Every finding on record at Westland House

Based on observation, interview, and document review, the facility failed to ensure the garbage dumpster (a movable waste container) lid was kept closed. This failure had the potential to attract insects, rodents, and other pests to the facility.Findings:During a concurrent observation and interview 9/4/25 at 3:05 p.m., with the Dietetic Technician Registered (DTR), there were two dumpsters in the facility's designated waste area. One of the receptacles was for cardboard and one receptacle was for garbage. The receptacle lids for the garbage was open. The DTR confirmed the garbage dumpster lid was open. The trash had some flies flying around it. The DTR further stated the practice is it should be closed so no animals get in.During an interview with the Assistant Director of Environmental Services (ADEVS) on 9/4/25 at 3:54 p.m., the ADEVS verified the receptacle for garbage should be closed all the time to prevent pest.The United States Food and Drug Administration's 2022 Food Code indicated, Refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.Review of the facility's policy dated 2024, titled Disposal of Trash, indicated, It is the policy of the [facility] to comply with local, state, and federal laws in the storage and disposal of trash.

Based on interview and record review, the facility failed to ensure a medication was administered timely in accordance with the physician order for one of 12 sampled residents (Resident 46). This failure had the potential for adverse health outcomes related to incorrect medication administration time.Findings:During a review of Resident 46's Medications Order Summary Report (MOSR), dated 9/4/25, the MOSR indicated Resident 46 had an order for Pantoprazole EC (or Enteric Coated--a polymer barrier applied to oral medication that prevents its dissolution or disintegration in the gastric (stomach) environment) tablet 40 mg [milligrams, unit of measure]. MOSR indicated to start the order on 8/27/25 with instruction to administer one tablet daily at 6:00 AM for the prevention of NSAID (medications used to relieve pain, reduce fever, and decrease inflammation) induced gastric ulcer.During a concurrent interview and record review on 9/4/25, at 11:34 AM, with Charged Nurse (CRN), CRN confirmed the nurses had been given this medication to the Resident 46 around 9:00 AM since 8/28/25, and she did not know why it was set up in the system to be given at 9:00 AM instead of the scheduled time of 6:00 AM. The CRN further acknowledged the staff is supposed to contact the physician to get the order changed if the resident cannot take the medication at 6:00 AM.During a review of the facility's policy and procedure (P&P) titled, Medication of Administration dated 12/2024, the P&P indicated, Healthcare practitioners are accountable for giving the right patient, the right drug, the right dose, at the right time, via the right route.

Based on observation, interview, and record review, the facility failed to prevent the spread of infections during kitchen observation when a staff member did not perform hand hygiene after touching a contaminated item. This failure had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff.Findings:During the initial kitchen tour observation with the Dietetic Technician Registered (DTR) on 9/3/25 at 9:09 a.m., the DTR picked up a dry mop (used to clean and extract dirt) on the floor under the three-compartment sink, then threw the mop in the garbage bin container. The DTR did not wash his hands.During an interview with the DTR on 9/03/25 at 9:13 a.m., the DTR confirmed that hand washing was not done after picking up the dry mop on the floor. The DTR further stated hand washing should be done after every task.During an interview with the Infection Preventionist (IP) on 9/4/25 at 2:15 p.m., the IP stated hand hygiene should be done, after touching anything that touched the floor, because of cross contamination.Review of the facility's policy dated 2025, titled, Storage Handling, Preparation, Serving (Infection Prevention Policy),, indicated, To store, handle, prepare, and serve foods in a manner that prevents the growth of microorganisms in order to reduce or eliminate the risk of foodborne infection. Handwashing: Handwashing is critical to safe food service. To prevent transfer of bacteria and viruses to food, food service workers must pay particular attention to handwashing. B. Hands of food handlers must washed according to Nutrition Service Department requirements: 2. After handling trash .

Based on interview and record review, the facility failed to identify appropriate interventions for two of 12 residents (Resident 4 and 38):1. Resident 4's dysphagia (difficulty in swallowing foods or liquid) care plan had no interventions; and2. Resident 38's wound care plan did not indicate wound care interventions.This failure had the potential to compromise the facility's ability to implement interventions. Findings:1. Review of Resident's 4 medical record indicated Resident 4 was admitted on [DATE] and had diagnoses including Herpes zoster encephalitis (a rare but serious complications of herpes zoster ([shingles] infection), hypertension (high blood pressure), acute kidney infection (AKI, inflammation of the kidney caused by bacterial infection), diabetes mellitus 2 (a disorder characterized by difficulty in blood sugar control).A review of Resident 4 's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) completed on 8/4/25 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 10 out of 15. A score of 8 to 12 indicated the resident's cognition was moderately impaired.Review of Resident 4's diet report indicated the resident had a dysphagia diet (a modified diet designed for individuals with difficulty swallowing); 4-pureed (food); 2-mildly thick (Nectar Thick liquid).During a concurrent interview and record review with MDS A on 9/4/25 at 11:23 a.m., MDS A stated Resident 4's had a dysphagia diet. Resident 4's had a care plan for dysphagia and confirmed there was no intervention identified. MDS A further stated the intervention should be listed in the care plan because Resident 4 has a dysphagia diet and got food for oral gratification.During a concurrent interview and record review with the Interim Director of Nursing (DON) on 9/5/25 at 2:19 p.m., the interim DON stated the care plan should have an intervention that was specific and specific to the resident. The Interim DON confirmed that there was no intervention in Resident 4's care plan. She stated the goals were set, but the intervention was missing.2. Review of Resident 38's medical record indicated Resident 38 was admitted on [DATE] and had diagnoses including end stage renal disease (ESRD, a chronic condition where the kidneys have permanently lost most of their function).A review of Resident 38's MDS completed on 8/28/25 indicated a BIMS score of 13 out of 15. A score of 13 to 15 indicated the resident was cognitively intact.During an observation inside Resident 38's room on 9/2/25 at 10:19 a.m., Resident 38 was observed with several skin tears on the lower extremities.During a concurrent interview and record review with MDS A on 9/4/25 at 11:13 a.m., MDS A verified Resident 38 had a care plan for the wounds on the right radius left upper extremities (lue, referring to left arm, shoulder and hand) and the right knee left tibia (lower leg bone). MDS A confirmed there was no intervention for Resident 38's wound care plan and stated an intervention should be there. MDS A stated the interventions should reflect what we are providing the resident. MDS A further stated the nurse should be the one putting the intervention into the care plan.During a concurrent interview and record review with the Interim DON on 9/5/25 at 2:41 p.m., the DON verified there was no intervention for the wound care plan in place.Review of facility's policy and procedure (P&P), titled, Care Planning (General Patient Care Policy), dated 2025, indicated, Patient care planning is an interdisciplinary effort, resulting in an individualized plan of care. Evidence of implementation of an individualized plan of care is contained within the patient's record. Routine documentation of patient assessment, order, patient care and discharge planning is considered evidence of care planning. A. the care planning process includes patient assessment, problem identification, goal setting, intervention, referral to other health care is contained within the patient's record. Routine documentation of patient assessment, orders, patient care and discharge planning is considered evidence of care planning.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails ((adjustable rigid bars attached to the side of a bed) for 25 of 25 sampled residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170) when: 1. The facility failed to assess for the risk of entrapment from side rails prior to use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 2. The facility failed to review the risks and benefits of side rails with the resident or resident representatives (RP) and obtain informed consent (a process which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 3. The facility failed to attempt alternative measures prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 4. The facility failed to ensure physician orders were obtained prior to the use of the side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). These failures had the potential to put all 25 residents at risk of entrapment and serious injury. Findings: Review of the U.S Food and Drug Administration (FDA) Hospital Bed Safety Workgroup Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, indicated the FDA issued a Safety Alert entitled, Entrapment Hazards with Hospital Bed Side Rails. This alert indicated National surveys of patient deaths occurring in the bed environment demonstrate the risk of entrapment when a patient slips between the mattress and bed rail or when the patient becomes entrapped in the bed rail itself. The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement . that cause them to move about the bed or try to exit from the bed. During an observation on 4/29/24 at 9 a.m., in the resident's room, Resident 120's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:10 a.m., in the resident's room, Resident 121's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:14 a.m., in the resident's room, Resident 175's bed had 4 side rails installed with the three side rails in the upright position. During an observation on 4/29/24 at 9:16 a.m., in the resident's room, Resident 122's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:24 a.m., in the resident's room, Resident 125's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:29 a.m., in the resident's room, Resident 126's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:37 a.m., in the resident's room, Resident 128's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:38 a.m , in the resident's room, Resident 173's bed had 4 side rails installed with one upper side rail in the upright position. During an observation on 4/29/24 at 9:41 a.m., in the resident's room, Resident 127's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:50 a.m., in the resident's room, Resident 123's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 11:32 a.m., in the resident's room, Resident 170's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 2:54 p.m., in the resident's room, Resident 70's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 71's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 72's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 73's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 75's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 76's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:33 p.m., in the resident's room, Resident 74's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:42 p.m., in the resident's room, Resident 79's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 171's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 174's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 172's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 10:23 a.m., in the resident's room, Resident 1's bed had 4 side rails installed with the two upper side rails in the upright position. During a concurrent interview and record review on 4/30/24 at 10:53 a.m., with Registered Nurse (RN) B, RN B reviewed the electronic records of some residents, then RN B stated that all residents were assessed and informed about the use of side rails but there was no documentation about the risk and benefits for the use of side rails given to all residents. RN B further stated there was no need for physician orders for the use of side rails unless if it was used as a restraint. RN B also stated there was no alternatives to the use of side rails discussed with any of the residents and their responsible parties. During a concurrent interview and record review on 4/30/24 at 1:21 p.m., with RN C, RN C reviewed all the 25 residents' electronic records and stated that all the residents must always have the side rails in the upright position. RN C stated that no alternatives were used because every patient (meant Resident) must have the two side rails up. RN C further stated the use of side rails does not need to have a consent and physician orders. RN C also stated that residents were assessed and informed of the risk and benefits of the use of side rails verbally but there was no documentation done. RN C also stated there was no policy for the use of side rails. During an observation on 5/1/24 at 2:55 p.m., in the resident's room, Resident 77's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 5/1/24 at 2:57 p.m., in the resident's room, Resident 78's bed had 4 side rails installed with the two upper side rails in the upright position. During an interview on 05/02/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated there was no alternatives for the use of side rails. The DON stated consent and physician order were not required because the use of side rails was an intervention used to prevent falls. The DON stated that assessment was done for the prevention of falls and not for the use of side rails. The DON also stated they have no side rails policy. 45853 46939

Based on observation, interview, and record review, the facility failed to ensure food items were labeled properly and expired food were not stored in the kitchen and accessible to be used in preparing foods for 23 of 25 residents. This practice had the potential to result in the residents ingesting expired food, which can result in foodborne illnesses. Findings: During a concurrent observation and interview on [DATE], at 8:43 a.m., with [NAME] A, in the walk-in refrigerator, three stalks of [NAME], and two bunches of cilantro were noted to be in a clear plastic container on the top shelf. No dates or labels were noted on the produce or the container which held the produce. Another clear plastic container held approximately 7 green squash with no labels on the produce or the container. [NAME] A stated there are no labels on these produce or the containers, they are supposed to have a receive date and a use by date. During a review of the facility's policy and procedure (P&P) titled, Food Safety: Storage Handling, Preparation, serving, dated 2019, the P&P indicated, 4. Food is covered, labeled, dated, and used within the specified time periods, and is stored off the floor.

Based on observation and interview, the facility failed to ensure two of 25 residents (Residents 74 and 79)'s foot boards of their beds were properly locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: During a concurrent observation and interview on 4/29/24 at 3:34 p.m. in Resident 74's room, there was a six-inch (a unit of length or distance) gap between Resident 74's mattress and the foot board of the bed. The resident stated he did not like the bed. During a concurrent observation and interview on 4/29/24 at 3:40 p.m. in Resident 79's room, there was a six-inch gap between Resident 79's mattress and the foot board of the bed. The resident had just finished his Physical Therapy session with Physical Therapist (PT) D, PT D stated, all beds are adjustable, the gap between the foot board and the mattress was here when she got here this morning, she had to check with the resident's nurse to find out why there was a gap. During a concurrent observation and interview on 5/2/24 at 8:55 a.m. in Resident 74's room with Registered Nurse (RN) E, there was still a gap between the food board and the mattress, and the resident's blanket had fallen into the gap. RN E stated maybe when the resident slid down to the foot of the bed, the foot board was pushed. RN E and Certified Nursing Assistant (CNA) F then pushed the foot board back until there was no more gap. During an interview on 5/2/24 at 9:50 a.m. with CNA F, CNA F stated she double checked the bed, the foot board just needed to be pushed back in and locked in place. She further stated there should be no gap between the mattress and the board because it can potentially cause the resident to get injured. During an interview on 5/2/24 at 11:28 a.m. with RN G, RN G stated if there was a gap between the mattress and the foot board, potentially the resident can slide down and get injured. During an interview on 5/2/24 at 1:20 p.m. with the Director of Nursing, the DON stated the staff should make sure the foot board was locked and secured, the mattress could slide down due to there was a gap. During a review of the facility's policy and procedure (P&P), titled Fall Mitigation PC-4039, the P&P indicated, Hospital Bed Safety Features & Exit Alarm 2. Before leaving the patient room, check that iBED awareness lights are illuminating green. Key Point: The lights flash amber if the bed does not meet the safety parameters set. i. Review the digital display control panel at the foot of the bed to determine the alert and adjust the bed to appropriate configuration. [ .] iii. Set the bed to the appropriate configuration (set brake, raise side rail, etc.).

Based on interview and record review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC, informs beneficiaries on how to file an appeal before their insurance coverage ends) timely for two of three sampled residents (Resident 80 and 81). This deficient practice had the potential to result in residents not being able to exercise their right to file an appeal. Findings: During a review of Resident 80's face sheet (a document that contains a summary of a resident's personal and demographic information) and NOMNC, it indicated Resident 80 was admitted to the facility on [DATE] and her stay was paid by Medicare (federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities) until 11/1/23. The NOMNC also indicated it was signed by the resident one day prior to her last day of Medicare coverage on 10/31/23. During a review of Resident 81's face sheet and NOMNC, it indicated Resident 80 was admitted to the facility on [DATE] and her stay was paid by Medicare until 1/19/24. The resident was discharged on [DATE], and the NOMNC was signed by the resident's responsible party on the discharge day. During an interview on 5/1/24 11:29 a.m. with the Social Services Designee (SSD), the SSD stated usually the facility issues the NOMNC 72 hours prior to a resident's last covered date. For Resident 80, the NOMNC should have been delivered on 10/30/23, because it required at least 48 hours window for the resident to file an appeal. For Resident 81, her initial discharge date was on 1/18/24, but she had a change in condition, so the facility held the discharge and issued a new NOMNC that day. During an interview on 5/1/24 at 11:47 a.m. with the Patient Care Coordinator (PCC), the PCC stated the facility should have issued a NOMNC on 1/18/24 with last covered date 1/20/24 for Resident 81 to be compliant with the regulation. During a review of the facility provided Centers for Medicare & Medicaid Services (CMS) form instruction (FI), titled Form Instruction for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, OMB Approval 0938-xxxx, the FI 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.

Based on interview and record review, the facility failed to ensure the plan of care for one of 25 sampled residents (Resident 1) was individualized and revised to reflect the resident's current care needs and interventions. This failure had the potential to result in not meeting the residents' needs. Findings: During an observation on 4/30/24 at 9:10 a.m., in the resident's room, Resident 1 was sitting at the edge of the bed with the two upper side rails in upright position. Review of Resident 1's clinical record indicated she was admitted on [DATE] with a diagnosis of Cellulitis of the left hand. Review of Resident 1's care plans indicated care plans for problems addressing return activities of daily living status to a safe level of function and at risk for fall. There was no care plan addressing the use of side rails. During a concurrent interview and record review on 4/30/24 at 10:43 a.m., with Registered Nurse (RN) B, RN B reviewed the care plans of Resident 1 and stated the care plan for side rails are incorporated in the care plan addressing risk for fall. RN B further stated there was no care plan for the use of side rails. During a concurrent interview and record review on 4/30/24 at 1:21 p.m., with RN C, RN C reviewed the care plans for Resident 1and stated they use the fall care plan to address the side rails. RN C further stated there was no care plan specific for the use of side rails. During an interview on 5/2/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated there was no specific care plan for side rails. The DON stated the facility has no policy specific for side rails.

Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained for one of three ice machines when an ice machine had a brown-yellow substance in an interior part of the machine was exposed to ice. This failure had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins). The ice machine was used to provide ice for the residents. Findings: During an observation and concurrent interview, with Engineering Services Technician C (EST C) on 5/3/23 at 10:25 A.M., at nurses' station AA's clean utility room, the rim of an ice chute (a dispensing tube of the interior bucket of the ice machine) was wiped with a clean white paper towel to check for residuals. The wiping yielded a brown-yellow substance onto the clean paper towel. EST C acknowledge this observation and stated he was unsure what the substance was. During an observation and concurrent interview with EST D and the Director of Nursing (DON) on 5/3/23 at 11:43 A.M., EST D and the DON acknowledged the brown-yellow substance from the ice machine. EST D confirmed the last preventive maintenance on the ice machine was in 4/2023 and stated, I may have missed that part. During an interview and concurrent record review, with EST E on 5/5/23 at 2:24 P.M., the preventive maintenance (PM) logs indicated the last PM for the ice machine was completed 12/9/22. EST E confirmed the sticker on the side of the machine, dated 4/2023, was an additional cleaning. The Nursing Station AA ice machine log lacked a PM entry on 4/2023. Review of the facility's policy Environment of Care: Inspecting, Testing and Maintenance, dated 2021, indicated, The Engineering Services technicians perform assigned activities and return completed documentation to managers . All documentation of the maintenance activity will be completed by the Engineering Services technicians, reviewed by the appropriate supervisor, and filed or the information entered into the work order system.

Based on observation and interview, the facility failed to ensure proper storage of medical supplies when expired hypodermic safety needles (medical tool, designed for safe one-time use, to inject or extract fluids from the body via a thin hollow tube with a sharp tip), were stored in an active use area inside the medication storage room. This deficient practice had the potential for use of expired medical tools on residents. Findings: During an observation and interview at the medication storage room [ROOM NUMBER] (MSR 1) with registered nurse A (RN A), on [DATE] at 12:20 p.m., five hypodermic safety needles, labeled with expiration dates for [DATE], were stored among medical supplies for active use on residents. RN A confirmed the five hypodermic safety needles were expired and stated that they should have been discarded.

Based on observation and interview, the facility failed to ensure garbage was disposed of properly in the outside garbage area when a dumpster lid was left open, garbage and linen bags were left outside the dumpsters, and garbage was on the ground. This failure had the potential to attract vermin (pests or animals that spread diseases). Findings: During an observation and interview at the facility's garbage area with the Dietetic Technician, Registered (DTR) on 5/3/23 at 9:59 A.M., two plastic containers, one small white plastic container, two plastic utensils, cardboard, multiple blue gloves, a water bottle, and a cardboard box lay on the ground outside of the trash dumpsters. A clear bag filled with contents was on top of a trash bin, and a blue bag filled with contents was on the ground between dirty linen containers. A dumpster containing cardboard had an open lid. During a concurrent interview with the DTR, the DTR confirmed the observation and stated, It should not look like this. During an observation and concurrent interview on 5/3/23 at 4:00 P.M. with Environmental Services F (EVS F) at the facility's designated garbage area, EVS F stated, It is dirty . trash should not be on the ground. During an observation and interview at the facility's garbage area with the Infection Preventionist (IP) on 5/4/23 at 8:21 A.M., a garbage dumpster was propped open with overflowing garbage bags. Three black garbage bags sat outside of the dumpster. Surgical masks and multiple gloves were on the ground outside of the trash bins. Flies were present. The IP confirmed the situation could attract vermin. During an observation and interview at the facility's garbage area with EVS G on 5/5/23 at 11:48 A.M., there were multiple gloves, a water bottle, a large rusted can labeled diced pears, cardboard, and two small containers on the ground near the trash bins. Flies were present. EVS G confirmed the observation. Review of The U.S. Food and Drug Administration's 2022 Food Code section 5-501.116 indicated, Cleaning Receptacles: Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control strategies when a certified nursing assistant with long fingernails took care of residents. This failure resulted in increased risk of disease transmission to residents via long fingernails, which provide more area(s) where microbes may harbor compared to short fingernails. Findings: During an observation at station AA (ST AA) on 5/4/23 at 8:35 a.m., certified nursing assistant B (CNA B) was in a hallway with long fingernails going to a resident's room. During an interview with the infection preventionist (IP) on 5/4/23 at 9:25 a.m., the IP confirmed that certified nursing assistants should maintain short nails for infection control purposes. During an interview with CNA B on 5/4/23 at 9:54 a.m., she confirmed that she should have maintained her fingernails trimmed short for infection control purposes, but forgot to. Review of the facility's policy and procedure Professional Appearance and Grooming Standards: Nails, effective December 2022, indicated, All employees must be properly groomed . Maximum nail length of natural nail tips is 1/4 inch (unit of length).

Based on interview and record review, the facility failed to honor one of two sampled residents' (Resident 1) rights of the visitation when Resident 1's family members were denied indoor visitation. This failure had the potential to negatively impact the physical and emotional well-being of the resident in the facility. Findings: Review of Centers for Medicare & Medicaid Services (CMS) Quality Safety & Oversite (QSO) Memorandum for Nursing Homes (Reference QSO-20-39-NH (revised 11/12/2021), indicated, Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE, facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling. Failure to facilitate visitation, per 42 CFR S 483.10(f)(4), which states The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident, would constitute a potential violation and the facility would be subject to citation and enforcement actions. Review of the CDPH All Facilities Letter (AFL) 20-22.9, dated 8/12/21, titled, Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs), indicated, Facilities shall conduct visitation through different means based on the facility's structure and residents' needs for circumstances beyond compassionate care situations, such as in resident rooms, dedicated visitation spaces, and outdoors; however, facilities must adhere to the core principles of COVID-19 infection prevention at all times. Visitation must be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. SNFs must also enable visits to be conducted with an adequate degree of privacy and should be scheduled at times convenient to visitors (e.g., outside of regular work hours). Required visitation: All facilities must comply with state and federal resident's rights requirements pertaining to visitation. Facilities should follow CDPH and local public health department guidance when implementing visitation policies. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a violation of resident's rights and the facility would be subject to citation and enforcement actions. Review of the undated facility's policy, titled, Visitor Policy, indicated, VISITS: Can be scheduled with the Visitation Coordinator for up to 30 minutes; Monday - Friday, from 9:00am to 16:45, no weekends or holidays; Two visitors are allowed to visit inpatients, max of 2 in one day. During an interview with the Certified Nursing Assistant (CNA), on 7/7/2022 at 11:15 a.m., CNA stated Resident 1's family members visited back in December 2021, it was a little bit after lunch. CNA stated Resident 1's visitors were not allowed inside the facility because they did not have an appointment. CNA stated Resident 1 was wheeled in the front entrance to talk to her family members. CNA stated they have a designated visiting area inside the facility's lobby by the living room. During an interview with the Visitation Coordinator (VC), on 7/7/2022 at 11:39 a.m., VC stated visitation was by appointment only. VC stated visitation was Monday-Friday from 9:00 a.m. -4:45 p.m. and visits were only 30 minutes in visitation area. VC further stated no visitation on weekends and holidays. During an interview with the Director of Nursing (DON) on 8/16/2022 at 1:25 p.m., DON stated AFL 20-22.9 was used to guide their visitation.

Based on observation, interview, and record review, the facility failed to ensure standards of infection control practice when staff did not sanitize their hands when entering and exiting resident room A. The failure had the potential to result in transmitting and spreading the COVID-19 infection to residents and staff. Findings: 1. During an observation and concurrent interview on 11/17/2020 at 10:15 a.m., Certified Nursing Assistant A (CNA A) did not sanitize her hands when she entered Resident 1's room. CNA A stated she should have sanitized her hands before she entered the resident's room. Review of facility's current policy Hand Hygiene, Fingernails, and Glove Use, indicated that before touching clean equipment, sterile equipment, or having patient contact, staff must clean hands. The Centers for Disease Control (CDC) guidance, Hand Hygiene in Healthcare Settings dated 1/21/2020, indicated hand hygiene should be performed After contact with blood, body fluids or contaminated surfaces and Immediately after glove removal. Guidance is located at https://www.cdc.gov/handhygiene/providers/index.html

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices when: 1.There were no signage posted outside of the residents' rooms (Rooms A, B, C, D, E, and F) of the appropriate personal protective equipment (PPE, helps protect health care personnel and resident when providing care. PPE, such as gowns, mask, face shields, gloves) to be used and type of precautions required prior to entering the residents' rooms in the yellow zone (designated area for newly admitted residents who are being observed and monitored for signs and symptoms of respiratory infection); 2.Registered Dietitian was wearing a cloth mask in the kitchen instead of a surgical mask; 3.The in-service for infection control prevention was not complete, evidenced by no signature verification from the employees; and 4.Incomplete documentation of staff/visitors' screening logs. These failures had the potential to spread infection. Findings: 1. During an observation on 11/3/2020 at 9:50 a.m., while in the yellow zone there were no signage posted outside of resident's rooms (Rooms A, B, C, D, E, and F) to inform staff of the appropriate PPE and types of precautions required upon entry into the resident's room. During an interview on 11/3/2020 at 11:15 a.m., with Licensed Vocational Nurse (LVN A), she was unable to verbalize the type of precautions that should be observed in the yellow zone. Review of the CDC's guideline Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings (https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf), updated 6/25/2020, indicated Signs are posted immediately outside of resident rooms indicating appropriate Infection Prevention and Control precautions and required PPE. 2. During an observation on 11/3/2020 at 10:00 a.m., with Registered Dietitian A (RD A), she did not wear her cloth mask while in the kitchen area. She stated she did not wear her mask because she did not provide direct resident care. During an interview on 11/3/2020 at 10:05 a.m., RD A stated she had her surgical and N95 mask. Review of CDC guideline, Interim Infection and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE], indicated HCP should wear a facemask at all times while they are in healthcare facility, including in breakrooms or other spaces where they might encounter co-workers .Cloth mask should NOT be worn instead of a respirator or facemask. 3. During a record review of personnel in-service training on 11/3/2020 at 2:30 p.m., six out of eighteen staff received training on 9/8/2020 under Hand Hygiene topic. Six out of forty-one staff received training on 10/6/2020, and five out of forty-one on 10/12/2020; missing were signature verifications on the sign-in sheet. In-service topic for 10/6/2020 was about zones (red, yellow, green) and on 10/12/2020 was an update on the Revised Mitigation Plan. During an interview with the assistant director of nursing (ADON) on 11/3/2020 at 2:35 p.m., she confirmed the record review and stated it should have been done in October. A review of the CDC's guideline, Guidelines for Isolation Precaution (https://www.cdc.gov/infectioncontrol/guidelines/isolation/recommendations.html), updated 7/2019, indicated Provide job- or task-specific education and training on preventing transmission of infectious agents associated with healthcare during orientation to the healthcare facility; update information periodically during ongoing education programs. Target all healthcare personnel for education and training, including but not limited to medical, nursing, clinical technicians, laboratory staff; property service (housekeeping), laundry, maintenance and dietary workers; students, contract staff and volunteers. Document competency initially and repeatedly, as appropriate, for the specific staff positions. 4. During an interview on 11/3/2020 at 2:30 p.m., Administrator E (ADM E) stated when staff came in to work, they used the Conversa app (a virtual communication platform) to screen. If it had been cleared, they weere allowed to enter the facility. If they had symptoms, it would be sent directly to the employee health. During a review of the staff/visitors' screening logs dated 8/9/2020, indicated the paper log was missing temperature readings and symptoms screening; on the same day the Conversa screening app's report showed no temperatures. Review of CDC website Preparing for COVID-19 in Nursing Homes, updated June 25, 2020, indicated Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19.

Based on interview and record review, the facility failed to implement their abuse policy and procedure for one sampled resident (Resident 1), when: 1. Resident 1's allegation that she was molested by a female staff was not reported to the local law enforcement agency 2. The alleged abusers/perpetuators indicated in the S[NAME] 341 were not suspended. 3. Care plans regarding the abuse allegation and the presence of altered skin integrity after thoracentesis (a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall to remove excess fluid, known as a pleural effusion, from the pleural space to help breathe easier) were not developed. These failures had the potential to affect the resident's safety and care, and protection from possible harm. Findings: 1. A review of Resident 1's medical record indicated admission on 1/10/2020. Her admission minimum data set (MDS, an assessment tool) dated 1/14/2020, indicated brief interview for mental status (BIMS, tool to assess cognition) score of 15 or intact cognition. During an interview on 1/24/2020 at 8:50 a.m. with registered nurse B (RN B), RN B stated she was the morning Charge Nurse on duty when registered nurse A (RN A) reported Resident 1's allegation that she was molested by a female staff on the evening of 1/14/2020. RN B then reported this allegation to the social worker (SW) for further investigation. RN A completed the S[NAME] 341, and faxed it to the Ombudsman and the California Department of Public Health. There was no indication the local law enforcement agency was notified. During a telephone interview on 1/24/2020 at 10:02 a.m., RN A stated she worked the morning shift on 1/15/2020 when Resident 1 told her a female staff molested her. RN A then reported the allegation to her charge nurse (RN B) and the SW. RN A did not notify the police. During an interview on 1/24/2020 at 10:38 a.m., the SW confirmed the local law enforcement (police department) was not notified. 2. During a review of Resident 1's nursing note, dated 1/15/2020, indicated the nurse asked permission from Resident 1 to check her back because she had a [MEDICATION NAME] (wound dressing) and the resident agreed so she lifted her gown but refused her front to be assessed. The social worker note dated 1/15/2020, indicated RN A reported Resident 1 made an allegation of abuse that occurred on the previous evening that involved two female staff (CNA D and RN C). During a review of the facility's daily assignment schedule dated 1/14/2020, indicated the alleged abusers/perpetuators worked the night shift (23:00 to 0730) when the abuse allegation happened and on 1/15/2020 after the incident. During a telephone interview on 1/24/2020 at 9:18 a.m., registered nurse C (RN C) confirmed she worked the night shift on 1/14 to 1/15/2020 During a telephone interview on 1/24/2020 at 10:15 a.m., certified nursing assistant D (CNA D) confirmed she worked the night shift on 1/14 to 1/15/2020. 3. During a review of Resident 1's medical record, care plans on allegation of abuse and presence of altered skin integrity related to thoracentesis procedure were missing and were not developed. During an interview on 1/24/20 at 10:08 a.m., with the director of nursing (DON), she reviewed Resident 1's medical record, confirmed care plans on allegation of abuse and presence of altered skin integrity post thoracentesis were not developed. During a review of the facility's undated policy and procedure, General Patient Care: Westland House Abuse Prevention Program, indicated an employee suspected to have committed abuse against a resident will be suspended immediately, pending investigation. Abuse Prevention Program Coordinator will report suspected abuse to all mandated agencies. A plan of care will be written and verbally communicated to all employees.

Based on observation, interview, and record review the facility failed to ensure nursing staff implemented accepted standards of infection control practice for two of three sampled residents (3 and 169) when an aseptic technique was not maintained during peripherally (away from the central part of the body) inserted central catheter (PICC, a long catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body, used for intravenous (IV, into vein) medication administration) line dressing changes. This failure had the potential to result in catheter related blood stream infections (CRBSI). Findings: 1. During an observation on 10/9/19 at 2:25 p.m. of Resident 3's PICC line dressing change, registered nurse C (RN C) removed Resident 3's PICC line dressing and measured his PICC line length. RN C next donned sterile gloves and with a disinfectant soaked swab, scrubbed the skin of Resident 3's right arm, beginning with the area furthest away from and surrounding the PICC line insertion site. RN C next scrubbed Resident 3's skin close to the PICC line insertion site, and with the same swab, then wiped the PICC line insertion site and tubing. During an interview with the minimum data set (MDS, an assessment tool) coordinator on 10/9/19 at 3:10 p.m., she stated when scrubbing the skin during a PICC line dressing change, the nurse should have cleaned the PICC line insertion site first and then gradually should have cleaned the surrounding skin, working out away from the insertion site. The MDS Coordinator stated the nurse should have never cleaned the PICC line site after cleaning the arm, if using the same cleaning stick. During an interview with the director of staff development (DSD) on 10/9/19 at 3:12 p.m., she stated the nurse should have cleaned the PICC line insertion site and first few inches of PICC line tubing with a new cleaning stick first, prior to cleaning the surrounding area. Review of Peripherally Inserted Central Cather - Dressing Change at https://medlineplus.gov/ency/patientinstructions/ 2.htm indicated to first clean the catheter, slowly working away from the insertion site, then clean the skin around the site. 2. During an observation on 10/10/19 at 10:48 a.m. of Resident 169's PICC line dressing change, RN D donned sterile gloves and removed the dressing from the PICC line site. RN D then held a measuring tape along the length of the PICC line, stabilized the tape next to the PICC line insertion site by placing her first two gloved fingers onto Resident 166's skin, causing the gloves to no longer be sterile. RN D then placed the same first finger, which had just touched Resident 169's skin onto the PICC line insertion site while holding the measuring tape to finish the measurement. During an interview with RN D on 10/10/19 at 11:15 a.m., she acknowledged she should not have placed her finger on the PICC line insertion site while measuring the PICC line. During an interview with the DSD on 10/9/19 at 3:12 p.m., she stated the nurse should have not touched the PICC line insertion site with a contaminated item. Review of the facility's undated policy, Peripherally Inserted Central Catheter (PICC) Dressing Change, indicated to place a transparent dressing over the PICC line insertion site, remove gloves, and then measure the PICC line catheter. Review of CDC guidelines at https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf (p. 33) indicated to maintain aseptic technique (using practices and procedures to prevent contamination with germs) during care of a PICC line, to inspect the PICC line insertion site visually during a dressing change and to palpate (touch) the PICC line insertion site through an intact dressing.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported in a timely manner by staff for one of 22 residents (Resident 61), when after hearing of an alleged abuse, certified nursing assistant A (CNA A) did not report the allegation to anyone. This failure had the potential of other residents potentially being abused. Findings: During an interview with Resident 61 on 10/8/19 at 11 a.m., she stated the physical therapist B (PT B) had hurt her during her physical therapy session on 10/7/19. During an interview with the administrator (ADM) on 10/8/19 at 3:33 p.m., when told of the abuse allegation, she stated it was the first time she had heard of the abuse allegation. During a telephone interview with CNA A on 10/10/19 at 9:43 a.m., she stated Resident 61 had told her of the abuse allegation. CNA A stated she did not tell anybody. CNA A stated she told Resident 61 to report it. The facility's policy and procedure, General Patient Care: Westland House Abuse Prevention Program, dated 03/2017, indicated .As mandated reporters, employees are required to report any knowledge of known or suspected abuse and/or neglect of a resident immediately to the Ombudsman, State of California Department of Public Health (CDPH), and the facility Abuse Prevention Program Coordinator/Administrator.

Based on interview and record review the facility failed to develop, revise, and/or implement a person-centered care plan (a document which provides direction for individualized care of the resident; a means of communicating and organizing the residents' new and ongoing problems and nursing actions of a constantly changing staff; includes an ongoing identification of the resident's existing and changing needs, goals, and interventions to address these needs) for three of 12 sampled residents (163, 166 and 168) when: 1. For Resident 163, the facility did not develop a care plan that identified and addressed redness and wounds of the right buttock. 2. For Resident 166, the facility did not develop an activity care plan to include her individual activity preferences; facility staff did not implement 1:1 activities as indicated on the care plan. 3. For Resident 168, the facility did not update the care plan for a medication kept at the bedside. These failures had the potential to result in the residents not receiving the appropriate care necessary to maintain their highest level of well-being. Findings: 1. A review of the clinical record for Resident 163 indicated she was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. Resident 163 had a brief interview for mental status (BIMS, a tool to assess cognitive status) score of 15 (scores of 13-15 indicate intact cognition). During an interview with Resident 163 on 10/09/19 at 9:13 a.m., she stated she had a wound on her back side that developed in the hospital. During an interview and concurrent record review with the minimum data set coordinator (MDS, an assessment tool) on 10/10/19 at 9:32 a.m., she reviewed Resident 163's clinical record and an admission skin assessment dated [DATE], indicated a wound on Resident 163's upper buttock area. Further review of Resident 163's clinical record, indicated the following skin assessments and interventions: 9/29/19: moist buttocks redness and application of foam dressing. 9/30/19: moist buttocks redness and application of [MEDICATION NAME] (moisture barrier) 10/1/19: moist buttocks redness and application of [MEDICATION NAME] (moisture barrier) 10/2/19 no buttocks wound assessment was done 10/3/19: no buttocks wound assessment was done 10/4/19: buttock redness 10/5/19: no buttocks wound assessment was done 10/6/19: no buttocks wound assessment was done 10/7/19: buttock redness 10/8/19: no buttocks wound assessment was done 10/9/19: buttock redness During the concurrent interview, the MDS Coordinator stated there was no care plan that identified the presence of a buttock wound or interventions to treat the wound. The MDS Coordinator stated Resident 163 had a care plan for impaired skin integrity but the facility's computer program was unable to personalize Resident 163's care plans to include identification of her actual buttock wound and specific treatment for [REDACTED]. Review of the facility's undated policy, General Patient Care Policy: Pressure Injury and Wound Care, indicated nursing staff, upon identification of an issue with skin integrity should update and maintain the resident's individualized care plan. 2. A review of the clinical record for Resident 166 indicated she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an interview with Resident 166 on 10/8/19 at 10:32 a.m., she stated she was blind and deaf and she was unable to watch television or to leave her bed and she was not offered alternate room activities since her admission. Resident 166 stated she discussed activities with someone over a week ago and would like to be involved in some things during her stay. Review of Resident 166's Activity assessment dated [DATE], indicated Resident 166 was hard-of-hearing and blind and had a preference for activities in her room including cards and games. Review of Resident 166's Activity Care Plan dated 9/27/19, indicated to provide 1:1 activities if resident does not prefer group activity. There was no evidence in Resident 166's Clinical Chart 1:1 activities were provided. During an interview with the activity coordinator (AC) on 10/10/19 at 8:36 a.m., she stated she had other responsibilities at the facility and had not yet set up any activities for Resident 166 in her room. The AC stated, she should have offered Resident 166 an activity such as reading the newspaper to her. Review of the facility's undated policy, Westland House Activity Assessment, indicated each resident's activity plan shall be part of the overall plan of care . shall include consideration of individual interests, former life-style . and include identified limitations and precautions. 3. A review of the clinical record for Resident 168 indicated she was admitted to the facility on [DATE] and had a history of [REDACTED]. During an interview and concurrent observation with Resident 168 on 10/8/19 at 10:03 a.m., she stated she kept medication at her bedside for her asthma, while pointing to an inhaler (a portable device for administering a drug which is to be breathed in) on her bedside table. Resident 168 stated she needed to have it next to her to use it when she was unable to breathe. Review of Resident 168's Physician Orders, dated 10/7/19, indicated [MEDICATION NAME]-[MEDICATION NAME] (IA, medication to control symptoms of asthma) inhaler two puffs, four times per day for shortness of breath: OK to keep at patient's bedside. Review of Resident 168's undated Respiratory Care Plan, indicated the use of the IA inhaler during incidents of shortness of breath was not included in the list of interventions, nor was the direction to keep the IA inhaler at the resident's bedside for urgent use for episodes of shortness of breath. During an interview with the administrator (ADM) on 10/10/19 at 11:30 a.m., she stated the program used in the facility's electronic clinical record program did not allow for personalization of the care plan. The ADM stated they needed to work with the computer program company to add this ability to their system. Review of an article at (http://lippincottsolutions.lww.com/blog.entry.html/2014/08/11/nursing_care_plans-J2v6.html) indicated the nursing care plan should drive every single thing done with the patient . clinical reasoning, diagnosis, and appropriate treatment planning is a key component of professional nursing practice.

Based on interview and record review, the facility failed to provide professional standards of quality of care for one of two sampled residents (1) when occupational therapy (OT) staff failed to use a gait belt (device used to transfer or ambulate people who have problems with balance) and a wheelchair (WC) to safely ambulate the resident. This failure resulted in a fall for the resident with injuries and ongoing pain. Findings: Resident 1's clinical record was reviewed on 12/5/16. His minimum daily set (MDS, an assessment tool) dated 11/13/16 indicated he required one person physical assistance to walk. A physician's orders [REDACTED]. Review of an Occupational Therapy Evaluation dated 11/7/16 indicated Resident 1 was a fall risk due to weakness. His plan of care included safety training, ADL retraining, and home management skills. A physician's orders [REDACTED]. Review of a narrative PT progress note dated 11/10/16, during the p.m., authored by the doctor of physical therapy (DPT), indicated Resident 1 consented to PT, but when the resident sat on the edge of the bed, he complained of some dizziness. DPT notified nursing staff who confirmed the resident had a low blood pressure (LBP) of 87/46 millimeters of mercury (mm/Hg, a unit of measure). The note indicated when the resident stood and took a few steps he began to lose his balance. The resident sat down and reported he still felt dizzy. He was helped back to bed, his legs were elevated, and his nurse was notified. During an interview on 12/5/16 at 11 a.m. with the DPT, she stated Resident 1 was good about telling her how he felt. She stated on 11/10/16 at the beginning of his PT treatment, he stated he felt dizzy. She stated the RN checked his BP that indicated he had a (LBP) of 87/46 mm/Hg. She stated she had planned to walk the resident, but as his BP was so low, she did not. She stated the resident was assisted to a wheelchair (WC) to rest. During a continued interview on the above date and time, the DPT stated ninety-five percent of the time staff were required to use gait belts to walk residents. She stated rehabilitation staff, including the OTs, should have been using a gait belt with Resident 1 at all times, especially since he had been dizzy. The DPT stated the OT should have been aware of Resident 1's LBP on 11/10/16 by reading DPT's PT notes dated 11/10/16. Review of a narrative progress note dated 11/11/16 authored by occupational therapist A (OT A) indicated Resident 1 consented to OT treatment and wanted to walk outside of his room. The note indicated the resident agreed to use his front wheeled walker (FWW, a tool for people who need additional support walking) as he had had an episode of LBP on 11/10/16 during PT. OT A stated the resident walked out of his room and complained of feeling woozy (dizzy). It indicated OT A asked staff for a WC after the resident was stabilized against the wall, however the resident fell on his left side. The note indicated nursing staff arrived and the resident stated he was able to get up. The resident stood up and was transferred to the wheelchair with moderate assistance of two registered nurses (RNs) and OT. During an interview on 12/5/16 at 9:50 a.m. with OT A, she stated she walked the resident out of his room using his FWW. Resident 1 complained of feeling woozy and asked for a WC. OT A stated she stabilized the resident against the wall outside his room and was trying to hold him by his waist. He fell to the floor on his left side. There was a WC in the hallway for him in case he got dizzy, but it was not in a reachable area near the resident. Staff arrived to assist, and OT A assisted the resident to the WC. She stated when the resident was walking with her she was guiding him with her hand on his waist at his side. During a continued interview on the above date and time with OT A, she stated the WC should have been within reaching distance of Resident 1, but it was not. She was aware the resident had [MEDICAL CONDITION] (LBP) and during the resident's OT treatment on 11/10/16, OT A had been holding on to the WC while walking with the resident. During a continued interview on the above date and time with OT A, she stated she did not use a gait belt with Resident 1 when walking with him. She stated she only used one if the resident was a two-person transfer or when the resident had a balance deficit. She stated Resident 1's LBP was a balance deficit and she probably should have used a gait belt. During an interview on 12/5/16 at 11:17 a.m. with OT A, she stated she had read the previous day's PT note authored by DPT, indicating Resident 1 had LBP. She stated maybe she should have withheld his treatment on 11/11/16, or given him treatment while he remained in bed. During an interview on 12/5/16 at 11:30 a.m. with Resident 1, he stated he had a fall on 11/11/16 while walking with OT. He stated he continued to be in a lot of pain, and he stated he has had severe back pain ever since his fall. Review of a physician's progress noted dated 11/18/16 indicated Resident 1 had a fall with OT after feeling lightheaded and having labile (unstable) BPs. The back pain was new and an MRI of the spine was ordered. A physician's orders [REDACTED]. Review on 12/5/16 of Resident 1's MRI dated 11/25/16 indicated he had an acute compression fracture (force downward on a vertebra (backbone)) of the superior L1 (lumbar) endplate (top of vertebrae) of L2 with minimal loss of vertebral body height. (Height loss is an indicator for the presence of vertebral fractures). Review of a physician's orders [REDACTED]. Review of a [MEDICAL CONDITION] Drug Record dated 11/11/16 through 12/4/16 indicated Resident 1 had received [MEDICATION NAME] for back pain two to four times daily since his fall for moderately strong to severe pain levels (pain levels documented were mostly between 6 and 9 on the pain scale). A pain scale is a rating of pain on a scale of 1 to 10 with 0 being no pain and 10 being the worst pain one can imagine. Review of the POS [REDACTED] BP taken after the fall was 90/57 mm/Hg. A BP lower than 90/60 mm/Hg indicated a LBP. The pain assessment indicated the resident had moderate aching back pain with a pain scale of 6 after the fall. Review of the Standards of Practice for Occupational Therapy (http://AOTA.org terms) indicated an occupational therapist is responsible for all aspects of occupational therapy service delivery, and is accountable for the safety and effectiveness of the occupational therapy service delivery process. Review of the facility's 11/10/2009 policy, OCCUPATIONAL THERAPY SCOPE OF SERVICES indicated Clinical interventions by OT services include, Evaluation and re-evaluation of the patient's level of function. Review of the facility's 11/17/2009 policy, OT Progress Notes indicated daily documentation, including a narrative note, will be reviewed from any previous treatment.