**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary and comfortable homelike environment for one of 25 resident rooms when:1. room [ROOM NUMBER] bed A's privacy curtain was visibly soiled with a thick brown substance.2. room [ROOM NUMBER]'s ceiling vent had visible accumulation of a thick brown dripping substance.These failures had the potential to result in the spread of infection in four medically fragile residents that resided in room [ROOM NUMBER].Findings:1.During a concurrent observation and interview on 9/9/25 at 9:24 a.m. with Maintenance Assistant (MA) in room [ROOM NUMBER], Bed A's privacy curtain, closest to the closet, had numerous areas of a thick black substance dripping down. The MA confirmed the privacy curtain was dirty and stated he needed to replace it. During an interview on 9/9/25 at 3:45 p.m. with the Administrator (Admin), the Admin stated she had gone and viewed room [ROOM NUMBER] Bed A's privacy curtain and confirmed it was dirty. The Admin stated the privacy curtain should have been changed.During a review of the facility's policy and procedure (P&P) titled, Cleaning/Repairing Carpeting and Cloth Furnishings, dated December 2009, the P&P indicated, .cloth furnishings shall be cleaned regularly and repaired promptly.2.During a concurrent observation and interview on 9/9/25 at 9:24 a.m. with MA, in room [ROOM NUMBER], the ceiling vent above bed C had visible accumulation of a thick brown dripping substance. MA confirmed the ceiling vent was dirty and stated it needed to be cleaned.During an interview on 9/9/25 at 3:44 p.m. with the Admin, the Admin stated she had gone and viewed the ceiling vent, and confirmed it was dirty. The Admin stated it was maintenance department's responsibility to clean the ceiling vents, and it should have been completed.Facility did not provide a policy and procedure for cleaning the vents in resident rooms.

Based on interview and record review, the facility failed to ensure one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. This failure had the potential to result in the facility not preventing individuals with a criminal history of abuse, neglect and exploitation to provide care to a medically vulnerable population of 56 residents.Findings:During a concurrent interview and record review on 9/10/25 at 3:26 p.m. with the Administrator (Admin), CNA 1's employee file was reviewed. CNA 1's employee file was missing a background check. The Admin confirmed with HR (human resources) that CNA 1 did not have a background check completed. The Admin stated all employees were supposed to go through the background check process to ensure the facility did not hire an individual that had a criminal history because it could impact the resident's safety.During a review of the facility's policy and procedure (P&P) titled, Background Screening Investigations, dated March 2019, the P&P indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on interview and record review, the facility failed to assess and submit accurate data for one of 14 sampled residents (Resident 27) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 27's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).Findings: During a concurrent interview and record review on 9/11/25 at 11:20 a.m. with Minimum Data Set Coordinator (MDSC), Resident 27's MDS 3.0 Section I- Active Diagnoses, dated 8/1/25, and Active Orders, undated, were reviewed. Resident 27's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 27 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 27's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 27 was admitted to the facility with a previous diagnosis of Chronic Viral Hepatitis C and confirmed Resident 27 had not received any treatment or medication for Chronic Viral Hepatitis C. During an interview on 9/11/25 at 11:40 a.m. with the Administrator (ADMIN), the ADMIN stated Resident 27's Chronic Viral Hepatitis C should not have been coded in MDS under active diagnoses because he was not receiving any treatment or medication for that diagnosis. During a review of CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2024, CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 43) received a shower or bed bath for 16 days. This failure resulted in Resident 43 expressing a level of dissatisfaction with grooming and wanting to be groomed more often.Findings:During a review of Resident 43's admission Record, dated 9/11/25, the admission Record indicated Resident 43 was admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting right dominant side (loss of ability to move the right side of the body due to loss of oxygen to the brain).During a review of Resident 43's Minimum Data Set (MDS- an assessment tool used to guide resident care) Section GG- Functional Abilities, dated 9/5/25, the MDS Section GG indicated Resident 43 required maximal assistance (when a resident requires 50-75% of help from staff) for showering/bathing.During a concurrent observation and interview on 9/8/25 at 4:08 p.m. with Resident 43, Resident 43 had an accumulation of dirt underneath her fingernails and dry flaky skin to the palm of her right hand. Resident 43 stated she only received a couple of bed baths in the past month. Resident 43 further stated she did not receive consistent showers and would like to shower more.During a concurrent interview and record review on 9/11/25 at 9:45 a.m. with the Director of Nursing (DON) the following documents were reviewed:-the facility's Shower Schedule, undated, the facility Shower Schedule indicated Resident 43 was scheduled to be showered on Wednesday's and Sunday's PM (evening) shift.-Resident 43's Task: Shower, dated 8/13/25 to 9/11/25, the Task: Shower indicated Resident 43 did not receive a shower or bed bath for 16 days, during the period of 8/18/25 to 9/2/25.The DON confirmed there was no documentation of Resident 43 refusing a shower or bed bath. The DON stated Resident 43 should have received four showers or bed baths within the 16-day period.During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity, dated February 2020, the P&P indicated, Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction . residents are groomed as they wish to be groomed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the prescribed left hand roll (rolled up wash cloth or towel used to support and position the hand and wrist to prevent contractures-permanent shortening or tightening of muscles resulting in limited range of motion and stiffness in the hand) was applied as ordered by the physician for one of 14 sampled residents (Resident 54). This failure had the potential to result in Resident 54's decline in functional abilities.Findings:During a review of Resident 54's admission Record, dated 9/11/25, Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE] with a diagnosis of left-hand contracture.During a review of Resident 54's Care Plan Report, dated 3/4/18, the Care Plan Report indicated, [Resident 54] has an ADL [Activities of Daily Living-basic personal tasks] self-care performance deficit r/t [related to] limited mobility, Dementia [progressive decline in cognitive abilities], contracture of left hand (admitted with). Requires total care with all ADLs . is not able to initiate needs request and requires staff support to have needs are and concrete addressed and met by staff . CONTRACTURES: has contracture of the left hand . Left Hand roll on in AM and off in PM .During multiple observations on 9/8/25 between 1:39 p.m. to 2:52 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair (specialized recliner designed for individuals with limited mobility) with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During multiple observations on 9/9/25 between 8:45 a.m. to 4:21 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During a concurrent observation and interview on 9/9/25 at 4:21 p.m. with the Infection Preventionist (IP), in Resident 54's room, Resident 54 was sitting in her Geri-chair with left wrist bent downward at an angle and did not contain a brace, splint or hand roll. IP stated Resident 54 should have had a hand roll in her left hand.During a concurrent interview and record review on 9/9/25 at 4:30 p.m. with the Director of Nursing (DON), Resident 54's Physician Order, dated 4/5/21 was reviewed. Resident 54's Physician Order indicated Place Hand Roll in Left Hand, On in the Morning and off at Night. Approximately 8 hours. The DON stated Resident 54 should have had a hand roll applied to her left hand.During an interview on 9/10/25 at 10:03 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 54's preventative measure for worsening of the contracture was to follow the physician order and apply the hand roll daily.Facility did not provide a policy and procedure for following physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when one of two licensed nurses were observed and made the following medication errors:1. Resident 74 did not receive the correct dosage of Baclofen (muscle relaxant medication used to treat muscle stiffness, spasms and pain) in accordance with the physician order.2. Metformin (medication used to treat type 2 diabetes- chronic condition when the body does not regulate blood sugars) was not given with breakfast in accordance with the physician order for Resident 12.These failures resulted in two identified medication errors out of 30 opportunities for medication administration. The facility's overall medication error rate was 6%.Findings:1.During a review of Resident 74's admission Record, dated 9/11/25, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome (consistent pain that significantly interferes with daily life).During a concurrent observation and interview on 9/9/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 removed 1 tablet of baclofen 10mg (milligram- unit of measurement) from the blister pack (packaging of medication that is individually sealed in plastic with cardboard backing), cut the tablet in half and added it to a medicine cup containing eight pills. LVN 1 counted all medications in the medicine cup and stated there was a total of ten pills, including the medication that was cut in half. LVN 1 then administered all medications to Resident 74.During a concurrent interview and record review on 9/9/25 at 12:38 p.m. with LVN 1, Resident 74's Physician Order, dated 9/3/25 was reviewed. The Physician Order indicated, Baclofen Oral Tablet 15 MG, Give 1 tablet by mouth three times a day for muscle spasms. LVN 1 confirmed he administered only 10 mg of Baclofen to Resident 74 and stated he should have given an additional half tablet of baclofen to equal the physician order of 15 mg.During an interview on 9/9/25 at 3:29 p.m. with the Director of Nursing (DON), the DON stated the expectation for nurses administering medication, was to confirm the dosage given with the physician order.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medication. Pour the correct number of tablets or capsules into the medication cup.2.During a review of Resident 12's admission Record, dated 9/11/25, admission Record indicated Resident 12 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.During an observation on 9/9/25 at 9:43 a.m., Resident 12 was in her room and no breakfast tray was observed. LVN 1 removed 1 tablet of Metformin 500 mg from the blister pack that had a label Give 1 tablet by mouth with Breakfast and Dinner. LVN 1 then administered the Metformin to Resident 12 without breakfast.During a concurrent interview and record review on 9/9/25 at 12:26 p.m. with LVN 1, Resident 12's Physician Order, dated 12/11/23 was reviewed. The Physician Order indicated, metFORMIN. Give 500 mg by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA with breakfast and dinner. LVN 1 confirmed Resident 12 ate breakfast prior to medication administration and stated breakfast meal trays were distributed at 7 a.m. LVN 1 further stated Resident 12's Metformin should have been given within 30 minutes of eating breakfast.During an interview on 9/9/25 at 3:31 p.m. with the DON, the DON stated when medication was ordered to be administered with breakfast, the medication was expected to be administered while eating breakfast.During an interview on 9/11/25 at 11:14 a.m. with the Pharmacist (Pharm), the Pharm stated manufacturer recommends to administer Metformin with food to prevent GI (gastrointestinal- stomach) discomfort.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Medications that require specific instructions for administration are administered in a way that complies with manufacturer's recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely store drugs in accordance with acceptable standards of practice when Resident 30's Naloxone (fast-acting medication that reverses an opioid [pain medication] overdose) had an expiration date of [DATE] and stored in a medication cart. This failure had the potential for Resident 30 to be administered an expired medication.Findings:During a review of Resident 30's admission Record, dated [DATE], admission Record indicated Resident 30 was admitted to the facility on [DATE] with a diagnosis of diverticulitis (inflammation and/or infection of the large intestines that can cause sudden or intense pain).During a concurrent observation and interview on [DATE] at 5:05 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 30's naloxone nasal spray had an expiration date of 7/2025 in a medication cart. LVN 2 stated the naloxone should have been discarded.During an interview on [DATE] at 4:21 p.m. with the DON, the DON stated all medications that were expired should have been discarded.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure three of four outside dumpsters' were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 56 residents.Findings:During a concurrent observation and interview on 9/8/25 at 1:30 p.m. with the Dietary Manager (DM) outside of the building near the kitchen, there were three dumpsters with overflowing garbage that were uncovered. There was foul odor and many flies coming from the dumpsters. The DM stated the dumpsters should have been covered.During a follow up interview on 9/11/25 at 10:37 a.m. with the DM, the DM stated the maintenance department was responsible for ensuring the dumpsters were maintained and closed. The DM further stated dumpsters needed to remain closed to prevent an attraction of pests that could lead to contamination of food. During a review of the facility's policy and procedure (P&P) titled Food-Related Garbage and Refuse Disposal dated October 2017, the P&P indicated, .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement an infection prevention and control program when:Personal Protective Equipment (PPE-specialized clothing or equipment used to provide a barrier and reduce exposure to hazards or infections) was not disposed correctly outside of Resident 67's room.Seven of seven residents (Resident 18, 24, 32, 45, 52, 66, and 73) were on Enhanced Barrier Precaution (EBP-infection control intervention used to prevent the spread of MDROs- bacteria that is resistant to most antibiotics) and did not have PPE available immediately outside the resident's room in accordance with The Center for Disease Control and Prevention (CDC) guidelines.These failures had the potential to place residents at risk for cross contamination that could lead to illness.Findings: 1.During a review of Resident 67’s “admission Record,” dated 9/10/25, the “admission Record” indicated Resident 67 was admitted to the facility on [DATE] with a diagnosis of COVID-19. During an observation on 9/8/25 at 2:16 p.m. outside of Resident 67's room (room [ROOM NUMBER]), there was a face shield hanging on the back side of the resident’s door, facing towards the inside of the room. The face shield had unlabeled and undated. Resident 67's room did not have a sign indicating the resident was on any isolation precautions (preventative measures used to prevent the spread of germs by creating barriers and implementing safe practices). During an interview on 9/10/25 at 2:55 p.m. with the Licensed Vocation Nurse (LVN) 1, LVN 1 stated Resident 67 was positive for COVID-19 upon admission to the facility, but had been cleared to come off isolation precautions. LVN 1 stated the face shield should have been removed after Resident 67 was taken off of isolation precautions for COVID-19. During an interview on 9/11/25 at 10:48 a.m. with the Infection Preventionist (IP), the IP stated the face shield in Resident 67's room should have been discarded since Resident 67 was cleared from isolation precautions. The IP further stated the face shield could have led to cross-contamination. During a review of the facility policy and procedure (P&P) titled, Isolation - Initiating Transmission-Based Precautions, the undated P&P indicated, .When Transmission-Based Precautions are implemented, the Infection Preventionist .clearly identifies the type of precautions, the anticipated duration and the personal protective equipment that must be used .Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met . 2. During an observation on 9/8/25 at 1:53 p.m. Resident 18, 24, 32, 45, 52, 66 and 73 had EBP signs posted on the wall above the resident name tags. In addition, there was no PPE posted outside of Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). During a concurrent interview and record review on 9/9/25 at 3:32 p.m. with the Infection Preventionist (IP), the Director of Nursing (DON) and the Administrator (Admin), the following documents were reviewed: -The “California Department of Public Health (CDPH)’s All Facilities Letter (AFL) 24-15,” dated 6/13/24, the document indicated, “California SNFs [Skilled Nursing Facilities] should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) . for guidance and tools for implementing EBP…” -CDC’s “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),” dated 4/2/24, the document indicated, “When implementing… Enhanced Barrier Precautions, it is critical to ensure staff have… access to appropriate supplies. To accomplish this… Make PPE, including gowns and gloves, available immediately outside of the resident room…” The IP, DON, and Admin confirmed the PPE was not available immediately outside Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). The IP, DON and Admin further stated the PPE should have been available immediately outside of the resident rooms. During a review of the facility’s policy and procedure (P&P) titled, “Enhanced Barrier Precautions,” dated December 2024, the P&P indicated, “Personal protective equipment and alcohol-based hand-rub are readily accessible to staff…”

Based on interview and record review, the facility failed to provide a Report of the results of their investigations to the State Survey Agency, within 5 working days of the incident. This was for one of one reports of alleged elder abuse. This failure has the potential for the facility to miss data and not make the needed changes to prevent abuse. Findings: During a review on 3/17/25 at 9:00 a.m., the report of suspected dependent adult/elder abuse, dated 3/14/25, was reviewed. The document indicated the alleged incident occurred on 3/14/25. During an interview on 3/17/25 at 10:25 a.m., the Administrator stated the 5-day report was in process and acknowledged that the 5-day report needed to be completed and sent to the department in one or two days. During record review on 3/24/25 at 9:20 a.m., the 5-day report from the facility about their investigation into the alleged abuse, was not available. The Department sent an email to the facility administrator on 3/24/25 at 9:20a.m., to request a copy of the 5-day report and documentation that the report had been sent timely. During an interview on 3/24/25 3:00 p.m., Administrator stated that she was busy with personal business and forgot to send in the 5-day report to the department. Administrator stated she would send the report as soon as possible. During a review of emails, paper mail, and attachments in the federal electronic program, on 3/27/25 at 9:30 a.m., the 5-day report was not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to develop and implement person-centered care plans for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for Resident 20. (Cross reference F684) Findings: A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. During an interview and concurrent record review with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about the facility's policy for care planning, the DON stated resident's change of condition should have care plan. She stated nurses in charge of the resident should initiate a care plan then the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) including the DON were responsible to review and make sure the care plan was in place. After review of Resident 20's electronic record, the DON stated there was no care plan developed for Resident 20 to address the care needed after his left eye surgery. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., when Licensed Staff D was asked about the facility's policy for care planning, Licensed Staff D stated nurses were expected to initiate a care plan should a resident have a change of condition. A review of the Facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised on March 2022 indicated, The comprehensive, person-centered care plan: a) includes measurable objectives and time frames; b) describes the services that are to be furnished to obtain or maintain the residents highest practicable physical, mental, and psychosocial well-being.; . e) reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to follow their Medication Storage Policy, when 3 expired COVID 19 Vaccines and 1 box of Arginaid (wound healing nutrition) were found in the facility's Medication Storage room and another expired box of Arginaid was found in Medication Cart 1. This failure had the potential to result in Residents being injected with an expired ineffective COVID 19 vaccine resulting in an unvaccinated status as well as expired deteriorated Arginaid being ineffective for wound healing. Findings: During an observation on [DATE] at 12:55 p.m., in Medication Cart 1, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 12:59 p.m., in the Medication Storage room, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 1 p.m., in the Medication Storage room, 3 expired Covid 19 vaccines were observed with an expiration date of [DATE] in the medication refrigerator as well as 1 box of expired Arginaid found on the shelf with an expiration of [DATE]. During an interview with Licensed Staff C on [DATE] at 1:10 p.m., Licensed Staff C queried as to the risk to Resident safety if the Resident were to receive an expired Covid 19 vaccine. Licensed Staff C stated, she thinks the risks would be the Resident would not be effectively vaccinated due to the deterioration of the COVID 19 medication in the vial. Licensed Staff C queried as to what the risks would be to Resident safety if the Resident were to receive expired Arginaid for their wound. Licensed Staff C responded, she doesn't believe the expired Arginaid would be beneficial to support wound healing and the wound could get larger. During a review of the facility's policy and procedure titled, Medication Storage dated, 2007, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Medication storage conditions are monitored on a regular basis as a random quality assurance check. During a review of the Infection Preventionist Job Description, Revised [DATE], indicated, monitor the designated shelf life of sterizlied and packaged supplies; reprocess as necessary. Order inventories of vaccines to be adminsitered to staff and residents in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to assess and monitor for signs of after surgery complications for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure had the potential for Resident 20 to develop an unidentified bacterial eye infection which could result in Resident 20's discomfort. Findings: A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., when Licensed Staff D was asked about the facility policy for resident's who had a change of condition (COC), Licensed Staff D stated nurses would monitor the resident for any complications from the COC. Licensed Staff D concurred that Resident 20's left eye surgery was considered a COC. When Licensed Staff D was asked what should the nurses monitor after Resident 20's eye surgery, Licensed Staff D stated nurses would monitor for signs of eye infection like eye discharges, redness, itching and eye discomfort. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about her expectation from the nurses after Resident 20 had eye surgery, the DON stated she expected the nurses to assess and monitor for any signs of complications from the eye surgery, like eye infection and pain every shift for seventy two (72) hours as standard practice and document their observations. After review of the nurses' progress notes from 4/9/24 to 4/19/24 with the DON, the DON stated there was no documentation from the nurses to show Resident 20 was assessed and monitored for signs of complications after the eye surgery. Review of the Facility policy and procedure titled Acute Condition Changes - Clinical Protocol revised on March 2018 under Monitoring and Follow-up indicated, The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure Ophthalmic (pertaining to the eye) medications were administered according to the doctor's order for two of 15 sampled residents (Resident 20 and Resident 41) when: 1. a. Resident 20 who had left eye surgery did not receive the ordered Ofloxacin Ophthalmic Solution 0.3%, (an antibiotic used to treat bacterial infections of the eye) three days after the medication was ordered, and (b) Resident 20 did not receive the medication according to the ordered administration time. These failures had the potential risk for Resident 20 to develop bacterial eye infection and eye discomfort. (Cross reference F684) 2. Resident 41 who had a diagnosis of Glaucoma (an eye diseases that can cause vision loss and blindness) did not receive his eye medications according to the ordered administration time. These failure had the potential risk for Resident 41 to experience eye pain and deterioration of visual function. Findings: Resident 20 During an interview with Resident 20 on 4/15/24 at 4:02 p.m., Resident 20 stated he had a new order for eyedrop after his eye surgery and did not get the medication until after two days. Resident 20 stated he was supposed to have the eyedrops at 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. but the nurses were late in giving his eye drops. A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. A review of the document titled Order Summary Report indicated a Physician's Order written on 4/10/24 for Ofloxacin Ophthalmic Solution 0.3%, to give one drop in left eye four times a day. a. A review of the document titled Pharmaceuticals Shipping Manifest dated 4/14/24 indicated the Ofloxacin 0.3% eye drop was received on 4/14/24 at 10:53 p.m. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., Licensed Staff D stated Resident 20 had left eye surgery and currently receiving antibiotic eye drops. A review of the Medication Administration Record (MAR) for Resident 20 with Licensed Staff D from 4/10/24 to 4/13/24 indicated 3 with the nurse's initials under the Ofloxacin order. When Licensed Staff D was asked what 3 stand for, she stated to hold (an order to suspend the medication administration under specific conditions) the medication and to see nurses' notes for reason of holding the medication. However, after review of the nurses' progress note with Licensed Staff D, Licensed Staff D stated the progress note did not indicate reason for holding the medication. She stated the medicine could be unavailable. When Licensed Staff D was asked about the risks for Resident 20 for the delayed administration of eye antibiotic after his eye surgery, she stated Resident 20 could be at risk for eye infection and eye pain. During a review of the MAR for Resident 20 and concurrent interview with Licensed Staff C on 4/19/24 at 10:31 a.m., Licensed Staff C verified the order for Ofloxacin was written on 4/10/24 and that nurses documented 3 from 4/10/24 to 4/13/24. When Licensed Staff C was asked why was the eye antibiotic not given for three days, Licensed Staff C stated she called the pharmacy and was told the medicine won't be delivered until 4/16/24 due to Resident 20's medical insurance. When Licensed Staff C was asked if Resident 20's physician was notified that the medicine won't be delivered until 4/16/24, she stated she was not sure if Resident 20's physician was notified. When Licensed Staff C was asked about the risks for Resident 20 for the delayed administration of the eye antibiotic, Licensed Staff C stated Resident 20 had the potential risk for eye infection, swelling, redness, pain and burning sensation. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about the facility's medication administration policy for new ordered antibiotic, the DON stated antibiotic medications should be given as soon as possible, within 4 hours. When the DON was asked if she was aware that the Ofloxacin delivery was delayed due to Resident 20's medical insurance, the DON stated no. She stated if she was notified that the medicine could not be delivered on time, she could fill up an authorization form to expedite the process to avoid the delay. The DON stated risks for delayed treatment would be eye infection. b. A review of the document titled Medication Administration Audit Report indicated Resident 20 received Ofloxacin Ophthalmic Solution 0.3% one drop to his left eye on the following dates and times: - On 4/15/24, Resident 20 received the medication at 12:22 p.m. for the scheduled 8:00 a.m. dose. - On 4/16/24, Resident 20 received the medication at 10:15 a.m. for the scheduled 8:00 a.m. dose; and 6:00 p.m. for the scheduled 4:00 p.m. dose. - On 4/17/24, Resident 20 received the medication at 11:04 a.m. for the scheduled 8:00 a.m. dose; and 6:28 p.m. for the scheduled 4:00 p.m. dose. - On 4/19/24, Resident 20 received the medication at 1:57 p.m. for the scheduled 8:00 a.m. dose; and 6:14 p.m. for the scheduled 4:00 p.m. dose. - On 4/20/24, Resident 20 received the medication at 10:04 a.m. for the scheduled 8:00 a.m. dose; 6:31 p.m. for the scheduled 4:00 p.m. dose; and 10:55 p.m. for the scheduled 8:00 p.m. dose. - On 4/21/24, Resident 20 received the medication at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with Licensed Staff D on 4/22/24 at 1:34 p.m., when asked about the facility's policy for medication administration, Licensed Staff D stated nurses could administer scheduled medications an hour early or an hour late and expected to document on the resident's MAR immediately after administering the medications. Resident 41 During an interview with Resident 41 on 4/15/24 at 3:38 p.m., Resident 41 stated he often gets his medicines including his eye drops a couple of hours late. He stated he was supposed to get the eyedrops three times a day in the morning, at noon and at night. A review of the document titled admission Record indicated Resident 41 was admitted on [DATE] with diagnosis including but not limited to Glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight) and Hypertension (High Blood Pressure). A review of the document titled Order Summary Report indicated a Physician's Order written on 2/26/24 for Prolensa Ophthalmic Solution 0.07% (used to treat pain or swelling of the eye following cataract surgery [a procedure to remove the lens of the eye] to give one drop in right eye two times a day for Glaucoma; a Physician's Order written on 3/19/24 for Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2% (used to treat increased pressure in the eye caused by glaucoma) to give one drop in right eye two times a day for Glaucoma, and Timolol Maleate Ophthalmic Solution 0.5% (used to treat high pressure inside the eye due to glaucoma) to give one drop in right eye two times a day for Glaucoma. A review of the document titled Medication Administration Audit Report indicated Resident 41 received Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2%; Timolol Maleate Ophthalmic Solution 0.5%; and Prolensa Ophthalmic Solution 0.07% on the following dates and times: - On 4/16/24, Resident 41 received the medications at 10:19 a.m. for the scheduled 8:00 a.m. dose. - On 4/17/24, Resident 41 received the medications at 11:45 a.m. for the scheduled 8:00 a.m. dose. - On 4/20/24, Resident 41 received the medications at 10:13 a.m. for the scheduled 8:00 a.m. dose. - On 4/21/24, Resident 41 received the medications at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with the DON on 4/23/24 at 1:41 p.m., when the DON was asked about the facility's policy for medication administration, she stated nurses have one hour before and one hour after the scheduled time to give the medications and nurses were expected to document as soon as the medications were given to the residents. Review of the Facility policy and procedure titled Medication Administration General Guidelines dated 9/2018 indicated, Medications are administered in accordance with written orders of the prescriber . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center.

Based on observation, interview and record review, the facility failed to ensure two of two residents, Resident 9 and Resident 19, received action, obtain feedback, and conduct systematic investigations to improve quality of care, quality of life and resident's safety during Quality Assurance and Performance Improvement (QAPI) meetings when: 1) The Director of Staff Development (DSD) did not report an incident reported by an Ombudsman of verbal abuse and mocking (imitating behavior) towards Resident 9 by Unlicensed Staff L. DSD did not inform the Administrator of the abuse allegation. ADM was the abuse coordinator. 2) Resident 19 attempted to complain to DSD regarding an alleged verbal abuse by Unlicensed Staff M & Unlicensed Staff N . DSD did not follow up with Resident 19 about the allegation and did not inform ADM nor the Inter Department team (IDT) during their daily IDT meeting & monthly meetings of QAPI. Findings: (1) During a concurrent interview and record review on 4/19/24 at 9:39 a.m. the Director of Staff Development (DSD) stated that she was the supervisors for the Certified Nursing Assistance (CNA). When asked the DSD if an Ombudsman reported to her about a CNA who was verbally aggressive to a resident, DSD answered yes. DSD stated that the Ombudsman reported to her about a staff who was imitating a resident. DSD filled out a form titled Employee warning/coaching documentation for Unlicensed Staff L (CNA). A review of the form dated 2/26/24 indicated that Ombudsman notified DSD/DON (Director of Nursing) Under Action taken verbal warning, corrective action by employee was an in-service title residents/patients' rights and will not imitate noise of resident's voice/sound. When asked DSD, did you inform the Administrator (ADM) regarding the alleged verbal abuse incident, DSD answered not sure, maybe I have. DSD stated she knew that the Director of Nursing (DON) was aware of this alleged abuse. When asked DSD, did you notify a law enforcement and State Agency, DSD answered No. During an interview on 4/1824 at 11:32 a.m., the administrator (ADM) stated that she was the Abuse Coordinator. ADM stated her managers made rounds once per week, talked with residents, report any type of abuse to social worker, managers, to reach out to family or conservator. ADM stated that all types of abuse was to be reported to her. ADM stated that once she received any allegation of abuse that she would investigate, interview resident, staff to determine if abuse occurred. ADM stated that part of the abuse was to report to State Agency, Ombudsman, Law enforcement, and Medical Doctor. When asked ADM, did you know about an incident happened between Unlicensed staff L allegedly imitating the noise that Resident 9 made, ADM stated, she was not aware of that incident. ADM stated that no one had informed her. When asked ADM, what was your expectation from your management when there was an alleged abuse, DM stated that she expected her management to inform her of alleged abuse. ADM stated that they meet Monday thru Friday in the morning for management meeting. When asked ADM if she recalled any report about this incident between Unlicensed Staff L and Resident 19 during the daily meeting, ADM stated No. (2) During a concurrent interview and record review on 4/17/24 at 12:44 p.m., in Resident 19's room, Resident 19 stated that Unlicensed Staff M and N scolded her saying you are stressing me out. Resident 19 stated that she was upset from being scolded, so she said that she yelled at them back. Resident 19 stated that she informed the DSD briefly and DSD said that she would be back, it happened approximately last week, not sure of the exact date. Resident 19 stated that she did not hear back from DSD. Resident 19 stated that Unlicensed Staff M & N were not assigned to her anymore. During an interview on 4/18/24 at 11:32 a.m. ADM stated that she was not aware that Resident 19 had a verbal altercation with the Unlicensed Staff M & N. ADM stated that DSD did not mention it to her. ADM stated that she met with the Management Team (IDT) from Monday through Friday to discussed new issues. When asked ADM, do you recall when your Management Team discussed these verbal altercations between Unlicensed nurses L, M & N and Residents 9 and Resident 19, ADM stated No, she was not aware. During an interview on 4/19/24 at 10:30 a.m. with the DSD, DSD stated Resident 19 requested to speak to her for an alleged verbal altercation between resident and staff. DSD stated, she recalled that Resident 19 wanted to speak to her, but she was not able to go back to Resident 19's room. When asked DSD, did you inform another management or ADM that Resident 19 would like to report a verbal altercation, DSD stated No. During a concurrent interview and record review on 4/22/24 at 1:19 p.m. ADM stated that if a resident complains, it would be discussed in management (IDT) meeting. ADM stated that during IDT meeting daily, the abuse events were discussed or reported. ADM stated that the Ombudsman never informed her regarding abuse that involved Resident 9 and Unlicensed Staff L. ADM stated that the Ombudsman asked her about a specific last name of an Unlicensed Staff, but she never told her why. ADM stated that the topic or issues discussed during QAPI, personnel improvement plan and employee health files. When asked ADM, during your QAPI meeting, had any of your management mentioned anything about alleged verbal altercation or abuse, ADM stated, No, there were no discussion. A review of the facility's Policy & Procedure titled Quality Assurance and Performance Improvement (QAPI) Plan revised 4/2014 indicated This facility shall develop, implement and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolved identified problems Under objectives, 1) Provide a means to identify and resolve present and potential naive outcomes related to resident care and services: 3) Provide structure and processes to correct identified utility and/or safety deficiencies: 4) Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5) Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively ad to delineate lines of authority, responsibility and accountability. Under Authority: 1) The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program. 2) The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.

Based on observation, interview and record review, the facility failed to ensure the posted daily staffing schedule had an additional required information such as census (number of residents in the facility), the total numbers of Licensed and Unlicensed staff and the actual hours worked individually, reflect staff absences on that shift due to call-outs and illness, and clearly identify the staff's name in a clear and readable format. This failure had the potential to result in poor and inadequate care that compromised the health and safety of residents. Findings: During a concurrent observation and interview on 4/18/24 at 4 p.m. with the Administrator (ADM), during a tour to the nurses' station where the daily staffing was located, the daily staffing for Licensed and Unlicensed nurse was located inside a binder. ADM stated that the daily staffing was readily available to read to all visitors, staff, and residents. During a concurrent interview and record review on 4/18/24 at 4 p.m. at the nurses' station, when Administrator (ADM) was asked do you have the census written on the daily staffing, ADM answered no. When asked ADM, how do you differentiate the staff's name listed on the daily staff list as there were no last name or last name initial, since you have multiple staff with the same first name, ADM answered, yes, she does not see the last name. ADM stated, she would change the format of the posting for daily staff assignments.

Based on observation, interview and record review, the facility failed to provide a fully credentialed Infection Preventionist (nurse who surveys and monitors infection prevention and control). This failure had the potential for Residents to obtain infections and be placed on unnecessary medications due to lack of infection control surveillance. During an interview with the DON on 4/16/24 at 10:30 a.m., DON queried as to who the Infection Preventionist is for the facility. DON stated, the nurse who has been working as the Infection Preventionist (Licensed Staff H) resigned 12/29/23. DON stated, Licensed Staff H and Licensed Staff I have been filling in. DON queried for the facility's staffing sign in sheets for Licensed Staff H and Licensed Staff I from 1/3/24 to 4/15/24. DON also queried for the timecard accounting for License Staff H and Licensed Staff I from 1/3/24 to 4/15/24. During a record review of Licensed Staff H's timecard for the time frame 1/3/24 to 4/15/24. License Staff H's worked day shift on 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24. During a record review of Licensed Staff H's Staffing Sign in sheets for 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24, Licensed Staff H's timecard revealed that none of these dates was Licensed Staff H signed in to work as the Infection Preventionist. During a record review of Licensed Staff H's HR File, Certificate of Training for Infection Prevention 2-Day Course from CDPH (California Department of Public Health), dated, 9/12/19. No other Infection Preventionist training was found in Licensed Staff H's file as well as no annual continuing education CEU's. During a record review of Licensed Staff I's timecard for the time frame of 1/3/24 to 4/15/24, Licensed Staff I worked day shift on 1/4/24, 1/11/,24, 1/12/24, 1/16/24, 1/17/24, 1/25/24, 2/1/24, 2/5/24, 2/6/24, 2/12/24, 2/18/24, 2/20/24, 2/22/24, 2/26/24, 3/26/24 and was signed in on the Staffing Sign In sheets as the Infection Preventionist. Licensed Staff I worked as an Infection Preventionist from 1/3/24 -4/15/24 for a total of 15 shifts. During a record review of Licensed Staff I's HR File, Certificate of Training for infection Prevention 2-Day Course from CDPH, dated, March 1, 2024. This Certificate was 2.5 months after License Staff H resigned. Licensed Staff I started working as an Infection Preventionist on 1/4/23 without Infection Preventionist certification. No other credentialing prior to March 1, 2024, was found in Licensed Staff I's HR File. During an interview with the DON on 4/15/24 at 10:30 a.m., DON queried for the facility's policy for Infection Preventionist. No policy received. DON queried if both the DON position and the DSD position required a full-time nurse. DON responded, yes. During a review of the CDPH's Entrance Conference Worksheet, dated 4/15/24, Line 21, indicated, Name of facility's infection preventionist (IP). Documentation of the IP's primary professional training and evidence of completion of specialized training in infection prevention and control. This information was requested in writing from the ADM but no name or certification was received for the facility's Infection Preventionist. During a review of the facility's policy and procedure titled, Antibiotic Stewardship - Staff and Clinician Training and Roles Revised 2016, indicated, The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship Program, including appropriate prescribing, monitoring and surveillance of antibiotic use and outcomes. Nursing and Direct Care Licensed Staff - Nurses will receive initial orientation and ongoing training on: The facility's Antibiotic Stewardship Program, including the need for judicious use of antibiotics; how to utilize the standardized assessment and communication tool for resident suspected of having an infection; How to communicate with resident and family about the need for appropriate use of antibiotic; specific information that should be reported to the physician or provider upon identifying sign and symptoms of possible infection and specific information that should be obtained when an order for an antibiotic is received. Director of Nursing and the Infection Preventionist - Administration and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on: the facility's antibiotic Stewardship Program; the rationale for judicious use of antibiotics; how to use surveillance tools to monitor infection rates, antibiotic usage patterns and outcomes; how and when to gather data to present to the Infection Prevention and Control Committee for scheduled meetings; and individual roles and responsibilities in maintain antibiotic stewardship. The DON will monitor individual resident antibiotic regimens, including reviewing clinical documentation supporting antibiotic orders; and compliance with start/stop dates and/or days of therapy. The IP will audit, and the DON will provide feedback to providers on antibiotic prescribing practices. IP will monitor over time and report to the IPCC. a) measures of antibiotic start, resident days, and days of therapy. b) antibiotic susceptibility patterns (antibiogram data for specific timeframe) and c) negative outcomes or events related to antibiotic use for example C difficile infections, adverse drug event and antibiotic resistance rates. The IP will obtain, and the DON will provide to healthcare practitioners, educational resources and materials about antibiotic resistance and opportunities for improved antibiotic use. During a review of the facility's policy and procedure titled, Facility Assessment revised, April 2023, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the following: Administrator, A representative of the governing body, Medical Director, DON, and Infection Preventionist. Once the reviews of the resident needs and the facility resources are conducted, the facility assessment consists of systematically evaluating how well aligned these are. Each department provides input on current or potential gaps in care or services due to possible misalignment or lack of appropriate resources. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. This assessment is based on information acquired during a facility-based infection control risk assessment, as well as a community-based risk assessment. During a review of the facility's policy and procedure titled, Administrative Management (Governing Board) Revised April 2023, indicated, The governing board shall be responsible for the management and operation of the facility. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The administrator is appointed by and accountable to the governing board. The governing board is responsible for but is not limited to: Oversight of facility care and services in accordance with professional standards of practice and principles. Establishment and ongoing review of all administrative programs governing facility management and operations, including Corporate Compliance Program .Quality Assurance and Performance Improvement program, and Staff orientation, training and development programs. Creation of and participation in the annual facility-wide assessment: Provision of a safe physical environment equipped and staffed to maintain the facility and services. During a review of the DON's job description, revised October 2020, indicated, Safety and Sanitation Ensure that nursing services personnel follow established infection prevention and control procedures. During a review of the Infection Preventionists job description, revised October 2020, indicated, Primary Purpose of this position is to plan, organize develop, coordinate, and direct the facility infection prevention and control program and its activities in accordance with the current federal, state, and local standards, guidelines and regulations that govern such programs and as directed by the Administrator and the infection Prevention and Control Committee. Administrative Functions: Plan develop, implement, evaluate and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities. Establish and maintain an infection surveillance program that is based on standardized definitions of infections. Review, summarize and report data relative to key infection prevention and control initiatives including antibiotic stewardship, healthcare acquired infections, immunization programs and outbreaks. Present findings from special investigations and make recommendations to the Infection Prevention and Control Committee. Participate in the annual facility assessment, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.

Based on observation, interview, and record review the facility failed to adhere to safe injection practices when one Licensed Nurse (Licensed Nurse A) was observed recapping an insulin needle before injecting one Resident (Resident 1). This failure put the Licensed Nurse in danger of a needlestick injury which has the potential to cause a blood borne pathogen infection. Findings: During a med pass observation on 5/10/23 at 12:10 p.m. Licensed Nurse A drew up 2 units (a measurement) of insulin (medication used for diabetic persons) for Resident 1. Licensed Nurse A withdrew the needle from the insulin vial and then recapped the insulin needle with the orange cap using both hands. During an interview with the Assistant Director of Nurses on 5/10/23 at 12:24 p.m. when asked what her expectation was regarding the disposal of used needles, she stated, We cap them for safety and dispose in our sharps container. During a review of the facility's policy titled Standard Precautions, revised September 2022, indicated Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 8. Safe Needle Handling a. Used needles are never recapped or otherwise manipulated using two hands, or any other technique that involves directing the point of a needle toward any part of the body. A review of CDC/NIOSH (Centers for Disease Control/National Institute for Occupational Safety and Health) guidelines titled, Needlestick Injuries are Preventable, dated 2/1/21, indicated, Healthcare Personnel who use or may be exposed to needles are at increased risk of needlestick injury. Needlestick injuries can lead to serious or fatal infections with blood borne pathogens such as Hepatitis B virus, Hepatitis C virus, or HIV. The guidelines further indicated that needlestick injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe working practices for handling needles and related systems . Avoiding recapping needles. (https://www.cdc.gov/niosh/newsroom/feature/needlestick_disposal.html)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed provide pharmaceutical services that meet the needs of the residents when one of four sampled residents (Resident 1) did not receive four doses of Epoetin (a medication used to treat anemia, or low red blood cells, in people with serious kidney diseases), as ordered by the physician, over an eight-week period. This failure had the potential for Resident 1 to develop anemia, characterized by feeling weak or tired more often than usual, lightheadedness, and fast, irregular heartbeats, as the body does not get enough oxygen-rich blood. Findings: Record review revealed Resident 1 was admitted to the facility with diagnoses including acute and chronic respiratory failure with hypoxia (a long-term condition of failure in oxygen exchange in the lungs resulting in not enough oxygen in a person ' s blood), generalized muscle weakness, and chronic kidney disease. (When kidneys are damaged, they produce less erythropoietin [EPO], a hormone that signals your bone marrow—the spongy tissue inside most of your bones—to make red blood cells. With less EPO, your body makes fewer red blood cells, and less oxygen is delivered to your organs and tissues. - https://www.niddk.nih.gov). A review of Resident 1 ' s Medication Administration Records (MARs), dated [DATE] and [DATE], on 2/21/23 at 12:45 p.m., indicated an order for Epoetin Alfa Injection Solution every Tuesday, with codes marked on the following scheduled doses: 1. 1/3/23 = [check mark] 2. 1/10/23 = [check mark] 3. 1/17/23 = 7 4. 1/23/23 = 7 5. 1/31/23 = 7 6. 2/7/23 = [check mark] 7. 2/14/23 = 7, and 8. 2/21/23 = [check mark] Further review of the MARs revealed a Chart Codes/Follow Up Codes, indicating, [Check Mark] = Administered, 7= Other/See Nurse Notes. During an interview and concurrent review of Resident 1 ' s MARs on 2/21/23 at 1:15 p.m., Director of Nursing (DON) confirmed four of eight scheduled doses for Epoetin were marked 7, meaning Other/See Nurse Notes. During a concurrent review of Resident 1 ' s Progress Notes, DON stated she was unable to locate any nurse's notes corresponding to the Epoetin doses that were marked 7. DON stated she was unable to confirm if the medications marked 7 were administered, adding, The medication should have a check mark if it was given. During an interview and concurrent review of Resident 1 ' s January and February MARs on 3/27/23 at 1:50 p.m., Licensed Staff A confirmed she marked Resident 1 ' s Epoetin dose with 7 on 1/17/23. Licensed Staff A stated she could not recall the medication nor why the dose was marked 7. When asked if the dose was given to Resident 1, Licensed Staff A stated, I ' m not sure. Licensed Staff A stated 7 meant See Nurse Note but during a concurrent review of Resident 1 ' s Nursing Progress Notes, Licensed Staff A was unable to locate a corresponding note. Licensed Staff A stated there should have been a note when the dose was marked 7. During an interview on 3/27/23 at 2:20 p.m., DON stated Resident 1 did not receive four Epoetin doses, with three nurses not administering the medications as ordered, from 1/1/23 to 2/21/23. DON stated there should have been documentation on why medications were not given, for example if the doses were not held or refused by the resident. DON stated if the medications were not available it should have been documented and endorsed to the following shift. DON stated she expected staff to notify the physician and the pharmacy of the missed dose. During an interview on 3/27/23 at 2:30 p.m., Administrator stated she expected medications to be given as it was ordered. Administrator stated, There should have been more follow up,,adding Resident 1 ' s Epoetin was scheduled once a week and could have been given as soon as the missed dose was caught. During an interview on 3/28/23 at 3:27 p.m., Medical Director stated Epoetin was an important medication to help residents keep their red blood cell levels up which helps more oxygen to be delivered to their organs of the body. Medical Director stated this helped residents ' quality of life, to be more alert and active with decreased weakness. Medical Director stated he expected nurses to carry out and administer medications to residents as order by the physician. Medical Director stated he expected staff to identify why the medications were not administered and to notify and the pharmacy when medications were not given, adding, Then we could adjust the order so we could make up for it [missed dose] and have the medication administered as it becomes available. Medical Director stated he expected staff to make all efforts to provide the residents the medications they needed. A review of the facility policy titled, Documentation of Medication Administration, dated April 2007, indicated, A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR) . Documentation must include, as a minimum: .e. reason(s) why a medication was withheld, not administered or refused (as applicable) .

Based on observation, interview and record review, the facility failed to ensure immediate access to residents by family members and failed to ensure the rights of residents to receive visitors when the facility implemented a visitation policy in which family and visitors were asked to schedule visitation appointments, the visitation was restricted to certain hours of the day and family and visitors had no access to residents in their rooms, with visitation occurring only in the dining room. This failure created barriers for family and visitors to visit residents and had the potential for all residents who wished to receive visitors not to have visitors at the time and place of their choosing. Findings: A review of the Centers for Medicare & Medicaid Services (CMS) guidance QSO-20-39-NH titled Nursing Home Visitation - COVID-19, Revised 9/23/22, indicated: Facilities must allow indoor visitation at all times and for all residents . While previously acceptable during the PHR [Public Health Emergency], facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. During an interview on 1/12/23, at 8:05 a.m., the family of Confidential Resident 1 stated they had been prevented from visiting their relative at the facility because of visitation restrictions imposed by the facility. They stated in order to visit their relative the facility required visitors to (1) call the facility and make appointments 24 hours in advance; (2) visits could only take place from 9:30 a.m. to 11 a.m. and from 1 p.m. to 4:30 p.m. and (3) visits were only allowed in the dining room. The family stated these restrictions prevented them from visiting their relative because (1) facility staff did not always pick up the phone when they called to make visit appointment and/or they could not reach the person responsible for the appointments and/or (2) the family had other engagements during the allowed daily visitation hours. The family also reported because they were not allowed access to their relative in their room this prevented them from monitoring the care their relative was receiving at the facility, since they had to wait to for the resident at the dining room while staff got the resident ready for the visit. They further reported these restrictions prevented them from visiting during mealtimes, in which they could help their relative eat and which the resident enjoyed. They also stated their relative had dementia and it was important for their relative to see family often lest the relative forgot who their family were. They stated during a few visits their relative could not recognize them because the facility's visitation restrictions prevented them from visiting more frequently. During an interview on 1/12/23, at 9:45 a.m., the Administrator stated the facility had no current or recent COVID-19 outbreaks. The Administrator stated the last covid-19 outbreak at the facility was six months ago. During an interview on 1/12/23, at 10:08 a.m., Confidential Resident 2 stated they received visitors. They stated visitors and family were required to schedule visits in advance and could only visit during certain hours in the morning and afternoon and could not visit in their room, only in the dining room. During an interview on 1/12/23, at 10:15 a.m., Confidential Residents 3 and 4 stated both received visitors, but visitation was only allowed with prior appointments, which needed to be made with the activities department 24 hours in advance, visitation was only allowed from 10-11 a.m. and 1-4 p.m. and visitation was only allowed in the dining room, lobby or outdoors, not in resident rooms. During an interview on 1/12/23, at 10:20 a.m., Confidential Resident 5 stated they received visitors, but their visitors were required to make appointments in order to visit and could only visit during a few hours in the morning and afternoon and could only visit in the dining room. During an interview on 1/12/23, at 10:30 a.m., Confidential Resident 6 stated they received visitors. They stated family and visitors had to call ahead and could only come during certain hours, I believe 9-5, and had to visit in the dining room. During an interview on 1/12/23, at 11:35 a.m., Confidential Resident 7 stated they received visitors, but visitors had to make prior appointments and visits could only take place during limited hours and had to take place in the dining room. During an observation on 1/12/23, at 10:38 a.m., in front of the dining room, the Activities Assistant (AA) was transporting a resident on a wheelchair to the dining room. The AA stated she was taking this resident to a scheduled family visit in the dining room. The AA was asked to describe the process of visiting residents at the facility. The AA stated the facility asked family and visitors of residents to visit between 10-11 a.m. and 1-4:45 p.m. daily. The AA stated visits only took place in the dining room, not in resident rooms. The AA stated visitors were asked to call ahead 24 hours before they wanted to visit so staff could get the resident ready for the visits. The AA stated the scheduled visits for each day were listed on a board in the nurse's station and pointed to a board in the nurse's station. A review of this board indicated the date of 1/12/23 and six scheduled resident visits: at 9:30 a.m., 10 a.m., 10:30 a.m., and 1 p.m., 2 p.m. and 3 p.m. During an interview on 1/12/23, at 11 a.m., the family of Confidential Resident 8 stated in order to visit their relative they had to call 24 hours in advance and make an appointment. They stated it was a problem because it was hard to get a hold of staff on the phone to make the appointments. They stated several times they wanted to visit, but they were not able because no one answered the phone when they called to make the appointment. They stated as a result they missed their relative's birthday they intended to celebrate at the facility. They stated visit appointments were only available from 10-11 a.m. and from 1-4 p.m. They stated these limited hours many times conflicted with their other engagements, and they could not sometimes visit as a result. They stated they were not allowed to visit in the relative's room, which they preferred, instead they had to wait for staff to bring their relative to the dining room. During an interview on 1/12/23, at 11:25 a.m., the family of Confidential Resident 9 stated they had to call 24 hours in advance to schedule appointments to visit and then the staff either said Yes or No. They stated visits were only allowed from 10-11 a.m. and from 1-4 p.m. and they are not allowed to visit in the resident room, only in the dining room. During an interview on 1/12/23, at 11:45 a.m., the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked to describe the facility's visitation policy. The ADON stated family and visitors were asked to call in advance to let the facility know when they were coming so staff could get the residents ready for the visit. The ADON stated they preferred visits from 9 to 11:30 a.m. and from 1 to 4:45 p.m. and asked family and visitors to visit in the dining room as to not disturb other residents. The Administrator, DON, and ADON were asked if there was a clinical or safety reason for these visitation restrictions. The ADON stated they were based on an All Facilities Letter (AFL) issued by the Department and provided AFL 22-07.1, dated 11/6/22, titled Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs). A review of this AFL did not indicate facilities could require advance scheduling of visits, could limit visitation to certain hours and certain places or could prevent visitors to visiting residents in their rooms. A review of facility policy titled Visitation, dated August 2022, indicated: Residents are permitted to have visitors of their choosing at the time or their choosing .The facility provides 24-hour access to individuals vising with the consent of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to assess for self-administration of medication for 1 of 15 sampled residents (Resident 36) when Resident 36 was allowed to self-administer her oral inhaler. This failure had the potential for Resident 36 to develop medication side effects if medication was self-administered inappropriately. Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a diagnosis that include Chronic Obstructive Pulmonary disease (COPD - diseases that cause airflow blockage and breathing-related problems). During a clinical record review for Resident 36, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems) dated 1/28/22 indicated Resident 36 had a BIMS score of 11/15 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). During an observation on 2/28/22 at 10:15 a.m. in Resident 36's room, Resident 36 self-administered 2 puffs of the Budenoside Formoterol inhaler (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) that was on top of her overbed table, removed the mouthpiece from her mouth with no wait time and did not rinse her mouth with water after use. Resident 36 nodded her head when asked if she would normally self-administer her own oral inhaler,. During an observation, interview, and concurrent record review with Licensed Nurse D on 2/28/22 at 4:14 p.m., Licensed Nurse D verified the Budesonide Formoterol inhaler was still at Resident 36's overbed table. Asked Licensed Nurse D reason for Resident 36 keeping the inhaler at bedside, Licensed Nurse D stated, morning nurse must have forgotten to take it back. Licensed Nurse D verified Resident 36 had an order for Budesonide Formoterol inhaler to give 2 puffs with special instruction to rinse mouth with water after use. He stated Resident 36 self-administers her own oral inhaler and knew how to do it. Licensed Nurse D verified there was no care plan for self-administration of medication for Resident 36. During an interview and concurrent record review with Licensed Nurse C on 3/2/22 at 3:56 p.m. Asked Licensed Nurse C what the process was for allowing Resident 36 to self-administer her own oral inhaler, Licensed Nurse C stated she educated Resident 36 to rinse her mouth, but it was hard for Resident 36 to follow instructions. When asked should Resident 36 self-administer her inhaler if she was hard to follow instructions, she stated, No. Asked Licensed Nurse C about the risk for Resident 36 not rinsing her mouth after administration of Budesonide oral inhaler, Licensed Nurse C stated, because Budesonide is steroid, [Resident 36] could have gum sore, or patches on her tongue. Licensed Nurse C verified there was no care plan for self-administration of medication for Resident 36. During an interview and concurrent record review with the Director of Nursing (DON) on 3/3/22 at 2:25 p.m. Asked DON about the process when resident could self-administer his/ her own medication. DON stated resident would normally request to self-administer her own medication, the Interdisciplinary Team (IDT - health care professionals who work together toward the goals of the resident) would meet to discuss if resident was appropriate to self-administer, then the nurse would go in and assess the resident to see if resident was appropriate for self-administration. Asked DON if Resident 36 requested to self-administer her oral inhaler, DON stated Resident 36 recently requested if she could self-administer her own inhaler. DON stated the self-administration of medication assessment was initiated on 3/1/22 but was not completed and Resident 36 did not receive health teachings for self-administration due to Resident 36 was sent out to the acute hospital. Review of the Facility policy and procedure titled Self-Administration of Medications revised in February 2021 indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for resident to do so. Review of the Budesonide and Formoterol insert from Resident 36's medication box indicated, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol may cause serious side effects including Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol to help reduce your chance of getting Thrush (an infectious disease, caused fungus)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan for 1 of 15 sampled residents (Resident 36) when: 1. The facility did not develop a care plan for weight gain to indicate how the facility would monitor and maintain Resident 36's weight. 2. The facility did not develop a Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs) care plan to indicate what symptoms to expect, how often and what to monitor. (Reference F684) This failure resulted to Resident 36's continued weight-gain due to worsening bilateral leg edema and subsequently was transferred to the acute hospital due to shortness of breath. Findings: 1. During a clinical record review for Resident 36, the Face sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a multiple diagnosis that include Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs), Cardiomyopathy (heart loses its ability to pump blood effectively). During a clinical record review for Resident 36, the Care Plan created on 2/1/22 indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body has a dimple (or pit) after pressing it for a few seconds) worsening. During a clinical record review for Resident 36, the Weight and Vitals Summary record indicated Resident 36 had an 11 lbs. (5.54%) weight gain from 1/26/22 to 3/1/22. During a clinical record review for Resident 36, the Dietary Note dated 2/2/22 at 3:36 p.m. indicated Resident 36 weighed 205 lbs. with a significant weight gain of 5.4 lbs. in one week. During a clinical record review for Resident 36, the Doctor's Note dated 3/1/22 indicated, Patient had been gaining weight, refusing to be weighed intermittently, noted with worsening leg edema and weight gain. Doctor's lung assessment indicated Resident 36 had crackles (occur if the small air sacs in the lungs fill with fluid) to her bilateral lung fields. During an interview with Licensed Nurse J on 3/4/22 10:41 a.m., Asked Licensed Nurse J what to monitor for residents with CHF, Licensed Staff J stated she would monitor for edema, monitor resident's weight, notify the doctor for any changes, and initiate a care plan. Licensed Nurse J verified there was no weight gain care plan for Resident 36. During an interview and concurrent record review with the DON on 3/4/22 at 11:16 a.m., the DON was asked about their process in tracking weight changes for residents, the DON stated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) with the Registered Dietician would meet to identify residents who had a significant weight change. She stated the IDT met on 2/2/22 to discuss Resident 36's weight. The DON verified there was no care plan for Resident 36's weight gain. Review of the Facility policy and procedure titled Weight Assessment and intervention revised in September 2008 indicated, the threshold for significant unplanned and undesired weight loss/ gain will be based on the following: 1 month - 5% weight loss/ gain is significant; greater that 5% is severe 2. During a clinical record review for Resident 36, the Care Plan created on 2/1/22 indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body has a dimple (or pit) after pressing it for a few seconds) worsening. Ongoing fluctuations in fluid/ hydration status, CHF, cardiomyopathy. The care plan interventions did not indicate to monitor for signs of shortness of breath or to assess lung sounds for congestion. During an interview with Physician L on 3/3/22 at 10:55 a.m., Physician L stated Resident 36 was admitted to the acute hospital for CHF exacerbation (worsening of a disease). During an interview with Physician L on 3/4/22 10:34 a.m., Asked Physician L what his expectation from the nurses on what to monitor for residents with CHF, he stated he had a protocol for nurses on what to monitor for residents with CHF. He stated he expected the nurses to monitor for resident's weights, to maintain fluid and salt restrictions, monitor vital signs and perform respiratory assessments. During an interview with Licensed Nurse J on 3/4/22 10:41 a.m., Asked Licensed Nurse J what to monitor for residents with CHF, Licensed Staff J stated she would monitor for edema shortness of breath, presence of cough, perform lung assessment and notify the doctor for any changes. Licensed Nurse J verified there was no care plan specific to CHF to indicate what licensed nurses should monitor and when to report to the doctor. Review of the Facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised in December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plan are revised as information about the residents and the residents' condition change. Review of the Facility policy and procedure titled Heart Failure - Clinical Protocol revised in November 2018 indicated, The nurses will assess and document/report the following: Vital signs; General physical assessment. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to do a respiratory assessment and identify a large fluid filled blister approximately 8 cm in diameter for 1 of 15 sampled residents (Resident 36) when Resident 36 had bilateral (both sides) leg edema (swelling caused by fluid). This failure resulted in Resident 36 to experience discomfort and was subsequently sent to the acute hospital for shortness of breath and worsening of leg edema. Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with multiple diagnoses that included Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs), Cardiomyopathy (heart loses its ability to pump blood effectively), and Chronic Obstructive Pulmonary Disease (COPD - lung diseases that make it hard to breathe and gets worse over time). During a clinical record review Resident 36's Care Plan, created on 2/1/22, indicated, BLE (bilateral lower extremity) +4 pitting edema (swollen part of your body becomes indented (or pitted) after pressing it for a few seconds) worsening. Ongoing fluctuations in fluid/ hydration status, CHF, cardiomyopathy. The care plan interventions did not indicate to monitor for signs of shortness of breath or to assess lung sounds for congestion. During a clinical record review for Resident 36, the Nurse's Note dated 2/28/22 at 6:22 a.m. indicated, [Resident 36] wanted to sit on the edge of the bed several times but reminded her that her legs needed to be elevated due to increased swelling and they need to be wrapped, resident refused suggestions. During an observation on 2/28/22 at 10:15 a.m., Resident 36 was lying in bed with head of bed slightly elevated with no blanket. Both of her legs were swollen with clear fluid leaking from the left leg and a large fluid filled blister on top of her left foot. Resident 36 also had a moist cough during the initial encounter. During a concurrent interview with Resident 36, observation, and record review on 2/28/22 at 3:38 p.m., Resident 36 stated she had pain everywhere and requested to be assisted to sit up. A Certified Nurse Assistant (CNA) assisted Resident 36 to sit at the edge of the bed and during the process, Resident 36 had facial grimacing. She was catching her breath and her lips were slightly cyanotic (bluish). Resident 36 shook her head side to side and refused to talk when asked how she felt. Review of the Nurses Notes dated 2/27/22 to 2/28/22, did not indicate the staff were monitoring for signs and symptoms of respiratory distress. There was no documentation of the blister on the left foot. During an interview on 2/28/22 at 4:14 p.m., Licensed Nurse D stated there was no blister on Resident 36's left foot last time he worked two days ago. He verified the morning nurse made a change of condition report on 2/28/22 regarding a fluid filled blister on Resident 36 left foot. Licensed Nurse D verified a care plan for left lower extremity blister was also created on 2/28/22. Licensed Nurse D stated he had not observed Resident 36 showing signs of difficulty breathing. During a clinical record review for Resident 36, the nurse's progress note dated 2/28/22 at 11:29 p.m. indicated the blister on Resident 36 left foot measured 9X9 popped. During an observation and concurrent record review on 3/1/22 at 8:53 a.m., Resident 36 was sitting at the edge of the bed. Her left leg was wrapped with white gauze, and a moist cough observed. During a clinical record review for Resident 36, Physician L's Note dated 3/1/22 indicated, Patient had been gaining weight, refusing to be weighed intermittently, noted with worsening leg edema and weight gain. Physician L's note indicated Resident 36's lung sounds had crackles (occur if the small air sacs in the lungs fill with fluid) to her bilateral lung fields. During a clinical record review for Resident 36, the Weight and Vitals Summary record indicated Resident 36 had an 11 pound (5.54%) weight gain from 1/26/22 to 3/1/22. During an observation on 3/2/22 at 12:35 p.m., Resident 36 was partially in bed, part of upper body was in bed, right foot resting on the floor and left foot was resting on the floor with a pillow. A Certified Nurse Assistant (CNA) was inside the room passing Resident 36's lunch tray. Resident 36 was moaning and grimacing while she was assisted to sit at the edge of the bed and breathed through her mouth rapidly with audible wheezing (whistling sound). Resident 36 had a hard time responding to CNA when asked how she felt. She was not able to hold herself in a sitting position and fell back to her bed. During an interview with Licensed Nurse C on 3/2/22 at 3:52 p.m. Licensed Nurse C stated Resident 36 was sent out to the acute hospital due to shortness of breath and increased swelling of her legs. Licensed Nurse C stated Resident 36's vital signs (V/S - clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) was checked and was given oxygen (life-supporting component of the air) for shortness of breath prior to transfer to the acute hospital. Licensed Nurse stated she did not perform respiratory assessment for Resident 36. During an interview with Licensed Nurse C on 3/2/22 at 3:53 a.m., Licensed Nurse C stated she did not receive a report from night shift on 2/28/2022 regarding Resident 36's blister on her left foot. During an interview with Physician L on 3/3/22 at 10:55 a.m., Physician L stated Resident 36 was admitted to the acute hospital for CHF exacerbation (worsening of a disease). During an interview on 3/4/22 10:34 a.m., Physician L was asked what his expectation was from the nurses regarding monitoring for residents with CHF, and he stated he had a protocol for nurses on what to monitor for residents with CHF that included a respiratory assessment. During an interview on 3/4/22 10:41 a.m., when asked what to monitor for residents with CHF, Licensed Staff J stated she would monitor for shortness of breath, presence of cough, perform a lung assessment and notify the doctor of any changes. Licensed Nurse J stated she was not aware Physician L had a protocol on what to monitor for residents with CHF. During an interview on 3/4/22 at 11:03 a.m., Licensed Nurse A was asked what to monitor for residents with CHF, and Licensed Nurse A stated he would monitor for signs of respiratory distress. During an interview and concurrent record review with the DON on 3/4/22 at 11:16 a.m., the DON was asked what her expectation was from the nurses on what to assess for residents with CHF, and she stated she expected the nurses to monitor resident for signs of respiratory distress. When asked what risks the resident may have if not assessed timely, the DON stated, CHF exacerbation is pretty common, and the resident could have respiratory distress if their lungs were to fill fluids. Review of the Facility policy and procedure titled Heart Failure - Clinical Protocol revised in November 2018 indicated, The nurses will assess and document/report the following: Vital signs; General physical assessment.The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc.

Based on observation, interview and record review the facility failed to re-order one Resident's (Resident 95) blood thinner medication in a timely manner to ensure there were no missed doses. This failure caused Resident 95 to miss two doses of his blood thinner and had the potential to cause Resident 95 to develop a blood clot. Findings: During a review of the clinical record for Resident 95, Physician L ordered Enoxaparin (blood thinner) on 2/23/2022. The physician's order read: Inject 100mg/ml (milligrams per milliliter) subcutaneously (under the skin) two times a day for deep vein thrombosis (blood clot) prophylaxis (prevention of). During a medication administration observation on 3/2/2022 at 8:18 a.m., the day shift Licensed nurse A asked the night shift Licensed nurse B if the Enoxaparin for Resident 95 had come from the Pharmacy. The night shift Licensed nurse B stated No. During a medication administration observation on 3/2/22 at 8:29 a.m., Licensed nurse A stated he did not have the Enoxaparin for Resident 95. He stated the Enoxaparin was re-ordered from the Pharmacy on 3/1/22. Licensed nurse A called the Pharmacy on 3/2/22 at 8:29 a.m. and was told the medicine was delivered. Licensed nurse A checked the other two medication carts for the Enoxaparin, and it was not there. Licensed nurse A called the Pharmacy again on 3/2/22 at 8:38 a.m. to ask who received the medication at the facility. The Pharmacy then stated the medication was on the way. While Licensed Nurse A was on the telephone with the Pharmacy, the D.O.N. asked if she could help Licensed Nurse A. The D.O.N. stated she thought the medicine had been discontinued. The D.O.N. checked the paper chart for the MD order which indicated, continue the Enoxaparin. During an interview with Licensed nurse A on 3/2/2022 at 3:50 p.m. he stated the medicine had not arrived yet. At this point, two doses of Enoxaparin were missed, the a.m. dose and the p.m. dose. During an interview with the D.O.N. on 3/3/2022 at 10:00 a.m. when asked what her expectation was regarding the missed doses of Enoxaparin for Resident 95, the D.O.N. stated she reached out to the Pharmacy account manager yesterday (3/2/22), and they could not tell her what happened with the order for Enoxaparin. When asked what could happen if a Resident did not get his/her blood thinner? The D.O.N. stated they can develop a blood clot. When asked what actions the nurse should have taken, the D.O.N. stated, the nurse should report to Physician L and Physician U (the cardiologist), and the nurse faxes the lab results (PT/INR -A prothrombin time (PT) measures the time it takes for a clot to form in a blood sample. An INR is a calculation based on the results) range- to the cardiologist. The DON stated, they ordered the enoxaparin when they were on the last syringe. During an interview on 3/3/2022 at 10:15 a.m., with Licensed Nurse C, when asked what she would do if she found the facility was out of Enoxaparin for a resident, she stated, I would check the PT/INR. Licensed Nurse C stated she would check the medicine order and check the supply of the medicine, and re-order it if needed, and follow up to make sure the pharmacy sent the supply. During an interview with Licensed Nurse A on 3/3/2022 at 11:00 a.m., he stated Licensed nurse B told him the medication was delivered this morning at 2 a.m. During an interview with Licensed Nurse A on 3/3/2022 at 11:20 a.m., when asked why he charted in the MAR, on 3/2/2022, that the Enoxaparin was given, Licensed nurse A stated, it was a mistake, an error A record review of a progress note dated 3/2/2022 at 11:00 a.m., written by Licensed nurse A, indicated the MD was notified that Lovenox 100/ml had not been delivered and will arrive later today and the a.m. dose would be missed. A record review of progress note dated 3/2/2022 at 11:53 a.m., written by Licensed nurse A, indicated [Resident 95's] Enoxaparin not given charted given by mistake notified the oncoming nurse to give upon arrival. Notified MD INR ordered stat. During an interview with the D.O.N. on 3/3/2022 at 3:04 p.m., when asked what her expectation was regarding ordering Enoxaparin, she stated It shouldn't take more than one day. It's twice a day, that's two days, so I will now say four syringes. If you get the call in (to the pharmacy) by 1p.m., you should have it by the next run(delivery) . between 3-4 p.m. During a record review titled, Encounter-Office Visit, dated 3/3/2022 at 3:12 p.m., Physician L entered a note that indicated, [Resident 95] missed a dose of Lovenox (brand name for Enoxaparin), given today after supply available. Patient denies any bleeding, SOB (shortness of breath), CP (chest pain), HA (headache) (Potential symptoms of a blood clot formation). No fever. Plan: Check INR CBC (Complete Blood Count) CMP(Complete Metabolic Panel) today. Continue meds and rehab. No injury or observable side effects from related to missed dose of Lovenox. The facility policy and procedure titled Administering Medications dated 2001, (Revised April 2019), indicated 4. Medications are administered in accordance with prescriber orders, including any required timeframe. 6. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide proper monitoring of drug adverse effects when one of five residents sampled for unnecessary medication review (Resident 27) did not have ordered monitoring for signs and symptoms of bleeding while taking a blood thinner. This failure could potentially lead to Resident 27 having undetected bleeding. Findings: During a record review on 3/1/22 at 4:45 p.m., Resident 27's electronic medical record revealed Resident 27 was admitted on [DATE] and her medical diagnoses included chronic embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in the right leg). Resident 27's physician orders indicated she was taking Eliquis (a blood thinner) 2.5 milligrams (a unit of measure) twice a day for deep vein thrombosis (a blood clot). Further review of Resident 27's physician orders and medication administration record (MAR) revealed there was no order or documentation for nurses monitoring Resident 27 for signs or symptoms of bleeding. During an interview on 3/2/22 at 11:22 a.m., when asked what side effects he was monitoring for Resident 27's use of Eliquis, Licensed Nurse A stated he monitored her for excessive bleeding. When asked where he documented this monitoring, Licensed Nurse A stated he only documented a progress note if she had any bleeding. During a record review and concurrent interview on 3/4/22 at 9:41 a.m., Director of Nursing (DON) reviewed Resident 27's chart, and stated she was not seeing an order to monitor Resident 27 for side effects of Eliquis. DON stated the omission of monitoring got missed by pharmacy and us, and stated she was putting in the order. DON confirmed there should be an order for monitoring for side effects of blood thinners. Review of website dailymed.nlm.nih.gov revealed the drug label information for Eliquis, last updated 6/16/21, included the warning, ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. Review of facility policy and procedure Medication Therapy, last revised 4/2007, indicated, Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: . potential or suspected side effects are present.

Resident 36 During an observation on 2/28/22 at 10:15 a.m. in Resident 36's room, Resident 36 self-administered 2 puffs of the Budenoside Formoterol inhaler (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) that was on top of her overbed table, removed the mouthpiece from her mouth with no wait time and did not rinse her mouth with water after use. Asked Resident 36 if she would normally self-administer her own oral inhaler, Resident 36 nodded her head. During an observation, interview, and concurrent record review with Licensed Nurse D on 2/28/22 at 4:14 p.m., Licensed Nurse D verified the Budesonide Formoterol inhaler was still on Resident 36's overbed table. Licensed Nurse D was asked the reason for Resident 36 keeping the inhaler at bedside, and Licensed Nurse D stated, morning nurse must have forgotten to take it back. Licensed Nurse D verified Resident 36 had an order for Budesonide Formoterol inhaler to give 2 puffs with special instruction to rinse mouth with water after use. He stated Resident 36 self-administers her own oral inhaler and knew how to do it. Licensed Nurse D verified there was no care plan for self-administration of medication for Resident 36. During an interview with the DON on 3/3/22 at 2:25 p.m., when asked how licensed staff would monitor Resident 36 for proper administration of inhaler, the DON stated Resident 36 was provided with a locked box, nurses keep the key and would give the key to Resident when it's time for her take the medication. Licensed staff would be present during self-administration to monitor resident if she was doing it correctly. Review of facility policy Storage of Medications, last revised 11/2020, revealed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Based on observation, interview, and record review, the facility failed to properly secure residents' medications when two of 15 sampled residents, Residents 28 and 36, had inhalers stored on their bedside tables. This failure had the potential to result in other residents misusing the inhalers when they had unrestricted access to prescription medications. Findings: Resident 28 During an observation and concurrent interview on 2/28/22 at 11:08 a.m., Resident 28 had two inhalers on her bedside table. One was a puffer-style inhaler and one was a flat, purple, disk-shaped inhaler. Resident 28 stated she did not need help to use the inhalers. During a medical record review, Resident 28's physician orders indicated Advair Diskus 500-50 mcg (micrograms, a unit of measure)/act (activation) 1 inhalation orally two times a day for COPD (chronic obstructive pulmonary disease) and Albuterol Sulfate aerosol solution 108 mcg/act 2 puffs inhale orally every 4 hours related to COPD. Resident 28's Interdisciplinary Team (IDT) Progress note dated 3/2/22 at 5:26 p.m. indicated, Spoke to [Resident 28] about locking her inhaler in individual lock box kept at her bed side and the key given to nursing. She declines to have this done, in her opinion this will not work for her and would rather the nurse keep her inhalers for her. During an interview on 3/4/22 at 9:41 a.m., when asked about the IDT progress note written on 3/2/22, DON stated the note was written after they realized Resident 28 had her inhalers out on her table. DON stated they bought her a lock box, and the nurse would have to get Resident 28 the key when Resident 28 needed her inhalers. DON stated the inhalers were not supposed to be out on Resident 28's table unsecured. When queried, DON stated she did not know how the inhalers got there.

Based on observation, interview, and record review, one resident's urinary catheter bag and tubing (a device that drains urine from the bladder through a tube to a collection bag) were on the floor. This could potentially lead to the resident developing a urinary tract infection (UTI). Finding: During an observation and concurrent interview on 3/3/22 at 4 p.m., Resident 27 was in bed watching TV. Resident 27's urinary catheter bag and tubing were on the floor next to the bed. Infection Preventionist Nurse (IPN) came to Resident 27's room. When asked if the catheter bag was touching the floor, IPN stated it was covered with the bag (dignity bag, covers the collection bag so the resident's urine is not visible). When asked if the catheter tubing was on the floor, IPN stated, Yes. IPN stated the tubing should not be on the floor because it can cause an infection. During an interview on 3/4/22 at 11:58 a.m., when asked what measures she took to prevent a urinary tract infection for a resident with a urinary catheter, Staff M stated she checked the collection bag every two hours and measured how many cc's (cubic centimeters, a unit of measure), noted the color of the urine, and let the nurse know if it was smelly. Staff M stated she would encourage the resident to drink water. When asked if there were any other interventions, Staff M stated, No. Review of Resident 27's care plan revealed a focus area of The resident has (Suprapubic) Catheter . dated 5/21/21, with a goal of, The resident will show no [signs or symptoms] of Urinary infection through review date . The interventions on the care plan included monitoring for signs and symptoms of UTI, but did not include using clean technique in handling of the catheter device. Review of facility procedure Catheter Care, Urinary, last revised 9/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, residents were made to feel uncomfortable when staff spoke Spanish in front of residents and during care for two of 15 sampled residents (Residents 35 and 28), and seven of seven residents in a group interview. This caused Resident 35 to feel disoriented and wished staff would speak English in front of her, caused Resident 28 to feel upset, and caused residents in the group interview to feel left out. Findings: During an interview on 2/28/22 at 10:33 a.m., Resident 28 stated, I wish they (the staff) would speak English around us, it's hard to understand them. They speak Spanish (to each other) until they're talking to you. When I wake up and they're speaking Spanish it makes me feel like 'where am I?' They're real nice to me, but I wish they would speak English. During an interview on 2/28/22 at 11:51 a.m., Resident 35 stated she found it upsetting when staff spoke Spanish in front of her, and stated she felt like telling them to do that at home. During an observation on 2/28/22 at 4:23 p.m., two staff members were speaking Spanish in the hallway, one of the staff speaking Spanish was standing in the doorway of a resident room. During a group interview on 3/1/22 at 11:07 a.m., seven out of seven residents present stated they were made to feel uncomfortable when staff spoke Spanish in front of them. Residents also stated they felt left out when staff spoke Spanish in front of them and felt the staff could not understand what residents were asking of them. During an interview on 3/4/22 at 9:23 a.m., Infection Control Nurse stated, We expect the staff to speak in English in front of the residents. Review of facility policy Quality of Life - Dignity, last revised 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure accurate MDS assessments (The Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes) were submitted for two of two sampled residents (Residents 46 and 145) when they: 1.Failed to document the correct discharge disposition for one Resident, Resident 46. This failure led to an incorrect discharge disposition submitted on Resident 46 MDS which indicated Resident 46 was discharged to a hospital. 2. Failed to identify risk for pressure ulcers on one Resident, Resident 145. This failure could have potentially lead to Resident 145 not getting the pressure ulcer prevention she needs. Findings: 1. Review of the closed record/progress notes and care plan for Resident 46 on 03/03/22 at 11:00 am, indicated that Resident 46 did not get discharged to a hospital from the facility. Resident 46 was discharged to home with Home Health. During an observation and concurrent interview on 03/03/22 at 11:51 am, the MDS Nurse stated she was still learning [MDS]. the MDS nurse stated she had been the MDS nurse since September 2021. Resident 46 was admitted on [DATE]. When asked if Resident 46 was discharged to the hospital from the facility, the MDS nurse stated I'm thinking no. When asked where Resident 46 discharged to, the MDS nurse looked at the MDS record and stated, the notes say [Resident 46] discharged home with husband and home health. When the MDS nurse was shown the discharge disposition, from Part A on the MDS, dated [DATE], which indicated Resident 46 was discharged to a hospital, the MDS nurse stated, that was probably a mistake. I did make a mistake . I can do a modification. The facility policy and procedure titled Resident Assessments dated 2001 (Revised November 2019) indicated A comprehensive assessment of every resident's needs is made at intervals designated by OBRA(Omnibus Budget Reconciliation Act) and PPS (SNF Prospective Payment System) requirements. 1. The Resident Assessment coordinator is responsible to ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments-conducted for all residents in the facility. PPS required assessments-conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits. (7.) emergence of a new pressure ulcer at stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening pressure ulcer status. 2. During a record review on 2/28/22 at 4:45 p.m., Resident 145's electronic medical record (eMR) indicated she was [AGE] years old and had been admitted [DATE] with diagnoses including dysphagia (difficulty chewing or swallowing), protein-calorie malnutrition, dementia, gastrostomy (insertion of a feeding tube directly into the stomach through the wall of the abdomen), and failure to thrive. Resident 145's registered dietician note dated 2/16/22 indicated Resident 145's body mass index was 13 and she was severely underweight. Resident 145's Braden scale (a tool used for determining risk for pressure ulcers (bed sores)) dated 1/16/22, indicated Resident 145 was at moderate risk for pressure ulcers. An Interdisciplinary Team Skin Note dated 2/3/22 indicated Resident 145 had a deep tissue injury (an injury to skin caused by prolonged pressure) to her coccyx (tailbone area) that was 5 centimeters long and 0.5 centimeters wide. Resident 145's MDS (minimum data set, an assessment tool), Section M, with a reference date of 1/11/22 indicated Resident 145 was not at risk for developing pressure ulcers. During a record review and concurrent interview on 3/3/22 at 2:01 a.m., MDS Nurse reviewed Resident 145's MDS Section M with reference date 1/11/22. MDS Nurse stated, She (Resident 145) is at risk, it was a typo. I will do a modification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, one of 15 sampled residents (Resident 21's): 1. Fall Risk care plan and 2. Risk for Constipation care plan were not adequately updated with interventions to prevent falls from occurring and constipation. These failures contributed to Resident 21: 1. falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death and 2. Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Findings: 1. A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone) and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated Resident 21 had diagnosis including Alzheimer's Disease and lumbar 2/thoracic 3 fracture, status post fall resulted in inability to walk and decrease mobility, had no decision-making capacity, and was admitted on Fall Precautions. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), and personal hygiene. Resident 21 needed two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident 21 was total dependent on bathing. Resident 21 was not steady and needed assistance when moving from seating and standing position, walking with assistive device, moving on/off the toilet, and transferring between bed and chair or wheelchair. A review of Resident 21's admission Assessment V4-V3, dated 5/18/21, indicated Resident 21's primary diagnosis was fall. Resident 21 was a fall risk. Resident 21 was alert with forgetfulness, not a reliable historian, could stand, but unsteady. A review of Resident 21's document, Risk for Falls WH, dated 5/18/21, indicated Resident 21 had a fall in the last thirty days prior to admission, cognitive skills were moderately impaired (decisions poor/supervision required), gait: balance problems when standing, and while walking, and needed assistive devices, such as a walker and wheelchair. Resident 21 was a High Risk for falls. A review of Resident 21's Risk for Fall care plan, initiated 5/18/21, indicated fall risk interventions included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear (shoes with non-slip sole or non-skid socks) when ambulating or mobilized in wheelchair, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team - professional disciplines, such as physician, case manager, nurse, social services, etc. work together to provide the greatest benefit for the resident/family/responsible party), the resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position, handrails on walls, and personal items within reach. Fall One: A review of Resident 21's Change of Condition Assessment/SBAR (Situation, Background, Assessment and Recommendation), dated 5/20/21, indicated Resident 21 had an unwitnessed fall on 5/20/21 at approximently 6 p.m. Resident 21 was found on the floor laying on her back perpendicular to her bed. A review of the Fall IDT note, dated 5/21/2021, indicated Resident 21 stated, I was just trying to get over here from there. The IDT plan was to have Resident 21 will be up in her wheelchair at the nurse's station when awake. A review of Resident 21's short term Actual Fall with No Injury, created 5/20/21 and initiated 5/21/21, indicated to continue interventions on the At Risk Fall care plan, for no apparent acute injury. New interventions included: determine and address causative factors (Resolved 7/9/21), monitor/document/report to physician for sign/symptoms: pain, and change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (Resolved 7/9/21), and Resident 21 to participate in activities daily (Initiated 5/24/21 and Resolved 7/9/21). Resident 21's Risk for Falls care plan was not updated specifying the IDT plan for Resident 21 to be up in her wheelchair at the nurse's station when awake. The facility Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Two: A review of Resident 21's Change of Condition Assessment/SBAR, dated 5/25/21, and Nurses Progress Notes, dated 5/25/21, indicated Resident 21 had an unwitnessed fall on 5/25/21 at 4:20 a.m. Resident 21 was found by staff sitting down on her roommates fall mat. When Resident 21 was asked what she was trying to do, Resident 21 stated, This is my house and my business. Nurse noted redness to Resident 21's right hand/wrist. A review of Resident 21's short term Actual Fall with Minor Injury: Poor Balance, Unsteady Gait, created 5/25/21 and initiated 5/25/21, indicated to continue interventions on the At Risk Fall care plan. New interventions included: ensure resident has a floor sensor pad in place while resident is in bed to alert staff that Resident 21 is trying to get out of bed alone (Resolved 7/20/21), and plan is to have an up in wheelchair schedule for the resident throughout the day (Resolved 7/20/21). Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Three and Four: A review of Resident 21's Change of Condition Assessment/SBAR, dated 6/6/21, and Nurses Progress Notes, dated 6/6/21, indicated Resident 21 had two witnessed falls on 6/6/21 at 4:30 p.m. and 5:20 p.m., while Resident 21 was up in her wheelchair near Nurse's Station Two. Resident 21's Nurse's Progress Note, indicated Resident 21 had a behavior of inability to relax and kept propelling back and forth in her wheelchair, which led to her sliding out of her wheelchair and landing on her buttocks two times within a one-hour period while near Nursing Station Two. There was no documentation Resident 21 was being monitored/supervised closely when falls occurred. Resident 21 told nurse she was attempting to see her daughter. Aa review of Resident 21's IDT Progress Note, dated 6/9/21, indicated: IDT recommends placing sensor pad on wheelchair to alert staff when Resident 21 is attempting to standup. The IDT recommendation was not initiated on Resident 21's Fall care plan until 7/7/21 and no other interventions were initiated after Resident 21's two witnessed falls on 6/9/21. Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day. Fall Five: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/3/21, Nurse's Progress Note, dated 7/3/21, and Post Fall Evaluation, dated 7/3/21, indicated Resident 21 was found in the lying on the floor the bathroom floor at 4 p.m. on her right side with her head up. A review of Resident 21's short term Fall care plan for 7/3/21 fall, included the following short-term interventions: added floor mat, initiated 7/6/21 and resolved 8/23/21, monitor frequently for safety, initiated 7/3/21 and resolved 8/23/21, and provide redirection frequently, initiated 7/3/21 and resolved 8/23/21, During an observation on 2/28/22 at 4:08 p.m., Resident 21 was propelling self in hallway with no supervision and propelled self to the Physical Therapy (PT) room. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated most of the time the Health Care Personal (HCP) kept Resident 21 out by the Nurse's Station. Licensed Nurse A stated Resident 21 had no alarm on her bed and wheelchair. When Licensed Nurse A was asked how often Resident 21 was checked, Licensed Nurse A stated HCP checked on Resident 21 every two hours. Licensed Nurse A stated the Night shift probably checked on Resident 21 every two hours and frequently while awake. Licensed Nurse A could not explain what he meant by frequently except for Resident 21 was checked on every two hours. Fall Six: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/20/21, and Nurse's Progress Note, dated 7/20/21, indicated Resident 21 had an unwitnessed fall on 7/20/21at 11:45 a.m. Resident 21 was found on floor mat at bedside. Resident 21 stated to nurse she was trying to go to the bathroom. Resident 21 was assisted back to bed with one person assist. A review of Resident 21's short term Fall care plan for 7/20/21 fall, included one new short term intervention: Scheduled toileting every two hours while up in wheel, initiated 7/21/21 and resolved 8/23/21. Resident 21's Fall care plan did not specify scheduled toileting while in bed. Fall Seven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 8/5/21, and Post Fall Evaluation, dated 8/5/21, indicated Resident 21 was trying to stand from her wheelchair on her own and walk to the bathroom when she had an unwitnessed fall on 8/5/21 at 3:45 p.m. A review of Resident 21's Post Fall Evaluation, dated 8/6/21, indicated Resident 21's wheelchair alarm was going off, so a Certified Nursing Assistant (CNA) went to check on Resident 21. The CNA saw Resident 21 had fallen from her wheelchair in front of her bathroom. A review of Resident 21's Risk for Falls had no new interventions and there was no short term Fall care plan initiated for Resident 21's 8/6/21 unwitnessed fall. A review of Resident 21's Fall IDT Progress Note, dated 8/12/21, indicated IDT reviewed Resident 21's fall history with a plan to provide a wedge cushion for her wheelchair and anti-roll back wheel locks for the prevention of falls. Resident 21 continued with physical therapy for safety and functional mobility. The interventions addressed were not added to Resident 21's Fall Risk care plan. Fall Eight: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/2/21, Post Fall Evaluation, dated 11/2/21, and Nurse's Progress Notes, dated 11/2/21, indicated Resident 21 had a witnessed fall on 11/2/21 at 5:30 p.m. while up in her wheelchair in the hallway. Resident 21 was pulling herself down the hallway using the hall siderail while her wheelchair wheels were against the side of the wall. Resident 21 pulled herself forward causing Resident 21 to lose her body balance and fell forward out of her wheelchair whereby Resident 21 landed on the floor on her right side. Resident 21, who had poor safety awareness, had no HCP nearby monitoring Resident 21 to prevent her from falling out of her wheelchair. Nurse who witnessed fall was coming from the opposite direction. A review of Resident 21's short term Fall care plan, date initiated 11/2/21, indicated interventions included educate resident/family/caregivers about safety reminders and what to do if a fall occurs, continue PT, and plan was to have resident up in wheelchair at nursing station when awake. Resident 21 has fallen three times while up in hallway near nurse's station. There were no new recommendations to prevent further falls such as how staff was going to provide and monitor for supervision. Fall Nine: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/3/21, Post Fall Evaluation, dated 11/3/21 and Nurse's Progress Notes, dated 11/3/21, indicated Resident 21's chair alarm went off around 8:10 a.m. The CNA and nurse quickly went to Resident 21's room where Resident 21 was noted to have an unwitnessed fall. Resident 21 was found near the doorway and sink, laying on her left side facing the sink. Resident 21 withstood a small bump/redness to left forehead and back of right hand was discolored. A review of Resident 21's short term Fall care plan, date initiated 11/3/21, indicated one new intervention: Provide activities that promote exercise and strength building where possible Provide 1:1 activities if bed bound, which was resolved 11/18/21. A review of Resident 21's Quarterly MDS ), 11/24/22, indicated Resident 21's BIM (Brief Interview of Mental Status) of 3 (severely cognitively impaired) and Resident 21 was not steady, only could stabilize with staff assistance when moving from seating and standing position, moving on/off toilet, and transferring between bed and chair or wheelchair. Ambulation did not happen. Fall Ten: A review of Resident 21's Nurse's Progress Note dated 1/13/22 indicated and an IDT Note, dated 1/14/21, indicated Resident 21 had a witnessed fall on 1/13/21 around 4:15 p.m. right after room change. Resident 21 was in her new room in her wheelchair and attempting to stand. Resident 21 lost her balance and fell to her knees and then chest. Resident 21's roommate and activities were in the room and saw the fall. Resident 21 told the nurses she was trying to mess with her socks. A review of Resident 21's short term Fall care plan, date initiated 1/13/22, and short-term care plan for Recent Room Change, initiated 1/14/22 indicated three new short-term interventions: resident will be introduced to new staff that will be working with her, resident will be oriented to room and roommate and resident will be monitored closely times seventy-two hours after fall (Note: monitoring happened after each fall for seventy-two hours) and concerns related to new room. Monitor for confusion, disorientation more than normal and room move. The monitoring did not specify how staff was going to provide and monitor for supervision nor did the care plans define closely. The care plans did not specify how frequently staff would be checking on Resident 21. Both short term care plans were resolved on 1/20/22. Fall Eleven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 2/8/22, Post Fall Evaluation, dated 2/8/22 and IDT Progress Notes, dated 2/9/22, indicated Resident 21 had an unwitnessed fall around 6:45 p.m. Resident 21 was in her room and found sitting on her bottom. Resident 21 was attempting to transfer from her wheelchair to bed. A review of Resident 21's short term Fall care plan, initiated 2/8/22, indicated one new intervention: offer resident to lie down after dinner to prevent further falls. Resident 21's fall risk care plan indicated call light and personal items were in easy reach but did not specify: 1. How the facility would provide reminders so Resident 21, who was severely cognitively impaired, would remember to ask for assistance with transferring, and 2. How often the facility would do visual checks/supervision. A review of Resident 21's Impaired Cognitive Function/Dementia or Impaired Thought Process related to Alzheimer's, care plan, initiated on 5/18/21, one intervention included and initiated on 5/18/21, indicated: Cue, reorient and supervise as needed, but the intervention did not indicate how staff was going to provide and monitor for supervision and how often. A review of Resident 21'sCommunication Problem care plan initiated 5/28/21, one intervention initiated 8/16/21, indicated: 'Resident is not able to initiate needs request and requires staff support to have needs care and concrete addressed and met by staff. During an interview on 3/3/22 at 9:56 a.m., Physical Therapy (PT) Manager T stated Resident 21 was back on PT until 2/11/22 mainly to work on a safe transfer with assistance. PT Manager T stated Resident 21 should never be by herself when transferring from bed to wheelchair, wheelchair to bed . Resident 21 has always needed assistance with transfers, not steady. During an interview on 3/3/22 at 11:49 a.m., the Infection Preventionist Nurse (IPN) stated Resident 21 should not get up on her own. When the IPN was asked how Resident 21 was monitored closely to prevent her from falling, the IPN stated Resident 21 was out and about often in the hallways propelling herself in her wheelchair where she was watched because staff were out and about in the hallways. During an interview on 3/3/22 at 11:50 a.m., the Director of Nursing (DON) stated Resident 21 was monitored at least every two hours. When the DON was asked if six falls was too much, the DON did not answer. The DON stated a short term Fall care plan was started for Resident 21 after each fall, but the interventions were short term. Resident 21 was monitored frequently for three days after each fall. The frequent monitoring was not a long-term intervention. When the DON was asked how Resident 21 was monitored to prevent her from falling, the DON stated Resident 21 was cognitively impaired and she was out and about propelling herself in the hallways often, whereby Resident 21 was watched. The DON stated Resident 21 did not have an alarm on her bed, wheelchair and/or no floor sensory pad anymore. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 should be monitored every 15 to 30 min. Licensed Nurse C stated Resident 21 usually was propelling self in wheelchair in hallway after 2 p.m. During an observation on 3/3/22 at 4:05 p.m., Resident 21 was up in wheelchair in hallway propelling self and no staff was around supervising/monitoring Resident 21. Resident 21 was holding on to siderail across from Nurse's Station One and then crossed over into the hallway where her room was located. During an interview on 3/3/22 at 4:30 p.m., Staff P stated she checked on Resident 21 every two hours. Staff P stated Resident 21 was out in the hall a lot and people were around to watch her. Staff P stated Resident 21 could not get up on her own, Resident 21 needed assistance. During an observation on 3/3/22 at 4:45 p.m., while two surveyors were at Nurse's Station One, Resident 21 was observed propelling self in wheelchair nearby. There was no staff around supervising/monitoring Resident 21 who was majorly cognitively impaired, had poor safety awareness, impulsive, and had fallen eleven times within a nine month period. No one had checked on Resident 21`in the past 15 minutes. Fall Twelve: A review of Resident 21's Nurse's Progress Notes, dated 3/4/21, and Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM (Bowel Movement) from 1/28/22 through 2/2/22 (six days), so on 3/4/21 at 12 a.m., Resident 21 was given a Dulcolax Suppository 10 mg (milligrams) for constipation. Nursing Progress Notes indicated safety fall precautions were maintained, but at 1:50 a.m. Resident 21 was found laying on the floor by her bedside. Resident 21 had an extra-large BM in her brief. Note: Nurse's Progress Note indicated the nurse did not go back to check on Resident 21, who was severely cognitively impaired and had poor safety awareness for almost 2 hours after Resident 21 was given a suppository to stimulate a BM. During a concurrent observation and interview on 3/4/22 at 9 a.m., Surveyor went into Resident 21's room along with Staff K, who showed where Resident 21's drop mat was kept. Staff K stated it was placed on the floor next to Resident 21's bed when she was in bed. Resident 21 was up in her wheelchair next to her bed. Staff K stated Resident 21 did not have a bed alarm and/or a wheelchair alarm. During an interview on 3/4/22 at 9:03 a.m., Staff Q stated she checked on Resident 21 every two hours. Staff Q stated Resident 21 was walking when Resident 21 was first admitted , but with assistance. When Staff Q was asked what frequently monitoring meant, she could not answer. Staff Q stated she checked on Resident 21 every time she passed by Resident 21's room because Resident 21's door was always opened. Staff Q stated another CNA was passing by Resident 21's opened door and saw Resident 21 was trying to get up, so Staff K told Staff Q, who went to check on Resident 21 right away. Staff Q stated if she was not available, Staff K would have assisted Resident 21. Staff Q was asked again what frequent monitoring meant and Staff Q could not define. Staff Q stated Resident 21 could not get up on her own, unsafe. During an interview on 3/4/22 at 9:45 a.m. the DON stated Resident 21 went to Activities as much as possible. The DON stated Resident 21 could not stand on her own. The DON stated Resident 21 was using a four-wheel walker with seat when Resident 21 was first admitted , but the walker was not safe. The DON stated Resident 21 was cognitively impaired and it was impossible to watch her all the time. The DON stated none of the residents had a one-on-one sitter. The DON stated a one-on-one sitter would be impossible because of lack of staff. The DON stated no residents had alarms and Resident 21's was discontinued on 11/20/21. The DON stated the facility did not use any alarms anymore because the alarms were found not to worked and scared the resident. During an interview on 3/4/22 at 11:41 a.m., Activities Assistant R stated she only worked Friday and Saturdays. Activities Assistant R stated Resident 21 would come to activities occasionally. We would encourage her to come. Activities Assistant R stated today Resident 21 was at the sensory awareness activity the entire time. During an interview on 3/4/22 at 11:48 a.m., Interim Activities Director S stated Resident 21 would come to activities sometimes. Interim Activities Director S stated Resident 21 was encourage to come to activities, but often Resident 21 wanted to stay in her room. Interim Activities Director S stated Resident 21 would come to activities two to three times during the week, just depended on her mood. Interim Activities Director S stated Resident 21 liked the social coffee activity; Resident 21 really came to be around other residents though often did not engage. The Facility Policy/Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated: Policy heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment . e. lower extremity weakness . i. functional impairments . k. incontinence, 3. Medical factors that contribute to the risk of falls include: . e. balance and gait disorders, etc. 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 . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk: . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 2. A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone)and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated facility was to follow Bowel Care per Facility Protocol for Resident 21. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), personal hygiene, two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position (excludes to/from bath/toilet, total dependent on bathing and frequently incontinent of urine/bowel movement. During an interview on 3/1/22 at 11:15 a.m., Confidential Family Member stated Resident 21 was having diarrhea prior to being admitted to the facility and it was not like Resident 21 to not have BM daily or at least every other day. 1/2022: A review of Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), from 1/22/22 through 1/26/22 (5 days), and from 1/28/22 through 2/2/22 (six days). A review of Resident 21's Physician L's Protocol for Constipation, related to decreased mobility. indicated: If No BM in three days begin: MOM (Milk of Magnesia) Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn (as needed) for bowel care. Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if MOM is ineffective. Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if suppository is ineffective. If no results, contact MD (Doctor of Medicine). A review of Resident 21's Risk for Constipation care plan, initialed 5/18/21, indicated constipations interventions included : Follow facility bowel protocol for bowel management, MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for constipation daily, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for constipation if no results from oral laxative, and Fleet Enema 7-19 gm /118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for constipation if no results from suppository. If no results from enema, call MD. The licensed nurses were not following Resident 21's Risk for Constipation care plan per review of Resident 21's MARs, (Medication Administration Record), dated 1/2022, 2/2022, and 3/2022. A review of Resident 21's Order Summary Report, dated 1/2022, and MAR, dated 1/2022, indicated Resident 21 was administered Senna 8.6 mg (milligrams) give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. Resident 21 had an order for MOM Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 1/2022, Licensed Nurses did not start Physician L's Protocol for Constipation on Resident 21, who did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), and from 1/22/22 through 1/26/22 (5 days). Resident 21 was administered MOM on 2/1/22 at 11:59 a.m. after no BM from 1/28/22 through 2/1/22 (five days). Licensed Nurse did not follow Resident 21's Physician L's Protocol for Constipation when Resident 21 was not given the ordered Dulcolax Suppository after twenty-four hours of no BM the following day, 2/2/22. Resident 21 had a large, formed BM on 2/3/22 at 12:56 p.m. 2/2022: A review of Resident 21's Bowel Movement task, dated 2/2022, indicated Resident 21 did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). A review of Resident 21's Order Summary Report, dated 2/2022, and MAR, dated 2/2022, indicated Resident 21 was administered Senna 8.6 mg, give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. On 2/24/21, Docusate Calcium 240 mg was discontinued and Resident 21 started on DSS (Docusate Calcium) capsule 250 mg by mouth two times a day for constipation, start date 2/24/21 at 5 p.m. Resident 21 continued to have the Protocol for Constipation: MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm /118 ml - Insert one application rectally every twenty-four hours prn for bowel care if no BM ti[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician's Protocol for Constipation and Resident 21's Risk for Constipation care plan for one of 15 sampled residents (Resident 21) causing Resident 21 to not have a bowel movement (BM) anywhere from four to seven days in a row. This had the potential for Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone)and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical/Telemedicine Visit, dated 5/18/21, indicated the facility was to follow Bowel Care per Facility Protocol for Resident 21. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), 5/25/21, indicated Resident 21's BIM (Brief Interview of Mental Status) of 5 (severely cognitively impaired). Resident 21 needed one person physical assist with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), personal hygiene, two plus persons physical assist to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position (excludes to/from bath/toilet, total dependent on bathing and frequently incontinent of urine/bowel movement. During an interview on 3/1/22 at 11:15 a.m., Confidential Family Member stated Resident 21 was having diarrhea prior to being admitted to the facility and it was not like Resident 21 to not have a BM daily or at least every other day. 1/2022: A review of Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), from 1/22/22 through 1/26/22 (5 days), and from 1/28/22 through 2/2/22 (six days). A review of Resident 21's Physician L's Protocol for Constipation, indicated: If No BM in three days begin: MOM (Milk of Magnesia) Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn (as needed) for bowel care. Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if MOM is ineffective. Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if suppository is ineffective. If no results, contact MD (Doctor of Medicine). A review of Resident 21's Risk for Constipation care plan, initialed 5/18/21, indicated constipations interventions included : Follow facility bowel protocol for bowel management, MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for constipation daily, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for constipation if no results from oral laxative, and Fleet Enema 7-19 gm /118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for constipation if no results from suppository. If no results from enema, call MD. The licensed nurses were not following Resident 21's Risk for Constipation care plan per review of Resident 21's MARs, (Medication Administration Record), dated 1/2022, 2/2022, and 3/2022. A review of Resident 21's Order Summary Report, dated 1/2022, and MAR, dated 1/2022, indicated Resident 21 was administered Senna 8.6 mg (milligrams) give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. Resident 21 had an order for MOM Suspension 400 mg/5 ml -(milliliters) - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm (grams)/118 ml (Sodium Phosphates) - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 1/2022, Licensed Nurses did not start Physician L's Protocol for Constipation on Resident 21, who did not have a BM from 1/1/22 through 1/4/22 (four days), from 1/6/22 through 1/12/22 (seven days), and from 1/22/22 through 1/26/22 (5 days). Resident 21 was administered MOM on 2/1/22 at 11:59 a.m. after no BM from 1/28/22 through 2/1/22 (five days). Licensed Staff did not follow Resident 21's Physician L's Protocol for Constipation when Resident 21 was not given the ordered Dulcolax Suppository after twenty-four hours of no BM the following day, 2/2/22. Resident 21 had a large, formed BM on 2/3/22 at 12:56 p.m. 2/2022: A review of Resident 21's Bowel Movement task, dated 2/2022, indicated Resident 21 did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). A review of Resident 21's Order Summary Report, dated 2/2022, and MAR, dated 2/2022, indicated Resident 21 was administered Senna 8.6 mg, give 17.2 mg by mouth two times a day for constipation, start date 5/19/21 and Docusate Calcium 240 mg by mouth two times a day for constipation, start date 5/18/21. On 2/24/21, Docusate Calcium 240 mg was discontinued and Resident 21 started on DSS (Docusate Calcium) capsule 250 mg by mouth two times a day for constipation, start date 2/24/21 at 5 p.m. Resident 21 continued to have the Protocol for Constipation: MOM Suspension 400 mg/5 ml - Give 30 ml by mouth every twenty-four hours prn for bowel care if no BM times one day, start date 5/18/21, Dulcolax Suppository 10 mg - Insert 10 mg suppository rectally every twenty-four hours prn for bowel care if no BM times two days, start date 5/18/21, and Fleet Enema 7-19 gm /118 ml - Insert one application rectally every twenty-four hours prn for bowel care if no BM times three days, start date 5/18/21. Per Resident 21's MAR, dated 2/2022, Licensed Nurses did not start Physician L's Protocol for Constipation for Resident 21, who did not have a BM from 2/6/22 through 2/10/22 (five days), from 2/12/221 to 2/15/22 (four days), and from 2/26/22 through 3/2/22 (five days). During an interview on 3/2/22 at 4:29 p.m. when it was brought to Licensed Nurse N's attention Resident 21 had not had a BM from 2/26/22 through 3/2/22 (five days), Licensed Nurse N stated Resident 21 should have been started on Physician L's Protocol for Constipation after three days of not having a BM. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated Resident 21 should not go six days (2/26/22 to 3/3/22) before having a BM. Licensed Nurse A stated Resident 21's constipation was addressed to him at the change of shift this morning. Licensed Nurse A stated the Night shift nurse was responsibility to try to start the ordered Protocol for Constipation for Resident 21 if she has not gone for three days. Licensed Nurse A stated Resident 21 was non-compliant with the Night shift nurse; Resident 21 has severe dimension/cognitively impaired. Licensed Nurse A stated he was going to attempt to start Physician L's Protocol for Constipation today. When Licensed Nurse A was asked why Resident 21's Risk for Constipation care plan was not updated to address Resident 21 not being compliant with Physician L's Protocol for Constipation and why Physician L was not notified regarding Resident 21 being non-compliant. Licensed Nurse A could not answer. During an interview on 3/4/22 at 10:13 a.m., the Director of Nursing (DON) was asked why Resident 21's nurses did not follow Physician L's Protocol for Constipation when on multiple occasions Resident 21 went longer than three days before she had a BM. The DON stated Resident 21 had routine bowel care, softeners. The DON stated Physician L's Protocol for Constipation should occur after three days of no BM, and if the resident was non-compliant, the nurse should notify the resident's physician. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 had routine stool softeners, but if Resident 21 did not have a BM within a forty-eight-to-seventy-two-hour period, the nurse should start addressing the issue with prn bowel care orders for constipation. Licensed Nurse C stated if a resident was having continuous issues with having a BM, their Risk for Constipation care plan should be update with new interventions to address lack of BMS and non-compliant with bowel care, and their physician should be notified as well as their responsible party. Licensed Nurse C stated Yes, I have had issues understanding the Certified Nursing Assistant's (CNA's) coding under the BM task because the CNAs were not always consistent with their coding, making it difficult to understanding if the resident had a BM or not. Licensed Nurse C stated if the resident was cognitively intact, she would ask the resident if they had a BM. During an interview on 3/3/22 at 3:36 p.m., Staff O stated how the BM task electronic charting should be answered was as follows: 1. Incontinent/Continent or none, 2. Size of BM: small, medium or large or none and 3. consistency: loose, soft, formed. Staff O stated all questions should be answered. Both Licensed Nurse C and Staff O stated to understand if the resident had a BM would depend on how the CNA completed the documentation under the BM task. Licensed Nurse C stated she found the CNAs' BM documentation incorrect at times. The facility policy/procedure titled, (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 9/2017, indicated Assessment and Recognition: . 2. Examples of lower gastrointestinal tract conditions and symptoms include: a. Residents with history of diarrhea, b. Fecal incontinence . f. Alteration in bowel movements . 3. In addition, the nurse shall assess and document/report the following: . f. Abdominal assessment . h. Onset, duration, frequency, severity of signs and symptoms . Monitoring and Follow-up: 1. The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc . The facility job description titled, LVN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Ensure that all nursing service personnel are in compliance with their respective job description . Charting and documentation: . Report all discrepancies noted concerning . charting errors , to the Nurse Supervisor . Personnel Functions: . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Ensure that personnel providing direct care to the residents are providing such care in accordance with the resident's care plan and wishes . The facility job description titled, RN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Ensure that all nursing service personnel are in compliance with their respective job description . Charting and documentation: . Report all discrepancies noted concerning . charting errors , to the Nurse Supervisor . Personnel Functions: . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Nursing Care Function: .Review the resident's chart for specific treatments, medication orders . Ensure that personnel providing direct care to the residents are providing such care in accordance with the resident's care plan and wishes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident safety when staff did not evaluate, develop, and implement adequate interventions for 1 of 15 sampled residents (Resident 21), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to Resident 21 falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death. Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with diagnoses including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone) and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, muscle weakness, unsteadiness on feet, difficult in walking, cognitive deficit (confusion or memory loss), Alzheimer's Disease (progressive mental deterioration), amongst others. A review of Resident 21's History and Physical, dated 5/18/21, indicated Resident 21 had diagnosis including Alzheimer's Disease and lumbar 2/thoracic 3 fracture, status post fall resulted in inability to walk and decrease mobility, had no decision making capacity, and was admitted on Fall Precautions. A review of Resident 21's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/25/21, indicated Resident 21's BIMS score (Brief Interview of Mental Status) was 5 (severely cognitively impaired). Resident 21 needed one person physical assistance with walking in room, dressing, eating, toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), and personal hygiene. Resident 21 needed two plus persons physical assistance to transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident 21 was total dependent on bathing. Resident 21 was not steady and needed assistance when moving from seating and standing position, walking with assistive device, moving on/off the toilet, and transferring between bed and chair or wheelchair. A review of Resident 21's admission Assessment V4-V3, dated 5/18/21, indicated Resident 21's primary diagnosis was fall. Resident 21 was a fall risk. Resident 21 was alert with forgetfulness, not a reliable historian, could stand, but unsteady. A review of Resident 21's document, Risk for Falls, dated 5/18/21, indicated Resident 21 had a fall in the last thirty days prior to admission, cognitive skills were moderately impaired (decisions poor/supervision required), gait: balance problems when standing, and while walking, and needed assistive devices, such as a walker and wheelchair. The document indicated Resident 21 was a High Risk for falls. A review of Resident 21's Risk for Fall care plan, initiated 5/18/21, indicated fall risk interventions included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear (shoes with non-slip sole or non-skid socks) when ambulating or mobilized in wheelchair, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team - professional disciplines, such as physician, case manager, nurse, social services, etc. work together to provide the greatest benefit for the resident/family/responsible party), the resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position, handrails on walls, and personal items within reach. Fall One: A review of Resident 21's Change of Condition Assessment/SBAR (Situation, Background, Assessment and Recommendation), dated 5/20/21, indicated Resident 21 had an unwitnessed fall on 5/20/21 at approximently 6 p.m. Resident 21 was found on the floor laying on her back perpendicular to her bed. A review of the Fall IDT note, dated 5/21/2021, indicated Resident 21 stated, I was just trying to get over here from there. The IDT plan was to have Resident 21 up in her wheelchair at the nurse's station when awake. A review of Resident 21's short term Actual Fall with No Injury, created 5/20/21 and initiated 5/21/21, indicated to continue interventions on the At Risk Fall care plan, for no apparent acute injury. New interventions included: determine and address causative factors (Resolved 7/9/21), monitor/document/report to physician for sign/symptoms: pain, and change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (Resolved 7/9/21), and Resident 21 to participate in activities daily (Initiated 5/24/21 and Resolved 7/9/21). Resident 21's Risk for Falls care plan was not updated specifying the IDT plan for Resident 21 to be up in her wheelchair at the nurse's station when awake. The facility Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Two: A review of Resident 21's Change of Condition Assessment/SBAR, dated 5/25/21, and Nurses Progress Notes, dated 5/25/21, indicated Resident 21 had an unwitnessed fall on 5/25/21 at 4:20 a.m. Resident 21 was found by staff sitting down on her roommates fall mat. When Resident 21 was asked what she was trying to do, Resident 21 stated, This is my house and my business. Nurse noted redness to Resident 21's right hand/wrist. A review of Resident 21's short term Actual Fall with Minor Injury: Poor Balance, Unsteady Gait, created 5/25/21 and initiated 5/25/21, indicated to continue interventions on the At Risk Fall care plan. New interventions included: ensure resident has a floor sensor pad in place while resident is in bed to alert staff that Resident 21 is trying to get out of bed alone (Resolved 7/20/21), and plan is to have an up in wheelchair schedule for the resident throughout the day (Resolved 7/20/21). Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day, while Resident 21 was in bed or while up in a wheelchair. Fall Three and Four: A review of Resident 21's Change of Condition Assessment/SBAR, dated 6/6/21, and Nurses Progress Notes, dated 6/6/21, indicated Resident 21 had two witnessed falls on 6/6/21 at 4:30 p.m. and 5:20 p.m., while Resident 21 was up in her wheelchair near Nurse's Station Two. Resident 21's Nurse's Progress Note, indicated Resident 21 had a behavior of inability to relax and kept propelling back and forth in her wheelchair, which led to her sliding out of her wheelchair and landing on her buttocks two times within a one-hour period while near Nursing Station Two. There was no documentation Resident 21 was being monitored/supervised closely when falls occurred. Resident 21 told nurse she was attempting to see her daughter. Aa review of Resident 21's IDT Progress Note, dated 6/9/21, indicated: IDT recommends placing sensor pad on wheelchair to alert staff when Resident 21 is attempting to standup. The IDT recommendation was not initiated on Resident 21's Fall care plan until 7/7/21 and no other interventions were initiated after Resident 21's two witnessed falls on 6/9/21. Resident 21's Fall care plan did not specify how often the facility would do visual checks/supervision throughout the day. Fall Five: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/3/21, Nurse's Progress Note, dated 7/3/21, and Post Fall Evaluation, dated 7/3/21, indicated Resident 21 was found in the lying on the floor the bathroom floor at 4 p.m. on her right side with her head up. A review of Resident 21's short term Fall care plan for 7/3/21 fall, included the following short-term interventions: added floor mat, initiated 7/6/21 and resolved 8/23/21, monitor frequently for safety, initiated 7/3/21 and resolved 8/23/21, and provide redirection frequently, initiated 7/3/21 and resolved 8/23/21, During an observation on 2/28/22 at 4:08 p.m., Resident 21 was propelling self in hallway with no supervision and propelled self to the Physical Therapy (PT) room. During an interview on 3/3/22 at 8:48 a.m., Licensed Nurse A stated most of the time the Health Care Personal (HCP) kept Resident 21 out by the Nurse's Station. Licensed Nurse A stated Resident 21 had no alarm on her bed and wheelchair. When Licensed Nurse A was asked how often Resident 21 was checked, Licensed Nurse A stated HCP checked on Resident 21 every two hours. Licensed Nurse A stated Night shift probably checked on Resident 21 every two hours and frequently while awake. Licensed Nurse A could not explain what he meant by frequently except for Resident 21 was checked on every two hours. Fall Six: A review of Resident 21's Change of Condition Assessment/SBAR, dated 7/20/21, and Nurse's Progress Note, dated 7/20/21, indicated Resident 21 had an unwitnessed fall on 7/20/21at 11:45 a.m. Resident 21 was found on floor mat at bedside. Resident 21 stated to nurse she was trying to go to the bathroom. Resident 21 was assisted back to bed with one person assist. A review of Resident 21's short term Fall care plan for 7/20/21 fall, included one new short term intervention: Scheduled toileting every two hours while up in wheel, initiated 7/21/21 and resolved 8/23/21. Resident 21's Fall care plan did not specify scheduled toileting while in bed. Fall Seven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 8/5/21, and Post Fall Evaluation, dated 8/5/21, indicated Resident 21 was trying to stand from her wheelchair on her own and walk to the bathroom when she had an unwitnessed fall on 8/5/21 at 3:45 p.m. A review of Resident 21's Post Fall Evaluation, dated 8/6/21, indicated Resident 21's wheelchair alarm was going off, so a Certified Nursing Assistant (CNA) went to check on Resident 21. The CNA saw Resident 21 had fallen from her wheelchair in front of her bathroom. A review of Resident 21's Risk for Falls had no new interventions and there was no short term Fall care plan initiated for Resident 21's 8/6/21 unwitnessed fall. A review of Resident 21's Fall IDT Progress Note, dated 8/12/21, indicated IDT reviewed Resident 21's fall history with a plan to provide a wedge cushion for her wheelchair and anti-roll back wheel locks for the prevention of falls. Resident 21 continued with physical therapy for safety and functional mobility. The interventions addressed were not added to Resident 21's Fall Risk care plan. Fall Eight: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/2/21, Post Fall Evaluation, dated 11/2/21, and Nurse's Progress Notes, dated 11/2/21, indicated Resident 21 had a witnessed fall on 11/2/21 at 5:30 p.m. while up in her wheelchair in the hallway. Resident 21 was pulling herself down the hallway using the hall siderail while her wheelchair wheels were against the side of the wall. Resident 21 pulled herself forward causing Resident 21 to lose her body balance and fell forward out of her wheelchair whereby Resident 21 landed on the floor on her right side. Resident 21, who had poor safety awareness, had no HCP nearby monitoring Resident 21 to prevent her from falling out of her wheelchair. Nurse who witnessed fall was coming from the opposite direction. A review of Resident 21's short term Fall care plan, date initiated 11/2/21, indicated interventions included educate resident/family/caregivers about safety reminders and what to do if a fall occurs, continue PT, and plan was to have resident up in wheelchair at nursing station when awake. Resident 21 has fallen three times while up in hallway near nurse's station. There were no new recommendations to prevent further falls such as how staff was going to provide and monitor for supervision. Fall Nine: A review of Resident 21's Change of Condition Assessment/SBAR, dated 11/3/21, Post Fall Evaluation, dated 11/3/21 and Nurse's Progress Notes, dated 11/3/21, indicated Resident 21's chair alarm went off around 8:10 a.m. The CNA and nurse quickly went to Resident 21's room where Resident 21 was noted to have an unwitnessed fall. Resident 21 was found near the doorway and sink, laying on her left side facing the sink. Resident 21 withstood a small bump/redness to left forehead and back of right hand was discolored. Aa review of Resident 21's short term Fall care plan, date initiated 11/3/21, indicated one new intervention: Provide activities that promote exercise and strength building where possible Provide 1:1 activities if bed bound, which was resolved 11/18/21. A review of Resident 21's Quarterly MDS), 11/24/22, indicated Resident 21's BIM (Brief Interview of Mental Status) of 3 (severely cognitively impaired) and Resident 21 was not steady, only could stabilize with staff assistance when moving from seating and standing position, moving on/off toilet, and transferring between bed and chair or wheelchair. Ambulation did not happen. Fall Ten: A review of Resident 21's Nurse's Progress Note dated 1/13/22 indicated and an IDT Note, dated 1/14/21, indicated Resident 21 had a witnessed fall on 1/13/21 around 4:15 p.m. right after room change. Resident 21 was in her new room in her wheelchair and attempting to stand. Resident 21 lost her balance and fell to her knees and then chest. Resident 21's roommate and activities were in the room and saw the fall. Resident 21 told the nurses she was trying to mess with her socks. A review of Resident 21's short term Fall care plan, date initiated 1/13/22, and short-term care plan for Recent Room Change, initiated 1/14/22 indicated three new short-term interventions: resident will be introduced to new staff that will be working with her, resident will be oriented to room and roommate and resident will be monitored closely times seventy-two hours after fall (Note: monitoring happened after each fall for seventy-two hours) and concerns related to new room. Monitor for confusion, disorientation more than normal and room move. The monitoring did not specify how staff was going to provide and monitor for supervision nor did the care plans define closely. The care plans did not specify how frequently staff would be checking on Resident 21. Both short term care plans were resolved on 1/20/22. Fall Eleven: A review of Resident 21's Change of Condition Assessment/SBAR, dated 2/8/22, Post Fall Evaluation, dated 2/8/22 and IDT Progress Notes, dated 2/9/22, indicated Resident 21 had an unwitnessed fall around 6:45 p.m. Resident 21 was in her room and found sitting on her bottom. Resident 21 was attempting to transfer from her wheelchair to bed. A review of Resident 21's short term Fall care plan, initiated 2/8/22, indicated one new intervention: offer resident to lie down after dinner to prevent further falls. Resident 21's fall risk care plan indicated call light and personal items were in easy reach but did not specify: 1. How the facility would provide reminders so Resident 21, who was severely cognitively impaired, would remember to ask for assistance with transferring, and 2. How often the facility would do visual checks/supervision. A review of Resident 21's Impaired Cognitive Function/Dementia or Impaired Thought Process related to Alzheimer's, care plan, initiated on 5/18/21, one intervention included and initiated on 5/18/21, indicated: Cue, reorient and supervise as needed, but the intervention did not indicate how staff was going to provide and monitor for supervision and how often. A review of Resident 21'sCommunication Problem care plan initiated 5/28/21, one intervention initiated 8/16/21, indicated: 'Resident is not able to initiate needs request and requires staff support to have needs care and concrete addressed and met by staff. During an interview on 3/3/22 at 9:56 a.m., Physical Therapy (PT) Manager T stated Resident 21 was back on PT until 2/11/22 mainly to work on a safe transfer with assistance. PT Manager T stated Resident 21 should never be by herself when transferring from bed to wheelchair, wheelchair to bed . Resident 21 has always need assistance with transfers, not steady. During an interview on 3/3/22 at 11:49 a.m., the Infection Preventionist Nurse (IPN) stated Resident 21 should not get up on her own. When the IPN was asked how Resident 21 was monitored closely to prevent her from falling, the IPN stated Resident 21 was out and about often in the hallways propelling herself in her wheelchair where she was watched because staff were out and about in the hallways. During an interview on 3/3/22 at 11:50 a.m., the Director of Nursing (DON) stated Resident 21 was monitored at least every two hours. When the DON was asked if six falls was too much, the DON did not answer. The DON stated a short term Fall care plan was started for Resident 21 after each fall, but the interventions were short term. Resident 21 was monitored frequently for three days after each fall. The frequent monitoring was not a long-term intervention. When the DON was asked how Resident 21 was monitored to prevent her from falling, the DON stated Resident 21 was cognitively impaired and she was out and about propelling herself in the hallways often, whereby Resident 21 was watched. The DON stated Resident 21 did not have an alarm on her bed, wheelchair and/or no floor sensory pad anymore. During an interview on 3/3/22 at 3:25 p.m., Licensed Nurse C stated Resident 21 should be monitored every 15 to 30 min. Licensed Nurse C stated Resident 21 usually was propelling self in wheelchair in hallway after 2 p.m. Licensed Nurse C stated the CNAs started work at 6 a.m. to 2 p.m. and nurses started work at 7 a.m. to 3 p.m. During an observation on 3/3/22 at 4:05 p.m., Resident 21 was up in wheelchair in hallway propelling self and no staff was around supervising/monitoring Resident 21. Resident 21 was holding on to siderail across from Nurse's Station One and then crossed over into the hallway where her room was located. During an interview on 3/3/22 at 4:30 p.m., Staff P stated she checked on Resident 21 every two hours. Staff P stated Resident 21 was out in the hall a lot and people were around to watch her. Staff P stated Resident 21 could not get up on her own, Resident 21 needed assistance. During an observation on 3/3/22 at 4:45 p.m., while two surveyors were at Nurse's Station One, Resident 21 was observed propelling self in wheelchair nearby. There was no staff around supervising/monitoring Resident 21 who was cognitively impaired, had poor safety awareness, impulsive, and had fallen eleven times within a nine month period. No one had checked on Resident 21 in the past 15 minutes. Fall Twelve: A review of Resident 21's Nurse's Progress Notes, dated 3/4/21, and Resident 21's BM task, dated 1/2022, indicated Resident 21 did not have a BM (Bowel Movement) from 1/28/22 through 2/2/22 (six days), so on 3/4/21 at 12 a.m., Resident 21 was given a Dulcolax Suppository 10 mg (milligrams) for constipation. Nursing Progress Notes indicated safety fall precautions were maintained, but at 1:50 a.m. Resident 21 was found laying on the floor by her bedside. Resident 21 had an extra-large BM in her brief. Note: Nurse's Progress Note indicated the nurse did not go back to check on Resident 21, who was severely cognitively impaired and had poor safety awareness for almost two hours after Resident 21 was given a suppository to stimulate a BM. During a concurrent observation and interview on 3/4/22 at 9 a.m., Surveyor went into Resident 21's room along with Staff K, who showed where Resident 21's drop mat was kept. Staff K stated it was placed on the floor next to Resident 21's bed when she was in bed. Resident 21 was up in her wheelchair next to her bed. Staff K stated Resident 21 did not have a bed alarm and/or a wheelchair alarm. During an interview on 3/4/22 at 9:03 a.m., Staff Q stated she checked on Resident 21 every two hours. Staff Q stated Resident 21 was walking when Resident 21 was first admitted , but with assistance. When Staff Q was asked what frequently monitoring meant, she could not answer. Staff Q stated she checked on Resident 21 every time she passed by Resident 21's room because Resident 21's door was always opened. Staff Q stated another CNA was passing by Resident 21's opened door and saw Resident 21 was trying to get up, so Staff K told Staff Q, who went to check on Resident 21 right away. Staff Q stated if she was not available, Staff K would have assisted Resident 21. Staff Q was asked again what frequent monitoring meant and Staff Q could not define. Staff Q stated Resident 21 could not get up on her own, unsafe. During an interview on 3/4/22 at 9:45 a.m. the DON stated Resident 21 went to Activities as much as possible. The DON stated Resident 21 could not stand on her own. The DON stated Resident 21 was using a four-wheel walker with seat when Resident 21 was first admitted , but the walker was not safe. The DON stated Resident 21 was cognitively impaired and it was impossible to watch her all the time. The DON stated none of the residents had a one-on-one sitter. The DON stated a one-on-one sitter would be impossible because of lack of staff. The DON stated no residents had alarms and Resident 21's was discontinued on 11/20/21. The DON stated the facility did not use any alarms anymore because the alarms were found not to worked and scared the resident. During an interview on 3/4/22 at 11:41 a.m., Activities Assistant R stated she only worked Friday and Saturdays. Activities Assistant R stated Resident 21 would come to activities occasionally. We would encourage her to come. Activities Assistant R stated today Resident 21 was at the sensory awareness activity the entire time. During an interview on 3/4/22 at 11:48 a.m., Interim Activities Director S stated Resident 21 would come to activities sometimes. Interim Activities Director S stated Resident 21 was encourage to come to activities, but often Resident 21 wanted to stay in her room. Interim Activities Director S stated Resident 21 would come to activities two to three times during the week, just depended on her mood. Interim Activities Director S stated Resident 21 liked the social coffee activity; Resident 21 really came to be around other residents though often did not engage. The Facility Policy/Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated: Policy heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment . e. lower extremity weakness . i. functional impairments . k. incontinence, 3. Medical factors that contribute to the risk of falls include: . e. balance and gait disorders, etc. 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 . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk: . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The facility job description titled, RN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently. The facility job description titled, LVN - Charge Nurse, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently. The facility job description titled, Director of Nursing Services, dated 2003, indicated: Duties and Responsibilities: Nursing Care Functions: . Ensure that residents who are unable to call for help are checked frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. Foods were not stored in the refrigerator per facility storage guidelines including bread, premade cheese sandwiches, and gelatin, tomatoes had brown spots and felt mushy, and Romaine lettuce was not sealed and no open date, and 2. Test tray evaluation of lunch on 3/2/2022 at 12:57 p.m., found pureed Risotto tasted bland and had a gluey texture causing pureed risotto difficult to swallow, broccoli mushy and gray/green in color, and test tray evaluation of dinner on 3/2/2022 at 5:10 p.m., found the bottom bun of the grilled hamburger bun was hard, dry, and over cooked. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1. During the initial tour of the kitchen on 2/28/22 at 9:15 a.m., the walk-in refrigerator nearest the kitchen entrance had stored hot dog buns and hamburger buns, premade cheese sandwiches, which were wrapped and dated 2/22/22 and premade peanut butter and jelly sandwiches, which were wrapped and dated 2/26/22. The Dietary Director stated the date on the premade sandwiches indicated the date the sandwiches were made, and the Dietary Director stated all bread was stored in the refrigerator. The walk-in refrigerator nearest the prep sink had loaves of white and wheat bread, a large box of [NAME] tomatoes, which had brown spots and felt meshy, a large opened bag of Romaine lettuce, with no received or opened date, and diet Jell-O, dated 2/18/22. During an interview on 2/28/22 at 10:46 a.m., Resident 28 stated, The food is horrible, it's slop, it's awful, it should be thrown to the pigs. In the cauliflower chowder, the milk was curdled, I was looking forward to it. It's awful tasting, no spices. The meat is unrecognizable, gravy on everything . mystery meat. During a meeting with the Resident Council on 3/1/22 at 11:08 a.m., one out of seven residents stated the facility was using air bread, cheapest bread the facility could buy. Two out of seven residents stated they never ate the bread being served. Four out of seven residents stated bread was okay. Resident's stated vegetables were over cooked causing lack of flavor in the vegetables. Food was not good, all nutrients go down the drain. No seasoning. A lot of carbohydrates. During a concurrent observation and interview on 3/2/22 8:45 a.m., the walk-in refrigerator nearest the kitchen entrance had premade turkey on wheat bread with Mayonnaise sandwiches, dated 2/28/22, hot dog buns, dated 10/14/21 and 10/21/21, hamburger buns, dated 2/24/22, and the premade peanut butter and jelly sandwiches, dated 2/26/22, were still in the refrigerator. The Dietary Director stated the hamburger buns were going to be used for the residents' evening meal, which included smokey beef hamburger on a bun. The walk-in refrigerator nearest the prep sink had stored loaves of white bread, receive date 2/17/22, and loaves of wheat bread, receive date 2/22/22, the [NAME] tomatoes, which had brown spots and felt meshy, dated 2/14/22, were still in the refrigerator and the Romaine lettuce was tied, receive date 2/17/22. The Dietary Director stated today was when she cleaned outdated/old fruits/vegetables. The facility dietary document titled, Refrigerator Storage Guide, dated 2019, indicated: .gelatin, prepared, plain or with fruit, maximum refrigerator time of five days . The facility dietary document titled, Produce Storage Guidelines, dated 2018, indicated: . May use longer if no signs of spoilage are visible. lettuce, salad greens . refrigerator seven to ten days, tomatoes one to two weeks (at room temperature - preferably cool . The facility dietary document titled, Dried Goods Storage Guidelines, dated 2018, indicated: . bread - unopened and opened on shelf five-seven days and three months frozen . The facility policy/procedure titled, Storage of Food and Supplies, dated 2018, indicated: Policy: Food and supplies will be stored properly and in a safe manner. Procedures For Dry Storage: . 13. Bread will be delivered frequently and used in the order that is delivered to assure freshness. Bread products not used within five days can be frozen. Some breads do last five-seven days. Check manufactures recommendations. Do not store bread in the refrigerator . The facility policy/procedure titled, Labeling and Dating of Foods, dated 2019, indicated: Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Procedure: . Produce is to be dated with a receive dated . 2. On 3/2/22 at 1:15 p.m., a lunch test tray was completed. It was noted by surveyors and Registered Dietician, while the food temperatures were 131º F or greater, the pureed Risotto was bland and had a gluey [NAME], which caused the Risotto to stick to one's palate (the roof of mouth) and difficult to swallow. The surveyor noted broccoli was bland, mushy, and grayish/green. During an interview on 3/2/22 at 2:45 p.m., Resident 28 stated the broccoli served at lunch was mushy and overcooked. On 3/2/22 at 5:10 p.m., a dinner test tray was completed. It was noted by surveyors the hamburger bun tasted dry. The Dietary Director stated the bun was grilled on the outside not inside. The bottom part of the hamburger bun was hard to touch. The dietary document titled: Recipe: Pureed Starch (Rice, Pasta, Potatoes), undated, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk . If starch is already moist after pureed, you may not need much added milk. 4. Puree should reach a consistency slightly softer than whipping topping. May add more liquid if needed to reach this consistency. The dietary document titled, Recipe: Smokey Hamburger on a Bun, undated, indicated: Directions: . Special Diets: .Mechanical Soft: . Serve on bun . Note: There was no indication on the recipe to grill the outside of the hamburger buns. The facility policy/procedure titled, Meal Service, dated 2018, indicated: Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures .