Every finding on record at The Terraces at los Altos Health Facility

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when:There were whitish substances below the steamer and on a metal cart in front of the steamer; 2. There were whitish-grayish substances on a black cart in the dry storage area that was used to store utensils and food containers; 3. There were whitish substances on the edges of the food warmer cart in the dry storage area; 4. There were two open packs of brown grapes and one pack of raw broccoli that were unlabeled and undated in the walk-in refrigerator; 5. There were whitish substances on the outside surface of the ice machine; and, 6. Nine cutting boards were discolored, worn out, and had deep cuts and scratches.These failures had the potential to result in foodborne illness in a population of vulnerable residents with complex medical conditions.Findings:During a concurrent observation and interview with the Dining Director (DD) on 7/28/25, at 9:32 a.m., the following were observed: 1. There were whitish substances below the steamer and on a metal cart in front of the steamer; 2. There were whitish-grayish substances on a black cart in the dry storage area that was used to store utensils and food containers; 3. There were whitish substances on the edges of the food warmer cart in the dry storage area; 4. There were two open packs of brown grapes and one pack of raw broccoli that were unlabeled and undated in the walk-in refrigerator; 5. There were whitish substances on the outside surface of the ice machine; and, 6. There were nine cutting boards that were discolored, worn out, and had deep cuts and scratches. The DD acknowledged these observations and stated the above items that had substances on them should have been cleaned.During a concurrent observation and interview with the Executive Chef (EC) 7/28/2025, at 9:35 a.m., the EC acknowledged the above observations and stated that kitchen staff would clean the items that had substances on them. The EC also stated the nine cutting boards would be replaced. The EC confirmed the two open packs of brown grapes and one pack of raw broccoli should have been labeled with the date they were delivered to the facility.The Food and Drug Administration's 2022 Food Code indicated equipment, food contact surfaces, and utensils shall be clean to sight and touch . non-food-contact surfaces of equipment shall be kept free of accumulations of dust, dirt, food residue, and other debris . Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.The facility's policy titled Production, Purchasing, Storage, revised 1/2025, indicated, Date foods prior to placing in storage areas. Produce is labeled with the date received.

Based on interview and record review, the facility failed to complete and transmit the discharge Minimum Data Set (MDS, an assessment tool) for four of seven residents (Residents 46, 76, 105, and 2) . Failure to complete and transmit MDS assessments had the potential to compromise the accuracy of the facility's quality measures (reports that reflect the facility's performance in certain care areas). This could negatively affect the facility's ability to identify areas for improvement and implement interventions accordingly.Findings: 1. Review of Resident 46's medical record indicated he was admitted on [DATE] and discharged on 4/26/25. Resident 46's discharge MDS, dated [DATE], was incomplete and not transmitted. Review of Resident 76's medical record indicated she was admitted on [DATE] and discharged on 4/25/25. Resident 76's discharge MDS, dated [DATE], was incomplete. Review of Resident 105's medical record indicated she was admitted on [DATE] and discharged on 5/13/25. Resident 105's discharge MDS, dated [DATE], was incomplete. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 7/30/25, at 10:46 a.m., the MDSC explained the discharge MDS must be completed no later than 14 days after the resident's discharge date . The MDSC further explained the discharge MDS must be transmitted no later than 14 days after completion. The MDSC reviewed the medical records for Residents 46, 76, and 105 and confirmed the discharge MDS had not been completed and transmitted for these residents. 2. Review of Resident 2's medical record indicated he was admitted on [DATE] and discharged on 6/16/25. Resident 2's discharge MDS, dated [DATE], was incomplete. During an interview and concurrent record review with the MDSC on 8/1/25, at 8:23 a.m., the MDSC confirmed Resident 2 was discharged on 6/16/25 and his discharge MDS was incomplete. The MDSC stated the discharge MDS should have been completed 14 days after Resident 2's discharge. The MDSC confirmed Resident 2's discharge MDS was 32 days overdue. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS instruction manual), dated 10/2024, indicated the discharge MDS must be completed no later than 14 calendar days after a resident's discharge date , and the discharge MDS must be transmitted no later than 14 calendar days after the completion date.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. A nebulizer machine (device used to deliver medication in the form of a mist for inhalation) mask, chamber (part of the mask that holds the liquid medication), and tubing were stored inside the bedside drawer of resident 127 and the mask was touching the drawer surface;2. An inhaler chamber attachment (device that attaches to an inhaler to make it easier to breath the medication in) had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table;3. Garbage and recycle bins were open and exposed while three Residents were eating lunch; 4. A licensed nurse did not wear gloves when holding and cutting a medication; andThese failures could result in the spread of infection and cross-contamination that could affect the 28 residents who reside in the facility.1.During an initial tour of the facility on 7/28/25 at 10:56 a.m., Resident 127's nebulizer machine mask, chamber, and tubing were stored inside the resident's bedside drawer. The nebulizer mask was touching the drawer surface. During a concurrent observation and interview on 7/28/25 at 11:01 a.m., with Licensed Vocational Nurse A (LVN A), LVN A confirmed the above observation and stated Resident 127s nebulizer machine mask, chamber, and tubing should have been stored in a plastic bag to prevent contamination. During an observation on 7/29/25 at 2:48 p.m., Resident 127s nebulizer machine mask, chamber, and tubing were stored inside the bedside drawer. The nebulizer mask was touching the drawer surface. During a concurrent observation and interview on 7/29/25 at 2:50 p.m., with the infection Preventionist (IP), the IP acknowledged the above observation and stated the items should have been cleaned after use and stored in a plastic bag to prevent contamination. The facility's policy and procedure (P&P) titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated to rinse and disinfect the nebulizer equipment according to facility protocol and allow to air dry on a paper towel. The P&P further indicated when the equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 2. During an initial tour of the facility on 7/28/25 at 10:56 a.m., Resident 127's inhaler chamber attachment had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table. During an observation on 7/29/25 at 2:48 p.m., Resident 127's inhaler chamber attachment had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table. During a concurrent observation and interview on 7/29/25 at 2:50 p.m., with the IP, the IP acknowledged the above observation and stated Resident 127's inhaler chamber attachment should have been cleaned and stored inside a plastic bag to prevent contamination. 3. During a dining observation in the west dining area on 7/28/25 at 12:30 p.m., three residents were eating lunch. There was a medication cart in the dining area with a trash bin attached to it. There was garbage in the medication cart trash bin and the lid was open. During a concurrent observation and interview with the IP on 7/28/25 at 12:34 p.m., the IP confirmed the above observation and stated the trash bin lid should be closed for infection prevention. During dining observations on 7/28/25 at 12:22 p.m. and 12:38 p.m., trash and recycle bins were open and the contents of the bins were not covered in the west dining area. Three residents were eating lunch in the area during these observations. During a concurrent observation and interview on 7/28/25 12:39 p.m., with Certified Nursing Assistant E (CNA E), CNA E confirmed the above observations and stated the trash and recycle bin lids should have been closed at all times to prevent the spread of infection. The facility's (P&P) titled Sanitation and infection Prevention Control-Solid Waste Disposal, revised 1/2025, indicated, Garbage containers are clean, lined and covered at all times. 4. During a medication administration observation on 7/28/25 at 11:42 a.m., with Licensed Vocational Nurse A (LVN A), LVN A did not sanitize hands after holding a key and opening the medication cart. LVN A then prepared medication for Resident 123. Without wearing gloves, LVN A took two tablets of acetaminophen (medication used to reduce pain and fever) 500 milligrams (mg, unit of dose measurement) from the bottle, placed the tablets in her right hand, put the two tablets into a medicine cup, picked one tablet up and placed it into a pill cutter, cut the tablet, and placed half the tablet back into the medicine cup. During an interview shortly after the above observation, on 7/28/25 at 11:51 a.m., LVN A confirmed she did not use gloves when she was holding the two tablets of acetaminophen. She stated she did not wear gloves because she was outside the resident's room. During an interview with the IP on 7/31/25 at 1:30 p.m., the IP was asked if the nurse needed to wear gloves when touching the medication. The IP stated if they need to cut medication, the nurses have to perform hand hygiene and put gloves on when touching the medication. The IP further stated the nurses cannot touch the medication without gloves. During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administration of medications.

Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 82, 111, and 118) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings, or behavior) when:For Resident 82, his order for quetiapine fumarate (medication used to treat psychotic disorders) did not specify what dose do administer;For Resident 111, there was no documentation that staff were monitoring for side effects of venlafaxine (medication used to treat depression); andFor Resident 118, there was no documentation that staff were monitoring for side effects and target behaviors (behaviors intended to be changed or eliminated by the medication) for trazodone (medication used to treat depression).These failures had the potential to compromise the facility's ability to determine whether, or not, the psychotropic medications were safe and effective for the residents.Findings: 1. Review of Resident 82's medical record indicated he was admitted on [DATE] and had diagnoses including delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). Review of Resident 82's Order Summary Report indicated he had a physician's order, dated 7/29/25, for, QUEtiapine Fumarate Tablet Give 0.5 [half] tablet by mouth at bedtime for delusional psychosis AEB [as evidenced by] hallucinations [seeing, hearing, or feeling things that are not actually there]). The order did not specify how many milligrams (mg, unit of dose measurement) of quetiapine fumarate to administer to Resident 82. During an interview and concurrent record review with the Director of Staff Development (DSD) on 8/1/25, at 9:22 a.m., the DSD reviewed Resident 82's medical record and confirmed the order for quetiapine fumarate indicated to administer half a tablet, but did not specify how many milligrams the tablet was supposed to be. The DSD acknowledged that based on the existing order, the nurses would not know what dose of quetiapine fumarate to administer to Resident 82. During a follow-up interview with the DSD on 8/1/25, at 10:23 a.m., the DSD stated Resident 82's quetiapine fumarate order should have indicated to give half of a 25 mg tablet. The DSD acknowledged the nurses should have contacted Resident 82's doctor to obtain clarification for the quetiapine fumarate order. The facility's policy and procedure (P&P) titled Medication Orders, revised 11/2014, indicated, When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. 2. Review of Resident 111's medical record indicated he was admitted on [DATE] and had diagnoses including depression. Review of Resident 111's Order Summary Report indicated he had a physician's order, dated 7/22/25, for venlafaxine 150 mg one capsule by mouth one time a day for depression AEB voicing sadness. Review of Resident 111's medical record indicated there was no documentation that staff were monitoring for side effects from venlafaxine. During an interview and concurrent record review with Registered Nurse C (RN C) on 7/30/25, at 1:20 p.m., RN C confirmed that for residents taking psychotropic medications, the nurses should monitor for side effects every shift. RN C stated this monitoring should be documented on the medication administration record (MAR) or treatment administration record (TAR). RN C reviewed Resident 111's medical record and confirmed there was no documentation that the nurses were monitoring for side effects of venlafaxine. The facility's P&P titled Psychotropic Medication Use, revised 7/2022, indicated psychotropic medication management includes adequate monitoring for adverse consequences. 3. Review of Resident 118's clinical record indicated Resident 118 was admitted to the facility with diagnoses including essential primary hypertension (high blood pressure with no identifiable underlying medical cause). Review of Resident 118's physician's orders indicated an order, dated 7/23/25, for Trazodone 25 mg give 25 mg by mouth at bedtime for depression AEB inability to sleep. Further review of Resident 118's clinical record indicated there was no monitoring for the target behavior of inability to sleep and there was no side effects monitoring for trazodone. During a concurrent interview and record review on 7/31/25 at 2:32 p.m., with the Director of Nursing (DON), the DON Reviewed Resident 118's clinical record and confirmed there was no side effects monitoring for trazodone. The DON also confirmed there was no monitoring for the target behavior of inability to sleep. The DON stated residents taking psychotropic medications should have monitoring for side effects and target behaviors. The facility's P&P titled Psychotropic Medication Use, revised 7/2022, indicated, 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes. d. adequate monitoring for efficacy and adverse consequences. The P&P further indicated, 13. Residents receiving psychotropic medication are monitored for adverse consequences.

Based on interview and record review, the facility failed to ensure the long-term care Ombudsman (resident advocate) was notified of transfers or discharges for two of four residents (Residents 82 and 2). For Resident 2, the facility also failed to ensure a discharge summary was completed. Failure to notify the Ombudsman had the potential to compromise the residents' admission, transfer, and discharge rights. Failure to complete a discharge summary had the potential to compromise the facility's ability to ensure the resident received appropriate care and services after leaving the facility.Findings: 1. Review of Resident 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer and kidney failure. Review of Resident 82's progress notes, dated 4/15/25, indicated he had a change of condition and was transferred to the hospital. There was no documentation in the medical record that indicated the facility notified the Ombudsman of this hospital transfer. During an interview with the Social Service Designee (SSD) on 7/31/25, at 10:09 a.m., the SSD stated when a resident is transferred to the hospital, the facility is supposed to fill out a transfer form. The SSD further stated this transfer form should be faxed to the Ombudsman as soon as it is filled out. The SSD indicated she would look for documentation indicating the facility faxed a transfer form to the Ombudsman when Resident 82 was transferred to the hospital on 4/15/25. During a follow-up interview with the SSD on 7/31/25, at 11:00 a.m., the SSD confirmed she was not able to find documentation that the facility faxed a transfer form to the Ombudsman for Resident 82's hospital transfer on 4/15/25. 2. Review of Resident 2's medical record indicated he was admitted on [DATE] and had diagnoses including difficulty in walking, muscle weakness, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly), asthma (inflammatory disease of the airway that often causes wheezing, coughing, shortness of breath) and Dysphagia (difficulty in swallowing). Resident 2's medical record indicated he was discharged home on 6/16/25. There was no documentation in the medical record that the facility notified the Ombudsman of this discharge. During a concurrent interview and record review with the SSD on 8/1/25, at 2:16 p.m., the SSD confirmed there was no documentation in the medical record that indicated the facility notified the Ombudsman of Resident 2's discharge on [DATE]. The SSD could not provide fax confirmation that the facility notified the Ombudsman. The SSD stated if there was no documentation or fax confirmation about the notification to the Ombudsman, it was not done. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 8/1/25, at 9:14 a.m., the MDSC reviewed Resident 2's medical record and stated there was a physician's order for Resident 2 to be discharged on 6/16/25. The MDSC confirmed Resident 2's Discharge Instructions and Summary, initiated 6/13/25, was incomplete. The MDSC confirmed information was missing to include a recapitulation of the resident's stay, discharge note, nursing discharge assessment, name and signature of the nurse that provided discharge instructions. The facility's policy and procedure (P&P) titled Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated for residents who go on emergent leave, notice of transfer is provided to the long-term care Ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements). The P&P indicated, for residents with planned discharges, a notice is sent to the Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility's P&P titled Discharge Summary and Plan, revised 10/2022, indicated when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. The discharge summary shall include a description of the resident's current diagnosis, medical history, course of illness, physical and mental functional status, nutritional status, and mental and psychosocial status.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for one of thirteen sampled Residents (Resident 127). This failure resulted in a delayed plan of care for Resident 127.Findings:Review of Resident 127's medical record indicated he was admitted on [DATE] and had diagnoses including Congestive heart failure (inability of heart to pump enough blood), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), atrial fibrillation (irregular heartbeat where the heart to beats too quickly) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs, making it difficult to breathe).Review of Resident 127's physician's order, dated 7/25/25, indicated Nitroglycerine tablet sublingual (a fast-acting medication used to relieve and prevent chest pain) 0.4 milligram (mg, a unit of measurement) give one tablet sublingually (under the tongue) every five minutes as needed for chest pain. If symptoms are not significantly improved by one dose of nitroglycerine, repeat nitroglycerine every five minutes for a maximum of three doses and call MD if symptoms are not resolved completely. During a concurrent observation and interview on 7/28/25 at 10:56 a.m., with Resident 127, he stated the staff kept a bottle of nitroglycerine tablets at his bedside table since his admission to the facility on 7/24/25.Review of Resident 127's Minimum Data Set (MDS, an assessment tool), dated 7/29/25, indicated he had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact).Review of Resident 127's medical record indicated there were no baseline care plans for medication self-administration and nitroglycerine sublingual tablets completed within 48 hours of the resident's admission to the facility on 7/24/25.During a concurrent interview and record review on 7/31/25 at 11:43 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC confirmed the above findings and stated baseline care plans should be initiated and completed within 48 hours of admission.The facility's policy and procedure (P&P) titled Care Plans, Baseline, revised 3/2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The P&P further indicate, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. initial goals based on admission orders and discussion with the resident/representative .

Based on interview and record review, the facility failed to develop and implement care plans for one of 13 sampled residents (Resident 35) when a care plan for Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was not developed. This failure had the potential to not meet the residents' medical, nursing, mental and psychosocial needs.Review of Resident 35's medical record indicated she was admitted to the facility on [DATE] and had diagnoses including difficulty in walking, cellulitis (a skin infection) of left and right lower limbs (lower legs), hypertension (high blood pressure), and chronic venous hypertension (CVH, a condition where the veins in the legs experience elevated, persistent pressure due to impaired blood flow back to the heart) with inflammation of bilateral lower extremities (legs).Review of Resident 35's physician's order, dated 7/21/25, indicated Nystop External Powder 100,000 unit/gm (gm, a unit of weight in the metric system) apply to under-breast topically two times a day for fungal rash under breast.Review of Resident 35's care plans indicated there was no care plan developed to address her rashes under her breast and the use Nystop External Powder as ordered by the physician.During a concurrent interview and record review on 7/31/25 at 10:57 a.m., with the Director of Nursing (DON), the DON reviewed Resident 35's medical record and stated that she could not find a care plan for the rashes under Resident 35's breast. The DON acknowledged that a care plan should have been developed to address Resident 35's under-breast rash and the use of Nystop External Powder. The DON stated the care plan should be individualized and person-centered for each resident.The facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure three of 19 residents (Residents 119, 120, and 114) were free from unnecessary medications when:Resident 119 had no side effects monitoring for heparin (an anticoagulant [blood thinner] used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels); 2. Resident 120 had three identical orders for oxycodone (a potent controlled medication for pain); and 3. Resident 114 had no side effects monitoring for Eliquis (an anticoagulant medication used to treat and prevent blood clots).These failures resulted in unmonitored side effects of anticoagulant medications and duplicate orders that had the potential for excessive dose/adverse effects for the residents. Findings:1. Review of Resident 119's clinical record indicated Resident 119 was admitted to the facility with diagnoses including coronary artery dissection (tear in the inner layer of a coronary artery [blood vessel that supplies oxygen and nutrients to the heart muscle]). Resident 119's physician's orders indicated an order, dated 7/26/25, for Heparin Sodium Injection solution 5000 unit/ml (Milliliter, is a unit of volume) inject 0.5 ml subcutaneously (into the tissue layer between the skin and the muscle) three times a day for DVT (Deep Vein Thrombosis, a condition where a blood clot forms in a deep vein). There was no documentation of monitoring for side effects of heparin.During a concurrent interview and record review on 7/31/25 at 2:26 p.m., with the Director of Nursing (DON), the DON reviewed Resident 119's physician's orders and confirmed Resident 119 was on Heparin three times daily. The DON confirmed there was no monitoring for side effects of heparin. The DON stated residents taking anticoagulants should have monitoring for signs and symptoms for bleeding. 2. Review of Resident 120's clinical record indicated Resident 120 was admitted to the facility with diagnoses including chronic pain (pain that persists for three months or longer). Review of Resident 120's physician's orders indicated she had three active identical orders of oxycodone 5 mg with three different order dates, as follows:- Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for severe pain, dated 6/29/25.- Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for severe pain, dated 7/4/25.- Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for pain, dated 7/15/25.Review of Resident 120's July 2025 Medication Administration Record (MAR) indicated there were three entries for oxycodone 5mg orders.During a concurrent interview and record review on 7/31/25 at 2:35 p.m., with DON, the DON reviewed Resident 120's July 2025 MAR and confirmed there were three of the same orders for oxycodone 5 mg. The DON stated when the nurses received new orders for oxycodone, they should discontinue the old orders. 3. Review of Resident 114's clinical record indicated Resident 114 was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (A-fib, a type of irregular heartbeat that starts and stops on its own). Physician's orders indicated an order, dated 7/26/25, for Eliquis oral tablet 5 mg give 1 tablet by mouth two times a day for A-fib. There was no documentation of monitoring for side effects of Eliquis.During a concurrent interview and record review on 8/1/25 at 10:48 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 114's clinical record and confirmed Resident 114 was on Eliquis 5 mg. The DSD confirmed she did not see anticoagulant side effects monitoring in Resident 114's clinical record. During an interview on 8/1/25 at 1:31 p.m., with the DON, the DON stated residents on anticoagulants should have monitoring for side effects of bleeding.The facility's policy and procedure (P&P) titled Medication Therapy, revised 4/2007, indicated, 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition . 3. All medication orders will be supported by appropriate care processes . 2. All decisions related to medications shall include appropriate elements of the care process . 3. Upon or shortly after admission and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether. b. dosage is appropriate; c. the frequency of administration and duration of use are appropriate; and d. potential or suspected side effects are present. 8. The medical director and consultant pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff.

Based on observation, interview, and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during the medication administration for two out of 12 residents (Residents 111 and 67) when:1. For Resident 111, Registered Nurse B (RN B) did not follow a physician's order to hold midodrine (medication used to raise blood pressure) for systolic blood pressure (SBP, the top number in a blood pressure reading) greater than 120; and2. For Resident 67, Registered Nurse C (RN C) administered eyedrops and did not wait three to four minutes before instilling a second drop in each eye. These failures had the potential to result in the residents experiencing complications and not receiving the full therapeutic effects of medications. Findings:1. During the medication administration observation on 7/28/2025 at 12:17 p.m., RN B was observed preparing one medication tablet for Resident 111. The medication was midodrine 2.5 milligrams (mg, unit of dose measurement). RN B administered the medication to Resident 111. RN B did not appear to have checked the resident's blood pressure (BP) before administering the midodrine.During an interview and record review with RN B on 7/28/25 at 12:19 p.m., RN B was asked if he checked Resident 111's BP. RN B stated he did check the BP earlier at around 9:30 a.m., and the reading was 142/72. RN B reviewed Resident 111's midodrine instructions, which indicated to hold for SBP greater than 120. During an observation on 7/28/25 at 12:26 p.m., RN B went back to Resident 111 to recheck the BP, and the reading was 147/101. RN B stated he should have held the midodrine.Review of Resident 111's physician order, dated 7/23/25, indicated Midodrine 2.5 mg give 1 tablet by mouth three times a day for hypotension (low blood pressure) hold for SBP > (greater than) 120.During an interview on 7/28/25 at 5:23 p.m., with the Director for Nursing (DON), the DON stated for medications with BP parameters, the BP should be checked prior to giving the medication and the doctor's order should be followed. The DON further stated to hold the medication if the BP is above the parameters.During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P further indicated, Medications are administered in accordance with prescriber orders. 2. During the medication administration observation on 7/30/25 at 12:49 p.m., RN C was observed preparing and administering two eye drops to each of Resident 67's eyes. RN C instructed Resident 67 to look up, then pulled the resident's left lower eyelid, instilled two eye drops into the lower conjunctiva (transparent mucous membrane that lines the inner surface of the eyelids and covers the white part of the eyeball), wiped the left eye with Kleenex, and repeated the process on right eye. RN C was not observed waiting 3 to 4 minutes in between drops in each eye, and he did not apply pressure over the point where the lid meets the nose.During a follow-up interview with RN C on 7/30/2025 at 1:13 p.m., RN C stated he give two quick drops to Resident 67's eyes. RN C confirmed he did not wait a few minutes to administer the second drop to the same eye. He stated he should wait about 30 seconds to administer the second drop.Review of Resident 67's physician orders indicated an order, dated 12/20/24, for Refresh Tears (artificial tears used provide relief for dry, burning, irritated eyes) Ophthalmic Solution 0.5% instill 2 drops in both eyes three times a day for dry eyes.During an interview with the DON on 7/31/25 at 2:24 p.m., the DON was asked if the nurse needed to wait a few minutes before administering the second eye drop. The DON stated maybe about 2 seconds. She stated she would follow up.During an interview on 8/1/25 at 10:46 a.m., with the Director of Staff Development (DSD), the DSD was asked if the nurse needed to wait a few minutes when administering two drops of same eye drop. The DSD stated if it was the same eye drop, and there were no directions on the medication box, it was up to the nurse's discretion.During a phone interview on 8/1/25 at 11:29 a.m., with the Consultant Pharmacist (CP), the CP stated she would look for the policy. Shortly after, the CP stated if administering another drop of same eye drop, or a different medication, the nurse should wait 3 to 5 minutes. According to American Academy of Allergy Asthma & Immunology's (professional medical organization dedicated to advancing the knowledge and practice of allergy, asthma, and immunology for optimal patient care, https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/eye-drops) Tips For Administering Eye Drops, If more than one drop has been ordered, wait 3 to 4 minutes before putting another drop into the same eye. 8. After inserting the drops, close the eyelids and apply pressure for 1 to 2 minutes over the point where the lid meets the nose.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly in one medication cart and for two of 13 sampled residents (Resident 35 and 127) when:1. Two expired bottles of over the counter medication (OTC) medications were not removed from the medication cart;2. A bottle of Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was kept on Resident 35's bedside table unattended; and,3. A bottle of Nitroglycerine sublingual tablets (a fast-acting medication used to relieve and prevent chest pain) was kept on resident 127's bedside table unattended.These failures had the potential for unsafe and improper administration of medications. Findings: 1. During an inspection of Medication Cart X on [DATE] at 3:55 p.m., with Registered Nurse D (RN D), there was one opened bottle of Naproxen (medication used to relieve pain, inflammation, and fever) 220 milligrams (mg, unit of dose measurement) that had an expiration date of 6/2025. There was also one opened bottle of Zyrtec (medication used to relieve common allergy symptoms) 10 mg that had an expiration date of 2/2022. RN D confirmed the above medications were expired and stated they should not have been in the medication cart. During an interview on [DATE] at 2:44 p.m., with the Director of Nursing (DON), the DON stated any expired medication should be disposed. The DON further stated if something is expired, it needs to be removed from the medication cart. During a review of the facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 2. During an initial tour of the facility on [DATE] at 10:40 a.m., a bottle of Nystop External Powder 100,000 unit/gm (gm, a unit of weight in the metric system) was kept on Resident 35's bedside table unattended. During a concurrent observation and interview on [DATE] at 10:43 a.m., with Resident 35, she stated that the facility staff was using the powder to treat her under-breast rashes, and facility staff were keeping the powder bottle on her bedside table. During a concurrent observation and interview on [DATE] at 10:47 a.m., with Licensed Vocational Nurse A (LVN A), LVN A confirmed the above observation and stated the Nystop External Powder was used for Resident 35's under-breast rashes as ordered by the physician. LVN A stated that the bottle of Nystop powder should not have been kept at Resident 35's bedside table. She stated it should have been stored inside the treatment cart. LVN A further stated that self-administration assessment was not done by the facility staff for Resident 35. Review of Resident 35's face sheet indicated she had diagnoses of difficulty in walking, hypertension (high blood pressure) and cellulitis of left lower limb. Review of Resident 35's MDS dated [DATE], indicated she had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact). Review of Resident 35's physician's order, dated [DATE], indicated Nystop External Powder 100,000 unit/gm (Nystatin Topical) apply to under-breast topically two times a day for fungal rash under breast. 3. During an initial tour of the facility on [DATE] at 10:05 a.m., a bottle of Nitroglycerine tablet sublingual 0.4 mg. was kept on resident 127's bedside table unattended. During a concurrent observation and interview on [DATE] at 10:43 a.m., with LVN A , she stated that Resident 127 had an order to keep the Nitroglycerine at bedside. LVN A stated there was no self-administration assessment done by the facility staff. During a record review on [DATE] at 12:00 p.m., Resident 127 had no self-administration assessment done by facility staff or interdisciplinary team (IDT, staff from different departments who coordinates the residents care) assessment. During a concurrent observation and interview on [DATE] at 10:56 a.m., with Resident 127, he stated the bottle of nitroglycerine tablets was kept by the staff at his bedside table since he was admitted to the facility on [DATE]. Resident 127 stated the facility staff was not checking on the medication. Review of Resident 127's face sheet indicated he had diagnoses of Chronic systolic (Congestive) heart failure (inability of heart to pump enough blood), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), permanent atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). Review of Resident 127's MDS dated [DATE], indicated he had a BIMS score of 15. The facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2/2023, indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The facility's P&P titled Self -Administration of Medication, revised 2/2021, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the assessment, IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self- administered medications are stored in a safe places, which are not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored in a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for two of 13 sampled residents (Residents 82 and 119) when:For Resident 82, there was a typographical error in his order to monitor urine output; and,For Resident 119, the medical record did not accurately reflect the resident's refusal of a lab test.These failures had the potential to compromise the care and safety of the residents.1. Review of Resident's 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer, hydronephrosis (swelling of the kidneys caused by a backup of urine), and kidney failure. Further review of the medical record indicated Resident 82 had nephrostomy tubes (small flexible tubes inserted through the skin and into the kidneys to drain urine) in both kidneys. Review of Resident 82's Order Summary Report indicated he had a physician's order, dated 5/31/25, to measure output (amount of urine drained) from the left nephrostomy tube every shift. The order further indicated to record the amount of fluid every 24 hours, and if it was greater than 500 milliliters (ml, unit of measurement), notify the doctor. Further review of Resident 82's Order Summary Report indicated he had the same order for the right nephrostomy tube. During an interview and concurrent record review with the Director of Staff Development (DSD) on 8/1/25, at 9:22 a.m., the DSD reviewed Resident 82's medical record and confirmed there were orders to notify the doctor if the output from the nephrostomy tubes was greater than 500 ml in 24 hours. The DSD reviewed Resident 82's nephrostomy output documentation for the month of 7/2025 and confirmed the output was greater 500 ml on most days. However, the DSD confirmed she was only able to find documentation of doctor notification for two of those days. During a follow-up interview with the DSD on 8/1/25, at 10:23 a.m., the DSD explained Resident 82's physician's orders were supposed to indicate to record the amount of fluid from the nephrostomy tubes every 24 hours and notify the doctor if the output was less than (not greater than) 500 ml. The DSD acknowledged the nurses should have contacted the doctor to clarify the order. The facility's policy and procedure (P&P) titled Charting and Documentation, revised 7/2017, indicated documentation in the medical record will be complete and accurate. The facility's P&P titled Medication and Treatment Orders, revised 7/2016, indicated treatment orders will be consistent with principles of safe and effective order writing. 2. Review of Resident 119's clinical record indicated Resident 119 was admitted to the facility with diagnoses including coronary artery dissection (tear in the inner layer of a coronary artery [major blood vessel that leads to the heart muscle]). Review of Resident 119's physician's orders indicated an order, dated 7/25/25 for, PTT [Partial Thromboplastin Time, a blood test that measures how long it takes for a person's blood to clot] weekly while on heparin [a blood thinner] one time a day every Monday for monitoring, start date 7/28/25. Review of Resident 119's July 2025 medication administration record (MAR) indicated an order, dated 7/21/25, for heparin 5000 unit/ml inject 0.5 ml subcutaneously (into the tissue layer between the skin and the muscle) every 8 hours for blood clotting prevention. Review of Resident 119's July 2025 treatment administration record (TAR) indicated an order for PTT weekly while on heparin one time a day every Monday for monitoring, start date 7/28/25. The TAR was documented with a check mark on 7/28/25. The chart code on the TAR indicated a check mark meant the treatment was administered. During a concurrent interview and record review with the Director of Nursing (DON) on 7/31/25 at 2:31 p.m., the DON stated Resident 119 should have had a PTT on 7/28/25. The DON stated she would follow up to see if the PTT was done, or if the resident refused. During an interview with the DON on 8/1/25 at 1:32 p.m., the DON stated she could not find the PTT result for Resident 119. The DON stated she was waiting for the nurse to reply to find out if Resident 119 refused. The DON further stated if Resident 119 refused, there should be documentation and notification to the Medical Doctor. During an interview with the DON on 8/1/25 at 2:17 p.m., the DON stated the nurse said Resident 119 refused the PTT on 7/28/25. The DON confirmed there was no documentation of refusal. Review of the TAR indicated the following under Chart Codes/Follow Up Codes; check = administered.2 = drug refusal. During a concurrent interview and record review on 8/1/25 at 2:33 p.m., the DON reviewed Resident 119's TAR. The DON stated the nurse clicked (checked) the TAR to acknowledge that there were labs that needed to be done. The DON further stated the nurse just put late entry notes today, 8/1/25, for Resident 119. The facility's P&P titled Charting and Documentation, revised 7/2017, indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatment will include care-specific details, including:.e. whether the resident refused the procedure/treatment; f. notification of family, physician, or other staff.

Based on interview and record review, the facility's interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to review and revise the fall risk care plan after a fall incident for one of four residents (Resident 1). This failure had the potential to result in Resident 1 experiencing further falls. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility with diagnoses including pathological fracture (broken bones caused by disease) in neoplastic disease, pelvis, unspecified B-cell lymphoma (a type of cancer), severe obesity due to excess calories, and neoplastic related fatigue (persistent feeling of exhaustion caused by cancer and its treatments). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/3/24, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) score was 14 (a score of 13-15 indicates the resident is cognitively intact). Review of Resident 1's Post Fall Evaluation, dated 10/15/24, indicated Resident 1 had an unwitnessed fall inside her bedroom. Review of Resident 1's fall risk care plan, revised 10/9/24, indicated the care plan was not reviewed and revised after the fall incident on 10/15/24 to prevent further falls. During a concurrent interview and record review on 10/28/24 at 10:33 a.m., with the Director of Nursing (DON), Resident 1's fall risk care plan was reviewed. The DON confirmed Resident 1 was a fall risk and had fallen in the facility. The DON further confirmed the fall risk care plan was not updated when Resident 1 fell on [DATE]. During a follow-up interview with the DON on 10/28/24 at 12:54 p.m., the DON confirmed that if a resident falls, the fall risk care plan should be updated. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person -Centered, revised March 2022, the P&P indicated, 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. During a review of the facility's P&P titled, Falls - Clinical Protocol, revised March 2022, the P&P indicated staff will identify pertinent interventions to try to prevent subsequent falls.

Based on interviews and record review, the facility failed to ensure the correct administration of medication when the licensed vocational nurse A entered the medication order to the wrong resident. This failure resulted in one of three sampled residents (Resident 1) receiving a medication that was not prescribed for this resident. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE], with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review on 8/5/24 at 3:38 p.m., with the director of nursing (DON), stated she entered the medication Abrysvo (vaccine that protects against lower respiratory tract disease caused by respiratory syncytial virus [RSV])120 microgram (mcg) /0.5 milliliter (ml -metric unit used to measure volume) to the wrong resident. The DON stated the medication was administered to Resident 1. Resident 1 had an order for RSV vaccine entered into her records in error- the order was intended for a different resident. The vaccine was inadvertently given. During an interview with Director of Nursing (DON) on 9/25/24 at 1:09 p.m., DON stated LVN A administered the RSV vaccine to Resident 1 that were not prescribed for her. During an interview on 9/25/24 a 2:08 p.m., with LVN A stated the vaccine was input by the DON and the medication came from the Pharmacy with the name of the Resident 1. She confirmed she did not ask another staff to verify. Review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when: 1. medications were not administered as ordered by the physician; and, 2. Resident 1's physician was not informed regarding missed doses of medication. These failures had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including fractured shaft of right fibula (a break of the larger lower leg bone below the knee joint), atrial fibrillation (irregular heart rate), congestive heart failure (heart cannot pump enough blood to meet the body's needs), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure pressure), presence of cardiac pacemaker (implantable device that regulates heart muscle and contractions) Review of Resident 1's physician's order, dated 3/24/24, indicated she was to receive sotolol (medication used to treat heart rhythm problems) 80 milligram (mg, dose measurement) tablet, one half tablet two times a day. Review of Resident 1's medication administration record (MAR) indicated she did not receive her scheduled doses of sotolol on 4/9/24 at 9:00 a.m. and 5:00 p.m., 4/10/24 at 9:00 a.m. and 5:00 p.m., and 4/11/24 at 5:00 p.m. During an interview and concurrent record review with the director of nursing (DON) on 5/21/24 at 12:00 p.m., she reviewed Resident 1's MAR and confirmed Resident 1 did not receive sotolol on the above dates and times. The DON confirmed the MAR indicated the sotolol was not available. The DON stated the licensed nurses should follow up with the pharmacy when a medication is not available. 2. Resident 1's physician's order, dated 3/24/24, indicated she was to receive sotolol 80 mg tablet, one half tablet, two times a day. Review of Resident 1's medication administration record (MAR) indicated she did not receive her scheduled doses of sotolol on 4/9/24 at 9:00 a.m. and 5:00 p.m., 4/10/24 at 9:00 a.m. and 5:00 p.m., and 4/11/24 at 5:00 p.m. During an interview and concurrent record review with the DON on 5/21/24 at 12:45 p.m., she stated the licensed nurses should inform the physician when a resident does not receive prescribed medications. The DON confirmed there was no documentation indicating licensed nurses informed the physician when Resident 1 did not receive sotolol on 4/9/24, 4/10/24. and 4/11/24. Review of the facility's policy, Medication Ordering and Receiving From Pharmacy Provider, dated 2007, indicated medications are received from the provider pharmacy on a timely basis and to reorder routine medications by the reorder date on the label to assure an adequate supply is on hand. Review of the facility's policy, Medication Administration - General Guidelines dated 2007, indicated if a dose of regularly schedule medication is with withheld the MAR must be appropriately documented and if two consecutive doses of a vital medication are withheld the physician is notified.

Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives, explain risks and benefits, or obtain informed consent prior to the use of side rails in accordance with their bed rails (side rails, safety rails, and grab/assist bars) policy for 25 of 25 residents (137, 80, 16, 23, 179, 180, 181, 182, 14, 4, 138, 10, 18, 130, 11, 2, 12, 7, 6, 129, 131, 133, 136, 132, 30). These failures had the potential to place the residents at risk of entrapment and serious injury. For Resident 30, it resulted in the resident's left hand getting caught between the mattress and quarter [one-fourth, one part of a whole divided into four equal parts] side bed rail. Findings: During an observation in Resident 137's room on 4/2/24 at 8:29 a.m., Resident 137 was in bed with bilateral side rails. Review of Resident 137's physician order, dated 3/14/24, indicated he had an order for Side Rails: Quarter. Review of Resident 137's Side Rail Evaluation, dated 3/14/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 80's room on 4/2/24 at 8:37 a.m., Resident 80 was in bed with bilateral side rails. Review of Resident 80's physician order, dated 3/26/24, indicated he had an order for Side Rails: Quarter. Review of Resident 80's Side Rail Evaluation, dated 3/26/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 16's room on 4/2/24 at 8:41 a.m., Resident 16 was in bed with bilateral side rails. Review of Resident 16's physician order, dated 8/30/23, indicated he had an order for Side Rails: Quarter. Review of Resident 16's Side Rail Evaluation, dated 8/30/23, indicated quarter side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 23's room on 4/2/24 at 8:41 a.m., Resident 23 was in bed with bilateral side rails. Review of Resident 23's physician order, dated 2/25/24, indicated he had an order for Side Rails: Quarter. Review of Resident 23's Side Rail Evaluation, dated 2/25/24, indicated bilateral half rails were recommended, instead of the quarter side rails ordered. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 179's room on 4/2/24 at 9:09 a.m., Resident 179 was sitting up in bed with bilateral side rails. Review of Resident 179's physician order, dated 3/15/24, indicated an order for Side Rails: Quarter. Review of Resident 179's Side Rail Evaluation, dated 3/15/24, indicated there was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained an informed consent prior to the use of side rails. During an observation in Resident 180's room on 4/2/24, at 9:16 a.m., Resident 180 was sitting up in bed with bilateral side rails. Review of Resident 180's physician order, dated 3/13/24, indicated an order for Side Rails: Quarter. Review of Resident 180's Side Rail Evaluation, dated 3/14/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained an informed consent prior to the use of side rails. During an observation in Resident 181's room on 4/2/24 at 9:20 a.m., Resident 181 was sitting up in wheelchair. Resident 181's bed had bilateral side rails. Review of Resident 181's physician order, dated 3/16/24, indicated she had an order for Side Rails: Quarter. Review of Resident 181's Side Rail Evaluation, dated 3/16/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 182's room on 4/2/24, at 9:30 a.m., Resident 182 was sitting up in bed with bilateral side rails intact. Review of Resident 182's physician order, dated 4/1/24, indicated an order for Side Rails: Quarter. Review of Resident 182's Side Rail Evaluation, dated 4/2/24, indicated area left blank for recommendation of side rails. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 14's room on 4/2/24 at 11:13 a.m., Resident 14 was not in bed, and her bed had bilateral side rails. Review of Resident 14's physician order, dated 4/28/24, indicated he had an order for Side Rails: Quarter. Review of Resident 14's Side Rail Evaluation, dated 4/28/24, indicated bilateral half rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 4's room on 4/2/24 at 11:13 a.m., Resident 4 was in bed with bilateral side rails. Review of Resident 4's physician order, dated 12/20/23, indicated he had an order for Side Rails: Quarter. Review of Resident 4's Side Rail Evaluation, dated 9/11/22, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 138's room on 4/2/24, at 11:30 a.m., Resident 138 was sitting in chair, and his bed had bilateral side rails. Review of Resident 138's physician order, dated 3/21/24, indicated he had an order for Side Rails: Quarter. Review of Resident 138's Side Rail Evaluation, dated 3/21/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 10's room on 4/2/24 at 11:38 a.m., Resident 10 was in bed with bilateral side rails. Review of Resident 10's physician order, dated 12/16/23, indicated he had an order for Side Rails: Quarter. Review of Resident 10's Side Rail Evaluation, dated 12/16/23, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 18's room on 4/2/24 at 11:40 a.m., Resident 18 was in bed with bilateral side rails. Review of Resident 18's physician order, dated 3/4/24, indicated he had an order for Side Rails: Quarter. Review of Resident 18's Side Rail Evaluation, dated 3/4/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 130's room on 4/2/24 at 11:42 a.m., Resident 130 was in bed with bilateral side rails. Review of Resident 130's physician order, dated 3/29/24, indicated he had an order for Side Rails: Quarter. Review of Resident 130's Side Rail Evaluation, dated 3/29/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 11's room on 4/2/24 at 11:57 a.m., Resident 11 was in bed with bilateral side rails. Review of Resident 11's physician order, dated 5/10/23, indicated he had an order for Side Rails: Quarter. Review of Resident 11's Side Rail Evaluation, dated 5/9/23, indicated bilateral quarter rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 2's room on 4/2/24 at 12:02 p.m., Resident 2 was not in room, and his bed had bilateral side rails. Review of Resident 2's physician order, dated 10/8/23, indicated he had an order for Side Rails: Quarter. Review of Resident 2's Side Rail Evaluation, dated 9/27/23, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 12's room on 4/2/24 at 12:09 p.m., Resident 12 was in bed with bilateral side rails. Review of Resident 12's physician order, dated 2/27/24, indicated he had an order for Side Rails: Quarter. Review of Resident 12's Side Rail Evaluation, dated 2/28/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 7's room on 4/2/24 at 12:18 p.m., Resident 7 was in bed with bilateral side rails. Review of Resident 7's physician order, dated 4/8/24, and indicated it was a verbal order which was read back by the director of nursing (DON), indicated he had an order for Side Rails: Quarter. Review of Resident 7's Side Rail Evaluation, dated 4/8/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 6's room on 4/2/24 at 12:22 p.m., Resident 6 was not in the room , and the bed had bilateral side rails. Review of Resident 6's physician order, dated 3/7/24, and indicated it was a verbal order which was read back by the DON, indicated he had an order for Side Rails: Quarter. Review of Resident 6's Side Rail Evaluation, dated 3/7/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation on 4/2/24 at 3:37 p.m. in the rooms of Resident 129, Resident 131, Resident 133, and Resident 136, all four residents' beds had side rails. Review of Resident 129's physician order, dated 3/30/24, indicated he had an order for Side Rails: Quarter. Review of Resident 129's Side Rail Evaluation, dated 3/30/24, indicated there was no documentation that the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. Review of Resident 131's physician order, dated 4/1/24, indicated he had an order for Side Rails: Quarter. Review of Resident 131's Side Rail Evaluation, dated 3/31/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. Review of Resident 133's physician order, dated 3/27/24, indicated he had an order for Side Rails: Quarter. Review of Resident 133's Side Rail Evaluation, dated 3/27/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. Review of Resident 136's physician order, dated 3/24/24, indicated she had an order for Side Rails: Quarter. Review of Resident 136's Side Rail Evaluation, dated 3/24/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. During an observation in Resident 132's room on 4/3/24 at 10:39 a.m., Resident 132's bed had bilateral side rails. Review of Resident 132's physician order, dated 4/1/24, indicated he had an order for Side Rails: Quarter. Review of Resident 132's Side Rail Evaluation, dated 4/6/24, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. Review of Resident 30's Side Rail Evaluation, dated 12/26/23, indicated bilateral side rails were recommended. There was no documentation that indicated the facility offered and/or attempted alternatives, explained risks and benefits, or obtained informed consent prior to the use of side rails. Review of Resident 30's progress note, dated 1/10/24 indicated Resident 30's left hand was caught between the bedside rails and when asked what happened [Resident 30 stated] he slipped his hands unknowingly in between the rail that he felt the pain. The note also indicated Resident 30 had a small mark of redness with mild numbness on his left hand. Review of Resident 30's Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) note, dated 1/12/24 indicated, certified nursing assistant A (CNA A) was assigned to Resident 30 and [CNA A] stated she heard the resident yelling . and ran to the resident's room. She received [Resident 30] lying in bed, but with both feet on the ground and his left hand caught between the mattress and left bedside rail, palm facing the door. His palm could be seen from the bottom of the bedrail, the bedrail was raised. [CNA A] called for the charge nurse immediately and they were unable to get the resident's hand out. The charge nurse called 911 and [CNA A] stayed with the resident. [Certified nursing assistant B (CNA B)] came and assisted [CNA A] to pull the mattress down and back. CNAs cued [Resident 30] to move his hand up, slowly, until his hand was out from between the mattress and bedside rail. During an interview on 4/4/24 at 3:23 p.m., the director of nursing (DON) stated the interdisciplinary team discussed what happened to Resident 30's hand in an IDT meeting. The DON stated she could not see what the facility put in place as an intervention. During an interview on 4/4/24 at 3:32 p.m. with the director of staff development (DSD) and the DON, the DSD stated she does not know if the facility put anything in place after Resident 30's hand was caught between the mattress and the side rail. The DON stated all the residents in the facility have quarter side rails. When asked if alternatives are attempted prior to using bed rails, the DON stated nothing else is attached to the beds and the facility can ask the resident if they want them or do not want them. The DON stated informed consent is not obtained for the use of side rails because they are not considered a restraint. The DON also stated she did not see that the risks and benefits of side rail use are documented on the facility's side rail evaluation form. During an interview with the DON in her office, on 4/5/24 at 2:16 p.m., she stated she had called the facility's nurse consultant about the bed rails. The DON did not see anything in the side rail evaluation about risks versus benefits. She also stated the facility did not have consents for side rails for all the residents. The DON stated there were no alternatives for side rails use for any of the residents, since the facility did not consider them restraints. Review of the facility's policy, Bed Rails, dated 11/16, indicated, the facility will consider appropriate alternatives prior to installing or using a bed rail . a licensed nurse will review the risks and benefits of bed rails with the resident and/or the authorized representative and obtain written, informed consent from the resident or authorized representative prior to installation and/or use.

Based on observation, interview, and record review, the facilty failed to ensure sanitary conditions were maintained in the kitchen when: 1. Kitchen staff did not wear hair restraints while in the kitchen; 2. A red bucket was stored on the floor 3. A dietary aide picked up an item from floor and did not perform proper hand hygiene 4. Three of three ice machines had white residue or scale (the buildup of a white, chalk-like substance that forms where water collects or where water is dispensed) . These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1. During an kitchen observation on 4/2/24 at 8:27 a.m., the dishwasher did not have a hair restraint over his hair. During an observation on 4/3/24 at 3:07 p.m., a staff member walked through the kitchen with no hair restraint. During a concurrent observation and interview in the kitchen with the director of dining services (DDS) and nutritional care manager (NCM) on 4/3/24 at 3:18 p.m., the DDS was not wearing a hair restraint. The NCM confirmed the DDS had no hair restraint and stated everyone in the kitchen needs hair restraints. Review of the facility's policy, Uniform Dress Code, revised 1/2024 indicated, Wear the approved hair restraint when on duty regardless of length or presence of hair. Review of the Food and Drug Administration's (FDA) Food Code 2022, indicated food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, linens, and unwrapped single service and single-use articles. 2. During a kitchen observation and concurrent interview on 4/2/24 at 8:30 a.m., a red bucket was on the ground by the dishwasher. The NCM stated the red bucket was not supposed to be on the ground. Review of the facility's policy, Sanitizing Food Contact Surfaces, revised 1/2023 indicated, Red buckets should be placed on a lower shelf of the station . 3. During a dining observation on 4/3/24 at 12:27 p.m. in the kitchenette, dietary aide E (DA E) was providing residents their lunch trays. DA E picked up an item off the ground with her right hand. After opening the refrigerator, DA E removed the glove on her right hand, discarded it with her left hand, and put on a new glove. DA E did not wash or sanitize her hands, nor did she change the glove on her left hand. During an interview with DA E on 4/3/24 at 12:44 p.m., she confirmed she only changed one glove after picking up trash from the ground. When asked if she should have washed or sanitized her hands, DA E stated, I guess I should have. Review of the facility's policy, Food Handling Guidelines, revised 1/2024 indicated, Gloves are changed between tasks . Hands are washed after gloves are removed. 4. During a concurrent observation and interview with the director of building and grounds (DBG) on 4/4/24 at 8:40 a.m. , the ice machine in Kitchen 1 had white substances along the edges of the panel that opens to the ice maker. The DBG stated the ice machine needed some more cleaning and it was part of the facility's preventative maintenance. During a concurrent observation and interview on 4/4/24 at 9:01 a.m., the ice machine in Kitchen 2 had white substances along the edges of the panel that opens to the ice maker. The DBG stated it was not okay and should be cleaned. During a concurrent observation and interview on 4/4/24 at 9:05 a.m., the ice machine in the nourishment room had white substances on the ice chute where the ice is dispensed. The DBG stated it was scaling and he will have it cleaned.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the proper agencies per the facility's abuse policy for one of two residents (Resident 23) when Resident 23's abuse allegation was not reported after surveyor notified the administrator (ADM) and executive director (ED). This failure left information relevant to an allegation of abuse unreported to agencies required to be reported to for such allegations. Findings: Review of Resident 23's clinical information yielded a face sheet that indicated she was admitted with diagnoses which included atrial flutter (a type of abnormal heart rhythm, or arrhythmia), muscle weakness, and osteoarthritis (joint pain and stiffness). Resident 23's Minimum Data Set (MDS, an assessment tool) indicated she had full mental capacity per her brief interview of mental status, dated 2/29/2024, with a score of 15 (on a scale of 0-15, 15 being full capacity). During an interview with Resident 23 on 4/02/24 at 8:41 AM, in her room, she stated a nurse on night shift was rough when she was cleaning her. Resident 23 stated she screamed, and the nurse told her to stop screaming. She stated it happened last night and did not know the name of the staff. Resident 23 stated that it happened maybe once a week. This surveyor notified the ADM and ED, who were both in the ADM's office, of the allegation made by Resident 23. The ADM and ED both acknowledged the information. During an interview with ADM on 4/09/24 at 8:57 AM, she stated the facility did not have any suspicions of abuse with Resident 23, so they did not report the allegation to the Department. A review of the facility's policy and procedure titled California LPC-Elder Abuse Prevention, Identification, Response, Reporting, revised 10/2023, indicated, . E. Reporting Abuse, Exploitation, Neglect or Misappropriation. In Life Plan Communities Generally, the timeframe for reporting is to report immediately, but not later than 24 hours after the allegation of alleged violations involving abuse . d. The appropriate community leader makes any required verbal and written report to the local law enforcement and to the Department of Public Health . e. The community leader shall report allegations as dictated by state or local agencies (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interview and record review, the facility failed to follow a physician's order for one of three sampled residents (Resident 180) when weekly weights were not done as ordered by the physician. This failure of not following a physician's order resulted in the facility to be unaware of Resident 180's weight for over two weeks. Findings: Review of Resident 180's medical record face sheet (summary of important information) indicated she was admitted with diagnoses including pneumonia (an infection that affects one or both lungs) and muscle weakness. A physician's order, dated 3/13/24, was for weekly weights. The Resident Vital Sign Report indicated no documentation of weights since 3/18/24. During interview and concurrent record review with the admissions nurse on 4/9/24 at 2:02 p.m., she stated Resident 180 had no weights taken between 3/18/24 and 4/4/24. Review of the facility's policy titled, Weight Assessment and Intervention, revised 3/2022, indicated, Residents are weighed upon admission and at intervals established by the interdisciplinary team.

Based on interview and record review, the facility failed to prevent a pressure ulcer (damage to the skin caused by prolonged pressure) from developing for one of two residents (Resident 12) when a medical device was not placed properly. This failure resulted in a facility-acquired pressure ulcer for Resident 12. Findings: Review of Resident 12's medical record indicated he was admitted to the facility on [DATE] with a fractured left foot. Review of Resident 12's physician order, dated 2/28/24, indicated to keep left boot on at all times. Review of Resident 12's wound assessment, dated 3/9/24, indicated a facility acquired presssure injury to the left heel was identified on 3/9/24. Review of Resident 12's skin note, dated 3/12/24, indicated the resident was evaluated by the wound specialist on 3/12/24 for medical equipment related wound on his left heel. During an interview on 4/2/24 at 12:09 p.m., registered nurse D (RN D) stated Resident 12 developed a big blister on his heel from his boot about three weeks ago. She stated someone put Resident 12's boot on wrong and it resulted in the blister. During an interview on 4/2/24 at 12:25 p.m., RN D stated she saw Resident 12's boot placed on Resident 12's foot incorrectly. She stated someone removed the liner from the inside of his boot, so the plastic part of the boot was against his skin. RN D stated when she removed the boot, she saw the blister on Resident 12's heel. She stated his skin rubbing against the plastic boot caused the blister. Review of Resident 12's Care Plan Report indicated a skin integrity care plan, starting on 2/28/24 with a goal, Risk of skin integrity will be minimized . throughout their stay at the [facility].

Based on observation, interview, and record review the facility failed to 1. administer all physician ordered medications to one of three residents (Resident 2) when his Miconazole nitrate 2% topical cream (antifungal cream) was not administered during medication administration, and 2. ensure proper accounting of the controlled medication oxycodone (a semi-synthetic narcotic analgesic drug to relieve pain) in one of two medication carts (med cart 1) when the count of the oxycodone whole tablet (tab) and half tab were not correct. These failures had actual (for Resident 2) and potential implications for residents to not receive their prescribed medication(s) correctly. Findings: 1. Resident 2 was admitted with diagnoses which included psoriasis (a chronic (long-lasting) disease in which the immune system becomes overactive, causing skin cells to multiply too quickly. Patches of skin become scaly and inflamed). During an observation of a medication administration on 4/04/24 at 8:23 AM by licensed vocational nurse C (LVN C) for Resident 2, his Miconazole nitrate 2% topical cream was not observed administered. A review of Resident 2's physician orders, in his electronic record, indicated an order dated 3/18/24 for miconazole nitrate 2% topical cream topical, twice a day at 9 am and 9 pm. During an interview with LVN C on 4/04/24 at 10:40 AM, she stated she did not see the Miconazole in the MAR (medication administration record), but she sees it in the orders. LVN C stated she did not give the miconazole nitrate 2% cream. 2. During an observation of medications in med cart 1 and subsequent interview with the director of nursing (DON) on 4/04/24 at 11:25 AM, the controlled substance binder indicated Resident 133 had 13 half tablets of 2.5 mg (milligrams, a unit of dose measure) of Oxycodone 5 mg, while the pill pack of the half tablets of Oxycodone 5 mg was observed to have 12 half tablets. The controlled substance binder indicated Resident 133 had nine (9) whole tablets of Oxycodone 5 mg, while the pill pack was observed to contain 10 whole tabs. The DON stated it looked like someone gave a 1/2 tab and signed off for a whole tab. During an interview with registered nurse D (RN D) on 4/04/24 at 11:38 AM, she stated she had given a 1/2 tab, and signed off on the whole tab sheet. A review of the State Operations Manual (SOM) indicated in Section 483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

Based on interview and record review, the facility failed to prevent multiple falls for one of three sampled residents (Resident 1) when the facility: 1. failed to follow the physician's instructions to provide one to one (1:1, one caregiver to take care of one resident) caregiver for Resident 1 from 1/3/19 to 1/26/19; 2. failed to follow the physician's instruction to provide closely monitoring for the resident to prevent Resident 1's multiple falls; 3. failed to develop and/or implement resident-centered interventions to prevent recurred falls; 4. failed to do post fall assessment; the interdisciplinary team (IDT, heads from different department to discuss the care for residents) failed to discuss, addressed and provide proper interventions for Resident 1's multiple falls. 5. failed to turn on the tab alarm (a type of alarm attached to the bed or wheelchair and the resident's clothes to alert the staff when the resident attempted to get up from the bed or wheelchair. Tab alarm usage was one of the facility's intervention to prevent fall for Resident 1) when Resident 1 fell from the bed on 6/24/19. Resident 1 attempted to go to the bathroom without assist and fell . These failures resulted in Resident 1's seven falls, with two falls with compression fracture (break) of T11 ([MEDICATION NAME] spine fracture) and rib fracture, and one fall with skin abrasion (skin tear). Findings: 1a. Review of Resident 1's admission record indicated Resident 1 was admitted on [DATE], and had the [DIAGNOSES REDACTED]. mobility; and Anxiety disorders (feelings of worry, unease or nervousness). Review of Resident 1's nurse's notes dated from 12/19/18 to 6/30/19 indicated Resident 1 had total seven falls in the facility since her admission. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/26/18, indicated Resident 1's cognitive skills for daily decision making was moderately impaired, required extensive assistance (staff provide weight-bearing support) for transfer, walking and toileting. The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance for surface to surface transfers. Review of Resident 1's MORSE FALL SCALE (fall risk assessment tool) dated 12/19/18 indicated Resident 1's fall risk score was 80 (a score of 45 and higher indicated high risk for fall). Review of Resident 1's fall risk care plan, dated 12/19/18, indicated she was at risk for falls due to history of previous falls, impaired balance, impaired safety awareness and use of antidepressants (medication capable of affecting the mind, emotions and behaviors). Some interventions on the care plan include staff anticipate assistance needed for toileting or restlessness and assure commonly used items are within easy reach. Review of Resident 1's physician progress notes [REDACTED].is impulsive and frequently tries to get out of bed unassisted. Review of Resident 1's nurse note dated 12/29/18 at 12:38 a.m., indicated staff heard a loud noise from Resident 1's room and found the resident was on the bathroom floor with her head pressed against the bathroom wall. The facility sent the resident to the acute hospital for evaluation. Review of the hospital discharge note dated 12/29/18 indicated Resident 1 had traumatic compression fracture on T11 due to the fall. Review of Resident 1's clinical record indicated there was no evidence that the nurse staff did post fall assessment for fall risk for the resident. There was no evidence the facility IDT discussed Resident 1's fall and what proper interventions to implement to prevent the future falls for Resident 1. During a telephone interview with licensed vocational nurse A (LVN A) on 7/29/19 at 10:42 a.m., she stated she worked with Resident 1 on 12/29/18 at night shift. LVN A stated Resident 1 had an unwitnessed fall in the bathroom and was sent out to hospital. LVN A stated Resident 1 was forgetful and confused all the time and intend to get up and go to the bathroom by herself. LVN A stated Resident 1 needed one staff assist for transfer and toileting. LVN A further stated that nurse staff should check Resident 1 frequently because Resident 1 went to bathroom by self without using call light for assist and unable to follow the instruction. During an interview with the director of nursing (DON) on 7/29/19 at 2:30 p.m., she stated there was no documentation indicating IDT discussed Resident 1's fall and what proper interventions to prevent the future falls. The DON stated there was no post fall assessment for Resident 1 for the fall on 12/29/18. The DON stated the nurse staff should have done a post fall assessment and IDT should have documented how IDT addressed Resident 1's fall with proper interventions to prevent future falls. 1b. Review of Resident 1's post fall assessment dated [DATE] indicated Resident 1 had a second unwitnessed fall on 2/3/19 at 4:15 p.m. and was sent out to the hospital to rule out head injury. The post fall assessment indicated Resident 1 fell when she transferred herself from the bed to the wheelchair and went to the toilet by herself. The hospital emergency department note dated 2/3/19 to 2/4/19 indicated Resident 1 had no fracture or injury from this fall. Review of Resident 1's clinical record indicated there was no care plan for this fall and there was no evidence the IDT addressed this fall. During an interview with the DON on 7/29/19 at 3:27 p.m., she stated the nurse staff should revise the care plan for Resident 1's fall on 2/3/19. The DON stated there was no evidence the IDT addressed this fall. 1c. Review of Resident 1's nurse note dated 4/1/19 at 3:05 a.m., indicated Resident 1 had an unwitnessed fall and was sent out to the hospital. Review of the hospital's Emergency Department note dated 4/1/19 indicated Resident 1 had left second rib fracture due to the fall. During an interview with the DON on 7/30/19 at 11:21 a.m., she reviewed Resident 1's clinical record and stated regarding Resident 1's fall, there was no post fall assessment for Resident 1's fall on 4/1/19; there was no evidence IDT addressed the fall; there was no documents indicated when the facility sent the resident to the hospital and when the resident returned to the facility; there was no evidence the nurse staff monitor Resident 1 post fall status on 4/3/19 for 72 hours following a fall per policy. The DON stated the facility should document these missing assessment and monitoring. 1d. Review of Resident 1's nurse note dated 6/24/19 indicated Resident 1 had an unwitnessed fall on 6/24/19 at 2:00 a.m. with skin abrasion on left upper arm. Nurse note indicated Resident 1 was found lying on the floor. Per resident, she sated I need to go to the bathroom and I fell . Resident 1 was sent to the hospital for evaluation on 6/24/19 at 5:15 p.m. During a telephone interview with LVN B on 7/29/19 at 11:10 a.m., she stated she worked on 6/24/19 with Resident 1 when the resident fell . LVN B stated the staff heard Resident 1 yelled from the room and found the resident lying on the floor. LVN B stated the tab alarm was off when Resident 1 fell . LVN B stated staff forgot to turn the tab alarm on while Resident 1 was in bed. LVN B further stated, Unfortunately, the tab alarm was not on and should be on. LVN B stated Resident 1 was very forgetful, confused and attempting to get out of bed and go to bathroom by self. During an interview with the DON on 7/29/19 at 12 p.m., she stated the facility should have bladder and bowel training for Resident 1 because most of the resident's falls were related to toileting. The facility should have IDT documentation regarding discussion for Resident 1's multiple falls, the cause of the fall, proper intervention to prevent future falls. The DON stated if not document, means not done. The DON stated the facility should have proper and effective interventions for these falls. The DON sated there was no documented evidence indicating how often the staff monitored Resident 1. 1e. Review of Resident 1's nurse's notes from 12/19/18 to 6/30/19 indicated Resident 1 had seven falls in the facility since her admission in (MONTH) (YEAR). These seven falls occurred on 12/29/18, 2/3/19, 2/5/19, 3/17/19, 3/31/19, 4/1/19, and 6/24/19. There was no documented evidence that the facility IDT discussed and addressed these falls, what proper interventions the facility should implement to prevent these falls. Review of Resident 1's physician's notes dated 12/28/18 indicated Resident 1 was impulsive and frequently tried to get out of bed unassisted. Review of Resident 1's physician's note dated on 1/3/19 indicated Resident 1 .was impulsive and at high risk fall risk .requiring 1:1 caregiver support .continue close supervision for repeated falls . Review of Resident 1's physician's note dated on 1/26/19 indicated Resident 1 . .was impulsive and at high risk fall risk . The physician's note indicated the resident's 1:1 supervision for fall prevention had since discontinued. Review of Resident 1's physician's note dated 2/4/19 indicated Resident 1 needed .very close monitoring as patient forgets to call for help when getting out of bed . Review of Resident 1's physician's note dated 2/12/19 indicated Resident 1 .needed 24-hour supervision for safety optimally and even with that likely to fall again . due to multiple factors and poor safety awareness. Review of Resident 1's physician's note dated 3/21/19, 4/20/19, 5/16/19 and 7/11/19 indicated Resident 1 .need very close monitoring as patient forgets to call for help when getting out of bed . due to impulsivity and underlying cognitive issue. Review of Resident 1's clinical record indicated there was no evidence the facility followed the physician's instruction to provide 1:1 caregiver for Resident 1 from 1/3/19 to 1/26/19; there was no evidence the facility provide close monitoring for the resident to prevent Resident 1's multiple falls. Review of Resident 1's sitter schedule in (MONTH) 2019 indicated Resident 1 was scheduled to have a sitter to be with Resident 1 from 1/1/19 to 1/3/19 for 24 hours per day (from 7 a.m. to next day 7 a.m.); from 1/4/19 to 1/14/19 for 12 hours per day (from 7 p.m. to 7 a.m.). Review of Resident 1's nurse's note dated from 1/1/19 to 1/16/19 indicated nurse staff documented Resident 1 had a sitter accompanied during evening shift (8 hours per shift) on 1/1/19, 1/2/19, 1/3/19, 1/6/19, 1/7/19, 1/11/19 and 1/14/19. There was no documented evidence indicated the facility provided the sitter service to Resident 1 for the rest of the scheduled sitter days. During a telephone interview with the DON on 8/2/19 at 1:17 p.m., the DON stated per facility billing record that the facility hired a sitter (caregiver) to take care of Resident 1 on 1/3/19 for 24 hours and on 1/4/19 for 12 hours. The sitter's service ended on 1/15/19. The DON stated there was no documented evidence for each sitter service day regarding when and how the sitter took care of Resident 1 from 1/3/19 to 1/15/19. The DON stated there was no evidence the facility followed the physician's instructions regarding closely monitor Resident 1 due to multiple falls. Review of the facility's revised policy and procedure, Fall-Clinical Protocol dated (MONTH) 2013, indicated .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce failing or the consequences of falling. Review of the facility's revised policy and procedure, Falls and Fall Risk, managing dated (MONTH) 2007, indicated .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Review of the facility's policy and procedure, Assessing Falls and Their Causes dated (MONTH) 2010, indicated .Resident must be assessed in a timely manner for potential cause of falls. Review of the facility's revised policy and procedure, FALLS dated 7/27/17, indicated the nurse staff should chart residents' post fall status for 72 hours following a fall.