Valley Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary and homelike environment for nine out of 22 residents (Resident 2, Resident 17, Resident 21, Resident 45, Resident 54, Resident 55, Resident 63, Resident 65, and Resident 72). This failure had the potential to increase risk for falls, effect resident dignity, and result in low self-esteem.Findings: During a concurrent observation and interview on 1/27/26 at 8:45 a.m. with Administrator and Maintenance Supervisor (MS) the following was found:1.Resident 2's room had a large 10 inch (in.) by 10 in. area of unpainted plaster located on the wall.2. The north wing shower room had a 12 in. by 12 in. area in the shower stall of slimy black textured dots on the ceiling. MS stated it was mold.3. Residents 17's room had a plastic container that held what appeared to be electrical or phone wires detached from the north wall of the room and exposed the contents. The wall under where the windows are located had a 16 in. by 16 in. area of loosened wall that moves with slight touch. Administrator stated it was possibly water damage.4. Residents 21's room had an air conditioning unit with a large ventilation tubing measuring approximately 12 in. in diameter running through the room window. The tubing was not secured and air from the outside was coming into the room.5. Residents 45's room had a large area about 13 in. by 13 in. of unpainted wall plaster. Next to the area of unpainted wall plaster was three large 20 in. scratches into the wall exposing the plaster.6. Resident 54's room had missing flooring approximately 15 in. in length upon entry into the room and missing flooring approximately 15 in. length prior to entering the restroom.7. Residents 55's room had missing blinds to the windows and a large 12 in. circular hole to the wall beneath the windows that cold air can be felt coming through.8. Residents 63's room had a 15 in. by 15 in. area on the wall in the middle of the room with unpainted plaster.9. Residents 65's room had a 40 in. by 40 in. area on the wall of exposed unpainted plaster. Approximately two feet away from the center window in the room is an area of missing flooring approximately 10 in. by 10 in. in measurement.10. Residents 72's room had a wall that was broken into pieces in a circular pattern approximately 12 in. in diameter. Above the circular broken wall was 24 in. scratches into the wall exposing the plaster. The floor beneath Res 72's bed had a 10 in. piece of flooring missing.Administrator stated the room findings, Needs to be addressed.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 11/1/17, the P&P indicated, Purpose . To provide residents with a safe, clean, comfortable and home like environment. The Facility provides residents with safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following . Cleanliness and order . comfortable levels of ventilation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled Drug Disposition when two controlled medications were not accounted for on the facility's medication disposition form (document used to record the secure destruction or disposal of expired, discontinued or unwanted medication). This failure had the potential for abuse of controlled (highly, abusive) medication.Authenticate the medication for one of one sampled resident (Resident 56). This failure had the potential for Resident 56 to receive an unknown medication and not being monitored for side effects.
Findings:
During a concurrent interview and record review on [DATE] at 10:15 a.m. with Director of Nursing (DON), the controlled medications disposition forms undated, were reviewed. DON stated Ativan (benzodiazepine medication used to treat anxiety) oral concentration 2 milligrams (mg/milliliter [ml]) unopened 30 ml container, and lorazepam (benzodiazepine) 2 mg/ml with 7 ml left in container were not recorded on the medication disposition form. DON stated the process is when a controlled medication is discontinued or resident is discharged two licensed nurses will document the controlled medication on the medication disposition form with their signatures. DON stated the medication disposition form will include the medication name, prescription number, and signature of two licensed nurses. DON stated this process was not done for Ativan and lorazepam, and should have been done.
During a review of the facility's (P&P) titled, Drug Disposition undated, the P&P indicated, Drugs discontinued by a physician order and outdated drugs that cannot be returned to the pharmacy for credit, can be returned for pharmacy proper disposal, are to be properly marked and disposed of in accordance with California's Medical Waste Management Act. Documentation of disposal is to be maintained. 3. Discontinued or outdated controlled drugs are to be delivered to the Director of Nursing for storage in an appropriately locked and secured storage area separate from other discontinued drugs until disposed properly according to policy and procedure. 4. Controlled drugs to be disposed and witnessed per facility policy. 5. All drugs disposed of or returned to the pharmacy for credit are to be entered onto an appropriate medication disposition record. 6. Information that must be entered into the records include a). RX Number b). Pharmacy Name c). Drug Name and Strength d). Quantity of Doses Remaining e). Resident's Name f). Date of Disposal. 7. Controlled drugs must be prepared for disposal by a registered nurse employed by the facility and a witness. Disposition of records for controlled drugs must include the information listed above and the signatures of both the nurse and the witness.


2.During a concurrent interview and record review on [DATE] at 2:30 p.m. with Infection Prevention Nurse (IP), Resident 56's Electronic Medical Record (EMR), [undated] was reviewed. The EMR indicated Resident 56 came back from hospital on [DATE] and there was no order for Cresemba (antifungal medication). IP stated the medication was brought in by family [unspecified]. IP stated the medication Cresemba was not sent to the pharmacy to validate the medication.
During an interview on [DATE] at 4:23 p.m. with DON, the DON stated Cresemba was not verified with pharmacy. DON stated the facility staff [not specific] copied the order from the medication bottle on to the facility EMR without validating with pharmacy and dispensed it to Resident 56.

Based on observation, interview, and record review, the facility failed to ensure medications were stored at proper temperature. This failure had the potential for medication to be ineffective or harmful to residents and staff.Findings:During a concurrent observation and interview on 1/27/26 at 2:01 p.m. with Infection Prevention Nurse (IP) in the facility medication room, three boxes of Prevnar 20-valent Conjugate Vaccine (pneumococcal (flu) vaccine) was stored in the facility freezer temperature at 20 degrees. IP stated the pharmacist stated to store the extra boxes in the freezer. IP stated the box of Prevnar indicated Do not freeze, and the medication should be discarded and not stored in the freezer.During a review of Prevnar's Instructions for Use (IFU) [undated], the IFU's indicated, After shipping, Prevnar 20 may arrive at temperatures between 36 degrees F (Fahrenheit) to 77 degrees F. Upon receipt, store refrigerated at 36 degrees F to 46 degrees F. Do not freeze, Discard if the vaccine has been frozen.During a review of the facility's policy and procedure (P&P) titled , Drug Storage and Labeling undated, the P&P indicated, Policy: Drugs and biologicals will be stored in a safe, secure and orderly fashion, and will be accessible only to licensed nursing or pharmacy personnel. 8. Drugs that are stored at room temperature will be stored in an area no warmer than 86 degrees F. 9. Drugs stored under refrigeration will be stored between 36 degrees F & 46 degrees F.

Based on observation, interview, and record review, the facility failed to provide the correct amount of ingredients to a meal per the facility recipe for three of 22 residents (Resident 21, Resident 51, Resident 80). This failure had the potential for Resident 21, Resident 51, and Resident 80's nutritional and caloric intake to be inaccurate and result in unwanted weight loss or gain. Findings:During a concurrent observation and interview on 1/28/26 at 11:32 a.m. with Facility [NAME] (FC) 1 in the facility kitchen, FC was observed making five quesadillas as a substitute meal for Resident 21, Resident 51, and Resident 80. FC 1 was observed using his hands to grab cheese and dispense unmeasured amounts onto a tortilla. FC 1 stated he had not measured how much cheese was used for the quesadillas and did not know what the facility recipe required as far as amount. During a review of the facility document titled RECIPE: CHEESE QUESADILLA (RCQ), dated 2025, the RCQ indicated, Add 1/2 cup cheese per tortilla.

Based on observation, interview, and record review the facility failed to:Label and date opened food items. Maintain a clean refrigerator per policy and procedure (P&P) REFRIGERATOR AND FREEZER. Accurately document the temperature of the facility dry food storage area. These failures had the potential to cause food to spoil and cause foodborne illness.Findings:1.During a concurrent observation and interview on 1/26/26 at 8:02 a.m. with Certified Dietary Manager (CDM) in the facility kitchen, the following food items were observed to have no open date or label:One pound (lb.) container of paprika, One lb. container of ground thyme, One lb. container of ground rosemary, One lb. container of sesame seeds, One lb. container of ground cumin, One lb. container of lemon pepper seasoning, One lb. container of dill weed, One lb. container of bay leaves, and Three pink 32-ounce containers with whitish thick liquid substance found in the walk-in refrigerator. There was no indication of what the liquid was.CDM stated per the facility, process food items should have an 'open and used by' date, as well as a label to indicate what the food item is. CDM stated the spice food items observed did not have an open or use by date. CDM stated the three 32-ounce pink pitchers of thick liquid were a drink made for residents, and that should have been labeled to indicate what it was and dated when it was made.During a review of the facility's P&P titled, Dry Storage, [undated], the P&P indicated, Dry food items which have been opened, such as . spices . will be tightly closed, labeled and dated.2. During a concurrent observation and interview on 1/27/26 at 8:40 a.m. with CDM in the facility kitchen, the facility pastry refrigerator was observed. The pastry refrigerator had three levels of shelving that could not be observed due to a buildup of ice of about 1 to 1.5 inches. On the top shelf there was a 7.62 kilogram (kg) box of French fries, on the middle shelf a box of raw cookie dough (weight not specified), and on the bottom shelf a 7.62 kg box of French fires. The very top of the inside of the refrigerator was covered in about 2 inches of ice. CDM stated the facility pastry refrigerator needed to be defrosted (become free of accumulated ice) and cleaned. CDM stated she was not sure when the last time the facility pastry refrigerator was cleaned. During a review of the facility's P&P titled, REFRIGERATOR AND FREEZER, dated 2023, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. Refrigerator and freezer should be on a weekly cleaning schedule. Remove all items and clean shelves. Wipe with sanitizer. Periodically inspect shelves and replace if coating is chipped away exposing metal shelves.3. During a concurrent interview and record review on 1/28/26 at 10:09 a.m. with Dietary Aide (DA) 1, the facility's DRY STORAGE TEMP (Temperature) LOG (DSTL), dated 1/2026 was reviewed. DA 1 stated she placed the temperature entries for the log on 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/20/26, 1/22/26, 1/23/26, 1/25/26, 1/26/26, 1/27/26 and 1/28/26 and that they were all measured at 62 degrees Fahrenheit. DA 1 stated she documented the entries incorrectly as she did not read the thermometer in the dry storage room to get the reading but was looking at the setting of an air conditioner located in the dry storage room. DA 1 was unable to state what the actual temperature of the dry storage room was.During a review of the facility's P&P titled, CORRECTIVE ACTION WHEN FOOD IN THE STORE ROOM REACHES ABOVE 85 (degrees Fahrenheit), dated 2023, the P&P indicated, When temperature within the emergency or food storage room becomes higher than 85 (degrees Fahrenheit), corrective action must take place to ensure food has not become compromised. PROCEDURE . The Dry Food Storage Temperature Log . will be started to monitor storage unit temperatures.

Based on interview and record review facility failed to follow its policy and procedure (P&P) titled, Infection Prevention and Control Program, when there was no surveillance conducted on nursing staff. This failure had the potential for unsanitary conditions.Findings:During a concurrent interview and record review on 1/28/26 at 9:27 a.m. with Infection Prevention Nurse (IP), surveillance records (form that audit staff for infection control practices) were reviewed. IP stated there was no surveillance conducted for certified nursing assistants and Licensed and Registered nurses for any infection control practices. IP stated it should have been done. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 12/1/2021, the P&P indicated, V. Gathering Surveillance Data.E. At least on a monthly basis, the IP. will conduct an infection control audit.

Based on interview and record review the facility failed to implement their policy and procedure (P&P) titled DISHWASHING, when a facility dishwasher failed to reach the mandatory temperature to sanitize resident dishware and/or failed to document the temperature the dishwasher was reaching to ensure sanitation. This failure had the potential for a foodborne illness outbreak to occur resulting in harm up to and including death.Findings:During a concurrent interview and record review on 1/27/26 at 8:19 a.m. with Kitchen Supervisor (KS), the facility DISH MACHINE TEMPERATURE LOG (DMTL), was reviewed. KS stated the facility dish machine needs to reach a temperature of at least 120 degrees Fahrenheit (a unit of measurement) to sanitize resident dishware. KS stated the facility dish machine did not reach the temperature it should have to ensure sanitation of dishware on the following dates:June 30th there was no recorded temperature for the facility dish machine at dinner serviceAugust 28th there was no recorded temperature for the facility dish machine at dinner service. August 31st the facility dish machine was recorded to be at 100 degrees Fahrenheit at lunch service. August 31st there was no recorded temperature for the facility dish machine at dinner serviceOctober 17th, 21st, 22nd, 23rd, 28th and 29th 2025 the dish machine temperature was recorded to be at 100 degrees Fahrenheit for lunch serviceNovember 15th to the 30th 2025 (15 days total) the dish machine temperature was recorded to be at 100 degrees Fahrenheit for breakfast serviceKS stated he should have been made aware the facility dish machine was not reaching temperature, but he was not. KS stated if he was contacted about the facility dish machine not reaching temperature, he would have the dish machine serviced to fix the issue.During a review of the facility's Dish Machine Temperature Log (DMTL) dated 2023, the DMTL indicated, Please record wash and rinse temperatures . before each meal . Wash temperatures must be at least 120 (degrees Fahrenheit).During a review of the facility's policy and procedure (P&P) titled, DISHWASHING, undated, the P&P indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. A temperature log . will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing. If you cannot achieve the temperature, alert . Director or cook who will alert the Maintenance Department and stop washing dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms.Findings:During a review of facility documented titled Client Accommodation Analysis (CAA), (a facility document indicating the size of resident rooms), [undated], the CAA indicated the following room measurements:room [ROOM NUMBER]: 153 square feetroom [ROOM NUMBER]: 154 square feetroom [ROOM NUMBER]: 132 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 225 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 156 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetDuring a review of the Resident List Report (RLR) (a document indicating the number of residents in the facility and their respective rooms), dated 1/25/26, the RLR indicated the following number of residents in each room:room [ROOM NUMBER]: two beds (resulting in 76.5 square feet of space per resident)room [ROOM NUMBER]: two beds (resulting in 77 square feet of space per resident) room [ROOM NUMBER]: two beds (resulting in 66 square feet of space per resident) room [ROOM NUMBER]: three beds (resulting in 70 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 70 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 70 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 70 square feet of space per resident)room [ROOM NUMBER]: two beds (resulting in 75 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident) room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)room [ROOM NUMBER]: three beds (resulting in 73 square feet of space per resident)During an interview on 1/29/26 at 9:41 a.m., with the Administrator, the Administrator stated the above rooms did not measure at least 80 square feet per resident.During the survey, no residents in the above rooms identified with providing fewer than 80 square feet per resident were negatively affected by the size of their rooms.During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, dated 11/1/17, the P&P indicated, The Maintenance Department is responsible for . Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.

Based on observation, interview, and record review, the facility failed to ensure a call system was available and functional for the residents in two of two sampled shower rooms. This failure had the potential to put the residents at risk for falls. Findings:During a concurrent observation and interview on 1/27/26 at 2:08 p.m. with Maintenance Supervisor (MS) in the shower room in station 3, the shower room did not have a call system present. MS stated there was no call system available for residents using the toilet and the shower in the shower room in station 3. MS stated there should have been an alternative call system provided for the residents using the toilet and the shower in the shower rooms.During a concurrent observation and interview on 1/27/26 at 2:15 p.m. with MS in the shower room in station 2, there was a black wireless call button with a bell logo hanging on the hand rail next to the toilet. MS pressed the black wireless call button. MS went to the nurses station 1 but there was no alarm heard from the shower room in station 2. MS stated there should have been an alarm heard at the nurses station 1 alerting the staff somebody needed assistance in the shower room in station 2. MS stated he would replace the black wireless call button in the shower rooms, but the black wireless call buttons would go missing. MS stated there should have been a functional call system available for the residents using the toilet and the shower in the shower rooms.During an interview on 1/28/26 at 12:44 p.m. with Director of Nursing (DON), DON stated the facility had two shower rooms (station 2 and station 3). DON stated the call system had not been working in the shower rooms and it had been an ongoing issue in the facility. DON stated there should have been an alternative call system available for the residents. DON stated Resident 85 and Resident 14 were using the toilet in the shower room in station 3. DON stated Resident 85 and Resident 14 were at risk for falls. DON stated if there was no call system in the shower rooms, it would put the residents at risk for accidents and falls.During a review of Resident 85's Morse Fall Scale (MFS), dated 12/9/25, the MFS indicated, Resident 85 had a score of 55 (score of 45 and higher means high risk for falls).During a review of Resident 14's Minimum Data Set (MDS - an assessment tool), dated 12/31/25, the MDS indicated, Resident 14 had a BIMS (Brief Interview for Mental Status) score of 6 (score of 0-7 means severe cognitive impairment).During a review of Resident 14's MFS, dated 12/31/25, the MFS indicated, Resident 14 had a score of 60.During an interview on 1/28/26 at 1:26 p.m. with Resident 14, Resident 14 stated he was able to control his bladder and would independently use the toilet in the shower room in station 3. Resident 14 stated there was no call system in the shower room.During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, dated 11/1/17, the P&P indicated, Purpose To provide a mechanism for residents to promptly communicate with nursing staff. The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Should the primary call system become inoperable for any reason, the Facility shall provide a bell for each resident room. Call bells located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly.

Based on interview and record review the facility failed to have Certified Nursing Assistant (CNA)'s who have successfully completed either a nurse aide training or a competency evaluation program (is a structured and regulated process that measures an individual's knowledge, skills, and behaviors against establish job requirement) for three of three CNA's (CNA 1, CNA 2, and CNA 3). This failure resulted in CNA 1, CNA 2, and CNA 3 not be evaluated to determine if they were competent to provide resident care services.Findings:During a concurrent interview and record review on 1/28/26 at 10:07 a.m. with Director of Staff Development (DSD), CNA 1's personnel file (PF) was reviewed. DSD stated CNA 1 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 1 did not have the competency evaluation for: hand hygiene, universal precaution (a set of infection control practices that require treating all human blood and certain body fluids for infection), isolation technique (method used to separate a specific component, organism, or variable from a mixed, contaminated, complex environment), and applying and removing Protected Personnel Equipment (PPE- a gear worn to minimize exposure) completed.During a concurrent interview and record review on 1/28/26 at 10:10 a.m. with DSD, CNA 2's PF was reviewed. DSD stated CNA 2 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 2 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.During a concurrent interview and record review on 1/28/26 at 10:15 a.m. with DSD, CNA 3's PF was reviewed. DSD stated CNA 3 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 3 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.During a review of the facility's policy and procedure (P&P) titled All Departments - New Employee Orientation, [undated], the P&P indicated, all newly hired employees receive a comprehensive New Employee Orientation prior to assuming independent job responsibilities.No employee may work independently until required orientation components are completed.Director of Staff Development (DSD) .Coordinates and conducts orientation .Maintains orientation and competency records .Maintains employee personnel file.E. Competency and Supervision .Competency validation required prior to independent work. During a review of the facility's P&P titled Job Description, undated, the P&P indicated, Title: Director of Staff Development (DSD).Implement and oversee the facility's in-service training program, ensuring compliance with state and federal training regulations. Provide hands-on training, skill validation, and competency assessment for all nursing staff.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Change of Condition Notification, for one of three sampled residents (Resident 53). This failure resulted in Resident 53 having unmet care needs for high blood pressure (force of blood pushing when your heart beat) and heart rate (the number of times when the hear beats per minute) which could result in damage to the heart, kidneys, brain, and result in heart attack.Findings:During a review of Resident 53's ADMISISON RECORD (AR), dated 12/9/25, the AR indicated, Resident 53 has a diagnosis of Atrial Fibrillation (AFib - is a common heart arrhythmia [abnormal heart beat] characterized by an irregular and often rapid heart rate and effect blood pressure) and Hypertensive heart disease without heart failure (structural and functional changes in the heart). During a review of Resident 53's Minimal Data Sheet (MDS - Resident assessment Tool), dated 12/12/25, the MDS indicated, Resident 53's Brief Interview for Mental Status (BIMS - cognition assessment tool, 15-point scale: 13-15 cognitively intact, 8-12 moderate impairment ) score was 12.During an interview on 1/26/26 at 8:13 a.m. with Resident 53, Resident 53 stated she was considering going to the hospital a few days ago (unspecified date) because staff did not give her medication for AFib . Resident 53 stated she feels ill when she does not receive her AFib medication. Resident 53 stated it makes her feel scared when her heart rapidly beats and she doesn't know why the facility did not have her medication.During a review of Resident 53's Orders, dated 12/9/25, the Orders indicated, Resident 53 was prescribed Apixaban [blood thinner used to reduce the risk of blood clots in residents with AFib]) Oral Tablet 2.5 mg [milligram] give 1 tablet by mouth two times a day for A-Fib.During a review of Resident 53'3 Medication Administration Record (MAR), dated 1/1/26 -1/31/26, the MAR indicated, Monitor Vital Signs (assessment of blood pressure, heart rate, and breathing) Daily. The MAR indicated on 1/2/26 the vital signs indicated, Blood pressure (b/p) was 162/100 (normal is 120/60), Heart rate (HR) was 145 (normal is 60-100).During a concurrent interview and record review on 1/29/26 at 10:26 a.m. with Infectious Prevention Nurse (IP), Resident 53's medical record was reviewed. Resident 53's b/p on 1/2/25 at 9:07 a.m. was 147/100, and at 10:15 a.m. b/p was 148/100 with a HR of 145. IP stated the nurse should have rechecked Resident 53's vital signs but saw no documentation indicating that it was done. IP stated the facility practice is to re-check abnormal vital signs. During a concurrent interview and record review on 1/29/26 at 10:33 a.m. with IP, Resident 53's Progress notes (PN), were reviewed. Resident 53's PN indicated, Resident 53 was going to be sent to the hospital by the facility for high blood pressure but was not. Resident 53's hospital transfer got cancelled. IP stated the staff should have checked her vital signs and notified the physician but did not.During a review of the facility P&P titled, Vital Signs (VS), dated 11/1/17, the P&P indicated, Report abnormal or out of range vital signs promptly . the licensed nurse will assess the resident and notify the physician.notification interventions must be documented.During a review of the facility P&P titled, Change of Condition Notification (COC) dated 11/1/17, the P&P indicated, The licensed nurse will notify the residents attending physician when there is a.an accident involving the resident which.has the potential for requiring a physician intervention.a significant change in the residence physical mental or psychosocial status.clinical complicated.the licensed nurse will assess the residents change of condition and document the observation and symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have clear clinical justification to provide Zyprexa (a medication used to treat psychosis [mental state where you lose touch with reality, experiencing things that aren't real or hold strong false beliefs]) to one of 22 residents (Resident 82). This failure had the potential cause medication induced harm.Findings:During a review of Resident 82's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 82 was admitted to the facility on [DATE] with diagnosis of need for assistance with personal care, anxiety disorder (a mental health condition marked by excessive, persistent, and uncontrollable worry or fear), unspecified psychosis, and muscle weakness. During a review of Resident 82's Physician Order Sheet (POS), dated 1/6/26, the POS indicated, Resident 82 was to be on Zyprexa 5 mg (milligram) by mouth at bedtime for psychosis manifested by lack of motivation and trouble thinking. During a review of Resident 82's MEDICATION ADMINISTRATION RECORD (MAR), dated January 2026, the MAR indicated, Resident 82 received Zyprexa 5 mg at 9 p.m. on 1/6/26 to 1/28/26 (22 days). Under the section Monitor for number of episodes of lack of motivation and trouble thinking every shift, Resident 82 had no documented behavior episodes for the month of January 2026. During a concurrent interview and record review on 1/29/26 at 9:37 a.m. with Social Services Director (SSD), Resident 82's Electronic Health Record (EHR) was reviewed. SSD stated Resident 82 was admitted to the facility on [DATE] with a prescription for Zyprexa 5 mg. SSD stated on 7/29/24 Resident 82's order for Zyprexa was ordered to be discontinued as it was no longer needed. SSD stated Resident 82 went to the acute hospital on 1/4/26 and returned to the facility on 1/6/26 and the acute hospital may have mistakenly restarted Resident 82's Zyprexa 5 mg. SSD stated at the facility Resident 82's Zyprexa 5 mg was continued per the hospital order but there was no IDT (Interdisciplinary team - a team of professionals that meet to discuss resident safety, treatment, and goals) to discuss if the Zyprexa order should have been continued and if there was clinical justification for Resident 82 to take the Zyprexa. SSD stated there were no alternative treatments trialed prior to placing Resident 82 back on Zyprexa (the IDT would have discussed this) nor was a care plan (a written, personalized roadmap for a person's health, safety, and daily support needs, created by doctors, caregivers, and the individual) created.During an interview on 1/29/26 at 10:36 a.m. with Director of Nursing (DON), DON stated, the IDT did not meet for Resident 82 new order of Zyprexa 5 mg. DON stated the IDT should have met to discuss the appropriateness of the new order for Zyprexa and see if there was clinical justification. During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 11/1/17, the P&P indicated, Purpose . To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s). To ensure non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication. To ensure clinically significant adverse consequences are minimized. The IDT, in consultation with the Consulting Pharmacist and the resident's Attending Physician . will discuss the psychotherapeutic medications at least quarterly, or as needed. Interdisciplinary Team (IDT) Responsibility . The care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables and specific interventions. The resident's Care Plan will include the reason(s) for the drug and describe the behaviors the drug was prescribed to treat. The IDT note will include: reasons for the drug, manifestations for the drug, an analysis of the residents response to the drug and response to psychiatric consult or recommendations . new non-drug interventions and reasons for continuing same dose, decreasing dose and/or increasing dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting, for one of 22 sampled residents (Resident 3) when the facility did not report to the California Department of Public Health (CDPH) Resident 3's fall with injury (fracture [broken bone] of left leg) with subsequent hospitalization, need for surgical intervention, and rehabilitation. This failure resulted in the facility not reporting to CDPH and resulted in a lack of investigation. Findings:During a review of Resident 3's admission RECORD (AR), dated 1/26/26, the AR indicated, Resident 3 was admitted on [DATE] with diagnosis of muscle weakness, unspecified dementia (cognitive decline), depression, anxiety disorder, lack of coordination and history of falling.During a review of Resident 3's Change of Condition Evaluation (COC), dated 12/1/15, the COC indicated, at 3:31 a.m. Writer was called to residents' room by aide. Nurse found resident [3] sitting on floor on L [left] side of bed. ROM (range of motion) unable to complete d/t [due to] resident [3] not following instructions. C/o [complained of] hip pain at this time. Resident [3] unable to say why she wanted to get up.During a review of Resident 3's :admission H&P (AHP), dated 12/6/25, the AHP indicated, on 12/1/25 Resident 3 had a fall at the facility that resulted in left leg fracture. On 12/2/25 Resident 3 had surgery to correct the left leg fracture. During a concurrent interview and record review on 1/29/26 at 12:03 p.m. with Director of Nursing (DON), Resident 3's electronic health record (EHR) was reviewed. DON stated Resident 3 had a fall on 12/1/25 and was sent to acute hospital (12/1 thru 12/5/25) status post fall and pain in left hip. DON stated she was not aware of Resident 3's left leg fracture (12/1/25) until she reviewed the EHR today (1/29/26). DON stated she did not follow up on Resident 3's fall and report the incident as she had been unaware of Resident 3's fall with a fracture.During an interview on 1/29/26 at 2:17 p.m., with DON, DON stated Resident 3's fall with a femoral fracture was an unusual occurrence and should have been reported to the CDPH according to their policy.During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated November 2017, the P&P indicated, Purpose. To ensure that timely reports are made to designated agencies as required by state and federal law. 1. The facility reports the following events by phone and in writing to the appropriate Sate or Federal agencies . III. Unusual occurrence are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for three of 22 sampled residents (Resident 9, Resident 56, and Resident 64): Resident 64's use of mind altering substances (Marijuana) substance while driving vehicle. This failure had the potential to put Resident 64, other residents, staff, and visitors at risk for accidents. 2. Resident 9's continued behavior of non-compliance. This failure had the potential for unmet care needs. 3. Resident 56 was on anti-viral medication. This failure had the potential for unmet care needs. Findings:
1. During a review of Resident 64's Minimum Data Set (MDS – an assessment tool), dated 10/1/25, the MDS indicated on section C (Cognitive Patterns), Resident 64 had a BIMS (Brief Interview for Mental Status) score of 13 (score of 13-15 means cognitively intact). The MDS indicated on section GG (Functional Abilities), Resident 64 had functional limitation in range of motion (limit to which a part of the body can be moved around a joint) on one side for both upper and lower extremities, was wheelchair-bound, was unable to walk, required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with transferring to and from a bed to a chair or wheelchair, and required set up assistance (helper only assists prior to or following the activity) with wheeling himself using his wheelchair.
During a review of Resident 64's MD [Medical Doctor] Progress Note (MDPN), dated 12/15/25, the MDPN indicated, patient [Resident 64] has a history of: Need for assistance with personal care, generalized muscle weakness. Comments: Supervision and care 24 hours.
During a review of Resident 64's Behavior Note (BN), dated 1/12/26, the BN indicated, Resident [64] was seen sitting on his bed in his room preparing a marijuana cigar.
During a review of Resident 64's BN, dated 1/20/26, the BN indicated, was reported by nursing that [Resident 64] was in his car all night, blocked entrance way and way [sic] playing loud music. Was asked to move car but refused till [sic] staff informed him it will be towed.
During a concurrent observation and interview on 1/20/26 at 2:35 p.m. with Resident 64 in Resident 64's room, Resident 64 had dry dressing wrapped around his right foot. Resident 64 stated he had been going out of the facility and had been driving his car despite having amputation (surgically removed) of his right foot and smoking marijuana.
During an interview on 1/20/26 at 2:51 p.m. with Social Services Director (SSD), SSD stated Resident 64 had been seen using marijuana in the facility and had been driving his car. SSD stated Resident 64 had almost hit several cars in the parking lot.
During an interview on 1/20/26 at 3:30 p.m. with Director of Nursing (DON), DON stated Resident 64 had said he was driving his car. DON stated Resident 64 had been found to have marijuana on his bedside table. DON stated there was a concern for Resident 64's safety when he would go out and drive his car because of his substance use and unresolved surgical wound on his right foot.
During a concurrent interview and record review on 1/20/26 at 3:45 p.m. with DON, Resident 1's Care Plan (CP), dated 1/20/26, was reviewed. There was no care plan developed to address Resident 64's use of illegal substance and driving his car. DON stated the facility don't know how to keep Resident 64 safe when driving his car. DON stated there should have been a care plan developed for Resident 64 to ensure his safety when using a mind altering substance and when driving his car.
During a concurrent interview and record review on 1/26/26 at 11 a.m. with DON, the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, was reviewed. The P&P indicated, Purpose To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. DON stated P&P was not followed.
2. During a review of Resident 9's Medical Record (MR), [undated], the MR indicated Resident 9 went out with ex-wife on 5/6/25 and returned on 5/9/25.
During a concurrent interview and record review on 1/29/26 at 3:10 p.m. with SSD, Resident 9's Care Plan, was reviewed. SSD was unable to provide evidence a care plan was developed and implemented for Resident 9's leaving facility without informing the staff. SSD stated there was no care plan written for non-compliance.
3. During a concurrent interview and record review on 1/29/26 at 2:30 p.m. with Infection Prevention Nurse (IP), Resident 56's Care Plan, was reviewed. IP was unable to provide evidence a care plan was developed and implemented for Resident 56's medication Cresemba (medication for fungal infection).
During a review of Resident 56's Physician Orders (PO), dated 1/23/26, the PO indicated, Cresemba 186 milligram was started on 1/23/26 two capsules once time a day.
During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/2017, the P&P indicated, To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. Procedure. II. B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment.

Based on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) on:1. Out on Pass for one of three sampled residents (Resident 64) when Resident 64 was going out on pass without a physician order, and Resident 64 was not assessed by a licensed nurse prior to leaving out on pass and after coming back to the facility. These failures had the potential to jeopardize Resident 64's safety and had the potential for Resident 64 to receive delay in care. 2. Wound Management for one of two sampled residents (Resident 35) when Resident 35's gastrostomy tube (GT - small, soft tube placed through the skin directly into the stomach to deliver food, liquids, and medicine) site was not being treated as ordered by the physician and there was no care plan developed to manage Resident 35's skin irritation around the GT site. These failures had the potential to result in further skin breakdown.Findings:1. During a review of Resident 64's Minimum Data Set (MDS - an assessment tool), dated 10/1/25, the MDS indicated on section C (Cognitive Patterns), Resident 64 had a BIMS (Brief Interview for Mental Status) score of 13 (score of 13-15 means cognitively intact). The MDS indicated on section GG (Functional Abilities), Resident 64 had functional limitation in range of motion (limit to which a part of the body can be moved around a joint) on one side for both upper and lower extremities, was wheelchair-bound, was unable to walk, required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with transferring to and from a bed to a chair or wheelchair, and required set up assistance (helper only assists prior to or following the activity) with wheeling himself using his wheelchair.During a review of Resident 64's MD [Medical Doctor] Progress Note (MDPN), dated 12/15/25, the MDPN indicated, patient has a history of: Need for assistance with personal care, generalized muscle weakness. Comments: Supervision and care 24 hours.During a review of Resident 64's Social Services Note (SSN), dated 1/9/26, the SSN indicated, [Resident 64] purchased a vehicle and is leaving the facility with out [sic] a MD out on pass.During a review of Resident 64's Order Summary Report (OSR), dated 1/21/26, the OSR indicated, Resident 64 did not have a physician order to go out on pass.During a review of Resident 64's RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE (RRLA - log for residents to sign when going out on pass and coming back to the facility), dated January 2026, the RRLA indicated:a. On 1/2/26, Resident 64 signed out on pass and did not sign when he came back to the facility.b. On 1/5/26, Resident 64 signed out on pass and did not sign when he came back to the facility.c. On 1/6/26, Resident 64 signed out on pass and did not sign when he came back to the facility.d. On 1/9/26, Resident 64 signed out on pass and did not sign when he came back to the facility.e. On 1/13/26, Resident 64 signed out on pass and did not sign when he came back to the facility.f. On 1/14/26, Resident 64 signed out on pass and did not sign when he came back to the facility.g. On 1/19/26, Resident 64 signed out on pass and did not sign when he came back to the facility.During a concurrent observation and interview on 1/20/26 at 2:35 p.m. with Resident 64 in Resident 64's room, Resident 64 had dry dressing wrapped around his right foot. Resident 64 stated he had all his toes amputated (surgically removed) on his right foot and his surgical wound on his right foot was still healing. Resident 64 stated he had been going out of the facility and had been driving his car.During an interview on 1/20/26 at 2:51 p.m. with Social Services Director (SSD), SSD stated Resident 64 had been seen using a mind-altering drug (marijuana) in the facility and had been driving his car. SSD stated Resident 64 had almost hit several cars in the parking lot. SSD stated when Resident 64 would go out on pass, he would not notify the licensed nurses, and the licensed nurses would not be able to notify the doctor until they found out during their rounds that Resident 64 had gone out.During an interview on 1/20/26 at 3:30 p.m. with Director of Nursing (DON), DON stated Resident 64 had said Resident 64 was driving his car. DON stated Resident 64 would leave out on pass anytime without telling the staff. DON stated the facility don't know how to monitor Resident 64 of his whereabouts. DON stated there was a concern for Resident 64's safety when he would go out and drive his car because of his mind-altering drug (marijuana) use and unresolved surgical wound on his right foot. DON stated Resident 64 did not have a physician order to go out on pass. DON stated Resident 64 should have had an authorization from the physician prior to going out on pass.During a concurrent interview and record review on 1/20/26 at 4 p.m. with DON, Resident 64's Nurses Note (NN), dated 1/13/26, was reviewed. The NN (written at 7:56 p.m.) indicated, Morning nurse reported to pm [evening shift] nurse that resident signed out around 2:35pm [sic] to go on pass out of facility during nurse rounds resident was seen heading out facility, during med [medication] pass resident have not returned back to facility. The NN (written at 9 p.m.) indicated, Resident returned back to facility. DON stated Resident 64 was not assessed prior to leaving the facility and coming back to the facility. DON stated the licensed nurses should have assessed Resident 64 when coming back to the facility for injuries and changes in mental status because the facility was aware Resident 64 was also using a mind-altering drug (marijuana).During a concurrent interview and record review on 1/26/26 at 11 a.m. with DON, the facility's P&P titled, Out on Pass, dated 11/1/17, was reviewed. The P&P indicated, It is the policy of the Facility to meet residents' physical and psychosocial needs to go out on pass. The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights. If the Attending Physician and Psychiatrist (if applicable) determine that the resident may participate in activities outside the Facility, the Attending Physician will write/give an order for a pass on the physician order sheet. Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status. When the resident returns to the Facility, a Licensed Nurse will re-assess the resident to determine the resident's condition and any medication returned after going out on pass, if applicable. The resident/responsible person will verbally notify a Licensed Nurse prior to going out on pass and will sign out and back in on Form A - Resident Out on Pass Log. DON stated the P&P was not followed. 2. During a review of Resident 35's Nurses admission Record (NAR), dated 1/19/26, the NAR indicated, G tube [GT] with skin irritation.During a concurrent interview and record review on 1/27/26 at 3:22 p.m. with Treatment Nurse (TN), Resident 35's Order Summary Report (OSR), dated 1/27/26, was reviewed. The OSR indicated, Cleanse GT site with NS [normal saline (used to clean wounds)], pat dry then apply zinc oxide [medicated cream used for wound treatment] to peri wound [skin surrounding a wound], cover with T-Drain sponge [white dry dressing, pre-cut absorbent pad used to keep the GT insertion site dry] then secure with tape Q [every] shift. Order Date. 01/19/2026. Resident 35's Treatment Administration Record (TAR), dated January 2026, was reviewed. The TAR indicated, the treatment order started on 1/19/26 for Resident 35's GT site was being done every day and evening shift. TN stated the OSR was not followed. TN stated the treatment order for Resident 35's GT site should have been done three times a day (every day, evening, and night shift) as ordered by the physician on 1/19/26. TN stated Resident 35's skin irritation around the GT site would get worse if the physician order was not followed. The OSR indicated, there was no physician order to monitor Resident 35's GT site as needed. TN stated there was no order to monitor Resident 35's GT site as needed if the dressing needed to be changed.During a concurrent observation and interview on 1/28/26 at 11:39 a.m. with TN in Resident 35's room, Resident 35's dressing on her GT site was black and did not cover the GT insertion site. Resident 35's GT site had redness and was leaking yellow liquid from the GT insertion site. TN stated Resident 35's dressing on her GT site was wet because there was GT formula (specially designed liquid, high-nutrient food meant to provide all necessary nutrition directly into the stomach) leaking from the GT insertion site. TN stated the moisture around the GT site was causing irritation and redness on Resident 35's skin. TN stated Resident 35's GT site should have been monitored as needed to keep the GT site clean and dry. During an interview on 1/28/26 at 11:50 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she saw Resident 35 on 1/28/26 around 10:30 a.m. and the dressing on Resident 35's GT site was black and did not cover the GT site. CNA 4 stated she did not notify TN or any licensed nurse about Resident 35's GT site. CNA 4 stated she should have notified the TN or any licensed nurse to change the dressing on Resident 35's GT site.During a concurrent interview and record review on 1/28/26 at 12:44 p.m. with DON, Resident 35's Care Plans (CP), dated 1/28/26, was reviewed. The CP indicated there was no care plan developed to address Resident 35's skin irritation on her GT site. DON stated Resident 35's skin irritation on her GT site was caused by the GT formula leaking from the GT insertion site. DON stated there should have been a care plan to monitor if the dressing on Resident 35's GT site needs to be changed to prevent further skin breakdown. DON stated CNA 1 should have notified a licensed nurse when the dressing on Resident 35's GT site needed to be changed.During a concurrent interview and record review on 1/28/26 at 12:44 p.m. with DON, the facility's P&P titled, Wound Management, dated 11/1/17, was reviewed. The P&P indicated, Purpose To provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers. A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. A Licensed Nurse will develop a Care Plan for the resident based on recommendations from Dietary, Rehabilitation and the Attending Physician. Per Attending Physician order, the Nursing Staff will initiate treatment and utilize interventions for pressure redistribution and wound management. DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to provide the individualized activities services for one of 22 sampled residents (Resident 97). This failure had the potential for Resident 97 to have diminished functional needs to promote maximum participation in activities. Findings:During an observation on 1/26/26 at 9:15 a.m. in Resident 97's room, Resident 97 was lying in bed staring at the walls. During an interview on 1/26/26 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated, Resident 97 is in bed all the time. FM 1 stated he had requested activities to be provided to Resident 97 in the room because FM 1 feels that Resident 97 is depressed. During a review of Resident's 97's admission RECORD (AR), dated 11/15/25, the AR indicated, Resident 97 had muscle weakness, lack of coordination, and assistance with personal care.During a review of Resident 97's Care Plan (CP) Activities, [undated], the CP indicated, Resident 97 goal is, express satisfaction with type of activities and level of activity involvement when asked.During a concurrent interview and record review on 1/26/26 at 9:26 a.m. with Activities Director (AD), Resident 97's IN ROOM VISITS ACTIVTY RECORD (IRVAR) was reviewed, the IRVAR indicated, on 1/1/26 transfer to the hospital1/2/26 transfer to the hospital1/4/26 family visit1/5/26 slept1/7/26 Not Applicable1/9/26 family visit1/11/26 family visit1/19/26 Not Applicable1/21/26 CNA attending to him1/23/26 Not Applicable1/25/23 Family Visit1/27/26 SleptAD stated that Resident 97's activities is for one hour on Monday's, Wednesday's and Fridays. AD can't verify that staff attempted other times to involve Resident 97 in activities when family was present during the hour, when Resident 97 was sleeping, or when Resident 97 was being attended by a Certified Nursing Assistant (CNA). AD could not identify what Not Applicable meant. AD had no other log that attempted Resident 97 in activities or what activities were being presented to Resident 97 for participation. During a review of the facility's policy and procedure (P&P) titled, Room Visit Program, dated 4/1/21, the P&P indicated, The Facility will provide recreational opportunities for residents who are not physically able to or choose not to leave their room. Residents who prefer not to, or cannot, participate will be visited in their room on a regular scheduled basis.Room activities may include games, discussions, arts and crafts, and sensory stimulations, reading or educational programs, or adapted exercise.Activity staff will maintain a record of the activities provided for each resident when visited in the room.activities staff will document the activity the level of participation and response to the approach will be recorded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess, develop, and implement interventions as well as implement the facility's policy and procedures (P&P) for one of 22 Residents (Resident 3) when: Resident 3 had nine falls with injuries between admission date (9/5/25) to hospitalization (12/1/25). These failures resulted in Resident 3 having two hospitalizations (11/3/25 & 12/1/25) with multiple injuries including skin tears, a fracture (broken bone) in the neck of left femur (top part of leg bone is broken), which required surgical intervention, and need for rehabilitation (action of restoring someone to health or normal life through training and therapy after illness).Resident 3 was not accurately assessed for skin conditions based on shower sheets and Braden scale (assess a resident's risk of developing pressure injury/sore/ulcer - [serious wound extending through the skin often presenting as a deep crater]) resulting in a facility acquired stage III pressure injury.Findings: During a review of Resident 3's admission RECORD (AR), dated 1/26/26, the AR indicated, Resident 3 was admitted on [DATE] with diagnosis of muscle weakness, unspecified dementia (relating to the mental processes of thinking, knowing, learning, and understanding), depression, anxiety disorder, lack of coordination and history of falling. During a review of Resident's 3 Brief Interview of Mental Status (BIMS - screening tool to assess cognitive function from scale 0-15 [intact 13-5, moderate 7-12, and severe 0-6]) dated 9/8/25, Resident 3's BIMS score was 6 (severe cognitive decline). During a review of Resident 3's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/6/25 the MDS section GG (Resident assessment tool to assess functional abilities and goals) indicated, Resident 3 required: A. Eating - Setup clean-up assistance B. Oral hygiene - Supervision or touching assistance (helper provides verbal cues and/or touching resident to complete activity) C. Toileting hygiene - Partial/moderate assistance (helper does less than half the effort) D. Shower/bathe self - Dependent (helper does all the effort) E. Upper body dressing- Supervision or Touching assistance F. Lower body dressing - Partial/moderate assistance (helper does less than half the effort) G. Put on/taking off footwear-Partial/moderate assistance H. Personal Hygiene - Partial/moderate assistance 1.During an observation on 1/26/26 at 9:23 a.m., in Resident 3's room, Resident 3 was lying flat in bed on a low pressure air mattress (mattress used to prevent wounds), holding two stuff animals, oriented to self, unable to identify how to call for assistance, and confused. During a concurrent interview and record review on 1/29/26 at 2:17 p.m. with Director of Nursing (DON), Resident 3's Interdisciplinary Team [IDT - group of professionals working together to achieve common focused patient goals] Fall, was reviewed. The following IDT dated 9/8/25-12/1/25 indicated: A. The IDT dated 9/8/25 indicated, Resident 3 had a fall on 9/7/25 at midnight. DON stated Resident 3 was found in the bathroom putting her pants back on and laying on the floor. DON stated interventions were to not leave Resident 3 unattended in bathroom and there were no other interventions initiated. B. The IDT dated 9/9/25 indicated, Resident 3 had a fall on 9/8/25 at 7:15 p.m. DON stated Resident 3 had been getting out of bed and fell on her left side. DON stated interventions were to put a fall mat on left side of bed and there were no other interventions initiated. C. The IDT dated 9/11/25 indicated, Resident 3 had a fall on 9/10/25 at 8:10 a.m. DON stated Resident was found in her room, on her bottom on floor to the left side of the bed. DON stated interventions were to replace fall mat was with landing strips (a non slip material on the floor to assist with prevention of the fall) on left side and there were no other interventions initiated. DON stated Resident 3 acquired a skin tear on her left upper arm from the fall. D. The IDT dated 10/7/25 indicated, Resident 3 had a fall on 10/6/25 at 7 a.m. DON stated Resident 3 was found on her bottom in her room. DON stated interventions were to schedule a neurology (specialist of the brain) consult and had an appointment for December but was unable to go. DON stated there were no other interventions for Resident 3's fall. E. The IDT dated 10/8/25 indicated, Resident 3 had a fall on 10/7/25 at 2:20 a.m. DON stated Resident 3 acquired skin tears on her left and right elbow from the fall. DON stated new interventions were to keep overhead light on at all times during the night shift and there were no other interventions initiated. F. The IDT dated 11/3/25 indicated, Resident 3 had a fall on 11/3/25 at 10 a.m. DON stated Resident 3 was in her wheelchair and bent forward and fell to floor near the dining room. DON stated Resident 3 was sent to the emergency department but had no injuries. DON stated interventions were to have orthostatic blood pressures (the measurement of blood pressure [force of blood pushing against the wall of arteries] while sitting, standing and lying) monitoring weekly and there were no other interventions initiated. G. The IDT dated 11/5/25 indicated, Resident 3 had a fall on 11/4/25 at 4:30 a.m. DON stated Resident 3 was found in the hallway outside of her room and found on her knees. DON stated interventions were a referral to a psychiatrist (medical practitioner specializing in the diagnosis of mental illness) to review her medications. DON stated Resident 3 was seen the same day by the psychiatrist with no changes to her medications. DON stated there were no other (new) interventions initiated and nothing was changed regarding Resident 3's falls. H. The IDT dated 11/13/25 indicated, Resident 3 had a fall on 11/12/25 at 4 a.m. DON stated Resident 3 was found on her left side on her bottom, on the floor in her room. DON stated interventions were to place Resident 3 in a room closer to the nurses station and there were no other interventions initiated. I. The IDT dated 12/1/25 indicated, Resident 3 had a fall on 12/1/25 at 4:06 a.m. in Resident 3's room. DON stated Resident 3 had a lot of falls in the previous two months (9), and she did not like that Resident 3 was falling all the time. DON stated she had recommended Resident 3 to have a 1:1 (provides a dedicated staff member dedicated for one resident for complex medical needs) in the past (unspecified dates) to prevent further falls, but it was not approved (did not indicate who declined). There was no new intervention added after this fall. During a concurrent interview and record review on 1/29/26 at 3:10 p.m. with DON, Resident 3's Bowel and Bladder Program Screener (B&B - restorative nursing program designed to improve continence [the ability to control movement of the bowels and bladder] through scheduled toileting), dated 9/5/25 at 6:33 p.m. was reviewed. The B&B indicated, Resident 3 was a good candidate for retraining (learning a skill so job can be done differently). DON stated Resident 3 had a B&B score of 19 which would indicate a need for bowel and bladder training. DON stated a B&B retraining with care plans was not done and they should have been done to address Resident 3's falls. During a review of Resident 3's Change of Condition Evaluation (COC) dated 12/1/25 at 3:31 a.m., the COC indicated, Writer [not identified] was called to residents' [Resident 3] room by aide. Nurse found resident [3] sitting on floor on L [left] side of bed. ROM (range of motion) unable to complete d/t [due to] resident [3] not following instructions. C/o [complained of] hip pain at this time. Resident [3] unable to say why she wanted to get up. During a review of Resident 3's Acute Rehab Facility's admission H&P (AH&P-History and Physical), dated 12/6/25, the AH&P indicated, Resident 3 was female with medical history of. anxiety disorder, major depressive disorder. dementia, and wheelchair-bound over the past several months due to imbalance. The [Resident 3] is currently living at [Skilled Nursing Facility (SNF)] for the last four months. The [Resident 3] arrived to [Acute Hospital] after sustaining a ground-level fall. ED [emergency department] work up revealed a left femoral [thigh] fracture. The [Resident 3] is alert and oriented to name and DOB [DATE of birth ] . On 12/2/25, the patient underwent open reduction and internal fixation [surgical procedure used to treat severe, displaced bone fracture that cannot heal properly with casting alone and secure them using metal plates, screws, or rods] of left femoral neck fracture. Resident 3 required acute rehabilitation for 18 days (12/5/26-12/23/26) before being able to be safely discharged back to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give one of 22 sampled residents (Resident 35) oxygen per the physicians' orders. This failure had the potential for hypoxia (insufficient oxygen reaching body tissues to maintain normal function causing shortness of breath, confusion, rapid heart rate, bluish skin, and other negative outcomes up to and including death).Findings:During a review of Resident 1's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 35 was admitted to the facility on [DATE] with diagnosis of muscle weakness, need for assistance with personal care, hypertensive heart disease (damage to the heart muscle, valves, or blood vessels caused by long-term high blood pressure [measures the pressure your blood is pushing when the heart beats] with heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), acute (severe, sudden) on chronic (persistent long lasting condition) combined systolic (blood pressure when the heart is at work) and diastolic (blood pressure when the heart is at rest) heart failure. During a review of Resident 35's Physician order sheet (POS), dated 1/25/26, the POS indicated, Resident 35 was ordered by the physician to be on oxygen two liters (a unit of measurement) via nasal cannula (nc - a lightweight, flexible tube worn around the ears inserted into the nostrils to deliver supplemental oxygen) as needed for shortness of breath.During a concurrent observation and interview on 1/26/26 at 8:48 a.m. with Treatment Nurse (TN), in Resident 35's room, Resident 35 was observed lying in bed with oxygen being delivered via nc. TN observed the oxygen setting and stated it was at 1 liter not two liters of oxygen as ordered for her shortness of breath. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 11/1/17, the P&P indicated, Purpose . To prevent or reverse hypoxemia and provide oxygen to the tissues. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include . oxygen flow rate . procedure . check the physician's order . Turn on the oxygen at the prescribed rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 98, Resident 97, and Resident 35) had staff with skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services when: 1.Registered Nurses (RN 1, RN 2, RN 3, RN 4, RN 5, and Director of Nursing [DON]) were not competent to provide TPN (total parenteral nutrition - is a method of delivering all essential nutrients-such as protein, carbohydrates, fats, vitamins, and minerals-directly into the bloodstream through an PICC ( a long, this, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line for two of two sampled residents (Resident 98 and Resident 97). This failure had the potential for TPN associated negative outcomes up to and including death. 2. Certified Nursing Assistants (CNA 1, CNA 2, and CNA 3) were not competent to provide direct care to residents that included: hand hygiene, bed making, infection control measures, clean and dirty linen handling, Activities of a Daily Living (ADLs -everyday task people do to live independently which includes bathing, dressing, eating, using the toilet, and moving around), razor disposal, cleaning/storing bed pans and urinals, feeding residents. This failure had the potential for all residents to be exposed to negligent care and compromised safety. 3. Five of Five sampled RN's (RN 1, RN 2, RN3, RN 4, and RN 5) were not competent to provide Dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to perform these functions naturally) Catheter Care (an access point created surgically for patients undergoing dialysis). This failure had the potential for Dialysis Catheter Care negative outcomes such as infection, up to and including death to occur. Findings:
1. During a review of Resident 98's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 98 was admitted to the facility on [DATE] with diagnosis of muscle weakness, need for assistance with personal care, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), mild protein-calorie malnutrition (a nutritional state from insufficient protein and energy, showing subtle signs like fatigue, recurrent infections, or losing some weight/muscle/fat), electrolyte and fluid imbalance (a condition where the body's water levels and essential minerals like sodium, potassium, calcium, and magnesium are too high or too low, disrupting normal, vital functions), and disorder of plasma-protein metabolism (a condition in which is characterized by the faulty production, processing, or regulation of proteins in the blood).
During a review of Resident 98's Physicians Order Sheet (POS), dated 1/23/26, the POS indicated, Resident 98 was to be placed on TPN at 50 ml (milliliter) an hour (hr) for one hour then increase to 100 ml/hr for 14 hours then decrease back to 50 ml/hr for one hour then stop. Repeat every night. 500 ml 20% (percent) lipid (fatty compounds that perform a variety of functions in your body) four times a week (Monday, Wednesday, Friday, and Sunday) infused separately, one time a day.
During a review of Resident 98's Care Plan Report (CP), dated 1/26/26, the CP indicated, Resident 98 has nutritional problems or potential for nutritional problems related to taking TPN. The interventions listed on the CP indicated to provide TPN as ordered by the physician.
During a review of Resident 98's IV MAR (Intravenous Medication administration record) (IVMAR), dated January 2026, the IVMAR indicated, Resident 98 received TPN on 1/24/26, 1/25/26, 1/27/26, and 1/28/26.
During a concurrent interview and record review on 1/28/26 at 2:48 p.m. with Director of Nursing (DON), the facility staff competencies were reviewed. DON stated five RN's (RN 1, RN 2, RN 3, RN 4, RN 5) and DON provided Resident 98 with IV TPN. DON stated there were no competency test or assessments done on the facility RNs including herself (DON) to show that they are competent in providing TPN care. DON stated RN 1 had previous experience with TPN and verbally instructed the other RNs on how to provide TPN to Resident 98. DON stated there was no documented proof that RN 1 provided appropriate competency training on TPN to the RN's.
During an interview on 1/28/26 at 3:03 p.m. with RN 1, RN 1 stated, he taught RN 2, RN 3, RN 4, RN 5, and DON how to provide TPN to Resident 98. RN 1 stated he had no documented proof that he provided the TPN education. RN 1 stated the experience he had with providing TPN was when he was out of the country in 2022 and had a patient (resident) that required it. RN 1 stated he had no other experience with giving TPN to residents or educating other staff on how to safely provide TPN.
During a review of Resident 97's Care Plan (CP), dated 11/17/25, the CP indicated, Administer TPN daily X 24 Hours. Access PICC line for S/SX [signs and symptoms] of infection infiltration.
During a review of Residents 97's POS, dated 12/7/25, the POS indicated, MIX EACH BAG WITH 10ml [milliliters] INFUVITE [ daily multivitamin maintenance supplement ] (BLUE AND WHITE), THEN INFUSE 1 IV BAG VIA IV PUMP AS FOLLOWING: 77 ML/HR X 24 HOURS/DAY, (1560ML CLINIMIX 5%-20%, 250ML INTRALIPIDS 20%, 5ML STERILE WATER) ELECTROYLTES: 1ML TRACE ELEMENTS. EVERY 24 HOURS FOR TPN.
During a review of Resident 97's IVMAR, dated 11/25, the IVMAR indicated, Resident 97 received the TPN on the following days; 11/16/25, 11/17/25, 11/18/25, 11/19/25, 11/21/25, 11/22/25,11/23/25,11/25/25,11/26/25, 11/27/25,11/28/25,11/29/25.11/30/25.
During a review of Resident 97's IVMAR, dated 12/25, the IV MAR indicated, Resident 97 received the TPN on the following days;12/1/25, 12/2/25, 12/3/25,12/4/25,12/5/25,12/6/25,12/7/25,12/8/25,12/9/25,12/10/25,12/11/25,12/12/25,12/13/25,12/14/25,12/15/25,12/16/25,12/17/25,12/18/25,12/19/25,12/20/25,12/21/25,12/22/25,12/23/25,12/24/25,12/26/25,12/27/25,12/28/25,12/29/25,12/30/25.
During an interview on 1/29/26 at 9.44 a.m., with DON, DON stated there was no training for PICC Line or TPN prior to Resident 97's receiving TPN.
During a review of the facility's policy and procedure (P&P) titled Total Parenteral Nutrition, dated 11/1/17, the P&P indicated, Registered nurses completes all pre administration checks. 3. Central lines assessed using strict aseptic techniques. 4. TPN administered via infusion pump only. 5. Monitor lab values blood glucose intake/output, and vital signs. 6 Manage complications per provided orders. 7. Discontinued of TPN is performed by an RN only.Forms: RN TPN Competency Checklist.
During a review of the facility's policy and procedure (P&P) titled, Staff Competency Policy and Procedure, dated 11/1/17, the P&P indicated, Purpose . To ensure that all staff at (facility) demonstrate and maintain the knowledge, skills, abilities, and professional behaviors necessary to safely and effectively perform their assigned job duties, in compliance with federal, state, and local regulations, and to promote quality resident care. All staff are competent prior to independently performing assigned duties. Competency: The demonstrated ability to safely and effectively perform assigned job duties . NURSING SERVICES . IV therapy (RN only, if applicable) . TPN management.
2. During a concurrent interview and record review on 1/28/26 at 10:07 a.m. with Director of Staff Development (DSD), CNA 1's personnel file (PF) was reviewed. DSD stated CNA 1 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 1 did not have the competency evaluation for: hand hygiene, universal precaution (a set of infection control practices that require treating all human blood and certain body fluids for infection), isolation technique (method used to separate a specific component, organism, or variable from a mixed, contaminated, complex environment), and applying and removing Protected Personnel Equipment (PPE- a gear worn to minimize exposure) completed.
During a concurrent interview and record review on 1/28/26 at 10:10 a.m. with DSD, CNA 2's PF was reviewed. DSD stated CNA 2 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 2 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.
During a concurrent interview and record review on 1/28/26 at 10:15 a.m. with DSD, CNA 3's PF was reviewed. DSD stated CNA 3 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 3 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.
During a review of the facility's policy and procedure (P&P) titled All Departments - New Employee Orientation, [undated], the P&P indicated, all newly hired employees receive a comprehensive New Employee Orientation prior to assuming independent job responsibilities.No employee may work independently until required orientation components are completed.Director of Staff Development (DSD) .Coordinates and conducts orientation .Maintains orientation and competency records .Maintains employee personnel file.E. Competency and Supervision .Competency validation required prior to independent work.
During a review of the facility's P&P titled Job Description, undated, the P&P indicated, Title: Director of Staff Development (DSD).Implement and oversee the facility's in-service training program, ensuring compliance with state and federal training regulations. Provide hands-on training, skill validation, and competency assessment for all nursing staff.
3.During a review of Resident 35's AR, dated 1/19/26, the AR indicated, Resident 35 had a diagnosis of, DEPENDENCE ON RENAL [Kidneys] DIALYSIS.END STAGE RENAL DISEASE [also known as renal failure-the final, irreversible phase of kidney failure where dialysis is required].
During a review of Resident 35's POS, dated 4/30/25, the POS indicated, (Dialysis catheter) Site: Right Femoral [thigh region] MONITOR FOR ANY S/S [sign and symptoms] OF INFECTION AT ACCESS SITE. Right Femoral MONTIOR FOR ANY ITCHING AT ACCESS SITE .
During a review of Resident 35's CP, dated 1/20/26, the CP indicated, Potential for complications related to hemodialysis [a life-sustaining treatment for kidney failure that uses a machine and a specialized filter (dialyzer) to remove waste, toxins, and excess fluid from the blood ] for diagnosis of Chronic [persistent for long time or constantly recurring illness] Renal Failure. Check shunt [catheter] site for s/s of infection, pain or bleeding daily and PRN [as needed].
During an interview on 1/29/26 at 3:07 p.m. with Treatment Nurse (TN), TN 1 stated, I have not had any training on dialysis catheter care.
During an interview on 1/29/26 at 3:11 p.m. with RN 1, RN 1 stated I have not had any training on dialysis catheter care.
During an interview on 1/29/25 at 4:22 p.m. with DON, DON stated she does not have complete documentation that the staff was trained on dialysis catheter care.
During a review of the facility's P&P titled All Departments - New Employee Orientation, [undated], the P&P indicated, Competency and Supervision .Competency validation required prior to independent work.
During a review of the facility's P&P titled Job Description, [undated], the P&P indicated, Job Titled: Director of Nursing Services.Evaluate all Registered Nurse in the facility including Supervisory and Charge Nurse and Staff Development.

Based on interview and record review, the facility failed to report results of investigation of the allegation of abuse to the California Department of Public Health (CDPH) within five days of the incident for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the investigation of the abuse allegation incident.Findings:During a review of facility document titled SOC 341 - Report of Suspected Dependent Adult/Elder Abuse (SOC 341-a state form used in California for mandated reporters to report suspected elder and dependent adult abuse or neglect. The SOC stands for Social Services, and 341 is the specific document number for this report), dated 9/1/25, the SOC 341 indicated an allegation of resident-to-resident abuse involving Resident 1 and Resident 2 on 9/1/25.During an interview on 9/11/25 at 12:25 p.m. with the Director of Nursing (DON), DON stated the facility became aware of an allegation of abuse involving Resident 1 and Resident 2 on 9/1/25 and reported it to the CDPH on 9/2/25 using the SOC 341. DON stated the facility investigated the incident and completed an investigative report but had not yet submitted it to the CDPH. DON provided a copy of results of the investigation of allegation of abuse on 9/11/25 (10 days later).During a review of facility policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program, dated January 31, 2020, the P&P indicated, The administrator will provide the state survey agent. with a copy of the investigative report within 5 days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4,and Resident 5). This failure had the potential to cause resident harm, decrease resident comfort, and affect resident dignity. During an observation on 7/2/25 at 1:31 p.m. in Resident 1's room, the following was observed in the shared resident restroom/shower room (Resident 1's restroom is also used by the facility to provide showers for the other residents): a. On the ceiling directly over the sink was an oval shaped approximately 12-inch (a unit of measurement) area of multiple orange and black shaped dots scattered around. b. On the ceiling toward the shower stall entry was approximately 24-inch in length by 24-inch in width area of exposed wood with three exposed screws.c. The tile ramp leading into the shower stall was a triangular shaped approximately two-inch piece of missing tile. d. The shower stall by the entrance, there were two hexagonal (a shape) shaped tiles missing that are approximately two-inch in length and two-inch in width each.e. The shower drain had three hexagonal shaped tiles missing, each tile measuring approximately two inches in length and two inches in width. f. In the bottom left corner of the shower is approximately a 10-inch circular area of grout (a substance that fills in the gaps between tile) that was discolored with an unknown slimy texture green to black in color.During an observation on 7/2/25 at 2:04 p.m. in Resident 2 and Resident 3's room, the following were observed:a. The right side of the room window had approximately 40-inch length of window which was not attached or sealed, creating a gap that is approximately one-inch wide allowing for hot air from outside to come into the room.b. The middle portion of the room window was approximately 12-inch in length and one-inch in width area of window that is not attached or sealed in creating a gap that is allowing hot air from outside to come through.c. The window by left side of the room was approximately 60 inches in length and one inch in width gap that allowed hot air from the outside to come through. During a review of the state cell phone weather application (app - a software program designed for a specific purpose) on 7/2/25 at 2:08 p.m., the app indicated the current weather conditions outside of the facility was 98 degrees Fahrenheit (a unit of measurement). During an interview on 7/2/25 at 2:14 p.m. with Resident 2, Resident 2 stated he sleeps in the bed closest to the room window which causes discomfort from the hot air coming through. During a review of Resident 2's Minimum Data Set (MDS) Assessment (comprehensive assessment tool), dated 4/4/25, the MDS indicated Brief Interview for Mental Status (BIMS - an assessment of cognition, how well a person thinks, remembers, and learns) score was 15 (score of 13-15 means cognitively intact).During an observation on 7/2/25 at 2:20 p.m. in Resident 4's room, the following were observed: a. The wall behind Resident 4's bed had three large deep scratches exposing the drywall (an interior facing panel used for walls and ceilings) approximately 12 inches in length, two inches in width, and one inch in depth. b. In Resident 4's restroom, the ceiling above the sink is an approximately 10-inch square of peeling paint exposing the drywall surrounding the air vent. During an observation on 7/2/25 at 2:35 p.m. in Resident 5's room, the following were observed: a. By Resident 5's window, there was an approximately 60 inch in length area that was not attached or sealed, creating a gap that is approximately one inch wide allowing hot air from outside to come into the room. b. In the Resident 5's restroom, behind the toilet, there was a section of wall baseboard that is approximately 15 inches in length and half an inch in width that was discolored with a slimy textured substance that is red to orange in color. During an interview on 7/2/25 at 2:36 p.m. with Resident 5, Resident 5 stated at times his room gets warm from the outside hot air entering through the gap in his window. During a review of Resident 5's MDS dated [DATE], the MDS indicated the BIMS score was 12 (score of 8-12 means moderate cognitively intact). During a concurrent observation and interview on 7/2/25 at 3:50 p.m. with Administrator, Administrator went into Resident 1's, Resident 2's, Resident 3's, Resident 4's, and Resident 5's rooms, and stated the facility needed to fix the issues identified.During a concurrent interview and record review on 7/28/25 at 2:14 p.m. with Maintenance Worker Director (MWD), the facility MAINTENANCE LOG (ML), dated 2025 was reviewed. MWD reviewed the ML and stated request for maintenance to fix the issues identified in Resident 1, 2, 3, 4, and 5's rooms were not made. MWD stated his staff goes to residents' rooms Monday through Friday in order to identify any needs. MWD stated he was not aware of any issues in Resident 1, 2, 3 ,4, and 5's room.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 11/1/17, the P&P indicated, Purpose . To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following . Cleanliness and order . Comfortable levels of ventilation . Comfortable temperatures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address the hydration (the process of replenishing the water content in the body) needs of one of three sampled residents (Resident 1) who was dependent on hydration and nutrition via gastrostomy tube (G-Tube is a tube inserted through the belly that brings nutrition and hydration directly to the stomach), and who had an order for nothing by mouth (NPO) when there was no physician's order for hydration/water flushes, the physician was not notified of the Registered Dietician's (RD) recommendations for hydration, RD did not follow up timely to ensure the recommendations for hydration was carried out, and the facility did not follow their policy and procedure (P&P) on Intake and Output Recording to monitor and record intake and output of residents with feeding tube. These failures had the potential to result in insufficient fluids to maintain proper hydration for Resident 1.
Findings:
During a review of Resident 1's History and Physical Examination (HPE), dated 5/21/25, the HPE indicated, PEG [percutaneous endoscopic gastrostomy tube is a feeding tube inserted through the abdominal wall into the stomach, allowing for direct feeding into the stomach] Tube in place
During a review of Resident 1's Dehydration Risk Screener (DRC-assessment for dehydration risk), dated 5/21/25, the DRC indicated, Score: 10, Score of 10 or higher indicates a resident is at risk for dehydration.
During a review of Resident 1's Interdisciplinary Team Care Conference (IDTCC), dated 5/22/25, the IDTCC indicated, Resident [1] admitted to facility 5/21/25, on G-tube feeding. She [Resident 1] requires maximum total assistance with ADL's [activities of daily living-basic tasks that individuals perform to maintain their daily life and care for themselves]. Nutritional/Diet Order: NPO [nothing by mouth].
During a review of Resident 1's Order Summary Report (OSR), dated 5/22/25, the OSR indicated, Diagnoses: Encounter for attention to Gastrostomy, Dietary: NPO [nothing by mouth]. The OSR had no physician's order for water hydration.
During a review of Resident 1's Medication Administration Record (MAR), dated 5/2025, the MAR indicated there was no order of water hydration/flushes.
During a concurrent interview and record review on 6/26/25 at 2:23 p.m. with Director of Nursing (DON), DON reviewed Resident 1's clinical record. DON stated there was no documented water hydration given to Resident 1 during Resident 1's five day stay in the facility on 5/21/25 until 5/26/25. DON stated there was no documentation of a physician's order for water hydration.
During a review of Resident 1's admission Record (AR), dated 5/28/25, the AR indicated, Resident 1 was a [AGE] year-old female resident admitted on [DATE] with diagnoses of Cerebral Infarction (a condition where a part of the brain tissue dies due to a lack of blood flow), Gastrostomy tube, Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (lung disease), Mild Protein-Calorie Malnutrition (lacking nutrition in the body), and need for assistance with personal care.
During a concurrent interview and record review on 6/30/25 at 2:12 p.m. with DON, DON reviewed Resident 1's clinical record. After reviewing the clinical record, DON stated the licensed nurses did not document the intake (how much fluid entered the resident's body) and did not document output (amount of something produced, excreted, or released by the body, e.g. urine). DON stated for residents with feeding tube, the intake and output (I&O) should be monitored and recorded.
During an interview on 6/30/25 at 2:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she completed the admission assessment and clinical record for Resident 1 upon Resident 1's admission to the facility on 5/21/25. LVN 1 stated she failed to obtain a physician's order for water flushes/hydration.
During a review of Resident 1's Nutrition Risk Assessment (NRA), dated 5/22/25, the NRA indicated, Rec: [recommendation] Flush order 150 cc [cubic centimeter/milliliter] q [every] 6 hours = 600 cc [for 24 hours].
During an interview on 6/30/25 at 2:18 p.m. with LVN 1, LVN 1 stated she communicated with Certified Dietary Manager (CDM) but did not document the Registered Dietician (RD) recommendation. LVN 1 stated, I think we [staff] just missed it [RD recommendation for water hydration]. I did not document about the flush [water hydration recommendation].
During an interview on 7/1/25 at 3:32 p.m. with CDM, CDM stated when Resident 1 was admitted , the DON approached him and asked him to call the RD because Resident 1 did not have a physician's order for water flushes/hydration. CDM stated he called the RD, and RD recommended giving the resident 150 milliliters (ml) of water every six hours. CDM stated he verbally informed LVN 1 of the RD's recommendation. CDM stated he did not document the RD recommendation in Resident 1's clinical record.
During an interview on 7/2/25 at 9:35 a.m. with RD, RD stated she documented Resident 1's nutrition risk assessment on 5/22/25 (next day from admission) and recommended 150 cc water flushes every six hours. RD stated she was supposed to follow up if her recommendation was followed up with the physician in two to three days from admission for feeding tube dependent residents. RD stated she did not follow up on Resident 1 in two to three days due to the third day being Sunday and the fourth day (5/26/25) when Resident 1 was sent to the acute care hospital was a holiday. RD stated, Unfortunately, I did not follow up if my recommendations were followed.
During a review of Resident 1's Change in Condition Evaluation (CCE), dated 5/26/25 (five days later from admission date), the CCE indicated, Signs and Symptoms Identified: SOB [shortness of breath] with gurgling sounds with high pulse rate [sic]. Pulse: 123 [normal pulse is 60-100].
During a review of the Hospital's ED (Emergency Department) Physician's Notes (EDPN), dated 5/26/25, the EDPN indicated, Diagnosis: Sepsis (life threatening infection), Hypernatremia (too much sodium in blood caused by dehydration), and Severe Dehydration. Plan: Free water deficit [not enough water in the body] is 2.4 L [liters].
During a review of the facility's P&P titled, Intake and Output [I&O] Recording dated 11/1/17, the P&P indicated, I&O may be instituted per an Attending Physician's order or by a Licensed Nurse for any resident with the following: A. Enteral (providing nutrition by delivering nutrients directly into the stomach through a tube) feedings. Residents receiving enteral feedings will be placed on I&O for the length of time needed to evaluate tolerance of the feeding.
During a review of the facility's P&P titled, Nutrition/Hydration Management dated 11/1/17, the P&P indicated, The DNS [Director of Nursing Services] is responsible for ensuring that residents are assessed for nutrition/hydration on admission. The concept of nutrition management is an interdisciplinary process. The key components of this system are: C. Implementing the nutrition and hydration program.
During a review of the facility's P&P titled, Tube Feeding/TPN dated 11/1/17, the P&P indicated, The physician order and information communicated to the dietary department should include: B. Amount of formula and fluid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan (a detailed document outlining how the facility staff will provide care to meet the resident's specific needs) interventions as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals who collaborate to provide comprehensive care to a patient) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling on 5/28/25 and sustaining an acute fracture (clean and immediate break in the bone) of her pelvis (bowl-shaped bony structure in the lower part of your body located between your lower back and your legs) S3 and S4 region (third and fourth sacral [triangular bone at the base of the spine] vertebrae [backbone]) and subluxation (when bones are moved out of place resulting in pressure and irritation) of S2 and S3 (second and third sacral bone -area of the pelvis) requiring the resident to be transferred to the acute hospital (from 5/28/25 to 6/1/25).Findings: During a review of Resident 1's admission RECORD (AR), dated 6/4/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of epilepsy (a brain condition that causes recurring seizures [electrical disturbances in the brain]), dementia (a progressive state of decline in mental abilities), muscle weakness, cognitive (the way our brains think, learn, and understand things) or emotional (having to do with feelings) deficit (absence of) following cerebral infarction (loss of blood flow and/or oxygen to part of the brain), and osteoporosis (weak and brittle bones). During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 5/16/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact. A score of 99 suggest the resident was unable to complete the interview and therefore the assessor is unable to determine the resident's cognition), the BIMS score was 07. Under section GG (assesses functional abilities and goals), Resident 1 was documented to require supervision or touching assistance (staff provides verbal cues and/ or physical contact like touching, steadying as the resident performs an activity) for the following physical movements: A. Move from sitting to standing position B. Transfer from bed to chair or chair to bed C. Transfer on and off toilet D. Walk 10 feet (a unit of measurement) E. Walk 50 feet with two turns F. Walk 150 feet G. Wheel herself in a wheelchair 50 feet with two turns H. Wheel herself 150 feet in a wheelchair. During a review of Resident 1's Morse Fall Scale (MFS - a tool used to assess a patient's risk of falling. A score of 0-24 indicates low fall risk, 25-45 indicates moderate fall risk, and scores above 45 indicates high fall risk), dated 11/27/24 the MSF indicated, Resident 1 had a score of 70. The MSF dated 1/8/25 indicated Resident 1 had a score of 75. The MSF dated 5/23/25 indicated Resident 1 had a score of 75. The MSF dated 5/28/25 indicated Resident 1 had a score of 75. During a review of Resident 1's IDT Fall (IDTF - document used by the IDT during their meetings), dated 11/28/24, the IDTF indicated, on 11/27/24 at 2:30 p.m. Resident 1 was found in the facility outdoor patio on the floor. The IDTF indicated Resident 1 stated, I just fell. IDTF recommendations were for housekeeping to keep the area clean due to Resident 1 wanting to clean up the area by reaching down to the floor from wheelchair to pick up trash. The IDTF dated 1/9/25 indicated, on 1/8/25 at 3:18 p.m., Resident 1 was found on the floor face down in the outdoor facility patio. The IDTF recommendations were to provide Resident 1 with gardening tools and plants on a table to limit her need to reach down and garden around her area. The IDTF dated 5/26/25, indicated on 5/23/25 at 3:14 p.m. Resident 1 fell in the outdoor facility patio. The IDTF recommendations were to encourage and educate Resident 1 about taking medications due to Resident 1 falling after having a seizure. The IDTF on 6/4/25 indicated, on 5/28/25 at 5:20 a.m. Resident 1 was found on the floor in her room and was unable to state what happened. The IDTF indicated Resident 1 had a diagnosis of cognitive social (how we store, process, and use information about other people) or emotional deficit, following cerebral infarction that may have contributed to her fall. The IDTF indicated Resident 1's doctor was informed of Resident 1's fall on 5/28/25 and the physician ordered the licensed nurses to send Resident 1 to the emergency room for further evaluation. The IDTF recommendations were to place non-skid strips (sticky strips placed on surfaces to prevent slips and falls) on the right side of Resident 1's bed on the floor. During a review of Resident 1's acute hospital History and Physicals (H&P), dated 5/28/25, the H&P indicated, Resident 1 was brought into the acute hospital after being found at the facility on the ground in a fetal position (bodily posture where someone lies curled up on one side, with their arms and legs drawn toward their chest). The H&P indicated Resident 1 was diagnosed with an acute fracture of her pelvis S3 and S4 region and subluxation of S2 and S3. Resident 1 was admitted to the acute hospital for observation and laboratory studies. During a concurrent interview and record review on 6/3/25 at 11:58 a.m. with Charge Nurse (CN) 1, Resident 1's Care Plan Report (CP), was reviewed. The CP titled high risk for falls, dated 4/25/23, the CP indicated, Resident 1 had falls in the facility on 11/27/24,1/8/25, 5/23/25 and 5/28/25. CN 1 reviewed the CP for Resident 1's falls on 11/27/24,1/8/25, 5/23/25, and 5/28/25, and stated there were no revisions to the fall care plan to add and/or modify interventions to prevent further falls after the 1/8/25 fall on the facility outdoor patio, after the fall on 5/23/25, and after her fall on 5/28/25. During a concurrent interview and record review on 6/24/25 at 4:06 p.m. with Director of Nursing (DON), Resident 1's CP titled High risk for falls, dated 4/25/23, was reviewed. DON reviewed the CPs for Resident 1's falls on 11/27/24, 1/8/25, 5/23/25, and 5/28/25, and stated there were no new interventions to prevent Resident 1 from falling after 1/8/25. DON stated, We (facility) are not doing it correctly (revising/modifying interventions in the CP). We (facility) are talking about it (interventions) in the IDT and addressing different interventions in the IDT but not [adding the interventions to] the care plans. DON stated facility staff do not know what interventions the IDT decided to implement to prevent Resident 1's falls due to the IDT interventions not being documented or added into the care plans. DON stated staff are to follow the resident care plan to implement interventions. DON stated, The (facility) staff are not expected to read the IDT notes but expected to follow the (resident) care plan. DON stated she did not know what interventions the licensed nurses or Certified Nursing Assistants (CNA) are expected to implement due to the interventions not being added to the CPs resulting in staff not having the ability to decrease Resident 1's risk for falls. During a review of the facility's policy and procedure (P&P) titled, Response to Falls, dated 11/1/17, the P&P indicated, Purpose . To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer term fall prevention. The Interdisciplinary Team (IDT) will review the investigative reports on a regular basis, as they may occur, and make systemic changes to reasonably limit future occurrences, consider change in . interventions, system changes . Following each resident fall, the Interdisciplinary Team (IDT) Falls Committee will review the Post Fall Assessment & Assessment within 72 hours, or as soon as practicable. Based on the Post Fall Assessment & Investigation, the IDT Falls Committee will review fall prevention interventions and modify the plan of care as indicated. Documentation . Licensed Nurse . Revise resident's Care Plan as necessary. During a review of the facility's P&P titled, Fall Management Program, dated 11/1/17, the P&P indicated, Purpose . To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The Facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. Based on the information gathered from the history and assessment of the resident, the Nursing Staff and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls. The Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. The Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident in multiple resident rooms. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms.
Findings:
During a review of facility document titled Client Accommodations Analysis (CAA) (a facility document indicating the size of resident rooms), dated 3/12/18, the CAA indicated the following room measurements:
room [ROOM NUMBER]: 153 square feet
room [ROOM NUMBER]: 154 square feet
room [ROOM NUMBER]: 132 square feet
room [ROOM NUMBER]: 210 square feet
room [ROOM NUMBER]: 210 square feet
room [ROOM NUMBER]: 210 square feet
room [ROOM NUMBER]: 225 square feet
room [ROOM NUMBER]: 210 square feet
room [ROOM NUMBER]: 156 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
room [ROOM NUMBER]: 220 square feet
During a review of the Resident List Report (RLR) (a document indicating the number of residents in the facility and their respective rooms), dated 3/24/25, the RLR indicated the following number of residents in each room:
room [ROOM NUMBER]: two residents (resulting in 76.5 square feet of space per resident)
room [ROOM NUMBER]: two residents (resulting in 77 square feet of space per resident)
room [ROOM NUMBER]: two residents (resulting in 66 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 70 square feet of space per resident)
room [ROOM NUMBER]: two residents (resulting in 75 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
room [ROOM NUMBER]: three residents (resulting in 73 square feet of space per resident)
During an interview on 3/27/25 at 3:25 p.m., with the Administrator, the Administrator stated the above rooms did not measure at least 80 square feet per resident.
During the survey, no residents in the above rooms identified with providing fewer than 80 square feet per resident were negatively affected by the size of their rooms.
During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated: The Maintenance Department is responsible for . Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.

Based on interview and record review the facility Quality Assurance and Performance Improvement (QAPI-systematic process for ensuring that products and services ensure quality care) committee failed to maintain, identify, and correct a physical environment deficient practice identified by the survey team (reference tag F-919). This failure resulted in a non-functional resident restroom call light system and an unsafe physical environment of care for all 85 facility residents.
Findings:
During a concurrent interview and record review on 3/27/25 at 2:03 p.m. with Medical Director (MD), the facility document titled, Facility Assessment Tool, dated 11/25/24 was reviewed. MD stated he reviewed the completed facility assessment as part of the QA committee. MD stated the facility assessment tool included the facility's call light system. MD stated there was no resident restroom call light deficits the QA committee was aware of. MD stated the residents' nonfunctional restroom call lights were a safety concern and needed to alarm staff of an emergency.
During a concurrent interview and record review on 3/27/25 at 2:26 p.m. with Administrator, the facility's QAPI binder, dated 2/12/25 was reviewed. The QAPI binder indicated no physical environment deficits. Administrator stated there was no documentation that the residents' restroom call lights were not working. Administrator stated the resident restroom call lights should work to ensure safety and meet the communication needs of residents.
During an interview on 3/27/25 at 2:47 p.m. with Maintenance Supervisor (MS). MS stated there was no documentation to provide that the resident restroom call lights were checked. MS stated he did not know the residents' restroom call lights did not work.
During a review of the facility's document titled, Facility Assessment Tool, dated 11/25/24, the Facility Assessment Tool indicated, Requirement Nursing facilities will conduct, document, and review a facility-wide assessment, which includes. the resources the facility needs to care for their residents. 3. Facility resources needed to provide competent care for residents. physical environment and building needs. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population During Day-to-Day Operations and During Emergencies. 3. Technology and Communication Systems. b. Call light and alert system for resident safety.
During a review of facility's policy and procedure (P&P) titled, Quality Assessment & Assurance Program, dated 11/1/17, the P&P indicated, Purpose To ensure that all services provided by the Facility to residents meet the level of quality as required. Implementation. F. Individual departments or services develop quality indicators for programs and services in which they are involved and which affect their function. VI. Focus - The following areas are monitored for quality and appropriateness of resident care, and any trends in performance and outcomes. G. Physical Environment.

Based on observation, interview, and record review, the facility:
1. Failed to ensure three of three dietary staff (DS 1, DS 2 and DS 3) washed their hands according to the Centers for Disease Control and Prevention (CDC) guidelines on hand washing and failed to ensure its policy and procedure (P&P) on Hand Hygiene conformed to the CDC guidelines on hand washing. This failure had the potential for the spread of infectious diseases in the facility.
2. Failed to ensure it kept an inventory of Personal Protective Equipment (PPE - gowns, gloves, masks, goggles and faceshields). This failure had the potential for the facility to run out of PPE and placing residents at risk of infectious diseases.
Findings:
1. During an observation on 3/26/25 at 6:10 a.m., in the kitchen, with DS 1, DS 1 washed her hands in the handwashing sink as follows: DS 1 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them.
During an observation on 3/26/25 at 6:12 a.m., in the kitchen, with DS 2, DS 2 washed her hands in the handwashing sink as follows: DS 2 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them.
During an observation on 3/26/25 at 6:15 a.m., in the kitchen, with DS 3, DS 3 washed her hands in the handwashing sink as follows: DS 3 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them.
During an observation on 3/26/25 at 6:30 a.m., there was a sign on the top of the kitchen handwashing sink which indicated the following: Handwashing Procedure . Wet hands and forearms first . Add soap and rub hands . for at least 20 seconds .rinse hands .dry hands .
During an interview on 3/26/25 at 9:16 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated facility staff should wash their hands observing the following steps in the following order: wet hands, apply soap, rubs hands for 20 seconds, rinse and dry hands.
During a review of the CDC document titled About Handwashing, dated 2/16/24, the CDC guidelines indicated the following steps:
1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers,
and under your nails.
3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.
4. Rinse your hands well under clean, running water.
5. Dry your hands using a clean towel or an air dryer.
During a review of facility's P&P titled, Hand Hygiene, dated 11/1/17, the P&P indicated the following hand hygiene technique: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds under a moderate stream of running water . rinse hands thoroughly under running water . dry hands thoroughly .
2. During a concurrent observation and interview on 3/26/25 at 10:23 a.m., with the IPN and the Supplies Supervisor (SS), at the supplies room, where the facility kept its stock of PPE, the IPN and the SS, stated the facility maintained a stock of PPE but did not keep a written inventory or record of how many masks, gowns, face shields and gloves were in kept in stock. The SS stated she monitored the PPE inventory by eyeing the supplies in the supply room and if she thought the facility was running low she ordered more PPE supplies.
During a review of facility policy and policy (P&P) titled Personal Protective Equipment - Infection Control Manual, dated 4/28/20, the P&P indicated: Personal protective equipment appropriate to specific task requirements is available at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 18 of 18 resident bathrooms and three of three resident shower rooms had operational call lights within reach of residents. This failure had the potential for all 85 residents not to be able to call for help if they required assistance while using the bathrooms and shower rooms.
Findings:
During a concurrent observation and interview on 3/27/25 at 9:10 a.m., with the Maintenance Supervisor (MS), the call light systems located in resident bathrooms and shower rooms were checked for proper functioning and placement. The MS stated resident bathrooms and shower rooms were equipped with a call light system that when activated alerted staff at the nurse's station.
The call light in the bathroom shared by residents in Rooms #1 and #3 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #4 and #6 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #5 and #7 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #11 and #12 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #14 and #15 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. The call light was next to the sink and not accessible to residents using the toilet. This bathroom was also a shower room and there was no call light accessible to residents in the shower stall.
The call light in the bathroom shared by residents in Rooms #17 and #18 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but there was no corresponding visual or auditory alarm outside the room or in the nurse's station. This bathroom was also a shower room and there was no call light accessible to residents in the shower stall.
The call light in the bathroom shared by residents in Rooms #21 and #22 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #23 and #24 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. A sign next to the toilet indicated: Do not get up alone. Pull the string to call for the nurse, and wait for help.
The call light in the bathroom shared by residents in Rooms #25 and #26 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The call light in the bathroom shared by residents in Rooms #27 and #28 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
There was no call light system in the bathroom shared by residents in rooms #29 and #30.
The call light in the bathroom shared by residents in Rooms #31 and #32 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The bathroom shared by residents in rooms #33 and #34, which also functioned as a shower room, had no call light system.
The call light in the bathroom shared by residents in Rooms #35 and #36 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station.
The MS stated none of the bathroom call lights system in the facility were working.
During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated: The Maintenance Department is responsible for . Maintaining all mechanical, electrical, and patient care equipment in safe operating condition.
During a review of the facility's P&P titled, Communication - Call System, dated 11/1/17, the P&P indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities.

Based on interview and record review, the facility failed to ensure a Responsible Party (RP) 1 was notified when a change in diet texture was ordered for one of four sampled residents (Resident 35). This failure resulted in RP 1 not being aware of changes in Resident 35's status.
Findings:
During an interview on 3/24/25 at 3:01 p.m. with RP 1, RP 1 stated Resident 35 was placed on a pureed (pudding-like consistency) diet and the facility did not inform her. RP 1 stated she was speaking on the phone with Resident 35 and Resident 35 told her the facility was feeding her baby food. RP 1 stated Resident 35 can eat a regular diet if she is sitting up.
During a concurrent interview and record review on 3/25/25 at 3:03 p.m. with Director of Nursing (DON), DON stated Resident 35 saw another resident in the dining room eating a pureed diet and requested one. DON stated nurses can change a resident's diet order, without informing the physician, if the diet consistency is being downgraded. The Physician Order dated 7/15/24 indicated Resident 35's diet order was Regular with a thin consistency [diet with no restrictions on food textures or liquid thickness, allowing for all types of foods, including those that are thin liquids like water, juice, and milk]. DON stated there were no nurse's notes indicating RP 1 was informed of Resident 35's change in diet consistency. The Progress Notes dated 3/7/25 indicated Resident 35's diet consistency was changed to pureed. DON stated RP 1 should have been notified of the change in Resident 35's diet consistency.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification dated 11/1/17, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.

Based on interview and record review the facility failed to ensure resident assessments were completed for two of two sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 8 and Resident 59). This failure resulted in an incomplete assessment of Resident 8 after dialysis, and an incomplete assessment of Resident 59 before and after dialysis.
Findings:
During a concurrent interview and record review on 3/26/25 at 7:40 a.m. with Registered Nurse (RN) 1, Resident 8's Nursing Dialysis Communication Record (NDCR), dated 3/5/25 was reviewed. The NDCR indicated no pain assessment was done after dialysis for Resident 8. RN 1 stated Resident 8's pain should have been assessed. RN 1 stated a nursing assessment of Resident 8 was very important after dialysis for the early identification of complications.
During a concurrent interview and record review on 3/26/25 at 7:50 a.m. with RN 2, Resident 59's NDCR, dated 2/12/25 was reviewed. The NDCR indicated Resident 59 did not have her respirations (breathing rate) assessed before dialysis.
During a concurrent interview and record review on 3/26/25 at 7:52 a.m. with RN 2, Resident 59's NDCR, dated 2/26/25 was reviewed. The NDCR indicated Resident 59 did not have her pain assessed after dialysis. RN 2 stated Resident 59's after dialysis care should have included a pain assessment.
During a concurrent interview and record review on 3/26/25 at 8:44 a.m. with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Dialysis Care, dated 11/1/17 was reviewed. The P&P indicated, Policy I. The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment. V. Documentation A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. DON stated the P&P was not followed and should have been.

Based on interview and record review that facility failed to ensure one of five sampled residents (Resident 13) psychotropic medication (medication that alters mood, behavior, and mentation), Oxcarbazepine (medication prescribed for bipolar-mood disorder) was reviewed quarterly (every 3 months) by the interdisciplinary team (IDT- healthcare professionals including physician, pharmacist, social services, activities, and nursing). This failure resulted in Resident 13 not having an IDT medication review for Oxcarbazepine and had the potential for unnecessary medications.
Findings:
During a concurrent interview and record review on 3/26/25 at 11:29 a.m. with Social Service Director (SSD), Resident 13's Physician Order (PO) dated 2/21/25 was reviewed. The PO indicated Resident 13 was prescribed Oxcarbazepine 600 mg by mouth once daily for bipolar disorder. SSD stated Resident 13 had been taking Oxcarbazepine as prescribed daily.
During a concurrent interview and record review on 3/26/25 at 11:57 a.m. with SSD, Resident 13's Gradual Dose Reduction Binder (GDRB- attempts made to lower strength or frequency of medication), dated February 2024 to March 2025 was reviewed. The GDRB indicated Resident 13 did not have his prescribed medication Oxcarbazepine reviewed during the facility IDT meetings. SSD stated there was no documentation that Resident 13 had an IDT medication review for Oxcarbazepine. SSD stated psychotropic medications were supposed to be reviewed quarterly by the IDT team. SSD stated, We didn't address the medication Oxcarbazepine in any of the IDT meetings.
During a concurrent interview and record review on 3/26/25 at 2:45 p.m. with SSD, the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 11/30/20 was reviewed. The P&P indicated, Purpose. To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident's ability to interact positively with his/her environment. VII. Interdisciplinary Team (IDT) Responsibility F. The IDT. will discuss the psychotherapeutic medications at least quarterly, or as needed. i. The IDT note will include: reasons for the drug, manifestations for the drug, and analysis of the resident's response to the drug. SSD stated the facility's P&P was not followed and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Med Pass for two of three sampled medication carts (Medication Cart 1 and Medication Cart 2). This failure had the potential for residents, staff, and visitors to unsafely access medications.
Findings:
During a concurrent observation and interview on 3/26/25 at 6:02 a.m. with Director of Nursing (DON) in the South Main Hallway, Medication Cart 2 was unaccompanied in the corner of the hallway in front of the nurse's station. All of Medication Cart 2's drawers, except for the controlled medication (drug or substance regulated by the government due to its potential for abuse and addiction) drawer, were unlocked and able to be opened. There was no nurse in the proximity of Medication Cart 2. DON was in the hallway; she was able to open the unlocked drawers. DON attempted to lock the cart but was unable to secure the locking mechanism. DON stated the unlocked medication cart had the potential for residents to open the cart and take medications.
During an observation on 3/26/25 at 6:45 a.m. in the North Hallway outside of room [ROOM NUMBER], Registered Nurse (RN) 3 prepared to give Resident 41 medications including Lactulose (used to treat constipation and reduce ammonia levels in alcoholics). RN 3 poured the prescribed amount of Lactulose into a medication cup from a large jar of the medication. RN 3 placed the jar of Lactulose on top of Medication Cart 1 and went into Resident 41's room to administer the medications.
During a concurrent observation and interview on 3/26/25 at 6:48 a.m. with RN 3, in the North Hallway by Medication Cart 1, RN 3 picked up the bottle of Lactulose and stated she usually does not leave medications on carts unattended.
During a review of the facility's P&P titled, Med Pass, (undated), the P&P indicated, MEDICATION STORAGE IN THE FACILITY STORAGE OF MEDICATIONS Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure its food preparation sink in the kitchen had an air gap (a backflow prevention device consisting of vertical space between the water outlet and flood level of a sink designed to ensure contaminated water does not flow back into the clean water supply). This failure had the potential to contaminate residents' food supply and exposure to infectious diseases.
Findings:
During an observation on 3/26/25 at 6:33 a.m., in the kitchen, there was no air gap in the two compartment sink.
During an interview on 3/26/25 at 6:50 a.m., in the kitchen, with the Consultant Dietary Services Manager (CDSM), the CDSM stated the two compartment sink in the kitchen was used to wash produce and food for residents. The CDSM stated the two compartment sink in the kitchen had no air gap.
During an observation on 3/26/25 at 7:25 a.m., in the kitchen, dietary staff washed fresh strawberries in the two compartment sink.
During a concurrent observation and interview on 3/26/25 at 10:54 a.m., with the Director of Maintenance (DM), in the kitchen, the DM stated the two compartment sink in the kitchen had no air gap. The DM stated it was not possible to create an air gap in the two compartment sink in the kitchen. The DM stated the facility did not have a policy and procedure on air gaps.
During a review of the U. S. Food and Drug Administration 2022 Food Code (FDA Food Code), version 1/18/23, the FDA Food Code indicated:
5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue. To prevent the introduction of this liquid into the water supply through back siphonage, various means may be used. The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow.
5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non-FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).
5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13; or (B) Installing an APPROVED backflow prevention device as specified under § 5-202.14.
During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 11/1/17, the P&P indicated, The Maintenance Department is responsible for. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.

Based on interview and record review, the facility failed to ensure care plans were developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience accidents and injuries.
Findings:
During a review of Resident 1's Fall Risk Assessment, (FRA) dated 11/28/24, the FRA indicated Resident 1 scored a 45 (High risk 45 and higher, moderated risk 25-44 and low risk 0-24) Resident 1 was at high risk for falls.
During a concurrent interview and record review, on 12/10/24 at 4:24 p.m. with Director of Nursing (DON), Resident 1's FRA, dated 11/28/24 was reviewed. There was no fall risk care plan noted in the clinical record. DON confirmed there was no fall risk care plan developed for Resident 1.
During a review of Resident 2's FRA, dated 4/3/24, the FRA indicated Resident 2 scored a 60, Resident 2 was at high risk for falls.
During a review of Resident ' 2 s SBAR (situation, background, assessment, recommendation- form used to communicate information) Summary for Providers, (SBAR) dated 6/21/24, the SBAR indicated Resident 2 sustained a fall and suffered abrasion on mid back and bruising to left thumb.
During a review of Resident 2's SBAR, dated 7/12/24, the SBAR indicated Resident 2 sustained a fall and suffered a skin tear to right lower arm.
During a concurrent interview and record review, on 1/13/25 at 12:36 p.m. with DON (DON), Resident 2's FRA, dated 4/3/24 was reviewed. Resident 2's SBAR, dated 6/21/24 and 7/12/24 were reviewed. DON confirmed Resident 2 was high risk for falls and Resident 2 had two fall incidents (6/21/24 and 7/12/24) in the facility. Resident 2's care plans were reviewed. DON confirmed fall risk care plan was initiated on 7/15/24. DON stated fall risk care plans were not developed prior to falls on 6/21/24 and 7/12/24 and stated the fall risk care plans should be created and implemented to prevent falls.
During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, revised November 1, 2017, the P&P indicated, The Facility will ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. I. The Facility assesses all resident upon admission and periodically for their risk of falling. The facility uses this information to develop both individualized plans of care and Facility-wide fall prevention measures. A. The licensed Nurse will use the Fall Risk Assessment . to help identify individuals with a history of falls and risk factors for subsequent falling. C. Based on the initial information gathered, the Interdisciplinary Team (IDT- a group of healthcare professionals who work together to provide personalized care for a patient) will identify and implement appropriate interventions to reduce the risk of falls.

Based on interview and record review, the facility failed to consistently implement care plans for two of three sampled residents (Resident 1 and Resident 3).This failure had the potential for Resident 1 and Resident 3 to have unmet psychosocial and physical needs.
Findings:
During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3.
During an interview on 10/15/24 at 2:11p.m. with Registered Nurse (RN) 1, RN 1 stated for allegations of abuse he would create a care plan for delayed injury and psychosocial outcome and monitor for 72 hours.
During a review of Resident 1 ' s care plan with the focus on Alleged incident of physical abuse, initiated 10/9/24. The care plan indicated one of the intervention was to Monitor For Pyschosoical [sic] Well Being X (times) 72 Hours.
During a review of Resident 3 ' s care plan with the focus on Alleged incident of neglect on unspecified date, initiated 10/9/24. The care plan indicated one of the intervention was to Monitor For Pyschosoical [sic] Well Being X 72 Hours.
During a concurrent interview and record review on 10/15/24 at 2:28 p.m. with DON, Resident 1 and Resident 3 ' s medical record was reviewed. DON confirmed the psychosocial monitoring was not documented consistently over the 72 hour period for Resident 1 or Resident 3.
During a review of the facility ' s policy and procedure (P&P) titled, Care Planning, revised 10/24/22, the P&P indicated, II. The care Plan serves as a course of action where the resident . to help the resident move toward resident specific goals that address the resident ' s medical, nursing, mental and psychosocial needs. III. A licensed Nurse will initiate the Care plan . and updated as indicated for change in condition, onset of new problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when two of three sampled residents (Resident 1 and Resident 3) medical doctor (MD) was not notified regarding the allegation of abuse and one of three sampled residents (Resident 1) responsible party (RP) was not notified of the allegation of abuse. These failures had the potential for Resident 1 and Resident 3 ' s MD and Resident 1 ' s RP not to be aware of Resident 1 and Resident 3 ' s allegation of abuse.
Findings:
During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3.
During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], the AR indicated Resident 1 had a responsible party.
During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted on [DATE], the AR indicated Resident 3 was his own responsible party.
During a concurrent interview and record review on 10/15/24 at 2:28 p.m. with DON, Resident 1 and Resident 3 ' s medical record was reviewed. DON confirmed there was no documentation Resident 1 ' s MD or RP were notified of the abuse allegation. DON confirmed there was no documentation Resident 3 ' s MD was notified of the allegation of abuse. DON stated If is not documented it's not done.
During an interview on 10/15/24 at 3:03 p.m. with Administrator, Administrator confirmed the MD and RP notification was not documentation in Resident 1 and Resident 3's medical record. Administrator stated MD and RP notification should be documented in a progress note.
During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised 1/31/20, the P&P indicated, To ensure the Facility establishes, operationalize, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The Facility will report allegations of abuse, neglect, exploitation, mistreatment . ii. The resident ' s attending physician and responsible party, if applicable, will also be notified of the of the [sic] allegations and outcome of the investigation.

Based on interview and record review, the facility failed to provide reasonable access to a telephone that provided privacy for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in a violation of residents' rights to a private conversation.
Findings:
During an interview on 5/28/24 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents wanting to use the phone need to be able to get up out of bed and use the phone in the Administrator's office and/or use the facility main office phone.
During an interview on 5/28/24 at 11:44 a.m. with LVN 2, LVN 2 stated residents want to use the phone were taken to the nursing station to make phone calls. LVN 2 stated if the call needed to be private it is difficult as there are no cordless phones for the residents to use to allow privacy.
During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under the section Brief interview for Mental Status (BIMS – an assessment tool for cognition [mental processes including perception, memory, and thought], dated 5/5/24, the BIMS indicated, Resident 1 had a score of 15 (cognitively intact).
During an interview on 5/28/24 at 11:49 a.m. with Resident 1, Resident 1 stated, There is no way for the facility to provide a private conversation for residents, since there is not a portable phone that can be used. There are [other] residents that have the same concerns.
During a review of Resident 2's MDS under the section BIMS, dated 5/6/24, the BIMS indicated, Resident 10 had a score of 10 (moderate cognitive impairment).
During an interview on 5/28/24 at 11:57 a.m. with Resident 2, Resident 2 stated there is no way for a resident to have a private phone conversation in the facility.
During an interview on 5/28/24 at 12:03 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated residents had no private phone conversation. CNA 1 stated, Right now since there are no portable phones, we need to get the residents up and bring them to the [nurses] station to take the phone call.
During an interview on 5/28/24 at 12:07 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 3. CNA 2 stated she would have to take Resident 3 to the nurses station to talk to her family on the phone.
During an interview on 5/28/24 at 12:20 p.m. with Administrator in Training (AIT), AIT stated the facility had no portable phones for the residents since June of 2023. AIT stated calls for residents were done by taking them to the nursing station or having a family member call a staff member cell phone and providing the call to the resident. AIT stated there was no current way for a private phone call to be made for the residents.
During a review of the facility's policy and procedure (P&P) titled, Telephone Access, dated 11/1/17, the P&P indicated, Purpose . To ensure access to a telephone by residents at the Facility. The Facility makes telephones available and accessible to residents, visitors, and Facility staff. Designated telephones are available to residents to make local telephone calls and to receive private telephone calls that may not be overheard by others. The Facility makes a private telephone line available, installs a line in the resident's room or permits the resident to use a cellular phone. Facility Staff phone lines are used for the purpose of conducting day-to-day business and are not used for private calls by residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when:
1. Resident 1 was not assessed for risk for developing pressure injuries upon admission.
2. Physician was not notified to obtain treatment for Resident 1's left heel redness.
3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness.
4. Interdisciplinary team (Team members from different disciplines working collaboratively with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting was not conducted to address Resident 1's left heel redness.
These failures resulted in Resident 1 sustaining a facility acquired Stage 3 (Full-thickness loss of skin, in which adipose [fat] is visible) pressure injury to the left heel.
Findings:
During a review of Resident 1's admission Record (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), muscle weakness, and reduce mobility.
During a review of Resident 1's Nursing admission Screening/History (NASH) dated 3/14/24, the NASH indicated Resident 1 was alert and oriented to person, place, time, and situation and Resident 1's cognition (mental action or process) was intact. The NASH indicated, Skin . Face . Dryness . (no other documented skin issues).
During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool) dated 3/20/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) a score of 12 (a score of 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), and sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), and Resident 1 was dependent (helper does all the effort) for chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair).
1. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (Braden-a medical instrument used to measure residents' risk of developing pressure injuries) dated 3/14/24, the document was noted blank.
During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with Director of Nursing (DON), Resident 1's Braden Scale for Predicting Pressure Sore Risk dated 3/14/24, was reviewed. DON confirmed Resident 1 was admitted on [DATE]. DON reviewed Resident 1's Braden Scale for Predicting Pressure Sore Risk dated 3/14/24, and DON stated the Braden Scale for Predicting Pressure Sore Risk was not completed.
2. During a review of Resident 1's Skin Observation Tool, (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission).
During a review of Resident 1's Treatment Administration Record, dated 3/2024, the TAR indicated no documented treatment for Resident 1 left heel redness.
During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's SOT dated 3/15/24 was reviewed. The SOT indicated Resident 1 left heel redness. DON reviewed Resident 1's medical record and stated the physician was not notified to obtain treatment for Resident 1's left heel redness.
3. During a review of Resident 1's Skin Observation Tool, (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission).
During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's SOT dated 3/15/24 was reviewed. DON confirmed the SOT indicated Resident 1's left heel redness. DON reviewed Resident 1's care plans and stated there was no care plan developed to address Resident 1's left heel redness.
During a review of Resident 1's Wound Weekly Observation Tool (WWOT) dated 4/4/24 (20 days after the admission), the WWOT indicated, Resident 1 had a SDTI (suspected deep tissue injury-intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [small bubble on the skin filled with serum]) to the left heel. The WWOT indicated the SDTI was intact, measuring 20 mm (millimeters-unit of measure) in length by 20 mm in width.
During a review of Resident 1's WWOT dated 4/10/24, the WWOT indicated Resident 1's SDTI to the left heel worsened to a Stage 3 pressure injury measuring 25 mm in length by 25 mm in width and 1 cm (centimeter-unit of measure) in depth. The WWOT indicated slough (yellow, tan, white, or stringy material noted in the wound) and necrotic (dead skin tissue-brown, black, leather, scab-like) tissue.
During a concurrent observation and interview on 4/17/24 at 12:39 p.m. with Resident 1, in Resident 1 room, Resident 1 had his left foot elevated on a pillow. Resident 1 stated he was not admitted to the facility with pressure injury to the left heel. Resident 1 stated two weeks ago (4/4/24) a wound care provider took something off the bottom of his left foot, he stated the wound care provider came in today and scrapped and scrapped at my left foot again. Resident 1 stated, I was ready to go home but they won't let me go because of the wound [left heel].
During an interview on 4/24/24 12:32 p.m. with Treatment Nurse (TN), TN stated the facility process for new admitted resident identified with wounds was for the treatment nurse to measure the wounds, contact the physician to obtain treatment orders, develop a care plan, perform weekly wound assessment with the wound specialist, and update the treatment order and care plan as needed.
During an interview on 5/15/24, at 11:25 a.m. with DON, DON confirmed Resident 1's SDTI to the left heel was now a Stage 3.
4. During a concurrent interview and record review on 5/20/24 at 11:56 a.m. with DON, Resident 1's medical record was reviewed. There was no IDT meeting noted to address Resident 1's left heel redness. DON stated Resident 1 did not have an IDT meeting to address Resident 1's left heel redness on the month of March 2024.
During a review of facility's P&P titled, Pressure Ulcer Prevention, revised 11/1/17, the P&P indicated, Purpose To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. Policy: The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. Procedure I. Risk Identification and Assessment: A. The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. B. Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly and as needed. a. If the resident is identified as having wound upon admission, findings will be documented on the Resident admission Assessment . and a Wound Monitoring Record . will be implemented. c. A Wound Monitoring Record will be implemented for each identified wound. II. Plan of Care: A. The Licenses Nurse will develop a Care Plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the following: i. Attending Physician ii. Interdisciplinary Team (IDT)- Skin Committee iii. Registered Dietician iv. Director of Rehabilitation Services B. Nursing Staff will monitor interventions for effectiveness and resident tolerance. C. The Care Plan will be revised as indicated. III. Ongoing Monitoring: .C. The Licensed Nurse will document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) medical records were accurate. This failure resulted in inaccurate information in Resident 1's medical record.
Findings:
During a concurrent interview and record review on 5/15/24 at 11:25 a.m. with Director of Nursing (DON), DON reviewed Resident 1's Wound Weekly Observation Tool, (WWOT) dated 4/4/24. DON confirmed Resident 1 had an SDTI (suspected deep tissue injury-intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [small bubble on the skin filled with serum]) to the left heel and skin intact. DON reviewed Resident 1's care plan with the focus on stage 3 (Full-thickness loss of skin, in which adipose [fat] is visible) pressure injury (is localized damage to the skin and underlying soft tissue usually over a bony prominence) to left heel initiated on 4/4/24 and the interventions were initiated on 4/3/24 (one day before the care plan was initiated). DON confirmed Resident 1 had a left heel SDTI on 4/4/24, not a stage 3 pressure injury. DON stated the documentation was not accurate.
During a review of the facility's policy and procedure (P&P) titled, Completion &Correction, revised 5/1/19, the P&P indicated, The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. II. Entries will be recorded promptly as the events or observations occur. III> entries will be complete, legible, descriptive, and accurate. V. Entries should be written in chronological sequence. If it is necessary to chart out of sequence during, the appropriate date and time will be entered. A. When adding an entry at a later date, the entry is to be clearly identified as a late entry. XV. An event is never to be documented before it occurs.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Discharge Against Medical Advice, on contacting Adult Protective Services (APS - a program that promotes the safety, independence, and quality-of-life for vulnerable adults) when one of three sampled residents (Resident 1) left the facility against medical advice (AMA - leaving a facility prior to a doctor recommends discharge). This had the potential for adverse health outcomes.
Findings:
During a review of Residents 1's AMA Form [AMAF], dated 5/1/24, the AMAF indicated Resident 1 signed himself out of the facility AMA on 5/1/24.
During an interview on 5/6/24 at 2:18 p.m. with Administrator, Administrator stated Resident 1 is his own responsible party (RP - the person responsible for making decisions). Administrator stated Resident 1 signed himself out AMA from the facility on 5/1/24.
During a review of Resident 1's admission RECORD (AR), dated 5/6/24, the AR indicated, Resident 1 was not his own RP. The AR indicated Resident 1 Family Member (FM) 1 is his responsible party and emergency contact. The AR indicated Resident 1 had a diagnosis of metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), muscle weakness, alcohol abuse and withdrawal, need for assistance with personal care, hemiparesis/hemiplegia (inability to move one side of the body) to the right side, noncompliance with medication and end stage renal disease (point to where the kidneys no longer function on their own).
During a review of Resident 1's Minimum Data Set (MDS - an assessment tool) under the section Brief Interview for Mental Status (BIMs - an assessment tool for cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), dated 4/24/24, the BIMs indicated, Resident 1 had a score of 10 (moderate cognitive impairment).
During a review of Resident 1's History and Physical Examination (H&P), dated 4/22/24, the H&P indicated, Resident 1's Medical Doctor (MD) stated he was alert and oriented times (x) 2 (knows who they are and where they are, but not what time it is or what is happening to them) and he had periods of confusion.
During an interview on 5/6/24 at 3:08 p.m. with Social Services Director (SSD), SSD stated Resident 1 was on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) three times a week and arrangements were not made for Resident 1 to continue dialysis since he left AMA. SSD stated Resident 1 was homeless prior to admitting into the facility. SSD stated attempts to contact FM 1 were unsuccessful. SSD stated APS was not notified of Resident 1 leaving the facility AMA.
During a review of the facility's P&P titled, Discharge Against Medical Advice, dated 6/1/21, the P&P indicated, A resident may discharge his/herself from the Facility against the advice of his/her physician. If the resident demonstrates impaired cognition or is at risk of harm to self or others, Adult Protective Services will also be notified.

Based on observation, interview, and record review, the facility failed to ensure the air mattress (a pressure-relief device that is constantly being inflated with air to prevent skin breakdown, wounds and/or assist with the healing of wounds) for three of three sampled residents (Resident 1, Resident 2 and Resident 3) was in safe operating condition. This failure had the potential to impact the safety of the residents.
Findings:
During a concurrent observation and interview on 4/22/24 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1 was observed laying on an air mattress in bed. LVN 1 observed the air mattress setting and stated it was set at 290 pounds (lbs.).
During a review of Resident 1's Weights and Vitals Summary (WAVS), dated 3/3/24, the WAVS indicated, Resident 1 weighed 110 lbs.
During an interview on 4/22/24 at 2:17 p.m. with Treatment Nurse (TN), TN stated the facility maintenance sets up the air mattresses for the residents. TN stated she has not been educated nor does she know how to set up an air mattress or its settings for the residents.
During a concurrent observation and interview on 4/22/24 at 2:23 p.m. with TN in Resident 2's room, Resident 2 was observed laying on an air mattress in bed. Resident 2 stated to TN her mattress was uncomfortable. TN looked at Resident 2's air mattress settings and stated it was set at 350 lbs.
During a review of Resident 2's WAVS, dated 4/3/24, the WAVS indicated, Resident 2 weighed 158 lbs.
During a concurrent observation and interview on 4/22/24 at 2:27 p.m. with TN in Resident 3's room, Resident 3 was observed laying on an air mattress in bed. TN looked at Resident 3's air mattress settings and stated it was set at 1000 lbs.
During a review of Resident 3's WAVS, dated 4/5/24, the WAVS indicated, Resident 3 weighed 448 lbs.
During an interview on 4/22/24 at 2:34 p.m. with Facility Maintenance Worker (FMW), FMW stated he does not set up the air mattresses for residents. FMW stated he brings in the air mattresses when requested by the nurse, cleans them, sets them on the bed and turns the machine on. FMW stated he thought the facility nurses set the settings on the resident air mattresses.
During an interview on 4/22/24 at 2:41 p.m. with Director of Staff Development (DSD), DSD stated she does not provide training to the facility nurses on how to set up the air mattress settings. DSD stated the facility Director of Nursing (DON) was supposed to provide any type of Inservice training to the licensed nurses. DSD stated she had not received any type of training on how to set up an air mattress.
During an interview on 4/22/24 at 2:46 p.m. with DON, DON stated air mattresses were to be set up according to resident weight. DON stated if the air mattresses were set up to be too high or to be too low in weight, it could cause more damage to the resident's skin. DON stated the facility had not provided any training on how to set up an air mattress to any of the licensed nurses.
During a review of the facility Licensed Nurse List (LNL), undated, the LNL indicated, the facility had 28 nurses (LVN 1, TN, DSD, Registered Nurse (RN) 1, RN 2, RN 3, RN 4, RN 5, RN 6, LVN 2, LVN 3, LVN 4, LVN 5, LVN 6, LVN 7, LVN 8, LVN 9, LVN 10, LVN 11, LVN 12, LVN 13, LVN 14, LVN 15, LVN 16, LVN 17, LVN 18, LVN 19 and LVN 20) in the facility that had not received training on resident air mattresses.
On 5/7/24 at 4:02 p.m. a request was made for facility policy and procedures regarding licensed nurse training and/or competencies and DON stated the facility did not have any policies for licensed nurses training and/or competencies.

Based on observation, interview, and record review, the facility failed to provide oxygen per physician's orders for one of three sampled residents (Resident 1). This failure had the potential for negative outcomes.
Findings:
During a concurrent observation and interview on 4/22/24 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1 was observed with oxygen being given via nasal canula (a flexible tube with two protruding tips that sit inside the nostrils to deliver oxygen) at six liters (a unit of measurement). LVN 1 stated Resident 1 had the oxygen set at six liters, but it was supposed to be set at two liters.
During a review of Resident 1's Order Summary Report (OSR), dated 4/22/24, the OSR indicated, Resident 1 diagnosis including Chronic Obstructive Pulmonary Disease (COPD – a common lung disease causing restricted airflow and breathing problems), Pneumonia (infection of the lung) and Respiratory failure (a serious condition that makes it difficult to breathe on your own). The OSR indicated Resident 1 had a physician's order to receive oxygen at 5 liters via nasal canula as needed for oxygen saturation (the amount of oxygen circulating in the blood) less than 93 percent (%).
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 11/1/17, the P&P indicated, Purpose . To prevent or reverse hypoxemia [low oxygen levels] and provide oxygen to the tissues. Procedure . Check the physician's order. turn on the oxygen at the prescribed rate.

Based on interview and record review, the facility failed to:
1. Ensure Pharmacy Consultant conducted Medication Regimen Review (MRR- a thorough evaluation of the residents' medications and minimizing adverse consequences) for two of two sampled residents (Resident 15 and Resident 55) on psychotropic (refer to antidepressants, anti-anxiety, stimulants, antipsychotic, and mood stabilizers) medications.
2. Ensure Pharmacy Consultant conducted monthly medication review for all 71 residents in the facility .
These failures had the potential for adverse consequences when there is no pharmacy oversight and monitoring of medications.
Findings:
1. During a concurrent interview and record review on 3/27/24 at 8:31 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC) 1, Resident 15's Medication Administration Record (MAR), dated 3/1/24/ to 3/26/24, was reviewed. The MAR indicated Abilify 30 mg (milligram), give one tablet one time a day for bipolar disorder (mental illness causing extreme mood swings that include emotional highs and lows) manifested by (m/b) sexual behavior. Oxcarbazepine (medication that helps to stabilize mood, control emotions, and improve overall functioning) 600 mg one tablet by mouth one time a day for bipolar disorder m/b mood swings. Depakote Delayed Release 500 mg give one tablet by mouth two times a day for Seasonal Anxiety Disorder (type of depression related to changes in seasons) m/b inappropriate sexual behavior towards staff.
During a concurrent interview and record review on 3/27/24 at 10 a.m. with MDSC 1, the Pharmacy MRR Binder Report for Resident 15's MRR, dated 1/2024, 2/2024, and 3/2024, were reviewed. The Pharmacy MRR Binder indicated, No record of the pharmacist report of MRR conducted for Resident 15 for the last three months.
During a review of Resident 55's MAR, dated 3/1/24 to 3/26/24, the MAR indicated, Quetiapine Fumarate 50 mg one tablet by mouth in the afternoon for Psychosis (mental disorder characterized by a disconnection from reality) m/b having aggressive behaviors such as wanting to hit staff and/or other residents. Quetiapine Fumarate 80 mg one tablet a day in the afternoon for Unspecified Dementia (the loss of cognitive functioning: thinking, remembering, and reasoning the extent it interferes with a person's daily life and activities) m/b behavior involving agitation. Donazepil 5 mg give one tablet by mouth at bedtime for unspecified dementia. Memantine (medication to treat memory loss in dementia) 10 mg one tablet by mouth two times a day for unspecified dementia. Lorazepam 1 mg one tablet by mouth every 12 hours as needed for anxiety for 14 days m/b by restlessness, such as pacing up and down.
During a concurrent interview and record review on 3/27/24 at 1:55 p.m. with MDSC 1, The Pharmacy MRR Binder Report for Resident 55's MRR, dated 1/2024, 2/2024, and 3/2024, were reviewed. MDSC 1 was unable to find in the Pharmacy MRR Binder the pharmacy consultant reviewed the medication regimen for Residents 55 on 1/2024, 2/2024/and 3/2024. MDSC 1 stated there was an MRR dated 11/26/23 that indicated, Limit lorazepam to 14 days. MDSC 1 was unable to find pharmacy consultant review for other medications.
2. During a concurrent interview and record review on 3/27/24 at 2:29 p.m. with Director of Nursing (DON), the facility's Census Report (CR) dated 9/20/23,10/18/23, 11/26/23, 12/27/23, 1/22/24, and 2/12/24, and Med [medication] Regimen Review Report [MRRR) dated 9/20/23, 10/18/23, 11/26/23, 12/27/24, and 2/12/24 were reviewed. The CR and MRRR indicated the following:
09/20/23, the census was 78, 58 residents MRRR were not reviewed by the pharmacist,
10/18/23, the census was 77, 64 residents MRRR were not reviewed by the pharmacist.
11/26/23, the census was 68, 50 residents MRRR were not reviewed by the pharmacist.
12/27/23, the census was 72, 34 residents MRRR were not reviewed by the pharmacist.
01/22/24, the census was 76, 56 residents MRRR were not reviewed by the pharmacist.
02/12/24, the census was 71, 51 residents MRRR were not reviewed by the pharmacist.
DON stated he had been aware of the pharmacist not reviewing all the records, and had alerted the Administrator -in-Training (AIT), and stated the Pharmacist should review every Residents' medications and document the MRRR monthly.
During a review of the facilities policy and procedure (P&P), titled Medication Monitoring [undated], the P&P indicated, The consultant pharmacist reviews the medication regimen of each resident at least monthly.
During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review (Monthly Report), [undated], the P&P indicated, The consultant pharmacist reviews the medication regimen of each resident at least monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a language-assistance service for one of one sampled resident (Resident 64). This failure had the potential for unmet care needs.
Findings:
During a concurrent observation and interview on 3/25/24 at 7:05 a.m. in Resident 64's room, Resident 64 was seated at the edge of the bed trying to say something in [NAME] (language native to the Punjab region of Pakistan and [NAME]). Certified nursing assistants (CNA) 2 and CNA 3 entered Resident 64's room. CNA 3 spoke in one syllable words and made gestures to communicate with Resident 64. Resident 64 and CNA 3 could not clearly communicate and understand each other. Resident 64 put both her elbows on the overbed table, held her hair and put her head down.
During an interview on 3/25/24 at 7:10 a.m. with CNA 3, CNA 3 stated she (CNA 3) communicated with Resident 64 using body language and action. CNA 3 stated Resident 64 understood bathroom. CNA 3 stated there are two staff members who speak the [NAME] language, but she (CNA 3) had to use Google Translate to communicate with Resident 64, whenever we have to ask Resident 64 questions. CNA 3 stated the facility does not have a translation service. CNA 3 stated it was very difficult to care for Resident 64 because it was hard to understand her. CNA 3 stated, I feel frustrated sometimes because I do not know what she (Resident 64) wants.
During an interview on 3/25/24 at 12:06 p.m. with Administrator-in-Training (AIT), AIT stated there were two non-English speaking residents (Resident 64 and Resident 6). AIT stated the facility ensured the staff assigned to provide care for Resident 64 and Resident 6 spoke the residents' language. [Resident 64] speaks [NAME] and Resident 6 speaks Farsi (the official language of [NAME]). AIT stated, We have to call the staff-on-call at home if needing translation. For Farsi, we contact the Ombudsman for social services. AIT stated the use of Google Translate is not acceptable, make sure it is a native speaker. AIT stated, We do not have a translation service.
During a review of the facility's policy and procedure (P&P) titled, Translation or Interpreter Services, dated 6/1/21, the P&P indicated, 1. During Admission, facility staff will conduct an initial language assessment and notify the Social Services Department of the resident's need for translation or interpreter services. The Director of Social Services or his/her designee is the coordinator of the Facility's translation and interpretation services. Qualified interpreters are defined as those who have demonstrated proficiency in speaking and understanding at least spoken English and the spoken language in need of interpretation; and are able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such language(s) and English. using any necessary specialized vocabulary, terminology, and phraseology.

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 135 and Resident 44) were free from medication error rate of greater than five percent (%) when two medication errors occurred within 29 opportunities resulting in a 6.9 % error rate. This failure had the potential for Resident 135 and Resident 44 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes.
Findings:
During an observation and interview on 3/27/24 at 8:20 a.m. in Resident 135's room, Registered Nurse (RN) 1 administered Resident 135's medication. At 8:27 a.m. RN 1 stated she did not administer Resident 135's Eliquis (medication used to thin the blood) 5 milligram as she did not have any in her medication cart to administer.
During a concurrent observation and interview on 3/27/24 at 8:56 a.m. in Resident 44's room, Licensed Vocational Nurse (LVN) 5 administered Resident 44's medications. LVN 5 stated she did not have Resident 44's inhaler (Trelegy Ellipta Aerosol Powder Breath Activated Inhaler - medication to treat chronic obstructive pulmonary disease COPD - progressive lung disease) and will call the pharmacy.
During a review of Resident 135's Medication Administration Record (MAR) dated 3/1/24 - 3/31/24, the MAR indicated, Apixaban (Eliquis) Oral tablet 5 mg Give 1 tablet by mouth two times a day for Deep Vein Thrombosis (DVT-blood clot in the vein) was not given at 9 a.m. on 3/27/24.
During a review of Resident 44's MAR, dated 3/1/24 - 3/31/24, the MAR indicated, Trelegy Ellipta Aerosol Powder Breath Activated . in the morning for COPD was not given at 9 a.m. on 3/27/24.
During an interview on 3/27/24 at 9:54 a.m. with RN 1, RN 1 stated she called the pharmacy and stated hopefully the medication will arrive today.
During an interview on 3/27/24 at 9:57 a.m. with Director of Nursing (DON), DON stated the nurses are to call the pharmacy four or five days prior to running out of the medication to ensure the Residents do not run out of their medications.
During a review on the facility's policy and procedure (P&P) titled Medication Administration dated 11/1/17, the P&P indicated, 1. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. V. Medications may be administered one hour before or after the scheduled medication administration time.

During a concurrent observation and interview on 3/25/24 at 8:51 a.m. with Resident 15, in Resident 15's room, the call light was hanging on the wall located in the back of Resident 15's headboard. Resident 15 was unable to find his call light in his bed. Resident 15 stated he could push the call light, but the call light is not here.
During a concurrent observation and interview on 3/25/24 at 8:55 a.m. with Licensed Vocational Nurse (LVN) 1, the call light was hanging on the wall in the back of the headboard. LVN 1 stated Resident 15's call light was on the wall. LVN 1 stated definitely, the call light should be within resident's reach.
During a review of the facility's policy and procedure (P&P) titled, Call Lights, dated 7/02, the P&P indicated, All residents are provided with a call system that they are able to operate. 4. The call light will be put within reach of the resident.
Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and Resident 26) had access to a call light. This failure had the potential for unmet care needs.
Findings:
During a concurrent observation and interview on 3/25/24 at 10:37 a.m. with Resident 26, in Resident 26's room, Resident 26 was sitting on her bed with no call light visible. Resident 26 stated she knew how to call for help and pointed to the bed's remote control attached to the side rail.
During a concurrent observation and interview on 3/25/24 at 10:40 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 retrieved Resident 26's call light from the floor at the end of her roommate's bed and attached it to Resident 26's side rail. CNA 4 stated the call light should have been where Resident 26 could reach it.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Notification of Responsible Party, when the responsible party was not notified of a change of condition for one of four sampled residents (Resident 17). This failure had the potential to result in family not being involved in Resident 17's care.
Findings:
During a concurrent interview and record review on 3/26/24 at 2:33 p.m. with Treatment Nurse (TN), Resident 17's eInteract Change in Condition Evaluation-V 5.1 (COC), dated 2/25/2024, was reviewed. The COC indicated, Resident 17 had a skin tear on toe and under Resident Representative notification had self. TN stated, Resident 17 doesn't have capacity to make her own decisions. TN stated Resident 17 had the COC on 2/25/24. TN stated Resident 17's representative was never notified about Resident 17's COC.
During a record review of Resident 17's History and Physical Examination (H&P), dated February 2024, the H&P indicated, [Resident 17] does not have the capacity to understand and make health care decisions.
During an interview on 3/26/24 at 2:07 p.m. with Resident 17's Responsible Party (RP) 1, RP 1 stated she last heard from facility on 12/15/23.
During a review of the facility's P&P titled, Notification of Responsible Party, [undated], the P&P indicated, The appropriate resident's responsible party is to be notified upon admission, discharge, and or for any significant change of condition. Policy: It is the facility's policy that the appropriate resident's responsible party is notified of any changes involving the resident's health. 5. The charge nurse is responsible for notifying the responsible party of the significant change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate transfer/discharge documents signed by the Responsible Party for one of one sampled resident (Resident 55) with dementia (group of symptoms affecting memory, thinking and social abilities). This failure had the potential to result in an unsafe and unorderly transfer for Resident 55 without the family being aware.
Findings:
During a review of Resident 55's admission Record (AR), the AR indicated, Resident 55 is an [AGE] year-old-female admitted on [DATE] with diagnosis including, Unspecified Dementia, Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations), and Adult Failure to Thrive (group of symptoms including weight loss, decreased appetite and poor nutrition, and inactivity accompanied by dehydration and depression).
During a review of Resident 55's Minimum Data Set (MDS-resident assessment tool), the MDS Section C-Cognitive [thinking, reasoning, remembering ability] Patterns, dated 11/17/23, indicated, BIMS [Brief Interview for Mental Status-a point system ranging from 0 to 15: 0 to 7 points: severe cognitive impairment, 8 to 12 points: moderate cognitive impairment, 13 to 15 points: cognition intact] Score: Three.
During a concurrent interview on 3/26/24 at 11:54 a.m. with Social Services Director (SSD), SSD stated Resident 55's Family Member (FM 1) requested that (Resident 55) be placed in an assisted living (for people who need help with daily care, but not as much help as a nursing home provides) residence in Fresno where (Resident 55) could be close to FM 1. SSD stated arrangements were being made for (Resident 55)'s transfer, although not in Fresno. SSD stated the facility was just waiting for FM 1 to sign the transfer documents.
During a concurrent interview and record review on 3/26/24 at 12 PM with SSD, Resident 55's transfer packet was reviewed. The transfer packet included, but not limited to the following documents: Consent for Telehealth, Patient Consent to Receive Services and Certification, Authorization to Release Personal and Health Information, Assisted Living Waiver Amenity Form, Assisted Living Waiver Patient's Rights, and Assisted Living Freedom of Choice Form. Resident 55 signed the above documents on 11/28/23. SSD stated she was aware [Resident 55]'s BIMS Score was three (severe cognitive impairment), and her mental status was not stable. SSD stated, I am aware and have a copy of the physician certification that stipulated [Resident 55] did not have the capacity to understand and make healthcare decisions. [Resident 55] cannot sign and make decisions for herself.
During a review of Resident 55's History and Physical (H&P), dated 9/18/23, the H&P indicated, [Resident 55] does not have the capacity to understand and make healthcare decisions.
During an interview on 3/26/24 at 12:15 p.m. with Resident 55's FM 1, FM 1 stated [Resident 55] had never signed any documents regarding her healthcare. FM 1 stated [Resident 55] does not have the capacity to understand and sign documents.
During an interview on 3/26/24 at 12:30 p.m. with SSD, SSD stated, I do not know who signed for [Resident 55].
During an interview on 3/26/24 at 12:13 p.m. with FM 1, FM 1 stated, [Resident 55] is not capable of signing any paperwork. I sign all the paperwork/document for [Resident 55]. I am not aware [Resident 55] signed transfer documents; nobody notified me. FM 1 asked, Am I being forced to move [Resident 55] out.
During a review of the facility's policy and procedure (P&P) titled, Notification of Responsible Party, [undated], the P&P indicated, The appropriate resident's responsible party is to be notified upon admission, discharge, and or for any significant changes of condition. Policy: It is the facility's policy that the appropriate residents responsible party is notified of any changes involving the resident's health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure activity assessments were completed for 16 of 16 sampled residents (Resident 6, Resident 9, Resident 12, Resident 27, Resident 60, Resident 82, Resident 135, Resident 185, Resident 200, Resident 201, Resident 202, Resident 203, Resident 204, Resident 205, Resident 206, Resident 207). This failure had the potential for residents to not meet their physical, mental, and psychosocial well-being.
Findings:
During a concurrent interview and record review on 3/26/24 at 2:41 p.m. with Activity Director (AD), Resident 60's admission Record (AR), dated 3/18/24, was reviewed. The AR indicated, Resident 60 was admitted on [DATE]. AD stated, Resident 60 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:46 p.m. with AD, Resident 200's AR, dated 3/13/24 was reviewed. The AR indicated, Resident 200 was admitted on [DATE]. AD stated, Resident 200 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:47 p.m. with AD, Resident 135's AR, dated 3/16/24 was reviewed. The AR indicated, Resident 135 was admitted on [DATE]. AD stated, Resident 135 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:48 p.m. with AD, Resident 12's AR, dated 2/16/24 was reviewed. The AR indicated, Resident 12 was admitted on [DATE]. AD stated, Resident 12 did not have activity assessment completed in 7 days.
During a concurrent interview and record review on 3/26/24 at 2:50 p.m. with AD, Resident 9's AR, dated 3/18/24 was reviewed. The AR indicated, Resident 9 was admitted on [DATE]. AD stated, AD stated, Resident 9 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:52 p.m. with AD, Resident 201's AR, dated 2/27/24 was reviewed. The AR indicated, Resident 201 was admitted on [DATE]. AD stated, Resident 201 did not have activity assessment completed in 7 days.
During a concurrent interview and record review on 3/26/24 at 2:53 p.m. with AD, Resident 27's AR, dated 2/27/24 was reviewed. The AR indicated, Resident 27 was admitted on [DATE]. AD stated, Resident 27 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:54 p.m. with AD, Resident 202's AR, dated 2/22/24 was reviewed. The AR indicated, Resident 202 was admitted on [DATE]. AD stated, Resident 202 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:55 p.m. with AD, Resident 6's AR, dated 2/22/24 was reviewed. The AR indicated, Resident 6 was admitted on [DATE]. AD stated, Resident 6 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:56 p.m. with AD, Resident 203's AR, dated 3/7/24 was reviewed. The AR indicated, Resident 203 was admitted on [DATE]. AD stated, Resident 203 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:57 p.m. with AD, Resident 204's AR, dated 3/13/24 was reviewed. The AR indicated, Resident 204 was admitted on [DATE]. AD stated, Resident 60 did not have activity assessment completed.
During a concurrent interview and record review on 3/26/24 at 2:58 p.m. with AD, Resident 82's AR, dated 2/26/24 was reviewed. The AR indicated, Resident 82 was admitted on [DATE]. AD stated, Resident 82 did not have activity assessment completed in 7 days.
During a concurrent interview and record review on 3/26/24 at 3 p.m. with AD, Resident 205's AR, dated 3/6/24 was reviewed. The AR indicated, Resident 205 was admitted on [DATE]. AD stated, Resident 205 did not have activity assessment completed in 7 days.
During a concurrent interview and record review on 3/26/24 at 3:01 p.m. with AD, Resident 206's AR, dated 3/12/24 was reviewed. The AR indicated, Resident 206 was admitted on [DATE]. AD stated, Resident 206 did not have activity assessment completed in 7 days.
During a concurrent interview and record review on 3/26/24 at 3:02 p.m. with AD, Resident 185's AR, dated 3/17/24 was reviewed. The AR indicated, Resident 185 was admitted on [DATE]. AD stated, Resident 185 did not have activity assessment completed done in 7 days.
During a concurrent interview and record review on 3/26/24 at 3:04 p.m. with AD, Resident 207's AR, dated 3/14/24 was reviewed. The AR indicated, Resident 207 was admitted on [DATE]. AD stated, Resident 207 did not have activity assessment completed in 7 days.
During an interview on 3/26/24 at 3:06 p.m. with AD, AD stated Activity assessment should be done within 7 days of admission. AD stated the purpose of activity assessment is to find out what is the best activity for each resident. AD stated activities will improve the residents' mental health.
During a review of the facility's policy and procedure (P&P) titled, Activity Assessment/Care Plan, dated 2021, the P&P indicated, To assess each resident's preferences for customary routine and activity interests, and to develop an individualized Care Plan for each resident. Within seven (7) days of a resident's admission to the Facility, an activity assessment is completed by the Activity Director or designee to assist in developing an Activities Care Plan that reflects the choices and preferences of the resident. As appropriate, the Interdisciplinary Team (IDT) may use information from the Activity Assessment to develop care plans to address resident needs.

Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 43, Resident 52, and Resident 3) had Minimum Data Set (MDS- resident assessment tool) assessments completed timely. This failure had the potential to result in unidentified health problems.
Findings:
During a concurrent interview and record review on 3/28/24 at 10:21 a.m. with MDS Coordinator (MDSC) 1, Resident 43's Quarterly MDS assessment, dated 12/31/23, was reviewed. Resident 43's Quarterly MDS Assessment indicated a status titled, Export Ready. MDSC 1stated the Quarterly MDS assessment was completed on 3/20/24 but had not been transmitted. MDSC 1 stated, Yes, it is late.
During a concurrent interview and record review on 3/28/24 at 10:28 a.m. with MDSC 1, Resident 52's Quarterly MDS assessment, dated 12/29/23, was reviewed. Resident 52's Quarterly MDS Assessment indicated a status titled, Export ready. MDSC 1 stated Resident 52's Quarterly MDS assessment had not been sent and was late.
During a concurrent interview and record review on 3/28/24 at 10:29 a.m. with MDSC 1, Resident 3's Annual MDS assessment, dated 1/24/24, was reviewed. Resident 3's Annual MDS Assessment indicated a status titled, In Progress. MDSC 1 stated Resident 3's Annual MDS assessment was in progress and had not been submitted. MDSC 1 stated comprehensive assessments of residents must be submitted quarterly and annually in a timely manner.
During a review of the facility's policy and procedures (P&P) titled, Policy Statement Resident Assessments, dated 11/19, the P&P indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA [Omnibus Budget Reconciliation Act- also known as the Nursing Home Reform Act] and PPS [Prospective Payment System- a method of reimbursement for Medicare payments] requirements. 1. The resident assessment coordinator is responsible for 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: . (2) Quarterly Assessment- Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type; . (4) Annual Assessment (Comprehensive)- Conducted not less than once every twelve (12) months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 15, Resident 19, Resident 56, and Resident 209) received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 15, Resident 19, Resident 56, and Resident 209.
Findings:
During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was readmitted on [DATE] after a recent hospitalization. Resident 15 had a diagnosis including Type 2 Diabetes Mellitus (DM-high levels of blood sugar) with Polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and development of foot ulcers), and Hemiplegia (one-sided paralysis)/hemiparesis (loss of strength in the arm, leg, and face on one side of the body) affecting the left dominant side.
During a concurrent interview and record review on 3/26/24 at 3:59 p.m. with Minimum Data Set (MDS-resident assessment tool) Coordinator (MDSC) 1, Resident 15's BCP, dated 2/29/24, was reviewed. The BCP indicated, the sections for social services and rehabilitation services were incomplete. MDSC 1 stated Resident 15 was not provided a copy of the baseline care plan summary as there was no signature of the resident or Resident 15's representative indicating receipt of the BCP.
During a review of Resident 19's AR, the AR indicated, Resident 19 was admitted on [DATE] with diagnosis including Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood due to illness or organs that are not working as well as they should), Sepsis (a serious condition in which the body responds improperly to an infection), and Altered Mental Status (a change in mental function that stems from illnesses, disorders, and injuries affecting one's brain).
During a concurrent interview and record review on 3/26/24 at 4:05 p.m. with MDSC 1, Resident 19's BCP, dated 1/22/24, was reviewed. BCP indicated Nursing, Social Services, Physical Therapy, and Dietary Services entered a brief assessment and plan of care. MDSC 1 stated there was no signature of Resident 19's representative on the BCP indicating receipt of the BCP.
During a review of Resident 56's AR, the AR indicated Resident 56 was admitted on [DATE] with diagnosis including Unspecified Dementia (a disease affecting memory, thinking and social abilities) without behavioral disturbance, Type 2 Diabetes Mellitus (a disease characterized by high blood sugar), and Mood Disorder (psychiatric conditions that affect a person's emotional state, leading to periods of joy, mania [state of elevated energy, mood, and behavior], sadness, and/or depression).
During a concurrent interview and record review on 3/26/24 at 4:10 p.m. with MDSC 1, Resident 56's BCP, dated 11/6/23, was reviewed. The BCP indicated Nursing, Social Services, Dietary, Physical Therapy, and Activities entered a brief assessment and plan of care three days after Resident 56 was admitted . MDSC 1 stated Resident 56 was not provided his baseline care plan summary within 48 hours of admission.
During a concurrent interview and record review, on 3/19/24 at 3:41 p.m. with Director of Nursing (DON), Resident 209's BCP, dated 2/18/24, was reviewed. DON stated Resident 209's BCP was not completed .
During a review of the facility's policy and procedure (P&P) titled Care Plans- Baseline, undated, the P&P indicated, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed with in forty-eight (48) hours of the resident's admission. 3. The baseline care plan will be until the staff can conduct the comprehensive assessment and develop an interdisciplinary person -centered care plan.
During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow UP: Role of the Nurse. dated 9/2012, the P&P indicated, Gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan .

2. During a concurrent interview and record review on 3/19/24 at 3:41 p.m. with DON, DON reviewed Resident 55's medical record. DON stated Resident 55 fell on 3/12/24. DON was unable to provide documented evidence the facility developed and implemented a care plan for Resident 55 fall on 3/12/24, DON stated a care plan should have been developed and implemented.
During a review of the facility's policy and procedure (P&P) titled Assessment and Management of Residents Falls, undated, the P&P indicated, It is the policy . to prevent falls among resident as humanly possible and to provide interventions that may address resident's specific risks and causes of residents falls . Cause Identification 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling.
During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated 4/2009, the P&P indicated, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.
Based on interview and record review, the facility failed to develop and implement a care plan for two of two sampled residents (Resident 208 and Resident 55). This failure had the potential for negative outcomes.
Findings:
1. During a review of Resident 208's Progress Notes (PN), dated 1/24/24, at 7:46 p.m., the PN indicated Resident 208 refused to go to the hospital for an unidentified change of condition.
During a review of Resident 208's PN dated 1/29/24 at 7:10 a.m. the PN indicated Resident 208 refused to have his blood sugar checked.
During a review of Resident 208's PN dated 2/16/24 at 8:10 p.m. the PN indicated Resident 208 had a blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]) of greater than 240/110 (extremely high, normal range is 120/80) despite being given two medications to control it. Resident 208 refused to be sent out for higher level of care.
During a review of Resident 208's PN dated 3/2/24 at 11:01 a.m. the PN indicated Resident 208 refused to take his medications, refused his blood sugar checked and refused to go to dialysis (mechanical process of filtering the blood when the kidneys are not working).
During a review of Resident 208's IDT Note (IDTN), dated 3/1/24, the IDTN indicated, Resident 208, has been refusing medications here and there ever since he first came into the facility and or he tells licensed nursing staff to come back at another time that is more convenient to him after being encouraged plenty of times of the importance of staying on schedule. The resident [Resident 208] is nice as far as is behavior, however, stubborn and wants things done his way which can most definitely complicate his health issues. Blood sugar can also fluctuate do [sic] to his refusal and or him wanting to change the times of blood sugar checks.
During a review of Resident 208's IDTN, dated 3/13/24, the IDTN indicated, Resident 208, DON [Director of Nursing] explained to family that on multiple occasions patient [Resident 208] refused treatment and to be sent to hospital.
During a concurrent interview and record review on 3/19/24 at 12:20 p.m. with DON, Resident 208's Electronic Health Record (EHR) dated January 2024 to March 2024 was reviewed. DON reviewed the EHR, and stated Resident 208 did not have a care plan in place for noncompliance with care, refusing medications, refusing dialysis and for refusing care. DON stated there should be specific care plans in place for Resident 208 regarding any issues that complicate his care, and the care plans should not be vague.

Based on interview and record review the facility failed to administer medication according to the physician's order for one of three sampled residents (Resident 209). This failure had the potential for adverse outcomes for Resident 209.
Findings:
During a concurrent interview and record review on 3/26/24 at 10:12 a.m. with Director of Nursing (DON). DON reviewed Resident SC's Medication Administration Record, (MAR) dated 2/2024. DON confirmed the following:
Percocet [combination of medication used to relieve severe pain] Oral Tablet 10-325 MG [milligram- unit of measure] .Give 1 tablet by mouth every 4 hours as needed for severe pain (7-10) . -Order Date- 2/19/2024 1543 [3:43 p.m.]
2/18/24 at 12:30 a.m., Percocet was administered for a pain level of 5.
2/18/24 at 4:47 a.m., Percocet was administered for a pain level of 6.
2/19/24 at 4:53 a.m., Percocet was administered for a pain level of 5.
2/20/24 at 6:30 a.m., Percocet was administered for a pain level of 6.
2/22/24 at 6:17 a.m., Percocet was administered for a pain level of 5.
DON stated Percocet was given outside of physician ordered pain scale five times. DON stated nurses should follow the order, go off the pain scale and contact the physician if adjustments need to be made.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frames.

Based on interview and record review, the facility failed to:
1. Notify a Medical Doctor (MD) of a change in one of three sampled residents (Resident 208) condition.
2. Conduct an Interdisciplinary team (IDT - a group of various professionals that coordinate assessment and treatment for residents, so that problems can be dealt with consistently and comprehensively) for one of three sampled residents' (Resident 208) change in condition.
These failures had the potential for Resident 208 to not obtain the proper treatment, not have consistent care given, not identify the best course of action for Resident 208's concerns, and potentially lead to harm up to and including death.
1. During a review of Resident 208's Progress Notes (PN), dated 2/16/24 at 8:10 p.m, the PN indicated Resident 208 had a blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]) of 240/110 (extremely high, normal range is 120/80) despite being given two medications to control it. Resident 208 refused to be sent out for higher level of care.
During a concurrent interview and record review on 3/19/24 at 12:20 p.m. with Director of Nursing (DON), Resident 208's Electronic Health Record (EHR) dated January 2024 to March 2024 was reviewed. DON stated there was no documentation that Resident 208's MD was notified on 2/16/24. DON stated MD should have been informed, Due to the possibilities with complications that the resident [Resident 208] may have.
2. During a concurrent interview and record review on 3/19/24 at 11:54 a.m. with Treatment Nurse (TN), Resident 208's Care Plans (CP) were reviewed. The CP indicated the following:
A. On 11/29/23 Resident 208 was noted to have acquired at the facility a pressure wound (an injury that breaks down the skin and underlying tissue) stage 4 (involves the muscle and/or bone) to his right thigh.
B. On 1/26/24 Resident 208 was noted to have skin abrasions (minor wounds) to his left and right middle finger.
C. On 3/1/24 Resident 208 was noted to have necrotic (dead) tissue to his right hand, multiple fingers (not specific) and left second toe.
TN stated an IDT was not done for the wound issues on 11/29/23, 1/26/24 and 3/1/24. TN stated an IDT should have been done, To notify [facility] staff and everyone [facility staff] can be aware of what to do.
During an interview on 3/19/24 at 12:20 p.m. with DON, DON stated the facility process for any resident with new wounds is, [New wounds are] a change of condition, MD is notified, document [the wounds in resident chart], [obtain an] MD order to treat wound, [an] IDT meeting [to be done] to make sure facility [staff] is all on the same page and inform the family what is going on.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition Status, dated 5/2017, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . significant change in the resident's physical/emotional/mental condition . need to alter the resident's medical treatment significantly . need to transfer the resident to a hospital/treatment center. a 'significant change' of condition is a major decline or improvement in the resident status that . will not normally resolve itself without intervention by staff .

Based on observation, interview, and record review the facility failed to:
1. Provide preventive measures for pressure injuries (break down of the skin and underlying tissue) for one of two sampled residents (Resident 5).
2. Ensure weekly wound assessments for two of two sampled residents (Resident 5 and Resident 21).
These failures had the potential to result in the development of additional pressure injuries and the inability to determine the healing progress of current wounds.
Findings:
1. During a review of Resident 5's admission Record (AR), dated 3/27/24, the AR indicated Resident 5 diagnoses included quadriplegia (paralysis of all four limbs), cellulitis (skin infection) of buttocks, muscle wasting and atrophy (decrease in size) of both shoulders, generalized muscle weakness, reduced mobility, and a history of Stage 2 pressure injury (partial thickness loss of skin cause by pressure or shearing forces presenting as a shallow ulcer or fluid filled blister) to right buttocks.
During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool)- Section M- Skin Conditions, dated 12/18/23, the MDS indicated, Risk of Pressure Ulcers 1. Yes was checked. The MDS indicated Resident 5 had two Stage 2 pressure ulcers present. The MDS indicated, Skin and Ulcer Treatments. B. Pressure reducing device for bed was checked.
During a concurrent observation and interview on 3/26/24 at 10:26 a.m. with Treatment Nurse (TN) 1 in Resident 5's room, TN 1 changed Resident 5's dressings. Resident 5 had dressings to a left knee abrasion, right second toe pressure injury, right outer ankle pressure injury, right forearm skin tear, and a sacrococcygeal area (tailbone and surrounding skin pressure injury. TN 1 placed non-padded dressings over bony prominence's (areas where the bone is close to the surface of the skin) during the dressing changes. TN 1 stated she was aware that padded dressings were available but were not used for Resident 5. Resident 5's entire tailbone area was discolored. Resident 5 was on a regular mattress. A pillow was on the nightstand, at the end of the bed. TN 1 stated Resident 5 had a regular mattress. TN 1 stated the pillow was sometimes used to lift Resident 5's right ankle off the bed.
During an interview on 3/26/24 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 5 had a regular mattress. LVN 1 stated, I think he [Resident 5] should have a pressure relieving mattress. I'm not sure why he [Resident 5] doesn't have one. LVN 1 stated staff makes sure Resident 5 had a pillow under his right calf. LVN 1 stated Resident 5 did not have any other heel or ankle protective devices.
During an interview on 3/27/24 at 8:10 a.m. with Director of Nursing (DON), DON stated for prevention of pressure ulcers, repositioning and good skin care was important, especially over bony prominences. DON stated the facility does not use Mepilex (a popular brand of foam dressings) dressings. DON stated Resident 5 moves a lot and creates friction on his ankle. DON stated more pressure reducing preventive measures could be implemented for Resident 5.
During an interview on 3/27/24 at 10:41 a.m. with Resident 5, Resident 5 stated, They have never offered me anything. Absolutely in a heartbeat, I would accept an air mattress. Resident 5 stated he was up in his wheelchair for extended lengths of time, sometimes waiting two to three hours to be put back to bed. Resident 5 stated he believed this was the cause of his skin breakdown. Resident 5 stated staff told him he was too hard to deal with and if they put him back to bed, then they would not be able to get him up again. Resident 5 stated a treatment plan was initiated a few months ago to roll him side to side to prevent skin issues but it was not followed through.
During a review of the facility's Policy and Procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, (undated) the P&P indicated, Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive [a type of wound dressing that provides a healing environment], absorptive, etc.), and application of topical agents.
During a review of the facility's P&P titled, Pressure Ulcer Risk Assessment, (undated) the P&P indicated, Additional factors That Indicate Residents at Risk. The following are additional clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk: . 3. Paraplegia (loss of movement in two limbs)/ quadriplegia (loss of movement in four limbs).
2. During a concurrent interview and record review on 3/27/24 at 3:54 p.m. with TN 1, Resident 5's Skin Observation Tool (SOT), dated 2/22/24 was reviewed. The SOT indicated Resident 5 had the following pressure injuries:
a. Right top of the second toe- measuring 1 centimeter (cm) in length and 1 cm in width;
b. Right outer ankle - suspected Deep Tissue Injury (serious pressure injury, progresses rapidly from purplish discoloration to full-thickness skin and soft tissue loss) - measuring 2.5 cm in length, 2.5 cm in width, and 0.2 cm in depth;
c. Tailbone - Unstageable Pressure Injury (full thickness skin loss covered by yellowish or blackish dead skin)- measuring 26 cm in length, 28 cm in width, and 0.2 cm in depth.
The SOT indicated, Seen by Wound specialist [WS] on 2/21/24 with new wound treatment orders verified and carried out. TN 1 stated Resident 5's pressure injuries were first discovered on 2/21/24, documented by the WS in a visit report, and documented on the SOT on 2/22/24 by the treatment nurse.
During a concurrent interview and record review on 3/27/24 at 4:10 p.m. with TN 1, Resident 5's Wound- Weekly Observation Tool (WWOT), dated 2/29/24 was reviewed. The WWOT indicated Resident 5 was seen by WS on 2/28/24. The WWOT indicated Resident 5's pressure injury to the right outer ankle, acquired on 2/21/24, was now a Stage 3 pressure injury (full thickness tissue loss). TN 1 stated wounds should be assessed weekly, and their progress should be documented on the WWOT by the treatment nurse. TN 1 stated this was the last assessment and documentation on the WWOT for Resident 5's pressure injury to the right lateral malleolus. TN 1 stated Resident 5 was up in a wheelchair on 3/13/24 so was not assessed by the WS. TN 1 stated the WS did not see residents on 3/20/24 or 3/27/24, so no wound assessments were done. TN 1 stated she changed Resident 5's dressing on those dates but did not complete a wound assessment or document on the WWOT.
During an interview on 3/27/24 at 4:15 p.m. with TN 1, TN 1 stated wounds should be assessed weekly, and their progress should be documented on the WWOT by the treatment nurse. TN 1 stated Resident 5's pressure wounds were not assessed, and weekly documentation was not done on 3/13/24, 3/20/24, and 3/27/24.
During an interview on 3/28/24 at 8:42 a.m. with Director of Nursing (DON), DON stated, weekly assessments should have been done for all of Resident 5's wounds.
During a concurrent interview and record review on 3/28/24 at 9 a.m. with TN 2, Resident 5's WWOTs, dated 2/29/24, and 3/7/24, were reviewed. TN 2 stated no other WWOTs were found for Resident 5. TN 2 stated wounds should be assessed and documented on weekly. TN 2 stated if the WS was not here, then the treatment nurses were responsible for the weekly documentation.
During an interview on 3/27/24 at 1:51 p.m. with TN 1, TN 1 stated a wound assessment should be done once a week until wound is healed.
During a concurrent interview and record review on 3/27/24 at 1:52 p.m. with TN 1, Resident 21's WWOT, [undated] was reviewed. TN 1 stated Resident 21's wound on sacrum started on 11/4/23 and reopened on 1/29/24. TN 1 stated there were no assessments from 11/4/23 through 1/29/24 to monitor Resident 21's wound.
During an interview on 3/27/24 at 2:23 p.m. with DON, DON stated there should be a wound assessment done once a week.
During a review of the facility's Policy and Procedure (P&P) titled, Wound Management, dated 11/1/17, the P&P indicated, Purpose. To provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers. Policy. A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Procedure. I. Assessment. A. A licensed Nurse will perform a skin assessment upon admission, readmission, weekly and as needed for each resident. III. Documentation . B. Wound documentation will occur at a minimum of weekly until the wound is healed. Documentation will include: i. Location of wound. ii. Length, width, and depth measurements recorded in centimeters. Iii. Direction and length of tunneling and undermining (if applicable). Iv. Appearance of wound base. V. Drainage amount and characteristics including color, consistency, and odor. vi. Appearance of wound edges. vii. Description of the peri-wound condition or evaluation of the skin adjacent to the wound. viii. Presence or absence of new epithelium and wound rim. ix. Presence of pain.
During a review of the Treatment Nurse Job Description (TNJD), [undated] the TNJD indicated, GENERAL DUTIES AND RESPONSIBILIES: CLINICAL . Document skin assessment findings during the weekly assessment on weekly Nurse's Skin Wound Progress Report form .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) 2 and LVN 4 performed skin assessment through direct observations, licensed nurses developed a care plan for the condition of the feet, licensed nurses notified the attending physician regarding the condition of the feet, Certified Nursing Assistant (CNA) 2 reported to the licensed nurses the condition of the feet, CNAs documented their observations of the condition of the feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist provided appropriate medical foot care and treatment for two of two sampled residents (Resident 15 and Resident 36). This failure resulted in pain, discomfort, and neglect (state of not receiving enough care or attention) of Resident 15 and Resident 36's skin and foot care.
Findings:
During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 is an [AGE] year old male, admitted on [DATE] and readmitted on [DATE] after recent hospitalization, with diagnosis including, Chronic Obstructive Pulmonary Disease (COPD- lung disease that causes airflow blockage and breathing-related problems), Type 2 Diabetes Mellitus (DM-characterized by high blood sugar) with Polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and development of foot ulcers), and Hemiplegia (one-sided paralysis)/hemiparesis (loss of strength in the arm, leg, and face on one side of the body) affecting the left dominant side.
During a concurrent observation and interview on 3/25/24 at 9:48 a.m. with Resident 15, in Resident 15's room, Resident 15 was lying in bed, awake and conversant, with the lower portion of the body covered with a blanket. Resident 15 was unable to move the left side of his body, and complained of pain on the left knee.
During a concurrent observation and interview on 3/25/24 at 9:50 a.m. with CNA 1, in Resident 15's room, CNA 1 pulled Resident 15's blankets off to look at the left knee. Resident 15 had foot drop (inability to lift the forefoot due to weakness of the muscles of the foot for movement) on his left foot. CNA 1 removed the socks and exposed both feet. Resident 15 had pain and discomfort when the left foot was touched. The left foot had an appearance of a small wound on the forefoot of the left 3rd medial phalanx (bone of the toe), redness and swelling of the left foot and five toes, dry and scaly skin on the foot, toes, and blackish discoloration in-between the toes. There was yellowish/blackish discoloration on the 4th toe nail; long and yellowish discoloration of the 2nd, 3rd, and 5th toenails; thick, hard, deformed left big toenail with upward growth of the nail and fungus-like appearance: discolored, thickened, and crumbled at the edge. Resident 15's right foot and toes also had dry, scaly, flaky skin, yellowish discoloration and long toenails on the right 2nd, 3rd, and 4th toes, and the right big toenail was thick, yellowish in color, deformed with toenail growth upward, and fungus-like appearance. CNA 1 stated,It looks like the feet have not been cleaned. I will call his nurse.
During an interview on 3/25/24 at 9:52 a.m. with Treatment Nurse (TN) 1and Licensed Vocational Nurse (LVN) 1, TN 1 stated, I have not seen the resident's feet. The cart nurses (referring to the nurses passing medications) do the weekly assessments of the residents. LVN 1 stated, I also have not seen the resident's foot. TN 1 stated, The feet have not been properly showered and cleaned. The right lower extremity has redness and dry skin. The right big toe is thick and has fungus-like appearance. Resident 15 needs podiatry (treatment of disorders of the foot, ankle and lower limb) care, but podiatry is not covered by insurance. Podiatrist comes to the facility every three months.
During an interview on 3/25/24 at 10:11 a.m. with CNA 2, CNA 2 stated she noticed Resident 15 had flaky skin on both lower extremities. CNA 2 stated she noticed the feet were red, but she did not check in between the toes. CNA 2 stated she did not document her observations regarding Resident's feet on the person figure on the shower form, and she did not report her observation to the nurse.
During an interview on 3/25/24 at 10:12 a.m. with Resident 15, Resident 15 stated it was about two to three months ago when his feet were cleansed.
During a concurrent observation and interview on 3/25/24 at 10:13 a.m. with Director of Nursing (DON), in Resident 15's room, DON came to evaluate Resident 15's lower extremities. DON stated, [Resident 15] had bilateral lower extremities redness, scattered. The skin was dry and with scabs on the shin, possible rash, and with unopened wound on the left lateral area of the left lower leg. The left foot has foot drop, with some redness and swelling. The nails were large, hypertrophic (thickening, excessive growth in cells/tissues), joints were getting contracted (hardening of muscles, tissues leading to deformity/rigidity of joints). The left 3rd toe, metatarsal (five long bones in the midfoot) had dry scab. [Resident 15] needs hygiene, definitely needs attention from wound care, and needs podiatry care. DON continued to evaluate Resident 15's right foot and stated, There is redness, swelling, and dryness on the toes. The nails are large on the right big toe, 3rd, 4th, and 5th toenails. There are no wounds observed in between the toes. The left foot is worse than the right foot. DON stated the social worker is responsible for arranging podiatry visits for the residents. DON stated in the past, [Resident 15] had been seen by the podiatrist, but in looking at his feet, it's not recent.
During a concurrent observation and interview on 3/25/24 at 11 a.m. with TN 1, in Resident 15's room, TN 1 measured the thickness and the length of the toenails for both feet. The following were the toenail measurements for both feet:
Left Foot Toenails:
Big toenail: Length 1.4-centimeter (cm) Thickness 1.8 cm.
2nd toenail: Length 0.5 cm Thickness 1 cm
3rd toenail: Length 0.5 cm Thickness 1 cm
4th toenail: Length 1.7 cm Thickness 1 cm
5th toenail: Length 1 cm Thickness 0.7 cm
Right Foot Toenails:
Big toenail: Length 1.3 cm Thickness 2 cm
2nd toenail: Length 0.7 cm Thickness 0.5 cm
3rd toenail: Length 1.9 cm Thickness 0.6 cm
4th toenail: Length 1.9 cm Thickness 1 cm
5th toenail: Length 1 cm Thickness 1 cm
During a concurrent interview and record review on 3/25/24 at 11:21 a.m. with Social Worker (SW), Resident 15's Podiatric Evaluation and Treatment Form (PETF), dated 3/20/24, was reviewed. The PETF indicated, Chief Complaint: pain, edema (fluid retendtion in the body tissues). Skin: Check mark for Atrophy (decrease in size of tissue), Hydration, and Growth. Nails: Right and Left 1,2,3,4,5. Check mark for hypertrophic, yellow, brittle, thick subungual (under the fingernail/toenail) debris. With Pain: Check mark for pain. Edema: +2 (measurement of edema in tissue). Loss of protective sensation: Left. Check mark for: No other significant changes. Check mark for: Nails debrided (removal of infected, damaged or dead tissue) to patient's tolerance only. PETF physician' signature was blank. SW stated Podiatry comes every 45-60 days and they see all the residents. SW stated the podiatrist was last here on 3/20/24 and saw [Resident 15]. SW looked at Resident 15's feet and stated podiatrist did not provide aggressive treatment for Resident 15's feet nor made any recommendations based on the documented podiatrist notes. SW verified the podiatrist did not sign the PETF dated 3/20/24. SW was unable to find other podiatrist PETF documentation on previous visits in the chart.
During a review of Resident 15's Shower Schedule, dated 3/5/24, 3/12/24, 3/19/24, and 3/22/24. the shower schedule indicated, Resident 15 is scheduled every Tuesdays and Fridays.
During a concurrent interview and record review on 3/25/24 at 2:18 p.m. with TN 1, Resident 15's Skin Monitoring: Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), dated 3/5/24, 3/19/24, and 3/22/24, were reviewed. The CCNASRF indicated, On 3/5/24, Resident 15 had completed shower and needed his toenails cut. No visual observation was documented on the person figure on the shower review form. On 3/19/22, [Resident 15] refused to shower. CNA 2 documented Resident 15 needed his toenails cut. No documentation of CNA 2's skin observation on the person figure of the shower review form. On 3/22/24, Resident 15 had full shower, but refused to have lotion applied on the legs due to pain. No documentation of CNA 2's skin observation on the person figure of the shower review form. TN 1 verified the findings and stated the CNAs must document their skin observation on the shower form.
During a concurrent interview and record review on 3/25/24 at 2:30 p.m. with TN 1, Resident 15's Care Plan, dated 2/29/24 to 3/25/24, were reviewed. TN 1 was unable to find care plans for skin integrity, and problems with feet and toenails, and stated there were no care plans written.
During a concurrent interview and record review on 3/25/24 at 2:40 p.m. with TN1 , Resident 15's Weekly Assessments, dated 1/10/24 to 3/22/24, were reviewed. The weekly assessments indicated the following:
1/10/24 Licensed Vocational Nurse (LVN) 2 documented toenails clean, no foot problem. No skin assessment performed.
1/16/24 LVN 2 documented toenails clean, no foot problem. No skin assessment performed.
1/22/24 LVN 2 documented no foot problem. No skin assessment performed.
2/4/24 LVN 3 documented no foot problem, no skin issue, toenails clean.
2/16/22 LVN 4 documented left lower leg front, no skin issues, toenails clean, no skin issues.
2/22/24 LVN 2 documented left lower leg no skin issues, fingernails/toenails clean, no foot problem.
3/10/24 LVN 2 documented left lower leg no skin issue, fingernails/toenails clean, foot problem, none.
3/16/24 LVN 4 documented fingernails/toenails clean, foot problems none, weekly assessment not completed.
3/22/24 LVN 2 documented foot problem none, fingernails/toenails clean.
TN verified the above findings and stated the documentations were copied and pasted.
During a concurrent observation, interview, and record review on 3/26/24 at 2:30 p.m. with Physician 2 and LVN 1, in Resident 15's room, Physician 2 examined Resident 15's feet. Physician 2 stated Resident 15 needs to be seen by another Podiatrist. Physician 2 verified Resident 15 has left foot edema and needs proper foot care. LVN 1 verified Resident 15 was on aspirin (medication with blood thinning properties). Physician 2 spoke with LVN 1 and verbally ordered to stop aspirin for two weeks due to presence of petechiae (pinpoint, round spots that form on the skin) on both lower extremities. A review of Physician's Progress Notes, dated 3/26/24, indicated Physician 2 did not document his evaluation of Resident 15's feet.
During an interview on 3/27/24 at 2:59 p.m. with LVN 2, LVN 2 stated she reviews the Treatment Assessment Record (TAR) if there is any order for skin and wound issues, and if there is none, she documents no skin issues on her weekly assessment.
During an interview on 3/27/24 at 4:32 p.m. with LVN 4, LVN 4 stated the weekly assessment is done whenever he passes his medications. The certified nursing assistants look at the residents' bodies when they give showers, and they notify the nurses of their observations. LVN 4 stated that's how he records his weekly assessment. LVN 4 stated, It is impossible to do head-to toe assessments for all residents. I just copy and paste. They are the same findings.
During a review on 3/27/24 at 10 a.m. with Minimum Data Set (MDS-resident assessment tool) Coordinator (MDSC) 1, Resident 15's Nursing Progress Notes, dated 3/1/24-3/22/24, were reviewed. MDSC 1 was unable to find documentation the attending physician was notified of Resident 15's skin and feet condition: red rash to bilateral lower extremities, edema, dry, flaky skin, yellowish discoloration, thick, hard, upward growth of nails on the left and right big toes, and unopened wound to the 3rd phalanx of the left foot, scabs on both shins, and unopened wound on the left lateral aspect of the lower extremity. MDSC 1 stated the only physician notification documented regarding Resident 15's skin and foot condition was on 3/25/24 at 4 p.m.
During a review of Resident 36's Order Summary Report (OSR) [undated}, the OSR indicated, Resident 36 was admitted on [DATE].
During an interview on 3/25/24 at 10:39 a.m. with TN 1, TN 1 stated she had put in a progress note regarding Resident 36 needing podiatry care and a physician order was initiated but Resident 36 has not received any podiatry care.
During a review of Nurses Notes (NN) dated 12/26/23 at 10 a.m., the NN indicated, Assessment and recommendation for podiatry consultation for resident [36], focusing on the concern of thickened toe nails. This condition is causing discomfort, unable to provide regular nail care.
During a review of Order Details (OD) dated 12/28/23, the OD indicated, Podiatry Care every 60-61 days as needed.
During a concurrent observation and interview on 3/25/24 at 10:50 a.m. with DON, TN 1 and Resident 36, in Resident 36's Room, Resident was lying in his bed, awake and alert, with a blanket covering his feet. TN 1 exposed Resident 36's feet, and DON and TN 1 examined the feet of Resident 36. DON stated Resident 36's has a hypertrophied nail on right big toe growing upward, third toe nail has black on it and looks like dried blood. DON stated, left foot all toes have long nails, and both feet are dry and flaky. TN 1 measured the length of the toenails and stated the large toe is approximately 2 cm in thickness and measures in length 1.7 cm from the skin. DON stated Resident 36 is in need of podiatry care and these needs have not been met. Resident 36 stated his feet and toes had been hurting him.
During a concurrent interview and record review on 3/25/24 at 11:22 a.m. with DON, Resident 36's Podiatric Evaluation and Treatment (PET) dated 9/8/23 was reviewed. DON stated Resident 36 last podiatry treatment had been completed on 9/8/23.
During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, dated 11/1/17, the P&P indicated, XVlll. Report any changes in the color of the skin around the nail or nail bed to the attending physician. XlX. Document procedure in the resident's medical record and update resident's care plan as needed.
During a review of the facility's P&P titled, Showering a Resident, dated 11/1/17, the P&P indicated, XVl. Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. XVll. Update the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a fall risk for assessment two of three sampled residents (Resident 209 and Resident 55). These failures had the potential for Resident 209 and Resident 55 to have unmet care needs and potential for injury.
Findings:
During a review of Resident 209's admission Record, (AR), the AR indicated, Resident 209 was admitted on [DATE], with diagnoses including lack of coordination, muscle wasting, reduced mobility, and need for assistance with personal care.
During a concurrent interview and record review on 3/19/24 at 3:41 p.m. with the Director of Nursing (DON), Resident 209 and Resident 55's medical records were reviewed. DON stated a fall risk assessment should be completed on admission, quarterly, and after a fall. DON reviewed Resident 209's medical record. DON confirmed Resident 209 did not have a fall risk assessment on admission. DON stated a fall risk assessment should have been completed for Resident 209. DON reviewed Resident 55's medical record. DON stated Resident 55 had a fall on 3/12/24. DON stated Resident 55 last fall risk assessment was completed on 10/5/23 (no quarterly fall risk assessment and no fall risk assessment after fall on 3/12/24).
During a review of the facility's policy and procedure (P&P) titled Assessment and Management of Residents Falls, undated, the P&P indicated, It is the policy . to prevent falls among resident as humanly possible and to provide interventions that may address resident's specific risks and causes of residents falls . 1. As part of the initial assessment, the attending physician will help identify individuals with history of falls and risk factors for subsequent falling . 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk . Cause Identification 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling.

Based on interview and record review, the facility failed to ensure five of five sampled residents (Resident 15, Resident 19, Resident 41, Resident 55, and Resident 56) were assessed to determine the level of risk for bed entrapment (an event in which an individual is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed frame) prior to the application of bedrails. This failure places residents at risk for harm when bed entrapment risk assessment has not been completed.
Findings:
During a concurrent observation and interview on 3/27/24 at 11 a.m. with Maintenance Supervisor (MS), in Resident 15, Resident 19, Resident 41, Resident 55, and Resident 56's room, all five residents's beds had quarter siderails up on each side of their beds. MS stated we just discussed bed entrapment two weeks ago with the Administrator-in training (AIT). MS stated, I do not have a log specific for the siderails and I do not have a record of bed rail measurements. I am aware of the bed entrapment requirements from previous employment, but we do not have that implemented here yet.
During an interview and record review on 3/27/24 at 11:16 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC) 1 Resident 55's bed entrapment risk assessment was reviewed. MDSC 1 stated the facility has not started assessing residents for bed entrapment MDSC 1 stated, It was only two weeks ago when we had the discussion about the risk of bed entrapment, and nothing has been implemented yet. MDSC 1 was unable to provide documentation of Resident 55's bed entrapment risk assessment.
During a concurrent interview and record review on 3/27/24 at 11:20 a.m. with MDSC 1, in Resident 56's room, MDSC 1 was unable to provide documentation of Resident 56's bed entrapment risk assessment.
During a concurrent interview and record review on 3/27/24 at 11:25 a.m. with MDSC 1, MDSC 1 was unable to provide documentation of Resident 15's bed entrapment risk assessment.
During a concurrent interview and record review on 3/27/24 at 11:30 p.m. with MDSC 1, MDSC 1 was unable to provide documentation of Resident 19's bed entrapment risk assessment.
During a concurrent interview and record review on 3/27/24 at 11:35 p.m. with MDSC 1, MDSC 1 was unable to provide documentation of Resident 41's bed entrapment risk assessment.
During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated 11/1/17, the P&P indicated, 1. If bed rails are to be used the assessment form-Bed Rail Entrapment Risk Assessment will be completed by a licensed nurse: A. Before installing a bed rail the facility will: i. Assess the resident for risk of entrapment from bed rails and ii. Ensure the bed's dimensions are appropriate for the resident's size and weight.

Based on interview and record review, the facility failed to ensure staff competencies for five of five sampled Licensed Nursing Staff (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were evaluated and completed. This failure had the potential to result in harm to residents.
Findings:
During an interview on 3/27/24 at 3:43 p.m. with TN 1, TN 1 stated she took a three-day class and then a test to become a Certified Wound Nurse. TN 1 stated she did not receive on-the-job training, even for the computerized medical record, and had to figure it out for herself.
During an interview on 3/28/24 at 9:24 a.m. with Director of Nursing (DON), DON stated there used to be a competency checklist for staff, but he was updating the form and the competency checklist was not available for use. DON stated he reviewed nurses' resumes for level of experience, but no competency assessments were currently being done.
During a concurrent interview and record review on 3/28/24 at 1:43 p.m. with Director of Staff Development (DSD), Employee Educational Records (EER) were reviewed for RN 1, RN 2, RN 3, LVN 4, and LVN 6. The EERs indicated there were no skills competency assessments for any of the licensed employees. DSD stated she has no competency skills assessment documentation on any of the Licensed Nurses.
During an interview on 3/28/24 at 4:24 p.m. with the Administrator- in-Training (AIT), AIT stated no performance evaluations had been done on current nursing staff.
During a review of the facility's Policy and Procedure (P&P) titled, On-the-Job Training, dated 2008), the P&P indicated, On-the-job training programs will be conducted when necessary to assist employees in performing their assigned tasks. 1. On-the-job training is provided to train each employee in his/her respective job assignment and our methods of performing such tasks. 3. On-the-job training begins on the first day of employment and is completed when the department director is satisfied that the employee can perform his/her assigned duties, within the time frame allotted for each particular function, without any further supervision. 7. Training records will be filed in the employee's personnel file or may be maintained by the department supervisor.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.
Findings:
During a concurrent interview and record review on 3/28/24 at 10:26 a.m. with Director of Nursing (DON), the nursing staffing schedule dated October 2023, November 2023, December 2023 were reviewed. The nursing staffing scheduled indicated, In October 10/1/23, 10/2/23, 10/7/23, 10/8/23, 10/13/23, 10/14/23, 10/19/23, 10/20/23, 10/25/23, 10/26/23, 10/31/23, 11/1/23, 11/6/23, 11/12/23, 11/18/23, 11/19/23, 11/24/23, 11/25/23, 11/30/23, 12/1/23, 12/6/23, 12/7/23, 12/12/23, 12/13/23, 12/18/23, 12/19/23, 12/24/23, 12/25/23, 12/30/23, 12/31/23 there was no Registered Nurse (RN) on duty on above dates. DON stated there was no RN working on the floor 8 hours a day on above dates.
During a review of the facility's policy and procedure (P&P) titled, Nursing Department-Staffing, Scheduling & Postings, dated 2006, the P&P indicated, To ensure an adequate number of nursing personnel are available to meet resident need.B. If the Facility is licensed for 60 to 99 beds, it will have the following: i. At least one Registered Nurse. in the Facility at all times, day and night, in addition to the Director of Nursing Services (DON).

Based on observation, interview, and record review, the facility failed to ensure safe administration of medication for one of 66 sampled residents (Resident 8) when medications were found at Resident 8's bedside table. These failures had the potential for medications to be administered incorrectly and unsafely.
Findings:
During a review of Resident 8's Order Summary Report (OSR), dated 3/26/24, the OSR indicated, ProAir HFA inhalation Aerosol Solution 108 (90 microgram per actuation (MCG/ACT) (Albuterol Sulfate--Medication used to prevent and treat breathing and shortness of breath) 2 puffs inhale orally every 6 hours for Chronic Obstructive Pulmonary Disease (COPD-lung disease caused by airflow blockage that can cause difficulty breathing).
During an observation on 3/25/24 at 6:30 a.m. in Resident 8's room, an albuterol inhaler was on the bedside table.
During a concurrent observation and interview on 3/25/24 at 6:34 a.m. with Licensed Vocational Nurse (LVN) 7 in Resident 8's room, Resident 8 had an albuterol inhaler on the bedside table. LVN 7 stated, That should not be on the table.
During a concurrent observation and interview on 3/25/24 at 6:38 a.m. with LVN 8 in Resident 8's room, the albuterol inhaler was on the bedside table. LVN 8 stated, I forgot this inhaler here accidentally.
During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, [undated], the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dietary staff was assigned to conduct assessment of food preferences for one of one sampled resident (Resident 56). This failure had the potential to result in unplanned weight loss.
Findings:
During an interview on 3/26/24 at 9:05 a.m. with Resident 56, Resident 56 stated he did not like the food served at the facility. Resident 56 stated no one has come to talk to him about his food preferences.
During a concurrent interview and record review on 3/27/24 at 9:54 a.m. with Dietary Supervisor (DS) and Certified Dietary Manager (CDM), Resident 56's dietary food card was reviewed. The dietary food card indicated, Resident 56 disliked fish. DS stated he was responsible for asking residents their food likes and dislikes, but he had not seen Resident 56 since he talked to the resident during his admission to the facility on [DATE]. CDM stated, Resident 56's food preference needs to be updated.
During a review of the facility's policy and procedure (P&P) titled, Food Preferences, dated 2023, the P&P indicated, Food preferences will be obtained as soon as possible through the initial resident screening .Updating of food preferences will be done as the resident's needs change and/or during the quarterly review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a pureed diet (a texture-modified diet useful for people who have difficulty chewing and swallowing foods and liquids) was served according to the physician's order for one of 66 sampled residents (Resident 8). This failure had the potential to adversely affect the resident's health.
Findings:
During a review of Resident 8's admission Record (AR) dated 3/28/24, the AR indicated, Resident 8 is a [AGE] year-old female, admitted on [DATE], with diagnosis of cerebral infarction (lack of adequate blood flow to brain), hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness), and dysphagia (difficulty in swallowing).
During a review of Resident 8's Diet Card (DC) [undated], the DC indicated, Resident 8 is on a Regular, Puree, Nectar Thick Liquids.
During a review of Resident 8's Order Summary Report (OSR) dated 3/25/24, The OSR indicated, Regular Diet: Pureed texture, Nectar consistency, large portion.
During a concurrent observation and interview on 3/25/24 at 7:36 a.m. with Certified Nursing Assistant (CNA) 5 and Certified Dietary Manager (CDM), in the dining room, Resident 8 was observed being fed a mechanical soft diet by CNA 5. CNA 5 stated she had thought Resident 8's diet had changed but did not look at Resident 8's diet card. CDM stated they gave the wrong diet to Resident 8.
During a review of the facility's policy and procedure (P&P) titled, Diet Orders (DO) dated 2023, the DO indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department.

Based on observation, interview, and record review, the facility failed to:
1. Ensure the kitchen was maintained in a sanitary manner for 71 of 71 sampled residents.
2. Ensure food was properly stored and labeled for 71 and 71 sampled residents.
3. Ensure employees followed dress code policy for two of two sampled staff (Dietary Supervisor (DS) and [NAME] 2 (CK) 2).
4. Ensure food was served in a sanitary manner for one of one sampled resident (Resident 61).
These failures had the potential for the spread of foodborne illnesses throughout the facility.
Findings:
1. During a concurrent observation and interview on 3/25/24 at 6:10 a.m. with CK 1 in the kitchen, a tall dirty ladder was leaning against a rack of clean plastic pitchers and storage bins on the right wall near the entrance, paint spatters were on the floor, and scaffolding containing paint supplies were at the end of the kitchen spanning over two freezers. CK 1 stated they were repairing and painting the ceiling in the kitchen over the past weekend.
During an interview on 3/25/23 at 6:45 a.m. with Certified Dietary Manager (CDM), CDM stated after the maintenance department finished painting, they should have removed the latter and scaffolding.
During an interview on 3/26/24 at 2:23 p.m. with Maintenance Supervisor (MS), MS stated he started the repair and painting of the kitchen ceiling on Friday evening after dietary staff had left for the day and finished at 4:30 a.m. on Monday morning (3/25/24). MS stated he did not have assistance to remove the scaffolding at that time and thought he could do it later. MS stated the expectation is to have everything put away after a job is completed. MS stated, I know the kitchen has to be cleaned.
During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order . 8. The Maintenance Department will assist Food & Nutrition Services as necessary in maintaining equipment and in doing janitorial duties which the Food & Nutrition Services employee cannot do and maintain maintenance records on all equipment.
2. During a concurrent observation and interview on 3/25/24 at 6:15 a.m. with CK 1 in the kitchen, the contents of two freezers located to the right of the stove were noted to have cardboard boxes lined with plastic bags containing pepperoni, sausage patties, thin crust pizza dough and rolls were unsealed and open, exposing food to the environment. CK 1 stated the bags should be sealed.
During a concurrent observation and interview on 3/25/24 at 6:30 a.m. with CDM in the kitchen were two freezers. One freezer contained several cardboard boxes of French fries and potato patties in plastic bags. The plastic bags were open, exposing the food to the environment. Three of the boxes had no received or opened dates. The second freezer contained corn with a ripped bag. CDM verified the findings and stated the food should have been wrapped and should have received and open dates.
During a concurrent observation and interview on 3/25/24 at 6:40 a.m. with CDM in the kitchen, the walk-in refrigerator there was one container of prune juice with no open date.
During a concurrent observation and interview on 3/25/24 at 6:50 a.m. with CDM in the dry storage room, food thickener, lasagna noodles, and croutons were in an unsealed bag. CDM stated the foods should not be stored like that.
During a review of the facility's P&P titled, Labeling and Dating of Food, dated 2023, the P&P indicated, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines within this section.
3. During a concurrent observation and interview on 3/26/24 at 12:16 p.m. with DS and CDM in the kitchen, DS and CK 2 had facial hair that was not covered. DS stated he only covers his facial hair when it gets to a certain length. CDM stated it is policy that all men with facial hair wear a mask or beard cover, no matter the length of the facial hair.
During a review of the facility's P&P titled, Dress Code, dated 2023, the P&P indicated, Proper Dress . 8. If applicable, beards and mustaches (any facial hair) must wear beard restraint.
4. During a concurrent observation and interview on 3/26/24 at 12:03 p.m. with DS and CDM in the kitchen, DS was removing an already plated portion of turkey breast for Patient 61 and returning it to the tray serving line because it was not the right portion size. DS stated, I shouldn't have done that. I got nervous. CDM stated, I had told him not to do that.
During an interview on 3/26/24 at 12:12 p.m. with Registered Dietitian (RD), RD stated it was not appropriate to return food to the tray serving line after it had been plated for a resident.
A policy and procedure was requested but none was provided.

During a concurrent observation and interview on 3/25/23 at 2:30 p.m. with Physician 2 and Licensed Vocational Nurse (LVN) 1, in Resident 15's room, Physician 2 entered Resident 15's room with his cup of coffee and placed it on the bedside table. Physician 2 did not perform hand hygiene prior to putting on a pair of gloves. Physician 2 examined Resident 15's lower extremities and feet with gloves on. After touching Resident 15's lower extremities and feet, Physician 2 removed his gloves. Without performing hand hygiene, Physician 2 picked up his cup of coffee, exited Resident 15's room, and proceeded to the Director of Nursing (DON)'S Office. LVN 1 verified the findings and stated [Physician 2] should have washed his hands.
2. During a concurrent observation and interview on 3/27/24 at 4:30 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 carried a trash bag with her bare hands outside the building and disposed of the trash into the white trash bin located just outside the laundry dirty sorting area. CNA 4 returned inside the facility and entered Resident 3's room. CNA 4 did not perform hand hygiene after disposing the trash and before entering Resident 3's room. CNA 4 stated, I did not wash my hands.
During a concurrent observation and interview on 3/28/24 at 10:45 a.m. with Laundry Aide (LA) in the dirty section of the laundry room, LA was sorting soiled linens and clothing with mask, apron, and gloves on. After sorting, LA removed the gloves she used for sorting dirty laundry and proceeded to the clean area of the laundry room without performing hand hygiene.
During a concurrent observation and interview on 3/28/24 at 11:15 a.m. in the
Station 2 Hallway, the Housekeeper (HSK) 1 was carrying two trash bags with bare hands and threw them into the white trash bins near the laundry. HSK 1 entered the building, and without performing hand hygiene, put on a new pair of gloves she got from the housekeeping cart, and started sweeping the floor. HSK 1 stated, I did not wash my hands. I was rushing because I have to go lunch.
During a review of the facility's policy and procedure (P&P) titled, Handwashing /Hand Hygiene, [undated], the P&P indicated, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with patients . i. After contact with resident's intact skin . m. After removing gloves .
During a concurrent observation and interview on 3/27/24 at 4:03 p.m. with Infection Preventionist (IP), outside Resident 27's room. The following were observed:
- A Contact Precaution signage was posted outside the door of Resident 27's room. - Resident 27's room was wide open and there was no trash can in the room by the exit door.
- A three- tiered isolation cart outside the room contained the following:
1st drawer: gloves: medium/large
2nd drawer: plastic gowns
3rd drawer: larger gowns, plastic
-The isolation cart did not have masks, goggles, face shields, and did not have hand sanitizer.
- There was no hand sanitizer mounted outside the room.
IP stated Resident 27 has Methicillin Resistant Staphylococcus Aureus on the lateral aspect of the right foot discovered on 3/21/24. IP stated, they do not put trash cans in the room; they only have plastic bags. The staff put the trash inside the plastic bags, and they take them out and dispose of them in the white regular trash bins. IP stated, All infectious wastes go in the white trash bins. IP also stated, she stocks the isolation cart based on the type of transmission-based precaution. IP stated, I should fully stock the Isolation cart with all the Personal Protective Equipment required.
During a review of the facility's P&P titled, Resident Isolation-Initiating Transmission Based Precautions, dated 11/1/17, the P&P indicated, V. When transmission-based precautions are implemented, the Infection Control Coordinator (or designee): A. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need .C. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, is placed in or near the resident's room.
During a concurrent observation and interview on 3/28/24 at 10:53 a.m. with LA in the clean section of the laundry room, there were comforters and residents' clothes inside plastic bags, piled on top of each other, over pillows and blankets, and some on the floor. LA stated the clothing were residents and some donated clothes that have already been washed. Also noted was a pile of washed unfolded linens on one side of the counter, with some of the linen clothing hanging down and touching the floor.
During a concurrent observation and interview on 3/28/24 at 11 a.m. with LA in the laundry washing machine area, across the room is the Eye Wash Station. There were two eyewash solutions mounted on the wall. The outside of the eyewash solution bottles looked worn out, with grayish black debris. The two eyewash solutions labeled Physician Care Purified water 98.3 %, Ophthalmic (pertaining to the eye) Solution Eyewash had expiration date 11/20/20. LA stated, It's expired. No one has checked the eyewash station. In case of emergency, we are supposed to drop them into our eyes to wash our eyes.
Facility policy and procedure related to expired medications or biologicals was requested, and none was provided.
Facility policy and procedure on eye wash was requested, and none was provided.
During a review of the facility's P&P titled Infection Prevention and Control Program, dated 12/1/21, the P&P indicated, Risk-Exposure Categories: i. The Infection Control Committee (ICC) advises the Administrator about working conditions and specific tasks that Facility Staff are expected to encounter that may pose an infection risk. ii. The administrator ensures that appropriate Facility Staff perform infection control-related tasks, including a. Evaluating the workplace .Monitoring the effectiveness of work practices and protective equipment .
3. During an interview on 3/28/24 at 11:05 a.m. with IP, IP stated the facility conducts infection control surveillance activities on the following:
Hand hygiene all staff: use of hand sanitizers.
Housekeeping disinfection on frequently touched points.
No staff is walking in the hallways with gloves.
Disinfection of beds after resident discharge.
During a concurrent interview and record review on 3/28/24 at 11:10 a.m. with IP, Hand hygiene surveillance/monitoring was reviewed. IP stated she did not have a record of the hand hygiene monitoring. IP stated, It's all visual. I just watch the staff perform hand hygiene. IP had no hand hygiene indicators for surveillance, and was unable to provide data collected on hand hygiene, no tracking and trending of surveillance activities, and no overall data analysis of any of the surveillance activities mentioned above.
During a review of the facility's P&P titled, Surveillance for Infections, dated 7/2016, the P&P indicated, Gathering Surveillance Data: 1. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. Data Collection and Recording: Daily-record detailed information about the resident and infection on an individual infection control report. Monthly-summarize data for each nursing unit by site and by pathogen. Monthly/Quarterly-Identify predominant pathogens or sites of infection among residents in the facility or particular units by recording them month by month and observing trends. Compare incidences of current infections to previous data to identify trends and patterns. Compare subsequent rates to the average rate to identify possible increases in infection rates.
4. During an interview on 3/28/24 at 11:20 a.m. with IP, IP stated the Infection Control Committee comprised of TN 1, Director of Staff Development (DSD), and IP. IP stated DON sometimes attends the meeting. The meetings are conducted casually on Fridays. IP was unable to provide meeting minutes for their weekly infection control committee meetings.
During a review of the facility's P&P titled, Infection Prevention and Control Committee, dated 2016, the P&P indicated, Duties of the Committee: 15. Maintain a written account of meetings conducted and action taken by the committee (minutes of meeting) .19. Provide the Quality Assurance and Process Improvement (QAPI- data driven and proactive approach to quality improvement) Committee with a copy of all Infection Prevention and Control Committee meetings held .Composition of the Committee: Administrator, Director of Nursing, Medical Director, Infection Preventionist, Dietitian/Food Services Director, Environmental Services Director/Supervisor, Maintenance Director/Supervisor, Laundry Director, Others as appropriate.
Based on observation, interview, and record review, the facility failed to:
1. Ensure infection control practices were implemented for 4 of 4 sampled residents (Resident 27, Resident 5, Resident 48, and Resident 15) in accordance with nationally recognized infection control and prevention guidelines. This failure had the potential to transmit infectious diseases.
2. Ensure staff implemented infection control practices for handling trash, transmission-based precautions, and laundry services for 71 of 71 residents residing in the facility. This failure had the potential to transmit infectious diseases or parasite infestations throughout the facility.
3. Conduct infection prevention surveillance activities (collection and analysis of data) on hand hygiene effectively. This failure resulted in the facility's inability to have measurable data to improve resident health outcomes, and to identify, address, and correct departures from nationally recognized infection control practices.
4. Ensure the facility has an effective Infection Control Program for 71 of 71 residents in the facility. This failure had the potential to result in unsafe and unsanitary working environment, which could lead to development and transmission of infectious diseases.
Findings:
1. During an observation on 3/25/24 at 6:51 a.m., outside Resident 27's room, a sign indicating Contact Isolation was taped outside of door along with a three-drawer plastic bin with PPE (Personal Protective Equipment - gown, gloves, mask, and protective eyewear).
During a review of Resident 27's Order Summary Report (OSR) dated 3/28/24, the OSR indicated, Contact Isolation due to MRSA (methicillin -resistant Staphylococcus aureus - infection difficult to treat because of resistance to some antibiotics) in wound on foot. one time only until 4/04/24.
During an observation on 3/28/24 at 2:40 p.m. in Resident 27's room, Treatment Nurse (TN) 2 without wearing a gown began removing Resident 27's dressing on right foot.
During an interview on 3/28/24 2:50 p.m. with TN 2, TN 2 stated, OMG (Oh My God), I am so sorry. TN 2 stated he should have been wearing a gown before entering and providing care to Resident 27.
During a concurrent observation and interview on 3/26/24 at 10:31 a.m. with TN 1, TN 1 was changing a dressing to Resident 5's sacrum. Resident 5 had smears of bowel movement in the buttock area. TN 1 removed the dirty dressing and cleansed the sacrum, including some of the buttock area with wound cleanser. TN 1 did not do hand hygiene after she removed the dirty dressing and cleansed the area. TN 1 placed a clean dressing on Resident 5's right sacrum with dirty gloves. TN 1 stated she should have done hand hygiene and put on clean gloves prior to the clean dressing.
During a concurrent observation and interview on 3/25/23 at 7:45 a.m. with Resident 48 in Resident 48's room, Resident 48 was having breakfast and his ostomy's adhesive was open. There was a bowel movement leakage on Resident 48's stomach and onto his gown. Resident 48 stated it always leaks from adhesive area.
During an interview on 3/25/24 at 7:50 a.m. with TN 1, TN 1 stated Resident 48 has skin irritation and it's hard for us to keep the ostomy adhesive in place. TN 1 stated, most of the time the ostomy adhesive comes off. TN 1 stated it is not sanitary for him to eat in this condition because the stool is leaking, and patient has his breakfast tray.
During a review of the facility's policy and procedure (P&P) titled, Colostomy and Ileostomy Care-General, dated 2017, the P&P indicated, To maintain resident hygiene, control odor, prevent skin irritation or breakdown, and provide supportive care to the resident.vii. Center the skin barrier wafer over the stoma, adhesive side down, and press it to the skin.

Based on interview and record review, the facility failed to ensure the Infection Control Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained Influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and Pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi) vaccinations for all current residents in the facility. This failure had the potential for the residents to not have the immunity for certain infectious diseases, which could be detrimental to their health and well-being.
Findings:
During a concurrent interview and record review on 3/28/24 at 11:38 a.m. with IP, the Immunization Report, dated 8/7/23 - 3/31/24, was reviewed. Eleven of 71 current residents were not included on the immunization report. IP was not able to provide influenza vaccination for 11 residents currently residing in the facility. IP was not able to verify receipt or refusal of pneumonia vaccination for 40 of 71 residents. IP confirmed the facility census was 71 and only 60 residents were on the Immunization Report. IP stated she does not have a record or a vaccination log for resident vaccinations.
During a concurrent interview and record review on 3/28/24 at 12:10 p.m. with IP, Residents' Consents for Vaccinations (CV) were reviewed. There were only seven of 71 residents who signed the declination for either influenza vaccine, pneumonia vaccine, or both. IP verified the findings and was unable to provide proof of other residents' declination statements signed.
Facility policy and procedure related to influenza/pneumonia vaccination was requested, and none was provided.
During a review of the Centers for Disease Control (CDC) Guidelines, titled Vaccination Programs: General Best Practice Guidelines for Immunization, dated 7/12/17, the Guidelines indicated, All health-care providers, whether they provide immunizations or not, should incorporate immunization needs assessment into every clinical encounter, strongly recommend needed vaccine(s) and either administer vaccine(s) or refer patients to a provider who can immunize, stay up-to-date on, and educate patients about vaccine recommendations, implement systems to incorporate vaccine assessment into routine clinical care, and understand how to access immunization information systems (i.e., immunization registries).

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained an accurate record of the Employee COVID-19 (a highly contagious respiratory illness caused by coronavirus) Vaccination for 110 of 159 employees. This failure resulted in incomplete employee COVID-19 vaccination record and unaccounted number of employees with or without immunity to the type of infection.
Findings:
During a concurrent interview and record review on 3/28/24 at 11:53 a.m. with IP, Employee COVID-19 Vaccination Records were reviewed. IP stated she did not have a log of the employee COVID-19 vaccinations, not manually or electronically.
IP stated she has a binder where she keeps the employee COVID-19 vaccination cards. IP stated, Not everyone has proof of COVID-19 vaccination. I have some of the vaccination cards. There's a lot of employee movement, coming and going.
During a review of the active Employee Roster on 3/28/24 at 12 PM with IP, the Active Employee Roster (AER) was reviewed. The AER indicated there were 159 active employees employed in the facility.
During a review of the Employee Vaccination Cards Binder (EVCB) on 3/28/24 at 12:05 p.m., there were 49 COVID-19 employee vaccination cards on file.
During an interview on 3/28/24 at 12:10 p.m. with IP, IP was aware only 49 employee vaccination cards were on file out of 159 active employees. IP stated, I requested the cards from the employees verbally, but I did not follow up.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 12/1/21, the P&P indicated, C. Duties and Responsibilities: x. Provides guidelines for, and help monitor the health status of all employees, ensuring that all personnel receive (as necessary) appropriate skin tests, chest x-rays, physical's, etc. prior to and during employment as outlined in the personnel policies, and in accordance with federal and state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the minimum square footage as required by the regulation in 13 of the facility's resident bedrooms. This failure had the potential for insufficient space for residents' mobility, safety, and nursing care.
Findings:
During a concurrent interview and record review on 2/26/23 at 2:40 p.m. with Administrator in Training (AIT), the facility's Client Accommodation Analysis (CAA) dated 3/26/24, and Daily Census (DC) dated 3/24/24 was reviewed. The CAA and DC indicated the following rooms had 3 residents and less than 80 square foot per resident. AIT verified the findings.
room [ROOM NUMBER]- 210 sq. ft.-3 residents
room [ROOM NUMBER]- 225 sq. ft.-3 residents
room [ROOM NUMBER]- 218 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft.-3 residents
room [ROOM NUMBER]- 220 sq. ft- 3 residents
room [ROOM NUMBER]- 220 sq. ft- 3 residents
room [ROOM NUMBER]- 220 sq. ft- 3 residents
The residents had a reasonable amount of privacy. Closets and storage were adequate. Bedside stands were available. There was sufficient space for nursing care and for residents to ambulate and/or use wheelchairs. Toilet facilities were accessible. The health and safety of the residents will not be adversely affected by the room waiver.

Based on interview and record review, the facility failed to ensure five of five Licensed Nurses (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were trained to meet the behavioral health requirements of 29 of 29 sampled residents (Resident 1, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 17, Resident 21, Resident 27, Resident 28, Resident 30, Resident 31, Resident 36, Resident 37, Resident 43, Resident 44, Resident 46, Resident 48, Resident 53, Resident 55, Resident 56, Resident 60, Resident 61, Resident 71, Resident 76, Resident 135, Resident 185, Resident 202, and Resident 204). This failure had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs.
Findings:
During an interview on 3/28/24 at 9:24 a.m. with the Director of Nursing (DON), DON stated no competency assessments were currently being done for any staff on anything.
During a concurrent interview and record review on 3/28/24 at 1:43 p.m. with Director of Staff Development (DSD), Employee Educational Records (EER) were reviewed for RN 1, RN 2, RN 3, LVN 4, and LVN 6. The EER's had no documentation that staff were trained to meet the needs of residents with behavioral health requirements. DSD stated no training was provided to any of the nursing staff specific to psychological or mental disorders of residents in the facility.
During a concurrent interview and record review on 3/28/24 at 5:45 p.m. with the Administrator, the facility's Diagnosis Report (DR), dated 3/28/24 was reviewed. The DR indicated the facility had current residents with the following diagnoses:
Anxiety Disorder- A condition in which a person has excessive worry and feelings of fear, dread, and uneasiness that can be manifested by sweating, irritability, fatigue, poor concentration, rapid heartbeat, trouble breathing, and trouble sleeping. (Resident 12, Resident 13, Resident 14, Resident 15, Resident 21, Resident 27, Resident 30, Resident 31, Resident 37, Resident 43, Resident 44, Resident 46, Resident 55, Resident 56, Resident 60, Resident 61, Resident 76, Resident 135, Resident 185, and Resident 202)
Major Depressive Disorder- A mood disorder causing persistent feelings of sadness leads to physical and emotional problems and difficulty in performing day-to-day activities. (Resident 12, Resident 36, Resident 53, and Resident 60)
Schizophrenia- A disorder involving delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, disorganized thinking and speech, and paranoid thoughts or hearing voices. (Resident 1, Resident 14, Resident 28, Resident 30, Resident 31, Resident 71, and Resident 204)
Psychosis- A condition where person losses contact with reality and may have difficulty recognizing what is real and what is not real. (Resident 11, Resident 17, and Resident 48)
The Administrator stated this list was obtained from medical records and was the current record of patients with psychiatric diagnoses in the facility.
During a review of the Facility Assessment Tool (FAT), dated 3/1/24, the FAT indicated, Common diseases/conditions, physical and cognitive (mental) disabilities that the facility can manage: . Psychiatric/ Mood Disorders, Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post- Traumatic Stress Disorder (a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), Anxiety Disorder, Behavior that Needs Interventions, Behavioral and Psychological Symptoms of Dementia (BPSD). The FAT indicated, 3.4 Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/OR post-traumatic stress disorder, and implementing nonpharmacological interventions.

Based on interview and record review, the facility failed to ensure treatment orders were administered per physician orders for one of three sampled residents (Resident 1). This failure had the potential for worsening of Resident 1's wounds.
Findings:
During a concurrent interview and record review on 1/10/24 at 4:51 p.m. with Director of Nursing (DON), DON reviewed Resident 1 ' s Treatment Administration Record, (TAR) for 11/23 and 12/23, and confirmed the following:
Right Inner Thigh MASD [Moisture-associated skin damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture]: Clean with wound spray, pat dry, apply xeroform gauze [occlusive dressing for use on wounds] and cover with bordered gauze [dressing with adhesive border] everyday shift -Order Date- 11/24/23 0909 [9:09 a.m.] -D/C Date- 12/8/23 1557 [3:57 p.m.]
11/30/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank).
12/1/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank).
12/2/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank).
12/8/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank).
Sacral [is a triangular bone located at the base of the spine] Pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin]: Clean with wound spray, pat dry, apply medihoney [dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds], then apply calcium alginate dressing, apply skin barrier to periwound [the surrounding area of the wound edge] and secure with bordered gauze every day shift -Order Date- 11/24/23 0925 [9:25 a.m. -D/C Date- 12/8/23 1127 [11:27 p.m.]
11/30/23, there was no documentation the Sacral Pressure ulcer treatment was administered (blank).
12/1/23, there was no documentation the Sacral Pressure ulcer treatment was administered (blank).
12/2/23, there was no documentation the Sacral Pressure ulcer treatment was administered (blank).
DON confirmed the findings. DON stated the expectation was to follow the physician order and document.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration-General Guidelines, undated, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders of the attending physician.Topical medications used in treatments are listed on the Treatment Administration Record (TAR). The resident ' s MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication . If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time . the MAR for that dosage administration is initialed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 71 of 71 sampled residents residing at the facility when:
1a. Two of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with multiple (approximately 15 pieces) rodent- (small gnawing mammals) like shiny black granular-size droppings 1/2 - ¼ inch (in - unit of measurement).
1b. A live mouse (small rodents with pointed snout) observed by Certified Nursing Assistant (CNA) 1 in room [ROOM NUMBER] (occupied by Resident 3, Resident 4, and Resident 5), room [ROOM NUMBER] (occupied by Resident 1 and Resident 2), and room [ROOM NUMBER] (occupied by Resident 6, Resident 7, and Resident 8) on 11/7/23, 11/8/23, and 11/9/23.
1c. A live mouse observed by one of 17 sampled residents (Resident 14) on 11/9/23.
2. room [ROOM NUMBER] (empty) had a hole on the floor measured 36 inches by 32 inches (36 X 32 in).
3. room [ROOM NUMBER] (occupied by Resident 9, Resident 10, and Resident 11) had hole on the wall measured 7 inches by 6.5 inches (7 X 6.5 in).
4. Ice machine drainage (approximately 2 inches in diameter) on the floor in the kitchen does not have a drain cover.
These failures resulted in pest entering the facility which placed all 71 residents, staff, and visitors at risk to contract diseases caused by rodents.
Findings:
1a. During a concurrent observation and interview on 11/9/23 at 6:05 a.m. with Licensed Vocational Nurse (LVN) 1, inside room [ROOM NUMBER] (a three-bed room) occupied by Resident 1 and Resident 2, multiple (approximately 15 pieces) rodent-like shiny black granular size droppings measured 1/2 - ¼ inch were observed on the floor inside Resident 1's, and Resident 2's closet. LVN 1 stated, It was mouse droppings.
During a concurrent observation and interview on 11/9/23, at 6:29 a.m. with Housekeeper (HK) 1, inside room [ROOM NUMBER], HK 1 stated the multiple (approximately 15 pieces) rodent-like shiny black granular-size droppings measured 1/2 - ¼ in. observed on the floor inside the Resident 1's, and Resident 2's closet are mouse droppings. HK 1 stated HK 2 told her (HK 1) about the mouse droppings (approximately two weeks ago), and they (HK 1 and HK 2) thought it (mouse droppings) was coming from the other room (room [ROOM NUMBER] - empty room) because room [ROOM NUMBER] was under construction for about a month now since 9/14/23. HK 1 stated room [ROOM NUMBER] was always locked and only the MS had the key because he (MS) was the one working in the construction.
During a concurrent observation and interview on 11/9/23 at 8 a.m. with AIT, in room [ROOM NUMBER] (empty) observed multiple (approximately 12 pieces) rodent-like shiny black granular-size droppings measured 1/2 - ¼ in. on the floor inside room [ROOM NUMBER]'s closet. AIT stated, when any staff saw the rodent droppings on 9/14/23, the pest control was called to start service.
1b. During an interview on 11/9/23 at 6:43 a.m. with CNA 1, CNA 1 stated on 11/7/23, at around 12 midnight while she was sitting outside room [ROOM NUMBER] (occupied by Resident 15, Resident 16, and Resident 17), she saw a live mouse coming out of room [ROOM NUMBER] (occupied by Resident 3, Resident 4, and Resident 5) and ran towards room [ROOM NUMBER] (occupied by Resident 12, Resident 13, and Resident 14). CNA 1 stated on 11/8/23, at around 12 midnight, while CNA 1 was outside room [ROOM NUMBER] (occupied by Resident 6, Resident 7, and Resident 14), she saw a live mouse coming out of room [ROOM NUMBER]. CNA 1 stated on 11/9/23, at 6 a.m. when she was caring for Resident 3, she saw a live mouse coming out of room [ROOM NUMBER]'s bathroom to room [ROOM NUMBER]'s window.
1c. During a concurrent observation and interview on 11/9/23 at 7:10 a.m. with Resident 14, in room [ROOM NUMBER] (occupied by Resident 12, Resident 13, and Resident 14), Resident 14 was lying in bed, awake and was about to start eating breakfast. Resident 14 stated right before breakfast today (11/9/23), she saw one live mouse ran from outside her hallway towards the shower room (located in between room [ROOM NUMBER] and room [ROOM NUMBER]) while pointing outside across her room. Resident 14 stated she did not tell anybody because she thought the nurses knew already.
During a review of Resident 14's Annual Minimum Data Set (MDS-resident screening tool), dated 8/15/23, the MDS Section C - Cognitive patterns indicated, Resident 14 had a BIMS (Brief Interview for Mental Status - level of cognition) score of 14 (intact cognition).
During a concurrent interview and record review on 11/9/23 at 8:15 a.m. with AIT, the facility's Pest Control Service Agreement/Request for Pest Control Service (SA), dated 10/27/23, was reviewed. The SA indicated, Rodent Report, Interior: Kitchen, Inspection in kitchen found possible entry points repair gaps around plumbing and gaps around tiles and gaps around electrical pipes. Set traps to monitor activity. Serviced bait station outside kitchen. AIT stated he requested service from the facility's pest control because of the concerns that were brought up to him by the staff on 9/14/23.
During a concurrent interview and record review on 11/9/23 at 8:20 a.m. with AIT, the facility's Pest Control Service Slip/Invoice (SSI), dated 11/1/23, was reviewed. The SSI indicated, Target Pest: Rodents, description: Follow up at kitchen. No activity at the moment found. AIT stated the pest control service was an ongoing process and anytime there were rodent droppings or live mouse seen inside the facility, the Pest Control was called for service.
2. During a concurrent observation and interview on 11/9/23 at 9 a.m. with Housekeeping/Laundry Supervisor (HLS), in room [ROOM NUMBER], a hole on the floor covered with three plywoods (strong wooden board consisting of sheets of wood glued or cemented together to form a thicker flat sheet) was observed and measured 36 in X 32 in. from the wall to the floor which was going outside the facility. HLS stated room [ROOM NUMBER]'s floor was torn up and created a hole (36 X 32 in).
During an interview on 11/9/23 at 10:36 a.m. with Maintenance Supervisor (MS), MS stated on 9/14/23, he started to work in room [ROOM NUMBER] because the floor was weak (shaky and made squeaky sound when stepped on). MS stated he removed the weak flooring and covered the hole (36 X 32 in) with plywood because he was waiting to purchase the new floor, however, there was no confirmed date when to purchase the new floor. MS stated he should have sealed the gaps underneath the room [ROOM NUMBER]'s door and sealed the gaps underneath the room [ROOM NUMBER]'s shared bathroom to contain the rodents.
3. During a concurrent observation and interview on 11/9/23 at 10 a.m. with HLS, in room [ROOM NUMBER] (occupied by Resident 9, Resident 10, and Resident 11), a hole on the wall located underneath room [ROOM NUMBER]'s window was observed and measured 7 in X 6.5 in. HLS stated the hole was originally for ventilation of the portable air conditioner (AC), but it should be sealed around and not left open with a hole. HLS stated the hole may possibly be an entry point for rodents.
4. During a concurrent observation and interview on 11/9/23 at 7:15 a.m. with Assistant Dietary Supervisor (ADS), in the kitchen, the ice machine drainage on the floor was observed without a drain cover, resulted in an open (exposed) hole (approximately 2 inches in diameter) towards the kitchen. ADS stated, I did not notice that there was no cover on the drain, it (drainage) should be covered and no open hole that was exposed. ADS stated it (open hole) can be an entry point for rodents. ADS stated there should be no entry points for rodents in the kitchen because all resident's food were being prepared, cooked, served, and stored in the kitchen.
During a concurrent interview and record review on 11/9/23 at 11:30 a.m. with PCT, Issued Invoices (receipt of service and not a description of service), dated 6/22/23, 7/6/23, 7/20/23, 8/10/23, 8/17/23, 9/7/23, 9/21/23, 9/22/23, 10/05/23, and 10/19/23 were reviewed. The Issued Invoices indicated, Bill to: Name of facility, Address of facility, Invoice number, Customer number, Customer info, Service type, Date serviced, Service memo, Technician, Service amount, and Total amount. PCT stated, They ' only' issued Invoices and not a detailed description of service provided. PCT stated, on 10/27/23 and 11/1/23 they (PCT) came back to service the facility's kitchen and for follow-up services for rodent activity. PCT stated, they started providing the facility with a description of services provided and not invoices only.
During a concurrent interview and record review on 11/9/23, at 2 p.m. with AIT, the facility's policy and procedure (P&P) titled, Pest Control, dated 8/2008, the P&P indicated, Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 3. Windows are screened at all times. AIT stated, The facility had an on-going pest control service, however, the possible entry points such as holes and gaps for rodents' entry should be sealed and contained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 1) Percutaneous indwelling central catheter (PICC) line (long tube that is inserted through a vein). This failure had the potential for infection.
Findings:
During a review of Resident 1's Nurses Note (NN), dated 10/7/23 at 8:54 p.m. Resident 1 was readmitted back to the facility (10/7/23), with a PICC line on left upper arm related to IV (intravenous) therapy until 10/10/23. The baseline care plans were reviewed and noted no care plan developed for Resident 1's PICC line.
During an interview on 10/20/23 at 12:25 p.m. with Director of Nurses (DON), DON stated Resident 1 was re-admitted on [DATE], with a PICC line to left upper arm. DON reviewed Resident 1's baseline care plans and confirmed no care plan was developed for Resident 1's PICC line. DON stated, There should have been one.
During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 2017, the P&P indicated, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

Based on interview and record review, the facility failed to implement discharge planning for one of three sampled residents (Resident 1) when Resident 1 was discharged home with no medications. This failure resulted in Resident 1 missing to take her medications for two days after being discharged and had the potential to place Resident 1 at risk for adverse health outcomes.
Findings:
During an interview on 9/27/23 at 1:11 p.m. with Resident 1, Resident 1 stated she was discharged home without the following medications:
a) Fluconazole (medication for fungal infections)
b) Gabapentin (medication to treat seizures -involuntary movements and nerve pain)
c) Low dose aspirin (medication to reduce the risk of heart attack)
d) Metoprolol (medication to treat high blood pressure)
Resident 1 stated she was discharged home without medication and was told by the Licensed Vocational Nurse (LVN) 1 to call the pharmacy (a store where medication is dispensed and sold) to get her medications but the pharmacy stated it (medications) will take about three to four days to have the medications delivered to her home. Resident 1 stated she did not take her medications for two days because she had no medication supply to take.
During a review of Resident 1 ' s Order Summary Report (OSR), dated September 2023, the OSR indicated:
a) Diflucan Tablet 200 mg (milligram-units of measurements) (Fluconazole) Give 4 tablet by mouth one time a day related to COCCIDIOIDOMYCOSIS, UNSPECIFIED [Valley Fever-fungal infection)
b) Gabapentin Capsule 100 mg Give 1 capsule orally two times a day related to POLYNEUROPATHY, UNSPECIFIED damaged peripheral (away from the center of the body) nerves
c) Aspirin Tablet Give 81 mg by mouth one time a day for CVA [Cerebral Vascular Accident-an interruption in the flow of blood to cells in the brain] Prophylaxis (action taken to prevent disease)
d) Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 mg Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (high blood pressure) hold for SBP (systolic blood pressure-pressure in arteries when heart beats])<100 (greater than 100) or DBP (diastolic blood pressure-pressure in arteries when the heart rests) <60 (less than 60)
During an interview on 9/27/23 at 3 p.m. with Director of Nursing (DON), DON stated Resident 1 left on Friday (9/8/23). DON stated Resident 1 had orders for Aspirin, Fluconazole, Gabapentin, and Metoprolol. DON stated no medications were sent home with Resident 1 on Friday (day of discharge-9/8/23).
During a review of Resident 1's Care Plan (CP), dated 8/21/23, the CP indicated, Assist in locating resources or services in the community available to support community return.
During an interview on 9/27/23 at 3:19 p.m. with Licensed Vocation Nurse (LVN) 1, LVN 1 stated the pharmacy did not deliver Resident 1's medications on that night (day of discharge, 9/8/23). LVN 1 stated she did not call the pharmacy for the medications of Resident 1. LVN 1 stated she did not notify the doctor about Resident 1 did not have medications on the day of discharge (9/8/23).
During an interview on 9/27/23 at 3:26 p.m. with LVN 2, LVN 2 stated she signed the Discharge Medication Instructions which indicated medications were explained and released to Resident 1 but no medication was given to Resident 1. LVN 2 stated she did not contact the pharmacy or the doctor when Resident 1 was discharged without medication.
During an interview on 9/29/23 at 2:55 p.m. with Pharmacy Technician (PT), PT stated the pharmacy delivered Resident 1 ' s one month supply of medication on 9/1/23. PT stated pharmacy delivered another one month supply on 9/13/23 and should have had medication still available on day of discharge (9/8/23).
During an interview on 10/4/23 at 10:38 a.m. with Social Services Director (SSD), SSD stated Resident 1's discharge was planned and she was not made aware Resident 1 did not have home medications available on day of discharge (9/8/23).
During a review of the facility's document untitled (provided by the DON), dated 10/2/23, the document indicated, Resident [1] ended up leaving the facility with caregiver with all her personal belongings, but no medications.
During a review of the facility ' s policy and procedure (P&P) titled, Discharge Medication, dated December 2016, the P&P indicated, A physician must be contacted for an order to discharge a resident with medications before they will be dispensed. The Charge Nurse shall verify that the medications are labeled consisted with current physician orders including instructions for use. The nurse will reconcile pre-discharge medications with the resident ' s post-discharge medications.
During a review of the facility ' s policy and procedure (P&P) titled, Transfer or Discharge, Preparing a Resident for, dated December 2016, the P&P indicated, Nursing services is responsible for: Preparing the medications to be discharged with the resident (as permitted by law).

Based on observation, interview, and record review, the facility failed to assist one of three sampled resident's (Resident 1) with personal hygiene when Resident 1 had dark debris under her long fingernails. This failure had the potential for Resident 1 to have skin breakdown and spread of infection.
Findings:
During a concurrent observation and interview on 8/30/23 at 3:15 p.m., in Resident 1's room, with Director of Staff Developer (DSD), Resident 1 had dark debris under her long fingernails. DSD stated Resident 1's nails should be trimmed and cleaned which was not done.
During an interview on 8/30/23 at 3:15 p.m. with Resident 1, Resident 1 stated, I didn't know they [fingernails] were long and dirty.
During a review of Resident 1's Care Plan (CP), dated August 2023, the CP indicated, Resident 1 requires extensive assist by one staff for personal hygiene.
During a review of Resident 1's Minimum Data Set (MDS – comprehensive assessment tool), dated August 2023, MDS indicated, BIMS (Brief Interview for Mental Status) score was 13 (score 13-15 means cognitively intact).
During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, dated November 2017, the P&P indicated, Nail care is given to clean and keep nails trimmed. Fingernails are trimmed by Certified Nursing Assistants .

Based on observation, interview and record review, the facility failed to follow infection control practices when:
1. The Activity Assistant (AA) in the dining room area did not performed hand hygiene and changed his gloves for one of 13 sampled residents (Resident 1) after touching the aloe vera wipe used to clean Resident 1's hand and threw the aloe vera wipe in the trash can.
2. All visitors were not screened prior to entering the facility when there was a known Covid-19 outbreak in the facility per recommendation from the local public health department.
These failures had the potential to spread infection to residents, staff, and visitors.
Findings:
1. During a concurrent observation and interview on 8/16/23, at 11:15 a.m. with AA in the dining room, AA was assisting the residents in the dining area to clean their hands before lunch with aloe vera wipes followed by the hand sanitizer. The following residents were in the dining room before lunch:
1. Resident 1
2. Resident 2
3. Resident 3
4. Resident 4
5. Resident 5
6. Resident 6
7. Resident 7
8. Resident 8
9. Resident 9
10. Resident 10
11. Resident 11
12. Resident 12
13. Resident 13
AA was wearing gloves while passing the aloe vera wipes to the residents in the dining room and passing the hand sanitizer. AA picked up the aloe vera wipe used to clean Resident 1's hand and threw away the used aloe vera wipe in the trash can. After AA threw away the aloe vera wipe used by Resident 1, AA proceeded to assist and pass the hand sanitizer to the other residents in the dining room using the same gloves without performing hand hygiene and changing his gloves. AA stated, he should have performed hand hygiene and changed his gloves after touching the used aloe vera wipe from Resident 1 and before proceeding to pass the hand sanitizer to the other residents in the dining room before lunch.
During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, undated, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap. and water for the following situations. Before and after contact with residents. After handling used. contaminated equipment, etc. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
2. During an interview on 8/16/23, at 4:50 p.m. with Infection Preventionist (IP), IP stated, We don't have a log for screening visitors prior to entering the facility. IP stated, the facility was not screening visitors before entering the facility. IP stated, the local public health department recommended to screen visitors due to the current outbreak of Covid-19 in the facility. IP stated, the facility should be screening the visitors before entering the facility and the facility should have a visitor log per recommendation from the local health department.
During a concurrent interview and record review on 8/16/23, at 4:50 p.m. with IP, the local public health department instruction and directives to the facility, undated, indicated, VISITATION: All visitors need to be screened prior to entering the facility. visitors with temperatures above 100.4 degrees F [Fahrenheit - a unit of measurement to measure body temperature] and are showing COVID - 19 symptoms MUST reconsider visitation and come back after symptoms have improved. IP stated the facility should be screening visitors prior to entering the facility.

Based on interview and record review, the facility failed to follow its policy and procedure titled Care Plans, Comprehensive Person-Centered for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 ' s pain to not be managed appropriately, following a change in condition.
Findings:
During a review of Resident 1 ' s Change in Condition Report (CIC), dated 7/4/23, the CIC indicated, [Certified Nursing Assistant] CNA [1] was in [Resident 1 ' s] room when she witnessed resident jump out of bed and threw himself to the floor face first.resident has open wound approximately 4 inches long on his chin.
During an interview on 7/17/23, at 9 a.m., with Director of Nursing (DON), DON stated, he was informed Resident 1 had a fall on 7/4/23, and a later X-ray finding on 7/4/23, indicated, Resident 1 had fractured his mandible (jaw bone).
During a review of Resident 1 ' s Care Plan, dated 7/6/23, there was no care plan noted for pain management following the change in condition after Resident 1 had fractured his mandible on 7/4/23.
During an interview on 7/17/23, at 11:10 a.m., with Minimum Data Set Coordinator (MDSC), MDSC stated, she was the staff member who created the new care plan for Resident 1 after his fall, and there was no care plan for pain management.
During an interview on 8/2/23, at 2:45 p.m., with MDSC, MDSC stated, Yes we should have made a separate care plan for pain management. MDS stated, I added ' PRN Norco ' to the fall risk care plan, after [Resident 1 ' s] fall. MDS stated, That is not enough, it is not measurable.
During a review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, 8. The comprehensive, person-centered care plan will: a Include measurable objectives and timeframes.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' condition change.

Based on interview and record review, the facility failed to ensure physicians' orders were carried out timely for four of ten sampled residents (Resident 4, Resident 9, Resident 11, and Resident 14). These failures had the potential for Resident 4, Resident 9, Resident 11, and Resident 14 to have a delay in care.
Findings:
During a concurrent interview on 7/27/23, at 2:15 p.m., with Social Services Director and Registered Nurse (RN 2), SSD stated, on 6/13/23, she was informed by Director of Business Development (DBD) that Physician 1 and Physician 2's resident would need to transfer to other physicians' care. SSD stated, she called and notified the family and responsible party (RP) and spoke to the residents prior to implementing the order. RN 2 stated, once the notification was made, the order was taken to the nurse and the nurse carried out the order, then the order was taken to the front office for billing purposes, and medical record was notified to place the sticker on hard chart.
During an interview on 7/27/23, at 2:29 p.m., with DBD, DBD stated, around 6/13/23, she was notified Physician 1 and Physician 2's resident would need to be re-assigned to other physicians' care. DBD stated, the facility notified the residents and families first then carried out the orders.
During a concurrent interview and record review, on 7/27/23 at 2:39 p.m., with Director of Nursing (DON), DON reviewed the following:
Resident 4's Progress Note, (PN), dated 6/15/23, the PN indicated Resident 4 was notified of physician change.
Resident 4's Physicians Order, (PO) dated 7/20/23, the PO indicated Resident 4's physician was changed.
Resident 9's PN, dated 6/21/23, the PN indicated Resident 9's RP was notified of physician change.
Resident 9's PO dated 6/28/23, the PO indicated Resident 9's physician was changed.
Resident 11's PN, dated 6/23/23, the PN indicated Resident 11's RP was notified of physician change.
Resident 11's PO dated 6/28/23, the PO indicated Resident 11's physician was changed.
Resident 14's PN, dated 6/26/23, the PN indicated Resident 14's RP was notified of physician change.
Resident 14's PO dated 6/28/23, the PO indicated Resident 14's physician was changed.
DON confirmed the above orders were not carried out timely. DON stated, orders should be carried out within 24hr [hour] if not sooner when it is topics like these. DON reviewed the policy and procedure titled, Physician Orders, revised July 2016, DON stated orders should be carried out Immediately.
During a review of the facility's P&P titled, Physician Orders, revised July 2016, the P&P indicated, 2. Physician orders shall be carried out immediately. 8. Physician orders must be recorded immediately in the resident's chart by the person receiving the order .

Based on interview and record review, the facility failed to protect the residents' rights for eight of 50 sampled residents (Resident 2, Resident 3, Resident 8, Resident 20, Resident 21, Resident 23, Resident 25, and Resident 33). These failures resulted in Resident 2, Resident 3, Resident 8, Resident 20, Resident 21, Resident 23, Resident 25, and Resident 33 not to be fully informed of change in physician, the rights to choose a physician and participate in decisions and care planning.
Findings:
During an interview on 7/18/23, at 11:31 a.m., with Resident 2, Resident 2 stated, the facility offered her choice of two physicians, and she picked one.
During an interview on 7/18/23, at 11:45 a.m., with Resident 8, Resident 8 stated, she changed physicians recently. Resident 8 stated, the reason for the change was new owners.
During an interview on 7/18/23, at 11:57 p.m., with Resident 33, Resident 33 stated, the facility changed her physician. Resident 33 stated, she liked her prior physician.
During an interview on 7/18/23, at 12:10 p.m., with Resident 25, Resident 25 stated, no one has talked to him about changing physicians. Resident 25 stated, the physician just showed up.
During an interview on 7/18/23, at 12:15 p.m., with Resident 23, Resident 23 stated, no one has talked to him about changing physician.
During an interview on 7/18/23, at 12:29 p.m., with Resident 3, Resident 3 stated, the facility told me I had to change doctor. Resident 3 stated, No issues with [Physician 1's] care I saw him regularly.
During an interview on 7/18/23, at 12:18 p.m., Licensed Vocational Nurse (LVN 1), LVN 1 stated, It is the residents' choice to change physicians. LVN 1 stated, If the resident expressed, they would like to change physicians, I will notify Social Services.
During an interview on 7/18/23, at 12:57 p.m., with Registered Nurse (RN 1), RN 1 stated, if a resident is unhappy with their physician, she would notify the Director of Nursing (DON) and Social Services Director (SSD).
During an interview on 7/18/23, at 1:12 p.m., with SSD, SSD stated, she was told due to new ownership they have new contracted doctor. SSD confirmed changes were not done due to complaints or issue from residents.
During an interview on 7/18/23, at 2:22 p.m., with DON, DON stated, the owners have physicians they prefer to work with.
During a review of Resident 20's Physicians Order, (PO) dated 6/7/23, the PO indicated, Resident 20 was sent to an acute care hospital by Physician 2.
During a review of Resident 20's Progress Notes, (PN) dated 6/10/23, the PN indicated, Resident 20 returned to the facility under the care of Physician 4.
During a review of Resident 21's PN, dated 6/4/23, the PN indicated, Resident 21 was sent to acute hospital, by Physician 2.
During a review of Resident 21's PN, dated 6/8/23, Resident 21 returned to the facility under the care of Physician 4.
During concurrent interview and record review, on 7/27/23, at 2:39 p.m., with DON, DON reviewed Resident 20's PO and PN. DON confirmed Physician 2 was Resident 20's physician prior to being sent out to the acute care hospital. DON reviewed Resident 20's medical records (MR) and confirmed there was no documentation the change in physicians was discussed with Resident 20 or responsible party (RP). DON reviewed Resident 21's PN and confirmed Physician 2 was Resident 21's physician prior to being sent to the acute care hospital. DON stated, Physicians are the residents' choice. DON stated, The residents were not given the full story and it was not their choice.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised December 2016, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .p. be informed of, and participate in, his or her care planning and treatment; . s. Choose an attending physician and participate in decision-making regarding his or her care; .

Based on interview and record review, the facility failed to implement a neurological assessment (an assessment to identify if there is an injury to a person's brain, spinal cord or nerve function) for one of three sampled residents (Resident 1) after a fall incident with head injury. This failure had the potential for negative health consequences up to and including death.
Findings:
During a review of Resident 1's admission RECORD (AR), dated 6/15/23, the AR indicated, Resident 1 diagnoses included history of heart failure (a condition where the heart does not pump enough blood), diabetes (a disease that effects blood sugar in the body) and circadian rhythm sleep disorder (a disorder in which the sleep/wake cycle is out of sync with the 24-hour day).
During a review of Resident 1's NURSES' admission RECORD (NAR), dated 5/25/23, the NAR indicated, Resident 1 returned to the facility from the acute hospital after an unwitnessed fall in her room. Resident 1 had a diagnosis of head injury due to the fall incident. Resident 1 had 15 staples to the back of her head placed at the acute hospital. The NAR indicated Resident 1, APPEARS TO BE WEAK AT THIS TIME.
During a review of Resident 1's Interdisciplinary Team Special Meeting 2.0 (IDTSM), dated 5/26/23, the IDTSM indicated, Resident 1 Resident [1] had an unwitnessed fall on 5/25/23 at [3:39 AM]. Per staff, resident [1] woke up that morning, tried to get up, lost balance and fell. She [Resident 1] thought she held on to the side rails but it was the side table. sustained laceration [a deep cut or tear in skin] on posterior [back] head. Md [medical doctor] and hospice notified. Resident [1] sent to [hospital]. 5/25/23 at around [11:45 AM], resident [1] came back to the facility with staples on her head. MD and RP [Responsible Party] aware. Resident [1] was feeling tired and lethargic [lack of energy]. Resident [1] normally uses her walker for ambulation [walking] but was advised this time not to get up by herself yet and to use her call light to ask for assistance.
During a concurrent interview and record review on 6/15/23, at 12:31 PM, with Director of Nursing (DON), Resident 1's physical and electronic medical record (PEMR) was reviewed. The PEMR had no indication Resident 1 had neurological assessments conducted after her fall incident on 5/25/23. DON stated, he could not find any evidence Resident 1 had neurological assessments done after her fall incident on 5/25/23. DON stated, they should have been done for at least 72 hours after the fall incident on 5/25/23. DON stated, the neurological assessments would have ensured Resident 1 did not have any type of brain injury. DON stated, he could not find any facility policy and procedure regarding neurological assessments.
During a review of the facility's policy and procedure (P&P) titled, Assessment and Management of Resident Falls, undated, the P&P indicated, It is the policy of [Facility] to prevent falls among resident as humanly possible and to provide interventions that may address resident's specific risks and causes of residents falls. In addition, the nurse shall assess and document/report the following . Neurological status . Delayed complications such as late fractures [break in bone] and major bruising may occur hours or several days after a fall, while signs of subdural hematomas [serious condition where blood collects between the brain and the skull] or other intracranial [within the skull] bleeding could occur up to several weeks after a fall.