Every finding on record at Alameda Care Center

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen Aide (KA) 1 was not wearing hair net in the kitchen. 2. Two (2) and a half pack of cheese in refrigerator had no date. 3. Seven (7) veggie burger patties in freezer had no date. 4. The facility's Ice Scoop Cleaning Log was missing the time and staff initials from 6/12/2026 to 6/14/2026. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 83 of 86 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 6/15/2026 at 7:54 a.m. in the kitchen, observed KA 1 was not wearing hair net. KA 1 stated he is not wearing a hair net because he forgot. KA 1 stated he received in-services that he has to always wear the hair net. During a concurrent interview and record review on 6/15/2026 at 8:15 a.m. with the Cook, the facility form titled, Ice Scoop Cleaning Log, for June 2026, was reviewed. The [NAME] stated the form titled, Ice Scoop Cleaning Log, was missing the time and initial for the dates of 6/12/2026, 6/13/2026, and 6/14/2026. The [NAME] stated kitchen staff are required to initial and record the time each time the Ice Scoop is washed and cleaned, which is usually early morning. The [NAME] stated the ice scoop is used to place ice in containers for residents. The [NAME] stated ice scoops should be cleaned to prevent potential contamination of ice. The [NAME] stated without this documentation, there is no confirmation that the Ice Scoop was cleaned. During a concurrent observation and interview on 6/15/2026 at 8:17 a.m. with the [NAME] inside the refrigerator, observed 2 and a half full packs of cheese with no date. The [NAME] stated there are 2 and a half packs of cheese with no date when they were delivered and when it was opened. The [NAME] stated that all items stored in the refrigerator must be dated when they were received and when they were opened from the original packaging. The [NAME] stated the potential outcome of not having these dates recorded is that items may remain in use past their safe timeframe, increasing the risk that the product could be expired and cause harm to residents. The [NAME] stated that any item received should be labeled with both the received date and the open date to ensure staff know how long the item is good for and when it must be discarded. During a concurrent observation and interview on 6/15/2026 at 8:33 a.m. with KA 2 inside the freezer, observed 7 veggie burger patties with no date. KA 2 stated that there were 7 veggie burger patties in the freezer with no date of when it was delivered and when it was opened. KA 2 stated that he does not know when the veggie burgers were received, when they will expire, or when they should be discarded. KA 2 stated per facility policy, all items stored in the freezer must be properly dated to ensure safe use and to prevent expired food from being given to residents. During an interview on 6/15/2025 at 8:43 a.m. with the Dietary Supervisor (DS), the DS stated all staff must wear hair nets in the kitchen to prevent hair from falling into food and causing contamination. The DS stated all products in the kitchen - refrigerator, dry storage, and freezer- must be labeled with the delivery date and open date to know when items should be discarded and/or expired. The DS stated the potential outcome of using expired food is harm to residents such as food poisoning. The DS stated that staff must clean the ice scoop daily and record the time and their initials when it was cleaned to maintain accurate documentation, and to know when the scoop was last cleaned as required on the ice scoop cleaning log. The DS stated the ice scoop should be properly cleaned to prevent potential illness coming from contaminated ice. During a review of the facility's policy and procedure (P&P) titled, Dating and labeling, last reviewed on 4/15/2026, the P&P indicated to ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer area. All items should have the following appropriate dates delivery date -upon receipt, and open date-open containers. During a review of the facility's P&P titled, Sanitation and Infection Control, last reviewed on 4/15/2026, the P&P indicated food service employee will follow infection control policies to ensure the department operates under sanitary condition at all times. A hair net or head covering which completely covers all hair should be worn at all times. During a review of the facility's P&P titled, Ice Machine Cleaning, last reviewed on 4/15/2026, the P&P indicated dietary staff to clean and sanitize the ice scoop and container daily and as needed. Wash ice scoop with soapy water, rinse, sanitize and air dry. Ice scoop will be washed daily.

Based on interview and record review, the facility failed to complete an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of five sampled resident (Resident 3) who was prescribed Mirtazapine (an antidepressant used to treat depression [mood disorder that causes a constant, heavy feeling of sadness and a loss of interest in things you once enjoyed]). This failure violated the resident's and/or responsible party's right to be fully informed about the care and treatments being provided, as well as the available alternative treatment options. Findings: During a review of Resident 3's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 11/13/2025 and readmitted on [DATE] with diagnoses including, but not limited to, diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 3's History and Physical Examination (HP - a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician on 1/13/2026, the HP indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated the Resident 3's cognition (can think, learn, remember, use judgement, and make decisions) is severely impaired. The MDS indicated Resident 3 is on high-risk Drug Antidepressant. During a review of Resident 3's Order Summary Report, active orders as of 6/17/2026, the order summary report indicated to give Mirtazapine 15 milligrams (mg - a unit of measure for mass) one (1) tablet by mouth at bedtime for depression starting on 1/30/2026 with no end date. During a review of Resident 3's Medication Administration Record (MAR) from 6/1/2026 to 6/31/2026 the MAR indicated Resident 3 received Mirtazapine oral tablet 15 mg at bedtime for depression from 6/1/2026 to 6/16/2026. During a review of Resident 3's Psychotropic Drug Informed Consent, dated 1/30/2026, the inform consent indicated: a. Prescriber Signature: By signing below, I declare that I have personally examined, provided, and discussed with the Resident and/or Resident's Representative the following material information but not limited to the reason for the treatment, and the nature and seriousness of the Resident's illness. The nature, degree, duration and probability of the side effects and significant risks, commonly known by the health professions. The reasonable alternative treatments and risks, and why the health professional is recommending this treatment. The Resident's and/or Resident's Representative's right to accept or refuse the proposed treatment, and if they consent, their right to revoke their consent for any reason at any time. The possible nonpharmacologic approaches that could address the Resident's needs The lines designated for the physician signature and date were left blank. b. By signing, the licensed nurse is confirming that the Resident or Responsible Party gave their consent to treatment with the psychotropic drug. The lines designated for the licensed nurse's printed name and signature were left blank. During a concurrent interview and record review on 6/17/2026 at 12:04 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 3's medical record, including Psychotropic Drug informed Consent, dated 1/30/2026, was reviewed. LVN 2 stated that Resident 3's Psychotropic Drug Informed Consent for use of mirtazapine did not include the licensed nurse's signature or the name of the nurse who obtained the consent. LVN 2 stated that the informed consent form requires a licensed nurse's signature to verify that the Resident and/or Responsible Party was informed and provided consent for the treatment. LVN 2 further stated that because the form did not contain the licensed nurse's name and signature, the consent is not complete and valid. LVN 2 stated informed consent is required per policy to administer any antidepressant. During a concurrent interview and record review on 6/17/2026 at 12:15 p.m. with the Director of Nursing (DON), Resident 3's Psychotropic Drug informed Consent, dated 1/30/2026, was reviewed. The DON stated that Resident 3's Psychotropic Drug Informed Consent form was missing the physician's signature as well as the licensed nurse's name and signature. The DON stated that any resident receiving psychotropic medication must have an informed consent form, which includes the signatures of both the licensed nurse and the physician. The DON stated that Resident 3 is currently receiving mirtazapine, which the facility classifies as an antidepressant medication. According to facility policy, staff are required to obtain informed consent from the resident or responsible party prior to administering such medications. The DON emphasized that it is the resident's and/or responsible party's right to be informed of all treatment. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Informed Consent, last reviewed on 4/15/2026, the P&P indicated to ensure the resident and resident representative are fully informed of benefits, risk, possible side effect before initiating administering the psychotropic the prescriber must sign an informed consent form after explaining all necessary information to the resident or their representative. The licensed nurse will verify the consent information and sign it to confirm its accuracy and complete. During a review of the facility's P&P titled, Psychotropic Medication Use, last reviewed on 4/15/2026, the P&P indicated drugs in the following category are considered psychotropic: Anti-depressants. During a review of the facility's P&P titled, Resident's Right, last reviewed on 4/15/2026, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed of, and participate in, their care planning and treatment.

Based on interview and record review, the facility failed to provide written information concerning the resident`s right under state law to make decision concerning medical care and offer assistance in formulating an Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) to the residents or the resident`s responsible party for two out of eight sampled residents (Resident 49 and 90) investigated during review of advance directive care area. This deficient practice had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment. Findings: a. During a review of Resident 49's admission Record (AR), the AR indicated the facility admitted the resident on [DATE] with diagnoses including, anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life). During a review of Resident 49`s History and Physical (H&P - is the most formal and complete assessment of the patient and the problem), dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. The H&P also indicated that the resident`s daughter is the primary decision maker (PMD). During a concurrent interview and record review on [DATE] at 3:35 p.m. with the Social Services Director (SSD), Resident 49`s Advance Directive Acknowledgment (ADA), dated [DATE], was reviewed. The ADA indicated that Resident 49 is not capable of making preferred intensity of care decision at this time. The ADA form did not contain the signature of the PMD to indicate that the form was discussed and written information was provided. The SSD stated that they have not provided the residents or family members with written materials about their rights to formulate an advance directive, The SSD stated that it's only now that their corporate office has provided the facility with brochure to be given to the residents or their responsible parties regarding their rights to formulate an AD. During an interview on [DATE] at 4:55 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated that upon admission, the facility needs to inquire from the resident or responsible party if the resident has an advance directive. The SSD stated if there is no existing advance directive, the facility shall provide written information regarding the residents right to formulate and advance directive and offer assistance if the resident or the responsible party would want to formulate an advance directive. The MDSC stated it`s a violation of the resident`s rights if they are not provided with written information and if no assistance is offered. b. During a review of Resident 90's AR, the AR indicated the facility admitted the resident on [DATE] from a General Acute Care Hospital (GACH) with diagnoses including pulmonary fibrosis (a serious, progressive lung disease that occurs when lung tissue becomes damaged and scarred). During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 90 was dependent (helper does all the effort; resident does none of the effort to complete the activity) on staff for eating, dressing, and personal hygiene. During a review of Resident 90's H&P, dated [DATE], the H&P indicated the resident does not have the capacity to understand and make decisions. The H&P indicated there was no advance directive executed and Cardiopulmonary Resuscitation status (CPR - emergency life-saving procedure involving chest compressions) was not indicated whether there was to be full CPR or no CPR. During a review of Resident 90's Interdisciplinary Team (a group of healthcare professionals, such as nursing, social services, and dietary who meet with a resident to help the resident to form goals for their healthcare) Notes, dated [DATE], the IDT notes indicated the responsible party attended the IDT meeting. Resident 90's IDT notes did not indicate any code status (whether or not to attempt CPR) for the resident. During a review of Resident 90's Care Plan for Advance Directive, initiated [DATE], the care plan indicated a goal to respect the resident's and family's wishes ongoing until the next assessment. The care plan did not indicate an advance directive was initiated which would include CPR status. The care plan indicated an intervention to respect the resident's and/or family's wishes. During an interview with the Medical Records Director (MRD) on [DATE] at 10 a.m., the MRD stated Resident 90 does not have an advance directive. During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 10:35 a.m., Resident 90's medical records were reviewed. The DON stated a resident's code status is discussed with a resident's family and will reflect on the advance directive. The DON stated after the discussion. the resident's doctor will be made aware. Resident 90's H&P, Social Services Assessments, Advance Directive Care Plan, and Resident 90's IDT Notes were reviewed and did not indicate Resident 90's code status. The DON stated Resident 90 should have an advance directive or documentation of Resident 90's code status. The DON stated it is important to have an advance directive or advance directive acknowledgment because it is a resident's right, and so that the licensed nurses will know how to conduct their care for the resident during an emergency. During an interview with the SSD on [DATE] at 11:10 a.m., the SSD stated she emailed Resident 90's responsible party inquiring about an advance directive, but Resident 90's responsible party did not respond. The SSD stated she did not follow up with the family after that. The SSD stated she should have followed up with the responsible party regarding Resident 90's code status. The SSD stated Resident 90's code status should have been discussed during the IDT meeting with the family. The SSD stated this this is important so that the licensed nurses will know how to conduct Resident 90's care. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed [DATE], the P&P indicated the following: - Advance Directive is a written instruction recognized by state law, relating to the provisions of health care when the individual is incapacitated. - Upon admission, the resident or representative is provided written information concerning their rights under state law to make decisions concerning medical care. - Upon admission the IDT assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. - If the resident is incapacitated and unable to receive information about their right to formulate an advance directive, the information may be provided to the resident's legal representative.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from physical restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of two sampled residents (Resident 51) when staff did not remove the restraint as directed by the physician's order and care plan. This failure had the potential to increase the risk of harm including decreased circulation, skin breakdown, and decline in mobility. Finding: During a review of Resident 51's Face Sheet (admission Record), the Face Sheet indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (constant feeling of sadness). During a review of Resident 51's History and Physical Examination (HP, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician on 4/1/2026, the HP indicated Resident 51 does not have the capacity to understand and make decisions. During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 51 cognitive ability is moderately impaired (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 51 require maximum assist (helper dose more than half of the effort) for sit to lying, lying to sitting, sit to stand, chair/bed transfer, toilet transfer). The MDS indicated Resident 51 has a trunk restraint. During a review of Resident 51's Physician Order Summary Report active orders, as of dated 6/16/2026, the Order Summary Report indicated an order dated 8/2/2025 for the following: - Support and safety device - Non-Self Release Belt (NSRB: Soft belt) while in wheelchair for safety secondary to resident continuously attempts to up/slide down and out of the wheelchair unassisted get due to Parkinson's disease and dementia. - Support and safety device-Release restrain every 2 hours for Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily), activities, and mealtime. During a review of Resident 51 Care Plan for Focus on Support & Safety device, initiated 5/6/2026, the care plan indicated release restraint every two (2) hours for ADL care, activities and mealtimes. The care plan goal indicated will minimize injury from the use of restraint and will minimize any complication from the use of restraint. During an observation on 6/15/2026 at 1:21 p.m. in the hallway in front of Resident 51 room, Resident 51 was seated in his wheelchair with NSRB fastened around his waist and the wheelchair. Observed Certified Nursing Assistant (CNA) 1 feeding Resident 51. Resident 51 was calm with no agitation while eating a meal. The clasp of the gait belt was fastened behind the back of the wheelchair. During a concurrent observation and interview on 6/15/2026 at 1:26 p.m. with Licensed Vocational Nurse (LVN) 2 in the hallway, Resident 51 was seated in his wheelchair with NSRB fastened around his waist and the wheelchair. Observed CNA 1 feeding Resident 51. Resident 51 was calm, with no agitation while eating a meal. LVN 2 stated Resident 51 was seated in his wheelchair with NSDR around his waist and the wheelchair. LVN 2 stated there is a physician order to remove the NSRB during mealtime, the NSRB should be removed based on physician orders during mealtime. LVN 2 stated there is a risk of harm such as preventing circulation and violating residents' rights. During an interview on 6/15/2026 at 1:34 p.m. with CNA 1, CNA 1 stated she was supposed to remove the NSRB during mealtime, however, she forgot. CNA 1 stated the NSRB is a restraint which restricts Resident 5 movement. During a concurrent interview and record review on 6/17/2026 at 8:34 a.m. with the Director of Nursing (DON), Resident 51's Order Summary Report, active orders as of dated 6/16/2026 with order dated 8/2/2025, were reviewed. The DON stated the Order Summary Report indicated an order for NSRB, while in wheelchair for safety secondary to resident continuously attempts to up/slide down and out of the wheelchair unassisted due to Parkinson's disease and dementia. The Order Summary Report indicated an order to release restraint every 2 hours for ADL, activities, and mealtime. The DON stated the NSRB is considered a restraint and based on the physician order, it should be released during mealtime to minimize injury from the use of restraints. During a concurrent interview and record review on 6/17/2026 at 8:38 a.m. with the DON, Resident 51's care plan on support & safety device, initiated 5/6/2026, was reviewed. The care plan indicated to release restraint every 2 hours for ADL care, activities and mealtimes with a goal to minimize injury from the use of restraint and will minimize any complication from the use of restraint. The DON stated care is developed to provide guidance for staff to provide necessary care for Resident 51. The DON stated the care plan was not followed. During a review of the facility's policy and procedure (P&P) titled, Residents Right, last reviewed on 4/15/2026, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms. During a review of the P&P titled, Medication and treatment Administration, last reviewed on 4/15/2026, the P&P indicated medication and treatment shall be administered as prescribed. During a review of the P&P titled, Policy: Physical Restraint, last revised on 4/14/2026, the P&P indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The P&P indicated the Plan of Care shall specify the reason for the use of the restraint, the type, when and where it is to be used. During a review of the P&P titled, Care Plans, Comprehensive Person-Centered, last revised on 4/14/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure one of five (5) sampled residents (Resident 69's) diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) was reflected in the resident's list of active diagnoses in the Minimum Data Set (MDS - a resident assessment tool). This failure resulted in Resident 69 having an inaccurate MDS assessment. Findings: During a review of Resident 69's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 12/30/2020 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 69's History and Physical Examination (HP, a comprehensive physician's note regarding the assessment of the resident's health status), signed by the attending physician on 5/6/2026, the HP indicated Resident 69 does not have the capacity to understand and make decisions. During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69's cognition (can think, learn, remember, use judgement, and make decisions) was severely impaired. The MDS did not indicate Resident 69 had depression under the Active Diagnoses section. During a review of Resident 69's psychiatric progress note, dated 2/23/2026, the psychiatric progress note documented that Resident 69's chief complaint included depression, emotional mood swings, and neurocognitive impairment. The psychiatric progress note indicated diagnoses of schizophrenia and major depressive disorder. During a review of Resident 69's psychiatric progress note, dated 4/29/2026, the psychiatric progress note documented that Resident 69's chief complaint included depression, emotional mood swings, and neurocognitive impairment. The psychiatric progress note indicated diagnoses of schizophrenia and major depressive disorder. During a concurrent interview and record review on 6/16/2026 at 3:26 p.m. with Minimum Data Set Coordinator (MDSC) 1, Resident 69's MDS, dated [DATE], was reviewed. MDSC 1 stated Resident 69's MDS did not indicate a diagnosis of depression under the Active Diagnoses section despite being included in Face Sheet. MDSC 1 stated the diagnosis of depression should be in the MDS because Resident 69 has diagnoses of depression. During a concurrent interview and record review on 6/17/2026 at 8:38 a.m. with the Director of Nursing (DON), Resident 69's Face Sheet was reviewed. The DON stated there is a diagnosis of Depression listed on the resident's Face Sheet. The DON stated the Face Sheet is accurate. During a concurrent interview and record review on 6/17/2026 at 8:40 a.m. with the DON, Resident 69's MDS, dated [DATE], was reviewed. The DON stated the MDS did not indicate a diagnosis of depression under the Active Diagnoses section despite being included in Face Sheet. The DON stated Resident 69's MDS should include the diagnosis of depression so that the assessment contains all necessary information so that the care plan includes appropriate monitoring of the resident's behavior, and because CMS (Centers for Medicare & Medicaid Services) requires facilities to report all active diagnoses on the MDS. The DON stated the MDS is not accurately coded. During a review of the facility's policy and procedure (P&P) titled, MDS Assessment Coordinator, last reviewed on 4/15/2026, the P&P indicated each individual who completes a portion of the assessment MDS must certify the accuracy of that each portion of the assessment by dating and signing the assessment and identifying each section completed.

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information for two of four sampled residents (Resident 46 and 7), when Licensed Vocational Nurse (LVN) 3 left the residents' electronic health record (EHR- a digital version of a resident's paper chart) open and unattended. This deficient practice violated Resident 7 and 46's right to privacy and confidentiality of medical records. Findings: a. During a review of Resident 46's admission Record, the admission Record indicated that the facility originally admitted Resident 46 on 2/23/2024 and readmitted on [DATE] with diagnoses including unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and unspecified mood disorder (mental disorders characterized by a disturbance in mood which is abnormally depressed or elated). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 5/31/2026, the MDS indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). The MDS further indicated that Resident 46 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, upper and lower body dressing and substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a medication pass observation on 6/16/2026 at 3:57 p.m., observed LVN 3 step away and left the medication cart in the hallway with the laptop computer screen open on top of the medication cart. The computer screen displayed Resident 46's medication information and was visible while in the hallway while LVN 3 was in the resident`s room administering medication. b. During a review of Resident 7's admission Record, the admission Record indicated that the facility originally admitted Resident 7 on 6/25/2018 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms) and seizure (a sudden, uncontrolled surge of electrical activity in the brain). During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 7 was totally dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a medication pass observation on 6/16/2026 at 4:22 p.m., observed LVN 3 step away and left the medication cart in the hallway with the laptop computer screen open on top of the medication cart. The computer screen displayed Resident 7's medication information and was visible while in the hallway while LVN 3 was in the resident`s room administering medication. During an interview on 6/16/2026 at 4:25 p.m. with LVN 3, LVN 3 stated that she should not have left the computer screen open and visible in the hallway while she was in the Resident 46 and 7`s room to administer medication. LVN 3 stated that leaving the computer screen open and with the resident's information visible is a violation of the resident`s right to privacy of their medical records. During an interview on 6/18/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that residents have the right to privacy of their medical records. The DON stated that LVN 3 should have closed her computer while she was in the resident`s room to ensure no unauthorized persons can view or access a resident`s medical records to protect their identity and privacy and in keeping with their policy on HIPAA (Health Insurance Portability and Accountability Act - a U.S. federal law designed to keep your personal medical information private and secure). During a review of the facility`s policy and procedure (P&P) titled, The Health Insurance Portability and Accountability Act (HIPAA), last reviewed on 4/15/2026, the P&P indicated the policy`s purpose is To follow HIPAA guidelines to ensure [resident's] privacy.physical safeguards include: computer terminals are in areas accessible only to those who require access.

Based on interview and record review, the facility failed to follow-up with the Preadmission Screening and Resident Review (PASRR- a mandatory federal program requiring all applicants to Medicaid-certified nursing facilities to be screened for serious mental illness [SMI] or intellectual disability [ID/DD]) to obtain a PASRR Level II evaluation (an in-depth, mandatory assessment conducted when a Level I screen indicates a potential SMI, ID/DD, or related condition [RC]) for one of five sampled residents (Resident 8). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services needs for Resident 8. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 12/8/2020 and readmitted Resident 8 on 11/22/2022 with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 8`s History and Physical (H&P- is the most formal and complete assessment of the resident and the problem), dated 4/21/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 8`s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 8 required supervision or touching assistance (helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 8's PASRR Level I screening, dated 11/22/2022, the PASRR Level I indicated that Resident 8 has a serious diagnosed mental disorder (schizoaffective). During a concurrent interview and record review on 6/16/2026 at 3:11 p.m. with the Director of Nursing (DON), Resident 8`s PASRR Level I and a letter from Department of Health Care Services (DHCS) letter, dated 12/6/2022, were reviewed. The DON stated that the result of the PASRR Level I screening indicated that the resident had a diagnosis of schizoaffective disorder. The DON stated that the DHCS letter of 12/6/2022 indicated that the department was not able to complete the PASRR Level II because at that time the resident was isolated as a health or safety precaution. The DON stated that it was the time wherein multiple residents were in isolation due to the COVID-19 pandemic. The DON stated that after the period of isolation, the facility should have resubmitted a new PASRR Level I screen and request for a PASRR Level II evaluation. The DON stated that they missed conducting a new PASRR Level I screen for Resident 8. The DON stated that it is important for the PASRR Level II screen to be completed and ensure the resident will be placed in an appropriate setting and if any specialized services are needed. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening Level Resident Review (PASARR ), last reviewed 4/15/2026, the P&P indicated the policy`s purpose is To ensure each resident with serious mental illness (SMI) and/or intellectual developmental disability/related to conditions (ID/DD/RC) will have the appropriate setting, as well as if any specialized services and/or rehabilitative services would be needed.the facility`s designated staff will review the available information from the PASRR Online System regularly, follow up with the DHCS/DDS` contractor on Level II determination/recommendation, and document and maintain records.

Based on observation, interview, and record review, the facility failed to follow facility policy for gastrostomy tube (G-Tube - a plastic tube inserted into the stomach to administer medications and food) medication administration when Licensed Vocational Nurse (LVN) 1 was observed giving a resident medications by slow push (a method to give medications by slowly depressing a syringe plunger by hand) and not by gravity (giving medications by pouring medications into a syringe, and letting gravity pull the liquid into the stomach) for one of nine residents (Resident 11) observed during the medication administration observation. This had the potential for nausea, vomiting, or cramping when given by slow push. Findings: During a review of Resident 11's Face Sheet (or admission record, the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 8/29/2020 and re-admitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 11 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 11 has a G-Tube. During a review of Resident 11's Physician's Orders, the orders indicated the following: - Enteral Feed (feeding through the stomach) order as needed, may slow push meds [medications] and fluids via G-Tube as needed if not contraindicated, dated 10/11/2025. - Enteral Feed Order, every shift, may crush all crushable medications and administer via G-Tube, dated 10/11/2025. - Acetaminophen (medication used to treat pain) Liquid 160 milligrams per five (5) milliliters (mg/ml, a metric unit of measurement, used for medication dosage and/or amount) give 20 ml via G-Tube two times a day for pain management related to osteoarthritis, dated 10/11/2025. - Metoprolol Tartrate (medication used to treat high blood pressure) Oral Tablet, give 12.5 mg enterally twice a day with feeding for congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hold for systolic blood pressure (the top number in a blood pressure reading measuring the maximum pressure exerted on artery walls when the heart beats) is less than (<) 110 millimeters of mercury (mm Hg, a unit of measure for blood pressure) or heart rate < 60 beats per minute, dated 10/11/2025. During a review of Resident 11's Care Plan for Skin Integrity Impairment, initiated 9/12/2025, the care plan indicated Resident 11 was at risk for skin integrity impairment and potential for infection manifested by G-Tube wound site. The care plan indicated an intervention to administer medication as ordered. During a medication administration observation with LVN 1 on 6/16/2026 at 4:32 p.m., observed LVN 1 administering medications to Resident 11 through her G-Tube. Observed two medications administered, acetaminophen and metoprolol, with each one being given by a slow push method. When asked what the facility's policy is regarding slow push vs. gravity method, LVN 1 stated she did the slow push so that she would not mix the medications. LVN 1 stated she is fairly new and can get the answer from the Director of Nursing (DON). During a concurrent interview and record review with the DON on 6/17/2026 at 10:19 a.m., the DON reviewed the facility's policy and procedure titled, Administering Medications through an Enteral Tube, last reviewed 4/15/2026. The DON stated the policy indicates for a licensed nurse to administer each medication separately by gravity flow and may gently push if necessary. The DON stated LVN 1 should have followed the policy by at least trying to administer the medications by gravity first, and then if there was resistance to then conduct a slow push. The DON stated if necessary in the policy meant if there is resistance to medications going in by gravity or if the resident was anxious and the licensed nurse needed to administer medications faster than waiting for gravity to work. The DON stated this is important to prevent a faster accumulation of medication into the stomach. During a review of the facility's policy and procedure titled, Administering Medications through an Enteral Tube, last reviewed 4/15/2026, the policy indicated the following: - Administer each medication separately by gravity flow: a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly. May gently push if necessary.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 46`s Depakote (also known as divalproex sodium, medication primarily used to treat certain types of seizures [epilepsy], prevent migraine headaches, and manage manic or mixed episodes associated with bipolar disorder [a mental health condition that causes extreme, cyclical shifts in mood, energy, activity levels, and concentration]) Oral Tablet Delayed Release 125 milligram (mg - a unit of measure for mass) was administered as a whole tablet and not crushed. 2. Ensure Resident 7's medications Buspirone HCL (medication used to treat certain anxiety disorders or to relieve the symptoms of anxiety) Oral 2.5 mg tablet, Keppra (also known as levetiracetam, a medication used alone or together with other medicines to help control certain types of seizures) Oral Tablet 1000 mg, and Sinemet (a combination medication of carbidopa and levodopa used to treat symptoms of Parkinson's disease [a progressive nervous system disorder that affects movement]) 10-100 mg were administered as whole tablets and not crushed. This deficient practice had the potential to place two of 10 sampled residents (Resident 46 and 7) observed during medication administration at increased risk for stomach irritation and toxic side effect due to overdosing when the drugs are no longer released and absorbed gradually. Cross-reference F759. Findings: a. During a review of Resident 46's admission Record, the admission Record indicated that the facility originally admitted Resident 46 on 2/23/2024 and readmitted on [DATE] with diagnoses including unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and unspecified mood disorder (mental disorders characterized by a disturbance in mood which is abnormally depressed or elated). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 5/31/2026, the MDS indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). The MDS further indicated that Resident 46 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, upper and lower body dressing and substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 46`s Physician`s Orders (PO), dated 5/20/2026, the PO indicated an order for Depakote Oral Tablet Delayed Release 125 mg, give one (1) tablet by mouth two times a day for mood disorder m/b uncontrollable mood swings causing anger interfering with activities of daily living. DO NOT CRUSH and give with food. During a medication pass observation on 6/16/2026 at 3:57 p.m., in Resident 46`s door, by the hallway, observed Licensed Vocational Nurse (LVN) 3 preparing to administer medications to Resident 46. After verifying the medications that are due for administration from Resident 46`electronic chart, LVN 3 proceeded to take out the medication from the bubble pack (a blister pack, a method of packaging pills into individual, sealed compartments) of Depakote Oral Tablet Delayed Release 125 mg. LVN 3 then crushed the Depakote Oral Tablet Delayed Release and mixed it with apple sauce then administered the medication to Resident 46. b. During a review of Resident 7's admission Record, the admission Record indicated that the facility originally admitted Resident 7 on 6/25/2018 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms) and seizure (a sudden, uncontrolled surge of electrical activity in the brain). During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 7 was totally dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 7's PO, the PO indicated an order for the following: - Buspirone HCL Oral Tablet 2.5 mg tablet by mouth three times a day dated 8/27/2025; - Keppra Oral Tablet 1000 mg, 1 tablet by mouth two times a day dated 1/6/2025; - Sinemet 10-100 mg, give 1 tablet by mouth before meals twice a day dated 1/06/2025. During a medication pass observation on 6/16/2026 at 4:22 p.m., in Resident 7`s door, by the hallway, observed LVN 3 preparing to administer medications to Resident 7. After verifying the medications that are due for administration from Resident 7`s electronic chart, LVN 3 proceeded to take out the medications from the bubble packs of Buspirone HCL Oral Tablet 2.5 mg, Keppra Oral Tablet 1000 mg, and Sinemet 10-100 mg. LVN 3 crushed the medications and placed the medications on a separate medication cups then mixed them with apple sauce and administered the medications using a spoon. During an interview after the medication pass observation on 6/16/2026 at 4:25 p.m., upon verifying with LVN 3 if the medication orders included a direction to crush the medications of Resident 46 and 7, LVN 3 stated that there is no direction to crush the medications. LVN 3 stated that during her (LVN 3) training, she (LVN 3) observed the nurses crush Resident 46 and 7's medications to prevent choking that`s why she (LVN 3) also crushed them. LVN 3 stated that she (LVN 3) should have confirmed with the provider if the medications can be crushed for resident`s safety. LVN 3 stated that the efficacy of the medications can be affected if they are crushed instead of administering them as a whole tablet due to different absorption time. LVN 3 stated that she (LVN 3) was not following the doctor`s order in this case since there was no direction to crush the medications. During an interview on 6/18/2026 at 1:55 p.m., with the Director of Nursing (DON), the DON stated that the nurses should follow what is in the order and not to crush a medication that there is no direction to crush. The DON stated that for the Depakote Delayed Release tablet, it must not be crushed because it can cause irritation to the stomach and can potentially cause stomach bleeding. The DON stated that the Buspirone, Keppra and Sinemet are to be taken as a whole tablet since there is no direction to crush the medications to maintain its efficacy. During a review of the facility`s policy and procedure (P&P) titled Administering Medications, last reviewed on 4/15/2026, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist`s (CP) Medication Regimen Review (MRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) recommendation to consider a dose reduction, if appropriate, for Seroquel (also known as quetiapine, a medication used to treat certain mental/mood disorders) and Lexapro (also known as escitalopram, medication used to treat depression [mood disorder that causes a persistent, heavy feeling of sadness and a loss of interest in things you usually enjoy] and anxiety [mental health condition that involves excessive fear, worry, or nervousness that interferes with daily life]) for one of five residents (Resident 13) reviewed for Unnecessary Medications. This deficient practice placed the resident at increased risk for adverse effect of higher doses of Seroquel and Lexapro, such as heart rhythm issues which can lead to life-threatening arrhythmias (an irregular, too-fast, or too-slow heartbeat caused by a malfunction in the heart's electrical system) and Orthostatic Hypotension (a dangerous drop in blood pressure when standing up too quickly, which can lead to dizziness, fainting, and falls). Findings: During a review of Resident 13's admission Record (AR), the AR indicated that the facility originally admitted the resident on 3/21/2018 and readmitted on [DATE], with diagnoses including muscle weakness and paranoid schizophrenia (a severe mental health disorder where individuals