Every finding on record at Yucaipa Hills Post Acute

Based on observation, interview, and record review, the facility failed to assess the use of a respiratory equipment for one of three sampled residents (Resident 1) when an incentive spirometer (a handled device used to encourage deep breathing and to keep the lung expand) remained at Resident 1's bedside without a physician's order for continued use, documented assessment or documented resident and family education. This failure had the potential for Resident 1 to use the device incorrectly, placing her at risk for atelectasis (collapse of small air sacs in the lungs) retained respiratory secretions, and pneumonia (an infection that makes it harder to breathed). Findings: During a review of Resident 1's admission Record (contains demographic and clinical information), it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (long - term condition in which the lungs cannot provide enough oxygen to the body, requiring supplemental oxygen), chronic obstructive pulmonary disease (COPD- a chronic lung disease that makes it difficult to move air in and out of the lungs causing shortness of breath and increasing the risk of lung infections) and obstructive sleep apnea (a condition in which breathing stops and starts during sleep because the airway becomes blocked) During an observation on July 15, 2026, at 10:55 a.m., in Resident 1's room, Resident 1 was lying in bed with the head of the bed slightly elevated. Resident 1's eyes were closed and appeared to be sleeping. Resident 1 was receiving oxygen at 4 Liters (the prescribed amount of oxygen delivered through the nasal cannula each minute to help the resident breathe and maintain adequate oxygen levels) per minute via nasal cannula (a plastic clear tube through her nose). Resident 1's husband was present at the bedside. During further observation, inside Resident 1's room, at the right side of her bed was a nightstand. On top of her nightstand were the following devices: i. Oxygen concentrator (a machine that takes air from the room and delivers oxygen to help a person breathe)ii. Nebulizer (a device that turns liquid medication into a fine mist so it can be inhaled into the lungs) iii. CPAP (Continuous Positive Airway Pressure - a machine that delivers continuous air pressure through a mask to keep the airway open and help the resident breathe, during sleep) iv. Incentive spirometer (a handheld device used to encourage deep breathing and help keep the lungs expanded to reduce the risk of lung complication) During an interview with Resident 1's husband, on July 15, 2026, at 10:56 a.m., Resident 1's husband stated the incentive spirometer had remained at the resident's bedside during her stay at the facility. He stated neither he nor the resident had been instructed on how to use the incentive spirometer or informed of its purpose. The husband stated he had not observed nursing staff or any other staff encouraging the resident to use the device. During a concurrent observation and interview with License Vocational Nurse (LVN 1), on July 15, 2026, at 11:15 a.m., LVN 1 confirmed an incentive spirometer at Resident 1's room and stated its purpose was to expand the lungs and help prevent pneumonia. LVN 1 stated residents were generally encouraged to use the device every one to two hours while awake. LVN 1 further stated the Respiratory Therapist (RT) was generally responsible for providing education regarding the incentive spirometer; however, if RT was unavailable, licensed nursing staff may also provide the education. LVN 1 further stated she could not identify who had instructed Resident 1 or the resident's husband regarding its use or where resident education or use of the device was documented. During a review of Resident 1's [Name of Acute Hospital] - Discharge Summary dated June 17, 2026, indicated, more dyspnea (shortness of breath) 6/12/26, CXR (Chest x-ray- imaging test that creates black-and-white pictures) rpt (repeat), continue to monitor, incentive spirometry (a handheld breathing device that encourages slow, deep breaths to help expand the lungs, improve breathing, and reduce the risk of complications such as pneumonia). During a review of Resident 1's clinical record, there was no documented evidence to indicate the incentive spirometer had a physician order confirming continued use, documented assessment or documented resident and family education. During a telephone interview with the Director of Nursing (DON), on July 24, 2026, at 8:32 a.m., the DON stated the facility did not immediately refer Resident 1 to Respiratory Therapy because the nursing staff believed the resident's respiratory condition remained stable with oxygen therapy. The DON acknowledged Resident 1's husband's concern regarding the reported lack of instruction for the use of the incentive spirometer. During a telephone interview on August 5, 2026, at 8:54 AM, the DON acknowledged that Resident 1's clinical record did not contain a physician's order or clarification to continue or discontinue incentive spirometry, or documentation that the resident or her husband received instructions on its use. The DON acknowledged that the facility did not follow their Incentive Spirometry policy. During a review of the facility's policy and procedure titled Incentive Spirometry, dated revised January 16, 2026, the policy indicated, It is the policy of this facility that an incentive spirometry device may be used by a resident to assist with maximal lung ventilation. Obtain a physician's order for initiation of incentive spirometry.,2. Explain procedure to the resident stressing the importance of performing this exercise regularly for optimal effect. 5. instruct the resident to insert the mouthpiece in his/her mouth and to close lips tightly around it. 6.Instruct the resident to exhale normally and then inhale slowly and as deep as possible. If the resident has difficulty with this step, tell him/her to suck, as he/she would do through a straw, but to do it more slowly., 8.Evaluate the resident's ability to cough effectively and encourage him/her to cough after each effort. Observe any expectorated secretions., 13. Record treatment in the medical record may include resident teaching, resident condition before and after treatment, tolerance of procedure and/or progress made with the device.

Based on observation, interview, and record review, the facility failed to ensure one of two crash carts (a wheeled cart carrying emergency equipment and medications for use in case of emergency) were checked and documented daily by staff as per facility's policy and procedure (P&P) titled, Emergency Medical supplies and equipment when the crash cart in the upper unit (CCUU) was not checked and documented. This failure had the potential to cause delay in availability and functionality of emergency equipment and medications in case of an emergency which will impact the health and safety of all residents in the facility.Findings:During a concurrent observation and interview on January 7,2026, at 11:00 AM, with Infection Preventionist nurse (IP), the facility's crash cart in the upper unit (CCUU) was checked and observed to have missing signatures for the following dates:July 1, 2025, through July 31, 2025 (31 days on night shift were missing signatures)August 6, 2025, and August 7, 2025 (2 days on night shift were missing signatures)August 15, 2025 (PM shift was missing signature)August 13, 20, 21, 26, and 27, 2025 (5 days on AM and PM shifts were missing signatures)September 5, 6, 11, 12, 17, 25, 30, 2025 (7 days AM and PM shifts missing signatures)September 18, 2025 (missing signatures on 3 shifts)September 19, 2025 (night shift was missing signatures)October 1, 2, 3, 8, 9, 15, 16, 17, 22, 23, 29, 30, and 31, 2025 (13 days on AM and PM shifts missing signatures)October 13 and 14, 2025 (2 days were missing night shift signatures)November 31, 2025 (AM and PM shift were missing signatures)December 4, 2025 supplies were not checked in the crash cart.The IP stated, the staff are required to check the crash cart each shift and sign the log. The IP acknowledged that there were multiple shifts had missing signatures indicating that the crash cart in the upper unit (CCUU) was not checked or inspected.During an interview on January 7, 2026, at 11:30 AM, with Director of Nursing (DON), the DON stated, The licensed staff are educated to check the crash cart every shift and sign the log. The DON further stated, There is no specific policy for crash cart in the facility. The DON acknowledged that there are missing signatures in multiple shifts.During a concurrent interview and record review on January 8, 2026, at 1:40 PM, with DON, facility's P&P titled, Emergency Medical Supplies and equipment, undated, was reviewed. The P&P indicates, Policy: It is the policy of this facility to maintain an adequate inventory of emergency medical supplies and equipment all times. Procedures:.4. Supplies/equipment are checked daily and as necessary/appropriate. The DON stated, the policy was not followed as we are missing signatures.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for Foods brought by family/visitors when one of 6 sampled residents (Resident 47) reviewed for nutrition received food from a visitor of another resident. This failure had the potential to compromise dietary compliance and risk Resident 47's health and nutritional needsFindings:During an observation on January 7, 2026, at 12:45 PM, in activity/dining room, Resident 47 was sitting on table one with other residents . One of the resident's (Resident 19) wife (not a resident in the facility/visitor) brought snacks including potato chips, marshmallows, a packet of hot [NAME] powder (a package of powder which contains chocolate and sugar and can be mixed with water or milk to make hot chocolate) were handed by the visitor to Resident 47. Resident 47 opened the packet and put some powder on his desert, and swallowed the remaining powder directly. It was also observed that the visitor was offering potato chips to resident 47.During a concurrent observation and interview on January 7, 2026, at 1:00 PM, with Director of Nursing (DON), the meal tray for Resident 47 had an open and empty package of [NAME] powder packet. The DON stated, that the [NAME] powder did not come with the meal tray.During an interview on January 7, 2026, at 1:05 PM, with Director of Activities (DA), the DA stated that Resident 19's visitor comes to the facility every day during lunch time.During a review of Resident 47's admission Record (demographic data), the admission Record indicates, Resident 47 was admitted to the facility on [DATE], with the diagnosis of Traumatic brain injury (injury to the brain caused by force), type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol in blood), hypertension (high blood pressure).During a review of Resident 47's document titled, order summary report, dated October 8, 2025, the order summary report indicated, Resident 47's diet order was consistent Carbohydrate Diet(CCHO- a diet ordered for a diabetic patient with controlled carbohydrate to regulate blood sugar) with thin consistency. Resident 47 also had orders for Glipizide oral tablet (a medication for the treatment of blood sugar) 10 mg (milli gram- a unit of measurement) 1 tablet (a form of medication) by mouth two times a day for diabetes mellitus and Metformin HCL (hydrochloride- an acid salt form from an organic base for treatment of diabetes mellitus) 1000 mg ,1 tablet by mouth two times a day for diabetes mellitus.During a review of Resident 47's document titled, Care Plan Report, dated October 10, 2025, the care plan report indicated, Resident 47's Diet changes should be made and evaluated by a registered dietician.During a concurrent interview and record review on January 8, 2026, at 1:30 PM, with DON, the facility's Policy and Procedure (P&P) titled, Foods brought by family/Visitors, undated, was reviewed. The P&P indicated, Policy statement Foods brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a home-like environment with nutritional and safety needs of the residents. Policy interpretation and implementation.2. Foods brought by family/visitors for individual residents are not shared with or distributed to other residents. The DON stated, that it is expected not to share outside food with other residents. The DON acknowledged that the policy was not followed.

Based on observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, Oxygen Administration, for one out of one sampled resident (Resident 7) when oxygen was not administered according to the physician's order. This failure had the potential to compromise Resident 7's respiratory status which would risk resident 7's health and well-being.Findings:During a concurrent observation, and interview, on January 6, 2026,at 10:26 AM, with Infection Preventionist Nurse(IP) in Resident 7's room, Resident 7 was lying on bed with eyes closed. Resident 7 had nasal canula (a clear plastic tube through which the oxygen is delivered to the nostrils) which was connected to oxygen on her face but the nose piece (the opening where the oxygen is delivered to the patient) was away from Resident 7's nostrils. The IP stated, the oxygen was not on Resident 7's nose and she might have pulled that out. The IP acknowledged that nurses are responsible for checking the placement and delivery of oxygen to the residents.During a concurrent observation and interview on January 6,2026, at 10:30 AM, with Licensed Vocational Nurse 2 (LVN 2), the LVN 2 checked the oxygen saturation (amount of oxygen in the blood) for Resident 7 and was noted as 89 (less than normal) percentage (unit of measurement for gases). The LVN 2 stated, Resident 7 was ordered for continuous oxygen therapy as per physician.During a review of Resident 7's document titled, admission Record (demographic data), the admission Record indicates, Resident 7 was re admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure (a condition in which lungs are unable to get enough oxygen from blood and remove carbon dioxide).During a review of Resident 7's document titled, order summary report, dated September 29, 2025, the order summary report indicates, Resident 7 has the order for continuous oxygen of 2 to 5 liters per minute by nasal canula to maintain an oxygen saturation at 92 percentage.During a concurrent interview and record review on January 8, 2026, at 1:35 PM, with the Director of Nursing (DON), the facility's P&P titled, Oxygen Administration, undated, was reviewed. The P&P indicated, Policy: it is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can obtained. The DON stated, that it was a miss, and the nurses should have checked her. The DON further stated, that the policy was not followed.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when there was visible accumulation of grime and debris within an actively used oven and the continued presence of a non-functional refrigerator in the food preparation area. This failure had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents, which could place the health and safety of 81 highly vulnerable residents who receive food from the kitchen at risk.Findings:During a concurrent observation on January 5, 2026, at 7:57 AM, with the Dietary Supervisor (DS), an initial tour of the kitchen was conducted. A non-functional refrigerator, labeled out of order was observed in the kitchen food preparation area. The DS stated, the refrigerator had been non-operational for approximately two weeks and was not being used. The refrigerator continued to take up space in the kitchen and had not been relocated to another area.During a concurrent observation on January 5, 2026, at 8:02 AM, with the DS, an oven was observed to have visible accumulation of grease and debris trapped between the glass panels. The DS stated, the oven was actively used for resident meal preparation and the kitchen staff cleaned equipment regularly. However, staff were unable to access the area between the glass panels for cleaning. The DS further stated, maintenance had attempted to remove the glad panels but was unable to do so.During a concurrent interview and record review on January 6, 2026, at 3:20 PM, with the DS, the facility policy and procedure (P&P) titled, Ranges and Ovens, revised in 2023, was reviewed. The policy indicated, .Ovens .Cleaning Procedure: .5. Clean the exterior of the oven according to manufacturer's instructions. The DS confirmed she was responsible for overall kitchen cleanliness, including the oven, and acknowledged the oven should not have visible buildup. The DS stated, the facility did not follow policy for cleaning ovens, and did not refer to manufacturer instructions.During a further interview on January 6, 2026, at 3:28 PM, with the DS, the DS stated, the non-operational refrigerator should not remain in the kitchen. The expectation is that non-functioning equipment should be removed immediately.During an interview on January 6, 2026, at 3:32 PM, with the Maintenance Director (DOM), the DOM confirmed he was aware of the oven condition, and that it had visible grime and debris for an extended period of time. The DOM further stated, manufacturer guidance had not been reviewed. The DOM also stated, the non-functional refrigerator should not remain in the kitchen and the expectation was to have it removed immediately.During a concurrent interview and record review on January 6, 2026, at 3:56 PM, with the Administrator (Admin), the following facility P&Ps were reviewed: Ranges and Ovens, revised in 2023, and Sanitation, revised in 2023. The P&P, Ranges and Ovens, indicated, .Ovens .Cleaning Procedure: .5. Clean the exterior of the oven according to manufacturer's instructions. The P&P, Sanitation, indicated, .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over stove, which will be cleaned by the maintenance staff . The Admin confirmed facility policy requires kitchen equipment to be maintained in a clean and sanitary condition, and the unused refrigerator should not have remained in the kitchen once it was no longer functional. Admin further stated, the facility did not follow both policies.During a review of the US FDA (United States Food and Drug Administration) Federal Food Code, dated 2022, section 6-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch .The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The FDA Food Code, Section 4-601.11, further indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control practices for one of 18 sampled residents (Resident 6) when an indwelling urinary catheter (Foley-a tube that stays inside the bladder to drain the urine into a bag) drainage bag was observed resting on the floor.This failure had the potential to promote the transmission of infection by allowing contamination of the urinary catheter drainage system and increasing the risk of urinary tract infection. Findings: A review of Resident 6's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 6 was admitted on [DATE] with diagnoses which included urinary tract infection (UTI-an infection in the bladder or urinary system that can cause pain, burning, frequent urination, fever or confusion), neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder do not work properly, making it difficult to urinate or causing leakage), and dementia (a condition that affects the brain, making it difficult to think, remember, and make decisions).A review of Resident 6's Physician's Order dated November 18, 2025, indicated, Indwelling catheter.to closed drainage bag, may change as needed for leaking, dislodged [moved out of place] or clogged.A review of Physician Order dated November 20, 2025, indicated, Foley catheter care every shift for catheter management.During a concurrent observation and interview on January 5, 2026, at 9:30 AM with the Director of Nursing (DON) in Resident 6's room, the foley catheter bag was observed resting on the floor. The DON stated that the nursing staff should have hung the catheter on the bed and it should not be on the floor.During an interview on January 7, 2026, at 11:17 AM, with the Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated both the Certified Nursing Assistants (CNAs) and LVNs are in charge of the foley care. LVN 1 further stated, the foley bag should hanging on the side of the bed and it is never acceptable to find the bag on the floor.During a concurrent interview and record review on January 7, 2026, at 11:30 AM, with the DON, the facility's policy and procedures (P&P) titled, Catheter Care, Indwelling, dated January 2025 indicated, Purpose: to promote hygiene, comfort and decrease risk of infection for catheterized residents.12. Keep tubing below level of the bladder. The DON stated that the nursing staff did not follow the policy and noted that it is not acceptable for the bag to be on the floor for infection control purposes.During an interview on January 8, 2026, at 9:14 AM with the Infection Preventionist (IP), the IP stated that the foley bag should not touch the floor as it can cause back flow into the bladder and increase the risk of bacteria.

