Every finding on record at The Villas at Saratoga Skilled NSG & Assisted LVG

Based on observation, interview, and record review, the facility failed to ensure a safe environment when one resident (Resident 1) out of five sampled residents did not receive adequate supervision when Resident 1 was able to leave the facility alone unattended on 4/7/26. This failure resulted in Resident 1 becoming intoxicated due to alcohol consumption while outside the facility and put Resident 1 at risk for physical injury, dehydration, and psychosocial distress. Upon return to the facility, Resident 1 was sent via 911 (emergency services) to acute hospital for evaluation. During an interview on 4/8/26 at 11:03 a.m. with the Director of Nursing (DON), the DON stated Resident 1 left the faciity on 4/7/26 and returned at around 10 p.m. intoxicated (being drunk or under the influence of drugs, where alcohol or substances impair a person's physical and mental abilities). The DON stated Resident 1 was also brought to the hospital to be checked and returned this morning of 4/8/26.During a tour and observation of the facility on 4/8/26 at 12:16 p.m. with the DON, the DON verified:The entrance and exit gate at the back of the facility towards the parking lot and onto the street was unlocked without alarm.The facility doors on the left and right of the gate were also unlocked without alarms.There was no staff supervising the doors and the gate.Multiple doors that open towards the patio and straight to the gate were also unlocked without alarms.There were no staff in the hallways and nurse station in Resident 1's area.During a concurrent observation and interview on 4/8/26 at 12:25 p.m. with Resident 1, Resident 1 was sitting on a chair beside the bed. Resident 1 stated he left the faciity on 4/7/26 at around 12:30 p.m. and nobody saw him or stopped him. Resident 1 also stated he took three bus rides and came back with alcoholic drink.During an interview on 4/8/26 at 1:33 p.m. with Registered Nurse (RN) A, RN A stated she was assigned to care for Resident 1 on 4/7/26 during the morning shift, from 7 a.m. to 3 p.m. RN A stated Resident 1 was wearing Wanderguard (bracelets that trigger door locks or alarms if a resident gets too close to a secured exit) on 4/7/26. RN A also stated it was around 1 p.m. when she noticed Resident 1 did not eat his lunch and started to look for him. RN A stated she did not hear Wanderguard alarm on 4/7/26 and it was supposed to alarm in several places. RN A stated Resident 1 was alert. RN A stated there were unlocked entrance/exit doors that lead to the patio straight to the unlocked entrance/exit gate in Resident 1's area and was not safe for the residents. RN A also stated there were no staff to supervise the exit gate.During an interview on 4/8/26 at 1:46 p.m. with Certified Nurse Aide (CNA) B, CNA B stated she was assigned to Resident 1 on 4/7/26 during the morning shift. CNA B stated she was on her lunch break and stayed in her car from 12:10 to 12:40 p.m. on 4/7/26. CNA stated she told two other CNAs she was going to have her lunch break. CNA B also stated when she came back from lunch to check on Resident 1, Resident 1's lunch tray was still in his room and Resident 1 was not there. CNA B stated she did not hear a Wanderguard alarm on 4/7/26. CNA B also stated entrance/exit doors were always unlocked in Resident 1's area.During an interview on 4/8/26 at 1:51 p.m. with the DON, the DON stated entrance/exit doors were not locked even at night. The DON also verified there were no assigned staff to supervise the doors. The DON stated any alert residents can go in and out of the patio. The DON also stated Resident 1 was very alert.A review of Resident 1's medical record indicated an admission date of 3/11/26. Resident 1's diagnoses included but were not limited to sepsis due to methicillin resistant staphylococcus aureus (a life-threatening, emergency situation where a stubborn, antibiotic-resistant staph infection spreads into the blood, causing the body's immune system to overreact and damage its own organs); essential [primary] hypertension; difficulty in walking, not elsewhere classified; bipolar disorder, unspecified (a mental health condition characterized by extreme, often unpredictable shifts in mood, energy, and activity levels); and depression, unspecified (a common, serious mood disorder that causes persistent feelings of sadness, worthlessness, and a loss of interest in activities).A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/16/26, indicated a brief interview for mental status score of 15 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact].A review of Resident 1's Progress Notes dated 4/7/26 by Licensed Vocational Nurse (LVN) C indicated, At approximately 2052 [8:52 p.m.], patient entered the building and was observed walking in to his room. The supervisor, charge nurse and 2 additional male staff assisted Ln [licensed nurse] during assessment and evaluation. The patient appeared intoxicated and had a grocery bag on the floor. He was asked to show the contents of the bag and initially revealed only sparkling cider then bear [beer] in a can. Upon further inspection and request to show all items, the patient took out a flat bottle of vodka that is 3/4 less full. Patient opened the bottle and drink in front of the staff and pour more vodka into his water jug that's on his table. Due to intoxication state, mood and behavior, supervisor and charge nurse determined that it was unsafe for both the patient and other resident and staff in the unit. 911 was called to request for transport to the hospital for further evaluation.The patient left the building at approximately 2205 [10:05 p.m.] via gurney, accompanied by two ambulance personnel, two sheriffs, and 3 fire department personnel.A review of Resident 1's Elopement assessment dated [DATE] indicated, Elopement Risk: Has attempted to leave the building 1-2 times within a week unattended.A review of Resident 1's hospital medical records indicated Emergency Department admission date of 4/7/26 at 10: 30 p.m. It also indicated, .Re-Evaluation & MDM [Medical Decision Making].The patient was seen on arrival. He was brought to the ED by EMS. EMS and the patient report no recent trauma. Other than ETOH [alcohol] intoxication, there was no abnormal finding.However, the patient was extremely agitated during transport, trying to swing and spit.The patient was observed in the ED [Emergency Department] for several hours. During that time, his mental status and physical coordination gradually improved until he eventually achieved clinical sobriety [a medical determination that a person is no longer impaired by alcohol or drugs, characterized by having a stable mental state, walking without assistance]. Work up was negative other than ETOH intoxication.He was able to ambulate safely and without difficulty and converse normally prior to discharge.Patient advised to refrain from heavy alcohol use in the future. Patient was discharged in stable condition A review of facility's policy and procedure (P&P) entitled Wandering and Elopements revised March 2019, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.A review of facility's policy and procedure (P&P) entitled Safety and Supervision of Residents revised July 2017, the P&P indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Individualized, Resident-Centered Approach to Safety.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.5. Monitoring the effectives ness of interventions shall include the following:.b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed.

Based on interview and record review the facility failed to ensure to notify local police, ombudsman (independent official, who advocates residents), and state agency in a timely manner following an allegation of abuse reported by facility's staff member for one out of two sampled resident (Resident 1). This failure had the potential for further abuse and delay implementation of appropriate corrective actions for sampled Resident 1.Findings:Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted in facility on 4/11/2025.Review of Resident 1's admission diagnoses included dementia (a decline in mental ability such as memory, reasoning, and communication, severe enough to interfere with daily life) and anxiety (persistent and excessive worry and fear of danger).Review of Resident 1's minimum data set (MDS, clinical and functional assessment tool) assessment dated [DATE] indicated Resident 1 had short-term (time period, typically 15-30 seconds) and long-term (time period ranging from hours to a lifetime) memory problem.Review of Resident 1's change of condition (COC, any significant physical, mental or functional condition change from a resident's baseline status) document dated 12/21/2025 indicated, Incident regarding husband, resident, and CNA (certified nursing assistant). Further review of this COC indicated Resident 1's medical doctor (MD) recommended to monitor signs and symptoms for emotional distress for Resident 1 when licensed nursing staff reported above allegation to MD.Review of Resident 1's nurse's notes dated 12/21/2025 indicated, morning shift CNA A reported to licensed vocational nurse C (LVN C) a witnessed an alleged incident of Resident 1's husband made a gestured motion towards the Resident 1's face. Resident 1's husband being rough/upset at the Resident 1 for not sitting in a wheel chair to go to dining hall. This notes also indicated CNA A reported Resident 1 was appeared to be shaken and somewhat fidgeting after the alleged event.Review of Resident 1's all documented person- centered care plans (an individualized, collaborative document that focuses on a resident specific needs, goals, interventions, and preferences) indicated there was a care plan for alleged hand gesture to resident's face, dated 12/21/2025 with interventions.During an interview over the telephone with LVN/supervisor B (LVN/S B) on 2/25/2026 at 2:15 p.m., LVN/S B confirmed above documentation for Resident 1's COC dated 12/21/2025. LVN/S B stated investigation following the abuse allegation indicated no abuse happened to Resident 1, he did not report to necessary entities. LVN/S B also stated not sure facility reported this abuse allegation.During an interview with LVN C on 2/25/2026 at 2:39 p.m., LVN C stated CNA A reported to her of above abuse allegation for Resident 1. LVN C reported this allegation to LVN/S B after separated husband from Resident 1. LVN C stated LVN/S B started the investigation and discussed with facility's administrator (ADMN) and director of nursing (DON) right away. LVN C also stated she was not aware if facility reported this allegation of abuse or not.During an interview with CNA A over the telephone on 2/26/2026 at 10;07 a.m., CNA A stated he witnessed Resident 1's husband pushed Resident 1 to sit in wheelchair (w/c, a mobility device designed for who cannot walk to enabling independence with mobility and transportation) and punched on Resident 1's face near chin area while CNA A was passing by in hallway. CNA A also stated he could see above abuse clearly from hallway. CNA further stated Resident 1's body was shaken and appeared fearful after this incident when CNA A walked in to Resident 1's room to separate husband from Resident 1. CNA A stated what husband did to Resident 1 was an abuse, it should have been reported.During an interview with facility's DON on 3/3/2026 at 2:02 p.m., DON stated based on facility's investigation for abuse allegation indicated there was no abuse happened to Resident 1 and did not report this allegation to ombudsman, law enforcement, and state agency. During a concurrent record review of Resident 1's COC of an allegation on 12/21/2025 and interview with facility's regional administrator (R ADMN) on 3/3/20026 at 3:20 p.m., R ADMN stated he was ADMN for this facility when above allegation happened. R ADMN confirmed he was aware of staff reported an allegation for Resident 1 and her husband. R ADMN stated based on the discretion of allegation's investigation, facility's management considered the allegation was not an abuse and not reported to necessary entities. R ADMN also stated Resident 1's husband was denied the allegation. Review of facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2024, the P&P indicated, 1. If resident abuse, neglect, exploitation, misappropriation of resident's property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman (an independent, neutral, and resident's advocate); e. Law enforcement officials (government officials including police, responsible for public safety);

Based on observation, interview and record review, the facility failed to ensure to maintain standard infection prevention and control practices to prevent the spread of infections when: 1.Unlabeled wash basins left on floor in resident's bathroom and in sink;2.Clean and used equipment storage areas were not separated in oxygen (O2, colorless, odorless, and tasteless gas essential for life) supplies storage room;3.House Keeping staff did not perform hand hygiene after removed gloves. These failures had the potential for all currently residing 84 residents in facility at increased risk of healthcare- associated infections. Findings:1.During an observation on 2/25/2026 at 10:13 a.m., noted two unlabeled wash basins (a plastic basin used for personal care for residents) left next to sink on floor in room [ROOM NUMBER]'s bathroom and one unlabeled wash basin left in sink in Room1.During room [ROOM NUMBER] observation on 2/25/2025 at 10:20 a.m., noted one unlabeled wash basin left in sink in room [ROOM NUMBER].During an interview with certified nursing assistant B (CNA B) on 2/25/26 at 10:25 a.m., CNA B acknowledged above observations. CNA B stated above wash basins currently were in use for residents. CNA B stated wash basins should labeled with resident's name when bathroom and resident room sharing between multiple residents. CNA B also stated wash basins should not be left on floor on in sink when not in use. CNA B further stated nursing staff should have been cleaned wash basins and stored in a resident's closet after each use to prevent risk for using for unassigned resident and spreading infection between residents. During an interview with facility's infection preventionist (IP) on 3/3/2026 at 12:03 p.m., IP stated resident's care items including wash basins should be labeled with resident's name before started using and store in a plastic bag in resident's closet when not in use to prevent the risk for spread of infection between residents. 2. During a concurrent observation of O2 supplies storage room in Building 1and interview with license vocational nurse A (LVN A) on 2/25/2026 at 2/25/2026 at 12:45 p.m., both observed storage room was cluttered and unorganized with multiple free standing emergency O2 tanks (E tank, E tank, a heavy, portable, and high pressure metal cylinder containing pure medical-grade O2) were on floor and multiple room air concentrator (RAC, a medical device that draws in room air, filters and provides purified O2) machines along with attached long electric cords on the floor. We both also noted there was no sign or area dedicated storage area for clean and used equipment in this room. LVN A stated unable to identify clean from used (need to sanitize before reuse for residents) O2 equipment since they were not separated and there was no sign posted in this room for clean and used equipment storage area. LVN A stated nursing staff should be organized all O2 supplies and separated clean from used equipment at dedicated area to follow standard infection control practices.During an interview with facility's IP on 2/25/2026 at 2:22 p.m., IP stated O2 supplies storage room should be cleaned, organized, and used equipment storage area separated from clean equipment area. IP also stated clean oxygen equipment should be placed in a plastic bag to store to protect from dust. IP further stated clean and used equipment storage area sign should have been posted in this area for infection control. 3.During an observation on 2/25/2026 at 1:10 pm., noted housekeeping C (HK C) staff came out of the room [ROOM NUMBER] with gloves on both hands. HK C doffed (removed) both gloves, opened housekeeping cart cabinet door with her right hand and closed while holding doffed (dirty gloves) in her left hand. HK C taken cell phone with her right hand from her uniform's pocket, doffed gloves placed in her uniform's pocket with her left hand. HK C did not perform hand hygiene after removed gloved During an interview with HK C on 2/25/2026 at 1:15 p.m., HK C confirmed above observation. HK C stated she should have discarded removed gloves and washed her hands before reached out to housekeeping cart and cell phone.During an interview with facility's IP on 2/25/3026 at 2:22 p.m., IP stated all staff should perform hand hygiene before and after use of gloves and in between tasks for infection control practice. Review of facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised June 2011, the P&P indicated, Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge.Review of facility's P&P titled, Fire Safety and Prevention, revised May 2011, the P&P indicated, Keep all storage rooms clean at all times, Store oxygen in clean, dry location. Tag or properly label all oxygen cylinders to indicate the contents of the cylinders. (i.e., full, half-full, empty, etc). Use plugs, caps and plastic bags to protect equipment not in use from dust and dirt.Review of facility's P&P titled, Handwashing/Hand Hygiene, revised August 2019, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for following situations: After removing gloves,

Based on interview and record review, the facility failed to offer pneumonia (PNA, an infection in one or both lungs [a pair of spongy organs in the chest that serve as the main components for breathing], that can cause mild to serious illness) vaccine (substance that making body stronger against specific harmful germs) timely for one of five sampled resident (Resident 2). This failure had the potential to negatively affect Resident 2's health and well-being.Findings:Review of Resident 2's clinical record indicated Resident 2 was admitted to facility on 6/2/2021 with diagnoses including congestive heart failure (a chronic and progressive condition where heart muscle too weak to pump blood efficiently, causing fluid to back up into the lungs), chronic kidney (bean shaped organ, that filters waste products from blood to produce urine) disease (a long-term, progressive condition often irreversible loss of kidney function), and hypertension (high blood pressure).Review of Resident 2's immunization audit report indicated Resident 2 received PCV 13 (Prevnar 13, type of PNA vaccine) on 1/13/2019. There was no documented evidence that Resident 2 was offered or received follow up PNA vaccine after received PCV 13.During a concurrent Centers for Disease Control and Prevention (CDC, a federal agency, its core mission to protect public health by controlling and preventing diseases, injury and disability)'s PNA vaccine recommendations and interview with facility's infection preventionist (IP) on 3/3/2026 at 1:01 p.m., IP confirmed CDC recommended one dose of PCV 20 (type of PNA vaccine) or one dose of PVC 21(another of type of PNA vaccine) at least one year after received last PCV 13. IP also confirmed facility did not offer or provide any one those PNA vaccine for Resident 2 as recommended by CDC after Resident 2 received PCV 13 on 1/13/2019. IP stated Resident 2 should have offered and received either PCV 20 or PCV 21 one year after received PCV 13. IP also stated she will offer today for Resident 2.Review of facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, revised March 2022, the P&P indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated.

Based on interview and record review, the facility failed to ensure to develop and implement a person-centered care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, preferences and values) for speech therapy (ST, a specialized healthcare service that diagnoses and treat communication, language, cognitive, and swallowing disorders for residents) for one of 3 sampled resident (Resident 1). This failure had the potential to result in not meeting Resident 1's plan of care needs. Findings:Review of Resident 1's face sheet (FS, a document that provides resident's information at quick glance) indicated Resident 1 was admitted to facility on 10/23/2025.Review of Resident 1's diagnoses included parkinsonism (a condition characterized by slow body movements, stiffness, balance issues and resting tremors (shaking), spasmodic torticollis (a painful, chronic disorder causing involuntary contractions [a sudden, involuntary tightening of muscles, causes pain, stiffness, and reduced movement] of the neck muscles).Review of Resident 1's order review history report indicated an order for ST 3x/week (3 times per week) x 4 weeks for PO (by mouth) trails, education on aspiration (accidental swallowing of food, liquid or saliva into the lungs [[a pair of spongy body organ, primary function for breathing]) precautions, swallow compensatory strategies., ordered, dated 11/7/2025, and discontinued, dated 12/6/2025.Review of Resident 1's ST notes indicated Resident 1 received ST services 3x/week for 4 weeks as ordered above.Review of Resident 1's clinical documentation indicated there was no documented evidence of person-centered care plan for ST services.During a concurrent record review of Resident 1's orders, all care plans and interview with facility's director of rehabilitation (DOR) on 2/25/2026 at 1:20 p.m., DOR confirmed Resident 1 received ST for 4 weeks as ordered. DOR also confirmed there was no person-centered care plan for ST for Resident 1. DOR stated Resident 1 should have a care plan for ST when received ST services. DOR also stated therapy staff should have developed and implemented a care plan for ST for Resident1.During an interview with facility's director of nursing (DON) on 2/25/2026 at 2:56 p.m., DON confirmed there was no care plan for ST for Resident 1. DON stated therapy staff should have developed and implemented a person-centered care plan for ST when Resident 1 received ST.Review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, The interdisciplinary team (IDT, a group of healthcare professionals work together to ensure all aspect of resident's health and care been addressed), in conjunction with the resident and his /her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: receive the services and/or items included in the plan of care; and.

Based on observation, interview, and record review, the facility failed to ensure to provide safe environment to prevent the risk for accident hazard in one of 3 sample resident room (room [ROOM NUMBER]) and in oxygen (O2, colorless, odorless, and tasteless gas essential for life) supplies storage room when: One emergency oxygen tank (E tank, a heavy, portable, and high pressure metal cylinder containing pure medical-grade O2) on floor, free standing, and not secured in a sturdy portable cart (a mobile, wheeled device designed for the quick, safe transport of E tank and prevents accidents by securely holding when not in use) when not in use in room [ROOM NUMBER];Cluttered and not organized O2 supplies storage room in Building 1 with E tanks on floor, free standing, not secured in a portable cart and several room air concentrators (RAC, a medical device that draws in room air, filters and provides purified O2) on floor. Above failures had the potential for accident hazard with or without injury and safety for residents in room [ROOM NUMBER] and staff in facility.Findings:During facility rounds on 2/25/2026 at 12:39 p.m., observed one E tank was not in use, left on the floor in a corner in room [ROOM NUMBER]. Noted this E tank was free standing, not secured in a portable cart.During an interview with facility's license vocational nurse A (LVN A) on 2/25/2026 at 12:42 p.m., LVN A confirmed E tank was not in use, not secured in a cart, left on floor in room [ROOM NUMBER]. LVN A stated E tank should be secured in a metal portable cart for safety when not in use for safety.During observation of facility's storage room for oxygen supplies in Building 1 along with license vocation nurse A (LVN A) on 2/25/2026 at 12:45 p.m., we both observed this storage room was cluttered and unorganized with E tanks, and several RAC machines along with attached long electric cords on the floor. We both also observed 5 E tanks were on floor, free standing, not secured in a portable cart or in a metal rack. Clean and used oxygen equipment storage areas were not separated in this room. During an interview with LVN A on 2/25/2026 at 12:50 p.m., LVN confirmed above observations of unsecured E tanks, and unorganized oxygen supplies in storage room. LVN A stated all 5 E tanks should be placed in a metal rack or in a portable stand for safety. LVN A also stated this room should organized with oxygen supplies to have safe access for staff in an emergency situations.During an interview with director of nursing (DON) on 2/25/2026 at 3:00 p.m., DON stated nursing staff should not left E tanks without stored in a cart or on the floor in resident's room when not in use. DON also stated nursing staff were responsible to place E tanks in a cart or in a rack in storage room when not in use for safety. DON further stated oxygen supplies storage room in Building 1 should be organized and clean and dirty equipment storage areas separated for staff to have access for clean oxygen equipment safely when needed to use for residents.Review of facility's policy and procedure (P&P) titled, Fire Safety and Prevention, revised May 2011, the P&P indicated, Keep all storage rooms clean at all times. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. Do not store oxygen cylinders in any resident room or living area.

Based on interview and record review, the facility failed to ensure to administer pain medication as needed when nursing staff noted with signs and symptoms (S/S including moaning, groaning, restlessness, agitation, crying, facial grimacing and guarding the affected area) of pain for one of three sampled resident (Resident 1) to meet professional standards of care.This failure had the potential to affect Resident 1's pain management, health condition and well-being. Findings:Review of Resident 1's face sheet (a document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on 3/13/2024.Review of Resident 1's order review history report for August,2025 indicated Resident 1's had an order for acetaminophen (medication used to relieve mild to moderate pain) 325 MG (milligram, a unit of weight or mass, equal to a thousandth of a gram) every 4 hours as needed for mild pain . dated 6/28/2024.Review of Resident 1's change in condition evaluation (COC: any significant shift in physical, mental or functional status from baseline need timely intervention and medical attention as needed) document dated 8/31/2025, indicated Resident 1 was found sitting on the floor mat (a specialized thick foam mat to provide cushion and prevent injury in the event of the fall) in her room. This document also indicated license nurse noted resident was moaning, groaning of pain, and unable to lift right arm. This document further indicated Resident 1 complained of pain on right shoulder and Resident 1 stated, help me it hurts. Resident 1 was transferred to hospital for further evaluation of right shoulder pain.Review of Resident 1's EMAR for August,2025 indicated there was no documented evidence of facility administered pain medication as needed for mild pain for Resident 1 on 8/31/2025 after fall. Resident 1's verbalized of pain and with pain signs/symptoms.During record review of Resident 1's medication order for acetaminophen for August, 2025, COC on 8/31/2025, and EMAR for August,2025 and interview with facility's assistant director of nursing (ADON) on 12/11/2025 at 1:47 p.m., ADON confirmed above findings. ADON stated license nurse should have administered acetaminophen as ordered for pain management when nursing staff noted with signs and symptoms of pain and Resident 1 verbalized right shoulder pain after the fall on 8/31/2025 while waiting for transfer to hospital for further evaluation.Review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised October 2022, the P&P indicated, Developing and implementing approaches to pain management. Pain management interventions reflect the sources, type and severity of pain. Implementing Pain Management Strategies, current medication regimen. Combining long-acting medications with PRNs (pro re nata, as needed) for breakthrough pain.

Based on interview and record review, the facility failed to ensure to provide moderate assistance (helper does less than half the effort) for bed mobility, transfer, ambulation, maximum assistance (helper does more than half the effort) for toileting hygiene (process of using commode for urination and bowel movement), and failed to document comprehensive risk for fall care plan with person centered interventions for staff's assistance for bed mobility, transfer, ambulation, toileting and hygiene to prevent a fall for one of three sampled resident (Resident 2). Above these failures were resulted in an unwitnessed fall with right femur neck ((part of the largest, and strongest thigh bone that connects the ball shaped head of the femur to the rest of the bone, critical structural component of the hip joint) fracture (broken bone) and underwent surgery (a medical procedure, often involving cutting into the body) to fix the fracture for Resident 2.Findings:Review of Resident 2's face sheet (a document that gives resident's information at a quick glance) indicated Resident 2 was admitted to facility on 8/25/2025. Resident 2's admission diagnoses included diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), open wound (a break or injury in the skin) to right foot, lack of coordination (a condition that affects the body's ability to control and execute smooth and precise movements), muscle weakness (a condition where muscles lose their strength), congestive heart failure (a chronic condition where heart muscles weakened, difficult for the heart to pump blood effectively throughout the body), peripheral vascular disease (a condition that affects blood vessels, typically in the legs), and depression (a serious mental condition with persistent feelings of sadness, hopelessness, and loss of interest in daily activities).Review of Resident 2's minimum data set (MDS: clinical and functional assessment tool) assessment dated [DATE], section C for brief interview for mental status (BIMS) indicated, score of 4/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition), severely impaired cognition.Review of Resident 2's MDS assessment dated [DATE] for functional limitation in range of motion (ROM: full movement capability of a joint or series of joints) assessment indicated, impairments on both sides of lower extremities (legs), required moderate assistance for lying to sitting on side of bed, sit to stand, chair to bed-to chair transfer, toilet transfer, and walk 10 feet, and maximum assistance for toileting hygiene needs.Review of Resident 2's history and physical notes dated 8/25/2025, documented by Resident 2's primary care physician (PCP: a healthcare professional who serves as point of contact for general medical needs and routine check-ups) indicated, does not have capacity to make medical decisions. Reason-cognitive impairment.Review of Resident 2's morse fall scale (a common healthcare tool used to quickly assess a resident's risk for fall) assessment dated [DATE], indicated, moderate risk for fall.Review of Resident 2's bowel and bladder program screener, dated 8/25/2025, indicated, continent of bowel and bladder with 1 person assistance with get to bathroom, transfer to toilet/commode/urinal, and adjust clothing and cleaning.Review of Resident 2's physical therapy (PT: a healthcare specialty that focuses on restoring, maintaining, and improving physical function) notes dated from 8/26/2025 to 9/24/2025, musculoskeletal system assessment indicated, impaired left lower extremity strength, hip, knee and ankle. Functional mobility assessment indicated, Resident 2 needed moderate assistance with transfers and ambulation. This notes also indicated, Resident 2 required fall risk precautions.Review of Resident 2's occupational therapy (OT: a healthcare profession that aims to improve ability to participate in activities of daily living [ADL]) notes dated from 8/26/2025 to 9/24/2025, indicated, poor standing balance, impaired safety awareness, impaired short-term memory (information only held for a brief period, generally 15 5o 30 seconds before it begins to fade away) and risk for fall. This notes was also indicated Resident 2 needed moderate assistance with toileting, transfer to commode, and personal hygiene.Review of Resident 2's speech therapy (ST: a healthcare profession that focuses on improving and restoring cognitive communication) notes, dated from 8/26/2025 to 9/24/2025, indicated, Resident 2 was oriented to person only and impaired insight (awareness of a problem or situation).Review of Resident 2's change of condition (COC: a significant change from baseline health, function or mental status, that requires interventions to address) dated 10/2/2025, indicated, around 10 p.m., nursing staff heard a thud (sound that made when something heavy falls or hits something else) and found Resident 2 lying on floor next to left side of his bed, unwitnessed fall.Review of Resident 2's nursing post fall evaluation notes dated 10/2/2025, indicated, fall was occurred in the Resident 2's room and fall was not witnessed. This notes was also indicated Resident 2 was attempting to use toilet by himself at the time of the fall.Review of Resident 2's COC dated 10/3/2025 indicated Resident 2 complained of right thigh pain during repositioning and was observed slight bluish-green discoloration, swelling, and right leg size longer than left leg. MD ordered an x-ray (an exam to create pictures of inside the body) to right leg.Review of Resident 2's right hip x-ray results, dated 10/4/2025, indicated, Age-indeterminate femoral neck fracture of the right femur. Presumed acute fracture.Review of Resident 2's nurse's notes, dated 10/4/2025, indicated, Resident 2 was sent out to acute hospital (AH: a medical facility that provides short-term and intensive care with severe or urgent health conditions) for further evaluation.Review of Resident 2's AH medical doctor's documentation, dated 10/6/2025, indicated, Resident 2 was fell at a nursing facility and sustained a displaced right femoral neck fracture. This documentation also was indicated Resident 2 underwent hemiarthroplasty (a type of partial hip replacement surgery to treat hip fracture) to right hip on 10/6/2025 and discharged back to facility on 10/9/2025.Review of Resident 2's comprehensive care plan for at risk for falls with or without injury, date initiated on 8/25/2025, indicated, there was no documented evidence of person centered interventions for staff to provide moderate assistance for bed mobility, transfer, ambulation, toileting, and maximum assistance for personal hygiene for Resident 2. During an interview with certified nursing assistant B (CNA B) on 10/22/2025 at 11:38 a.m., CNA B stated Resident 2 alert to name only, risk for fall, and depends on one staff's physical assistance with transfers, bed mobility, toileting and personal hygiene since Resident 2's admission to facility. CNA B also stated Resident 2 unable to ambulate self without one staff's assistance for safety to prevent a fall.During an interview with license vocational nurse A (LVN A) on 10/22/2025 at 12:10 p.m., LVN A stated Resident 2 required one staff's physical assistant with his transfers, bed mobility, ambulation, toileting and hygiene. During an interview with MDS coordinator C (MDSC C) on 10/23/2025 at 12:50 p.m., MDSC C stated based on MDS assessment, dated 9/1/2025, Resident 2 needed one person physical assistance with bed mobility, transfers, ambulation and bathroom use. MDSC C also stated based on nursing documentation at the time of the fall on 10/2/2025 indicated, there were no staff present to provide moderate assistance for Resident 2 to prevent the fall with fracture. MDSC further stated there was no nursing documentation indicated Resident 2 placed call light or not and called for assistance or not before the fall happened on 10/2/2025.During a concurrent review of Resident 2's PT, OT and ST notes dated from 8/26/2025 to 9/24/2025 and interview with occupational therapist (OT: a healthcare specialist who helps residents to improve ability to engage in activities of daily living) on 10/23/2025 at 1:24 p.m., OT reviewed above notes, confirmed Resident 2 was required moderate assistance from staff for transfers, ambulation, toileting, and maximum assistance for personal hygiene. OT stated Resident 2 was required one staff's physical assistance to complete above tasks. OT also stated Resident 2 was risk for fall and had poor safety awareness. OT further stated if staff were provided moderate assistance as Resident 2 needed, fall with injury could be avoided for Resident 2 on 10/2/2025.During an interview with facility's director of nursing (DON) on 10/23/2025 at 3:02 p.m., DON confirmed Resident 2 was high risk for fall since admission and was required fall precautions to prevent fall with or without injury. DON also confirmed Resident 2 required for staff to provide moderate assistance with activities of daily living. DON further confirmed no staff were present to provide physical assistance to Resident 2 to prevent the fracture after the fall on 10/2/2025 with his bed mobility or transfer, or ambulation, or toileting or hygiene needs. DON stated based on nursing documentation at the time of the fall indicated, no documented evidence for Resident 2 called for staff's help or not, before the fall happened. DON stated fall with fracture could be prevented if staff were provided assistance as needed for Resident 2 to use bathroom that day.During a concurrent review of Resident 2's care plan for risk for plan, date initiated 8/25/2025 and interview with MDSC D on 11/12/2025 at 12:47 pm., MDSC D reviewed above care plan and confirmed there were no documented evidence of person centered interventions for staff to provide moderate assistance for bed mobility, transfer, ambulation, toileting and maximum assistance for personal hygiene based on Resident 2's MDS assessment dated [DATE]. MDSC D stated this care plan should have documented evidence of person centered interventions to provide required moderate to maximum assistance for above tasks to prevent fall with or without injury for Resident 2. During an interview with facility's DON on 11/12/2025 at 1:04 pm., DON stated MDS staff were responsible for person centered care plans based on MDS assessment and ADL needs for each resident. DON also stated MDS staff should have reviewed, updated, and documented risk for fall care plan with person centered interventions to provide required assistance to prevent falls for Resident 2. Review of facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised March 2018, the P&P indicated, Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish . Appropriate care and services will be provided to residents who are unable to carry out ADLs independently including appropriate support and assistance with:b. Mobility (transfer and ambulation, including walking):c. Elimination (toileting).Review of facility's P&P titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.Review of facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P 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 interdisciplinary team (IDT: a group of professionals from different backgrounds who collaborate to provide person-centered care to residents), in conjunction with resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure medications (chemicals or compounds used to cure, halt, or prevent diseases or illnesses) left unattended in resident's room for one of three sampled resident (Resident 1)'s room. This failure had the potential for residents to have an unsafe access to medications. Findings: During an observation on 10/22/2025 at 11:08 a.m., noted 4 purple color capsules, 5 clear yellow color capsules, 1 pink color tablet and 1 white color tablet inside in a small clear plastic medication cup (used to carry medications to take to resident's room to administer), clear thick liquid 10 milliliter (ml: volume of liquid, equal to one thousandth of one liter) in another medication cup, and glass of water on a tray table next to Resident 1's bed while Resident 1 in bed. No license staff presence in Resident 1' room. Review of Resident's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on 8/19/2025. FS also indicated Resident 1's diagnoses included atrial fibrillation (irregular and rapid hear beat), anemia (not enough healthy red blood cells), and immunodeficiency (weak immune system, making it difficult to fight off infections).Review of Resident 1's minimum data set (assessment tool) assessment dated [DATE] indicated Resident1's brief interview for mental status (BIMS) indicated Resident 1's BIMS score of 5 out of 15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition).Review of Resident 1's order summary report indicated an order for medication Zyflamend herbal pain relief (a herbal supplement to support a healthy joint and mobility function) 4 capsules three times a day, dated 9/27/2025, Apixaban (used to prevent and treat blood clots) 5 milligram (mg: unit of mass/weight equal to a thousandth of a gram) two times a day, dated 8/19/2025, cod liver oil (a supplement derived from the cod fish, used to relieve joint pain) 10 ml two times a day, dated 9/9/2025, fish oil (a supplement widely used for heart health) 5 capsules, three times a day, dated 10/4/2025, progesterone (used for hormone replacement) 100 mg capsule once a day, dated 8/19/2025.During an interview with license vocational nurse A (LVN A) on 10/22/2025 at 11:12 a.m., LVN A confirmed Zyflamend, fish oil capsules, Apixaban, progesterone tablets and cod liver oil liquid in medication cups in Resident 1's room. LVN A was also confirmed these medications were ordered by medical doctor (MD) for Resident 1. LVN A stated she prepared and left medications in cups in Resident 1's room. LVN A also stated Resident 1 would take the medications when her son comes to visit. LVN A also stated medications should have been kept in a locked compartment till administer to residents. LVN further stated medications should not have left in Resident 1's room without presence of license staff.During an interview with facility's director of nursing (DON) on 10/22/2025 at 11:23 a.m., DON stated medications should not be in resident's room without license staff presence. During an interview with facility's consultant pharmacist (CP) on 10/22/2025 at 11:27 a.m., PC all medications should have been in a locked area, license staff should not have left medications unattended in resident's room for safety and security.Review of facility's policy and procedure (P&P) titled, Storage of Medications, revised November 2020, the P&P indicated, Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepared and administer medications have access to locked medications.

Based on observation, interview, and record review, the facility failed to ensure to provide resident's room free from sound for one of three sampled resident (Resident 1). This failure had the potential to affect Resident 1's health and well-being. Findings:During telephone interview with Resident 1's significant family member (SFM) on 10/21/2025 at 1:09 pm., SFM stated noise from metal plate from facility's drive way making Resident 1 not having quiet time in the room. SFM also stated every time people step on or cars passing by on metal plate, making sound, can hear from Resident 1's room.During an observation on 10/22/025 at 10:52 a.m., noted metal plate located on driveway, outside, near Resident 1's room, made sound metal plate moved when stepped on. Also heard the sound when car passed on this metal plate after few minutes later.During an observation on 10/22/2025 at 10:55 a.m., noted another metal plate located near the end of drive way where delivery trucks parking to unload, made sound when stepped on the plate.During concurrent observation and interview with facility's maintenance supervisor (MS) on 10/22/025 at 10:58 a.m., MS verified both metal plates and confirmed both plates were made sounds when stepped on and cars passing by. MS stated metal plates making sounds due to plates were not fitted tight to the ground. MS stated drive way metal plate, covering facility's emergency water supply source, unable to bolt the plate to ground to have access to shut off water during an emergency as needed. MS also stated will fix this metal plate with foam or some other material to prevent sound. MS further stated second metal plate covering electrical wiring, belongs to electrical supply company. MS stated he will reach out to them to fix the loose bolt for this metal plate. MS stated sound from metal plates had the potential for lack of quiet place for resident in room near to this area. Review of facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable sound levels.

Based on observation, interview and record review the facility failed to ensure a resident received adequate supervision to prevent an elopement for one of three sampled residents (Resident 1) when Resident 1 eloped and found on the street after being monitored by the nursing staff.This failure placed residents at risk for further elopement. Findings: Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/6/24, indicated the resident had severe impairment in daily decision-making skills.Review of Resident 1's Nurse's Note, dated 6/22/25 at 2:43 p.m., indicated the resident was alert with confusion, had an episode of going to another resident's room, and tried to awaken a resident by touching and shaking.Review of Resident 1's care plan, dated 6/22/25, indicated to monitor behavior of going to other resident room, with an approach to redirect resident to her room or activity room. On 6/24/25, a care plan was developed addressing the resident was at risk for elopement/wandering related to dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with an approach to monitor whereabouts frequently and the care plan did not specify how often to monitor. On 6/30/25, another care plan was developed indicating a wander guard (device to put on the resident to prevent elopement) was placed on Resident 1's right wrist to alert staff when resident attempted to leave alarmed exits.Review of the Nurse's Note, dated 8/5/25 at 7:25 p.m., indicated around 6:20 p.m., the resident was missing greater than 15 minutes. Around 8:30 p.m., a staff found the resident on the ground in a parking lot across a bookstore, was noted to have a bump on her forehead, abrasion on left knee, and bruise on left elbow.Review of the Interdisciplinary Team (IDT, members of health team that meet to discuss and plan resident care) Note, dated 8/6/25 at 1:59 p.m., indicated the resident was unable to recall the incident, walked, independently, and had poor safety awareness. It indicated to ensure the resident was wearing an active wander guard, and approaches to monitor hourly with frequent checks, and change room near a nursing station were noted.During an interview on 8/14/25 at 12:25 p.m., Resident 1 did not respond when she was asked about her elopement.During an interview on 8/18/25 at 1:20 p.m., the Director of Nurses (DON) who reviewed the record stated the resident was not placed on hourly or more frequent monitoring until after the elopement (8/6/25) because she did not have behavior of trying to leave and she did not think the resident would elope.On 8/18/25 at 3 p.m., an interview and tour of the facility was conducted with the maintenance director (MD).The MD stated he reviewed the facility's cameras for about six hours to figure out how Resident 1 eloped, she exited from the assisted living second floor (AL2) and walked along the building because she was found near a bookstore in that direction. The tour included the path from Resident 1's unit to the exit outside the facility (AL2); from St [NAME] Unit to St [NAME] Unit, to AL2, which had five turns in the facility. The MD then confirmed there were no alarms at St [NAME], St [NAME] and AL2. The MD stated on 8/7/25 (day after elopement), a wander guard alarm was installed to the exit door of AL2. The path to where Resident 1 exited showed the final turn in AL2 was a long hallway where assisted living residents resided. The AL2 door led to a concrete stairway with a landing in the middle of stairs, at the bottom of the stairs to the left was a metal grate approximately three feet in height, and to the left was the ALS building in a forest like secluded setting with redwood trees that led to a side street. The MD stated Resident 1's elopement path in the building was about five blocks long. The path along the building from AL2 to the street was at least two city blocks in length. Resident 1's wander guard alarm did not sound during elopement because there were no installed alarms at where she walked.During an observation at the time of the tour on 8/18/25 at 3 p.m., the alarm to AL2 was activated and it took four minutes and 45 seconds for the assisted living supervisor (ALS) to respond. The MD then acknowledged the response time was long. During an interview on 8/18/25 at 3:19 p.m., the ALS stated some skilled nursing facility residents dine and attend activities in AL2, she did not know which resident were confused, and if a confused resident asked for help we call the nurse's station.Review of the facility and assisted living floorplan with the MD on 8/20/25 at 4 p.m. indicated there were eleven exits outside the facility, and five exits to the first floor of assisted living were not alarmed.During an interview on 8/20/25 at 4 p.m., the assistant director of nurses (ADON) stated any exit door for a confused resident was not safe and the nursing staff should have monitored the residents to prevent elopement.Review of the Elopement policy, revised April 2021, did not provide guidance for what to do to prevent elopement.

Based on interview and record review the facility failed to timely suspend two certified nurse assistants (CNA) who had an allegations of resident mistreatment in accordance with their abuse policy for two of two sampled residents (Residents 1 and 2). This failure had the potential to place residents at risk for further mistreatment should the allegation be proven.Findings:1.Review of Resident 1's Nurses Notes, dated 5/17/25 at 1:50 p.m., indicated the resident reported CNA A and told Resident 1 to shut up and mind your own business on 5/16/25. The same note indicated Resident 1 stated there were a few other times when the resident was verbally disrespected by the same CNA A and she felt belittled.During an interview on 7/2/25 at 12:29 p.m., the registered nurse (RN) B stated when she learned about Resident 1's allegation she did not suspend CNA A.2.Review of Resident 2's Nurse's Notes, dated 6/13/25 at 6:47 p.m. indicated the resident reported to therapy staff that she was punched and poked on the sides of her abdomen while being changed by CNA B when Resident 2 cannot urinate past 11 p.m.During an interview on 7/3/25 at 12:15 p.m., licensed vocational nurse C (LVN C) stated when she received a message from a therapist regarding the above incident, she changed the assignment and did not suspend the CNA B.During an interview on 7/31/25 at 10:50 a.m., the director of staff development (DSD, person who develops training programs and onboards new staff) stated when a staff member was accused of abusing a resident, licensed nurses were take a statement from the staff member, report the incident and send the staff member home immediately.Review of the Abuse, Neglect or Misappropriation - Report and Investigating policy, revised September 2024, indicated any employee who was accused of resident abuse was to be placed on leave with no resident contact until the investigation was complete.

Based on interview and record review the facility failed to meet professional standards of care when staff did not intervene for a resident who was known to feed a roommate with swallowing problems (Residents 1 and 2). For Resident 3 she was not adequately monitored to prevent elopement and there was no policy addressing wander guard (alarm device such as a wrist band that sound when a person exits) maintenance and function for two of four sampled residents (Residents 1, 2 and 3). These failures placed residents at health and safety risk.Findings:1. Review of Resident 2's face sheet (document summarizing a resident's essential medical information) indicated she had diagnoses including dysphagia (difficulty swallowing food or liquid) and dementia (group of thinking and social symptoms that interferes with daily function). Her Minimum Data Set (MDS, an assessment tool, dated 4/18/25, indicated Resident 2 had severe problems with daily decision-making skills.Resident 2 had a physician's order, dated 6/5/25, indicating specific feeding instructions to provide close supervision, assist with cutting items, palpate (touch) resident while giving solids to ensure initiation of swallow, provide verbal cues as needed, slow rate, small bolus (amount) and ensure resident is awake and alert.During an interview on 7/30/25 at 12 noon, the speech language pathologist (SLP, healthcare professional who diagnoses and treats people with communication and swallow disorders) stated Resident 2 required one on one supervision to eat safely, needed to be alert during meals and was at medium risk for aspiration (inhalation of food or liquid into the lungs).Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/27/25, indicated the resident had moderate difficulty with daily decision-making skills.During an interview on 7/2/25 at 6:20 p.m., the CNA A stated he witnessed Resident 1 trying to feed her roommate (Resident 2) a lot and also gave Resident 2 fluids.During an interview on 7/3/25 at 12:14 p.m., CNA F stated Resident 1 fed Resident 2 about two to three times a week since they became roommates and did not report it to the charge nurse.Review of Resident 1's record indicated there was no care plan developed addressing Resident 1's behavior of feeding other residents until requested on 7/2/25.During an interview on 7/3/25 at 12:10 p.m., LVN C stated she had heard about Resident 1 feeding Resident 2 once or twice and did not do anything.During an interview on 7/3/25 at 12:58 p.m., LVN D stated she heard Resident 1 fed and applied lotion to her roommate and she informed the social worker to have residents change rooms.Review of Resident 1's Census list form indicated the resident resided in Room A from 4/26/25 to 6/20/25.Review of Resident 2's Census list form indicated the resident resided in Room A from 4/28/25 to 7/1/25.During an interview on 7/30/25 at 10:35 a.m., the director of nurses (DON) stated residents were not allowed to feed other residents and there should have been a room change between the two residents and the room change did not occur and there was no policy addressing who could feed residents.Review of Resident 2's hospital Discharge summary, dated [DATE] at 9:03 p.m., indicated the resident was being treated with a diagnosis including aspiration pneumonia (type of lung infection caused by inhaling something other than air into the lungs).2. Review of Resident 3's face sheet indicated the resident had diagnoses including dementia. Resident 3's MDS, dated [DATE], indicated the resident had severe problems with daily decision-making skills.During an interview on 7/2/25 at 11 a.m. licensed vocational nurse (LVN) C stated Resident 3 was confused, always walking around the facility, looking for exits, and she wandered into other resident rooms about once every shift (8 hours).During an interview on 7/3/25 at 1:30 p.m., LVN D stated Resident 3 was very confused especially in the afternoon after 4 p.m. and she wandered into other resident's rooms.Review of Resident 3's Nurse's Note, dated 3/16/25 at 8:05 a.m., indicated the resident was brought back to her room three times, she was peeking into other resident's rooms, and she had suddenly swiped food from another resident's room and explanation was given to a family member. There was no care plan developed addressing Resident 3's behavior of wandering into other resident rooms.Review of Resident 3's Change in Condition Evaluation (CICE), dated 4/6/25 at 4:01 p.m., indicated a staff reported a family member saw Resident 3 walking outside the facility and was found on Oak Street and brought back to St [NAME] Station.Review of Resident 3's Elopement Evaluation note, dated 4/10/25 at 2:32 p.m., indicated the resident had a history of elopement at home, had wandering behavior likely to affect safety or well-being of self and others and was identified to be at high risk for elopement. A plan was made to apply personal safety alarm device (wander guard), document specific behaviors on the behavior log, monitor location frequently and to notify staff. A care plan was developed on 4/10/25 addressing Resident 3's elopement an approach to monitor resident whereabout, especially during meals, shift changes, or when visitors were presentThere was no interdisciplinary team (IDT, health care members who meet to discuss and plan residents' care) about the 4/6/25 elopement.Review of Resident 3's Medication Administration Record (MAR) indicated she was monitored once a shift on the day, evening and night shift for elopement and wander guard to left wrist from 4/11/25 to May 2025. The MAR did not specify when, such as meal times.Review of Resident 3's CICE, dated 5/13/25 at 8:40 p.m., indicated at 7:45 p.m. the resident eloped from the facility again when she was noted to be missing and found on Oak Street around 8:15 p.m.Review of Resident 3's IDT notes, dated 5/15/25 at 8:12 a.m., indicated the resident was alert to self/name only, had a diagnosis of dementia, had previous attempts to leave the facility including trying to open doors, was found exiting from the elevator and wander guard was active and linked to the unit exit door. The resident was unable to recall the incident, was placed on hourly monitoring with frequency checks and directed staff to assess for triggers such as pain, loud noises that may cause wandering.During a tour with the maintenance director (MD) and environmental service director (EVS) on 6/30/25 at 4 p.m., it was observed St [NAME] Station had 4 exits, including an elevator from the second floor. The elevator, and an exit from St [NAME] second floor leading to stairs and an exit at St [NAME]'s first floor that led out from the building did not have alarms alerting staff of residents placed on wander guard. The first floor exit at St [NAME] was not alarmed and led to a gate approximately 20 feet away that led to a parking lot. To get to Oak St., a person had to travel down a hill over a block long.During an interview on 6/30/25 at 4:15 p.m., the MD stated Resident 3 was trying to go into the elevator frequently and there currently was no elevator alarm.During an interview on 7/30/25 at 1:19 p.m., the medical record director (MRD) who reviewed the record stated there should have been an elopement care plan developed by the next day (4/7/25), and an IDT note addressing the 4/6/25 elopement and said her job included auditing medical records for completeness.During an interview on 7/3/25 at 11:55 a.m., the MD stated the facility just initiated a wandering log to check the alarms and there was no policy or manufacturer's instruction addressing the maintenance and checking of wander guard function.During an interview on 7/30/25 at 2:34 p.m., the DON stated a care plan should have been develop when a problem arose such as a change in conditionDuring a follow-up telephone interview with the DON on 7/31/25 at 10:15 a.m., a request was made for Resident 3's behavior and frequent monitoring log as documented in the 4/10/25 Elopement Evaluation and assessment of resident triggers for elopement as noted in the 5/15/25 IDT notes and the information were not provided.Review of the Care Planning - Interdisciplinary Team policy, revised March 2022, indicated the IDT was responsible for the development of resident care plan and did not specify the timeframe i.e. timeframe after when a resident problem was identified.

Based on observations, staff interviews, and document reviews, the facility failed to ensure overall dietetic services systems for food safety and sanitation were met, according to standards of practice and facility policy. This failure exposed the residents to contaminants (potentially harmful substances) in foods and unsanitary practices, which could have further compromised their nutritional status. The facility census was 84. Cross reference F802, F803, F804, F808, F812, and F908 Findings: During the initial kitchen tour on 12/16/24 starting at 9:07 A.M., multiple observations of unsanitary and unsafe equipment cleaning and food production practices in dietetic services were observed, including: the lack of kitchen cleanliness monitoring, lack of dish machine sanitizing monitoring, lack of recent kitchen staff food safety training, lack of kitchen staff following standardized recipes and therapeutic menus, and lack of an emergency menu for therapeutic diets. 1) Food Safety Storage and Production-Preparation: a. During the initial kitchen tour observation on 12/16/24 at 9:08 A.M., a two-door reach-in meat refrigerator thawing red meat did not have an internal thermometer. The Foodservice Director (FSD) stated the refrigerator should have a thermometer inside to monitor the food temperature. b. During an observation and interview on 12/16/24 at 9:30 A.M., a [NAME] (CK-K) prepared eleven pureed meals by blending 2 cups of tap water with three chopped salmon fillets. CK K then used an unmeasured scooper to add two scoops of thickener from a large white rubber bin 3/4 full of thickener to the liquid salmon mixture. The bin with thickener had a label with a smeared written prep date of 5-27-24. CK K stated she did not know how much thickener she added to the mixture because the scooper did not have numbers on it. CK K stirred the liquid mixture with thickener for 30 seconds, then poured it in a small metal pan and placed it in the oven for the lunch meal service. The FSD acknowledged CK K did not use the recipe for pureed meats and stated CK K has been working here for thirty years, so she's been cooking a long time and knows the recipes. FSD also stated the white bin with thickener should have had the current date or should not have been used since it was dated 5/27/24. A review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and the time and temperature guidelines . c. During a kitchen observation and interview on 12/16/24 at 3:33 P.M., there was a 32-quart size container of tuna salad with a prep date of 12/16/24 inside the nourishment refrigerator. Diet Aide (DA-L) stated she prepared the tuna this morning at around 11:00 AM but she didn't know the exact time. DA-L stated she mixed a large 10 ounce can of tuna from the dry storage room, a scoop of mayonnaise, and cup of chopped celery together in a clear plastic container. Then DA-L stated she used a green scooper to scoop out some tuna to place on a slices of wheat bread to make about ten tuna sandwiches for the residents. DA-L stated she placed the sandwiches and the container with the remaining tuna salad, inside the refrigerator. DA-L stated she did not take the temperature of the tuna salad before preparing the sandwiches. DA-L stated the sandwiches were served at the lunch meal service that started at 11:45 AM. DA-L stated she was not trained to chill the tuna salad down to 41 degrees Fahrenheit (F) or below before serving the sandwiches. The FSD stated he also did not know the tuna salad should have been cooled to 41 degrees before the sandwiches were made. During an observation on n12/16/24 at 3:36 P.M., the temperature of the dry storage room where the canned tuna was stored, was 63 degrees Farenheit (F). A review of the undated tuna salad sandwich recipe indicated, .Ingredients: Tuna, water packed .celery, finely chopped; Onions, finely chopped; large .eggs, hard cooked, finely chopped; mayonnaise, chilled; wheat bread .Directions: 1. Wash celery and onions well under cold running water. 2. Combine all ingredients for salad and make sandwiches: #12 scoop salad/sandwich. 3 .Prior to serving, store sandwiches covered in refrigerator. Keep chilled at less than 41 degrees F until service . d. During a kitchen observation and interview on 12/17/24 at 11:30 A.M., Diet Aide (DA-M) was observed about to take food temperatures on the lunch tray line. DA-M was asked to demonstrate how to calibrate a thermometer. DA-M filled a cup with water, placed a few ice cubes in it, then placed the thermometer inside the cup. DA-M stated the temperature should be 41 degrees F to calibrate it. The Dietary Assistant Director (AFSD) acknowledged DA-M did not know the correct temperature to calibrate the thermometer should be 32 degrees F. The AFSD stated he calibrates the thermometers at least monthly but does not record on a log. A review of facility policy titled Thermometer Use and Calibration, dated 2023 Policy: Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .Checking the Accuracy and Calibrating .Food thermometers are to be calibrated each week, after one is dropped, or when a thermometer is new. It is recommended to put thermometer calibration on a cook's .sanitation list that must be initialed upon completion . 2) Kitchen Sanitation: a. During the initial kitchen tour observation on 12/16/24 at 9:21 A.M., a dinner meal from the previous night was found inside the kitchen microwave. The dinner meal was a meat entree, broccoli, rice, and a dinner roll. During the initial tour on 12/16/24 at 9:48 A.M., two big white fans with gray and black lint and debris were found mounted to the wall facing the food prep counter area. The FSD acknowledged the fans were dirty and could pose a problem if the dirt fell into the food during food prep. On 12/16/24 at 12:15 P.M., an observation of the kitchen microwave was conducted and the dinner meal was inside, unmoved. b. During the initial kitchen tour, an observation and interview was conducted at the dish machine on 12/16/24 at 10:02 A.M with Diet Aide Dishwasher (DA-L) and the FSD. DA-L described how he tested the sanitizing step of the high temperature dish machine by checking if the thermostat on the dish machine reached 180 degrees. DA-L stated sometimes they used a test strip to check the temperature by dipping it into the water solution on the clean side of the machine to see if it turned a different color. The FSD stated DA-L should have placed the test strip on a plate dish, run it through the dish machine, then checked to see if the strip turned black from a gray color. The FSD stated they did not keep a dish machine sanitizing log to monitor the sanitizing temperature level. A review of the facility's policy titled Dishwashing, dated 2023, indicated Policy: All dishes will be properly sanitized through the dishwasher .8. A temperature log .will be kept and maintained by the dishwashers to assure the dish machine is working correctly . c. During an observation and interview on 12/17/24 at 2:37 PM of the emergency food supply, the Foodservice Director (FSD) stated there was several cases of over a thousand gallons of emergency water in blue cans that have a 20-year shelf life. The FSD further stated the cases of food items were enough for the 88 licensed beds, 37 assisted living residents, and 100 facility staff. The FSD stated the emergency food plan did not include visitors. The FSD and the Registered Dietitian (RD) both stated they had a 5-day regular menu for the cases of food, but they did not have a therapeutic menu for the therapeutic diets. The FSD stated the emergency plan binder was buried somewhere behind the cases of food in the storage closet. During an interview with the DON on 12/18/24 at 3:19 PM, the DON stated it was important for the facility to have an accurate emergency food menu plan for residents, facility staff, and visitors to use in the event of an emergency. A review of the facility's policy titled Emergency and Disaster Procedures dated 2023, indicated, Policy: Facilities will have a written plan of action which includes emergency menus to be used in the event of an emergency or disaster .Facilities will maintain an emergency food supply on the premises to last for a three-day period .11. Texture Modifications and Thickened Liquid Diet Orders, Residents with either prescribed texture and/or thickened liquid diet orders should be given the appropriate modifications .14. Emergency Menu and Spreadsheets .This menu is designed for a disaster .15. Emergency inventory will provide for the number of beds in the hospital as well as the staff and visitors . 3. Fortified Therapeutic Diets: During a review of Facility Diet Order Tally Report-All Special Diets dated 12/16/24, indicated 21 residents were listed to receive a Fortified Diet (a diet designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status). During an observation of the lunch meal trayline service on 12/17/24 at 12:00 PM, the Dietary Aide (DA N) who assembled and checked the meal trays did not call out to the AFSD the residents on fortified diets. During an interview on 12/18/24 at 2:06 p.m., with the RD, the RD stated her expectation is the resident receives their physician-ordered therapeutic diet, which included Fortified diets. The RD also stated the facility's electronic health record program and the tray card software program perform monthly audits to ensure the tray cards match so residents are served the correct diets. The RD further stated it is important for the resident to receive the diet appropriate for their medical condition, and the kitchen staff should know how to serve the correct fortified foods during meal service. During an interview with the Director of Nursing (DON) on 12/18/24 at 3:19 PM, the DON stated the Licensed nurse (LN) will check the trays vs the tray card with the diet order and stated if they found a discrepancy, they are supposed to notify the kitchen. The DON further stated it was important to serve the correct physician-ordered diets to residents. A review of the facility's Diet manual dated 2024, indicated .Fortified Diet: is a regular diet that has added margarine, gravy, cheese, and mayonnaise. The diet adds 300-400 calories a day . A review of the facility policy titled Diet Orders dated 2023 indicated, Diet orders as physician as prescribed by the Physician will be provided by the Food & Nutrition Services Department. 50855

Based on observation, interview, and record review, the facility did not ensure food and nutrition services staff performed their job tasks competently according to standards of practice and facility policy when: 1. A Dietary Aide did not follow the recipe for puree salmon and a Diet Aide did not follow the recipe for tuna sandwiches. 2. A Dietary Aide did not properly test the sanitizing step of the high temperature dishwasher machine. 3. A Dietary Aide did not correctly demonstrate how to calibrate a food thermometer. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 84. Cross reference F800, 803 Findings: 1. a) During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K then added 2 scoops of thickener to salmon mixture and started mixing it. CK K stated did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. CK K then stated she would add more thickener if needed to make it thick. During an interview on 12/18/24 at 2:31 p.m., with the Registered Dietitian (RD), the RD stated the staff should be following the facility approved recipes and measurements for accurate calorie counts and nutrition, based on the instructions and spreadsheet. During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared.2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and the time and temperature guidelines . b) During a concurrent observation and interview on 12/16/24 at 3:31 p.m., with Dietary Aide M (DA M) was observed making tuna sandwiches for resident snacks. DA M stated she used 1 twelve ounce can of tuna from the dry storage room, chopped celery, and some mayonnaise to make the tuna salad. DA M stated she made it about an hour ago but did not check the temperature of tuna salad before she started making the sandwiches to ensure they reached 41 F before serving them. During an interview on 12/18/24 at 2:40 p.m., with the RD, the RD stated she expected the staff to know how make tuna sandwiches safely and to follow recipes. During a review of recipe titled Tuna salad sandwich there is a direction indicated, .3. Suggest cut into four sections, cut to corner. Prior to serving, store sandwiches covered in the refrigerator. Keep chilled at less than 41 F until services. Serve in a pan on ice on tray line. During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance .7. Hold food prior to service for as short as time as practical. A maximum for 1-hour holding time is recommended. Hot foods should be held prior to service at 140 F or above and cold foods at 41 or below. Keeps food covered during holding . According to the Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna P. 2. During a concurrent observation and interview on 12/16/24 at 10:01 a.m. with Dietary Aide L (DA L) and the Foodservice Director (FSD), DA L was asked to test the sanitizing step in the high temperature dishwasher machine. DA L stated I believe you have to check if the temperature is 180 degrees on the temperature gauge and that's all. The FSD acknowledged DA L did not know how to test the sanitizing process in the high temperature dish machine, then stated we use an Ecolab test strip on a dish rack that is run through the dish machine. The FSD told DA L to attach an Ecolab test strip to a dish and run it through the dishwashing machine. The test strip was gray then turned black after it went through the dishwash machine. The FSD stated the result was okay. Review of the Ecolab test strip indicated when indicator turns black, stated temperature has been achieved 160 degrees F/ 71 C. During an interview on 12/18/24 at 2:37 p.m., with the RD, she stated she expected the staff to know how to use the test strips to test the sanitizing step of the high temperature dish machine and record it on the log. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-204.113 Warewashing Machine, Data Plate Operating Specifications, indicated, .A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: (A) Temperatures required for washing, rinsing, and SANITIZING . During a review of facility's (P&P) dated, 2023 titled Dishwashing indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order .9. The dishwasher will run the dish machines until the temperature is within the manufacturer's recommendations . if you cannot achieve this temperature, alert the FNS Director or cook who will alert the Maintenance Department and stop washing dishes . High-temperature machine: if you do not have the manufacturer recommendations, use the machine at a temperature of 150 F to 165 F or higher for the wash and 180 F of or above for rinse. If you do not achieve the proper temperature, resort to the manual of dishwashing. 3. During a concurrent observation and interview on 12/17/24 at 11:07 a.m., with Dietary Aide N (DA N) and Assistant Foodservice Director (AFSD), DA N was asked to calibrate the thermometer used for the trayline. DA N filled a cup with ice, added water, then she placed the thermometer stem inside the cup with ice. The thermometer reading was 34 degrees F, then she removed the thermometer and stated the 34 F was correct. DA N further stated she did not get trained on how to calibrate a thermometer. AFSD acknowledged the thermometer was not at 32 degrees and stated, I know the temperature should reach 32 degrees, because I calibrated it this morning and it did. AFSD further stated he calibrates his thermometer about once a week but does not write it on a log. During an interview on 12/18/24 at 3:05 p.m., with the RD, the RD stated she expected the kitchen staff to know how to calibrate a thermometer and document it on a log. According to the 2019 California Retail Food Code, section 113928 titled Temperature measuring device, TEMPERATURE MEASURING DEVICE means a thermometer, thermocouple, thermistor, or other device that indicates the temperature of FOOD, air, or water. 114159 (e) FOOD TEMPERATURE MEASURING DEVICEs shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. During a review of facility's (P&P) dated, 2023 titled Thermometer use and calibration indicated, Food thermometer are to be used properly and calibrated to ensure accurate temperature reading . Checking the Accuracy and Calibration .1 Fill a large glass with crushed ice and add a clean tap water until slush is formed. Stir the mixture well. 2. Put the thermometer's stem into the ice water to so that the sensing area is completely submerged (a dimple marks the end of the sensing area). Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must remain in the ice water one minute and during calibration process. 3. If the thermometer does not read 32 F, then the thermometer must be calibrated or discarded .

During observations, interviews, and record reviews, the facility did not ensure safe and sanitary practices were followed and maintained for food production and storage according to standards of practice and facility policy when: 1. An old dinner meal plate from the previous day was found inside the kitchen microwave the following day at 11:50 am. 2. Two dirty electric fans were inside the kitchen's food preparation and clean dish areas; 3. A cracked, dented, and worn aluminum measuring cup was used to make puree meals; These failures had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84. Cross reference F800, F802, F803 Findings: 1. During the initial kitchen tour observation on 12/16/24 at 9:30 a.m., a plate with a meat entree resembling a pork chop, rice, broccoli, and a wheat dinner roll was found inside the microwave. During a follow up kitchen observation on 12/16/24 at 11:50 a.m., the meal plate was still inside the microwave. On 12/16/24 at 3:20 p.m., during an observation of the microwave, the microwave was empty and the meal plate was removed. During a review of the facility's Cook's Spreadsheet, Winter Menus, Week 3, Sunday 12/15/24 indicated .Regular IDDSI Level 7: Roast Pork Maple glazed sauce 1-2 tbsp., Baked potatoes, Broccoli with cheese sauce, wheat roll . During an interview on 12/18/24 with the Registered Dietitian (RD) at 2:29 p.m., the RD stated the meal found inside the microwave should not have been left inside the microwave overnight. The RD further stated the microwave should have been checked by the kitchen staff working on Sunday night and Monday morning so it would have been thrown out. 2. During the initial kitchen tour observation in the kitchen on 12/16/24 at 9:35 a.m., two Electric fans attached to the kitchen walls were observed was dusty with dark grey lint and black debris on the fan blades and covers. One fan was directly facing over the food preparation counter where kitchen staff were observed making snacks and sandwiches. During an interview on 12/18/24 at 1:54 p.m., with the Maintenance Director (MDR), the MDR stated cleaning the electric fans were not part of his maintenance duties. During an interview on 12/18/24 at 2:34 p.m., with the Registered Dietitian (RD), the RD stated the last time the fans were cleaned, it was by maintenance. The RD stated now the janitorial environmental services department cleans them, and they should have been cleaned. During a review of the facility's policy and procedure titled Sanitation dated 2023 indicated, .8. The Maintenance Department will assist Food & Nutrition Services department as necessary in maintaining equipment and in doing janitorial duties which the Food & Nutrition Services employe cannot do and maintenance records on all equipment .1. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 3. During a concurrent observation and interview on 12/16/24 at 9:37 a.m., a [NAME] K (CK K) was observed making a puree salmon, she added 2 cups of water using a cracked, dented, worn out aluminum measuring cup, then she blended it in a blender. The number measurements were unreadable and scraped. CK K stated she did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. During an interview on /16/24 at 9:44 a.m., with the Foodservice Director (FSD), the FSD confirmed the aluminum measuring cup had a crack below the rim, dents around the cup, and unreadable number measurements. The FSD further stated they should have purchased new utensils for the Cooks to use. During an interview on 12/18/24 at 2:29 p.m., with the RD, the RD stated, the broken aluminum measuring cup is not acceptable and should be replaced. During a review of the facility's policy and procedure titled Sanitation dated 2023 indicated, The Food & Nutrition Services department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food .All equipment shall be maintained as necessary and kept in working order .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .

Based on interviews and record review, the facility failed to ensure three of 4 residents (Residents 16, 62 and 84) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatments patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in the inability to make medical decisions, and could lead to the delivery of unnecessary or inappropriate medical services. Findings: a. Review of Resident 16's face sheet (FC, a document that gives a resident's information at a quick glance) indicated, Resident 16 was admitted to facility on 7/8/15. Review of Resident 16's clinical record, indicated, there was no documentation of whether Resident 16 had an advance directive. Resident 16's POLST form's section D, which was designed to indicate whether the resident had an advance directive, was not completed. During a concurrent interview and record review with social service director (SSD) on 12/19/24 at 11:48 a.m., for AD for Resident 16, the SSD confirmed there was no AD currently in place for Resident 16's POLST form section D. The SSD further stated the facility has verbal power of attorney but not translated to the POLST section D. b. Review of Resident 62's FC indicated Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's clinical record, indicated, there was no documentation of whether or not Resident 62 had an advance directive. Resident 62's POLST form's section D, dated 11/15/24, was not completed. During a concurrent record review interview with social service director (SSD) on 12/19/24 at 11:40 a.m., for an AD for Resident 62, the SSD confirmed there was no AD for Resident 62. The SSD stated the facility should have made attempts to obtain and discussed the importance of health care directive. c. Review of Resident 84's FC indicated Resident 84 was admitted to the facility on [DATE].Review of Resident 84's clinical record, indicated, there was no documentation of whether or not Resident 84 had an advance directive. Resident 84's POLST form's section D, dated 11/22/24, was reviewed and was not completed. During a concurrent record review interview with social service director (SSD) on 12/19/24 at 11:44 a.m., for an AD for Resident 84, the SSD confirmed there was no AD for Resident 84. The SSD stated the facility should fill up and update once they have the AD section D. During an interview with director of nursing (DON) on 12/19/2024 at 11:29 a.m., the DON confirmed, there were no advance directives for Residents 16, 62 and 84. The DON also confirmed, section D of the residents' POLST forms were not completed. The DON further stated for the POLST, the Interdisciplinary team (IDT) goes over it during the admission conference, and asks if the family has an AD, and includes it in the resident' files. Review of the facility's policy and procedure (P&P) titled, Advance Directives/Individual health Care Instructions, revised September 2022, the P&P indicated, Prior to or upon admission of a resident, the social services director or designee inquires of the resident his /her family members and /or her legal representatives, about the existence of any written advance directives. If the resident does not have an Advance Directive . 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.

Based on observation, interview, and record review, the facility failed to follow their bed rail (adjustable rigid bars attached to the side of a bed) policy for 12 of 18 sampled residents (Residents 2, 4, 8, 16, 20, 23, 33, 43, 51, 67, 70 and 82). The facility failed to follow their bed rail policy for use of grab bars when: 1. For Resident #2 there was no physician order for the use of grab bars; 2. For Resident #43 and Resident 67 there was no physician order for the use of grab bars; 3. For Residents # 23, 33, 8, and 82, there were no care plans for the use of grab bars; 4. For Resident # 70, there was no physician order or care plan for the use of grab bars; 5. For Resident # 4, and 20 there was no physician order or care plan for the use of grab bars; 6. For Resident # 4, 16, 20, and 51 there were no care plans for the use of grab bars; These failures had the potential to compromise the residents' health and safety. Findings: 1. During an observation on 12/16/24 at 1:08 p.m., in Resident 2's room, Resident 2 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. Review of Resident 2's Bed Rail Use Evaluation, dated 11/18/24, indicated, the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was to assist Resident 2 with bed mobility and for positioning assistance. Review of Resident 2's physician orders indicated there were no physician order for the use of the grab bars for Resident 2. During an interview and concurrent record review with the director of nursing (DON) on 12/18/24 at 10:50 a.m., she confirmed Resident 2 was using grab bars on the bed, and confirmed there was no physician order for the use of the grab bars. The DON further stated residents who have grab bars in use should have a physician order in place for it. 2. During an observation on 12/16/24 at 9:58 a.m., in Resident 43's room, Resident 43 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. Review of Resident 43's Bed Rail Use Evaluation, dated 9/28/24, indicated the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was for positioning assistance. During an observation on 12/16/24 at 10:28 a.m., in Resident 67's room, Resident 67 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. Review of Resident 67s Bed Rail Use Evaluation, dated 10/2/24, indicated, the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was to assist Resident 67 with bed mobility and for positioning assistance. Review of Resident 43 and Resident 67's physician orders indicated there were no physician orders for the use of the grab bars for Resident 43 and Resident 67. and 48935 3. During an observation on 12/16/17/24 at 12:37 PM, in Resident 8's room, Resident 8 had two grab bars fixed on the bed in the upright position. Review of Resident 8's physician order, dated 7/8/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 8's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 1:54 PM, in Resident 23's room, Resident 23 had two grab bars fixed on the bed in the upright position. Review of Resident 23's physician order, dated 11/5/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 23's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 9:47 AM, in Resident 33's room, Resident 33 had two grab bars fixed on the bed in the upright position. Review of Resident 33's physician order, dated 9/6/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 33's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 10:01 AM, in Resident 82's room, Resident 82 had two grab bars fixed on the bed in the upright position. Review of Resident 82's physician order, dated1121/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 82's care plan indicated there was no care plan for the use of the grab bars. During an interview and concurrent record review with the DON on 12/19/24 at 11:29 a.m., the DON confirmed Residents 8, 23, 33 and 82 were using grab bars on their beds, and had care plans that were initiated on 12/18/24, during the survey period. The DON further stated residents who had bed rails in use should have a care plan for the use of grab bars. 4. During an observation on 12/16/17/24 at 9:47 a.m., in Resident 70's room, Resident 70 had two grab bars fixed on the bed in the upright position. Review of Resident 70's physician orders indicated there was no physician order for the use of grab bars. Review of Resident 70's care plan indicated there was no care plan for the use of the grab bars. During an interview and concurrent record review with the DON on 12/19/24 at 11:29 a.m., the DON confirmed Resident 70 was using grab bars on his bed, and had a physician order dated 12/18/24, and a care plan that was initiated on 12/18/24, during the survey period. The DON further stated residents who had bed rails in use should have a physician order and a care plan for the use of grab bars. 46553 5.During an observation in Resident 4's room on 12/16/24 at 10:22 a.m., Resident 4 had bilateral (both side) grab bars. During a review of Resident 4's physician orders indicated there was no physician order for the use of grab bars. During an observation in Resident 20's on 12/16/24 at 9;47 a.m., Resident 20 had bilateral (both side) grab bars. During review of Resident 20's physician orders indicated there was no physician order for the use of grab bars. During a concurrent interview and record review with Minimum Data Set Director (MDSD) on 12/19/24 at 11:14 a.m., the MDS confirmed there were no physician orders for the use of grab bars for Resident 4 and 20. During a concurrent interview and record review with DON on 12/19/24 at 4:39 p.m., DON confirmed no physician order for the used of grab bar for Resident 4 and 20. The DON further stated physician order should be entered and bedrail evaluation done quarterly. 6.During an observation in Resident 4's room on 12/16/24 at 10:22 a.m., Resident 4's had bilateral (both side) grab bar. During a review of Resident 4's care plan indicated there was no care plan for the use of the grab bars. During an observation in Resident 16 on 12/16/24 at 11:03 a.m., Resident 16's had bilateral (both side) grab bar. During review of Resident 16's physician order, dated 2/12/24 indicated Resident 16 had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility every shift. During review of Resident 16's care plan indicated there was no care plan for the use of the grab bars During an observation in Resident 20's ([NAME]) on 12/16/24 at 9;47 a.m., Resident 20's had bilateral (both side) grab bar. During review of Resident 20's care plan indicated there was no care plan for the use of the grab bars During an observation in Resident 51's room on 12/16/24 at 11:15 a.m., Resident 51's had bilateral (both side) grab bar. During review of Resident 51's physician order, dated 8/16/24, indicated Resident 51 had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility every shift. During review of Resident 51's care plan indicated there was no care plan for the use of the grab bars. During a concurrent interview and record review with Minimum Data Set Director (MDSD) on 12/19/24 at 11:14 a.m., the MDS confirmed there was no care plans for the use of grab bars for Resident 4,16, 20 and 51. During a concurrent interview and record review with DON on 12/19/24 at 4:39 p.m., DON confirmed no care plan for the use of grab bar for Resident 4 ,16, 20 and 51. The DON further stated there should be a care plan specific for the grab bar. During a review of the facility's policy and procedure (P&P) titled, Use of Side Rails /Bed Rails,undated , the P&P indicated, Purpose: The purpose of these guidelines are to ensure the safe use of side rails/bed rails as resident mobility aids 5. The use of side rails /grab bars will be addressed in the resident's care plan .11. Facility staff , in conjunction with the Attending Physician , will evaluate and documents the resident risk for injury .

Based on observations, interviews, and record review, the facility did not ensure standardized recipes for pureed meals and menus, which includes the emergency food supply were followed as printed, according to facility policy when: 1. A kitchen staff did not follow the facility's pureed diet lunch menu on 12/16/24 and 12/17/24. 2. A facility emergency menus unavailable These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status for 77 residents consuming food from the kitchen. Cross reference 800, 802 Findings: 1.a) During a review of the facility's Winter Menus, Week 3-Monday 12/16/24, the lunch meal pureed diet includes Fish Fillet with Tarragon Sauce, Tartar Sauce, Cajun Country Rice, Creamed Spinach, Parsley Sprig Garnish, Sweet Corn Salad, and Fruit Bavarian Cream. During an observation on 12/16/24 at 1:02 p.m., with Resident 56, Resident 56 was observed eating her lunch meal in front of St. Catherine's nurse's station. Resident 56 had no puree spinach on her plate. During a review of Resident 56's meal tray ticket, the tray ticket did not indicate a dislike for spinach or vegetables. During a concurrent interview and record review on 12/18/24 at 2:42 p.m. with the Registered Dietitian (RD), the RD stated she did not know the pureed spinach was not served to residents on the pureed diet. The RD stated she expected the kitchen staff to follow the menus for pureed diets, and all the other therapeutic diets. b) During a review of the facility's Winter Menus, Week 3-Tuesday 12/17/24, the lunch meal pureed diet includes Italian Lasagna, Seasoned Broccoli, Parsley Garnish, Garlic bread, peanut butter Cup Milk. During a test tray observation and interview on 12/17/24 at 12:48 p.m., with Foodservices Director (FSD) and RD, they confirmed residents on puree diet are getting puree wheat bread not a garlic bread from Menu dated 12/17/24. The FSD stated because it's hard to blend them [garlic bread]. During a concurrent interview and record review on 12/18/24 at 2:43 p.m., with the Registered Dietitian RD, the RD stated she expect the kitchen staff to follow the facility's menus for the residents to receive accurate calories and nutrition in order to meet their needs. During a review of facility's policy and procedure (P&P) dated, 2023 titled Menu Planning indicated, .3. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook may be kept. Only the Facility Registered Dietitian, FNS Director or Cook, can make these changes. The FNS Director is to receive the Facility Registered Dietitian's approval for any permanent changes. The Facility Registered Dietitian is to sign and date spreadsheets when changes are made.4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the Facility Registered Dietitian prior to the beginning of each quarterly menu cycle . 2.During a tour at emergency supply room observation and interview on 12/17/24 at 2:45 p.m., with the RD and the FSD, the written emergency binder with plan for water and food contained a 3-day regular menu for food. The emergency food binder did not include a menu for residents on therapeutic diets. The FSD stated the emergency plan included food for 88 licensed beds, 100 staff, but no visitors. The FSD further indicated there may be enough for 37 residents in Assisted living. The FSD stated the emergency binder was buried behind the cases of water and cases of disaster food items inside the small room near the employee break room. The RD and FSD both acknowledged it was important for the facility to have an accurate emergency menu with correct food and water amounts to meet the needs of the resident licensed beds, staff and visitors in the event of an emergency. During an interview on 12/18/24 at 2:46 p.m., the RD, the RD stated they followed up with a company for to obtain their emergency menu analysis portion and are still waiting for a response. During a review of facility's P&P dated, 2023 titled Emergency and Disaster Procedures indicated, Facilities will have a written plan of action which includes emergency menus to be used in the event of an emergency or disaster (e.g., fire, earthquake, explosion, flood, or strike). There may be disruption of the following: electricity, gas, water, or telephones. Facilities will maintain an emergency food supply on the premises to last for a three-day period . 4. Emergency Menu and Spreadsheets, Emergency and Disaster Procedures with completed Emergency Information form (refer to page 9.5), a can opener, and flashlight will be kept with the emergency food and paper supplies. Label area clearly with a sign, Emergency Food-Menus-Procedures (refer to next page or sign). This menu is designed for a disaster, which may disrupt gas, electricity, and water. All food may be served cold.15. Emergency inventory will provide for the number of beds in the hospital as well as the staff and visitors. The Administrator and FNS Director will agree on the number to provide for .

Based on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the puree diet was followed as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of twelve residents on puree diets. Cross reference F800 and F805 Findings: During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K then added 2 scoops of thickener to salmon mixture and started mixing it. CK K stated did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. CK K then stated she would add more thickener if needed to make it thick. During a review of recipe titled Pureed Meats there is a direction indicated, 1. Complete regular recipe. Measure out the number of portions for puree diets.2. Puree on low speed to a paste consistency before adding any liquid . During an interview on 12/18/24 at 2:31 p.m., with the Registered Dietitian (RD), the RD stated the staff should be following the facility approved recipes and measurements for accurate calorie counts and nutrition, based on the instructions and spreadsheet. During a review of the facility job description for .Cook . Revision date 9/01/16 indicated .Essential job functions: .Follow recipes and prepares foods that correspond to menu cycles and recipes prepared by Dietitian . During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and the time and temperature guidelines .

Based on interview and record review, the facility failed to provide free of accident hazard during transfer for one of three residents (Resident 1) when the facility failed to complete a fall risk evaluation for Resident 1 upon admission, Certified nursing assistant A (CNA A) did not follow the Hoyer (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) lift's user instruction manual when CNA A did not check the sling which suitable for the particular resident, the correct size, and CNA A did not follow the policy and procedure about using a mechanical lifting machine to gently support the resident as she moved. These failures resulted in Resident 1's fall and send to acute hospital that caused Resident 1 small left sub-insular (a lobe in the brain) white matter and post-central gyrus (region of the brain that perceives various sensations from the body including touch, pressure, temperature, and pain) intracranial hemorrhage (bleeding in the brain). Findings: During a review of Resident 1's clinical record, indicated she was admitted on [DATE] and had the diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (stroke; a result of disrupted blood flow to the brain) affecting right dominant side, aphasia (loss of ability to understand or express speech caused by brain damage), unspecified abnormalities of gait and mobility, and dysphagia (difficulty swallowing). Resident 1's weight was 104.2 pounds (lbs., unit of measurement) and height of 55 inches (in., unit of measurement). During a record review on 3/25/24, Resident 1's Fall Risk Evaluation, dated 12/16/23, the fall risk evaluation was not completed on admission on 12/16/23. During a review of Resident 1's Minimum Data Set (MDS, an admission assessment tool), dated 12/22/23, indicated chair/bed-to-chair transfer required assistance of two or more persons to complete the activity. The MDS also indicated the brief interview for mental status (BIMS, an assessment tool) had score of 0, which means Resident 1 rarely/never understood. During a concurrent interview and record review on 5/28/24 at 10:40 a.m., with the Director of Nursing (DON), the DON reviewed Resident 1's N Adv - Fall Risk Evaluation and confirmed that the fall risk evaluation was not completed on admission to prevent fall. During a concurrent interview and record review titled, N ADV - Fall Risk Evaluation, on 5/28/24 at 11:22 a.m., with Minimum Date Set Coordinator (MDSC), MDSC confirmed the fall risk evaluation was not completed on admission. MDSC stated it should have been completed. During a review of the facility's policy and procedure titled, Admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, indicated 9. Conduct supplemental assessment (following facility forms and protocol) including the Fall risk assessment . During a review of Resident 1's limited physical mobility care plan related to stroke, revised on 12/19/23, indicated the intervention was to provide assistance in activities of daily living (ADL, tasks of everyday life include eating, dressing, getting in and out of bed or chair)) as needed and use Hoyer lift when transferring Resident 1 from bed to wheelchair. During a review of the physical therapy treatment encounter notes, dated 12/21/23 at 9:30 p.m., indicated bed mobility and wheelchair transfers for Resident 1 required total dependence of two people assist. During a record review of Resident 1's nursing progress notes, dated 12/22/23 at 3:34 p.m., indicated, Resident 1 during the Hoyer lift transfer was moving and immediately slide down the sling. The progress notes further indicated the facility sent Resident 1 to acute hospital for evaluation. During an interview on 3/25/24 at 2:29 p.m., with CNA A, CNA A stated Resident 1's family member (FM) asked her to transfer Resident 1 to the wheelchair on 12/22/23. CNA A stated she told the resident's FM that she needs another staff to help with the transfer. CNA A stated there were no other CNA available to help. CNA A asked the therapist who was assigned to Resident 1. Registered Occupational Therapist (ROT) was the assigned therapist. CNA A stated she placed a small-sized sling under the resident and hooked the sling to the Hoyer lift. CNA A stated she was operating the Hoyer lift. ROT will place the wheelchair under the resident during the transfer. CNA A stated she raised the sling with the resident on it and pulled the Hoyer lift away from the bed. CNA A then started to turn the Hoyer lift to the right when Resident 1 started to move backward and fell to the floor. During an interview on 3/27/24 at 1:17 p.m., with ROT, the ROT stated CNA A asked him for assistance to help transfer Resident 1 from bed to wheelchair using the Hoyer lift. When ROT got to Resident 1's room, the Hoyer lift was in the room and the sling was already underneath the resident. ROT and CNA A attached the sling to the lift. ROT stated he was standing in between the resident and the wheelchair next to the bed. ROT stated CNA A was operating the Hoyer lift. ROT stated he was at beside the bed holding the wheelchair while Resident 1 was being lifted off the bed. ROT stated during the transfer Resident 1 fell . ROT stated he did not see how Resident 1 fell . ROT stated the resident probably slipped through the bottom of the sling. ROT stated Resident 1 fell butt first then hit her head on the floor. During an interview on 5/28/24 at 10:07 a.m., with Licensed Vocational Nurse (LVN) B, LVN B stated she heard a loud noise coming from Resident 1's room. LVN B stated she found Resident 1 was on the floor when she entered the room. LVN B stated she was told by the ROT that the resident slipped through the bottom part of the sling during the transfer and fell on the floor. During a concurrent interview and record review on 5/28/24 at 11:51 a.m., with the Director of Rehab and Physical Therapy (DRPT), the DRPT reviewed Resident 1's PT Evaluation & Plan of Treatment dated 12/18/23 and OT Evaluation & Plan of Treatment dated 12/17/23 and stated there was no documentation that Resident 1 was evaluated for the use of the Hoyer lift. DRPT stated rehab staff does not evaluate the residents for the use of mechanical lifting device because it was not considered a skilled transfer. DRPT stated the CNA used the mechanical lifting device based on discharge orders from acute hospital and their training for the use of the Hoyer lift. During an interview on 6/19/23 at 10:36 a.m., with DSD, DSD stated CNA A had the return demonstration with the use of Hoyer lift on 11/5/23 and ROT on 8/24/23 . DSD stated whole body sling was supposed to be used for Resident 1 to prevent fall. DSD stated the recommendation for this resident was whole body sling. DSD stated certified nursing assistants assessed by looking at the resident's size and weight to determine what size of sling to be used. DSD stated they do not use any measuring device to determine the size and weight of the resident . During a review of Resident 1's post fall evaluation, dated 12/22/23, indicated, fall occurred while being transferred and resulted in hospitalization . During an interview on 5/28/24 at 8:57 a.m., with CNA A, she stated that the sling was not appropriate to use for Hoyer transfer to a chair. CNA A stated she was operating the Hoyer lift, and the ROT was holding the wheelchair to be placed under the resident. CNA A stated no one was holding and supporting the sling during Resident 1's transfer from bed to the wheelchair. CNA A stated the sling should have been supported and guided during Resident 1's transfer on 12/22/23. During an interview on 5/28/24 at 9:05 a.m., with the ROT, ROT stated the sling used during the transfer was not the usual sling that the facility used for transfer. The ROT stated no one was supporting the sling while Resident 1 was being transferred from bed to the wheelchair. During an interview on 5/28/24 at 10:03 a.m., with the DSD, the DSD stated the sling used on Resident 1 was the U-shaped sling and not the full body sling which was not appropriate. The DSD stated the sling should have been guided and supported during Resident 1's transfer on 12/22/23. Review of Resident 1's acute hospital record titled Neurocritical Care (NCC)- Primary Service ICU History and Physical dated 12/22/2023, indicated, admitted : 12/22/2023 . Today, the patient presented from SNF (Skilled Nursing Facility) s/p (status post, means after) witnessed ground level fall (one that begins when a person has his or her feet on the ground) at facility with head strike at mental status baseline. Initial CTH (CT -Head, computed tomography scan - a non-invasive diagnostic imaging procedure using X-Rays to create detailed pictures of the inside of the Head) with concern for possible hemorrhagic conversion of recent ischemic stroke . ( a process which involves the bleeding of brain tissue that has been affected by the stroke). admitted to NCC for stability and neuro checks. Review of Resident 1's CT Head Cervical Spine without contrast (substance taken by mouth or injected into an intravenous line that causes the particular organ or tissue under study to be seen more clearly) imaging, dated 12/22/23, indicated .demonstrates extensive cortical lamellar necrosis (a permanent brain injury that occurs due to lack of oxygen) with small areas of hemorrhagic transformation (a process which involves the bleeding of brain tissue that has been affected by the stroke) in the subinsular white matter (a lobe in the brain) and post central gyrus (region of the brain that perceives various sensations from the body including touch, pressure, temperature, and pain). Review of Resident 1's acute hospital Stroke Discharge Summary indicated, admitted [DATE], discharge date [DATE], Resident 1's discharge diagnosis, indicated, small left subinsular white matter, post-central gyrus, and intracranial hemorrhage. Resident 1 was discharge from acute hospital on 12/31/23. Resident 1 did not return to the facility. Review of the facility's training lesson plan titled, Patient Lifts Safety Guide, undated, indicated 3. Check patient's condition before using a patient lift, check .patient's medical condition .make sure you have correct lift and sling for patient's condition .4. Select patient's sling size: assess patient's size, weight, hip measurement, and choosing correct sling size is critical for safe patient transfer. Review of an in-service sign-in sheet, dated 11/5/23, indicated the facility conducted a training titled, Hoyer Lift Transfer, the training course content indicated, Staff must understand to hold and support the patient while in the sling. Review of the facility's policy and procedure, titled Using a Mechanical Lifting Machine, revised 7/2017, indicated Measure the resident for proper sling size and purpose, according to manufacturer's instructions. Gently support the resident as he or she is moved. A review of the Hoyer lift's user instruction manual Safety Precautions indicated, Always check the sling is suitable for the particular patient and is of the correct size and capacity. Always fit the sling according to the instructions provided (user instructions). For the safety of the patient and carer, before using a sling a full risk assessment must be conducted to ensure that the correct sling choice, method of positioning in the sling and procedure for transfer has been determined for the patient.

Based on interview and record review, the facility failed to provide toileting assistance for one of four residents(Resident 1) when Resident 1 was found on the floor close to the bathroom in her room. This failure caused Resident 1 to have a right hip and right wrist fracture and Resident 1 was transferred to an acute care hospital. Findings: Review of Resident 1's clinical record indicated, she had [DIAGNOSES REDACTED]. Review of Resident 1's fall risk assessments dated 2/12/18, 2/21/18, and 5/15/18 indicated she was at high risk for falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/10/18, indicated Resident 1's balance was not steady when moving from seated to standing position, walking, turning around, and during surface-to-surface transfers. The same MDS indicated, Resident 1 had impairment on one lower extremity and would require extensive assistance (staff provide weight-bearing support) from one person for transfer, walk in room, locomotion on and off the unit, bed mobility, and toilet use. Resident 1 had mild to moderately impaired cognition. Review of Resident 1's nurse's weekly summaries dated 5/8/18, 5/18/18, 5/22/18, 5/29/18, 6/5/18, 6/12/18, and 6/19/18, indicated she had impairment on both lower extremities. Review of Resident 1's clinical record indicated, the Situation Background Assessment Recommendation (SBAR, a communication tool) dated 2/21/18 at 5:00 p.m., indicated on 2/21/18 at 4:00 p.m., Resident 1 was found lying on the floor near the entrance to her room, after she walked without assistance. Review of Resident 1's SBAR dated 5/14/18 at 10:41p.m., indicated on 5/14/18 at 7:50 p.m., Resident 1 was found sitting on the floor by the bedside in her room. It indicated the resident slipped down from her wheelchair to the floor. The SBAR indicated Resident 1's gait was impaired and she could not walk unassisted. During an interview with CNA B on 7/13/18 at 3:15p.m., CNA B stated, on 6/25/18 at 5:00 p.m., Resident 1 was found on the floor near the bathroom door in her room. CNA B also stated, Resident 1 needed one person assist with walking, toilet use, and bed mobility. CNA B further stated, Resident 1 had a balance problem standing and walking, and when she used the walker. During an interview with licensed vocational nurse A (LVN A) on 7/16/18 at 2:10 p.m., LVN A stated on 6/25/18 at around 5:00 - 5:30 p.m., certified nursing assistant B (CNA B) reported to LVN A that Resident 1 sat on the floor while CNA B was providing care to another resident. LVN A stated, Resident 1 required limited assistance with bed mobility, transfers, walking, and toilet use with one person due to Resident 1's balance problem when standing and walking. Review of Resident 1's SBAR dated 6/25/18 at 8:19 p.m. indicated, CNA B reported to LVN A on 6/25/18 at 5:00 p.m., Resident 1 sat on the floor while CNA B was providing care. The SBAR indicated Resident 1's gait was impaired and she could not walk unassisted. During an interview on 7/16/18 at 2:10 p.m., LVN A stated, on 6/25/18 at 7:00 p.m., two hours after Resident 1 was found on the floor, Resident 1 complained of severe pain on her right hip and wrist, which was swollen, too. LVN A stated, she performed a head to toe assessment and called the MD, who ordered x-rays for both areas. Review of nurse's progress notes dated 6/26/18, at 10:24 a.m., indicated Resident 1 had a right hip and right wrist fracture and was sent out to the acute care hospital. Review of Resident 1's interdisciplinary team notes (IDT, group of staff from different departments who work together to plan and provide care), dated 6/26/18 (noted as a late entry, at 8:58 a.m.), indicated around 5:00 p.m. on 6/25/18, CNA B saw Resident 1 sitting on the floor in Resident 1's room and reported the issue to LVN A. LVN A went to Resident 1's room and saw her sitting on the floor with both knees flexed. Review of Resident 1's risk for falls care plan which was initiated 10/6/17, indicated Resident 1 was at risk for falls related to gait/balance problems, poor safety awareness, lack of coordination, difficulty walking, cognitive impairment and noncompliance in calling staff for assistance. During a concurrent record review and interview with the assistant director of nursing (ADON) on 7/17/18 at 11:00 a.m., she stated the bed alarm for fall prevention was implemented on 2/21/18 and it was discontinued on 6/6/18, because Resident 1 would get agitated by the noise. She confirmed no new intervention was in place after the bed alarm was discontinued. The ADON also stated, an intervention dated 5/15/18, indicated staff should monitor Resident 1 closely for safety concerns and provide assistance in transfers and mobility. The ADON admitted there was no documented evidence that Resident 1 was closely monitored.