Every finding on record at Valley Oaks Post Acute

Based on interview, record review, and facility policy and procedure review, the facility failed to ensure the accurate reconciliation, documentation, and accountability of controlled medications for one of two sampled residents (Resident 1). This failure resulted in the loss and potential diversion of 30 controlled -substance tablets. During a review of the facility's policy and procedure (P&P) titled, Drug Diversion Policy and Procedure, undated, the P&P indicated, controlled substance counts shall be completed at every shift change by two licensed nurses. Any medication discrepancy shall be reported immediately.During a review of Resident 1's admission Record (AR), dated 7/9/26, the AR indicated, Resident 1 was admitted in the facility on 4/24/26 with diagnoses including Palliative care (focuses on easing pain, stress, and heavy symptoms from a serious illness), chronic pain syndrome, and dementia (decline in mental abilities severe enough to interfere with daily life).During a review of Resident 1's Order Summary (OS), dated 5/11/26, the OS indicated, Oxycodone - Acetaminophen Oral Tablet 7.5 - 325 mg. Give tablet by mouth every 8 hours as needed for moderate to severe pain.During the review of the Packing Slip Proof of Delivery (PSPD), the PSPD indicated that the Oxycodone/APAP (Oxy/APA) 7.5 mg / 325 mg were delivered to the facility on 6/22/26 at 2:39 PM.During an interview on 6/30/26 at 3 PM., with Licensed Vocational Nure (LVN), LVN confirmed that she received and signed for the medication delivered by the pharmacy on 6/22/26. She further stated that she and another nurse placed the medication in the narcotic section of the medication cart and completed and signed the narcotic count sheet.During a concurrent interview and record review on 6/30/26 with Director of Nursing, DON confirmed that 30 tablets of Oxycodone/APAP 7.5 mg / 325 mg was delivered on 6/22/26. DON stated that the entire bubble pack and controlled substance count sheet were missing and that staff did not identify the loss until Resident 1 requested the medication on 6/24/26.During an interview on 7/9/26 at 2:30 PM., with Assistant Director of Nursing ADON, the ADON stated that the staff searched both medication carts but were unable to locate the medication. A replacement Oxy/APA was subsequently reordered from the pharmacy.

Based on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician medication orders and instructions were not followed for three of six sampled residents (Residents 13, 6, and 3).These failures had the potential to result in unsafe nursing care practices which could compromise the health and safety of these residents.Findings:1. During a review of Resident 13's admission Record (AR), dated 2/11/26, the AR indicated, Resident 13 is an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including, Chronic Obstructive Pulmonary Disease (COPD - a common lung disease causing restricted airflow and breathing problems), Paroxysmal Atrial Fibrillation (irregular heart rhythm), presence of a pacemaker (a small, battery-powered device that prevents the heart from beating too slow), and Essential Hypertension [HTN - high blood pressure (BP)].During a review of Resident 13's Order Audit Report (OAR), dated 2/12/26, the OAR indicated, the medication order, Metoprolol Succinate [a medication that lowers BP and heart rate (HR)] . 25 milligrams (mg) give 0.5 (one-half) tablet by mouth one time a day for HTN Hold if SBP (systolic BP - the top number in a BP reading) less than (<) 110 or HR < 60, with an order date of 8/5/25.During a review of Resident 13's Medication Administration Records (MARs), for the months of November and December 2025 respectively, the staff administration documentation under the medication order, Metoprolol Succinate 25 mg were reviewed. The review indicated that staff failed to follow the medication order instructions when Resident 13 received the medication with SBP readings outside the ordered parameter on these dates: on 11/25/25 with a BP reading of 108/46, and on 12/27/25 with a BP reading of 108/67.During a concurrent interview and record review on 2/11/26 at 3:30 p.m. with the Director of Nursing (DON), Resident 13's MARs, for the months of November and December 2025, specific to staff administration documentation of the medication Metoprolol Succinate 25 mg were reviewed. DON verified the discrepancies found and acknowledged that staff did not follow physician orders and should have. 2. During a review of Resident 6's AR, dated 2/12/26, the AR indicated, Resident 6 is a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a condition where high blood sugar and high BP damage kidney filters), Essential Hypertension (high BP), and encounter for surgical aftercare following surgery of the circulatory system.During a review of Resident 6's OARs, dated 2/12/26, the OARs indicated the following physician orders: Monitor BP: SBP Goals 100-160, If SBP >160, administer Hydralazine (a medication primarily used to treat high BP) [see PRN (as needed)] every six (6) hours. (order date: 11/14/25), Hydralazine HCl Oral Tablet 25 mg . Give one (1) tablet by mouth every six (6) hours as needed for SBP over 160 (order date: 11/14/25), and Hydrocodone-Acetaminophen (a prescription medication used to relieve moderate to severe pain) Oral Tablet 5-325 mg . Give one (1) tablet by mouth every eight (8) hours as needed for severe pain 7-10/10 [a series of numbers used to rate pain intensity categorized as: mild (1-3), moderate (4-6), and severe (7-10)] (order date: 12/10/25).During a review of Resident 6's MAR for the month of November 2025, staff administration documentation for the orders, Monitor BP . and Hydralazine 25 mg ., were reviewed. Discrepancies were noted when Hydralazine 25 mg . was not administered, as ordered, to manage Resident 6's elevated blood pressures on these specific dates/times: 11/15/25 at 1200, BP = 177/66, on 11/20/25 at 1800, BP = 202/90, and on 11/24/25 at 1800, BP = 176/71. During a review of Resident 6's MAR for the month of January 2026, staff administration documentation for the order, Hydrocodone 5-325 mg . give one tablet by mouth every eight (8) hours . was reviewed. The review indicated that staff did not follow instructions when to administer the medication to Resident 6 based on the resident's reported pain levels. The medication was administered to Resident 6, who reported a pain level of six (6) out of ten (10), on these dates: 1/2/26, 1/9/26, 1/15/26, 1/22/26, 1/23/26, and 1/25/26. During a concurrent interview and record review on 2/11/26 at 3:40 p.m. with the DON, Resident 6's MARs for the months of November 2025 and January 2026, specific to staff administration documentation for the orders, Monitor BP . Hydralazine 25 mg ., and Hydrocodone 5-325 mg were reviewed. DON confirmed the discrepancies found and acknowledged that staff should have thoroughly checked and followed physician orders. 3. During a review of Resident 3's AR, dated 2/12/26, the AR indicated, Resident 3 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including nondisplaced fracture of the second metatarsal bone, right foot, (fracture of the right midfoot), Stage 4 pressure ulcer of the right buttock (bed sore extending through the skin into the muscle, tendon or bone), and post-traumatic osteoarthritis (a disease that breaks down one or more joints in the body) of the right ankle and foot. During a review of Resident 3's OAR, dated 2/12/26, the OAR indicated, the medication order Hydrocodone-Acetaminophen Oral Tablet 10-325 mg (Hydrocodone-Acetaminophen) 'Controlled Drug' give one (1) tablet by mouth every four (4) hours for pain 1-6/10 and give one (1) tablet by mouth every eight (8) hours as needed for breakthrough pain related to pressure ulcer right buttock, stage 4 (order date: 10/7/25).During a review of Resident 3's MARs for the months of November and December 2025 respectively, staff administration documentation for the order, Hydrocodone 10-325 mg . give one (1) tablet by mouth every four (4) hours for pain 1-6/10 were reviewed. The review indicated that staff failed to follow specific order instructions and could have potentially undermedicated (given insufficient medication) Resident 3 when the medication was administered at reported pain levels between seven (7) to nine (9) out of ten (10) on these dates: 11/2, 11/3, 11/4, 11/7, 11/8, 11/9, 11/10, 11/16, 11/20, 11/21, 11/22, 11/23, 11/27, 11/28, 12/1, 12/2, 12/8, 12/9, 12/13, 12/14, 12/20, 12/21, 12/22, 12/23, and 12/24/25.During a concurrent interview and record review on 2/11/26 at 3:50 p.m. with the DON, Resident 3's MARs for the months of November and December 2025, under the staff administration documentation for the medication order, Hydrocodone 10-325 mg . give one (1) tablet by mouth every four (4) hours for pain 1-6/10. were reviewed. DON confirmed and acknowledged that staff did not follow the order instructions and should have reassessed Resident 3's pain levels before administering the medication. DON agreed staff not following the order instructions could have potentially resulted in ineffective pain management for Resident 3.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated in part, Policy Statement . Medications are administered in a safe and timely manner and as prescribed. The P&P further indicated, Policy Interpretation and Implementation . 4) Medications are administered in accordance with prescriber orders, including any required time frame . 11) The following information is checked/verified for each resident prior to administering medications: a) Allergies to medications; and b) Vital signs, if necessary.A review of [NAME] and Perry's 7th Edition of Mosby's Fundamentals of Nursing, on page 419 under the section titled Legal Implications in Nursing Practice, it is stated that Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients.

Based on observation, interview and record review, the facility failed to ensure that medications were stored in a sanitary manner and separated from non-medication and food items when: The facility failed to remove two unidentified and unlabeled medication tablets found in one of two medication carts (West Cart). 2. The facility failed to remove two open syringes from medication cart. 3. The facility failed to remove one open containers of pudding from the medication cart. 4. The facility failed to maintain original pharmacy packaging for one resident (Resident 64) when combined two syringes of Enoxaparin (a medication that treats of prevents blood clots) 40 mg (milligram)/0.4 ml (milliliter), expires on 03/2028 in same bag as four syringes of same medication expiring 8/2028. These failures had the potential to compromise resident safety and result in medication errors, cross-contamination, or the administration of adulterated or expired drugs. During an observation on 2/10/26 at 6:10 a.m. of one of two medication carts (West Cart). [NAME] cart observation: 1. Bottom drawer contained two unidentified unlabeled medications 2. Drawer for room [ROOM NUMBER]c drawer with open syringe 3.Top drawer open container of pudding During an observation on 2/10/26 at 6:53 a.m. of one of two medication carts (East Cart). East cart observation: 2. 1 open syringe in medication drawer 4. 2 syringes of Enoxaparin 40 mg/0.4, expires 03/2028 in same bag as 4 syringes of same medication expiring 8/28 2.1 open syringe in medication drawer During interview 2/10/26 at 7:14 a.m. with the Charge nurse. Charge nurse stated the two meds in bottom drawer not suppose to be there, no open syringes or open pudding in drawers and medication should be kept in the original bag for different expiration dates. During a review of facilities P&P titled, Storage of Medications, undated. P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer recommendations or those of the supplier. A. the provider pharmacy dispenses medications in containers that meet legal requirements .Medications are kept in these containers. transfer of medications from one container to another is done only by the pharmacy. During a review of facilities P&P titled, Medication Destruction, undated. P&P indicated A.Tablets, capsules and liquids are disposed of in accordance with the provisions of the MWMA (Medical Waste Management Act). K. All medical waste pharmaceuticals shall be disposed of in accordance with the provisions of the MWMA.

Based on observation, interviews, and record reviews, the facility failed to ensure identifiable information was secured and kept confidential when: one resident (Resident 51) patient identification sticker was left unattended on top of the locked medication cart. This failure had the potential to result in unauthorized access to protected health information (PHI) and a violation of the resident's right to privacy and confidentiality. During observation on 2/10/26 at 6:18 a.m. of [NAME] medication cart. One patient identification label on top of medication cart left unattended.During an interview on 2/10/26 at 7:14 a.m. with Charge Nurse. Charge nurse stated patient identification label should not be left unattended on cart.During a review of facility's Policy and Procedure (P&P) titled, HIPPAA Compliance, dated 9/30/13. P&P indicated the facility will adopt guidelines and procedures that are compliant with the [Omnibus Health Insurance Portability and Accountability Act] HIPPAA Privacy and Security Rules and other related HIPPAA rules and the practices established by the rule as well as other applicable federal and state laws. Policies and Procedures and training will include at a minimum: .Access to {Protected Health Information} (PHI)- manual and electronic. During a review of facilities P&P titled, Protected Health Information (PHI), Safeguarding Electronic, dated 2001. P&P indicated This facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained received or transmitted by our information system.

Based on record review and interview, the facility failed to develop an individualized comprehensive care plans for two of four sampled residents (Residents 9 and 40) when: Resident 9 did not have an initial care plan addressing the use of Trazodone (a medication used to treat anti depressive disorder).Resident 40 did not have a care plan in place for Sacro coccyx pressure injury. These failures had the potential to affect residents' health and safety by not providing staff with appropriate guidance to meet identified needs. Findings: 1. During a review of Resident 9's admission Record (AR) dated 2/11/26, the AR indicated that Resident 9 is a [AGE] year-old male who was initially admitted to the facility on [DATE] with the following diagnoses: Moderate Protein-Calorie Malnutrition (a state of nutritional deficiency characterized by 5-10% weight loss in 6 months, BMI of 17.9-18.9, or 70-80% of ideal body weight); Dementia (progressive decline in cognitive function); Alcohol Dependence (a chronic condition where the body and mind rely on alcohol to function); Anxiety Disorder (persistent, excessive, and uncontrollable fear or worry); and Gastroesophageal Reflux Disease [a condition where stomach acid frequently flows back into the esophagus (the tube connecting the mouth and stomach)]. During a review of Resident 9's Order Summary Report (OSR), dated 2/11/26, the OSR indicated, the medication order Trazodone HCL (medication to treat depression with insomnia) 50 milligrams (mg) give 1 tablet by mouth at bedtime with an order date of 11/30/25. During a review of Resident 9's Care Plan (CP), CP indicated that the CP for Trazodone HCL was initiated on 1/28/26 and revised on 2/11/26. The review indicated that the facility failed to create a CP for Trazadone HCL on 11/30/25. During a concurrent interview and record review on 02/11/2026 at 10:00 a.m. with MDSC, Resident 9's CP indicated that a CP for Trazodone HCL was not initiated on 11/30/25. MDSC acknowledged that the facility should have initiated the CP for Trazodone on 11/30/25 the same date it was ordered. During a concurrent interview and record review on 02/11/2026 at 10:50 a.m. with DON, Resident 9's CP indicated that the CP for Trazodone HCL was not initiated on 11/30/25. DON acknowledged that the facility failed to create CP for Trazodone on 11/30/25 the same date it was ordered. 2. During a review of Resident 40's admission Record (AR), dated 2/11/26, the AR indicated, Resident 40 is an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses to include, Myelodysplastic Syndrome (blood cancer where bone marrow fails to produce sufficient healthy blood cells), Atrial Fibrillation (irregular heart rhythm), Transient Ischemic Attack (temporary blockage of blood flow to the brain), Megaloblastic Anemias (blood disorder). During a review of Resident 40's Progress Notes (PN), dated 2/11/26, the physician's PN indicated that wound number three, a sacrococcyx pressure injury, was unstageable with a date of service of 12/17/25. Subsequently, the wound assessment report dated 12/17/25 confirmed that the sacrococcyx pressure injury was assessed and treated. During a record review of Resident 40, CP indicated that there was no CP for sacrococcyx pressure injury created on 12/17/25. The review indicated that the facility failed to create a CP for the newly noted unstageable sacrococcyx pressure injury. During a concurrent interview and record review on 02/11/2026 4:25 at p.m. with DON, Resident 40's CP indicated that a CP for unstageable sacrococcyx pressure injury was not created on 12/17/25. DON acknowledged that facility failed to create CP for the unstageable sacrococcyx pressure injury on 12/17/25. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person Centered, revised March 2022, the P&P indicated in part, Policy Statement . A Comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated, Policy Interpretation and Implementation .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview and record review, the facility failed to maintain accurate medical records for one resident (Resident 1) when it was documented a medication was administered when in fact the resident left the facility, and the medication was administered by an outside provider.This failure resulted in Resident 1's medication administration record (MAR) reflecting inaccurate documentation of prescribed medication.Findings:During a review of Resident 1's Medication Administration Record (MAR), dated 8/2/25 through 8/7/25 the MAR indicated, on 8/3/25 and 8/7/25 medication given.During a review of Resident 1's outside provider's Medication Dosing Log (MDL), dated 8/2/25 through 8/7/25 the MDL indicated, on 8/3/25 and 8/7/25 medication was administered at their facility.During an interview on 9/22/25 at 4:30 p.m. with Director of Nursing (DON), DON verbalized, the resident did not receive the medication in the facility, was receiving the medication from an outside provider.Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 609 in the section titled, Medication Administration, indicated, After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered.

Based on interview and record review, the facility failed to document a comprehensive nursing assessment for one of two residents sampled (Resident 1). This failure had the potential for the receiving facility not to have sufficient information necessary to develop and implement a plan of care to meet Resident 1's needs. Findings: During a concurrent interview and record review on 7/3/25 at 4:27 p.m. with Director of Nursing (DON), Resident 1's Nursing Progress Notes (NPN), dated 3/13/25 through 3/19/25 were reviewed. There was no evidence in the NPN that a comprehensive assessment was completed before Resident 1 was sent to the Emergency Department (ED) for coffee ground emesis (is a sign of upper gastrointestinal [GI] bleeding). DON stated there was no assessment documented and there should have been. Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 365 in the section titled, Informatics and Documentation, indicated, Documentation is a key communication strategy that produces a written account of pertinent data, clinical decisions and interventions, and patient responses in a health record. Documentation in a patient's health record is a vital aspect of nursing practice.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received treatment for two pressure ulcers. This failure had the potential for the pressure ulcers to become worse and delay healing. Findings: During a review of Resident 1's admission Record (AR), [undated], the AR indicated in part, Resident 1 was admitted to the facility on [DATE] with diagnoses including, pressure ulcer of sacral region (base of the spine) stage 4 (most severe stage of a bedsore that is an open wound with extensive tissue damage that extends to muscle, bone, tendon, or other supporting structures), pressure induced deep tissue damage of left heel (a severe form of pressure ulcer where the injury originates beneath the skin's surface with damage to underlying soft tissue), Type 2 Diabetes Mellitus (the body cannot use insulin [a hormone which regulates the amount of glucose in the blood] correctly and sugar builds up in the blood), chronic kidney disease stage 4 (condition in which kidneys have moderate to severe damage and cannot filter blood as well as they should), acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels (hypoxemia) without a significant increase in carbon dioxide levels), and bacteremia (presence of bacteria in the bloodstream). During a review of Resident 1's Order Summary Report (OSR), [undated], the OSR indicated in part, an order dated 5/23/25, Left heel dark purple discoloration pressure ulcer: Cleanse with NS. Pat dry. Apply triad cream to wound bed and cover with foam dressing. Change every day shift. An additional order dated 5/23/2025 indicated, Stage 4 pressure ulcer sacro-coccyx: Cleanse with NS. Pat dry. Apply hydrogel to wound bed. Cover with foam dressing. Change every day shift. During a concurrent interview and record review on 7/2/25 at 2:15 p.m. with the director of nurses (DON), Resident 1's Treatment Administration Record (TAR) schedule for May 2025 was reviewed. The TAR indicated, missing entries on 5/23/2025 and 5/24/2025 for Left heel dark purple discoloration pressure ulcer: Cleanse with NS. Pat dry. Apply triad cream to wound bed and cover with foam dressing. Change every day shift. Order Date 5/23/25 1444, and missing entries on 5/23/2025 and 5/24/2025 for Stage 4 pressure ulcer sacro-coccyx: Cleanse with NS. Pat dry. Apply hydrogel to wound bed. Cover with foam dressing. Change every day shift. Order Date 05/23/2025 1444. The DON verbalized blank indicates it wasn't done, and if it was done there should be a checkmark. The DON further stated, This is a new admit and it's the weekend. They should have been started. It's there already and supposed to be done. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, P&P indicated 2. In addition, the nurse shall describe and document/report the following: (a) Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .d) Current treatments, including support surfaces . According to Fundamental of Nursing, by [NAME] and [NAME], Eighth Edition, on page 336, under the section, Physicians' Orders indicated, Nurses follow physician orders unless they believe the orders are in error or harm patients.

Based on interview and record review, the facility failed to ensure assessments and notifications of change in conditions were completed for one of three sampled residents (Resident 1) when: 1. A change in condition (COC) was not completed for Resident 1's right eye. 2. A post fall risk assessment was not completed. 3. Family was not notified of Resident 1's COCs. 4. Interdisciplinary Team (IDT) meeting was not conducted within 72 hours of Resident 1's COCs. These facility failures resulted Resident 1's medical record not reflecting accurate change in condition and assessment, family not notified of Resident 1's changes in conditions, hospice not notified of Resident 1's fall, delayed interdisciplinary team review of Resident 1's changes in conditions and had the potential for Resident 1 to not receive adequate care to meet Resident 1's highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 1's admission Record (AR), [undated], the AR indicated in part, Resident 1 was admitted to the facility on [DATE] with diagnoses including, pressure ulcer of sacral region (base of the spine) stage 4 (most severe stage of a bedsore that is an open wound with extensive tissue damage that extends to muscle, bone, tendon, or other supporting structures), pressure induced deep tissue damage of left heel (a severe form of pressure ulcer where the injury originates beneath the skin's surface with damage to underlying soft tissue), Type 2 Diabetes Mellitus (the body cannot use insulin [a hormone which regulates the amount of glucose in the blood] correctly and sugar builds up in the blood), chronic kidney disease stage 4 (condition in which kidneys have moderate to severe damage and cannot filter blood as well as they should), acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels (hypoxemia) without a significant increase in carbon dioxide levels), and bacteremia (presence of bacteria in the bloodstream). 1. During an interview on 7/2/25 at 12:49 p.m., with Licensed Nurse (LN 1), LN 1 stated, I saw (Resident 1) when one eye was blood shot. I think therapy was telling me the resident was nauseous and was trying to throw up and when he looked back up his eye was red, so he was straining too hard. LN 1 further stated, It should be documented because it's a COC. During a concurrent interview and record review on 7/2/25 at 2:09 p.m. with the Director of Nursing (DON), Resident 1's medical record was reviewed. A Situation Background Assessment Recommendation (SBAR) (a document to provide essential, concise information regarding a change in condition) related to a change in Resident 1's right eye was not located in Resident 1's medical record. The DON verbalized there was no COC completed for Resident 1's eye, and there should be one. The DON further verbalized there was a notification on the same day that the doctor and hospice were notified, but there was no actual assessment and there should have been. The DON stated, For the COC it should have been written by the SBAR and there is none. During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, dated May 2017, the P&P indicated, 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's P&P titled, Charting and Documentation, dated 2001, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the IDT regarding the resident's condition and response to care .2) The following information is to be documented in the resident medical record .d) Changes in the resident's condition; e) Events, incidents or accidents involving the resident . 2. During an interview on 7/2/25 at 11 a.m. with the Director of Nursing (DON), DON stated Resident 1 fell one time on 5/31/2025 and was found sitting on the floor. During a concurrent interview and record review on 7/2/2025 at 2:09 p.m., with the DON, Resident 1's medical record was reviewed. A post fall assessment was not located in Resident 1's medical record. DON verbalized there's no policy that says you have to do a post fall assessment and further stated, The post fall assessment was not done for this patient, and it's something that should be done. I agree, and if we're doing it, it should be in our policy and procedure and unless I'm missing it, I didn't see any that talked about it . It's part of our orientation and education upon hire. During a review of Nurse Orientation Procedures and Documentation (NOPD), [undated], the NOPD indicated, Falls. 3) Assessment post fall. During a review of the facility's P&P titled, Assessing Falls and their Causes, dated March 2018, the P&P indicated, The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . Performing a Post-Fall Evaluation: 1) After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort . Documentation. When a resident falls, the following information should be recorded in the resident's medical record: 5) Completion of a falls risk assessment. 3. During a concurrent interview and record review on 7/2/25 at 11 a.m., with the DON, the facility's P&P titled, Change in a Resident's Condition or Status, was reviewed. The P&P indicated, Policy Statement - Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation 2. Unless otherwise instructed by the resident, a nurse will notify the resident's represenative when: a. The resident is involved in any accident or incident that results in an injury . b. There is a significant change in the resident's physical . The DON stated Resident 1 fell one time, was found sitting on the floor, didn't complain of any pain. There was an incident after that, (Resident 1) was nauseated 2-3 days after and coughing and (Resident 1's) right eye was blood shot. The doctor was notified and Hospice was aware also. When Resident 1 fell, we notified hospice. Resident 1 fell on 5/31/25. DON stated, I'm not seeing that the family was notified . If a patient is alert and oriented we ask if they want their family notified. I'm not sure if the nurse had the conversation with the patient as to if they want family to be notified and it should have been done. No one other than hospice was notified of the fall. Resident 1 had blood shot eyes, and the hospice was notified. Both responsible parties should have been notified. The nurses note has doctor notified and (Name of Hospice) on 6/3/25. During an interview on 7/2/2025 at 12:49 p.m., with Licensed Nurse (LN 1), LN 1 stated If a patient falls, we notify the provider and family . It is standard practice at the facility to call family if a patient falls. 5. During a concurrent interview and record review on 7/2/225 at 2 p.m., with the DON, Resident 1's Interdisciplinary Team Note, dated 6/20/25 at 05:22 indicated, IDT MET: 06/17/2025 at 2 p.m. Patient had a fall incident on 5/31/25 at 3:45 p.m. MD/RP/(name) Hospice was notified of the incident. Patient also noted with right eye bloodshot (subconjunctival hemorrhage) on 6/3 (6/3/25) . Hospice and MD were notified by LN. Hospice notified RP . (family) from out of the area came to visit patient on 6/16, discussed with (family) the fall incident . Possible cause of red eye discussed with (family) . (family) in agreement with POC at this time. Hospice aware. DON stated, It (IDT meting) should be in 72 hours, so this wasn't done. I will take responsibility of that fall. During a review of the facility's P&P titled, Charting and Documentation, dated 2001, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2) The following information is to be documented in the resident medical record .d) Changes in the resident's condition; e) Events, incidents or accidents involving the resident .

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received quality care when Resident 1 was admitted to the facility with a diagnosis of Type 2 Diabetes ([DM2] a chronic condition when blood sugar levels are persistently high [hyperglycemia]) and continued to have high blood glucose levels. This failure resulted in Resident 1 being transferred to the hospital and had the potential to contribute to the resident's death the following morning. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included: DM2 with neuropathy (a type of nerve damage that can occur if you have diabetes), Chronic Obstructive Pulmonary Disease ([COPD] lung disease causing restricted airflow and breathing problems), Pneumonia (an infection of the lungs), atherosclerotic heart disease (a buildup of fats, cholesterol and other substances in the arteries), chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (heart muscle is weakened or damaged and cannot pump blood well), high blood pressure, transient ischemic attack (interruption in blood flow to the brain), and cerebral infarct (stroke-disrupted blood flow to the brain). During a review of Resident 1's documents from the acute hospital located in the facility's medical record for Resident 1 indicated, History & Physical (H&P), dated 12/31/24, the H&P indicated, Resident 1 had an active diagnosis of DM2. Under Additional Current Orders . insulin lispro sliding scale. In addition, under Assessment and Plan . resume lantus (a long-acting insulin used to control high blood sugar) 5 units daily and ssi (sliding scale insulin). Further review of documents from the acute hospital indicated, a physician progress note dated 1/5/25 under Assessment/Plan 3: dm2-continue lantus 5 units daily and ssi. A physician progress note dated 1/6/25, indicated, Resident 1 was on Lantus sliding scale. The medication reconciliation sheet from the acute hospital, dated 1/2/25 indicated, insulin lispro sliding scale. There was no discharge summary from the acute hospital in the facility's medical record for Resident 1. During a concurrent interview and record review on 1/27/25 at 12:40 p.m. with the Director of Nursing (DON), Resident 1's Medical Record was reviewed. DON verbalized Resident 1 had a diagnosis of DM2 and was not admitted to the facility with an insulin sliding scale order, but they have a protocol in place to check the sugar and they checked it daily. The admission nurse put the resident on the protocol for finger stick checks. Our facility protocol is to call the doctor if the blood sugar result is over 400 and if it is below 70, we have a hypoglycemia protocol in place and we call the doctor. There were some high blood sugar results like 380 and it was more consistently high. It was 230 at some points and sugar checks are early in the morning at 6:30 a.m. Resident 1 was admitted for respiratory, maybe the flu. During a review of Resident 1's Progress Note, dated 1/14/25, by the Physician Assistant, the Progress Note indicated, This is an [AGE] year-old gentleman with significant past medical history of coronary artery disease with diastolic dysfunction, COPD, and multiple other medical issues who was admitted for shortness of breath. Patient was found to have COPD exacerbation with upper respiratory infection with rhinovirus. Medically, patient was treated and subsequently was sent here for further rehabilitation. The only mention of Resident 1 having DM2 is under the heading Current Medications, Glucose gel. Under Assessment/Plan there is no mention of a plan for Resident 1's DM2. The only mention of Resident 1 having DM2 is under the heading Current Medications, Glucose gel. Under Assessment/Plan there is no mention of a plan for Resident 1's DM2. During a review of Resident 1's Progress Notes, dated 1/15/25, the Progress Note indicated, Dr. (name) was notified at approximately 0550 because the resident ' s finger stick was HI. It was taken twice. Dr. (name) said to give him 10 units of Lispro and recheck in one hour. At approximately 0715 the finger stick was retaken and it still read out HI. Message left with Dr. The AM nurse was told about this resident ' s finger sticks and the insulin was given. She was told that the fingerstick was retaken and it read out HI. There was no order written or signed by the physician for the 10 units of Lispro. There were no further progress notes regarding Resident 1's glucose until 1/17/25. Resident 1's blood glucose level was documented on the MAR on 1/16/25 as 388. During a concurrent interview and record review on 1/27/25 at 1:05 p.m. with Licensed Nurse (LN 1) Resident 1's Medication Administration Record (MAR) was reviewed and indicated, blood sugar checks began on 1/9/25 with a result of 144 fasting. LN 1 further verbalized Resident 1's blood sugar kept getting higher, it was 252 the next day then 385 and the next day 390. Our standard is to notify the doctor if it is above 400. The night shift nurse notified the doctor on 1/15/25 at 5:58 a.m. and the order received from the doctor was to give 10 units of Lispro and check in one hour, then it was checked at 7:15 a.m. and it was reading HI and that was during shift change and Resident 1 was endorsed to the next nurse. LN 1 verbalized there was no further documentation about blood sugars until 1/17/25 when Resident 1's blood sugar had another high result and that is when they sent Resident 1 out. During a review of Resident 1's Health Status Note, created 1/25/25, the Note indicated Late entry, This note is a follow up to: 1/17/2025 06:55 Health Status note. Effective Date 1/18/25 at 01:21. Administered 10 units of Lispro as per order at 0645. Resident is alert and verbally responsive. Rechecked fingerstick at 0720am, result 482mg/dl. Oncoming nurse made aware. During a review of Resident 1's Health Status Note, created 1/26/25, the Note indicated Late entry, This note is a follow up to: 1/17/2025 16:14 Health Status note. Effective Date 1/17/25 at 10:05. 7:30 Pt in bed, arousable. Breakfast being served to the residents. Around 8:15, pt in bed awake and responsive. Fingerstick re checked, high. MD was notified. Aware of the 10 units administered in the morning. MD stated he will do rounds. Around 9, pt awake in bed and stated he did not feel like eating. But routine morning meds given and tolerated well. VS WNL. O2 at 96 via NC. Fingerstick re checked at this time at 398. Around 9:40 MD in the facility was notified of patients events regarding his BS (blood sugar) . During a review of Resident 1's, Order Summary Report, dated 1/17/25, the Order indicated, Insulin Lispro subcutaneous Pen-Injector 200 unit/ml inject as per sliding scale . subcutaneously before meals for Hyperglycemia. Notify MD if BS <70 or >400; Insulin Lispro subcutaneous Pen-Injector 200 unit/ml inject as per sliding scale . subcutaneously at bedtime for Hyperglycemia . During a review of Resident 1's Weights and Vitals Summary (WVS), the WVS indicated, blood sugar results as follows: 1/9/25 - 144 mg/dl (milligrams per deciliter, a unit of measurement) at 6:38 a.m. 1/10/25 - 252 at 6:47 a.m. 1/11/25 - 385 at 6:30 a.m. 1/12/25 - 390 at 6:17 a.m. 1/13/25 - 296 at 6:30 a.m. 1/14/25 - 389 at 6:24 a.m. 1/15/25 - 498 at 6:10 a.m. 1/16/25 - 388 at 5:31 a.m. 1/17/25 - 500 at 6:03 a.m. During a review of American Medical Response (AMR), document, dated 1/17/25 at 9:48 a.m., the AMR indicated, The patient was found laying on his bed at the SNF. He was A/Ox0. Staff said he is normally A/Ox4. They said he wasn ' t acting normal and they checked his BG. They said it read High. I was unable to get a BG, ours read E-S. He was trauma. Skin signs were normal. Lung sounds rhonchi (low pitched rattling sound) No signs of vomiting. He had a clear open airway. Report and transfer care to the RN. During a review of Resident 1's Emergency Department (ED), document, dated 1/17/25, ED indicated, Reason for visit; clinical diagnosis: altered mental status . Medication list, home meds as of 1/17/25 insulin glargine order date 7/22/18, insulin Lispro order date 7/22/18 . During a review of Resident 1's hospital Discharge Summary, dated 1/18/25, the Discharge Summary indicated, Final diagnoses: 1. Diabetic ketoacidosis with coma. 2. Acute kidney injury related to diabetic ketoacidosis. 3. Ventricular tachycardia (serious heart rhythm disorder with a rapid, irregular heartbeat . Resident 1 (name) is an unfortunate [AGE] year-old man who presented to the ED from the nursing home he was rehabilitating at and was noted to have obtundation. He was sent to the ED and was found to be in diabetic ketoacidosis with his blood glucose at 862. He was with AKI (Acute Kidney Failure) as well with a creatinine of 2.5 and a BUN of 50 . he was extremely dehydrated, somnolent, not really responding to questions appropriately and confused. He was given IV fluid, started on insulin drip and admitted to the ICU. Overnight, the patient ' s blood glucose levels dropped into the 250 range . he had sporadic low blood pressures . later he was noted in the ICU to have persistent bradycardia into the 50's and then at 3:35 he developed ventricular tachycardia and subsequently asystole. Time of death was 3:38 a.m. on 1/18/25. During a review of the facility's policy and procedure (P&P) titled, Nursing care of the older adult with diabetes mellitus, revised November 2020, the P&P indicated, Purpose. To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes. Symptoms associated with Diabetes 1) Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugar above target levels) . 2) Diabetic ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy . DKA is a life-threatening emergency that needs immediate medical attention . During a review of the facility's P&P titled, Attending Physician Responsibilities/Documentation, revised August 2014, the P&P indicated, The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. Each attending physician will be responsible for the following: 1) Accepting responsibility for initial and subsequent resident care; 4) Providing appropriate resident care; 5) Providing appropriate, timely medical orders; Providing appropriate, timely, and pertinent documentation . Accepting Responsibility for Resident Care 1) The Attending Physician will assess new admissions in a timely fashion, according to the individual's medical stability. 2) The Attending Physician will seek, provide, and analyze information regarding a resident ' s current status, recent history, and medications and treatments to enable safe, effective continuing care . 2b) The review should be extensive enough to ensure that the current approach overall is consistent with the individual's medical condition, goals, prognosis, and wishes. Providing Appropriate Care 3) In consultation with facility staff, the Physician will identify appropriate treatments and services, consistent with each individual's diagnoses, condition, prognosis, and wishes .

