Every finding on record at Vista Manor Nursing Center

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1.Occupational therapist A (OT A) did not perform hand hygiene (HH - to clean the hands, including washing with soap and water or using an alcohol-based hand rub [like hand sanitizer]) after removal of gloves and before donning (putting on) of a new pair of gloves and did not change gloves after assisting Resident 2 with toileting; and2.Certified nursing assistant B (CNA B) did not perform hand hygiene after touching Resident 3's environment.These failures had the potential to compromise resident's health and safety, and spread infections to residents, staff, and visitors.Review of Resident 1's clinical record titled, admission Record, dated 4/4/2025, indicated Resident 1 was admitted to the facility with diagnoses including fracture of unspecified part of neck of left femur (a break in the bone just below the hip joint), fibromyalgia (a chronic condition that causes widespread musculoskeletal pain, fatigue, and sleep problems) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe).Review of Resident 1's admission/5-day minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact).During a phone interview with Resident 1 on 4/2/2025 at 1:15 p.m., Resident 1 stated she had some concerns with infection control while she was admitted at the facility. Resident 1 further stated a certified nursing assistant (CNA) went inside her room wearing gloves, picked up her used commode (a piece of furniture that serves as a portable toilet, often used by individuals with mobility limitations), empty it in the bathroom, then CNA returned the commode to her bedside with same gloves on and started to touch her stuff inside the room. Resident 1 stated when she asked the CNA if her gloves were clean, the CNA asked her if she wanted her to change her gloves.1.During an observation on 4/4/2025 at 10:38 a.m., at the hallway across Room AA, the OT A was wearing a pair of gloves and assisted Resident 2 in walking to the bathroom with use of front wheeled walker (FWW - a mobility aid with two wheels at the front and two legs at the back). OT A went inside the bathroom with Resident 2 and after a few minutes, OT A went out of the bathroom, waiting with the same gloves on. OT A was observed to remove the right-hand gloves, did not perform HH, donned a new glove to her right hand, touched and moved Resident 2's wheelchair, touched the bedside drawer handle and took clothes for Resident 2 and went back to the bathroom. At 10:44 a.m., OT A stepped out of the bathroom still wearing the same gloves, stood outside the bathroom door. OT A changed her gloves without HH and went back to the bathroom. At 10:49 a.m., OT A was observed assisting Resident 2 to walk out of the bathroom wearing the same pair of gloves and had Resident 2 sat at the edge of the bed. OT A touched Resident 2's FWW to set aside and started to assist Resident 2 with some arm exercises with the same pair of gloves. At 11:01 a.m., Resident 2's exercise with OT A was completed. OT A folded the FWW with the use of the same pair of gloves.During an interview with OT A on 4/4/2025 at 11:03 a.m., OT A confirmed the above observations and stated she should have performed HH whenever she changed her gloves. OT A stated she should have changed her gloves after she assisted Resident 2 with toileting.During a review of the facility's policy and procedure titled, Personal Protective Equipment - Using Gloves, date revised 9/2010, indicated, Objectives 1. To prevent the spread of infection.Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient.Wash hands after removing gloves.2. During an observation on 4/4/2025 at 10:54 a.m., at the hallway across Room AA, CNA B entered Room AA and spoke to OT A then went beside Resident 3's bed. CNA B observed touching and held Resident 3's overbed table and started to talk to Resident 3. After talking to Resident 3, CNA B stepped out of Room AA without performing HH, touched the shower room's doorknob across Room AA and went inside the shower room.During a follow up interview with CNA B on 4/4/2025 at 10:56 a.m., CNA B confirmed the above observations, and stated she should always perform HH every time she stepped out of the resident's room.During an interview with the director of nursing (DON) on 4/4/2025 at 11:09 a.m., DON confirmed the glove usage was a barrier for infection control and stated gloves should be changed after exiting the bathroom. DON further stated, Hand hygiene should be performed before exiting the room, that's why we have hand sanitizer right outside the door.During an interview with the infection preventionist (IP) on 7/9/2025 at 12:06 p.m., IP confirmed they had a policy related to HH wherein staff should gel in and gel out (use of hand sanitizer before coming in and before exiting the room), which meant, before they make contact with the resident or resident's environment, they have to gel in. IP further stated, staff should also perform HH upon exiting the resident's room. IP confirmed staff should perform hand hygiene before donning gloves and after removal of gloves.During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, date revised 10/2023, indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Hand hygiene is indicated: after touching the resident's environment.

Based on observation, interview, and record review the facility failed to store food and maintain the kitchen under sanitary conditions when: 1. Several food items were undated for use by dates in the refrigerators, freezers, and dry goods area, 2. Ice buildup was noted on the Dessert Freezer #2, 3. A black electric fan had dust accumulated on its surface, 4. Black residue was on the caulking of the dishwasher round sink and 3-compartment sink. Failure to follow facility procedures and standards of practice for food safety has the potential of exposing residents, who are served food from the kitchen, to foodborne illnesses. Findings: 1. During a kitchen observation and interview on 10/7/24 at 8:11 a.m., with the Registered Dietician (RD), several food items were observed with no use by dates (NUBD) in the following areas/locations and were acknowledged by the RD: 1a. Freezer #1 contained: A pack of diced carrots, with open date 9/29/24 lacked a use by date (NUBD). 1b. Freezer #3: (Meat Freezer) contained: A box of diced grilled chicken breast with open date 10/5/24 lacked a NUBD. A box of cheese pizza box, with open date 9/28/24 lacked a NUBD. A blue cup containing ice was found inside this Freezer #3 lacked a NUBD. 8 cups of butter pecan ice cream were found in this Freezer #3 (Meat Freezer) with no open dates or use by dates. 3 cups of sherbet were found with no open dates or use by dates. The RD agreed the staff should not store ice cream cups in the meat freezer. 1 box of Bean and Cheese Burritos w lacked a NUBD. 1 pack of Tortillas with open date 9/12/24 lacked a NUBD. 1 box of Pork Sausage with open date 9/12/24 lacked a NUBD. 1c. Two-Door Refrigerator contained: Marinara sauce, dated 9/24/24, lacked a NUBD. Ketchup, dated 9/24/24, lacked a NUBD. Black Bean sauce, dated 9/1/24, lacked a NUBD. Oyster sauce, dated 9/7/24, lacked a NUBD. Hoisien Sauce, dated 10/01/24, lacked a NUBD. 1d. Freezer #4 (2-Door) contained: a box of Apple Turnover with open date 9/18/24 lacked a NUBD. A box of Waffles with open date 10/01/24 lacked a NUBD. 1e. Dry Goods Area contained: A container of Dry [NAME] Peas had received date of 6/18/24 and lacked a NUBD. A container of Dry Lentil had a received date of 10/01/24 and lacked a NUBD. A container of [NAME] Rice had a received date of 7/2/24 lacked a NUBD. 2. During observation and interview with the RD on 10/7/24 that started at 8:11 a.m., Dessert Freezer #2 was observed with ice buildup on the sides. The RD stated, I just noticed it this weekend . 3. During an observation with the RD on 10/7/24 that started at 8:11 a.m., a black electric fan hanging by the dishwashing area was observed with dust and debris (visible particles that can accumulate on surfaces). The RD confirmed this observation and stated, Yes, definitely needs cleaning. 4. During observation and interview with the RD and [NAME] E on 10/7/24 that started at 8:11 a.m., black residue was on the caulking of the round sink in the dish washing area. A 3-Comparment sink had black residue on the caulking. [NAME] E stated, I think it is molds. The RD acknowledged the observation. Review of facility policy and procedure titled Food Storage, dated 2023, indicated, Sufficient storage facilities will be provided to keep foods safe, wholesome, an appetizing. Food will be stored in an area that is clean, dry, and free from contaminants . Food should be dated as it is placed on the shelves if required by state regulation . Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS (Time and Temperature Control) food should be consumed, sold, or discarded . All containers or storage bags must be legible and accurately labeled and dated . Refrigerated food storage . All foods should be covered, labeled, and dated and routinely monitored to assure that foods will be consumed by their use by dates, or frozen (where applicable) or discarded . Frozen Foods . All foods will be checked to assure that foods will be consumed by their use by dates or discarded . Review of facility's undated policy and procedure titled Dietary Services - Sanitation, indicated, The food service area shall be maintained in a clean and sanitary manner . All kitchen, kitchen areas, and dining areas shall be kept clean . All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair. Seals, hinges, and fasteners will be kept in good repair . Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and as needed.

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for two of five residents (Resident 19 and 64) under enhanced barrier precautions (EBP, used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) when: 1. For Resident 19, proper PPE (Personal Protective Equipment) was not worn during a medication administration, 2. For Resident 64, the family member (FM) did not wear proper PPE while assisting staff to render care. These failures had the potential to place the residents at risk of transmissible infections. Findings: 1. Review of Resident 19's medical record indicated she was admitted on [DATE] and had diagnoses including diabetes mellitus (too much sugar in the blood) with foot ulcer (breakdown of the skin and tissues creating an open wound), cutaneous abscess (localized collection of pus in the skin) of the right foot, and long-term antibiotics use. Review of Resident 19's MAR (Medication Administration Record) indicated she had an order to administer Cefazolin Sodium (antibiotic used to treat bacterial infections) 1 GM (GM -a unit of measure) intravenously (into or within a vein) every 8 hours for right ankle cellulitis (a bacterial infection that affects the skin and underlying tissues) for six weeks. Review of Resident 19's Order Summary Report, dated 8/28/24, indicated an order for Enhanced Barrier Precautions (EBP) for high resident care activities related to PICC line (Peripherally Inserted Central Catheter, a thin, soft, long catheter [tube] that is inserted into a vein of the arm or leg and the tip of the catheter is positioned in a large vein that carries blood into the heart). During an observation on 10/7/24, at 2:00 p.m., Resident 19 had a room signage indicating EBP were in place, which required the use of PPE for high-contact resident care activities. The signage indicated that, providers and staff must also wear gloves and a gown for the following High-Contact Activities . Device care or use of . central line . During an observation and concurrent interview with registered nurse A (RN A) on 10/7/24 at 2:20 p.m., RN A administered Resident 19's intravenous antibiotic medication. RN A wore gloves during the medication administration, but she did not not wear any additional PPE. When RN A exited Resident 19's room after the medication administration, she was alerted to the signage for the EBP outside Resident 19's room. RN A was asked why she did not donn (To put on an article of clothing) a gown during the medication administration. RNA stated, I never wear a gown when I give Resident 19 her intravenous medication. During an observation and concurrent interview with the infection preventionist (IP, professional who ensures healthcare workers and residents are practicing infection prevention measures) on 10/7/24 at 2:35 p.m., she confirmed the signage outside of Resident 19's room door that indicated EBP were in place for Resident 19. The IP stated that administering an intravenous medication, via a PICC line would require the licensed nurse to wear gloves and a gown. The IP confirmed that RN A should have worn a gown during the administration of Resident 19's intravenous medication. A review of the facility's policy titled Enhanced Barrier Precautions, dated May 2024, indicated, Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO's) to residents. EBPs employ targeted gown and glove use during high contact resident care activities . Examples of high -contact activities requiring the use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheters, feeding tubes .). 38243 2. Review of Resident 64's clinical record indicated he was admitted on [DATE] with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (muscle weakness of partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, Dysphagia (difficulty in swallowing) following cerebral infarction and Encounter for attention for Gastrostomy (surgical procedure used to insert a tube, often referred as G-Tube, through the abdomen and into the stomach). Review of Resident 64's Order Summary Report, printed 10/8/24, indicated he had enteral feeding orders that started 4/17/24, and orders for Enhanced Standard Precautions (ESP) for high contact resident care activities r/t (related to) RISK FACTORS Indwelling Medical Device: G-Tube Perform hand hygiene & apply personal protective equipment (PPE), gloves, gown and/or goggle/face shield worn if risk of splash/spray during high contact resident care activities, every shift for Prevents Transmission of unknown MDROs (Multidrug resistant organism) . with the start date of 5/8/2024. Review of Resident 64's care plan Enhanced Barrier Precautions/Enhanced Standard Precautions (EBP/ESP) ., with an initiated date of 5/10/24, included, Approaches/Tasks: Educate resident's family members and visitors on helping resident understand the importance of personal hygiene and enhanced barrier/standard precautions. Date initiated: 5/13/24. During observations on 10/6/24 at 2:21 p.m. and 10/7/24 at 10:15 a.m., Resident 64' room had a sign hanging outside the room door and on the wall above the head of his bed that indicated, STOP, ENHANCED BARRIER PRECAUTIONS, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing; Bathing and Showering; Transferring; Changing Linens; Providing Hygiene; Changing briefs or assisting with toileting; Device care or use of central line, urinary catheter, feeding tube . Wound care: any skin opening requiring a dressing; Cleaning and disinfecting the environment. During an observation on 10/7/24 at 10:20 a.m., Resident 64 was observed being transferred to a shower chair by certified nursing assistant (CNA) G from his bed. CNA G wore a PPE and gloves, but the family member (FM) who was assisted CNA G only wore gloves, and no other PPE. Licensed Vocational Nurse (LVN) D was called, and LVN D also called LVN C, to come and translate in Resident 64's primary language. LVN C pointed to CNA G to indicate that the resident's wife only wore gloves. LVN C and CNA G reminded the FM to wear the PPE (gown and gloves) in her primary language. After Resident 64 left on the shower chair with CNA G, the wife was also observed cleaning his bed while wearing only the same pair of gloves. LVN C reminded the wife in her primary language to wear PPE every time. LVN C stated the FM said she understood. During an observation on 10/9/24 at 3:30 p.m. with LVN D, who was about to perform a bolus tube feeding to Resident 64, the FM was present and sitting on a chair, was observed wearing PPE of gown and gloves. After LVN D was done with the Tube Feeding, the FM received a towel/big bib from another staff distributing them. The FM placed the folded towel/big bib just below Resident 64's G-Tube site that was covered with a dry clean dressing. During a concurrent observation and interviews with LVN C and with the FM on 10/10/24 at 2:53 p.m., LVN C translated for the FM and Resident 64 in their preferred language. FM was in the room wearing a mask and was sitting on a chair. Resident 64 was sitting up in his wheelchair and facing the window. FM was asked if she was informed before 10/7/24 to wear a gown (PPE) when helping to care for Resident 64 and was asked when she was informed to wear the PPE when she helped to take care of Resident 64. LVN C talked to FM in her language and stated, They told her before but sometimes she forgot, she is supposed to wear the gown, she only remembers the gloves, sometimes the weather is very hot, and it's hard to wear the gown, she only wears the gloves, LVN C pointed to the PPE RACK hanging on the door to the bathroom and reminded the FM she must wear the gown (PPE) when she helps to care for Resident 64 (touch him) to protect herself from say secretions/splashes, since Resident 64 had an indwelling G-Tube, and also to do hand hygiene before and after PPE to protect herself, her family and the community from spreading infection. LVN C also reminded the FM to make sure to take off the PPE after use, to place it in the trash can inside the room, and to do hand hygiene. The FM agreed. Resident 64 listened and also stated in his language that the FM knew and that she was informed before about wearing the PPE. LVN C was informed that, on 10/7/24, CNA G could have reminded FM to wear a gown while FM was helping to transfer Resident 64 to a shower chair. Review of Facility policy titled Enhanced Barrier Precautions, dated May 2024 indicated, . 2. EBPs employ targeted gown and glove use during high contact resident care activities and when cleaning/disinfecting the environment when contact precautions do not otherwise apply . a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens . i. environmental cleaning and disinfection . 4. EBP are indicated for residents with any of the following . 2) Wounds and wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage . or similar dressing and/or indwelling medical devices, device care or use . feeding tube . even if the resident is not known to be infected or colonized with a MDRO.

During observation, interview and record review, the facility failed to maintain equipment for one of 19 sampled residents (Resident 10) when Resident 10's bedside rolling table edge trimmings were peeled off and the footboard of her bed was wobbly (shaky). These failures posed as hazardous risks for injury to Resident 10. Findings: Review of Resident 10's face sheet (summary page of a patient's important information) indicated she was admitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness of partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (a disorder that makes it difficult to speak) following cerebral infarction, Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 10's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level), dated 7/18/2024, indicated a score of 99, which meant Resident 10 was unable to complete the interview. During an observation and interview on 10/9/24 at 9:41 am in Resident 10's room, certified nursing assistant (CNA) B wheeled Resident 10 from the bathroom to her bedside. The rolling table positioned over Resident 10's wheelchair/lap had a black strip of trimming that was peeling off. After CNA B left the room, Resident 10 was asked by surveyor if she was okay. Resident 10 stated, No, and pointed at the footboard of her bed. During a concurrent interview and observation in Resident 10's room with licensed vocational nurse (LVN) C on 10/9/24 at 9:47 am, Resident 10 sat on her wheelchair while LVN C stated, She (Resident 10) understands but will only answer 'okay'- she agrees or disagrees only . Sometimes [when] she yells okay, she will not use the call light, but that means she needs help. Resident 10 showed the peeling strip on the edges of her rolling table. LVN C was asked if it could hurt Resident 10, LVN C stated, Yes, I will ask maintenance to change her table now. LVN C asked the maintenance assistant (MA) to call the maintenance director (MD). LVN C was asked again if it is a hazard, and she stated, Yes, we will wait for maintenance to get a new table. The MA got another rolling table, cleaned it, and changed the one with the peeling edges. At 9:55 am the MD arrived. This surveyor pointed to the footboard of the bed that had two metal bars on it, one of which was loose and made it the footboard wobbly. The MD stated he would get his screwdriver, left the room, came back, and fixed the foot board of the bed. When it was done, Resident 10 smiled in agreement. During a concurrent observation and interview with licensed vocational nurse (LVN) C on 10/10/24 at 8:48 am, she stated Resident 10 went to therapy. Surveyor checked both the footboard of the bed and the rolling table in Resident 10's room. The footboard of the bed was no longer wobbly, and the rolling table had no peeling strips. LVN C stated, We are supposed to tell maintenance, but I did not know . Resident (10) didn't tell me, but maintenance came yesterday and fixed it. Review of facility's policy Maintenance Schedules/Equipment, dated December 2004, indicated, Preventive maintenance schedules shall be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner. Policy Interpretation and Implementation: 1. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Review of facility policy Bed Safety and Bed Rails, dated August 2022, indicated, Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications.

