Every finding on record at Trabuco Hills Post Acute

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 4) was assessed for safe self-administration of his medications. * Resident 4 self- administered his testosterone transdermal gel without a prior self-administration of medication evaluation, a physician's order, or a care plan. This failure had the potential for Resident 4 to have a medication administration error.Findings: Review of the facility's P&P titled Self-Administration of Medication revised 12/19/22, showed a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The P&P further showed the care plan must reflect the resident's self-administration for such medications. On 6/11/26 at 0809 hours, a medication pass observation and concurrent interview was conducted with LVN 1. During the administration of the Testosterone Transdermal Gel 1.62 %, LVN 1 put one pump of the Testosterone gel into Resident 4's outstretched, ungloved, right hand. Resident 4 then applied the gel from his right hand onto his left forearm. Resident 4 did not wash his hands after applying the gel. Immediately following the medication pass for Resident 4, LVN 1 stated Resident 4 should have had an order to self-administer the Testosterone gel and Resident 4 should have washed his hands immediately after applying the medication. LVN 1 verified they should not have let Resident 4 self-administer without an assessment and order. Medical record review for Resident 4 was initiated on 6/11/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 6/9/26, showed Resident 4 had the capacity to understand and make medical decisions. Review of Resident 4's Order Summary Report showed a physician's order dated 6/9/26, to administer Testosterone Transdermal Gel 1.62 % (hormone replacement). Apply one pump transdermally one time a day for hormone replacement. Further review of Resident 4's Order Summary Report failed to show a physician's order was created for Resident 4 to self-administer the Testosterone Transdermal Gel. Review of Resident 4's medical record failed to show documented evidence an assessment to self-administer the medication was completed. Additionally, there was no documented evidence a care plan was initiated to address Resident 4's self- administration of the medication. On 6/23/26 at 1230 hours, an interview was conducted with the DON. The DON confirmed the above findings.

Based on observation, interview , medical record review, and facility P&P review, the facility failed to protect the resident's belongings from theft or loss for one of three sampled residents (Resident 1) who were transferred to the acute care hospital. * The facility failed to ensure Resident 1's belongings were accounted for and properly stored after being transferred to the acute care hospital. This failure resulted in the facility being unable to locate and return the resident's personal belongings after being discharged from the facility. Findings: Review of the facility's P&P titled Resident Personal Belongings dated 12/19/22, showed all the residents' personal items will be inventoried at the time of admission, and any additional items brought in after will be added to the personal belonging inventory list. The facility will care for the protection of the resident's property from theft or loss. Following the discharge of a resident, all personal belongings will be given to the resident's representative. On 5/21/26 at 1500 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was transferred to the acute care hospital on 5/11/26, without his personal belongings. Family Member 1 stated when the facility called her about a bed hold, she informed the facility he would not be coming back and asked about his personal belongings especially Resident 1's cellphone, eyeglasses, and wallet with the driver's license. The facility staff told her she could come in and pick up Resident 1's belongings. Family Member 1 stated she went to the facility and facility staff was unable to locate Resident 1's belongings. Closed medical record review for Resident 1 was initiated on 5/22/26. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care hospital on 5/11/26. Review of Resident 1's Resident's Clothing and Possessions form dated 5/7/26, the section for On Admission showed the resident's clothing, cellphone and eyeglasses. However, the form did not indicate the wallet with the driver's license. The section for On Discharge showed blank entries. Review of Resident 1's eINTERACT Transfer Form V5 dated 5/11/26, showed the resident was transferred to the acute care hospital at 1340 hours. The form showed a section for Personal belongings sent with resident/patient. There were multiple boxes to select on which items to were sent, including a box for other with a space provided to specify. However, there were no check marks on any of the boxes. On 5/22/26 at 1557 hours, an interview was conducted with SSD 3. SSD 3 stated she had been in contact with Resident 1's family about the resident's belongings. SSD 3 stated she was unable to locate any but was still checking around the facility and trying to locate Resident 1's belongings. The SSD stated she informed the resident's family the facility will try and locate the items indicated in the resident's Clothing and Possessions form and would reimburse the resident for any items they were unable to locate. On 5/27/26 at 1252 hours, an interview and concurrent record review was conducted with the DON. The DON stated the facility would reimburse any missing resident belongings that were listed on the inventory list. The DON stated she was aware the SSD was attempting to locate Resident 1's reported missing items.

Based on interview, medical record review, facility P&P review, and facility document review, the facility failed to follow their P&P after one of four sampled residents (Resident 2) made an allegation she was raped by CNA 1. * The Abuse Coordinator was not timely notified of the abuse allegation. * The facility failed to immediately remove CNA 1 from the resident care areas to protect all the residents from potential abuse. * The facility failed to protect Resident 2 from further abuse and negative outcomes when LVN 1 [NAME] CNA 1 back to Resident 2's room to verify if CNA 1 was the CNA the resident stated raped her. These failures had the potential to put the resident at risk for further abuse and resulted in a delay in the facility initiating their abuse investigation.Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation dated 12/19/22, showed abuse allegations will be immediately investigated. The facility will ensure all residents are protected from abuse during and after the investigation to include responding immediately to protect the alleged victim and integrity of the investigation, room or staffing changes to protect the resident(s) from the alleged perpetrator. Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/ Neglect/ Exploitation dated 12/19/22, showed when an abuse allegation occurs, the licensed nurse will remove the accused employee from resident care areas and notify the Administrator or designee. The Administrator or designee will obtain statements from staff and suspend the accused employee pending the investigation completion. Review of the facility's SOC 341 dated 5/7/26, showed at around 1600 hours, the facility was made aware Resident 2 made a sexual abuse allegation against CNA 1. Medical record review for Resident 2 was initiated on 5/22/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. On 5/22/26 at 0926 hours, an interview was conducted with CNA 1. CNA 1 stated approximately two weeks ago, LVN 1 came up to him and told him Resident 2 stated he raped Resident 2. CNA 1 stated LVN 1 then grabbed his arm and brought him to Resident 2's bedside and asked the resident to verify if it was him. CNA 1 stated Resident 2 stated yes that he raped the resident and that he beat up her brother and put him in the ICU. CNA 1 stated he stayed quiet and did not say anything to the resident, he left the room and LVN 1 told him not to go back in Resident 2's room. CNA 1 stated he had been trained on the facility's abuse procedure and knew he should not have gone back to the resident's room, but LVN 1 brought him in there and he did not know what to do. CNA 1 stated he went to the first floor to let the DSD know what happened and then he went back to work. On 5/22/26 at 0945 hours, an interview was conducted with LVN 1. LVN 1 stated on the day Resident 2 made the allegation, he went into her room at around 0900 hours, to give her routine morning medications. When he went to the resident, Resident 2 told him CNA 1 assaulted her and she wanted him to call the police. LVN 1 stated he asked the resident if she was sure, because this was serious. LVN 1 stated SSD 1 was already on their unit doing his rounds so he notified him immediately, then continued to finish the rest of his medication administrations. LVN 1 stated he also went downstairs and notified the ADON and Administrator. On 5/22/26 at 1049 hours, an interview was conducted with SSD 1. SSD 1 stated his usual routine was to do rounds on the 2nd floor every morning at around 0900 hours, before he goes downstairs to attend the daily stand-up meeting at 0930 hours, and then he would go directly to the clinical meeting which was also downstairs. SSD 1 stated at around 1600 hours, LVN 1 informed him and the ADON to follow up with Resident 2, and he and the ADON went to Resident 2's room. SSD 1 stated Resident 2 stated a male CNA was in her room but Resident 2 was confused and not able to get more information from the resident. On 5/22/26 at 1157 hours, an interview was conducted with the ADON. The ADON stated she was first made aware of Resident 2's allegation in the afternoon, when SSD 1 informed her of a concern with Resident 2. The ADON stated the SSD was not sure what specifically what Resident 2's concern was, but they went upstairs to speak with the resident. The ADON stated Resident 2 informed her someone may have sexually abused her, and she notified the Administrator who was also the facility's abuse coordinator. On 5/22/26 at 1228 hours, an interview was conducted with the DSD. The DSD stated he did not recall talking to CNA 1 on the day Resident 2 made her allegation. The DSD stated he left before noon that day and he was in a rush to get his tasks done before leaving. On 5/22/26 at 1509 hours, a follow up interview was conducted with LVN 1. LVN1 verified after Resident 2 made the allegation, LVN 1 brought CNA 1 into Resident 2's room and asked the resident if CNA 1 was the CNA she was talking about. LVN 1 stated the resident pointed at the CNA and stated yes, it was him. On 5/22/26 at 1637 hours, an interview was conducted with the Administrator. The Administrator stated in the afternoon of 5/7/26, the ADON and SSD 1 spoke to Resident 2. The Administrator stated the ADON informed him but it was not clear what allegations were being made by Resident 2 and rape had not been mentioned by the resident. The Administrator stated he went upstairs to talk to Resident 2 and her story was not very clear, but she eventually stated CNA 1 raped her. The Administrator stated to his knowledge, that was the first time the resident mentioned being raped. The Administrator stated he was not informed Resident 2 made a rape allegation in the morning.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for 16 residents who received pureed food. * [NAME] 1 failed followed the recipe when preparing pureed zucchini and yellow squash for the lunch meal on 2/26/26. This failure posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings: Review of the facility's document titled Diet Count by Modification / Portion dated 2/26/26, showed 16 of 161 residents received pureed food preparation from the kitchen, with no restrictions to zucchini and yellow squash. Review of the facility's diet spreadsheet titled Daily Spreadsheet for 2/26/26, showed the lunch menu included pureed zucchini and yellow squash #10 (scoop size #10 is equivalent to 3/8 cup) for the Minced and Moist diet (MMS), Pureed diet (PU4), and CCHO Pureed diet (PU4). Review of the facility's pureed recipe titled Pureed Vegetables Recipe dated 2/26/26, showed for 20 servings, portions size per spreadsheet:* Ingredients:- Seasoned vegetables, cooked and drained (reserve liquid) - 2-quart and 2 cups; and- Food Thickener - 2 Tablespoons. * Directions:- Remove portions required from regular prepared recipe; Drain and reserve cooking liquid. Place in food processor or blender and process until smooth;- If necessary, add a small amount of reserved cooking liquid or hot water;- If needed gradually add thickener and process until smooth in consistency;- Scrape down sides with rubber spatula and reprocess for 30 seconds;- Ensure mixture achieves smooth, lump free and extremely thick consistency; and- Serve using appropriate scoop size. On 2/26/26 at 1020 hours, an observation of the puree preparation and concurrent interview was conducted with [NAME] 1, [NAME] 2, the RD, and DSS. The following was observed:- [NAME] 2 was observed straining the prepared vegetables. [NAME] 2 did not reserve the cooking liquid of the vegetables;- [NAME] 2 served as a Spanish translator for [NAME] 1;- [NAME] 1 began the puree preparation for 25 portions in two separate batches. [NAME] 1 referred to the English version of the puree vegetable recipe;- For the first batch of pureed vegetables, [NAME] 1 used a #10 scoop to measure 12 portions of the prepared vegetables into the robot coupe. [NAME] 1 pureed the vegetables and then added one quart of honey consistency thickened chicken broth. [NAME] 1 poured the pureed vegetable mixture into a steam pan;- [NAME] 1 was asked how he knew how much liquid to add to the vegetables. [NAME] 1 pointed to the recipe where it showed seasoned vegetables, cooked and drained (reserve liquid) 2-quart and 2-cup and stated that is how much liquid the recipe said to use;- For the second batch of pureed vegetables, [NAME] 1 used a #10 scoop to measure 13 portions of the prepared vegetables into the robot coupe. [NAME] 1 pureed the vegetables and then added one cup of the honey consistency thickened chicken broth. [NAME] 1 poured the second batch of pureed vegetables into the steam pan with the first batch and mixed them together. [NAME] 1 stated the mixture was too runny. [NAME] 1 stirred in two teaspoons of thickener to the pureed vegetable mixture. [NAME] 1 placed the steam pan into the oven and stated he would wait to see if the pureed vegetable mixture thickens up over time, if not he would need to add more thickener; and- [NAME] 1 was asked how he read and followed the recipes if he did not speak English. [NAME] 1 stated he could ask for help with translation from [NAME] 2 or asked for the Spanish version of the recipe. On 3/2/26 at 1113 hours, an interview was conducted with the DSS. The DSS stated there were Spanish versions of the recipes if the staff need them and he was always there to help if they did not understand the recipe. The DSS stated the pureed food should be similar to the regular foods without altering it too much. The DSS verified [NAME] 1 was preparing his own version of the puree vegetable recipe and the recipe for pureed zucchini and yellow squash was not followed when an excess of liquid was added to the puree zucchini.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The dish machine sanitizer ppm was less than the required concentration. * Dietary Aide 2 failed to wash his hands and change his gloves between the handling of dirty dishes and clean dishes. * The food preparation equipment was not air dried. * The food preparation equipment was not properly cleaned. * The wall in the kitchen behind the refrigerator was not clean. * Two meal carts were repaired with methods that were not smooth, cleanable surfaces. These failures had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Count by Modification/Portion dated 2/26/26, showed 161 residents (including 16 residents on puree diet) who resided in the facility consumed food prepared in the kitchen. 1. Review of the facility's document titled Dishwashing Procedure dated 11/19/19, showed the concentration of the sanitary solution during the rinse cycle is 50-100 ppm with chlorine sanitizer on low temperature dish machines. On 2/25/26 at 0900 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. Dietary Aides 1 and 2 were washing the breakfast dishes. Dietary Aide 2 was asked to test the concentration of the sanitizing solution during the rinse cycle. Dietary Aide 2 placed a test strip in the water of the rinse cycle. The test strip resulted in a very light purple color. When the test strip was compared to the legend on the test strip bottle, it showed the sanitizer concentration was below 50 ppm. The DSS verified the result and found the tubing that connects the sanitizer to the dishwashing machine was twisted and stated they would rewash all the breakfast dishes. 2. Review of the facility's document titled Dishwashing Procedure dated 11/19/19, showed either two people are in the dish room, one on the dirty side, one on the clean side. If one person does both they must wash their hands between dirty and clean areas. Review of the facility's P&P titled Handwashing Guidelines for Dietary Employees dated 12/19/22, showed under Frequency of Handwashing, the dietary employees shall clean their hands and expose portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and in the following situations: After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. On 2/26/26 at 0915 hours, an observation of the dishwashing station and concurrent interview was conducted with the DSS. Dietary Aide 2 was observed loading dirty dishes into the dish machine. Dietary Aide 2 proceeded to unload clean dishes from the dish machine without washing his hands and changing his gloves The DSS verified Dietary Aide 2 was required to wash his hands and change his gloves when he moved from the dirty side to the clean side of the dish machine. 3. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. Review of the facility's P&P titled Air Drying - Dishes and Utensils dated 12/19/22, showed dishes must be stored to promote air drying. Review of the facility's P&P titled Dish and Utensil Procedure dated 3/3/20, showed dishes, trays, and utensils shall be air dried before storage. On 2/25/26 at 0900 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. The following was observed:- One heavy-duty blender stored with the lid on with water inside the blender; and- One robot coupe stored with water inside. The DSS acknowledged the above findings and stated the blender and robot coupe would be washed again. 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Dish and Utensil Procedure dated 3/3/20, showed any dish, tray, or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized. On 2/25/26 at 0900 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. There was one robot coupe stored with food particles inside. The DSS acknowledged the above findings and stated the robot coupe would be washed again. 5. Review of the facility's P&P titled Sanitation Inspection dated 12/19/22 showed the following:- It is the policy of this facility, as part of the Departments sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations; and- Inspections will be conducted but not limited to the following areas: Dry storage, freezer, refrigerator, dish room, compartment sink area, main production area, and food preparation area. On 2/26/26 at 1135 hours, an observation and concurrent interview was conducted with the DSS. The wall above the reach-in refrigerator in the main production area was covered with a brown fuzzy residue. The DSS stated the walls are cleaned by kitchen staff at the end of every shift but verified the wall was not clean and would call maintenance to clean it. 6. According to the USDA Food Code 2022, 4-101.11 Characteristics, materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (D) finished to have a smooth, easily cleanable surface; and (E) resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 2/26/26 at 0900 hours, an observation and concurrent interview was conducted with the Director of Maintenance. The following was observed:- Meal Cart A with duct tape to secure the door latch; and- Meal Cart B with the upper and lower corners repaired with a blue, plaster-like material. The Director of Maintenance stated he was not aware Meal Carts A and B needed to be repaired. The Director of Maintenance stated tape should never be used for repairs, and it appeared Bondo (a filler consisting of resin and a hardener used to repair, fill, and reshape dents, holes, and scratches) was used to repair Meal Cart B and it should have been sanded, and a primer should have been applied over the Bondo to complete the repair. On 2/26/26 at 0924 hours, an interview was conducted with the DSS. The DSS verified the duct tape on Meal Cart A and stated the weekend maintenance staff placed the duct tape to cover a sharp edge on the latch, but did not notify the Director of Maintenance to correctly repair Meal Cart A. The DSS verified Meal Cart B was not correctly repaired to have a smooth, cleanable surface.