experience intense paranoia, delusions, and auditory hallucinations). During a review of Resident 13`s Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 13 had the ability to sometimes makes self-understood and had the ability to sometimes understand others. The MDS indicated that the resident required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, lower body dressing and partial/moderate assistance helper does less than half the effort) with upper body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review on 6/18/2026 at 11 a.m. with the Director of Nursing (DON), the CP's recommendations for Resident 13 for January and February 2026 and Resident 13's electronic Medication Administration Record (eMAR- the digital equivalent of traditional paper records used by healthcare professionals to track, document, and manage resident medications) were reviewed. The CP's recommendations for February and March 2026 indicated: - On 1/30/2026, the CP recommended to consider dose reduction of Seroquel 50 milligrams (mg - a unit of measure for mass) at hours of sleep (QHS) which the resident was taking since 9/22/2025; - On 2/28/2026, the CP recommended to consider dose reduction of Lexapro 10 mg once a day (QD) which the resident was taking since 8/22/2025. Resident 13's eMAR indicated: - For February 1 to 28, 2026, Seroquel 50 mg, one (1) tablet by mouth at bedtime was administered the entire month. - For March 1 to 31, 2026, Seroquel 50 mg, 1 tablet by mouth at bedtime was administered the entire month, - For March 1 to 31, 2026, Lexapro 10 mg, 1 tablet by mouth one time a day was administered the entire month. The DON stated the MRR is conducted every month and the objective is to determine if the medication is appropriate for the resident`s condition/diagnosis, has an appropriate duration, and has any potential drug to drug interaction and side effects. The DON stated that if a resident is on a psychoactive or psychotropic medication (that changes brain function, altering your mood, perception, thoughts, or behavior), the review will include if a gradual dose reduction (GDR) is appropriate and if any laboratory blood works are to be monitored. The DON stated psychoactive or psychotropic medications can impair the resident`s function and prolonging the use of Seroquel and Lexapro can result in adverse side effects. The DON stated that for these two months of medication regimen review (January and February 2026), the recommendation for a dose reduction was not communicated to the resident`s physician and no attempt at dose reduction was conducted per CP recommendation. The DON stated that the resident could unnecessarily experience adverse effects of the higher dose of these medications and a dose reduction can minimize the risks of the adverse effects. During a review of the facility`s policy and procedures (P&P) titled Medication Regimen Reviews, last reviewed on 4/15/2026, the P&P indicated A licensed Pharmacist reviews the medication regimen of each resident at least monthly.the purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. During a review of the facility`s P&P titled Psychotherapeutic Medications, last reviewed on 4/15/2026, the P&P indicated that GDR will be attempted during at least two quarters during the first year unless clinically contraindicated.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 30 total opportunities contributed to an overall medication error rate of 13.33% affecting two of 10 residents (Resident 46 and 7) observed for medication administration. The medication errors were as follows: 1. The facility failed to ensure Resident 46`s Depakote (also known as as divalproex sodium - medication primarily used to treat certain types of seizures [epilepsy], prevent migraine headaches, and manage manic or mixed episodes associated with bipolar disorder [a mental health condition that causes extreme, cyclical shifts in mood, energy, activity levels, and concentration]) Oral Tablet Delayed Release 125 milligram (mg - a unit of measurement for mass) was administered as a whole tablet and not crushed. 2. The facility failed to ensure Resident 7's medications Buspirone HCL (medication used to treat certain anxiety disorders or to relieve the symptoms of anxiety) Oral 2.5 mg tablet, Keppra (also known as levetiracetam, a medication used alone or together with other medicines to help control certain types of seizures) Oral Tablet 1000 mg, and Sinemet (a combination medication of carbidopa and levodopa used to treat symptoms of Parkinson's disease [a progressive nervous system disorder that affects movement]) 10-100 mg were administered as whole tablets and not crushed. These failures had the potential to result in Resident 46 and 7 receiving suboptimal (less than standard) care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that medication may have) and resulting in Residents 46 and 7's health and well-being negatively impacted. Cross-reference F755. Findings: a. During a review of Resident 46's admission Record, the admission Record indicated that the facility originally admitted Resident 46 on 2/23/2024 and readmitted on [DATE] with diagnoses including unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and unspecified mood disorder (mental disorders characterized by a disturbance in mood which is abnormally depressed or elated). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 5/31/2026, the MDS indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). The MDS further indicated that Resident 46 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, upper and lower body dressing and substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 46`s Physician`s Orders (PO), dated 5/20/2026, the PO indicated an order for Depakote Oral Tablet Delayed Release 125 mg, give one (1) tablet by mouth two times a day for mood disorder m/b uncontrollable mood swings causing anger interfering with activities of daily living. DO NOT CRUSH and give with food. During a medication pass observation on 6/16/2026 at 3:57 p.m., in Resident 46`s door, by the hallway, observed Licensed Vocational Nurse (LVN) 3 preparing to administer medications to Resident 46. After verifying the medications that are due for administration from Resident 46`electronic chart, LVN 3 proceeded to take out the medication from the bubble pack (a blister pack, a method of packaging pills into individual, sealed compartments) of Depakote Oral Tablet Delayed Release 125 mg. LVN 3 then crushed the Depakote Oral Tablet Delayed Release and mixed it with apple sauce then administered the medication to Resident 46. b. During a review of Resident 7's admission Record, the admission Record indicated that the facility originally admitted Resident 7 on 6/25/2018 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms) and seizure (a sudden, uncontrolled surge of electrical activity in the brain). During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 7 was totally dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 7's PO, the PO indicated an order for the following: -Buspirone HCL Oral Tablet 2.5 mg tablet by mouth three times a day dated 8/27/2025; -Keppra Oral Tablet 1000 mg, 1 tablet by mouth two times a day dated 1/6/2025; -Sinemet 10-100 mg, give 1 tablet by mouth before meals twice a day dated 1/06/2025. During a medication pass observation on 6/16/2026 at 4:22 p.m., in Resident 7`s door, by the hallway, observed LVN 3 preparing to administer medications to Resident 7. After verifying the medications that are due for administration from Resident 7`s electronic chart, LVN 3 proceeded to take out the medications from the bubble packs of Buspirone HCL Oral Tablet 2.5 mg, Keppra Oral Tablet 1000 mg, and Sinemet 10-100 mg. LVN 3 crushed the medications and placed the medications on a separate medication cups then mixed them with apple sauce and administered the medications using a spoon. During an interview after the medication pass observation on 6/16/2026 at 4:25 p.m., upon verifying with LVN 3 if the medication orders included a direction to crush the medications of Resident 46 and 7, LVN 3 stated that there is no direction to crush the medications. LVN 3 stated that during her (LVN 3) training, she (LVN 3) observed the nurses crush Resident 46 and 7's medications to prevent choking that`s why she (LVN 3) also crushed them. LVN 3 stated that she (LVN 3) should have confirmed with the provider if the medications can be crushed for resident`s safety. LVN 3 stated that the efficacy of the medications can be affected if they are crushed instead of administering them as a whole tablet due to different absorption time. LVN 3 stated that she (LVN 3) was not following the doctor`s order in this case since there was no direction to crush the medications. During an interview on 6/18/2026 at 1:55 p.m., with the Director of Nursing (DON), the DON stated that the nurses should follow what is in the order and not to crush a medication that there is no direction to crush. The DON stated that for the Depakote Delayed Release tablet, it must not be crushed because it can cause irritation to the stomach and can potentially cause stomach bleeding. The DON stated that the Buspirone, Keppra and Sinemet are to be taken as a whole tablet since there is no direction to crush the medications to maintain its efficacy. During a review of the facility`s policy and procedure (P&P) titled Administering Medications, last reviewed on 4/15/2026, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to maintain an accurate and up-to-date Face Sheet (admission Record) for one (1) of 30 residents (Resident 3) reviewed for medical record accuracy when the facility staff did not remove an outdated diagnosis of dysphagia (difficulty swallowing) from Resident 3's Face Sheet. This failure had the potential to cause staff to implement unnecessary or inappropriate care interventions based on inaccurate clinical information. Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/13/2025 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia. During a review of Resident 3's History and Physical Examination (HP, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician on 1/13/2026, the HP indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated the resident cognition (ability to think, learn, remember, use judgement, and make decisions) is severely impaired. The MDS did not indicate a diagnosis of dysphagia. During a review of Resident 3's Speech Therapy (ST) telephone order, dated 5/5/2026, the ST order indicated discontinue the medical diagnosis of dysphagia. During a concurrent interview and record review on 6/16/2026 at 4:10 p.m. with Minimum Data Set Coordinator (MDSC) 1, Resident 3's Face Sheet was reviewed. MDSC 1 stated Resident 3's Face Sheet indicated diagnosis of dysphagia; however, ST discontinued the dysphagia diagnosis on 5/5/2026. MDSC 1 stated the Face Sheet is not accurate and was not updated, which can lead to confusion for staff when providing care. During an interview on 6/17/2026 at 9:10 a.m. with the Director of Nursing (DON), the DON stated Resident 3's Face Sheet is not accurate since it includes a diagnosis of dysphagia that was discontinued on 5/5/2026 by the ST. The DON stated it is important to have update and accurate diagnosis to provide necessary care for residents. During an interview on 6/17/2026 at 11:01 a.m. with the ST, the ST stated Resident 3 does not have a diagnosis of dysphagia based on her assessment and Resident 3's dysphagia diagnosis was discontinued on 5/5/2026. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 4/15/2026, the P&P indicated the documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to: a. Ensure one (1) of 1 sampled resident (Resident 17) investigated under respiratory care nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. b. Report within 24 hours to the California Department of Public Health (CDPH) a resident with a new diagnosis of syphilis (a curable sexually transmitted infection caused by bacteria), which is a reportable disease (a disease that is to be appropriate county or health department officials) for one of three sampled (Resident 92) residents investigated for infection control. This deficient practice had the potential to place other residents at risk for spread of infection. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated the facility originally admitted the resident on 9/11/2024 and readmitted on [DATE] with diagnoses including acute respiratory failure (a sudden, life-threatening condition where the lungs fail to oxygenate the blood adequately) and shortness of breath (he uncomfortable feeling of not being able to catch your breath or get enough air into your lungs). During a review of Resident 17's Minimum Data Set (MDS – a resident assessment tool), dated 6/2/2026, the MDS indicated the resident had the ability to sometimes makes self-understood and the ability to sometimes understand others. The MDS further indicated that Resident 17 required supervision or touching assistance (helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 17`s Order Summary Report, dated 6/13/2026, the Order Summary Report indicated a physician`s order to administer Oxygen at two (2) liters (a unit of measure for volume) per minute (LPM) via nasal cannula and may be titrated up to five (5) LPM for oxygen saturation (the amount of oxygen that's circulating in the blood) less than 92% every shift. During the initial tour observation on 6/15/2026 at 9:44 a.m., observed Resident 17 in his bed sleeping. The resident was connected to an oxygen concentrator via a nasal cannula tubing. The nasal cannula tubing formed a loop with the middle part of the nasal cannula tubing laying on the floor. During a concurrent observation and interview on 6/15/2026 at 10:30 a.m. with the Infection Preventionist Nurse (IPN) in Resident 17`s room, observed the resident connected to an oxygen concentrator (a medical device that draws in ambient air, filters out nitrogen, and delivers concentrated oxygen (up to 95% pure) for residents requiring supplemental oxygen therapy) via a nasal cannula tubing that was forming a loop with the middle part touching the floor. The IPN stated that if the nasal cannula tubing is touching the floor, it can increase the risk of infection because the floor is dirty and can contaminate the tubing. The IPN stated that to prevent the tubing from touching the floor they will place portion of them length of the tubing in the plastic bag that is hanging in the oxygen concentrator machine. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, last revised 1/2026, the P&P indicated the facility has written policies and procedures in accordance with current infection control standards of practice based on recognized guidelines and the facility assessment. During a review of the Centers for Disease Control (CDC) source material titled, Guidelines for Environmental Infection Control in Health-Care Facilities, dated 2003, the source material indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. b. During a review of Resident 92's AR, the AR indicated the facility admitted the resident on 1/26/2026 and re-admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and syphilis. During a review of Resident 92's MDS, dated [DATE], the MDS indicated Resident 92 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 92 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 92's Physician's Orders, dated 6/9/2026, the physician's orders indicated an order for Doxycycline Hyclate Oral Tablet (a broad-spectrum antibiotic to treat bacterial infections) 100 milligrams (mg – a unit of measure for mass), give 1 tablet by mouth two times a day for syphilis for 30 days, give with a snack. During a review of Resident 92's Care Plan for Infection: Syphilis, initiated 6/9/2026, the care plan indicated a goal that Resident 92's infection will be resolved by the next assessment. The care plan indicated the following: - Administer antibiotic therapy as ordered, initiated 6/9/2026. - Follow up with CDPH regarding guidance and recommendations related to the resident with syphilis diagnosis. Will follow up with CDPH again in the morning, initiated 6/15/2026. - Followed up with general acute care hospital (GACH) for more information related to the resident's syphilis diagnosis. Will follow up with GACH infection manager again in the morning, initiated 6/15/2026. During a review of Resident 92's GACH Physician Progress Notes, dated 5/28/2026, the notes indicated the following: Resident 92 had a history of Rapid Plasma Reagin positive, ratio 1:1 (RPR, a test used to detect syphilis), and Fluorescent Treponemal Antibody-Absorption (FTA-ABS, a highly specific blood serum test used to detect antibodies targeting the bacteria that causes syphilis) positive test. We will check with Public Health regarding previous syphilis treatment; we will initiate treatment. During a review of Resident 92's GACH Laboratory Report, resulted 5/28/2026, the labs indicated Resident 92 had a positive RPR and FTA-ABS result. During a review of Resident 92's Sexually Transmitted Disease – Confidential Morbidity Report (an official, privacy-protected document used by healthcare providers to alert local or state public health departments about the diagnosis or suspicion of a reportable sexually transmitted disease), dated 6/16/2026, the report indicated the facility is reporting Resident 92 has syphilis to the County of Los Angeles Public Health department. During an interview with the Director of Nursing (DON) on 6/15/2026 at 3:45 p.m., the DON stated the facility did not report Resident 92's syphilis diagnosis to public health. The DON stated this is a new diagnosis and was discovered during Resident 92's last hospitalization. During a phone interview with the CDPH PHN on 6/16/2026 at 9:55 a.m., the CDPH PHN stated the facility is a mandated reporter (regarding an infection which is a legal obligation placed on healthcare providers to report specific, dangerous communicable diseases to local or state health authorities) because they are providing treatment for Resident 92. During a concurrent interview and record review with the IPN on 6/16/2026 at 1:45 p.m., the facility's P&P titled, Reportable Diseases, last reviewed 4/15/2026, was reviewed. The IPN stated Resident 92's Psychiatrist (PSYCH MD) called the GACH physician to find out more information. The IPN stated the GACH physician told the PSYCH MD that GACH did not report the case to public health but only inquired if he had been treated in the past. The IPN stated the facility is a mandated reported because the facility is providing treatment. The IPN stated he should have reported Resident 92's syphilis diagnosis to the public health nurse within 24 hours according to the facility's policy. The IPN stated it is important to report timely to keep track of the infection and to follow any public health nurse recommendations to ensure other residents are not at risk for infection. During an interview with the DON on 6/18/2026 at 1 p.m., the DON stated the facility should have reported Resident 92's diagnosis of syphilis within the required 24-hour time frame. The DON stated this is important for infection control. During a review of the facility's P&P titled, Reportable Diseases, last reviewed 4/15/2026, the P&P indicated the following: - Reportable diseases are infections, illness or conditions with public health significance that must be reported to the local and/or stated health department. - When a resident(s) presents with a suspected or confirmed infection, illness or condition that is reportable, the Infection Preventionist (or designee) notified the local health department within the required timeframe. The local health department will report to the state and/or provide further instructions for the facility. During a review of County of Los Angeles Public Health document titled, Reportable Diseases and Conditions, last revised 9/19/2025, the document indicated syphilis is to be reported by electronic transmission, telephone, or mail within 1 working day from identification.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to:1. Ensure Licensed Vocational Nurse 1 (LVN 1) document accurately the time Family Member 1 (FM 1) was notified of Resident 1's change of condition on 2/13/2026.2. Ensure Registered Nurse 1 (RN 1) and LVN 2 document obtaining of urine sample through straight catheterization (a medical procedure, also known as intermittent or in-and-out catheterization, where a flexible tube is inserted through the urethra into the bladder to drain urine, then immediately removed) of Resident 1.3. Ensure nurses document notification of the physician of Resident 1's laboratory test result on 2/17/2026 and 2/20/2026.These failures had the potential to result in confusion in care and the medical records containing inaccurate documentation.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. Certified Nursing Assistant 1 (CNA 1) reported to LVN 1 that Resident 1 had diaper with blood-tinged (a small amount of blood) urine. LVN 1 noted Resident 1 with hematuria (bloody urine) but had no pain and no burning sensation. The COC indicated on 2/13/2026, at 6:30 a.m., CNA 1 reported to LVN 1 the second episode of blood-tinged urine in Resident 1's diaper. The COC indicated notification to FM 1 on 2/13/2026, at 12 midnight.During a concurrent interview, and record review on 3/10/2026, at 12:18 p.m., with the Director of Nursing (DON), Resident 1's COC, dated 2/13/2026, was reviewed. The DON stated LVN 1 documented notification of FM 1 on 2/13/2026, at 12 midnight but the blood-tinged urine did not happen until 2/13/2026, at 3 a.m. and 6:30 a.m. The DON stated 12 midnight was not the accurate time. The DON stated LVN 1 should have documented accurately the time she (LVN 1) called FM 1.b. During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated the following orders:- Urinalysis (urine test) with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).- May do straight catheterization for urine collection, if unable to obtain clean catch (a technique for collecting a sterile, midstream urine specimen).During a concurrent interview, and record review on 3/6/2026, at 1:48 p.m., with RN 2, Resident 1's Physician Order, dated 2/13/2026, were reviewed. RN 2 stated the physician ordered urinalysis, culture and sensitivity to Resident 1's using straight catheterization for urine collection.During an interview on 3/10/2026, at 10:37 a.m., with RN 1, RN 1 stated on 2/13/2026, she (RN 1) with the help of LVN 2, had straight-catheterized Resident 1 and obtained urine sample for urinalysis, culture and sensitivity but there was an issue with the labelling so on 2/14/2026, LVN 2 had to straight-catheterized Resident 1 again with RN 2.During an interview on 3/10/2026, at 11:10 a.m., with LVN 2, LVN 2 stated on 2/13/2026, she (LVN 2) assisted RN 1 to straight-catheterized Resident 1 in obtaining urine sample for urinalysis, culture and sensitivity. LVN 2 stated she (LVN 2) did not document the straight catheterization of Resident 1 on 2/13/2026. LVN 2 stated RN 1 should have documented since she (RN 1) was the one who performed the procedure on 2/13/2026. LVN 2 stated she (LVN 2) placed the urine sample in a specimen cup but was informed on 2/14/2026, that it should have been in a tube. LVN 2 stated on 2/14/2026, she (LVN 2) had straight-catheterized Resident 1 again. LVN 2 stated she (LVN2) did not document that she (LVN 2) performed the straight catheterization to Resident 1 on 2/14/2026. LVN 2 stated she (LVN 2) should have documented in Resident 1's medical record because it happened and it was an invasive procedure (a medical action that enters the body by cutting, puncturing the skin, or inserting instruments [example given, catheters, scopes {thin, flexible or rigid tubes equipped with cameras and lights, used by specialists to visualize, diagnose, and treat internal organs and body cavities without major surgery}] through natural orifices [opening]) so documentation of how the Resident 1 tolerated the procedure is important and for completeness of Resident 1's medical record.During an interview on 3/10/2026 at 12:18 p.m., with the DON, the DON stated RN 1 and LVN 2 should have documented nursing procedures like straight catheterization and how well Resident 1 tolerated (how well a resident's body accepts a certain treatment or medication) the procedure. The DON stated the facility failed to document two invasive procedures in Resident 1's medical record.c. During a review of Laboratory Results Report, dated 2/17/2026, the Laboratory Results Report for urinalysis indicated on 2/17/2026, at 4:39 a.m., the laboratory received the urine specimen. The Laboratory Results Report indicated on 2/17/2026, at 7:37 p.m., the laboratory reported the urinalysis result to the facility and on 2/20/2026, at 5:45 p.m., the laboratory reported the urine culture result to the facility.During a concurrent interview, and record review on 3/10/2026, at 8:51 a.m. with RN 1, Resident 1's Laboratory Results Report, dated 2/17/2026, and Progress Notes, dated 2/17/2026 and 2/20/2026, were reviewed. The Laboratory Results Report indicated the urinalysis result reported to the facility on 2/17/2026, at 7:37 p.m. and the urine culture result reported to the facility on 2/20/2026 at 5:45 p.m. RN 1 stated there was no documentation in Resident 1's medical record that the physician was notified on 2/17/2026, of the urinalysis result and on 2/20/2026, of the urine culture result. RN 1 stated she (RN 1) worked on both days on 2/17/2026, and 2/20/2026, but only until 3 p.m. RN 1 stated after 3 p.m. the assigned LVNs in Station 1 or in Station 2 should have received the fax (the telephonic transmission of scanned printed material normally to a telephone number connected to a printer or other output device) of any laboratory results and send a copy thru electronic message (text) to the physician on 2/17/2026, and on 2/20/2026. RN 1 stated Resident 1's urinalysis and culture result may have indicated signs of urine infection. RN 1 stated the nurses should have documented that physician was notified of the urinalysis and urine culture test result on 2/17/2026, and 2/20/2026.During an interview on 3/10/2026, at 11:58 a.m. with the DON, the DON stated there was no documented evidence in Resident 1's medical record that the nurses have notified the physician on 2/17/2026, and 2/20/2026, of the urinalysis and urine culture test result. The DON stated it is important to document notification of the physician of the laboratory test result for the continuity and communication of care and to obtain physician order like medication such as antibiotics (medication used to treat infection) appropriate for the laboratory test result. The DON stated failing to document means physician notification was not done. The DON stated the facility's policy for charting was not followed and Resident 1's medical record was not complete and accurate.During a review of facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial (the interrelation of social factors and individual thought and behavior) condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: . c. Treatments or services performed;3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/ treatment; d. how the residents tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) who had an episode of hematuria (presence of blood in the urine) accurately.This failure had the potential for confusion and may delay in the delivery of necessary care and services to Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. and at 6:30 a.m. Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had diaper with blood-tinged (a small amount of blood) urine.During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated the following orders:-Urinalysis (urine test) with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).-May do straight catheterization (a thin, flexible, single-use tube inserted temporarily through the urethra to drain urine and removed immediately after) for urine collection, if unable to obtain clean catch (a technique for collecting a sterile, midstream urine specimen).During a review of Resident 1's Care Plan, dated 2/13/2026, about episodes of hematuria, the Care Plan indicated the following interventions:Monitor indwelling catheter (a hollow tube that is inserted into your bladder to drain urine) and change catheter or bag as ordered.Foley catheter (a specific, common type of indwelling catheter) cares every shift or as ordered.Maintain proper alignment of foley catheter to promote proper drainage.During an interview on 3/10/2026, at 11:10 a.m., with LVN 2, LVN 2 stated on 2/13/2026, she (LVN 2) assisted Registered Nurse 1 (RN 1) in obtaining urine sample for urinalysis, culture and sensitivity to Resident 1's using straight catheterization. LVN 2 stated Resident 1 had no indwelling catheter.During a concurrent interview and record review on 3/10/2026, at 12:18 p.m., with the Director of Nursing (DON), Resident 1's Care Plan, dated 2/13/2026, about hematuria was reviewed. The DON stated Resident 1's Care Plan should have been individualized to reflect use of straight catheter instead of indwelling catheter. The DON stated indwelling catheter is a continuous use of catheter. The DON stated the care plan was not accurate because Resident 1 never had an indwelling catheter. The DON stated a care plan should be individualized to be consistent and accurate in providing care specific to Resident 1.During a concurrent interview and record review on 3/10/2026, at 12:45 p.m., with the DON, facility's policy and procedure (P&P) titled, The Resident Care Plan, undated and last reviewed on 1/14/2026, the P&P indicated, To provide an individualized nursing care plan and to promote continuity of resident care.Record the following: 1. Procedures directly ordered by the physician; 2. Procedures associated with specific resident teaching; 3. Care necessitated by the resident's individual needs. The DON stated Resident 1's Care plan should be individualized for Resident 1's needs.

Based on interview and record review, the facility failed to notify the physician promptly (acting immediately, without delay, or exactly at a scheduled time) for one of three sampled residents (Resident 1) by:1. Failing to notify the physician promptly when Resident 1 had a change of condition with blood-tinged (a small amount of blood) urine on 2/13/2026, at 3 a.m.2. Failing to notify the physician promptly when the facility received Resident 1's urinalysis (urine test) result on 2/17/2026.These failures had the potential for a delay in the delivery of necessary care and services and had the potential for increased risk of infection to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had diaper with blood-tinged urine. LVN 1 noted Resident 1 with hematuria (bloody urine) but had no pain and no burning sensation. The COC indicated on 2/13/2026, at 6:30 a.m., CNA 1 reported to LVN 1 the second episode of blood-tinged urine in Resident 1's diaper. The COC indicated Registered Nurse 1 (RN 1) notified the physician at 7:13 a.m.During a concurrent interview and record review on 3/6/2026, at 1:48 p.m., with RN 2, Resident 1's COC, dated 2/13/2026, was reviewed. RN 2 stated LVN 1 should have informed the physician right away on the first sign of hematuria on 2/13/2026, at 3 a.m. RN 2 stated Resident 1's condition can worsen because of delay in physician notification.During an interview on 3/6/2026, at 2:34 p.m., with LVN 2, LVN 2 stated physician should be notified immediately if there was a blood-tinged urine. LVN 2 stated that delay in physician notification can delay care and worsen Resident 1's hematuria and could lead to urinary tract infection (UTI- an infection in the bladder/urinary tract).During an interview on 3/10/2026, at 8:51 a.m. with RN 1, RN 1 stated her (RN 1) work starts from 7 a.m. to 3 p.m. RN 1 stated on 2/13/2026, she (RN 1) was informed by LVN 1 that Resident 1 had hematuria at 3 a.m. and again at 6:30 a.m. and the physician was not yet notified so as soon as she (RN 1) came she (RN 1) notified the physician. RN 1 stated LVN 1 should have notified the physician on the first sign of blood-tinged urine on 2/13/2026 at 3 a.m. RN 1 stated delay in physician notification can result to infection and possible sepsis (a life-threatening blood infection).During an interview on 3/10/2026, at 12:18 p.m. with the Director of Nursing (DON), the DON stated LVN 1 should have notified the physician on 2/13/2026, at 3 a.m., on the first sign of hematuria despite no complaints of pain. The DON stated that timely notification of physician is important to inform the physician and obtain an order for laboratory test (a medical procedure analyzing samples of blood, urine, or tissue to gather data on a patient's health). The DON stated there was a delay in Resident 1's physician notification that could worsen Resident 1's hematuria.b. During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated an order for urinalysis with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).During a concurrent interview and record review on 3/10/2026, at 8:51 a.m. with RN 1, Resident 1's Laboratory Results Report, dated 2/17/2026, and Progress Notes, dated 2/17/2026, were reviewed. The Laboratory Results Report indicated the urinalysis result reported to the facility on 2/17/2026, at 7:37 p.m. RN 1 stated there was documentation in Resident 1's medical record that the physician was notified on 2/17/2026, of the urinalysis result. RN 1 stated she (RN 1) worked that day on 2/17/2026, but only until 3 p.m. RN 1 stated after 3 p.m. the assigned LVNs in Station 1 or in Station 2 should have received the fax (the telephonic transmission of scanned printed material normally to a telephone number connected to a printer or other output device) of any laboratory results and send a copy thru electronic message (text) to the physician on 2/17/2026. RN 1 stated Resident 1's urinalysis result may have indicated signs of infection, and the physician should have been notified right away.During a concurrent interview and record review on 3/10/2026, at 11:58 a.m. with the DON, the text messages from the facility phone, dated 2/17/2026, and 2/18/2026, were reviewed. The facility phone indicated a text of a picture of Resident 1's urinalysis result sent to the physician on 2/18/2026, at 3:37 p.m. The DON stated the facility phone did not indicate notification to the physician on 2/17/2026.During an interview on 3/10/2026, at 12:18 p.m. with the DON, the DON stated the LVNs should have notified the physician of the urinalysis result on 2/17/2026. The DON stated physicians should be notified of laboratory test results to proceed with appropriate plan of care to address the problem, obtain a new set of laboratory test or obtain new medication like antibiotic (medication used to treat infection) to fight the infection. The DON stated delay in physician notification can cause further complication (something that makes a situation more difficult) and lead to Resident 1's infection.During a review of facility's policy and procedure (P&P), titled, Change in Condition, dated 1/24/2017, and last reviewed on 1/14/2026, the P&P indicated, A change in condition is a sudden or marked difference in resident's.4. Output (example given low urine output, hematuria.).5. Laboratory or radiology reports.A. All changes of condition in a resident shall be handled promptly.C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions: Physician shall be called promptly.-If for some reason physician cannot be reached, alternative physician shall be contacted.- If alternate cannot be reached, Medical Director is to be contacted.- All contacts or attempts to contact shall be documented and include the correct time of the activity.- If no physician is available, arrangements are to be made for physician services that may include transfer to emergency room for appropriate care.

Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for three of five sampled residents (Residents 1, 6, and 7), by failing to:1. Ensure treatment for rashes was provided to Resident 1 as per physician order. Resident 1's Treatment Administration Record (TAR) was blank on 1/16/2026, 1/20/2026, and 1/27/2027.2. Obtain a physician order for Resident 6's treatment for rashes from 11/1/2025 to 11/13/2025.3. Ensure Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) was notified as per physician order on 5/17/2025. Resident 6 was never seen by a Dermatologist for eight months after a physician order.4. Ensure Dermatologist was notified as per physician order. Resident 7 had physician order for Dermatologist consultation on 12/25/2025 and was not seen until 1/26/2026. These failures had the potential for Residents 1, 6, and 7's delay in Dermatologist treatment and could potentially lead to worsening of residents' rashes. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2025, and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)-bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and chronic viral hepatitis B (a long-term [lifelong] infection of the liver caused by the hepatitis B virus (HBV) that lasts for more than six months. It means the immune system could not clear the virus, allowing it to remain in the blood and liver, potentially causing silent damage, scarring or liver cancer over time).During a review of Resident 1's Skin Reassessment, dated 1/15/2026, the Skin Reassessment indicated Treatment Nurse 2 (TN 2) documented Resident 1 had rashes to chest and abdomen.During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order to clean chest and abdominal rash with normal saline (salt in water solution), pat dry, apply hydrocortisone (medication used to treat inflammation, itching and swelling) cream one percent (%-one part in every hundred) on affected area and leave open to air daily on day and evening shift for four weeks.During a review of Resident 1's Treatment Administration Record (TAR), dated 1/2026, the TAR indicated blank on the following dates and times:1. 1/16/2026, at day and evening shift,2. 1/20/2026, at day shift3. 1/27/2026, at day shift.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool,) dated 2/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/17/2026, at 9:03 a.m., with TN 1, Resident 1's Order Summary Report, dated 1/15/2026, and TAR, dated 1/2026, were reviewed. TN 1 stated Resident 1's TAR was left blank on 1/16/2026, 1/20/2026, and 1/27/2026.During an interview on 2/18/2026, at 10:15 a.m., with the Registered Nurse Supervisor (RNS), the RNS stated blank TAR means rashes treatment was not signed and treatment was not provided to Resident 1.During an interview on 2/18/2026, at 10:57 a.m., with the Minimum Data Set nurse (MDSN), the MDSN stated blank TAR means treatment was not provided to Resident 1. The MDSN stated Resident 1's rashes can worsen since treatment for rashes was not provided.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the MDSN, facility's policy and procedure (P&P), titled, Administering Medications, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Medications are administered in accordance with prescriber's orders, including any required time frame.20. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.21. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any adverse or undesired result;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.b. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/4/2024, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia and unspecified dermatitis (a common, non-contagious inflammation of the skin characterized by itching, redness, rashes, and dryness).During a review of Resident 6's Physician Order, dated 10/2/2025, the Physician Order indicated to clean generalized rashes to bilateral upper extremities (BUE), bilateral lower extremities (BLE) and chest with normal saline, pat dry, apply clotrimazole (medication used to treat skin infections)-betamethasone (medication used to reduce itching, redness, swelling, and inflammation from skin conditions) external cream 1 %-0.05 % to affected areas and leave open to air daily on day and evening shift for unspecified dermatitis for four weeks.During a review of Resident 6's Skilled Nursing Facility (SNF) Wound Care notes, dated 10/28/2025, the Wound Care notes indicated the Nurse Practitioner (NP) for wound care assessed Resident 6 with generalized unspecified dermatitis and documented plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily.During a review of Resident 6's Treatment Administration Record (TAR), dated 11/2025, the TAR indicated no treatment was provided to Resident 6 from 11/1/2025, to 11/13/2025.During a review of Resident 6's SNF Wound Care notes, dated 11/11/2025, the Wound Care notes indicated the NP assessed Resident 6 with generalized unspecified dermatitis and documented plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/17/2026, at 8:53 a.m., with TN 1, Resident 6's TAR, and Physician Order, dated 11/2025 were reviewed. TN 1 stated Resident 6 still had rashes on BUE, BLE and chest on 11/1/2025 until 11/13/2025. TN 1 stated on 10/29/2025, TN 1 documented in Skin Rash Report that Resident 6 had rashes to BUE, BLE and chest with treatment was clotrimazole and betamethasone. TN 1 stated no documented physician order for Resident 6's rashes and no treatment was provided to Resident 6 from 11/1/2025 to 11/13/2025. TN 1 stated the treatment order was not renewed. TN 1 stated it the responsibility of the TNs to call the physician to obtain order to renew the treatment order. TN 1 stated if there was no documented treatment, Resident 6's rashes were not treated from 11/1/2025 to 11/13/2025. TN 1 stated Resident 6 rashes can worsen and spread if no treatment was provided.During an interview on 2/18/2026, at 10:06 a.m., with the RNS, the RNS stated if there was no physician order on 11/1/2025 for Resident 6 rashes, it means no treatment was provided to Resident 6. The RNS stated Resident 6's rashes could worsen if treatment was not provided for 13 days.During an interview on 2/18/2026, at 10:57 a.m., with the MDSN, Resident 6 rashes can worsen since no treatment was documented for 13 days. The MDSN stated TNs should have called the physician to renew the order for Resident 6's treatment for rashes.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Administering Medications, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Medications are administered in a safe, timely manner and as prescribed. The RNS stated Resident 6 should have received the treatment for rashes since it was documented that he (Resident 6) still had rashes. The RNS stated treatment for Resident 6 should not have stopped. The RNS stated because treatment was not provided to Resident 6 for 13 days, Resident 6's rashes can worsen and cause Resident 6 discomfort from itching.During a review of facility's P&P titled, Non-Pressure Sore Management, undated and last reviewed on 1/14/2026, the P&P indicated, Notification of physician and orders for non-pressure sore treatment.During a review of facility's P&P, titled, Alteration in Skin Integrity, undated and last reviewed on 1/14/2026, the P&P indicated, Residents with alteration in skin integrity will be assessed, orders for treatment will be obtained and care plans will be developed. Procedure:1. Skin alteration will be assessed by licensed staff to include: a. Distribution of skin alteration (measurement of affected skin areas). b. Description of actual affected area(s), including degree of skin alteration. c. Symptoms, if any, manifested by resident, including degree of itching, mild, moderate, severe.2. Physician will be notified and appropriate orders obtained.c. During a review of Resident 6's Order Summary Report, dated 5/17/2025, the Order Summary Report indicated an order for Dermatology consultation and follow up treatment as indicated.During a review of Resident 6's SNF Wound Care notes, from 2/25/2025 to 12/25/2025, the SNF Wound Care notes indicated the NP documented the following:2/25/2025, 3/4/2025, 3/11/2025, 3/18/2025, 4/1/2025, 4/15/2025, and 5/1/2025 - Resident 6 had generalized fungal dermatitis (a widespread skin infection characterized by itchy, red, scaly, and sometimes blistering rashes caused by fungi)6/17/2025, 7/15/2025, and 8/19/2025 -Resident 6 had generalized unspecified dermatitis, other (widespread skin inflammation of unknown origin, often appearing as extensive rash, redness, itching, and scaling [the visible shedding, peeling, or flaking of the skin's outer layer]).9/2/2025, 9/16/2025, 9/30/2025, 10/14/2025, 10/28/2025, 11/11/2025, 11/25/2025, 12/9/2025, and 12/25/2025 - Resident 6 had generalized unspecified dermatitis.During a concurrent interview and record review on 2/13/2026, at 3:21 p.m., with the Infection Preventionist (IP), Resident 6's Transfer Form, dated 1/16/2026, was reviewed. The Transfer Form indicated Resident 6 was transferred to General Acute Care Hospital 1 (GACH 1) on 1/16/2026, due to altered mental status (AMS- a non-specific, often acute change in brain function, resulting in confusion, decreased alertness, disorientation) and abnormal vital signs (measurements falling outside established healthy ranges for adults, typically indicating physiological distress). The IP stated Resident 6 was transferred to GACH 1 with body rashes.During an interview on 2/17/2026, at 8:53 a.m., TN 1 stated Resident 6 was never seen by the Dermatologist only by the NP who was a wound care specialist.During an interview on 2/17/2026, at 9:03 a.m., TN 1 stated the Dermatologist came and visited the facility on 1/26/2026, and Resident 6 was already transferred out to GACH 1 on 1/16/2026.During a concurrent interview and record review on 2/18/2026, at 9:53 a.m., with the IP, Resident 6's Oder Summary Report, dated 5/17/2025, was reviewed. The IP stated Resident 6 had order for dermatology consultation since 5/17/2025.During an interview on 2/18/2026, at 10:06 a.m., with the RNS, the RNS stated the Dermatologist did not come and did not assess Resident 6 rashes from 5/17/2025, (date of physician order) to 1/16/2026, (day of transfer to GACH 1), for almost eight months. The RNS stated the NP is not a Dermatologist but a wound care specialist. The RNS stated Resident 6 rashes can worsen if not seen by the Dermatologist for eight months. The RNS stated if the Dermatologist was notified of Resident 6 ongoing rashes, the Dermatologist could have ordered skin scraping (a common, minimally invasive diagnostic procedure where a technician uses a dull scalpel blade to collect surface skin cells, debris, or parasites for microscopic examination) and treatment for rashes before Resident 6 was transferred to GACH 1 and preventing Resident 6 from testing positive in GACH 1 for scabies (a skin infestation resulting in intense itching and a pimple-like rash, especially at night) which can possibly result to spread of scabies amongst staff and resident. The RNS stated if Resident 6 was seen earlier by the Dermatologist scabies outbreak (a sudden, unexpected increase in cases of a specific disease within a particular, often localized, geographic area or population, exceeding what is normally expected) could have been prevented.During an interview on 2/19/2026, at 12:34 p.m., with the NP, the NP stated he (NP) did brought up to the Director of Nursing (DON) the scabies test and treatment before the 12/25/2025, but he (NP) was informed not to order the scabies test and treatment since the holiday was coming up and the facility might have a potential scabies outbreak and affect the staffing. The NP stated the facility informed him (NP) not to make aggressive treatment for scabies. The NP stated the facility intervened with him (NP) by preventing him (NP) ordering scabies tests and treatment for scabies. The NP stated he (NP) was notified on 1/2026, that the Department was in the facility for scabies outbreak. The NP stated before 1/2026, the facility had no Dermatologist for two years.During a review of facility's P&P, titled, Wound Care, dated 3/2023, and last reviewed on 1/14/21026, the P&P indicated, The purpose of this procedure is to provide guideline for the care of wounds to promote healing. Preparation:1. Verify that there is a physician's order for this procedure.During a review of facility's submitted document titled, Acute Communicable Disease Control Program- Scabies Prevention and Control Guidelines for Healthcare Setting (the Guideline), dated 7/2019 was reviewed. The Guideline indicated, Access to and use as needed of the diagnostic skills of a clinician and or other healthcare consultant experienced in recognizing scabies to evaluate difficult or unusual; cases or response to treatment.Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients/residents or healthcare worker.d. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 1/27/2023, with diagnoses that included unspecified cerebral infarction (a type of ischemic stroke caused by a blocked blood vessel, leading to brain tissue death [necrosis] due to oxygen deprivation), unspecified dementia and unspecified pneumonia (an infection/inflammation in the lungs).During a review of Resident 7's Order Summary Report, dated 12/25/2025, the Order Summary Report indicated Dermatology Consult and follow-up treatment as indicated.During a review of Resident 7's Skin Reassessment, dated 12/26/2025, the Skin Reassessment indicated Resident 7 had rashes to BUE, BLE, chest and back.During a review of Resident 7's Care Plan, dated 1/5/2026, about rash, the Care Plan indicated an intervention to notify Dermatologist of non-response. During a review of Resident 7's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/8/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decisions were intact.During a concurrent interview, and record review on 2/13/2026, at 3:21 p.m., with the IP, Resident 7's Skin Rash Report, dated 1/9/2026, and 1/24/2026, were reviewed. The Skin Rash report indicated Resident 7 had rashes to BUE, BLE and back.During a review of Resident 7's TAR, dated 1/2026, the TAR indicated Resident 7 received triamcinolone (medication used to reduce inflammation, itching, and redness in skin conditions) twice a day for dermatitis from 1/1/2026 to 1/31/2026.During an interview on 2/17/2026, at 9:03 a.m., with TN 1, TN 1 stated Resident 7 was Resident 6's roommate (tested positive for scabies in GACH 1 on 1/22/2206). TN 1 stated Resident 7 had rashes since 12/26/2025. TN 1 stated Resident 7 was not seen by the Dermatologist until 1/26/2026, when the Dermatologist came to the facility to assess and evaluate nine residents with rashes and after Resident 6 tested positive for scabies.During an interview on 2/18/2026, at 10:15 a.m., with the RNS, the RNS stated the facility should have followed the physician order for dermatologist consultation. The RNS stated a delay of Dermatologist notification for one month can worsen Resident 7's rashes.During a concurrent interview, and record review on 2/19/2026 at 8:41 a.m., with TN 1, Resident 7's SNF Wound Care notes were reviewed. TN 1 stated there were no Wound Care notes after 12/25/2025, when the physician ordered the Dermatologist consultation. TN 1 stated Resident 7 was last seen by the NP on 12/9/2025, for right lower leg cellulitis (a skin infection that causes swelling and redness) and not for rashes. TN 1 stated the NP should have been notified on 12/25/2025, upon readmission with rashes and the Dermatologist should have been notified as per physician order. TN 1 stated Resident 7 was seen by the Dermatologist one month after the physician order. TN 1 stated Resident 7 's rashes can worsen since he (Resident 7) was not seen by the NP and the Dermatologist timely.During an interview on 2/19/2026, at 10:36 a.m., with TN 1, TN 1 stated Registered Nurse (RNs) obtains Dermatologist consultation order. TN 1 stated Dermatologist are informed thru fax (a way to transmit a paper document, image, or text from one location to another instantly) or thru phone of the consultation. TN 1 stated she (TN 1) did not call the Dermatologist because the facility does not have a Dermatologist until 1/26/2026.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Non-Pressure Sore Management, undated and last reviewed on 1/14/2026, the P&P indicated, Notification of physician and orders for non-pressure sore treatment.During a concurrent interview and record review on 2/20/2026, at 3:13 p.m., with the RNS, facility's P&P, titled, Change in Condition, dated 1/24/2027, and last reviewed on 1/14/2026, the P&P indicated, To ensure proper assessment and follow-through for any resident with a change of condition. A change in condition is a sudden or marked difference in residents: .11. Bruises, lacerations, blisters, rashes or skin tears. Upon a change in condition for any reason, nursing staff members are to take the following actions: Physician shall be called promptly. The RNS stated that when Resident 7 had rashes on 12/26/2026, a change of condition should have been created, and physician order should have been followed.

Based on interview and record review, the facility failed to implement infection control measures for six of fifteen sampled residents (Residents 1, 2, 3, 4, 5, and 6) after a scabies (a highly contagious [an illness or condition that can be easily spread from one person to another] skin infestation [the state of being invaded or overrun by pests or parasites] caused by the microscopic [too small to be seen by the naked eye] mite [relatives of spiders and ticks found in nearly all habitats] Sarcoptes scabiei [the human itch mite], which burrows [make a hole or tunnel], into the skin to lay eggs causing intense itching especially at night and a pimple-like rash) outbreak (occurs when there is a sudden, unexpected increase in the number of people getting sick with a specific illness in a particular place) was identified in the facility on 1/27/2026, by failing to:1. Ensure Resident 1's Skin Rash Report was completed weekly following Resident 1's readmission on [DATE].2. Notify the Wound Care Physician (WCP) that Resident 1 was readmitted on [DATE], with skin rashes.3. Ensure Treatment Nurse (TN) 1 and TN 2 informed the Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders), who was present in the facility on 1/26/2026, of Resident 1's rashes and informed of an order for a dermatology consultation.4. Document the notification received on 2/9/2026, from General Acute Care Hospital 2 (GACH 2) that Resident 1 tested positive for scabies. 5. Report the scabies outbreak to the State Survey Agency (SSA) on 2/9/2026, upon notification of the second confirmed case of scabies involving Resident 1.6. Perform and document daily skin assessments for four residents (Resident 2, 3, 4, and 5) exposed to Resident 1.7. Provide training and education to ensure TN 1 and TN 2 were competent (having the necessary skills, knowledge, and ability to perform a task or role effectively) in performing skin scrapings (procedure used to collect surface or deep skin cells usually with a scalpel [sharp, small, straight-bladed knife] blade and mineral oil to identify mites, parasites, or fungal infections under a microscope [an instrument that is used to magnify small objects]).8. Ensure Certified Nursing Assistant 1 (CNA) 1, who developed lower back rashes on 1/28/2026, was assessed for scabies via skin scraping.9. Develop a line list (a table that contains key information about each case in an outbreak), identifying CNA 1's resident contacts for the six weeks prior to the onset of symptoms (beginning 12/17/2025) through 1/28/2026, when CNA 1 developed rashes on her lower back.10. Follow its facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) /Skin Breakdown, last reviewed on 1/14/2026, that indicated, Inspect skin condition weekly for any new skin breakdown and changes in skin conditions such as skin tears, bruising, pressure injuries, skin rash.11. Follow its P&P titled, Alteration in Skin Integrity, last reviewed on 1/14/2026, that indicated Weekly skin progress reports will be completed using the non-pressure skin form.12. Follow its P&P titled, Non-Pressure Sore Management, last reviewed on 1/14/2026, that indicated Wound Physician notification for physician, indicating non pressure sore.13. Follow its P&P titled, Reporting Communicable (one that is spread from one person to another) Disease, last reviewed on 1/14/2026, that indicated, the Infection Preventionist (IP) is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable disease.14. Follow the facility provided document titled, Acute Communicable Disease Control Program on Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, that indicated, the following: a. Report healthcare-associated scabies outbreak (two or more cases) to Los Angeles County (LAC)-Department of Public Health. b. Confirm the presence of scabies by microscopic identification of mite or its products in one or more symptomatic resident or employee. c. Prepare a line listing of symptomatic healthcare workers from six weeks before the onset of symptoms until current date and symptoms in household or other close contact. d. Outbreak reported to LAC Health Facilities Inspection Division (HFID) or California Department of Public health Licensing and Certification local office. e. Resident line list completed. f. Daily skin assessment/ documented on all exposed residents.These failures had the likelihood for the residents with scabies, that is not detected by the facility, to continue to transmit and spread scabies to other residents, staff, and visitors. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2025, and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)-bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and chronic viral hepatitis B (a long-term [lifelong] infection of the liver caused by the hepatitis B virus (HBV) that lasts for more than six months. It means the immune system could not clear the virus, allowing it to remain in the blood and liver, potentially causing silent damage, scarring or liver cancer over time). During a review of Resident 1's Skin Reassessment, dated 1/15/2026, the Skin Reassessment indicated TN 2 documented Resident 1 had rashes to the chest and abdomen.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/19/2026, at 8:41 a.m., with TN 1, Resident 1's Skin Reassessment, dated 1/15/2026, Skin Rash Reports, and Treatment Administration Record (TAR), dated 1/2026, and 2/2026, were reviewed. TN 1 stated the facility readmitted Resident 1 on 1/15/2026, and the Skin Reassessment, dated 1/15/2026, indicated TN 2 documented Resident 1 had rashes to chest and abdomen and TN 2 notified the Primary Physician (PP). TN 1 stated there were no weekly Skin Rash Report after 1/15/2026, until Resident 1 was transferred to GACH 2 on 2/6/2026. TN 1 stated the TAR, dated 1/2026, and 2/2026, indicated administration of hydrocortisone (medication used to treat inflammation, itching and swelling) twice a day to Resident 1 for rashes to chest and abdomen from 1/15/2026, to 2/6/2026. TN 1 stated weekly skin rash report should have been documented in Resident 1's medical record to keep track of the progress of the rashes and to find out if treatment was effective. TN 1 stated the weekly Skin Rash Report was not started on 1/15/2026. TN 1 stated as a TN she (TN 1) should have made sure it was done and documented weekly. TN 1 stated as TN they failed to perform and document skin rash report on 1/22/2026, 1/29/2026 and 2/5/2026. TN 1 stated they check residents' skin weekly every Thursday and rash report should have been documented.During an interview on 2/19/2026, at 10:36 a.m., with TN 1, TN 1 stated TN 2 did Resident 1's Skin Reassessment on 1/15/2026, and TN 2 should have opened the Skin Rash Report and documented. TN 1 stated Skin Rash Report was not done and not documented in Resident 1's medical record for three weeks.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the Minimum Data Set Nurse (MDSN), facility's policy and procedure (P&P), titled, Prevention of Pressure Injuries/Skin Breakdown, dated 1/2026, was reviewed. The P&P indicated, Inspect skin condition weekly for any new skin breakdown and changes in skin condition such as skin tear, bruising, pressure injuries, skin rash. Non pressure wound will be documented in the non-pressure wound report and skin rash report, which will be updated weekly until skin problem is resolved or resident discharged from the facility. The MDSN stated there were no documented weekly skin rash report in Resident 1's medical record after the readmission on [DATE]. The MDSN stated the P&P was not followed. The MDSN stated TNs should do a weekly skin rash report assessment and documentation. The MDS stated if weekly skin rash report was not done and not documented, staff might miss some interventions and can worsen Resident 1's rashes.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Body Checks, undated and last reviewed on 1/14/2026, the P&P indicated, To help reduce skin impairment in geriatric (specialized medicine, care, and conditions associated with older age, focusing on complex health needs, often involving multiple chronic illnesses, rather than just chronological age) residents, residents lose sensitivity in their skin and may not feel discomfort until it's too late, and a condition has become severe. It is important to inspect these residents during daily care and also on a weekly basis. The RNS stated the facility's policy was not followed. The RNS stated Resident 1's rashes can worsen if skin rashes are not assessed weekly.During an interview on 2/21/2026, at 9:10 a.m., with TN 2, TN 2 stated Resident 1's skin rash report should have been assessed and documented weekly. TN 2 stated without weekly skin rash report there will be no documentation of the progress of rashes if worsening or getting better. TN 2 stated Resident 1's rashes can worsen if not checked weekly. During a review of facility's P&P, titled, Alteration in Skin Integrity, undated and last reviewed on 1/14/2026, the P&P indicated, Weekly skin progress will be completed using the non-pressure skin form.b. During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order for chest and abdominal rash to be cleanse with normal saline (salt in water solution), pat dry, apply hydrocortisone cream, one percent (%-one part in every hundred) on affected area and leave open to air every day and evening shift.During a concurrent interview and record review on 2/17/2026, at 9:03 a.m., with TN 1, Resident 1's Skilled Nursing Facility (SNF) Wound Care notes were reviewed. TN 1 stated there were no documented SNF Wound Care notes from the WCP or the Nurse Practitioner (NP) after 1/15/2026 readmission. TN 1 stated if there was no documentation it means Resident 1 was not seen by the WCP or the NP.During a concurrent interview, and record review on 2/19/2026, at 8:41 a.m., with TN 1, Resident 1's Skin Reassessment, and Progress Notes, dated 1/15/2026, were reviewed. The Skin Reassessment indicated TN 2 documented the NP will reassess and change order if needed. TN 1 stated there was no documentation that the NP was informed of Resident 1's rashes on readmission on [DATE]. TN 1 stated if not documented it was not done. TN 1 stated if the NP was not informed, he (NP) will not be aware of the Resident 1's rashes and will not see the resident. TN 1 stated Resident 1's rashes could worsen if the NP was not informed.During an interview on 2/19/2026, at 9:31 a.m., with the IP, the IP stated TNs should inform the NP who was the wound care provider that oversees skin and wound care that Resident 1 was readmitted on [DATE], with rashes. The IP stated if the NP was not informed appropriate treatment could not be provided to treat Resident 1's rashes. The IP stated Resident 1's rashes can worsen.During an interview on 2/19/2026, at 11:08 a.m., with the MDSN, the MDSN stated TNs should have informed the NP and document the notification. The MDSN stated if not documented, the NP was not informed and if the NP was not informed, right treatment for rashes could not be provided to Resident 1.During an interview on 2/19/2026, at 12:34 p.m., with the NP, the NP stated he (NP) was not informed of Resident 1's rashes. The NP stated if he (NP) was informed he (NP) would have seen Resident 1 and left a documentation. The NP stated if Resident 1 was not seen, correct diagnosis and treatment would not be provided to treat the rashes. The NP stated evaluation could not be done if the treatment was effective for Resident 1's rashes.During an interview on 2/19/2026, at 2:06 p.m., with RN 1, RN 1 stated wound care provider which is the NP should have been notified of Resident 1's rashes. RN 1 stated if the NP was not notified Resident 1's rashes could potentially exacerbate (to make a disease, condition, or its symptoms worse, more severe, or more intense).During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Non-Pressure Sore management, undated and last reviewed on 1/14/2026, the P&P indicated, Procedure: . 3. Notification of physician and orders for on-pressure sore treatment. 7. Wound Physician Notification for Physician, indicating Non-Pressure Sore. The RNS stated the WCP or the NP should have been notified of Resident 1's rashes on readmission on [DATE]. The RNS stated there is a potential spread of scabies if the physician was not notified. The RNS stated Resident 1 was not evaluated for scabies while the facility had scabies outbreak.During an interview on 2/21/2026, at 9:10 a.m., with TN 2, TN 2 stated he (TN 2) had called Resident 1's Primary Physician (PP) of Resident 1's readmission with rashes on 1/15/2026 but was not sure if he (TN 2) had called and notified the WCP or the NP. TN 2 stated he (TN 2) did not document if he (TN 2) had called the NP. TN 2 stated if it was not documented, the NP was not notified of rashes on 1/15/2026. TN 2 stated if the WCP or the NP was not notified Resident 1's rashes can worsen.c. During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order for Dermatology Consult and follow up treatment as indicated.During a review of Resident 1's Care Plan Report, dated 1/15/2026, on alteration in skin integrity-rashes, the Care Plan Report indicated an intervention for Dermatologist consult as per physician order.During an interview on 2/19/2026, at 11:41 a.m., with the IP, the IP stated TNs should have informed the Dermatologist who was here on 1/26/2026, of Resident 1's rashes so Dermatologist could assess and order skin scraping for early detection of scabies if necessary and obtain an order for Elimite cream to prevent spread of scabies. The IP stated if Resident 1 was seen by the Dermatologist on 1/26/2026, she (Resident 1) would have been tested for scabies and received Elimite and will have less chance of testing positive in GACH 2. The IP stated because it was not detected early, Resident 1 could have spread scabies among staff, residents and staff in GACH 2.During an interview on 2/19/2026, at 2:41 p.m., with the Dermatologist, the Dermatologist stated when he (Dermatologist) came to the facility on 1/26/2026, he (Dermatologist) was provided with a list of residents with rashes and he (Dermatologist) went around and ordered skin scraping and elimite cream. The Dermatologist stated he (Dermatologist) cannot remember if he (Dermatologist) had evaluated Resident 1's rashes. The Dermatologist stated if Resident 1 was evaluated on 1/26/2026, and was provided with Elimite cream there will be less chance of her (Resident 1) testing positive for scabies, resulting in less chance of spreading scabies.During a concurrent interview, and record review on 2/19/2026, at 4:08 p.m., with the ADM, residents Dermatologist Progress Notes, dated 1/26/2026, were reviewed. The Dermatologist Progress Notes, indicated the Dermatologist seen, evaluated, ordered skin scraping and Elimite application to nine residents (Residents 3, 7, 8, 9, 10, 11, 13, 14, and 15). The ADM stated the Dermatologist only saw nine residents. The ADM stated TN 1 should have notified the Dermatologist of all residents with rashes including Resident 1. The ADM stated she (ADM) had expected the Dermatologist to have assessed and evaluated all residents on 1/26/2026. During an interview on 2/20/2026, at 8:36 a.m., with the IP, the IP stated the Dermatologist returned and evaluated resident on 2/2/2026. The IP stated it was TNs second chance to inform the Dermatologist of Resident 1's rashes but still was not done.During an interview on 2/20/2026, at 11:42 p.m., with the Medical Director (MD), the MD stated he (MD) was not informed of Resident 1's rashes while the facility was on scabies outbreak. The MD stated if he (MD) was informed he (MD) would have ordered skin scraping to check for the presence of scabies and order Elimite cream for Resident 1.During a review of facility's P&P, titled, Scabies: Prevention and Control, undated and last reviewed on 1/14/2026, the P&P indicated, Nurses and other healthcare workers will be trained to recognize and report any patient, themselves or other healthcare worker with signs and symptoms compatible with scabies infestation.During a review of facility's P&P, titled, Change of Condition, undated and last reviewed on 1/14/2026, the P&P indicated, A change in condition is a sudden marked difference in residents. 11. Bruises, lacerations, blisters, rashes or skin tears. Upon a change in condition for any reason, nursing staff members are to take the following actions. 1. physicians shall be called promptly: If for some reason physician cannot be reached, alternative physician. shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity.d. During an interview on 2/17/2026, at 10:01 a.m., with the Marketer, the Marketer stated GACH 2 called him (Marketer) on his (Marketer) personal phone to notify him (Marketer) that Resident 1 was positive for scabies. The Marketer stated he (Marketer) did not remember the date he (Marketer) was notified. The Marketer stated he (Marketer) did not document in Resident 1's electronic medical record because he (Marketer) does not have access to the electronic medical record. The Marketer stated he (Marketer) reported to the ADM. During a concurrent interview and record review on 2/17/2026 at 10:08 a.m., with the ADM, Resident 1's Progress Notes, dated 2/9/2026, were reviewed. The ADM stated on 2/9/2026, the Marketer notified her (ADM) that Resident 1 tested positive for scabies in GACH 2. The ADM stated she (ADM) reported to the IP and IP should have documented it in Resident 1's medical record.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the MDSN, facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The MDSN stated there should be a documentation that the facility was notified of Resident 1 testing positive for scabies in GACH 2. The MDSN stated the policy was not followed. The MDSN stated Resident 1's medical record was not complete.e. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/4/2024, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia and unspecified dermatitis (a common, non-contagious inflammation of the skin characterized by itching, redness, rashes, and dryness).During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2025, the MDS indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 6's Change of Condition (COC) Assessment Form, dated 1/16/2026, the COC indicated Resident 6 was transferred to GACH 1 on 1/16/2026, due to altered mental status (illnesses, disorders and injuries affect brain function) and abnormal vital signs (measurements falling outside established healthy ranges for adults).During a review of Resident 6's Scabies Examination, dated 1/18/2026, the Scabies Examination resulted in presence of scabies tested in GACH 1.During an interview on 2/13/2026, at 3:21 p.m., with the IP, the IP stated Resident 6 tested positive for scabies in GACH 1 and the facility was informed on 1/22/2026. The IP stated the facility then had a second case of positive scabies when Resident 1, who was transferred to GACH 2 on 2/6/2026, tested positive in GACH 2 and the facility was informed on 2/9/2026. The IP stated 12 residents who developed rashes were skin scraped for scabies in the facility since Resident 6 tested positive and one staff (CNA 1) had developed lower back rashes on 1/28/2026, and was treated with Elimite cream.During an interview on 2/17/2026, at 10:01 a.m., with the Marketer, the Marketer stated GACH 2 called him (Marketer) on his (Marketer) personal phone to notify him (Marketer) that Resident 1 was positive for scabies. The Marketer stated he (Marketer) did not remember the date he (Marketer) was notified. The Marketer stated he (Marketer) reported to the ADM.During an interview on 2/17/2026, at 10:08 a.m., with the ADM, the ADM stated on 2/9/2026, she (ADM) was notified by the Marketer that Resident 1's tested positive for scabies in GACH 2. The ADM stated she (ADM) did not report to SSA because they were already on scabies outbreak and she (ADM) already reported the first case of scabies on 1/23/2026 when Resident 1 tested positive for scabies in GACH 1.During an interview on 2/18/2026, at 10:15 a.m., with RNS 1, RNS 1 stated positive cases of scabies should be reported to SSA.During an interview on 2/19/2026, at 11:41 a.m., with the IP, the IP stated scabies outbreak is when there are two cases of scabies and should have been reported to SSA as soon as possible within 24 hours.During an interview on 2/19/2026, at 12:31 p.m., with the IP, the IP stated the facility was on scabies outbreak since 1/27/2026.During a concurrent interview, and record review on 2/19/2026, at 12:56 p.m., with the ADM, facility's policy and procedure (P&P) titled, Unusual Occurrences, undated and last reviewed on 1/14/2026, the P&P indicated, The facility is to report unusual occurrences to the local health department within 24 hours of each occurrence. The examples listed below are not intended to be an all-inclusive list of unusual occurrences. This list is not to replace sound, professional judgment.2. An epidemic (a widespread occurrence of an infectious disease in a community at a particular time) outbreak of any disease, prevalence of communicable disease or infestation by parasites or vectors. The ADM stated Resident 6's scabies were reported to SSA and Public Health on 1/23/2026, under unusual occurrence. The ADM stated the facility was notified by Public Health that one case of scabies should not be reported as outbreak.During a concurrent interview, and record review on 2/19/2026, at 1:19 p.m., with the ADM, facility's policy and procedure (P&P) titled, Scabies: Prevention and Control, undated and last reviewed on 1/14/2026, the P&P indicated, Immediate action when the threshold for scabies outbreak has been reached will include: Reporting to local Public Health Nurse and Licensing and Certification (SSA) when two or more suspected cases of scabies are treated with Elimite five % within a 14-day period, regardless of whether confirmed cases are identified. The ADM stated she (ADM) did not report the second case of scabies because her (ADM) QANC did not advise her (ADM) to report. The ADM stated the P&P indicated to report scabies if there were two confirmed, two alleged or two or more clinically suspected. The ADM stated she (ADM) should have reported that the facility had a second confirmed case of scabies under scabies outbreak to Public Health and SSA as per the facility's P&P. The ADM stated the P&P was not followed.During an interview on 2/20/2026, at 8:36 am with the IP, the IP stated scabies outbreak should be reported to SSA for further investigation.During an interview on 2/20/2026, at 2:59 p.m., with RNS 1, facility's submitted guidelines titled, Acute Communicable Disease Control Program-Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, was reviewed. The Guideline indicated, Outbreak definition: Two (2) or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six (6) week time period.Report healthcare-associated scabies outbreaks (two or more cases) to LAC Department of Public Health. RNS 1 stated scabies outbreak should have been reported to SSA to prevent the spread of scabies among staff and residents and to get help on how to control the spread.During an interview on 2/21/2026, at 3:31 p.m. with the ADM, the ADM stated she (ADM) should have reported the second case when Resident 1 tested positive for scabies to SSA to prevent delay in investigation. The ADM stated delay in investigation can potentially cause spread of scabies among staff and residents.During a review of facility's P&P titled, Reporting Communicable Disease, dated 4/2023, and last reviewed on 1/14/2026, the P&P indicated, the Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable disease.f. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2026, with diagnoses that included unspecified encephalopathy (a broad term for any disease or dysfunction of the brain, causing altered mental state, confusion, memory loss, and personality changes), unspecified dementia and generalized muscle weakness.During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/15/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired.During a review of Resident 2's Care Plan, dated 2/9/2026, about contact isolation (are steps that healthcare facility visitors and staff need to follow before going into a patient's room) precaution for suspicious rashes, the Care Plan indicated an intervention to observe contact isolation.During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/17/2025, with diagnoses that included unspecified dementia, unspecified dermatitis and history of falling.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were severely impaired.During a review of Resident 3's Dermatology Progress Notes, dated 1/26/2026, the Dermatology Progress Notes indicated the Dermatologists ordered Elimite, skin scraping, oral (by mouth) and topical (applied directly to a specific, local surface area of the body most commonly the skin) steroids (medications used to reduce inflammation, swelling, and allergic reactions throughout the body).During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 10/14/2021, with diagnoses that included unspecified dementia, history of falling and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 4's H&P, dated 1/17/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive for daily decisions were severely impaired.During a review of Resident 4's TAR, dated 2/2026, the TAR indicated Resident 4 received Elimite cream on 2/11/2026, at 11:16 p.m.During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/1/2022, with diagnoses that included unspecified dementia, unspecified encephalopathy and unspecified cataract (a common, age-related clouding of the eye's natural lens that causes blurry, faded vision, glare, and difficulty seeing at night).During a review of Resident 5's H&P, dated 5/1/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions was intact.During a review of Resident 5's TAR, dated 2/2026, the TAR indicated Resident 5 received Elimite cream on 2/12/2026 at 4:09 a.m.During a concurrent interview and record review on 2/19/2026, at 2:06 p.m., with RN 1, facility's submitted guidelines titled, Acute Communicable Disease Control Program-Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, was reviewed. The Guideline included an Appendix B-Scabies Outbreak Management Checklist that indicated daily skin assessment documented on all exposed residents. RN 1 stated daily skin assessment should be done and documented in resident's medical record.During an interview on 2/20/2026, at 8:36 a.m., with the IP, the IP stated Resident 1 had contact with Residents 2, 3, 4, and 5 before Resident 1 tested positive for scabies in GACH 2. The IP stated Resident 2 was Resident 1's roommate and Residents 3, 4, and 5 were exposed to Resident 1 while seated on the dining during mealtimes. The IP stated there were no documented daily skin assessments on four residents (Resident 2, 3, 4, and 5) who were exposed to Resident 1. The IP stated if there were no daily skin assessment the facility would not know if the four residents (Resident 2, 3, 4, and 5) had developed rashes that could potentially delay treatment and could potentially spread scabies.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's policy and procedure (P&P) titled, Scabies Identification, Treatment and Environmental Cleaning dated 8/2016, and last reviewed on 1/14/2026, the P&P indicated, A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has been resolved. The RNS stated according to the P&P, daily skin assessment should have been done until the case was resolved. The RNS stated Resident 1's roommate was Resident 2. The RNS stated if daily skin assessment was not done to check for the presence of rashes, possible spread of scabies can occur.g. During an interview on 2/20/2026, at 8:36 a.m., with the Director of Staff Development (DSD)/IP, the DSD stated there was no inservice, education or training provided to TN 1 and TN 2 on skin scraping. The DSD stated TN 1 and TN 2 were not checked for skin scraping competency. The DSD stated TN 1 and TN 2 should have been taught by the NP of the Dermatologist. The DSD stated if TN 1 and TN 2 were not competent in skin scraping, the procedure would not be done correctly and might affect the result of the skin scraping.During an interview on 2/20/2026 at 2:59 p.m., with the RNS, the RNS stated no training was provided to the staff before skin scraping on 1/26/2026. The RNS stated training should have been done and competency should have been evaluated before 1/26/2026, when skin scraping was done to residents. The RNS stated the importance of providing training and competency for skin scraping was for accurate specimen collection. The RNS stated if staff were not trained, an inaccurate result could possibly happen causing a potential spread of scabies.During an interview on 2/2

