Every finding on record at Adventist Health Delano

Based on interview and record review the facility failed to conduct pre-hire reference checks on Certified Nursing Assistant (CNA) 1 who was providing care for one of three sampled residents (Resident 1). This failure had the potential to expose vulnerable residents to abuse and/or other negative effects.Findings:During an interview on 6/3/26 at 10:14 a.m. with Quality Assurance (QA), QA stated on 5/24/26 Resident 1 had reported an allegation of abuse to his daughter that an unidentified male worker had struck him on the head. The daughter reported the allegation the same day (5/4/26). QA stated the facility identified two male workers that had recently worked with Resident 1. One of the workers was CNA 1.During a concurrent interview and record review on 6/3/26 at 11:23 a.m. with Human Resources (HR), CNA 1's employee file (EF) was reviewed. The EF indicated CNA 1 was hired on 9/30/24. The EF indicated no reference checks were conducted for CNA 1. HR stated the facility had stopped conducting reference checks in August of 2023 (specific date not indicated). HR stated a reference check for CNA 1 was not done.During a review of the facility's policy and procedure (P&P) titled, RECRUITMENT AND HIRING PROCESSPOLICY, dated 8/28/24, the P&P indicated, (The facility) will recruit and hire qualified candidates for available positions. (The facility) is committed to providing an inclusive and welcoming environment for all members of our communities and to ensuring that employment decisions are based on individuals' abilities and qualifications. Inquiries into the background of employees, volunteers and prospective employees are intended to comply with federal and state laws and are required as per the (facility) corporate compliance plan.

Based on observation, interview, and record review, the facility failed to develop, update, and implement a person-centered care plan (CP) for three of 15 sampled residents (Resident 39, Resident 17, and Resident 5). This failure had the potential for residents' immediate care needs to not be met. Findings: During a record review of Medical Record,Resident 39 was in a persistent vegetative state (appears awake but has no awareness of their environment) and post cranial post flap (surgical procedure removes a section of your skull) surgery. During an interview on 5/28/26 at 9:08 a.m. with Administrative Assistant (AA), AA stated she did not find updated care plan under neurology following the resident's post-surgical procedure. During a concurrent interview and record review on 5/28/26 at 9: 38 a.m. with Registered Nurse (RN) 1, Resident 39's CP was reviewed. RN 1 stated there should be a CP for neuro checks (check for changes in personality and behavior) after residents post cranial surgery. During a concurrent observation, interview, and record review, on 5/28/26 at 2:09 p.m. with RN 1, Resident 17 was in bed and had a bed alarm (a sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on. Resident 17's Medical Record (MR), [undated] was reviewed. RN 1 stated Resident 17 had a bed alarm for bed and for chair. RN 1 stated there was no care plan for the bed and chair alarm. During a concurrent observation, interview, and record review, on 5/28/26 at 2:52 p.m. with RN 1, Resident 5 was in bed and had a bed alarm on. Resident 5's Medical Record (MR), [undated] was reviewed. RN 1 stated Resident 5 had a bed alarm while in bed and when up in chair. RN 1 stated there was no care plan for the bed or chair alarm. RN 1 stated bed and chair alarm is considered a restraint and there should be a care plan prior to applying bed and chair alarm. During a review of the facility's policy and procedure (P&P) titled, Plan: Activities Assessments And Care Plan, dated 8/25/23, the P&P indicated, The plan is utilized by the nursing staff and nurse assistant to encourage and help the resident to participate in appropriate activities. The plan is updated every three months.

Based on observation, interview, and record review, the facility failed to ensure: 1) Two of two sampled residents (Resident 7 and Resident 2) had physician orders for foley catheter (a hollow tube inserted into the bladder to drain or collect urine) change and a feeding tube (a surgical opening fitted with a device to allow feedings to be) dressing change. These failures had the potential for Resident 7 and Resident 2 to have complications related to foley catheter and feeding tube care. 2) Blood pressure (physical force of circulating blood pushing against the walls of your arteries as your heart pumps through your body) was checked before administering the medication for one of four sampled residents (Resident 44). This failure had the potential not to meet Resident 44's needs.3) To follow its policy and procedure (P&P), tilted Nursing Assessment and Reassessment for Patients, for one of 15 sampled resident (Resident 39) when Resident 39 had no neurological assessments. This failure had the potential for adverse effects for Resident 39. Findings: 1. During a review of Resident 7's Electronic Health Record (EHR), dated 5/1/26, the EHR indicated Resident 7 had his foley catheter changed on 5/1/26. During a review of Resident 7's EHR, dated 4/11/26, the EHR indicated Resident 7 had his foley catheter changed on 4/11/26. During a review of Resident 7's EHR, dated 3/31/26, the EHR indicated Resident 7 had his foley catheter changed on 3/31/26. During a concurrent interview and record review on 5/28/26 at 1:43 p.m. with Registered Nurse (RN) 2, Resident 7's Physician Orders (PO), dated 2/20/26 was reviewed. The PO indicated, Foley Care BID (twice a day) Wound Management. RN 2 stated there was no PO for foley catheter change. RN 2 stated the RN's should get a PO for each foley catheter change for 5/1/26, 4/11/26, and 3/31/26. During a concurrent observation and interview on 5/28/26 at 3 p.m. in Resident 7's room with Licensed Vocational Nurse (LVN) 2, Resident 7 had a split gauze under his feeding tube. LVN 2 stated each resident that does not have any skin issues with their feeding tube gets a split gauze. LVN 2 stated Resident 7 does not have a PO for feeding tube dressing change. During a concurrent interview and record review on 5/28/26 at 3:30 p.m. with RN 2, Resident 7's Care Plan (CP), dated 12/10/25 was reviewed. The CP indicated, Tube feeding Insertion Care, Monitor for Complication. RN 2 stated there was no PO to change the dressing daily. During a review of the facility's policy and procedure (P&P) titled, Physician Services – Physician Orders, dated August 2025, the P&P indicated, All medications and treatments administered to the patient [resident] must be ordered by the attending physician such orders must be in writing and signed and dated by the prescribing. During a review of the facility's P&P titled, Administration of Medication, Feedings, via gastrostomy [feeding tube] . and Tube Site Care, dated August 2025, the P&P indicated, Dress the site per order. 2. During a review of Resident 44's Physician Order Review (POR), dated 10/14/24, the POR indicated metoprolol tartrate (used to treat high blood pressure) 25 milligram (mg - unit of measure) two times a day, hold this dose if heart rate (number of times our heart beats in one minute) less than 50, systolic (first beat) blood pressure less than 90 or diastolic (last beat) blood pressure less than 50. During a concurrent observation and interview on 5/28/26 at 9:32 a.m. with LVN 1, outside of Resident 44's room, LVN 1 was prepping the medication for Resident 44. LVN 1 prepped metoprolol tartrate 25 mg one tablet in the medication cup. LVN 1 stated blood pressure was checked around 8 a.m. by Certified Nursing Assistant. LVN 1 stated he did not recheck the blood pressure before administering the medication. During an interview on 6/1/26 at 8:53 a.m. with Pharmacist 1, Pharmacist 1 stated blood pressure for medication administration should be checked 10-15 minutes prior to administration of medication. 3. During a review of Resident 39's Medical Record (MR), undated, The MR indicated Resident 39 was in a persistent vegetative state (appears awake but has no awareness of their environment) and post cranial post flap (surgical procedure removes a section of your skull) surgery. During a concurrent interview and record review on 5/28/26 at 11:22 a.m. with RN 2, Resident 39's Nursing Progress Notes (NPN), dated 4/23/26 to 4/28/26 were review. The NPN indicated there were no neurological notes. RN 2 stated there were no NPN's. During an interview on 6/1/26 at 9:49 a.m. with Medical Doctor (MD), MD stated residents should get routine neurological checks and be documented by the nurses. During a review of the facility's P&P titled, Nursing Assessment and Reassessment for Patients, Policy #10215 dated 8/1/2019, the P&P indicated, Process of Ongoing Assessment. 3. RN's must perform a focused re-assessment [sic] for the following: C. To assess response to specific treatments/interventions.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement infection prevention and control action database identified by the survey team (F690). This failure placed all facility residents at risk for a Urinary Tract Infection (UTI-infection in the urine). Findings: During an interview and record review on 5/28/25 at 9 a.m. with Infection Preventionist Director (IPD), The Facility-Level Quality Measure (QM) Report, date 11/1/25 through 4/30/26 was reviewed. The QM indicated, the facility national percentage of UTI was at a 93 percentage. IPD stated the facility does not map UTI's. During an interview on 6/1/26 at 12:08 p.m. with Infection Preventionist (IP), the IP stated she was unaware of how the data is being reported and needs to get better at tracking the urinary catheter and UTI's. During a review of facility's Special Care Unit (SCU) Quality Assurance Meeting Minutes (Meeting Minutes), dated 1/21/26 was reviewed, the Meeting Minutes indicated Infection Preventionist Report denoted antibiotic utilization no action plan. During a review of the facility's Meeting Minutes, dated 4/29/26 was reviewed, the Meeting Minutes indicated Infection Preventionist Report denoted Prevention . [2025-74] UTI's requiring treatment. No action plan. During a review of the facility policy and procedure (P&P) titled, Team Conferences, dated 8/12/25, the P&P indicated, To ensure that the plan of care is appropriate with set goals that are meant to meet residents' needs and geared towards the provision of the highest quality care possible.

Based on interview and record review, the facility failed to ensure psychotropic (medication to treat mental disorders) medication consents were completed appropriately for two of four (Resident 17, and Resident 19) sampled residents. This failure had the potential for the residents to receive psychotropic medication without knowing all the risks and benefits.Findings:During a review of Resident 17's Psychotherapeutic Drug Informed Consent Form (PDICF), dated 3/27/26, the PDICF indicated, 10. Caution and Warning Summary.c) Black Box Warning Label was checked No. The PDICF was for Risperidone (used for mental disorders) 0.25 milligram (MG).During a review of Resident 17's PDICF, dated 3/27/26, the PDICF indicated, 10. Caution and Warning Summary.c) Black Box Warning Label was checked No. The PDICF was for Risperidone 0.5 MG.During an interview on 6/1/26 at 8:46 a.m. with Pharmacist 1, Pharmacist 1 stated risperidone does have black box warning. Pharmacist 1 stated black box warning label should be checked yes and risk and benefits should be explained to the resident or resident representative. During a concurrent interview and record review on 6/1/26 at 11:40 a.m. with Nurse Manager (NM), Resident 19's Consent for the Administration of Psychotropic Medications (CAPM), dated 9/24/25 was reviewed. NM stated the CAPM was for Zoloft (used to treat mental disorders) 25 mg and there was only one consent that was obtained on 9/24/25 and there was no other consent in Resident 19's chart.During a review of Psychotherapeutic Drug Informed Consent Form Instruction Sheet (PDICFIS), [undated] the PDICFIS indicated, 2. Within six months after the consent form is signed, and every six months thereafter during which the resident receives the psychotherapeutic drug, the facility shall reissue the Informed Consent form.10. Caution and Warning Summary - REQUIRED to select Yes/No for EACH item (a-c).During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Consent, dated 4/13/26, the P&P indicated, General Guidelines 1. All mental health patients have the right to accept or refuse antipsychotic medication and shall be treated with such medication only after completion of the informed consent process.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P), tilted Advanced Healthcare Directive, Surrogate Decision Maker, for two of 15 sampled residents (Resident 44 and Resident 7) who were unable to sign an Advance Directive (AD - legal document indicating resident preference on end-of-life treatment decisions). This failure had the potential for Resident 44 and Resident 7 wishes not to be honored.Findings:During a review of Resident 44's California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities (admission Agreement), dated 11/17/23, the admission Agreement indicated, the box on the admission and readmission Agreement Signature Sheet, which was meant to be checked or left blank for All signed Advance Directive, was left unmarked.During a review of Resident 44's Physician Orders for Life-Sustaining Treatment (POLST), dated 11/17/23, the POLST indicated, no advance directiveDuring a review of Resident 44's Social Services Evaluation (SSE), dated 5/13/26, the SSE indicated, Advance Directive .Pt [patient/resident] wishes to receive info [information] .Unable to obtain response from patient.During an interview on 5/27/26 at 2:01 p.m. with Family Member (FM) 1, and Registered Nurse (RN) 1, in Resident 44's room. FM 1 stated he told the facility he would sign for Resident 44 but did not sign any AD paperwork.During an interview on 5/27/26 at 4:11 p.m. with Social Services (SS), SS stated Resident 44 was incapacitated and unable to sign the admission Agreement that is why it is left blank. SS stated she did not have Resident 44's family or responsible party (RP) sign for the AD.During a review of Resident 7's admission Agreement, dated 3/17/26, the admission Agreement indicated, the box on the admission and readmission Agreement Signature Sheet, which was meant to be checked or left blank for All signed Advance Directive, was left unmarked.During a review of Resident 7's SSE, dated 5/20/26, the SSE indicated, Advance Directive .Pt wishes to receive info .Unable to obtain response from patient.During an interview on 5/28/26 at 2:36 p.m. with SS, SS stated Resident 7 was incapacitated and unable to sign the admission Agreement that is why it is left blank. SS stated she did not have Resident 7's family or responsible party (RP) sign for the AD During a review of the facility's P&P titled, Advanced Healthcare Directive, Surrogate Decision Maker, Policy # 13509, dated 9/17/24, the P&P indicated, 4. When a patient [resident] who lacks present decision making capacity (as determined by the admitting physician in consultation with family members and or close friends of the patient) is admitted to the hospital, the person responsible for documenting the admission shall provide information regarding advanced directives and direct questions regarding the existence of advanced directive to a relative or friend accompanying the patient. Regarding advanced directives, an inquiry into the existence of advanced directives shall be directed to the patient surrogate decision maker once the surrogate decision maker has been identified by the attending physician or licensed care provider.

Based on observation, interview, and record review, the facility failed to obtain physician's orders prior to the application of bed alarm (a sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of three sampled residents (Resident 5). This failure had the potential to result in violation of residents' rights.Findings:During a concurrent observation, interview, and record review, on 5/28/26 at 2:52 p.m. with Registered Nurse (RN) 1, Resident 5 was in bed and had a bed alarm on. During a review of Resident 5's Medical Record (MR), [undated] was reviewed. RN 1 stated Resident 5 had a bed alarm while in bed and when up in chair. RN 1 stated there was no physician order for the bed or chair alarm. RN 1 stated bed and chair alarm is considered a restraint and there should be a physician order prior to applying bed and chair alarm.During a review of facility's policy and procedure (P&P) titled, Physical Restraint and Reduction, dated 5/30/26, the P&P indicated, A physician's order is required before reducing restraints.9. A physical or Occupational Therapist shall be required to assess the following when restraint reduction is indicated: a. Kind of restraint used and time applied. B. Reason for reduction. C. Time released or removed and the length of time off.

Based on interview and record review, the facility failed to obtain a physician order for foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine) change for one of two sampled resident (Resident 2). This failure had the potential to result in Resident 2 having a Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) with the possibility of sepsis (a life-threatening blood infection).Findings:During a review of Resident 2's Care Plan (CP), dated 8/6/25, the CP indicated, Eval [Evaluate] for Symptoms of UTI.Plan Removal of Indwelling Cath [foley catheter].During a review of Resident 2's Flowsheet (FS), dated 5/16/26, the FS indicated, Resident 2 was running a 101.1 Fahrenheit (normal range from 97 - 100.4 ) temperature. During a review of Resident 2's Clinical Note Nursing (CNN), dated 5/21/26, the CNN indicated, Therapy for Sepsis. During a concurrent interview and record review on 5/28/26 at 3:36 p.m. with Registered Nurse (RN) 2, Resident 2's Physician Orders (PO), dated 2/17/26 was reviewed. The PO indicated, Resident 2 had no PO for a foley catheter change. RN 2 stated there should be a PO for foley catheter change. The PO dated 5/21/26 indicated ceftriaxone (Rocephin [antibiotic]) was ordered for a UTI. RN 2 stated Resident 2 had a UTI.During a concurrent interview and record review on 5/28/26 at 3:38 p.m. with RN 2, Resident 2's Urinary Catheter group (UC), dated 2/20/26 was reviewed. The UC indicated, Resident 2's last foley catheter change was on 2/20/26. RN 2 stated the process is foley catheters are changed every three months.During an interview on 5/28/26 at 3:45 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the process is foley catheters are changed every three months.During an interview on 5/28/26 at 3:47 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated foley catheter is changed two to four weeks by the LVN or RN that is the process with the order. CNA stated but the RN gets the order. During an interview on 5/28/2026 at 3:51 p.m. with LVN 3, LVN 3 stated the foley catheter is changed every 3 months. LVN 3 stated if there is sediment in the catheter, the catheter is not properly draining, or if it is clogged, then we (nursing) change it.During an interview on 6/1/26 at 10:11 a.m. with Infection Preventionist (IP), IP stated she expects the nurse to call the physician after the resident has had a foley catheter in for a long time and ask the physician if a foley change is needed. IP stated there is no length on time for the physician notification. IP stated the length of time Resident 2's foley catheter was not changed could have been the source of the infection.During a review of the facility's policy and procedure (P&P) titled, Performing Urinary Catheter Care, undated, the P&P indicates, Monitoring of signs/symptoms of catheter-associated UTI (CAUTI).monitor for fever.During a review of the facility's P&P titled, CAUTI Prevention Urinary Catheter Insertion and Maintenance, dated 5/16/25, the P&P indicated, Daily review of catheter necessity and prompt removal of unnecessary catheters is vital to CAUTI prevention.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 44 and Resident 14) maintain a medication error rate of less than five percent (5%) during the medication pass observation. This failure resulted in a medication error rate of 16% consisting of four medication errors in a sample size of 25 opportunities for error. Findings:During a concurrent observation and interview on 5/28/26 at 9:32 a.m. with Licensed Vocational Nurse (LVN) 1, outside of Resident 44's room, LVN 1 was prepping the medication for Resident 44. LVN 1 poured valproic acid (medication used to control seizures) 250 milligram (mg)/ml (milliliter -unit of measure), poured 5 ml in the medication cup. LVN 1 stated there was 5 ml of medication in the medication cup.During a concurrent interview and record review on 5/28/26 at 10:14 a.m. with LVN 1, Resident 44's Physician Order Review (POR), dated 5/20/26, was reviewed. The POR indicated valproic acid give 1500 mg (30ml) two times a day. LVN 1 stated wrong dose of medication was administered and not full dose of medication was administered.During a observation and interview on 5/28/26 at 10:43 a.m. with LVN 1, outside of Resident 14's room, LVN 1 was preparing the medication for Resident 14. LVN 1 prepared omeprazole (used to decrease the amount of acid in stomach) 40 mg capsule, losartan (treat high blood pressure) 25 mg 1 tablet, and amlodipine (to treat high blood pressure) 5 mg 1 tablet in medication cup. LVN 1 stated these medications were due at 9 a.m. LVN 1 stated time frame of giving medications was an hour before and an hour after. LVN 1 stated, I am little late today.During a review of facility's policy and procedure (P&P) titled, Medication Dosing Times, dated 4/28/26, the P&P indicated, Medications prescribed more frequently than daily but less frequently than every 4 hours - 2 hour window for medication administration.

Based on observation, interview, and record review, the facility failed to implement their intervention to turn and reposition one of three sampled residents (Resident 1) every two hours to prevent pressure ulcers (damage to the skin and underlying tissue from constant pressure, often on bony areas like the tailbone or heels, reducing blood flow, which can cause redness, blisters, and open sores, especially in people who can't move easily). This failure had the potential to cause further skin damage and/or prevent healing for Resident 1.Findings: During a review of Resident 1's PHYSICIAN FACE SHEET (PFS), 7/5/25, the PFS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including severe sepsis (a life-threatening medical emergency where the body's extreme response to an infection triggers a chain reaction, causing widespread inflammation that can damage tissues, lead to organ failure [a group of different tissues working together to perform a specific job in a living thing], and potentially death) with septic shock (a life-threatening stage of sepsis where a severe infection triggers an extreme immune response, causing widespread inflammation, dangerously low blood pressure, and organ dysfunction, meaning organs aren't getting enough blood and oxygen, leading to potential organ failure), ALS (Amyotrophic Lateral Sclerosis- a progressive brain and spinal cord disease that attacks nerve cells controlling voluntary muscles, causing them to weaken, waste away, and eventually stop working, leading to paralysis [inability to move] and difficulty with walking, talking, swallowing, and breathing, but typically leaves the mind and senses unaffected), and ventilator dependence (a machine that helps a person to breathe because they are unable to on their own). During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/3/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 0 (severe memory/thinking problems). Under section GG (assesses functional abilities and goals), Resident 1 was assessed to be completely dependent on staff for all aspects of care. Under section H (Bladder and Bowel), Resident 1 was documented to be always incontinent (unable to control bowel or bladder) of bowel and bladder. Under section M (Skin Conditions), Resident 1 was assessed to be at risk for developing pressure ulcers and was required to be on a turning/repositioning program. During a review of Resident 1's Wound Picture (WP), dated 10/15/25, the WP indicated, Resident 1 was assessed and found to have sacrum (a triangular bone shaped area at the base of the spine) shearing (a wound/injury that occurs when skin layers slide in opposite directions). The wound measured 3.5 by 5 by 0.2 cm (centimeters - a unit of measurement). During a review of Resident 1's Wound Pressure Injury Photo Note (WPIPN), dated 11/5/25, the WPIPN indicated, Resident 1 was identified to have a stage 3 pressure ulcer (skin has broken down that the fatty tissue underneath is visible and is prone to infection) to the sacrum. The WPIPN indicated, Pressure Injury (ulcer) NOT present on admit . (Resident 1) is complete assist in repositioning. Today's (11/5/25) wound assessment showed deterioration as evidenced by increased measurements and now with undermining (the tissue underneath the skin's surface has broken down, creating a 'pocket' or 'shelf' under the intact skin around the wound's edges, making the wound much larger and deeper than it looks). Please still continue interventions such as repositioning every two hours left and right . Reeducated staff about repositioning left and right . The WPIPN indicated the wound measured 3.3 x 4 x 1.5 cm with 1.5 cm of undermining. During a review of Resident 1's Resident Care Team Meeting (RCTM), dated 11/10/25, the RCTM indicated, Resident 1 had a sacral (sacrum) acute (a condition that started suddenly) skin failure full thickness wound (a wound that passes the two layers of the skin and exposes the fat underneath) with MASD (moisture associated dermatitis - inflammation of the skin caused by being continually moist, typically from bowel movements and urine) . Continue turning and repositioning (every) 2 hours . During an observation on 11/19/25 in Resident 1's room, the following was observed:On 11/19/25 at 11:25 a.m. - Resident 1 was lying on his left side with pillows to his backOn 11/19/25 at 1 p.m. - Resident 1 was lying on his left side with pillows to his backOn 11/19/25 at 1:15 p.m. - Resident 1 was lying on his left side with pillows to his backOn 11/19/25 at 2 p.m. - Resident 1 was lying on his left side with pillows to his back During an interview on 11/19/25 at 11:52 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was assigned to Resident 1 for the day. LVN 1 stated his concerns with Resident 1 was his pressure ulcer. LVN 1 stated the Certified Nursing Assistants (CNAs) should be turning and repositioning Resident 1 every two hours. During an interview on 11/19/25 at 12:41 p.m. with CNA 1, CNA 1 stated Resident 1 is to be turned and repositioned every two hours but sometimes the facility is short staff and CNAs could not turn and reposition the residents every two hours. CNA 1 could not explain how staff know when it is time to turn and reposition Resident 1. During an interview on 11/19/25 at 12:53 p.m. with CNA 2, CNA 2 could not answer how she knew when it was time to turn and reposition residents every two hours. CNA 2 stated most days residents wait more than two hours to be turned and repositioned. CNA 2 stated it possibly goes up to three hours before residents were turned and repositioned. During an interview on 11/19/25 at 1 p.m. with CNA 3, CNA 3 could not answer how she knew it was time to turn and reposition residents every two hours. CNA 3 stated she would try to remember when to turn and reposition the residents. CNA 3 stated residents at times have to wait to be turned and repositioned more than two hours when facility staff are busy. During an interview on 11/19/25 at 1:05 p.m. with Registered Nurse (RN) 1, RN 1 stated she was assigned to Resident 1. RN 1 stated Resident 1 is to be strictly turned and repositioned every two hours due to his stage 3 pressure ulcer. RN 1 stated she was not sure but believed Resident 1 was last turned at 11 a.m. During an interview on 11/19/25 at 1:16 p.m. with CNA 4, CNA 4 stated she attempts to turn and reposition her residents every two hours but at times it can go up to more than 30 minutes past due to not having enough staff. CNA 4 stated there was no organized method for staff to know when it is time to turn and reposition residents. During an interview on 11/19/25 at 1:21 p.m. with Wound Nurse (WN), WN stated Resident 1 had a stage 3 pressure ulcer to his sacrum. WN stated CNAs are to turn and reposition Resident 1 every two hours and she believed they (CNAs) know when it is time to turn. During a review of Resident 1 Electronic Medical Chart (EMC) under the section activity dated 11/19/25, the EMC indicated Resident 1 was last turned to his left side at 10:05 a.m. During a concurrent observation and interview on 11/19/25 at 1:47 p.m. with WN in Resident 1's room, WN stated Resident 1 was on his left side with pillows to his back and he should have been turned and reposition around 12 p.m. During an interview on 11/19/25 at 1:53 p.m. with Risk Manager (RM), RM stated the facility does not have a set process when it comes to knowing when it is time to turn and reposition a resident. During a review of the facility's policy and procedure (P&P) titled, PRESSURE INJURY OR SKIN/WOUND CONDITIONS -ASSESSMENT, PREVENTION AND MANAGEMENT, dated 5/4/22, the P&P indicated, For the purposes of this policy, a pressure injury refers to previous terminology used for pressure and decubitus ulcers. Unless contraindicated, reposition the patient at least every 2 hours if they are unable to reposition themselves, this can be accomplished through but not limited to repositioning in the bed, bed to chair, chair to bed, sit to stand, etc. Stage 1 Recommendations . Turn and reposition patient every 2 hours unless contraindicated . Offload (relieve pressure) affected area as much as possible. Stage 3 or 4 Recommendations . Follow Stage 1 nursing recommendations.

Based on observation, interview, and record review the facility failed to provide oral hygiene (the practice of keeping your mouth clean and disease-free) for one of three sampled residents (Resident 1). This failure had the potential to cause sickness and disease, tooth decay, bad breath, and decrease Resident 1's feelings of self-worth.Findings: During a review of Resident 1's PHYSICIAN FACE SHEET (PFS), dated 7/5/25, the PFS indicated Resident 1 is a [AGE] year old male who was admitted to the facility on [DATE] with the following diagnosis:a. Severe sepsis (a serious condition in which the body responds improperly to an infection) with septic shock (a life-threatening condition caused by infection),b. ALS (Amyotrophic lateral sclerosis - a disease that progresses over time causing loss of muscle control),c. Ventilator (a machine that blows air in and out of lungs) dependence, and;d. Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) During a review of Resident 1's MDS (minimum data set - an assessment tool) Assessment, dated 9/3/25, under section GG (assesses functional abilities and goals), Resident 1 was completely dependent on staff for all activities of daily living (ADL refers to the basic, everyday tasks a person does which includes personal care and hygiene (including oral), eating, dressing, bathing, moving, and using the bathroom. During an observation on 11/5/25 at 11:32 a.m. in Resident 1's room, Resident 1 was in bed unable to verbally respond and minimally able to move eyes up and down when spoken to. Resident 1's lips were dry and had dry flaky skin particles throughout the upper and lower lips. Resident 1's teeth were covered in a white to yellowish sticky debris. Resident 1's tongue was covered with white to yellow debris/film (bacteria and food get caught between the tiny bumps on your tongue's surface if not properly and consistently cleaned) that elevated approximately 1/16 of an inch (a unit of measurement). During a concurrent observation and interview on 11/25/25 at 11:39 a.m. with Director of Staff Development (DSD - a nurse who oversees the training and development of nursing staff in a healthcare facility) in Resident 1's room, Resident 1's mouth and tongue were observed. DSD stated Resident 1's mouth and tongue, Needs to be cleaned. they [staff] should be doing it [oral hygiene] every shift . I think they [staff] do it [oral care for Resident 1], but they need to do it [oral care] better. During an interview on 11/25/25 at 11:53 a.m. with Respiratory Technician (RT 1), RT 1 stated, he had provided Resident 1 oral care earlier in the day (11/25/25) but Resident 1 is difficult to clean (could not specify). RT 1 stated he had not reported difficulties with cleaning Resident 1's mouth with his nurse and/or his supervisor. During a concurrent interview and record review on 11/25/25 at 12:09 p.m. with Quality Assurance Professional (QAP), Resident 1's Dental Care Plan (DCP), dated 8/2/25 was reviewed, the DCP indicated Resident 1 was to have staff assist with oral care to remove food debris. QAP reviewed the CPs and was not able to find documentation indicating Resident 1 had or caused difficulties with provision of oral care. During a review of the facility's policy and procedure (P&P) titled, ORAL CARE UTILIZING SUCTION TOOTHBRUSH, SOFT TOOTHBRUSH AND (PLAC-VAC) ORAL EVACUATOR BRUSH [an instrument for dental cleaning], dated 12/18/24, the P&P indicated, The purpose of the procedure is for all residents to receive appropriate oral care for hygiene and to contribute to the resident's sense of well-being. Brush cheeks, palate and tongue to remove mucous film . Apply petroleum based lubricant, if mouth or lips are cracked and dry.

Based on interview and record review, the facility failed to implement their policy and procedure on abuse for one of three sampled residents (Resident 1) when the staff accused was not separated from providing resident care. This failure had the potential for other residents to be abused. Findings: During a review of Resident 1's CODING SUMMARY (CS), dated 4/10/25, the CS indicated Resident 1 had a diagnosis of Tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] through the front of the neck. This opening allows a tube to be inserted to maintain an airway and allow breathing) status, and cerebral infarction (loss of blood flow to a part of the brain resulting in brain tissue death).During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 7/10/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is), the BIMS score was 15 (cognition intact). During a review of Resident 1's Investigation Report Summary (INRS), dated 8/18/25, the INRS indicated on 8/17/25 Resident 1 made an allegation using a communication/letter board (a tool used to facilitate communication for patients who may have difficulty expressing their needs verbally) that Certified Nursing Assistant (CNA) 1 was, bullying him. The INRS indicated, Per investigation the resident (1) expressed his concern on 8/17/2025. He is alert and able to express wants and needs using a letter board to communicate. During an interview on 8/20/25 at 11:08 a.m. with Nursing Facility Supervisor (NFS) and Quality Assurance Nurse (QAN), NFS stated he was made aware that Resident 1 made an allegation of abuse on 8/17/25 when he arrived at work on 8/18/25. NFS stated he is the abuse coordinator for the facility. NFS and QAN both stated CNA 1 was not removed from the facility nor supervised after the allegation of abuse was made. During a review of the facility's Employee Timecards (ETC), dated 8/17/25 (date allegation of abuse was made), the ETC indicated, CNA 1 worked on 8/17/25 from 6:57 a.m. to 7:28 p.m. During an interview on 8/20/25 at 2:44 p.m. with CNA 1, CNA 1 stated on 8/17/25 she assisted CNA 2 with providing care to Resident 1 sometime in the morning (time not specific). CNA 1 stated around 11:48 a.m. Resident 1 made an allegation of abuse that she was bullying him. CNA 1 stated Registered Nurse (RN) 1 was made aware of the allegation and instructed CNA 1 to no longer go into Resident 1's room. CNA 1 stated she continued to work her shift but did not return to Resident 1's room. CNA 1 stated she was not supervised nor asked to be removed from the facility after the allegation of abuse was made.During an interview on 8/20/25 at 3:27 p.m. with RN 1, RN 1 stated she worked on 8/17/25. RN 1 stated sometime during late morning (specific time not given) CNA 2 reported to her that Resident 1 made an allegation of abuse regarding CNA 1 bullying him. RN 1 stated she spoke with CNA 1 and asked her to stay away from Resident 1's room. RN 1 stated she did not remove CNA 1 from the facility and/or have her supervised.During a review of the facility's policy and procedure (P&P) titled, ,Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation dated 5/2/24, the P&P indicated, Patients (Residents) have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this (facility) to protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members . In instances of investigations concerning a staff member's behavior, it is preferable to assign the involved staff member non-patient care activities, if possible. The (facility) has the obligation and responsibility to protect both the rights of the staff member and the rights of the patient. The staff member's investigation should be conducted fairly and in a confidential manner, involving only those individuals in the investigation that have a need to know. The staff member should not be unjustly accused because an allegation has been rendered. All allegations should be immediately and thoroughly investigated until conclusion. However, the rights and protection of the patient should not be compromised in the essence of fairness toward the staff member. Therefore, it is the responsibility of the hospital to separate the staff member and the patient until conclusion of the investigation. The hospital must also protect other patients from the acts of the staff member should these acts prove true. Therefore, assignment of the involved staff member to non-patient care activities would be optimum. If circumstances do not allow for this option, the staff member's interaction with patients must be monitored at all times during the investigation.

Based on observation, interview, and record review, the facility failed to provide services to maintain vision for one of three sampled residents (Resident 1) when the facility failed to: 1. Administer Lumigan (prescription medicated eye drops that helps reduce intraocular pressure-the fluid pressure in the eyes. If the pressure is too high, it can cause irreversible vision loss) as ordered by the ophthalmologist (OPTH - medical doctors who specialize in all aspects of eye care). 2. Arrange the follow-up appointment with OPTH as ordered for continued eye assessment and care management. These failures resulted in Resident 1 experiencing pain, headaches, photosensitivity (sensitivity to light), blurry vision, increased intraocular pressure, and potential to result in neovascularization (abnormal blood vessel growth that can result in bleeding, swelling, and vision loss) in the left eye due to presumed (suppose that something is the case on the basis of probability) ischemia (lack of blood supply).Findings:1. During a review of the facility Resident Appointment Calendar (RAC), dated 2025, the RAC indicated Resident 1 was seen by OPTH on 2/11/25. During a review of Resident 1's OPTH Notes (OPTHN), dated 2/11/25, the OPTHN indicated Resident 1 was to start Lumigan eye drops at night. During a review of Resident 1's ORDER SHEET (OS), dated 2/11/25, the OS indicated Resident 1 was to start Lumigan one drop to both eyes for 12 months starting on 2/11/25. During a review of the facility Social Services Concern Log (SSCL), dated 4/9/25, the SSCL indicated, Resident 1 wanted all the lights in his room to remain off due to pain in his eyes from the light. The SSCL indicated Social Services Director (SSD) informed Resident 1 that his roommate (Resident 2) had the right to have his side of the room light on. The SSCL indicated Resident 1 requested to be moved to another room where the entire room lights can remain off, but the facility was not able to accommodate. On 6/17/25 the SSCL indicated, Resident [1] attended [OPTH appointment] on 6/17/25. Found out his [Resident 1] drops (Lumigan) had not been continuous [sic] and did not attend March [2025] f/u [follow up appointment]. During an interview on 7/2/25 at 9:57 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had a loss of vision to his left eye due to the facility not giving his Lumigan eye drops as ordered by the OPTH. During a review of Resident 1's CODING SUMMARY (CS), dated 4/10/25, the CS indicated Resident 1 had a diagnosis of Tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] through the front of the neck. This opening allows a tube to be inserted to maintain an airway and allow breathing) status, and cerebral infarction (loss of blood flow to a part of the brain resulting in brain tissue death). During a review of Resident 1's Minimum Data Set (MDS - comprehensive assessment tool), dated 7/10/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - an assessment of how well a person thinks, remembers, and learns) score was 15 (score of 13-15 means mentally intact). During a concurrent observation and interview on 7/15/25 at 2:01 p.m. with Resident 1 in Resident 1's room, Resident 1 was lying in bed in his darkened room with all lights off. Resident 1 had reddened lines to the white portion of his left eye. Resident 1 was using a communication board (a board with letters, symbols, and/or photos that allow a person who cannot speak to communicate) and using his head in a yes or no fashion. Resident 1 stated, I am going blind. Resident 1 stated he had pain in both eyes at a level of 9 out of 10 pain scale (A pain scale score of 9 signifies excruciating, very severe pain that is difficult to bear). During an interview on 7/15/25 at 2:15 p.m. with Registered Nurse (RN) 1, RN 1 stated, she was assigned to Resident 1 and had been assigned to him in the past several months. RN 1 stated Resident 1's room is kept dark because the light bothers his eyes. RN 1 stated there was recently an issue with Resident 1 not getting his medicated eye drops (was not specific on name of medication) for approximately a month and a half. During an interview on 7/15/25 at 2:40 p.m. with SSD, SSD stated during an interdisciplinary meeting (IDT - a gathering of healthcare professionals from various disciplines to discuss and coordinate a patient's care plan) (date not given) with FM 1 regarding Resident 1. SSD stated Resident 1's Lumigan eye drops were stopped after he had to go to the emergency department (ED) for chest pain (date not specific) and when he returned there was a miscommunication (not specified) about the Lumigan eye drop orders, and they (eye drops) were not resumed despite no order to discontinue. During an interview on 7/15/25 at 3:17 p.m. with Nursing Facility Supervisor (NFS), NFS stated Resident 1 was sent to the ED (Emergency Department/Hospital) on 4/10/25 for complaints of chest pain and was admitted to the acute hospital. NFS stated Resident 1 returned to the facility on 4/12/15 but the orders for his Lumigan eye drops were dropped for some unknown reason. NFS stated Resident 1 did not start his Lumigan eye drops again until after his OPTH appointment on 6/17/25 (two months and five days after his last dose). NFS stated, My opinion is they [acute hospital] dropped the ball [Resident 1's Lumigan eye drop order] and we [facility staff] should picked it [Lumigan eye drop] back up. During a review of Resident 1's Medication Administration Record Report ([NAME]), dated 2025, the [NAME] indicated the following: a. 4/1/25 until 4/9/25, Resident 1 received his Lumigan eye drops to both eyes. b. 4/12/25 4/30/25 - After returning from the acute hospital, Resident 1 was not given his Lumigan eye drops. c. 5/1/25 until 5/31/25, Resident 1 did not receive his Lumigan eye drops. d. 6/1/25 until 6/17/25, Resident 1 did not receive his Lumigan eye drops. e. 6/18/25 until 6/30/25, Resident 1 was restarted on Lumigan eye drops to both eyes. During a review of Resident 1's OPTH Specialist Note (OPTHSN), dated 7/29/25, the OPTHSN indicated, On December 19, 2024, [Resident 1] . intraocular pressure was 17 mmHg [millimeters of mercury, a unit of measurement of pressure exerted by a column of mercury one millimeter high] in the right eye and 46 (mmHg) in the left eye. Moderate ptosis [drooping/sagging of the upper eyelid] was present as well as cataract [a medical condition in which changes to the lens of the eye causes blurred vision and whitening] changes. Lumigan drop(s) was ordered to the left eye for his elevated intraocular pressure. His next visit was in three to four weeks. On February 11, 2025, he [Resident 1] was seen for a follow up examination. He was not on the eyedrops (Lumigan) that were prescribed. His intraocular pressure was 13 and 34 in the right and left eye respectively. Corneal edema [a condition where the cornea, the clear front surface of the eye, swells due to excess fluid] was present in the left eye. He was reordered the Lumigan to the left eye . His next follow up was in approximately next month. He was seen on June 17, 2025. The patient relayed a history of pain with headaches, photosensitivity and blurry vision. Ascertained (found out) at 20/400 (mmHg) in the right eye and no light perception [the ability to detect the presence or absence of light, distinguishing it from darkness] in left eye. The examination is noteworthy for dense milky white cataract, left eye much worse than right. He also was not using his prescribed eyedrops. Patient [Resident 1] was also noted to have neovascularization in the left eye due to presumed ischemia. Orders for the Lumigan . to both eyes were prescribed. During a review of the facility's policy and procedure (P&P) titled, MEDICATION ADMINISTRATION (MA), dated 4/10/24, the P&P indicated, All patient care areas where medications are administered are affected by this policy . Medications at [facility] will be administered only upon the order of physicians . Nursing staff assumes the responsibility of retrieving and administering medications based on complete and validated orders. In all areas, this includes responsibility for accurate documentation of medication administration. 2. During a review of Resident 1's RESIDENT PROGRESS NOTES (RPN), dated 2/11/25, the RPN indicated, Resident 1's OPTH scheduled Resident 1 to be seen again on 3/11/25 at 2:30 p.m. During a review of the facility RAC, dated 2025, the RAC indicated Resident 1 was not scheduled by the facility for the 3/11/25 appointment per OPTH. During an interview on 7/2/25 at 9:57 a.m. with FM 1, FM 1 stated Resident 1 did not go to his OPTH appointment on 3/11/25. FM 1 stated she was unaware of Resident 1's appointment on 3/11/25 until Resident 1 was seen by OPTH in June 2025. During an interview on 7/15/25 at 2:40 p.m. with SSD, SSD stated Resident 1 missed his OPTH appointment on 3/11/25 because the nurse (not specified who) did not place it into the RAC. During an interview on 7/17/25 at 1:22 p.m. with NFS, NFS stated the process the facility takes for resident appointments is to verify the order, log the appointment in the facility RAC, notify family of appointment, and ensure appropriate staff are scheduled to go with the resident. NFS stated it appeared as, the nurse (not specified) who received orders on 2/11/25 for Resident 1's follow up with OPTH on 3/11/25 did not verify the order nor place it into the facility RAC. During an interview on 8/8/25 at 1:49 p.m. with Quality Assurance Nurse (QAN), QAN stated the facility did not have a policy and procedure for resident appointments.

Based on interview and record review the facility failed to follow their policy and procedure on, ADVERSE EVENT (an undesirable medical occurrence) REPORTING, for one of three sampled residents (Resident 1) when a medication error resulting in harm was not reported to the California Department of Public Health (CDPH). This failure had the potential for Resident 1 continually experience adverse health outcomes. Findings:During an interview on 7/2/25 at 9:57 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had a loss of vision to his left eye due to the facility not giving his Lumigan (prescription medicated eye drops) for intraocular pressure (the fluid pressure in the eyes. If the pressure is too high, it can cause irreversible vision loss. Normal pressure is from 10 and 21 mmHg [millimeters of mercury - a unit of measurement]) as ordered by his ophthalmologist (OPTH - medical doctor who specialize in all aspects of eye care). During a review of Resident 1's ORDER SHEET (OS), dated 2/11/25, the OS indicated, Resident 1 was to start Lumigan one drop to both eyes for 12 months starting on 2/11/25.During an interview on 7/15/25 at 2:15 p.m. with Registered Nurse (RN) 1, RN 1 stated, she was assigned to Resident 1 and had been assigned to him in the past several months. RN 1 stated Resident 1's room is kept dark because the light bothers his eyes. RN 1 stated there was recently in issue with Resident 1 not getting his medicated eye drops (not specified) for approximately a month and a half. During an interview on 7/15/25 at 2:40 p.m. with SSD, SSD stated during an interdisciplinary meeting (IDT - a gathering of healthcare professionals from various disciplines to discuss and coordinate a patient's care plan) (date not given) with FM 1 regarding Resident 1. SSD stated Resident 1's Lumigan eye drops were stopped after he had to go to the emergency department (ED) for chest pain and when he returned there was a miscommunication (not specified) about the Lumigan eye drop orders, and they were not resumed despite no order to discontinue. During an interview on 7/15/25 at 3:17 p.m. with Nursing Facility Supervisor (NFS), NFS stated Resident 1 was sent to the ED on 4/10/25 for complaints of chest pain and was admitted to the acute hospital. NFS stated Resident 1 returned to the facility on 4/12/15 but the orders for his Lumigan eye drops were dropped for some unknown reason. NFS stated Resident did not start his Lumigan eye drops again until after his OPTH appointment on 6/17/25 (two months and five days after his last dose). NFS stated, My opinion is they [acute hospital] dropped the ball [Resident 1's Lumigan eye drop orders] and we should of picked it [Lumigan eye drop] back up. During a review of Resident 1's Medication Administration Record Report ([NAME]), dated 2025, the [NAME] indicated the following:a. April 1st to the 9th - Resident 1 received his Lumigan eye drops to both eyes. b. April 12th to the 30th - After returning from the acute hospital, Resident 1 was not given his Lumigan eye drops.c. May 1st to the 31st - Resident 1 did not receive his Lumigan eye drops. d. June 1st to the 17th - Resident 1 did not receive his Lumigan eye drops.e. June 18th to June 30th - Resident 1 was restarted on Lumigan eye drops to both eyes.During a review of OPTH Specialist Note (OPTHSN), dated 7/29/25, the OPTHSN indicated, On December 19, 2024, [Resident 1] . intraocular pressure was 17 [mmHg-millimeter mercury, unit of pressure measurement] in the right eye and 46 [mmHg] in the left eye. Moderate ptosis [drooping of the upper eyelid] was present as well as cataract [a medical condition in which changes to the lens of the eye causes blurred vision and whitening] changes. Lumigan drop(s) was ordered to the left eye for his elevated intraocular pressure. His next visit was in three to four weeks. On February 11, 2025, he [Resident 1] was seen for a follow up examination. He was not on the eyedrops [Lumigan] that were prescribed. His intraocular pressure was 13 and 34 in the right and left eye respectively. Corneal edema (a condition where the cornea, the clear front surface of the eye, swells due to excess fluid) was present in the left eye. He was reordered the Lumigan to the left eye . His next follow-up was in approximately next month. He was seen on June 17, 2025. The patient relayed a history of pain with headaches, photosensitivity and blurry vision. Ascertained [found out] at 20/400 (mmHg) in the right eye and no light perception [the ability to detect the presence or absence of light, distinguishing it from darkness] in left eye. The examination is noteworthy for dense milky white cataract, left eye much worse than right. He also was not using his prescribed eyedrops. Patient [Resident 1] was also noted to have neovascularization in the left eye due to presumed ischemia. Orders for the Lumigan . to both eyes were prescribed. During a concurrent interview and record review on 7/15/25 at 3:35 p.m. with Quality Assurance Nurse (QAN), the facility's policy and procedure (P&P) titled, ADVERSE EVENT REPORTING, dated 5/9/23 was reviewed. The P&P indicated, This policy ensures complaint with the requirements of applicable federal and state laws and the standards of applicable accrediting organizations as they relate to reportable event requirements. In addition this policy clarifies and delineates the responsibilities of staff members with respect to reportable events and provides opportunities for integrating risk reduction strategies into patient safety activities. Adverse events are events that include any of the following . Patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment or drug selection and dose. QAN stated the facility had not reported the adverse event regarding Resident 1's Lumigan eye drops. QAN stated, We [facility] obviously did not follow the policy [on adverse event reporting].

Based on observation, interview, and record review, the facility failed to have a qualified full-time Director of Activities (the staff responsible for facility's resident activities program), for 45 of 45 residents. This failure had the potential for residents' activities needs to go unmet. Findings: During an interview on 4/9/25 at 3:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was taught how to fill out the Activities Evaluation in CERNER (an electronic health record charting system) and in paper chart by a unit clerk last month. CNA 1 stated the Director of Activities had been out on medical leave since February 2025. During an interview on 4/9/25 at 3:59 p.m. with Registered Nurse Manager (RNM) 1, RNM 1 stated the facility's Director of Activities had been out on medical leave since February 2025. RNM 1 stated the facility did not have an interim Director of Activities. RNM 1 stated there were CNAs who were trained to assess and complete the Activities Evaluation and to ensure activities were conducted in the facility. RNM 1 stated the facility did not currently have a Director of Activities. The facility was unable to provide a Job Description for Activities Director upon request. During a review of the facility's policy and procedure (P&P) titled, FACILITY POLICY: ACTIVITIES PROGRAM - GENERAL POLICIES, dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: The purpose of the activities program is to provide the highest quality of life possible for each resident. f. Responsibilities .ii. It is the responsibility of the Director of Nursing of Adventist Health [NAME] [sic] to see that the activities person is hired, trained and provided with necessary equipment to run the program .iv. It is the responsibility of the activities person for the daily activities functions of the program and for developing a quality assurance program for the unit .D. ACTIVITIES PROGRAM SUPERVISON 1. The resident activity program is under the direct supervision of an Activities Coordinator. 2. The Activities Coordinato [sic] is responsible for: a. Planning, Coordinating, and directing a program of activities that provides entertainment, Intercommunication, exercise, relaxation, opportunity to express creative talents, and to fulfill basic psychological, social and emotional needs .c. Working with the residents attending physician and with nursing services, as well as other support services, in planning the residents individualized activities plan .e. Paticipating [sic] in resident assessents [sic], resident care meeting, etc., in planning for the resident's total plan of care. 3. The Activities Coordinator, in conjunction with the Clinical Director, has the responsibility and accountability to implement the esblished [sic] resident activity policies and procedures.

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: STORAGE OF FOODS/PHYSICAL ENVIRONMENT, when two of six canned garbanzo beans with dents (Can 1 and Can 2) were not removed from the dry storage room. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) in all 12 of 45 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 4/7/25 at 7:40 a.m. with Lead [NAME] (LC), in the Dry Food Storage Room, LC inspected the 12 ounce cans of garbanzo beans for dents. LC removed two cans from the six cans of garbanzo beans. Can 1, 12-ounce garbanzo bean can, had a dent at the seam approximately 2 inch long and 1/2 inch deep; Can 2 had an approximately 2 inch long and 1/2 deep dent. LC stated the dented garbanzo bean cans should not be in the dry food storage area with other canned foods for resident use. LC stated two out of six garbanzo bean cans had dents. LC stated the dented garbanzo bean cans posed a food safety risk and should be removed. During a concurrent interview and record review on 4/7/25 at 10:25 a.m. with LC, the facility's policy and procedure (P&P) titled, FACILITY PROCEDURE: STORAGE OF FOODS/PHYSICAL ENVIRONMENT, dated 5/1/24 was reviewed. The P&P indicated, Department food equipment and products must be maintained in a manner that ensures an acceptable level of safety and quality. 2. Separate storage area shall be provided for the following items. A. Food (canned) . R. Any dented can shall be placed in the dented can section for return/credit. LC stated the P&P was not followed and should have been.

Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff disinfected a glucometer (a device that measures the amount of sugar in the blood) with approved wipes for three of three sampled residents (Resident 17, and Resident 40). This failure had the potential to cause infection and spread of bacteria to residents. 2. Implement their policies and procedures titled FACILITY POLICY:ENHANCED BARREIR PRECAUTIONS IN SCU [Specialty Care Unit], and FACILITY POLICY: Infection Control in SCU for four of four sampled residents (Resident 37, Resident 32, Resident 12 and Resident 2) when: 2a.Correct Infection Control Precaution (ICP, actions taken to reduce potential of transmitting infections/germs) signage was not posted for two of four sampled residents (Resident 37, Resident 32, and Resident 12). This failure had the potential to spread disease causing organisms (germs) to other residents, staff and ultimately the community. 2b. Emergency Medical Technician Transport (EMTT) did not dispose of his personal protective equipment (PPE- disposable gown, gloves, mask, and eye protection) and clean his hands after providing care for one of four sampled residents (Resident 2). This failure had the potential to spread germs to other residents, staff and ultimately the community. Findings: 1. During a concurrent observation and interview on 4/8/25 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 used a Super Sani-Cloth Germicidal Disposable Wipe (cleaner and disinfectant) to disinfect the glucometer after checking Resident 17's finger stick blood sugar (FSBS). LVN 1 stated she always used the purple top (Super Sani-Cloth Germicidal Disposable Wipe) Sani-Cloth to clean the glucometer after each resident use. During an observation on 4/8/25 at 11:34 a.m. in the hallway, LVN 1 used a Sani-Cloth wipe to disinfect the glucometer after checking Resident 40's FSBS. During an observation on 4/8/25 at 11:42 a.m. in the hallway, LVN 1 used a Sani-Cloth wipe to disinfect the glucometer after checking Resident 34's FSBS. During an interview on 4/9/25 at 9:54 a.m. with Infection Preventionist Interim (IPI), IPI stated the facility uses the Sani-Cloth wipes to disinfect glucometers. IPI stated the Sani-Cloth wipes do not contain bleach. IPI stated the Sani-Cloth wipes contain 55% Isopropyl Alcohol. During a review of the glucometer machine's manufacturer guidelines titled MODEL PROCEDURE: POINT OF CARE TESTING NOVA STATSTRIP GLUCOSE METER, (Manufacturer Guidelines), dated 5/9/24, the Manufacturer Guidelines indicated, 2. Clean the meter .b. Clean the meter with hospital approved germicidal bleach products that are EPA [Environmental Protection Agency]-registered to be bactericidal, virucidal . During a review of the Super Sani-Cloth Germicidal Wipes Material Safety Data Sheet (MSDS, provides information about product including chemical make-up), dated 09/07/2023, the MSDS indicated 3. Composition/information on ingredients .Isopropyl alcohol, Quaternary ammonium compounds [antimicrobial, preservative], n-Alkyl Dimethyl Benzyl Ammonium Chloride [cleaning agent]. During a review of the facility's policy and procedure (P&P) titled, INFECTION CONTROL IN SCU, dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: To provide a safe environment for residents in Special Care Unit for a prolonged period of time, if not for the remainder of their lives, and to prevent the development and transmission of disease and infection. 47095 2a. During a concurrent observation and interview on 4/7/25 at 8:10 a.m. with LVN 1, in Resident 37's room doorway, a Contact (type of precautions to take) ICP sign was on the door. LVN 1 stated Resident 37 was on Contact precautions. LVN 1 stated she did not know about the different types of infection control precautions. LVN 1 stated she would need to ask the charge nurse what contact precautions were and why Resident 37 had contact precautions. LVN 1 stated she should know about the different types of ICPs and the reason a resident was on ICP. During a concurrent interview and record review on 4/7/25 at 8:21 a.m. with Registered Nurse (RN) 1, Resident 37's Medical Record Isolation Section (MRIS) was reviewed. The MRIS indicated Resident 37's current ICP was standard (no additional precautions). The MRIS did not indicate Resident 37 currently had contact precautions ordered. RN 1 stated Resident 37's Contact ICP signage was incorrect. RN 1 stated the facility's residents were on Enhanced Barrier Precautions (EBP, set of precautions designed to reduce the transmission of multidrug-resistant organism germs [MDRO]) unless other precautions were ordered. RN 1 stated Contact ICP was different from EBP. RN 1 stated Contact ICP was ordered and implemented when a resident had an existing infection. RN 1 stated Resident 37 did not have an existing infection. RN 1 stated Resident 37 should be on EBP. During an observation on 4/8/25 at 8:10 a.m. EBP signage was posted on Resident 32's door. During a concurrent interview and record review on 4/8/25 at 9:05 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), Resident 32's MRIS was reviewed. The MDSC stated Resident 32's MRIS indicated Resident 32' was on contact precautions. During a concurrent observation and interview on 4/8/25 at 9:07 a.m. with MDSC, an EBP sign was posted on Resident 32's door. MDSC stated Contact precautions were ordered for Resident 32 MDSC stated she did not know why EBP signage was posted when the current order was contact. During a concurrent interview and record review on 4/8/25 at 9:14 a.m. with MDSC, Resident 32's Order Sheet (OS), dated 6/10/24 was reviewed. The OS indicated, Isolation. Continuous Order, Contact Precautions, C-Auris [Candida Auris, MDRO] Positive. MDSC stated Resident 32 should have the most current isolation order implemented. MDSC stated Resident 32's current order was for contact precaution. During a concurrent observation and interview on 4/7/25 at 9:30 a.m. with LVN 3, at Resident 12's room, an enhanced barrier precautions (EBP- infection control to protect high risk for infection residents) sign was posted on the door. LVN 3 stated Resident 12 was on EBP's, and she did not know what EBP meant. LVN 3 stated she should know about the different types of ICPs and the reason a resident was on ICP. During a concurrent interview and record review on 4/9/25 at 9 a.m. with Registered Nurse Manager (RNM) 2 the facility's document titled, Sign In Sheet, dated 6/3/24 was reviewed. The Sign In Sheet indicated, Meeting Title: EBP Meeting Begins: 0900 Ends: 09:10 Length: 10 mins Location SCU. Name. [LVN 3 attendance signature]. [LVN 4 attendance signature]. ENM 2 stated LVN 1 signature was not on the attendance training log. During a concurrent interview and record review on 4/9/25 at 1:56 p.m. with Registered Nurse Manager (RNM) 2, the facility's document titled, Contact Isolation LIST SPECIAL CARE UNIT undated was reviewed. The Contact Isolation LIST indicated four residents were on contact isolation. RNM 2 stated the Contact Isolation List was last updated on 4/7/25. The Contact Isolation LIST indicated Resident 32 was on the list of four residents on the Contact Isolation List. RNM 2 stated Resident 32 was on contact precautions. During a review of the facility's ICP sign titled, Contact Precautions (undated), the ICP sign indicated Everyone must:/Todos deben: [spanish translation] Clean hands when entering and leaving the room .Wear a gown before entering the room .Wear gloves before entering the room .Equipment/upplies: Dedicate the use of non-critical patient care equipment to a single patient when possible (Thermometer, stethoscope, blood pressure cuff) Disinfect reusable equipment with a hospital approved disinfectant wipe after use on a patient. During a review of the facility's ICP sign titled, Enhanced Barrier Precautions (undated), the ICP sign indicated Everyone must: Clean their hands, including before entering and leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering/ Transferring, Changing Linens, Providing Hygiene .Do not wear the same gown and gloves for the care of more than one person. During an interview on 4/10/25 at 11:41 a.m. with IPI, IPI stated he was responsible for updating the precaution levels for residents. IPI stated ICP's were expected to be accurate, current, and implemented as ordered. IPI stated the nurses were expected to be up to date with ICP education and knowledgeable regarding the ICPs. 2b. During an observation on 4/8/25 at 10:07 a.m., in the doorway of Resident 2's room, EBP sign was posted on Resident 2's door. EMTT assisted transfer of Resident 2 from a gurney (bed on wheels) back to Resident 2's bed wearing a gown and gloves. During an observation and interview on 4/8/25 at 10:12 a.m., in the hallway near Resident 2's room, with LVN 4, EMTT exited Resident 2's room with his gown and gloves on. EMTT did not remove his gown, gloves, and clean his hands before exiting Resident 2's room. LVN 4 stated EMTT should have removed the used gown, gloves, and cleansed his hands prior to exiting Resident 2's room. During an interview on 4/8/25 at 10:14 a.m. with EMTT, EMTT stated he should have removed his used gown, gloves, and cleansed his hands prior to exiting Resident 2's room. EMTT stated it was important to follow infection control procedures to prevent the spread of germs. During a review of the facility's ICP sign titled, Enhanced Barrier Precautions (undated), the EBP sign indicated, EVERYONE MUST: Clean their hands, including.when leaving the room. During an interview on 4/10/25 at 11:41 a.m. with IPI, IPI stated all staff including transportation services were expected to follow ICP's and perform hand hygiene before and after provided care. During a review of the Centers for Disease Control and Preventions (CDC, National Health Organization) document titled Standard Precautions for All Patient Care dated 4/3/24. the document indicated Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare provides from infection and prevent the spread of infection from patient to patient. During a review of the facility's P&P titled, FACILITY POLICY:ENHANCED BARREIR PRECAUTIONS IN SCU, dated 4/7/25, the P&P indicated, Special Care Unit (SCU) adopts the following California Department of Public Health (CDPH) Enhanced Barrier Precautions (EBP) to prevent transmission of multidrug-resistant organisms (MDRO). C. Implement Enhanced Barrier Precautions (EBP) for high-risk residents: 1. Use of EBP is based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission. 3. Use of Gloves and Gowns. b Hand hygiene, gowns and gloves prevent the transfer of infectious agents from the resident's skin, clothing, bedding and environmental surfaces to the HCP skin and clothing. d. Gowns and gloves should always be removed inside the room when the care activity is complete. Gowns and gloves should not be worn outside of the room when resident care is not being performed. Perform hand hygiene after glove removal. During a review of the facility's P&P titled, FACILITY POLICY: Infection control in SCU [Special Care Unit], dated 5/2/24, the P&P indicated, POLICY SUMMARY/INTENT: To provide a safe environment for residents in Special Care Unit. and to prevent the development and transmission of diseases and infection. C. Care of the Residents. 9. Personal protective equipment will be utilized by staff members during care of residents as needed and to be disposed of immediately at the point of use. D. In-service Education: 2. At least one in-service Education Program will be conducted by the Infection Control Nurse annually. 3. Additional Education programs will be presented by Infection Control Nurse as needed depending upon observed practice of the problems within the department.

Based on interview and record review, the facility failed to obtain and complete informed consent (a process in which residents are given important information about medical procedures and medications) for psychotropic medications (drugs that affect a person's mental state) for two of four sampled residents (Resident 21 and Resident 13). This failure had the potential for Resident 21 and Resident 13 to not be aware of the risks and benefits of taking psychotropic medications. Findings: During a concurrent interview and record review on 4/9/25 at 9:40 a.m. with Minimum Data Set Coordinator/Registered Nurse (MDSC), Resident 21's Consent for the administration of psychotropic medications (Consent), dated 2/12/25 was reviewed. The Consent indicated, Resident 21 was on Seroquel (a medication used for mental illness) 25 mg at bedtime. The Consent indicated nurses signed on 2/12/25 and physician signed on 2/20/25. MDSC stated nurses obtain consent from family/resident and physician signs the consent when they visit the resident. During a concurrent interview and record review on 4/10/25 at 2:22 p.m. with RN 1, Resident 13's Consent dated 9/25/24 was reviewed. The Consent indicated, Resident 13 was on Risperidone (medication for mental illness) 1 mg at bedtime. The Consent indicated nurses signed on 9/25/24 and the physician signed on 10/14/24. RN 1 stated nurses obtain the medication consents from family and resident in the facility. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Consent, dated 3/27/2023, the P&P indicated, It is the responsibility of the physician to review medication information with the patient/legal guardian and obtain informed consent. To obtain informed consent, the prescribing physician reviews medication information with the patient/legal guardian prior to initial administration of medication. A. The physician may obtain informed consent for antipsychotic medication from the patient/legal guardian/conservator in person or over the telephone. If the consent is obtained by telephone, a licensed nursing staff must listed (sic) to both parties in the conversation, and directly hear the patient/legal guardian give verbal consent in order to act as the witness to the patient's signature on the consent form.

Based on interview and record review, the facility failed to review and accurately complete the annual Pre-Admission Screening Assessment and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of one sampled resident (Resident 13). This failure had the potential for Resident 13 to be placed in an inappropriate setting and not receive required services. Findings: During a review of Resident 13's Preadmission Screening Resident Review (PASRR) Level 1 Screening, dated 5/6/24, the PASRR indicated, 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder [a mental health condition characterized by persistent sadness and loss of interest], Anxiety Disorder [excessive worry, fear and other physical and behavioral symptoms that interfere with daily life], Panic Disorder [frequent and unexpected panic attacks], Schizophrenia/Schizoaffective Disorder [a chronic and severe brain disorder that disrupts a person's ability to think clearly, manage emotion, make decisions, and relate to others], or symptoms of Psychosis [a state where an individual experiences a loss of touch with reality, often characterized by hallucinations [seeing or hearing things that aren't there] and delusions [false beliefs), Delusions, and/or Mood Disturbance [significant and persistent changes in mood, energy levels, and behavior that can indicate a mood disorder]? Indicated No. The PASRR indicated, 12. The Individual has been prescribed psychotropic [drugs that affect a person's mental state] medications for mental illness. Indicated No. During a concurrent interview and record review on 4/7/25 at 2:40 p.m. with Registered Nurse (RN) 1, Resident 13's Diagnosis List was reviewed. The DL indicated Resident 13 has Bipolar Disorder [a mental health condition characterized by extreme mood swings, including periods of intense emotional highs and lows] disease, chronic upon admission. RN 1 stated diagnoses are listed on the Diagnosis List but not on the PASRR. During a review of Resident 13's Orders dated 9/25/24, the Orders indicated Resident 13 was on Risperidone (medication to treat bipolar disorder) 1 mg at bedtime for Bipolar Disorder. During an interview on 4/7/25 at 2:44 p.m. with Administrative Assistant (AA), AA stated PASRR was completed by the hospital upon admission but once the resident was admitted to the facility, it was the facility's responsibility to review and determine the need to complete an additional PASRR if necessary. During an interview on 4/9/25 at 11:53 a.m. with Risk and Regulatory Analyst (RRA), RRA stated the facility did not have a policy for PASRR.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 followed the facility policy and procedure (P&P) titled MEDICATION ADMINISTRATION THROUGH A FEEDING TUBE, and professional standards for one of five sampled residents (Resident 4) with a Gastrostomy Tube (GTube-a device to allow feedings and medications to be administered directly to the stomach) when LVN 2 did not flush with water between medications. This failure had the potential for medications to clog or block the GTube resulting in Resident 4 not receiving the medication. Findings: During an observation on 4/9/25 at 8:22 a.m. in Resident 4's room, LVN 2 administered Docusate Sodium (medication to manage or treat constipation) via GTube to Resident 4. LVN 2 administered the next medication. LVN 2 did not flush the GTube with water after administering Docusate Sodium and prior to administring the next medication. During an interview on 4/9/25 at 8:29 a.m. with LVN 2, LVN 2 stated she did not flush the GTube with water after administering the Docusate Sodium. LVN 2 stated she should have flushed the GTube after administering the Docusate Sodium. During a review of Resident 4's Registration Record, (RR) dated 8/25/23, the RR indicated Resident 4's admitted was 8/25/23. During a review of Resident 4's Order Information for: Tube Feeding, Continuous, and NPO [Nothing by Mouth], (OIFTFCAN) dated 11/22/24, the OIFTFCAN indicated, Feeding Type - My Multi Select Tube Feeding. During a review of the facility's policy and procedure (P&P) titled, MEDICATION ADMINISTRATION THROUGH A FEEDING TUBE, undated, the P&P indicated, PROCEDURE: COMPLIANCE - KEY ELEMENTS . J. Administer medication using a 60 ml [milliliter] syringe into resident's feeding tube slowly. (IF giving multiple medications, flush tube with 5-10 mL water in between meds [sic]).

Based on observation, interview, and record review, the facility failed to: 1. Ensure podiatry (the medical field that specializes in the diagnosis, treatment, and study of disorders affecting the foot, ankle, and lower leg) care and treatment for one of three sampled residents (Resident 1). This failure resulted in Resident 1 requiring surgical intervention (a procedure performed on the body to treat a medical condition) and Intravenous (IV - given through the vein) antibiotics (medicines that treat bacterial infections [invasion and growth of germs in the body] by killing bacteria or preventing them from reproducing) for the infection to his left (first and second) foot and right (fourth) foot. 2. Administer IV antibiotics as ordered by the physician for one of three sampled residents (Resident 1) infection to his left (first and second) foot and right (fourth) foot. This failure resulted in a delay in care and had the potential for continued skin breakdown and infection. 3. Follow the physician order for podiatry consult for one of three sampled residents (Resident 2). This failure had potential to affect the resident's foot health and contribute to injury and/or infection. Findings: 1. During an interview on 10/9/24 at 8:50 a.m. with Family Member (FM) 1, FM 1 stated she had been asking the facility for almost a year to get Resident 1 seen by a podiatrist due to issues (not specific) with his left and right toenails. FM 1 stated, I never got a response and Resident 1 was finally, seen by a podiatrist recently (9/25/24) and was diagnosed with three ingrown toenails (occurs when the toenail grows into the skin next to it. It's a problem that can cause pain, inflammation, and infection) (not specific on what foot the ingrown toenails were) that were infected and required IV antibiotics. During a review of Resident 1's CODING SUMMARY (CS), dated 11/14/23, the CS indicated, Resident 1 diagnosis including Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord [bone structure that supports your body] injury), Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease causing difficulty in breathing). Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), Diabetes Mellitus (DM - condition characterized by high blood sugar). Resident 1's annual Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status - an assessment of cognition [mental processes including perception, memory, and thought]), dated 10/10/24, the BIMS indicated, Resident 1 had a score of 15 (cognition intact). The MDS under the section GG (an assessment of the level a care a resident requires), dated 7/10/24, the GG indicated, Resident 1 was dependent on staff for lower body dressing and taking off/putting on footwear. During a review of Resident 1's Physician Orders (PO), dated 10/1/23, the PO indicated, Resident 1 had an order for podiatry consult for foot care. During a review of Resident 1's care plan for skin integrity (CPSI - skin integrity is the overall health and condition of your skin) dated 2/12/24, the CPSI indicated, Resident 1 had a, right 4th toe redness/ingrown (toenail). Interventions included, Skin Evaluation Scheduled with Care. There was no care plan noted for Resident 1 left (first and second) foot infection. During a review of Resident 1's Podiatry Note (PN), dated 9/25/24, the PN indicated, Resident 1 was seen by a podiatrist for complaint of painful nails (did not specify where). The PN indicated Resident 1 had infected ingrown toenails to both left and right foot. The PN indicated Resident 1 had mechanical debridement (the removal of damaged or infected tissue from the nail bed and surrounding areas) of the toenails to both left and right foot. The PN indicated the left first and second toe and the right fourth toe required partial avulsion (a surgical procedure that removes part or all the nail plate from the nail bed. Commonly used for ingrown toenails and nail infections). The PN indicated Resident 1 would start on IV antibiotics (9/25/24) for the infected toenails to the left and right foot. During a review of Resident 1's General Surgery Consultation (GSC), dated 10/2/24, the GSC indicated, Resident 1 was one-week post-(after) surgery for nail avulsion to the left hallux (big toe), left second toe and right fourth toe. During a concurrent interview and record review on 10/9/24 at 1:18 p.m. with Registered Nurse (RN 1), Resident 1's Podiatry Service Note (PSN), dated 2/23/24 was reviewed. The PSN indicated Resident 1 had Onychomycosis (a fungal infection of the nail that causes discoloration, thickening, and separation from the nail bed) to both left and right foot which gradually worsened. The PSN indicated, Resident 1 had long thick toenails to both left and right foot requiring care and Resident 1 was to return for further podiatry care in 9 weeks as needed. RN 1 stated Resident 1 was seen recently by a podiatrist in September 2024 (approximately 30 weeks) after his last appointment on 2/23/24. During an interview on 10/22/24 at 2:25 p.m. with Risk and Regulatory Analyst (RRA), RRA stated the facility did not have any documentation of any type regarding assessments or monitoring of Resident 1's left and right foot prior or after his podiatry appointment on 2/23/24. 2. During a review of Resident 1's Prescription Order (RX), dated 9/25/24, the RX indicated, Resident 1 was to start Ancef (an antibiotic used to treat different types of bacterial infection including infections of the skin, bone, and joints [IV]) 500 mg (milligram - a unit of measurement) every eight hours. During a review of Resident 1's ORDER SHEET (OS), dated 9/28/24, the OS indicated, Resident 1 was started on Ancef 500 mg IV every 8 hours for infected toenails (left and right foot) on 9/28/24 (three days after order was made) for 7 days (end date 10/5/24). The Medication Administration Record dated 9/28/24 was reviewed and there was no documentation regarding the Ancef 500 mg IV every 8 hours for infected toenails (left and right foot) on 9/28/24. During an interview on 10/9/24 at 8:50 a.m. with FM 1, FM 1 stated she visited Resident 1 on 9/27/24 and noticed Resident 1 did not have IV access to provide the IV antibiotics for Resident 1's left and right foot infection. FM 1 stated she called the facility nurse (cannot recall name) to see if Resident 1 was getting his IV antibiotics and the nurse told FM 1 the IV antibiotics order was not carried out and Resident 1 had not been receiving the antibiotics as he should have. During an interview on 10/9/24 at 1:16 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1's podiatrist ordered IV antibiotics after the procedure on 9/25/24. RN 1 stated the IV antibiotics was not started timely (not sure of exactly when it was started) due to the physician order being missed. RN 1 stated the expectation was for IV antibiotics to be started as soon as the order is received from the physician. During a review of the facility's policy and procedure (P&P) titled, Physician Services - Physician Orders, dated 2/28/24, the P&P indicated, This policy outlines the management of physician orders . All orders will be double-checked by the night nurse every 24 hours to be sure they have been carried out or reviewed. 24-hour Chart Checks are documented in the resident's electronic medical record. 3. During a review of Resident 2's Physician Orders (PO), dated 10/1/23, the PO indicated, Resident 2 had an order for podiatry consult every two months for foot care. Resident 2's CPSI dated 10/7/23, the CPSI indicated, Skin Evaluation Scheduled with Care. During a review of Resident 2's CODING SUMMARY (CS), dated 11/21/23, the CS indicated, Resident 2 diagnosis including Diabetes Mellitus (DM - condition characterized by high blood sugar), and Bed confinement status. Resident 2's Quarterly MDS under the section BIMS, dated 6/28/24, the BIMS indicated, Resident 2 had a score of 14 (cognitively intact). The MDS under the section GG, indicated, Resident 2 was dependent on staff for lower body dressing and taking off/putting on footwear. During a concurrent observation and interview on 10/9/24 at 12:23 p.m. with Resident 2 in Resident 2's room, Resident 2 was in bed watching TV. Resident 2 stated she had been in the facility for a few years (not specific). Resident 2 stated she gets her toenails trimmed to both feet occasionally, but it had been almost a year since the last time they were trimmed. Resident 2's toenails on her left and right foot were overgrown approximately 1/8thof an inch (a unit of measurement) past the tips of the toes. The toenails to Resident 2's both feet appeared discolored, thick, and brittle with areas of jagged (rough) sharpness. During a concurrent interview and record review on 10/9/24 at 1:04 p.m. with Quality Assurance (QA), Resident 2's PSN, dated 2/23/24, was reviewed. QA stated the last time Resident 2 was seen by a podiatrist was on 2/23/24 with a note to see podiatrist again in nine weeks as needed. The PSN indicated Resident 2 had long thick toenails on both feet requiring care. The PSN indicated Resident 2 had a diagnosis of Onychomycosis to both feet in which the progress had worsened. QA stated Resident 2 had not been seen by the podiatrist since 2/23/24. During a concurrent observation and interview on 10/9/24 at 1:16 p.m. with RN 1, RN 1 stated the nurses know residents are to be referred to podiatry when there are noted issues with the feet which included long toenails. RN 1 observed Resident 2's toenails to both feet and stated Resident 2 needed to be referred to podiatry. During an interview on 10/22/24 at 2:25 p.m. with RRA, RRA stated the facility did not have any documentation of any type regarding assessments or monitoring of Resident 2's feet prior or after her podiatry appointment on 2/23/24. Requested for the facility podiatry policy and procedure and none was provided.

Based on interview and record review, the facility failed to implement their policy and procedures (P&P's) titled, Braden Scale and Prevention of Skin Breakdown and Turning Schedule, when staff did not turn and reposition three of nine sampled residents (Resident 3, Resident 19 and Resident 37) every two hours. This failure resulted in: 1. Resident 3 developed a new pressure ulcer (breakdown of skin and underlying tissue resulting from prolonged pressure and a loss of blood flow), stage II (partial skin loss, may look like a wearing away of the skin, a blister, or a shallow crater) on right hip. 2. Resident 19 developed two new pressure ulcers on right occipital (back of the head) pressure injury stage III (extends to the tissue beneath skin forming small crater), left occipital pressure injury stage II, and a worsening pressure ulcer of the coccyx (bone at the base of the spine). 3. Resident 37's worsening of coccyx pressure ulcer stage 4 (deep wound reaching the muscles, ligaments or bones). Findings: 1. During a review of Resident 3's History and Physical Reports (HPR), dated 9/16/22, the HPR indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including but not limited to respiratory failure (a condition in which a patients' blood does not have enough oxygen), Mental Retardation, Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance and posture), Percutaneous Endoscopic Gastrostomy (PEG - placement of feeding tube insertion through the skin and the stomach wall), and Epilepsy (a disorder marked by problems in the normal functioning of the brain which can produce seizures, unusual body movements and loss of consciousness). During a review of Resident 3's Minimum Data Set (MDS - screening assessment tool), dated 1/5/23, the MDS indicated, Resident 3's cognition (a mental process including perception, memory, and thought) as assessed by staff, was severely impaired - never or rarely made decisions. The MDS indicated, Resident 3 required total dependence (staff performed all the activity without assistance from patient/resident) from staff for bed mobility, transfer, eating, toilet use and personal hygiene. During a review of Resident 3's Pressure Ulcer/Injury Plan of Care (IPOC), dated 3/1/23, the IPOC indicated, Resident 3 had right hip pressure injury. The IPOC indicated, reposition every two hours while in bed; or every one hour while in chair. During a review of Resident 3's Incision/wound flowsheet (IWF), dated 3/1/23, the IWF indicated, Resident 3 had a new stage II pressure injury on the right hip, measuring 0.5 centimeters (cm - unit of measurement) length X (by) 0.2 cm width. During a review of Resident 3's Braden Score flowsheet (BSF- a tool to assess patient's risk in developing pressure ulcers score of 19-23 no risk; 15-18 mild risk; 13-14 moderate risk; less than 9-severe risk), dated 3/2/22 and 3/9/22, the BSF indicated, Resident 3's Braden scale score for both dates were 13 and at moderate risk in developing pressure ulcer. During a review of Resident 3's IWF, dated 3/9/23, the IWF indicated, Resident 3's pressure injury stage II, on the right hip, had increased in size to 1.8 cm length X 3.0 cm width X 0.1 cm depth. During a review of Resident 3's Resident Rounding (RR), dated 3/1/23 through 3/16/23, the RR indicated Resident 3's position at the following dates and times:, on 3/2/23, at 6:41 AM, lying on right side, on 3/2/23, at 10:48 AM, lying on right side, on 3/2/23, at 12:23 PM, lying on left side; on 3/2/23, at 9:52 PM, lying on left side, at 2:20 AM, lying on left side, on 3/3/23, at 4:28 AM, supine (on back); on 3/3/23, at 6:18 PM, lying on left side, on 3/2/23, at 10:59 PM, lying on left side, to 3/3/23, at 11:07 PM, supine; on 3/4/23, at 2:41 PM, lying on left side, on 3/4/23, at 5:30 PM, lying on left side; at 9:39 PM, lying on left side, to 3/5/23, at 12 AM (midnight), supine; on 3/6/23, at 8:18 PM, supine, on 3/6/23, at 10:59 PM, supine; on 3/7/23, at 12:53 AM, lying on left side on 3/7/23, at 12:53 AM, lying on left side, on 3/7/23, at 2:38 AM, lying on left side, on 3/7/23, at 4:32 AM, supine; on 3/7/23, at 6:16 AM, lying on left side, on 3/7/23, at 8:17 AM, lying on left side, on 3/7/23, at 10:36 AM, lying on right side; on 3/7/23, at 9:50 PM, Semi-Fowler's (head of bed elevated), on 3/8/23, at 12:50 AM, Semi-Fowler's, on 3/8/23, at 3:26 AM, supine; on 3/8/23, at 6:17 AM, lying on left side, on 3/8/23, at 8:20 AM, lying on left side, on 3/8/23, at 12:27 PM, lying on right side; on 3/10/23, at 10:59 PM, lying on left side, on 3/10/23, at 12:26 AM, lying supine; on 3/10/23, at 2:44 AM, lying on left side, on 3/10/23, at 8:41 AM, lying on left side, on 3/10/23, at 12:41 AM, lying supine, on 3/10/23, at 4:40 AM, lying supine,; on 3/11/23, at 4:46 AM, lying supine, on 3/11/23, at 11:17 AM, lying supine, on 3/11/23, at 12:50 PM, lying on left side, on 3/11/23, at 6:37 AM, lying on left side, on 3/11 23, at 10:54 PM, lying on left side, on 3/11/23, at 5:28 PM, lying supine; on 3/12, 12:51 AM, lying supine, on 3/12/23, at 8:20 AM, lying on left side, on 3/12/23, at 6:34 AM, lying on left side, on 3/12/23, at 12:32 PM, lying on left side, on 3/12/23, at 2:02 PM, lying on left side, on 3/12/23, at 8:21 PM, lying on left side; on 3/13/23, at 2:49 PM, lying on left side; on 3/14/23, at 6:03 PM, lying on left side, on 3/14/23, at 9:17 PM, lying on left side; on 3/15/23, at 3:53 AM, lying supine, on 3/15/23, at 4:57 PM, lying supine. 2. During a review of Resident 19's Face Sheet, dated 11/2/18, the Face Sheet indicated, the facility admitted Resident 19 on 11/2/18. During a review of Resident 19's Minimum Data Set (MDS, Resident Assessment Tool) dated 9/4/22, the MDS indicated, Resident 19's Brief Interview of Mental Status (BIMS, assesses mental processes, Score of 0 to 7 severely impaired, 8 to 12 moderately impaired, 13 to 15 cognitively intact) score was 8. The MDS indicated, Resident 19 was Total Dependence - full staff performance every time during entire 7-day period for all Activities of Daily Living (ADL's). During a review of Resident 19's BSF, dated 3/1/23 through 3/15/23, the BSF indicated, Resident 19's score was between 11-13. During an interview, on 3/14/23, at 10:53 AM, with Treatment Nurse (TXN), TXN stated, Resident 19 had two new skin injuries, a stage III, on the right occipital and a stage II on the left occipital, identified on 3/9/23. TXN stated, residents are not being turned often enough and that puts the residents at risk for pressure ulcers. During a review of Resident 19's Nursing Note (NN), dated 3/9/23, the NN indicated, Wound consultant made her rounds, she add [sic] no sting barrier [film to protect skin] as TX [treatment] for right Ear, for coccyx cont [continue] same tx, and there are new skin issue on his [Resident 19's] right and left occipital head pressure injury. see order for treatment. During a review of Resident 19's IPOC dated 3/9/23, the IPOC indicated, Outcomes Right occipital pressure injury stage III will be healed. Interventions: Reposition Q [every] 2h [two hours] While in Bed; or Q1h[every hour] While in Chair (INT). The IPOC indicated, Outcomes Pressure injury to left occipital stage II will be healed. Interventions: Reposition Q2h While in Bed; or Q1h While in Chair (INT). During an interview, on 3/16/23, at 2:30 PM, with Licensed Vocational Nurse (LVN) 8, LVN 8 stated, last Thursday (3/2/23) Resident 19's pressure ulcer injury to the coccyx was almost healed, but this week (3/16/23) the pressure ulcer was worse. LVN 8 stated, Resident 19's wounds were deteriorating because he was not turned every two hours. During a review of Resident 19's IWF, dated 5/3/22-3/17/23, the IWF indicated, on 3/2/23 the coccyx pressure injury was improving and measured 0.5cm length, 0.4cm width and 0cm depth. The IWF indicated, on 3/9/23, the coccyx pressure injury measured 1.2 cm length, 1.0cm width and 0.1cm depth. During a concurrent interview and record review, on 3/16/23, at 10:24 AM, with Registered Nurse (RN) 2, Resident 19's RR, dated 2/23/23 through 3/15/23, indicated Resident 19's position on the following dates and times: on 2/24/23, at 8:33 PM, lying supine, on 2/24/23, at 10:28 PM, lying supine, on 2/25/23, at 12:31 AM, lying on right side. on 2/25/23, at 2:20 AM, lying on left side, on 2/25/23, at 4:06 AM, lying on left side, at 6:23 AM, lying on right side. on 2/25/23, at 6:23 AM, lying on right side, on 2/25/23, at 10:23 AM, lying on right side, on 2/25/23, at 2:29 PM, lying on right side, on 2/25/23, at 8:02 PM, lying on left side. on 2/25/23, at 10:16 PM, lying on right side, on 2/26/23, at 12:09 AM, lying on right side, on 2/26/23, at 2:12 AM, lying on right side, on 2/26/23, at 4:17 AM, lying on left side. on 2/26/23, at 6:02 AM, lying on right side, on 2/26/23, at10:42 AM, lying on right side, on 2/26/23, at 2:20 PM lying on right side, on 2/26/23, at 6:13 PM, lying on left side, on 2/26/23, at 8:21 PM, lying supine. on 2/26/23, at 8:21 PM, lying supine, on 2/26/23, at 10:25 PM, lying supine, on 2/27/23, at 12:12 AM, lying on right side. on 2/27/23, at 10:13 PM, lying on right side, on 2/28/23, at 12:03 AM, lying on right side, on 2/28/23, at 2:09 AM, lying on right side, on 2/28/23, at 4:04 AM, lying supine. on 2/28/23, at 12:08 PM, lying on left side, on 2/28/23, at 2:12 PM, lying on left side, on 2/28/23, at 4:28 PM, lying on left side, on 2/28/23, at 6:19 PM, lying on right side. on 2/28/23, at 10:18 PM, lying on right side, on 2/29/23, at 12:06 AM, lying on right side, on 2/29/23, at 4:04 AM, lying on left side. on 3/1/23, at 2:15 PM, lying on left side, on 3/1/23, at 6:08 PM, lying on right side. on 3/1/23, at 8:10 PM, lying on left side, on 3/1/23, at 11:02 PM, lying on left side, on 3/2/23, at 1:28 AM, lying on left side, on 3/2/23, at 2:35 AM, lying on right side. on 3/2/23, at 8:08 AM, lying on left side, on 3/2/23, at 12:10 PM, lying on right side. on 3/2/23, at 2:28 PM, lying on left side, on 3/2/23, at 6:29 PM, lying on right side. on 3/2/23, at 8:16 PM, lying on left side, on 3/2/23, at 11:17 PM, lying on right side. on 3/3/23, at 1:09 AM, on left side, on 3/3/23, at 3:15 AM, lying on left side, on 3/3/23, at 8:07 AM, lying on left side, on 3/3/23, at 2:15 PM, lying on right side. on 3/4/23, at 6:03 AM, lying on right side, on 3/4/23, at 9:52 AM, lying on left side. on 3/4/23, at 9:52 AM, lying on left side, on 3/4/56, at 2:37 PM, lying on right side. on 3/4/23, at 5:17 PM, lying supine, on 3/4/23, at 8:36 PM, lying on left side. on 3/4/23, at 10:27 PM, lying on right side, on 3/5/23, at 2:31 AM, lying on right side, on 3/5/23, at 4:04 AM, lying supine. on 3/5/23, at 12:36 PM, lying on right side, on 3/5/23, at 5:50 PM, lying on right side, on 3/5/23, at 8:23 PM, lying on left side. on 3/6/23, at 10:15 AM, lying on right side, on 3/6/23, at 2:17 PM, lying on left side. on 3/7/23, at 2:07 AM, lying supine, on 3/7/23, at 6:05 AM, lying on left side. on 3/7/23, at 6:05 AM, lying on left side, on 3/7/23, at 8:04 AM, lying on left side, on 3/7/23, at 10:04 AM, lying supine. on 3/7/23, at 3:52 PM, lying supine, on 3/7/23, at 8:06 PM, lying supine, on 3/7/23, at 10:37 PM, lying on left side. on 3/8/23, at 6:05 AM, lying on right side, on 3/8/23, at 10:11 AM, lying on left side. on 3/8/23, at 10:11 AM, lying on left side, on 3/8/23, at 12:22 PM, lying on left side, on 3/8/23, at 2:21 PM, lying on left side, on 8/8/23, at 4:12 PM, Resident 19 lying on left side, on 3/8/23, at 6:16 PM, lying on right side. on 3/8/23, at 8:18 PM, lying on left side, on 3/9/23, at 12:05 AM, lying supine. on 3/10/23, at 2:13 PM, lying on left side, on 3/10/23, at 5:11 PM, lying on left side, on 3/10/23, at 6:23 PM, lying on right side. on 3/10/23, at 6:23 PM, lying on right side, on 3/10/23, at 9:27 PM, lying on left side. on 3/10/23, at 9:27 PM, lying on left side, on 3/11/23, at 1:03 AM, lying on right side. on 3/12/23, at 1:58 AM, lying on left side, on 3/12/23, at 4:26 AM, on left side, on 3/12/23, at 6:25 AM, lying on right side. on 3/12/23, at 6:41 PM, lying on right side, on 3/12/23, at 9:46 PM, lying on left side. on 3/12/23, at 9:46 PM, lying on left side, on 3/13/23, at 1:18 AM, lying on right side. on 3/13/23, at 8:25 PM, lying on left side, 3/14/23, at 2 AM, lying on right side. on 3/14/23, at 2 AM, lying on right side, on 3/14/23, at 5:54 AM, lying on right side, on 3/14/23, at 2:23 PM, lying on right side, on 3/14/23, at 6:07 PM, lying on right side, on 3/14/23, at 10:04 PM, lying on left side. on 3/14/23, at 10:04 PM, lying on left side, on 3/14/23, at 1 AM, lying in Semi-Fowler's (body position with head of bed up at 30 degrees). on 3/15/23, at 1 AM, in Semi Fowler's, on 3/15/23, at 5:57 AM, lying on right side. on 3/15/23, at 5:57 AM, lying on right side, on 3/15/23, at 9:46 AM, lying on left side. RN 2 stated, Resident 19 was not being turned every two hours. RN 2 stated, the expectation was that all residents, including Resident 19, should be turned every two hours since they are all completely dependent and at risk for skin integrity issues. During an interview, on 3/15/23, at 10:42 AM, with LVN 9, LVN 9 stated, there used to be two CNAs per team, now it was one CNA and one LVN. LVN 9 stated, one CNA and one LVN were assigned to 11 residents who were completely dependent for care. LVN 9 stated, It is hard to get everything done with just the two of us. LVN 9 stated, they were not able to meet all of the resident's needs. During an interview, on 3/15/23, at 11:16 AM, with CNA 4, CNA 4 stated, all the residents were completely dependent on staff for care. CNA 4 stated, our care team was one CNA and one LVN, and we had to work together to provide care to all 11 of our residents. CNA 4 stated, we were not able to turn the residents every two hours, it was sometimes three or more hours. 3. During a review of Resident 37's HPR, dated 5/3/22, the HPR indicated, the facility admitted Resident 37 on 5/3/22 with diagnoses including anemia (not enough healthy red blood cells), Small Bowel Obstruction (a partial or complete blockage of the small intestine), and acute hypoxia (decrease in the oxygen supply to a tissue). During a review of Resident 37's MDS, dated [DATE], the MDS indicated, the facility was unable to assess Resident 37's mental status on 5/9/22, 8/9/22, 11/7/22, or 2/5/23. The MDS indicated, Resident 37 required total dependence from staff for bed mobility, transfer, eating, toilet use and personal hygiene. During a review of Resident 37's IPOC, dated 1/1/23, the IPOC indicated, Resident 37 had coccyx decubitus (pressure injury). The IPOC indicated, interventions included reposition every two hours while in bed; or every one hour while in chair. During a review of Resident 37's Pressure ulcer/injury flowsheet, dated 3/2/23, the flowsheet indicated, Resident 37 had pressure injury stage 4 on her coccyx measuring 3.3 cm length X 2.2 cm width X 1.0 depth. During a review of Resident 37's Pressure ulcer/injury flowsheet, dated 3/9/23, the Pressure ulcer/injury flowsheet, indicated, Resident 37's pressure injury stage 4 on the coccyx measured 3.6 cm length X 3.3 cm width X 1.4cm depth, surrounding tissue with maceration (softening and breaking down of skin as a result of prolonged exposure to moisture), wound tunneling (passageways under the skin), undermining (passageways under the skin) location/depth of 12 to 6 o'clock (imaginary clock, the head is 12:00 and the feet are 6:00 - essential elements of wound evaluation). During a review of Resident 37's RR, dated 3/1/23 through 3/16/23, RR indicated Resident 37's position on the following dates and times: on 3/2/23, at 8:11 AM, lying on left side, on 3/2/23, at 12:07 PM, lying on left side, on 3/2/23, at 2:26 PM, lying on right side, on 3/2/23, at 2:26 PM, lying on right side, on 3/2/23, at 6:34 PM, lying on right side, on 3/2/23, at 9:55 PM, lying on right side, on 3/3/23, at 2:22 AM, lying on left side; on 3/4/23, at 12:08 PM, lying on left side, on 3/4/23, at 4:04 PM, lying on left side, on 3/4/23, at 6:04 PM, lying on right side; on 3/4/23, at 9:41 PM, lying on left side, on 3/5/23, at 12:28 AM, lying on left side, on 3/5/23, at 2:38 AM, lying on right side; on 3/5/23, at 12:18 PM, lying on left side, on 3/5/23, at 2:05 PM, lying on left side, on 3/5/23, on 3/5/23, at 4:02 PM, lying on left side, on 3/5/23, at 5:47 PM, lying on right side, on 3/9/23, at 12:28 PM, lying on left side, on 3/9/23, at 2:05 PM, lying on left side, on 3/9/23, at 4:23 PM, lying on left side, on 3/9/23, at 4:23 PM, lying on right side; on 3/12/23, at 2:04 PM, lying on right side, on 3/12/23, at 6:28 PM lying on right side, on 3/12/23, at 8:23 PM, lying on left side; on 3/14/23, at 2:18 PM, lying on right side, on 3/14/23, at 6:04 PM, lying on right side, on 3/14/23, on 3/14/23, at 9:28 PM, lying on left side; on 3/15/23, at 6:41 PM, lying on left side, on 3/15/23, at 10:05 PM, lying on left side, on 3/15/23, at 11:09 PM, lying on right side; on 3/16/23, at 6:31 AM, lying on right side, on 3/16/23, at 10:43 AM, lying on right side. During an interview on 3/15/23, at 2:13 PM, with Registered Nurse (RN) 2, RN 2 stated, the CNAs cannot reposition and change the residents without the LVNs' supervision. During an interview on 3/16/23, at 9:09 AM, with RN 1, RN 1 stated, she prepared the nursing staffing assignment by following the (staffing) grid which started on March 1st. The (staffing) grid for 47 patients needed nine licensed nurses and four CNAs. On Thursdays, the Wound Consultant (WC) comes in and both our two wound nurses go with the WC to assess patient's wounds and pressure ulcers. RN 1 stated, the four LVNs and the four CNAs in each team were assigned to 12 patients. Each team of one LVN and one CNA shared the task of performing RNA exercises, but it was impossible to do all [RNA Exercises] because it was a lot for the [Teams]. The Grid was impossible to work effectively because the patients would suffer. The patients would not be attended to with their needs faster and would not be turned and repositioned every two hours. During an interview on 3/16/23, at 11:22 AM, with CNA 2, CNA 2 stated, they (CNAs) cannot do turning and repositioning every two hours. When they (CNAs) come in at 7 AM they (CNAs) wait for the LVN to help them turn, reposition and provide care to their 12 assigned patients. CNA 2 stated, this care was provided between 9 AM to 11 AM, between 1 PM to 3 PM, and between 4 PM to 6 PM. During an interview on 3/16/23, at 11:39 AM, with LVN 7, LVN 7 stated, Four CNAs have 12 patients each. The CNAs are tasked with patient care, RNA [restorative nursing assistant] exercises, and turning and repositioning the patients every two hours. Since December when it was eight patients for each CNA, CNA could no longer complete their tasks. LVN 7 stated, now that CNAs have 12 patients each, the patient care, changing, turning and repositioning of patients was only done three times per day at 9 AM, 1 PM, and 4 PM only. During an interview on 3/16/23, at 11:39 AM, with LVN 6, LVN 6 stated, There were two treatment nurses per shift. I do my rounds and get supplies at the start of my shift, if the treatment is at patient's bottom, I wait for the CNA's assistance. The patient's turning and repositioning every two hours was not done and it was potentially the reason why patients have pressure injuries. During a review of the facility's P&P titled, Procedure: Braden Scale and Prevention of Skin Breakdown, dated 3/1/22, the P&P indicated, Procedure Summary/Intent: Each resident shall be given care to prevent the formation or progression of pressure ulcers. A. Goal: 1. Identify at risk individuals needing prevention and the specific factors placing them at risk. To maintain and improve tissue tolerance to pressure in order to prevent injury. B. Procedure: The licensed nurse completes a Risk Assessment using the Braden Scale, to determine resident's potential for skin breakdown . 2. For a score of 16 or less on the Braden Scale Risk Assessment the licensed nurse is responsible to initiate the use of appropriate prevention protocol. Some suggested preventive protocols are listed below. a. Prevent Pressure: i. Assist and encourage turning and repositioning every two hours while in bed or in chair. During a review of the facility's P&P titled Procedure: Turning Schedule, dated 10/2/20, the P&P indicated, A. All residents in the unit will be turned every two (2) hours. B. The turning schedule is initiated on all residents within two (2) hours of admission to the unit, C. The residents are to be turned routinely or as prescribed by physician. 47444

Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (4) was free from pain during care of his wound. This failure resulted in Resident 4 having pain during the procedure. Findings: During a review of the clinical record for Resident 4, with a [DIAGNOSES REDACTED]. Resident 4 is completely dependent for all aspects of care. During a review of the clinical record for Resident 4 the Wound Consultant Notes dated 9/29/16, at 5:53 PM, indicated Resident 4 had a stage 4 coccyx (tail bone) wound. The wound nurse documented the wound was tender and necrotic (dead tissue), with slough (yellow tissue that consist of pus). The Infectious Disease Consultation report dated 10/5/16, by the Infectious Disease Medical Doctor (IDMD) indicated Resident 4's wound was deep . able to probe the bone. During an observation on 10/12/16, at 9:55 AM, in Resident 4's room, the resident was observed on his right side. Wound Nurse (WN) 1 was observed removing the dressing to Resident 4's coccyx. Licensed Vocational Nurse (LVN) 3 was assisting WN 1 with the wound care. When WN 1 began to peel the dressing from the bed of the wound, Resident 4 was observed to be in pain. He began to flail (to wave or swing wildly) his left arm, his body tensed, and his facial expression became tense. After the dressing was removed, Resident 4's body and facial expression relaxed and he stopped flailing his left arm. However, when the IDMD began to assess the size and depth of the wound by placing his gloved hand into the wound, Resident 4 once again began to flail his left arm, and again his body and facial expression became tense. When the IDMD removed his hand from the wound Resident 4 immediately stopped flailing his arm, his body and facial expressions became relaxed. At that time the IDMD asked staff if Resident 4 could feel pain. Staff did not respond. The IDMD gave verbal instructions for staff to pack (with material to increase wound healing) and cover Resident 4's wound. While WN 1 was packing and covering the wound of Resident 4, he once again began to flail his left arm, and again his body,and facial expressions became tense. Resident 4 appeared to be in pain during the entire dressing change procedure. During an interview with WN 1, on 10/12/16, at 11:25 AM, he stated Resident 4 was only able to move his left arm. He was also non-verbal and the only way to assess his pain was by observing his facial expressions. WN 1 stated the non-verbal indicators (arm flailing, facial, and body tensing) were an indication Resident 4 was in pain, and stated, I was so focused on the wound I failed to see that the resident was in pain. During an interview with LVN 3, on 10/12/16, at 11:50 AM, she stated, He (Resident 4) was showing signs and symptoms of pain . Now looking back, I would have pre-medicated the resident before doing any wound care . We will do it from now on. During an interview with the Administrator/Director of Nursing, on 10/12/16, at 12:03 PM, she stated Resident 4's behaviors during the wound care were an indication he was in pain, and staff should have pre-medicated him. The wound extends to the bone . I think we really have an issue with education . During an interview with LVN 5, on 10/12/16, at 2:45 PM, she stated Resident 4 did not have an order to pre-medicate him prior to his wound care, and she had never been asked to pre-medicate him prior to his wound care. During a review of the clinical record for Resident 4, the care plan titled Alteration in Comfort: PAIN, dated 8/5/16, indicated staff are to anticipate need for [MEDICATION NAME] (a drug to relieve pain) to relieve pain, and to assess for pain characteristics. The facility policy and procedure titled Pain Assessments for Adults, dated 10/2015, indicated all clinical staff are responsible for screening patients for pain. When screening for pain, staff are to consider the resident's physical and cognitive limitations. It also indicates that staff must evaluate the non-verbal cues of pain such as restlessness, tenseness, and jerking.

Based on observation, interview, and record review, the facility failed to ensure one resident (1) was free from verbal and physical abuse from two Certified Nursing Assistants (CNA 1 and 2) which resulted in Resident 1 being afraid and experiencing mental anguish from the verbal and physical abuse. Findings: During an interview with the Social Worker Assistant (SWA), on 2/23/15, at 3 PM, she stated, "I received a message from a charge nurse that Resident 1 complained to her that she (Resident 1) was scared of the two Certified Nursing Assistants (CNA 1 and 2)... The incident happened 2/5/15 and was reported to me on 2/6/15... They were changing her (Resident 1) and a CNA (1) made a comment that if she (Resident 1) can use her computer (tablet), then she (Resident 1) can use the remote of her bed. They were rough with her." During an interview with the Administrator, on 2/23/15, at 3:15 PM, she stated, "... The CNA 1 was suspended and terminated later. She was also suspended before because of allegation of being rude to a patient (resident)." During a concurrent observation and interview with Resident 1 in her room, on 2/23/15, at 3:30 PM, she stated while holding her tablet, "...They (CNA 1 and 2) need to put the bed flat and I was using my tablet. I told them to be careful with my operation, they said (CNA 1 and 2) they could but still they pulled my arms when they turned me. They were rough with me and hurt me. I asked them to sit me back up. I didn't have strength on my finger. One of the CNA's (1) told me if I can use and play with my tablet, then I can use the remote of the bed to move on ... I was afraid that's why I told my husband to stay ...The CNA (1) on the left side was the one who talked to me about the tablet." During a review of the clinical record for Resident 1, the SWA notes dated 2/9/15, at 1500 (3:00) PM, read, "...The email stated (sic) that (sic) Resident 1 had complained to her (Registered Nurse) and to RT (Respiratory Therapist) that (sic) she (Resident 1) was scared of two CNA's. She stated that (sic) she was afraid because they were rude to her, had made comments that (sic) made her upset and were laughing at her while cleaning her ...The resident (1) stated that (sic) there were two CNA's ...that (sic) they were rude to her and mistreated her. She stated that (sic) the two CNA's had attitude and when she asked them to be careful they would sigh and say, "We know we know we know." The resident said, "I was asking them to be careful because I didn't think they could turn me between the two of them, but they said they could but they pulled my arms. They (CNA 1 and 2) were rough with me and hurt me." She also said, "When they were moving me they moved my bed and I was not comfortable so I asked them to move my bed and they said well if you can play on your computer you can move the bed and they threw the remote at me." During a review of the clinical record for Resident 1, the SWA notes dated 2/11/15, at 16:39 (4:39) PM, read, "...Resident awoke with verbal stimulation but had sad facial expression... Resident began to cry and was stating that she was upset because she was not sure if she did the right thing by reporting because she felt like that staff was treating her different... the resident stated, "When they come in now they don't talk to me they just do what they need to do and they leave." During a review of the personnel file of CNA 1 dated 4/29/14, a disciplinary action, final written warning was issued to her on 4/29/14. It read, "...(CNA) 1 was reported being rough to Resident (A.M.). This resident (A.M.) stated that she is rough during care and seems in a rush each time. This resident was emotionally affected, was crying and insisted on not having her (CNA 1) again as her CNA. The husband confirms with the resident and really concern about other residents that are not able to communicate." During an interview with Registered Nurse (RN) 1, on 3/27/15, at 5:50 AM, she stated, "The resident (1) informed me that one of the CNA's (1) told her if she can play with the computer she can also push the button of the bed remote herself... She even told me that while they were changing her pad they were rough with her." During an interview with the Respiratory Therapist (RT), on 3/27/15, at 6:15 AM, she stated, "It was in the resident's (1) room with the Charge Nurse. She (Resident 1) told us the two CNA's (1 and 2) were rough with her (Resident 1) while changing her. She asked one of the CNA's (1) to adjust her bed but she said CNA (1) responded that 'if you can use your computer then you can do it with your remote'. She (CNA 1) threw the bed remote to her (Resident 1)." The facility policy and procedure titled "Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation" dated 8/22/12, under Policy read, "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of the hospital (D/P SNF) to protect patients from real or perceived abuse, neglect, exploitation from anyone, including staff members, students,volunteers, other patients,visitors or family members."