Vacaville Convalescent And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure hazardous chemicals were secured and inaccessible to residents when a housekeeping closet containing cleaning chemicals was left unattended, with the key hanging on the wall next to the door. This deficiency increased the risk of unauthorized access to hazardous chemicals and potential harm to the residents. Findings: During a concurrent observation and interview on 3/6/26 at 1:13 p.m. with the Administrator (Admin) in the hallway near room [ROOM NUMBER], an unattended housekeeping closet with a key hanging next to the door was observed. The Admin opened the closet using the key on the wall, and the closet contained bleach and other cleaning chemicals. The Admin confirmed that leaving the key out increased the risk of unauthorized access to the chemicals, including confused residents who may be harmed by misuse of these chemicals. During a review of the facility's policy and procedure (P&P) titled, Hazardous Materials Management Program,, dated 1/15/98, the P&P indicated, Storage of hazardous chemicals will be in a locked closet with only authorized and qualified personnel having access.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention practices when materials that had contact with room surfaces were brought from Resident 124's and Resident 129's rooms back to the clean treatment cart. This failure increased the potential for the spread of infections among residents in a census of 87.Findings: During a review of Resident 124's admission Record (AR), dated 3/5/26 (print date), the AR indicated that Resident 124 was admitted to the facility in February of 2026 with diagnoses which included bladder cancer and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 129's AR, dated 3/5/36 (print date), the AR indicated that Resident 129 was admitted to the facility in February of 2026 with diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and ESRD (End Stage Renal Disease-irreversible kidney failure). During an observation on 3/5/26 at 9:16 a.m. in Resident 124's room, Treatment Nurse (TN 1) prepared treatment supplies and creams at the treatment cart outside the room. TN 1 brought a hand sanitizer bottle to the bedside table inside the room, along with wound treatment supplies. After TN 1 completed wound treatment for Resident 124, she moved the hand sanitizer bottle from the bedside table to the table by the sink and, upon exit, took it back to the top of the treatment cart. TN 1 wiped the surface of the cart down with sanitizing wipes and then settled the hand sanitizer bottle down on its surface. During an observation on 3/5/26 at 9:40 a.m. TN 1 continued to provide wound treatment care to the residents and moved from Resident 124's room to Resident 129's room. TN 1 carried one tube of 2.5% lidocaine & 2.5% prilocaine (percent concentration, local anesthetic medication) cream and a box of plastic food wrap film to the bedside and set them on the blanket by the feet end of the bed. Resident 129 was in a wheelchair by the bedside. TN 1 applied cream treatment to the left arm and wrapped the area with a plastic wrap piece, which she took out of the box. After completing treatment, TN 1 carried the tube of cream and the box of plastic wrap back to the treatment cart and put them into the drawers with other creams and clean supplies. During an interview on 3/5/26 at 9:48 a.m. with TN 1, TN 1 confirmed that the hand sanitizer bottle was placed on table surfaces inside Resident 124's room and taken back to the treatment cart. TN 1 also confirmed that the tube of cream and the box of plastic wrap were taken to Resident 129's room and set on the bed surface. TN 1 further confirmed that the cream tube and the plastic wrap box were taken back to the treatment cart and placed in the drawers with creams and supplies used for other residents in the facility. TN 1 agreed that taking items from residents' rooms back to the treatment cart increased the risk of cross-contamination. During an interview on 3/6/26 at 9:18 a.m. with the Infection Preventionist (IP), IP confirmed that bringing hand sanitizer, cream tube, and a box of plastic wrap from resident rooms to the clean treatment cart presented a risk of cross-contamination and the spread of infections among facility residents. During a review of the facility's policy and procedures (P&P) titled, Medication Administration-General Guidelines, dated 3/18, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

Based on observations and interviews the facility failed to ensure the facility garbage and refuse was properly contained for a census of 87, when two out of two dumpsters were continually left open and uncovered. This failure had the potential for pest infestations, environmental hazards and foul odors to affect the residents' surrounding environment.Findings: During an observation on 3/3/26 at 7:33 a.m. in the small parking lot adjacent to the facility kitchen, a gray metal dumpster was observed with the lid open. During a concurrent observation and interview on 3/3/26 at 8:35 a.m. with the Registered Dietician (RD) and the Dietary Services Supervisor (DSS), in the small parking lot, two large dumpers were observed uncovered. The RD and DSS confirmed one dumpster contained garbage and refuse, and the other dumpster contained cardboard for recycling. The RD and DSS confirmed dumpster lids needed to be closed to keep rodents away. During an interview on 3/6/26 at 1:04 p.m. with the Administrator (Admin), the Admin acknowledged the dumpster lids were difficult to close and remained open and uncovered throughout the duration of the survey and confirmed the dumpster lids should be closed to keep pests away. The Admin acknowledged the facility did not have a policy and procedure for the containment and disposal of garbage and refuse containers.

Based on observation, interview and record review, the facility failed to provide care and services in accordance with the current professional standards of nursing practice for two of 24 sampled residents (Resident 40 and Resident 124), when:Wound care orders were not updated and implemented as written for Resident 40; and,Wound care orders were not updated and implemented per the physician's verbal order for Resident 124.These failures had the potential for Resident 40 and Resident 124 to receive inadequate wound care with increased risk of complications.Findings:
1. A review of Resident 40's admission Record (AR) indicated Resident 40 was admitted to the facility in February 2026 with diagnoses which included chronic osteomyelitis (a persistent, long-term bone infection leading to bone destruction) in the right arm and polyneuropathy (damage to multiple peripheral nerves in the hands and feet).
During a review of Resident 40's Wound Care Plan (WCP), dated 3/2/26, the WCP indicated, Cleanse with normal saline (a sterile, isotonic solution), skin prep on periwound (area around the wound), collagenase [brand name] (a prescription, sterile enzymatic debriding agent used to remove dead tissue from severe burns and chronic skin ulcers, facilitating wound healing), alginate, pack with 1/2 inch iodoform packing (per surgeon) and cover with DSD (dry sterile dressing) foam.
During a concurrent observation and interview on 3/5/26 at 8:53 a.m. in Resident 40's room, with Treatment Nurse (TN) 2, Resident 40's wound care was observed. TN 2 stated Resident 40's wound care indicated to pack the wound with iodoform strip (sterile cotton gauze ribbons with iodoform, an antiseptic compound used to pack open or infected wounds), cover the iodoform strips with a small square of calcium alginate (a highly absorbent and sterile dressing) and cover the wound with a foam dressing.
During a concurrent interview and record review on 3/5/26 at 9 a.m. Resident 40's treatment order dated 2/23/26 was reviewed with TN 2. Resident 40's treatment order indicated, Apply skin prep around the wound bed, calcium alginate on top and pack with 1/2 inch iodoform strips and apply foam dressing. TN 2 stated, The order is a bit confusing, the iodoform strips go on first, then the calcium alginate, that's what the surgeon wanted. TN 2 indicated wound rounds were conducted every Monday with the wound care specialist and the facility treatment nurse.
During a review of Resident 40's Wound Care Plan (WCP), dated 3/2/26, the WCP indicated, Cleanse with normal saline (a sterile, isotonic solution), skin prep on periwound (area around the wound), collagenase [brand name] (a prescription, sterile enzymatic debriding agent used to remove dead tissue from severe burns and chronic skin ulcers, facilitating wound healing), alginate, pack with 1/2 inch iodoform packing (per surgeon) and cover with DSD (dry sterile dressing) foam.
During a concurrent interview and record review on 3/5/26 at 3:08 p.m. with Licensed Nurse (LN) 4, Resident 40's WCP dated 3/2/26 was reviewed. LN 4 confirmed the WCP form was the physician's updated treatment order. LN 4 stated, Every Wednesday there is a team meeting where residents' wounds are discussed, and treatment orders are reviewed and updated. LN 4 confirmed Resident 40's treatment orders had not been updated.
During a concurrent interview and record review on 3/5/26 at 3:15 p.m. with TN 2, Resident 40's WCP dated 3/2/26 was reviewed. TN 2 confirmed Resident 40's wound care orders had not been updated after wound rounds on 3/2/26. TN 2 confirmed the wound care provided to Resident 40 since 3/2/26 was incorrect. TN 2 acknowledged the importance of updating treatment orders within a timely manner and as written, to ensure appropriate wound care was provided to prevent wounds from deteriorating. TN 2 stated physician orders should be followed as written to determine what treatment was working or if a different treatment might need to be started.
During an interview on 3/6/26 at 11:50 a.m. with the Director of Nursing (DON) the DON stated licensed nurses were expected to follow physician orders as written and to contact the physician for clarification if needed. The DON acknowledged following the physician orders for wound treatment allowed the treatment nurse and physician to evaluate if the treatment was working and beneficial for the patient.
During a review of the facility's policy and procedures (P&P) titled, Wound Care, dated 2021, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Verify that there is a physician's order for this procedure.
2. During a review of Resident 124's AR, dated 3/5/26 (print date), the AR indicated Resident 124 was admitted to the facility in February of 2026 with diagnoses which included bladder cancer and anemia (a condition where the body does not have enough healthy red blood cells).
During a concurrent observation and interview on 3/5/26 at 9:16 a.m. with Treatment Nurse (TN) 1 providing wound care to Resident 124, TN 1 prepared treatment supplies at the treatment cart outside the room. TN 1 mixed zinc oxide (a type of topical medication) with A&D ointment (a type of topical medication enriched with vitamins A and D) in approximately equal proportions in the same medication cup. TN 1 brought the mixed ointments along with other supplies to the bedside and removed the old dressing and exposed Resident 124's wound at the tailbone. The wound measured approximately 1.5 centimeters (cm, unit of measurement). TN 1 cleansed the area with saline (salty water solution) moistened gauze and applied prepared zinc oxide and A&D ointment mixture to the wound.
During a concurrent interview and record review on 3/5/26 at 2:16 p.m. with TN 1, Resident 124's Medications Administration Record (MAR) for March 2026 was reviewed. The MAR indicated the prescribed current treatment order of applying zinc oxide to the tailbone wound, but no orders for mixing in A&D ointment were found. TN 1 confirmed that there were no orders to mix these ointments.
During an interview on 3/5/26 at 2:32 p.m. with LN 2, LN 2 stated that Resident 124 probably had a verbal order by the doctor to mix in zinc oxide and A&D ointments together, and it wasn't updated in the system.
During an interview on 3/5/26 at 2:46 p.m. with Medical Doctor (MD 1), MD 1 confirmed that mixing of zinc oxide and A&D ointments for Resident 124's wound treatment was talked about.
During a concurrent interview and record review on 3/6/26 at 2:05 p.m. with LN 2, Resident 124's original treatment order dated 2/27/26 was reviewed and indicated zinc oxide treatment. LN 2 confirmed that when TN 1 mixed zinc oxide with A&D ointments together on 3/5/26, she was not following the order as written, and nurses were expected to follow the orders.
During a review of the facility's P&P titled, Medication and Treatment Orders, dated July 2016, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing.All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order.Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.
During a review of the facility's P&P titled, Medication Administration-General Guidelines, dated March 2018, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.Medications are administered in accordance with written orders of the attending physician.
During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5)

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 42) was free from unnecessary medications, when Resident 42 was prescribed a psychotropic medication (any drug that affects behavior, mood, thoughts or perception) with no adequate indications. This failure had the potential to place Resident 42 at risk for adverse effects of the psychotropic medication.Findings: During a review of Residents 42's admission Record (AR), the AR indicated Resident 42 was admitted in late 2024 with diagnoses which included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a review of Resident 42's Medication Review Report (MRR), dated 12/27/24, the MRR indicated. [Resident 42] has the Capacity to Make Medical Decision. During a review of Resident 42's Medication Review Report (MRR), dated 12/22/25, the MRR indicated a physician's order, Lorazepam [an antianxiety medication], 0.5 mg. tablet, by mouth every 8 hours as needed [PRN] for anxiety/Muscle Spasms m/b [manifested by] Fearful Feelings Affecting Quality of Life. The lorazepam order had no end date and was indefinite. During a review of Resident 42's Medication Administration Record (MAR), the MAR indicated the lorazepam 0.5 mg was administered 25 times after the medication review date of 1/5/26. During a concurrent observation and interview on 3/3/26 at 10:36 a.m. in Resident 42's room, Resident 42 was alert and verbally responsive, calm and in no distress. When asked about her care, Resident 42 indicated she had frequent pain but were handled and taken care of and had no concerns. During a concurrent interview and record review on 3/6/26 at 11:24 a.m. with Licensed Nurse (LN) 3, LN 3 confirmed Resident 42's lorazepam last order date was 12/22/25 and indicated the order should have been reviewed and could be ineffective or could cause adverse effects to Resident 42. LN 3 stated Resident 42's lorazepam could have needed a discontinuation for lack of use. During a concurrent interview and record review on 3/6/26 at 11:50 a.m. with Director of Nursing (DON), the DON indicated all PRN psychotropic medications needed to have a 14-day end date and confirmed Resident's 42 lorazepam did not have an end date. The DON stated, The nurse will monitor during the care of the resident [on psychotropic medications] and the doctor will recheck the resident every two weeks. expected every 14 days review with new orders or discontinuation of order.to avoid risk to the patients.make sure the medication is working and beneficial for the patient. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2/25, the P&P indicated, 3. PRN orders for psychotropic medications are limited to 14 days.a. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order.

Based on observations, interviews, and record reviews the facility failed to ensure complete nurse staffing data was displayed and accessible for residents and visitors, for a census of 82 residents, when actual hours worked was not displayed.
This failure had the potential to mislead residents and visitors of the actual hours worked by staff responsible for providing direct care to residents.
Findings:
During an observation on 12/4/24 at 2:50 p.m. at the North Nursing station, the Daily Staffing form was displayed. The form included the number of Licensed Nurses (LN) and Certified Nursing Assistants (CNA) scheduled for each of the facility's shifts. However, the form did not include the actual hours worked by the LNs and CNAs, who are directly responsible for resident care.
During a concurrent observation and interview on 12/4/24 at 3:20 p.m., at the North Nursing station, with the Medical Records Director (MRD), the MRD confirmed the Daily Staffing form displayed did not include the total number and actual hours worked per shift for LNs or CNAs. The MRD stated, I never thought I had to post the actual hours .I've never posted it since I've been [working] here.
During a concurrent interview and record review on 12/5/24 at 1:32 p.m., with the Administrator (ADM), the daily Staffing form was reviewed. The ADM confirmed the form did not include the actual hours worked per shift for LNs or CNAs providing direct care.
During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, the P&P indicated, .Our facility will post on a daily basis for each shift, nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following .The actual time worked during that shift for each category and type of nursing staff . total number of licensed and non-licensed nursing staff working for the posted shift .

Based on interview and record review, the facility failed to develop a comprehensive dementia (a progressive state of decline in mental abilities) care plan for one out of 21 sampled residents (Resident 57), when there was no dementia care plan for Resident 57.
This deficient practice had the potential to delay dementia treatments and services needed for Resident 57.
Findings:
A review of Resident 57's admission record indicated the resident was admitted to the facility in October 2024, with diagnoses that include senile degeneration of the brain (decline in cognitive function) and dementia.
A review of Resident 57's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/18/24, indicated the resident has moderate cognitive impairment and non-Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia.
During a concurrent interview and record review on 12/5/24 at 1:54 p.m., with Licensed Nurse 1 (LN 1), Resident 57's care plans were reviewed. LN 1 confirmed there was not a dementia care plan for Resident 57. LN 1 stated that the care plan is important to assess the resident properly, informs staff how to interact with the resident, what behaviors to monitor and what are appropriate interventions for the resident.
During an interview on 12/5/24 at 3:59 p.m., with the Director of Nursing (DON), the DON stated she expected that residents with dementia have a dementia care plan, so staff knows how to monitor and interact with the resident and implement proper interventions.
During a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .care plan includes measurable objectives and timetables to meet the resident's psychosocial and functional needs . and, .services that are to be furnished to attain or maintain the resident's highest practicable mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed and implemented within 48 hours of admission for one (1) out of 21 sampled residents (Resident 238) when Resident 238 had been ordered anti-seizure medication without related seizure monitoring and care plan.
This failure had the potential to place Resident 238 at risk for unmet care needs.
Findings:
A review of Resident 238's admission record indicated Resident 238 was admitted to the facility in November of 2024, with diagnoses including a fracture of the left femur (a thigh bone) and a fall with subsequent encounter (aftercare).
A review of Resident 238's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for November and December of 2024 indicated order initiated on 11/19/24 for Divalproex Sodium 250 MG (milligram, unit of mass) two times a day for seizure prevention, with medication marked as given daily per order with few occasional exceptions due to refusals. No orders for monitoring seizure symptoms were found in the record.
A review of Resident 238's Care Plan History indicated no care plans specific to seizure monitoring.
A review of Resident 238's Physician's Progress Note, dated 11/19/24, indicated, [Brand medication name] (Divalproex) 250 mg tablet, delayed release . Give 1 tablet by mouth two times a day for Seizure Prevention (Do not crush)
During a concurrent interview and record review on 12/5/24 at 2:59 p.m. with the Licensed Nurse (LN 3, Unit Manager) Resident 238's orders and care plans were reviewed and LN 3 confirmed that Resident was on divalproex for seizures, had no seizure monitoring in place and no seizure specific care plan. LN 3 stated that she expected residents on anti-seizure medications to be monitored for seizures and to have a corresponding care plan.
During an interview on 12/6/24 at 12:06 p.m. with the Director of Nursing (DON), DON stated that for residents on anti-seizure medications, she expected seizure monitoring and a seizure-specific care plan to be implemented.
A review of facility policy and procedure (P&P) titled, Seizures and Epilepsy- Clinical Protocol, dated November 2018, indicated, The physician and staff will help identify individuals who have a history of seizure or epilepsy, and individuals who are receiving antiepileptic medications for any reason; for example, seizure prophylaxis after a recent stroke or treatment for behavioral symptoms related to dementia . In addition, the nurse shall assess and document/report the following . Neurological assessment . Change in level of consciousness . Any seizure activity in detail (location, duration, severity, recurrence, etc.) . Injury occurring with seizure . Monitoring . The staff and physician will monitor the progress of individuals with a new seizure or a seizure disorder and will modify interventions accordingly. They should document periodically and objectively the presence or absence of seizure activity . For Individuals who have been seizure-free for an extended time, the physician will periodically consider tapering antiepileptic medications especially when their initial use was for idiopathic seizures, an underlying acute medical cause was corrected, or seizure prophylaxis had been initiated in the absence of an identifiable structural cortical [brain region] lesion.
A review of facility P&P titled, Care Plans - Baseline, dated March 2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders .

Based on interview and record review the facility failed to provide services according to professional standards when anticoagulant (medications that prevent or reduce blood clotting) monitoring was not in place for Resident 63.
This failure had the potential to put Resident 63 at risk for having complications related to excessive bleeding.
Findings:
A review of an admission record indicated Resident 63 was admitted to the facility in February 2023 with diagnoses including pulmonary embolism (blood clot in an artery in the lung), embolism and thrombosis of the left leg (a blood clot blocks or narrows an artery in the leg).
During a review of Resident 63's, Medication Administration Record, on 12/4/24 at 10:04 a.m., the record indicated Resident 63 was receiving apixaban (medication that decreases the clotting ability of the blood) tablet twice a day. The record did not indicate an order to monitor side effects such as excessive bleeding or bruising.
During a review of Resident 63's Care Plan, on 12/4/24 at 10:05 a.m., it did not indicate an anticoagulant monitoring care plan.
During an interview and record review on 12/5/24 at 11:08 a.m., with Licensed Nurse 1 (LN 1), LN 1 confirmed that there were not any orders or a care plan for anticoagulant monitoring. She stated that not having the care plan can put the resident at risk for not being monitored for side effects of apixaban and any signs of bleeding may be missed.
During an interview on 12/5/24 at 12:14p.m., with the Director of Nursing (DON), the DON stated that her expectations are that all residents on anticoagulants have orders to monitor side effects and an anticoagulant monitoring care plan, not having them can lead to residents not being monitored for bleeding.
During a review of the facility's policy titled, Anticoagulation - Clinical Protocol, dated 2001, indicated, staff and physician will monitor for possible complications . and . If an individual on anticoagulation therapy shows signs of evidence of bleeding, the nurse will discuss the situation with the physician .
During a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered , revised March 2022, indicated, .care plan includes measurable objectives and .establishing the expected goals and outcomes of care.

Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of care and facility policy, for one (1) resident (Resident 240), out of 21 sampled residents, when:
1.
Resident 240's nasal cannula (NC- nasal cannula, special tubing that delivers gas to the nostrils) was unlabeled with a date it was changed; and
2.
facility's orders and practices in changing humidifier bottle (a bottle of distilled water inserted into an oxygen delivery system to add moisture when being administered oxygen) and nasal cannula were not in agreement with facility's policy.
These failures increased the risk for resident 240 to develop respiratory infections.
Findings:
A review of Resident 240's admission record indicated that Resident 240 was admitted to the facility in November of 2024 with diagnoses including respiratory failure with hypoxia (problems with breathing and low oxygen levels).
A review of Resident 240's order summary report (OSR), dated 12/6/24, included the following active orders:
O2 [oxygen gas] at 2 L/min [liters per minute, rate] via NC as needed for shortness of breath, chest pain, O2 saturation less than 90% .]. Initiated on 11/23/24.
O2 at 2-3 L/min via NC continuously every shift. Initiated on 12/4/24.
Change Humidifier Bottle &Tubing [NC] When O2 Used - Clean Filters of O2 Concentrators with Warm Soap Water, Pat Dry & Replace on O2 Concentrator when Changing Humidifier Bottle every night shift every 5 day(s). Initiated 12/4/24.
During a concurrent observation and interview on 12/4/24 at 3:58 p.m., with the Infection Preventionist (IP), the IP stated NC and humidifier bottle should each be labeled with dates when first used/opened and changed on a weekly basis. IP entered Resident 240's room and confirmed that Resident 240's NC was not labeled, and the humidifier bottle was labeled with date 12/3.
During an interview on 12/5/24 at 9:21 a.m. with Licensed Nurse (LN 3, Unit Manager). LN 3 stated the facility's practice was to change humidifier bottle and NC together and date only the bottle. LN 3 confirmed Resident 240 had an order to change the bottle and nasal cannula every 5 days.
During concurrent observation and interview on 12/5/24 at 9:40 a.m. with Resident 240 lying in bed with NC applied and oxygen running at 2L/min. Resident 240 stated that she had been on continuous oxygen therapy via NC since she was admitted to the facility. There was still no date labeled observed on NC and the humidifier bottle was still labeled 12/3.
In an interview on 12/5/24 at 9:46 a.m. with Licensed Nurse (LN 5), LN 5 stated that she was taking care of Resident 240, and the resident was on oxygen therapy via NC since admission. LN 5 also stated that she expected NC tubing and humidifier bottle to be changed every 3 days and they should be labeled with dates separately.
During concurrent observation and interview on 12/6/24 at 9:50 a.m. with LN 5 in Resident 240's room. LN 5 confirmed observation that Resident 240's NC tubing was still not labeled with a date and the humidifier bottle was still labeled 12/3. LN 5 stated the bottle and tubing should be changed every 5 days, and they each should be labeled with dates.
In an interview on 12/6/24 at 9:59 a.m. with the Director of Nursing (DON), the DON confirmed the humidifier bottle and NC are expected to each be labeled and the facility's practice of changing bottle and tubing as one unit was not in agreement with the policy that required bottle changes every 24 hours and tubing changes every 7 days.
A review of facility policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, undated, indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after twenty-four (24) hours . Infection Control Considerations Related to Oxygen Administration . [NAME] bottle with date and initials upon opening and discard after twenty-four (24) hours . Change the oxygen cannula and tubing every seven (7) days, or as needed .

Based on observation, interview, and record review, the facility failed to ensure that medications were stored according to accepted professional principles for a census of 82 residents, when loose pills were found in a medication cart and medication refrigerators were not maintained.
This deficiency had the potential for residents to have an increased risk of receiving compromised medications.
Findings
During a concurrent observation and interview on 12/4/24 at 2:07 p.m., with Licensed Nurse 2 (LN 2) of north hall medication cart A, 8 loose pills were found in the bottom of the medication drawer. LN 3 confirmed the presence of the loose pills and stated that loose pills could be accidently given to residents.
During a concurrent observation and interview on 12/4/24 at 2:31p.m. of north station medication room with LN 1, LN 1 confirmed the medication refrigerator was:
1.
noted to have thick ice buildup which prevented the freezer door to be opened,
2.
puddles of water were seen at the bottom of the fridge and shelving, and
3.
damage was noted on the external areas of the fridge.
LN 1 stated that if the fridge is not working and maintained properly medications could be compromised and the residents could potentially receive ineffective medications or experience a reaction.
During a concurrent observation and interview on 12/4/24 at 2:51 p.m., with LN 3 in the south station medication room. LN 3 confirmed the medication fridge thermometer indicated a temperature of 24 Fahrenheit (F - a unit of measure), and the medication fridge temperature expected range is 36-46 F. LN 3 stated that the medication fridge temperature is out of range which could potentially damage the medication and cause it to be ineffective.
During an interview on 12/5/24 at 12:14p.m. with the Director of Nursing (DON), the DON stated loose pills shouldn't be in the cart and should be disposed of appropriately. The DON added, nurses are responsible for monitoring temperatures and general fridge maintenance such as cleaning and defrosting the fridge.
During a review of the facility's policy and procedure titled, Medication labelling and storage, dated 2001, indicated, .the facility stores all medications .under proper temperature . and, .nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when:
1. The wound treatment nurse (TN): took a container of medication from a resident's room and put back in the clean supply cart, failed to sanitize equipment between uses for different residents, and did not label wound dressings.
2. Housekeeping staff did not perform hand hygiene between cleaning different resident rooms and the same mop and sanitizing solution was used to clean multiple rooms.
3. Enhanced Barrier Precautions were not applied for residents with wounds and indwelling medical devices.
These failures had the potential to result in infection spread among a facility census of 82 residents.
Findings:
1. During wound treatment observation on 12/4/24 commencing at 1:55 p.m., the TN was observed providing wound care to Resident 141 and Resident 242. The TN brought supplies including scissors and an entire container of powdered nystatin (an antifungal medication) into Resident 141's room. The TN removed old dressings, that were not labeled with date or initials, from both knees of Resident 141. The TN used scissors to trim new dressings and applied new dressings to the knee wounds, but the TN did not label new dressings with a date or initials. The TN applied the nystatin powder to Resident 141's groin area, and then placed the nystatin container back in the treatment supply cart with other clean supplies. The TN took the scissors from Resident 141's room and placed them on the top of the treatment supply cart without disinfecting them. The TN removed four clean packages of dressings and placed them on top of the treatment supply cart where they touched the potentially contaminated scissors. The TN then took the four packages of dressings from the top of the treatment supply cart into Resident 242's to do a dressing change. The TN removed old dressings from Resident 242's right leg, old dressings were not labeled with date or initials, and then applied new dressings without labeling with date or initials.
In an interview on 12/4/24 at 2:45 p.m., the TN admitted he took the entire nystatin powder container from Resident 141's room back to the clean cart. The TN acknowledged he was not supposed to bring the entire nystatin powder container into the resident's room and should have taken a small portion in a disposable medication cup for use inside the resident's room. The TN confirmed the old dressings, that were removed from both Resident 141 and 242, were not labeled with dates or initials, and he did not label new dressings as expected. The TN confirmed that he did not use readily available disinfectant wipes to sanitize the scissors that were brought from Resident 141's room nor did he sanitize the top of the treatment cart between providing treatments to two different residents.
In an interview on 12/6/24 at 9:59 a.m. with the Director of Nursing (DON), the DON stated entire medication containers should not be taken into resident rooms but rather the needed dose must be taken into the room in a disposable medication cup. The DON added, medication containers that have been taken into the residents' rooms should not be brought back to the clean supply cart. The DON also stated she expected wound dressings to be labeled with date and initials and reusable equipment, including scissors and a treatment supply cart surface, must be sanitized between different residents with provided disinfecting wipes.
A review of facility policy and procedure (P&P) titled, Dressings, Dry/Clean, undated, indicated, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings . The following equipment and supplies will be necessary when performing this procedure . Clean dressing(s); Cleaning solution, as ordered; Tape; Scissors; and Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed) . Clean bedside stand, Establish a clean field . Label tape or dressing with date, time, and initials. Place on clean field. Using the clean technique, open other products . Apply the ordered dressing and secure it with tape or bordered dressing per order. (Note: Use nonallergenic tape as indicated.) Label with date and initials to top of dressing .
2. During an observation on 12/5/24 commencing at 8:21 a.m., Housekeeper 1 (HK 1) was observed cleaning resident rooms. HK 1 took the mop from the mop bucket with sanitizing solution and mopped the floor in RM [ROOM NUMBER]. After moping room [ROOM NUMBER], HK 1 put the mop with the mop head back into the bucket with sanitizing solution. Then, without conducting hand hygiene or changing the mop head, HK 1 went to clean the floor in room [ROOM NUMBER]. HK 1 took the mop from the bucket with sanitizing solution, mopped the floor in room [ROOM NUMBER], and placed the mop back into the solution bucket.
In an interview on 12/5/24 at 8:29 a.m. HK 1 confirmed that he did not perform hand hygiene when he moved from room [ROOM NUMBER] to room [ROOM NUMBER] and he used the same mop head and solution to clean both rooms. He stated that he routinely uses the same mop head and sanitizing solution to clean three to four rooms.
During an observation on 12/5/24 commencing at 9:57 a.m. HK 2 was observed working in room [ROOM NUMBER]. HK 2 grabbed the mop with the wet mop head and mopped the floors in room [ROOM NUMBER]'s restroom. Then HK 2 placed the mop in a sanitizing bucket with a solution. HK 2 then grabbed gloves and the basket with cleaning supplies and went to room [ROOM NUMBER] to clean inside that restroom.
In an interview on 12/5/24 at 9:57 a.m. HK 2 stated she uses the same mop head and solution to clean 5 restrooms before changing the solution.
In an interview on 12/6/24 commencing at 9:59 a.m. DON agreed that using the same mop head and sanitizing solution in multiple rooms increases the risk of cross-contamination. She also stated she expected housekeeping staff to perform hand hygiene between different rooms.
A review of facility P&P titled Cleaning and Disinfecting Residents' Rooms, dated August 2013, indicated, Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently . Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60-minute intervals . Perform hand hygiene after removing gloves . Change mop solution water at least every three (3) rooms, or as necessary .
3. In an interview on 12/4/24 at 3:58 p.m., the Infection Preventionist (IP) stated that Enhanced Barrier Precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms-MDROs during high contact care activities). Was used by the facility only on residents colonized or having a history of MDROs.
During concurrent observation and interview on 12/6/24 at 9:09 a.m. in the facility's hallways with Licensed Nurse 3 (LN 3, Unit Manager). LN 3 stated that residents on EBP had a red dot against their name on the room entry signage. LN 3 provided a list of 10 residents with in-dwelling medical devices. Six (6) reviewed residents were not placed on EBP. LN 3 stated that she was not aware that these residents had to be placed on EBP.
In an interview on 12/6/24 at 9:59 a.m. the DON confirmed EBP should have been implemented, but had not been, for residents with wounds and in-dwelling devices.
A review of facility P&P titled, Enhanced Barrier Precautions, dated August 2022, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .

Based on interviews and record reviews, the facility failed to ensure all Certified Nursing Assistants (CNAs) were provided mandatory abuse training when documentation for the required training was unavailable for the 13 CNAs assigned to the night (NOC) shift.
This failure had the potential for all 82 residents in facility to experience physical, mental, or psychosocial harm.
Findings:
During an interview on 12/04/24 at 4:21 p.m. with the DSD, the DSD stated in-services were scheduled two times a week on Tuesday's and Thursday's from 2:30 p.m. to 3:30 p.m. When questioned if the DSD provided in-services to the NOC shift staff, the DSD did not provide a response.
During an interview on 12/05/24 at 8:09 a.m. with the DSD, the DSD stated she tracked staff participation for required in-services by ensuring staff write their name and signature on a sign in sheet accompanying the in-service. The DSD confirmed the mandatory abuse prevention training had not been provided during 2024.
During an interview on 12/05/24 at 10:58 a.m., When requested the NOC shifts training records, the DSD admitted , I don't provide in-services to the NOC shift staff .I make sure they get the information, but they don't sign a sign in sheet or attend in-services in person.
During a review of the facility's policy and procedure (P&P) titled, In-Service Training, Nurse Aide, revised August 2022, the P&P indicated, All nurse aide personnel participate in regular in-service education .Required training topics for all staff (including nurse aides) included: c. abuse, neglect and exploitation of residents .Nurse aid participation in training is documented by the staff development coordinator, or his or her designee and includes: the date and time of the training, the topic of the training, the method used for training, a summary of the competency assessment and the hours of training completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of abuse when Resident 2 slapped Resident 1 on the back.
This failure resulted in an increase in Resident 1's potential for social withdrawal and fear for his safety.
Findings:
A review of an admission record indicated Resident 1 was admitted to the facility in 2023 with diagnoses which included syncope (fainting) and collapse and dementia (a chronic condition which results in a decline in the person ' s ability to think, remember, and reason). A review of a Minimum Data Set (MDS, an assessment tool) dated 8/2/24 indicated Resident 1 had a score of 10 on a Brief Interview for Mental Status (BIMS, a questionnaire used to determine if a person's cognition (the process of thinking) is intact. A score of 15 suggests intact cognition).
A review of an admission record indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included orthopedic aftercare (care after surgery involving the musculoskeletal system) and hypertension (high blood pressure). A review of an MDS dated [DATE] indicated Resident 2 had a BIMS score of 14.
A review of Resident 2's progress note dated 7/8/24 at 1:45 a.m. indicated, At [1:20 a.m.] .Resident [2] .[had] an outburst/angry behavior towards the roommate [Resident 1] about his disturbance of sleep caused by the roommate [Resident 1] .Resident [2] stated that he is really fed up and had enough of his patience and can't deal with it anymore .
A review of Resident 1's progress note, dated 7/8/24 at 4:04 a.m. indicated, At [1:20 a.m.] Resident [1] was moved out of the room d/t [due to] the roommate [Resident 2] complaint of sleep disturbance .While the 2 CNA [Certified Nursing Assistants] assigned was assisting the Resident [1], they witnessed the aggressive behavior of the roommate [Resident 2] approached the Resident [1] yelling at him and slapping Resident [1] on his upper back while saying to him that he already had enough of the noise and being disturb [sic] on his sleep .
A review of Resident 1's care plan initiated on 7/8/24 indicated Resident 1 had the potential to experience social withdrawal and fear for his safety related to an incident of aggression from his roommate, Resident 2.
In an interview on 9/30/24 at approximately 4:50 p.m., Resident 2 confirmed he had slapped Resident 1 on the back. Resident 2 stated Resident 1 had become annoying one night when he tried to get some sleep because Resident 1 kept getting out of bed and was not following the staff's instructions. Resident 2 stated he had gotten frustrated and lost his temper.
In an interview on 9/30/24 at approximately 5:13 p.m., CNA 1 confirmed she had witnessed Resident 2 hit Resident 1. The CNA 1 stated Resident 1 had gotten out of bed and was confused so CNA 1 and another CNA tried to redirect Resident 1 back to bed; however, Resident 2 woke up, got into his wheelchair, and hit Resident 1. The CNA 1 stated Resident 2 seemed angry when he hit Resident 1 and Resident 2 stated he was tired of Resident 1's behavior.
A review of the facility's policy titled Abuse Prevention and the Reporting of Alleged Abuse and Suspicion of Crime revised on November 2016, indicated, .Each resident has the right to be free of .verbal .physical, mental abuse .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement guidance and recommendations to prevent the spread of Covid 19 infections to 18 out of 54 residents, Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, one (1) contractor and one (1) staff when:
1) The facility did not screen staff and visitors for any sign and symptoms of fever and cough before entering the facility. The staff, visitors and residents did not wear a N95 mask in the facility. The facility continued communal dining, activity, and physical therapy sessions.
2) The facility did not inform the Local Department Public Health in a timely manner when a Covid-19 outbreak, three (3) or more confirmed residents with Covid-19, occurred on 4/1/24. The facility reported the outbreak on 4/2/24. The facility did not inform the State Department of Public Health (CDPH) of the Covid-19 outbreak.
3) The facility did not screen residents and staff for Covid-19, who were exposed to Covid-19, as recommended by State and Center for Disease Control (CDC) Guidance. The facility did not have a current Policy & Procedure (P&P) for Prevention of Covid-19 infection.
These failures resulted in an outbreak of Covid-19 to 18 residents, one (1) contractor and one (1) staff, from 3/29/24 – 4/7/24. Resident 15, who contracted Covid-19, was transferred to emergency room for dehydration due to Covid-19 infection and low blood pressure.
Findings:
(1)
During a concurrent observation and interview on 4/5/24 at 10:45 a.m., upon entrance to the facility, there was a box of facial masks on the stand and hand hygiene solution; visitors and staff walked in hallways not wearing masks and did not use hand hygiene. The Director of Nursing (DON), was asked whether wearing masks was mandatory. The DON stated, No, we encouraged them to wear masks. When the ADM was asked if the facility had an assigned staff to screen staff and visitors in the front desk, the ADM stated, No. The ADM stated they had residents who were confirmed for Covid-19 infection as well as one contracted staff. The IP stated she followed the guidelines under the Policy & Procedures for Covid-19. The IP stated she did not conduct Covid-19 tests to exposed residents and staff if they did not present symptoms of cough or colds. The IP stated it was not required to conduct Covid-19 tests to exposed residents or staff.
During a concurrent interview and record review on 11/8/24 at 11 a.m., the Director of Nursing (DON) and IP reviewed the names of residents who were Covid-19 positive, with the corresponding room assignments from 3/29/24 until 4/7/24. The DON stated there were fifteen (15) residents who were positive for Covid-19. As off today, 4/8/24, the Infection Preventionist (IP) stated, currently there were a total of six (6) residents who were positive for Covid-19 infection. The IP stated an additional three residents converted to positive for Covid 19. Resident 20 and one active staff converted positive for Covid-19. The IP stated it was not mandatory for residents, staff, and visitors to wear facial masks in the facility. The IP stated it was only mandatory to wear facial masks for staff and visitors when entering the isolation room of residents who were positive for Covid-19 infection. The IP stated residents would be out of isolation after six days without symptoms and after finishing the medication for Covid-19.
During a concurrent observation and interview on 4/8/24 at 12 p.m., with the IP and DON, while on a tour of the facility, a family member (wife) put on an isolation gown outside a resident room, and the IP assisted and helped her put on her face shield. The wife entered the room (an isolation room with Covid 19) to visit Resident 12. This Surveyor immediately asked the IP if the wife wore an appropriate mask to protect herself from Covid-19 infection. The IP checked the mask the wife wore and then asked wife to change her mask to N95 (protective mask to wear for Covid-19 isolation). The activity room had residents present without wearing masks. The community dining room was filled with residents without wearing masks. Staff in the dining room wore regular masks, not N95. The Physical Therapist was actively treating residents without wearing masks in the Physical Therapy room.
During an interview on 4/8/24 at 12:30 p.m. in the ADM ' s office with the ADM, the IP and the DON, the IP was asked what guidance she followed for Covid-19 prevention. The IP stated she followed the Covid-19 Guidance by the State. The IP stated the reason she did not test all residents was because of psychosocial concerns. The IP stated the State and CDC guidelines provided only, recommendation to conduct Covid-19 tests to exposed residents, it did not say, required. The IP stated that fit testing for N95 was done in 2022. The IP stated the fit testing was not done yearly. When asked if this outbreak was reported to the State Public Health, the IP stated, No only to the Local Public Health thru, Spot (computer reporting to LPH). When the DON was asked if she conducted exposed residents from any other source of airborne infection such as Tuberculosis (TB), the DON stated, Yes to detect if anyone was infected with TB to prevent the spread of infection and treat it accordingly. The ADM stated the Policy & Procedures (P&P) they followed was the letter from the Director of State Public Health.
A review of the Policy & Procedure (P&P) titled, Infection Prevention and Control Program, dated 10/2018), indicated: An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under Policy Interpretation and implementation: 1) The infection prevention and control program are developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary 4) the elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety 10) Outbreak Management B) Outbreak management is a process that consists of . 3) preventing the spread to other residents; 4) reporting the information to appropriate public health authorities 9) recommending new or revised policies to handle similar events in the future.
During an interview on 4/8/2024 at 3:55 p.m., Licensed Nurse (LN) D stated she provided in-services for Personal Protective Equipment (PPE). LN D stated everyone was responsible to teach the family how to put on and remove PPE. LN D stated, residents who were treated for Covid-19 were isolated for five days, did not repeat the Covid-19 test, and they only tested if residents had symptoms or family asked to do a test for their loved ones. LN D stated Resident 15, who tested positive for Covid-19 was transferred to emergency room (ER) today for low blood pressure 87/60 (normal blood pressure value 120/80), pulse at 111 (normal pulse 60-100), no fever, with mild shortness of breath. Resident 15 refused to wear a mask. LN D stated she called the ER, and was informed Resident 15 would be admitted in the hospital due to low blood pressure and a fast heart rate.
During a telephone interview on 4/10/2024 at 2 p.m., the Local Public Health Epidemiologist (LPH) stated the facility must follow the most stringent regulations and guidelines for prevention of Covid-19 in Long Term Care facilities (LTC). The LPH stated the facility reported an outbreak of Covid 19 in their facility, dated 4/2/24, via the, SPOT portal (electronically-reported Covid 19). The LPH stated they provided the facility with LPH outbreak guidance as well. The LPH was asked if they helped the facility when an outbreak occurred,and the LPH stated the facility did not ask for an assistance.
(2)
A review of the IP ' s list of residents who were confirmed positive for Covid-19 as follows:
3/29/24-Resident 1, positive for Covid
4/01/24-Residents 3, 5, 7, 18
4/02/24-Residents 2, 6, 19, 10
4/03/24-Residents 11, 9
4/04/24-Residents 8, 12
4/05/24-Resident 4
4/06/24-Resident 13
4/7/24-Resident 14, & Resident 15
4/8/24- Resident 20
The IP did not provide a list of names of staff and the contractor who were positive for Covid-19 in the facility. The IP provided list of residents who were exposed with no Covid-19 tests done.
A review of the Local Public Health Recommendations for the Prevention and Control of Viral Respiratory illness in Long Term Care Facilities, dated 10/23, indicated under definition of outbreak of Covid-19: >3 people with confirmed diagnostic test for Covid-19 within seven days who are epi-linked to the facility. Discontinue group activities, unless necessary. Discuss with Local Public Health any group activity/therapy that needed to continue. Close communal dining; serve meals in resident rooms
(3)
During an interview on 4/8/2024 at 12: 40, the ADM submitted to this Surveyor a letter from the Director of State Public Health. The ADM stated this was the facility ' s Policy & Procedure that was used. A letter from the Director of State Public Health, dated 1/09/24, addressed to, Public Health Officials, Healthcare Provider and Laboratories, under the subject, Updated Covid-19 Testing Guidance, indicated, under, Who should have diagnostic testing? Diagnostic testing is recommended for all people with new symptoms of Covid-19 .Diagnostic testing is recommended for exposed people without symptoms who are at higher-risk of severe Covid-19 infection and may benefit from treatment if infected or who have contact with people at high risk for severe infection. What is diagnostic screening testing? Diagnostic screening testing is testing of people without symptoms or known exposure to detect Covid-19 early, stop transmission, and prevent outbreak or control outbreaks. When the ADM was asked whether the facility tested the exposed residents and staff for Covid-19, the ADM stated the facility did not test exposed residents without symptoms. The facility only tested residents with symptoms of Covid-19. The ADM stated, since the State and Center for Disease Control (CDC), recommended not required to test exposed residents, We don ' t have to follow recommendations. The ADM submitted a copy of facility ' s committee-approved Policy & Procedure titled, Covid-Manual, dated 4/20/23. The ADM identified the, Mitigation Plan for Recommendations for testing as the facility's Covid-Manual. The ADM stated the facility did not use the Mitigation Plan anymore because it was obsolete. The ADM presented the All-Facility Letter (AFL) 22-13.1, dated 10/5/22, which indicated, This AFL is no longer in effect and is for historical purposes only. Please refer to the most recent CDC guidance.
A review of the email response from the IP, dated 4/12/24 at 4:31 p.m., the IP stated she received the Local Public Health Guidance for Covid-19 in October 2023. When the IP was asked which guidance the facility followed when it had multiple guidance's in hand, the IP replied, We follow the most recent.
During a telephone interview on 4/13/24 at 10 a.m., a hospital staff member stated Resident 15 was admitted on [DATE], for low blood pressure, a fast heart rate, and dehydration due to a Covid-19 infection.
A review of Guidelines from California Department of Public Health (CDPH) Health Association-Infection Program indicated, Recommendations for Prevention and Control of COVID-19, Influenza, and Other Respiratory Viral Infections in California Skilled Nursing Facilities – 2023-24. This CDPH guidance aligns with the Centers for Disease Control and Prevention (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes (www.cdc.gov/longtermcare/prevention/viral-respiratory-toolkit.html).

Based on interview and record review, the facility failed to maintain documentation that an alleged abuse violation was thoroughly investigated.
This failure to maintain documentation of an abuse investigation had the potential to delay implementation of corrective action(s) to protect the resident from further abuse and/or emotional harm.
Findings:
Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified.
During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23.
During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator stated he talked with Licensed Nurse A after he was notified that resident 1 believed she was sexually assaulted during the catheter procedure. Administrator stated he was the Abuse Coordinator, and he did not routinely report alleged abuse until after he had investigated it. Administrator stated he did not believe any abuse occurred, so he did not report the allegation. Administrator stated he did not have any written record of his investigation.
During an interview on 2/20/24 at 1:25 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she became aware during a Care Conference on 12/29/23 of Resident 1's allegation that she was sexually assaulted during a catheter procedure. The ADON stated she investigated the allegation. The ADON and the facility did not provide any documentation of an investigation.
During an interview on 2/20/24 at 1:45 p.m. with the Administrator, the Administrator stated he did an internal investigation of the allegation.
During an interview on 2/21/24 at 10:55 a.m. with the Social Services Director (SSD), SSD stated she attended the Care Conference for Resident 1 on 12/29/23. DDS stated the alleged abuse of Resident 1 was discussed. SSD stated the Assistant director of Nursing (ADON) took notes during the meeting. SSD further stated that each discipline documented their own notes.
A record review of a document titled Interdisciplinary Team Conference Notes dated effective 12/29/23 at 11:03 a.m. and signed by the ADON, included a summary of discussion for each discipline. Under paragraph V., section 1. Nursing summary states .reviewed all family .concerns and follow up in place . No further documentation of abuse allegation was provided by the facility.
A record review of a policy and procedure, titled Abuse Training and Reporting Policy dated May 2003, Paragraph 5, Investigation states, Staff members will be trained to report anything that may cause injury toa resident .If abuse is suspected, the Administrator and /or Abuse Coordinator must be notified and an investigation is initiated. Record received from the Administrator who indicated it was the current policy.

Based on interview and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made.
This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation.
Findings:
Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified.
During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23.
During an interview on 2/20/24 at 12:14 p.m. with the DON, the DON further stated that Resident 1's Family Member 1 reported at a Care Conference (meeting of facility management staff, resident and family, if indicated) on 12/29/24 that Resident 1 believed she was sexually assaulted during the catheter procedure.
During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator stated he talked with Licensed Nurse A after he was notified that resident 1 believed she was sexually assaulted during the catheter procedure. Administrator stated he was the Abuse Coordinator, and he did not routinely report alleged abuse until after he had investigated it. Administrator stated he did not believe any abuse occurred, so he did not report the allegation.
During an interview on 2/20/24 at 1:25 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she became aware during a Care Conference on 12/29/23 of Resident 1's allegation that she was sexually assaulted during a catheter procedure. The ADON stated she investigated the allegation.
During an interview on 2/20/24 at 1:45 p.m. with the Administrator, the Administrator stated he did an internal investigation of the allegation. Administrator further stated he had 24 hours to report abuse to the State Agency.
During an interview on 2/21/24 at 10:20 a.m. with Family Member 1, Family Member 1 stated he visited Resident 1 on 12/28/23 and Resident 1 told him she had been held down and sexually assaulted during the night. Family Member 1 stated he was the Responsible Party (decision maker) for Resident 1.
During an interview on 2/21/24 at 10:20 a.m. with Family Member 1, Family Member 1 stated he attended a Care Conference for Resident 1 on 12/29/23. The Care Conference was attended by Family Member 1, Family Member 2, the ADON, the Social Services Director, and the Physical Therapy Manager. Family Member 1 expressed concerns about Resident 1's sexual assault allegation. Family Member 1 stated that Resident 1 continued to suffer trauma from the event.
During an interview on 2/21/24 at 10:55 a.m. with the Director of Social Services (DSS), the DSS stated she was present at the Care Conference for Resident 1 on 12/29/23. The DSS stated Family Member 1 discussed Resident 1's allegation of sexual assault during the meeting.
During an interview on 2/21/24 at 3:58 p.m. with the Manger of PT Services (MPT), the MPT stated she attended a Care Conference for Resident 1 on 12/29/23. The MPT stated during the Care Conference Family Member 1 stated Resident 1 told him she was held down and then assaulted.
During an interview on 2/22/24 at 12:15 p.m. with Licensed Nurse B, an employee of a Home Health Agency, Licensed Nurse B stated Resident 1 was her Home Health client after she left the facility. Licensed Nurse B stated Resident 1 said she may have been sexually assaulted at the facility. Resident 1 reported this to Licensed Nurse B on 2/6/24. Licensed Nurse B stated Resident 1 appeared to be traumatized. Licensed Nurse B reported the abuse allegation to Adult Protective Services on 2/6/24.
During an interview on 2/22/24 at 2:20 p.m. with Licensed Nurse A, Licensed Nurse A stated she reported allegations of abuse to the DON. Licensed Nurse A stated she had 24 hours to report alleged abuse.
During an interview on 2/22/24 at 2:32 p.m. with the DON, the DON stated we reported alleged abuse right away if we felt it needed to be reported. DON stated regulations said to report within 24 hours.
A record review of a policy and procedure, titled Abuse Training and Reporting Policy dated May 2003, Paragraph #7, Part A states, The Administrator and or designee will oversee the abuse policy, conduct a thorough investigation, and notify the appropriate agencies within 24 hours .The required ' State of California Report of Suspected Dependent/Elder Abuse (SOC 341)' form will be submitted to the appropriate agencies within 2 working days. Record received from the Administrator who indicated it was the current policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician's Protocol for Constipation for one of 5 sampled residents (Resident 280), causing Resident 280 to not have a bowel movement (BM) for eight days in a row. This had the potential for Resident 280's abdomen feeling full and bloated, and cause pain, hemorrhoids (swollen veins in your lower rectum) and unexplained weight loss, which could lead to Resident 280 being hospitalized .
Findings:
A review of Resident 280's admission Record, dated 12/15/22, indicated Resident 228 was admitted on [DATE], with a diagnosis including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), gastro-esophageal reflex disease (GERD, a chronic disease where stomach acid goes up into the esophagus (the muscular tube through which food passes from the throat to the stomach), causing inflammation and pain), dysphagia (swallowing difficulties), altered mental status, severe sepsis (infection causes organ damage) with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), amongst others.
A review of Resident 280's admission MDS (Minimum Data Set, a clinical assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/12/22, indicated Resident 280 was not able to complete the BIMS (Brief Interview of Mental Status) interview, he had a memory problem, and Resident 280's cognitive skills were moderately impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 280 needed one-person physical assist with toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, cleanses self after elimination), was frequently incontinent of urine, and bowel continence was not rated (meant resident did not have a bowel movement for the entire 7 days).
A review of Resident 280's Admit/Readmit Screener - V2, dated 12/6/22, indicated Resident 280 was totally dependent on staff assistance for toilet use and Resident 280 had a small, formed BM last night (12/5/22), which was the day before he was admitted to the facility.
A review of Resident 280's Bowel and Bladder Elimination, dated 12/6-12/15/22, indicated Resident 280 had not had a BM since he was admitted on [DATE], total of eight days.
A review of Resident 280's Skilled Nursing Assessment, dated 12/8/22 at 1:05 a.m. and 12:02 p.m., indicated Resident 280's bowel function was unchanged. incontinent of BM, and bowel sounds were present. Resident 280's Skilled Nursing assessment dated [DATE] at 12:45 a.m., indicated Resident 280's bowel function was unchanged and bowel sounds were present. Resident 280's Skilled Nursing Assessment, date 12/10/22 at 5:29 p.m. and 12/11/22 at 3:22 p.m., indicated Resident 280's bowel function was unchanged. Resident 280's Skilled Nursing Assessment, dated 12/12/22 at 3:06 p.m., 12/13/22 at 3:54 p.m., and 12/14/22 at 3:03 p.m., indicated Resident 280's bowel function was not assessed. Resident 280's Skilled Nursing Assessment, date 12/15/22 at 3:44 p.m., indicated Resident 280 had bowel sounds and was constipated (condition of the bowels in which the stool is dry and hardened and evacuation is difficult and infrequent).
A review of Resident 280's Medication Review Report, dated 12/6/2022, indicated Resident 280 was to be given Colace 100 mg (milligrams) one tablet by mouth prn (as needed) for constipation, two to three times per day. Resident 280 was to be given MOM (Milk of Magnesia) 30 ml every 24 hours prn for constipation. Resident 280 was to be given a Bisacodyl suppository (form of medication that is inserted into the rectum), every 24 hours prn for constipation if MOM is ineffective.
A review of Resident 280's MAR (Medication Administration Record), dated 12/2022, indicated Resident 280 was given Colace 100 mg by mouth on 12/10/22 at 7:53 a.m., the fourth day after no BM. No other medication for constipation was given to Resident 280 until 12/14/22 at 5:16 p.m., when MOM 30 ml by mouth was given, eight days after no BM. Resident 280 had not been given the MOM until the surveyor had pointed out to the DON and Licensed Staff A Resident 280 had not had a BM in eight days.
A review of Resident 280's Nurse's Progress Notes, dated 12/6/22 - 12/15/22, indicated Resident 280's issue with constipation was not addressed until 12/15/22 at 11:54 a.m., whereby the nurse indicated Resident 280 had not had a BM, Resident 280's physician was aware, and interventions were in place.
During a concurrent interview and MAR review on 12/14/22 at 5:07 p.m., the Director of Nursing (DON) stated Resident 280 was given Colace 100 mg one tablet by mouth for constipation on 12/10, which was the fourth day of no BM. The DON stated a resident would normally be started on the physician's bowel care orders addressing constipation after the third day of no BM. The DON stated the resident would be given Colace first and if Colace did not work, MOM would be given. The DON stated the nurse giving report to the oncoming nurse should have made the nurse aware Resident 280 was having an issue with constipation. The DON stated if the Colace and MOM did not work, the nurse should have given Resident 280 the Bisacodyl suppository. The DON stated it was the nurse's responsibility to make sure a resident was having a BM routinely. The DON stated there was no Policy and Procedure on Bowel Care for constipation; it was a Standard Nursing Practice to make sure a resident has a BM routinely.
During an interview on 12/14/22 at 5:11 p.m., Licensed Staff A stated she had not been informed by the A.M. nurse giving her report about Resident 280 not having a BM since he was admitted on [DATE], eight days ago.
During an interview on 12/15/22 at 11:00 a.m., Unlicensed Staff B stated she if the resident had not had a BM by the second and third day, she would inform the resident's nurse.
During an interview on 12/15/22 at 11:05 a.m., Licensed Staff C stated if a resident did not have a BM after one day, she would give them a stool softener or a laxative such as Senna. Licensed Staff C stated if the stool softener and laxative did not work by the next day, she would give the resident MOM per the physician's order. Licensed Staff C stated if the MOM did not work, she would give the resident a suppository. Licensed Staff C stated there was an electronic tab alerting the nurse in regard to the resident not having a BM in so many days. Licensed Staff C stated the oncoming nurse should have been notified about a resident not having a BM by the nurse giving them report and/or by the CNA caring for the resident, and by the charge nurse. Licensed Staff C stated the nurses should have been charting in the resident's Nurse's Progress Notes about the resident having issues with constipation and what the nurse had done to address the issue. Licensed Staff C stated normally the CNA would make her aware of the resident not having a BM daily. Licensed Staff C stated if the resident was not having a routine BM and it had been several days, she would assess the resident for abdominal extension, bowel sounds, and pain. Licensed Staff C stated the resident's physician should be notified if the medication ordered for constipation did not help the resident have a BM. Licensed Staff C stated a resident should have been started on the physician's Bowel Protocol for constipation if a resident had not had a BM in six days and the physician should have been made aware.
During an interview on 12/15/22 at 11:10 a.m., Licensed Staff D stated Resident 280's wife stated Resident 280 had a BM the Saturday before his admission, which was 12/5/22. Licensed Staff D stated if a resident had not had a BM by the third day, she would start giving the resident the stool softener first and then MOM if the stool softener did not give results per the physician's orders. Licensed Staff D stated if no medication ordered for constipation was helping the resident have a BM, she would check the resident's abdomen for bowel sounds, abdominal extension, and abdominal pain. Licensed Staff D stated she would then call the resident's physician. Licensed Staff D stated normally the CNA would let the resident's nurse know if the resident had not had a BM that day. Licensed Staff D stated the nurse giving report to the oncoming nurse should let the nurse know the resident had not had a BM in so many days. Licensed Staff D stated Resident 280's nurse should have documented in the Nurse's Progress Notes about what had been done to help Resident 280 have a BM and the results, if any. Licensed Staff D stated if a resident refused medication to treat their constipation, the nurse should have documented.
The facility job description titled, Charge Nurse, dated 7/10/17, indicated: . Essential Duties and Responsibilities include the following: . Supervises and evaluates all direct resident care provided by nursing staff to ensure adherence to facility guidelines and initiates corrective action as necessary . Conducts resident rounds daily initiating corrective action as necessary and reports problem areas to nurse supervisor promptly. Provides oncoming charge nurse with concise, accurate report and takes follow-up action as necessary. Assumes responsibility for compliance with federal, state and local regulations within the station on the assigned shift of duty .
The facility job description titled, Certified Nurses Aide, dated 7/10/17, indicated: Summary: Cares for patients and performs basic nursing tasks directed toward the safety, comfort, personal hygiene and protection of patients in convalescent facility, under direction and supervision of (licensed) nursing and medical staff, by performing the following duties. Must possess a genuine interest and concern for geriatric and disabled persons . Assist patients need for elimination with correct use of bedpan, commode, urinal . Be aware of routine measures to prevent constipation . Records and reports observations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases) for five of five sampled residents (Resident 4, 50, 8, 29, and 42). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result to serious respiratory infections.
Findings:
RESIDENT 4
During a record review for Resident 4, the Face sheet (A one-page summary of important information about a resident) indicated Resident 4 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Hypertension (High Blood Pressure) and Spondylosis (abnormal wear on the cartilage and bones of the neck). Resident 4 was [AGE] years old.
During a record review for Resident 4, the Immunization Record indicated Resident 4 received PCV13 (PneumoConjugate) on 3/27/2015. The Immunization Record indicated Resident 4 was past due for Pneumococcal 23 since 5/22/2015.
RESIDENT 50
During a record review for Resident 50, the Face sheet indicated Resident 50 was admitted on [DATE] with diagnoses including Dementia, Anxiety (intense, excessive, and persistent worry and fear about everyday situations) and Depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). Resident 50 was [AGE] years old.
During a record review for Resident 50, the Immunization Record indicated Resident 50 received PCV13 on 11/06/2017. The Immunization Record indicated Resident 50 was past due for Pneumococcal 23 since 1/01/2018.
RESIDENT 8
During a record review for Resident 8, the Face sheet indicated Resident 8 was admitted on [DATE] with diagnoses including Diabetes (chronic [long-lasting] health condition that affects how body turns food into energy), Chronic Kidney Disease (CKD - gradual loss of kidney function) and Dementia. Resident 8 was [AGE] years old.
During a record review for Resident 8, the Immunization Record indicated Resident 8 received PCV13 on 12/22/2016. The Immunization Record indicated Resident 8 was past due for Pneumococcal 23 since 2/16/2017.
RESIDENT 29
During a record review for Resident 29, the Face sheet indicated Resident 29 was admitted on [DATE] with diagnoses including Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath ), Hypertension and Dementia. Resident 29 was [AGE] years old.
During a record review for Resident 29, the Immunization Record did not indicate Resident 29 received Pneumococcal vaccine. The Immunization Record indicated Resident 29 was past due for Pneumococcal 23 since 10/26/1991.
RESIDENT 42
During a record review for Resident 42, the Face sheet indicated Resident 42 was admitted on [DATE] with diagnoses including Malignant Neoplasm of Prostate (cancer of the prostate gland), Anemia (condition in which the body does not have enough healthy red blood cells) and Anxiety. Resident 42 was [AGE] years old.
During a review of the document titled Pneumococcal Immunization Informed Consent indicated Resident 42 received Pneumococcal vaccine few years ago.
During a record review for Resident 42, the Immunization Record did not indicate Resident 42 received Pneumococcal vaccine.
During an interview with the Medical Director on 12/15/2022 at 1:36 p.m., when asked about the resident's pneumococcal vaccination status, the Medical Director stated he was not aware that resident's did not get the recommended Pneumococcal vaccine. He stated nurses would have to let him know if the resident's pneumococcal vaccine was not up to date. The Medical Director stated he would coordinate with the facility and start giving the Pneumococcal vaccine according to ACIP recommendation.
During a record review and concurrent interview with the Infection Preventionist Nurse (IPN) on 12/15/2022 at 1:55 p.m., the IPN verified the immunization record for Residents 4, 50, 8, 29 and 42 indicated the residents did not receive the recommended Pneumococcal vaccine. The IPN stated she was not aware of the ACIP Pneumococcal vaccine recommendation therefore residents were not offered of the PPSV23 (pneumococcal polysaccharide vaccine - protects against 23 types of pneumococcal bacteria) ; however, she stated the facility will start working on the consents to be sent to the residents and to the resident's representatives.
During an interview with the Director of Nursing (DON) on 12/16/22 at 9:14 a.m., the DON stated she was not aware of the ACIP Pneumococcal vaccine recommendation. The DON stated they had called the pharmacy and confirmed the vaccine is available and now working on getting the consent from the residents and resident's representatives. DON stated the vaccines have already been ordered. When the DON was asked about the risks for the residents of not having the right Pneumococcal vaccine, she stated residents were prone for Pneumonia (lung inflammation caused by bacterial or viral infection).
Review of the Facility policy and procedure titled Influenza and Pneumococcal Vaccinations of Residents revised in 11/2016 indicated, All residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated.
The Centers for Disease Control and Prevention (CDC) recommended Pneumococcal vaccination for adults [AGE] years old and older; adults 19 through [AGE] years old with certain underlying medical condition or other risk factor including: Generalized malignancy, Alcoholism, Chronic Heart Disease, Chronic Liver Disease, Chronic Lung Disease, Cigarette Smoking, Diabetes Mellitus, CDC recommended revaccination of PPSV23 at least 1 year after PCV13 (Pneumococcal conjugate vaccine) dose and at least 5 years after any PPSV23 dose for resident over [AGE] years old with underlying medical condition. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Skilled Nursing Advanced Beneficiary Notice of Noncoverage (SNF-ABN, a notice provided to Medicare recipients informing them of the upcoming end of Medicare reimbursement for a particular medical service) to the responsible parties for two of three sampled residents (Residents 47 and 62) receiving Medicare Part A benefits, when facility stated they did not know the facility had to provide a SNF-ABN. This failure did not ensure resident rights to appeal the non-coverage determination and had the potential to expose each resident to unnecessary financial liability associated with receiving non-covered services (e.g., services not covered by Medicare Part A).
Findings:
RESIDENT 47
During a record review for Resident 47, the Face sheet (A one-page summary of important information about a resident) indicated Resident 47 was readmitted on [DATE], with diagnoses including Benign Neoplasm of Meninges (tumor that grows from the meninges, the protective membranes that cover the brain and spinal cord), Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Cardiomyopathy (disease of the heart muscle in which the heart loses its ability to pump blood effectively).
During a record review for Resident 47, the Minimum Data Set (MDS, an assessment tool completed by clinical staff), dated 11/04/2022, indicated Resident 47 started receiving Medicare benefits at the facility as of 10/29/2022. The MDS indicated Resident 47 received Physical Therapy and Occupational Therapy.
Review of the Centers for Medicaid & Medicare Services (CMS) form titled SNF (Skilled Nursing Facility) Beneficiary Notification Review indicated that 12/6/22 was Resident 47's last day of coverage for Medicare Part A services (Nursing and Rehab services either Physical Therapy, Occupational and Speech therapy). The form indicated the facility had initiated Resident 47's discharge from Medicare Part A Services when the resident's benefit days had not exhausted (e.g., the resident had skilled benefit days remaining). Further, the form indicated facility staff did not provide the SNF-ABN form to Resident 47 because the resident had already been discharged from the facility.
During an interview and concurrent record review with SSD (Social Service Director) E on 12/15/2022, at 9:30 a.m., SSD E was asked reason why the SNF-ABN was not provided to Resident 47, and SSD E stated Resident 47 was discharged from the facility after she received the Notice of Medicare Non-Coverage (NOMNC, a form completed by the facility to notify a resident of his or her right to a decision of non-coverage for services). During concurrent review of the electronic health record for Resident 47 with SSD E, SSD E verified Resident 47 was still admitted in the facility. When SSD E was asked when facility staff should issue the SNF-ABN form to the residents, SSD E stated she had never provided the SNF-ABN form to residents and did not know what the form looked like. Also, SSD stated she did not know she had to issue a SNF-ABN if the resident expected to stay at the facility after the last day of Medicare coverage. SSD E stated Business Office Manager (BOM) F was responsible for discussing with residents or a resident's representative about their potential financial obligations after the issuance of the NOMNC.
During an interview with BOM (Business Office Manager) F on 12/15/2022, at 9:45 a.m., BOM F was asked who was responsible for issuing a SNF-ABN form to residents or their representatives, BOM F stated SSD E would issue the notices and BOM F was responsible for retaining resident-signed notices.
RESIDENT 62
During a record review for Resident 62, the Face sheet indicated Resident 62 was admitted on [DATE] with diagnoses including Left Femur Fracture (a break in the thigh bone), Hypertension (High Blood Pressure) and Chronic Obstructive Pulmonary Disease (COPD, diseases that cause airflow blockage and breathing-related problems).
During a record review for Resident 62, the MDS, dated [DATE], indicated Resident 62 began receiving Medicare benefits at the facility as of 10/17/2022. The MDS indicated Resident 62 received Orthopedic aftercare (e.g, the care provided after initial treatment of femur fracture has been performed, to aid the healing or recovery phase, or for the long-term consequences of the disease) at the facility.
Review of the form SNF Beneficiary Notification Review indicated Resident 62's last covered day of Medicare Part A Services was on 11/19/2022. The form indicated the facility initiated Resident 62's discharge from Medicare Part A Services when his benefit days were not exhausted. The facility indicated a SNF-ABN form was not provided to Resident 62 as the resident had been discharged from the facility and did not receive non-covered services.
During an interview and concurrent record review with SSD E on 12/15/2022, at 9:30 a.m., SSD E was asked why the SNF-ABN was not provided to Resident 62, and SSD E stated Resident 62 was discharged from the facility after he received the NOMNC. After review of the electronic health record for Resident 62 with SSD E, SSD E verified Resident 62 was still in the facility.
Review of the Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections, revised 1/21/2022, indicated: A [SNF-ABN] is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a [SNF-ABN] must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool completed by clinical staff) was accurately completed for five of five sampled residents (Resident 4, 50, 8, 29, and 42) when Residents 4, 50, 8, 29, and 42 did not receive follow-up Pneumococcal vaccination as recommended by the Centers for Disease Control and Prevention (CDC) but the MDS for each resident indicated their Pneumococcal vaccination was up-to-date. This failure resulted to residents not getting the recommended Pneumococcal vaccine, putting each at-risk for increased respiratory infection. (Reference F883).
Findings:
RESIDENT 4
During a record review for Resident 4, the Immunization Record indicated Resident 4 received PCV13 (PneumoConjugate, a version of pneumococcal vaccine) on 3/27/2015. The Immunization Record indicated Resident 4 was past due for Pneumococcal 23, since 5/22/2015.
During a record review for Resident 4, Section O0300 of the MDS, dated [DATE], indicated Resident 4's Pneumococcal vaccination was up-to-date.
RESIDENT 50
During a record review for Resident 50, the Immunization Record indicated Resident 50 received PCV13 on 11/06/2017. The Immunization Record indicated Resident 50 was past due for Pneumococcal 23, since 1/01/2018.
During a record review for Resident 50, Section O0300 of the MDS, dated [DATE], indicated Resident 50's Pneumococcal vaccination was up-to-date.
RESIDENT 8
During a record review for Resident 8, the Immunization Record indicated Resident 8 received PCV13 on 12/22/2016. The Immunization Record indicated Resident 8 was past due for Pneumococcal 23, since 2/16/2017.
During a record review for Resident 8, Section O0300 of the MDS, dated [DATE], indicated Resident 8's Pneumococcal vaccination was up-to-date.
RESIDENT 29
During a record review for Resident 29, the Immunization Record did not indicate Resident 29 received Pneumococcal vaccine. The Immunization Record indicated Resident 29 was past due for Pneumococcal 23, since 10/26/1991.
During a record review for Resident 29, Section O0300 of the MDS, dated [DATE], indicated Resident 29's Pneumococcal vaccination was up-to-date.
RESIDENT 42
During a review of the document titled Pneumococcal Immunization Informed Consent indicated Resident 42 received Pneumococcal vaccine few years ago.
During a record review for Resident 42, the Immunization Record did not indicate Resident 42 received Pneumococcal vaccine.
During a record review for Resident 42, Section O0300 of the MDS, dated [DATE], indicated Resident 42's Pneumococcal vaccination was up-to-date.
During an interview and concurrent record review with the MDS Coordinator (MDSC) on 12/16/2022, at 9:25 a.m., the MDSC was asked how she reviewed data related to a resident's Pneumococcal vaccination status and entered that data into residents' medical records. The MDSC stated she would either get the information through resident interview or record review. The MDSC stated residents over [AGE] years old would be given a one-time dose of Pneumococcal vaccine and she recorded each administered dose in the resident's MDS, indicating resident's Pneumococcal vaccination was up-to-date. The MDSC stated she was not aware of CDC or ACIP recommendations that PPSV23 (pneumococcal polysaccharide vaccine, which can protect against 23 types of pneumococcal bacteria) should be administered at least one year after a resident received PCV13.
Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, effective October 2019, under Section O0300: Pneumococcal Vaccine, indicated: 'Up to date' in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations.
Review of the Pneumococcal Vaccine Timing for Adults indicated, CDC recommends 1 dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least 1 year after PCV13 was received. Their pneumococcal vaccinations are complete. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf