluation, dated 2/2023 indicated, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident . Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her inidividual needs.

Based on interview and record reviews, the facility failed to ensure that the nurse staffing information was kept and maintained for at least eighteen months when their direct care service hours per patient day (DHPPD, a critical staffing metric for skilled nursing facilities requiring a minimum of 3.5 total hours of which 2.4 hours per patient day must be performed by certified nursing assistants or CNA) for 7/1/25 to 9/30/25, were not available and provided when requested.This failure had the potential to affect the quality of care that were provided to the forty-six residents residing in the facility that could also affect the residents' quality of life and well-being. Findings: Review of the Centers for Medicare and Medicaid Services (CMS, United States federal agency managing Medicare, Medicaid, Children's Health Insurance Program or CHIP and the health insurance marketplace), Certification and Survey Provider Enhanced Reporting's (CASPER's, tools used by skilled nursing facilities and CMS to monitor, review, and report the daily staffing hours and resident census data) Payroll-Based Journal (PBJ, quarterly submission by nursing homes to the CMS detailing direct care staff hours and resident census) Staffing Data Report from 7/1/25 to 9/30/25 indicated, excessively low weekend staffing and one star staffing rating (much below average staffing levels compared to other facilities). During the concurrent interviews with the director of nursing (DON) and the administrator (ADM) on 1/12/26 at 2:01 p.m., they both acknowledged that they currently did not have the DHPPD staffing data reports from 7/1/25 to 9/30/25 that would dispute the excessively low weekend staffing and one star rating for these dates. They further acknowledged the above CASPER's PBJ staffing data report from 7/1/25 to 9/30/25. Review of the facility's DHPPD staffing data reports from 7/1/25 to 9/20/25 that were emailed late on 1/14/26 at 12:15 p.m., by the DON indicated, they have low actual staffing and certified nursing assistants' DHPPD for the following dates: 1.7/6/25 - 3.3086 actual staffing DHPPD and 2.3475 actual CNA DHPPD; 2. 7/12/25 - 3.4060 actual staffing DHPPD and 2.3503 actual CNA DHPPD; 3. 8/30/25 - 3.4322 actual staffing DHPPD and 2.3765 actual CNA DHPPD. No DHPPD staffing data reports were provided for 9/21/25 to 9/30/25.Review of the Centers for Medicare and Medicaid Services, State Operations Manual (SOM, provides federal rules, guidelines and procedures from CMS), Appendix PP, Guidance to Surveyors for Long Term Care Facilities, issued 7/3/25 indicated, .The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: except when waived.licensed nurses; and other nursing personnel, including but not limited to nurse aides.The facility must, upon oral or written request, make sure staffing data available to the public for review at a cost not to exceed the community standard.The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Based on interview and record review the facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding transfers for two of three sampled residents (Residents 3 and 7). This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge.Findings: Review of Resident 3's clinical record indicated she was transferred to the hospital on [DATE] due to hypotension (low blood pressure) and desaturation (low oxygen levels in the blood. There was no documentation that indicated a notice was sent to the Ombudsman regarding Resident 3's transfer. Review of Resident 7's clinical record indicated she was transferred to the hospital on [DATE] due to hyperglycemia (increased blood sugar) and altered level of consciousness. There was no documentation that indicated a notice was sent to the Ombudsman regarding Resident 3's transfer. During an interview on 1/8/26 at 3:48 p.m., the social services director stated the notices regarding Residents 3 and 7's transfers were not sent to the Ombudsman. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022 indicated Notice of Transfer is provided to the long-term (LTC) ombudsman when practicable.

Based on observation, interview and record reviews, the facility failed to ensure the residents assessments were reviewed and updated for effectiveness and accuracy for two of fifteen sampled residents, (Residents 12 and 40), when their activity assessments were not reviewed and revised quarterly. These failures had the potential to result in the residents not receiving the appropriate plan of care and interventions necessary to maintain their highest level of well-being. Findings: 1.During the initial observation of Resident 12 on 1/6/26 at 12:40 p.m., Resident 12 was laying in his bed. Resident 12 was calm, comfortable, confused and could not answer questions.Review of Resident 12's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) dated 1/8/26 indicated, Resident 12 was readmitted to the facility on [DATE] with the primary diagnosis of catatonic schizophrenia (subtype of schizophrenia characterized by significant disruptions in motor behavior and extreme psychological disturbances).Review of Resident 12's assessments indicated, Resident 12's activity assessment was not reviewed and updated quarterly for effectiveness and accuracy. It was last updated on 4/26/22. During the concurrent review of Resident 12's activity assessment and interview with assistant director of nursing/infection preventionist (ADON/IP) on 1/9/26 at 10:20 a.m., ADON/IP verified that the last activity assessment of Resident 12 was done on 4/26/22 and would follow up on it. During the concurrent review of Resident 12's activity assessment and interview with the activity director (AD) on 1/9/26 at 2:05 p.m., AD confirmed that she was not able to update the activity assessment of Resident 12 quarterly and his last activity assessment was done on 4/26/22. AD then stated that she would do the activity assessment updates every three months or quarterly.During the interview with the director of nursing (DON) on 1/9/26 at 2:13 p.m., DON verified that assessments including activity assessments are updated quarterly and would follow up on this concern.2. During the observation of Resident 40 on 1/6/26 at 12:45 p.m., Resident 40 was laying in her bed. Resident 40 was comfortable, alert, oriented and able to answer questions.Review of Resident 40's admission record dated 1/8/26 indicated, Resident 40 was admitted to the facility on [DATE] with the primary diagnosis of encounter for palliative care (specialized medical care that focuses on improving quality of life, providing relief from pain and other symptoms of a serious illness).Review of Resident 40's assessments indicated, Resident 40's activity assessment was not reviewed and updated quarterly for effectiveness and accuracy. Last update was on 5/27/25. During the concurrent review of Resident 40's activity assessment and interview with AD on 1/9/26 at 2:08 p.m., AD confirmed that she was not able to update the activity assessment of Resident 40 quarterly and her last activity assessment was done on 5/27/25. AD then stated that she would do the activity assessment updates every three months or quarterly. During the interview with the DON on 1/9/26 at 2:13 p.m., DON verified that assessments including activity assessments are updated quarterly and would follow up on this concern. Review of the facility's policy and procedure titled, Activity Evaluation, revised February 2023 indicated, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities.The completed activity evaluation is part of the resident's medical record and is updated as necessary but at least quarterly.

Based on interview and record review, the facility failed to follow the recommendations of the Preadmission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Individualized Determination Report for one of three residents (Resident 39). This failure had the potential to result in the resident not receiving appropriate care and services for a mental health condition. Findings: Review of Resident 39's clinical record indicated he was admitted to the facility with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 39's physician orders indicated staff was monitoring the resident for picking skin on his fingers, fidgeting, verbalization of sadness related to his health condition, difficulty sleeping, inappropriate sexual behavior, and rapid speech leading to exhaustion. Review of Resident 39's PASARR Individualized Determination Report, dated 5/19/25 indicated the resident required Specialized Add-on Services to address mental health needs. The report indicated one of the recommended Specialized Add-on Services was Psychiatry consultation (psych consult) and/or follow-up care. During an interview on 1/8/26 at 8:20 a.m. the social services director stated the Psychiatric Mental Health Nurse Practitioner (psych NP) was coming in the afternoon today to speak to Resident 39 in response to two abuse allegations involving Resident 39. Review of Resident 39's Social Services Notes, dated 1/8/26 indicated the resident was seen by the psych NP on 1/8/26. The notes indicated Resident 39 stated he had a plan to harm another resident. The notes also indicated Resident 39 was transferred to a psychiatric facility on a 5150 hold (an emergency intervention which allows a person experiencing a mental health crisis to be held involuntary for up to 72 hours) for emergency psychiatric evaluation and treatment. There was no documentation that indicated Resident 39 had a psych consult after his PASRR Individualized Determination Report on 5/19/25 and before the psych NP visit on 1/8/26. During an interview on 1/12/26 at 1:16 p.m., the Director of Nursing (DON) stated there were no psych consults for Resident 39 after May 2025 and stated, Just the latest one (referring to the psych NP visit on 1/8/26). Review of the facility's policy, admission Criteria, dated 3/2019 indicated, Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate . The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.