Based on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident.This failure had the potential to negatively impact resident comfort, dignity, and safety by limiting adequate space for movement, equipment placement and staff assistance of four residents (Resident 1, 27, 35, and 57) who reside in the two rooms.Findings:During an interview on January 5, 2026, at 8:28 AM with the Director of nursing (DON) and the Administrator (Admin) the admin stated, the facility had two rooms (rooms [ROOM NUMBERS]) that were smaller than the required 80 Sq feet. The Admin stated they did not have any type of waiver variance for the room size.During an observation on January 5, 2025, at 9:32 AM, in room [ROOM NUMBER], no residents were currently in the room. The room was free of clutter, no concerns with the beds, bedside table, and the room was wheelchair accessible.During a concurrent observation and interview on January 5, 2025, at 10:19 AM with the residents (Resident 1 and 35) in room [ROOM NUMBER] the following was observed:Bed 11 A was occupied by Resident 35, who was observed resting comfortably in bed. Resident 35 did not verbalize any concerns with the room size. There were no concern with the beds, bedside tables, and wheelchairs which are accessible to the room.Bed 11 B was occupied by Resident 1 who was observed resting comfortably in bed watching television. Resident 1 did not verbalize any concerns with the room size. There were no concerns with the beds, bedside tables and wheelchairs which are accessible to the room.During an observation and interview on January 5, 2025, at 12:01 PM in the dining room, Resident 57 who is staying in room [ROOM NUMBER] A was seen in a wheelchair waiting for lunch. Resident 57 did not verbalize any concerns with the room size.During an observation and interview on January 5, 2025, at 12:07 PM in the dining room, Resident 27 who is staying in room [ROOM NUMBER] B was seen in a wheelchair waiting for lunch. Resident 27 did not verbalize any concerns with the room size.During a concurrent observation and interview on January 5, 2025, with the Maintenance Director (DOM) during an environmental tour of rooms [ROOM NUMBERS], the following measurements were noted as follows:1. room [ROOM NUMBER] measured 12 feet (Ft. -unit of measurement) 10 inches (In.-unit of measurement) x (by) 11 feet 1 inches = (equals) 142.24 SQ Ft. total (71.12 SQ Ft per resident). The DOM verified that room [ROOM NUMBER] did not have the required 80 Sq Ft of space for each resident.2. room [ROOM NUMBER] measures 12 Ft. 9 In. x 11 Ft. 1 in. = 142.38 Sq Ft. total (71.19 SQ Ft per resident). The DOM verified that room [ROOM NUMBER] did not have the required 80 SQ Ft of space for each resident.During the course of the survey, room [ROOM NUMBER] and 11 were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.

Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1) when Resident 1, a resident who was at high risk for falls and fully dependent upon staff for mobility while in bed, fell from his bed while being changed by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 to sustain a head injury which included a bleeding laceration to his right eyebrow and a subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it). Findings: During a review of Resident 1's Admission Record (contains medical and demographic information), the record indicated Resident 1 was admitted on [DATE], with diagnoses which included cerebral palsy (neurological disorder that causes permanent problems with movement, balance, and posture), parkinson's disease (a disorder of the central nervous system that affects movement), disorders of bone density and structure (medical conditions that affect the strength and composition of bones which can significantly impact bone structure and increase fracture risk), and epilepsy (a brain disorder that causes recurring, unprovoked seizures). During an interview on November 4, 2024, at 3:25 PM, with the Director of Nursing (DON), the DON stated on October 18, 2024, Resident 1 fell off his bed when CNA 1, who was a contracted registry staff member (an employee provided by a contracted staffing agency), turned the resident away from her (rolled the resident towards the opposite side of the bed from which the CNA was standing) when cleaning up the resident's bowel movement. During a continued interview on November 4, 2024, at 3:35 PM, with the DON, the DON stated CNA 1 should have had another staff member assist with turning the resident in bed since the resident had contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The DON further stated as a result of the fall, Resident 1 sustained an abrasion to his right eyebrow and was subsequently sent to the hospital where it was identified that the resident also had a subarachnoid hematoma. During a review of Resident 1's Minimum Data Set assessment (MDS - a computerized resident assessment tool), dated October 18, 2024, the MDS assessment indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 1 (score of 0-7 is severe cognitive impairment). During a further review of Resident 1's MDS assessment, dated October 18, 2024, section GG (section regarding functional abilities), indicated for rolling left and right in bed, Resident 1 was dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 [two] or more helpers is required for the resident to complete the activity. During a review of Resident 1's fall assessment titled, Fall Risk Assessment, (a scored assessment of Resident 1's fall risk) dated October 20, 2024, the fall risk assessment indicated Resident 1 was identified to be at high-risk for falls, with a score of 14. The document further indicated, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . During a review of Resident 1's care plan (an individualized plan for the medical care of a resident) (untitled), dated April 14, 2023, the care plan indicated, [Name of Resident 1] is high risk for falls r/t [related to] confusion .balance problems, incontinence [involuntary loss of bowel or bladder control], poor communication/comprehension, psychoactive drug use [A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior], unaware of safety needs .goal the resident will be free of falls through the review date . interventions included, Anticipate and meet the resident's needs .follow facility fall protocol. During a review of the written statement from CNA 1, dated October 18, 2024, the statement indicated, at approx. [approximately] 5:30-5:40 [AM] I was providing patient care to [Name of Resident 1] who had BM and urine spillage since his previous brief was shifted while wiping and cleaning mattress I had patient turned facing the door when patient fell off the bed that was about mid-thigh height. I imeddiately [sic] notified nurse and put patient back on mattress. Patient hit his face on floor resulting in cut to the side of his eye. CNA 1 was not available for interview. During a review of Resident 1's hospital paperwork from [name of Hospital] the document titled, History of Present Illness, dated October 18, 2024 indicated, BIBA [brought in by ambulance] from care facility for evaluation s/p [status post] fall that occurred this morning .CT head shows small subarachnoid hemorrhage along the bilateral bifrontal sulci [portion of the frontal lobe of the brain] .Condition: serious . During a review of the facility's policy and procedure (P&P) titled, Fall Prevention, dated December 2023, the P&P indicated, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury .

An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024, at 4:53 PM, regarding the elopement of Resident 27 from the facility on October 16, 2024. An IJ was called in the presence of the Administrator. A corrective action plan was requested on October 16, 2024, at 4:53 PM. The immediate Jeopardy was removed after the corrective action plan was verified to be implemented through observations interviews, and record reviews on October 17, 2024, at 2:46 PM in the presence of the Administrator. Free of Accident Hazards / Supervision/Devices CFR (s): 483.25(d)(2)(2) S483.25 (d) Accidents. The facility must ensure that. S483.25(d)(1) The resident environment remains as free of accidents hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide supervision to one of 36 residents (Resident 27) in the locked memory care unit (a locked unit which is a secure area within the skilled nursing facility where people with dementia live. The locked unit prevents the residents from wandering off or leaving the facility willingly) on October 16, 2024, when staff was unaware Resident 27 (a confused resident with cognitive deficit and a history of falls) had left the facility. It was not until Surveyor 1 (a member of a survey team not employed by the facility) informed facility staff that the resident had eloped (the act of leaving the premises or safe area without authorization or supervision to do so) and was in a field adjacent to the facility building. This failure had the potential to result in serious harm or death to Resident 27 who was at risk for injuries which may occur as a result of being exposed to environmental elements, accident hazards or being without resources such as food, water and shelter. Findings: During a review of Resident 27's clinical record, the Admission Record (contains medical and demographic information), it indicated Resident 27 was initially admitted to the facility on [DATE], with diagnoses which included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, that interferes with daily life), encephalopathy (any brain disease, disorder, or damage that affects the brain's structure or function), altered mental status, fall on or from other stairs and steps [subsequent encounter], unsteadiness on feet, and hemiplegia (paralysis on one side of the body). During a review of Resident 27's Minimum data set (MDS - an assessment of a residents functional and health status), dated August 19, 2024, section GG0115 indicated Resident 27 had lower extremity impairment on both sides (impairment in both legs) in section, Functional Limitation in Range of Motion -code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days . Further review of Resident 27's MDS dated [DATE], indicated the type of assistance the resident required for walking 10 feet included, supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance [caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task] as resident completes activity . During a review of Resident 27's Interdisciplinary Team Note (IDT - A group of professionals from different disciplines that work together to meet the needs of residents using their different perspectives and expertise.), dated October 16, 2024, the IDT note indicated Resident 27 had .confusion and disorientation secondary to diagnosis of dementia. His BIMS score [Brief Interview for Mental Status score - a score of 0-15 used to determine cognitive functioning] is 6 [severe impairment] and does not have the capacity to make decisions . During a review of Resident 27's Physical Therapy PT Evaluation & Plan of Treatment, with a certification period of July 30, 2024, through August 28, 2024, the physical therapy evaluation indicated, .Reason for referral/current illness: Patient referred to PT [physical therapy] due to new onset of decrease in functional mobility, falls/fall risk and increased need for assistance from others .PMHX [past medical history] Pt [patient] .change in function post fall with facial bruising .hx [history] of fall at home with difficulty walking and encephalopathy . and decreased cognition . Further review of the Physical Therapy PT Evaluation & Plan of Treatment, indicated the resident had impaired functioning in his left and right hip, knee, and ankle and his Safety Awareness was impaired. During a review of Resident 27's care plan (an individualized plan for the medical care of a resident), titled, [name of Resident 27] has hesitancy to ambulate [walk] and unsteady shuffling gait which limits physical mobility, dated September 9, 2024, the care plan indicated, .Goal .will remain free of complications related to immobility, including .fall related injury through the next review date .will maintain current level of mobility 2 person assist for 15 ft [feet] through review date .Interventions - Provide supportive care, assistance with mobility as needed . During an observation on October 16, 2024, at 11:08 AM, Resident 27 was observed by Surveyor 1 to be walking unassisted in a field behind the facility's parking lot. There was no staff nearby or within eyesight of the resident. During an interview on October 16, 2024, at 11:11 AM, the Administrator (ADMIN) was informed by Surveyor 1 that Resident 27 was in a field next to the parking lot and was unaccompanied by staff. During an interview on October 16, 2024, at 12:15 PM, with the ADMIN, the ADMIN stated supervision in the locked memory care unit included a supervising Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs) with a one to 10 ratio (1 CNA per 10 residents). The ADMIN further stated on October 16, 2024, it was a surveyor (Surveyor 1) who initially informed him that Resident 27 had left the facility and was in a field. The ADMIN stated facility staff were unaware Resident 27 had left the facility prior to notification from the surveyor. The ADMIN stated he believed Resident 27 had exited out the facility door (which led to the outside) at the far end of a hallway, within the locked memory care unit, and then jumped over a locked gate. Upon being brought back into the facility by staff, the ADMIN stated Resident 27 told him he had jumped over the locked gate. The ADMIN further stated the facility exterior door remained unlocked, but the gate was locked with a keypad code that staff would enter and exit the facility through to gain access to the laundry room and garbage dumpster. When asked if the facility exterior door had an audible alarm to indicate the door had been opened, the ADMIN stated the door had not been alarmed since he started working at the facility within the last three years. During an interview on October 16, 2024, at 12:26 PM, with Certified Nursing Assistant 1 (CNA 1) stated on October 16, 2024, he was at lunch when he received a phone call at 11:13 AM from CNA 2 informing him Resident 27 had left the facility building and was in a field. CNA 1 further stated there was supposed to be at least one CNA stationed in each of the two halls in the memory care unit to provide supervision to the residents. CNA 1 stated he informed CNA 2 and a charge nurse that he was going to lunch, and it was CNA 2 who was supposed to be supervising residents while he was at lunch at the time Resident 27 eloped. CNA 1 stated the door leading to the exterior of the building (in the hall in which Resident 27 allegedly eloped from), used to have an alarm in the past but did not any longer. During an interview on October 16, 2024, at 12:43 PM, with CNA 2, CNA 2 stated the memory care unit (two total hallways) was supposed to have at least one CNA supervising each hallway. CNA 2 further stated there was usually four CNAs assigned to the memory care unit (2 for each hallway), but at the time Resident 27 had eloped, the two CNAs (CNA 1 and CNA 4) assigned to the hallway where Resident 27's room was located and where the door Resident 27 used to go outside was also located, were at lunch at the same time. CNA 2 stated she was assigned to the other hallway but was tasked with supervising both hallways. When asked where CNA 3 was (the third of four CNAs assigned to the memory care unit), CNA 1 stated CNA 3 was in the activity room (located in the memory care unit) and that CNA 3 was supposed to be helping her supervise the residents but did not know why CNA 3 was in the activity room instead. CNA 2 stated she also saw Licensed Vocational Nurse 1 (LVN 1) at the nurses' station in the memory care unit. During an interview on October 16, 2024, at 1:07 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there were four CNAs assigned to the memory care unit to supervise residents. LVN 1 further stated the CNA's in the halls were supposed to take lunch opposite each other so there was one CNA at a time taking a lunch from each hallway. This would leave one CNA in each hallway to supervise residents. LVN 1 stated she was just covering the lower dementia [locked memory care unit] unit as extra eyes while LVN 2 was at lunch. LVN 1 further stated she was aware CNA 1 was on lunch but didn't know if any of the other CNAs were on lunch or break. LVN 1 stated she saw CNA 2 supervising the hallways but didn't see any other CNAs in the hallways. LVN 1 stated she was aware CNA 3 was providing supervision to residents in the activity room. LVN 1 stated LVN 2 came back from her lunch at approximately 11:05 AM and she (LVN 1) then went to lunch while LVN 2 went to go check a resident's blood sugar (test to determine the level of sugar in the blood) in a resident's room. During an interview on October 16, 2024, at 1:30 PM, with LVN 2, LVN 2 stated she came back from lunch and at the time Resident 27 eloped, she was doing a blood sugar check on a resident in the resident's room. LVN 2 further stated she knew CNA 1 was supervising the halls but did not know where CNA 4 was. During an interview on October 16, 2024, at 1:39 PM, with CNA 3, CNA 3 stated she was supervising the hallways earlier in the day but was asked by an activities staff member to come and help provide supervision in the activities room because there was more than 10 residents in the activity room and they needed more than 1 staff member to provide supervision. CNA 3 further stated she was aware CNA 1 and CNA 4 were on lunch which meant there was only her and CNA 2 left to supervise the hallways but stated she (CNA 3) could only be in one place at a time so she decided to go to the activity room to help the activities staff member. CNA 3 stated after approximately 20-30 minutes of being in the activity room, she was walking back to the hallway from the activity room when she was made aware Resident 27 had eloped. During a concurrent observation and interview on October 16, 2024, at 5:24 PM, with Resident 27, Resident 27 was observed to be in his room which was located immediately adjacent to a facility exit door located at the end of the hallway where there was a locked gate upon exiting the building. Resident 27 was alert and oriented x (times) 1 (one) (oriented to person but not oriented to place, time, or situation). Resident 27 stated he didn't know where he was, what day or month it was and stated he thought he was on TV during our discussion. Resident 27 was unable to answer if he recalled if or how he left the facility. During an interview on October 18, 2024, at 9:59 AM, with the Director of Staff Development (DSD), the DSD stated the staffing schedule (in use at the time Resident 27 eloped) did not indicate who was supposed to cover each hallway during staff breaks and lunches and it was facility practice to ensure verbally with each other that there was someone in each hallway to supervise residents. During a review of the facility's policy and procedure (P&P) titled, Elopement/Unsafe Wandering, dated December 2023, the P&P indicated, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement .Elopement is when a resident leaves the facility premises or a safe area without authorization (i.e. [for example] an order for discharge or leave of absence) and/or any necessary supervision to do so . An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024 at 4:53 PM, after it was determined that Resident 27 did not receive supervision and monitoring required to keep the resident safe on October 16, 2024, when the resident was found to have eloped from the facility and was found by a surveyor in a field behind the facility's parking lot. The IJ was called in the presence of the Administrator (ADMIN). A Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on October 17, 2024, at 12:48 PM and included the following: - On October 16, 2024, upon notification of incident, Resident 27 was assessed by the Director of Nursing (DON) and a physician. Body assessment was done with no apparent injury. The attending physician ordered Complete Blood Count (CBC - blood tests), Complete Metabolic Panel (CMP-blood tests) and Urinalysis with culture and sensitivity (urine tests) STAT (immediately). - Resident 27 was placed on 72-hour change of condition (change in a resident's health or functioning that can be short-term or significant) monitoring and 1:1 (one on one) supervision with closed visual check. No change was noted related to incident. - On October 16, 2024, the Facility Administrator installed a functional audio alarm system on all exit doors in the lower unit. - All exterior doors in the lower/Memory care unit will be checked every 15 minutes by a designated staff for the next 30 days along with the installation of alarm system. - Director of Nursing and designees evaluated 80 residents' elopement and wandering risk on October 16, 2024, to identify any residents that were at high risk for elopement and wandering. No other residents were affected. - Director of Nursing and designees ensured that identification of all 80 residents was in place such as wrist bands and or photo on the electronic medical record (PCC) on October 16, 2024. All residents had a wrist band and/or photos were uploaded in PCC. - Facility staff received an in-service and training from the Director of Staff Development (DSD) on October 16, 2024, regarding Policy and Procedure Incident/Accident with emphasis with Elopement/Wandering Incidents. In-services will continue October 17, 2024, and will be given to all staff before the beginning of their next shift. - Director of Staff Development initiated in-service with the Licensed Nurses and Certified Nursing Assistants on October 16, 2024, about coverage during breaks and lunch. The licensed nurse is responsible for creating the daily shift assignment form including the scheduled break and lunch time to ensure that the floor has adequate staff and supervision provided to the residents. In an event that a staff is running late for the scheduled break and lunch, it is the staff's responsibility to notify the Charge Nurse or Registered Nurse (RN) supervisor so that, if necessary, the Licensed Nurse can make the adjustment to ensure adequate supervision is provided to the residents. In-services will continue October 17, 2024 and be given to all licensed nurses and certified nursing assistants before the beginning of their next shift. - Director of Staff Development and or Charge Nurse will ensure that daily shift assignment is completed and scheduled breaks and lunch time is covered. - Administrator initiated the in-service on October 16, 2024, regarding the policy, monitoring, and maintenance alarm system in all exterior door in the lower unit. - All Exterior doors in the lower unit will be checked every 15 minutes. - Maintenance Supervisor will test the alarms weekly and will be maintained according to manufacturer guideline. - A log of maintenance and testing will be kept by the Maintenance Supervisor The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was removed on October 17, 2024, at 2:46 PM, in the presence of the Administrator.

Based on interview, and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for thirteen of thirteen residents (Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76) reviewed for residents' assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: A. During a review of Resident 54's Admission Record, (contains demographic and medical information), the Admission Record, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). During a review of Resident 54's Electronic Health Record (EHR), a quarterly MDS assessment with an ARD (specific end point of look-back periods in the MDS assessment process) date of September 7, 2024, indicated it was completed on October 10, 2024 (33 days past the ARD). During a concurrent interview and record review on October 17, 2024, at 9:47 AM, with the Resource MDS Nurse (RMN), Resident 54's MDS assessment dated [DATE], was reviewed. The RMN stated the quarterly MDS assessment dated [DATE], was supposed to be completed within 14 days of September 7, 2024, but it was not completed until October 10, 2024. The RMN further stated he did not know why it was completed late. During an interview on October 17, 2024, at 9:52 AM, with the Director of Nursing (DON), the DON stated MDS assessments were supposed to be done on time but the facility had been having difficulties filling the MDS nurse (a nurse whose primary responsibility is to perform MDS assessments and related tasks) position because the previous MDS nurse left the company and the new MDS nurse is on leave. B. During a review of Resident 55's Admission Record, the Admission Record, indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life), major depressive disorder and Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 55's Electronic Health Record (EHR), an MDS assessment with an ARD (specific end point of look-back periods in the MDS assessment process) date of September 7, 2024, indicated it was completed on October 11, 2024 (34 days past the ARD). During a concurrent interview and record review on October 17, 2024, at 9:45 AM, with the RMN, Resident 55's MDS assessment dated [DATE], was reviewed. The RMN stated the quarterly MDS assessment dated [DATE], was supposed to be completed within 14 days of September 7, 2024, but it was not completed until October 11, 2024. The RMN further stated he did not know why it was completed late. 50575 C. During a review of Resident 27's Admission Record, the Admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), and cerebral ischemia (occurs when the brain doesn't receive enough blood flow or oxygen). During an interview with Resource MDS Nurse (RMN), on October 17, 2024, at 10:22 AM, RMN stated that current Minimum Data Set Nurse (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) is out of the country due to a family emergency. RMN checked Resident 27's quarterly assessment that was done on August and MDS was transmitted for completion on October 10, 2024. He stated that he does not know why it was not turned in on time. During a continued interview and record review with RMN on October 17, 2024, at 11:25 AM, a clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, for Resident 27 was reviewed. MDS quarterly assessment record and Assessment Reference Date (ARD- specific end point of look-back periods in the MDS assessment process) date was on August 19, 2024, but it was completed on October 10,2024, which was 52 days past the ARD. He stated that he does not know why it was not turned in on time. D. During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included ( diabetes (condition that happens when your blood sugar is too high), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), and osteoarthritis (a chronic degenerative joint disease that occurs when the cartilage in a joint break down and becomes rough). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 15's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 15's MDS quarterly assessment record and (ARD) was on September 9, 2024, but it was completed on October 12,2024, which was 33 days past the ARD. He stated that he does not know why it was not turned in on time. E. During a review of Resident 35's Admission Record, the Admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), atherosclerosis of aorta (condition where plaque builds up in the walls of the aorta, the body's largest artery), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17. 2024, at 11:53 AM, with RMN, Resident 35's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 35's MDS quarterly assessment record and ARD was on September 9, 2024, but it was completed on October 14,2024, which was 35 days past the ARD. He stated that he does not know why it was not turned in on time. F. During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a disorder of the brain characterized by repeated seizures). During a concurrent interview and record review on October 17,2024, at 11:53 AM, with RMN, Resident 40's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 40's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. G. During a review of Resident 47's Admission Record, the Admission Record indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 47's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 47's MDS quarterly assessment record ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. H. During a review of Resident 49's Admission Record, the Admission Record indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 49's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 49's MDS quarterly assessment record and ARD was on August 30, 2024, but it was completed on October 12,2024, which was 43 days past the ARD. He stated that he does not know why it was not turned in on time. I. During a review of Resident 51's Admission Record, the Admission Record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review on October 17, 2024, at 11: 53 AM, with RMN, Resident 51's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 51's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. J. During a review of Resident 62's Admission Record, the Admission Record indicated Resident 62 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and diabetes (condition that happens when your blood sugar is too high). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 62's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 62's MDS quarterly assessment record and ARD was on August 24, 2024, but it was completed on October 10,2024, which was 47 days past the ARD. He stated that he does not know why it was not turned in on time. K. During a review of Resident 63's Admission Record, the Admission Record indicated Resident 63 was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (a buildup of fats, cholesterol and other substances in and on the artery walls), schizophrenia (a mental illness that is characterized by disturbances in thought), and Hodgkin lymphoma (a type of cancer that develops in the lymph system). During a concurrent interview and record review on October 17, 2024, at 11: 53 AM, with RMN, Resident 63's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 63's MDS quarterly assessment record and ARD was on August 31, 2024, but it was completed on October 12,2024, which was 42 days past the ARD. He stated that he does not know why it was not turned in on time. L. During a review of Resident 66's Admission Record, the Admission Record indicated Resident 66 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), diabetes (condition that happens when your blood sugar is too high), hypertensive heart disease (disease (problems with your heart that can develop if you have high blood pressure), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 66's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 66's MDS quarterly assessment record and ARD was on August 26, 2024, but it was completed on October 12,2024, which was 47 days past the ARD. He stated that he does not know why it was not turned in on time. M. During a review of Resident 76's Admission Record, the Admission Record indicated Resident 76 was admitted to the facility on [DATE], with diagnoses which included fracture (a break in a bone) of right lower leg, and diabetes (high blood sugar). During a concurrent interview and record review on October 17,2024, at 11: 53 AM, with RMN, of Resident 76's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 76's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 10,2024, which was 34 days past the ARD. He stated that he does not know why it was not turned in on time. During an interview with the Director of Nursing (DON) on October 17, 2024, at 3:51 PM, the DON stated the facility did not have a policy and procedure (P&P) regarding completion of the MDS assessments and the facility follows the guidelines from the RAI (Resident Assessment Instrument - helps gather definitive information on a resident's strengths and needs) manual. DON acknowledged that quarterly assessments were not submitted on time. She further stated that they don't have MDS nurse because previous MDS nurse left early of September of this year and current MDS nurse is on leave. During a review of CMS Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, version 1.18.11, the manual indicated on pages 2-35, indicated, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type.

Based on observation, interview, and record review, the facility failed to ensure one of eighteen residents (Resident 36) reviewed for advanced directives had a Physician Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) accurately completed when there was conflicting information documented regarding medical interventions. This failure had the potential for Resident 36 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the resident wanted. Findings: During a review of Resident 36's Admission Record, (contains medical and demographic information), the Admission Record indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) affecting left non-dominant side, heart failure, chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), and Chronic Obstructive Pulmonary Disease (COPD - lung disease that causes breathing problems and restricted airflow). During a review of Resident 36's POLST, signed by a clinician on [DATE], the POLST indicated in Section A, Attempt Resuscitation/CPR [cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating] . further review of Section A indicated, .selecting CPR in Section A requires selecting Full Treatment in Section B) .Section B of the POLST Medical Interventions, indicated two options; the first option was full treatment - Primary goal of prolonging life by all medically effective means .use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated . The second option was Selective Treatment - goal of treating medical conditions while avoiding burdensome measures .do not intubate .generally avoid intensive care . Of the two options, Selective Treatment was checked instead of Full Treatment as specified in Section A if Attempt/Resuscitation/CPR was selected. During a concurrent interview, and record review on [DATE], at 7:30 AM, with the Director of Nursing (DON), the DON stated if a resident wishes to have CPR/attempt resuscitation indicated in Section A of the POLST, then Section B must have full treatment checked as indicated on the instructions of the form. Resident 36's POLST was reviewed and the DON confirmed Attempt Resuscitation/CPR was checked in Section A and Section B had Selective Treatment selected. The DON stated Resident 36's POLST form needed to be clarified with the nurse who completed it. The DON further stated the POLST was supposed to be reviewed quarterly and upon admit for accuracy and completeness. The DON stated the POLST forms were important because it provides orders regarding what life sustaining treatments the resident desires. During an interview on [DATE], at 9:47 AM, with the Social Services Director (SSD), the SSD stated she was the one that completed the POLST for Resident 36, dated [DATE]. The SSD further stated she had the POLST revised by a physician today because it was not completed correctly. States the physician discussed with her the correct way to complete the POLST. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], the policy indicated, The physician Orders for Life-Sustaining Treatment (POLST) is a physician order form that complements an advance directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders. It is designed to be a statewide mechanism for an individual to communicate his or her wishes about a range of life-sustaining and resuscitative measures. It is designed to be portable, authoritative and immediately actionable physician order consistent with the individual's wishes and medical condition, which shall be honored across treatment settings .Completion of a POLST form should reflect a process of careful decision-making by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care decision maker, in consultation with the physician, about the resident's medical condition and known treatment preferences .Reviewing/Revising the POLST. 1. The POLST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference .

Based on interview, and record review, the facility failed to ensure staff reported an allegation of abuse to the required parties and in the timelines specified by the facility's policy and procedures (P&P) and as required by federal regulations. This failure resulted in an allegation of abuse to not be reported and subsequently investigated which had the potential to place Residents 36 at risk for ongoing abuse or mistreatment due to a delay in the reporting and investigation of the alleged incident. Findings: A review of Resident 36's Admission Record (contains medical and demographic information), indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis) affecting left non-dominant side, heart failure, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a condition that causes excessive feelings of fear, dread, and worry that can interfere with daily life). During a concurrent observation and interview on October 14, 2024, at 3:00 PM, with Resident 36, Resident 36 was in her bed and was watching TV. Resident 36 stated staff would sometimes tell her she uses her call light too much and would take her call light away from her and put it where she couldn't see it or access it. During an interview on October 14, 2024, at 3:03 PM, with Resident 46 (roommate of Resident 36), Resident 46 stated she had seen staff tell Resident 36 that she uses the call light too much and take her call light away. During an interview on October 14, 2024, at 3:28 PM, with the Administrator (ADMIN), the ADMIN was informed by a surveyor regarding the allegation of abuse made by Resident 36. During an interview on October 17, 2024, at 6:41 PM, with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 36 uses her call light ten to fifteen times throughout a shift and usually requires a lot of attention. CNA 6 further stated although she has not heard of Resident 36 having her call light taken away, she has heard of other residents who have told her that they had their call light taken away from them too. CNA 6 then stated she had informed her supervisor regarding the incident but could not remember who she informed. During an interview on October 17, 2024, at 7:06 PM, with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated a resident had informed her in May of 2024, that a Certified Nursing Assistant working in the facility would take the residents call light away from them if the resident used the call light too much. CNA 7 stated she never reported the incident to anyone and only recalled mentioning it to another staff member but could not remember who. During an interview on October 18, 2024, at 9:22 AM, with the ADMIN, the ADMIN stated he was the facility's abuse prevention coordinator and has been so since July 1, 2021. The ADMIN further stated he had never in the past been informed of facility staff allegedly taking call lights away from residents. The ADMIN stated if staff suspected abuse or were made aware of an abuse allegation, they were supposed to report it to him immediately. During a review of the facility's P&P titled, Abuse Investigation and Reporting, (undated), the policy indicated, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .Reporting .1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative .d. law enforcement officials; e. The residents attending physician; and f. the facility medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24 hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 14 and 11) received care and services as specified In their care plans (individualized plans for the medical care of a resident) when: 1) For Resident 14, the facility did not ensure staff kept the resident's smoking materials. This failure had the potential to result in in accident or injury to Resident 14 and other residents residing in the facility as a result of increased fire hazard. 2) For Resident 11, the facility did not ensure staff checked the residents blood sugar before meals. This failure has the potential to affect Resident 11's blood sugar management and could lead to inaccurate blood sugar readings, which may result improper insulin administration (medication use in the treatment and management of diabetes) and increased risk of hyperglycemia (elevated blood sugar). Findings: 1) During a review of Resident 14's clinical record, the Admission Record (contains medical and demographic information), indicated Resident 14 was admitted [DATE], with diagnoses which included Hemiplegia and hemiparesis (paralysis and weakness on one side of the body) on right dominant side, history of falls, and heart failure. During an interview on October 15, 2024, at 11:08 AM, with Resident 14, Resident 14 stated he was a smoker and kept his own smoking materials with him. During a concurrent observation, and interview, on October 17, 2024, at 4:09 PM, in Resident 14's room, with Resident 14, and in the presence of Certified Nursing Assistant 5 (CNA 5), Resident 14 was observed to have a nasal cannula (an oxygen delivery device) and was receiving oxygen. Resident 14 stated he kept his own smoking supplies in his bedside end table. CNA 5 opened Resident 14's bedside end table and there was one empty pack of cigarettes, another pack of cigarettes with 7 cigarettes left, and two lighters. During an interview on October 17, 2024, at 4:31 PM, with the Activities Director (AD), the AD stated staff were supposed to have Resident 14's smoking supplies and Resident 14 was not supposed to have any smoking supplies. During an interview on October 17, 2024, at 4:41 PM, with the Director of Nursing (DON), the DON stated Resident 14 was not supposed to keep his own smoking supplies and that the facility's practice was for staff to keep all smoking supplies. During a review of Resident 14's care plan titled, Resident is a smoker ., dated October 11, 2024, the care plan indicated, Interventions .Provide direct supervision to resident while smoking .smoking materials are to be kept by staff .Remove oxygen prior to smoking . During a review of Resident 14's Minimum data set (MDS - an assessment of a residents functional and health status), dated August 25, 2024, indicated Resident 14 had a Brief Interview for Mental Status score (BIMS score - a score of 0-15 used to determine cognitive functioning) of 12 (moderate cognitive impairment). During a review of Resident 14's Smoking Assessment-V1 (an assessment of the residents' level of risk associated with smoking), dated October 10, 2024, the assessment in section B. Cognitive indicated the resident was not able to recognize the smoking areas, and did not exhibit knowledge of the facility smoking rules. The Assessment section D. Current Tobacco Consumption per day, indicated the resident smoked 3-5 times a day. Section F. Safety, of the assessment indicated the resident was not able to hold, light and extinguish his own cigarettes, his personal items were not free from evidence of burn holes, the resident could not state or indicate that no smoking materials may be given to another resident and that the facility was to store the residents lighter and cigarettes. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, (undated), the policy indicated, This facility has established and maintains safe resident smoking practices .11. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc. except under direct supervision . 47098 2) During a review of Resident 11's Admission Record (contains demographic and medical information), indicated Resident 11 was admitted to the facility on [DATE] with the medical diagnoses which included diabetes (a condition where the body can't control the blood sugar level in the body). During an observation on October 17, 2024, at 7:34 AM, Resident 11 was seating in the dining room eating her breakfast. During an observation on October 17, 2024 At 7:51 AM in the dining room, staff were observed moving Resident 11 from the dinning room to her room to administer her medications. The Director of Nursing (DON) who was assisting the night shift License Vocational Nurse 3 (LVN 3) prepared to give Resident 11 her medications. During a futher observation on October 17, 2024 At 7:51 AM, the DON checked Resident 11's blood sugar, but Resident 11 had already started eating her meal. During a review of Resident 11's Physician Orders dated February 13, 2023, indicated, Novolog Insulin Aspart (a type of insulin to used to treat high blood sugar) inject as per sliding scale: if 70-119=4 [units of insulin] hold if blood sugar is below 70; 120-300=7 units of insulin], subcutaneously (below the skin) before meals for diabetes. Resident 11's blood sugar was to be checked before meals. During an interview with the DON on October 17, 2024, at 7:55 AM, the DON acknowledged that Resident 11's blood sugar should have been checked before the breakfast meal and not after. During a review of Resident 11's care plan (an individualized plan for the medical care of a resident), titled At risk for hyperglycemia and hypoglycemia related to diagnosis of Type 2 Diabetes Mellitus, undated, the care plan indicated Resident 11 was at risk for hyperglycemia (elevated blood sugar) and hypoglycemia (low blood sugar), with the goal of having no complications related to diabetes, evidenced by the absence of signs or symptoms of hyperglycemia or hypoglycemia. The interventions included: Administering insulin subcutaneously for Diabetes Mellitus Type 2 as ordered by the physician . During a concurrent interview, and record review, on October 18 at 9:01 AM with the DON, the facility 's policy and procedure (P&P) titled, Insulin Administration, undated, was reviewed. The P&P indicated, 1. Check blood glucose per physician order or facility protocol. The DON stated the P&P was not followed and acknowledged that Resident 11's blood sugar should have been checked before meals.

Based on observation, interview, and record review, the facility failed to monitor and document the low air loss mattress (specialized mattress designed to help prevent and treat pressure ulcers) according to the physician's order for one of two sampled residents (Resident 40) who had a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 40 not to receive the necessary treatment and services. Findings: A review of Resident 40's Admission Record, (contains demographic and medical information), indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and epilepsy (a disorder of the brain characterized by repeated seizures). During an observation on October 15, 2024, at 8:36 AM, Resident 40 was observed in her room, laying on her left side and asleep on a low air loss mattress bed. During a review of Resident 40's physician order, dated September 24, 2024, it indicated, Low Air Loss Mattress for tissue load management, check placement, setting, and monitor every shift. During a concurrent interview and record review on October 16, 2024, at 1:13 PM with the Treatment Nurse, Treatment Nurse stated Resident 40 has a stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) opening on her coccyx. The physician's order and Treatment Administration Record (TAR-a document that tracks the time and type of treatments administered to a patient) for Resident 40 were reviewed. Treatment Nurse acknowledged there is a gap or missing documentation on the following dates and shift indicating monitoring of low air loss mattress bed was not completed: a. October 1, 2024, day, and eve shift b. October 2, 2024, night shift c. October 3, 2024, night shift d. October 4, 2024, eve shift e. October 6, 2024, eve shift f. October 7, 2024, eve shift g. October 9, 2024, eve shift h. October 11, 2024, eve shift i. October 12, 2024, eve shift j. October 13, 2024, eve, and night shift k. October 14, 2024, eve shift l. October 15, 2024, eve shift During a continued interview and observation with the Treatment Nurse, on October 16, 2024, at 1:14 PM, in Resident 40's room, Treatment Nurse demonstrated how she checks the low air mattress bed setting when she comes in every morning. She stated the low air mattress bed machine should be plugged in and set according to the red sticker. During an interview with the Licensed Vocational Nurse 1 (LVN 1) on October 17, 2024, at 9:19 AM, LVN 1 stated it is important to make sure Resident 40 is being repositioned. LVN 1 stated her, and the Treatment Nurse are responsible for monitoring low air loss mattress on day shift. She further stated it is important to check the settings of low air loss mattress because Resident's 40 main issue is her pressure ulcer. During a concurrent interview and record review on October 17, 2024, at 3:28 PM with Director of Nursing (DON), the Treatment administration record, for resident 40 was reviewed. The DON stated the nurse could have checked the low air mattress, and it could be just a documentation error. During a review of the care plan (an individualized plan for the medical care of a resident) for Resident 40, on October 17, 2024, at 6:29 PM, titled, At risk for skin breakdown related to history of pressure injury, immobility, Alzheimers, Dementia, Chronic Respiratory Failure, Bipolar disorder, dated September 24, 2024, the care plan interventions indicated Administer treatments as ordered and monitor for effectiveness. During a record review of the facility's policy and procedure titled, Pressure and Non-Pressure - Clinical Protocol, (undated), the policy indicated, Assessment and Recognition . 2. In addition, the nurse shall describe and document/report the following .d. Current treatments, including support surfaces

Based on observation, interview, and record review, the facility failed to document a gradual dose reduction (GDR) for one of eight sampled residents (Resident 55) when a recommended a decrease in Trazadone (a medicine that helps people who are feeling very sad or having trouble to sleep) from 100 mg (milligrams unit of measurement) to 50 mg was not done and documented. This failure has the potential to result in over medication and increased risk of side effects for Resident 55. Finding: During a review of Resident 55's Admission Record (contains demographic and medical information), indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mental health condition characterized by persistent sadness and loss of interest), and bipolar disorder (a mental health condition where a person has extreme mood swings). During a review of Resident 55's pharmacist's recommendation dated October 7, 2024, indicated a recommended GDR of Trazadone dose from 100 mg to 50 mg due to the Resident 55's stable condition. During a review of Resident 55's physician orders for October 2024, there is no documented evidence Trazadone has been decreased from 100 mg to 50 mg. Further review of Resident 55's physician's orders indicated Resident 55 has been receiving trazadone 100 mg since June 5, 2024. During a review of Resident 55's care plan (an individualized plan for the medical care of the resident) titled, Depression Management, undated, the care plan indicated Resident 55 had episodes of depression manifested by inability to sleep. The goal was to minimize the risk of adverse side effects of medication usage, including Trazadone, through appropriate interventions. The interventions included administer antidepressant medication as per physician's order, monitor and record episodes of behavior per psychotropic policy .Gradual Dose Reduction (GDR) as indicated . During a review of the Resident 55's Nurse Practitioner's (NP) Progress notes dated October 7, 2024, the NP progress notes indicated Resident 55 had been evaluated and was found to be stable. A GDR for Trazodone was recommended reducing the dose from 100 mg to 50 mg. Further review of NP's progress notes dated October 7, 2024; it indicated Resident 55 had agreed to the GDR during the NP's evaluation. During an observation, and interview, with Resident 55's on October 17, 2024, at 2:29 PM, Resident 55 was observed lying down on her bed with her eyes open and able to verbalize her needs. Resident 55 agree to be interviewed and she was aware she had been taking Trazadone 100 mg at night because it helps her sleep. Resident 55 expressed that she wanted to continue taking this dose. During an interview on October 15, 2024, at 5:16 PM with Director of Nurses (DON), the DON confirmed that Resident 55 was still taking Trazodone 100 mg per the physician's orders. The DON further explained that she had attempted to obtain Resident 55's consent for the dose reduction, but Resident 55 refused, expressing her preference to continue with the Trazadone 100 mg dose. The DON further stated that she notified the Nurse Practitioner (NP) of Resident 55's decision to continue with Trazadone 100 mg but acknowledged that she forgotten to document both Resident 55's refusal of GDR and the communication with the NP. The DON agreed this was a discrepancy in her documentation and that it should have been recorded. During an interview on October 18, 2024, at 9:07 AM, with the DON, the facility's policy, and procedure (P&P) titled, Nursing Documentation dated December 2023, was reviewed. The P&P indicated, 3. Refusal of treatments: Documentation pertaining to resident refusal of treatment should include: A. the date and time the treatment was attempted. B. The treatment attempted .D. Documentation that the resident was informed of the purpose of the treatment and the consequences of not receiving the care . The DON acknowledged the P&P was not followed and agreed Resident 55's refusal of the GDR and the communication with NP should have been documented.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for labeling and dating of food items when a bottle of [brand name] creamer was found on top of a table inside the kitchen at room temperature without an open date. This failure has the potential to increase the risk of foodborne illness or contamination due to improper storage practices. Finding: During an observation on October 14, 2024, at 8:16 AM, during a tour inside the kitchen area, a bottle of [brand name] coffee creamer was observed on top of a table inside the kitchen area. The bottle was open and halfway already used, and there was no open date written on the bottle to indicate when it was first opened. During an interview on October 14, 2024, at 8:18 AM, with the Dietary Services Supervisor, (DSS 1), the DSS 1 confirmed that the creamer was found open, used and unlabeled. The DSS 1 stated that the bottle of creamer should be labeled and properly stored according to facility's P&P. The DSS 1 further stated that the bottle of creamer will be dispose immediately. During a concurrent interview, and record review, on October 18, 2024, at 8:50 AM, with the DSS 1, the facility's P&P titled, Labeling and dating of foods dated 2023, was reviewed. The P&P indicated, All food items in the store room, refrigerator, and freezer need to be labeled and dated .Procedure: Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines .

Based on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Resident 55, 28, 64, and 44) who reside in the two rooms. Findings: During an interview with the Administrator (ADMIN) on October 17, 2024 at 8:11 AM, the ADMIN stated the facility has two rooms with square footage waivers, rooms [ROOM NUMBERS]. The ADMIN further stated the facility submitted a room waiver variance sometime within the last week. During concurrent observations, and interviews with the residents (55 and 28) in room [ROOM NUMBER], on October 17, 2024 at 8:13 AM the following were observed: Bed 7A was occupied by Resident 55, who was observed resting comfortably in bed. Resident 55 did not verbalize any issues or concerns with the size of the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. Bed 7B was occupied by Resident 28, who was observed resting comfortably in bed. Resident 28 did not verbalize any issues or concerns with the size of the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. During concurrent observations, and interviews with the residents (Resident 64 and 44) in room [ROOM NUMBER], on October 17, 2024, at 8:19 AM, the following were observed: Bed 11A was occupied by Resident 64, who was observed in the room. Resident 64 did not verbalize any issues or concerns with the size room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. Bed 11B was occupied by Resident 44, who was observed in the room. Resident 44 did not verbalize any issues or concerns with the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. During an environmental tour of rooms [ROOM NUMBERS], with the Maintenance Director on October 17, 2024 at 8:13 AM, the following measurements were noted as follows: 1. room [ROOM NUMBER] measured 12 feet 10 inches x 11 feet 4 inches = 145.43 square feet total (72.7 square feet per resident)room [ROOM NUMBER] did not have the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. 2. room [ROOM NUMBER] measured 12 feet 9 inches x 11 feet 2 inches = 142.61 square feet total (71.3 square feet per resident)room [ROOM NUMBER] did not have the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. During the course of the survey, rooms [ROOM NUMBERS] were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.

Based on observation, interview, and record review, the facility failed to follow a system for controlling the spread of a communicable disease for one of four sampled residents (Resident 1) when Resident 1 was on transmission-based droplet precautions (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions) for a coronavirus disease (COVID-19-an infectious disease caused by a virus) exposure and was allowed to participate in activities with 11 other residents. This failure had the potential to cause the spread of COVID-19 to other residents in the facility. Findings: A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 1 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 5 had diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform basic tasks). A review of Resident 5 ' s COVID-19 laboratory test dated September 18, 2024, indicated, Results: positive and symptomatic. A review of Resident 1 ' s care plan dated September 18, 2024, indicated, Focus: [Resident 1] with COVID-19 exposure. Date Initiated: [September 18, 2024] Revision on: [September 18, 2024]. Goal: Prevent the spread of COVID-19 in the facility Date Initiated: [September 18, 2024] Target Date: [October 2, 2024]. Interventions: Encourage/Remind Resident to wear mask and maintain social distancing. Date Initiated: [September 18, 2024] . Initiate transmission-based precaution (DROPLET). Staff to implement full PPE [Personal Protective Equipment] use (mask, face shield/goggles, gown, gloves) when providing direct care to the resident. Date Initiated: [September 18, 2024] Keep the number of staff assigned to enter the room at a minimum and staff to bundle resident care activity. Date Initiated: [September 18, 2024] Educate resident and provide information regarding COVID-19. Date Initiated: [September 18, 2024] Promote social distancing; and avoid communal dining/group activities. Provide means of communication/engagement with family members, resident representatives and/or friends while visitation is restricted. Provide individualized activities of choice. Date Initiated: [September 18, 2024] . During an observation on September 23, 2024, at 1:34 PM, arrived at Resident 1 and Resident 5's room. The room's door was closed, and an Isolation Precautions-Droplet sign was posted. PPE was available outside the door: N95 mask (a respiratory protective device), face shield, gown and gloves. The Surveyor performed hand hygiene and donned (put on) the PPE. The Surveyor knocked on the door and entered the room. Resident 5 was sitting on the bed closest to the door. The Surveyor introduced herself to Resident 5 and asked how she was feeling. Resident 5 looked at the Surveyor but did not respond. Resident 1's bed farthest from the door was empty. The Surveyor looked around the room and in the adjoining bathroom but Resident 1 was nowhere to be found. The Surveyor doffed (took off) her PPE, performed hand hygiene and left the room. During an observation and interview with Resident 1 and an Infection Preventionist Nurse (IP Nurse) on September 23, 2024, at 1:40 PM, Resident 1 was in the dining room, seated at a table and working on a word search activity. The dining room held eleven other residents and one activity staff member. All the residents were engaged in a variety of tabletop activities. Resident 1 was wearing a short sleeve shirt, long pants, and socks, but no face mask. Resident 1 was clean and well groomed; no injuries were visualized. Resident 1 did not appear to be in distress. The IP Nurse confirmed Resident 1 was not wearing a mask and was participating in activities with eleven other residents, in a common area. The IP Nurse confirmed Resident 1 shared a room with Resident 5 who had tested positive for COVID-19 and had displayed symptoms. The IP Nurse confirmed Resident 1 resided in a room placed on Isolation Precautions-Droplet because she had been exposed to COVID-19 by Resident 5. The IP Nurse stated Resident 1 refused to wear a mask and was allowed to come and go from her isolation room. During an interview with the Director of Nursing on September 23, 2024, at 3 PM, The DON confirmed Resident 1 was on Isolation Precautions-Droplet for a COVID-19 exposure. The DON confirmed Resident 1's care plan indicated Encourage/Remind Resident to wear mask and maintain social distancing. Promote social distancing; and avoid communal dining/group activities. Provide means of communication/engagement with family members, resident representatives and/or friends while visitation is restricted. Provide individualized activities of choice. The DON stated Resident 1's care plan was not followed. The DON stated it was the facility's responsibility to minimize the spread of COVID-19 to other residents. A review of the facility ' s policy and procedure titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, undated, indicated, Policy Statement: This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementation: . f. implementing source control measures.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s call light was found hanging from a light fixture on a wall. 2. Resident 3 ' s call light was found behind a nightstand on the floor. These failures had the potential to result in resident harm and unmet needs for Residents 1 and 3. Findings: 1. During a review of Resident 1 ' s Admission Record (contains demographic and medical information), the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a condition where a person experiences a decline in their memory, thinking and reasoning skills), unsteadiness on feet, and repeated falls. During a concurrent observation and interview, on March 12, 2024, at 10:19 AM, with Resident 1, in her room, Resident 1 ' s call light was hanging from the light fixture on the wall, inaccessible. Resident 1 stated she did not know where the call light was. Resident 1 further stated she needed to use the restroom. During a concurrent observation and interview, on March 12, 2024, at 10:20 AM, with the Director of Staff Development (DSD) and a Certified Nurse Assistance (CNA 1), in Resident 1 ' s room, the DSD and CNA 1 acknowledge Resident 1 ' s call light was not within reach and should have been. 2. During a review of Resident ' s 3 Admission Record indicated Resident 3 was admitting on December 6, 2020, with diagnoses of dementia (condition where a person experiences a decline in their memory, thinking and reasoning skills), peripheral vascular disease (condition that affects the blood circulation in their body), and respiratory failure (when the lungs can ' t provide enough oxygen to the body.). During an observation, on March 12, 2024, at 10:19 AM, at Resident 3's room, Resident 3 was lying down in bed with her eyes closed. Residents 3 ' s call light was found on the floor, inaccessible. During a concurrent observation and phone interview, on March 12, 2024, at 10:24 AM, with the DSD and CNA 1, in Resident 3 ' s room, the DSD and CNA 1 acknowledge that Resident 3 ' s call light was behind the nightstand on the floor, and stated the call light should be within the resident ' s reach. During a concurrent phone interview and record review, on April 9, 2024, at 2:16 PM, the Administrator (Admin) reviewed the facility ' s policy and procedure (P&P) titled, Answering the Call Lights, dated September 2022, which indicated .5. Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and form the floor . The Admin stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. This failure resulted in Resident 1 to experience a fall. Findings: An unannounced visit was made to the facility on [DATE], at 5:30 PM, to investigate a Facility Reported Incident (FRI) regarding quality of care/treatment. During an observation on November 30, 2023, at 5:35 PM, in Resident 1's room, Resident 1 was lying down on her bed on her back, with head of the bed elevated. Resident 1 had a bandage wrapped around her leg and heel protector on feet. During an interview on November 30, 2023, at 5:45 PM, in Resident 1's room, Resident 1 stated she did not remember when she had a fall. During a review of Resident 1's face sheet (a document which contain basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis which include cerebral infarction (stroke), Glaucoma (a disease of the eyes which causes blindness) and osteoporosis (a bone disease which causes brittle bones). During a review of Resident 1's History and physical (H&P) dated June 16, 2023, indicated Resident 1 has a history of falls, and history of compression fracture vertebra (a broken bone that cause the back to collapse, making them shorter). Further Review of Resident 1's H&P dated June 16, 2023, indictated Resident 1 can make decisions. During a review of Resident 1's Fall Risk assessment dated [DATE], indicated, Score 9, category: Low Risk . Further review of the Resident 1's Fall Risk assessment dated [DATE], indicated under section, 4. Vision, Resident 1's vision was adequate. Further review of the Resident 1's Fall Risk assessment dated [DATE], indicate under section, 7. Medications indicated Resident 1 was taking 1- 2 of these medications currently and /or within last 7 days. Further review of the Resident 1's Fall Risk assessment dated [DATE], indicated under section 9 predisposing diseases indicated Resident 1 had 1 to 2 present. During a telephone interview with Director of Staff Development 2 (DSD 2) on December 13, 2023, at 2:30 PM, DSD 2 stated, the Fall Risk assessment dated [DATE], was inaccurate. DSD 2 further stated there was a discrepancy on sections 4. VISION STATUS. DSD 2 stated Resident 1 had a diagnose of Glaucoma and it should have been noted. DSD further stated there was a discrepancy on Section 7 MEDICATIONS. DSD 2 stated Resident 1 was taking two blood pressure medications and one nacrotic and it should have been noted. DSD 2 stated there was a discrepancy on Section 9. PRESDISPOSING DISEASE. DSD 2 stated Resident 1 had diagnosis of CVA, Osteoporosis and History of compression fracture and should have been noted. The DSD 2 stated Resident 1's Fall Risk Assessment the score should had been higher than 9, which would have indicated Resident 1 was a high risk for falls. During an interview with DSD 2 conducted via phone on December 14, 2023, at 2:32, DSD stated, that Resident 1, should had been place on a fall prevention program prior the fall but that Resident 1's was not place in the fall prevention program until after the fall. During a review of the policy and procedure titled, Fall Risk Assessment, undated, indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Further review of the policy and Procedure indicated, 1.Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. 2.The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 3.The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. 4.The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. 5.The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as de-creased vision and peripheral neuropathy) that may predispose to falls. 6.Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis).

Based on interview and record review, the facility failed to ensure one on one (1:1) supervision (direct one on one monitoring of a resident by a staff member) was implemented for one of 80 residents (Resident 1) as ordered by a physician on April 13, 2023 when Resident 1 was found on the floor of his room with his door closed and unaccompanied by staff with a laceration (a cut or skin wound) injury to his head after he sustained an unwitnessed fall. This failure resulted in Resident 1 sustaining a head injury which required treatment and evaluation in a hospital. Findings: During a review of Resident 1 ' s clinical record, the Admission Record (contains demographic and medical information), indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included diffuse traumatic brain injury (head injury), dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning), unsteadiness on feet, epilepsy (a brain disorder that causes recurring seizures), schizoaffective disorder (a disorder characterized by a combination of hallucinations or delusions, and mood disorder symptoms such as depression or mania) and altered mental status (altered state of mental functioning). During a review of Resident 1 ' s Minimum Data Set ( MDS - an assessment of the resident ' s functional and health status), dated April 10, 2023, the MDS indicated Resident 1 had a severely impaired mental status according to the Brief Interview for Mental Status (BIMS - a screening tool used to determine mental status; A score of 13 to 15 suggests the patient is cognitively (the ability of the brain to think and reason) intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Resident 1 scored a 4 (severely impaired). During a review of Resident 1 ' s Fall Risk assessment dated [DATE], the assessment indicated the resident was at High Risk for falls and had sustained .3 or more falls in past 3 months. During a review of Resident 1 ' s Initial Psychiatric Evaluation dated April 11, 2023, indicated, .Treatment Plan: .-Staff will assure the client of safety .Resident on monitoring for increased aggressive behavior and recent falls . During a concurrent interview and record review on August 23, 2023, at 11:26 AM, the DON provided an untitled document which listed incidents when Resident 1 fell in the facility for the month of April 2023. The untitled document dated April 1, 2023, through April 30, 2023, indicated Resident 1 had fallen three times in the month of April 2023 (April 7, 2023, April 9, 2023, and April 13, 2023). During a review of Resident 1 ' s physician ' s orders, an order dated April 10, 2023, indicated, 1:1 [one on one] monitoring by CNA [Certified Nursing Assistant]. During a telephone interview on August 8, 2023, at 4:48 PM with Certified Nursing Assistant 1, CNA 1 stated he worked at the facility [name of facility] on April 13, 2023, when Resident 1 fell and sustained a head injury and had to be sent to the hospital. CNA 1 stated Resident 1 was one of the residents assigned to him during his shift. CNA 1 stated he could not remember which Licensed Vocational Nurse (LVN) but stated an LVN told him that he was on a 1:1 (one to one) assignment with Resident 1 and that he needed to keep checking in on Resident 1 throughout his shift. CNA 1 stated he was also responsible to help other residents throughout his shift even though he was assigned 1:1 with Resident 1. CNA 1 stated when Resident 1 fell on [DATE], the resident was in his room with the door closed and was not accompanied by any staff members inside the room. CNA 1 stated at the time Resident 1 fell , he (CNA 1) was outside the Resident 1 ' s room and was attempting to redirect another resident who was trying to open Resident 1 ' s door. CNA 1 stated he did not want Resident 1 to be woken up and that ' s when he heard Resident 1 yell and as he opened the door and entered the room, he found Resident 1 had fallen and hit the back of his head on the floor and was bleeding. CNA 1 further stated he was the first to respond to the fall. During an interview on August 16, 2023, at 12:15 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was working at the facility [name of facility] on April 13, 2023, when Resident 1 fell during her shift. LVN 1 stated CNA 1 was assigned to do 1:1 monitoring with Resident 1 that day and when Resident 1 fell , CNA 1 was outside the door of Resident 1 ' s room. LVN 1 further stated Resident 1 required 1:1 monitoring due to his history of falls and stated Resident 1 was unsteady on his feet. During an interview on August 16, 2023, at 4:15 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated he was working at the facility on April 13, 2023, when Resident 1 fell . CNA 2 stated CNA 1 was assigned to do 1:1 with Resident 1 because Resident 1 kept getting up all the time and had a history of falls. CNA 2 stated throughout his shift, he saw CNA 1 outside Resident 1 ' s room with the door closed on multiple occasions (could not quantify how many times). CNA 2 further stated when he saw CNA 1 outside Resident 1 ' s room, he (CNA 1) was just standing there and sometimes talking to staff but was not performing any particular tasks. CNA 2 further stated on other occasions when he saw other staff members assigned to 1:1 monitoring, they were in the room with Resident 1 and not outside the room with the door closed, but stated this time was different. During an interview on August 23, 2023, at 9:20 AM, with the Director of Nursing (DON), the DON stated Resident 1 had behaviors and would at times be unsteady on his feet and had physician orders for 1:1 (one on one) supervision. The DON stated her expectation was that if a staff member was assigned to do 1:1 (one on one) with a resident, they should always be in the room with the resident. The DON further stated any staff assigned to do 1:1 monitoring of a resident should be next to the resident or near them and in the line of sight of the resident at all times. The DON stated it would be unacceptable for a staff member to be outside a room of a resident on 1:1 monitoring with the door closed. The DON stated 1:1 monitoring is important for the safety of the resident and other residents within the facility. During a concurrent interview and record review, on August 23, 2023, at 9:46 AM, with the DON, the written statement from CNA 1, dated April 13, 2023, was reviewed. The statement indicated, I, [name of CNA 1] making a statement about [name of Resident 1] ' s fall incident. I was assigned to do one on one with [name of Resident 1]. Around 7:20 PM I was redirecting another patient not to get in into [sic] [name of Resident 1] ' s room because I don ' t [sic] want the patient to be disturbed onto [sic] his sleep. I heard [name of Resident 1] yelled and I immediately came up to him and I found him laying [sic] on the floor . The DON stated, Reading the statement from the CNA, it sounds as though it was an unwitnessed fall. The DON further stated it would have been unacceptable if the staff member was outside of the room of a resident with the door closed while on 1:1 monitoring. The DON further stated if the door is closed, the staff should be inside the room with the resident. During an interview on August 23, 2023, at 4:00 PM, with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she worked on April 13, 2023, when Resident 1 fell . CNA 3 stated she recalled seeing CNA 1 assigned to do 1:1 supervision for Resident 1 and stated she saw CNA 1 sitting in a chair outside Resident 1 ' s room on multiple occasions while the resident was in the room with the door closed. During a review of Resident 1 ' s document titled, [name of hospital] .ED [emergency department] Provider Report . dated 4/13/23, the document indicated, [name of Resident 1] .History of Present Illness .Fall Injury .62 y/o [year old] male .BIBA [brought in by ambulance] from [name of facility] after sustaining an unwitnessed fall today. Per EMS [emergency medical services] pt was noted to have a hematoma [a collection or pooling of blood outside a blood vessel] to the back of his head .he's had a total of 3 falls this week .CT [computated tomography- an imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body] scanning .Impression: Small posterior right parafalcine and tentorial subdural hemorrhage [bleeding in the posterior (rear) aspect of the brain], 3 mm [Millimeters - a unit of measure] in thickness .Posterior scalp 3 cm [centimeters - a unit of measure] partial-thickness laceration .3 staples placed without incident .Diagnosis: Altered mental status fall, close head injury, scalp laceration, subdural hemorrhage .Condition: Critical . During a review of the facility ' s policy and procedure titled, Falls and Fall Risk, Managing, revised March 2018, the policy indicated, .Resident conditions that may contribute to the risk of falls include: .c. Delirium [a mental state in which you are confused, disoriented, and not able to think or remember clearly] and other cognitive impairment; .i. functional impairments . 3. Medical factors that contribute to the risk of falls include: .e. balance and gait [manner of walking] disorders .Resident-Centered Approaches to Managing Falls and Fall risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a concurrent interview and record review on August 23, 2023, at 10:18 AM, with the DON, the facility ' s policy and procedure titled, Safety and Supervision of Residents, (undated), the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .4. Implementing interventions to reduce accident risks and hazards shall include the following routine checks of resident or 1:1 supervisions to ensure safety .d. ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; . The DON stated the policy was not followed. During an interview on August 14, 14, 2023, at 4:05 PM, with the DON, the DON stated the facility did not have a policy and procedure regarding 1:1 supervision.

Based on observation, interview, and record review, the facility failed to employ a full-time (35 hours per week) qualified dietitian or designate a person to serve as director of food and nutrition services when their Dietary Services Supervisor quit on June 11, 2021. This resulted in the food services department lacking in oversight which led to unsanitary conditions in the kitchen when the following were found: A. Shelf was deteriorating from water damage. B. The floors under all shelving and equipment and in the dry storage were dirty with food debris and trash. C. The two stoves had a black grime, and the floor underneath the stoves had a build-up of black grime and rotting food. D. Dead rodents and roaches were found. E. The enclosed area under the food prep sink was dirty with a brown grime. F. The patched wall behind the three-compartment sink (three separate sink compartments, one for each step of the dishwashing procedure: wash, rinse, and sanitize) was not smooth which made the surface not easily cleanable. These failures resulted from lack of qualified oversight to do daily inspections, provide feedback to staff, ensure staff is doing their job which had the potential to cause foodborne illness to 73 of 73 residents who were medically compromised. Findings: During an interview on June 29, 2021, at 7:25 AM, the Dietary Services Supervisor (DSS 1), stated that she works at their sister facility and comes to the facility a two times per week to help. The previous Dietary Services Supervisor (DSS 2) quit a few weeks prior. During a tour of the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 between 7:25 AM and 8:26 AM, the following were observed: a. The shelf that was holding the coffee maker and the juice machine had water damage and the edges were deteriorating. The DSS 1 stated that they plan to get that cabinet replaced. b. The floor under the ice machine and where the food carts were stored was with food particles and dirt. The floor under the three-compartment sink was dirty with debris and trash. The floor under the metal rack that contained clean pots and pans had food debris and dirt. The baseboard had a sticky yellow residue. The floor under the convection oven was dirty with a greasy residue. The DSS 1 stated that the floors should be kept clean. c. The knobs on the stove that lights the burners were covered in a black grime and the front of the stove around the knobs was covered in black grime. The floors under the two stoves had a black grime. Under the stove to the right, there was a whole tomato rotting and the floor was covered in a black grime. d. A glue trap was found in the oven with four dead mice. The DSS 1 stated that she did not know that the mice were there. A sticky trap was observed under the shelf in the dry storage room with five dead roaches. The DSS 1 stated that staff should have discarded the trap. During a follow up observation and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 30, 2021 at 8:46 AM, the following were observed: e. The enclosed area under the food prep sink was dirty with a thick layer of brown grime. This area is adjacent and open to the 3 drawers containing clean utensils for serving food. f. The wall behind the 3-compartment sink appeared to have been repaired. Some spackle was used to cover the edges, but the drywall was visible, and the wall was not smooth. It had lumps of spackle. During an interview on June 29, 2021, at 9:28 AM, the Registered Dietitian (RD 2) stated that she has been there two months. She was covering for the RD 1 because she is on maternity leave. RD 2 stated she was not full-time, but she comes every Wednesday. The RD 2 verified that they currently do not have a full-time Dietary Services Supervisor. During an interview on July 1, 2021, at 10:00 AM, the Administrator stated that they were splitting the time with the Registered Dietitian 2 and the DSS 1 from the sister facility and he was not aware it had to be one person full time to manage the Food and Nutrition Services. According to the Health and Safety Code 1265.4, (a) A licensed health facility, as defined in subdivision (a), (b), (c), (d), (f), or (k) of Section 1250, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to Title 22 (a) A dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis. A written record of the frequency, nature and duration of the consultant's visits shall be maintained. (b) If a dietitian is not employed full-time, a full-time dietetic services supervisor shall be employed to be responsible for the operation of the food service. The dietetic supervisor may also cook, provided sufficient time is allowed for managerial responsibilities. During a review of an email resignation from the former Dietary Services Supervisor (DSS 2), dated June 7, 2021, the resignation indicated This letter is to inform you that I am resigning from my current position of Dietary Service Supervisor at [Facility Name], effective June 11, 2021. During a review of the FDA Federal Food Code 2017, indicates Except as specified in (B) of this section, the permit holder (entity that: (1) Is legally responsible for the operation of the food establishment such as the owner, the owner's agent, or other person; and (2) Possesses a valid permit to operate a food establishment) shall be the person in charge or shall designate a person in charge and shall ensure that a person in charge is present at the food establishment during all hours of operation. Designation of a person in charge during all hours of operations ensures the continuous presence of someone who is responsible for monitoring and managing all food establishment operations and who is authorized to take actions to ensure that the Code's objectives are fulfilled. During the day-to-day operation of a food establishment, a person who is immediately available and knowledgeable in both operational and Code requirements is needed to respond to questions and concerns and to resolve problems. In addition, The designated person in charge who is knowledgeable about foodborne disease prevention, Hazard Analysis and Critical Control Point (HACCP) principles, and Code requirements is prepared to recognize conditions that may contribute to foodborne illness or that otherwise fail to comply with Code requirements, and to take appropriate preventive and corrective actions. During a review of the FDA [Federal Food and Drug Administration] Food Safety.gov, last reviewed July 2020, the document indicated, Good food safety practices are vital in long term care facilities, as seniors are at an increased risk for hospitalization and death from foodborne illnesses. Seniors living in nursing homes face 10 times the risk of dying from bacterial gastroenteritis (an infection or inflammation in the stomach and intestine) than people in the community. The gastrointestinal tract (mouth, esophagus, stomach and intestines) holds onto food for a longer period of time, allowing bacteria to grow. The liver and kidneys may not properly rid the body of foreign bacteria and toxins. The stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Underlying chronic conditions, such as diabetes and cancer, may also increase a person's risk of foodborne illness. An immediate jeopardy (IJ) (immediate corrective action is necessary because the provider's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called on June 29, 2021 at 1:30 PM, under §483.60(a)(2) Staffing- If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The survey team verbally notified the Administrator of the IJ failure to have a full-time director of food and nutrition services. This failure led to unsanitary conditions in the kitchen that had the potential to cause food-borne illness to the highly susceptible residents who received food from the kitchen. The Corrective Action Plan (CAP) included the following: 1. The RD 2 Consultant will have responsibility to oversee the kitchen full-time starting June 29, 2021. 2. The RD 2 Consultant in-serviced Dietary Services Supervisor (DSS 1) and newly hired Dietary Services Supervisor (DSS 2) on maintaining proper sanitary conditions in the kitchen June 29, 2021. 3. The Administrator was in-serviced by, Chief Clinical Officer regarding F801 ensuring the facility is staffed with a qualified full-time Dietary Services Supervisor and/or full time Registered Dietician and proper sanitation in the kitchen. 4. Plan will be addressed at the next QAPI (Quality Assurance Performance Improvement) Meeting scheduled for June 30, 2021. The IJ was lifted on June 30, 2021 at 1:56 PM, in the presence of the Administrator, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews and record reviews

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen were implemented when: 1. The Facility didn't address the broken door sweep that the pest control company identified as a pest entry point and four dead mice were found in the oven stuck to a glue trap. Rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 2. A glue trap in the dry storage was found with dead roaches. Insects are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 3. The walk-in refrigerator was not maintaining 41° Fahrenheit (a scale of temperature on which water freezes at 32° and boils at 212° under standard conditions) to prevent bacterial growth and toxin production in food that is time/temperature controlled for safety. 4. Floors behind the ice machine and under the food carts, under the three- compartment sink (three separate sink compartments, one for each step of the dish washing procedure: wash, rinse, and sanitize), under the shelf storing clean metal pots and pans and under the shelves in the dry storage had food debris and trash. The floor and baseboard under the convection oven had a sticky yellow residue and the floor under the two stoves had a black grime and rotting food. Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 5. The knobs on the stove and the front of the stove had a black grime, which had the potential to contaminate food. 6. The cabinet holding the coffee and juice machine had water damage and the edges were deteriorating, which made the surface not easily cleanable. 7. The food preparation sink did not have an air gap, which had the potential for back flow from the drain to contaminate the sink. 8. The area under the food preparation sink, that was adjacent to the clean utensil drawers was dirty with a thick film of brown grime. 9. The wall behind the three-compartment sink was repaired but not made smooth, this made the surface not easily cleanable. The facility's failure to ensure safe and sanitary conditions in the kitchen resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which could cause food-borne illnesses to a population of 73 of 73 residents who received food from the kitchen and were medically compromised. Findings: 1. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, at 8:04 AM, a glue trap was found in the oven with four dead mice. DSS 1 stated that she did not know that the mice were there. During an interview on June 29, 2021, at 8:13 AM, the Maintenance Supervisor (MS) stated that the pest control company comes monthly and performs the minimum frequency of pest control and more often if needed. The MS stated, the pest control company will check for roaches, rodents, possums and set exterior [NAME] traps. During an observation on June 29, 2021 at 9:49 AM, of the back door in the kitchen, leading outside, the door sweep was damaged, sunlight was visible inside from the bottom of the back door, allowing for pests to enter. During an interview on June 29, 2021, at 10:05 AM, the MS stated that the door sweep gets cracked at the door stop because staff have to prop the door open for deliveries. During an interview with the Registered Dietitian (RD 2) on July 1, 2021, at 9:08 AM, she stated that her expectation is that they do not find any pests and if they do, they should respond immediately. During a review of the report from the Pest Control Company, titled Service Summary Report, dated from March, 25, 2021, the inspection findings indicate that yesterday one of them (mice) was caught on one of our glue boards and was thrown away. During a review of the Pest Control Company reports, titled Service Summary Report, dated March 25, 2021 - June 21, 2021, Under Client Actions it indicates that, Action required: door sweep damaged/missing (kitchen). Replace door sweep. Kitchen receiving door has gaps allowing pest entry. Opened on 12/30/20. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. During a review of the facility policy titled Sanitation: Miscellaneous Areas, dated 2018, the policy indicated that Fly and Vermin Control: all doors and windows must be properly screened. During a review of the FDA Federal Food Code 2017, indicated Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. And Rodent bait shall be contained in a covered, tamper-resistant bait station. Open bait stations may result in the spillage of the poison being used. Also, it is easier for pests to transport the potentially toxic bait throughout the establishment. Consequently, the bait may end up on food-contact surfaces and ultimately in the food being prepared or served. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 2. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 at 8:20 AM, there was a sticky trap under the shelf in the dry storage room with five dead roaches. DSS 1 stated that staff should have discarded the trap. During an interview with the Registered Dietitian (RD 2) on July 1, 2021 at 9:08 AM, she stated that they should not have open sticky traps in the dry storage and as soon as pests are trapped, they should be removed. During a review of the FDA Federal Food Code 2017, Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 3. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, 8:08 AM, the walk-in refrigerator thermometer read 48° Fahrenheit, but should have been 41° Fahrenheit according to DSS 1. The refrigerator contained time/temperature controlled for safety food such as milk, cheese, yogurt, and meat. The temperature of a carton of milk was 49° Fahrenheit and the yogurt was found to be at 52° Fahrenheit. (Safe temperature should be at 41° Fahrenheit or below). The DSS 1 stated that the door to the refrigerator had been open because they just got a food delivery. During an observation on June 29, 2021 at 4:30 PM, the thermometer in the refrigerator read 45° Fahrenheit. The temperature of a milk was 48° Fahrenheit and a block of sliced cheese at 50° Fahrenheit. Safe refrigerator temperature of food is 41° Fahrenheit or below. During an interview with the Registered Dietitian (RD 2) on June 29, 2021 at 5:07 PM, she stated they had this same issue with the refrigerator on June 15th and they had the refrigerator serviced. She stated because they cannot determine if the refrigerator and the food lowered to 41° degrees during the time from 8:00 AM to 4:30 PM on June 29, 2021, they would need to discard all the TCS (time/temperature controlled for safety) foods. During a review of facility document titled Kitchen Sanitation and Food Safety Inspection, dated April 21, 2021, the Registered Dietitian (RD 2) reported that the freezer had frost around freezer door and on the floor- slipping hazard and seal at bottom of fridge door pulling away. A review of the FDA Federal Food Code 2017, indicates that Maintaining TCS (foods that require time and temperature control to prevent pathogen growth) foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness and Except during preparation, cooking, or cooling ., time/temperature control for safety food shall be maintained: at 41° Fahrenheit or less. During a review of facility document titled Cold Storage Temperature Logging, dated 2018, indicates Refrigerator temperature standards are less or equal to 41° Fahrenheit. The goal is to keep the temperature at 34° - 39° Fahrenheit. This will allow for a 2° rise in temperature when the door is opened throughout the day. They will also keep the food at less than 41° Fahrenheit. 4. During an observation and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 between 7:25 AM and 8:04 AM, floors behind the ice machine and under the food carts, under the three compartment sink, under the shelf storing clean metal pots and pans and under the shelves in the dry storage had food debris and trash. The floor and baseboard under the convection oven had a sticky yellow residue and the floor under two stoves had a black grime and rotting food. The DSS 1 stated that the floors should be kept clean. During an interview on July 1, 2021, at 9:08 AM, the Registered Dietitian (RD 2) stated that she was under the impression that the floor was being mopped after each meal. She stated that the person responsible for doing the cleaning was not doing a good job and the areas that she was responsible for were not getting done. She stated that she had identified some issues with temperatures of food on her last inspection in May 2021, so the cleanliness was not a high priority. She had talked to the previous Dietary Services Supervisor (DSS 2) about doing deep cleaning, but she was short staffed at the time and was getting things done slowly. She stated that her expectation was that there should be no food left on the floor and that the stove should be moved to clean under it. During a review of facility policy titled, General Appearance of Food & Nutrition Department, dated 2018, indicated that 1. Floors must be mopped at least once per day, 2. Sweep the floor, pushing all debris forward. Use a dust-pan to remove and dispose of debris as it accumulates . 7. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil marks from baseboards and walls. During a review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 5. During an observation in the kitchen on June 29, 2021 at 7:38 AM, the knobs on the stove that light the burners were covered in a black grime and the front of the stove around the knobs was covered in black grime. During an interview on July 1, 2021 at 9:08 AM, the Registered Dietitian (RD 2) stated that the stoves should be completely clean and not have any buildup. During a review of facility policy titled Ranges and Ovens, dated 2018, indicated, .3. Back apron of the range and other range surfaces should be washed with a hot detergent solution following manufacturer's instructions to remove grease. During a review of the FDA Federal Food Code 2017, indicates Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 6. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, at 7:25 AM, the shelf that was holding the coffee maker and the juice machine had water damage and the edges were deteriorating. The DSS 1 stated that they planned to get that cabinet replaced. During an interview with the Registered Dietitian (RD 2) on July 1, 2021 at 9:08 AM, the RD 2 stated that she documented and put in a request in May 2021 to get the shelf replaced and the Administrator said he would get back to her. During an interview with the Administrator and concurrent record review of the Kitchen Sanitation & Food Safety Inspection, completed by the Registered Dietitian (RD 2) dated in May 2021, it indicated that the shelf holding the coffee maker and the juice machine needed to be replaced. The Administrator stated that he had gotten a quote to get it fixed but has not scheduled for the shelf to get replaced. Review of the facility policy titled Sanitation, dated 2018, indicated All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. During a review of the FDA Federal Food Code 2017, indicates Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and to facility maintenance. Also, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 7. During an observation in the kitchen on June 30, 2021, at 8:46 AM, the food preparation sink drain was directly connected to the sewer and did not have an air gap. During an interview with the Maintenance Supervisor (MS), on July 1, 2021, at 8:21 AM, the MS stated he did not know that the food preparation sink needed an air gap. During a review of the FDA Federal Food Code 2017, indicates A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under 5-202.12. 5-202.13 indicated An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. In addition, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of the plumbing fixture or equipment prevents contamination that may be caused by backflow. 8. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 30, 2021, at 8:46 AM, the enclosed area under the food preparation sink was dirty with a thick layer of brown grime. This area is adjacent and open to the three drawers containing utensils for serving food. The DSS 1 stated that the utensils are clean and could be potentially contaminated by the dirty area adjacent. During an interview with the Registered Dietitian (RD 2) on July 1, 2021, at 9:08 AM, she stated that she expects that area to be clean and not have the potential to contaminate the clean utensils. Review of the facility policy titled Sanitation, dated 2018, indicates All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. 9. During an observation in the kitchen on June 30, 2021, at 8:46 AM, the wall behind the three-compartment sink appeared to have been repaired. Some spackle was used to cover the edges, but the drywall was visible, and the wall was not smooth. It had lumps of spackle. During an interview on July 1, 2021, at 8:21 AM, the Maintenance Supervisor (MS), stated in the room behind the three-compartment sink, there used to be a beauty shop. The sink for the beauty shop water line was connected to the same line as the three-compartment sink. They turned that beauty shop into an office and removed the sink. He stated they did not do a good patch job. During a review of the FDA Federal Food Code 2017, indicates Non-food-contact surfaces shall be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and to facility maintenance. Also, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. During a review of the Facility Census, dated June 29, 2021, it indicates that there were 73 residents. An immediate jeopardy (IJ) (immediate corrective action is necessary because the provider's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called on June 29, 2021 at 1:30 PM, under 483.60(i)(2) - Food Safety Requirements Store, prepare, distribute and serve food in accordance with professional standards for food service safety. The survey team verbally notified the Administrator of the IJ unsanitary conditions in the kitchen. Failure to maintain sanitary conditions in the kitchen had the potential to cause food-borne illness to the highly susceptible residents who received food from the kitchen. The Corrective Action Plan (CAP) included the following: 1 The integrity of the dry goods food was inspected and discarded as needed. 2. In-services were completed by RD 2 Consultant and will be on-going for all dietary staff related to maintaining safe and sanitary conditions of the kitchen. Cleaning of the kitchen will be completed at the beginning and end of the shift. Staff will be in-serviced on where the enclosed traps are located. 3. The sticky trap with 4 dead mice found inside the oven was immediately discarded. 4. The sticky trap in the dry storage with roaches was immediately discarded. 5. The floors under all shelves, and under food carts have food debris and trash were cleaned and trash removed. 6. The floors under the three-compartment sink with food debris were cleaned and trash removed. 7. The floors in the dry storage under shelves with food debris were cleaned and trash removed. 8. The floors under the two stoves and the convection oven with black grime and old food were cleaned. The whole red tomato found rotting under the stove was immediately discarded. 9. The baseboards behind the convection oven with a greasy sticky film and dirt was cleaned. 10. The two drawers storing clean serving utensils with food crumbs were cleaned. 11. The wall behind the dish sprayer spotted with food was cleaned. 12. The knobs on the stove to turn on the burners covered with grime were cleaned. 13. A thorough deep cleaning of the kitchen will be completed June 29, 2021. 14. A pest control company is scheduled to make a visit on June 29, 2021 at 4:00 PM to treat for rodent and roach control of the kitchen and the rest of the facility. The facility is changing pest control companies and the contracted pest control company will be on-site June 29, 2021 at 8:00 PM, and will continue to treat the facility every other week (or more often as needed) for the next six weeks. 15. Preventative measures to include fix kitchen door sweep June 29, 2021. Weekly review of the kitchen by Maintenance Staff will be conducted for any issues that need to be resolved. Pest control reports will be followed up by the Administrator to ensure findings are addressed. 16. A review of all residents will be conducted to monitor for any potential food-borne illness for the next three days. 17. Food temperatures in the refrigerator were obtained. Food items were found to be within acceptable range except for the dairy foods. The dairy food items were discarded and ordered June 29, 2021 to be delivered June 30, 2021. 18. [MEDICATION(S)] sandwiches, three bean salad, milk (replaced from sister facility), thickened juice, ready care 2.0 (High calorie, high protein nutritional drink) for thicken milk, ice cream, and canned pasteurized pears (for puree diets) were served to residents for dinner. Pasta was also purchased as an alternative for patients. 19. The inner seal on the bottom half of the refrigerator was fixed to ensure the refrigerator door shut completely and with minimal effort. The refrigerator temperature will be checked every two hours to ensure 41 degrees Fahrenheit is maintained for the next 12-24 hours. The Refrigeration Specialist will be in to check the refrigerator tomorrow morning June 30, 2021. If it is determined that the refrigerator temperatures cannot be maintained and/or the refrigerator cannot be repaired, the refrigerator will be replaced with a new one. 20. The emergency menu will be used, which does not use refrigerated items, until it is determined that correct refrigerator temperature can be maintained. 21. A refrigerator will be purchased June 29, 2021 to maintain food which has sustained the correct holding (41° Fahrenheit or below) temperature. 22. The Plan will be addressed at the next QAPI (Quality Assurance Performance Improvement) Meeting scheduled for June 30, 2021. The IJ was lifted on June 30, 2021 at 1:56 PM, in the presence of the Administrator, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews and record reviews.