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for three of three residents (Residents 9, 16, and 22) reviewed for hospice services. * The facility failed to ensure Resident 9's facility plan of care included the frequency of visits by each hospice staff. * The facility failed to ensure Resident 16's medical record contained the visit notes by the hospice aide for February 2026, failed to ensure the hospice visitation calendar showed the scheduled hospice staff visits for February 2026 and failed to ensure the hospice plan of care was incorporated into the facility's care plan to include the frequency of visits for each hospice staff. * The facility failed to ensure future hospice visits were available in Resident 22's medical records. In addition, the facility failed to ensure schedule for the hospice staff visit was included in the facility plan of care. * The facility failed to ensure the physician's order was accurately reconciled for Resident 22. * The facility failed to ensure hospice staff were included in Resident 22's interdisciplinary team meeting. These failures posed the risk for delay in communication and/or uncoordinated medical care between the facility and hospice providers which may affect Residents 9, 16, and 22's care.Findings: Review of the facility's P&P titled Coordination of Hospice Services revised 11/1/23, showed the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physician, mental, and psychosocial well-being. A coordinated plan of care between the facility, hospice agency and resident/representative will be developed and shall include but not limited to the resident's rights, directives for managing pain and other uncomfortable symptoms and respite care program. The care plan and any related forms shall be revised and updated as necessary to reflect the resident's current status. 1. Review of the facility's contract with Hospice Provider B dated 7/25/24, showed Hospice will determine the appropriate course of hospice care, including the determination to change the level of services provided. Hospice will provide Hospice Services at the same level and to the same extent as those services would be provided if the facility resident were in his/her own home according to the frequency specified in the Hospice Plan of Care, including the following: a. Facility visits by hospice nurses. b. Facility visits by hospice social workers. c. Facility visits by hospice counselor. Medical record review for Resident 9 was initiated on 2/26/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Order Summary Report showed a physician's order dated 6/5/25, to admit Resident 9 under Hospice Provider B. Further review of the Order Summary Report failed to show the frequency of the hospice staff visits. Review of Resident 9's plan of care showed a care plan problem dated 8/8/25, addressing Resident 9's terminal prognosis and admission under Hospice Provider B. However, the plan of care failed to include the frequency of the visits by each hospice staff member. Reviews of Resident 9's MDS assessment dated [DATE], showed Resident 9 had severely impaired cognitive skills for daily decision making. Review of Hospice Provider B's plan of care for Resident 9 dated 1/8/26, showed the following information: - skilled nurse planned visit frequency: two times per week; - social worker planned visit frequency: as needed; and - hospice aide planned visit frequency: one time per week. On 3/4/26 at 0858 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON stated the residents who were receiving hospice services should have a schedule of when each hospice staff member would come to the facility to provide the care to the residents. The DON stated there should be a hospice plan of care as well as the facility's own plan of care and the hospice plan of care should be incorporated into the facility's care plan. The DON further stated the facility's care plan for the resident should include the frequency of visits for each hospice staff member. The DON reviewed Resident 9's medical records and verified the above findings. 2. Review of the facility's contract with Hospice Provider C dated 4/18/25, showed the following: - Hospice and the facility will establish a method of communication to ensure that the needs of the hospice patient are addressed and met twenty-four (24) hours a day including, regularly scheduled meeting in in person; and - The facility and hospice shall prepare and maintain complete and detailed clinical records concerning each hospice patient receiving facility services and hospice services under this agreement in accordance with prudent recordkeeping procedures as required by applicable federal and state laws and regulations. Each clinical record shall completely, promptly, and accurately document all services provided and event concerning each hospice patient. Medical record review for Resident 16 was initiated on 2/25/26. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 16's care plan for terminal prognosis related to Alzheimer's disease and admission to Hospice Provider C dated 10/3/23, failed to show the frequency of visit by each hospice staff member. Review of Resident 16's Order Summary Report showed a physician's order dated 4/18/25, to contact Hospice Provider C for any questions or concerns. The Order Summary Report failed to show the frequency of the hospice staff visits. Review of Resident 16's hospice records showed the Visit Note Report by the Hospice RN on 2/12 and 2/19/26. Further review of Resident 16's hospice records failed to show any hospice aide progress notes for February 2026. Review of Resident 16's hospice visitation calendar for February 2026 failed to show the scheduled weekly visits by the skilled nurse or the hospice aide for the month. On 3/4/26 at 0832 hours, an interview was conducted with CNA 10. CNA 10 stated he was familiar with Resident 16's care. CNA 10 stated Resident 16 was receiving hospice services and the hospice aide came once a week to shower the resident. On 3/4/26 at 0841 hours, an interview and concurrent medical record review for Resident 16 was conducted with the MRD. The MRD stated the medical records team was responsible for printing the hospice information/records and placing them into the hospice binder and uploading the documents into the resident's electronic health records. The MRD stated the hospice notes should be sent to the facility weekly and placed into the resident's medical records as soon as possible. The MRD verified she did not receive any hospice aide notes for Resident 16 for the month of February. On 3/4/26 at 0858 hours, an interview and concurrent medical record review for Resident 16 was conducted with the DON. The DON stated for the residents who were receiving hospice services there should be a calendar to show the days the hospice aide and hospice nurses would be at the facility to see the resident. The DON stated the purpose of the calendar was so the facility could coordinate and plan care for the hospice residents. The DON stated the hospice plan of care should be incorporated into the resident's care plan and should include the frequency of visits for each hospice staff member. The DON was asked about the frequency and days of the hospice aide visits for Resident 16 in February. The DON reviewed Resident 16's medical record and verified the above findings. The DON stated the hospice visitation calendar for February was incomplete, the hospice aide visit notes were not uploaded in the resident's medical records or available in the resident's hospice binder, and the facility's plan of care did not include the frequency of hospice staff visits. On 3/4/26 at 1358 hours, a follow-up interview was conducted with the DON. The DON stated Resident 16 was seen by the hospice aide on 2/2, 2/5, 2/9, 2/12, 2/16, 2/19, 2/23, and 2/26/26. The DON stated the February hospice visitation calendar should have included those visits and the visit notes should have been sent to the facility and uploaded in the resident's medical records. The DON was informed and acknowledge the above findings. 3. Review of the facility's P&P titled Hospice Services Facility Agreement dated 12/19/22, showed it is the policy of this facility to provide and arrange for hospice services in order to protect residents right to a dignified existence, self-determination, and communication with, and access to, persons and service inside and outside of the facility. Review of the facility's Agreement with Hospice A dated 5/10/24, showed under the section hospice services a registered nurse will be assigned to coordinate and supervise care and services for patients and families. Registered nurses' responsibilities include: - coordination and implementation of each hospice patient's plan of care with facility staff. - provision of care as specified in each hospice patient's plan of care. - participation in interdisciplinary team, utilization review, and discharge planning meetings. Medical record review for Resident 22 was initiated on 2/25/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Hospice A medication list showed a physician's order dated 9/2/25, for morphine concentrate 20 mg/ml oral, to administer 5 mg every one hour as needed for shortness of breath or pain. Review of Resident 22's Order Summary Report showed following orders: - dated 9/2/25, to administer morphine sulphate (pain medication) oral solution 20 mg per 5 ml to give 0.25 ml (i.e.1 mg) by mouth every two hours as needed for severe pain; and - dated 2/15/26, to admit Resident 22 to Hospice A with terminal diagnosis of sarcoma (a rare, complex cancer arising from connective tissues like bone, fat, muscle, nerves, and blood vessels). Review of Hospice A's Interdisciplinary Group (IDG) Meeting dated 2/4/26, showed the following visit frequencies for hospice staff: - Chaplain: One visit per month for two months, scheduled from 2/1/26 through 3/31/26. - Nursing: One visit per week for six weeks, scheduled from 2/2/26 through 3/14/26. - Nursing (PRN): Up to three as needed visits, authorized from 1/10/26 through 3/10/26. - Social Worker: One visit per month for two months, scheduled from 2/1/26 through 3/31/26. - Social Worker (PRN): Up to three as needed visits, authorized from 1/10/26 through 3/10/26. Review of Resident 22's IDT Care Conference note dated 2/20/26, for behavioral and psychotropic medication management showed the IDT met with the psychiatric nurse practitioner for the resident's monthly behavior assessment and gradual dose reduction (GDR) review. The resident's current medication regimen has stabilized their behavior. A dose reduction or GDR was not recommended at that time because the resident was receiving hospice care, and the dosage is necessary to maintain emotional and physical comfort during the end of life process. Further review of IDT Care Conference document did not show if the Hospice A staff were the part of the IDT meeting. Review of Resident 22's Hospice A Monthly Calendar for March 2026 showed Resident 22 was visited by Hospice A Chaplin on 3/2/26; however, the calendar did not show the schedule of the Hospice staff visits for the rest of March 2026. Further review of Resident 22's medical record did not show if the frequency of Hospice A staff visits were included in the facility plan of care to provide coordinated patient care. On 3/3/26 at 0838 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 22 was receiving hospice services. LVN 5 stated he was not sure when and how often the hospice staff were visiting Resident 22. LVN 5 stated he was not sure who was the hospice coordinator for the facility. On 3/3/26 at 0930 hours, an interview and concurrent medical record review for Resident 22 was conducted with RN 2. RN 2 verified Resident 22 was receiving hospice services through Hospice A. RN 2 stated he was unable to locate any future schedule indicating when Hospice A staff were expected to visit the resident. RN 2 also confirmed the frequency of hospice staff visits were not included in the facility's plan of care. RN 2 verified the physician's order for the morphine sulfate medication had not been accurately reconciled from the hospice medication list. RN 2 stated the hospice order was for morphine sulfate 20 mg/ml, with instructions to administer 5 mg (0.25 ml) as needed. However, the corresponding order in the facility's system listed the medication concentration as 20 mg per 5 ml. RN 2 acknowledged administering 0.25 ml of this concentration would provide only 1 mg instead of the prescribed 5 mg. RN 2 stated this discrepancy could lead to inadequate pain control for Resident 22. On 3/3/26 at 1347 hours, a follow up interview and concurrent medical record review for Resident 22 was conducted with RN 2. RN 2 stated Hospice A staff should participate in the facility's IDT meetings for residents receiving hospice services. RN 2 verified the IDT meeting conducted for Resident 22 on 2/20/26, which addressed behavioral status and psychotropic medication management, did not include participation from Hospice A staff. On 3/4/26 at 0957 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to ensure the water management program was established and implemented to include the implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they had in place. * The facility failed to ensure there were no soiled, stained towels on top of a drawer in the clean linen area and the washing machine had no dust accumulation. * Housekeeping staff's personal water bottle and a cup of vitamins for personal use were stored in the cart with cleaning supplies, paper towels and tissue papers for resident rooms. * The facility failed to ensure LVN 5 performed hand hygiene after disconnecting Resident 46's feeding tube and before touching the medication cart and keys. * The facility failed to ensure the urinals were not stored hanging on the trash bins for two final sampled residents (Residents 194 and 195). * The facility failed to ensure Resident 68 was placed in isolation precaution for suspected C. diff. infection when the resident had four loose stools in less than 24 hours. In addition, the facility failed to ensure Resident 68's visitor was educated and followed the contact isolation precautions for suspected C. diff and the clinical staff performed hand washing upon leaving the room of Resident 68, who was in contact isolation for suspected C. diff. infection. * The facility failed to ensure Medication Cart E compartment where the pill cutter and label stickers were stored did not have the orange and brown-colored residues, the pill cutter was cleaned after every use, the glucometer did not have the brownish-orange stain and did not have the staff personal keys inside. * The facility failed to ensure CNA reported Resident 200's documented loose stools resulting in no further follow up and change to the residents' isolation precautions. These failures posed the risk for transmission of disease-causing microorganisms and infections to the resident, staff, and visitors.Findings: 1. According to the CDC's guidelines for Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings dated 9/30/25, under the section elements of a water management program showed the following steps: - to establish a water management program team, - to describe water system using text and flow diagrams, - to identify areas where legionella could grow and spread. - decide where control measure should be applied and how to monitor them - establishing the ways to intervene control limits are not met. - make sure program is running as designed and is effective. - document and communicate all the activities. Further review of the CDC guideline showed control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth: Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring, Water heaters should be maintained at appropriate temperatures, Decorative fountains should be kept free of debris and visible biofilm, Disinfectant and other chemical levels in cooling towers and hot tubs should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (i.e., slime) should be cleaned. Under section Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program is being implemented as designed. This step is called verification. Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called validation. Review of the facility's P&P tiled Water Management Program dated 12/19/22, showed it is the policy of the facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens in the facility's water system based on nationally accepted standards. Further review of the P&P showed a risk assessment will be conducted by the water management team annually to identify where legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Review of the facility's P&P titled Legionella Surveillance dated 12/19/22, under the section principles of legionella transmission showed legionella grows best in water temperature of 77-108 degrees Fahrenheit, particularly in water that I not moving or that does not have enough disinfectant to kill germs. Primary prevention strategies under temperature controls showed hot water shall be stored above 140-degree Fahrenheit and circulated at a minimum return temperature of 124-degree Fahrenheit. Review of the facility's Water Safety Program (legionella) dated 1/31/24, showed facility to describe facility water system using diagram and identify areas where legionella can grow and spread. On 2/26/26 at 1001 hours, an observation and concurrent interview was conducted with the Director of Maintenance. The water heater that supplies water to the resident care area was observed to be set at temperature of 119 degrees Fahrenheit. The Director of Maintenance verified the above observation. When asked what temperature the facility stored the cold temperature at, the Director of Maintenance was not able to answer. On 2/26/26 at 1553 hours, an interview and concurrent facility document review was conducted with the IP. The IP was not able to show if the risk assessment for the legionella prevention was conducted in the facility water system. In addition, the IP was not able to show the facility water system using a diagram and areas in the water system where the legionella could grow. When asked what control measures was being used to prevent legionella growth in the facility water system, the IP stated the facility used temperature control and visual inspection; however, the IP was not able to show specific control measures that was being applied in each control area in the facility water system. 2. Review of the facility's P&P titled Handling Clean Linen dated 12/19/22, showed it was the policy of the facility to handle, store, process and transport clean linen in a safe and sanitary method to prevent contamination of linen which can lead to infection. a. On 02/26/26 at 0942 hours, an observation of the laundry area and concurrent interview was conducted with the Housekeeping Supervisor. Two soiled, stained towels were observed on top of a drawer in the clean linen area. The Housekeeping Supervisor verified the observation and stated the soiled towels should not be stored in the clean linen area. The Housekeeping Supervisor was then observed removing the soiled towels and transporting them to the designated soiled laundry area. b. The resident's personal clothing washing machine was observed with dust accumulated around the top of the unit. The Housekeeping Supervisor verified the observation and stated the washing machine should have been cleaned. On 3/4/26 at 0957 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. On 2/27/26 at 0949 hours, an observation and concurrent interview was conducted with Housekeeping Staff 1. Housekeeping Staff 1 was observed standing in the doorway of a resident room with a housekeeping cart in front of her in the hallway. Housekeeping Staff 1 was observed drinking from a reusable water bottle, then placed the bottle inside of the housekeeping cart and then closed the cart door. When asked what was stored inside the cart, Housekeeping Staff 1 opened the door and the water bottle, a clear cup with orange tinted water, paper towels, and toilet paper, and a spray bottle were observed on a shelf. Housekeeping Staff 1 stated it was her water bottle and the cup had her vitamins. Housekeeping Staff 1 grabbed the clear cup with orange tinted water and drank it. Housekeeping Staff 1 stated there were also cleaning chemicals, paper towels and toilet paper for restocking resident rooms. Housekeeping Staff 1 verified she should not have drinks or personal items in the cart. On 2/27/26 at 0954 hours, an interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated the housekeeping carts contain cleaning chemicals as well as supplies to stock the resident rooms including paper towels, toilet paper and hand sanitizer, and no drinks or personal belongings should be in the housekeeping carts. 4. On 2/25/26 at 1020 hours, an observation of the room for Residents 194 and 195 was conducted. Resident 194 was observed with two urinals hanging on the side of the trash bin and Resident 195 had a urinal hanging on the edge of Resident 195's trash bin. Resident 194 stated his urinals had been stored there since he had been using them. The Resident 194 stated the trash bin was not an ideal place to store the urinals, but he did not want the urinals on his bedside tray table and didn't have anywhere else to place them and would still be within his reach. a. Medical record review for Residents 194 was initiated on 2/25/26. Resident 194 was admitted to the facility on [DATE]. b. Medical record review for Residents 195 was initiated on 2/25/26. Resident 195 was admitted to the facility on [DATE]. On 2/25/26 at 1029 hours, an observation and interview was conducted with the DSD. The DSD verified the urinals were stored on the residents trash bins and stated the urinals should not be store hanging on the trash bin due to infection control concerns. 5. Medical record review for Resident 68 was initiated on 2/2/5/26. Resident 68 was readmitted to the facility on [DATE]. Review of the CDC's C. diff Facts for Clinicians dated 3/5/24, showed C. diff is a spore-forming bacteria that is shed in feces, and any surface, device or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores, and can be transferred to other residents. If a resident has three or more stools in a 24 hour period, the resident should be places in isolation for possible and wear gloves and a gown when treating resident's with potential infectious diarrhea. Review of the CDC's C. diff Facts for Clinicians dated 3/5/24, showed C. diff is a spore-forming bacteria that is shed in feces, and any surface, device or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores, and can be transferred to other residents. The guidance also showed hand sanitizer does not kill C. diff. a. Review of Resident 68's Nurse Progress Note dated 2/26/26 at 2236 hours, showed the resident had two loose stools. Review of Resident 68's eINTERACT SBAR Summary for Providers note dated 2/26/26 at 1057 hours, showed the resident had one loose stool yesterday and one this morning. An order was obtained to get a stool specimen and test for C. diff. On 2/26/26 at 1213 hours, an observation and concurrent interview was conducted with Resident 68 at bedside. The resident was on EBP; however, did not have contact isolation precautions implemented. Resident 68 stated he did not feel well and had been having loose stools all night and was still having them. On 2/26/26 at 1254 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 68 had two loose stools so far for her shift. On 2/26/26 at 1255 hours, an interview was conducted with the IP. The IP stated for a resident with three loose stools, they should be placed on isolation for suspected C. diff. When asked why Resident 68 was not in isolation after having four loose stools in less than 24 hours, the IP stated she would double check. The IP verified Resident 68 was not on contact isolation precautions. On 2/26/26 at 1256 hours, an interview and record review was conducted with LVN 1. LVN 1 stated Resident 68 had one loose stool yesterday per the shift report and two today. LVN 1 reviewed Resident 68's medical record and verified the record showed Resident 68 had two loose stools last night and there were four loose stools in 24 hours. LVN 1 stated he obtained a physician's order to obtain a stool specimen to test for C. diff. When asked at what point the resident would be placed on contact isolation, LVN 1 replied when the stool specimen results comes back as positive for C. diff. On 2/26/26 at 1301 hours, an interview was conducted with the IP Lead. The IP Lead stated Resident 68 should have been placed on contact isolation precautions for suspected C. diff since he had four loose stools in 24 hours. b. On 2/26/26 at 1502 hours, an interview was conducted with the DON. The DON stated Resident 68 was now on contact isolation precautions for suspected C. diff. On 2/27/26 at 1051 hours, an observation and concurrent interview was conducted with Family Member 2 in Resident 68's room. Family Member 2 was observed inside Resident 68's room. A Contact Isolation signage was posted outside the room next to Resident 68's doorway. The signage showed to wear an isolation gown and gloves. Family Member 2 was observed not wearing any PPE. Family Member 2 stated no one had told her she needed to wear PPE. Family Member 2 also stated no one told her she had to wash her hands instead of using ABHR. Family Member 2 stated the staff told her Resident 68 was on isolation for his stool. Family Member 2 stated she asked the facility if she could still visit and the facility informed her she could. Family Member 2 further stated the facility never mentioned about needing to wear anything in Resident 68's room. Family Member 2 stated she was at the facility yesterday too and no one had said anything. On 2/27/26 at 1502 hours, an observation and concurrent interview was conducted with NP 1. NP 1 was observed inside Resident 68's room and a contact isolation signage was posted outside the doorway. NP 1 was observed taking off an isolation gown and gloves, used ABHR located outside the doorway, picked up papers on top of the PPE cart, walked to the nurses' station, wrote on a paper, and handed the paper to LVN 1. NP 1 stated she was keeping the resident on isolation pending the test results, since he was recently in the acute care hospital and who knows what he was exposed to in acute hospital. When asked if she washed her hands after leaving the resident's room, NP 1 replied that was why she came to the nurses' station. NP 1 was then observed entering the station and washed her hands. On 2/27/26 at 1534 hours, an interview was conducted with the IP. The IP stated when leaving a room with contact isolation for C. diff., the clinical staff should use ABHR when leaving the room and then go directly to the nurses' station to wash their hands without handling or touching anything else. On 2/27/26 at 1134 hours, an interview was conducted with LVN 1. LVN 1 stated they notified Family Member 2 of the resident being on isolation for suspected C. diff and believed he spoke to her about PPE and hand washing but could not recall specifically. LVN 1 also stated he saw Family Member 2 earlier but could not recall if the family member was in the hallway or the resident's room. 6. On 2/26/26 at 0943 hours, a medication administration observation for Resident 46 was conducted with LVN 5. LVN 5 was observed donning the gown and gloves and entering Resident 46's room. LVN 5 then placed Resident 46's enteral feeding on hold and disconnected the enteral feeding tubing from Resident 46. LVN 5 stated he forgot his stethoscope and was observed retrieving the keys to the medication cart from his pockets. LVN 5 then unlocked the medication cart and removed the stethoscope. LVN 5 was not observed doffing the gloves and performing hand hygiene prior to retrieving the keys and unlocking the medication cart. On 2/26/26 at 1008 hours, an interview was conducted with LVN 5. LVN 5 verified he did not remove the gloves after disconnecting Resident 46's enteral feeding tubing and before touching the medication cart. LVN 5 stated his gloves were contaminated after he touched the resident's GT and he should have removed the gloves, and performed hand hygiene before touching his medication cart, for infection control purposes. 7. On 2/26/26 at 1158 hours, an inspection of Medication Cart E and concurrent interview was conducted with LVN 5. The following were observed: - the compartment storing the pill cutter and label stickers was observed with orange-colored and brown-colored residue, - one pill cutter was observed with significant white powder residue, - the glucometer was observed with multiple brown-orange colored stains, and - one set of personal keys observed in the bottom drawer of the medication cart. LVN 5 verified the above findings. LVN 5 stated the glucometer and pill cutter should be cleaned and disinfected after every use. On 3/4/26 at 0919 hours, an interview was conducted with the DON. The DON stated the licensed nurses were responsible for cleaning the medication carts at the end of every shift. The DON stated the mediation carts should be kept clean at all times and the equipment should be cleaned after every use for infection control purposes and to prevent cross contamination. The DON stated the personal items should not be stored inside the medication carts. On 3/4/26 at 1105 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 8. On 2/25/26 at 0957 hours, during an initial tour of the facility, an observation was conducted for Resident 200. Resident 200 was observed with a signage indicating the resident was on Enhanced Barrier Precautions. On 3/3/26 at 0830 hours, an interview was conducted with Resident 200. Resident 200 verbalized he had a total of four loose stools on 3/2/26. Per Resident 200 the poop ran through me like sift. Per Resident 200 he was wearing diapers. On 3/3/26 at 0847 hours, an interview was conducted with CNA 6. When asked about Resident 200's bowel movements, CNA 6 stated she received a report from the previous shift Resident 200 had two loose stools. Per CNA 6 she was to monitor Resident 200's bowel movements. On 3/3/26 at 0851 hours, an observation, medical record review and concurrent interview was conducted with LVN 7. LVN 7 stated he did not receive any report about Resident 200 having loose bowel movements. LVN 7 was observed asking Resident 200 about his bowel movements and Resident 200 stated he had diarrhea on 3/2/26. Resident 200 was observed with signage indicating Resident 200 was on Enhanced Barrier Precautions. LVN 7 stated Resident 200 wore diapers because he was incontinent. Review of Resident 200's progress notes with LVN 7 showed there were no progress notes mentioning any episodes of diarrhea for Resident 200 on 3/2 or 3/3/26. LVN 7 looked for any change in condition notes and there were no changes in condition documentation related to Resident 200's bowel movements in Resident 200's medical record. Medical record review for Resident 200 was initiated on 3/3/26. Resident 200 was admitted to the facility on [DATE]. Review of his H&P examination dated 2/18/26, showed Resident 200's diagnoses included diabetes and seizure disorder. Review of Resident 200's Documentation Summary Report dated 3/3/26, Resident 200's bowel movements were documented as loose/diarrhea consistency, a total of three times during the day shift. On 3/3/26 at 1515 hours, a concurrent interview and medical record review was conducted with LVN 7 with the DON also present. LVN 7 verified the above findings on 3/3/26, and stated the information were not reported to him. On 3/3/26 at 1540 hours, a follow-up observation was conducted for Resident 200. Resident 200 had signage indicating he was still on Enhanced Barrier Precautions. On 3/4/26 at 0942 hours, a follow up interview was conducted with LVN 7. LVN 7 stated he obtained a stool sample from Resident 200 to rule out C diff. Per LVN 7 the stool sample was more putty-like but it did have a distinct smell to it. On 3/4/26 at 0955 hours, an interview was conducted with CNA 6. When asked about Resident 200's bowel movements documentation on 3/3/26, as having loose consistency, CNA 6 verbalized Resident 200 had no diarrhea but Resident 200 complained he was having diarrhea. CNA 6 stated she changed Resident 200's diaper four to five times at 0730, 1030, and 1200 hours. Per CNA 6 Resident 200's bowel movements were like baby food texture. CNA 6 further stated Resident 200's bowel movements were not watery or loose but they were not formed; therefore, CNA 6 stated she did not know how to document. CNA 6 stated Resident 200 said he felt okay. CNA 6 stated she did not report Resident 200's bowel movements to the nurse because it was not really like diarrhea. CNA 6 stated there was not a good option in the electronic health record system to describe Resident 200's bowel movements.

Based on observation, interview, and facility document review, the facility failed to maintain the cleanliness and sanitation of the essential equipment for two of two ice machines (Ice Machines A and B). * The facility failed to ensure Ice Machine A was cleaned and sanitized using the recommended solution as per the manufacturer's guidelines. * The facility failed to ensure Ice Machine B was cleaned and sanitized as per the manufacturer's guidelines. In addition, the facility failed to ensure the correct solution ratio was used to clean Ice Machine B as per the cleaning agent instruction for use label. These failures had the potential for the essential equipment to be not cleaned and sanitized properly and could cause food contamination and food-borne illnesses to the residents.Findings: Review of the facility's document titled Diet Count by Modification/Portion dated 2/26/26, showed 161 residents who resided in the facility consumed an oral diet. a. Review of the Ice Machine A's manufacturer's guidelines titled Descaling/Sanitizing Procedure (undated) showed the following:- The ice machine and bin or dispenser requires disassembly, descaling and sanitizing every six months. Ice machine descaler is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime.- Only use Manitowoc approved ice machine descaler and sanitizer for this application:Manitowoc Descaler Part Number: 94-0546-3Manitowoc Sanitizer Part Number: 94-0565-3 b. Review of Ice Machine B's manufacturer's guidelines titled User Manual - Modular Ice Machines (undated) showed the Monthly Cleaning Process. The Note showed to empty the bin of ice in advance; clean and sanitize the bin and do a complete rinsing; and clean and sanitize the ice sliding board, water distribution line, water supply line, and water pump, then do a complete rinsing. The process included to put in the proper amount of sanitizing solution manually into the water trough followed by the clean and sanitizing process instruction.Refer to your cleaner and sanitizer for proper mixing and code instructions. On 2/25/26 at 1125 hours, an interview and concurrent observation of Ice Machines A and B was conducted with the Director of Maintenance. The Director of Maintenance stated he would clean Ice Machines A and B. The Director of Maintenance stated he would follow the procedure recommended by the manufacturer to clean and sanitize Ice Machines A and B. The Director of Maintenance presented two bottles of solution he would use to clean and sanitize Ice Machines A and B. The first bottle was labeled Essential Values Ice Machine Cleaner & Descaler and the second bottle was labeled HydroBalance H.B. 30 Ice Machine Cleaner. The Director of Maintenance verified he was using two cleaning solutions instead of having one cleaning solution and one sanitizing solution. The Director of Maintenance further stated he did not have the Manitowoc cleaner in stock and was using the HydroBalance and Essential Value brand cleaners to clean and sanitize Ice Machine A. The Director of Maintenance verified he should have followed the manufacturer's guidelines using Manitowoc brand to clean and sanitize Ice Machine A. Furthermore, the Director of Maintenance also verified he was using HydroBalance and Essential Value brand cleaners to clean and sanitize Ice Machine B. The Director of Maintenance stated he would follow the instructions on the cleaning solution bottle. The Director of Maintenance stated when cleaning Ice Machine B, he would use 6 to 7 ounces of cleaning solution per gallon of water. On 2/25/26 at 1456 hours, an observation and concurrent interview was conducted with the Director of Maintenance. An observation of the Essential Values Ice Machine Cleaner and Descaler bottle was conducted. The back label of the cleaning solution showed Instructions for Use: Remove all ice prior to cleaning. Mix 4 ounces of ice machine cleaner with one gallon of water. Do not mix with any other cleaner or chemicals prior to use. Follow the manufacturer's recommended cleaning instructions. For severe scale buildup repeated cleaning cycles may be required with fresh cleaning solution. The Director of Maintenance verified he was not using the correct ratio of the cleaning solution to water when cleaning Ice Machine B.

Based on observation, interview, and facility P&P review, the facility failed to ensure an effective pest management program was in place. * The facility failed to ensure there were no small flies in the residents dining room. This failure posed the risk of pest contamination during residents mealtimes.Findings: Review of the P&P titled Control of Pests dated 6/2024 showed the community must have a pest control program in place. The section for Procedure - 11. Pest control operators should conduct additional treatments if pests are observed in the community. On 2/25/26 at 0930 hours, an observation of the resident dining was conducted, six small flies resembling fruit flies (a tiny common household pest that can carry bacteria that can contaminate food) were observed. The wall in the resident dining room had a dark pinprick-sized specks residue which resembled fruit fly excrement. On 2/26/26 at 0900 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the facility had an outside pest control company that would service the facility monthly. When asked about the small flies and dark pinprick-sized residue on the walls in the dining room, the Director of Maintenance stated he was not aware of the flies and did not know what the dark pinprick-sized residue were. The Director of Maintenance stated he would call the pest control company. Review of the pest control reports dated 11/19 and 12/16/25, and 1/6 and 2/3/26, did not show the treatment for flies. On 2/26/26 at 0924 hours, an interview was conducted with the DSS. The DSS confirmed he was responsible for the dining room and kitchen areas. The DSS stated if he saw any type of pest he would report it. The DSS stated he was not aware of the small flies or the dark pinpricked-sized residue in the resident dining room. On 2/26/26 at 1020 hours, a follow-up observation of the resident dining room and concurrent interview was conducted with the Director of Maintenance. The facility staff were observed cleaning the walls of the resident dining room. The Director of Maintenance stated he took a picture of the dark pinprick-sized residue on the walls of the dining room and would show it to the pest control company. On 3/2/26 at 1056 hours, a telephone interview was conducted with the Pest Control Vendor 1. Pest Control Vendor 1 stated he treated the dining room for flies on 2/26/26. When asked about the dark pinprick-sized residue on the walls of the dining room, the pest control technician stated the dark pinprick-sized residue could be fruit fly excrement, but he would not confirm if it was fruit fly excrement.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 32 final sampled residents (Resident 187) and one nonsampled resident (Resident 162) was assessed, had a care plan and a physician's order to self-administer the medications. * The facility failed to ensure safe self- administration of a medication for Resident 162. * Resident 187's bedside table had an eye drop medications (artificial tears and refresh plus lubricant). There were no self-administration assessment, care plan or physician's order to self-administer the medications and physician's order for the eye drop medications. These failures had the potential for the residents to administer the medications inaccurately and negatively impact the residents' physiological well-being.Findings: 1. Review of the facility's P&P titled Resident Self- Administration of Medication dated 12/19/22, showed a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. A self-administration assessment was conducted by the interdisciplinary team and the assessment are recorded on the medical records. Medications at bedside are with physician's order in the same manner as other medications. On 2/25/26 at 0928 hours, during the initial tour of the facility, Resident 187 was observed in bed. There were eye drop medications (artificial tears and refresh plus lubricant) on the top of the bedside drawer. On 2/26/26 at 1121 hours, an observation and concurrent interview with LVN 10 was conducted at Resident 187's bedside. LVN 10 verified two eye drops medications were on top of Resident 187's bedside drawer. LVN 10 stated the eye drop medication did not belong to Resident 187 and was uncertain to whom they belonged. Medical record review for Resident 187 was initiated on 2/26/26. Resident 187 was admitted to the facility on [DATE]. Review of Resident 187's H&P examination dated 2/14/26, showed Resident 187 had the capacity to make decisions. Review of Resident 187's Order Summary Report dated 2/26/26, failed to show a physician's order for the artificial tears and refresh plus lubricant eye drops medication. In addition, there was no physician's order to self- administer medication was obtained for Resident 187. Further review of Resident 187's medical record failed to show documented evidence a self-administration of medication assessment was conducted. On 2/26/26 at 1316 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 187 used her eye drops medication at home and used to administering by herself the eye drop medication. Family Member 1 stated she was not sure if the nurses evaluated and assessed Resident 187 on self-administering the eye drop medications. On 2/26/2026 at 1545 hours, an interview and concurrent medical record review for Resident 187 was conducted with RN 2. RN 2 stated they need to have a physician's order for the medication and the resident should be assessed for self-administration of medication. RN 2 verified there was no physician's order for artificial tears and refresh eye lubricant for Resident 187. RN 2 verified there was no assessment, physician's order, or care plan for self-administering medications for Resident 187. On 3/4/26 at 1056 hours, an interview and concurrent medical record review for Resident 187 was conducted with the DON. The DON was informed and verified the above findings. 2. Review of the facility's P&P titled Resident Self- Administration of Medication dated 12/19/22, showed a resident may only self-administer medication after the facility's interdisciplinary team has determined which medication may be self-administered safely. All nurses and aids are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. On 2/25/26 at 0938 hours, an observation and concurrent interview with Resident 162 was conducted at Resident 162's bedside. There was an eye drop medication at the bedside. Resident 162 stated her eye doctor prescribed the medication for her cataracts (a common age-related clouding of the eye's natural lens, causing blurry vision, glare, and faded colors) and she has been administering the medication by herself at the facility. Resident 162 stated she has been storing the eyedrop medication at the bedside and the facility staff were aware that she had the eyedrop at the bedside. Medical record review for Resident 162 was initiated on 2/25/26. Resident 162 was admitted to the facility on [DATE]. Review of Resident 162's H&P examination dated 5/29/25, showed Resident 162 had the capacity to understand and make decisions. Review of Resident 162's Self-Administration of Medication dated 8/18/25, showed Resident 162 was capable of self-administration of the medication. However, the above assessment did not show if Resident 162 could safely administer the eye drops stored at the bedside. Further review of Resident 162's medical record failed to show a physician's order for the eye drop medication. On 2/25/26 at 0941 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified the observation. LVN 5 stated the eye drop medication should not have been stored unlocked at the bedside. LVN 5 further stated there was potential for unauthorized access to other residents and visitors. LVN 5 verified there was no physician's order for the eye drop medication and verified the above findings. LVN 5 stated the eye drop medication should be stored in a locked container. On 3/4/26 at 0957 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the Advanced Directive for one of six final sampled residents (Resident 107) investigated for Advanced Directives. * Resident 107's Advanced Directive was not in the medical record. This failure had the potential for the resident's wishes related to the provision of medical treatment and services to not be followed if the resident was unable to make medical decisions for themselves.Findings: Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives dated 12/19/22, showed on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. In the event the resident is unable to formulate an advanced directive due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. Medical record review for Resident 107 was initiated on 3/3/26. Resident 107 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 107's Physician Orders for Life Sustaining Treatment (POLST) dated 1/20/26, showed Resident 107 had the capacity and the advance directive not available. Review of Resident 107's Internal Medicine History & Physical / Progress Note dated 1/21/26, showed Resident 107 had the capacity to make decisions. Review of the Advance Directive Acknowledgement form dated 1/21/26, showed Resident 107 have executed an advance directive and signed by the resident. Review of Resident 107's Social Service assessment dated [DATE], failed to show whether Resident 107 had an advance directive. Further review of Resident 107's medical record failed to show a copy of the advance directive was obtained and maintained in the medical record. In addition, the medical records failed to show documented evidence the facility staff followed up with the resident or their family representative. On 3/3/26 at 1445 hours, an interview was conducted with Resident 107. Resident 107 verified and acknowledged he had an advance directive and provided a copy to facility staff when he was admitted to the facility. Resident 107 stated he formulated his advance directive a few months ago. On 3/3/26 at 1451 hours, an interview and concurrent medical record review for Resident 107 was conducted with SSD 1. SSD 1 stated if the resident had an advance directive, they would request a copy and keep it in the medical records. SSD 1 reviewed Resident 107's medical record and verified Resident 107 had an advance directive based on the acknowledgement form. SSD 1 stated he was not able to locate a copy of Resident 107's advance directive and verified the findings. On 3/4/26 at 1033 hours, an interview and concurrent medical record review for Resident 107 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident privacy for one of four final sampled residents (Resident 68) investigated for tube feeding. * Resident 68 was not provided privacy during a GT feeding administration. This failure had the potential for the resident to experience a negative outcome and feel exposed.Findings: Review of the facility's P&P titled Promoting/Maintaining Resident Dignity dated 9/2/22, showed the staff will maintain resident privacy. Review of the facility's P&P titled Flushing A Feeding Tube dated 12/19/22, showed to provide privacy by pulling the privacy curtain. Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's Order Summary Report showed the following physician's orders:- dated 2/24/26, for Jevity 1.5 (enteral feeding formula) to be administered via GT at 65 ml/hr for 20 hours; and- dated 2/24/26, to flush the GT with water at 65 ml/hr for 20 hours. On 2/25/26 at 1221 hours, an observation of RN 1 starting Resident 68's GT feeding and water flush was observed in Resident 68's room. The resident's privacy curtain was pulled between the resident and the doorway to the hallway, however there was no privacy curtain pulled between Resident 68 and their roommate. Both residents were sitting in their wheelchairs approximately two feet from each other. RN 1 lifted Resident 68's hospital gown exposing the resident's abdomen and incontinence brief, placed a stethoscope on the resident's abdomen to check tube placement, and then aspirated gastric contents with a 60 ml syringe. RN 1 then connected the tubing for the Jevity 1.5 and water flushes, and put the resident's gown back down. RN 1 verified he did not pull the privacy curtain between Resident 68 and his roommate before exposing the resident's abdomen and incontinent brief. On 2/27/26 at 0817 hours, during an interview with the DON, the DON stated the privacy curtain should have been pulled between Resident 68 and his roommate for GT care to ensure privacy.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of 32 final sampled residents (Residents 3, 13, and 16) were free from the unnecessary psychotropic medications. * The facility failed to ensure the nonpharmacological interventions were provided to Resident 3 when Resident 3 had behavior episodes related to the use of quetiapine (antipsychotic medication) and lorazepam (antianxiety medication). * The facility failed to ensure the behaviors were monitored related to the use of quetiapine for Resident 13. In addition, orthostatic blood pressure was not monitored related to the use of the quetiapine medication for Resident 13. * The facility failed to ensure Resident 16's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the quetiapine medication. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of the psychotropic medications.Findings: Review of facility's P&P titled Use of Psychotropic Medication Use dated 12/19/22, showed resident do not receive psychotropic medications unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident response to the medications. Resident who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Further of the P&P showed the resident's response to the medication (s), including progress towards goal and presence /absence of adverse consequences, shall be documented in the resident medical records. The effects of the psychotropic medication on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: - upon physician evaluation routine and as needed, - during the pharmacist monthly medication regimen review, - during significant change, and - in accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer specification, and residents comprehensive plan of care. 1. Medical record review for Resident 3 was initiated on 2/25/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/24/25, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 5/22/24, lorazepam tablet 0.5 mg to give one tablet by mouth in the afternoon for anxiety as manifested by inability to relax as evidenced by persistent screaming; - dated 5/26/25, for quetiapine fumarate oral tablet 25 mg, to give one tablet by mouth two times a day for schizoaffective disorder as manifested by sudden angry outburst; - dated 5/26/25, for quetiapine fumarate oral tablet 50 mg, to give one tablet by mouth at bedtime for schizoaffective disorder as manifested by sudden angry outburst; - dated 9/23/24, to monitor behavior related to use of antipsychotic medication for schizoaffective disorder as manifested by sudden angry outburst. To monitor number of episodes of behavior observed. Nonpharmacological interventions include relaxation, adjust room temperature/lighting, reposition, toileting, music/television, and snacks; and - dated 11/5/24, to monitor behavior related to use of antianxiety medication Ativan for anxiety as manifested by inability to relax as evidenced by persistent screaming. To monitor number of episodes of behavior observed. Nonpharmacological interventions include relaxation, to adjust room temperature/lightening, repositioning, toileting, music/television, and snacks. Review of Resident 3's MAR dated for February 2026 showed the following: * For episodes of sudden angry outbursts related to the use of quetiapine: - dated 2/3/26, during the evening shift (1900–0700 hours), Resident 3 had two episodes of the behavior; - dated 2/10/26, during the evening shift, Resident 3 had one episode of the behavior; and - dated 2/28/26, during the morning shift (0700–1900 hours), Resident 3 had one episode of the behavior. * For episodes of persistent screaming related to the use of lorazepam: - dated 2/3/26, during the evening shift, Resident 3 had two episodes of the behavior; and - dated 2/28/26, during morning shift, Resident 3 had one episode of the behavior. Further review of the MAR did not show if nonpharmacological interventions were provided when Resident 3 had the above episodes of the behavior related to the use of quetiapine and lorazepam medications. On 3/3/26 at 0953 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 2. RN 2 verified the physician's orders for quetiapine and lorazepam included monitoring behaviors of sudden angry outburst related to the use of quetiapine, and persistent screaming related to the use of lorazepam and providing the nonpharmacological interventions as needed. RN 2 verified Resident 3 had the above behavior episodes related to the use of quetiapine and lorazepam medications. RN 2 also verified there was no documented evidence to show the nonpharmacological interventions were provided during these episodes. 2. Medical record review for Resident 13 was initiated on 2/25/26. Resident 13 was admitted to the facility on [DATE]. Review Resident 13's H&P examination dated 12/18/25, showed Resident 13 had no capacity to understand and make medical decisions. a. Review of Resident 13's Order Summary Report showed an order dated 12/17/25, for quetiapine fumarate oral tablet 25 mg, to give one tablet by mouth two times a day for psychosis as manifested by disorganized thinking. Review of Resident 13's MAR for January 2026 showed an order dated 12/17/25, to monitor the resident for psychosis manifested by disorganized thinking. There was no documented evidence the resident was monitored for their behaviors after 1/4/26. Review of Resident 13's medical record failed to show documented evidence Resident 13's behaviors related to the use of quetiapine were being monitored since 1/4/26. b. Review of Resident 13's MAR for January 2026 showed an order dated 12/21/25, to monitor the resident's orthostatic blood pressure due to antipsychotic every day shift every Sunday sitting, standing and lying down positions. There was no documented evidence the resident's BP was being monitored in either sitting, standing or lying down positions. Review of Resident 13's Change in Condition Notes dated 2/2, 2/20, and 3/2/26, showed Resident 13 had fall incidents on 2/2, 2/20, and 3/2/26. Further review of Resident 13's medical record failed to show documented evidence the resident's orthostatic blood pressure was monitored related to the use of antipsychotic medication. On 3/3/26 at 1352 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 2. RN 2 verified the physician's order for the quetiapine medication for Resident 13 was due to psychosis manifested by disorganized thinking. RN 2 confirmed the behavior of disorganized thinking had not been monitored since 1/4/26. RN 2 also verified the orthostatic blood pressure monitoring, which was required for residents receiving antipsychotic medications, was not being completed. RN 2 stated that antipsychotic medications can cause orthostatic hypotension, which increases the risk of falls for residents receiving these medications. RN 2 further verified Resident 13 had experienced three fall incidents since February 2026. On 3/4/26 at 0957 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 16 was initiated on 2/25/26. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 16's Order Summary Report dated 2/26/26, showed the following physician's orders: - dated 10/30/24, for the use of the quetiapine antipsychotic medication, to monitor Resident 16's orthostatic blood pressure in the lying position every Sunday during the day shift; - dated 10/30/24, for the use of the quetiapine antipsychotic medication, to monitor Resident 16's orthostatic blood pressure in the sitting position every Sunday during the day shift; - dated 10/30/24, for the use of the quetiapine antipsychotic medication, to monitor Resident 16's orthostatic blood pressure in the standing (if able) position every Sunday during the day shift; and - dated 9/10/25, to administer quetiapine 50 mg by mouth two times a day for schizophrenia manifested by extreme paranoia as evidenced by visual/auditory hallucinations. Review of Resident 16's MAR for February 2026 showed the following documentation of Resident 16's blood pressure readings: - dated 2/1/26, the BP readings were 122/73 mmHg for the lying, sitting, and standing positions; - dated 2/8/26, the BP readings were 130/64 mmHg for the lying, sitting, and standing positions; - dated 2/15/26, the BP readings were 127/68 mmHg for the lying and sitting positions; and - dated 2/22/26, the BP readings were 121/65 mmHg for the lying and sitting positions. On 3/3/26 at 1534 hours, an interview and concurrent medical record review for Resident 16 was conducted with the DON. The DON stated for the resident on an antipsychotic medication, residents were monitored for behavior every shift as well as monitoring for side effects. The DON further stated the residents on the antipsychotic medications were monitored for orthostatic hypotension weekly. The DON reviewed Resident 16's medical record and verified the above findings. The DON stated the monitoring for orthostatic hypotension was done inaccurately for Resident 16. On 3/4/26 at 1105 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 68) investigated for hospitalization was readmitted to their prior room upon return to the facility. * Resident 68 was not readmitted to the same room after returning from the acute care hospital after two days. This failure resulted in the resident being upset having to switch his room once readmitted to the facility. Findings: Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 68's Order Summary Report showed a physician's order dated 2/22/26, for a bed-hold for seven days. Review of Resident 68's Nurse Progress Note dated 2/22/26 at 1920 hours, showed the resident was transferred to an acute care hospital. Review of Resident 68's N ADV Clinical admission Assessment Note dated 2/24/26 at 2057 hours, showed the resident arrived back at the facility by ambulance. Review of Resident 68's Census List (undated) showed the resident was admitted to Room A on 2/6/26, and was readmitted to Room B on 2/24/26. Review of the facility's facility midnight census reports dated 2/22 to 2/24/26, showed Room A was empty. On 2/26/26 at 1213 hours, an interview was conducted with Resident 68. Resident 68 stated he was readmitted to the facility into a new room and was expecting and wanting to be in his original Room A. On 2/27/26 at 1051 hours, a follow-up interview was conducted with Resident 68 and Family Member 2. Family Member 2 stated she was surprised when Resident 68 was readmitted to a different room because they had a bed-hold and assumed Resident 68 would return to his original Room A. On 2/27/26 at 1333 hours, an interview and concurrent medical record review for Resident 68 was conducted with the DON. The DON verified Resident 68 had a physician's order for a bed-hold and the resident was not readmitted to his previous room even though it was available. (Cross reference with 628).

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of two final sampled residents (Resident 68) investigated for hospitalization. * Resident 68 was not provided a bed-hold notice when he was discharged from the facility to the acute care hospital on 2/22/26. This failure resulted in the resident being upset having to switch his room once readmitted to the facility. Findings: Review of the facility's P&P titled Bed Hold Notice Upon Transfer dated 12/19/22, showed before a resident is transferred to the hospital, the facility will provide to the resident or the responsible party written information about the duration of the bed-hold policy and the reserve bed payment, if any. Medical record review for Resident 68 was initiated on 2/25/26. Resident 68 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 68's Bed Hold Notification Informed Consent form dated 2/16/26, showed the resident was notified of his right to a bed-hold. The form was only completed on the top section which showed On Admission, and was blank for the Confirmation of Transfer & Bed-hold Provision and 24 Hour Notification sections. The form failed to show the estimated daily rate and whether a bed hold was offered to the resident on 2/22/26. Review of Resident 68's Order Summary Report showed a physician's order dated 2/22/26, for a bed-hold for seven days. Review of Resident 68's Nurse Progress Note dated 2/22/26 at 1920 hours, showed the resident was transferred to an acute care hospital. Review of Resident 68's N ADV Clinical admission Assessment Note dated 2/24/26 at 2057 hours, showed the resident arrived back at the facility via ambulance. Review of Resident 68's Census List (undated) showed the resident was admitted to Room A on 2/6/26 with an active status, stop billing status on 2/22/26, and was readmitted to Room B on 2/24/26 with an active status. Review of Resident 68's medical record failed to show a bed-hold was offered and/or accepted when the resident was transferred to an acute care hospital on 2/22/26. On 2/26/26 at 1537 hours, an interview and concurrent medical record review for Resident 68 was conducted with the DON. The DON stated on admission, the resident or their responsible party will sign information regarding a bed-hold. The DON stated if the resident leaves the facility for a hospitalization, staff will ask the resident if they would like a bed-hold and if accepted, sign the bed-hold consent. The DON stated the facility would then get a physician's order for a bed-hold. The DON stated if the resident's insurance would not cover the bed-hold payment, the business office would follow up on it. The DON stated Resident 68 had a physician's order for a seven day bed-hold dated 2/22/26. The DON further stated since the facility had an order, she would expect consent was obtained for a bed-hold. The DON reviewed Resident 68's census list and stated on 2/22/26, it showed to stop billing, which was done by the business office staff to discharge the resident. The DON stated the business office staff must have discharged the resident because his insurance did not cover the bed-hold rate. On 2/27/26 at 1048 hours, an interview was conducted with the MRD. The MRD stated there was no closed chart for Resident 68's 2/6/26 admission. The MRD stated it was part of the resident's active chart because the resident was out on a bed-hold and not discharged from the facility. The MRD stated she was unable to find a signed bed-hold consent in the resident's medical records for 2/22/26. On 2/27/26 at 1051 hours, a follow-up interview was conducted with Resident 68 and Family Member 2. Family Member 2 stated she was surprised when Resident 68 was readmitted to a different room because they had signed a bed-hold and assumed Resident 68 would return to his original Room A. Family Member 2 and Resident 68 stated no one from the facility told her if insurance would not cover the resident's bed-hold, or what the daily rate would be. On 2/27/26 at 1105 hours, an interview and concurrent medical record review for Resident 68 was conducted with the BOM. The BOM stated the residents can have a bed-hold if they have MediCal. The BOM stated the facility would then get a physician's order for a seven day bed-hold. The BOM stated if the resident did not have MediCal, the business office would contact the family about the daily $750 bed-hold rate. The BOM stated Resident 68 did not have MediCal for his bed-hold and was discharged . The BOM stated she believed she spoke to the resident's wife but could not recall. The BOM stated she did not have access to the resident's clinical record to document, and did not have any notes to show she discussed a bed-hold rate with the resident or Family Member 2. The BOM stated maybe she heard Family Member 2 did not want a bed-hold from the admissions department. The BOM reviewed Resident 68's file and stated the resident was self-responsible. On 2/27/26 at 1113 hours, an interview was conducted with the Admissions Director and Admissions Staff. The Admissions Director and Admissions Staff both stated they were not part of the bed-hold process and were not aware of any specific information regarding Resident 68's bed-hold. (Cross reference with 627).

Based on interview and medical record review, and facility P&P review, the facility failed to ensure the PASARR recommendations were followed up and incorporated into the resident care for one of three final sampled residents (Resident 3) reviewed for PASARR. * Resident 3's PASARR - level II determination recommendations were not followed up and incorporated into the resident's care. This failure had the potential for Resident 3 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by an appropriate state-designated authority.Findings: Review of the facility P&P titled Resident Assessment-Coordination with PASARR Program dated 12/19/22, showed recommendations such as any specialized services, from a PASARR level II determination and PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of the facility's P&P titled Comprehensive Care Plans dated 12/19/22, showed the comprehensive care plan will describe any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. Medical record review for Resident 3 is initiated on 2/25/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/24/25, showed Resident 3 had no capacity to understand and make decisions. Review of the Department of Health Care Services' letter sent to Resident 3 dated 10/27/25, showed the PASARR level II evaluation was conducted on 10/27/25. The letter further showed the facility staff would receive the copy of the determination report and discuss the result with Resident 3 and would incorporate the recommendations into Resident 3's care plan. Review of Resident 3's PASARR Individualized Determination Report dated 10/27/25, showed Resident 3 required nursing facility services due to a medical and/or mental health condition. The PASARR Individualized Determination Report further showed special services were recommended. Further review of Resident 3's medical record did not show the recommendations from the PASARR Individualized Determination Report was followed up. Review of Resident 3's care plans failed to show a care plan was developed for addressing the recommendations from the PASARR Individualized Determination Report. On 2/27/26 at 1017 hours, an interview and a concurrent medical record review for Resident 3 was conducted with MDS Coordinator 3. MDS Coordinator 3 verified the above findings and stated he could not find documented evidence showing the recommendations from the PASARR level II determination was followed up. MDS Coordinator 3 reviewed the care plan and stated he could not find the care plan problem addressing the recommendation for specialized services as per the PASARR Individualized Determination Report. MDS Coordinator 3 stated Resident 3 was receiving services recommended from PASARR level II determination even before PASARR level II evaluation was conducted and were already part of Resident 3's care plan. However, MDS Coordinator 3 stated the care plan did not address the PASSAR level II evaluation and its result. The MDS Coordinator acknowledged there was a possibility the recommendation from the PASSAR level II evaluation could have been missed. On 3/4/26 at 0957 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan for two of 32 final sampled residents (Residents 7 and 90). * The facility failed to develop a care plan to address Resident 7's preference to lower his head of the bed during GT feeding. Additionally, there was no care plan developed to address Resident 7's use of hearing devices. * The facility failed to develop a care plan to address Resident 90's weight loss of 11.5% in one month. These failures had the potential for the resident's needs not being communicated to the IDT and placed the resident at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed the care planning process will include an assessment of the resident's strength's and needs, and will incorporate the resident's personal preferences. The care plan will describe any services that would otherwise be furnished, but are not provided due to the resident's exercises of his right to refuse treatment. The P&P further showed the following: - The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change; - The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change; and - Procedure for reviewing and revising the care plan when a resident experiences a status change: The care plan will be updated with the new or modified interventions. 1. Medical record review for Resident 7 was initiated on 2/25/26. Resident 7 was readmitted to the facility on [DATE]. a. Review of Resident 7's Order Summary Report showed the following orders:- dated 1/6/26, to elevate the head of the bed 30-45 degrees while tube feeding is infusing; and - dated 1/26/26, for Jevity 1.5 to be administered at 65 ml/hr for 20 hours a day. Review of Resident 7's care plan for swallowing with the goal of not having an injury related to due aspiration dated 1/23/26, showed interventions including to keep the head of the bed elevated at least 30-45 degrees during tube feeding. On 2/25/26 at 1251 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated for the residents with a tube feeding infusing, the head of the bed should be elevated to 30-45 degrees as an aspiration precaution. LVN 1 went to Resident 7's bedside and verified the resident's tube feeding was infusing and the head of the bed was elevated 16 degrees using an electronic level, not the required 30-45 degrees. LVN 1 stated the resident puts the head of the bed down himself, elevated the head of the bed and reminded the resident to keep it elevated. Resident 7 confirmed he put it down himself. On 2/26/26 at 1600 hours, Resident 7 was observed sleeping in bed with the tube feeding infusing, the head of the bed elevated 17 degrees using an electronic level. On 2/27/26 at 0750 hours, Resident 7 was observed sleeping in bed with the tube feeding infusing, the head of the bed elevated 15 degrees using an electronic level. On 2/27/26 at 0822 hours, an interview and concurrent medical record review for Resident 7 was conducted with the DON. The DON stated Resident 7's head of bed should be elevated 30-45 degrees. The DON stated LVN 1 told her earlier the resident preferred to keep it lower. The DON verified Resident 7's care plan failed to address the resident preference to keep his head of the bed lowered. b. Review of Resident 7's Resident's Clothing and Possessions form dated 10/14/25, showed the resident's left and right hearing aids and charger were brought to the facility. Review of Resident 7's N Adv – Clinical admission – V 29 assessment dated [DATE], showed the resident had right and left hearing aids, which were worn on admission. Review of Resident 7's Activity Assessment – V4 dated 1/9/26, showed the resident used hearing aids in both ears. Review of Resident 7's care plan for impaired hearing initiated 1/23/26, failed to mention Resident 7 used hearing devices. On 2/25/26 at 1250 hours, Resident 7 was observed in bed. When attempting to talk to Resident 7, he replied I can't hear well. When asked if he had hearing aids while pointing to ears, Resident 7 stated they forgot to charge them last night. After writer attempted in a louder voice closer to the resident, the resident still could not understand and started to get frustrated. On 2/27/26 at 1019 hours, during an observation, Resident 7 was in bed. Resident 7 stated he charged his hearing aids himself last night, but only wanted to wear the left one right now. Resident 7 stated he keeps his hearing aids at his bedside and charges. On 2/27/26 at 1137 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 1. LVN 1 stated residents with hearing aids should have a physician's order for hearing aids. LVN 1 stated Resident 7 did not have hearing aids. LVN 1 reviewed the above records and verified Resident 7 did in fact have the hearing aids. LVN 1 verified the resident's care plan showed the resident was hard of hearing, but failed to address use of the hearing aids. On 3/4/26 at 0939 hours, the DON stated resident care plans should address the use of the hearing aids. (Cross reference with F693 example 2, and F685) 2. Medical record review for Resident 90 was initiated on 3/2/26. Resident 90 was admitted to the facility on [DATE]. Review of Resident 90's Weights from December 2025 to February 2026 showed the following: - dated 12/28/25, a weight of 154.0 lbs.; - dated 1/7/26, a weight of 156.0 lbs.; - dated 1/29/26, a weight of 156.0 lbs.; and - dated 2/4/26, a weight of 138.0 lbs. Review of Resident 90's IDT Care Conference Note dated 2/4/26, showed Resident 90 had a weight loss of 11.5% in one month. The RD's recommendations included for the resident to have large entree portions TID. Review of Resident 90's H&P examination 2/19/26, showed Resident 90 had the capacity to make medical decisions. Review of Resident 90's care plans failed to show a care plan was developed for the resident's weight loss of 11.5% in one month. Additionally, there was no indication the RD's recommendation to have large entrée portions TID was implemented by the facility per the IDT meeting on 2/4/26. On 3/2/26 at 1429 hours, an interview and concurrent medical record review for Resident 90 was conducted with the RD. The RD verified there was no care plan developed for the resident's weight loss of 11.5%. The RD verified the above finding.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three final sampled residents (Resident 174) reviewed for accidents. * The facility failed to ensure Resident 174 was accurately assessed for the neurological evaluations after a fall incident on 2/9/26. The facility documented the same vitals signs from the previous neurological evaluations. In addition, the facility failed to ensure Resident 174's blood pressure readings for the sitting, lying, and standing positions were obtained, as per the care plan intervention for Resident 174's fall. These failures had the potential for Resident 174 to not receive the necessary care and services to maintain the resident's highest physical well-being.Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed when any resident experiences a fall, the facility will:- assess the resident.- complete a post-fall assessment.- complete an incident report.- notify the physician and family.- review the residents care plan and update as indicated.- document all assessments and actions.- obtain witness statements in the case of injury. Review of the facility's P&P titled Comprehensive Care Plan revised 12/19/22, showed the comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Medical record review for Resident 174 was initiated on 2/25/26. Resident 174 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 174's H&P examination dated 12/1/25, showed Resident 174 had the capacity to make medical decisions. Reviewed of Resident 174's Progress Notes dated 2/9/26 at 1700 hours, showed a note titled einteract SBAR Summary for Providers for Resident 174's change in condition related to a fall. Under Primary Care Provider Feedback-Recommendations, showed the NP was present in the building and ordered the neurological check for 72 hours. Review of Resident 174's care plan for unwitnessed fall dated 2/9/26, showed the following interventions:- to conduct neurological checks for 72 hours; and- to obtain vital signs as ordered. Take the blood pressure for the lying, sitting, and standing, one time in the first 24 hours. Review of Resident 174's Neurological Flowsheet initiated 2/9/26 at 1700 hours, showed the following documentation for the neurological assessments/evaluations:- 2/9/26 at 1900 hours, the most recent BP was 138/80 mmHg, the most recent pulse was 70 beats per minute, the most recent respiration was 18 breaths per minute. The documentation showed the above vital signed were obtained on 2/9/26 at 1911 hours;- 2/9/26 at 2000 hours, the most recent BP was 134/78 mmHg and the most recent pulse was 72 bpm (both were obtained on 2/9/26 at 2043 hours); and the most recent respiration was documented as 18 breaths per minute (however, the documentation showed the respirations were obtained on 2/9/26 at 1911 hours);- 2/9/26 at 2100 hours, the most recent BP was 134/78 mmHg and the most recent pulse was 72 bpm (both were obtained on 2/9/26 at 2043 hours); the most recent respiration was documented as 18 breaths per minute (however, the documentation showed the respirations were obtained on 2/9/26 at 1911 hours); the most recent pain level was documented as 0 (out of 10, however, the documentation showed the pain level was obtained on 2/9/26 at 1912 hours);- 2/9/26 at 2300 hours, the most recent pulse was 72 beats per minute (however, the documentation showed the pulse was obtained on 2/9/26 at 2043 hours); the most recent respiration was 18 breaths per minute (however, the documentation showed the respiration were obtained on 2/9/26 at 1911 hours); and- 2/11/26 at 0100 hours, the most recent BP was 108/60 mmHg (obtained on 2/10/26 at 2304 hours), the most recent pulse was 87 beats per minute (obtained on 2/10/26 at 2022 hours), the most recent respirations was 18 breaths per minute and most recent pain level was 0 (both obtained on 2/1026 at 2221 hours). Further review of Resident 174's medical record failed to show the documented evidence Resident 174's BP was obtained in the sitting, lying, and standing positions within the first 24 hours of Resident 174's fall, as per the care plan interventions for Resident 174's fall on 2/9/26. On 3/3/26 at 0825 hours, an interview and concurrent medical record review for Resident 174 was conducted with RN 2. RN 2 stated for the unwitnessed falls at the facility, the residents would be assessed for injuries and if the resident remained at the facility following the fall incident, the neurological evaluations would be completed per the facility protocol. RN 2 stated the purpose of the 72- hour neurological evaluations was to determine if the resident had any neurological complications related to the fall, which may occur over time. RN 2 stated the neurological evaluations assessed the resident for pupillary size and response, speech and motor responses, and level of consciousness. RN 2 stated new sets of vital signs should be obtained for every neurological evaluation, including the assessment for pain. RN 2 stated following each neurological evaluation, the licensed nurse should compare the assessment findings to the previous and baseline findings, to determine if there were any significant changes. RN 2 reviewed Resident 174's medical records and verified the above findings. RN 2 reviewed Resident 174's care plan addressing the resident's fall on 2/9/26. When asked to show the documentation Resident 174's BP was obtained as per the care plan interventions, RN 2 verified there was no documented evidence Resident 174's BP readings were obtained in the sitting, lying, and standing positions. On 3/4/26 at 0919 hours, an interview was conducted with the DON. The DON stated following an unwitnessed fall at the facility, the licensed nurses should conduct the 72-hour neurological evaluations as per the facility protocol. The DON stated new vital signs should be obtained for every neurological evaluation and the assessment findings of each evaluation should be compared to determine if there were any changes in the resident's condition. On 3/4/26 at 1105 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 7) investigated for hearing received proper assistance with devices to maintain hearing abilities. * Resident 7 had no physician's order for hearing aid use, and the facility did not charge or assist him with his devices. This failure resulted for the resident having difficulty communicating with others. Findings: Medical record review for Resident 7 was initiated on 2/25/26. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's Resident's Clothing and Possessions form dated 10/14/25, showed the resident's left and right hearing aids and charger were brought to the facility. Review of Resident 7's N Adv - Clinical admission - V 29 assessment dated [DATE], showed the resident had right and left hearing aids, which were worn on admission. Review of Resident 7's Activity Assessment - V4 dated 1/9/26, showed the resident used hearing aids in both ears. On 2/25/26 at 1250 hours, Resident 7 was observed in bed. When attempting to talk to Resident 7, he replied I can't hear well. When asked if he had hearing aids while pointing to ears, Resident 7 stated they forgot to charge them last night. After writer attempted in a louder voice closer to the resident, the resident still could not understand and started to get frustrated. On 2/27/26 at 1019 hours, during an observation, Resident 7 was in bed. Resident 7 stated he charged his hearing aids himself last night, but only wanted to wear the left one right now. Resident 7 stated he kept his hearing aids at his bedside and charges. On 2/27/26 at 1137 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 1. LVN 1 stated the residents with hearing aids should have a physician's order for hearing aids. LVN 1 stated Resident 7 did not have hearing aids. LVN 1 reviewed the above records and verified Resident 7 did in fact have hearing aids. LVN 1 verified the resident's care plan showed the resident was hard of hearing, but failed to address use of the hearing aids. On 3/4/26 at 0939 hours, the DON stated the residents should use the hearing aids, and the nurses were responsible to insert the hearing aids every morning, to store when not in use, and to charge or change the hearing aid batteries. (Cross reference with F656 example b).

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to ensure the LAL (Low Air Loss) mattress setting was consistent with Resident 9's weight. Resident 9's current weight was 102 lbs., whereas the LAL mattress setting was set at 150 lbs. This failure posed the risk for Resident 9 to not benefit from the therapy provided by the LAL mattress.Findings: Review of the manual titled DynaRest Airfloat 100 Air Mattress with Pump (undated), showed the DynaRest AirFloat 100 Air Mattress is designed for bed sore and wound care therapy treatment and prevention, which may occur during an extended hospital stay and nursing home/long term care environment. Under the section Pressure Adjust Knob (adjustable by patient's weight) showed to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide. On 2/26/26 at 1030 hours, Resident 9 was observed lying in bed and the LAL mattress was observed on and set at 150 lbs. Medical record review for Resident 9 was initiated on 2/25/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had severely impaired cognitive skills for daily decision making. Further review of the MDS showed Resident 9 was at risk for developing pressure ulcers/injuries and Resident 9 required substantial to maximal assistance (where the helper does more than half the effort) for rolling from left and right in bed. Review of Resident 9's Weights and Vitals Summary dated 2/26/26, showed on 2/10/26, Resident 9 weighed 102 lbs. On 2/26/26 at 1239 hours, Resident 9 was observed lying in bed and the LAL mattress was observed on and set at 150 lbs. On 2/26/26 at 1255 hours, an observation, interview, and concurrent medical record review for Resident 9 was conducted with LVN 8. LVN 8 stated the LAL mattress was used for the residents who were at risk for developing pressure ulcers or who currently had pressure ulcers. LVN 8 stated the LAL mattress provided alternating therapy to relieve pressure while the residents were lying on the mattress. LVN 8 stated the LAL mattress device should be set based on the resident's current weight and the treatment nurses were responsible for changing the weight settings. LVN 8 reviewed Resident 9's medical record and verified the residents current weight was 102 lbs. LVN 8 verified Resident 9's LAL mattress setting did not match the resident's weight and verified the above findings. On 2/26/26 a 1303 hours, an interview was conducted with LVN 3. LVN 3 stated the LAL mattress was used as a preventative measure and to help heal existing pressure wounds. LVN 3 stated the LAL mattress setting was checked every shift by the treatment nurses during the day shift and by the charge nurses in the evening shift. LVN 3 stated when checking the LAL mattress, the licensed nurses should review the resident's medical records for the most recent weight and adjust the LAL mattress setting appropriately. When asked about the settings on the LAL mattress, LVN 3 stated the LAL mattress setting should be set based on the resident's weight. LVN 3 further stated if the LAL mattress was set too firm, it would not provide adequate offloading and pressure relief, and if the LAL mattress was set too soft, it could make the wound worse by not providing the adequate support. On 2/26/26 at 1541 hours, Resident 9 was observed lying in bed and the LAL mattress was observed on and set at 150 pounds. On 3/4/26 at 919 hours, an interview was conducted with the DON. The DON stated for the resident's with a LAL mattress, the licensed nurses were responsible for ensuring the LAL mattress setting was appropriately set to the resident's weight On 3/4/26 at 1105 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide care and promote dignity and respect for one of 26 final sampled residents (Resident 43) and one nonsampled resident (Resident 18). * Resident 43's braided hair was cut off by a CNA against Resident 43's will while providing care for Resident 43. This resulted in Resident 43 becoming tearful and not wanting to leave her room because her hair had been cut off. * The facility failed to answer Resident 43 and 18's call lights in a timely manner. This resulted in Residents 43 and 18 becoming distressed, disturbed, and upset when they had to sit in wet, soiled diapers for long periods of time. These failures lead to the residents and family members feeling devastated and frustrated. Findings: Review of the facility's P&P title Concern & Comment Program dated 2/2007 showed if the concern is of major importance, the staff should contact the Administrator, DON, or designee as soon as possible. The Concern & Comment Form is routed to the Administrator or designee, and to the appropriate department manager who will investigate and resolve the concern. 1. Medical record review for Resident 43 was initiated on 5/8/18. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's MDS dated [DATE], showed Resident 43 was cognitively intact. a. On 5/14/18 at 0957 hours, an interview was conducted with Resident 43 and Family Member 2. Family Member 2 stated while providing care to Resident 43, CNA 3 could not remove the rubber band from Resident 43's braided hair. Resident 43 stated she told CNA 3 not to cut off Resident 43's braided hair; Family Member 2 would come and help her. CNA 3 cut Resident 43's braided hair off anyway. Family Member 2 stated she reported the incident to the nurses at the nurses' station, SSA 2, and the Assistant Administrator. Family Member 2 also discussed this incident in the care plan meeting. Family Member 2 stated the facility acknowledged the incident and did not assign CNA 3 to Resident 43 again. Family Member 2 stated Resident 43 was a hair stylist and felt devastated about her hair being cut and cried every day. Resident 43 did not want to see CNA 3. Family Member 2 stated Resident 43 remembered the incident each time she saw CNA 3 and cried. On 5/14/18 at 1340 hours, an interview was conducted with the Administrator regarding the incident of CNA 3 cutting off Resident 43's braided hair. The Administrator stated he was not aware of the incident. On 5/14/18 at 1345 hours, an interview was conducted with the Assistant Administrator. When asking about CNA 3 cutting off Resident 43's braided hair, the Assistant Administrator stated he was not aware of the incident. The Assistant Administrator stated he had not had any report or investigation regarding this incident. On 5/15/18 at 0822 hours, an interview was conducted with CNA 3. CNA 3 stated the former Assistant DON asked her (CNA 3) why she cut Resident 43's hair. CNA 3 stated, I never cut her hair. I did not have scissors. I made a ponytail for her. CNA 3 stated Family Member 2 came to the nurses' station and asked why Resident 43's hair had been cut off. On 5/15/18 at 0848 hours, an interview was conducted with CNA 4. When asked about Resident 43's braided hair being cut off, CNA 4 stated she was aware of this incident. CNA 4 stated someone cut Resident 43's hair. CNA 4 came back to work the day after Resident 43's hair had been cut off and saw Resident 43's hair was very short and could not be braided. CNA 4 stated Resident 43 had long hair before. CNA 4 stated Resident 43 told her (CNA 4) she felt worse and stated it was not right to cut her hair. On 5/15/18 at 1500 hours, an interview was conducted with the DSD. The DSD stated she was given a report about CNA 3 cutting off Resident 43's hair. The DSD stated she did not assign CNA 3 to Resident 43 again. When asked if she reported the incident to anyone, the DSD stated she talked to SSA 2 and the former DON; however, she did not recall what they had discussed. On 5/16/18 at 1527 hours, a concurrent interview and facility document review was conducted with the DSD. The DSD stated she asked CNA 3 if CNA 3 had cut off Resident 43's hair against Resident 43's will. CNA 3 told the DSD no. The DSD stated she did not believe there was an investigation; she just took CNA 3's word. When asked if she assessed Resident 43, the DSD stated, I was kind of new at that time. I don't think I knew her well to assess her. The DSD verified she did not assess Resident 43 and could not provide any documented evidence she had spoken to Resident 43 about the incident. On 5/16/18 at 1655 hours, an interview was conducted with Resident 43 at the bedside. Resident 43 stated CNA 3 had cut off her hair. Resident 43 stated she felt devastated, wanted to stay in her room, and thought she could not go out with her hair like that. Resident 43 stated she reported the incident to the facility. On 5/18/18 at 1042 hours, a telephone interview was conducted with SSA 2. SSA 2 stated around August, Resident 43 reported CNA 3 cut off her hair. SSA 2 stated Resident 43 had short braided hair, and the hair was matted. CNA 3 could not undo the rubber band from around the braided hair so CNA 3 cut Resident 43's braided hair. SSA 2 assessed Resident 43's hair and saw the difference of Resident 43's hair before and after being cut. Resident 43's hair was shorter and uneven. SSA 2 stated she reported to this to the DSD. The DSD talked to Resident 43. After the DSD learned CNA 3 was the person who cut Resident 43's hair, the DSD did not assign CNA 3 to Resident 43 again. When asked if Family Member 2 brought up this incident in Resident 43's care plan meeting, SSA 2 stated yes, but she could not find the quarterly care plan meeting for (MONTH) (YEAR) in Resident 43's medical record. b. Review of Resident 43's MDS dated [DATE], showed Resident 43 was cognitively intact and required one to two persons' extensive assistance for transfers and toileting. Review of Resident 43's care plan showed a care plan problem dated 4/2/18, to address Resident 43's weak bladder control. The approaches included to offer Resident 43 scheduled toileting every 2 hours. On 5/14/18 at 0957 hours, an interview was conducted with Resident 43 and Family Member 2. Family Member 2 stated Resident 43 had to wait at least 45 minutes for her call light to be answered, and there were several times the call light waiting times were one and a half hours. Family Member 2 stated she asked the Assistant Administrator what the realistic time was for the call light to be answered. The Assistant Administrator stated five to twenty minutes. Family Member 2 stated she called from outside the facility to get the nurses to help Resident 43 to the bathroom. Family Member 2 read the text messages between herself and Resident 43 from the phone. The text messages showed on Thursday 5/10/18, Resident 43 called Family Member 2 at 0603 hours; she had not been helped by 0643 hours. On 5/13/18 at 2233 hours, Resident 43 texted Family Member 2, to please call in as it had been 45 minutes. Resident 43 texted she was crying and wanting to go to the bathroom; she did not want to go in her diaper. On 4/2/18 at 1350 hours, a CNA came to answer the call light and refused to take Resident 43 to the bathroom. The CNA told Resident 43 she would get off work in 10 minutes. Family Member 2 insisted the CNA take Resident 43 to the bathroom. The CNA roughly transferred Resident 43 to the wheelchair. Without cleaning Resident 43, the CNA pulled the diaper up and put Resident 43 to bed. Family Member 2 stated the facility put Resident 43 on a toileting schedule every two hours, and the toileting schedule was posted on the resident's bathroom door. However, the toileting schedule every two hours had not been carried out. Resident 43 stated they wanted me to go in her diaper. They put another diaper inside her diaper to absorb. One time the gown and the diaper were wet, and she had to eat while sitting in the soaking wet diaper and wet gown. Family Member 2 stated the CNA told her they did not have time to help Resident 43 because the resident went to the bathroom too many times. On 5/15/18 at 0848 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 43 needed two persons' assistance for transfers and toileting. CNA 4 was aware of Resident 43's toileting schedule. CNA 4 stated she had helped Resident 43 to the bathroom every two hours; however, CNA 4 did not document she had helped Resident 43 to the bathroom every two hours in Resident 43's medical record. On 5/15/18 at 0933 hours, a concurrent interview and medical record review was conducted with RN 4. When asked how she monitored the nursing staff answering the call lights and implementing the toileting schedule every two hours for Resident 43, RN 4 stated they monitored the call lights and the call light waiting time was about 15 minutes. RN 4 stated the facility arranged a toileting schedule for Resident 43. However, there was no documentation in Resident 43's medical record showing the toileting schedule was carried out and monitored by nursing staff. 2. On 5/8/18 at 1035 hours, during an initial tour, a concurrent observation and interview was conducted with Resident 18. Resident 18 was observed resting in bed, wearing a diaper. Resident 18 had a second diaper folded inside his diaper. Medical record review for Resident 18 was initiated on 5/8/18. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's MDS dated [DATE], showed Resident 18 was cognitively intact and required two persons' extensive assistance for transfers and toileting. On 5/14/18 at 1414 hours, an interview was conducted with Resident 18 at the bedside. Resident 18 stated it took ridiculously long, four to five hours for his call light to be answered. Resident 18 stated he called at night and fell to sleep while waiting for the staff to change him. Resident 18 stated when he woke up, he was still wet, and the call light was off. In the morning, the call light waiting was often one to one and a half hours. Resident 18 stated he looked at the clock on the wall to determine the call light waiting time. Resident 18 was observed wearing a diaper and had a second diaper folded inside his original diaper. Three clean diapers were observed on top of Resident 18's bedside table. When Resident 18 was asked why he had another diaper inside his diaper, Resident 18 stated he put another diaper inside his diaper so he would not wet the bed when the CNAs could not change him. Resident 18 stated he felt disturbed and upset. On 05/15/18 at 0848 hours, an interview was conducted with CNA 4. CNA 4 stated she was aware Resident 18 put another diaper inside his diaper. CNA 4 stated Resident 18 was alert and oriented. On 5/16/18 at 1607 hours, an interview was conducted with LVN 2. LVN 2 stated she was aware Resident 18 had a second diaper folded inside of his original diaper. When asked if LVN 2 educated Resident 18 regarding the risk of having another diaper inside his diaper, LVN 2 stated she did not provide any education to Resident 18; however, the CNA told Resident 18 not to put another diaper inside his diaper. LVN 2 stated she did not have documentation regarding this concern. No education was provided to Resident 18 and no care plan problem and approaches were developed to address Resident 18's use of two diapers being used to prevent wetting the bed linens.

Based on interview and clinical record review, the facility failed to ensure three of 24 sampled residents (Residents 19, 11, and 2) were free from unnecessary medications. *Resident 19 was admitted to the facility with good cognition on 7/6/12, and documented by the physician as being alert, oriented and having the capacity to make medical decisions regarding her health care. On admission she weighed 170 pounds. Resident 19 is now receiving five psychopharmacological medications ([MEDICATION NAME] and [MEDICATION NAME]; used to treat anxiety, [MEDICATION NAME] and [MEDICATION NAME]; antidepressant medications, and [MEDICATION NAME]; an antipsychotic medication used to treat psychoses) with no documented behaviors to warrant the continued need for these medications, except three incidents of anxiety in October, 2012. The DON stated Resident 19's family members were requesting the antipsychotic medications and did not want them reduced in fear the resident might suffer pain or hallucinations. The facility did not address this issue with the family. On admission, the resident was receiving [MEDICATION NAME] (a benzodiazepine used to treat anxiety) for dizziness. The facility did not reassess the appropriate use of this medication and is not monitoring the incidents of dizziness to determine if the medication is necessary. The resident was started on another antianxiety medication, [MEDICATION NAME] 0.5 mg routinely four times a day. There are three documented incidents of restlessness since the medication was prescribed, occurring in October 2012. Resident 19 was prescribed [MEDICATION NAME], an antipsychotic medication (a medication used to treat severe mental disorders), for hallucinations on 8/3/12. Resident 19 had no [DIAGNOSES REDACTED]. A family member reported Resident 19 was having hallucinations and crying, but the facility did not verify these behaviors. This has resulted in significant decline in Resident 19 since admission to the facility. Resident 19 has had a decline in her cognitive status and can no longer make informed consent regarding her healthcare. Resident 19 had a significant weight loss of 28 pounds (16%) from 7/6/12 through 12/1/12 (a significant weight loss of greater than 10% in six months). *Resident 11 was being administered [MEDICATION NAME] (antipsychotic medication) daily since 11/21/12. The facility failed to have a specific indication for its use and to have behavior data available in a consolidated manner to monitor the effectiveness of the antipsychotic medication. *Resident 2 was receiving treatment with medication used to treat high blood pressure without adequate monitoring of vital signs. Findings: 1. According to the facility's P&P titled Psychopharmacological Medication Use dated 11/31/11, when a physician orders [REDACTED]. Facility staff should monitor behaviors, episodes or triggers. Observations of Resident 19 on 3/22/13 at 0740, 0910, 1100, and 1400 hours, showed the resident in bed, appearing to be asleep. At 1400 hours, the resident was addressed by saying, hello. The resident answered, "hello," but did not open her eyes. Clinical record review for Resident 19 was initiated on 3/22/13. Review of the Face Sheet showed Resident 19 was admitted on [DATE], with diagnoses of dizziness, history of stroke and depression. Review of the Weight History showed Resident 19 weighed 170 pounds on admission. Review of the Physician admission orders [REDACTED]. Review of the physician's orders [REDACTED]. Lexi-Comp Online shows [MEDICATION NAME], a benzodiazepine, may cause confusion, depression, drowsiness, fatigue, anxiety, weight loss, [MEDICAL CONDITION], hallucinations, psychoses, restlessness, sleep disturbances and [MEDICAL CONDITION] (dizziness). Due to its long-acting metabolite, [MEDICATION NAME] is not considered a drug of choice in the elderly. Guidelines from the Centers for Medicare and Medicaid Services strongly discourage the use of this agent in residents of long-term care facilities. This medication is considered to be potentially inappropriate in this patient population (Beers Criteria: Quality of evidence - high; Strength of recommendation - strong). Lexi-Comp Online shows [MEDICATION NAME] may cause lack of appetite and is considered to be potentially inappropriate in the geriatric patient population (Beers Criteria: Quality of evidence - moderate; Strength of recommendation - strong). [MEDICATION NAME] side effects include visual disturbance, weight loss and hallucinations. Lexi-Comp Online shows to use [MEDICATION NAME], a benzodiazepine, with caution in elderly or debilitated patients. In older adults, benzodiazepines increase the risk of impaired cognition, [MEDICAL CONDITION], falls, and fractures. This medication is considered to be potentially inappropriate in this patient population (Beers Criteria: Quality of evidence - high; Strength of recommendation - strong). Review of the history and physical documented by Physician 1 dated 7/9/12, showed Resident 19 had the capacity to understand and make medical decisions. Review of the Physician's Progress Note dated 7/16/12, documented by Physician 2, showed Resident 19 was alert and oriented times 4. Physician 2 documented the resident was sleeping well and had no dizziness. Further review showed Resident 19 had a new UTI. The resident was started on an antibiotic. Review of the Progress Note documented by Physician 1 dated 7/23/12, showed Resident 19 had no anxiety. The facility did not reassess the need for the psychopharmacological medications after the treatment of [REDACTED]. Resident 19 had no documented hallucinations, crying or restlessness since then, but continues on the medications. The Progress Note dated 7/26/12, showed Resident 19 was dehydrated and was started on intravenous fluids for the dehydration. Review of the Behavior Intervention Monthly Flow Sheet for July 2012, showed no behavior of sadness throughout the month. There was no documentation available regarding the monitoring of the [MEDICATION NAME]. An interview with the DON was initiated on 3/22/13 at 0830 hours. The DON confirmed the resident is taking both benzodiazepines. When asked if the medications were duplicate therapies, the DON stated the medications are being used for different reasons. An interview with the Consultant Pharmacist for the CDPH was initiated on 3/27/13 at 0800 hours. The pharmacist stated both medications are benzodiazepines and are considered duplicate therapies. According to Lexi-Comp Online, use of [MEDICATION NAME] in elderly patients with dementia is associated with an increased risk of mortality and [MEDICAL CONDITION] (strokes); avoid antipsychotic use for behavioral problems associated with dementia unless alternative nonpharmacologic therapies have failed and the patient may harm self or others. Any changes in disease status can result in behavior changes. Evaluation of disease status should be done before initiating [MEDICAL CONDITION] drug therapy for behavior changes. Many elderly patients receive antipsychotic medications for inappropriate nonpsychotic behavior. Before initiating antipsychotic medication, the clinician should investigate any possible reversible cause; any disease can cause acute "confusion." Most commonly acute changes in behavior are due to the addition of new drugs to the regimen, infections, and changes in environment. In light of significant risks and adverse effects in the elderly population compared with limited data demonstrating efficacy in the treatment of [REDACTED]. This medication is considered to be potentially inappropriate in the geriatric patient population (Beers Criteria: Quality of evidence - moderate; Strength of recommendation - strong). On 8/3/12, Resident 19 was started on [MEDICATION NAME] 12.5 mg twice a day for hallucinations. According to the Progress Note dated 8/8/12, Physician 1 showed Resident 19 had acute [MEDICAL CONDITION] (sudden kidney failure) which was improving. A physician's orders [REDACTED]. Review of the Consultation Report dated 8/16/12, showed the pharmacist requested an appropriate associated [DIAGNOSES REDACTED]. The Monthly Flow Records dated October, November, December 2012, and January, and February 2013, showed Resident 19 had no incidents of hallucinations, inability to sleep, anxiety or sadness. An interview with the SSD was initiated on 3/22/13 at 0830 hours. The SSD was asked about the use of [MEDICATION NAME]. The SSD was asked if, after Resident 19's kidney failure had resolved, did anyone reassess the need for the [MEDICATION NAME]. The SSD stated, no. She was asked, prior to starting the [MEDICATION NAME], did the facility try any nonpharmacological interventions in lieu of the medication. The SSD stated, no. Review of the Progress Note dated 8/23/12, showed the RNP increased the [MEDICATION NAME] to 2 mg three times a day due to a family members request. There was no documentation to show the resident was having increased dizziness. A physician's orders [REDACTED]. The Monthly Flow Record for the month of August 2012, showed Resident 19 had no other hallucinations except for the hallucination on 8/3/12. Resident 19 had three incidents of anxiety in August, no sadness or inability to sleep. Resident 19's weight as of 8/10/12, was 162 pounds. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. A Progress Note dated 9/24/12, by Physician 1, showed the resident was in a good mood with no depression. The physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the Monthly Flow Record for the month of September 2012, showed Resident 19 had no episodes of hallucinations, inability to sleep, sadness or anxiety. Review of the Weight Record showed Resident 19's weight on 9/28/12, was 156 pounds. Review of the pharmacy consultant's Consultation Report dated September 7, 2012 through September 11, 2012, showed the following recommendation: "(Resident's name) takes duplicate therapy of [MEDICATION NAME] 2 mg TID (three times a day) and has new order for [MEDICATION NAME] 0.5 mg Q6H (every six hours) for anxiety....Resident on low dose [MEDICATION NAME] 25 mg HS (bedtime)....consider further increasing dose while changing [MEDICATION NAME] to PRN (as needed) basis at this time?" "Recommendation: Please consider INCREASING [MEDICATION NAME] to 50 mg HS, while changing [MEDICATION NAME] order to PRN basis.." "If CONCOMITANT benzodiazepine therapies are necessary and benefit(s) outweigh risk(s), please document below so the facility can compliant (sic) with current regulations." The physician placed a hashmark in the box indicating he accepted the recommendation; however, did not change the [MEDICATION NAME] to PRN. The physician did not document a note to explain why he disagreed with changing the [MEDICATION NAME] to PRN. On 10/3/12, the [MEDICATION NAME] was increased to 50 mg daily. The Progress Note dated 10/8/12, showed Physician 1 documented the family felt the resident was still hallucinating. The physician's orders [REDACTED]. The Monthly Flow Record dated October 2012, showed Resident 19 had no incidents of sadness, inability to sleep, or hallucinations. The resident had three incidents of anxiety. The Weight Record dated 10/26/12, showed the resident's weight was 146 pounds. Resident 19's weight as of 12/1/12, was 142 pounds. No further weights have been documented. The MDS (an assessment tool) dated 1/8/13, showed Resident 19's cognition was moderately impaired and the resident is considered non-interviewable. On 1/17/13, Physician 3, a psychiatrist reduced Resident 19's [MEDICATION NAME] from 300 mg to 275 mg daily. A Care Plan Conference dated 1/17/13, showed the family member "does not want to see her hallucinating & crying when meds are titrated." A joint interview with the DON and the SSD was initiated on 3/22/13 at 0830 hours. The DON was asked why Resident 19 continued on the five psychopharmacological medications with no documented behaviors. The DON and SSD stated the behaviors of crying, restlessness and hallucinations have been observed by the family members, but have not been witnessed by the staff. The DON stated the family is very concerned about the resident suffering. The family was even considering hospice care at one time for the resident, but has decided against it. The family does not want the resident to be weighed and does not want the medications reduced in fear the resident might experience pain. The facility felt it had to comply with the family wishes to keep the resident on the medications. A psychiatric consultation was conducted on 1/17/13. The psychiatrist has reduced the [MEDICATION NAME] medication, but the family wants the medication increased again. The SSD stated the family reports the resident is crying and having hallucinations, but the staff have not been able to observe the behavior. The DON was asked if any plan was in place, such as a joint meeting with the physician, the ethics committee and family to decide the best plan for the resident. The DON stated, no. An interview with Resident 19's family member was initiated on 3/22/13 at 1130 hours. The family member stated she was concerned about Resident 19 having pain or hallucinations and she doesn't want the psychopharmacological medications reduced. 2. Review of Lexi-Comp Online, a professional resource, shows [MEDICATION NAME] carries a US boxed warning. The warning shows elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. On 3/21/13, clinical record review was initiated for Resident 11. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia. Review of the physician's orders [REDACTED]. Review of the [MEDICAL CONDITION] Review shows an entry dated 12/21/12, showing the use of [MEDICATION NAME] 5 mg daily; however, documentation to show the specific behavior for which [MEDICATION NAME] is targeted to treat and an assessment of Resident 11's behaviors was not documented. The areas on the form showing the care plan was updated, the MDS (standardized assessment tool) reviewed, the physician's orders [REDACTED]. The entry dated 3/7/13 shows "2/21/13 [MEDICATION NAME] 5 mg." Documentation to show the specific behavior to be monitored regarding the use of [MEDICATION NAME] and the number of behaviors exhibited for the quarter was not documented. On 3/21/13 at 0850 hours, an interview and clinical record review was conducted with the SSD. The SSD stated the IDT meets every three months with the psychiatrist to review and assess the residents' use of psychoactive medications (medications used to treat mental disorders) and documents on the [MEDICAL CONDITION] Review form. When asked for documentation to show the specific behavior being monitoring for Resident 11 regarding the use of [MEDICATION NAME], the SSD stated the licensed nurses document daily on the Behavior/Intervention Monthly Flow Record. When asked for consolidated documentation of monthly behavior monitoring, the SSD stated she keeps a separate log with number of behaviors exhibited, which is reviewed at the quarterly IDT meetings. When asked to provide documentation of the review of the targeted behaviors for the use of [MEDICATION NAME], the SSD was unable to provide documentation. When asked when the [MEDICATION NAME] was originally ordered for Resident 11, its indication for use and the specific behavior it was prescribed to treat, the SSD stated she would have to review the closed clinical record. On 3/21/13 at 1000 hours, an interview and closed clinical record review of Resident 11's previous admission was conducted with the SSD. The SSD stated [MEDICATION NAME] (antipsychotic medication) was discontinued and [MEDICATION NAME] 5 mg was ordered on [DATE], for depression and [MEDICAL CONDITION]. The physician's orders [REDACTED]. Review of the Behavior/Intervention Monthly Flow Record dated November 2012 shows [MEDICATION NAME] 0.25 mg was being administered twice a day for the behavior of "paranoid." The documentation shows one behavior was identified on 11/3/12, and zeros were documented for the rest of the month. When asked how the staff identified Resident 11's behavior of "paranoid," the SSD did not respond. The SSD verified the documentation did not show the [MEDICATION NAME] was discontinued. The SSD was unable to provide documentation to show Resident 11's behavior being monitored for the use of [MEDICATION NAME] for 11/21/12 through 12/14/12. The SSD verified the finding. The SSD stated the Behavior/Intervention Monthly Flow Record form should have been changed to show [MEDICATION NAME] was discontinued and [MEDICATION NAME] 5 mg for depression and [MEDICAL CONDITION] was started. The SSD stated the specific behavior to be monitored for the use of [MEDICATION NAME] should have been clarified when the order was written on 11/21/12. The SSD stated Resident 11 was readmitted to the facility on [DATE]. The physician's orders [REDACTED]. The order did not show the manifested behavior for which the [MEDICATION NAME] was being used to treat. Review of the Behavior/Intervention Monthly Flow Record dated 12/14/12, through 2/18/13, shows [MEDICATION NAME] 5 mg daily. The behavior on the forms show "verbalization of low self esteem." No behaviors of verbalization of low self esteem were documented. The SSD stated Resident 11 was transferred to the acute care hospital on [DATE], for an unrelated concern and was readmitted to the facility on [DATE]. The order dated 2/21/13, shows to administer [MEDICATION NAME] 5 mg daily for [MEDICAL CONDITION] manifested by screaming. Review of the Behavior Intervention Monthly Flow Record shows no documented behaviors of screaming have been identified since 2/21/13. The SSD was unable to provide documentation to show Resident 11 exhibited the behavior of screaming. 3. Review of Resident 2's clinical record was initiated on 3/20/13. The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan showed a care plan problem dated 6/14/11, to address cardiac distress. A goal showed the heart rate will be no less than 60, and an intervention showed to monitor vital signs as ordered. Review of the MAR for the month of March 2013, showed there was only documentation of a heart rate on 3/1/13 at 0900 hours, 3/3/13 at 0900 hours and on 3/16/13 at 0900 hours. Resident 2's heart rate was not taken twice daily prior to administration of [MEDICATION NAME] as prescribed by the physician. During an interview and clinical record review with LVN 2 on 3/22/13 at 0815 hours, the LVN was unable to find documentation to show the heart rate was monitored twice daily as ordered by the physician for the month of March from 3/1/13 through 3/21/13.

Based on interview and clinical record review, the facility failed to ensure Resident 1 was repositioned when sitting up in his wheelchair to prevent the development of a pressure ulcer. Resident 1 developed a Stage IV (the deepest type of pressure ulcer which extends into underlying muscles, tendons and bones) pressure ulcer on his left buttocks which required treatment at the acute care hospital. In addition, the resident developed a Stage II pressure ulcer on his right buttock area, and had a recent history of two Stage II pressure ulcers developing on his right buttocks which resolved. Findings: According to the USC (University of Southern California) Occupational Science Pressure Ulcer Prevention Project (11/12/06), the pressure on your bottom or tailbone (sacral area) when sitting can be 10 to 15 times higher than when there is no pressure. According to the Mayo Clinic (Mayoclinic.com "Pressure Sore - Prevention") residents using a wheelchair should change position as much as possible on their own every 15 minutes or they should have assistance with changes in position every hour if they can't reposition themselves. On 8/6/12, clinical record review for Resident 1 was initiated. The MDS (an assessment tool) dated 6/5/12, showed Resident 1 was alert and oriented, and dependent on staff for ADLs, including repositioning. The care plan problem titled Impaired Mobility revised 6/18/12, showed Resident 1 had impaired mobility due to [MEDICAL CONDITION] (partial or total loss of sensory and function to both arms and legs and torso). The Pressure Ulcer Status Record dated 6/12/12 (no time entered), showed the pressure ulcer was first identified on 6/12/12 and documented as a Stage I (intact skin with redness, which is not resolved within 30 minutes of pressure relief) fluid filled blister on the resident's left buttocks. The size of the blister measured 2 cm by 2 cm. The record showed another nurses entry documented on the same day 6/12/12, during the evening shift, identified the blister had progressed to a Stage II pressure ulcer. The ulcer measured 2 cm by 2 cm and was red. The record showed the next entry was documented on 6/19/12, and the pressure ulcer had progressed to a Stage III ulcer, which measured 3 cm by 2 cm. The pressure ulcer had a small amount of drainage and the color was yellow with slough (pieces of dead tissue or skin cells, which are cast off the surface of the skin) present. The care plan problem titled Stage I pressure ulcer dated 6/12/12, showed Resident 1 had a Stage I pressure ulcer on his left buttocks due to fragile skin and limited mobility. A goal showed the pressure ulcer would resolve within 30 days. Interventions listed showed the resident would be assisted with repositioning for pressure relief at least every two hours and as needed. Review of the care plan problem titled Impaired Mobility dated 6/18/12, showed no interventions related to repositioning Resident 1 when he was sitting up in his wheelchair. A physician's orders [REDACTED]. The care plan problem titled Stage III pressure ulcer dated 6/19/12, showed Resident 1 had now developed a Stage III pressure ulcer on his left buttocks, due to fragile skin and limited mobility. Interventions listed showed the resident would be assisted with repositioning for pressure relief at least every two hours and as needed. Review of the physician's progress note dated 6/20/12, showed Resident 1's left buttocks pressure ulcer was worsening. The pressure ulcer started as a blister with deep tissue injury underneath the blister, approximately two weeks prior. The pressure ulcer now had an odor (indicative of infection) and was believed by the physician and nursing staff to be a result of the resident sitting up in his wheelchair. The physician documented the pressure ulcer was a Stage III (full thickness tissue loss extending through the skin to the tissue underneath) ulcer and measured 3 cm by 2 cm in size. The pressure ulcer had a significant amount of necrotic (dead tissue) tissue with odor present. The skin surrounding the pressure ulcer was macerated (broken down or raw) and a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer was also present on the resident's right buttocks area, which measured 1 cm. The Resident Transfer Record dated 6/21/12, showed Resident 1 was transferred to the acute care hospital to receive treatment for [REDACTED]. Review of the acute care hospital's surgical consultation dated 6/25/12, showed Resident 1 had a pressure ulcer on his left buttocks which developed necrosis and had purulent (containing pus) drainage. The ulcer developed an abscess (a collection of pus) which extended in towards the left groin and suprapubic area (just above the pubic area). The physician noted the pressure ulcer measured 3 cm by 5 cm and there appeared to be a cavity (a space or hole) which extended to the left groin area and possibly involved the urinary structures. The physician diagnosed Resident 1 with left buttocks pressure ulcer necrosis with possible gangrene (a life threatening condition which occurs when a large amount of body tissue dies). The acute care hospital's physician's Discharge Summary dated 7/24/12, showed Resident 1 was admitted to the hospital with [REDACTED]. The abscess went through the perineum (a region of the body inferior to the pelvic diaphragm and between the legs) to the resident's left peri scrotal area (area around the testicle area) and left inguinal (groin) area. The resident required debridement (the removal of dead tissue)antibiotic therapy, pressure ulcer treatments and required a "wound VAC" (a special piece of equipment used to promote pressure ulcer healing). On 8/6/12 at 1130 hours, during an interview and clinical record review with LVN 1, the LVN stated Resident 1 refused to go back to bed after meals and preferred to stay up in his wheelchair most of the day. When asked if the facility had a plan to reposition the resident in the wheelchair, when he was sitting up and did not want to go back to bed, the LVN stated the resident could reposition himself in the wheelchair. However, on 8/6/12 at 1145 hours, during an interview and clinical record review with PT 1, the PT stated Resident 1 had only gross motor movements of his arms. The PT stated the resident was not strong enough to lift or reposition himself up in the wheelchair to relieve pressure. PT 1 stated the resident could move left to right, but would not be able to hold the position by himself. On 8/8/12 at 1030 hours, during an interview with Resident 1, the resident stated he did not have any sensation from his chest down. Resident 1 stated he would not be able to reposition himself in his current wheelchair. The resident stated staff did not assist him with repositioning when he was up in the wheelchair. The resident stated he required an elevated foot rests so he could recline by himself to relieve pressure of his buttocks area, but his current wheelchair, which he has had for about one year, was not equipped to do that. The resident stated the company which services wheelchairs recently came out to the facility to adjust it, but then he was transferred to the hospital. On 8/14/12 at 1350 hours, during an interview with the DON, the DON stated the facility has a plan in place to reposition dependent residents who are sitting up in their wheelchairs during activities at 1000 and 1500 hours. On 8/14/12 at 1400 hours, during an interview with RNA 1, the RNA stated they repositioned the residents at 1000 hours and then again at 1500 hours. The RNA stated technically a resident should be repositioned every two hours. RNA 1 stated sometimes Resident 1 would find the RNAs during the day and ask them for help repositioning.

Based on observation, interview and clinical record review, the facility failed to supervise five of 22 sampled residents (Residents 15, 16, 12, 17 and 19) to prevent accidents. Resident 15 was left in his room, unsupervised, and fell out of his wheelchair, which resulted in a left hip fracture. Resident 16's wheelchair was reclined when in a "tilt in space wheelchair" (manual customized wheelchair that adjusts tilt-in-space and the back reclines) to prevent falls, as ordered by the physician. The facility assessed Resident 16 to require supervision and a "tilted-in-space wheelchair" when sitting up for positioning and to prevent falls. However, on 3/27/12, Resident 16 was not positioned in a tilted position. As a result, Resident 16 fell out of her wheelchair, hitting her face and sustaining injuries. Resident 16 was transferred to the acute care hospital on [DATE], where she was diagnosed with [REDACTED]. The facility failed to assess Resident 12 for the use of a floor mat, and failed to follow up on a physical therapy recommendation the use of a pommel cushion (a pillow shaped like a saddle with a horn, used to hold the patient upright in a chair) when the resident is up in a tilted-in-space wheelchair. A CNA was pushing the resident's wheelchair into the dining room. Resident 12 bent her head forward and fell out of the wheelchair. Resident 19 fell prior to admission to the facility. The physician ordered fall precautions. Resident 19 was assessed by nursing, PT and OT as a high fall risk. No fall prevention interventions were instituted until after Resident 19 fell . Findings: 1. Closed clinical record review for Resident 15 was initiated on 4/4/12. Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 15's history and physical dated 12/2/11, shows he does not have the capacity to understand and make decisions related to his cognitive dysfunction. Review of Resident 15's Fall Risk Evaluations dated 11/21/11 and 12/1/11, showed scores of 18 and on 2/22/12 and 2/27/12, scores of 20 (a score of 10 or higher is a high risk for falls). a. Review of Resident 15's Witness Interview Form dated 11/21/11 at 1320 hours, showed a staff member found Resident 15 on the floor when she passed his room. Resident 15 tried to transfer himself from the wheelchair to the bed. Resident 15 is very confused. Review of Resident 15's Incident Follow-up and Recommendation Form dated 11/22/11, shows to keep Resident 15 in supervised areas when in a wheelchair. Review of Resident 15's care plan problem dated 12/1/11, to address his risk for falls shows an approach plan for frequent visual checks. Review of Resident 15's Occupational Therapy Evaluation dated 12/3/11, shows Resident 15 had decreased strength, endurance and standing balance and is a high fall risk. Resident 15 is oriented to person only, and his sitting balance is fair. In addition, Resident 15 can become noncompliant. Review of Resident 15's Physical Therapy Evaluation dated 1/27/12, shows Resident 15 is oriented to person only, and has impaired safety awareness and fair sitting balance. Resident 15 is a high fall risk. b. Review of Resident 15's Witness Interview Form dated 2/27/12 at 1815 hours, shows CNA 10 found Resident 15 lying on the floor. According to the resident, he tried to transfer himself from the wheelchair to the bed and the wheelchair tipped forward. Resident 15 complained of left hip pain. Review of Resident 15's Incident Follow-up and Recommendation Form dated 2/28/12, showed to apply anti-tippers to Resident 15's wheelchair and to keep Resident 15 in supervised areas after dinner, or put him back to bed right after dinner. Review of Resident 15's left hip x-ray results dated 2/27/12, show a possible femoral neck fracture. Review of Resident 15's hospital history and physical dated 2/28/12, shows Resident 15 got up out of his wheelchair due to dementia and, forgetting he has bilateral below the knee amputations, he fell and sustained an impacted left femoral neck fracture. During an interview on 4/4/12 at 0830 hours, the Activities Assistant stated Resident 15 was alert, but confused. She stated he has no behavioral issues, but if he has to go to the bathroom, he will scoot up in the wheelchair to stand up. During an interview on 4/4/12 at 0855 hours, CNA 11 stated Resident 15 is alert and oriented. He stated if Resident 15 is left alone, he will try to get out of his wheelchair. CNA 11 stated he has seen Resident 15 attempt to transfer himself from the wheelchair to the bed. During an interview on 4/4/12 at 1625 hours, RNA 2 stated Resident 15 is confused and unable to make his needs known. He stated, on the evening of 2/27/12, Resident 15 was sitting in his wheelchair in the hallway and asked RNA 2 to help him; he wanted to go back to his room. RNA 2 stated it was the end of his work shift and quickly pushed Resident 15 back to his room. When RNA 2 was asked if he notified any staff members that Resident 15 was alone in his room, he stated, "no." RNA 2 stated he did not see any staff members, so he told Resident 15 to stay there and watch television, and left the room. RNA 2 stated, before he was able to leave the facility, he heard an overhead page for him to return to Resident 15's room. When he re-entered Resident 15's room, he found Resident 15 lying on the floor. During a telephone interview on 4/5/12 at 0945 hours, RN 5 stated Resident 15 is confused and needs staff assistance for all his ADL care. He stated he heard Dr. Star (code to alert the staff a resident is on the floor) paged overhead and he entered Resident 15's room. RN 5 stated Resident 15 was on the floor in front of his wheelchair, and he assisted other staff members to lift Resident 15 into the bed. During a telephone interview on 4/5/12 at 1005 hours, CNA 10 stated Resident 15 is alert with intermittent confusion. She stated she was in another room, caring for a resident when she heard someone yelling "help me, help me." She stated, when she entered Resident 15's room, he was lying face down on his stomach and his wheelchair was on top of him. CNA 10 stated Resident 15 told her he wanted to go back to bed. She stated Resident 15 did not have a personal alarm (alarm to alert the staff of the resident's attempt to get up) and no floor mats were in the room. CNA 10 stated she was unaware Resident 15 was left alone in his room. During an interview on 4/5/12 at 1115 hours, the DON confirmed Resident 15's Incident Follow-up and Recommendation Form dated 11/22/11, showed to keep Resident 15 in supervised areas when in a wheelchair. She stated she was unaware of the reason Resident 15 was left alone in his room. 2. On 4/3/12 at 1230 hours, during meal observation in the facility's main dining room, Resident 16 was sitting up in a "tilt-in-space" wheelchair. The resident made eye contact when greeted, but was nonverbal. Resident 16 was observed with a laceration to the right side of her forehead, measuring approximately 1 cm, with stiches intact, and a quarter sized bruise (skin discoloration) near her right eye. RN 2 stated Resident 16 had a fall a week ago after dinner at 1900 hours. Resident 16 was transferred to the emergency room where she received stitches to repair the laceration. On 4/3/12, clinical record review for Resident 16 was initiated. Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 16 has short and long term memory problems. Resident 16's cognitive skills for daily decision-making are severely impaired with poor decisions. Resident 16 requires total staff assistance for bed mobility and transfers. The MDS also showed the wheelchair was a primary mode of locomotion and other persons wheeled. On 4/3/12 at 1300 hours, an interview was conducted with CNA 4. CNA 4 was asked what happened on 3/27/12, when Resident 16 fell . The CNA stated he brought her from the dining room and parked her wheelchair in front of the nurses' station. CNA 4 stated he did not lower the back of Resident 16's wheelchair in the lowest angle. CNA 4 stated, first, he brings all residents from the dining room upstairs, lines all the the wheelchairs up in front of the nurses' station, and later puts the residents in bed. On 4/3/12 at 1630 hours, an interview was conducted with the DON. The DON was asked how Resident 16 fell . The DON stated on 3/27/12 at approximately 1700 hours, Resident 16 was wheeled downstairs to the facility's main dining room for dinner. The back of the resident's wheelchair was positioned up, so the resident is able to eat at the table. When Resident 16 finished her meal, she was brought upstairs by CNA 4, who parked her wheelchair in front of the nurses' station, "a supervised area." Unfortunately the CNA forgot to put the back of the resident's wheelchair in a tilted position. Resident 16 fell on the carpet trying to get out of the wheelchair. Resident 16 was found lying on the floor by a family. The nurses heard the noise. On 4/3/12 at 1540 hours, an interview with the Rehabilitation Services Manager was conducted. She stated, during the IDT post fall meeting, the team decided a physical therapy evaluation was not recommended. The wheelchair should be tilted at 45 degrees, and the resident should sit all the way back in a cradle position. On 4/3/12 at 1640 hours, during a continued interview with the DON, she was asked why the licensed nurses did not witness Resident 16's fall since the resident was in front of the nurses' station, in a "supervised area." The DON stated, although Resident 16 was in a supervised area, the nurses were not in the nurses' station when the accident happened; it was 1900 hours, and the licensed nurses were changing shifts. On 4/4/12 at 0930 hours, an interview was conducted with the Director of Activities. She stated Resident 16 was brought after dinner, and her wheelchair seat was not tilted in space, in a maximally tilted position. She stated the IDT recommendation post fall was to ensure the resident's wheelchair is maximally tilted in position, so the resident won't fall forward. Review of the nurses' Notes dated 3/27/12 at 1900 hours, showed Resident 16 was on the floor lying on the right side, a skin tear on the right side of the forehead measured about 1 cm by 1 cm; also noted skin discoloration near the skin tear. Per a witness, the resident was trying to lean over from wheelchair, and eventually fell down. Resident 16 hit her head on the other resident's wheelchair. Resident 16 was transferred to an emergency room for further evaluation. Review of the Fall Risk Evaluation form dated 3/27/12, showed Resident 16 had a score of 20. A score greater than 10 shows the resident is at high risk for falls. Review of a physician's orders [REDACTED]. Resident to use "tilt-in-space" wheelchair for out of bed seating and positioning. Review of the Physical Restraint Informed Consent form dated 3/29/10, showed the type of restraint device: resident to be positioned in Broda chair (tilt-in-space wheelchair) with a wedge pommel cushion (cushion used to stabilize sitting position) to prevent falls, and aid in upright positioning every day when out of bed. The medical reason for the restraint device is degenerative joint disease, weakness, and osteoporosis with poor trunk balance. Review of the care plan showed a care plan problem dated 2/8/12, to address the fall risk related to impaired vision, cognition, poor safety, poor body balance/control, awareness and judgment, high fall risk score, history of fractures, osteoarthritis, osteoporosis, and dementia. The goal was will minimize/reduce risk for further fall/injury for 90 days. The approaches included: visibly observe resident frequently, keep call light within easy reach, "tilt-in-space" wheelchair with wedge pommel cushion for out of bed seating, comfort, positioning and safe locomotion while in special wheelchair as indicated. Review of the Acute Care Hospital Take Home Instructions form dated 3/27/12 at 2210 hours, showed the resident sustained [REDACTED]. Resident 16 received instructions for daily treatment. Pain medication was also recommended. Review of care plan showed another care plan problem dated 3/27/12, to address laceration and bruises on Resident 16's forehead. The approaches included keep special wheelchair maximally in tilted position, ensure breaks are secured, put resident back to bed after dinner, keep the resident a little distance from other residents when up in the special wheelchair. 