Based on observation, interview and record reviews, the facility failed to ensure, the resident's medication was administered as per physician's orders by one of two nurses observed when the furosemide (a powerful loop diuretic, given to help treat fluid retention and swelling) 40 milligrams (mg, unit of mass or weight) tablet of Resident 53 was still given, without following the medication's parameter order (specific components of a prescription order that define how a medication should be safely administered). This failure had the potential to compromise the resident's health, safety and well-being. Findings: During the medication pass observation of Resident 53 with licensed vocational nurse A (LVN A) on 1/7/26 at 9:48 a.m., LVN A gave furosemide 40 mg tablet, one tablet by mouth. Review of Resident 53's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) dated 1/12/26 indicated, Resident 53 was admitted to the facility on [DATE] with the primary diagnosis of chronic embolism (occurs when blood clots in the lungs don't fully dissolve, leading to organized scar tissue that blocks arteries causing high blood pressure in the lungs, shortness of breath, fatigue and potential right heart failure) and thrombosis (formation of blood clot inside a blood vessel) of left femoral vein (large left thigh blood vessel that carries deoxygenated blood from the left lower leg back to the heart). Review of Resident 53's order listing report dated 1/12/26 indicated, Resident 53 had an active physician's order of furosemide tablet 40 mg, give 1 tablet by mouth two times a day for congestive heart failure (CHF, long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply), hold for systolic blood pressure (SBP, the top number in the blood pressure reading, measuring the pressure in the arteries when the heart beats and pushes blood out) below 100 millimeters of mercury (mmHg, unit used to measure the force of blood against artery walls, recorded as two numbers, the top is the systolic blood pressure over the bottom which is the diastolic blood pressure or when the heart rests).Review of Resident 53's medication administration record (MAR, vital legal document in healthcare that tracks all medications given to a resident) for 1/6/26 indicated, Resident 53 was still given one tablet of Furosemide 40 mg at 9:00 a.m., even if his systolic blood pressure was 94 mmHg. During the interview with LVN A on 1/8/26 at 11:55 a.m., LVN A acknowledged that the furosemide 40 mg tablet of Resident 53 should not be given on 1/6/26 at 9:00 a.m., because his SBP was only 94 mmHg and would not do it next time.During the interview with the director of nursing (DON) on 1/8/26 at 4:50 p.m., DON verified that the medication parameter orders should be followed and the furosemide tablet of Resident 53 should not be administered on 1/6/26 at 9:00 a.m. and would follow up on this concern.Review of the facility's policy and procedure titled, Medication and Treatment Orders, revised July 2016 indicated, Orders for medications and treatments shall be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the undated facility's, Job Description: Licensed Vocational Nurse indicated, .Duties and Responsibilities; Administrative Functions:.Administers medications as prescribed by the healthcare provider.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented by one of two licensed vocational nurses observed during medication pass observation, when the licensed vocational nurse B (LVN B) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves prior to medication administration of Resident 38 after she threw garbage and touched the garbage container attached to the side of the medication cart with the gloved hand.These failures had the potential for the spread of infection and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could affect the forty-six residents residing in the facility, staff, and visitors.Findings:During the medication pass observation of LVN B on 1/8/26 at 5:06 p.m., LVN B was preparing medications for Resident 38 with her sanitized hands. When she was done preparing the medications of Resident 38, LVN B sanitized her hands again and put on a new pair of gloves. But then, LVN B threw garbage in the garbage container attached to the side of the medication cart, touching the garbage container to fix it with her gloved hand, then she proceeded to give the medications of Resident 38 without removing the dirty gloves, performing hand hygiene after and then putting on a new pair of gloves before the medication administration of Resident 38.During the interview of LVN B on 1/8/26 at 5:35 p.m., LVN B acknowledged the above concern. LVN B further acknowledged that she should have removed her dirty gloves because she contaminated it, sanitized hands and put on a new pair of gloves before she gave the medications of Resident 38 and would not do it next time.During the interview with the director of nursing (DON) on 1/8/26 at 5:50 p.m., DON verified that LVN B should have observed proper infection control and should have removed her dirty gloves, sanitized her hands and put on new pair of gloves before giving the medications of Resident 38 and would follow up on it.Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised August 2019 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:.before preparing or handling medications.after contact with objects.in the immediate vicinity of the resident.

Based on observation, interview, and record review, the facility failed to ensure multiple resident rooms with two beds (Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121) measured at least 80 square feet per resident. Less than 80 square feet per resident in resident rooms could adversely affect resident health and safety. Findings: Room measurements indicated multiple resident rooms with two beds were less than 80 square feet per resident. Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121 with two beds all measured 69.51 square feet per resident. None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and walkers were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern. Recommendation is for a continuance of the room waiver.

Based on observation, interview and record review, the facility failed to ensure, infection prevention and control practices were implemented when: 1. a laundry cart with clean linens was left in the passageway of the laundry room where the carts with dirty linens pass by; 2. laundry staff did not sanitize the laundry cart from outside before placing the clean linens in the cart; 3. a large bucket, full of soiled linens, was left open without cover; 4. there were missing logs in the laundry dryer cleaning inspection logs; 5. 2 out of 3 kitchen staffs did not know the sanitizer testing procedure; 6. cleaning chemicals were kept in the emergency food storage area and 7. a silverfish bug and a disposable spoon were found in the sink inside the medicine storage room. These failures had the potential to spread infection that could affect the 48 residents residing in the facility. Findings: 1. During the concurrent laundry room area observation and interview with the environmental services supervisor (EVSS) on 10/24/24 at 9:09 a.m., there was a rack full of clean clothes of residents and not covered, in the passageway where the dirty linens pass by, going to the washer. EVSS acknowledged that the uncovered rack full of clean clothes of residents should not be left there for infection control. EVSS further verified that those clean clothes should have been brought back right away to the residents. During an interview with the infection preventionist (IP) on 10/25/24 at 11:00 a.m., IP verified that the rack full of clean clothes of residents and not covered, should not be left in the passageway where the dirty linens pass by, going to the washer, for infection control. They should have been brought back to the residents right away after they are washed and dried. Review of the facility's policy titled, Laundry and Bedding, Soiled: Storage, dated 2001 indicated, Clean linen is stored separately, away from soiled linens, at all times Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination 2. During the concurrent laundry room observation and interview with laundry staff G (LS G) on 10/25/24 at 9:35 a.m., LS G brought inside the laundry room, a laundry cart from outside, to put in the clean resident clothes that were ready to be distributed back to the residents. LS G did not sanitize the laundry cart from the outside and he was about to put in the clean resident clothes in there. LS G was asked if he needed to sanitize the laundry cart first and he acknowledged that the laundry cart that was brought from outside should be sanitized first before putting in the clean clothes of the residents there. LS G then sanitized the laundry cart before putting in the clean resident clothes. During the interview with EVSS on 10/24/24 at 9:38 a.m., EVSS verified that LS should have sanitized the laundry cart from outside first before putting in the clean clothes of the residents for infection control. During an interview with IP on 10/25/24 at 11:00 a.m., IP verified that LS should have sanitized the laundry cart that was brought from outside first, before putting in the clean clothes of residents. IP further verified that she will remind the staffs about this. Review of the facility's policy titled, Laundry and Bedding, Soiled: Transport, dated 2001 indicated, Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule 3. During the concurrent laundry room observation and interview with EVSS on 10/24/24 at 9:45 a.m., there was a bucket full of dirty and soiled linens near the washer area that was left there uncovered. EVSS acknowledged that the bucket full of dirty and soiled linens near the washer area should not be left uncovered, when they were not washed yet. During an interview with IP on 10/25/24 at 11:00 a.m., IP verified that dirty and soiled linens in the laundry room should be covered and will remind the staffs about it. Review of the facility's policy titled, Laundry and Bedding, Soiled: Handling, dated 2001 indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. All used laundry is handled as potentially contaminated using standard precautions Contaminated laundry is bagged or contained at the point of collection 4. During the laundry room observation on 10/24/24 at 9:30 a.m., there were missing logs in the dyer cleaning log monitoring sheet that included the removal of the dryer lint (a collection of fine fabric and yarn pieces that accumulate in a dryer's filter while clothes were being dried). Review of the dryer cleaning log monitoring sheets of the laundry department, from 8/30/24 to 10/24/24 at 9:00 a.m., indicated that the 2 dryers were being checked that included the removal of the dryer lint, 5 times per day at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., and 3:00 p.m., and there were 124 missing signature logs by the laundry staffs. During the interview with EVSS on 10/24/24 at 9:32 a.m., EVSS verified the missing signature logs of the laundry staffs for the dryer cleaning log monitoring sheets of the laundry department that included the removal of the dryer lint. He further verified that there should be no missing signature logs of the laundry staffs. During the interview with IP on 10/25/24 at 11:00 a.m., IP verified that the dryer cleaning log monitoring sheets of the laundry department should have been completed and there should be no missing signature logs of the laundry staffs. Review of the undated facility's policy titled, Dryer Lint Policy, indicated, Proper care and maintenance of laundry equipment, including the management of dryer lint, are essential All staff involved in laundry operations will receive training on the importance of lint management and the procedures for proper removal and disposal. A log of lint removal and maintenance inspections will be maintained to ensure compliance with this policy 5. During the concurrent observation of the three compartments sink and red bucket testing with sanitizer, using the sanitizer test strips and interview with the dietary aide H (DA H) on 10/22/24 at 1:25 p.m., DA H checked the sanitizer concentration level using the test strips. DA H was then asked the meaning of the test strip readings after they were dipped in the sanitizer. DA H could not tell the meaning of the test strip reading results, whether the concentration level of the sanitizer was okay for use. During another concurrent observation of the three compartments sink and red bucket testing with sanitizer, using the sanitizer test strips and interview with cook I (COOK I) on 10/24/24 at 11:05 a.m., COOK I checked the sanitizer concentration level using the test strips. COOK I was then asked the meaning of the test strip readings after they were dipped in the sanitizer. COOK I could not also tell the meaning of the test strip reading results, whether the concentration level of the sanitizer was okay for use. During the interview with the registered dietitian (RD) on 10/24/24 at 11:10 a.m., RD verified that kitchen staffs should know the effective concentration level of the sanitizer and should know how to read the results of the sanitizer testing strip. RD then stated that she would do an in-service about it. Review of the facility's policy titled, Quaternary Ammonium Log Policy, dated 2023 indicated, The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution The Food and Nutrition Services worker will place the solution in the appropriate bucket labeled for it's contents and will test the concentration of the solution 6. During a concurrent observation of the emergency food storage room and interview with EVSS on 10/24/24 at 2:38 p.m., there were gallons and bucket of cleaning chemicals that were kept beside the plastic food containers. There were also food items stored in the emergency food storage room. EVSS acknowledged that the cleaning chemicals should not be stored in the emergency food storage room. During the interview with RD on 10/24/24 at 2:42 p.m., RD verified that the cleaning chemicals should be stored separately from the food items. RD further verified that she would remove the cleaning chemicals in the emergency food storage room and will store them separately. Review of the facility's policy titled, Storage of Food and Supplies, dated 2023 indicated, Food and supplies will be stored properly and in a safe manner Food storage areas should be used only for food. Items such as bleach, soap, and other cleaning supplies should be stored in entirely separate and specific areas 7. During an observation of the medication storage room on 10/20/24 at 2:43 p.m. with Licensed Vocational Nurse (LVN) D, a crawling silverfish bug and a white disposable spoon were found in the sink. The sink also had yellowish stains. During an interview on 10/22/24 at 1:06 p.m. with the Director of Nursing (DON), the DON stated that the medication room is cleaned daily by the housekeeper. DON also stated there is a log for the daily cleaning of the medication room. During a concurrent interview and record review on 10/24/24 at 3:29 p.m. with the Housekeeping Supervisor (HS), HS stated she cleaned the medication room that day 10/24/24. HS verified the document Med Room Cleaning/Disinfectation Log, and stated it is not her signature on date 10/24/24. HS confirmed her signature was not in the document. HS stated there was no log for cleaning the medication room and it was the first time she saw the document. The facility provided a document entitled Med Room Cleaning/Disinfectation Log, the document had seven columns corresponding to the months of June 2024 to December 2024. Written under each month were rows corresponding to the number of days of the month which indicated daily signatures except for 7/14/24. No other details were written in the document. A review of facility's policy and procedure (P&P) entitled Medication Labeling and Storage revised February 2023, the P&P indicated, .2. The nursing staff is responsible for maintaining medication and storage and preparation areas in clean, safe, and sanitary manner . 49345 51580

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when two live cock roaches were observed in the social services office by health facilities evaluator nurses, during a recertification survey. This finding had the potential to put residents and staffs' health and safety at risk. Findings: During an observation on 10/24/24, at 2:30 p.m., in the social services office, a live cockroach was observed on the floor under the desk. During an observation on 10/24/24, at 2:47 p.m., in the social services office, a live cockroach was observed on top of the desk. During a concurrent interview and record review, on 10/25/24, at 2:32 p.m., with the administrator (ADM), the facility's policy and procedure (P&P) titled, Pest Control, revised May 2008, was reviewed. The P& P indicated, This facility maintains an effective pest control program so that the facility is free of pests and rodents. ADM acknowledged an effective pest control program was to ensure a pest free environment. 44577