Based on interview and record review, the facility failed to prevent a financial abuse for one of three residents (Resident 1), when: 1. The previous Business Office Manager (BOM) A did not follow deposit processes after receiving blank checks from Resident 1 ' s daughter and deposited Resident 1 ' s checks into her personal bank account; 2. Business office staffs did not verify deposit slips and checks per their policy; 3. Business office staffs did not maintain copies of each deposit slip, receipt, and check in the month end closing folder per their policy; and, 4. The accounting department did not audit timely. This failure resulted to Resident 1 ' s share of cost payments were not deposited into resident ' s account and left an outstanding balance on her account after she was discharged from the facility. It also had the potential to negatively affect resident ' s emotional wellbeing. Findings: Review of the facility reported Incident (FRI), dated, 8/2/22, stated The facility had found reasonable suspicion that our previous Business Office manager [name of the manager] has committed financial abuse against one of our previous residents [Resident 1 ' s name]. The resident is currently residing at a different skilled nursing facility [name of the facility] .It was found that [the previous business office manager ' s name] deposited four of [Resident 1's name] ' s share of cost checks into her personal bank account . Upon an audit of [Resident 1] ' s account, it was found that she has an outstanding balance. It stated the current Business Office Manager (BOM) B sent a statement to Resident 1 ' s daughter, upon receipt of the statement, the resident ' s daughter informed BOM B and the Administrator (ADM) that she had paid the share of cost every month with both check and cash payments since her mother had been at the facility. It stated Upon further investigation and cooperation with the resident ' s daughter, the facility can substantiate that financial abuse had occurred by BOM A. A review of Resident 1 ' s Face sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history) indicated, the resident was admitted to the facility on [DATE] and discharged to an acute care hospital on 3/6/22. Resident 1 ' s daughter was next of kin (a person's closest living relative), who was also in charge of resident ' s finances. A review of Resident 1 ' s cashed checks that the facility provided indicated: - Resident 1 ' s personal check, dated, 7/3/21, indicated it made out to BOM A ' s name for $1896. A note under the comment section indicated, [Resident 1 ' s name] ' s rent. - Resident 1 ' s personal check, dated, 8/6/21, indicated it made out to BOM A ' s name for $1896; - Resident 1 ' s personal check, dated, 9/15/21, indicated it made out to BOM A ' s name for $1896; and, - Resident 1 ' s personal check, dated, 10/15/21, indicated it made out to BOM A ' s name for $1896. It further indicated the checks were signed by Resident 1 ' s daughter and on the back of the checks, it had BOM A ' s signatures. A review of Resident 1 ' s share of cost statements indicated: - On 6/23/21, there was a balance of $798 due; - On 7/31/21, the share of cost for 8/2021 was $1896 charged and the total balance was $2694. There was no evidence Resident 1 ' s check, dated 7/3/21, was deposited to the resident ' s account; - On 8/31/21, the share of cost for 9/2021 was $1896, and the total balance was $4590. There was no evidence Resident 1 ' s check, dated 8/6/21, was deposited to the resident ' s account; - On 9/21/21, the share of cost for 10/2021 was $1896, and a total balance was $2656 There was no evidence Resident 1 ' s check, dated 9/15/21, was deposited to the resident ' s account; - On 10/26/21, the share of cost for 11/2021 was $1896, and a total balance was $4552. There was no evidence Resident 1 ' s check, dated 10/15/21, was deposited to the resident ' s account. - On 4/20/22, after the resident was transferred to another facility, there was a balance of $3517.80 due. During an interview on 10/5/22, at 1:35 p.m., with BOM A, she stated Resident 1 ' s daughter trusted her, gave her blank checks to pay for resident ' s share of cost when she was working at the facility in 2021, and she deposited the checks into her personal bank account. She admitted it was a mistake and she should have not done it. During an interview on 10/18/22, at 1:37 p.m., with the Director of Nursing (DON), he stated BOM A voluntarily quit in January 2022, Resident 1 was transferred to the hospital for a change of condition in March 2022 and was discharged from the facility to another skilled nursing facility. BOM B found out there was an outstanding balance on Resident 1 ' s account in April 2022, and she reported it to the ADM. Upon investigation, the facility found that Resident 1 ' s account was affected, and the facility had validated the financial abuse incident between BOM A and Resident 1, they called police department and reported the incident to California Department of Public Health (CDPH) right away when they determined it was an abuse case. He further stated, business office should have settled the account for outstanding balance upon discharge. During an interview on 10/18/22, at 1:47 p.m., with BOM B, she stated she noticed there was a remaining balance on Resident 1 ' s account in the end of April, then she informed the ADM, she also contacted the resident ' s daughter. During an interview on 10/20/22, at 11:13 a.m., with DON, he stated the Resident1 ' s daughter received a statement for an outstanding balance due in March, and again in April 2022. Resident ' s daughter called the facility to question why she was receiving a statement in April because she believed she had paid all share of cost owed in full. This prompted the facility to initiate internal research into past payments Resident 1 ' s daughter claimed to have made. The facility worked with the daughter to trace checks she had provided to the facility, and she was able to provide the four cashed checks in July 2022 which made out to BOM A. Once the facility had this definitive proof that the checks had not been paid to the facility as intended, and then the matter was reported to authorities. During a concurrent interview and record review on 1/3/23, at 1:50 p.m., with BOM B, she stated, she was the bookkeeper back in March 2021 when she was working with BOM A, but she was not handling any funds. She was mainly in charge of insurance authorization. She stated when depositing a personal check, facility stamp should be on the back of the check. She further stated facility name should be always on the Payable To section of the check, if business office personnel received a blank check, they should inform the payer to properly fill out the check. She stated she could not provide monthly auditing reports, because the audits were not done between June 2021 and August 2022. She further confirmed BOM A should have copied the personal checks she received from Resident 1 ' s daughter and she also should have had the other business office staff to verify the checks. During a concurrent interview and record review on 1/3/23, at 2:40 p.m., with Registered Nurse Consultant (RNC), she stated if the incident affected and involved in Resident 1 and her finance, it should be identified as an abuse. She also confirmed State of California (SOC - Report of Suspected Dependent Adult/Elder Abuse) 341, dated 8/1/22, indicated, the reported incident was a financial abuse, and abuse should not happen to the resident. A review of the facility ' s Policy, Cash Receipts - Deposits and Posting, effective 8/2016, indicated, the business office is primarily responsible receiving payments from primary, secondary and tertiary payers, in addition to cash payments from patients and their representatives. The accounting department is responsible for auditing and reporting to the Business Office any discrepancies if found. The BOM and/or bookkeeper are responsible for keeping accurate records and making sure that all accounts are relieved as payments are received. It indicated Business Office Responsibility . Depositing Payment .Personal checks: To avoid any discrepancies between the written (legal) and numerical amount on a check, each check should be reviewed prior to acceptance from the payer, prior to making the deposit, each check is copied as backup for the deposit total. The bookkeeper is responsible for generating an itemized deposit slip for the payment(s), adding each deposit item on a printed adding machine tape to verify totals, clipping that tape to deposit slip along with the check, and having that tape verified by another Business Office Staff member. Copies of each deposit slip, receipt and check are all attached and maintained in the month end closing folder, the deposit is then taken to the back by a staff member that was not the same person who generated the back deposit. The back website will issue a receipt for the deposit with the total amount, date and time deposited. This receipt must be attached to the deposit copies and maintained in the month end closing folder. End User Responsibility: after the back deposit has been made; . Personal Check: If the patient or patient ' s representative pays with a personal check, the payment is posted using the deposit date as the transaction date. The money posted to the dates of service that are outstanding . Accounting for payment: Balancing: Each deposit must be entered on the Cash Summary Sheet on a daily basis. The Cash Summary is maintained on each facility ' s server with access to it by the user, the AR Consultant, and Accounting. Month End: as part of the month end closing procedure, all deposit totals are entered on the month end closing checklist, summarized by payer. The total on the checklist must match the total on the Cash Summary, which must match what was entered into the AR software. Recording: All deposits, with the backup documentation are maintained within the month end closing folder for not less than seven (7) years. A review of the facility ' s policy, Identifying Exploitation, Theft and Misappropriation of Resident Property, dated April 2021, indicated, 1. Exploitation, theft and misappropriation of resident property are strictly prohibited . 3. Exploitation means taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats or coercion. 4. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident ' s belongings or money without the resident ' s consent.

Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food safety when: 1. Two refrigerators did not have internal thermometers and; 2. A bag of food inside of the resident's refrigerator did not have a label, These failures had the potential to cause the growth of microorganisms and foodborne illness for the 64 residents eating at the facility. Findings: 1. During a concurrent observation and interview with the Registered Dietitian (RD) on 10/3/2022 at 11:49 a.m., in the kitchen, there was no thermometer inside the Refrigerator 1. The RD stated they should have a thermometer inside the refrigerator. During a concurrent observation and interview with the Dietary Supervisor (DS) on 10/3/2022 at 11:58 a.m., in the kitchen, there was no thermometer inside Refrigerator 2. The DS stated they should have a thermometer inside the refrigerator. During an interview with the Director of Nursing (DON) on 10/6/2022 at 11:35 a.m., the DON stated a thermometer should be inside each refrigerator. The DON further stated without the thermometer, the refrigerator temperature would not be properly monitored. The DON stated these would possibly affect the quality of the food and would cause foodborne illness. During an interview with the RD on 10/6/2022 at 1:29 p.m., the RD stated they should have an internal thermometer to monitor the temperature. The RD further stated the food were not safe to serve if they turned warm. A review of the facility's policy and procedure titled Food Storage, dated 2017, indicated every refrigerator must be equipped with an internal thermometer. 2. During a concurrent observation and interview with Licensed Vocational Nurse G (LVN G) on 10/5/2022 at 3:35 p.m., a bag of food without resident's name, room number, and date was observed in the residents' refrigerator. The LVN G stated they should have labeled the food brought from home with resident's name, room number, and date. The LVN G further stated resident's food should be kept for 24 hours. During an interview with the DON on 10/6/2022 at 11:35 a.m., the DON stated resident's food brought by the family should be stored in the refrigerator and should be labeled with name, room number, and date. A review of the facility's Policy and Procedure (P&P) titled Use and Storage of Food Brought to Resident, dated 10/26/2020, indicated that perishable food must be stored in the refrigerator in re-sealable containers with tightly fitting lids. Containers will be labeled with the resident's name, date initially covered, and the manufacturer use by date, as applicable.

Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when expired medications were found in two of two medication rooms. This failure could result to unsafe medication administration to residents. Findings: During a concurrent observation and interview with nurse supervisor F (NS F) on 10/3/22 at 11:32 a.m , in medication room A, a bottle of acidophilus (probiotic) with an expiration date of 7/2022., was found inside the medication refrigerator. A vial of [MEDICATION(S)] (a medication to treat anxiety) with an expiration date of 9/2022 was also found in the emergency kit. NS F stated it should have been thrown away and have discarded per their policy. During a concurrent observation and interview with NS F on 10/3/22 at 11:41 a.m , in medication room B, two bottles of Resident 58's lansoprazole (a medication to treat prevent and treat stomach ulcer) were found in the medication refrigerator. The first bottle had an expiration date of 9/22/22, and the other bottle was 10/2/22. NS F stated it should have been thrown away and discard per policy. During an interview with director of nursing (DON) on 10/4/22, at 1:41 p.m., expired medications should have been discarded. During a phone interview, on 10/5/22 at 2:26 p.m., with the facility's consultant pharmacist (CP), she stated expired medications should have been discarded. CP further stated that the facility should notify the pharmacy if medication in emergency kit was expired Review of facility's Storage of Medications policy, dated 7/1/2020, indicated that the facility ensure all drugs are stored in a safe , secure , and orderly manner. It further indicated that the facility shall not use discontinued , outdated, or deteriorated drugs' or biological . All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not wear N95 masks (a high filtering facepiece device designed to achieve a very close facial fit that filter at least 95% of airborne particles) properly; 2. Certified nursing assistant I (CNA I) did not disinfect the vital signs machine (blood pressure machine, pulse oximeter, thermometer in one machine attached to a pole with tray and wheels) after use; 3. Resident 35's oxygen tubing was not dated and labeled; 4. Licensed nurses did not label and date the oxygen tubing for Residents 12 and 24; 5. Staff did not perform hand hygiene during medication pass; 6. Staff did not disinfect the insulin vial rubber top; 7. Resident 7' oxygen tubing was not dated and labeled and nebulizer (breathing treatment machine) mask was not stored properly; 8. The director of nursing (DON) did not properly wear the N95 mask at the nurse station; 9. The certified nurse assistant K (CNA K) did not go through the COVID-19 (a highly contagious [CONDITION(S)] infection) screening (consists of a verbal symptom questionnaire and temperature check) assessment prior to entrance to the facility and; 10. Resident 322's oxygen concentrator's filter was not cleaned. These failures had the potential to result in transmission of infection in the facility that could affect 66 out of 66 residents. Findings: 1a. During an observation on 10/3/22 at 8:00 a.m., in the facility's main entrance, the facility receptionist (FR) was wearing an N95 incorrectly. The two straps of the N95 mask were observed behind each ear of the FR. The straps were not observed on the crown (topmost part of the head) or behind the neck of the FR. During additional observation on 10/3/22 at 8:34 a.m., near the facility's entrance, the two straps of the FR's N95 were observed behind each ear. The FR confirmed the observation and stated she did cut the straps of the N95. 1b. During an observation on 10/3/22 at 8:44 a.m., in the hallway near the resident's room, licensed vocational nurse H (LVN H) was wearing an N95 incorrectly. The two straps of the N95 mask were observed behind each ear of LVN H. There were no straps observed on the crown or behind LVN H's neck. During a concurrent interview with LVN H, she confirmed the above observation. During an interview with the infection preventionist (IP) on 10/6/22 at 4:22 p.m., the IP stated she had observed staff wearing N95 incorrectly. The IP further stated it was not ok for staff to wear N95 without the strap resting at the back of the head because it would not fit. According to the CDC's website (https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf How to Properly Put on and Take Off a Disposable Respirator indicated the top strap goes over and rests at the top back of your head. The bottom strap is positioned around your neck and below the ears. 2. During an observation on 10/4/22 at 8:23 a.m., certified nursing assistant I (CNA I) took Resident 32's vital signs (clinical measures of pulse rate, temperature, respiratory rate, blood pressure). During an observation on 10/4/22 at 8:28 CNA I went out from the room without disinfecting the medical equipment then proceeded to the nursing station and plug in the equipment. During an interview and concurrent observation with CNA I on 10/4/22 at 8:29 a.m., CNA I confirmed she took Resident 32's vital signs and acknowledged she did not disinfect the machine after use. CNA I further stated she should use a sanitizer wipe in the station. CNA I then look at the cabinets in the station and confirmed there was no sanitizer wipes. During an interview with the IP on 10/6/22 at 4:22 p.m., the IP stated staff should sanitize the vital signs machine after each resident use. Review of the facility's undated policy, Non-Critical Items-Cleaning & Disinfection indicated, Non-critical items that come in contact with intact skin but no mucous membranes and that have not become soiled will be cleaned periodically. 3. During an observation on 10/3/22 at 10:42 a.m., in Resident 35's room, Resident 35 was lying in bed with oxygen on at 2 liters per minute (LPM, flow of oxygen) via nasal cannula (NC, a device used to deliver supplemental oxygen to a person). The oxygen tubing was not dated and labeled when the last time it was changed. There was an oxygen tank at the foot of the bed with unlabeled oxygen tubing and it was not in bag. During a concurrent observation and interview with nurse supervisor F (NS F) on 10/3/22 at 3:21 p.m., in Resident 35's room, NS F confirmed Resident 35's oxygen tubing's were not labeled. NS F further stated all oxygen tubing at the bedside should be all labeled. Review of Resident 35's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Tubing and Bag. 4a. During an observation on 10/3/22 at 10:52 a.m., Resident 12 was in her room receiving oxygen via NC. The oxygen tubing was not labeled and dated. During an observation and concurrent interview with NS F on 10/3/22 at 3:15 p.m., Resident 12 was in her room receiving oxygen via NC. NS F looked at Resident 12's oxygen tubing and confirmed it was not labeled and dated. NS F stated licensed nurses were supposed to change oxygen tubing every week and label the tubing with the date it was changed. Review of Resident 12's medical record indicated there was no documentation indicating when her oxygen tubing was last changed. During an interview and concurrent record review with the director of nursing (DON) on 10/7/22 at 11:00 a.m., he reviewed Resident 12's medical record and confirmed there was no documentation indicating when her oxygen tubing was last changed. The DON acknowledged that since Resident 12's oxygen tubing was undated, there was no way to tell when it was last changed. Review of the facility's undated policy titled Oxygen Administration indicated, Oxygen tubing and humidifier will be changed every 7 days and as needed. 4b. During an observation on 10/3/22 at 11:03 a.m., Resident 24 was in her room receiving oxygen via NC. The oxygen tubing was not labeled and dated. During an observation and concurrent interview with NS F on 10/3/22 at 3:15 p.m., Resident 24 was in her room receiving oxygen via NC. NS F looked at Resident 24's oxygen tubing and confirmed it was not labeled and dated. NS F stated licensed nurses were supposed to change oxygen tubing every week and label the tubing with the date it was changed. Review of Resident 24's medical record indicated she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Tubing and Bag. 5. During an observation on 10/3/2022 at 9:26 a.m., in Resident 2's room, Licensed Vocational Nurse (LVN C) prepared the medications without doing hand hygiene after checking the Resident 2's blood pressure. At 9:31 a.m., she changed gloves with no hand hygiene after touching the trash can. During an interview with LVN C on 10/3/2022 at 9: 52 a.m. she stated she should do hand hygiene before and after medication preparation. During an interview with the Director of Nursing, on 10/4/2022, at 1:26 p.m., he stated the nurses should follow the Handwashing or Hand hygiene policy during medication passes and after removing and changing gloves. During a review of facility's policy Title: Handwashing /Hand Hygiene indicated use an alcohol -based hand rub containing at least 62 percent alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situation: Before preparing or handling medications; before donning sterile gloves; and after removing gloves. 6. During an observation on 10/3/2022, at 12:00 p.m., Registered Nurse (RN D) was preparing [MEDICATION(S)] [MEDICATION(S)] Solution (insulin) pen -injector. RN D inserted the needle on top of the vial without cleaning the top of the vial. During interview on 10/3/2022, at 12:04 p.m., RN D stated she should have wiped the rubber seal with an alcohol wipe before inserting the needle. During an interview on 10/04/202, at 1:28 p.m., with Director of Nursing (DON), he stated that licensed nurses should disinfect the insulin vial with a clean alcohol wipe. Review of facility's Insulin Administration policy, dated 7/1/2020, indicated licensed staff should follow the guidelines for the safe administration of insulin to residents with diabetes. It further indicated to disinfect the top of the insulin vial with an alcohol wipe. 7. Review of Resident 7's Physician Order, dated 5/6/2021, indicated, Oxygen at 2-3 liters/min via nasal cannula every shift. Change nasal cannula tubing/tubing and storage bag every week. Date tubing and bag. Review of Resident 7's Physician Order, dated 11/1/2017, indicated, [MEDICATION(S)] Nebulization Solution (a breathing treatment solution), 1 vial to be administered every 6 hours as needed for shortness of breath. During an observation on 10/3/2022 at 12:28 p.m., while at Resident 7's room. Resident 7 was lying in bed and receiving oxygen at two LPM via nasal cannula (NC, a device used to deliver supplemental oxygen), oxygen tubing was not labeled. There was also a nebulizer mask sitting on top of the drawer next to the bed without a protective covering. During an interview with the Licensed Vocational Nurse E (LVN E), on 10/3/2022 at 3:31 p.m., LVN E confirmed the above observation, and stated the nasal cannula should be labeled with Resident 7's name, room number, and date of when it was changed. LVN E further stated the nebulizer mask should be kept inside a plastic bag when not in use. Review of facility's policy and procedure, Administering Medications through a Small Volume Nebulizer, dated 7/1/2020, indicated, When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 8. During an observation on 10/05/2022 at 11:22 a.m., the DON was observed wearing N95 mask at the nurse station where the upper loop was placed on top of the N95 mask. Another observation on 10/05/2022 at 4:32 p.m., the DON was observed sitting at the nurse station with his N95 mask resting on his chin while talking to a visitor in front of the nurse station. During an interview with the infection preventionist (IP) on 10/06/2022 at 4:30 p.m., the IP confirmed the N95 mask should be worn properly, wherein the upper loop should be behind the top part of the head and the lower loop should be at the back of the neck. The IP further stated the mask should not be pulled down while talking to somebody. During an interview with the DON on 10/07/2022 at 11:15 a.m., the DON confirmed N95 mask should be worn properly especially at the nurse station with other staff and visitors. 9. During a concurrent observation and interview on 10/05/2022 at 3:00 p.m., the CNA K entered the facility thru the back door, passed by the hallway and nurse station to clocked in. The CNA K stated, I should have entered the front entrance to get screened. During an interview with the IP on 10/06/2022 at 4:27 p.m., the IP stated all staff should enter the front door to get screened for COVID-19 symptoms. The IP further stated COVID-19 screening should be done prior to entry to determine if staff are sick before working with residents. During an interview with the DON on 10/07/2022 at 11:15 a.m., the DON stated staff should enter at the front desk to get screened prior to entry to the facility. A review of the Centers for Disease Control and Prevention (CDC) Infection Control Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic, updated September 23, 2022, indicated, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2; 2) symptoms of COVID-19, or 3) close contact with someone with [CONDITION(S)]-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel - HCP). 10. During an observation on 10/03/2022 at 10:35 a.m., inside Resident 322's room, Resident 322 was sitting at the edge of bed on continuous oxygen using a nasal cannula. The oxygen concentrator's filter (black foam that catches dirt or dust) located at the back had a buildup of grayish substance. During an interview with the nurse supervisor F (NS F) on 10/03/2022 at 3:16 p.m., the NS F stated the maintenance were in charged of cleaning the oxygen concentrator once a resident was discharged from the facility. The NS F further stated maintenance staff should clean the oxygen filter, if needed. During a follow-up observation and interview with the NS F on 10/04/2022 at 11:29 a.m., inside Resident 322's room, the NS F confirmed the oxygen filter looks dusty. The NS F stated the oxygen filter should be cleaned. During another follow-up observation and interview with the IP on 10/05/2022 at 3:49 p.m., inside Resident 322's room, the IP confirmed the oxygen filter was not clean. The IP stated the maintenance and central supply staff should be checking the filter daily. Review of the oxygen concentrator's manufacturer's instructions, titled 7.3 Cleaning the Cabinet Filter, indicated, DO NOT operate the concentrator without the filter installed or with a dirty filter. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc.