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1), by:1. Failing to provide wound care treatments as per physician order on 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026 and 1/27/2026.2. Failing to perform head to toe skin assessment before Resident 1's transfer to General Acute Care Hospital (GACH) on 1/14/2026.3. Failing to obtain a physician order for the use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed).These failures had the potential for the development and worsening of Resident 1's pressure ulcers.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/18/2025, with diagnoses that included metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), stage four pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacral area (tailbone) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's admission Reassessment, dated 7/19/2025, the admission Reassessment indicated Resident 1 had left heel pressure ulcer and sacrococcyx (sacro-end of spine, coccyx-tailbone) pressure ulcer.During a review of Resident 1's Physician Order, dated 7/19/25, the Physician Order indicated the following:1. For left heel deep tissue injury (DTI- a serious form of pressure injury where soft tissue is damaged underneath intact skin) - cleanse with normal saline (salt in water), pat dry, paint with betadine (used to treat and prevent skin infections) and cover with foam dressing daily for wound care management for four weeks.2. For sacrococcyx DTI- cleanse with normal saline, pat dry, apply zinc oxide (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) to affected area and cover with foam dressing daily for wound care management for four weeks.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/23/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for toileting, showering, dressing, and personal hygiene. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 1 had two unstageable (a severe, full thickness wound where the base is completely covered by dead tissue, making it impossible to see how deep the damage goes) pressure ulcer present upon admission.During a review of Resident 1's Skin Issues, dated 12/11/2025, the Skin Issues indicated Resident 1 had one stage three (full-thickness loss of skin. Dead and black tissue may be visible) sacrococcyx pressure ulcer.During a review of Resident 1's Skin Issues, dated 1/6/2026, the Skin Issues indicated Resident 1 had four stage three pressure ulcers and one stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer.During a review of Resident 1's Treatment Administration Record (TAR), dated 8/2025, the TAR indicated on 8/3/2025, the treatment for left heel and sacrococcyx DTI was left blank.During a review of Resident 1's Physician Order, dated 11/11/25, the Physician Order indicated for sacrococcyx stage 3 pressure ulcer to be cleanse with quarter strength Dankins solution (bleach solution used as an antiseptic to clean, disinfect, and treat infected wounds), pat dry., apply Santyl ointment (medicine used to clean, heal, and remove dead tissue from serious wounds) 250 units per gram to wound bed and zinc oxide to peri-wound (around the wound), apply calcium alginate (a natural, gel-like material that is primarily used in advanced wound care to manage heavily draining wounds) over wound bed and cover with dry dressing every day for wound care treatment for four weeks.During a review of Resident 1's TAR, dated 11/2025, the TAR indicated on 11/25/2025, the treatment for sacrococcyx stage three pressure ulcer was left blank.During a review of Resident 1's Physician Order, dated 12/17/25, the Physician Order indicated for sacrococcyx stage three pressure injury- cleanse with normal saline, pat dry, apply Santyl external ointment 250 unit per gram to wound bed and zinc oxide to peri wound, apply calcium alginate over wound bed and cover with super absorbent dressing daily for wound care for four week.During a review of Resident 1's TAR, dated 12/2025, the TAR indicated on 12/24/2025, the treatment for sacrococcyx stage three pressure ulcer was left blank.During a review of Resident 1's Physician Order, dated 1/20/2026, the Physician Order indicated for sacrococcyx stage four pressure injury- cleanse with normal saline, pat dry, apply zinc oxide paste to peri wound, Santyl external ointment 250 unit per gram to wound bed, apply calcium alginate over wound bed and cover with dry dressing daily for wound care management for four weeks.During a review of Resident 1's TAR, dated 1/2026, the TAR on 1/2026 was reviewed. The TAR indicated on 1/20/2026 and 1/27/2026, the treatment for sacrococcyx stage four pressure ulcers was left blank.During a concurrent interview, and record review on 2/3/2026, at 9:28 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's TAR, from 8/2025, to 1/2026, were reviewed. The MDSN stated TAR were blank on 8/3/2025, 11/11/2025, 12/24/2025, 1/20/2026 and 1/27/2026. The MDSN stated blank TAR means the Treatment Nurse (TN) did not sign the TAR. The MDSN stated if TAR is not signed treatment was not done. The MDSN stated if treatment was not done, pressure ulcer could get worse.During an interview on 2/3/2026, at 10:19 a.m., with the Administrator (ADM), the ADM stated the facility had issues with wound treatments.During an interview on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), RN 1 stated if treatment not provided Resident 1's pressure ulcer could worsen.During a concurrent interview, and record review on 2/3/2026, at 12:29 p.m., with the Registered Nurse Supervisor (RNS), facility's policy and procedure (P&P) titled, Wound Care dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.1. Verify that there is a physician's order for this procedure.Documentation:The following information should be recorded in the resident's medical record1. The type of wound care given.2. The date and time of the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care. The RNS stated if TAR was left blank means treatment not done and could result in worsening of Resident 1's pressure ulcer. The RNS stated pressure ulcer treatment should be done as per physician order. The RNS stated the facility's policy indicated to verify wound treatment order and document date and time wound care was given. The RNS stated if treatment is not done, the TN need to document reason why, if Resident 1 refused or if the TN was busy to endorse to other staff for wound care treatment.b. During a review of Resident 1's Interact Assessment Form (COC), dated 1/14/2026, the COC indicated Resident 1 had generalized weakness and pocketing of food with overall decline in activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Discharge Summary Report, dated 1/14/2026, the Discharge Summary Report indicated Resident 1 was transferred to GACH on 1/14/2026, at 12:52 p.m.During a review of Resident 1's Resident Transfer Record, dated 1/14/2026, the Resident Transfer Record indicated Resident 1 was transferred with sacrococcyx stage three pressure ulcer.During an interview on 2/2/2026, at 10:50 a.m., with RN 1, RN 1 stated if the facility had to transfer a resident whether planned or unplanned a complete head to toe skin assessment is done and documented in the Resident Transfer Record form and reported to the accepting GACH.During an interview on 2/3/2026, at 12:47 p.m., with RN 2, RN 2 stated on 1/14/2026, the Director of Nursing (DON) instructed her (RN 2) to complete the Discharge Summary Report and Resident Transfer Record, dated 1/14/2026. RN 2 stated the DON was the one who completed the COC and should be the one to do the head-to-toe skin assessment prior to transfer to GACH. RN 2 stated when she (RN 2) completed the Resident Transfer Record, she (RN 2) just looked at the sacral area and did not perform a head to toe skin assessment therefore she (RN 2) was not sure if the resident had rashes (any noticeable change in the color, texture, or feel of your skin that makes it look irritated, inflamed, or swollen) anywhere on her body. RN 2 stated RNS are also responsible for head-to-toe skin assessment prior to transfer.During a concurrent interview, and record review on 2/3/2026, at 1:18 p.m., with the RNS, facility's P&P, titled, Transfer/Discharge, undated and last review on 1/14/2026, the P&P indicated, Purpose:1. To ensure that there is continuity of care when a transfer is necessary.2. To prevent transfer trauma.3. To ensure proper information is sent with the resident.7. Complete a body check when possible and document findings. the RNS stated RNs are responsible for the complete head to toe skin assessment before Resident 1's transfer to GACH. The RNS stated that without complete head-to-toe skin assessment, the facility would not know if Resident 1 had rashes and nothing will be documented in Resident 1's medical record. The RNS stated the facility's policy before transferring residents was to perform a complete body assessment when possible and document in resident medical record.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge.c. During an observation on 2/2/2026, at 9:39 a.m., inside Resident 1's room, observed a wedge pillow on Resident 1's left side.During an interview on 2/2/2026, at 9:47 am, with the TN, the TN stated Resident 1 had a wedge pillow used to keep Resident 1's sacral area off the bed to prevent worsening of the pressure ulcer.During a concurrent interview, and record review on 2/2/2026, at 10:50 a.m., with RN 1, Resident 1's Physician Orders were reviewed. RN 1 stated there was no physician order for the use of the wedge pillow.During an interview on 2/2/2026, at 1:42 p.m., with the TN, the TN stated the facility needs a physician order before wedge pillow can be used by Resident 1. The TN stated the DON or the RNS should have obtained an order.During an interview on 2/3/2026, at 10:54 a.m., with RN 1, RN 1 stated physician order should have been obtained for Resident 1's use of wedge pillow.During a review of facility's P&P, titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 4/2018, and last reviewed on 1/14/2026, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue) approaches, dressings and application of topical (a medication, cream, or treatment that is applied directly to a specific, localized part of the body) agents.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by:1. Failing to develop a care plan for Resident 2's behavior of spitting.2. Failing to develop a care plan on Resident 1's use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed).3. Failing to develop a care plan for Resident 1's refusal of repositioning.These failures had the potential for delays in the delivery of necessary care and services to Resident 1. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/12/2025, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and generalized weakness.During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 2 had the ability to sometimes understand others and make self-understood. The MDS indicated Resident 2 required supervision from staff with toileting and showering.During a review of Resident 2's Progress Notes, dated 1/6/2026, the Progress Notes indicated on 1/6/2026, Resident 2 had exhibited verbal and physical restlessness and anger outburst (a sudden, intense, and often disproportionate burst of rage, yelling, or aggression) before shower. The Progress Notes indicated Resident 2 calmed down and agreed to the shower but in the middle of the shower, Resident 2 became physically aggressive, yelled and spit at Certified Nursing Assistant 1 (CNA 1).During an interview on 2/2/2026 at 11:22 a.m., with the Director of Staff Development (DSD), the DSD stated on 1/6/2026, CNA 1 reported that Resident 2 had spit on her (CNA 1).During an interview on 2/2/2026, at 11:52 a.m., with the Administrator (ADM), the ADM stated on 1/6/2026, CNA 1 reported that Resident 2 yelled and spit at her (CNA 1).During a concurrent interview, and record review on 2/2/2026, at 12:28 p.m., with Minimum Data Set Nurse (MDSN), Resident 1's Care Plans were reviewed. The MDSN stated Resident 1 had a behavior of spitting and kicking. The MDSN stated there was no care plan on Resident 1's behavior of spitting.During an interview on 2/2/2026, at 12:57 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 2 had a behavior of kicking, but spitting was something new.During an interview on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), RN 1 stated care plan should have been developed for new behavior to provide utmost level of care and make sure Resident 2 received the care she (Resident 2) needed and to manage her (Resident 2)'s behavior.During a review of facility's policy and procedure (P&P), titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, and last reviewed on 1/14/2026, the P&P indicated, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial (the interrelation of social factors and individual thought and behavior) well-being in accordance with the comprehensive assessment and plan of care. 2. As part of the comprehensive assessment, staff will evaluate, based on input from the residents, family and caregivers, review of medical record, and general observations: a. the resident's usual patterns of cognition, mood and behavior; b. the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; c. the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and d. the resident's previous patterns of coping with stress, anxiety, and depression. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.b. During an observation on 2/2/2026, at 9:39 a.m., inside Resident 1's room, observed a wedge pillow on Resident 1's left side.During a concurrent interview, and record review on 2/2/2026, at 9:47 am, with the Treatment Nurse (TN), Resident 1's Care Plans were reviewed. The TN stated Resident 1 had a wedge pillow used to keep Resident 1's sacral (tailbone) area off the bed to prevent worsening of the pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence). The TN stated there was no care plan for Resident 1's use of wedge pillow.During a concurrent interview and record review on 2/2/2026, at 10:50 a.m., with RN 1, Resident 1's Care Plans were reviewed. RN 1 stated there was no care plan Resident 1's use of wedge pillow.During a concurrent interview, and record review on 2/2/2026, at 12:28 p.m., with Minimum Data Set Nurse (MDSN), Resident 1's Care Plans were reviewed. MDSN stated there was no care plan for Resident 1's use of wedge pillow. The MDSN stated there should be a care plan on the use of wedge pillows. The MDSN stated care plan provides nurses with a guide on how to take care of the resident.During an interview on 2/3/2026, at 10:54 a.m., with RN 1, RN 1 stated care plan should have been developed on the use of wedge pillow. RN 1 stated care plans guide the nurses on what intervention to provide to prevent pressure ulcers.During an interview on 2/3/2026, at 12:29 p.m., with the Registered Nurse Supervisor (RNS), the RNS stated interventions provided to Resident 1 to address the current problem which is pressure ulcer should have a care plan. The RNS stated without a care plan, nurses would not be able to evaluate if intervention is effective and could possibly cause worsening of Resident 1's pressure ulcer.During a review of facility's P&P, titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 4/2018, and last reviewed on 1/14/2026, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue) approaches, dressings and application of topical (a medication, cream, or treatment that is applied directly to a specific, localized part of the body) agents.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device.c. During an interview on 2/2/2026, at 9:47 a.m., with the TN, the TN stated Resident 1 was noncompliant with repositioning.During a concurrent interview and record review on 2/2/2026, at 12:28 p.m., with the MDSN, Resident 1's Care Plan was reviewed. The MDSN stated there was no care plan developed for Resident 1s' refusal to be repositioned. The MDSN stated care plan helps minimize further decline or prevent worsening of pressure ulcers. The MDSN stated that without the care plan for refusal to be repositioned, Resident 1's wound can worsen.During an interview on 2/2/2026, at 1:13 p.m. with LVN 4, LVN 4 stated Resident 1 refused to be repositioned. LVN 4 stated CNAs had reported Resident 1's refusal and she (LVN 4) would talk to Resident 1 and Resident 1 would still refuse. LVN 4 stated she (LVN 4) did not develop a care plan for Resident 1's refusal to be repositioned. LVN 4 stated RNs develop the care plan. LVN 4 stated she (LVN 4) did not report Resident 1's noncompliance to the RN. LVN 4 stated care plan should have been developed. LVN 4 stated that without the care plan for resident 1's refusal for repositioning, Resident 1's wound could worsen.During an interview on 2/3/2026, at 12:29 p.m., with the RNS, the RNS stated care plan should have been developed to address Resident 1's refusal for repositioning to make sure resident rights for refusal are followed to prevent worsening of Resident 1's pressure ulcer.During a review of facility's policy and procedure (P&P), titled, Wound Care, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Review the resident's care plan to assess for any special needs of the resident.a. For example, the residents may have pro re nata (PRN-as needed) orders for pain medication to be administered prior to would care.Documentation:The following information should be recorded in the resident's medical record: .8. Any problems complaints made by the resident related to the procedure.9. If the resident refused the treatment and the reason(s) why.During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans, dated 3/2022, and last reviewed on 1/14/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (I) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . e. reflects currently recognized standards of practice for problem areas and conditions.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview and record review, the facility failed to prevent a fall and injury for one of six sampled residents (Resident 4), who was identified as a high fall risk, with unsteady standing and walking balance, and poor safety awareness. The facility failed to: 1. Provide Resident 4 with contact guard assistance (CGA, the contact is made to help steady the body and help with balance) and hand-held assistance (HHA) while walking, as assessed by the physical therapist (PT, a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities). 2. Identify the fall risk posed by Resident 4's use of the post-op shoe (also called post-surgical shoe, or hard sole shoe - a medical shoe used to protect the foot and toes when there is an injury, a wound, or after surgery) to the right foot for wound management ordered on 4/27/2023. 3. Identify and make recommendations to address Resident 4's posture due to a hunchback (abnormal rounding of the upper back) that affected the resident's balance and caused the resident to look down while walking. 4. Review and revise Resident 4's care plan interventions that were person-centered and were individualized based on the resident's risks, physical, and mental condition. 5. Implement the facility's policies and procedure on Accident/Incident Prevention; Falls and Fall Risk, Managing; The Resident Care Plan; Falling Star Program; and Promoting Safety, Reducing Falls. As a result, on 5/25/2023 at 9:45 a.m., Resident 4 fell on to the floor while walking unassisted in the hallway and sustained a right shoulder fracture (broken bone). Findings: On 6/1/2023 at 10:10 a.m., during an observation and interview, noted Resident 4 with a hunchback and observed the resident sitting on a wheelchair in the activity room. Resident 4 was wearing a right shoulder sling (used to both support the weight of the arm and limits arm movement). Resident 4 stated she had a sling because of a fall but she did not remember the details and she did not answer further questions. The resident also had a black post-op shoe with a thick sole on the right foot and had a non-slip non-skid sock (improves the grip to help preventing slip and fall) on the left foot. A review of Resident 4's Admission Record indicated the facility initially admitted the resident on 11/2/2020 and readmitted the resident on 12/22/2020. Resident 4's diagnoses included type 2 diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with diabetic foot ulcers (open sores or wounds of patients with diabetes) on the right foot, muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/2/2023, indicated the resident had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 4 required limited assistance (staff provided guided maneuvering of limbs) with one-person physical assist with walking in room (how resident walks between locations in the room) and walking in corridor (how resident walks in corridor on unit). Resident 4's balance during transition and walking were not steady (only able to stabilize with staff assistance). Resident 4 used a wheelchair as mobility device. A review of Resident 4's Care Plan developed for the resident's self-care deficit and needing assistance with activities of daily living (ADLs, including walking, transfers, toilet use, bathing, dressing, and personal hygiene), initiated on 11/2/2020 and last revised on 5/13/2023, had a goal for the resident to be clean and dry daily and another goal to minimize decline. The care plan interventions included to assist with ADLs and provide a safe environment. A review of Resident 4's Care Plan on risk for fracture, initiated on 11/2/2020 and revised on 11/17/2021, indicated the goal of reducing the risk of injury. The interventions included assisting the resident with all transfers and ambulation as needed. A review of Resident 4's Care Plan on Falling Star Program (program that includes interventions for residents identified as fall risk), initiated on 11/2/2020 and last revised on 5/13/2023, indicated the resident was at risk for falls secondary to balance deficit, cognitive impairment, poor safety awareness, difficulty in walking, and muscle weakness. The goal was to reduce Resident 4's risk of falls through appropriate interventions. The interventions included to respect the resident's wishes for independence & dignity, to conduct frequent visual monitoring, and to place the resident close to the activity designee station for close observation. A review of Resident 4's Care Plan addressing secured unit placement, initiated on 11/2/2020 and last revised on 11/17/2021, indicated the resident was at risk for purposeless wandering (a common behavior in dementia [decline in mental ability severe enough to interfere with daily functioning/life] causing people to become lost or confused about their location) and potential for self-injury. The goals indicated were for the resident to have safe wandering and directed activities with no self-injury. The interventions included managing behavioral and psychological symptoms of dementia (BPSD). A review of Resident 4's Care plan on elopement (when a resident who is cognitively, physically, or mentally impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised) risk, initiated on 11/10/2022 and last revised on 11/24/2022, included interventions of monitoring the resident at frequent intervals and re-directing the resident to alternatives like activities, watching television, calling family contact, offering magazine, and providing one on one (1:1) supervision (one staff to be with the resident at all times) if indicated to redirect behavior on interim basis (temporarily). A review of Resident 4's Interdisciplinary Wound Management Care Plan forms dated 4/27/2023, indicated the wound on the right mid-foot metatarsal (the ball of the foot) had reopened. A review of Resident 4's Physician's Orders, dated 4/27/2023, indicated to apply the post-op shoe on the right lower extremity during functional mobility (while standing and walking). A review of Resident 4's Fall Risk Assessment, dated 5/2/2023, indicated the resident had a total score of 20. A total score above 18 represented high risk for falls. The level of consciousness/mental status section indicated Resident 4 had intermittent confusion, poor safety awareness, and noncompliance. The gait (manner of walking) and balance section indicated Resident 4 had unsteady gait (when a person is having trouble with their balance or the way they walk) with poor sitting or standing balance. A review of Resident 4's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who participate in the care of the resident) notes, dated 5/2/2023, indicated an IDT meeting was conducted due to Resident 4's re-opening of the right foot diabetic ulcer. The IDT meeting note indicated Resident was typically pacing (walking or moving repeatedly, often back and forth) around, even wandering around, was fully ambulatory, wearing proper footwear with non-skid socks but sometimes preferred only the non-skid socks. A review of Resident 4's Licensed Nurse Record from 5/21/2023 to 5/24/2023, indicated the resident required extensive assistance with one-person assist with gait and ambulation. A review of Resident 4's Physical Therapy (PT) Treatment Encounter Notes, dated 5/22/2023, 5/23/2023, and 5/24/2023, indicated the resident required CGA and HHA with walking on level surfaces. The PT notes did not address the post-op shoe Resident 1 was using that the thick sole would cause imbalance during standing and walking. A review of Resident 4's Change of Condition (COC) Assessment Form, dated 5/25/2023, indicated that at 9:15 a.m., the resident was seen multiple times walking in the hallways. At 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) saw the resident lying on the floor across the kitchen hallway. Upon checking Resident 4's right arm, the resident had facial grimace and complained of pain on the right shoulder. At 10:10 a.m., the physician was notified and ordered x-rays (a procedure that creates pictures of the inside of the body in different shades of black and white). At 2:34 p.m. the x-rays result showed acute fracture of the right shoulder. At 3:22 p.m., the physician ordered transfer to General Acute Care Hospital 1 (GACH 1). A review of Resident 4's IDT Narrative Notes, dated 5/25/2023 at 5:51 p.m., indicated the resident had confusion, disorientation, poor safety awareness, and impulsiveness. Resident 4 was ambulatory and required physical assist with ADLs. The IDT narrative notes indicated Resident 4's fall was not prevented because of the distance between the witness and the resident. A review of Resident 4's GACH 1 right shoulder x-ray report, dated 5/25/2023 timed at 7:46 p.m., indicated the resident sustained a mildly comminuted fracture (the breaking of a bone into several small pieces) and impacted fracture (happens when a bone is compressed causing parts of the bone to crumble) of the right proximal (at the shoulder level) humerus (the long bone of the upper arm). Resident 4 was sent back to the facility the same day with the sling and with instructions to have follow-up appointment with orthopedic surgery (the branch of surgery concerned with conditions involving the musculoskeletal [muscles and bones] system) in the next three months. On 6/1/2023 at 10:36 a.m., during an interview, CNA 2 stated Resident 4 walks while looking down on the floor. CNA 2 stated Resident 4 was standing at the hallway across the kitchen door, with no wheelchair, and falling forward tilting towards the right side. CNA 2 stated he was not able to reach Resident 4 to prevent the fall because of the distance between them. CNA 2 stated there was no other staff in the hallway at the time of Resident 4's fall. CNA 2 could not remember what footwear Resident 4 was wearing at the time of the fall. On 6/1/2023 at 11:02 a.m., during an interview, Registered Nurse 2 (RN 2) stated Resident 4 walks slowly looking down on the floor. RN 2 demonstrated Resident 4's posture (hunchback) during ambulation. RN 2 could not remember what footwear Resident 4 had at the time of the fall. On 6/1/2023 at 12:03 p.m. during an interview, CNA 3 stated Resident 4 could walk but needed assistance. CNA 3 stated Resident 4 stated that before the fall, Resident 4 was wearing the post-op shoe on the right foot and was sitting on the wheelchair in front of Nursing Station 2. CNA 3 stated Resident 4 constantly attempts to get out of the wheelchair. CNA 3 stated the resident was not safe walking with the post-op shoe because of the uneven footing from the sole thickness of the post-op shoe. On 6/1/2023 at 1:13 p.m., during a concurrent interview and record review, RN 3 stated Resident 4 was stable in ambulating before the right foot ulcer reopened. RN 3 stated Resident 4 walked wearing the post-op shoe during the MDS assessment. RN 3 defined limited assistance as resident's ability to perform 75% of the task with minimal staff assistance. Resident 4's MDS functional status section was reviewed with RN 3 and confirmed the resident was not steady and needed staff to be beside the resident while ambulating. RN 3 further stated Resident 4's use of the post-op shoes should have been evaluated as a fall risk and should have been included in the care plan. On 6/1/2023 at 1:58 p.m., during a concurrent interview and record review, the Director of Rehab (DOR) stated Resident 4 had unsteady gait and needed close supervision for redirecting. The DOR stated Resident 4 had a right diabetic foot wound and had been walking up to 125 feet with the post-op shoes during PT sessions. The DOR stated Resident 4 could walk more than 125 feet but required frequent rest periods. The DOR defined Resident 4's kyphotic (hunchback) posture as rounded spinal curvature (abnormal alignment of the backbone) which changed the resident's center of balance. The DOR stated a kyphotic posture was a contributing factor for Resident 4's unsteady gait. The DOR confirmed not addressing in the PT notes Resident 4's hunchback and the use of the post-op shoes as fall risk. The DOR stated Resident 4 required CGA and HHA during ambulation. On 6/1/2023 at 2:32 p.m., during a concurrent interview and record review, RN 2 stated Resident 4's MDS indicated the resident required limited assistance with one-person assist and the resident had unsteady gait. RN 2 stated Resident 4 should be closely supervised while walking. On 6/5/2023 at 10:15 a.m., during an interview, the Director of Nursing (DON) stated prior to the fall (on 5/25/2023) staff observed Resident 4 walking around the nursing stations, in the hallways two to three times at resident's normal pace. The DON stated there was no CGA provided to Resident 4 while walking in the hallways. The DON stated at the time of Resident 4's fall, there was no staff in the hallway except CNA 2 who was passing by at the end (opposite side) of the hallway. A review of the facility's policy and procedure titled, Accident/Incident Prevention, dated 2/10/2023, indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents. The policy also indicated to provide an environment that is free of accident hazards, that facility will provide care planning with implementation plans. A review of the facility's policy and procedure titled, Promoting Safety, Reducing Falls, dated 2/10/2023, indicated caregivers should regularly inspect the condition of a resident's feet to make sure that there were no deformities or open areas that might affect gait. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, revised 2/10/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the facility's policy and procedures titled, Falling Star Program, revised on 2/10/2023, indicated residents identified at risk for falls would participate in the Falling Star Program. The procedures included placing an identifying colorful star in personal resident areas such as the head of the bed, name plate on the entrance to the room, bathroom door, and wheelchair. Recommendations to ensure a successful program would be to include the following: .evaluation for appropriate useful interventions for fall reduction. A review of the facility's policy and procedures titled, Super Star Program - for Severely High-Risk Residents at Risk for Falls & Injuries, revised on 2/10/2023, indicated this special program was for residents who have a score of 8 or above on the Fall Risk Assessment and any of the following: 1. Noncompliant, 2. Very confused, .4. History of falls . The procedures included: 1. Discuss safety of room and replace furniture with plastic items or re-arrange furniture to provide a safe environment, .7. Non-skid footwear, .8. Location of room close to nursing station for closer observation

Based on interview and record review, the facility failed to ensure each resident was free from physical abuse for two of five sampled residents (Resident 1 and Resident 2). Resident 2 had an altercation with Resident 1, and Resident 1 had previous altercations with other residents (Residents 3, 4, and 5). The facility did not develop a specific care plan which contained adequate interventions to address Resident 1's physical aggressive behavior towards other residents. This deficient practice resulted in Resident 2 sustaining a fall and being transferred to the hospital for treatment of [REDACTED]. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 4/29/14, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 2/5/16 indicated Resident 1 was usually understood and could usually understand others. Resident 1 usually makes self understood and had ability to usually understand others, and was able to walk and move between all facility locations. A review of the MDS, dated [DATE] indicated Resident 1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing other sexually). On 5/18/16, at 8:30 a.m., an interview was conducted with the Administrator. She stated that the facility was a locked (secured) Alzheimer's / Dementia facility. A review of the clinical record indicated Resident 2 was admitted to the facility, on 8/6/10, with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident 2 was usually understood and had the ability to understand others. The MDS, dated [DATE], indicated Resident 2 was able to walk without assistance and moved between all facility locations. During the facility tour, on 5/18/16, at 8:30 a.m., Resident 2 was observed sitting on a wheelchair in the hallway. Resident 2 had a 1.5 centimeter scar/laceration, pink with bruising to her left upper side of the face and bruising (light pink with faded blue) to left lower eye. Resident 2 had a splint on her left little finger. The Director of Nursing (DON) spoke to Resident 2 and she responded with mumbling and intermittent laughs, the resident had a blank stare and did not appear to understand what the DON was asking. On 5/18/16, at 10:43 a.m., the incident surveillance video, dated 5/6/16, at 3:10 p.m., was observed. Resident 2 was walking around the station alone and eventually ended up in Resident 1's doorway. After an exchange of words, Resident 1 pushed Resident 2 twice and Resident 2 fell to the floor. The surveillance video indicated there was no staff present when the incident occurred. During an interview, on 5/18/16, at 9 a.m., the director of nursing (DON) stated that, on 5/6/16, at around 3 p.m., Resident 2 was walking and wandering through the stations and hallways and ended up standing by Resident 1's doorway. The residents were conversing and Resident 1 told Resident 2, move step back, then Resident 1 pushed Resident 2 who fell to the floor face down. The DON stated Resident 2 had a cut with moderate bleeding to the left upper forehead and the facility called 911 to transfer Resident 2 to the hospital. The DON stated Resident 1 had a history of [REDACTED]. On 5/18/16, at 11:46 a.m., an interview was conducted with the DON. She stated it had been a problem having Resident 1 at the facility because this is not a psych (iatric) facility. She stated that Resident 1 is paranoid and impulsive and she has called a few psychiatric and Skilled Nursing Facilities to see if they would take him but no facility would take him. The DON stated Resident 1 was hard to monitor and he was a risk to others because he thinks other residents want to harm him. On 5/18/16, at 2 p.m., an interview was conducted with the DON. She was asked to explain what she meant with an interaction that occurred between residents. She stated that the interactions that Resident 1 has had with other residents have been verbal or physical (pushing/striking). During an interview, on 5/18/16, at 2:28 p.m., the DON stated the facility failed to develop a care plan that addresses the specific behavior (physical aggression towards other residents) with specific interventions for Resident 1. The DON stated there had not been a specific monitoring system in place for Resident 1 and that Resident 1 had previously been involved in resident to resident altercations and in all instances, he had been the aggressor. A review of the monthly incident report logs, dated 10/3/15, 12/14/15, 3/23/16, and 5/6/16 indicated Resident 1 was involved in physical interactions with four different residents. All residents (including Resident 2) sustained falls due to the altercation with Resident 1. A review of the care plan, initiated on 10/3/15, indicated Resident 1 had a problem with interacting with peers and the goal was to have no further episode in the next 90 days. The care plan interventions indicated redirection, separating them if in close proximity, advice resident to call for help, psyche re-eval, and ask brother to remind resident of such behavior (not) appropriate. This care plan had a target date of 10/10/15 with a line across it and indicated resolved. The interventions to this care plan did not include a system to better monitor Resident 1 and was not renewed or modified. During an interview, on 5/18/16, at 2:28 p.m., the DON stated the care plan, dated 10/3/15, was not renewed or modified. A review of the general acute care hospital emergency department records, dated 5/6/16, at 5:37 p.m., indicated Resident 2 had a laceration which measured approximately 2 (centimeters) in length on the left-side forehead. The wound was repaired with sutures. A review of the physician's orders, dated 5/8/16, indicated an x-ray (left) little finger (5th digit) due to swelling/discoloration. On 5/8/16 x-ray results indicate that Resident 2 has subluxation (dislocation) of PIP joint (middle joint of the finger of the (fifth) finger. On 5/10/16, the physician ordered to Apply splint on (left) small finger (and) monitor for circulation. The Physical Therapy Evaluation & Plan of Treatment, dated 5/10/16, indicated Resident 2 fell on [DATE] and had difficulty in walking. The evaluation and plan of treatment indicated an approach of gait training therapy and a long-term goal was to, perform steady gait. The neuromuscular assessment results indicated Resident 2 had poor standing balance and impaired coordination. The functional mobility assessment results for walking (gait) indicated Resident 2 required total dependence with attempts to initiate and distance level surfaces walked = 0 feet. A review of the facility policy titled, Care of Wandering Resident Policy and Procedure, indicated that its purpose was to protect the wandering resident from injury .Wanderers are to be checked on a regular basis .Monitoring the resident's location with visual checks at least once every two hours. A review of the Secured Unit Policy indicated the Secured Unit would consider placement for residents who wander and were not otherwise a danger to themselves or others. Resident would be screened prior to admission to Secured Unit for appropriateness of placement. Placement in the Secured Unit would be for the resident's safety and for closer observation by facility staff. Residents would be observed at specific frequencies. A review of the facility's policy titled, Abuse & Mistreatment of [REDACTED]. The definition of abuse was the willful infliction of injury .with resulting physical harm or pain or mental anguish. The policy indicated the facility shall establish a system to prevent .abuse .Residents shall not be subjected to abuse by anyone, including .other residents. The facility shall also ensure comprehensive assessments and care planning for residents with needs and behaviors which might lead to conflict or neglect were initiated.