3. During initial tour on 4/2/12 at 1330 hours, accompanied by LVN 1, Resident 12 was observed lying in bed, alert, unable to answer basic questions, and her speech was unclear. The LVN stated the resident was alert, confused, with memory problems, and bed bound. A floor mat was observed on the floor along the left side of her bed. Clinical record review for Resident 12 was initiated on 4/2/12. Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE], showed Resident 12 is totally dependent on staff for all activities of daily living and locomotion, rarely understands, has short and long term memory deficits and has severe cognitive impairment. Review of a Fall Risk Evaluation form dated 3/27/12, showed Resident 12 had periods of restlessness and periods of altered perception. Resident 12 had a score of 20. A score greater than 10 shows the resident is at high risk for falls. Review of the Incident Follow-up & Recommendation form dated 5/13/11, showed at 1600 hours, Resident 12 was found lying on the floor with her head touching the floor; confused and disoriented. She tried to get out of bed by herself. The bed was in the lowest position, landing strips were on the floor. The alarm went off. Redness was noted on the right parietal area (right side of the head) and right forearm. Resident 12 was sent to the acute care hospital for further evaluation. Recommendation/Actions taken, low air loss mattress discontinued, change to concave mattress with bolsters. Review of the clinical record for Resident 12 showed no care plan problem was developed to address this fall. On 4/3/12 at 1400 hours, an interview was conducted with RN 2. RN 2 was asked why there was only one floor mat, on the left side of Resident 12's bed. She stated because the licensed nurses assess from where the residents tried to get up, and the floor mat is placed on that side of the bed. When asked why the resident fell from the right side of her bed, she had no answer. On 4/3/12 at 1430 hours, an interview was conducted with the DON. The DON stated Resident 12 is bed bound, and rarely gets up from the bed. Review of a physical therapy Plan of Treatment form dated 5/16/11, showed under precautions Resident 12 has severe dementia, non-English speaking, bilateral lower extremities flexion contractures, and a history of falls. Resident 12 requires total assistance for bed mobility and transfers from bed into a tilt-in-space wheelchair with a pommel cushion. On 4/3/12 at 0930 hours, Resident 12 was observed lying in bed. At this time, inspection of her tilt-in-space wheelchair was conducted. The wheelchair seat has a flat, three inch pad, with no protrusion in the center of the pad. RN 2 confirmed there was no pommel cushion in the resident's wheelchair. Review of the Incident Follow-up & Recommendation form dated 5/24/11, showed at 1830 hours, Resident 12 fell from the Broda wheelchair. A CNA was pushing her; suddenly the resident bent forward. Recommendation/Actions Taken: neurochecks initiated, educate CNA on safe transfer and proper positioning of the resident while in the Broda wheelchair. Rehabilitation will re-evaluate for positioning. Review of the care plan showed a care plan problem dated 7/22/11, to address the fall risk related to impaired cognition, poor safety, poor body balance/control, awareness, and restlessness. The approaches included to visibly observe the resident, safety devices, concave mattress, rolled bolster in bed and pommel cushion while up in the Broda wheelchair (tilt-in-space wheelchair). Review of a physician's orders [REDACTED]. Another order dated 4/26/11, showed the use of the Broda wheelchair when out of bed for proper positioning and safety in chair for meals daily. On 4/3/12 at 1535 hours, an interview was conducted with the Rehabilitation Services Manager. She confirmed the post fall rehab recommendations were a tilted-in-space wheelchair and a pommel cushion, to sit into the depth of the wheelchair to prevent the resident sliding from the wheelchair. She was unaware Resident 12 did not have the pommel cushion in place as ordered. 4. Review of the facility's Falling Star Program (undated) shows a fall risk assessment is completed upon admission, following a fall, quarterly, or after a significant change. If a resident scores "10" or above, they are assessed for the Falling Star Program. Along with consideration for the program, they will automatically have a Tab alarm (an alarm device that will alert staff if the resident attempts to get up unassisted) on their bed and wheelchair. Residents in the program will have a magnetic green star outside their door. Staff will recognize Falling Star residents have limited safety awareness, have a greater potential for fall, and require more diligent supervision. When passing by a Falling Star room, staff will take a few seconds to survey the resident's room to promote resident safety. Clinical record review for Resident 17 was initiated on 4/4/12. While at the facility, she fell six times from 5/2011 to 3/2012. Review of Resident 17's MDS dated [DATE], shows she usually understands and is usually understood. She is totally dependent on two or more persons for transferring between two surfaces, such as toilet, bed, or wheelchair. Review of Resident 17's Incident Follow-Up and Recommendation forms showed: *on 5/23/11 at 0615 hours, the resident was found halfway down the bed clinging to the side rail, wanting to go to the bathroom. She was alert with forgetfulness. Recommendations included an alarm while Resident 17 is in bed, a landing strip on the floor and scheduled toileting. *on 7/5/11 at 1230 hours, Resident 17's spouse and caregiver eased her down from the toilet to the floor. They were trying to help her get up off the toilet, but Resident 17 was too weak to bear weight. Recommendations included an x-ray of the left thigh and knee, educating the spouse and caregiver not to get her up by themselves, and a Sabina lift (a machine which lifts a resident from a sitting to a standing position) for transferring. *on 11/17/11 at 1915 hours, Resident 17 was found sitting on the floor near the bathroom door. She fell from the wheelchair and did not wait for assistance. A wheelchair alarm was not in use. The Witness form dated 11/17/12 at 1915 hours, shows Resident 17 had fallen as she attempted to "get out" of the toilet by herself. Recommendations included educating the resident to use the call light and wait for assistance, continuing the pommel cushion in the wheelchair, and staff making sure Resident 17 is correctly positioned in the wheelchair. *on 12/9/11 at 1915 hours, Resident 17 fell from her wheelchair when she tried to transfer back to bed by herself. A wheelchair alarm was not in use. Recommendations included educating the resident to call and wait for assistance when transferring, and putting her back to bed after dinner. *on 12/17/11 at 1335 hours, Resident 17 was found sitting in the bathroom when she tried to transfer herself from the wheelchair to the toilet. Her pommel cushion was in place. Recommendations included using a wedge Pommel cushion (the cushion is slanted towards the back of the chair, making it harder to stand up), scheduled toileting, and a urinalysis. *on 2/22/12 at 0620 hours, Resident 17 was yelling for help and was found dangling in bed while holding onto the side rail. She was eased down to the floor by the CNA. A bed alarm was not in use. Recommendations included prompt toileting, getting her up for breakfast by the night shift, and continuing the RNA ambulation program. Review of Resident 17's Fall Risk Evaluation forms shows a score of 10 or higher means a resident is at risk for falls. *on 5/27/11, her score was 18. *on 8/23 and 11/17/11, her score was 20. *on 6/17, 7/5, and 12/9/11, and 2/22 and 3/25/12, her score was 22. *on 2/14/12, her score was 24. Resident 17 was re-admitted to the facility on [DATE]. Review of the OT initial assessment dated [DATE], shows Resident 17 had a recent decline in her ADL and self-care abilities,causing weakness and pain in all extremities. She is a high fall risk and has poor safety awareness. Her sitting and standing balance is poor. Review of the PT initial assessment dated [DATE], shows Resident 17 demonstrated decrease in muscle strength, balance, endurance and poor activity tolerance. The reason for the PT evaluation is a recent pattern of falls, indicating safety concerns with balance and mobility. Review of Resident 17's care plan problem to address a fall risk dated 3/25/12, shows interventions which include having the call light within reach, a low bed, antithrust cushion (a cushion which has a raised area like a speed bump across the front of the cushion to help prevent a resident from sliding out of the chair) while up in a wheelchair, visibly observe resident frequently. During an interview with the DON on 4/4/12 at 1100 hours, she stated, when a resident is admitted , OT assesses the resident to see if they need to be in the Falling Star program or if they are at high risk for falls. The DON stated the Care Guide for the CNAs should show if a resident is a high risk for falls or if they are in the Falling Star program. A resident is put into the Falling Star program if they have had two or more falls. If a resident is in the Falling Star program it means the staff should watch the resident more closely. During an interview with the Director of Rehab on 4/4/12 at 1130 hours, she stated a resident should be put into the Falling Star program if they have a history or a trend of falls. A magnetic star is put on the door frame, which indicates to the staff the resident should not be left alone in the room, and has all the protective devices in place that are indicated for them. She stated landing strips and Tab alarms are usually the first interventions put in place for someone at high risk for falls. The IDT determines which side of the bed a landing strip is placed on. During an interview with CNA 8 on 4/5/12 at 0815 hours, she stated Resident 17 helps some with ADLs, and usually wants to transfer herself to the wheelchair. During an interview with Resident 17's family member on 4/5/12 at 0825 hours, they stated they usually come to see Resident 17 in the mornings. They stated, occasionally, they will come to the facility prior to breakfast and find Resident 17 up in her wheelchair alone in her room. During an interview with the DON on 4/5/12 at 1000 hours, after looking at the facility's Falling Star program, she stated Resident 17 should have been in the Falling Star program all along. When asked about the Tab alarm use as per the Falling Star policy, the DON stated they do not follow the policy regarding the use of the Tab alarms. She stated, the only time a Tab alarm is used for a resident is when rehab assesses the resident and decides the resident needs a Tab alarm. She went on to say, if the resident is admitted during the afternoon or night shift, and is trying to get out of bed by themselves, she would expect the nursing staff to place a Tab alarm on the resident. When asked when landing strips would be used, the DON answered the question by talking about a Tab alarm, and stated when a resident keeps attempting to get out of bed more than two times in a shift, a Tab alarm would be used. The DON was asked to explain what fall risk measures were put into place for Resident 17 when she was readmitted to the facility on [DATE], and scored 22 on her fall risk assessment. The DON stated we are just keeping her without pain and an assessment was done by rehab. She stated rehab should decide whatever interventions are necessary, such as Tab alarms, landing strips, wheelchair cushions, everything. The DON then stated rehab had determined Resident 17 should be put into the Falling Star program. During an interview with the Rehab Supervisor on 4/5/12 at 1030 hours, she stated any falls and residents determined to be a high fall risk are discussed in the IDT. Rehab and skilled nursing interventions are determined. When asked what is implemented if a resident is determined to be a high fall risk, the Rehab Supervisor stated a Tab alarm might be recommended. The Rehab Supervisor stated, after a fall, the IDT meets the next morning and determines if landing strips or Tab alarms are needed. During an interview with LVN 5 on 4/5/12 at 1145 hours, he stated Resident 17 thinks she can stand by herself, but she is very weak and he has to remind her many times not to stand by herself. When asked if Resident 17 is a fall risk, LVN 5 stated Resident 17 is not a high fall risk. He stated he reminds the CNAs to keep an eye on her, at least every two hours, to make sure she is not trying to get up. LVN 5 stated Resident 17 should never be alone. When asked if she has a Tab alarm on her bed or wheelchair, LVN 5 went into Resident 17's room and stated he did not see one. He stated, "Hold on, I'll go get one from the CNA team leader." During an interview with the DON on 4/5/12 at 1150 hours, when asked what supervision for high fall risk residents means, she stated is means to put a resident in an area where someone can watch whether they try to stand up - somewhere the resident can be seen with "eyes." She went on to say visual checks mean any staff can go into the room to make sure a resident is not getting up unassisted, and it is done every two hours. The DON stated if someone is in the Falling Star program, they need to be checked every hour. Using a Tab alarm or landing strip is up to nursing to decide to use them. After a fall, nursing is to determine what will be implemented. She then stated a landing strip and Tab alarm will be automatically implemented. On 4/5/12 at 1400 hours, Resident 17 is laying in her bed sleeping. No Tab alarm or landing strip is seen in her room. 5. Clinical record review for Resident 19 was initiated on 4/4/12. Resident 19 was admitted to the facility on [DATE], after a hospitalization following a fall at home. Review of the physician's orders [REDACTED].? side rail as enabler. Review of the Fall Risk assessment dated [DATE], shows a score of 18. The intervention documented is bed in the lowest position. Review of the facility's Fall Risk Assessment procedure (undated) shows the nurse(s) responsible for admitting the resident completes the initial Fall Risk Assessment form ...If the resident scores a 10 or greater on the Fall Risk Assessment or has a history of falls prior to admission, the resident is considered a HIGH RISK for falls. The admitting nurse will initiate a plan of care reflecting the resident's current safety status and initial interventions designed to minimize the potential for falls and injury. ...the nurse considers the following safety strategies and incorporates them into a resident specific plan of care as necessary: referral to the falling star/falling leaf program; referral to therapy to ascertain ...safety concerns; resident and family education. The Interim Care Plan dated 3/15/12, shows a Fall Risk score of 24 and a recent fall. The interventions show provide assistance for bed mobility, transfers and ambulation and a low bed. Review of a care plan problem dated 3/15/12, shows Resident 19 is at risk for falls/injury related to impaired cognition, poor safety awareness/judgment ...history of falls ... The interventions include provide ...safe ... environment, bed in lowest position, ? side rails, visibly observe ...frequently. Review of the history and physical examination [REDACTED]. Review of the PT and OT initial assessments dated 3/16/12, shows HIGH RISK OF FALLS. Review of the Nurse's Notes dated 3/21/12 at 0410 hours, shows charge nurse found Resident 19 on the floor by her bed ...no apparent injury. Resident 19 stated she got up, walked toward the door and slipped down. At 0500 hours, Resident 19's physician was notified and ordered a Tab alarm in bed to alert staff when getting out of bed unassisted. Review of the care plan problem dated 3/15/12, to address the risk for falls/injury related to impaired cognition, poor safety, awareness, judgment and history of falls shows a new entry dated 3/21/12, for a Tab alarm in bed; educate to ask (for) assistance if needed. Another entry dated 4/4/12, shows Falling Star program. Review of a care plan problem dated 3/21/12, shows a second problem to address the risk for falls/injury related to impaired cognition, poor safety awareness, judgment and a history of falls ...status [REDACTED].? side rails, visibly observe frequently. No mention of the Tab alarm or the Falling Star program is found in this care plan problem. During an interview with Resident 19's family members on 4/4/12 at 1600 hours, the family stated since Resident 19 had fallen prior to coming to the facility; they felt the staff should have utilized the Tab alarm sooner rather than wait until after Resident 19 fell . During an interview and clinical record review with the DON on 4/5/12 at 0915 hours, the DON was asked when a resident is placed on the Falling Star program. The DON stated the occupational therapist has to assess the resident and recommend the Falling Star program to nursing before a resident is placed on the program. When asked why nursing did not place Resident 19 on the Falling Star program when the Fall Risk Assessment score was 18, the DON again stated the OT has to assess the resident and recommend the Falling Star program to nursing before a resident is placed on the program. During an interview and clinical record review with LVN 4 on 4/5/12 at 0925 hours, LVN 4 stated the staff does the least restrictive interventions when a resident is admitted regardless of the fall history or the Fall Risk Assessment score. LVN 4 further stated a resident is only put on the Falling Star program after a fall. Review of the care plan for Resident 19 with LVN 4 shows Resident 19 was placed on the Falling Star program on 4/4/12. When LVN 4 was asked why Resident 19 was not placed on the Falling Star program after the fall on 3/21/12, LVN 4 stated Resident 19 should have been placed on the Falling Star program after the fall on 3/21/12. During a telephone interview with PT 1 on 4/5/12 at 1000 hours, PT 1 was asked how and when the therapists make recommendations for the Falling Star program. PT 1 stated after PT or OT completes their assessment, the therapist will determine if the resident is a high fall risk. The names of all residents found to be at high fall risk is placed on a list which is distributed to all the department heads. It is up to the department head to initiate the Falling Star program.