Based on observation, interview and record review, the facility had a medication error rate of 12.12% when four medication errors occurred out of 33 opportunities for four residents (Resident 27, Resident 12, Resident 46, and Resident 154): 1. For Resident 27, the nursing staff did not confirm the exact dose as ordered by the physician for the medicine Lamotrigine (a medicine used for seizure). 2. For Resident 12, the nursing staff administered the medication Metformin (a medicine used to lower the blood sugar) without a meal. 3. For Resident 46, the nursing staff did not administer Lidocaine 5% Patch (used to alleviate pain). 4. For Resident 154, the nursing staff did not administer an inhalation solution in accordance with the facility procedure. These failures resulted in medications not given in accordance to the manufacturer's instructions and/or physician's order and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 10/21/24 at 4:13 p.m., Licensed Vocational Nurse (LVN) B, took out a blister pack of lamotrigine 100 milligrams (mg, unit of measure) whole tablets and a blister pack of lamotrigine 100 mg in half tablets. LVN B took one whole tablet and another half tablet. At 4:15 p.m., LVN B administered a whole tablet of lamotrigine 100 mg and a half tablet of lamotrigine 100 mg to Resident 27. A review of Resident 27's physician order on 10/24/23 indicated, Lamotrigine Oral tablet 150 mg, give 1.5 tablet by mouth two times a day related to epilepsy (seizure disorder). During a concurrent observation, interview, and record review on 10/22/24 at 12:50 p.m. with the Director of Nursing (DON), DON verified the order for lamotrigine for Resident 27 and stated that a total 225 mg twice a day of lamotrigine should be given as written in the order. DON verified the stock doses of lamotrigine for Resident 27 in the medication cart were a blister pack of whole tablets of lamotrigine 100 mg and a blister pack of half tablets of lamotrigine 100 mg. During a concurrent interview and record review over the phone on 10/23/24 at 10:15 a.m. with the Consultant Pharmacist (CP), CP interpreted the order of lamotrigine for Resident 27 as a total of 225 mg two times a day. A review of Resident 27's hospital summary documents prior to admission indicated a physician's order, Lamotrigine 150 mg tab twice a day A review of facility's undated policies and procedures (P&P) entitled Administering Medications, the P&P indicated, .8. The individual administering the medication must ensure that the right medication, right dosage .are verified before the medication is administered. 2. During a medication pass observation on 10/21/24 at 4:38 p.m., LVN B administered metformin 500 mg tablet to Resident 12. There was no visible food or any snack on Resident 12's bedside table. During an interview with Resident 12 on 10/25/24 at 1:16 p.m., Resident 12 stated that dinner comes at 5:40 p.m. or sometimes 6:00 p.m. During an interview on 10/25/24 at 1:25 p.m. with Registered Dietician (RD), RD stated dinner is served at 5:30 p.m. RD showed the signage of meal times in the bulletin board that indicated, Meal Service Times .Dinner 5:30 p.m. During a concurrent interview, and record review on 10/22/24 at 12:50 p.m. with the DON, the DON verified the physician's order of metformin for Resident 12 indicated to be given with breakfast and dinner. A review of Resident 12's physician order indicated, Metformin Hcl tablet 500 mg, give 1 tablet by mouth two times a day for diabetes with breakfast and dinner. The order was dated 4/11/23. A review of Daily Med from National Library of Medicine (www.dailymed.nlm.nih.gov), a nationally recognized source for drug label information, indicated, Metformin hydrochloride should be given in divided doses with meals. A review of facility's undated policies and procedures (P&P) entitled Administering Medications, the P&P indicated, .3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal order. 3. During a medication pass observation on 10/22/24 at 7:50 a.m., LVN C stated that Resident 46's due medications included lidocaine 5% patch. LVN C stated that lidocaine 5% patch was not available. During a concurrent interview, and record review on 10/22/24 at 12:50 p.m. with the DON, the DON verified Resident 46's Medication Administration Record for 10/22/24 indicated that Lidocaine 5% patch was not given at 9 a.m. as ordered. A review of Resident 46's physician's orders indicated, Lidocaine Patch 5% apply to right shoulder topically one time a day for pain management r/t neuropathy apply to right shoulder or affected area, apply at 9am and remove at 9pm and remove per schedule The order was dated 8/29/24. A review of facility's undated policies and procedures (P&P) entitled Administering Medications, the P&P indicated, 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal order .7. Medications .must be administered within one hour of their prescribed time . 4. During a medication pass observation on 10/22/24 at 8:15 a.m., LVN C explained the indication of the medication budesonide and formoterol fumarate dihydrate (used to control or prevent difficulty in breathing) inhalation solution to Resident 154. LVN C shook the inhaler (device for giving medicines in the form of a spray that is inhaled) and asked Resident 154 to open his mouth. Resident 154 opened his mouth, LVN C inserted the mouthpiece in Resident 154's mouth, gave 1 puff and visible mist came out of Resident 154's mouth. LVN C instructed and assisted Resident 154 to gargle with water. During an interview on 10/22/24 at 9:30 a.m. with LVN C, LVN C was asked how to correctly administer an inhaled medication via inhaler. LVN C stated she should have asked Resident 154 to tightly close his lips onto the inhaler mouthpiece. During an interview with the DON on 10/22/24 at 12:50 p.m., the DON stated that when administering a medication via inhaler, resident must be instructed to exhale, then they inhale the medication as it is given and hold it for a few seconds and then exhale. A review of facility's policies and procedures (P&P) entitled Administering Medications through a Metered Dose Inhaler revised October 2010, the P&P indicated, Administer Medication: .d. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. e. Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around the mouthpiece g. Instruct the resident to inhale deeply and hold for several seconds. H. Remove the mouthpiece from the mouth and instruct the resident to exhale slowly through pursed lips. A review of facility's undated policies and procedures (P&P) entitled Administering Medications, the P&P indicated, 8. The individual administering the medication must ensure the right medication.and right method of administration are verified before the medication is administered.

Based on observation, interview and record review, the facility failed to ensure that the recipe (a set of instructions on how to prepare or make a particular food) for making vegetable puree (smooth, crushed, or blended food that has the consistency of a creamy paste or liquid) was being followed when the lead cook did not follow the recipe for making carrot puree. This failure had the potential to result in decreased palatability that could lead to decrease in food intake for the 6 residents with puree consistency diet order out of the skilled nursing facility census of 48. Findings: During the observation of making vegetable puree with the lead cook (LC), on 10/22/24 at 10:55 a.m., LC was making vegetable puree using carrots, good for 12 servings. LC put 48 ounces (oz, unit of weight) of carrots, 4 oz per serving, good for 12 servings, into the blender, added 2 cups (cooking measure of volume) of milk and then pureed them. LC then checked the consistency of the pureed carrots, added 1 cup of milk, then added food thickener and pureed them again. LC then set aside the pureed carrots in the oven after. Review of the facility's recipe: Pureed (IDDSI, international dysphagia diet standardization initiative, Level 4, level of food texture) Vegetables, dated 2024 indicated, Pureed on low speed to a paste consistency before adding any liquid. For 12 servings, add 1/4 cup to 3/4 cup of warm fluid such as milk .If needed: stabilizer: .commercial instant food thickener .Serve on trayline at the recommended temperature . The recipe did not indicate to add any liquid before pureeing. The recipe did not also indicate to add 2 cups of milk for 12 servings of pureed vegetables. The recipe indicated, to only add 1/4 cup to 3/4 cup of warm fluid such as milk, for 12 servings of pureed vegetables. The recipe did not indicate as well to add 1 cup of milk after pureeing. During a concurrent review of the recipe for making puree vegetables and interview with LC on 10/22/24 at 10:57 a.m., LC verified that the recipe for making puree carrots was not followed. He further verified that he would check and follow the recipe next time. During a concurrent review of the recipe for making puree vegetables and interview with registered dietitian (RD) on 10/22/24 at 11:00 a.m., RD verified that the lead cook should have followed the recipe for making puree carrots, but it was not followed. RD further verified that the recipe for making vegetable puree should be followed next time. Review of the facility's policy and procedure titled, Food Preparation, dated 2023 indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes, standardized to meet the resident census .Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines .

Based on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of quality for one (Resident 13) out of three sampled residents when Resident 13 had an unnecessary and improper blood sugar check done. This failure resulted in a potentially inaccurate blood sugar result and an additional finger prick which can be painful. Findings: During an observation on 10/21/24 at 11:47 a.m. with Licensed Vocational Nurse (LVN) A, LVN A cleaned Resident 13's left ring finger with an alcohol swab and immediately pricked Resident 13's finger. LVN A then placed the blood sugar strip connected to the glucometer (device used to check blood sugar) to the pricked finger to catch the drop of blood for the blood sugar test. After obtaining the blood sugar result of 136 milligram/deciliter (mg/dl, a unit of measurement; normal range is 80-110 mg/dl), LVN A stated I am going to hold her insulin right now. I am going to feed her at 2 p.m. She has a G-tube (a flexible, hollow tube that is inserted into the stomach through the abdominal wall). I will give it with her food. LVN A also stated that he will check Resident 13's blood sugar again before feeding. During an interview on 10/21/24 at 2:13 p.m. with LVN A, LVN A stated that part of the process for checking blood sugar is waiting for the alcohol to dry out before pricking the finger with lancet (a sharp point needle that is used to obtain blood for testing blood sugar). LVN A also stated, he was following the order to check blood sugar at 12 p.m. LVN A stated he should have checked it before feeding Resident 13 instead. During a concurrent interview and record review on 10/22/24 at 12:50 p.m. with the Director of Nursing (DON), DON stated they should wait for the alcohol to dry before poking the resident's finger during blood sugar check. DON verified there is no specific physician order to check blood sugar at 12 p.m. for Resident 13. DON also verified that blood sugar documentation is part of physician orders for insulin (a medication used in the treatment of high blood sugar). A review of Resident 13's Physician orders indicated, Enteral Feed Order every 8 hours .1 Can (250ml/cc) + 4 OZ SF Healthshake 2 pm It also indicated, Admelog Injection Solution 100 unit/ml (Insulin Lispro) Inject 3 units subcutaneously every 6 hours A review of Resident 13's Medication Administration Record for October 2024 indicated Enteral feed was scheduled daily at 6 a.m., 2 p.m. and 10 p.m. It also indicated, Admelog Injection was scheduled daily at 12 a.m., 6 a.m., 12 p.m., and 6 p.m. A review of facility's policy and procedure (P&P) titled Obtaining a Fingerstick Glucose Level revised October 2011, the P&P indicated 8. Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results .12 .If alcohol wipes are used, make sure the area is dry before taking blood sample A review of Daily Med from National Library of Medicine (www.dailymed.nlm.nih.gov), a nationally recognized source for drug label information, indicated, Administer the dose of ADMELOG subcutaneously within fifteen minutes before a meal or immediately after a meal A review of facility's undated P&P entitled Administering Medications, the P&P indicated, 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders .12. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR (Medication Administration Record) space provided for that particular drug .

Based on observation, interview, and record review, the facility failed to ensure that appropriate care and services were provided to one out of twelve sampled residents, (Resident 8), when the restorative nursing assistant (RNA) totally assisted Resident 8 in feeding instead of set-up help only. This failure had the potential, for the resident, not to maintain or achieve the highest level of self-care or independence in feeding. Findings: During the concurrent dining observation and interview with RNA on 10/21/2024 at 12:20 p.m., RNA was spoon-feeding Resident 8, totally assisting him with feeding. RNA acknowledged for totally assisting Resident 8 in feeding and for not checking the feeding care plan of Resident 8 prior to assisting him. During the interview with the Infection Preventionist (IP), who was overseeing the lunch dining area of the residents, on 10/21/2024 at 12:27 p.m., IP verified that Resident 8 had specialized adaptive utensils to help with grip and would help encourage self-feeding and should not be totally assisted with feeding. During the concurrent record review of the most recent minimum data set (MDS, a standardized, comprehensive assessment tool used to evaluate the health of residents in nursing homes) of Resident 8, dated 9/13/24, and interview with the director of nursing (DON) on 10/24/24 at 8:45 a.m., indicated that Resident 8 was coded 05, for his MDS, Section GG0130A: Eating, indicating, Set-up or clean-up assistance. The helper would provide assistance prior to or following the feeding activity. DON acknowledged the discrepancy between Resident 8's assessed needs in feeding and the assistance provided to him. DON further acknowledged that Resident 8 was not provided with the appropriate assistance in feeding by the RNA and will remind the staffs about providing the proper assistance to residents. 51580

Based on observation, interview and record review, the facility failed to ensure equipment is in safe operating condition for four (Residents 8, 23, 26 and 38) out of eight sampled residents when a commode with noticeable rust was found in their shared toilet. This failure had the potential to put residents at risk for harm during their usage of the rest room. Findings: During a concurrent observation and interview on 10/20/24 at 2:19 p.m. with LVN E, a commode with noticeable rust was positioned over the toilet bowl in the rest room shared by Resident 8, Resident 23, Resident 26, and Resident 38. LVN E stated we should have checked the commode before placing it in the resident's toilet. During an interview with the Maintenance Director/ Environment Services Supervisor (EVSS) on 10/23/24 at 1:49 p.m., EVSS stated that there is no log to monitor commodes. EVS also stated that nurses do the log for the commode maintenance and not the maintenance department. During a concurrent interview and record review on 10/23/24 at 1:55 p.m. with the Infection Preventionist (IP), the IP verified the Maintenance Log for October 2024 indicated there is no request to replace a commode. A review of facility's policy and procedure (P&P) entitled Maintenance Service revised December 2009, the P&P indicated, .1. The maintenance department is responsible for maintaining the .equipment in a safe and operable manner at all times .

Based on observation, interview, and record review, the facility failed to ensure multiple resident rooms with two beds (Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121) measured at least 80 square feet per resident. Less than 80 square feet per resident in resident rooms could adversely affect resident health and safety. Findings: Room measurements indicated multiple resident rooms with two beds were less than 80 square feet per resident. Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121 with two beds all measured 69.51 square feet per resident. None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and walkers were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern. Recommendation is for a continuance of the room waiver. 44577

Based on interview and record review, the facility failed to provide appropriate social services (SS) support for two of three residents (Residents 2 and 3) when: 1) There was no SS support following Resident 2 and Resident 3's altercation (a heated or angry dispute) on 1/15/23; and 2) There was no SS support following an abuse allegation against Resident 2 and no documentation on SS follow up to address Resident 2's psychosocial needs and behaviors. These failures resulted in a lack of timely social services interventions for Resident 2 and Resident 3. These failures had potential not to address Resident 2, Resident 3 and other residents' mental distress. Findings: 1. Review of Resident 2's Admission Record dated 3/6/2024 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including catatonic schizophrenia (a mental illness when the patient may not respond to what's happening around them, or they could have periods of high activity, where they could act violently), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a condition characterized by memory loss) with other behavioral disturbance (a pattern of disruptive behaviors). Review of Resident 2's quarterly minimum data set (MDS, an assessment tool), dated 7/14/2023, indicated, Resident 2 had short term (the capacity to recall a small amount of information from a recent time period) and long-term memory (the capacity to recall memories from a longer time ago) problem. Review of Resident 2's clinical record titled SBAR [Situation, Background, Assessment, Recommendation] & Initial COC [Change of Condition]/Alert Charting & Skilled Documentation, dated 1/15/2023, indicated, Resident slept on other resident's bed unoccupied at that time. Further review indicated, Resident 3 found Resident 2 on the bed which made Resident 3 angry, yelled at Resident 2 and grabbed Resident 2's right great toe but no injuries resulted. Review of both Resident 2 and Resident 3's progress notes following the incident on 1/15/2023, indicated there were no SS follow up or support found on both residents' progress notes dated 1/16/23 to 1/18/2023. During an interview with director of nursing (DON) on 5/22/2024 at 11:27 a.m., DON confirmed there was no SS follow up on both Resident 2 and Resident 3 after the altercation on 1/15/2023. During an interview with the administrator in training (AIT) on 5/22/2024 at 12:03 p.m., AIT confirmed there was no SS follow up on both Resident 2 and Resident 3 after the altercation on 1/15/2023. 2. Review of Resident 1's Admission Record dated 3/6/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced fracture (the trauma moves the bone fragments out of alignment) of base of neck of left femur (hip bone), presence of left artificial hip joint, displaced fracture of left radial styloid process (a bone found in the wrist area), displaced fracture of left ulna styloid process (another bone found in the wrist area) and history of falling. Review of Resident 1's admission minimum data set (MDS, an assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 13 [score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. Review of Resident 1's nurse's notes dated 6/15/2023, indicated, Around 9:30 p.m. as CNAs (certified nursing assistants) were making rounds to check on their groups, a resident was noted calling out for help .2 CNAs rushed to the room and noted resident (Resident 2) was sitting at the foot of the bed (of Resident 1) .This LN (licensed nurse) went to check on resident (Resident 1) and asked what happened to which the resident (Resident 1) replied that there was a patient (Resident 2) who came over and sat down at the foot of the bed .resident (Resident 1) was anxious for the time being about the resident (Resident 2) . During an interview with certified nursing assistant A (CNA A) on 3/6/2024 at 2:30 p.m., CNA A confirmed she was assigned to Resident 1 on 6/15/2023. CNA A stated, she was doing her rounds on 6/15/2023 at around 9:30 p.m. with another CNA. CNA A further stated, she was in Room AA when she heard the call light and there was somebody yelling for help. CNA A stated, she ran to check who was yelling and found out it was Resident 1 yelling while she was lying on her bed. CNA A confirmed she found Resident 2 seated at the left side of the foot of (Resident 1's) the bed. CNA A stated, Resident 1 did not know Resident 2. CNA A stated, she took Resident 2 out of the room because Resident 1 was yelling and then she reported to the nurse. CNA A further stated, the nurse talked to Resident 1 because she was so scared of Resident 2. During a concurrent interview and record review on 3/12/2024 at 11:24 a.m., social service director (SSD) reviewed Resident 2's progress notes dated 6/15/23 to 6/18/2023. SSD confirmed there was no SS follow up after the alleged abuse against Resident 2. SSD further confirmed she started working at the facility on 7/24/2023. SSD reviewed all the SS progress notes for Resident 2 and confirmed the last SS follow up with Resident 2 to address his behaviors was on 5/3/2023. At 11:30 a.m., SSD reviewed Resident 2's IDT (Interdisciplinary team - a team composed of members from different departments involved in resident's care) -Psychotropic Assessment (a periodic monitoring for medication prescribing issues including indications, dosages, efficacy, and side effects)/Review/GDR (gradual dose reduction, tapering of a medication dose) dated 12/7/2023, indicated, .GDR at this time will put resident at risk for escalation of behavioral symptoms .SSD to continue to provide non-pharmaceutical interventions, provide ongoing support, weekly room visits to monitor for any signs/symptoms of depression in mood/behavior. Provide positive reinforcement during visits . SSD confirmed she did not implement Resident 2's planned interventions discussed during their IDT Psychotropic Assessment to manage Resident 2's mood/behavior. SSD stated, she was not even aware about Resident 2's planned interventions to manage his mood/behavior. During a concurrent phone interview with Resident 1 and her family member C (FM C) on 3/13/2024 at 9:46 a.m., Resident 1 stated, on Thursday night, I was lying in bed watching TV, there was this guy [Resident 2] who entered my room and sat down on my bed. I rang the bell, but nobody came. The guy laid down on my broken leg and arm, and I started screaming. Resident 1 confirmed she started to see a therapist after the incident. Resident 1 stated, .this stresses me out, and I am still having nightmares. During a review of the undated facility's document titled, Job Description: Director of Social Service, indicated, The primary purpose of your job description is to assist in planning, developing organizing, implementing evaluating, and directing social service programs in accordance with current federal, state, and local standards, guidelines, and facility policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis .Make routine visits to residents and perform services as necessary. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. Perform other charting duties as necessary. 45853 Based on interview and record review, the facility failed to provide appropriate social services support following an abuse allegation for one of one resident (Resident 1) when there was no social service personnel onsite to assess residents ' psychosocial well-being. This failure resulted in a lack of timely social services intervention for a resident. Findings: Review of Resident 1 ' s facesheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated Resident 1 was admitted on [DATE], with diagnoses of status post left hip replacement surgery due to left femur neck fracture, major depressive disorder. Review of Resident 1 ' s Minimum Data Set (MDS, a clinical assessment tool) dated 6/16/23, indicated Resident 1 ' s Brief Interview for Mental Status (BIMS, a tool used to screen and identify the cognitive condition) score was 13, which meant the resident had no cognitive impairment. During an interview with Resident 1 on 8/17/23 at 9:16 a.m., she stated on the second day since her admission to the facility at around 8:00 p.m., a male stranger entered her room and sat on the end of her bed. Resident 1 stated she was unable to move due to a recent surgery; so, she told the man to leave, but he did not move. Resident 1 stated she felt scared to death and screamed for help. Resident 1 stated social service did not follow up with her regarding the incident. Resident 1 stated she requested to be discharged the next day because she was too scared and nobody addressed the issue. Resident 1 stated since she had been discharged from the facility, she had been seeing a mental health therapist for nightmares related to the event.During an interview on 8/23/23 at 3:09 p.m. with Resident 1 ' s mental health therapist, the therapist stated Resident 1 was showing symptoms of PTSD (Post-traumatic stress disorder, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event). The resident was on guard, fearful, and emotionally distressed. During an interview with the Social Service Director (SSD) on 9/13/23 at 10:57 a.m., she stated social service should have follow-up with both residents after this incident to provide psychosocial well-being support; and that, a Social Service Progress Note should be documented for each follow-up visit. During a concurrent interview and record review with the Administrator (ADM) on 9/13/23 at 12:00 p.m., the ADM stated there was no social service personnel on site between 6/7/23 and 7/23/23. The admission coordinator/case manager, the director of nursing, and herself were covering social service assessments for all residents during that period. There was no documented evidence in Resident 1 ' s clinical record to indicate a social service assessment focused on psychosocial well-being was done after the incident. During a review of the facility ' s policy and procedure Social Services, revised September 2021, it indicated, 1. The director of social services is a qualified social warker and is responsible for: f. meeting or assisting with the medically-related social service needs of residents. 3. the facility staff is able to identify and address factors that have a potentially negative effect on psychosocial functioning of a resident, for example: [ .] c. distress resulting from depression, chronic diseases, [ .] d. abuse of any kind; [ .] g. behavioral problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes); 4. The social worker/social services staff are responsible for: b. advocating for and assisting residents with asserting their rights in the facility; c. assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights and accommodation of needs; [ .] k. identifying and seeking ways to support resident needs through the assessment and care planning process; [ .] Review of the facility ' s undated job description for Director of Social Service, indicated, Social service duties and responsibilities: Interview residents/families as necessary. Evaluate social and family information and assist in determining plan for social treatment. Make routine visits to residents and perform services as necessary. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. [ .] Work with emotional problems including assisting resident/family with anxieties and stress, and the need for institutional and specialized care. Assist in providing solutions for social and practical environmental problems including [ .] discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 2 and 1) when: 1. Licensed nurses did not start to monitor Resident 2's whereabouts after the incident with Resident 3 on 1/15/2023; 2. Licensed nurses did not monitor Resident 2's whereabouts until the 6/15/2023's incident with Resident 1 and had some missing documentations on Resident 2's implementation of Elopement Risk/Wanderer care plan dated 6/15/2023; 3. Licensed nurses did not complete Resident 1's Admission Assessment in a timely manner, who was admitted on [DATE]; the Admission Assessment was only completed on 6/16/23; and 4. Licensed nurses did not complete Resident 2's follow-up assessment after the 6/15/2023 incident in a timely manner and the interdisciplinary team's (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) note was initiated three months after this incident on 6/15/2023; These failures had the potential to compromise Resident 1, Resident 2 and other residents' safety, health and well-being. Findings: 1. Review of Resident 2's Admission Record dated 3/6/2024 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including catatonic schizophrenia (a mental illness when the patient may not respond to what's happening around them, or they could have periods of high activity, where they could act violently), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a condition characterized by memory loss) with other behavioral disturbance (a pattern of disruptive behaviors). Review of Resident 2's quarterly minimum data set (MDS, an assessment tool), dated 7/14/2023, indicated, Resident 2 had short term (the capacity to recall a small amount of information from a recent time) and long-term memory (the capacity to recall memories from a longer time ago) problem. Review of Resident 2's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation] & Initial COC [Change of Condition]/Alert Charting & Skilled Documentation, dated 1/15/2023, indicated, Resident slept on other resident's bed unoccupied at that time. Further review indicated, Resident 3 found Resident 2 on the bed which made Resident 3 angry, yelled at Resident 2, and grabbed Resident 2's right great toe but no injuries resulted. Review of Resident 2's clinical record titled, Wandering/Elopement Risk Assessment, dated 1/18/2023, it revealed Resident 2 was ambulatory, cognitively impaired, had history of wandering and high risk for elopement. During an interview with certified nursing assistant B (CNA B) on 3/6/2024 at 11:45 a.m., CNA B confirmed Resident 2 had history of wandering. CNA B stated Resident 2 could walk before without any assistive device and wandered around the facility. CNA B further stated Resident 2 was not easily redirectable. During a concurrent interview with licensed vocational nurse C (LVN C) and observation on 3/6/2024 at 12:20 p.m., in Resident 2's room, Resident 2 was in bed, and LVN C confirmed Resident 2 had a wander guard (small device placed on the ankle or wrist of a resident, alarms to notify the staff if a resident tries to leave the facility) on his left ankle. LVN C stated, Resident 2 had history of wandering and an elopement risk. LVN C further stated, they (staff) should monitor Resident 2's whereabouts. During a concurrent interview and record review on 3/8/2024 at 9:36 a.m., nurse supervisor (NS) reviewed Resident 2's SBAR dated 1/15/2023. NS confirmed Resident 2 had history of lying on other resident's bed. NS stated nurses should have started to monitor Resident 2's whereabouts after the 1/15/2023 incident with Resident 3 and this would have prevented the 6/15/2023 incident with Resident 1. 2a. Review of Resident 1's nurse's notes dated 6/15/2023, indicated, Around 9:30 p.m. as CNAs (certified nursing assistants) were making rounds to check on their groups, a resident was noted calling out for help .2 CNAs rushed to the room and noted Resident (#2) was sitting at the foot of the bed (of Resident 1) .This LN (licensed nurse) went to check on 'Resident 1' and asked what happened to which 'Resident 1' replied that there was a patient who came over and sat down at the foot of the bed .Resident (#1) was anxious for the time being about the Resident (#2) . During an interview with certified nursing assistant A (CNA A) on 3/6/2024 at 2:30 p.m., CNA A confirmed she was assigned to Resident 1 on 6/15/2023. CNA A stated, she was doing her rounds on 6/15/2023 at around 9:30 p.m. with another CNA. CNA A further stated, she was in Room AA when she heard the call light and there was somebody yelling for help. CNA A stated, she ran to check who was yelling and found out it was Resident 1 yelling while she was lying on her bed. CNA A confirmed she found Resident 2 seated at the left side of the foot of the bed. CNA A stated, Resident 1 did not know Resident 2. During a concurrent interview and record review on 3/8/2024 at 9:36 a.m. with the NS, NS reviewed and checked Resident 2's clinical records for any monitoring of Resident 2's whereabouts. NS confirmed there was no documentation of Resident 2's wandering episodes or monitoring of his whereabouts prior to 6/15/2023 incident with Resident 1. During a concurrent phone interview with Resident 1 and her family member C (FM C) on 3/13/2024 at 9:46 a.m., Resident 1 stated, on Thursday night, I was lying in bed watching TV, there was this guy who entered my room, and sat down on my bed. I rang the bell, but nobody came. The guy laid down on my broken leg and arm, and I started screaming. Resident 1 confirmed she started to see a therapist after the incident. Resident 1 stated, .this stresses me out, and I am still having nightmares. 2b. Review of Resident 2's care plans titled, [Resident 2] is an elopement risk/wanderer r/t [related to] Impaired safety awareness, date initiated 6/15/2023, indicated some interventions, Identify [NAME] of wandering. Intervene as appropriate .MONITOR EPISODES OF WANDERING Q [every] SHIFT. During a concurrent interview and record review on 3/8/2024 at 11:04 a.m. with the Administrator in Training (AIT), the AIT reviewed Resident 2's June 2023 Medication Administration Record (MAR) and checked entries of licensed nurses' documentation on Resident 2's, WANDERING IN FACILITY MONITORING - MONITOR EPISODES OF WANDERING IN THE FACILITY UNASSISTED every shift. AIT confirmed there were missing documentations on 6/16/2023 at 11 p.m.; 6/17/2023 at 7 a.m., 3 p.m., 11 p.m.; 6/18/2023 at 7 a.m., 3 p.m., 11 p.m.; and 6/19/2023 at 7 a.m. AIT stated nurses should have initialed their name in the MAR to indicate that they monitored Resident 2's wandering in the facility. AIT confirmed there was no monitoring of Resident 2's wandering or whereabouts before 6/15/2023. During a review of the facility's policy and procedure titled, Wandering and Elopements, date revised March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. Review of Resident 1's Admission Record dated 3/6/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced fracture (the trauma moves the bone fragments out of alignment) of base of neck of left femur (hip bone), presence of left artificial hip joint, displaced fracture of left radial styloid process (a bone found in the wrist area), displaced fracture of left ulna styloid process (another bone found in the wrist area) and history of falling. Further review of Resident 1's Admission Record indicated; Resident 1 was discharged home on 6/16/2023. During a concurrent interview and record review on 3/8/2024 at 10:39 a.m., with the Director of Nursing (DON), the DON reviewed Resident 1`s Admission Nursing Assessment. DON confirmed Resident 1's admission assessment was signed and completed on 6/16/2023. DON stated the admission assessment should have been completed upon Resident 1's admission which was on 6/14/2023. During an interview with medical record director (MRD) on 3/22/2024 at 11:19 a.m., MRD stated the admission assessment should be done and completed by nurses on the day the resident was admitted . During an interview with LVN D on 3/22/2024 at 11:25 a.m., LVN D stated residents' admission assessment should be completed on the day of admission. 4a. During an interview with MRD on 3/22/2024 at 11:19 a.m., MRD stated when an assessment or documentation was initiated, it will be electronically signed and dated on the completion date. During a concurrent interview and record review on 3/22/2024 at 11:27 a.m., with the DON, the DON reviewed Resident 2's Alert Charting (a follow up assessment/documentation) related to the 6/15/2023 incident with Resident 1. DON confirmed Resident 2's Alert Charting on 6/15/2023 for night shift was signed completed on 1/28/2024; on 6/16/2023 for night shift was signed completed on 1/28/2024; and on 6/16/2023 for day shift was signed completed on 7/21/2023. DON stated Resident 2's Alert Charting were completed late. 4b. During a concurrent interview and record view on 3/22/2024 at 11:30 a.m., with the DON, the DON reviewed Resident 2's progress note date created 9/13/2023. DON confirmed she was the one who created Resident 2's progress notes on 9/13/2023 and it was an IDT note. DON stated she couldn't recall who were the attendees at that time because the documentation was lacking that information. DON further stated the note was a late entry for 6/17/2023. During a review of the facility's policy and procedure titled, Charting and Documentation, revised on 7/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.

Based on observation, interview and record review the facility failed to developed and implement hazard to three out of 14 sampled residents (Resident 195, Resident 32 and Resident 17) when: 1. The facility failed to have fall interventions appropriate to resident's cognitive status for one of 14 sampled residents (Resident 195) when Resident 195 had three falls in the facility. This failure resulted in Resident 195's bump on top of her head after the first fall, a right [MEDICAL CONDITION] (broken bone on right hip) after the second fall, and a bump and small head skin tear after the third fall. 2. The facility failed to assessed for fire hazard for Resident 32. This failure had a potential to cause harm to Resident 32. 3. The facility failed to implement care plan related to [MEDICAL CONDITION] (abnormal brain activity) for Resident 17. This failure had a potential to cause harm to Resident 17. Findings: 1. Review of Resident 195's clinical record indicated following admitting [DIAGNOSES REDACTED]. Review of Resident 195's minimum data set (MDS, an assessment tool), dated 10/18/18 Section C (MDS section that assess for cognition (process acquiring knowledge and understanding) status), indicated Resident 195 scored a 4 which is according to resident assessment instrument manual as severely impaired. Section G (MDS section that assesses the need for assistance for activities of daily living), indicated Resident 195 needed one person physical assist for toilet use. Review of Resident 195's nurse practitioner (NP) progress notes dated 8/28/18, 9/16/18, 10/17/18 and 11/29/18 indicated Resident 195 had difficulty in walking and was confused. During an interview with the physical therapist (PT) on 1/3/19 at 9:26 a.m., she stated Resident 195 would be able to ambulate with assistance for safety and the PT confirmed Resident 195 needed to be assisted when going to the rest room. 1a. First Fall Review of Resident 195's post fall assessment dated [DATE] indicated Resident 195's roommate reported to staff that Resident 195 fell out of the bed to transfer to the wheelchair on 4/3/18. During an interview with the director of nursing (DON) on 1/4/19 at 7:48 a.m., she stated the fall on 4/3/18 resulted in a bump on the left side of Resident 195's head. Review of Resident 195's care plan for falls dated 4/3/18 indicated under interventions included reminding her to call for help when transferring and reminding her to check the wheelchair brake if using it for support. 1b. Second Fall Review of Resident 195's post fall assessment dated [DATE] indicated Resident 195 was found sitting on the floor and indicated Resident 195 was trying to go the bathroom and apparently lost her balance and fell . It further indicated that Resident 195 complained of right hip pain after the fall. Review of Resident 195's acute care hospital's history and physical examination [REDACTED]. Review of Resident 195's acute care hospital's discharge summary dated 12/12/18, indicated right [MEDICAL CONDITION] with gamma nail pinning (broken bone of the hip with screws), dementia, hypertension (high blood pressure), [MEDICAL CONDITION] (high levels of lipids), [MEDICAL CONDITION] (overactive [MEDICAL CONDITION]), [MEDICAL CONDITION] (blood disorder), diabetes (high levels of sugar in blood). During an interview with the DON on 1/4/19 at 7:48 a.m., she stated Resident 195 was forgetful even though facility never failed to remind Resident 195 to call for help for toileting but she never did. A review of Resident 195's care plan for communication dated 6/24/14, indicated Resident 195 had problems understanding others due to not being an English speaker. During an interview with certified nursing assistant D (CNA D) on 1/4/19 at 1:50 p.m., she stated Resident 195 was forgetful and would try to get up to use bathroom without calling for help. Review of Resident 195's care plan for falls dated 12/5/18/ indicated new interventions included visual monitoring every hour and offer toileting after the second fall. During a follow-up interview with the DON on 1/4/19 at 7:48 a.m., she stated that there was no evidence for visual every hour monitoring and offering toileting for Resident 195 available in the record. 1c. Third Fall Review of Resident 195's post fall assessment dated [DATE] indicated Resident 195 tried to get up from her bed to go to the bathroom and fell which resulted to a right head bump with a skin tear to right side of her head. A review of the facility's policy, Safety and Supervision of Residents revised 12/2007, indicated The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 2. During the initial tour on 1/2/19 at 9:40 a.m. with licensed vocational nurse A (LVN A), while Resident 32 was lying in bed, there were two animal stuffed toys (toys with outer fabric sewn from a textile and then stuffed with flexible material such as plush toys, stuffed animals, etc.) kept on top of the lighted fluorescent light over Resident 32's head. During the concurrent interview and observation, LVN A immediately removed the stuffed toys and put them on top of Resident 32's side table. Per LVN A, the toys should not be kept there because it could fall and hit Resident 32's head, and it was also considered a fire hazard. During an interview on 1/3/19 at 12:59 p.m., the maintenance supervisor (MS) stated staff were aware that stuffed toys should not be kept on top of the overhead light because it could fall on the resident and it was a fire hazard. 3. During an observation on 1/2/19 11:10 a.m. Resident 17 was seen lying in bed with eyes closed and two upper side rails up. Side rails had no padding. During an interview on 1/3/19 at 3:11 p.m., registered nurse F (RN F) confirmed Resident 17 did not have padded side rails on her bed. RN F also stated side rails should be padded based on Resident 17's [DIAGNOSES REDACTED]. Review of Resident 17's clinical records confirmed a [DIAGNOSES REDACTED]. Review of the facility's policy dated 12/2007, Safety and Supervision of Residents, indicated interventions to reduce accident risks and hazards will be implemented.

Based on observation, interview and record review the facility failed to provide podiatry services (the medical care and treatment of [REDACTED]. Resident 2's long and overgrown toenails and calluses affected his mobility and ambulation. Findings: A review of Resident 2's face sheet included [DIAGNOSES REDACTED]. During the initial tour and observation on 1/02/19 at 10:49 a.m., Resident 2 was in his room sitting on his bed and showed his long, thick, curly, overgrown toenails with calluses on both feet. During the concurrent interview, Resident 2 stated he had requested to the admission coordinator/social services director (AC/SSD) about four months ago for podiatry treatment. Resident 2 stated his toenails were excessively long which made him experience foot pain and made him uncomfortable when putting his socks on and during walking. He stated this situation limited his activities and movements. He stated he was willing to pay the required fees because he himself was not able to trim his toenails. Resident 2 stated the nurses and certified nursing assistants (CNAs) were aware of the long toenails, because they would see it during the time they provided care for him. During a follow-up interview on 1/03/19 at 7:33 a.m., Resident 2 stated he wanted to use his shoes every time he would get up to walk, but his toenails' and foot conditions would make walking and wearing shoes very painful and uncomfortable. During an interview on 1/03/19 at 07:54 a.m., LVN B stated she was aware of Resident 2's long toe nails required a podiatry referral so she included Resident 2 on the list of residents that required a podiatry referral and gave it to the social services director on 11/17/18. During the concurrent interview with CNA C, she stated she was the regular CNA assigned for Resident 2 and her charge nurse was aware of Resident 2's long toenails. During a record review of the podiatry list dated 11/17/18 and a concurrent interview on 1/03/19 at 8:34 a.m., the AC/SSD stated she received from LVN B the list of residents for podiatry referral on 11/17/18 and the list included Resident 2. The AC/SSD stated she did not refer Resident 2 for podiatry treatment because she could have missed it. The AC/SSD checked the list of residents that the podiatrist seen and treated on 8/28/18 and 1/2/19. However, Resident 2 was not on the list of residents seen on those two podiatrist visits. A review of the Social Service Update dated 4/13/18, 7/10/18, and 10/5/18 indicated no podiatry services were provided for Resident 2. A review of the facility's undated policy, Podiatry Care, indicated the Podiatrist evaluates the resident as to necessary regime of podiatry care and write documentation for the nursing staff to consult and carry out; provides preventative care for people with diabetes, poor circulation and various forms of arthritis, routine foot care including removal of corns, ingrown toenails, calluses and warts, recognition of systemic medical conditions which may first manifest themselves within the foot and alleviation of the effects of these disorders such as inflammation or ulceration.