Based on observations, interviews, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure dishware was allowed to air dry before being stacked in 1 of 1 facility kitchen. Stacking the dishes while still wet/damp had the potential to create an environment conducive to microbial growth, which could result in foodborne illness. The failed practice had the potential to affect all 51 residents who resided in the facility and received meals from the kitchen. Findings included: An undated facility policy titled Dishwashing indicated, Dishes are to be air dried in racks before stacking and storing. The U.S. FDA 2022 Food Code requirement for drying equipment and utensils indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. On 12/17/2024 at 10:10 AM, Dietary Aide #2 was observed to stack three visibly wet dessert bowls on a tray on top of each other without allowing them to air-dry. There were also several visibly wet plate holders and plate covers that were observed stacked on top of each other. During an interview on 12/17/2024 at 10:10 AM, Dietary Aide #2 stated she normally processed the dirty dishes, and the cook would then put away the clean dishes. She stated that sometimes, she did help the cook put away plate holders and covers along with the dessert cups, and always stacked them on top of each other. She stated it was important not to stack dishes wet because it could lead to bacterial growth. During an interview on 12/17/2024 at 10:15 AM, [NAME] #1 stated she put plate holders and plate covers away after flipping them over to remove the excess water. She picked up a plate holder she had stacked, and it was still visibly wet. She stated she would let the plate covers sit for a couple of minutes after they came out of the dishwasher. She confirmed the plate holders and plate covers were not dry and stated if they did not dry properly before they were stacked, bacteria could grow. She confirmed the stacked dessert bowls were still wet as well. During an interview on 12/17/2024 at 10:25 AM, the Food Service Supervisor (FSS) stated the staff were to let everything that came out of the dishwasher air-dry and not wipe anything dry. She stated dishes should be dry before stacking. She stated the stacked plate holders, plate covers, and dessert bowls were still wet. She stated it was important for the dishes to be dry before stacking because bacteria could grow. She stated the facility had approximately 60 plate holders and 60 plate covers. During an interview on 12/17/2024 at 2:12 PM, the Director of Nursing (DON) stated she did not know the process for drying and storing dishes in the kitchen. She indicated she would expect kitchen staff to know the process behind properly drying and storing dishware. She stated all 52 residents in the facility received meals from the kitchen, and they had no residents on enteral (tube) feedings. (On 12/18/2024 at 8:51 AM, the facility corrected the previously provided census to 51 plus one bed hold). During an interview on 12/17/2024 at 2:41 PM, the Administrator stated the dishwasher had to reach a certain temperature, and then the dishes were supposed to be allowed to air-dry thoroughly before being stored. He stated if dishes were not dried and stored properly, it created an environment that could potentially grow bacteria. He expected the dishes to be dried and stored properly.

Based on observations, interviews, records reviews, and facility policy review, the facility failed to ensure an evaluation for causative factors was conducted and documented after each fall to facilitate the ability to develop effective fall prevention interventions and failed to ensure accurate information about residents' falls was maintained for 2 (Resident #36 and Resident #25) of 2 sampled residents reviewed for accidents. Findings included: A facility policy titled, Fall Risk Assessment, revised 03/2018, indicated, 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and to try to minimize complication from falling. The policy also specified, According to the Minimum Data Set (MDS), a fall is defined as: unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. [for example], a resident pushes another resident). According to the policy, A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The policy also indicated, 5) If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why current approaches remain relevant. 6) If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. A facility policy titled, Assessing Falls and Their Causes, revised 03/2018, indicated, The purposes of the procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying the causes of a fall. The policy specified, Defining Details of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding, or dropping from an object (e.g., from bed or chair to floor); b. Falling while attempting to stand up from a sitting or lying position. c. Falling while already standing and trying to ambulate. The policy indicated, Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments, etc. [et cetera]. 2. Evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or h. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. The policy also indicated, Documentation: When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found. 2. Assessment data, including vitals and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 1. An Admission Record indicated the facility readmitted Resident #36 on 01/04/2024. According to the Admission Record, the resident had a medical history that included diagnoses of hepatic encephalopathy, alcoholic cirrhosis, and chronic hypoxic respiratory failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/2024, revealed Resident #36 scored 7 on a Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment. According to the MDS, the resident used a walker for mobility, required substantial/maximal assistance with rolling to the left and right and with chair/bed transfer, and required partial/moderate assistance with moving from a lying to a sitting position and moving from a sitting to a standing position. The MDS indicated the resident did not have a fall at any time in the last two to six months prior to admission. A review of the care plan for Resident #36 revealed a focus area dated as initiated 01/04/2024 that indicated the resident was at high risk for falls related to gait/balance problems secondary to morbid obesity, generalized pain/weakness, incontinence, chronic anemia, and an unawareness of safety needs. Interventions dated as initiated on 01/04/2024 directed staff to anticipate and meet the resident's needs; be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed; ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair; follow the facility's fall protocol; and review information on past falls and attempt to determine the cause of falls, record possible root causes, alter or remove any potential causes if possible, and educate the resident / family / caregivers / interdisciplinary team (IDT) as to the causes. A document titled SBAR [Situation, Background, Appearance, Review] Communication Form and Progress Note for RNs [Registered Nurses]/LPNs [Licensed Practical Nurses]/LVNs [Licensed Vocational Nurses], dated 03/01/2024 and completed by Licensed Vocational Nurse (LVN) #6, indicated the LVN was notified at 9:35 PM that Resident #36 had fallen. According to the evaluation, a certified nurse aide (CNA) was providing incontinence care to the resident when the resident rolled to the right and rolled off the bed. The evaluation indicated the resident was seen on the side of the bed on their knees. According to the evaluation, the resident was assisted back to bed and complained of pain to their knees. The evaluation revealed that an abrasion was identified to the resident's right knee. The evaluation indicated acetaminophen was provided and that staff would continue to monitor. The evaluation indicated the physician was notified on 03/02/2024 at 10:00 PM. The resident's care plan did not contain evidence of any new interventions that were added after the resident's fall out of bed on 03/01/2024. As of 12/18/2024, all the interventions on the resident's fall prevention care plan were dated as initiated 01/04/2024. Review of Resident #36's medical record on 12/17/2024 revealed no evidence that the resident had experienced any further falls after 03/01/2024. An Incidents by Incident Type log, printed by the facility on 12/17/2024, revealed a list of the names of residents who had fallen between 01/01/2024 and 12/17/2024, as well as the dates of their individual falls; Resident #36's fall on 03/01/2024 was not included on the list. A Nursing Staffing Assignment and Sign-in Sheet, dated 03/01/2024 for the evening shift (the shift that began at 3:00 PM), indicated LVN #6 and Certified Nurse Aides (CNAs) #7, #8, #9, #10, #11, #12, and #13 were on duty on the date/shift of Resident #2's fall. During an interview on 12/18/2024 at 1:40 PM, LVN #6 stated he had worked a few shifts at the facility through a local staffing agency. LVN #6 stated he had not received any fall-specific training at the facility; however, he knew that when a resident fell while he was on duty, a change of condition form and a progress note must be completed after the resident was assessed. LVN #6 indicated he could not recall Resident #36 falling while he was on duty or any details related to any fall sustained by Resident #36. During an interview on 12/18/2024 at 2:05 PM, CNA #13 revealed that she had received fall training in the facility; however, she could not recall a fall sustained by Resident #36 while she was on duty. Attempts were made to contact CNAs #7, #8, #9, #10, #11, and #12 without success on the following dates/times: - CNA #7: 12/18/2024 at 2:46 PM (the surveyor left a message requesting a return call, but no return call was received). - CNA #8: 12/18/2024 at 2:48 PM (there was no option to leave a message). - CNA #9: 12/18/2024 at 2:49 PM (the surveyor left a message requesting a return call, but no return call was received). - CNA #10: 12/18/2024 at 2:56 PM (the surveyor left a message requesting a return call, but no return call was received). - CNA #11: 12/18/2024 at 2:52 PM (the surveyor left a message requesting a return call, but no return call was received). - CNA #12: 12/18/2024 at 3:04 PM (the surveyor left a message requesting a return call, but no return call was received). During an interview on 12/18/2024 at 10:03 AM, the Director of Nursing (DON) indicated that once a nurse completed an eInteract (SBAR) form, the fall was to be reviewed the next working day during the clinical stand-up meeting, which was attended by the Administrator, DON, Social Worker, Activity Director, and a nurse (either the Infection Preventionist or the Director of Staff Development). The DON stated that during a fall investigation, the facility attempted to interview the resident and/or their family, as well as any possible staff witnesses. The DON indicated that due to Resident #36's size, the facility would usually provide education to staff about the proper way to turn the resident to prevent falls from the bed. During an interview on 12/18/2024 at 1:57 PM, the DON revealed she was unable to locate any documentation that an investigation was completed related to Resident #36's 03/01/2024 fall, nor was she able to locate any documentation that the IDT had met to discuss the fall or that specific interventions were implemented to prevent further potential falls for Resident #36. During an interview on 12/19/2024 at 11:50 AM, the Director of Medical Records indicated she was responsible for conducting audits on all falls in the facility to ensure the nursing staff had conducted the proper assessments and completed all the required documentation in the resident's electronic medical record. She stated she had been responsible for these audits for approximately three years. She stated that the nurse must complete a communication note in the electronic medical record to alert her that a fall had occurred and was ready for review. She stated if the nurse did not initiate the communication note and someone started a change of condition form, that person could add a note in the change of condition book at the nurses' station. She indicated staff had to manually make the notation in this area; otherwise, she was not notified of the fall or change in condition. She stated she conducted audits twice weekly for missing documentation and provided notices to the nursing staff when documents were incomplete or missing, and then the nurse must initial the notice and return it to her when the documents were completed. During an interview on 12/19/2024 at 11:53 AM, the DON stated the nurse on duty at the time of a fall/incident should follow the guidance when recording an incident. She stated the SBAR notes did not notify management in any way and that the only way for management to know about an incident was for the nurse to fill out the communication note. During an interview on 12/19/2024 at 12:22 PM, the DON revealed that she utilized a screen called the dashboard on the electronic medical record system to notify her when a fall had occurred. She stated the nurse at the time of the fall was to enter a communication note in the electronic medical record and handwrite a note in the change of condition binder at the nurses' station. The DON explained if there was a communication note written after a fall, then the fall was discussed during the daily clinical meeting in order to determine the root cause of the fall and determine a plan for appropriate interventions. During an additional interview on 12/19/2024 at 2:56 PM, the DON stated she had no knowledge of Resident #36's 03/01/2024 fall prior to this week. She indicated the Medical Records Director would not be aware of a fall either, if the nurse did not complete a communication note. She stated her expectation was that nurses complete all required documents during the shift when the incident occurred. During an interview on 12/19/2024 at 3:12 PM, the Administrator indicated he expected the nurses to complete all required documentation on the shift when the incident occurred. During an interview on 12/19/2024 at 3:43 PM, the DON stated the last training the facility had provided on falls was in March of this year. 2. An Admission Record indicated the facility admitted Resident #25 on 10/06/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, subsequent encounter for an unspecified fall, and age-related osteoporosis. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #25 had short- and long-term memory impairment. The assessment indicated the resident was independent with ambulation and had sustained one fall with no injury since entry or since the prior assessment. Resident #25's care plan included a focus area (not dated) that indicated the resident was at risk for falls related to confusion, dementia, hypertension, psychoactive drug use, an unawareness of safety needs, wandering, and the use/side effects of medication. Interventions (not dated) directed staff to anticipate and meet the resident's needs; be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed; ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair; follow the facility's fall protocol; and review information on past falls and attempt to determine the cause of falls, record possible root causes, alter or remove any potential causes if possible, and educate the resident / family / caregivers / interdisciplinary team (IDT) as to the causes. A document titled SBAR [Situation, Background, Appearance, Review] Communication Form and Progress Note for RNs [Registered Nurses]/LPNs [Licensed Practical Nurses]/LVNs [Licensed Vocational Nurses], dated 06/19/2024 and completed by Registered Nurse (RN) #14, indicated Resident #25 sustained an unwitnessed fall and was found on the floor between room [ROOM NUMBER] and the [NAME] nurse's station. Resident #25 was sitting on their buttocks with their arms extended for support. The report indicated that Resident #25 sustained no apparent injury . During an interview on 12/19/2024 at 8:40 AM, RN #14 indicated he worked in the facility periodically since May of 2024. RN #14 stated he recalled Resident #25 but was not present at the time of Resident #25's fall on 06/19/2024; however, he had been asked by the facility's Infection Preventionist (IP) nurse to initiate the documentation when he came on duty on the morning of 06/19/2024. RN #14 explained he was told the fall had occurred on the shift prior to his, but the documentation was not done, so he was asked to initiate it. RN #14 stated he did not have all the details of the fall and, therefore, could not complete all required documentation, but the initiation of the documentation would allow the facility to complete the remainder when they knew more details. An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 10/04/2024 and completed by Licensed Vocational Nurse (LVN) #15, indicated Resident #25 sustained a fall on 10/04/2024 after being seen kicking a barrel in anger and losing their balance. During an interview on 12/19/2024 at 9:18 AM, LVN #15 indicated she was familiar with Resident #25; however, she was not present at the time of the resident's fall on 10/04/2024 but had come in as the charge nurse on day shift. LVN #15 stated she recalled the nurse present at the time of the fall had to leave the facility, and she was asked to initiate the eInteract form on the nurse's behalf. An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 10/17/2024 and completed by Licensed Vocational Nurse (LVN) #18, indicated Resident #25 sustained a fall on 10/17/2024; however, the document did not provide details related to how the fall occurred. Attempts were made to contact LVN #18 for a telephone interview on 12/18/2024 at 8:16 PM and 12/19/2024 at 10:22 AM (the surveyor left two messages requesting a return call, but no return call was received). An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 11/27/2024 and completed by Registered Nurse (RN) #17, indicated Resident #25 sustained a fall on 11/27/2024 due to weakness, low blood pressure, and seizure-like activity for a few seconds. An interview with RN #17 was not possible, as the Administrator informed the survey team that RN #17 was out of the country at the time of the survey. During an interview on 12/18/2024 at 10:03 AM, the Director of Nursing (DON) indicated that once a nurse completed an eInteract form, the fall was to be reviewed the next working day during the clinical stand-up meeting, which was attended by the Administrator, DON, Social Worker, Activity Director, and a nurse (either the Infection Preventionist or the Director of Staff Development). The DON stated that during the investigation, the facility attempted to interview the resident and/or their family as well as any possible staff witnesses. During an interview on 12/18/2024 at 1:57 PM, the DON indicated she was unable to locate any documentation that an investigation was completed and that the IDT had met to discuss the resident's falls, nor was she able to provide documentation of interventions that were initiated to prevent further potential falls for Resident #25. During an interview on 12/19/2024 at 11:50 AM, the Director of Medical Records indicated she was responsible for conducting an audit on all the falls in the facility to ensure the nursing staff had completed all required documentation in the resident's electronic medical record. She indicated that the nurse must complete communication documentation to alert her a fall had occurred and was ready for review. She stated she conducted these audits twice weekly for missing documentation and provided notices to the nursing staff when documents were incomplete or missing, and the nurse must initial the notice and return it to her when the documents were completed. During a follow-up interview on 12/19/2024 at 12:22 PM, the DON revealed that she utilized a screen called the dashboard on the electronic medical record system to notify her when a fall had occurred as well as complete a handwritten note in a binder located at the nurses' station. The DON explained if there was a communication note written after a fall, then the fall was discussed during the daily clinical meeting in order to determine the root cause of the fall and determine a plan for appropriate interventions. During an additional interview on 12/19/2024 at 2:56 PM, the DON stated she had no knowledge of Resident #25's falls prior to this week and that the Medical Records Director would not be aware of falls and start her audits either if no communication notes were done. She stated her expectation was that the nurses complete all required documents during the shift when the incident occurred. During an interview on 12/19/2024 at 3:12 PM, the Administrator indicated he expected the nurses to complete all required documentation on the shift when the incident occurred.