Based on observation, interview, and record review, the facility had a 17.6% medication error rate when five medication errors out of 28 opportunities were observed during medication administration for four residents (Resident 2,50,63, and 122). This failure had the potential to compromise the resident's medical health. Findings: 1. During a concurrent observation and interview on 10/3/22 at 9:27 am, licensed vocational nurse C (LVN C) administered the scheduled morning medications to Resident 2 except [MEDICATION(S)] (blood pressure medication). LVN C stated [MEDICATION(S)] was not available. Resident 2's blood pressure reading was 128/80 mm Hg, the systolic blood pressure(SBP) was 128. Review of Resident 2's physician order, dated 9/12/22, indicated to administer [MEDICATION(S)] 25 milligrams (mg, unit of measurement) 1 tablet two times a day for hypertension and hold if SBP was <110, HR<60. During an interview on 10/3/22 at 2:40 p.m., LVN C stated she missed giving the [MEDICATION(S)] as it was not available. Review of facility's policy, titled Administering Medications, dated 7/1/2020, indicated that medications should be administered in a safe and timely manner as prescribed by the healthcare provider 2. During an observation on 10/3/22 at 9:55 am, LVN E administered the scheduled morning medications to Resident 50 including [MEDICATION(S)] (urinary spasmosdics) , 20 mg tablet. Review of Resident 50's physician orders, dated 4/16/2021, indicated to administer [MEDICATION(S)] 20 mg 1 tablet two times a day for overactive bladder; at 9 a.m. and 5 p.m. During a concurrent interview and record review, on 10/03/22 at 2:54 p.m. with LVN E, she stated that there was no special instruction on the Resident 50' physician order, however, there was a pharmacy note to administer it on an empty stomach.The pharmacy note was posted on Resident 50's medication bubble pack. LVN E stated she gave it on a full stomach. Review of facility's Drug Handbook 2020, indicated to administer trospium at least 1 hour before meals or on an empty stomach. During an interview with the director of nursing (DON) on 10/5/22 at 3:20 p.m., DON stated trospium should be administered 30 minutes to 1 hour before meals. During a phone interview with the facility's consultant pharmacist (CP), on 10/5/22 at 2:26 p.m. ,she stated trospium should be administered in an empty stomach. 3. During an observation on 10/3/22 at 4:01p.m, LVN A administered [MEDICATION(S)] (rapid acting insulin) 3 units subcutaneously on Resident 63's right arm. Dinner was not served as of 5:15 pm. During an interview on 10/3/22 at 5:06p.m., LVN A , she stated [MEDICATION(S)] should be give 10-15 minutes before meals. Review of Resident 63's physician order, dated 10/22/21, indicated to administer [MEDICATION(S)] 3 units subcutaneously for blood sugar between 201-250; before meals and at bedtime for diabetes. Review of facility's Drug Handbook 2020 indicated to administer [MEDICATION(S)] immediately before meals. During an interview with the director of nursing (DON) on 10/4/22 at 1:28 p.m., DON stated [MEDICATION(S)] should be administered 30 minutes before meals. During a phone interview with the facility's CP, on 10/5/22 at 2:26 p.m.,she stated short acting and rapid acting insulin should be administered 15 minutes before meals or immediately after meals. 4. During an observation on 10/3/22 at 4:24 p.m., LVN B administered [MEDICATION(S)] R (short acting insulin) 5 units and [MEDICATION(S)] 2 units (rapid acting insulin ) subcutaneously to Resident 122's right arm at 4:25 p.m. Dinner was not served as of 5:15 pm. Review of Resident 122's physician orders, dated 9/17/22, indicated to administer [MEDICATION(S)] 2 units before meals and at bedtime for diabetes. Review of Resident 122's physician orders, dated 9/18/22, indicated to administer [MEDICATION(S)] R (short acting insulin) 5 units before meals and at bedtime for diabetes. Review of facility's Drug Handbook 2020 indicated to administer [MEDICATION(S)] R and [MEDICATION(S)] 30 minutes before meals. During an interview with the director of nursing (DON) on 10/4/22 at 1:28p.m., DON stated [MEDICATION(S)] should be administered 30 minutes before meals. During a phone interview with the facility's CP, on 10/5/22 at 2:26 p.m.,she stated short acting and rapid acting insulin should be administered 15 minutes before meals or immediately after meals. Review of facility's Insulin Administration policy, dated 7/1/2020 indicates licensed staff should follow the guidelines for the safe administration of insulin to residents with diabetes Review of facility's policy, titled Administering Medications, dated 7/1/2020 indicated that medications should be administered in a safe and timely manner as prescribed by the healthcare provider

Based on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 175 and 69) were free from unnecessary [CONDITION(S)] medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 175, licensed nurses did not monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by the [CONDITION(S)] medication); and 2. For Resident 69, licensed nurses did not consistently monitor for side effects and target behaviors, and did not complete an abnormal involuntary movement scale assessment (AIMS assessment, a tool used to monitor for abnormal bodily movements caused by antipsychotic medication). These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 175's medical record indicated she was admitted on [DATE] and had the diagnosis of unspecified dementia (mental disorder caused by brain disease or injury) with behavioral disturbance. Review of Resident 175's Order Summary Report indicated she had a physician's order, dated 9/22/22, for [MEDICATION(S)] (medication used to treat depression) 7.5 milligrams (mg, unit of dose measurement) 1 tablet by mouth at bedtime for depression manifested by poor appetite. Review of Resident 175's medication administration record (MAR) indicated Resident 175 received [MEDICATION(S)] 7.5 mg at bedtime from 9/22/22 onward. There was no documentation of side effects or target behavior monitoring for [MEDICATION(S)]. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 12:58 p.m., he stated for residents taking [CONDITION(S)] medications, licensed nurses should monitor for side effects and target behaviors every shift and document this on the MAR. The DON stated it was important to monitor side effects and target behaviors to determine if the [CONDITION(S)] medication doses needed to be adjusted, and to determine whether or not the medications were effective. The DON reviewed Resident 175's medical record and confirmed there was no documentation of side effects or target behavior monitoring for [MEDICATION(S)]. 2. Review of Resident 69's medical record indicated she was admitted on [DATE] and had the diagnosis of dementia with behavioral disturbance. Review of Resident 69's Clinical Physician Orders indicated she had orders, dated 9/7/22, for the following medications: 1) [MEDICATION(S)] (medication used to treat [CONDITION(S)]) 20 mg 1 tablet by mouth at bedtime for [CONDITION(S)] manifested by talking to self; 2) [MEDICATION(S)] (medication used to treat depression) 30 mg 1 tablet by mouth at bedtime for depression manifested by loss of interest to previous enjoyable activities; and 3) [MEDICATION(S)] (medication used to treat anxiety) 1 mg 1 tablet by mouth three times a day for anxiety manifested by inability to relax as evidenced by hand fidgeting. Review of Resident 69's MAR, dated 9/2022 and 10/2022, indicated licensed nurses were to monitor side effects and target behaviors for the above [CONDITION(S)] medications every shift. From 9/7/22 to 10/4/22, there were ten (10) shifts for which there was no documentation of side effects monitoring, and nine (9) shifts for which there was no documentation of target behavior monitoring for all three of the above [CONDITION(S)] medications. Further review of Resident 69's medical record indicated there was no documentation of an AIMS assessment upon admission. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 12:58 p.m., he stated for residents taking [CONDITION(S)] medications, licensed nurses should monitor for side effects and target behaviors every shift and document this on the MAR. The DON stated for residents taking antipsychotic medications (such as [MEDICATION(S)]), licensed nurses should complete an AIMS assessment upon admission and quarterly thereafter. The DON reviewed Resident 69's medical record and acknowledged there were several shifts with no documentation of side effects and target behavior monitoring. The DON confirmed the facility did not complete an AIMS assessment for Resident 69. Review of the facility's policy titled [CONDITION(S)] Medication Use, revised 3/2015 indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including [CONDITION(S)] medications. Nursing staff shall monitor for and report .side effects and adverse consequences of [CONDITION(S)] medications to the Attending Physician. Review of the facility's policy titled Behavior Assessment and Monitoring, revised 4/2007, indicated staff will document the number and frequency of specific problem behaviors. The policy also indicated the nursing staff and physician will monitor for side effects and complications related to psychoactive medications. Review of the facility's undated document titled Assessing Abnormal Involuntary Movement During Antipsychotic Therapy indicated to do an AIMS assessment prior to initiating antipsychotic therapy and every 6 months thereafter.

Based on observation, interview, and record review, the facility failed to follow the physician's order to apply compression stockings (elastic stockings apply to the legs) to one of 18 sampled residents (Resident 21) related to [CONDITION(S)] (swelling) of both lower extremity. This failure had the potential to affect the residents physical and mental well being in the facility. Findings: Review of Resident 21's clinical record, Resident 21 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 21's Physician Order, order date 8/13/2021, indicated, Compression stockings to both lower extremity (BLE) one time a day for [CONDITION(S)]. Apply stockings at 6:30 a.m. Remove stockings at bedtime. Review of Resident 21's Nursing Weekly Observations, dated 10/1/2022, indicated, [CONDITION(S)]: 1 plus (a grading system used to determine the severity of the [CONDITION(S)]) and pitting on both lower extremities. During an observation on 10/4/2022, at 10:54 a.m., while at Resident 21's room. Resident 21 was sitting in her wheelchair and Family Member 1 (FM 1) was standing next to the resident. Facility staff was applying the compression stockings to both of Resident 21's lower legs. Resident 21 was observed with swelling on both legs. During a concurrent interview with FM1, she stated Resident 21 was supposed to have the compression stockings put on in the morning, but that it doesn't always happen. FM 1 stated she was not informed of any episodes of refusal from Resident 21. During an interview with Certified Nursing Assistant L (CNA L) on 10/4/2022, at 1:34 p.m., CNA L stated Resident 21's compression stockings was not applied this morning. CNA L stated we sometimes apply the compression stockings on different times, CNA L further stated it should be applied in the morning before getting out of bed. During an observation and concurrent interview with Licensed Vocational Nurse M (LVN M) on 10/4/2022, at 1:37 p.m., while at Resident 21's room. LVN M stated Resident 21's compression stockings should be applied in the morning. LVN M stated they removed the compression stockings applied earlier and changed it to a bigger size because Resident 21 verbalized it was too tight. Surveyor observed facility staff putting on a new pair of compression stockings to Resident 21. During an interview and concurrent record review with the Director of Nursing (DON) on 10/6/2022, at 4:00 p.m., DON confirmed Resident 21's physician's order related to applying compression stockings in the morning. DON stated he expects facility staff to follow physician's order unless residents refuse. Upon further review of records, DON confirmed there was no record of refusal from Resident 21.

Based on observation, interview, and record review, the facility failed to adhere to appropriate professional standard of care for one of two sampled residents (Resident 58) when a licensed nurse forcefully introduces through a gastric-tube (g-tube inserted through the belly) the medication causing leakage. This failure had the potential for residents not to received complete dose of medication. Findings: During an observation on 10/3/22, at 4:56 p.m., in Resident 58's room, Licensed Vocational Nurse A (LVN A) administered medication forcefully via g-tube causing it to leak on Resident 58's abdomen. During interview on 10/3/22, at 5:06 p.m., outside Resident 58's room, LVN A stated that she should have not exerted pressure in giving medication thru g-tube. During an interview on 10/04/22, at 1:30 p.m., with Director of Nursing (DON), he stated, medication thru g-tube should be administered by gravity unless there was a prescriber's order to push. During a review of facility's policy titled Administering Medication Through an Enteral Tube, dated 7/01/2020, indicated, the purpose of this procedure was to provide guidelines for the safe administration of medications through an enteral tube. Administer medication by gravity flow.

Based on observation, interview and record review, the facility failed to develop care plans for four of 18 sampled residents (Residents 18, 24, 175 and 14). 1. For Resident 18, the facility did not develop a care plan to address the use of insulin; 2. For Resident 24, the facility did not develop a care plan to address the use of oxygen; 3. For Resident 175, the facility did not develop care plans to address the use of oxygen and antidepressant medication; and 4. For Resident 14, the facility did not develop a care plan to address the use of anticoagulant (blood thinner). This failure had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. A review of Resident 18's clinical record indicated Resident 18 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review with the minimum data set nurse (MDSN - a nurse responsible for a resident's scheduled assessment and care planning) on 10/06/2022 at 1:44 p.m., the MDSN reviewed Resident 18's list of care plans. The MDSN confirmed there was no care plan developed for insulin use. The MDSN stated there should have been a care plan developed for Resident 18's insulin use. During a review of the facility's policy and procedure titled, Care Plan Goals and Objectives, dated 07/01/2020, indicated, It was the policy of this facility that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 2. During observations on 10/3/22 at 11:03 a.m. and 3:15 p.m., Resident 24 was in her room receiving oxygen via nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source). Review of Resident 24's medical record indicated she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record indicated Resident 24 did not have a care plan to address her use of oxygen. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 8:16 a.m., he confirmed that all interventions provided to the residents must be addressed on the care plan. The DON reviewed Resident 24's medical record and confirmed the facility did not develop a care plan to address her use of oxygen. 3. During observations on 10/3/22 at 10:40 a.m. and 3:15 p.m., Resident 175 was in her room receiving oxygen via NC. Review of Resident 175's medical record indicated she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 175's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record indicated Resident 175 did not have care plans to address her use of oxygen and [MEDICATION(S)]. During an interview and concurrent record review with the DON on 10/5/22 at 8:16 a.m., he confirmed that all interventions provided to the residents must be addressed on the care plan. The DON reviewed Resident 175's medical record and confirmed the facility did not develop a care plan to address her use of oxygen. During a follow-up interview and concurrent record review with the DON on 10/5/22 at 12:58 p.m., he reviewed Resident 175's medical record and confirmed the facility did not develop a care plan to address her use of [MEDICATION(S)]. 4. Review of Resident 14's Physician Order, dated 4/6/2021, indicated, [MEDICATION(S)] (medication to prevent blood clot) 2.5 mg Give 1 tablet by mouth two times a day for [CONDITION(S)] (DVT, when a blood clot forms in a deep vein.) Review of Resident 14's clinical records, there was no care plan addressing the use of [MEDICATION(S)]. During an interview and concurrent record review with the DON on 10/6/2022 at 4:00 p.m., DON confirmed there was no care plan addressing the use of [MEDICATION(S)] and acknowledged there should have been a care plan. Review of the facility's policy titled Care Plan Goals and Objectives, dated 7/1/2020 indicated, the goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.

Based on interview and record review, the facility failed to ensure one of three employees was screened in accordance with their policies when there was no documentation that a background check was conducted prior to hire. This failure had the potential to compromise the safety and security of the residents. Findings: Review of a faxed letter from the facility to the California Department of Public Health, dated 3/11/22, indicated certified nursing assistant J (CNA J) was accused of hitting and making fun of a resident. Review of CNA J's personnel file indicated she was hired by the facility on 9/6/11. There was no documentation that the facility conducted a background check before hiring CNA J. During an interview with the director of staff development (DSD) on 10/6/22 at 1:36 p.m., the DSD confirmed the facility must conduct background checks before hiring employees. The DSD stated she was not able to find documentation that the facility conducted a background check before hiring CNA J. The DSD further stated she reached out to the facility's corporate, who was also unable to find such documentation. Review of the facility's policy titled Abuse Prohibition and Prevention Program, revised 3/2018, indicated the facility does not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law. This includes attempting to obtain information from previous employers, current employers, and checking with the appropriate licensing boards and registries prior to hire and annually thereafter. Review of the facility's undated policy titled Background Screening Investigations indicated, The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law for RCFE) on persons making application for employment with this facility. The checks will be conducted in order to verify that the individual is qualified to work in the position that they are applying for in the facility.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 328) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying then that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: A review of Resident 328's clinical records indicated, Resident 328 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility initiated a discharge of Medicare Part A services on 9/14/2022 with benefit days remaining. A review of Resident 328's NOMNC letter indicated, The Effective Date Coverage of Your Current Skilled Nursing & Rehab Services Will End: 9-14-2022. Further review of the NOMNC letter's second page indicated, RP (responsible party - a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action)) was notified via phone call on 9/15/22, also emailed her copy, dated 9/15/22. The NOMNC also indicated the RP's signature on 9/27/22. A review of the social service director's (SSD) progress note dated 9/15/2022 at 12:20 p.m., indicated, SSD called RP informed her resident was no longer receiving skilled services of 9-14-22 he will be transitioned to RNA (restorative nursing assistant - had special training and work alongside with rehab staff for patients with limited mobility and capacity of self-care) program explained to sister regarding NOMNC last covered days (LCD, days for skilled services) was 9-14-11, and LTC (long term care - services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing) as of 9-15-22. RP verbalized understanding of NOMNC. RP stated she was on vacation and to email her copy of NOMNC she will sign upon return. SSD emailed copy to RP on 9/15/22. During a concurrent interview and record review with SSD on 10/07/2022 at 10:02 a.m., the SSD reviewed Resident 328's NOMNC letter and progress note on 9/15/2022. The SSD confirmed she called Resident 328's sister who was the RP on 9/15/2022 to notify about the LCD of skilled services. The SSD stated the issuance and notification of the NOMNC letter's LCD should be done within 24 to 48 hours before the LCD for resident or RP to have time to appeal the decision. The SSD confirmed the notification of Resident 328's LCD to the RP was done the day after. During a review of CMS (Centers for Medicare & Medicaid Services) Form Instructions -NOMNC, titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS - indicated, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .A NOMNC must be delivered even if the beneficiary agrees with the termination of services.

Based on observation, interview, and record review, the facility failed to provide a safe environment for staff and residents when staff used paper towels to light the pilot light in the oven. These failures had the potential to cause staff injuries and a fire hazard for 66 residents in the facility. Findings: During an observation on 10/3/2022 at 11:22 a.m., in the kitchen, the cook (a person who prepares and cooks food as a job or in a specified way) lit the paper towels three times from the stove top and tried to start the oven's pilot light at the bottom of the oven multiple times. During an interview with the Registered Dietitian (RD) on 10/3/200 at 11:41 a.m., The RD stated that staff should not use paper towels to light the oven's pilot light. The RD further stated lighting up a pilot light using the paper towel was not a safe practice. During an interview with the cook on 10/4/2022 at 9:20 a.m., the cook stated it was wrong to use the paper towel to light the oven's pilot light, and he should not have done that. During an interview with the Director of Nursing (DON) on 10/7/2022 at 11:00 a.m., the DON stated they were not supposed to use paper towels to light the oven's pilot light. The DON further stated it might injure the staff and might cause a fire hazard. A review of the undated manufacturing instruction titled Standard Oven Lighting and Shutdown instructions indicated, . remove the lower panel, depress the red button on the safety valve and light the pilot, hold down the red button for at least 30 seconds, when the button is released, the pilot should remain it .if the pilot becomes extinguished, repeat the above procedure.

Based on interview and record review the facility failed to ensure a stat (urgent or rush) laboratory orders was timely carried out for one of three sampled residents (Resident 1). This failure had the potential for delaying treatment if the laboratory tests had abnormal results. Findings: Review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's record indicated laboratory tests of CBC, UA, and Chem 20 were collected on 12/9/21 at 6:50 p.m. During an interview on 12/13/21 at 9:39 a.m., the director of nurses (DON) who reviewed the record stated stat laboratory tests results should be available 24 hours after being ordered. He confirmed Resident 1's laboratory were obtained late on 12/9/21 and results were reported on 12/12/21. Review of the facility's policyRequest for Diagnostic Services, dated 7/1/2020, indicated orders for diagnostic series was to be promptly carried out as instructed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to provide medically-related social services to a resident who alleged a staff member had mistreated her for one of two sampled residents (Residents 4). There was a lack of social services and nurses follow-up notes addressing Resident 4's psychosocial status. This failure had the potential for missing opportunities in detecting psychosocial distress and in providing support to the resident. Findings: Review of Resident 4's care plan, dated 12/21/21 indicated the resident alleged a staff member pushed her out of bed during incontinence care. The record lacked follow-up to social services and nurses notes addressing the resident's psychosocial status. During an interview on 12/21/21 at 1:40 p.m., the director of nurses (DON) who reviewed the record, stated there should have been daily social service follow-up notes for three days and licensed nurse documentation every shift for three days to check if the resident had any untoward signs and symptoms. Review of the facility's policy Change in a Resident's Condition or Status - Episodic, dated November 2017, indicated the nurse was to record in the medical record information relative to changes in the resident's medical/mental condition or status every shift for at least 72 hours. A social services policy addressing the need to follow-up on residents' psychosocial status was requested and not provided.

Based on observation, interview, and record review, the facility failed to properly implement the strategies to prevent the spread of coronavirus 2019 (COVID-19, a new strain of virus which could cause mild to severe illness) when: 1. Housekeeping (HK A) did not perform hand hygiene after removing her gloves; 2. HK A and HK B did not follow the proper cleaning procedures for COVID-19 observation room; 3. HK A did not follow the proper contact time for disinfectant wipes; 4. Resident 1 and Resident 2 did not properly document the oxygen saturation daily for symptoms of COVID-19. These deficient practice had the potential to result in the spread of COVID-19 in the facility. Findings: 1. During an observation and interview with HK A on 9/14/21 at 9:10 a.m., HK A removed her gloves after cleaning the room and did not perform hand hygiene when she left the room. During a concurrent interview with HK A, she confirmed she did not perform hand hygiene after she removed her gloves. Review of the facility's 9/2021 policy, Mitigation Plan, indicated hand hygiene before and after contact with residents, after contact with contaminated surfaces or equipment and after removing personal protective equipment (PPE, such as gloves, gowns, goggles or faceshield). 2. During an observation and interview with HK B on 9/14/21 at 8:30 a.m., HK B stated he was assigned as a janitor and he cleaned the yellow zone (residents under COVID-19 observation room) first and then he cleaned the green zone (residents with no known exposure). During an observation and interview with HK A 9/14/21 at 9:12 a.m., she stated she cleaned the yellow zone first and then cleaned the green zone. During an interview with the director of nursing (DON) 9/14/21 9:40 a.m., he stated HK A and HK B should have cleaned the green zone first and then cleaned the yellow zone. According to the California Department of Public Health (CDPH) All Facilities Letter 20-74.1(AFL 20-74.1), COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category, dated 7/22/21, indicated to consider grouping activities such that health care provider care for all residents in the Green (residents with no known exposure to COVID-19)-negative area before caring for residents in the yellow (COVID exposed residents) areas. 3. During an interview with HK A on 9/14/21 at 9:14 a.m., she stated she used disinfectant to clean the contaminated surfaces with 20 minutes contact time. However, if the surface was not dirty it was fast. During an interview with the director of staff development (DSD) on 9/14/21 at 2:50 p.m., she stated HK A used a disinfectant with 3 minutes contact time. According to the Centers for Disease and Control Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/hcp/longterm care.html Cleaning and Disinfecting your Facility, indicated always follow the directions of the label to ensure safe and effective use of the product. The label will include safety information and application instructions. Many products recommend keeping the surface wet with a disinfectant for a certain period (see contact time on the product label). 4. During interview and record review with the DON on 9/14/21 at 11:45 a.m., the DON confirmed Resident 1 had no oxygen saturation from 9/1/21 to 9/13/21 and Resident 2 had no oxygen saturation from 7/27/21 to 9/11/21 for COVID-19 symptoms. According to the Centers for Disease and Control Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/hcp/longterm care.html, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 spread in Nursing Homes, indicated to actively monitor all residents upon admission and at least daily for fever (temperature ?100.0°F) and symptoms consistent with COVID-19. Include an assessment of oxygen saturation via pulse oximetry.

Based on interview and record review, the facility failed to ensure Resident 1's right to retain and use personal reach extender/grabber (grabber) device, when Certified Nursing Assistant A (CNA A) held onto the grabber and tried to take it away from Resident 1. This failure resulted in an injury to Resident 1. Findings: During a telephone interview on 11/13/2020 at 6:42 a.m., with CNA A, CNA A stated he went into Resident 1's room to answer the call light. The grabber was on the floor, so he picked it up and handed it to Resident 1. CNA A stated Resident 1 wanted to hit him with the grabber so he grabbed and held it. Resident 1 then tried to pull it out of CNA A's grasp. However, CNA A had firm hold on the grabber and did not let go. CNA A stated that was when Resident 1 received a skin tear to her hand. During a review of Care Plan for Resident 1, dated 9/27/2020, the Alleged Rough Care Care Plan, indicated Resident 1 had alleged she had rough care. During a review of the facility's policy and procedure, Resident Rights, dated 7/1/20, the policy indicated .the resident's right to: b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; and .ee. retain and use personal possessions to the maximum extent that space and safety permit.

Based on observation, interview and record review, the facility failed to provide two-person assistance during a change of her incontinent pads for one of 18 sampled residents (Residents 3). This failure resulted in Resident 3's fall with a fracture of the right femur (the bone located within the human thigh extending from the hip to the knee) and an open reduction internal fixation (ORIF-is a type of surgery used to stabilize and heal a broken bone). Findings: Review of Resident 3's clinical record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 3's Minimum Data Set (MDS, an assessment tool) dated 12/07/16, indicated the resident BIMS (Brief Interview for Mental Status- an assessment tool for cognition) score of 13 indicating cognitively intact and was totally dependent that required two or more persons physical assistance with bed mobility and toilet use. Review of Resident 3's Fall Risk assessment dated [DATE] indicated she had a score of 13. A score of 10 or more indicated high risk for fall. Review of Resident 3's Resident Data Collection dated 12/1/16 indicated she was dependent on personal hygiene and grooming. Resident 3's ADL records for the months of February and March 2017, indicated Resident 3 was dependent with two-person assistance for bed mobility and toilet use. Review of Resident 3's ADL impairment care plan dated 12/5/16, indicated she was dependent and required two-person assistance with activities of daily living (ADLs, such as bed mobility, transfer, toileting and personal hygiene) related to bilateral knee contractures, history of left shoulder fracture, gall [DIAGNOSES REDACTED] (CA - is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body), DM, HTN, depression, [DIAGNOSES REDACTED] (a condition in which there is an accumulation of cerebrospinal fluid (CSF - a clear fluid that surrounds the brain and spinal cord) within the brain. Review of Resident 3's Interdisciplinary team's (IDT, composed of different disciplines like nursing, social service, activities, rehabilitation, maintenance, who work together toward a common goal) care conference summary and quarterly review of bowel and bladder evaluation plan dated 3/8/17 indicated, she was totally dependent, incontinent with bladder and bowel and dependent from the staff for toileting needs. Review of Resident 3's toileting needs care plan dated 12/5/16, indicated Resident 3 was incontinent (unable to voluntarily control retention) of both bowel and bladder that required total assistance. Review of the potential for fall care plan dated 12/5/16 indicated Resident 3 was dependent for toileting status and had the potential to fall related to history of fracture left shoulder, right arm, and right foot osteo[DIAGNOSES REDACTED] (inflammation of bones), narcotic and analgesic (pain medication) use, antihypertensives (medications to treat high blood pressure), [DIAGNOSES REDACTED] (low blood sugar level) that required assistance with ADLs PRN (as needed). Review of Resident 3's Nurses notes dated 3/16/17 indicated the resident was found sitting on the floor, complained of pain on legs and thigh upon assessment and was given pain medication. The doctor was notified and an X-ray (procedure that creates imaging pictures of the inside of the body) was done. The physician's orders [REDACTED]. Review of Resident 3's Change in Condition Post Fall report dated 3/16/17 indicated the resident was seen sitting on the floor on the left side of her bed. Per report, the certified nursing assistant (CNA) while changing the resident's diaper turned the resident to the left side, the CNA tried to prevent the fall but because the resident's weight was too much she put the resident to sit on the floor. Review of Resident 3's Change in Condition Post- fall IDT done on 3/17/17 indicated, during an interview with the resident, she stated a CNA was helping her turn to her left side during incontinent care when she suddenly started to slip slowly out of bed. The CNA tried to put her back to bed but because of the resident's weight the CNA eased her down to the floor. The IDT post fall recommendation included two-person assistance for ADLs, educate and train CNA for proper technique during ADL care. Review of Resident 3's findings of the X-ray of the right femur (two views) done on 3/17/17 indicated, there was a relatively acute angulated and moderately displaced supracondylar (a round part at the end of a bone where it fits into another bone) fracture of the distal right femur. Review of Resident 3's nurses notes dated 3/17/17 indicated, the attending doctor was notified of Resident 3's X-ray findings with order to transfer Resident 3 to the acute hospital for further evaluation and management of right distal (situated away from the center of the body) fracture. Resident 3 was transferred to the acute hospital on [DATE] at 1:20 p.m. Review of the acute hospital's diagnostic imaging report done on 3/18/17 indicated, right femoral shaft fracture (a break of the long, straight part of the thigh bone) of uncertain age. The imaging report done on 3/19/17 after the surgery indicated fluoroscopic (an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object) spot images for intramedullary rod (also known as an intramedullary nail (IM nail) is a metal rod forced into the medullary cavity of a bone used to treat fractures of long bones of the body) placement right femur. Review of Resident 3's readmission to the facility on [DATE], included [DIAGNOSES REDACTED]. During Resident 3's observation and concurrent resident interview done on 11/14/17 at 8:30 a.m., Resident 3 stated, the fall happened when only one CNA assisted her to turn to her left side to change her diaper. She slipped out of bed after being turned to her left side, and fell on her right knee. Per resident, the CNA was alone at that time. The CNA should have asked for another staff for help which they usually do. During an interview with registered nurse F (RN F) on 11/15/17 at 7:42 a.m., she validated Resident 3 needed two-person assistance with all her ADLs. During a phone interview with registered nurse H (RN H) on 11/15/17 at 10:30 a.m., she confirmed that the CNA worked by herself when changing Resident 3's diaper. During an interview with licensed vocational nurse I (LVN I ) on 11/15/17 at 1:50 p.m., she stated that the CNA repoted working by herself when the resident was turned in bed while changing her diaper and fell on the floor. Per LVN, the CNA stated, she did not follow the two-person assistance needed during the ADL care. During an interview and record review with the assistant director of nursing (ADON) on 11/15/17 at 2:10 p.m., she stated Resident 3 was a high risk for falls and required two-person assistance during ADLs. Per the ADON, if the CNA followed the care plan indicating two-person assistance during the ADL care, the fall could have been prevented. Review of the facility's 10/14/15 revised policy on Falls Management, indicated a fall is an unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Each resident must be assessed on admission using the Fall Risk Assessment form for potential risk for falls in order to take preventive approach. Identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls.