Every finding on record at The Tamalpais

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week from January 2025 to August 2025 for all the residents residing in the facility.This failure had the potential to result in insufficient nursing care and services for the vulnerable residential population residing in the facility.During a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, dated Quarter 2 2025 (January 1 - March 31), the PBJ Staffing Data Report indicated, the facility had no RN hours for the following Sundays: 1/5/2025, 2/2/2025, 2/16/2025, 3/2/2025, and 3/30/2025.During a review of the facility's Skilled Daily Staffing, assignment report dated Sunday, 8/17/2025, the Skilled Daily Staffing report indicated there was no RN coverage for skilled nursing.During a review of the facility's Skilled Daily Staffing, assignment report dated Sunday, 8/31/2025, the Skilled Daily Staffing report indicated there was no RN coverage for skilled nursing.During an interview on 9/10/2025 at 7:47 a.m. with Administrator (Admin), the Admin stated there was no RN coverage for the skilled nursing facility on the dates indicated on the PBJ Staffing Data Report (1/5/2025, 2/2/2025, 2/16/2025, 3/2/2025, and 3/30/2025.)During an interview on 9/11/2025 at 10:12 a.m. with the Admin, the Admin confirmed there were additional dates not indicated on PBJ Staffing Data Report where there was no RN coverage for the skilled nursing facility. Admin stated the facility was unaware RN coverage was needed specifically for the skilled nursing facility, and confirmed there was no RN coverage scheduled for every other Sunday.

Based on interview and record review, the facility failed to have a dedicated full-time infection preventionist (IP) according to the California Assembly [NAME] (AB) 2644 (Chapter 287, Statutes of 2020). This failure had the potential to negatively affect the facility's infection prevention and control program and the residents' quality of care.Findings:During an interview on 9/10/25 at 3:21 p.m., with the IP, the IP stated her responsibilities included assist with infection surveillance, track and trend infections, train staff in infection control, keep up to date with infection control and prevention guidelines, and participate in the infection control committee and the quality assurance and performance improvement (QAPI). The IP stated she was employed as a full-time IP for the Continuing Care Retirement Community's (CCRC, a residential community for seniors that offers various levels of care on a single campus) 3 levels of care - independent living, assisted living, and the skilled nursing facility (SNF). IP stated she tries to devote most of her time to the SNF because the residents require a higher level of care, but her time oscillates to the three levels of care. The IP stated that when there was an outbreak in an area outside of the SNF, she would spend more time in that area. The IP stated she did not document how much time she spends as an IP in the SNF.During a concurrent interview and record review on 9/11/25 at 2:02 p.m., with the Administrator (Admin), the California All Facility Letter (AFL) 20-85 dated 11/9/2020 which had AB 2644 (Chapter 287, Statutes of 2020) and the IP's employment status were reviewed. AB 2644 indicated that effective 1/1/2021, a skilled nursing facility requires to have a full-time IP. The Admin stated the AFL 20-85 only indicated the need to employee a full-time IP, but it did not specify that the IP should only work in the SNF. The Admin stated the IP's primary job was a full-time infection preventionist in the healthcare level of care also known as their SNF. The Admin confirmed that the IP was not solely an IP for the SNF, but rather she was an IP for the CCRC. The Admin further stated the IP goes to the 2 other levels of care, independent living and assisted living, and works as an IP for those two levels of care as well.During a review of AFL 20-85 titled, Assembly [NAME] (AB) 2644 - Skilled Nursing Facilities: Infection Preventionists and Communicable Disease Reporting, dated 11/9/2020, the AFL 20-85 indicated, Effective January 1, 2021, AB 2644 requires a SNF to have a full-time IP, a role that may be shared by two staff members if the total time dedicated to the IP role is equivalent to one full-time staff member.During a review of the facility's policy and procedures (P&P) titled, Infection Preventionist, dated August 2023, the P&P indicated, Hours of Work 1. The infection preventionist is employed in accordance with state and federal regulations.During a review of the facility's position description titled, Infection Preventionist, dated 6/11/2020, the position description indicated, Essential functions: Plans, organizes, develops, coordinates, and directs the Infection Prevention Program and its activities in accordance with Federal and State laws and regulations. Acts as Community Infection Preventionist.

Based on observation, interview, and record review, the facility failed to remove one multidose vial of PPD diagnostic antigen (chemical used to indicate tuberculosis) from the medication refrigerator 30 days after opening per facility policy. This failure had the potential to expose all the residents to use of an outdated antigen which could lead to an incorrect medical diagnosis for Tuberculosis (bacterial respiratory infection.)During an observation and interview on 9/9/2025 at 3:02 p.m. in the medication refrigerator located in the nursing station, with the Director of Nursing (DON), the DON verified a vial of PPD diagnostic antigen label indicated an opening date of 7/25/2025. The DON stated that the vial should have been discarded 30 days after opening.During an interview on 9/10/2025 at 4:48 p.m. with DON, the DON indicated that the facility policy was to label a multidose vial with the date when opened and to discard the vial 30 days after opening. The DON stated that medications lose effectiveness or potency after opening. During a review of the facility's policy and procedures (P&P) titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 8/1/24, the P&P indicated, The facility should ensure that medications and biologicals . have an expiration date on the label . once . opened, facility should follow manufacturer/supplier guidelines.During a review of the www.fda.gov for APLISOL, dated 11/2013, the site stated, Vials in use more than 30 days should be discarded due to possible oxidation which may affect potency.

Based on interview and record review, the facility failed to ensure one of 2 sampled discharge residents (Resident 26), had a discharge order and discharge summary maintained in their medical record. This failure had the potential to adversely affect Resident 26's continuity of care after discharge. Findings:During a review of Resident 26's Face Sheet, the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), myocardial infarction (heart muscle damage), asthma (difficulty breathing), high blood pressure, and elevated liver enzymes.During a concurrent interview and record review on 9/10/2025 at 3:13 p.m. with Minimum Data Set Registered Nurse (MDSRN - nurse who specializes in collecting patient data in a long-term care facility), Resident 26's electronic medical record (EMR) was reviewed. The MDSRN indicated that the physician should write a discharge order and discharge summary to provide the resident guidance for continued medical treatment after discharge. MDSRN verified that no discharge order or discharge summary was in the EMR or provided to Resident 26.During an interview on 9/11/2025 at 10:00 a.m. with the Medical Director (MD) 1, the MD 1 indicated that it was the responsibility of the discharging physician to provide a discharge summary for the family and continuing care provider for continuity of care. MD 1 also stated the discharging physician was responsible for ensuring a signed discharge order was in the EMR.During a concurrent interview and record review on 9/11/2025 at 11:50 a.m. with the Director of Nursing (DON), Resident 26's EMR was reviewed. The DON verified that no doctor's discharge order, discharge note, or discharge summary was in Resident 26's EMR. During a concurrent interview and record review on 9/11/2025 at 3:00 p.m. with the Social Worker (SW), Resident 26's EMR was reviewed. The SW stated that the discharge physician should have provided a discharge order and discharge summary when it was determined the resident was ready for discharge. These documents should have been given to the resident upon discharge and forwarded to the primary care provider or specialist who will continue to care for the resident after discharge. The SW stated the importance of the summary was to make the primary care provider aware of the resident's current health status and any continued medical needs of the resident. The SW indicated that she did not forward a discharge summary to the primary care physician of Resident 26. The SW verified that Resident 26's EMR did not have a discharge order or discharge summary.During a review of the facility's policy and procedure (P&P) titled, Provision of physician services, alternate schedule for visits, and prompt notification of physicians, dated 4/2024, the P&P indicated, The resident shall be discharged only with a written order of the physician. A discharge summary shall be completed within 14 days of discharge.During a review of the facility's policy and procedure (P&P) titled, Discharge plan and post discharge plan of care, dated 3/2024, the P&P indicated, There shall be a physician order for discharge and the reason for discharge . At a minimum the discharge summary will contain a summary of the resident's status to include a description of the resident's medical condition, current medical status, . special treatments or procedures, . drug therapy and disposition of medications.

Based on observation, interview, and record review, the facility failed to develop a care plan (an individualized plan that provides direction on the type of care a resident needs) for one of 17 sampled residents (Resident 2). This failure had the potential for Resident 2 to not receive the specific services necessary to meet her needs.Findings: During a review of Resident 2's Profile Face Sheet (demographic), the Profile Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a femur (bone of the thigh) fracture and Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).During an observation on 9/8/25 at 5:38 p.m., outside of Resident 2's room, an Enhanced Barrier Precautions (EBP, are infection control interventions designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) sign was posted on the wall below Resident 2's name plate. The EBP indicated, Stop. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. CNA (Certified Nursing Assistant) 1 entered Resident 2's room and informed Resident 2 that dinner was being served. CNA 2 entered Resident 2's room with a meal tray. CNA 1 and CNA 2 were observed moving and repositioning Resident 2 on her bed, preparing her to eat. CNA 1 and CNA 2 did not have on gloves or gown while moving and repositioning Resident 2 in bed. During an interview on 9/8/25 at 5:43 p.m., with CNA 1, CNA 1 stated Resident 2 was in EBP because Resident 2 had a dressing on her leg. CNA 1 stated staff did not need to wear a gown or gloves when the staff reposition a resident in bed.During a review of Resident 2's interdisciplinary notes dated 8/23/25 - 9/10/25, there was no documented evidence when EBP was initiated or the reason why Resident 2 was on EBP.During a review of Resident 2's Baseline and Comprehensive Care Plan, there was no care plan for EBP.During an interview on 9/10/25 at 3:21 p.m., with the Infection Preventionist (IP), the IP stated moving a resident in bed was considered high-contact care. IP stated the certified nursing assistants should have worn gown and gloves when moving a resident who was on EBP. IP stated the facility uses the Centers for Disease Control and Prevention (CDC) EBP as a guideline. IP further stated the facility did not have an EBP policy and procedures.During a concurrent interview and record review on 9/11/25 at 9:32 a.m., with IP, Resident 2's medical record was reviewed. IP stated Resident 2 was on EBP because on 8/23/25 a skin tear was found on Resident 2's left leg. IP confirmed that between 8/23/25 - 9/10/25, Resident 2's interdisciplinary notes had no documented evidence when EBP was initiated or the reason why Resident 2 was on EBP. IP confirmed there was no documented evidence of EBP in Resident 2's care plan. During an interview on 9/11/25 at 11:44 a.m., with the IP, IP stated the CDC guidelines does not indicate that EBP was required to be care planned. The IP stated EBP was not part of the care planning process. During a review of the facility's policy and procedures (P&P) titled, Care Planning / Interdisciplinary Team Care Planning Conference, dated March 2024, the P&P indicated, All residents will have a comprehensive care plan to meet their individual needs that is prepared by an interdisciplinary Team within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Procedure . 9. Care plans are revised per RAI (Resident Assessment Instrument) schedules and as changes in the resident's condition dictates .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for two of 17 sampled residents (Resident 8 and Resident 22) when:1. Resident 8 was observed without a wanderguard device (a wearable device designed to help prevent residents at risk of wandering from leaving a designated area in a care facility) per physician's order and there was no elopement assessment prior to placing a wander guard device on Resident 8. These failures had the potential to adversely affect Resident 8's physical and psychosocial well-being.2. Resident 22's floor mats were not placed as ordered by the physician. This failure had the potential to cause injury to Resident 22. Findings: 1.During a review of Resident 8’s “Profile Face Sheet (demographic),” the “Profile Face Sheet” indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis of dementia (a general term for a decline in mental ability that is severe enough to interfere with a person’s daily life and functioning). During a review of Resident 8’s “Physician’s Orders,” dated 2/8/24, the “Physician’s Orders” indicated orders to change wanderguard as needed to the right wrist, to check the battery of the wander guard daily (on the right wrist), and to check the placement of the wander guard every shift. During a concurrent observation and interview on 9/9/25 at 11:56 a.m., with Resident 8’s Care Giver (CG) 1, Resident 8 was sitting on a wheelchair in the Sunroom. CG 1 stated she was familiar with Resident 8. CG 1 checked for a wanderguard device on Resident 8’s wrists and on Resident 8’s wheelchair. CG 1 stated there was no wanderguard device on Resident 8’s wrists nor on Resident 8’s wheelchair. During a concurrent observation, interview, and record review on 9/9/25 at 12:03 p.m., with Registered Nurse (RN) 1, RN 1 verified that Resident 8 had active physician’s orders for a wanderguard device. RN 1 stated the wander guard device was placed on her wheelchair because the wander guard bracelet would cut her skin. RN 1 checked the wheelchair Resident 8 was sitting on but was unable to locate the wanderguard device. During a concurrent interview and record review on 9/9/25 at 3:34 p.m., with RN 2, Resident 8’s medical record was reviewed. RN 2 confirmed Resident 8’s physician’s orders for wander guard device dated 2/8/24. RN 2 stated Resident 8 had a history of attempting to leave the unit by trying to go on the elevator on her own. RN 2 stated Resident 8 required supervision when she leaves the unit. RN 2 stated that on 2/8/25 at 10:25 p.m., the interdisciplinary note indicated Resident 8 was asking for the location of the elevator because she wanted to go back to her apartment and a wanderguard was put on Resident 8’s right wrist. RN 2 stated Resident 8 had only one “Elopement Risk Assessment” dated 4/15/24 which indicated Resident 8 was at risk for elopement. RN 2 stated a wanderguard device should have been on Resident 8’s right wrist and should always be on Resident 8. During an interview on 9/10/25 at 8:34 a.m., with the Director of Nursing (DON), the DON stated an elopement assessment is typically done upon admission, when there was a change of condition, and annually. The DON stated an elopement assessment for Resident 8 should have been completed prior to putting a wanderguard device on her. During a review of the facility’s policy and procedures (P&P) titled, “Elopement and Hazardous Wandering,” dated January 2016, the P&P indicated, “Prevention & Intervention I. Resident Assessments A. All new residents shall be assessed for risk of hazardous wandering. The assessment is completed during the admission process, annually, each time a resident moves to a different level of care, and more frequently in accordance with the resident’s condition.” 2. During a review of Resident 22’s “Profile Face Sheet (demographics),” the “Profile Face Sheet” indicated Resident 22 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (also known as ischemic stroke, when blood flow to the brain is interrupted causing damage to the brain tissue) and muscle weakness. During a review of Resident 22’s “Physician’s Orders,” dated 5/15/24, the “Physician’s Orders” indicated floor pads (mats) to the side of the bed. During a review of Resident 22’s “Post Fall Risk Assessment,” dated 4/4/25, the “Post Fall Risk Assessment” indicated Resident 22 was at high risk for falls. During an observation on 9/9/25 at 9:18 a.m., in Resident 22’s room, Resident 22 was sitting up in bed. There was a floor mat on the right side of the bed and another floor mat rolled up in between a chair and a dresser. During a concurrent observation and interview on 9/9/25 at 9:22 a.m., in Resident 22’s room, with the Director of Nursing (DON), the DON confirmed that a floor mat was rolled up in between a chair and a dresser. The DON stated Resident 22 could not walk and Resident 22 did not have a history of falls. The DON stated the floor mats were a precautionary measure, and they should have been on the floor on each side of the bed. During an interview on 9/9/25 at 9:23 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 22 should have the floor mats on each side of her bed because Resident 22 had tendencies to slide out of her bed. During a review of Resident 22’s care plan for “Falls” dated 3/20/24, the “Falls” care plan indicated floor mats to be placed on side of the bed. During a review of the facility’s policy and procedures (P&P) titled, “Physician Order Recap System,” dated April 2024, the P&P indicated, “. B. Receiving Physician Orders . 8. Licensed nurse shall be responsible for noting and implementing the order.”

Based on observation, interview, and record review, the facility failed to ensure the kitchen preparation area was maintained in a safe and sanitary manner when one of the staff with facial hair was observed cooking food not wearing a beard net. This failure had the potential to place all residents who received food prepared in the kitchen at risk for food contamination.During an observation on 9/8/2025 at 2:20 p.m. of the kitchen, [NAME] 1 was observed without a beard net covering his facial hair while standing next to the stove cooking.During a concurrent observation and interview on 9/10/2025 at 10:04 a.m. with Director of Dining Services (DDS), in the kitchen, the DDS verified that [NAME] 1 did not wear a beard net.During a record review of the facilities policy and procedure (P&P) titled, Uniform Dress Code, dated 1/2020, the P&P indicated, Restrain all facial hair with a beard net/restraint.During a review of the FDA Food Code 2022, 2-402 - Hair Restraints, the code states, Food employees shall wear hair restraints such . beard restraints . that covers hair, that are designed and worn to effectively keep their hair from contacting . FOOD.

Based on observation, interview, and record review, the facility failed to follow and implement infection control practices for two of 17 sampled residents (Resident 2 and Resident 7) when:1.Two staff members did not wear personal protective equipment (PPE) while providing care to Resident 2 who was in Enhanced Barrier Precautions (EBP, are infection control interventions designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) 2. One staff member did not clean and disinfect reusable blood pressure cuff in between resident use. These failures had the potential to cause the spread of infections to residents.Findings: 1.During a review of Resident 2’s “Profile Face Sheet (demographic),” the “Profile Face Sheet” indicated Resident 2 was admitted to the facility on [DATE] with a femur (bone of the thigh) fracture and Alzheimer’s Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). During an observation on 9/8/25 at 5:38 p.m., outside of Resident 2’s room, an Enhanced Barrier Precautions sign was posted on the wall below Resident 2’s name plate. The EBP indicated, “Stop. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing.” CNA (Certified Nursing Assistant) 1 entered Resident 2’s room and informed Resident 2 that dinner was being served. CNA 2 entered Resident 2’s room with a meal tray. CNA 1 and CNA 2 were observed moving and repositioning Resident 2 on her bed, preparing her to eat. CNA 1 and CNA 2 did not have on gloves or gown while moving and repositioning Resident 2 in bed. During an interview on 9/8/25 at 5:43 p.m., with CNA 1, CNA stated Resident 2 was in EBP because Resident 2 had a dressing on her leg. CNA 1 stated staff did not need to wear a gown or gloves when staff reposition a resident in bed. During an interview on 9/10/25 at 3:21 p.m., with the Infection Preventionist (IP), the IP stated moving a resident in bed was considered high-contact care. IP stated the certified nursing assistants should have worn gown and gloves when moving a resident who was on EBP. IP stated the facility uses the Centers for Disease Control and Prevention (CDC) EBP as a guideline. During a review of CDC’s guideline titled, “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),” dated 4/2/24, the guideline indicated for “Enhanced Barrier Precautions to expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.” 2. During a review of Resident 7’s Face Sheet (Resident Demographics), the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic heart failure (condition where the heart muscle becomes stiff and less able to relax between heartbeats) and dysphagia (difficulty swallowing). During an observation on 9/10/2025 at 9:03 a.m. with Registered Nurse (RN) 1, RN 1 was observed leaving Resident 20’s room after taking her blood pressure measurement and walking into Resident 7’s room. RN 1 was observed using the same blood pressure machine and reusable blood pressure cuff without cleaning or disinfecting them on Resident 7. During an interview on 9/10/2025 at 10:31 a.m. with RN 1, RN 1 stated blood pressure machine and reusable cuff needed to be cleaned and disinfected after each resident use. RN 1 confirmed blood pressure machine and reusable cuff were not cleaned and disinfected after Resident 20 use and before Resident 7’s blood pressure measurement was performed. During an interview on 9/10/2025 at 2:39 p.m. with the Infection Preventionist (IP), IP stated blood pressure machine and reusable blood pressure cuff were to be cleaned and disinfected in between resident use. IP also stated if blood pressure machine and reusable cuff were not cleaned and disinfected, and used on a resident, it could lead to microbe (microscopic organism that includes bacteria and viruses) transmission between residents. During a review of the facility’s policy and procedure (P&P) titled, “Cleaning and Disinfecting Non-Critical Resident-Care Items,” dated September 2025, the P&P indicated, “Reusable items are to be cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).”

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure proper infection control practices during medication administration for three (Residents #8, #12, and #87) of nine residents observed during medication administration. Findings included: A review of a facility policy titled Personal Protective Equipment - Gloves, revised in July 2009, revealed, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Further review of the policy revealed, 3. The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: a. when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure. A review of a facility policy titled Handwashing/Hand Hygiene, revised in August 2019, revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: f. Before and after direct contact with residents; g. Before preparing or handling medications. Further review of the policy revealed, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: u. when anticipating contact with blood or body fluids. A review of Resident #8's Profile Face Sheet revealed the facility admitted Resident #8 on 03/10/2020 with a diagnosis of glaucoma (A group of eye conditions that can cause blindness). A review of Resident #8's physician orders revealed an order dated 03/10/2020, for Simbrinza (eye drop medication used to treat glaucoma) 1%-0.2% one drop to both eyes two times daily. Observation and interview during medication administration on 12/05/2023 at 9:10 AM revealed Licensed Vocational Nurse (LVN) #3 administered Simbrinza eye drops to Resident #8 by touching the resident's lower eyelid with their left hand and with their right hand administered one drop of medication to the resident's right eye. Continued observation showed LVN #3 touched the resident's left lower eyelid and administered one drop of medication to the left eye without performing hand hygiene or donning gloves before administration. During an interview with LVN #3 at the time of the observation, he confirmed he did not wear gloves when he administered the eye drops. LVN #3 stated he would have to check to see if he needed to wear gloves when administering eye drops. A review of Resident #12's Profile Face Sheet revealed the facility admitted Resident #12 on 08/31/2017 with a diagnosis of blepharitis (inflammation of the eyelid). A review of Resident #12's physician orders revealed an order dated 11/12/2022 for lubricating eye drops, one drop to both eyes daily for dry eye syndrome. Observation of medication administration on 12/06/2023 at 8:00 AM revealed LVN #1 administered eye drops to Resident #12. Resident #12's eyes were matted, and with gloved hands, LVN #1 held the bottle of eye drops in their left hand and administered one drop to the resident's right eye using their right hand to open the resident's right lower eyelid. Continued observation showed with the same gloved hands, LVN #1 placed the eye drop bottle in their right hand and administered one drop to the resident's left eye while using their left gloved hand to open the resident's left lower eyelid. LVN #1 then placed the lid on the eye drop bottle and, without removing the gloves, adjusted the head of the resident's bed, pillow, and meal tray. LVN #1 removed the gloves and performed hand hygiene. A review of Resident #87's Profile Face Sheet revealed the facility admitted Resident #87 on 12/04/2023 with a diagnosis of right artificial hip joint. A review of Resident #87's physician orders revealed an order dated 12/04/2023 for ibuprofen (anti-inflammatory and pain medication) 400 milligrams (mg) two times a day and Lidocaine 4% (numbing medication used to decrease pain) topical patch to right hip. During observation of medication administration on 12/06/2023 at 8:15 AM, LVN #1 donned gloves and prepared and gathered Resident #87's medications. LVN #1 touched the medication cards for acetaminophen (non-narcotic pain medication), multivitamins, Vitamin D3, and Vitamin B12, the box that contained a blood thinner medication, the box for the lidocaine patch, and three bottles of Miralax (stool softener medication) while preparing the medications. Continued observation showed LVN #1, with the same gloved hands, removed two ibuprofen tablets from the blister pack by popping the pills from the blister pack into her gloved right hand and placed the pills in a medication cup for administration to Resident #87. During an interview with LVN #1, at the time of the observation, LVN #1 stated she wore gloves to prevent infection and stated the palm of her hand was clean. Further observation of medication administration with LVN #1 showed after administration of the oral medications, LVN #1, with gloved hands, removed a lidocaine patch from Resident #87's right hip area and wadded the removed patch with the covering of the new lidocaine patch into her hand, and with the same gloved hands applied the new patch to the resident's right hip. With the same gloves and the old dressing in her hand, LVN #1 retrieved a pen from her pocket, signed the new patch, and then placed the pen back in her pocket. LVN #1 then removed the gloves and performed hand hygiene. During an interview with the Infection Preventionist (IP) on 12/07/2023 at 3:15 PM, the Infection Preventionist (IP) stated staff should wear gloves when in contact with blood, body fluids, or mucous membranes. The IP stated it was best practice to wear gloves when administering eye drops and confirmed the nurse placing the pen back in her pocket after touching the old lidocaine patch was an infection control issue. During an interview on 12/08/2023 at 8:04 AM, the Director of Nursing Services (DNS) stated facility policy did not instruct staff to don gloves for eye drop administration; however, staff were trained to wear gloves when administering eye drops. The DNS confirmed there were cross-contamination issues when LVN #1 was observed touching other items with gloved hands and placing the ibuprofen pills into her gloved hand. The DNS stated she expected gloves to be changed after removing an old patch and before applying a new patch, and if staff anticipated touching mucous membranes or drainage, gloves should be worn. During an interview on 12/08/2023 at 8:33 AM, the Administrator stated he expected staff to follow procedures for infection prevention. During an interview on 12/08/2023 at 10:20 AM, LVN #1 stated she should not have touched Resident #12's bed control, pillow, and meal tray with gloved hands due to the risk of contamination. During an interview with the DNS, in the presence of the Administrator, on 12/08/2023 at 10:47 AM, the DNS stated the facility did not have an infection control policy that specifically addressed cross-contamination.

Based on interviews, record reviews, and facility document reviews, the facility failed to provide advance beneficiary notices 48 hours prior to discharge from Medicare Part A services for two (Resident #19 and Resident #21) of three sampled residents reviewed for beneficiary notices. Findings included: A review of Resident #19's Profile Face Sheet revealed the facility admitted Resident #19 on 08/17/2023 with diagnoses that included acidosis (a buildup of acid in the bloodstream), acute kidney failure, and chronic kidney disease. A review of Resident #19's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form indicated their last covered day was 09/01/2023. The form was signed and dated 12/04/2023. A review of Resident #21's Profile Face Sheet revealed the facility admitted Resident #21 on 06/16/2023 with diagnoses that included pneumonia (lung infection), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and Alzheimer's disease (A progressive disease that destroys memory and other important mental functions). A review of Resident #21's SNFABN form indicated the resident's last covered day was 07/07/2023. The form was signed and dated 12/04/2023. During an interview on 12/06/2023 at 9:40 AM, the Social Worker (SWK) said he did not know the SNFABN had to be provided until he was gathering information for the survey. The SWK stated the SNFABN form for Resident #19 and Resident #21 was provided on 12/04/2023. During an interview on 12/08/2023 at 8:04 AM, the Director of Nursing Services (DNS) stated the social worker was responsible for the Advance Beneficiary Notices (ABNs). The DNS stated she expected all notices to be provided timely. During an interview on 12/08/2023 at 8:33 AM, the Administrator stated the social worker was responsible for issuing ABNs. The Administrator said he expected the notices to be provided timely. During an interview on 12/08/2023 at 10:47 AM, the DNS stated the facility did not have a policy that addressed ABNs.

Based on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a significant change in status comprehensive assessment was completed within 14 days of hospice services election for one (Resident #24) of one sampled resident reviewed for hospice services. Findings included: A review of a facility policy titled Hospice Care, revised in May 2021, revealed, 5. If appropriate a change of condition Minimum Data Set (MDS) shall be completed per RAI guidelines. A review of the CMS Long-Term Care RAI 3.0 User's Manual, Version 1.18.11, dated October 2023, Chapter 2: Assessments for the RAI revealed, 03. Significant Change in Status Assessment (SCSA) (A0310A = 4) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. The user's manual further specified, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election. A review of Resident #24's Profile Face Sheet revealed the facility most recently admitted the resident on 10/06/2023 with diagnoses that included encephalopathy (A broad term for any brain disease that alters brain function or structure) and acute respiratory distress (a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen). A review of Resident #24's admission MDS, with an ARD of 10/12/2023, revealed Resident #24 had not received hospice services while a resident of the facility. A review of Resident #24's Transdisciplinary Notes revealed a note dated 11/07/2023 that indicated Resident #24 was admitted to hospice. A review of Resident #24's hospice record revealed the resident's hospice benefit period started on 11/07/2023. A review of Resident #24's MDS history revealed a SCSA MDS with an ARD of 12/04/2023 and a completion date of 12/05/2023. The MDS assessment history reflected there was no other SCSA MDS completed following Resident #24's admission to hospice services. During an interview on 12/07/2023 at 1:30 PM, the MDS Consultant confirmed Resident #24's SCSA MDS was not completed within the timeframe it should have been. The MDS Consultant said the SCSA MDS should have been completed within 14 days of Resident #24's admission to hospice. During an interview on 12/07/2023 at 1:44 PM, the Administrator stated Resident #24's SCSA MDS should have been completed within 14 days of the resident's admission to hospice.

Based on record review and interviews, the facility failed to ensure a pro re nata (PRN, as needed) psychotropic medication (medications that affect the mind, emotions, and behavior) order specified the duration of use or stop date for one (Resident #20) of five sampled residents reviewed for unnecessary medications. Findings included: A review of Resident #20's Profile Face Sheet revealed the facility most recently admitted the resident on 03/30/2023 with diagnoses that included mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and unspecified disorientation. A review of Resident #20's Baseline & Comp [comprehensive] Care Plan, undated, revealed a Problem area that indicated Resident #20 required the use of psychotropic medications to manage their mood and/or behavior symptoms. The care plan specified the resident required antianxiety medication related to anxiety (Intense, excessive and/or persistent worry and fear) under hospice care. A review of Resident #20's physician's orders revealed orders dated 03/30/2023 for lorazepam (an antianxiety medication) 0.5 milligram (mg), one tablet every four hours PRN (as needed) for mild anxiety and lorazepam 0.5 mg, two tablets every four hours PRN for moderate to severe anxiety. Neither PRN order specified the duration of use or a stop date. A review of a Gradual Dose Reduction Tracking Report, dated 09/20/2023, revealed the interdisciplinary team (IDT) discussed Resident #20's PRN lorazepam order during an IDT meeting on 09/20/2023. According to the report, the resident was receiving lorazepam per hospice protocol, and the IDT discussed having the hospice physician document the continued need for the medication. A review of a Physician Psychotropic Chart Review, dated 11/01/2023, revealed Resident #20's orders for PRN lorazepam were reviewed. The physician documented a gradual dose reduction was clinically contraindicated due to hospice care; however, the duration of use or stop date for the orders was not specified. A review of Resident #20's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/2023, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #20 had severe cognitive impairment. According to the MDS, Resident #20 received an antianxiety medication during the seven days prior to the assessment. During an interview on 12/06/2023 at 1:37 PM, the Medical Director (MD) stated all psychotropic PRN medications should have a stop date. During an interview on 12/07/2023 at 12:26 PM, the Director of Nursing Services (DNS) stated she thought because they had documented the rationale for continued use of Resident #20's lorazepam, a stop date was not needed. During an interview on 12/07/2023 at 1:30 PM, the Administrator stated PRN medications should have a stop date.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medications were not repackaged in one (third-floor medication cart) of two medication carts, and the facility failed to ensure an opened multi-dose vial was discarded in one (second-floor medication room) of one medication room observed. Findings included: During an interview on 12/08/2023 at 10:47 AM, the Director of Nursing Services (DNS) stated the facility did not have a policy that addressed repackaging medications. A review of a facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised on 04/01/2022, revealed, Once any medication or biological package is opened, Facility [sic] should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 1. Medication administration observation was conducted on 12/06/2023 at 7:59 AM with Licensed Vocational Nurse (LVN) #1. LVN #1 prepared Resident #12's medications, which included acetaminophen 325 milligrams (mg). LVN #1 removed one tablet from the bubble pack labeled #2 on the multi-dose medication card. The following bubble pack labeled #1 on the multi-dose medication card contained two tablets. Clear tape was observed on the back of the multi-dose medication card covering the bubble packs labeled numbers three through five. LVN #1 said it was okay to place medication tablets back in the open bubble packs on the multi-dose medication card. A review of the pharmacy label on the top of the medication card for Resident #12 revealed acetaminophen (a pain and fever medication) 325 mg tablet - take two tablets (650mg) by mouth every four hours as needed. A review of Resident #12's Physician's Orders dated 12/08/2023 revealed an order for Tylenol (acetaminophen) 325 mg tablet - two tablets by mouth every four hours PRN (pro re nata; as needed) for pain with an order date of 09/04/2017 and another order for acetaminophen 325 mg tablet - one tablet by mouth twice daily in addition to PRN with an order date of 05/22/2019. 2. An observation of the second-floor medication room was conducted on 12/06/2023 at 11:28 AM with LVN #1. An open multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was observed in the refrigerator, which was dated as opened on 10/19/2023. LVN #1 said the multi-dose vial should have been used within 30 days of opening. A review of the undated, Aplisol (Tuberculin Purified Protein Derivative) package insert, provided by the facility, revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During an interview on 12/08/2023 at 8:04 AM, the DNS said nurses should not tape medications back into the medication card and that a new card of acetaminophen should have been ordered. The DNS stated a multi-dose vial should be dated when opened and was good for 30 days after it was opened. The DNS said she expected multi-dose vials to be discarded after 30 days, and she expected medications not to be repackaged or taped in the medication card. During an interview on 12/08/2023 at 8:33 AM, the Administrator stated he expected multi-dose vials to be discarded if that was the policy. The Administrator said he expected the procedure to be followed regarding the repackaging of medications.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was maintained in the kitchen when a kitchen staff member handled dirty dishes and then handled clean dishes without washing hands in between. This could potentially spread infectious microorganisms in a vulnerable population. Findings: During an observation and concurrent interview on 10/23/19 at 11:56 a.m., a kitchen staff member loaded used coffee cups into a rack for the dishwasher. The kitchen staff member then went over to the clean side of the dishwashing area and placed clean dishes in plastic bins up on a shelf. The staff member did not wash his hands before handling the clean dishes. When queried, Director of Food Services stated his expectation was for the staff member to wash his hands and re-glove when switching from handling dirty dishes to clean dishes. In response to a request for a dish washing policy, an untitled document, not dated, was provided with the policy statement, Facility will adhere to the Safety standards to ensure high standards of cleanliness and sanitation will be maintained. The policy did not indicate hand hygiene should be performed after handling dirty dishes and before handling clean dishes. Facility policy titled Handwashing/Hand Hygiene, dated 8/2015, indicated policy statement, This facility considers hand hygiene the primary means to prevent the spread of infections. Section titled, Policy Interpretation and Implementation, indicated, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, staff interview, and record and document review, the facility failed to provide adequate supervision for 1 of 12 sampled residents (Resident 32) when the resident fell seven times in one year. This failure resulted in Resident 32 fracturing his hip following one of the falls, as well as sustaining several bruises, lacerations, and/or skin tears as a result of the falls. Findings: Resident 32 was a male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) (an assessment tool), dated 7/15/18, Resident 32 had a BIMS (Brief Interview for Mental Status) score of 4 (a BIMS score of 0-7 indicates severely impaired cognition, scores between 8-12 indicate moderately impaired cognition, and scores between 13-15 indicate intact cognition) and needed extensive assistance to transfer from the chair to bed and use the toilet, and one person assistance to move from his room to the hallway. During an observation on 10/26/18 at 11:50 a.m. with the Nurse Manager, Resident 32's bed did not have a pressure alarm on it (a pressure alarm is a device that alarms when the patient no longer puts pressure on it). During an interview and concurrent clinical record review on 10/26/18 at 11:05 a.m., the Nurse Manager was asked what safety measures had been employed for Resident 32 in order to prevent falls. When asked if Resident 32 had a pressure alarm on his bed, she stated: Not that I'm aware of. She stated he had refused to wear hip pads (hipsters) to cushion falls and requested that the bed alarm be removed. The Nurse Manager also stated staff tried an every two-hour toileting program with Resident 32, but he gets agitated and, therefore, toilets himself. She stated he often forgot to use his walker when ambulating. When asked if the facility utilized a staff member whose sole responsibility was to monitor residents by making regular safety rounds or one-to-one supervision, the Nurse Manager stated, No. Review of the fall log provided by the facility from 10/28/17 to 10/18/18 indicated Resident 32 fell seven times during the past year on 11/27/17, 12/22/17, 3/12/18, 4/24/18, 4/29/18, and 8/22/18. The fall on 11/27/17 resulted in Resident 32 fracturing his right hip. After review of nursing notes from 6/27/17 through 10/10/18, one more fall was found on 10/7/18 which was not listed on the Fall Log. Review of Physician orders [REDACTED]. A pressure bed alarm was ordered on [DATE] with no discontinue date. Hipsters (padding to cushion a fall) were ordered on [DATE] and discontinued on 3/20/18 because Resident 32 refused to wear them. Medications included 81 mg (milligrams) of aspirin (ordered 12/27/17 for [MEDICAL CONDITION] (an irregular heart beat) (aspirin is also a medication that prevents the blood from clotting) and 7.5 mg of [MEDICATION NAME] for sleep (ordered 10/31/17). A physician progress notes [REDACTED]. X-ray demonstrated acute [MEDICAL CONDITION] trochanter (hip bone) of the right hip which was minimally displaced .He was not admitted to the hospital but returned to the skilled nursing facility after the ED (Emergency Department) visit. Patient currently denies any pain in his right hip. He has no other complaints, but is quite confused which is his baseline. A physician note, dated 12/22/17, indicated: (Resident 32) found on floor at 6:30 this morning with scalp laceration (cut) left temple .Patient has no recollection of having fallen. That note also stated: Faint bluish ecchymosis (bruise) extends inferiorly to the periorbital area on the left (the resident had a black eye). Physician note, dated 1/30/18, under Assessment #19--[MEDICAL CONDITION]-patient sleeps poorly in spite of [MEDICATION NAME] therapy . Physician note, dated 1/30/18, under Assessment #2--Dementia exacerbated by surgery-remains neurologically stable with moderately severe dementia. Physician note, dated 2/6/18 indicated: (Resident 32) with moderately severe cognitive impairment noted after general anesthesia for general anesthesia for total hip arthroplasty. Patient has become increasingly emotionally labile and at times agitated .Not responding to [MEDICATION NAME] 7.5 mg. at bedtime. I suspect that the fatigue resulting from chronic [MEDICAL CONDITION] may be contributing to the patient's dysphoria (poor mood) and resultant antisocial behavior. Physician note, dated 3/23/18, indicated under Assessment #18--[MEDICAL CONDITION]-because of deterioration in sleep and wandering. Trazadone (an anti-depressant often used to help with sleep) was increased from 25 mg. up to 50 mg. at bedtime on 3/14/18. No clear improvement. Also on [MEDICATION NAME]. Physician note, dated 5/4/18, indicated: Accidental fall with history of repeated falls-patient has low safety awareness, multifactorial imbalance because of age and frailty, being tapered off [MEDICATION NAME] because of concern for its potential contribution to falls. Physician note, dated 5/4/18. indicated: (Resident 32) reported by staff to have sustained a superficial 3-4 cm (centimeter) skin dorsum (back of hand) left hand as a result of a recent fall. Patient denies pain or awareness of the fall. Physician note, dated 5/30/18, indicated: Patient continues to have [MEDICAL CONDITION] and nighttime wandering. Did not tolerate [MEDICATION NAME] as a sleep aid because it seemed to contribute to his falls. Currently on [MEDICATION NAME]. A physician note, dated 6/22/18, indicated: Dementia-remains neurologically stable with moderately severe dementia. Continues to be bothered by wandering and [MEDICAL CONDITION], but intolerant of sedative next due to increased fall risk. Currently on [MEDICATION NAME] with equivocal benefit. Physician note, dated 6/22/18, indicated: Patient continues to have [MEDICAL CONDITION] and nighttime wandering. On [MEDICATION NAME]. Physician note, dated 8/3/18, indicated: [MEDICAL CONDITION]-because of deterioration in sleep and wandering--on [MEDICATION NAME]. Physician note, dated 8/22/18, indicated under Assessment--Accidental fall with scalp laceration/contusion (cut/bruising) but no evidence of intracranial (inside the head) injury on CT scan (a special x-ray with contrast dye). Stapled laceration occiput (back of head)-stable should remain in place 12 days. A second physician note, dated 8/22/18, indicated: (Resident 32) suffered an accidental fall on 8/22, while ambulating with his walker. Apparently became fatigued and lost balance, falling and striking the back of his head against a bookshelf. No loss of consciousness was reported. Because of laceration, he was transported to the emergency department (at local hospital). He had a CT scan (special x-ray using contrast dye) of head which was negative. Acute. His occipital (back of head) wound was closed with staples #7 in number. No other significant injuries were identified. A physician note, dated 10/2/18, indicated under Assessment: Dementia-remains neurologically stable with moderately severe dementia. Continues to be bothered by wandering and [MEDICAL CONDITION], but intolerant of sedative next due to increased fall risk. Currently on [MEDICATION NAME] with equivocal benefit. Wanderguard (a bracelet worn by a patient that alarms when the patient passes near an electrical sensor) has been removed without elopement (leaving the premises) attempts reported. Review of Care Conference note, dated 7/14/17, indicated: Resident 32's safety measures included a Wanderguard. Care Conference note, dated 10/3/17, indicated safety measures as Falling Star program and Wanderguard. Care Conference note, dated 1/3/18, indicated safety measures were hipsters, falling star program and wanderguard. Care Conference note, dated 4/3/18, indicated safety measures as wanderguard and falling star program. Note, dated 7/5/18, indicated safety measures included a wanderguard. Note dated, 10/3/18, indicated safety measures included falling star program (Wanderguard discontinued 7/6/18). Review of nursing progress notes from 6/27/17 through 10/14/18, in general, frequently mention Resident 32 is: confused (i.e. 6/28/17, 7/3/17, 7/14/17, 7/29/17, 11/28/17, 4/27/18, 4/25/18, 5/10/18, 10/10/18); impulsive (i.e. 6/28/17); not sleeping (i.e. 7/2/17, 7/8/17, 7/10/17, 8/12/17, 8/15/17, 9/26/17, 10/20/17, 11/29/17, 5/10/18, 8/24/18); forgetful (i.e. 7/1/17, 11/28/17, 12/23/17, 3/14/18, 4/26/18); wandering (7/12/17, 10/30/17, 3/23/18, 5/10/18); weak and unsteady (12/24/17); exhausted/tired (2/14/18, 5/1/18, 8/22/18); non-compliant (5/1/18); agitated (i.e. 6/30/17, 7/3/17). Review of nursing progress notes from 6/27/17 through 10/14/18, specifically indicate: note, dated 11/27/17, Resident was found on the floor in a seated position by attending staff at 0230. Resident could not remember the circumstances surrounding the fall but suspected that he had lost his balance; prior to the fall there is already notable difficulty with the resident's ability to express ideas. Denies having hit his head. A note, dated 12/22/17, indicated: At 6:30 a.m. patient found resident (sic) sitting on the floor by the door alert, noted blood all over his clothes and on the floor, full body assessment done noted skin tears on his forehead, right thumb and (sic) left hand .Unable to say what he was trying to do due to dementia. Nursing progress note, dated 3/12/18, indicated: Unwitness fall at 9:45 p.m., here (sic) a loud noise in the hallway come to find r/p on the floor at the entrance of his room seating (sic) on his right side, unable to describe how he fell . Note, dated 4/24/18. indicated: Per CNA report she heard patient calling for help and saw (Resident 32) sitting on the floor body against his bed with scattered streaks of blood on his bedsheets. Checked resident for injuries, noted bruises to his right forearm and left elbow and skin tears x3 to right hand. Nursing note, dated 4/29/18, indicated: Heard cry out from room [ROOM NUMBER]S found resident on the floor in a seated position assess and brought to standing position .Noted to have sustained a skin tear to left dorsal hand. Nursing note, dated 8/22/18, indicated: While ambulating in his room w (with) fww (forward wheeled walker) resident fell hitting his occipital region of the left side of his head on the bookcase .Noted bleed in excess to the lt (left) occipital area .transfer to (local hospital). Note dated, 8/25/18, indicated: Resident had episodes of agitation this evening refused shower, and refused to be checked, adl (activities of daily living) care. Tried to redirect agitation but not effective so he was left alone sitting in his bedside chair. Note, dated 10/7/18, indicated: Resident was seen 1340 (1:40 p.m.) in a seated position in front of his blue chair. Unable to recall circumstances of the fall .Resident stating that he had slid down his chair. Review of Fall Risk Assessments indicated: on 7/14/14, a score of 7; on 9/26/17, a score of 12; on 1/5/18, a score of 15; on 3/28/18, a score of 13; and on 10/1/18, a score of 15. Review of Post-Fall Assessments indicated: on 11/27/17, a score of 9; on 12/22/17, a score of 14; on 3/12/18, a score of 15; on 4/25/18, a score of 18; on 4/29/18, a score of 15; on 8/22/18, a score of 18; and on 10/9/18, a score of 17. According to the Fall Risk Assessment tool, a score of 10 or above indicates high fall risk. Review of a Social Service note, dated 9/26/17, indicated: Resident is a .male who is at health center for temp custodial care due to cognitive deficit and need for significant supervision . A social service note, dated 1/3/18, indicated: Resident is a .male who is at health center for custodial care due to cognitive deficit and need for significant supervision . A note, dated 6/27/18, indicated: Resident is a .male who is at health center for custodial care due to cognitive deficit and need for constant supervision. Review of the Fall care plan indicated actions including the falling star program, remind resident of safety precautions, apply hip pads, consider toileting plan, and call maintenance to evaluate the doorway threshold for safety. There was no mention of one-to-one supervision or the use of hall monitors for safety. Review of the policy titled, Fall Prevention Program, review date 1/2018, did not find any mention of increased supervision for residents who are a high fall risk.

Based on observations, staff interviews, and document review, the facility failed to: 1. Date, label, and cover stored food; 2. Maintain cold food at acceptable serving temperatures; 3. Store dried pantry goods properly; 4. Cover ice cream containers; 5. Clean the pantry floor; and 6. Clean the wall-mounted oscillating fans. These failures had the potential to contaminate food and serve outdated, improperly stored food to residents. Findings: 1. During an initial tour of the kitchen on 10/22/18 at 7:55 a.m., sliced cake was stored in the refrigerator. All but one piece was covered, however, none of the pieces of cake were dated. There was also a tray of undated puddings and Jellos that were covered loosely with a piece of parchment paper. There were also many loaves of bread stored in the freezer that were undated. In refrigerator #7 was stored a half-gallon of whipping cream and a quart of half and half that was not dated with an open date. In the same refrigerator were five gallon containers of salad dressing that were open without open dates, along with a gallon container of mayonnaise without an open date. During a concurrent interview, the General Manager of Dining Services stated, They (the slices of cake) need to get disposed of right away. Regarding the pudding and Jello, the General Manager stated: They should have been dated. The General Manager also acknowledged the undated whipping cream, half and half and salad dressings in the refrigerator, stating, I don't see one (open date). During an observation on 10/24/18 at 10:13 a.m., several spices and condiments were found to be lacking open dates (whole caraway seeds, whole poppy seeds, marjoram leaves, cinnamon sticks, balsamic vinegar, box of cornstarch, bottle of sherry vinegar, bottle of low sodium soy sauce x2, ground mustard, whole sesame seeds, and ground [MEDICATION NAME]). During an interview and concurrent observation of the spices on 10/24/18 at 10:25 a.m., the General Manager of Dining Services stated he also did not see open dates on the spices or condiments. Review of the facility provided Food Safety Product Labeling and Dating Guide, reviewed 7/29/14, indicated: food needed to be labeled with the date received or use by date. 2. During an observation of tray line on 10/24/18 at 11:46 a.m., temperatures were taken by the Registered Dietician of pureed cake, pureed tuna salad, pureed macaroni salad, and regular texture tuna salad. Temperatures were as follows: pureed cake--55.6 degrees Fahrenheit (F); pureed tuna salad--54.1 degrees F; pureed macaroni salad--55.2 degrees F; regular texture tuna salad--51 degrees F. During an interview on 10/24/18 at 11:46 a.m., the Registered Dietician stated the temperature of the cold pureed cake, pureed tuna salad, pureed macaroni salad, and regular tuna salad should be 41 degrees F. Review of the facility provided HACCP (Hazard Analysis and Critical Control Points--standards to ensure food safety) standards for food temperatures indicated cold foods should be served below 40 degrees F. According to the (YEAR) Food Code: The person in charge shall ensure that: (I) Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures (2017 Food Code 2-103.11). 3. During an initial tour of the kitchen on 10/22/18 at 7:55 a.m., there was a 25 pound bag of panko bread crumbs that was opened in the panty. The crumbs were not stored in their original bag and not stored in a covered container. During an interview on 10/22/18 at 8:12 a.m., the General Manager of Dining Services stated, the panko bread crumbs should be in a bin and not stored as they were opened in the original bag. Review of the facility provided HACCP Food Safety Standards and Requirements, rev date 8/17/16, indicated: Dry food, which is opened or removed from original packaging, should be stored properly covered, in food grade containers and clearly labeled. 4. During an observation on 10/24/18 at 9:36 a.m., seven large containers of ice cream were uncovered in the ice cream freezer. In an interview on 10/24/18 at 10 a.m., the General Manager of Dining Services stated there were not adequate covers for the ice cream and that he needed to get some. Review of the facility provided document, Food Product Shelf Life Guidelines, rev date 1/12/17, indicated for ice cream: Overwrap to prevent ice crystals, freezer burn. 5. During an initial tour of the kitchen on 10/22/18 at 7:55 a.m., the pantry floor was found to be dirty. In an interview on 10/24/18 at 10 a.m., the General Manager of Dining Services acknowledged the dirty pantry floor and stated the floors were cleaned every night by dietary staff. He added that he did not assign specific staff to do specific jobs and did not have a sign-in sheet for chores. He stated, Clearly, they didn't do what they were supposed to do. During an interview on 10/26/18 at 8:20 a.m., the General Manager stated the most recent cleaning logs for the kitchen were from (MONTH) (YEAR). Review of the Daily Cleaning Lists from (MONTH) (YEAR) indicated the bread room floor was to be swept and mopped clean daily by the restocker. According to the (YEAR) Food Code: Physical facilities shall be cleaned as often as necessary to keep them clean (6-501.12 (A)). 6. During an observation on 10/24/18 at 10:30 a.m., five wall-mounted oscillating fans were found to be very dirty with black matter. They were all operating and distributing air across the kitchen during food production. In a concurrent interview, when the General Manager of Dining Services was asked whose job it was to clean the fans, he stated: That's a good question, adding that he was embarrassed he did not catch the fact that the fans were dirty. During an interview on 10/24/18 at 10:50 a.m., the Maintenance Man stated it was his responsibility to clean the kitchen fans, but that he did not remember when they were last cleaned. Review of maintenance documents indicated the kitchen fans were last cleaned on 4/3/18. According to the (YEAR) Food Code: During preparation, unpackaged food shall be protected from environmental sources of contamination (2017 Food Code 3-305.14).

Based on interview and record review, the facility QAPI (quality assurance and performance improvement) committee failed to develop an effective plan to address deficient practices in the kitchen. This had the potential to lead to food borne illness in a vulnerable population. (Cross reference F812) Findings: During an interview on 10/26/18 at 12:15 p.m., the Administrator stated the QAPI committee used a Plan, Do, Study, Act method of looking at a process they want to improve. He confirmed the kitchen was part of the QAPI plan. When queried about what plan the QAPI committee had in place for improving the unsanitary conditions and food handling issues in the kitchen, the Administrator stated he would have to look at the plan of correction for last year's survey. He stated the new dietary manager had only been on the job for two months, had never been through a survey before, and did not have a chance to meet the old manager or get any kind of hand off. Review of facility document titled (Facility name) QAPI, undated, revealed, QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities of improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. Section titled A=Act to Hold the Gain and Continue Improvement, revealed, The purpose of this Step of the PDSA (Plan, Do, Study, Act) model is to 'act to hold the gains and continue improvement.' This means institutionalizing the improvement and monitoring results over time.

Based on observation, interview, and record review, the facility failed to ensure nursing staff follow physician orders [REDACTED]. This failure resulted in residents receiving wrong dose of medications, wrong medication, or wrong form of medication. This failure also had the potential to negatively affect the residents' health. Findings: During an observation on 10/25/18 at 8:22 a.m., Licensed Nurse A administered half a tablet of [MEDICATION NAME] (a medication that helps lower blood pressure and regulate heart rate and rhythm) ER (extended release) 50 mg (milligrams, a unit of measure) to Resident 26. During an observation on 10/25/18 at 8:45 a.m., Licensed Nurse A administered one tablet of Vitamin D3 2000 IU (international units, a unit of measure) to Resident 4. During an observation on 10/25/18 at 8:58 a.m., Licensed Nurse A administered one tablet of chewable aspirin 81 mg to Resident 24. During a record review on 10/25/18 at 10 a.m., Resident 26's physician orders [REDACTED]. The physician orders [REDACTED]. Resident 4's physician orders [REDACTED]. Resident 24's physician orders [REDACTED]. During an interview on 10/25/18 at 12 p.m., Licensed Nurse A confirmed the [MEDICATION NAME] ER 25 mg had a stop date of 10/24/18. She stated that the new medication [MEDICATION NAME] 12.5 mg/[MEDICATION NAME] 12.5 mg for Resident 26 had not come in yet. She stated that if a medication had a stop date of 10/24/18 and the new medication had not come in yet, she should get a doctor's order to continue giving the old medication until the new medication came in. Licensed Nurse A confirmed she did not have an order to give chewable aspirin to Resident 24. Licensed Nurse A stated that if Resident 24's order was for delayed release aspirin and the resident only had chewable aspirin on hand, she should have gotten an order clarification from the doctor. During an interview on 10/26/18 at 11:35 a.m., the Nurse Manager stated that Resident 4's family had brought in the bottle of Vitamin D3 2000 IU. She stated Resident 4 was on hospice and the hospice nurse should have gotten the order changed. Facility policy titled Medication Administration, dated 04/02, last reviewed 2/18, revealed under section titled, Purpose, To accurately administer medication to residents, and under section titled Policy, Medications shall be administered as ordered by a licensed nurse upon the order of a physician/licensed independent practitioner. Section titled Procedure, revealed, 1. Medication and biological orders shall be reviewed by a licensed nurse prior to administration.

Based on observation, interview, and record review, the failed to ensure the medication error rate was less than 5% (percent) when physician medication orders were not followed for three sampled residents (Resident 4, 24, and 26). This failure resulted in a medication error rate of 11.5% when three of 26 medications were given in error. This failure also had the potential to negatively affect residents' health. Findings: During an observation on 10/25/18 at 8:22 a.m., Licensed Nurse A administered half a tablet of [MEDICATION NAME] (a medication that helps lower blood pressure and regulate heart rate and rhythm) ER (extended release) 50 mg (milligrams, a unit of measure) to Resident 26. During an observation on 10/25/18 at 8:45 a.m., Licensed Nurse A administered one crushed tablet of Vitamin D3 2000 IU (international units, a unit of measure) to Resident 4. During an observation on 10/25/18 at 8:58 a.m., Licensed Nurse A administered one crushed tablet of chewable aspirin 81 mg to Resident 24. During a record review on 10/25/18 at 10 a.m., Resident 26's physician orders [REDACTED]. The physician's orders [REDACTED]. Resident 4's physician orders [REDACTED]. Resident 24's physician orders [REDACTED]. During an interview on 10/25/18 at 12 p.m., Licensed Nurse A confirmed the [MEDICATION NAME] ER 25 mg had a stop date of 10/24/18. She stated that the new medication [MEDICATION NAME] 12.5 mg/[MEDICATION NAME] 12.5 mg for Resident 26 had not come in yet. She stated that if a medication had a stop date of 10/24/18 and the new medication had not come in yet, she should get a doctor's order to continue giving the old medication until the new medication came in. Licensed Nurse A confirmed she did not have an order to give chewable aspirin to Resident 24. Licensed Nurse A stated that if Resident 24's order was for delayed release aspirin and the resident only had chewable aspirin on hand, she should have gotten an order clarification from the doctor. During an interview on 10/26/18 at 11:35 a.m., the Nurse Manager stated that Resident 4's family had brought in the bottle of Vitamin D3 2000 IU. She stated Resident 4 was on hospice and the hospice nurse should have gotten the order changed. Facility policy titled Medication Administration, dated 04/02, last reviewed 2/18, revealed under section titled, Purpose, To accurately administer medication to residents, and under section titled Policy, Medications shall be administered as ordered by a licensed nurse upon the order of a physician/licensed independent practitioner. Section titled Procedure, revealed, 1. Medication and biological orders shall be reviewed by a licensed nurse prior to administration.

Based on observations, interviews, and record review, the facility failed to honor resident's right to be free from physical restraint when the facility restrained 1 of 12 sampled residents (Resident 15) with a lap tray for convenience without medical necessity. This failure denied Resident 15's right to be treated with dignity and respect. This failure also had the potential to negatively impact Resident 15's physical and psychosocial well-being. Findings: Resident 15 was a [AGE] year-old woman with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) (an assessment tool), dated 6/4/18, Resident had a BIMS (Brief Interview for Mental Status) score of 1. The MDS dated [DATE], indicated Resident 15 had a BIMS score of 8 (a BIMS score of 0-7 indicates severely impaired cognition, scores between 8-12 indicate moderately impaired cognition, and scores between 13-15 indicate intact cognition). During an observation and concurrent interview on 10/24/18 at 1:40 p.m., Resident 15 was sitting in a wheelchair in her room. There was a black tray across her lap. When asked if she could remove the lap tray, Resident uttered something incoherently. She was neither able to remove the lap tray, nor answer the surveyor's question. During an observation on 10/26/18 at 11:50 a.m. with the Nurse Manager, Resident 15 was found to have a functioning pressure alarm on her bed. During an interview and concurrent chart review on 10/26/18 at 11:05 a.m., the Nurse Manager was asked what measures had been put in place prior to the application of the lap tray. She stated Resident 15 was on an every two-hour toileting program and the Falling Star program (where residents who are high fall risks are identified and discussed at monthly Interdisciplinary (IDT) meetings). When asked if the facility had ever provided one-to-one supervision for Resident 15, the Nurse Manager stated: I don't think so. When asked if the facility utilized a staff member whose sole responsibility was to monitor residents by making regular safety rounds, the Nurse Manager stated, No. Review of all physician orders, provided by the facility, from 3/1/17 (day of re-admission following hospitalization in (MONTH) (YEAR)) through 8/26/18 (last day of survey) indicated an order to install lap tray restraint on patient's wheelchair when left unattended in order to prevent self injury due to falls, dated 5/16/17 (start date) with a stop date of 8/14/17. There was no other order for a lap tray. An order dated 3/1/17 indicated Resident 15 does not have the capacity to make healthcare decisions. There was no mention of a medical symptom for which the restraint was warranted. Review of physician progress notes [REDACTED]. Physician note, dated 4/8/17, indicated: Patient has no safety awareness and is able to get up from her wheelchair which may result in falls going forward. It was decided to trial a wheelchair tray to restrain the patient from self injury. Physician note, dated 5/2/17, indicated: Currently utilizing a wheelchair tray when patient is unattended in a wheelchair with good results. Patient tolerating this device well .status [REDACTED]. (Review of physician orders [REDACTED]. Physician note, dated 9/30/18, indicated: Also currently utilizing a lap tray restraint while patient is sitting in wheelchair while unattended to reduce risk of self injury from falls as patient has no safety awareness. It is felt that this device is necessary going forward because of the patient's ongoing risk of self injury from falls while on (sic) attended in a wheelchair. Its use is generally restricted to this situation. Physician note, dated 8/14/18, indicated: [AGE] year old female with severe dementia and complete lack of safety awareness. Has had history of falls when left unattended in her room which resulted in multiple rib fractures (date of fall 2/24/17). This fall risk is ongoing. It is the recommendation of the IDT and myself that we continue lap tray restraint when the patient is unattended in her room in a chair. Discontinuation of lap trait (sic) this time would likely result in recurrent falls and severe injury. There was no mention of a medical symptom for which the restraint was warranted in any of the physician notes. Review of all IDT care conference notes, provided by the facility, from 5/23/17 to 8/23/18 indicated Resident 15 had one fall on 5/1/18. The notes indicated the lap tray restraint was being used as a safety measure. The notes did not mention a medical symptom for which the lap tray restraint was warranted. Review of all nursing progress notes, provided by the facility, from 3/1/17 to 8/23/18 indicated Resident 15 had one fall on 5/1/18. With the exception of a note on 7/9/18, when the lap tray fell off Resident 15's wheelchair, the nursing notes did not mention the use of a lap tray restraint, nor a medical symptom for which the lap tray restraint was warranted. The nursing note dated 7/9/18, indicated: resident sustained [REDACTED]. Review of the nine quarterly Fall Risk Assessments from 3/22/17 to 8/24/18, indicated Resident 15 had scores between 12 and 14, with the exception of the assessment dated [DATE], which had a score of 8. According to the Fall Risk Assessment tool, a score of 10 or above indicates high fall risk. Review of Resident 15's Fall care plan from 3/1/17 to 8/26/18 included interventions of enrollment in the Falling Star program, personal alarms on her bed and chair, encouragement to sit in areas well supervised by staff, toileting every two hours, wearing of hipsters (padding to cushion a fall), and the installation of a lap tray on her wheelchair when left unattended. There was no mention of one-to-one supervision or the utilization of a staff member whose sole responsibility is to monitor residents by making regular safety rounds. Review of Resident 15's Physical Restraint care plan from 4/7/17 to 8/26/18 (start date 4/7/17) indicated the restraint was used due to the resident being a fall risk and having a history of failed attempts to transfer self. The related diagnosis/condition was dementia with behavior disturbance. Under Attempts at lesser restriction, were pad alarm, safety reminders and toileting plan. Under Resident specific information, were WC (wheelchair) tray to be used when resident is seated in WC without supervision. Under Goals was: (Resident 15) is unable to self release device and will remain free of restraint related complications . Review of Resident 15's care plans found conflicting dates for when the lap tray was first applied. Under Falls, the start date was 5/16/17 (the date of the physician order), while under Physical Restraints, the start date was 4/7/17. Review of the Consent to the Use of Physical Restraints, dated 6/6/17, indicated Resident 15's responsible party signed the consent to allow the use of a lap tray as a physical restraint. The reason listed for the restraint was self endangerment, up without assistance/safety. The consent form did not mention any medical symptom for which the restraint was warranted. Review of the policy titled, Fall Prevention Program, review date 1/2018, did not find any mention of increased supervision for a resident who is a high fall risk. Review of the policy titled, Physical Restraints, review date 2/2018, indicated under Purpose: To ensure that each resident can attain or maintain the highest level of functioning in a safe environment that utilizes the least restrictive measures and restraint alternatives whenever possible. Under Policy: Facility will honor the resident's right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Physical restraints shall be used only as a last resort measure, when deemed necessary by the Interdisciplinary Team and in accordance with the resident's comprehensive assessment and care plan. The least restrictive alternative will be used for the least amount of time and only under the most controlled circumstances. Under Procedure: 1. Following admission, quarterly and/or as a resident's condition necessitates, the responsible nurse and the Interdisciplinary Team (IDT) will complete a comprehensive assessment that identifies the resident's strengths, preferences, goals of care, needs, and safety risks. Should the assessment identify the presence of a specific medical symptom that puts the resident at risk, attempts will be made to utilize alternatives to physical restraints to treat that medical symptom whenever possible to reduce that risk .Should these alternative measures prove inadequate to protect the resident from harm related to the medical symptom, the IDT may determine that the situation, at least temporarily, requires the use of restraints. The assessment summary will include a description of how restraints will be used to treat the medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. 2 .The responsible nurse will document the medical conditions that warrant the use of restraints, all alternatives tried prior to consideration of the restraint, ongoing assessments and care plans in the medical record. The risk and benefits will be evaluated by the physician in determination of the need for a restraint. 3. If the physician determines that a restraint is necessary, the responsible nurse will obtain physician order [REDACTED].The surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms.

Based on observation, interview and record review, the facility failed to ensure that Resident 4, who was at high risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 4's nursing care plan to prevent further falls to keep Resident 4 safe. Resident 4 had nine falls during a 19 week period from 3/22/15 to 8/1/15, with no effective interventions to prevent further falls from the bed and/or wheelchair. These failures caused Resident 4 to sustain: 1. A left hip fracture when Resident 4 attempted, on 3/22/15, to leave the nursing unit, unassisted, on the elevator, became startled by the wanderguard alarm (a transmitter worn by the resident and a monitoring device or receiver with an alert that sounds an alarm if a residents attempts to leave the facility) and fell . Resident 4 required left hip surgery. 2. A 2 cm (centimeter) hematoma (a solid swelling of clotted blood within the tissues) to the head after Resident 4 attempted, on 4/9/15, to go to the bathroom unassisted, and fell next to her bed, hitting her head. 3. An abrasion to the posterior (back side) right shoulder after Resident 4 attempted, on 4/30/15, to go to the bathroom, unassisted, and fell on bathroom floor. 4. On 5/7/15, a subarachnoid hemorrhage, (bleeding in the area between the brain and the thin tissues that cover the brain and is considered a medical emergency) a subdural hematoma, (a collection of blood between the covering of the brain (dura) and the surface of the brain), a deep laceration (a deep cut or tear in skin or flesh) to the left side of face/forehead that required compression and stitches to slow the arterial (major blood vessel) bleeding, blood in the left tympanic membrane, (the eardrum, between the outer and middle ear), left wrist fracture and abrasions and skin tears to the left upper extremity (upper arm) after Resident 4 attempted, on 5/7/15, getting up from her wheelchair, unassisted, and fell on the floor. 5. An abrasion to the left shoulder after Resident 4 stood up, on 6/13/15, from her wheelchair, unassisted, stepped backwards and fell on the floor. 6. Right arm skin tear after Resident 4 stood up, on 6/20/15, from her wheelchair, lowered herself to a sitting position on the floor with her left hand holding onto the wheelchair and right arm rubbed against a stationary chair next to her. 7. Another fall after Resident 4 got out of bed, on 7/11/15, unassisted, and fell at the foot of the bed. 8. A contusion (injured tissue or skin/a bruise) to the right arm, and a hematoma/abrasion to the left hand after Resident 4 attempted, on 7/23/15, to get up from her wheelchair, unassisted, slid to the floor and fell . 9. A right hip fracture when Resident 4 attempted, on 8/1/15, going to the bathroom, unassisted, and fell on the floor beside her bed. Resident 4 required right hip surgery. Findings: Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., muscle weakness, and insomnia. An Admission Minimum Data Set (MDS, a resident assessment tool) dated 3/17/15, indicated Resident 4 was cognitively intact on admission, and required one person limited assistance with transfers, walking in room and corridor, and toilet use. Balance during transfers indicated Resident 4 was not steady, but able to stabilize without staff assistance. Resident 4 used a walker as a mobility device. The MDS indicated Resident 4 had had a fall in the last month prior to this admission. The Care Plan, dated 3/20/15, indicated, under Falls, Resident 4's risk factors that required monitoring and interventions included unsteady gait, hx (history of) dizziness, and hypertensive (high blood pressure) medication. The nursing interventions included: ensuring adaptive devices (walker, cane, wheelchair) were within reach and in good repair, encourage and assist placement of proper non-skid footwear, and observe for unsteady/unsafe transfer or ambulation and provide stand-by or balance support as needed. The goal was to prevent or reduce the incidence of falls. First Fall: Licensed nurse's notes, dated 3/22/15, indicated at 6:45 p.m., Resident 4 attempted to leave the unit on the elevator. The wanderguard ringing made her jump, lost her balance and fell . She was unable to stand or walk. Resident 4 had bruises to left arm and a skin tear on left elbow. The fall resulted in a left hip fracture. The Fall Risk Assessment, dated 3/22/15, performed by licensed nursing staff, indicated Resident 4 had a score of 13 (a score of 10 or more indicates High Risk for Falls.) Resident 4's Care Plan for falls, started on 3/27/15, included a goal that Resident 4 would have a reduction in falls or no falls with a goal target date by 6/25/15. Several interventions to prevent falls were listed such as: Observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended; minimize fall risk through reducing agitation and impulsive behavior; keep call light within reach at all times. A subsequent Fall Risk Assessment, dated 4/1/15, indicated Resident 4 had a score of 11, was post-operative from a repair of a fractured hip, was very fragile (sic), unsteady, and on rehab therapies for strengthening and balance s/p (status [REDACTED]. Additional interventions to Resident 4's care plan, dated 4/1/15, indicated: Maintain record of falls and evaluate for patterns; Falling Star symbol on door. Second Fall: The Nursing Post Fall Assessment, dated 4/9/15, indicated on 4/9/15, at 2:30 p.m., Resident 4 wanted to go to the bathroom and slipped out of bed hitting her head. Resident 4 sustained a 2 cm hematoma on the back of her head. The Post Fall Assessment also indicated Resident 4 had an unsteady gait, underlying health problems that may cause falls, was not wearing non-slip shoes. Casual factors noted Resident 4 was impatient to wait for assistance. The physician note dated 4/9/15, indicated Resident 4's fall was apparently caused by a miscalculation of foot placement .landed on her buttocks but did strike the back of her head on the floor. The physicians post fall plan was to continue to monitor. Resident 4's nursing Care Plan included short term interventions, as indicated by neurological (relating to the nervous system) checks and 72 hour post (after) fall charting, however, the facility did not add any long term interventions to prevent further falls. Fall Committee summary notes from 4/15/15, indicated Resident 4 remained on High Fall Risk list, continue to monitor. During an interview on 10/15/15, at 11:45 a.m., when asked who monitors Resident 4, Management Staff D stated, The nurses and CNA's (certified nurse assistants). When asked how Resident 4 is monitored, Management Staff D stated, Watch closely for interventions that could be used, to prevent further falls. When asked to explain watch closely, Management Staff D stated, it meant Eyes on Resident 4, and Heightened observation mode and checking in with her. Third Fall: The Nursing Post Fall Assessment, dated 4/30/15, indicated on 4/30/15, at 8 a.m., Resident 4 was found on the bathroom floor, and said to the nurse, I just fell ! Resident 4 was incontinent of stool. The Post Fall Assessment further indicated that Resident 4 was not compliant with instructions to call for help when necessary and that the call bell was within reach, however, forgets to use it, or thinks she is capable to .ambulate on her own. The nurse's note dated 4/30/15, indicated Resident 4 had a slight abrasion on her right posterior shoulder. A pad alarm was placed on Resident 4's bed; her wheelchair already had a pad alarm on it. The physician's note, dated 4/30/15, indicated Resident 4 appears unable (sic) to safely ambulate or to follow safety precautions to avoid falls .frequently incontinent of stools and instead of reporting .and requesting assistance she attempts to care for this herself. She appears to need 24-hour supervision for safety . The licensed nursing Skilled Daily Summary dated 5/4/15, indicated Staff oversees (Resident 4) to ensure safe transfers and ambulation secondary to several falls. The summary notes also indicated Resident 4 was reminded to use the call light when needing to get out of bed for any reason. During an observation and concurrent interview on 10/15/15, at 10:56 a.m., when asked if Resident 4 is able to use the call light for assistance, CNA R stated, No, never. CNA R stated, We still give her the call light when she's in bed, but she never use (sic) it. CNA R stated Resident 4 still gets up on her own and doesn't like help (assistance.) During an interview on 10/15/15, at 11:10 a.m., when asked if Resident 4 is able to use the call light for assistance, Licensed Staff P stated, She can't be relied on for that. When asked if Resident 4 had 24-hour 1:1 supervision, Licensed Staff P answered, Uh, days and P.M.'s. The Physical Therapist's note, dated 5/6/15, indicated Resident 4's goal for bed mobility-transfers-ambulation was not met and due to recent decline in cognitive status pt (patient) has recently regressed in her condition. Recommendations included remaining in the facility with supervision for all ADL's (activities of daily living.) Fourth Fall: The nurse's note dated 5/8/15, indicated on 5/7/15, at about 6 p.m., Resident 4's wheelchair alarm sounded and staff ran to her room and found Resident 4 lying on the floor on her left side, between the two beds. Resident 4 was bleeding extensively from a wound on the left side of her forehead and less so from her left forearm. Resident 4 was conscious but stunned. After being assisted to bed, Resident 4's blood pressure was 186/104 (normal blood pressure is below 120/80, American Heart Association, 2015) and her lacerations were dressed while the facility's physician tended to her. Resident 4 became less responsive as time passed and the physician ordered 911 to be called for emergent transport to the hospital. The ambulance arrived 45 minutes after the fall at which point Resident 4 was by now mostly nonverbal but conscious. During an interview and concurrent record review on 8/11/15 at 10:30 a.m., when asked for the Post Fall Assessment for the fall of 5/7/15, both Management Staff C and D were unable to locate it. The acute care hospital physician's notes and computed tomography (CT) scan results, dated 5/7/15, indicated Resident 4 sustained a left frontal intraparenchymal (subdural/within the brain tissue) hematoma, bilateral (both sides) subarachnoid hemhorrages, complicated laceration to the left temporal region of the head with arterial bleeding, blood in the left eardrum, L1 compression fracture, left wrist fracture, and abrasions and skin tears to left arm. Resident 4 was non-verbal but arousable (able to open eyes with prompting.) Resident 4's discharge summary, dated 5/13/15, from the acute care hospital, indicated she had acute [DIAGNOSES REDACTED], likely due to intracranial hemhorrage, (acute: sudden onset; [DIAGNOSES REDACTED]: disorder of the brain, of which common neurological symptoms are loss of cognitive function, memory loss, subtle personality changes, inability to concentrate, seizures, lethargy.) Upon readmission to the facility on [DATE], Resident 4's Care Plan for falls indicated the following interventions, which started on 5/15/15: Bed alarm, remind resident to call for assistance; Falling Star Program; and Prompted Toileting Program. A subsequent addition to the interventions, dated 5/28/15, was close supervision or 1:1 supervision to provide safety reminders and assistance with all transfers. The Fall Committee meeting summary notes dated 5/20/15, discussed placing sitters (with Resident 4) as an intervention, and continue to monitor. Licensed nursing notes dated, 5/22/15, indicated Resident 4's memory was poor and does not use the call bell when she wants to go to the bathroom .(Resident 4) states, 'I don't remember to call for help' During an interview on 8/10/15, at 10:20 a.m., Management Staff B stated Resident 4's 1:1 supervision was started in May, and decreased when Resident 4 was sleeping through the night and/or when behavior's decreased. Management Staff B stated, There was no capture of the need for a sitter on paper. At 10:50 a.m., when asked what other interventions are used to prevent falls, Management Staff A stated, the facility used alarms on wheelchairs and beds; and had used floor pads next to a resident's bed in the past. During an interview and concurrent record review on 8/11/15, at 12:50 p.m., of the facility's assignment log, Management Staff C and D stated the 24-hour 1:1 supervision with a CNA (certified nurse assistant) started on 5/22/15. The assignment log dated between 5/22/15 to 6/12/15 indicated no 1:1 supervision was provided for Resident 4 on the day shifts for: 5/26/15, 5/28/15, 5/31/15, 6/1/15, 6/2/15, 6/3/15, 6/4/15, 6/5/15, 6/9/15, 6/10/15, 6/11/15, and 6/12/15. When asked why the 1:1 supervision stopped on certain days, Management Staff C stated, We started a trial of no 1:1 (on 5/28/15) to see how she would do, when there is more staff in the facility during day shift to check on her, and there wasn't always staff available to fill the 1:1 post. The Fall Risk Assessment, dated 5/28/15, indicated Resident 4's score was now 16. The nurse's notes, dated 6/9/15, indicated on 6/8/15 Resident 4 got up without assist, two more times, once caregivers were no longer stationed at the bedside. CNA's in to assist with resident at 2130 (9:30 p.m.) to ensure she did not try to get up alone. The facility's assignment log for 6/8/15 indicated the 1:1 supervision on the P.M. shift (3 p.m. to 11 p.m.) ended at 9 p.m. and 1:1 supervision was re-instated for the night shift (11 p.m. to 7 a.m.) Fifth Fall: Licensed nurse's notes, dated 6/13/15, indicated Resident 4 was observed getting out of her wheelchair, time unknown, stepped backwards and fell to the floor hitting her left shoulder which sustained an abrasion. Additionally it was noted that Resident 4 was non-compliant, frequently trying to get out of her wheelchair. During an interview on 8/6/15, at 9:30 a.m., Administrative Staff C stated Resident 4 was stand-by assistance with transfers, if she stands up, she'll fall, and was very weak, uses a wheelchair, and can't really follow directions. Resident 4 was described as impulsive. The Fall Committee meeting summary notes dated 6/13/15, indicated, 1:1 continued, functional maintenance program, strengthening, balance & ambulation. Continue to monitor. The facility's assignment log indicated no 1:1 supervision was provided on the day shift between 6/13/15 and 6/19/15. Sixth Fall: Licensed nurse's notes dated 6/20/15 indicated on 6/20/14, at 2:40 p.m., Resident 4 had an observed fall as she stood up from her wheelchair, lowered herself to the floor while holding onto the wheelchair with her left hand and her right arm rubbed against a stationary chair next to her, thus causing a right arm skin tear. After being assisted back into the wheelchair, Resident 4 stood up again and the wheelchair alarm sounded. The wheelchair alarm did not sound at the time of the fall. Resident 4's nursing Care Plan did not reveal the fall on 6/20/15. The interventions did not include 1:1 supervision of Resident 4. During an interview and concurrent review of the assignment log on 8/11/15, at 12:50 p.m., Management Staff C confirmed Resident 4 did not have 1:1 supervision on any shift on 6/20/15. The assignment log dated between 6/20/15 to 7/10/15 indicated Resident 4 did not have 1:1 supervision on any day shifts, no 1:1 supervision on 7/1/15 for night shift and 7/4/15 for P.M. shift. During a telephone interview, on 9/2/15, at 4:18 p.m., Management Staff B was asked if a post-fall assessment was performed after the fall on 6/20/15. Management Staff B stated she would have to check Resident 4's records. During a subsequent telephone message received on 9/3/15, at 10:40 a.m., Management Staff B stated she looked in the computer (electronic health record for Resident 4) for the post-fall assessment from 6/20/15 and Could not find it. Management Staff B consulted with Management Staff H, who was the charge nurse on the day shift of 6/20/15, and Management Staff H facilitated another search in the computer, however, could not find the post-fall assessment for Resident 4's fall on 6/20/15. Seventh Fall: Licensed nurse's notes dated 8/10/15, indicated on 7/11/15 Resident 4's alarm sounded at 075, time unclear, when Resident 1 got out of bed unassisted and fell on the floor at the foot of her bed. The facility's assignment log indicated Resident 4 did not have 1:1 supervision for any shifts(day, p.m., or night) on 7/11/15 and 7/19/15. The assignment log indicated, between 7/11/15 to 7/22/15, Resident 4 did not have 1:1 supervision on any day shifts or night shifts, and 1:1 supervision ended at 8:30 p.m. on 7/21/15, and 9 p.m. on 7/22/15. Resident 4's nursing Care Plan dated 7/11/15 did not mention how staff were going to keep Resident 4 safe and provide 1:1 supervision. During an interview and concurrent record review on 8/11/15 at 10:30 a.m., when asked for the Post Fall Assessment for the fall of 7/11/15, both Management Staff C and D were unable to locate it. The Fall Committee meeting summary notes dated 7/15/15, indicated Resident 4 had 1:1 supervision, and a self-locking device was ordered for her wheelchair, and continue to monitor. Eighth Fall: The nursing Post Fall Assessment, dated 7/23/15, indicated on 7/23/15, time not documented, Resident 4 attempted to get up from wheelchair and slid to the floor in her bedroom. The Post Fall Assessment further indicated Resident 4 was not compliant with instructions to call for help when necessary. Licensed nurse's notes, dated 7/23/15 indicated Resident 4 fell at 9:45 a.m. while attempting to get up from her wheelchair, and slid to the floor. The pad alarm on the wheelchair was documented as functioning. Resident complained of right arm pain and an x-ray was ordered. The Care Plan for Resident 4 indicated the fall on 7/23/15 was added with a note that Resident 4 complained of pain to arm. Interventions listed after the fall on 7/23/15 included: 72 hour post fall charting, notification of family and M.D. per protocol, and X-ray per M.D. order. There were no effective interventions of how they were going to keep Resident 4 safe and provide adequate supervision. During an interview on 8/11/15, at 10:30 a.m., when asked if Resident 4 had 1:1 supervision on 7/23/15, Management Staff C checked the assignment log with Management Staff D and the 1:1 CNA was scheduled only on the evening shift until 9 p.m. There was no 1:1 CNA to supervise Resident 4 on the day shift or night shift on 7/23/15. The assignment log dated between 7/23/15 to 7/31/15, indicated Resident 4 had no 1:1 supervision on any day shifts and nights shifts. The shift assignment log indicated the 1:1 supervision for Resident 4 ended early on 7/24/15 at 9:30 p.m., 7/27/15 and 7/28/15 at 9:30 p.m., 7/29/15 at 8:30 p.m., 7/30/15 at 9 p.m. and 7/31/15 at 8:30 p.m. Ninth Fall: The Nursing Post Fall Assessment, dated 8/3/15, indicated on 8/1/15, at 18:15 (6:16 p.m.), Resident 4 had a fall in her room, and stated to the nurse, I just wanted to get to the bathroom. The post fall assessment indicated Resident 4 had had falls within the past 30 days and 60 days. Additionally, the post fall assessment indicated Resident 1 had cognitive impairment, anxious or inappropriate behavior, and was not compliant with instructions to call for help when necessary. Casual factors noted were, dementia and impatience. The post fall assessment noted Resident 4 had become increasing (sic) impatient and confused regarding her ability to care for herself without assist (assistance.) During an interview on 8/6/15, at 2 p.m., Licensed Staff I stated Resident 4 usually had 1:1 supervision but not on the evening shift of 8/1/15. Licensed Staff I described Resident 4 as being Very impatient, wants things done right away .very poor safety awareness, and staff constantly remind Resident 4 to use call light and safety precautions. Licensed Staff I stated, We keep a very close watch on her, she's impulsive. Licensed Staff I stated CNA J had just left Resident 4's room after assisting her into bed, and Resident 4's bed alarm sounded, She fell on her hip. When asked if Resident 4's care plan was updated after the fall on 8/1/15, Licensed Staff I stated usually that would be done but didn't personally do it, I passed all the information onto (Management Staff B and C.) During an interview on 8/6/15, at 3:05 p.m., CNA J stated Resident 4 had had 1:1 supervision on past days, but not on 8/1/15. During an interview on 8/6/15, at 3:30 p.m., when asked why 1:1 supervision was not provided on 8/1/15, Management Staff C stated Resident 4 was resting more in the evenings and 1:1 aides (CNA's) could go home around 8 p.m. and see how it goes. When asked when 24 hour 1:1 supervision was considered, Management Staff C stated it had been discussed during the staff's morning stand-up meeting a week prior to the fall on 8/1/15. The Fall Risk Assessment, dated 8/7/15, indicated Resident 4 had a score of 12, and had impaired mobility and ADL deficit. Resident 4's Initial Care Plan, dated 8/7/15, after being readmitted to the facility after surgical repair of her right fractured hip, indicated potential for falls and wandering with goals of Resident 4 to have no falls with serious injury and remain safe in the facility. An intervention documented was: Call bell orientation to use/location, and Verbal reminders to call for assist to transfer; 1:1 supervision for safety. The Care Plan revealed the following interventions: Approach #10 - Frequent observations/supervision to remind resident of need for assist with all transfers. Approach #12 - Repeat instructions/reminders for safety with patience and consistency, being mindful that resident has poor short term memory and is unable too retain safety. Approach #14 - Sitter to monitor and prevent falls. Approach #15 - Floor pad cushions on both sides of bed. During an interview on 10/15/15, at 12 noon, when asked if Resident 4 had 24-hour 1:1 supervision, Management Staff C answered, On days and P.M.'s. When asked if there is a 1:1 CNA assigned on night shift, Management Staff C said, No. During an interview on 10/15/15, at 12:05 p.m., Management Staff B was asked to describe how the facility continued to monitor Resident 4. Management Staff B stated, Rounds at least every hour or 2 hours; the physician tried to adjust Resident 4's medication for her impulsivity; we continue to have 1:1 and if meds (medication regimen) work we'll try to back down with the 1:1 .providing sitters is not .for the long term, the family needs to intervene. Upon further inquiry, Management Staff B stated Resident 4's son might not be able to afford a private sitter. The Policy and Procedure titled, Fall Prevention Program, revised 11/12 and reviewed 4/15, the purpose indicated, To prevent accident and injuries by providing an environment .over which the facility has control. The policy indicated, .all residents shall receive adequate supervision .to prevent accidents.