Based on observation, interview, record review, facility document review, facility policy review, and review of the Centers for Disease Prevention and Control (CDC) guidelines, the facility failed to ensure staff adhered to contact isolation precautions and donned the appropriate personal protective equipment while performing care or services in the room of a resident (Resident #26) with a known communicable disease (Clostridium difficile [C. diff]), to prevent the potential spread of C. diff infection to other residents. The failed practice was identified for 1 (Resident #26) of 1 resident reviewed for transmission-based precautions (TBP) and had the potential to affect 14 other residents who resided on the East Hall and were likely to receive care from staff assigned to Resident #26. Findings included: An undated facility policy titled, Standard and Other Precautions, indicated, Contact Precautions The following is adapted from CDC publication 2007 Guideline for Isolation Precautions: Preventing Transmission of Infections Agents in Healthcare Settings, which can be obtained at www.cdc.gov. The policy specified, Contact Precautions are followed by all personnel when instructed to do so by the health department, state licensing agency, resident's physician, or other infection control professionals. Procedure The following procedures are followed when a resident must be on Contact Precautions: 2. Personal Protective Equipment a. Personnel caring for a resident on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment b. Gloves i. Wear gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident (e.g. [such as], personal care equipment, bed rails). ii. [NAME] gloves upon entry into the room. c. Gowns i. [NAME] gown upon entry into the room. ii. Remove gown and observe hand hygiene before leaving the resident-care environment. iii. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other residents or environmental surfaces. d. Donning personal protective equipment upon room entry and discarding before exiting the resident room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE [Vancomycin-resistant Enterococcus], C. difficile, noroviruses and other intestinal tract pathogens. The CDC guidance titled, C. diff: Facts for Clinicians dated 03/05/2024 and obtained from https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html, indicated, C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. The guidance also indicated, Wear gloves and gown when treating patients with potential infectious diarrhea, including C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, handwashing alone may not be sufficient to eliminate all C. diff spores. The guidance indicated, If CDI [C. diff infection] is confirmed: Continue isolation and contact precautions. An Admission Record revealed the facility admitted Resident #26 on 11/20/2024. According to the Admission Record, the resident had diagnoses that included recurrent enterocolitis due to Clostridium difficile, end stage renal disease (ESRD), and need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS also revealed resident #26 had an active diagnosis of a multidrug-resistant organism (MDRO), had a urinary tract infection in the last 30 days, and was taking antibiotics and/or had taken them in the past seven days. Resident #26's care plan included a focus area, dated 11/21/2024, that indicated the resident had C. difficile. Interventions directed staff to administer antibiotics/medications as ordered; disinfect all equipment used before leaving the room; implement enhanced contact isolation, including wearing gowns and masks when changing contaminated linens and bagging linens tightly before taking them to laundry; and use as much disposable equipment as possible or use dedicated equipment such as a thermometer and blood pressure cuff. The resident's care plan also had a focus area, revised on 11/29/2024, that indicated the resident was on oral antibiotic therapy (Vancomycin) until 01/08/2025 related to C. diff. Interventions directed staff to administer antibiotic medications as ordered by the physician and monitor and document side effects and effectiveness every shift. An observation on 12/16/2024 at 9:07 AM revealed a sign was posted outside the door to Resident #26's room that indicated the resident was on contact precautions. The sign indicated everyone was to clean their hands before entering and when leaving the room and that providers and staff were to put on gloves and a gown before entering the room and discard the gloves and gown before exiting the room. During an observation on 12/16/2024 at 9:50 AM, Housekeeper #3 went into Resident #26's room wearing gloves and a mask but no gown. During an interview on 12/16/2024 at 10:54 AM, Housekeeper #3 revealed she knew she was supposed to wear a gown to go in Resident #26's room, where the resident was on contact precautions, but she had forgotten to put on a gown when she went in to clean the room. During an observation on 12/16/2024 at 11:11 AM, Certified Nurse Aide (CNA) #4 went into Resident #26's room without donning PPE. CNA #4 folded up Resident #26's wheelchair and moved it across the room. CNA #4 used hand sanitizer upon exiting the resident's room but did not wash her hands. CNA #4 then went into another resident's room. During an interview on 12/19/2024 at 10:40 AM, CNA #4 revealed she had been trained in the previous 30 days on infection control. CNA #4 stated that when she went into the room of a resident who was on contact precautions, she should put on a gown and gloves before going in. CNA #4 stated she would take the gown and gloves off and put them in the trash in the resident's room and then wash her hands. CNA #4 stated that when she moved Resident #26's wheelchair on 12/16/2024, she was busy and forgot to put on PPE. During an observation on 12/18/2024 at 4:19 PM, CNA #5 went into Resident #26's room and retrieved gloves from the box of gloves near the door on the inside the room. Without donning a gown, CNA #5 went to the resident's bedside and proceeded to rearrange and spread the bed linens, which touched her clothing at least twice. After rearranging the resident's top sheet and blankets, CNA #5 did not remove her gloves or wash or sanitize her hands before exiting the room with a wadded piece of material, which she placed in the linen hamper. After closing the linen hamper, she touched the lid of the hamper all over while still wearing the contaminated gloves, then proceeded to push the hamper down the hall. During an interview on 12/18/2024 at 4:19 PM, CNA #5 stated she was not required to wear a gown because she did not provide personal care to the resident. She asserted that a gown was only needed if she provided personal care to the resident. CNA #5 stated she did not remove her gloves because she was touching the linen hamper. During an interview on 12/19/2024 at 9:21 AM, the Infection Preventionist (IP) stated the types of infection control precautions used in the facility were standard, contact, droplet, and enhanced barrier. He stated if a resident was on contact precautions, any staff going into that cubicle (area around the resident's bed) needed to wear gown and gloves. The IP stated staff should use proper hand hygiene. He indicated Resident #26 was on contact precautions, and any staff who went into the resident's area of the room should wear a gown and gloves. He stated staff should remove the PPE before leaving the room and put it in the trash receptacle provided inside the resident's room. The IP stated that because Resident #26 had C. diff, all staff should have washed their hands with soap and water. He indicated staff should not have entered another resident's room or touched another resident without first washing their hands with soap and water. The IP stated staff should not wear gloves that they wore in Resident #26's room out into the hall. During an interview on 12/19/2024 at 11:45 AM, the Director of Nursing (DON) revealed that for a new admission, they used the hospital records to know what infection control precautions were needed. She stated if the resident had a change in their need for precautions, then they would verify the needs with the IP. She indicated the IP would post a sign for the appropriate precautions for staff. The DON revealed that for a resident on contact precautions, staff were required to wear gloves and a gown anytime they were touching the resident or areas with which the resident came into contact. She stated if they were touching the bedding or the resident's belongings, including the trash, the staff would be required to wear gloves and a gown. The DON stated the gloves and gown should be removed after providing for the resident's needs and before leaving the room. She stated the staff should go into the resident's bathroom and wash their hands with soap and water before leaving the resident's room. The Administrator sat in on the interview and agreed with the expectations expressed by the DON.