Based on observation, interview, and record review, the facility failed to ensure a safe environment which was free from abuse for four of eight sampled residents (Resident 2, 3, 4 and 5) when: 1. Resident 1 choked, hit (in the face) and kicked Resident 2 in the right lower back. This failure resulted in Resident 2 sustaining a purplish discoloration on her right lower back. 2. Resident 3 struck Resident 1, while trying to defend Resident 2 3. Resident 1 kicked and pushed Resident 4 to the floor. 4. Resident 1 kicked and threw Resident 5 to the floor. This failure resulted in Resident 5 to sustain an abrasion on her right lower knee twice. The facility's failure to protect Residents 2, 3, 4 and 5 from Resident 1's unprovoked assault on them resulted in physical injuries for Residents 2 and 5, and had the potential for psychological harm for Residents 2, 3, 4 and 5. Findings: 1. A review of Resident 1's clinical record Admission record (contains demographic information) indicated, Resident 1 was admitted on (MONTH) 25, 2019 with a [DIAGNOSES REDACTED]. A review of Resident 1's Interdisciplinary Team Note (IDT- a group of clinical staffs from nursing, dietary, activities and social services) dated (MONTH) 28, 2019, at 10:57 AM, indicated, a Licensed Vocational Nurse (LVN 3) who was at the nurses' station in (Memory Care Unit) heard screaming and a loud banging noises coming down from the hall way. When the LVN looked down the hall she saw a chair flying across Resident 1's room. The resident was angry and the LVN tried to get him to stop throwing chairs. He said, Get out of my way b .ch tried to swing, picked a chair up and threw it then walked away. (Name of Resident 1) walked behind resident (Resident 2) and grab(bed) her in a choking position, LVN 3 tried to separate (Name of Resident 1), he pushed her away and then hit resident (Resident 2) on the face, then she fell to the floor. (Name of Resident 1) kicked resident (Resident 2) on her lower back. Resident 2 was remove(d) to safety. (Name of Resident 1) went and pushed another resident (Resident 5) to floor then started to kick Resident 5 on her R(right) hip, Resident 5 was separated to safety. This (Resident 1) pushed another resident (Resident 4) down and kicked her as well. In the process of separating (Name of Resident 1) from hurting other resident, he strikes on the LVN 3. All 3 residents was (were) separated from the aggressor to safety to their individual rooms. Resident 1 continue to have increase agitation and pacing around. LVN 3 called for more help from the upper station and then called the law enforcement. During a review of Resident 1's clinical record History and Physical (H&P) and Discharge (DC) Note (Name of the hospital) dated (MONTH) 25, 2019, prior to Resident 1 being admitted to the facility indicated, Patient while hospitalized was noted on the earlier part of his hospital course to have had multiple code greens (emergency response for combative person) for agitation and combativeness. Psychiatry was consulted due to [MEDICAL CONDITION] (serious mental illness often loose in contact with reality) and agitation and recommended to continue [MEDICATION NAME] (antipsychotic medication) 10 mg (milligrams- a unit of measurement) by mouth every bedtime with [MEDICATION NAME] (antianxiety medication) 1 mg PO (by mouth) twice daily. A further review of the H&P, D/C Note indicated, the facility was made aware of Resident 1's behavior as follows. We were informed that receiving facility has bed alarms that alert staff that patient is out of bed. Receiving facility warned that patient does tend to wander and will need redirection. A further review of Resident 1's hospital discharge medications list included [MEDICATION NAME] 10 mg by mouth every evening at bed time. A review of the section in the hospital Case Management (CM) notes dated (MONTH) 25, 2019, reflected multiple attempts to place this resident which were unsuccessful due to not having skilled needs and due to young age. The notes indicated, reason for continued hospitalization placement in locked facility (a secured facility where a resident must be escorted off and on the unit by staff) vs (versus) home with family, no safe d/c plan. During an interview and record review with the Director of Nursing (DON) on (MONTH) 29, 2019, at 1:46 PM, she stated Resident 1 was initially on the upper station and had multiple attempts to exit from the facility. He never showed any aggressions, just verbalizing to walk out. The DON indicated that following a visit to the emergency room , he was placed on the Memory Care Unit (MCU) per his family's request, upon his return to the facility. During a follow up interview on (MONTH) 29, 2019, at 2:15 PM, with the Director of Nursing (DON) and a concurrent record review of Resident 1's H&P and DC Note(Name of Hospital) dated (MONTH) 25, 2019, she acknowledged the facility did not review this DC Note after Resident 1's admission to the facility. The DON stated, she was supposed to review the records after the resident was admitted and she did not know. The DON stated the facility gets only minimal information during admission. When asked if the facility was reviewing the records after admission, she stated, Yes, we are. During an interview and record review with the facility Case Manager (CM) on (MONTH) 29, 2019, at 2:49 PM, the CM reviewed Resident 1's clinical record and stated the resident had an order for [REDACTED]. During a follow up interview with the DON, on (MONTH) 30, 2019, at 11:00 AM, the DON provided two psychological evaluation assessments for Resident 1 dated (MONTH) 8, 2019, and (MONTH) 16, 2019, written by the psychologist, which the DON stated had been faxed to the facility the day before, after the CM had not been able to locate reports in Resident 1's clinical record. When asked the facility protocol for obtaining notes from the psychologist, the DON stated, He usually types them and he places progress notes in the chart. A review of Resident 1's Psychological Evaluation and Assessment (PEA) dated (MONTH) 8, 2019, written by a psychologist, indicated under symptoms/rationale for treatment: The patient reports symptoms of depression, anxiety, sadness, frustration over memory loss, dependence on staff for care in SNF (skilled nursing facilities) and being away from his family. Hx (history) of wondering (wandering). A further review of Resident 1's PEA dated (MONTH) 16, 2019, indicated, The patient has symptoms of anxiety and depression with frustration over physical problems with episodes of memory loss and wondering (wandering). During an interview with a Certified Nurse Assistant (CNA 1), on (MONTH) 29, 2019, at 3:30 PM, CNA 1 confirmed she worked on the day of the incident (August 27, 2019), when Resident 1 hit multiple residents. CNA 1 stated she came out from her lunch break and found Resident 1 was very aggressive and walking very crazy in the hallway and grabbed Resident 2, punched and threw her on the floor and kicked on her (Resident 2) back. During a telephone interview with the psychiatrist (mental illness physician) on (MONTH) 13, 2019, at 9:20 AM, the psychiatrist stated he never assessed or evaluated Resident 1. The Psychiatrist stated he could not recall about the psychiatry consultation for Resident 1 and was unsure whether they had some insurance problems. The Psychiatrist stated he was made aware of Resident 1 during [MEDICAL CONDITION] meetings at the facility for other residents. The Psychiatrist further stated if he would have seen the resident his notes would be there in the chart and he never assessed or met the resident or reviewed his records (Resident 1). During a review of Resident 2's clinical record Admission Record indicated, Resident 2 was admitted on (MONTH) 22, 2019, with a [DIAGNOSES REDACTED]. During an observation and interview with Resident 2 on (MONTH) 29, 2019, at 12:05 PM, Resident 2 was eating her lunch in the dining room. Resident 2 was awake, alert and Spanish speaking. Resident 2 was interviewed using a facility staff (LVN 1) to translate for Resident 2. LVN 1 stated that Resident 2 said she remembered the incident with Resident 1. Resident 1 was running around Resident 2 and kicked Resident 2. During an observation and interview, with Licensed Vocational Nurse (LVN 1) on (MONTH) 29, 2019, at 3:25 PM, in Resident 2's room, a purplish discoloration at the right lower back of Resident 2 was observed with her permission. LVN 1 stated Resident 2 developed this discoloration after Resident 1 kicked her on (MONTH) 27, 2019. During a review of Resident 2's clinical record IDT Note, dated (MONTH) 28, 2019, at 11:38 AM, indicated, On 8/27/19, an LVN (LVN 3) witnessed as (Name of Resident 2) was walking down the hallway, (when)another resident (Resident 1) walked behind her and placed both hands around her neck try to choke resident. The nurse tried to separate the abuser from (Name of Resident 2), but the other resident (abuser) pushed the staff away in the process hit (Name of Resident 2's) face, then resident fell to the floor and the other resident kicked (Resident 2) on her lower back. The LVN was hit in the process of separating the other resident from (Name of Resident 2). Neuro check and skin assessed, noted some redness around resident's neck with skin intact, no major injury noted. Resident 2 is alert oriented to self, confused, agitated, crying . During a review of Resident 2's clinical record the Progress Notes for nursing was documented as a late entry on (MONTH) 28, 2019, at 4:35 AM, Monitoring resident (Resident 2) for injuries s/p (status [REDACTED]. Resident is sleeping soundly in her own bed at this time. During a review of Resident 2's clinical record the Progress Notes dated (MONTH) 28, 2019, at 9:40 PM, indicated, Resident pacing halls of (Memory Care Unit-MCU), in apparent discomfort, crying and wandering in to other resident's rooms. Compliant with redirection. Upon assessment of bruised area to her right lower back, facial grimacing noted upon palpation. 2. During an observation and interview on (MONTH) 30, 2019, at 12:00 PM, Resident 3 was in the dining room having lunch. Resident 3 was alert and oriented, able to convey his needs and Spanish speaking. Resident 3 was interviewed using a facility staff (LVN 1) to translate for Resident 3. LVN 1 stated that Resident 3 stated he was able to recall the incident. Resident 3 pointed to Resident 2 and stated Resident 1 was kicking Resident 2 and she was on the floor. Resident 3 further stated he punched Resident 1's chest with his fist and Resident 1 was trying to throw a chair at Resident 3 and one of the staff took Resident 3 to his room. Resident 3 stated, Resident 1 was moved out from this unit (sent to the general acute care hospital psychiatric unit for evaluation). During a review of Resident 3's clinical record Admission Record indicated, Resident 3 was admitted on (MONTH) 3, 2019, with a [DIAGNOSES REDACTED]. During a review of facility's document titled Statement dated (MONTH) 27, 2019, by CNA 1, indicated, . When (Name of Resident 3) seen (Name of Resident 1) assaulting (Name of Resident 2), Resident 3's first reaction was to defend (Name of Resident 2). (Name of Resident 3) threw a self-defense punch when (Name of Resident 1) then turned around and charged at (Name of Resident 3). I then grabbed (Name of Resident 1) from charging towards (Name of Resident 3). Resident 1 got upset that I was trying to stop him from hitting (Name of Resident 3) he (Resident 1) started charging at me. I then grabbed (Name of resident 3) ran around the table and took (Name of Resident 3) to his room and blocked the door until (name of the staffs) showed up. 3. During an observation and interview with Resident 4 on (MONTH) 29, 2019, at 12:03 PM, Resident 4 was sitting in the dining room and having her lunch. Resident 4 was alert and oriented to her name. Resident 4 was unable to recall the incident with Resident 1. Resident 4 stated If someone punch me, I would punch him back. Resident 4 did not have any visible injury noted. During a review of Resident 4's clinical record Admission Record indicated, Resident 4 was admitted to the facility on (MONTH) 4, 2014, with a [DIAGNOSES REDACTED]. A review of Resident 4's H&P dated (MONTH) 2, 2019, indicated, Resident 4 can make needs known but cannot make medical decisions. During a review of Resident 4's clinical record the Progress Notes dated (MONTH) 27, 2019, at 8:20 PM, documented as incident note indicated, Resident (4) was ambulating (walking) in hallway when aggressor (Resident 1) pushed resident to the floor and started kicking her. assisted resident (Resident 4) to her room and assessed her head to toe and no noted injuries at this time, asked resident what happened and she has no recollection of the incident and no c/o pain or discomfort. A review of Resident 4's clinical record the IDT note dated (MONTH) 28, 2019, at 7:24 PM, indicated, On 8/27/19, LVN (LVN 3) witnessed resident walking down in hall way when another resident (Resident 1) pushed (Name of Resident 4) to the floor and kicked on resident. (Name of Resident 4) was separated to safety and assisted back to her room. Resident was assessed, no bruises, no redness or scratches, no physical injury noted. Resident 4 had no recollection of the incident event. AO x 0 (Alert, Oriented), confused, agitated, Resident was able to move both upper and lower extremities without any pain or discomfort. 4. A review of Resident 5's Admission Record indicated, Resident 5 was admitted on (MONTH) 23, (YEAR), with a [DIAGNOSES REDACTED]. During an observation and interview, on (MONTH) 29, 2019, at 12:11 PM, Resident 5 was lying in her bed covered with blanket. Resident 5 was alert, oriented to name and place. Resident 5 was unable to recall the incident with Resident 1. During a concurrent observation and interview with LVN 2 at Resident 5's room on (MONTH) 29, 2019, at 12:28 PM, LVN 2 verified Resident 5 had two abrasions on her right knee and that were sustained after the incident with Resident 1. During a review of Resident 5's history and physical examination [REDACTED]. A review of Resident 5's Clinical record the Progress Notes dated (MONTH) 27, 2019, at 8:26 PM, as incident note, indicated, While resident was ambulating down the hallways, she was approached by another resident(Resident 1), who pushed her to the floor and started kicking her on her right hip area. I (LVN 3) tried to separate resident from the aggressor who threw a chair at me and went to attack another resident I managed to help to her room and assessed her for injury and pain. A further review of Resident 5's clinical record dated (MONTH) 29, 2019, at 12:36 PM, indicated, new order per dr.[NAME] for right knee monitor small abrasion every day shift for abrasion for 7 days. A review of the facility's policy and procedure (P&P) titled Abuse Prevention Program revised (MONTH) (YEAR), the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, verbal, or physical abuse . As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members During a concurrent telephone interview and record review, on (MONTH) 12, 2019, at 11:11 AM, with the DON, the DON was requested to review the P&P titled, Abuse Prevention Program revised (MONTH) (YEAR). The DON reviewed the P&P and stated residents had the right to be free from abuse.

Based on observation, interview, and record review, the facility failed to ensure to provide supervision to prevent an avoidable fall for one of three sampled residents (Resident 1), when he was left unattended on his side and rolled off bed. This failure resulted in Resident 1 sustaining a nasal bone fracture (nose bone), cervical spine fracture (neck) which required the use of a C- collar (neck brace), left [MEDICAL CONDITION] which required sutures, and head concussion (bruising of brain). Findings: An unannounced visit was conducted on (MONTH) 12, 2019, at 11:24 AM, to investigate a facility reported incident of a fall with injuries. During an observation on (MONTH) 12, 2019, at 11:40 AM, in the dining room, Resident 1 was laying semi fowler's position (raised head and trunk between 30 to 45 degrees) in the Geri chair with his eyes closed. He had a cervical collar (C-color - neck brace) wrapped around his neck and L shaped suture (stitch) on his left forehead. He was covered with red blanket and well groomed. He was observed having slight eye movement to verbal command and was noted to flutter his feet. A review of Resident 1's face sheet (demographic data), indicated Resident 1 was an [AGE] years old male and admitted to the facility on (MONTH) 4, 2013 with the [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a facility assessment tool) dated (MONTH) 4, 2019, under section G bed mobility status indicated Resident 1 needed extensive assistant (one or two person needed for transfer) with a severe cognitive (memory and thinking abilities) impairment. During an interview and concurrent record review of Resident 1's nurses' progress notes dated from (MONTH) 10, 2019 through (MONTH) 11, 2019 with the Licensed Vocational Nurse (LVN 1), on (MONTH) 12, 2019, at 11:45 AM, LVN 1 stated he worked that morning (on (MONTH) 10, 2019) as a charge nurse when Resident 1 had rolled from the bed when a Certified Nursing Assistant (CNA 3) left him on his side unattended to get a wash cloth from the sink while providing an Activities of Daily living care (ADL care- bathing, feeding etc) at 5:00 AM. This resulted in Resident 1 sustaining a left [MEDICAL CONDITION] and being transferred to the hospital at 8:20 AM. LVN 1 further stated he got a report from the hospital emergency roiagnom on (MONTH) 10, 2019, at 6:00 PM, that Resident 1 had a stable cervical spine fracture, fracture of nose, and sutured left [MEDICAL CONDITION]. LVN 1 stated Resident 1 transferred back to the facility around 10:00 PM the same day with a C-collar and a sutured left [MEDICAL CONDITION]. LVN 1 stated he would never have left the Resident 1 unattended on his side and stepped away. He further stated would gather all supplies before ADL care and call for help when needed. During an interview and concurrent record review of Resident 1's hospital discharge summary, dated (MONTH) 10, 2019, at 9:26 AM, with the Administrator (ADM), on (MONTH) 12, 2019, at 2:35 PM, the ADM stated Resident 1 had a sutured facial laceration, nasal bone fracture, cervical spine (C2) fracture needed C-collar brace, and head concussion. During a review of Resident 1's diagnostic imaging test result from the hospital the following injuries were listed: a. Maxillofacial (face and jaws) CT scan (x ray images of face) result, dated (MONTH) 10, 2019, at 11:01 AM, indicated non displaced (the ends of fractured bone lines up and are not out of place) [MEDICAL CONDITION] bones; b. Cervical spine CT scan result, dated (MONTH) 10, 2019, at 11:05 AM, indicated Stable fracture of C2 (neck bone) with neuro surgery recommends cervical collar at all times. During an interview with the Director of Nursing (DON), on (MONTH) 19, 2019, at 10:00 AM, the DON stated it was an avoidable fall and she (CNA 3) shouldn't have left the resident on his side, lapse in her judgment caused avoidable fall. The DON further stated CNA 3 should have called for help. During a phone interview with CNA 3, on (MONTH) 14, 2019, at 10:45 AM, she stated Resident 1 was being provided ADL care on (MONTH) 10, 2019, around 5:00 AM, turned on his left side facing CNA 3, and CNA 3 stepped away to get a wash cloth from the sink. When she turned back, she saw Resident 1 was rolling out of bed and he fell on his left side with his face down. CNA 3 stated the height of the bed was at her waist level (her height was 5 feet 3 inch) and the distance from the bed to the sink was five steps away. When CNA 3 was calling for help she observed he had a left [MEDICAL CONDITION] (deep cut) with no active bleeding and he was transferred to the hospital for higher level of care. CNA 3 stated this fall was avoidable as she should have turned Resident 1 on his back before she stepped away or should have called for help. The facility policy and procedure titled Bath, Bed revised on February, (YEAR), indicated Steps in the procedure: 1. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached .15. Place wash basin on the over-bed table.