Based on interview, record review, and facility document review, the facility failed to ensure the quality assessment and assurance (QAA) committee developed and implemented appropriate plans of action to correct and identify quality deficiencies related to evaluation, tracking, and documentation of falls to facilitate the ability to identify any patterns, determine causal factors, and enable the facility to ascertain whether appropriate and effective interventions were implemented for 2 (Resident #25 and Resident #36) of 2 residents reviewed for falls. Findings included: The facility's Quality Assurance Performance Improvement (QAPI) Plan 2024, dated 01/2024, indicated, Feedback, Data Systems, and Monitoring a. Describe the overall system that will be put in place to monitor care and services, drawing data from multiple sources. The plan also specified several sources of data that would be monitored through QAPI, one of which was, Adverse events (incident reports, 24 hour report) and indicated that the interdisciplinary team (IDT) would review adverse events daily. The plan specified the processes by which the information would be communicated included a dashboard, monthly reports/graphs, logs, and minutes of all meetings. During the survey conducted from 12/16/2024 to 12/19/2024, review of Resident #36's and Resident #25's medical records revealed the following occasions when residents experienced falls and there was insufficient documentation to indicate the facility followed up on the falls in accordance with their established processes by discussing the falls in morning meetings, conducting root-cause analyses, developing and implementing interventions to address any identified root causes, and/or evaluating interventions for their effectiveness: a. A document titled SBAR [Situation, Background, Appearance, Review] Communication Form and Progress Note for RNs [Registered Nurses]/LPNs [Licensed Practical Nurses]/LVNs [Licensed Vocational Nurses], dated 03/01/2024 and completed by Licensed Vocational Nurse (LVN) #6, indicated the LVN was notified at 9:35 PM that Resident #36 had fallen. According to the evaluation, a certified nurse aide (CNA) was providing incontinence care to the resident when the resident rolled to the right and rolled off the bed. The evaluation indicated the resident was seen on the side of the bed on their knees. According to the evaluation, the resident was assisted back to bed and complained of pain to their knees. The evaluation revealed that an abrasion was identified to the resident's right knee. The resident's care plan did not contain evidence of any new interventions that were added after the resident's fall out of bed on 03/01/2024. An Incidents by Incident Type log, printed by the facility on 12/17/2024, revealed a list of the names of residents who had fallen between 01/01/2024 and 12/17/2024, as well as the dates of their individual falls; Resident #36's fall on 03/01/2024 was not included on the list. During an interview on 12/18/2024 at 1:57 PM, the DON revealed she was unable to locate any documentation that an investigation was completed related to Resident #36's 03/01/2024 fall, nor was she able to locate any documentation that the IDT had met to discuss the fall or that specific interventions were implemented to prevent further potential falls for Resident #36. b. An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 06/19/2024 and completed by Registered Nurse (RN) #14, indicated Resident #25 sustained an unwitnessed fall and was found on the floor between room [ROOM NUMBER] and the [NAME] nurse's station. Resident #25 was sitting on their buttocks with their arms extended for support. The report indicated that Resident #25 sustained no apparent injury. During an interview on 12/19/2024 at 8:40 AM, RN #14 indicated he was not present at the time of Resident #25's fall on 06/19/2024; however, he had been asked by the facility's Infection Preventionist (IP) nurse to initiate the documentation when he came on duty on the morning of 06/19/2024. RN #14 explained he was told the fall had occurred on the shift prior to his, but the documentation was not done, so he was asked to initiate it. RN #14 stated he did not have all the details of the fall and, therefore, could not complete all the required documentation. An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 10/04/2024 and completed by Licensed Vocational Nurse (LVN) #15, indicated Resident #25 sustained a fall on 10/04/2024 after being seen kicking a barrel in anger and losing their balance. During an interview on 12/19/2024 at 9:18 AM, LVN #15 indicated she was familiar with Resident #25 but was not present at the time of the resident's fall on 10/04/2024; however, she had come on duty as the charge nurse on the day shift following the incident. LVN #15 stated she recalled the nurse present at the time of the fall had to leave the facility, and she was asked to initiate the eInteract (SBAR) form on the nurse's behalf. An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 10/17/2024 and completed by Licensed Vocational Nurse (LVN) #18, indicated Resident #25 sustained a fall on 10/17/2024; however, the document did not provide details related to how the fall occurred. Attempts were made to contact LVN #18 for a telephone interview on 12/18/2024 at 8:16 PM and 12/19/2024 at 10:22 AM (the surveyor left two messages requesting a return call, but no return call was received). An SBAR Communication Form and Progress Note for RNs/LPNs/LVNs, dated 11/27/2024 and completed by Registered Nurse (RN) #17, indicated Resident #25 sustained a fall on 11/27/2024 due to weakness, low blood pressure, and seizure-like activity for a few seconds. An interview with RN #17 was not possible, as the Administrator informed the survey team that RN #17 was out of the country at the time of the survey. A completed Matrix for Providers (CMS-802) provided by the facility on 12/16/2024 indicated there were no residents who had experienced falls, with or without injury, in the past 120 days. Resident #25's falls in the past 120 days (as listed above) were not captured on the CMS-802. An Incidents by Incident Type log, printed by the facility on 12/17/2024, revealed a list of the names of residents who had fallen between 01/01/2024 and 12/17/2024, as well as the dates of their individual falls; Resident #25's falls on 06/19/2024, 10/04/2024, 10/17/2024, and 11/27/2024 were not included on the list. During an interview on 12/18/2024 at 1:57 PM, the DON indicated she was unable to locate any documentation that investigations were completed or that the IDT had met to discuss the resident's falls, nor was she able to provide documentation of interventions that were initiated to prevent further potential falls for Resident #25. The following interviews were conducted regarding the facility's processes for follow-up and audits related to falls: During an interview on 12/19/2024 at 11:53 AM, the Director of Nursing (DON) stated a communication note should be completed by the nurse at the time of an incident, and then the communication notes were reviewed during the daily morning meetings. The DON revealed that completion of an incident report did not trigger a notification to administration/management, and the only way the electronic health record (EHR) system would alert management of an incident was if the staff completed a communication note. During an interview on 12/19/2024 at 12:22 PM, the DON stated the dashboard of the electronic health record (EHR) system alerted her to review when there was a communication note. The DON stated the nurse had to choose Communication Note and New to initiate a communication note. She stated when an incident occurred, the nurse was also supposed add a handwritten note to the Change of Condition (COD) binder for the resident to be monitored. The DON stated the Medical Records staff audited the EHR communications and the COD binder. The DON indicated the nurse was required to initiate and complete a risk management report and that this would also populate a progress note. The DON stated that when there was a communication note regarding a fall, the IDT would discuss the incident during the clinical part of the morning meetings. She revealed the staff who attended that meeting were the DON, the Infection Preventionist (IP), the Activity Director, the dietitian, and the Administrator. The DON stated that during the meeting, they discussed incidents, including who was involved, how the incident happened, and what they could do about the issue. She stated the purpose of the meeting was to do a root-cause analysis and then decide on a plan of intervention. The DON stated they had identified an ongoing issue with the communication notes. The DON indicated registry (staffing agency) nurses were given a written process/checklist to follow for recording an incident and that filling out a communication form was on the list. According to the DON, when a registry nurse came to work in the building for the first time, the nurse who was going off duty showed the new or agency staff where to find the listed items in the EHR. During an interview on 12/19/2024 at 3:23 PM, the Administrator stated he was the QAA contact person. He explained that during QAA meetings, the IDT discussed issues that affected the entire facility. He indicated root-cause analyses were completed for all concerns that were discussed. The Administrator stated the QAA committee had discussed the audit processes but had not discussed the missing falls documentation. According to the Administrator, the facility had previously identified that registry staff had not completed all the required falls documentation. The Administrator revealed if documents were noted to be missing, the management staff reached out to registry staff to have them completed. The Administrator revealed the resolution of the issue was for the facility to no longer use registry staff. The Administrator stated they had put several things in place to attempt to recruit and hire permanent staff, including referral bonuses at each quarter for the new staff and the staff person who referred them, sponsoring the CNAs through training, advertising positions on job search websites, and hiring registry staff who performed well. The actions, as described the Administrator, did not specify how the QAA committee would identify and address when staff failed to initiate documentation to alert the IDT, management, or the QAA committee of falls and the lack of follow-up that occurred as a result of the missing documentation (evaluation for causative factors, development of interventions, follow-up monitoring) after a fall occurred.

Based on interviews, record review, and facility policy review, the facility failed to provide residents with access to their personal funds on weekends for 1 (Resident #20) of 5 residents sampled for personal funds . Findings included: A facility policy titled, Deposit of Resident Funds, revised 03/2021, revealed 1. Should the resident permit the facility to hold, safeguard, and manage his or her personal funds, the facility will: c. provide the resident access to funds of fifty (50) dollars or less within twenty-four (24) hours, and access to funds in excess of fifty (50) dollars within three banking days. 2. Funds not on deposit in the resident's account are deposited into the resident petty cash fund managed by the facility on behalf of the residents. The State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities guidance at tag F567 indicated, Resident requests for access to their funds should be honored by facility staff as soon as possible but no later than: - The same day for amounts less than $100.00 ($50.00 for Medicaid residents); - Three banking days for amounts of $100.00 ($50.00 for Medicaid residents) or more. An Admission Record revealed the facility admitted Resident #20 on 10/12/2022. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with hyperglycemia, hypothyroidism, and mixed hyperlipidemia. A quarterly MDS, with an ARD of 11/01/2024, revealed Resident #20 scored 15 on a BIMS, which indicated the resident had intact cognition. During an interview on 12/18/2024 at 12:41 PM, Resident #20 stated they had asked for funds on the weekend and were told they could not get any because, I have to ask the lady [Business Office employee] for it. The resident stated the Administrator could not give the money to them because, we have to ask on the weekdays. During an interview on 12/18/2024 at 3:02 PM, the Director of Nursing (DON) stated the Business Office employee was available five days a week. The facility would manage the residents' money for them, and whenever they asked for their money after hours and on weekends, they expected that the residents would have access to it. The DON indicated both the Administrator and the DON had access to the residents' funds. During an interview on 12/18/2024 at 3:59 PM, the Administrator stated that upon admission, the residents were encouraged to have their valuables and funds stored for them. The Administrator indicated that on the weekends, they wanted to limit who had access to the residents' funds. The Administrator stated he was available on weekends for an emergency but, if it can wait until Monday, then we encourage that. He indicated the facility tried to accommodate the residents before the weekend if they were aware.

Based on record review and interview, the facility failed to follow their policy and procedure (P&P) to review and revise a person-centered comprehensive care plan for one of three residents (Resident 1) who exhibited aggressive behavior towards other residents. This failure resulted in Resident 1 becoming aggressive and kicking another resident (Resident 2) in the leg and had the potential to place other residents at risk for serious injury. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including Dementia (loss of cognitive functioning; thinking, remembering, and reasoning and interferes with a person's daily life and activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), depression (a persistent feeling of sadness and loss of interest in activities) and hypertension (high blood pressure). During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/18/24, the NPN indicated, Change in Condition . Physical aggression, Verbal aggression, Danger to self or others. During a review of Resident 1's NPN dated 9/21/24, the NPN indicated, [Resident 1] became aggressive towards another resident. During a review of Resident 1's NPN dated 9/30/24, the NPN indicated, [Resident 1] is on alert charting for kicking another resident [Resident 2] in the leg after entering their room. During a review of Resident 1's Care Plan ([CP] a document that summarizes how a patient's needs will be met, and their care will be managed), dated 10/11/22, the CP indicated, Exhibits behavioral symptoms (verbal, or physical aggressiveness, socially inappropriate, disruption as exhibited by anger towards staff, anger towards family, yelling out, striking out. The care plan further indicated, Revision on: 7/8/24. During an interview on 9/30/24 at 3:49 p.m.,with the facility's director of nursing (DON), the DON confirmed Resident 1's care plan was not revised after Resident 1 had a change in status. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last revised March 2022, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized tool that measures health status in nursing home residents) assessment accurately reflected the residents status for one of three sampled residents (Resident 1). This failure resulted in the documentation of inaccurate assessments and had the potential for Resident 1's identified care needs to go unmet. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including, dementia (loss of cognitive functioning; thinking, remembering, and reasoning and interferes with a person's daily life and activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), depression (a persistent feeling of sadness and loss of interest in activities) and hypertension (high blood pressure). During a review of Resident 1's admission MDS - Section E -Behavior, dated 10/12/22, the MDS indicated, Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) = Behavior of this type occurred 1 to 3 days. During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/18/24, the NPN indicated, Change in Condition . Behavioral Status Evaluation: Physical aggression, Verbal aggression, Danger to self or others. During a review of Resident 1's NPN dated 9/21/24, the NPN indicated, [Resident 1] became aggressive towards another resident. During a review of Resident 1's NPN dated 9/30/24, the NPN indicated, [Resident 1] is on alert charting for kicking another resident in the leg after entering their room. During a concurrent interview and record review on 11/19/24 at 11:55 a.m. with the facility's director of nursing (DON), Resident 1's NPN dated 9/18/24 was reviewed. The DON acknowledged Resident 1 exhibited a change in condition and showed aggressive behavior towards other residents in the facility. During a review of Resident 1's MDS - Section E -Behavior, dated 10/4/24, the MDS indicated, Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) = Behavior not exhibited. During a concurrent interview and record review on 11/19/24 at 12:10 p.m. with the facility's DON, Resident 1's MDS Section E Behavior dated 10/4/24 was reviewed. DON acknowledged Resident 1's MDS assessment and confirmed the assessment dated [DATE] did not accurately reflect the status of Resident 1's aggressive behavior.

Based on record review and interview, the facility failed to submit the findings of an alleged abuse investigation to the State Survey Agency (Department) within five working days of the incident. This failure had the potential to compromise resident's health and safety, and delay necessary actions to protect residents from abuse. Findings: Review of a facility report incident (FRI) submitted by the facility to the Department dated 9/30/24, indicated, an alleged abuse incident involving two residents, (Residents 1 and 2) that occurred on 9/29/24 at 5:30 p.m. The FRI indicated, [Resident 2] was yelling because [Resident 1] was in his bed. [Resident 1] kicked at [Resident 2] and made contact with his leg. During an interview on 9/30/24 at 3:22 p.m. with the facility's administrator (ADM), the ADM confirmed an alleged abuse incident occurred on 9/29/24. The ADM indicated there would be an investigation into the incident between Residents 1 and 2. During an interview on 11/18/24 at 12:10 p.m. with the ADM, the ADM stated the investigation was completed but the results were not submitted to the Department. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, the P&P indicated, The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview and record review, the facility failed to ensure adequate supervision of food pocketing (holding food in the mouth without swallowing) behavior and assistance in oral care was provided to one of three sampled residents (Resident 1). These failures had the potential to impair Resident 1's health and nutrition which could result in serious complications. Findings: During a review of Resident 1's, Admission Record, dated 3/4/23, the record indicated, Resident 1 was admitted to the facility on [DATE], with admission diagnoses including, unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, muscle weakness, and unspecified lack of coordination. During a review of Resident 1's, Nutrition Care Plan, dated 3/6/23, a care plan focus indicated in part, The resident (Resident 1) has nutritional problem related to poor appetite . disease process (dementia). Care plan interventions included, Explain and reinforce to the resident the importance of maintaining the diet ordered . Monitor/document/report . pocketing . holding food in mouth During a review of Resident 1's, Health Status Note, dated 4/3/23, the note indicated in part, IDT [Interdisciplinary Team - a group of healthcare professionals (e.g., Physician/Medical Director, Administrator, DON, Nurse, Social Services, Dietitian, Activity Director, Pharmacist) with various areas of expertise who work together towards the goals of their residents] Met: .Patient (Resident 1) noted pocketing food on 3/29, no difficulty swallowing noted, no coughing at this time. MD notified and agreed to downgrade diet to mechanical soft, ground meat. Patient (Resident 1) this month weighed 165.8 lbs. (pounds), noted with weight loss During a review of Resident 1's, Nutrition Dietary Note, dated 4/4/23, the note indicated in part, . Intake continues to be low . Inadequate energy intake related to intake not meeting estimated needs, -5.0% (five percent significant weight loss), -8.8 lbs. (8.8 pounds weight loss) in one month During an interview on 4/13/23 at 10:23 a.m., with the Director of Nursing (DON), DON verbalized during an internal investigation, it was found CNA 1 did not provide adequate oral care to Resident 1 after eating on several occasions. During a review of the facility ' s, policy and procedures (P&P), titled, Mouth Care, dated 2/18, the P&P indicated in part, Purpose . The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection.

Based on observation, interview, and record review, the facility failed ensure one of two sampled residents (Resident 1) was free from physical harm and verbal abuse when they failed to: 1. Report an allegation of abuse as required to local state and federal agencies. 2. Suspend an employee alleged of resident abuse immediately pending outcome of investigation. 3. Notify Resident 1's representative, attending physician, and facility medical director of alleged abuse as required. These facility failures caused Resident 1 to sustain a fall with injuries, be verbally abused,, and had the potential to subject Resident 1 and other residents cared for by the staff member to additional physical, mental, and psychosocial harm. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, Resident was a [AGE] year old, with diagnoses that included, abnormal gait and mobility (abnormal walking), Alzheimer's disease (a disease of the brain that affects thinking), and history of fall. During a concurrent interview and record review on 2/6/23, at 4:50 p.m., with a student nurse (SN) the Incident Report (IR), dated 1/30/23 was reviewed. The IR for Resident 1 indicated, at approximately 8 a.m., Resident 1 was observed leaving the facility. The SN followed Resident 1 outside and attempted to redirect resident back to facility. A licensed nurse (LN1) approached Resident 1 with anger stating, We are not going to deal with this shit today. The SN stated, LN1 very aggressively linked his arm under Resident 1's arm and twirled him around so quickly the resident lost his footing, fell to the ground hard, hitting the left side of his cheek first, and then LN1 fell on top of Resident 1. LN1 did not assess if Resident 1 had injuries. LN1 then scooped Resident 1 up off the ground, dragged him back to the facility and plopped him on the couch. Resident 1 complained he couldn't breathe. The SN stated, the administrator trainee (ADMT) called me into his office, and I told him everything that happened, and stated, I am so shaken up about the situation, it's really abusive. The SN told the director of nursing (DON) that morning too. The SN asked the DON, Why are we not sending (Resident 1 name) out (to the hospital)? He hit his head hard. The DON stated, Resident 1's vital signs were fine, so the resident didn't need to be sent out. The SN indicated, an x-ray confirmed Resident 1 had a fractured rib. During a review of the Central Coast Portable Imaging Radiology Interpretation (CCPI),dated 1/27/23, for Resident 1, the CCPI indicated x-rays completed for left shoulder, left hand, right hand, and chest. The CCPI indicated, fracture of left seventh rib (broken rib). During an observation and concurrent interview on 2/7/23, at 1:27 p.m., Resident 1 was observed standing in the doorway of room. Resident 1 was alert to name and able to answer simple questions. Resident 1 looked at surveyor badge and stated, Another girl had one of these. This guy pushed me on the ground and fell on top of me. He thought he was being cute. I said you ' re a tough guy huh. Made me really angry, thought he was being cute. When asked if resident had any injuries, Resident 1 demonstrated hard to breath with fast and shallow inspirations and showed both hands that have reddish, purplish, brown discoloration on fingers and anterior of both hands. Resident 1 then looked down the hallway and saw LN1 and stated, That's the guy. Resident 1 motioned towards LN1, pointing with finger, The one that thought he was being cute. Resident 1 appeared fearful and concerned and watched LN1 who was about 20 feet away until LN1 was no longer there. Resident 1 stated, Being pushed down made me feel horrible, that guy thought he was being cute. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons and or agencies: the state licensing/certification agency, the local/state ombudsman, the resident's representative (sponsor) of record, adult protective services, law enforcement officials, the resident's attending physician; and the facility medical director. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source) and misappropriation of resident property will be reported immediately, but not later than 2 hours if the alleged violation involves abuse. During a review of LN1's Time Sheet (TS), dated 2/7/23, the TS indicated, LN1 continued to work until 6:27 p.m. on 1/27/23 despite the DON and ADMT being informed of the alleged abuse that morning by the SN. During a concurrent interview and record review on 2/7/23, at 1:50 p.m., with the DON, ADMT, and the SN, the facility P&P, Abuse Investigation and Reporting, was reviewed. The ADMT and the DON confirmed the facility did not follow the policy when a SN reported suspected abuse and should have.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance device to ensure safety from falls for one of two sampled residents, (Resident 1). Resident 1 was assessed as a high risk for fall with history of constantly leaning forward and was ordered by the physician to use lap buddy (a breakaway lap cushion that helps with positioning if a person tends to lean forward and is in danger of falling out of the wheelchair) while in wheelchair for safety. A certified nursing assistant (CNA 1) left resident unattended while the resident was seated in the wheelchair without the lap buddy on . As a result, Resident 1 fell forward from the wheelchair, sustained laceration on the left forehead and a skull fracture, requiring a transfer to the emergency room . Findings: During an observation on 6/27/19, at 9:00 [NAME]M., Resident 1, was sitting in a wheelchair at bedside, with lap buddy on, wearing pants and blouse, two nursing staff were assisting Resident 1 back to bed. Resident 1 had light brown and light green colored bruises on left cheek bone area. The resident was not inteviewable. During a review of the clinical record for Resident 1, the document titled, Client [DIAGNOSES REDACTED]. memory disorders, personality changes, and impaired reasoning), Restlessness and Agitation. Review of the the Minimum Data Set (MDS) (assessment of healthcare and functional needs and abilities), dated 6/4/19, indicated Resident 1 had short term and long term memory problems, and moderately impaired cognitive skills (decisions poor; cues/supervision required). Resident 1 required extensive assistance (resident involved in activity and staff provide weight-bearing assistance) with one person physical assist for transfers and walking. Resident 1's balance is not steady and only able to stabilize with staff assistance. Review of Fall Risk assessment dated [DATE] indicated Resident 1 was a high risk of falls, with a score of 13. The assessment showed a score from 8-16 was a high risk for falls related to the following risk factors: History of falls in the past 180 days, neuromuscular dysfunction (affects muscles and their direct nervous system control), balance deficit/unsteady gait, impaired judgment, wandering behavior, use of [MEDICAL CONDITION] (medication that affect a person's mental state), and narcotic (a drug, that in moderate doses dulls the senses, relieves pain, and induces profound sleep) medications, visual deficit (decreased ability to see to a degree that causes problems), bladder/bowel dysfunction (problems with urinating and passing stool), and required an assistive device to ambulate/transfer. Resident 1 has dementia and poor safety awareness, fell at home sustaining a fractured right hip, and does not use the call light due to dementia. Review of the document titled, (facility name) Resident Care Plan for falls, initiated on 5/23/19, indicated Resident 1 had poor safety judgement, was constantly leaning forward, and was unable to use a call light due to dementia, had a fall at home resulting in right [MEDICAL CONDITION]. Approaches in order to prevent injury from fall included the use of lap buddy (a breakaway lap cushion that aides in the prevention of falls) and not to leave Resident 1 unattended. Review of the document titled Physician Orders, dated 5/28/19, indicated an order to use lap buddy while Resident 1 is in wheelchair for safety measure due to resident's constantly leaning forward. Review of document titled CNA Documentation dated 6/13/19, at 5:27 [NAME]M. revealed, CNA 1 put Resident 1 in her wheelchair, went to get lap buddy and resident fell flat on her face. A review of a licensed nurse (LN 1) note, dated 6/13/19, at 8:52 [NAME]M., indicated, at 5:55 am, Resident 1 was in room when CNA (CNA 1) Resident 1 in the wheelchair, when CNA turned to grab the lap buddy, Resident 1 fell forward, hit her face on the floor, cutting her forehead open. Resident 1 was bleeding and 911 was called for transfer to the emergency room . During an observation and concurrent interview with CNA 1, on 9/18/19, at 7:45 [NAME]M., while at the resident's room where the fall incident occurred, CNA 1 demonstrated how the fall incident, on 6/13/19 occurred. CNA 1 demonstrated and explained that the alarm kept going off and Resident 1 was trying to get out of bed on left side. CNA 1 put Resident 1 in wheelchair with the wheelchair facing head of bed and then rolled the wheelchair back a couple of feet and turned to head out of the room. CNA 1 then realized, Oh, yes, the lap buddy, and turned to go get it. The lap buddy was on neighbor's bed side table. The distance was measured from resident's location to the lap buddy was six feet and 4 inches away. CNA 1 indicated she then took about four to five steps to get the lap buddy, heard a thump, and resident fell on the floor. During an interview with the Director of Nursing (DON), on 6/27/19, at 9:30 [NAME]M., the DON stated, We do a fall assessment upon admission and that is what triggers fall precautions, then we update it with any changes. Resident 1 was on Fall Precautions. The DON further stated, CNA 1 had gotten Resident 1 up in a wheelchair, turned to reach for the lap buddy, I don't even think CNA 1 took a step, but the resident (Resident 1), fell forward. CNA 1 should have had the lap buddy ready and with her to use. Review of Resident 1's hospital emergency room report, dated 6/13/19, indicated Resident 1 sustained a head injury and facial laceration (tissue tear) on her left forehead. Resident 1 received six stitches to the [MEDICAL CONDITION]. A review of the Computerized [NAME]ography (an X-ray image made using a form of tomography (technique for displaying a representation of a cross section through the human body using X-rays or ultrasound) in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces an image) report, dated 6/13/19, indicated Resident 1 sustained a [MEDICAL CONDITION] occipital condyle (undersurface protuberances of the main bone of the back and lower part of the skull). The facility policy and procedure titled, Fall Risk Assessment, dated (MONTH) (YEAR), indicated in part, 7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable The facility policy and procedure titled, Falls-Clinical Protocol, dated (MONTH) (YEAR), indicated in part, Monitoring and Follow-Up and, 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling ( instead of, or in addition to those that have already been identified) and also reconsider the current interventions

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food under sanitary conditions during the following: 1. When the main kitchen water pipe broke, the facility did not wash, rinse or sanitize dishware, did not handle food with proper hand washing techniques, and sanitized the counters, according to the Food Code 2013. Outside workers repeatedly entered and exited the kitchen without hand washing or hair nets. These failures created potential for growth of disease causing microorganisms and food borne illness to the 49 highly susceptible residents living in the facility, who were served with a total of 7 meals since the pipe broke. Immediate jeopardy (IJ) was called on 3/9/15 at 12:40 p.m., with the facility Administrator. On 3/9/15 at 6:50 p.m., the IJ was abated with the Administrator after providing an acceptable plan of correction. The plan of correction was as follows: A) The drain that was backing up into the kitchen was replaced at approximately 1:30 p.m.. The dish washing machine was reattached and put to use to wash dishes, silverware, pots and pans. The floor of the kitchen was washed with bleach 220 ppm (parts per million) two times to insure that the floor was sanitary. This was accomplished at approximately 3:30 p.m.. After the floor was sanitized the dishes, silverware, pots and pans were rewashed in the dish washing machine to make sure that they were sanitary. The counter tops were sanitized. All food that had been prepared within the past three days was thrown away and a new menu was selected for the evening. The new menu was prepared by the kitchen staff using food handling practices. B) Inservice training was held by administrator with six dietary staff on 3/9/15 regarding the proper technique for cleaning pots, pans and dishes when the dishwashing machine is not in service. The other two staff members will be inserviced on 3/10/15. Subsequent inservices will be scheduled quarterly with the Dietary Consultant regarding cleaning of pots, pans and dishes and the overall cleanliness of the kitchen. C) The administrator and the Food Service Supervisor (FSS) will inspect the kitchen on a weekly basis to insure cleanliness of all parts of the kitchen operation. The Dietary Consultant will test the dietary staff regarding cleanliness procedures on a quarterly basis. D) The kitchen was sanitized by 4:30 p.m. on 3/9/15. The inservice training will be completed by 3/10/15. The other inservice training will be done on a quarterly basis starting in March 2015. 2. The facility failed to maintain a clean and sanitary kitchen door jambs, floor plates, door sidings, and trash can. This failure created potential for growth of disease causing microorganisms and food borne illness to the 49 highly susceptible residents living in the facility. 3. The facility failed date and label food items stored inside the two refrigerators. This failure created potential for growth of disease causing microorganisms and food borne illness to the 49 highly susceptible residents living in the facility. Findings: 1. A review of the FDA (Food and Drug Administration) Employee and Personal Hygiene Handbook dated 9/13, under "Personal Hygiene", states in part, "..They (employees) should immediately wash their hands after engaging in activities that contaminate the hands and: When entering a food preparation area.." A review of Food Code 2013 under "When to wash", states in part, "..F. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.." A review of the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code 2013, specific recommendations for: manual washing and sanitizing using a 3 step process to include wash, rinse and sanitizing, states in part, "..The process includes immersion in either hot water (at least 171 degrees) for 30 seconds; or a chemical sanitization solution used according to manufacturer's instructions.." 1. During kitchen tour observation on 3/9/15 at 10:12 a.m., the entire kitchen floor was wet. Cook 1 stated, "We had a pipe break. If you (surveyors) had come in five minutes earlier, you would have seen towels and blankets all over the floor!" The kitchen was observed to have what appeared to be food particles on all the counters. Approximately 50 trays, glass, and dish holders located on the counters next to the sink, had white crusty substances. Several pans were piled up next to a large divided sink . At 10:15 a.m., Cook 1, dietary aide 1 (DA 1) and the FSS were observed going in and out the back kitchen door to the outside and to the facility hallway without washing hands or changing gloves. The kitchen had a strong musty smell. On 3/9/15, starting at 10:19 a.m., the following kitchen staff: Cook 1, DA 1, and FSS were interviewed. Cook 1 revealed, the dishwasher started backing up on 3/6/15 after 7 p.m. At 8 p.m., the Maintenance attempted to unclog the main kitchen drainage pipe but was unable. A plumber was called in on 3/7/15 in the morning. The plumber concluded, the problem was due to a broken pipe but was unable to repair it at that time. On 3/7/15 in the morning, the plumber told the kitchen staff not to use the kitchen drains until repaired. On 3/9/15 at 10:19 a.m., Cook 1 explained how they had been washing dishes, "We fill up both basins with water and put a splash or two of sanitizer in the one basin of water". When asked for further detail on the sanitizing process, Cook 1 confirmed, no testing with chemical test strips had occurred. On 3/9/15, starting at 10:19 a.m., interview with Cook 1 and DA 1 revealed, to empty the water out of the basins, they were filling up buckets of dirty used water from the sinks and carrying them through the kitchen and throwing the water out the kitchen back door. When asked how they were cleaning the counters during food preparation, Cook 1 and DA 1 indicated, the buckets used to throw the water out was filled with water from the dish sink to wash down the counters. When asked if they had been using this practice the entire time since the plumber told them not to use the drains on 3/7/15, Cook 1 and DA 1 both stated, "Yes." Interview with the FSS at the same time, validated, this was what had been happening. On 3/9/15, starting at 10:19 a.m., interview Cook 1 and DA 1 indicated, there was no dedicated hand washing sink as the sink was not connected to a drain. Concurrent observation at this time revealed, two plumber workers, with black marks on their hands and clothes, came from outside and through the kitchen without washing hands or placing hair nets on. The plumbers indicated, they had been digging the hole outside the kitchen and proceeded to lay on the kitchen floor while working under the dishwasher through a hole in the wall. 2. On 3/9/15 at 5 p.m., during a observation and concurrent interview with Cook 2 and FSS, a dark brown encrusted door jambs, floor plates and door sidings in the kitchen were observed. When asked if this was the usual condition, Cook 2 stated, "Yes." A kitchen trash can contained dark brown encrusted particles on the side and top. Cook 2 acknowledged, this was not "OK". FSS stated, the kitchen was cleaned "only once a month" and concurred once a month is not enough to maintain sanitation of the kitchen. During an interview with the administrator on 3/9/15 at 5:15 p.m., the administrator concurred, these dark brown encrusted areas of the kitchen did not demonstrate a clean kitchen. During an interview on 3/9/15 at 5:30 p.m., the RD was asked about her oversight of the kitchen's sanitary conditions, RD stated, "I do an every six month review with the dietary supervisor and I submit a report to the administrator." When asked about her overall impression of the cleanliness of the kitchen, RD stated, "It's a dirty kitchen." RD went on to reveal that the administrator does walk through every Tuesday but she was not aware of the findings of those walk through. On 3/9/15 at 6:15, the facility administrator was interviewed if he had a copy of the "every 6 month report" as mentioned by the RD, specific to the cleanliness of the kitchen prepared by the RD. Interview revealed, the administrator was not aware of a 6 month report, however, one report was found dated 5/14 that included one sentence, "The overall cleanliness of the kitchen could be improved." 3. A review of the facility's policy and procedure, "Food Storage and Preparation Policy", states in part, "..All food items in refrigerators are properly dated, labeled and placed in containers with tight fitting lids, or are wrapped. Once opened frozen food is dated, labeled, and wrapped.." Observation during the tour of the kitchen, on 03/09/15, at 10:45 a.m. revealed, refrigerator 1 contained a bag of ham, cold cuts, and raw hamburger that were not dated and labeled. Refrigerator 2, contained two chunks of yellow cheese wrapped in plastic with no date and label. During a concurrent interview with FSS, she concurred, not dating the food items was not right.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) who was identified by the facility to be at risk for elopement. This failure resulted in Resident 1 found in the street by an unidentified passerby, who called an ambulance that transported the Resident to the emergency room (ER). Resident 1 fell and sustained large hematoma (a collection of blood, usually clotted, outside of a blood vessel because of an injury) on her forehead and skin injuries. Findings: Observation on 9/9/14 at 3 p.m. revealed, Resident 1 sitting in her wheelchair with a large bump on her left forehead with a healing laceration in it. A dark resolving purple bruise under her left eye was observed with resolving yellowish, brown bruises on the left side of her face down to her left jaw and left upper neck. On 9/9/14, review of Resident 1's record revealed [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE], indicated Resident 1's cognitive skills (memory, logic, reasoning and attention) were severely impaired and displayed wandering behaviors four to six days over a seven day period of assessment. Resident 1 was able to walk with minimum supervision. Review of Resident 1's plan of care titled "Behavior Symptoms as manifested by wandering", initiated 9/3/13 and last updated 8/14, specified "wants to go home...sundowners (increased confusion at night), wants to drive home". Interventions included redirection, monitoring behavior, medication administration and frequent visual checks. Documentation by facility's "Psych Eval/Treatment" dated 1/23/14, stated in part "...(Resident 1) has since started to walk around and ask for help... It's constant tonight with her and desperately trying to leave". Review of the facility's "Careplan Conference Notes" dated 5/27/14, stated in part "...(Resident 1) wanders after three p.m. and has increase confusion. Wants to drive her car home... She was turning off her own alarms and hiding them...". Review of facility's "Psychotropic Summary Sheet" listed Xanax (a medication to treat anxiety). The targeted behavior for use of the medication was listed as wanting to go home. In June 2014, Resident 1 had 87 episodes of wanting to go home. In July 2014, Resident 1 had 82 episodes and in August 2014, 97 episodes of wanting to go home. Review of facility's "Unusual Occurrence Nurses Note" dated 9/4/14 revealed, on 9/3/14 at 9 p.m. Resident 1's husband phoned the facility and asked for his wife. A facility search was initiated. Resident 1's husband told facility staff that Resident 1 was in the ER. Resident 1 wandered out of the facility, had fallen in the street, and an ambulance took her to the ER. Body assessment revealed left eye bruises, left eye redness, swollen left forehead, and a 2.5 centimeter (cm) by 0.1 cm skin tear on left forehead. Resident 1's pain was 3 out of 10 on the pain scale. Review of acute hospital emergency room record dated 9/3/14 revealed, Resident 1 was admitted by ambulance at 8:24 p.m. after falling from a curb to the street and found by a passerby. Resident 1 was confused, disoriented, oriented to person only and could not recall the incident. Resident 1 sustained a large hematoma with small laceration above left eyebrow, bruising around left eye and abrasion to left side of eye. When interviewed on 9/9/14 at 4 p.m., licensed nurse (LN 1) recalled seeing Resident 1 in the facility lobby the evening of the incident after dinner. Resident 1 was asking "Can I go out that door?" and "I want to go home." LN 1 was passing medications at that time and attempted to redirect the resident. LN 1 stated, "No later than 7:30 p.m. was the last time I saw her (Resident 1). During an interview on 9/23/14 at 10 a.m., Resident 1's husband revealed, the facility was unaware of his wife's absence until his call. "I called to see if they knew where she (Resident 1) was. When they said they couldn't find her, I said she was in the emergency room !"