Every finding on record at All Saint's Subacute & Transitional Care

Based on observation, interview, and record review, the facility failed, for Residents 3, 4, 6 and 7, to ensure the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors. Findings: During an interview, on 8/18/25 at 9:50 a.m., the Medical Record Director (MRD) was requested to describe the scheduled medication accountability process. MRD's description included pharmacy Shipping Manifests were kept for 3-5 years and scheduled drug records were kept for 7-10 years. She stated the above records were kept onsite. She was asked to provide the pharmacy Shipping Manifests from 9/1/2022 - 12/31/22. During an interview, on 8/18/25 at 10:10 a.m., the Director of Nursing (DON) was requested to describe the scheduled medication accountability process. DON's description included the pharmacy delivered scheduled medication with a Shipping Manifest and a CDR. The receiving nurse confirmed the prescription details and signed the Shipping Manifest. The manifest was filed in medical records. The prescription was placed in the medication cart, and the CDR was filed in the cart's binder. She stated that when a scheduled medication was discontinued, and there were doses remaining, the medication and CDR were given to DON. DON and pharmacist destroyed the medication. DON and the pharmacist documented the destruction. During a concurrent interview and record review, on 8/18/25 at 12:35 p.m., the MRD identified pharmacy Shipping Manifests for prescriptions:-4329204 Resident 1 9/22/22 Hydrococone (narcotic pain reliever) /APAP (acetaminophen, pain reliever) 5/325 mg (milligram) tablet-4540388 Resident 2 9/30/22 Hydrococone/APAP 10/325 mg tablet-4470131 Resident 3 10/11/22 Oxycodone (narcotic pain reliever) 5 mg tablet-4701798 Resident 3 11/7/22 Oxycodone 5 mg tablet-4717751 Resident 4 11/10/22 Hydrocodone/APAP 10/325 mg tablet-4650367 Resident 5 10/26/22 Hydrococone/APAP 5/325 mg tablet-4846631 Resident 6 12/13/22 Hydrococone/APAP 5/325 mg tablet-4876197 Resident 8 12/20/22 Hydrococone/APAP 5/325 mg tablet She was requested to provide the CDRs for the identified prescriptions. During an observation, on 8/19/25 at 9:10 a.m., on TCU (nursing unit), medications were observed being administered using medication cart 1. During a concurrent interview and record review, on 8/20/25 at 1:15 p.m., MRD identified pharmacy Shipping Manifests for 4470131.01 Resident 3, 4717751 Resident 4, and 4846631 Resident 6. MRD stated that the corresponding CDRs could not be located. During an interview, on 8/20/25 at 2:20 p.m., the DON was requested to provide the Consultant Pharmacist reports from 6/2022-6/2023. During a concurrent interview and record review on 8/21/25 at 11:15 a.m., DON identified CDR 4821618.01 for Resident 7. DON was requested to compare the Oxycodone 5 mg tablet removed and the MAR. DON identified that the CDR documented doses were removed on 1/11/23 1300, 1/25/23 1430, 1/31/23 1632, 2/1/23 1600 and 2/4/24 0238. The doses identified were not documented in Resident 7's MAR. Continuing the interview, DON was aware the facility was unable to provide the CDRs for 4470131.01 Resident 3 Oxycodone 5 mg #10, 4717751 Resident 4 Hydrocodone/APAP 10/325 #16 and 4846631 Resident 6 Hydrocodone/APAP 5/325 #30. Continuing the interview, DON identified the Executive Quarterly Summary of Consultant Pharmacist's Medication Regimen Review (6/22-6/23). She reviewed the documents and stated there was no documentation of scheduled medication accountability problems. During an administrative record review, of the facilities Policy and Procedure for Ordering and Receiving Controlled Medications showed, Procedures, 1. The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications. 3. The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident. During an administrative record review, of the Facilities Executive Quarterly Summary of Consultant Pharmacist's Medication Regimen Review (6/22-6/23) did not show documentation of scheduled medication accountability problems.

Based on interview and record review, the facility failed to ensure a state- licensed Nursing Home Administrator was overseeing facility operations when the unlicensed Operations Manager (OM) had assumed the role of administrator for more than 11 months.This failure resulted in residents, staff and facility operations being supervised and directed by unqualified administrative leadership for more than 11 months.During a record review of state nursing home administrator licensing database titled, Licensing and Certification License Verification Page, the database indicated OM did not have a nursing home administrator license.During a review of state nursing home database titled, ELMS, the database indicated ADM 2 was the reported administrator of the facility from 11/4/2020 to 3/13/2023. Administrator 3 (ADM 3) was listed as the administrator from 3/14/2023 to 5/10/2024. OM was not listed as a former administrator of the facility.During a record review of two facility financial self-report to the state agency both titled, Long Term Care Facility Integrated Disclosure and Medi-Cal Cost Report, one report dated 12/31/2021 and the second report dated 12/31/2022, the report dated 12/31/2021 indicated OM was reported as the facility administrator from 12/15/21-12/31/2021 and ADM 2 was the facility administrator until 12/14/21. The report dated 12/31/2022 indicated OM was reported as the facility administrator from 1/1/22 to 11/2/22, and ADM 3 started as the facility administrator on 11/3/22.During a record review of facility resident council form titled, Department Responses to Issues, dated 10/1/22, the form indicated OM had signed as the Administrator.During a record review of facility grievance form titled, Concern Form (Front), dated 3/24/22, Resident 9 had a grievance about the facility environment. The form indicated a meeting regarding the grievance was attended by: [OM] (Administrator), [director of nursing] (DON), [social services director] (SSD) and [maintenance manager]. ADM 2 was not listed as the attendees.During a record review of facility grievance form titled, Concern Form (Front), dated 4/26/22, Resident 10, had a concern about contractors entering their room without announcement. The form indicated OM was the administrator assigned to investigate Resident 10's grievance. The form indicated a meeting was attended by OM with OM listed as (Administrator).During a record review of a facility contract titled [Contractor] Inpatient Services Agreement, dated 9/22/22, the contract indicated OM had signed the contract on 9/22/22 as the administrator.During a concurrent interview and record review on 7/3/26, at 11:00 a.m., with the Director of Nursing (DON), a facility document titled, [Facility], dated 7/3/26, was reviewed. The document indicated OM was the facility administrator from [DATE] - [DATE]. DON stated OM was the facility's administrator from [DATE] - [DATE] and ADM 3 was the next administrator.During a review of state health and safety code titled, California Code, Health and Safety Code 1416.6, the code indicated it shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the holder of an active nursing home administrator's license.A person who is acting as an administrator shall notify the program in writing within five days of acting in this capacity and provide factual information and specific circumstances necessitating the use of an acting administrator.No person shall act as an administrator for more than 10 days unless arrangements have been made for part-time supervision of his or her activities by a nursing home administrator who holds a license or provisional license under this chapter. Supervision shall include at least 8 hours per week of direct onsite supervision by the licensed administrator. The program shall be notified in writing of the nature of this arrangement. No person shall act as an administrator for more than two months without the written approval of the program.During a review of state regulation titled, Title 22, Chapter 3. Skilled Nursing Facilities, 72007 Administrator, the regulation defined an administrator as a person licensed as a nursing home administrator by the California Board of Examiners of Nursing Home Administrators.

Based on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for two of five sampled residents (Resident 1 and Resident 2) for tracheostomy (a surgical procedure that creates an opening through the front of the neck directly into the trachea [windpipe]) care when:1. Resident 1 did not have a physician order for tracheostomy suctioning (a sterile procedure that uses a flexible catheter inserted through the tracheostomy to mechanically clear excess mucus or secretions from the trachea [a critical tube that connects voice box to lungs]) as indicated in Resident 1's care plan, and the facility did not have time-specific documentation demonstrating when the tracheostomy suctioning was provided to Resident 1. 2. Resident 2's manual resuscitator bag (also known as bag-valve-mask, is a hand-held device used in emergencies to provide manual, positive pressure ventilation to patients who are not breathing adequately) maintained at the bedside for emergency respiratory use, was stored unlabeled and without a protective covering on top of the portable oxygen cylinder (provide compressed medical-grade gas for respiratory support), with the attached tubing in contact with the floor. These failures had the potential to result in failure to provide timely tracheostomy suctioning, inability to verify that necessary respiratory care was provided, increased risk tracheostomy related complications, including airway obstruction and trachea in the lungs bleeding (most frequently a complication caused by localized irritation, suctioning trauma, or life-threatening erosion into a major nearby blood vessel), and increased risk of infection associated with inadequate tracheostomy care and the improper storage and potential contamination of emergency respiratory equipment.1. During a record review of Resident 1's admission Record (AR), dated 6/23/26, AR indicated Resident 1 was originally admitted to the facility in March 2015 with diagnoses including traumatic brain injury (TBI, a disruption in normal brain function caused by an outside physical force), persistent vegetative state (a severe neurological condition where an individual has completely lost cognitive function and awareness of their environment, yet retains basic, involuntary autonomic functions like breathing, heartbeat, and regular sleep-wake cycles) and tracheostomy.During a record review of Resident 1's Care Plan for tracheostomy, initiated on 10/18/25, indicated Resident 1 required a tracheostomy and was at risk for complications related to tracheal bleeding. The Care Plan furthermore indicated an intervention to suction Resident 1's tracheostomy for airway clearance as per physician order and as needed for emergency care.During a record review of Resident 1's Order Summary Report (ORS) ' dated 6/23/26, the ORS did not include an order for tracheostomy suctioning.During a record review of Resident 1's Respiratory Therapy (RT) Airway Assessment (RTAA), dated from 6/1/26 through 6/16/26, RTAA indicated that tracheostomy suctioning was provided every two hours and as needed. However, the RTAA did not include time-specific documentation that identified and verified when each routine and as needed suctioning intervention was performed.During a phone interview on 6/22/26 at 3:46 p.m., with Registered Nurse (RN) 1, RN 1 stated she was assigned to provide respiratory care to Resident 1 on 6/16/26. RN 1 stated she documented the tracheostomy suctioning that she provided in the RT's notes; however, the RT notes did not include the time-specific documentation identifying when each suction intervention was performed.During a concurrent record review and interview on 6/23/26 at 11:43 a.m., with the Respiratory Therapist Manager (RTM), Resident 1's tracheostomy 's Care Plan and the facility's undated policy and procedure (P&P)'s Suctioning were reviewed. Despite the facility's P&P required verification of a physician's order before performing suctioning, RTM stated tracheostomy suctioning was considered part of the facility's standard practice and was understood to be performed for residents with tracheostomies regardless of whether a physician's order existed. RTM stated it was more important to obtain a physician's order directing staff not to perform tracheostomy suctioning than to obtain an order authorizing suctioning for residents who required it. RTM stated that RTs and/or RNs determined when to perform suctioning based on endorsement (shift hand off or verbal report from one staff member to another) rather than a scheduled time. RTM stated he assumed RTs and/or RNs were providing tracheostomy suctioning because that was what they had been instructed to do. RTM stated he did not believe documenting the time suctioning was performed was necessary as long as RTs and/or RNs were providing respiratory care. RTM stated he verified that suctioning was being provided to residents with tracheostomies by communicating with RTs and/or RNs verbally and through resident care reports. RTM stated he was unsure why Resident 1 did not have a physician's order for tracheostomy suctioning while other residents did. RTM further stated he did not know why Resident 1's Care Plan directed suctioning to be performed as ordered by the physician. RTM stated Resident 1's Care Plan should have been followed because it reflected the physician's orders. RTM stated if the suctioning care plan was not followed, Resident 1 was at risk of infection.During an interview on 6/23/26 at 12:23 p.m., with the Infection Preventionist (IP), IP stated that suctioning tracheostomies required a physician's order because the procedure was considered invasive. IP stated if suctioning was required every two hours, staff were expected to follow the schedule strictly and document the time it was performed, because without documentation the facility would not have known whether Resident 1 was being suctioned in a timely manner. IP further stated if suctioning was not performed timely according to the physician's order and the care plan, Resident 1 was at risk for infection because secretions could have accumulated and grown bacteria in the mouth, tracheostomy, and lungs. IP stated Resident 1 also could have experienced respiratory arrest (when breathing stops) if suctioning was not performed as ordered.During a phone interview on 6/23/26 at 1:36 p.m., with RT 1, RT 1 stated tracheostomy suctioning should be performed as clinically indicated and should not be delayed when necessary. RT 1 furthermore stated excessive tracheostomy suctioning may increase the risk of tracheal bleeding.During a record review of the facility's undated P&P, titled, Suctioning, the P&P indicated Pre-procedure assessment.1. Verify provider order and patient identity.Assess and document.a. breath sounds b. Respiratory effort and rate c. SpO2 (saturation of peripheral oxygen, is an estimate of the percentage of hemoglobin in your red blood cells that are carrying oxygen) level.e. Amount, color, consistency of secretions.9. Documentation Requirements.Indication for suctioning.Type of suction.Description of secretions.any complications and interventions.2. During a record review of Resident 2's AR dated 6/23/26, AR indicated Resident 2 was admitted in May 2026 with diagnoses including respiratory failure, tracheostomy status, ventilator (a medical machine that mechanically moves breathable air into and out of the lungs to deliver oxygen and remove carbon dioxide) dependence and pneumonia (an infection that inflames the air sacs in one or both lungs).During an observation on 6/22/26 at 2:10 p.m., with Resident 2, Resident 2 was sleeping in bed while connected to the ventilator. Resident 2's emergency respiratory supplies maintained at bedside did not include a manual resuscitator bag. An unlabeled manual resuscitator bag was observed immediately outside the shared room's bathroom door, stored without a protective covering on top of a portable oxygen cylinder, with the attached tubing in contact with the floor.During an interview on 6/22/26 at 2:14 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the manual resuscitator bag belonged to Resident 2. LVN 1 stated it should not have been next to the bathroom door and should have been kept inside Resident 2's emergency supplies. LVN 1 stated the manual resuscitator bag had already been exposed to dirt and should have been replaced. LVN 1 further stated the manual resuscitator bag should have been stored in a protective bag to prevent risk of infection.During an interview on 6/22/26 at 4:08 p.m., with the Respiratory Therapist Manager (RTM), RTM stated, Resident 2 routinely likes to bring and use the manual resuscitator bag when goes to the bathroom. RTM stated the same manual resuscitator bag remained designated for emergency use if Resident 2 experienced respiratory distress (serious medical emergency where the body struggles to get enough oxygen). RTM stated the manual resuscitator bag should have been stored properly in a protective bag to prevent risk of contamination and infection and should have been readily accessible for Resident 2 in case of respiratory emergency.During a record review of the facility's undated P&P, titled, Departmental (Respiratory Therapy) -Prevention of Infection, the P&P indicated The purpose of this procedure is to guide prevention of infection associated with respiratory tasks and equipment, including ventilators, among residents and staff.Transport respiratory therapy equipment to designated soiled utility area for decontamination.keep oxygen cannula and tubing used as needed in a plastic bag when not in use.

Based on interviews and record reviews, the facility failed to ensure the implementation of hydration monitoring for one of three sampled residents (Resident 1), when Resident 1's intake (I, fluid consumed) and (&) output (O, fluid excreted) monitoring during the PM shift (7:00 p.m. to 7:00 a.m.) was not maintained and the total 24-hour I&O (it is the clinical window used to evaluate fluid balance and it sums all fluid consumed against all fluid excreted over the preceding 24 hours to track trends and detect dehydration [loss of fluid] or fluid overload [too much fluid in the body]) was not calculated on 6/15/26, to evaluate Resident 1's overall fluid balance and hydration status.This deficient practice placed Resident 1 at risk for delayed identification of changes in fluid balance, including dehydration or fluid overload, and delayed implementation of appropriate interventions.During a record review of Resident 1's admission Record (AR), dated 6/23/26, AR indicated Resident 1 was originally admitted to the facility in March 2015, with diagnoses including traumatic brain injury (TBI, a disruption in normal brain function caused by an outside physical force), post traumatic seizures (abnormal electrical disturbances in the brain caused by a TBI), gastrostomy status (a surgical opening into the stomach (G-tube) used for long-term nutritional support) and persistent vegetative state (a severe neurological condition where an individual has completely lost cognitive function and awareness of their environment, yet retains basic, involuntary autonomic functions like breathing, heartbeat, and regular sleep-wake cycles).During a record review of Resident 1's Care Plan (CP), the CP for dehydration (occurs when your body loses more fluid than it takes in) initiated on 4/7/25, indicated Resident 1 was at risk for dehydration or electrolyte imbalance (occurs when minerals in your body like sodium, potassium, or calcium become too high or too low) related to enteral nutrition (delivers liquid formulas containing essential nutrients directly into the stomach or small intestine). Additionally, Resident 1's CP for indwelling catheter (often called a Foley catheter, is a flexible tube inserted through the urethra into the bladder to continuously drain urine) initiated on 9/22/16, indicated Resident 1 had an indwelling catheter related to neurogenic bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Both CPs indicated monitoring for Resident 1's intake and output in accordance with the facility protocol as an intervention.During a record review of Resident 1's Order Summary Report (ORS) dated 6/23/26, the ORS indicated Resident 1 had a physician order dated 4/28/26, to monitor I&O each shift, calculate the total 24-hour I&O every night shift by combining the total I&O from the previous AM shift (7:00 a.m. to 7:00 p.m.) and PM shift, and to report any significant changes in Resident 1's fluid balance to the physician.During a record review of Resident 1's Medication Administration Record (MAR) dated from 6/1/26 through 6/30/26, the MAR did not reflect Resident 1's I&O monitoring for PM shift and the calculated total 24-hour I&O for 6/15/26, as ordered by the physician. During a concurrent interview and record review on 6/23/26 at 11:25 a.m., with the Director of Nursing (DON), Resident 1's MAR dated 6/1/26 through 6/30/26 was reviewed. DON confirmed Resident 1's MAR did not reflect the PM shift I&O monitoring and the 24-hour total I&O on 6/15/26 was not implemented and recorded. DON stated the licensed nurse should have provided and documented the I&O monitoring to determine Resident 1's hydration status because monitoring and documenting total I&O were necessary to identify potential dehydration or fluid imbalance.During a record review of the facility's undated policy and procedures (P&P), titled, Intake, Measuring and Recording, the P&P indicated The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period.Preparation.1. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy.Steps in Procedure.8. Record the amount noted on the intake side of the I&O record.9. Record the time the intake was measured.Documentation.3. The amount of liquid consumed.During a record review of the facility's undated P&P, titled, Output, Measuring and Recording, the P&P indicated The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. Preparation.1. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy.Steps in the Procedure.8. Record the amount noted on the output side of the I&O record .Documentation.4. The amount and character of output.

Based on interviews and record reviews, the facility failed to ensure accurate and complete clinical documentation for one of three sampled residents (Resident 1), when the licensed nurse documented that medications were administered to Resident 1 on 6/16/26 at 5:00 a.m., the medications administration were not documented on Resident 1's Medication Administration Record (MAR- It is the official clinical record log that nurses and caregivers use to document what prescribed medication a patient receives, the dosage, the time it was administered, and the route).This deficient practice resulted in Resident 1's inaccurate and incomplete clinical record, which could affect Resident 1's ongoing clinical assessment, treatment decisions, and continuity of care.During a record review of Resident 1's admission Record (AR), dated 6/23/26, AR indicated Resident 1 was originally admitted to the facility in March 2015, with diagnoses including traumatic brain injury (TBI, a disruption in normal brain function caused by an outside physical force), post traumatic seizures (abnormal electrical disturbances in the brain caused by a TBI), gastrostomy status (a surgical opening into the stomach used for long-term nutritional support) and persistent vegetative state (a severe neurological condition where an individual has completely lost cognitive function and awareness of their environment, yet retains basic, involuntary autonomic functions like breathing, heartbeat, and regular sleep-wake cycles).During a record review of Resident 1's Progress Notes dated 6/16/26, the Progress Notes documented by the PM shift (7:00 p.m.- 7:00 a.m.) licensed nurse indicated Medications administration at 0500 (5:00 a.m.) per orders.During a phone interview on 6/22/26 at 3:46 p.m., with Registered Nurse (RN) 1, RN 1 stated she was assigned to Resident 1's respiratory care on 6/16/26. RN 1 stated another licensed nurse was assigned to administer Resident 1's medications. RN 1 furthermore stated the licensed nurse had confirmed and reported to RN 1 that Resident 1's medications were administered at 5:00 a.m.During a concurrent interview and record review on 6/23/26 at 11:25 a.m., with the Director of Nursing (DON), Resident 1's MAR dated 6/1/26 through 6/30/26 and the Progress Note dated 6/16/26, were reviewed. DON confirmed that Resident 1's MAR did not reflect the medications administered on 6/16/26 at 5:00 a.m., DON stated there were two possible medications administered by the licensed nurse: valproic acid (an anti seizure medication) and propranolol (a medication for high blood pressure). DON stated these medications were scheduled for administration at 6:00 a.m., and the licensed nurse was permitted to administer medications up to one hour before the scheduled time. DON stated they were unsure why the licensed nurse did not document the medications administered to Resident 1. DON stated the medications given should have been documented on the MAR. DON further stated that this practice could have negatively impacted adherence to the five rights of medication administration, including verifying the right patient, the right medication, the right route, the right dose, and the right time, which compromised Resident 1's safety.During a record review of the facility's undated P&P, titled, Administering Medications, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.21. As required of 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.g. the signature and title of the person administering the drug.

Based on observation, interview and record review, the facility failed to ensure staff adhered to its infection control policies for one of three sampled residents (Resident 3) when housekeeper (HK 1) entered and cleaned Resident 3's room without wearing the required isolation gown (protective barrier to prevent the transfer of germs between patients and staff) while Resident 3 was on contact isolation precautions (safety measure to wear gloves and gown when in contact with an infected resident, surfaces or equipment) for MRSA (methicillin-resistant staphylococcus aureus, bacteria that does not respond to antibiotics) associated wounds to the left foot and left leg, increasing the risk of cross-contamination and transmission of healthcare-associated infections. This failure exposed residents and staff to potential cross-contamination and increased risk of transmission of infectious organisms.Findings: During a review of Resident 3's admission Record, indicated Resident 3 was admitted in the facility on 11/18/24, with diagnoses of Tracheostomy (a surgically created hole in the neck that leads directly into the windpipe, usually holding a tube open to breathe). During a review of Resident 3's doctor's order dated 3/20/25, under Order Summary Report indicated Resident 3 was on contact precautions related to MRSA related to wound on the left foot and leg. During an observation on 6/22/26 at 1:48 p.m., a Contact Precautions signage was posted on the outside of Resident 3's room door. Resident 3 was in the room, in her bed, her bed was right next to the door. The HK 1 was inside Resident 3's room, wearing a pair of gloves and using a moist towel to wipe an unoccupied bed which was located near the window in that room, without wearing an isolation gown. HK 1 walked past Resident 3's privacy curtain and bed multiple times, to get in and out of the room to get cleaning supplies, continued wiping the unoccupied bed, climbed up a ladder with gloved hands, removed used privacy curtains, stepped out of the room to discard used towels. During an interview on 6/22/26 at 2:02 p.m., with HK 1, HK 1 stated when cleaning surfaces in a Contact Precautions room, they were required to wear a gown and gloves. HK 1 stated they should use this applies even when the bed is unoccupied because germs can get on their clothes and may be spread to other residents. During an interview on 6/23/26 at 12:12 p.m., with the Infection Preventionist (IP), IP stated housekeepers were required to wear an isolation gown and gloves when cleaning the surfaces/environment in a room where residents' were on Contact Precautions, even when not every bed in the room was occupied, because the whole environment in the room was considered contaminated (something has been made dirty or unsafe because something harmful has been added to it) and microorganisms (germs, tiny living things that are too small to be seen with the naked eye) could remain on surfaces for days, creating a risk of spreading them to other residents causing fever or cough. The IP stated since Resident 3 had tracheostomy and a wound on her leg, it placed Resident 3 at higher risk for acquiring further infections if staff did not follow infection control practices. During a review of the facility's Policy and Procedure (P&P) titled, Contact Precautions, dated 2001, the P&P indicated, Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on interview and record review, the facility failed to provide services to meet professional standards of quality for one of three sampled Residents (Resident 1), when Resident 1 did not have their blood sugar level checked and/or received Insulin [medication for Diabetes Mellitus (DM - a chronic condition where the body cannot properly manage sugar in the blood leading to high levels that can damage organs)] as ordered by their physician. This failure had the potential for Resident 1 to experience life-threatening emergencies as well as severe organ damage.During a review of Resident 1's admission Record, dated 12/15/25, the admission Record indicated Resident 1 was admitted to the facility in April 2023 with multiple diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar) and Gastrostomy Status (indicates a feeding tube (G-tube) placed directly into stomach through the abdominal wall used for long-term feeding, fluids, or medicine when a patient cannot eat enough by mouth).During a review of Resident 1's Minimum Data Set Assessment (MDS- a federally mandated resident assessment tool), dated 10/25/25, the MDS assessment indicated Resident 1 had a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15. Meaning Resident 1 has intact cognition. MDS also indicated, Resident 1 had multiple diagnoses that included Diabetes Mellitus.During a review of Resident 1's care plan (document that outline resident's care needs), dated 4/20/2023, the care plan indicated Resident 1 had imbalanced nutrition related to insulin resistance (when body cannot easily absorb glucose from the blood for energy). Care plan also revealed Resident 1 was at risk for complications such as unstable blood glucose and cardiovascular disease (condition that can lead to heart attack and stroke) and one of the interventions were Diabetes medication as ordered by doctorDuring an interview on 12/15/25 at 2:30 p.m. in Resident 1's room in the presence of both Resident 1 and Resident 1's Responsible Party (RP), Resident 1 stated, they did not have blood sugar checked and did not receive insulin on multiple occasions. RP added, Resident 1 did not get their blood sugar checked and/or received insulin on the evening of 7/5/25. During a concurrent interview and record review on 2/9/26 at 11:29 a.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) for 7/5/25 was reviewed. DON stated the MAR for 7/5/25 at 6:00 p.m. indicated Resident 1's blood sugar had not been checked, and Resident 1 also did not receive insulin as ordered. DON added, the licensed nurse did not document justification for missed insulin administration for Resident 1. During a review of Resident 1's Physician's Order Summary Report, dated 5/5/24, the Order Summary Report indicated Resident 1 had a prescription for Humalog Insulin Injection Solution 100 UNIT/ML (unit per milliliter) (Humalog Insulin-a medication used to treat DM) Inject as per sliding scale (personalized chart that dictates how much fast acting insulin to give before a meal based on current blood sugar reading). every 6 hours for DM.During a review of Resident 1's MAR for the month of July 2025, the MAR indicated Resident 1 did not receive Humalog insulin on 7/5/25 at 6:00 p.m. as scheduled.During a review of facility's policy and procedures (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, undated, revealed under Medication Management 1. Follow the provider orders for blood for blood glucose monitoring.7. Assist the resident with his or her specific medication regimen, as ordered and as needed.During a review of facility's P&P titled, Administering Medications, undated, under policy statement, Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame.6. Medications are administered within one (1) hour their prescribed time, unless otherwise specified.

Based on observation, interview and record review, the facility failed to observe infection control measures for two of six sampled residents (Resident 1 and Resident 2 ) when the following was observed: 1. House Keeper (HK) 1 was seen inside Resident 1's room who was on Contact Precaution (extra safety steps healthcare workers take to stop spread of germs) without Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and did not perform hand hygiene after exiting Resident 1's room.2. Registered Nurse (RN) 1 did not wear PPE or wash their hands after giving a subcutaneous (medication delivered through injection under the skin) injection to Resident 1.3. Certified Nursing Assistant (CNA) 1 emptied Resident 2's urinary drainage bag with gloved hands and exited Resident 2's room without removing gloves or performing hand hygiene. These failures had the potential to spread infections among residents at the facility.1. During a review of Resident 1's admission Record, dated 12/15/25, the admission Record indicated Resident 1 was admitted to the facility April 2023 with multiple diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar) and Gastrostomy Status (indicates a feeding tube (G-tube) placed directly into stomach through the abdominal wall used for long-term feeding, fluids, or medicine when a patient cannot eat enough by mouth). During a concurrent observation and interview on 12/15/25 at 1:15 a.m. in Resident 1's room, HK 1 was observed inside Resident 1's room not wearing PPE. HK 1 then exited Resident 1's room and did not perform hand hygiene. HK 1 explained, she just cleaned and emptied Resident 1's bathroom and trash bins. HK 1 then proceeded to fill up PPE supplies on Resident 1's supply rack. HK 1 stated, they knew they were supposed to wear PPE when cleaning Resident 1's room. HK 1 added, there was no supply of PPE this morning. During a review of Resident 1's Physician's Order Summary Report, dated 3/20/25, the Order Summary Report, indicated Resident 1 was on contact precaution as ordered by the physician. During a review of facility's infection control signage posted outside Resident 1's door, the infection control signage indicated CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. The signage also indicated PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. During a review of facility's infection control signage posted outside Resident 1's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated .3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; .g. immediately after glove removal. 2. During a review of Resident 2's admission Record, dated 12/15/25, the admission Record indicated Resident 2 was admitted to the facility in November 2024 with multiple diagnoses that included tracheostomy (surgical opening in the neck that allows a person to breathe through a tube) status, gastrostomy status and ventilator associated pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 12/15/25 at 1:35 p.m. with RN 1 in Resident 1's room, RN 1 was observed inside Resident 1's room not wearing PPE. RN 1 then exited Resident 1's room and did not perform hand hygiene. RN 1 stated, she did not wear PPE inside Resident 1's room because the PPE supply rack on Resident 1's door was empty. RN 1 further stated, PPE supply was kept at the nurse's station, not near Resident 1's room. RN 1 added, PPE was supposed to be worn because Resident 1 was on contact precaution. When asked if RN 1 had direct contact with Resident 1, RN 1 stated, yes because she had given medication to Resident 1 via G-tube, checked Resident 1's blood sugar check and gave insulin to Resident 1. RN 1 acknowledged she did not perform hand hygiene after direct contact with Resident 1. RN 1 added, there was increased risk of transmission of infection for not wearing PPE and not performing hand hygiene after giving direct care to Resident 1. During a review of Resident 2's Physician's Order Summary Report, dated 3/20/25, indicated Resident 2 was on contact precaution as ordered by the physician. During a review of Resident 2's care plan care plan (document that outline resident's care needs), dated 10/4/24, the care plan indicated Resident 2 was on contact precaution and one of the interventions were, staff will perform hand washing after completing care and leaving the room. The care plan also showed, use of personal protective equipment was required. During a review of facility's infection control signage posted outside Resident 2's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated.3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment;.g. immediately after glove removal. 3. During a concurrent observation and interview on 12/15/25 at 1:39 p.m. in Resident 2's room, CNA 1 was observed at Resident 2's bedside emptying their urinary drainage bag into a container, CNA 1 was wearing gown and gloves. CNA 1 exited Resident 2's room, removed and discarded the gown in the trash bin outside Resident 2's room. CNA 1 did not remove his dirty gloves. CNA 1 then walked towards the nurse's station while removing his gloves and then touched a clean pack of gowns that were located in the nurses' station. CNA 1 stated, he removed the dirty gown in the hallway because the garbage bin was outside Resident 2's room. CNA 1 also stated, he did not perform hand hygiene after emptying urinary bag because he did not think about it. CNA 1 added, the PPE supply rack on Resident 2's door was empty this morning so had to go to the nurse's station where PPE supplies are stored. During an interview on 12/15/25 at 3:38 a.m. with Director of Nursing (DON), DON stated, it was acceptable for CNA 1 to remove dirty gown in the hallway and discard the dirty gown in the garbage bin that was placed immediately outside Resident 2's room. DON also stated, RN 1 was expected to wear PPE when in direct contact with Resident 1 who was in contact precaution. DON added, CNA 1 was expected to disinfect hands with ABHR after removing dirty PPE and before donning new ones to prevent spread of infection. During a review of facility's infection control signage posted outside Resident 2's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated, .3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; .g. immediately after glove removal.

Based on observation, interview and record review, the facility failed to ensure all 59 residents who lived in the subacute building were free from environmental hazards when:1. A free-standing propane (flammable gas used for cooking or heating) tank and a propane tank attached to a gas grill were stored indoors in the subacute building in a hallway next to the kitchen and where a year's supply of emergency supplies were stored.2. Four ceiling mounted televisions (TV) were found partially detached from the ceiling and dangling over four of the 59 current residents (Resident 3, 7, 33 and 69) who were unable to move or protect themselves.These failures placed:1. All residents at risk of fire and explosion potentially causing serious harm and death and had the potential to disrupt kitchen services for any residents who depended on meals from the kitchen.2. Residents 3, 7, 33 and 69 under falling equipment hazards which had the potential to cause injuries and dislodge critical life sustaining medical equipment potentially causing death.The failures to ensure all 59 residents who lived in the subacute building were free from environmental hazards resulted in an Immediate Jeopardy situation (IJ, a situation which facility noncompliance has place the health and safety of residents at risk for serious harm, injury, serious impairment or death). The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 8/20/25, at 2:23 p.m. The facility submitted an acceptable Plan of Action on 8/22/25, at 2:40 p.m. and based on observation, staff interviews and record review, the IJ was lifted onsite during the recertification survey exit conference on 8/22/25, at 5:20 p.m.1. During an observation on 8/20/25, at 9:49 a.m., in the hallway on the first floor of the subacute building, two propane tanks, one freestanding and another connected to a gas grill were observed. There were no staff in the area. At the other end of the hallway was the staff break room which had an exit that provided a clear and direct line of sight to the gas grill and propane tanks. The kitchen was located across the hall from where the propane tanks and gas grill were observed. The markings on the propane tanks indicated a 47 lb. (pounds, unit of weight measurement) tank weight.A review of the facility map titled [Facility Name] North Top Floor, printed 8/18/25, indicated resident rooms were located on the second floor of the two-floor subacute building, directly above where the gas grill and the two propane tanks were being stored. The second floor also included 17 Residents who were on ventilators (medical equipment that supports or replaces a person's breathing when they cannot breathe adequately on their own).During a second observation in the first-floor hallway of the subacute building on 8/20/25, at 12:17 p.m., the gas grill and the two propane tanks were in the same location. There were no staff in the area.During a concurrent observation and interview on 8/20/25, at 3:55 p.m., with Registered Dietitian (RD), RD was in their office in the same hallway as the gas grill and the propane tanks. The RD stated they were responsible for oversight of kitchen equipment and didn't know who put the gas grill and propane tanks in the hallway. The RD stated the gas grill and propane tanks had been in the hallway for at least a week.During a concurrent observation and interview on 8/20/25, at 4:29 p.m., with Maintenance Supervisor (MS) and RD, MS stated the kitchen was behind the wall across from where the gas grill and propane tanks were located, and the room behind the gas grill and propane tanks was the emergency supply room. RD stated paper products and emergency water were stored in the emergency supply room. The emergency supply room was adjacent to the gas water boiler room. MS stated there were two water boilers which were heated by gas.During an interview on 8/21/25, at 11:40 a.m, with MS, MS stated the propane tanks and gas grill were moved from an outdoor shed into the hallway about a year ago. MS stated they didn't know it was unsafe to store propane tanks indoors.During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated propane tanks stored indoors were a fire hazard. The DON stated the staff lounge on the first floor was used by staff during breaks and lunchtime. The DON stated they expected all staff to report hazardous conditions to the fire safety coordinator.During an interview on 8/22/25, at 11:51 a.m., with ADM, ADM stated MS was the fire safety coordinator for the facility. ADM stated MS was responsible for ensuring the facility was free of fire hazards.During a review of the facility's policy and procedure (P&P) titled, Fire Safety and Prevention, undated, the P&P indicated flammable items should be stored in separate areas away from resident living areas or store outside.During a review of National Fire Protection Association (NFPA) code titled, 2024 NFPA-58 Liquefied Petroleum Gas Code, dated 2024, the code indicated on Table 8.3.1 a maximum of 2 lbs. of propane stored in 1 lb. containers was allowed to be stored indoors in a health care setting. 2. A review of Resident 7's admission Record indicated Resident 7 was admitted on [DATE], with a diagnosis of anoxic brain damage (brain damage due to lack of oxygen), acute respiratory failure, cognitive communication deficit, gastrostomy (tube surgically placed in the abdomen to provide nutrition and medications) and tracheostomy (tube surgically placed in the neck to provide a hole for breathing).During a record review of Resident 7's minimum data set (MDS, an assessment tool to guide resident care), dated 7/28/25, the MDS indicated Resident 7 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 7 was unable to understand others and could not make themselves understood.During a record review of Resident 7's weekly nursing summary titled, Nursing - Weekly Summary - V3.0, dated 8/15/25, the summary indicated Resident 7 was dependent on staff for transfers and bed mobility.A review of Resident 33's admission Record indicated Resident 33 was admitted on [DATE], with a diagnosis of chronic respiratory failure, tracheostomy, gastrostomy, muscle wasting, muscle weakness and dependence on respirator [ventilator] status.During a record review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 7 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 7 was unable to understand others and could not make themselves understood.A review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE], with a diagnosis of quadriplegia (loss of function of all limbs), long term use of anti-coagulants (medications used to prevent blood clots and increases risk of bleeding), gastrostomy, tracheostomy, respiratory failure, and cerebral infarction (occlusion of a blood vessel in the brain).During a record review of Resident 3's minimum data set (MDS, an assessment tool to guide resident care), dated 7/29/25, the MDS indicated Resident 3 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 3 was to understand others but could not make themselves understood.A review of Resident 69's admission Record indicated Resident 69 was admitted on [DATE] with a diagnosis of acute respiratory failure, gastrostomy, tracheostomy, anoxic brain damage and long-term use of anti-coagulants.During a record review of Resident 69's nursing assessment titled, Nursing - Daily Skilled Charting Form - [Facility], dated 8/20/25, the assessment indicated Resident 7 was dependent on staff for transfers and bed mobility.During a concurrent observation and interview on 8/20/25, at 10:09 a.m., with Registered Nurse 1 (RN 1), the television ceiling mount over an unoccupied bed in room [ROOM NUMBER] was observed. RN 1 stated the condition of the mount was loose and dangerous to potential occupants of the bed. The ceiling mount had a visible gap between the mount base and the ceiling and upon manual manipulation, the mount could be swung back and forth at the base of the mount.During an observation on 8/20/25, at 10:14 a.m., Resident 3, 7 and 33's TV ceiling mounts in their shared room were inspected. All three mounts were over the resident beds with Resident 3, 7 and 33 in their respective beds. A family member was present with Resident 7. All three TV ceiling mounts had a visible gap between the mount base and the ceiling and could be manually swung back and forth at the base of the mount. All three residents were non-interactive.During a concurrent observation and interview on 8/20/25, at 12:40 p.m., with Resident 3's resident representative (RP), RP stated Resident 3's TV mount had been wobbly because the ceiling mount was loose. RP stated RP kept hitting their head on the TV because it was too low. RP stated the facility attempted to fix the ceiling mount, but the TV mount was still wobbly. RP stated they were scared the TV was going to fall on top of Resident 3. RP stated they were concerned if staff moved the curtain to where the TV was it could potentially make the TV fall.During a concurrent observation and interview on 8/20/25, at 4:40 p.m., with MS and ADM, the TV ceiling mount in Resident 69's room was inspected. Resident 69 was in bed below the TV mount. MS was able to swing the TV mount manually and stated the mount was loose. MS stated for the loose mounts found in Resident 3, 7 and 33's room, the mounting hardware was not installed into a secure structure and repeated contact by Hoyer Lifts (machine used to lift and transfer residents out of bed) caused fasteners to become detached from the ceiling. MS stated some of the loose mounts were held up by only one fastener.During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated Residents 3, 7, 33 and 69 could not protect themselves from environmental hazards and were dependent on staff for safety.During a review of the facility's P&P titled, Maintenance Service, dated 2001, the P&P indicated the maintenance department is responsible for maintaining .equipment in a safe and operable manner at all times.functions of maintenance personnel include.maintaining the building in good repair and free from hazards.

Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: The ice machine had black and brown particles on the inside parts. The resident refrigerator-freezer temperature was not monitored.Unlabeled and undated food items were stored in the resident refrigerator-freezer.Beyond use by and best by date food items were stored in the resident refrigerator-freezer.Food items were stored less than six inches above the floor.These failures had the potential for contamination of food resulting in food borne illness for the 59 residents who lived at the facility. During an observation on 8/18/25, at 9:51 a.m., the ice machine was observed with black and brown particles on the inside parts. During an observation on 8/18/25, at 11:20 a.m., the resident refrigerator-freezer was observed with a sign posted on the refrigerator-freezer's front door that indicated Please be aware that opened food/drinks can only last 3 days. During an observation on 8/18/25, at 11:37 a.m., the resident refrigerator-freezer was observed. The freezer had one plastic container of orange slices undated and not labeled with resident name and one opened soda bottle with an expiration date of 7/21/25 and not labeled with resident name. The refrigerator had one half and half carton with a best buy date by date of 8/6/25 and not labeled with resident name, one salad dressing bottle with a best buy date of 7/26/25 and not labeled with resident name and one jar of an unknown food item not labeled with date or resident name. During a review of the Resident's Refrigerator Temperature Log, dated August 2025, the Log indicated the temperature was not recorded 8/1/25 through 8/12/25 and on 8/15/25 through 8/17/25. During an observation 8/18/25, at 3:09 p.m., central supply was observed with nutritional beverages and tube feeding formulas stored less than six inches above the floor. During an interview on 8/21/25, at 10:39 a.m., with Registered Dietician (RD), RD stated the ice machine should have been clean and an unclean ice machine could have had unsafe water and could have been a risk for infection. RD stated the resident refrigerator-freezer temperature should have been monitored and documented daily, otherwise they could have served food that was stored in the danger zone (the food danger zone is the temperature range between 40 Farenheit and 140 Farenheit, where bacteria grow rapidly, increasing the risk of foodborne illness). RD stated food in the resident refrigerator-freezer should have been labeled with resident name and date received. RD stated if food was not labeled with resident name, it could have caused residents to get the wrong diet, choking and cross contamination. RD stated if food was not labeled with date received, staff may not have known how old the food was and could have caused resident sickness. RD stated the resident refrigerator-freezer should not have had food that was beyond their use by date, beyond their best buy date or expired. RD stated beyond use by date, beyond best buy date and expired food items placed residents at risk for sickness, stomach aches, vomiting and diarrhea. RD stated resident food should have been stored at least six inches above the floor. RD stated food stored less than six inches above the floor was a risk for contamination from pests, could have altered the food temperature and had the potential to cause resident sickness. During an observation and interview on 8/21/25, at 11:32 a.m., with the Maintenance Director (MainD), the ice machine was observed. The inside parts of the ice machine did not have black and brown particles. MainD stated the ice machine was cleaned on 8/20/25. MainD stated it was clean and there was a big difference from before. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated 2001, the P&P indicated, Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and closing in the evening. During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised March 2022, the P&P indicated, Containers are labeled with the resident's name, the item and the use by date. The P&P indicated, The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example . past due package expiration dates). During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 2001, the P&P indicated, Foods and Snacks Kept on Nursing Units . All foods belonging to residents are labeled with the resident's name, the item and the use by date. The P&P indicated, Food in designated dry storage areas are kept at least six (6) inches off the floor.

Based on interview, and record review, the facility failed to ensure sufficient staffing when the weekend staffing levels were excessively low across four fiscal year (FY) quarters, and the minimum requirement of 2.4 Direct Hours Per Patient Day (DHPPD - refers to the minimum number of direct care service hours a facility is required to provide to each resident per day) of direct nurse aide coverage was not met on 15 audited days. This failure had the potential to result insufficient nursing staff and inadequate nursing care for the facility residents. During a record review of a document, titled, Payroll Based Journal (PBJ) Staffing Data Report (a system where nursing homes submit auditable information about the hours worked each day by different types of staff), the PBJ Staffing Data Report showed the following quarters were triggered for excessively low weekend staffing:FY Quarter 4 2024 (July 1 - September 30)FY Quarter 3 2024 (April 1 - June 30)FY Quarter 2 2025 (January 1 - March 31)FY Quarter 1 2025 (October 1 - December 31) During an interview on 8/21/25 at 11:20 a.m. with the Administrator (ADM), the ADM stated the facility did not have a staffing waiver (an official permission granted by a state agency to allow a skilled nursing facility to operate below the state's minimum staffing requirements for a temporary period, usually due to a demonstrated workforce shortage) from 7/1/24 to 6/30/25. During an interview on 8/21/25 at 1:45 p.m. with the Staffing Coordinator (SC), the SC stated she determined the daily staffing levels needed to care for residents based on the calculated DHPPD. SC stated DHPPD result below 2.4 for CNAs indicated short staffing, which could have negatively impacted the facility's ability to provide necessary care and services to residents. During a concurrent interview and record review on 8/22/25 at 9:06 a.m. with Staffing Coordinator (SC), the facility's records, titled, Census and DHPPD on various dates between 1/1/25 through 6/30/25 were reviewed. The Census and DPHPPD data were as follows: 1/18/25 CNA DHPPD was 2.201/21/25 CNA DHPPD was 2.301/27/25 CNA DHPPD was 2.312/9/25 CNA DHPPD was 2.362/11/25 CNA DHPPD was 2.302/12/25 CNA DHPPD was 2.362/13/25 CNA DHPPD was 2.362/14/25 CNA DHPPD was 2.322/16/25 CNA DHPPD was 2.352/17/25 CNA DHPPD was 2.302/19/25 CNA DHPPD was 2.302/21/25 CNA DHPPD was 2.135/12/25 CNA DHPPD was 2.285/19/25 CNA DHPPD was 2.386/23/25 CNA DHPPD was 2.32 During an interview on 8/22/25 at 10:45 a.m. with the Director of Nursing (DON) the DON stated the CNA DHPPD below 2.4 was risk for staffing burnout and could have affected the resident care. During a record review of the facility's undated policy and procedure (P&P), titled, Nursing Hours Per Patient Day (NHPPD) Licensed Nurse (LN) and CNA, the P&P indicated, The facility shall ensure that all residents receive safe, effective, and timely nursing care by maintaining at least 3.5 DHPPD, of which a minimum of 2.4 hours shall be provided by the CNAs.

Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three of 23 sampled residents (Residents 6, 45 and 58) when:Facility did not provide proper oral care for Resident 45 and 58Facility did not provide timely incontinent care for Resident 6These failures had the potential for Resident 45 and Resident 58 to suffer from oral infections, discomfort and an increased risk for pneumonia, and for Resident 6 to not received the necessary care and services to maintain skin integrity. 1.During a record review of Resident 45’s “admission Record” (AR), printed on 8/20/25, the “AR” indicated Resident 45 was admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury (widespread damage occurs to the brain, often resulting in prolonged loss of consciousness and potential long-term disability), dependence on ventilator status (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe), and gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding). During a record review of Resident 58’s “AR”, printed on 8/20/25, the ‘AR” indicated Resident 58 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) following cerebral infraction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain ), dependence on ventilator status, and gastrostomy status. During an interview and record review on 8/20/25 at 11:30 a.m., with Minimum Data Set Coordinator (MDSC), Residents 45's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized carte plan) dated 6/21/25 and Resident 58's MDS assessment dated [DATE] were reviewed. The MDSC stated Residents 45 and 58 were totally dependent on the staff for oral hygiene. During an observation on 8/18/25 at 9:34 a.m., Resident 45 was lying in bed with eyes closed and mouth open. Dried, light, tan-colored matter was noted on Resident 45’s lips and brown-colored, dry matter at the corners of the mouth. When Resident 45 was smacking their lips, sticky, creamy matter was observed between the lips and inside the mouth. During an observation on 8/18/25 at 9:40 a.m., Resident 58 was lying in bed with eyes open and non-verbal. Resident 58’s upper lip was dry and coated with off white, thick, peeling layer of skin. During an observation and interview on 8/19/25 at 8:17 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 45 and 58’s shared room, LVN 1 stated Resident 58’s mouth was dry, peeling and needed oral care. LVN 1 stated both Resident 45 and 58 tended to bite their lips and teeth to cause bleeding, and maybe the brown dry matter around Resident 58’s mouth was dried blood. LVN 1 further stated the night shift Respirator Therapist (RT) should have performed oral care for Residents 45 and 58 during the night shift. During an interview on 8/20/25 at 9:01 a.m., with Director of Nursing (DON), the DON stated poor oral care could lead to bacteria growth in the mouth, cause tooth decay, and increase risk for aspiration pneumonia (when food, liquid, saliva, or vomit accidentally goes down into the lungs instead of the stomach and cause an infection in the lungs). During a concurrent interview and record review on 8/20/25 10:34 a.m., with RT Manager (RTM), reviewed Resident 45 and 58’s oral care performed by RT records, printed on 8/20/25. The records indicated Resident 45 and 58’s oral care was performed by RT on 8/17/25 at 02:21 a.m. and 8/17/25 at 02:22 a.m. RTM stated that RT staff were supposed to perform oral care with Chlorohexidine solutions (a special liquid often used in medical setting to clean the skin, mouth or medical equipment to prevent infection by killing germs) every shift and as needed for each resident. RTM stated it usually took a day or two to build up thicken, creamy matter in their mouths. RTM stated poor oral care could cause oral odors, dental problems and make residents feel unwell. Review of facility’s policy (P&P) titled “Oral Care for the Residents with Special Needs” released July 2025, indicated “The facility will provide oral care to residents with special needs every shift and as needed”. 2.During a review of Resident 6's Annual-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 7/23/25, the MDS indicated Resident 6 was comatose (a state of coma meaning in a deep, prolonged and unarousable state of unconsciousness, unresponsive to stimuli). MDS indicated Resident 6 used external urinary condom catheter (is a urine collection device fits like a condom over penis). MDS indicated Resident 6 was always incontinent of bowel. MDS indicated Resident 6 was dependent for toileting hygiene, care givers do all the effort to complete the activity, or the assistance of two or more helpers is required to complete activity. MDS indicated Resident 6's diagnoses included Traumatic Brain Injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). During a telephone interview on 8/20/25 at 8:59 a.m. with Family Member (FM 1), FM1 stated she visited Resident 6 on 8/14/25 in the morning around 10:00 a.m. and found Resident 6 laid on a draw sheet saturated with dry urine up to his shoulders and upper body. FM1 stated nursing staff did not reposition and changed Resident 6's soiled linen. FM 1 stated she reported incident to the facility staff. During a concurrent observation and interview 8/20/25 at 9:20 a.m. with Licensed Vocational Nurse (LVN 5) in Resident 6's room, Resident 6 laid in bed unconscious with tracheostomy (a surgical procedure that creates an opening in the neck to help the patient breathe) and on ventilator (breathing machine). LVN 5 stated Resident 6 used a condom catheter and was cleaned, repositioned and provided incontinent care. LVN 5 stated Resident 6 condom catheter was changed every shift and as needed. During a telephone interview on 8/20/25 at 3:41 p.m. with Certified Nursing Assistant (CNA 4), CNA 4 stated he was assigned to care for Resident 6 on 8/14/25 night shift ending 7:30 am. CNA 4 stated Resident 6's condom catheter sometimes came off and it took time for licensed nurse to replace condom catheter. CNA 4 stated he provided Resident 6 incontinent care and repositioned Resident 6 every two hours. CNA 4 stated he did not observe Resident 6's draw sheet with urine stained. During a concurrent observation and interview on 8/20/25 at 9:02 a.m. with CNA 5, Resident 6 laid in bed. CNA 5 stated she was assigned to care for Resident 6 on 8/14/25 morning shift start time 7a.m. CNA 5 stated she checked on Resident 6 at around 8a.m. CNA 5 stated Resident 6 was clean and reposition. CNA 5 stated she does walk rounds with night shift CNA to check residents and make sure residents were cleaned and repositioned. CNA 5 stated she returned to Resident 6 around 10 a.m. for care because she has other residents to attend and was busy. CNA 5 said she did not see that Resident 6's draw sheet was stained with urine. During an interview on 8/20/25 at 10:18 a.m. with Director of Staff Development (DSD), DSD stated he was informed that Resident 6's FM1 complained that Resident 6's draw sheet was saturated with urine stain and not changed overnight. DSD stated CNA 5 was interviewed and stated Resident 6's condom catheter was loose and may be leaking. DSD stated he was shown a picture of Resident 6 wet bed with saturated urine-stained draw sheet underneath Resident 6. DSD stated he followed up with night shift nurse CNA 4 and reminded CNA 4 and CNA 5 to check, clean and reposition Resident 6 every two hours and stress the importance of checking residents' incontinence episodes. During an interview on 8/21/25 at 11:21 a.m. with Administrator (Admin), Admin stated facility was aware of a complaint on 8/14/25 that Resident 6 laid on a draw sheet that was saturated and stained with urine and had started investigation. During a concurrent interview and record review on 8/22/25 at 10:15 a.m. with Director of Nursing (DON), Resident 6's bladder and bowel continence records, safety checks every 2 hours including positioning and assistance in bowel and bladder records were reviewed. The safety checks every 2 hours records indicated on 8/14/25, Resident 6 was checked at 12:06 a.m. and next check was at 6:44 a.m. DON stated her expectation was for nursing staff to follow the safety protocol, and check residents every 2 hours for positioning, incontinence care so residents are comfortable, clean and prevent wounds. During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 2001, the P&P indicated, Residents who are in bed should be on at least an every-two-hour (q2hour) repositioning schedule. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting dated 2001, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure the Medical Director (MD) perform duties and responsibilities when MD stated did not regularly attend quality assurance and performance improvement (QAPI) committee and did not participate in the development of the facility assessment or development and evaluation of policy and procedures for two years.This failure had the potential for all residents to have substandard quality of care due to lack of physician oversight of patient quality assurance and facility performance.During an interview on 8/22/25, at 3:48 p.m., with MD, MD stated they had been the medical director for two years. MD stated they had not regularly attended QAPI meetings. MD stated they had attended two QAPI meetings in recent memory and was not getting regular invites to meetings until recently. MD stated they did not review or update any facility policy and procedures (P&P). MD stated they were not involved in the development of the facility assessment (assessment used to determine what services the facility is capable of offering). MD stated they would be involved in assessing individual residents for admission, but did not provide input into the overall scope of services provided.A review of facility QAPI sign in sheets for 2025, indicated MD was present for three of seven QAPI meetings (January, June and July).A review of California Department of Public Health (CDPH) All facilities letter titled, Assembly [NAME] (AB) 48 - Nursing Facility Resident Informed Consent Protection Act of 2023, dated 2/28/24, indicated residents have the right to be free of psychotherapeutic drug (medication used to treat psychiatric disorders).AB 48 requires the facility to obtain written informed consent and specifies disclosure of material information for proper informed consent.must include: possible nonpharmacological approaches that could address the resident's needs. Whether the drug has a current boxed warning label.whether the drug is prescribed for a purpose that has or has not been approved by the United States Food and Drug Administration (FDA). Possible interactions with other drugs .facilities must review and revise their P&Ps to ensure compliance with the new law. The P&Ps must specifically consider and plan for how the facility will verify the resident provided informed consent or refused treatment or a procedure pertaining to the administration of psychotherapeutic drugs.A review of facility P&P titled, Antipsychotic Medication Management, dated August 2022, indicated the P&P was last revised in August 2022. The P&P indicated Residents (and/or resident representatives) will be informed of the recommendation, risk, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents.may refused medications of any kind. The P&P did not indicate antipsychotic medication use required written informed consent and did indicate the consent contained specific information pertaining to nonpharmacological approaches, medication warning label, medication use approval by FDA and possible interactions with other medications.During a record review of MD's contract titled, Medical Director Services Agreement, dated 1/1/23, the contract indicated the MD serve as a member of the facility's quality assurance committee.be involved in developing, reviewing and implementing policies and procedures regarding clinical care of residents to ensure clinical validity and consistency with current standards of care.provide input into the facility's: scope of services provided to residents .and review and updating of policies and procedures to reflect current standards of practice.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) for six of eight sampled residents (Residents 1, 2, 4, 5, 23 and 55) when:1. Residents 1, 2, 4, 23 and 55 enteral feeding items were unlabeled. 2. Resident 5's enteral feeding formula was unlabeled and the water flush (the process of gently pushing water through the feeding tube to prevent it from becoming clogged and to help with hydration) bag was not administered per physician's order.These failures had the potential to cause Residents 1, 2, 4, 5, 23, and 55 to receive incorrect administration of feeding formulas and water flush, potentially causing serious harm, including but not limited to respiratory aspiration (occurs when stomach contents or feeding formula enters the lungs), foodborne illness (illnesses caused by consuming contaminated food or beverages), dehydration (absence of enough water in the body) or discomfort. 1.During an observation on 8/18/25 at 9:20 a.m., Resident 55's feeding formula, water flush, and syringe were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an observation on 8/18/25 at 10:33 a.m., in Resident 23 and 2's shared room, Resident 23's feeding formula, Resident 2's feeding formula and water flush were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an observation on 8/18/25 at10:51 a.m., in Resident 1 and 4's shared room, Resident 4's feeding formula, and Resident 1's feeding formula and water flush were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an interview on 8/20/25 at 9:01 a.m., Director of Nursing (DON) stated nurses should label the feeding formula, water flush and syringes with resident's name, date, and time to ensure residents receive the correct formula, the correct flow rate and the correct amount of water. DON stated that without proper labeling, residents were at risk of receiving expired food (formula), experiencing upset stomach and developing foodborne illness such as diarrhea. During a concurrent interview and record review on 08/21/2025 11:19 a.m., with Infection Control and preventionist (IP), in tube feeding supply storage, IP stated it was the nursing standard practice to label the formula, water flush and syringes. IP stated the nurses should label the formula, water and syringe when hanging new bags, to ensure syringes not being shared among residents in the same room and to track how long a syringe had been in use, since syringes should be disposed of after 24 hours. During a review of the facility's policy and procedure (P&P), titled, Enteral Feedings - Safety Precautions, dated November 2023, the P&P indicated, .2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.Preventing misconnection errors.1. Ensure that all enteral formula labels indicate Not for intravenous (IV, into the vein) Use .3. Regularly inspect tubing for proper and secure connections. 2. During a record review of Resident 5's admission Record (AR), printed on 8/19/25, the AR indicated Resident 5 was admitted to the facility in August 2024 with diagnoses including anoxic brain damage (occurs when the brain receives no oxygen at all), dependence on ventilator status (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe), gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding) and type 2 diabetes mellitus (a long-term disease in which the body cannot regulate the amount of sugar in the blood) with unspecified complications. During a record review of Resident 5's Order Summary Report (OSR), dated 8/19/25, the OSR indicated an order for Enteral feed every shift tube feeding formula: Diabetisource AC (is a specialized formula to meet the nutritional needs of individuals with diabetes) at 60 milliliters/hour (ml/hr) via gastrostomy tube via feeding pump continuous for 20 hours/day (off at 10:00 a.m. to 2:00 p.m. or until total 1200 ml is given) and Flush tube with water to run at 60 ml/hr via feeding pump continuous for 20 hrs/day for total 1200 ml free water per day. Hold at 10:00 a.m. and on at 2:00 p.m. During an observation on 8/18/25 at 9:53 a.m. with Resident 5, Resident 5 had an ongoing tube feeding administration of Diabetisource AC feeding formula. Resident 5's feeding formula and water flush bags were unlabeled and did not have Resident 5's information such as name, date and time the formula and water flush were started, and the physician's order for feeding and water flush rate. Resident 5 also had approximately 1000 ml remaining in the unlabeled water flush bag. During an observation and interview on 8/18/25 at 10:17 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 checked the enteral feeding and water flush bags and stated she did not know why the bags were unlabeled. LVN 4 stated Resident 5's feeding formula and water flush bag were started on the previous day, 8/17/25. LVN 4 stated she was unsure why the water flush bag remained full and why it was not administered. LVN 4 stated if the water flush had been properly administered to Resident 5, the volume in the water flush bag should have decreased accordingly. LVN 4 further stated the feeding formula and water flush bag should have been labeled correctly including Resident 5's name and the date and time the feeding started. LVN 4 stated not labeling the feeding formula and water flush bag, Resident 5 had the risk of receiving the wrong formula and/or volume amount that could have caused Resident 5 complications of diabetes such as high or low blood sugar. During an interview on 8/22/25 at 10:45 a.m. with the DON, the DON stated licensed nurses were expected to provide monitoring for the residents who had enteral feeding and make sure the feeding formulas and water flush bags had complete and accurate labels. The DON further stated licensed nurses should have verified if the feeding pump (a medical device that delivers liquid nutrition, fluid, and medications directly into a person's gastrointestinal tract through a feeding tube when they cannot consume food or liquids orally) was working properly. The DON stated administering the water flush as ordered by the physician was important to ensure residents maintain proper hydration. During a review of the facility's policy and procedure (P&P), titled, Enteral Feedings - Safety Precautions, dated November 2023, the P&P indicated, Promoting feeding tolerance.3. Feeding pumps must be calibrated periodically to ensure that the pump delivers the prescribed volume within 10 percent accuracy .Preventing errors in administration .1. Check the enteral nutrition label against the order before administration . 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.Preventing misconnection errors.1. Ensure that all enteral formula labels indicate Not for intravenous (IV, into the vein) Use .3. Regularly inspect tubing for proper and secure connections.

Based on observation, interview, and record review the facility failed to provide the appropriate foley catheter (a flexible tube used to empty the bladder and collect urine) care and services for one of one sampled resident (Resident 4) when Resident 4's indwelling urinary catheter bag and tube were touching the floor. This failure had the potential for Resident 4 to develop a urinary tract infection (UTI, an infection in any part of the kidneys, bladder, or urethra (the tube which empties urine from the bladder). During a record review of Resident 4's admission Record (AR) printed on 8/19/25, the AR indicated Resident 4 was admitted to the facility in June 2025 with diagnoses of cardiac arrest (when the heart suddenly stops breathing) and pseudomonas (a type of bacteria that can cause serious infections), and pressure ulcer (develops when one or more layers of skin and tissue are damaged from continuous pressure to the area) of sacral region stage four (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). During a record review of Resident 4's Order Summary Report (OSR) dated 8/19/25, the OSR indicated, .foley catheter 16#French (Fr, a unit used to measure the size of catheter and tubes) . Indication of use: wound management. During a concurrent observation and interview on 8/19/25 at 11:10 a.m. with Certified Nurse Assistant (CNA) 2, Resident 4's foley catheter bag was not properly secured to the bed and was found completely resting on the floor. CNA 2 stated whoever lowered the bed must have forgotten to check the foley catheter bag. CNA 2 stated the foley catheter bag should have been completely off the floor because it had the risk of contamination and infection. CNA 2 further stated if she had the foley catheter, she would not want her foley catheter bag on the floor. During an interview on 8/20/25 at 10:51 a.m. with Infection Preventionist (IP), IP stated it was unacceptable for the foley catheter bag to be on the floor. IP stated Resident 4 was at risk for catheter-associated urinary tract infection (CAUTI, happens when a bacteria enters the bladder or urinary tract though a urinary catheter which can lead to complications like bladder infections, kidney infections, and even sepsis or an extreme reaction to an infection).During a record review of the facility's policy and procedure (P&P), titled, Catheter Care, Urinary, revised in August 2022, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including UTI.Infection Control.2. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 8 and 53) of four sampled residents when Resident 8's MDS section B vision did not reflect limited vision. Resident 53's MDS section L oral/dental status did not reflect missing and cracked teeth. This failure had the potential for residents to not receive appropriate care and services. During a review of Resident 8's admission Record (AR), AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Glaucoma (a group of eye conditions that can cause blindness) and vision loss. During a review of Resident 8's visual impairment care plan, dated 11/12/18, the care plan indicated Resident 8 had impaired visual related to diagnosis of glaucoma. During a review of Resident 8's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated June 20, 2025. MDS section B indicated Resident 8 had adequate vision, sees fine details such as regular prints in newspapers/books. During a concurrent interview and record review on 8/20/2025 at 1:54 p.m. with Director of Nursing (DON), MDS coordinator (MDSC) and Social Services Director (SSD), Resident 8's MDS section B was reviewed. MDSC stated Resident 8's section B vision was completed by SSD. SSD stated she was assigned to complete Resident's 8 MDS section B. SSD stated she thought Resident 8 liked to close his eyes. SSD stated she did not know Resident 8 had vision problems. SSD stated she did not interview Resident 8's care givers. MDSC stated Resident 8's section B was not coded accurately for vision. During a review of Resident 53's admission Record (AR), AR indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During an observation on 8/18/2025 at 12:15 p.m. in the dining area, Resident 53 had lunch of salad in the dining area and suddenly coughed and cried. Licensed Vocational Nurse (LVN 2) and CNA 3 at Resident 53's dining table side encouraged Resident 53 to cough out.During an interview on 8/18/25 at 12:20 p.m. with Certified Nursing Assistant (CNA3), CNA 3 stated Resident 53 had missing and cracked teeth. CNA 3 stated that it was the first time for Resident 53 had this episode of coughing while eating. CNA 3 stated it will be beneficial for Resident 53 to have dentures for Resident 53 to chew better.During an observation and concurrent interview on 8/18/25 at 12:20 p.m. in the dining area Resident 53 had missing and cracked teeth in the front and side of mouth. Resident 53 stated she was doing ok.During a review of Resident 53's Oral Health Care patient notes, dated March 21, 2025, indicated Resident 53 was unable to eat with existing dentition. During a review of Resident 53's MDS, dated [DATE], MDS section L for oral/dental status indicated Resident 53 had no chipped, cracked, broken, loose teeth or difficulty with chewing. During a concurrent interview and record review on 8/19/2025 at 11:24 a.m. with MDS coordinator (MDSC), Resident 53's MDS section L dental/oral status dated 1/29/25 was reviewed. MDS section L indicated Resident 53 had no dental problems. MDSC stated MDS section L was not coded accurately.During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated October 2023, the P&P indicated Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on observation, interview and record review, the facility failed to ensure one (Resident 8) of five sampled residents was free from unnecessary drugs when:Resident 8 was administered Seroquel an antipsychotic medication for dementia with behavior of biting.For Resident 8, facility did not document use of non-pharmacological interventions that have been attempted to relieve behavior.(Antipsychotic medication are drugs that affects brain activities associated with mental processes used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior). This failure had the potential for Resident 8 to receive unnecessary medications and the potential to suffer adverse medication side effects. During a review of Resident 8's Annual-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 6/20/25, MDS indicated Resident 8's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 8's score was 03 and indicated poor cognition. MDS indicated Resident 8 had no serious mental illness. MDS indicated Resident 8 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing, or screaming at others. MDS indicated Resident 8 had no other behavioral symptoms not directed towards others (e.g., hitting, scathing self, screaming or disruptive sounds) MDS indicated Resident 8's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function, or language).During a review of Resident 8's Order Summary Report (OSR), dated 8/5/2025, the OSR indicated physician prescribed Resident 8, Seroquel oral tablet 50mg give one tablet by mouth at bedtime for dementia with behaviors-biting. OSR also indicated physician prescribed Resident 8, Seroquel oral tablet 50mg give one tablet by mouth in the morning for dementia with behaviors-biting. During a review of Resident 8's Medication Administration Record (MAR), dated 7/1/2025 through7/31/2025, and 8/1/2025 through 8/19/2025, the MAR indicated Resident 8 was administered Seroquel as ordered by the physician. The MAR indicated Resident 8 had one episode of biting behavior in July 2025 and no behavior of biting in August 2025. During an observation on 8/18/25 at 10:51 a.m. Resident 8 laid in bed in his room asleep. During an interview on 8/19/25 at 9:53 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated that Resident 8 was on hospice care. CNA1 stated that Resident 8 was legally blind and liked to close his eyes. CNA 1 stated Resident 8 randomly get agitated except during shower. CNA1 stated Resident 8 get agitated during shower when shaved. CNA1 stated Resident 8 previously had behavior of biting on hospital gown and randomly bite on his blanket. CNA1 stated Resident 8 no longer wear hospital gown and had linen covers while in bed. During an interview on 8/20/25 at 1:55 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 8's behaviors include occasional outburst mostly at night and during shower probably because Resident 8 was legally blind. During an interview on 8/21/25 at 1:12 p.m. with LVN 3, LVN 3 stated Resident 8 randomly chew on his blanket otherwise Resident 8 had no behaviors. LVN 3 stated Resident 8 stayed in bed. During a review of Resident 8's Preadmission Screening and Resident Review (PASRR), dated 5/28/25, the PASRR indicated Resident 8 has no diagnoses or suspected serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). During a concurrent interview and record review on 8/21/25 at 1:20 p.m. with Director of Nursing (DON), Resident 8's medical records, physician orders, progress notes, interdisciplinary notes and care plans were reviewed. There was no documentation that non-pharmacological approaches have been attempted. DON stated facility process was to review use of psychotropic medication for appropriate diagnosis or indication if appropriate for use of psychotropic medication, reach out to psychiatrist as needed. DON stated her expectation was that nursing staff implement nonpharmacological intervention with documentation. DON could not provide documentation that staff provided Resident 8 non-pharmacological interventions with use of antipsychotic medication.According to the Seroquel manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). {Reference: https://[NAME].com/seroquel} During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Management revised August 2022, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will not be used if only symptoms are one or more of the following: wandering, restlessness, impaired memory, inattention or indifference to surroundings, fidgeting, nervousness, uncooperativeness .

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 5), received proper infection control measures for tracheostomy (surgically created hole in the trachea or windpipe that provides an alternative airway for breathing) care when Resident 5's two Ambu bags or manual resuscitator bag (is a hand-held device used in emergencies to provide manual, positive pressure ventilation to patients who are not breathing adequately) were left exposed in the room without any protective coverings. This failure resulted in Resident 5 being at risk of acquiring life-threatening infections including but not limited to ventilator (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe) associated pneumonia (an infection that inflames the air sacs in one or both lungs) that can also lead to sepsis (the body's extreme and harmful reaction to an infection) if the contaminated Ambu bags were used. During a record review of Resident 5's admission Record (AR), printed on 8/19/25, the AR indicated Resident 5 was admitted to the facility in August 2024 with diagnoses of anoxic brain damage (occurs when the brain receives no oxygen at all), dependence on ventilator status, gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding) and chronic respiratory failure (a gradual-onset condition where the lungs can't get enough oxygen into the blood to meet the body's needs).During a record review of Resident 5's Order Summary Report (OSR), dated on 8/19/25, the OSR indicated Resident 5 had a physician order dated 1/15/25 for continuous ventilator setting. The Order Summary record also indicated Resident 5 had a physician order, dated 5/19/25, for a full code (a medical status indicating if the person's heart and breathing stop, all resuscitative measures are to be performed, including chest compressions, Ambu bag ventilation, electric shocks, etc.) status.During an observation on 8/19/25 at 10:16 p.m. in Resident 5's room, Resident 5 was sleeping while the tracheostomy was connected to a ventilator. An Ambu bag without any protective covering was on top of a bedside table, tucked between the wall and a medium-sized fan. Another Ambu bag was also found inside the basket of a rolling stand, left exposed without any protective covering. During an interview on 8/19/25 at 10:22 p.m. with Respiratory Therapist (RT) 1, RT 1 confirmed there were two uncovered Ambu bags without protective coverings in Resident 5's room and were likely left exposed when Resident 5 had a shower. RT 1 stated Ambu the two Ambu bags should have been stored inside a sealed plastic bag to prevent contamination. RT 1 further the improper storage of the Ambu bags placed Resident 5 at risk for contracting infections, including pneumonia, particularly if the exposed Ambu bags were used on Resident 5's respiratory care.During an interview on 8/20/25 at 10:47 a.m. with Infection Preventionist (IP), IP stated any respiratory equipment including an Ambu bag should have been properly inside a protective bag after use to prevent contamination. IP stated the two Ambu bags left exposed were considered contaminated. IP stated the Ambu bags could have been picked up from the floor or may have belonged to another resident. IP stated Resident 5 was at increased risk for developing hard-to-treat bacterial infections. During a record review of facility's policy & procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, the P&P indicated, Resident- care equipment, including reusable items and durable medical equipment will be cleaned and disinfected.b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms.

Based on observation, interview, and record review, Facility 2 failed to follow infection control practices to prevent the spread of infection in Facility 2 when the following were identified: 1. Facility 2 did not follow the recommendations to stop the spread of infection as outlined by the local public health department (LPHD). The recommendations were as follows: a. .Close Facility 2 to new admissions and halt movement of residents from other buildings to the facility . b. .Submission of adherence monitoring logs for hand hygiene, PPE (personal protective equipment, any piece of clothing or equipment that ' s worn by the employees to minimize exposure to biological, chemical, or any physical hazards on work site) use, and environmental cleaning at weekly intervals and contact precaution (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their contaminated environment) and hand hygiene observations of staff to 50 per shift . c. .Implement infection control committee meetings if not currently in place, including lead staff from all disciplines. Provide meeting cadence and participant list to LPHD . d. .Provide documentation of outbreak notification and education provided to residents and families . e. .Notify licensing California Department of Public Health about infection outbreak . 2. Certified Nursing Assistant (CNA) 1 and CNA 2 entered Resident 1 and Resident 2 ' s room without performing hand hygiene. 3. Facility 2 failed to separate direct care staff (assists with tasks such as bathing, dressing, personal hygiene, and medication management) for residents who were infected with MDRO (multi-drug resistant organism, are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria) from non-infected residents. These failures resulted in an increase of Carbapanemase-Resistant Organism (CRO, bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in Facility 2. The cross-contamination resulted in non-infected residents becoming infected, including: -Residents 10, 49, 50, 52, 53, 54, and 56 were infected with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, bacteria that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). -Residents 1, 6, 7, 8, 9, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 48 were infected with MDRO -Residents 4, 5, 11, 12, 13, 14, 15, 16, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38 were infected with Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria that can cause human infections of the blood, urinary tract, lungs, wounds, and other body sites. CRAB is a multidrug-resistant, making infections very difficult to treat) and/or with New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of Facility 2 to follow infection control practices to prevent the spread of infection among Facility 2 ' s 63 residents. The Administrator (ADM) was verbally notified of the IJ situation on 3/13/25 at 7:45 p.m. During a visit to Facility 2 on 3/25/25, Facility 2 provided an acceptable plan of action and the IJ was removed at 2:50 p.m. Findings: Upon entrance to Facility 2 on 3/13/25 at 12:30 p.m. with Infection Preventionist (IP), a request was made to provide a line list (a table that contains key information about each case in an outbreak) for Facility 2. During a record review of Facility 2 ' s document, titled, CRO Line List, dated March 2025, CRO Line List did not contain laboratory test dates for the residents who tested positive for CROs. During an interview on 3/14/25 at 3:31 p.m. with IP, IP was requested to provide an updated line list for Facility 2 with laboratory test dates for the residents who tested positive for CRO infections. During a phone interview on 3/20/25 at 8:04 a.m. with IP, IP was requested to provide another updated line list for Facility 2 with the laboratory test dates included. During a review of a document titled, CRO List, dated March 2025, sent via email by Medical Record Director (MRD) on 3/20/25 at 10:09 a.m., the CRO List included Facility 2 ' s updated line list but was missing test dates for Residents 42 and 56. Furthermore, Facility 2 did not provide laboratory results for Resident 42 and Resident 56 to confirm the dates the infection was identified. During a review of Resident 1 ' s admission Record (AR), printed on 3/14/25, the AR indicated Resident 1 was admitted to Facility 2 in February 2025 with diagnoses that included quadriplegia (a severe medical condition that causes partial or total loss of sensation and movement of all four limbs) and acute respiratory failure (ARF, results from inadequate gas exchange by the respiratory system). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 1 tested positive for an MDRO on 2/18/25. During a review of Resident 4 ' s AR, printed on 3/14/25, the AR indicated Resident 4 was admitted to Facility 2 in April 2016 with a diagnosis of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 4 tested positive for CRAB and NDM infections on unknown test date. During a review of Resident 5 ' s AR, printed on 3/14/25, the AR indicated Resident 5 was admitted to Facility 2 in May 2018 with a diagnosis of nontraumatic intracerebral hemorrhage (a type of stroke or bleeding within the brain tissue). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 5 tested positive for CRAB and NDM infections on unknown test date. During a review of Resident 6 ' s AR, printed on 3/14/25, the AR indicated Resident 6 was admitted to Facility 2 in February 2025 with diagnoses of ARF and dependence in ventilator (a machine that helps an individual breathe) status. The AR showed Resident 6 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 6 tested positive for an MDRO on 2/2/25. During a review of Resident 7 ' s AR, printed on 3/14/25, the AR indicated Resident 7 was admitted to Facility 2 in November 2024 with a diagnosis of amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord that can cause loss of muscle control). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 7 tested positive for an MDRO on 2/15/25. During a review of Resident 8 ' s AR, printed on 3/14/25, the AR indicated Resident 8 was admitted to Facility 2 in February 2025 with diagnoses of quadriplegia and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis). The AR showed Resident 8 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 8 tested positive for an MDRO on 2/2/25. During a review of Resident 9 ' s AR, printed on 3/14/25, the AR indicated Resident 9 was admitted to Facility 2 in January 2025 with diagnoses of cerebral infarction (stroke), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), affecting right dominant side, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 9 tested positive for an MDRO on 2/15/25. During a review of Resident 10 ' s AR, printed on 3/14/25, the AR indicated Resident 10 was admitted to Facility 2 in February 2025 with diagnoses of nontraumatic intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside) and dependence on ventilator status. The AR showed Resident 10 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 10 tested positive for CRPA on 2/23/25. During a review of Resident 11 ' s AR, printed on 3/14/25, the AR indicated Resident 11 was admitted to Facility 2 in January 2025 with diagnoses of anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), ARF, and cardiac arrest (when the heart stops beating suddenly). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 11 tested positive for CRAB on 2/15/25. During a review of Resident 12 ' s AR, printed on 3/14/25, the AR indicated Resident 12 was admitted to Facility 2 in February 2025 with diagnoses of critical illness myopathy (is a form of generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness), COPD, and tracheostomy status. The AR showed Resident 12 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 12 tested positive for CRAB on 2/15/25. During a review of Resident 13 ' s AR, printed on 3/14/25, the AR indicated Resident 13 was admitted to Facility 2 in January 2025 with diagnoses of quadriplegia, ARF, and ventilator dependence status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 13 tested positive for CRAB and NDM infections in February 2025. During a review of Resident 14 ' s AR, printed on 3/14/25, the AR indicated Resident 14 was admitted to Facility 2 in January 2024 with diagnoses of cardiac arrest, secondary malignant neoplasm (cancer) of left lung, tracheostomy status and dependence in ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 14 tested positive for CRAB in August 2024. During a review of Resident 15 ' s AR, printed on 3/14/25, the AR indicated Resident 15 was admitted to Facility 2 in September 2024 with diagnoses of cervical spine fusion (a surgical procedure that connect two or more bones in the spine), tracheostomy status and dependence in ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 15 tested positive for CRAB on 2/15/25. During a review of Resident 16 ' s AR, printed on 3/14/25, the AR indicated Resident 16 was admitted to Facility 2 in September 2024 with diagnoses of chronic respiratory failure, tracheostomy status, and unspecified pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 16 tested positive for NDM on 10/23/24. During a review of Resident 24 ' s AR, printed on 3/14/25, the AR indicated Resident 24 was admitted to Facility 2 in January 2024 with diagnoses of acute and chronic respiratory failure, encephalopathy (a brain disease that alters functions or structure), COPD, tracheotomy status and severe sepsis (an infection in the blood). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 24 tested positive for CRAB on 12/29/24. During a review of Resident 25 ' s AR, printed on 3/14/25, the AR indicated Resident 25 was admitted to Facility 2 in September 2024 with diagnoses of nontraumatic intracerebral hemorrhage, chronic respiratory failure, quadriplegia, and resistance to multiple antibiotics. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 25 tested positive for CRAB on unknown test date. During a review of Resident 26 ' s AR, printed on 3/14/25, the AR indicated Resident 26 was admitted to Facility 2 in November 2023 with diagnoses of sepsis, cerebral infarction, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 26 tested positive for CRAB in December 2023. During a review of Resident 27 ' s AR, printed on 3/14/25, the AR indicated Resident 27 was admitted to Facility 2 in October 2023 with diagnoses of paraplegia (the inability to voluntarily move the lower parts of the body), severe sepsis, and ventilator associated pneumonia. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 27 tested positive for CRAB in November 2023. During a review of Resident 28 ' s AR, printed on 3/14/25, the AR indicated Resident 28 was admitted to Facility 2 in March 2023 with diagnoses of ARF, sepsis, pressure ulcer of right and left hip stage 4, attention to tracheostomy, and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 28 tested positive for CRAB on unknown test date. During a review of Resident 29 ' s AR, printed on 3/14/25, the AR indicated Resident 29 was admitted to Facility 2 in March 2024 with pneumonia, ARF, nontraumatic intracerebral hemorrhage, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 29 tested positive for CRAB in October 2024. During a review of Resident 30 ' s AR, printed on 3/14/25, the AR indicated Resident 30 was admitted to Facility 2 in September 2024 with diagnoses of cerebral infarction, ARF, tracheostomy status, and resistance to multiple antimicrobial drugs. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 30 tested positive for CRAB on 11/23/24. During a review of Resident 31 ' s AR, printed on 3/14/25, the AR indicated Resident 31 was admitted to Facility 2 in April 2023 with diagnoses of ARF, COPD with exacerbation, and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 31 tested positive for CRAB on 2/15/25. During a review of Resident 32 ' s AR, printed on 3/14/25, the AR indicated Resident 32 was admitted to Facility 2 in October 2024 with diagnoses of chronic respiratory failure, enterocolitis due to clostridium difficile (inflammation in your intestinal lining and colon), and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 32 tested positive for CRAB on 11/23/24. During a review of Resident 33 ' s AR, printed on 3/14/25, the AR indicated Resident 33 was admitted to Facility 2 in May 2023 with diagnoses of ARF, cerebral palsy (a group of conditions that affect movement and posture), tracheostomy status, and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 33 tested positive for CRAB on 11/23/24. During a review of Resident 34 ' s AR, printed on 3/14/25, the AR indicated Resident 34 was admitted to Facility 2 in August 2024 with diagnoses of ARF, severe sepsis with septic shock, tracheostomy status, and pressure ulcer of sacral region (stage 4). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 34 tested positive for CRAB on 11/23/24. During a review of Resident 35 ' s AR, printed on 3/14/25, the AR indicated Resident 35 was admitted to Facility 2 in December 2022 with diagnoses of quadriplegia, cerebral infarction, attention to tracheostomy, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 35 tested positive for CRAB on 11/23/24. During a review of Resident 36 ' s AR, printed on 3/14/25, the AR indicated Resident 36 was admitted to Facility 2 in October 2024 with diagnoses of nontraumatic subarachnoid hemorrhage (a type of stroke, bleeding in the space between the brain and the tissues that cover the brain), tracheostomy status, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 36 tested positive for CRAB on 11/23/24. During a review of Resident 37 ' s AR, printed on 3/14/25, the AR indicated Resident 37 was admitted to Facility 2 in November 2024 with diagnoses of ARF, anoxic brain damage (occurs when oxygen is cut off completely from the brain), tracheostomy status, paraplegia, carrier of CRE, and resistance to multiple antimicrobial drugs. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 37 tested positive for CRAB in December 2024. During a review of Resident 38 ' s AR, printed on 3/14/25, the AR indicated Resident 38 was admitted to Facility 2 in June 2024 with diagnoses of ALS, severe sepsis with septic shock, tracheostomy status, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 38 tested positive for CRAB in July 2024. During a review of Resident 39 ' s AR, printed on 3/14/25, the AR indicated Resident 39 was admitted to Facility 2 in November 2024 with diagnoses of Diabetes Mellitus Type 2, Essential Hypertension, and Malignant Neoplasm of Kidney. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 39 tested positive for an MDRO on 2/4/25. During a review of Resident 40 ' s AR, printed on 3/14/25, the AR indicated Resident 40 was admitted to Facility 2 in November 2023 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus Type 2, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 40 tested positive for an MDRO on 2/15/25. During a review of Resident 41 ' s AR, printed on 3/14/25, the AR indicated Resident 41 was admitted to Facility 2 in October 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus Type 2, Malignant Neoplasm of Unspecified Breast, and Deep Tissue Damage of the Sacral Region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 41 tested positive for an MDRO on 2/18/25. During a review of Resident 42 ' s AR, printed on 3/14/25, the AR indicated Resident 42 was admitted to Facility 2 in January 2024 with diagnoses of Tracheostomy, Ventilator Dependence and Diabetes Mellitus type 2. During a review of Facility 2 ' s CRO Line List, dated March 2025, received on 3/14/25, showedResident 42 ' s positive test result for MDRO was hand written in as January 2024. An updated CRO Line List, dated March 2025, received on 3/20/25 no longer showed the date Resident 42 tested positive for an MDRO. During a review of Resident 43 ' s AR, printed on 3/14/25, the AR indicated Resident 43 was admitted to Facility 2 in December 2016 with diagnoses of Resistance to Multiple Antibiotics, Diabetes Mellitus type 1, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 43 tested positive for an MDRO on 12/29/22. The CRO Line List also showed Resident 43 refused to be tested again. During a review of Resident 44 ' s AR, printed on 3/14/25, the AR indicated Resident 44 was admitted to Facility 2 in October 2018 with diagnoses of Hemiplegia of both Right and Left Sides, Diabetes Mellitus type 2, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 44 tested positive for an MDRO on 2/18/25. During a review of Resident 45 ' s AR, printed on 3/14/25, the AR indicated Resident 45 was admitted to Facility 2 in April 2023 with diagnoses of Tracheostomy, Ventilator Dependence, Gastrotomy, Diabetes Mellitus type 2, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 45 tested positive for an MDRO in November 2023. The CRO Line List also showed Resident 45 refused to be tested again. During a review of Resident 46 ' s AR, printed on 3/14/25, the AR indicated Resident 46 was admitted to Facility 2 in April 2023 with diagnoses of Tracheostomy and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 46 tested positive for an MDRO on 2/18/25. During a review of Resident 47 ' s AR, printed on 3/14/25, the AR indicated Resident 47 was admitted to Facility 2 in October 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus type 2, Essential Hypertension, Latent Tuberculosis, and Unstageable Pressure Injuries of the Right Heel and Sacral Region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 47 tested positive for an MDRO on 2/15/25. During a review of Resident 48 ' s AR, printed on 3/14/25, the AR indicated Resident 48 was admitted to Facility 2 in August 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Essential Hypertension, and Myotonic Muscular Dystrophy. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 48 tested positive for an MDRO on 10/22/24. During a review of Resident 49 ' s AR, printed on 3/14/25, the AR indicated Resident 49 was admitted to Facility 2 in January 2025 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that cause long-term breathing problem) and Pneumonia (lung infection often cause by virus, bacteria or fungi), and tracheostomy status, dependence on ventilator status, and atelectasis (lung collapse). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 49 tested positive for CRPA on 1/27/25. During a review of Resident 51 ' s AR, printed on 3/14/25, the AR indicated Resident 51 was admitted to Facility 2 in October 2023 with diagnoses of Traumatic subdural hemorrhage (bleeding near the brain) and acute respiratory failure (low blood oxygen levels). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 51 tested positive for CRPA on 2/15/25. During a review of Resident 52 ' s AR, printed on 3/14/25, the AR indicated Resident 52 was admitted to Facility 2 in February 2018 with diagnoses of Chronic Respiratory Failure, dependence on ventilator status, encounter for attention to tracheostomy, sepsis due to MRSA, severe sepsis with septic shock and personal history of traumatic brain injury. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 52 tested positive for CRPA with an unknown test date. During a review of Resident 53 ' s AR, printed on 3/14/25, the AR indicated Resident 53 was admitted to facility in June 2023 with diagnoses of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), tracheostomy status and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 53 tested positive for CRPA on 10/18/23. During a review of Resident 54 ' s AR, printed on 3/14/25, the AR indicated Resident 54 was admitted to Facility 2 in July 2024 with diagnoses of diffuse traumatic brain injury (severe type of brain injury), sepsis (life-threatening infection of the bloodstream) due to other specified staphylococcus (bacteria), bacteremia (condition where bacteria enter the bloodstream), resistance to multiple antibiotics, tracheostomy status and dependence of ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 54 tested positive for CRPA on 1/27/25. During a review of Resident 55 ' s AR, printed on 3/14/25, the AR indicated Resident 55 was admitted to the Transitional Care Unit (TCU) in December 2024 with diagnoses of acute respiratory failure with hypercapnia, acute respiratory failure with hypoxia, tracheostomy status, dependence on ventilator status, atelectasis and pneumonia. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 55 tested positive for CRPA with an unknown test date. During a review of Resident 56 ' s AR, printed on 3/14/25, the AR indicated Resident 56 was admitted to the TCU in November 2022 with diagnoses of chronic respiratory failure with hypoxia, respiratory failure unspecified with hypoxia and pseudomonas (a group bacterial infection commonly found in the environment, like soil and water that can affect skin, blood, lungs, and other parts of the body.) During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 56 ' s positive test result for CRPA was hand written in as October 2022. An updated CRO Line List, dated March 2025, received 3/20/25, no longer showed the date Resident 56 tested positive for CRPA. 1.(a.1) During a review of a letter from the LPHD, dated 1/8/25, the letter indicated On 11/15/2024, LPHD provided recommendations to mitigate transmission of these organisms .including closure of Facility 2 .This includes halting resident movement from Facility 1 to Facility 2 .We do not recommend any movement of residents into Facility 2 at this time . During a review of Facility 2 ' s Admission/Discharge To/From Report, printed on 3/14/25, the Admission/Discharge To/From Report indicated Residents 1, 6, 7, 8, 9, 10, 11, 12, 13, and 14 were discharged from Facility 1 and admitted to Facility 2 between 12/1/24 to 3/14/25. During an interview on 3/13/25 at 12:46 p.m. with IP, IP confirmed and stated the LPDH recommended Facility 2 not admit new residents to Facility 2 since November 2024. IP stated despite the recommendations from LPHD, Facility 2 still moved residents from Facility 1 to Facility 2 because of their insurance ' s last day of coverage. IP stated when they moved the residents from Facility 1 to Facility 2, it was considered a new admission because Facility 1 and Facility 2 operated under two different licenses. 1.(a.2) During a review of Resident 2 ' s AR, printed on 3/14/25, the AR indicated Resident 2 was originally admitted to Facility 2 in August 2023 with multiple diagnoses that included COPD and pneumonia (lung infection often cause by virus, bacteria or fungi), and tracheostomy status. During a review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/6/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 15, indicating Resident 2 had intact cognition. During a concurrent observation and interview on 3/13/25 at 2:50 p.m. with CNA 2, CNA 2 entered Resident 2 ' s room without performing hand hygiene or donning PPE. The room had a contact precaution (an infection control measures used to prevent the spread of diseases that are transmitted through direct or indirect contact with an infected person or environment) sign posted on the door. CNA 2 then embraced Resident 2. CNA 2 then stated, she established good rapport with Resident 2 when Resident 2 was in Facility 2 where CNA 2 worked. CNA 2 added, Resident 2 was transferred to the TCU from Facility 2 one month ago and wanted to give Resident 2 a hug. CNA 2 then exited from the TCU building and into the parking lot. 1.(a.3) During a review of Resident 3 ' s AR, printed on 3/14/25, the AR indicated Resident 3 was recently re-admitted to Facility 2 in March 2025 with multiple diagnoses that included, acute respiratory failure with hypoxia and atelectasis (collapsed lungs). During a concurrent interview and record review on 3/19/25 at 3:35 p.m. with Social Worker (SW), Facility 2 ' s resident census (the number of residents currently under care at Facility 2 at that time), dated 3/19/25, indicated the following: a. Resident 2 was transferred to the TCU building in Facility 2 from Subacute building in Facility 2 on 1/4/25. b. Resident 3 was originally admitted to Facility 1 on 12/6/24. Resident 3 was discharged from Facility 1 on 3/11/25 and then admitted to the TCU building in Facility 2 on 3/11/25. During an interview on 3/14/25 at 11:36 a.m. with IP, IP stated Resident 2 was transferred to the TCU building in Facility 2 from

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (a document that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) for four of six sampled residents (Residents 11, 12, 15, and 31), when Residents 11, 12, 15, and 31 did not have a care plan to address their antibiotic-resistant infection called Carbapenemase-Producing Organisms (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used as a of last-line treatment for serious infections) specific to enzyme New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). This failure had the potential for Residents 11,12, 15. And 31 to not receive person-centered appropriate care, monitoring, and treatment. Findings: During a review of Resident 11 ' s admission Record, printed on 3/14/25, the AR indicated Resident 11 was admitted to Facility 2 in January 2025 with diagnoses to include anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), acute respiratory failure (ARF), and cardiac arrest (when the heart stops beating suddenly). During a review of Resident 1 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 11 tested positive for NDM organism infection. During a review of Resident 12 ' s AR, printed on 3/14/25, the AR indicated Resident 12 was admitted to Facility 2 in February 2025 with diagnoses to critical illness myopathy (a form of generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness), chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow making breathing difficult), and tracheostomy status. During a review of Resident 12 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 12 tested positive for NDM organism infection. During a review of Resident 15 ' s AR, printed on 3/14/25, the AR indicated Resident 15 was admitted to Facility 2 in September 2024 with diagnoses to include cervical spine fusion (a surgical procedure that connect two or more bones in the spine), tracheostomy status and dependence in ventilator status. During a review of Resident 15 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 15 tested positive for NDM organism infection. During a review of Resident 31 ' s AR, printed on 3/14/25, the AR indicated Resident 31 was admitted to Facility 2 in April 2023 with diagnoses to include ARF, COPD with exacerbation, and dependence on ventilator. During a review of Resident 31 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 31 tested positive for NDM organism infection. During a review of Residents 11, 12, 3, 15, and 31 ' s Care Plan, Residents 11, 12, 3, 15, and 31 did not have a comprehensive care plan to address their NDM infection. During an interview on 3/19/25 at 1:58 p.m. with Director of Nursing (DON), DON stated the facility should have developed the care plans for all residents who had infections especially during the outbreak (usually caused by an infection, transmitted through person-to-person contact, animal-to-person contact, or from the environment or other media) in the facility. DON stated he did not think about implementing and creating an individualized care plans for infected residents. DON stated they were only focused on the type of isolation each resident needed and not the specific infection each resident had. DON stated the facility should have had a person-centered or individualized care plan for all the residents who became infected. DON stated a comprehensive care plan should have been created to provide quality of care because each resident had different medical conditions and situations. During a review of the facility ' s policy and procedure (P&P), titled, Care Plans – Comprehensive, revised in September 2010, indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing mental, and psychological needs is developed for each resident .3. Each resident ' s comprehensive care plan is designed to .a. Incorporate identified problem areas .b. Incorporate risk factors associated with identified problems .8. Assessments of residents are ongoing, and care plans are revised as information about the resident ' s condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .a. where there has been a significant change in the resident ' s condition.

Based on interviews and record review, the facility failed to implement their written abuse policy and procedure that prohibited neglect for one of three sampled residents (1), when Resident 1 was found in bed screaming in pain by CNA (Certified Nursing Assistant) 4 with an oral use lemon swab protruding from her anus. This failure resulted in Resident 1 suffering physical and emotional pain. Findings: A confidential complainant reported to the Department of Public Health that on 1/24/15, Resident 1 was found with an oral use lemon swab sticking out of her anus during an incontinence change by CNA 4. Resident 1's record was reviewed on 1/28/15 at 12:00 noon during an unannounced onsite visit to the facility. According to the face sheet Resident 1 was a [AGE] year old individual admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS- an assessment tool) dated 9/9/14, showed Resident 1 lacked the ability to recall events; required total assistance of two people for personal hygiene needs and for turning side to side and repositioning her body while in bed. She had limited range of motion of her upper and lower extremities. The nurses notes for Resident 1, dated 1/24/15 at 1:30 p.m., showed, "Pt (patient) noted with a (oral lemon) swab stick, sticking out of pt's anus area." The facility's abuse policy and procedure last revised 1/2012 read, ''Abuse, neglect will not be tolerated in this facility at any time. The facility will take every proactive measure to prevent the occurrences of alleged abuse of any resident. The Administrator has over all responsibility for implementation and oversight of the Abuse Prevention Program. All suspected abuse will be investigated and reported. Neglect means the negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a like position would exercise. Failure to protect from health and safety hazards. Failure to provide services necessary to avoid physical harm, mental anguish or mental illness." An interview was attempted with Resident 1 on 1/28/15 at 12:15 p.m., but she did not respond to questions. During an interview with charge nurse 5 on 1/28/15 at 1:45 p.m., she stated, "The CNA (4) was cleaning the Resident (1) and felt resistance and called me. I looked at the Resident (1) and told the CNA (4) to take the swab out. I did a digital exam. The swab was one half way into her rectum. I faxed the report to the doctor." During a telephone interview with CNA 4, on 2/4/15 at 12:30 p.m., she stated, "I usually work with that Resident (1). I was going to do another Resident, but she (Resident 1) was screaming. It's normal for her to scream. But she was screaming,"Ouch." So I decided to do her first. When I cleaned her front she was fine. But when I turned her to clean her buttocks, I noticed a little bowel movement. While I was wiping the bowel movement with a wet wipe, I felt something on my finger tip. I got another wipe and wiped again. I saw a plastic stick coming out of her anus. I was cleaning her by myself. I usually get help to get her up in the chair, but not for bed bath and turning her in bed. I stopped and called my charge nurse. The charge nurse watched me while I cleaned the plastic stick. The charge nurse told me to remove it. When I removed it, the cotton was still on (attached to) the tip of the lemon swab. She (Resident 1) would not have been able to put the swab up ( inside her anus) herself; she can't reach that far in back of her." During a telephone interview with the Director of Nurses on 2/19/15 at 10:11 a.m., she re-reviewed the facility's Abuse Policy and Procedure for date and content and stated the policy was current. __________________________________________________________ Class "B" Citation No. 02-1614- 76-F The facility violated the aforementioned regulation by failing to implement their written abuse policy and procedure that prohibited abuse for one of three sampled residents (1). Resident 1 was found in bed screaming in pain by CNA (Certified Nursing Assistant) 4 with an oral use lemon swab protruding from her anus.This failure resulted in Resident 1 suffering physical and emotional pain. A confidential complainant reported to the Department of Public Health that on 1/24/15, Resident 1 was found with an oral use lemon swab sticking out of her anus during an incontinence change by CNA 4. Resident 1's record was reviewed on 1/28/15 at 12:00 noon during an unannounced onsite visit to the facility. According to the face sheet Resident 1 was a [AGE] year old individual admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS- an assessment tool) dated 9/9/14, showed Resident 1 lacked the ability to recall events; required total assistance of two people for personal hygiene needs and for turning side to side and repositioning her body while in bed. She had limited range of motion of her upper and lower extremities. The nurses notes for Resident 1, dated 1/24/15 at 1:30 p.m., showed, "Pt (patient) noted with a (oral lemon) swab stick, sticking out of pt's anus area."The facility's abuse policy and procedure last revised 1/2012 reflected, ''Abuse, neglect will not be tolerated in this facility at any time. The facility will take every proactive measure to prevent the occurrences of alleged abuse of any resident. The Administrator has overall responsibility for implementation and oversight of the Abuse Prevention Program. All suspected abuse will be investigated and reported. Neglect means the negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a like position would exercise. Failure to protect from health and safety hazards. Failure to provide services necessary to avoid physical harm, mental anguish or mental illness."An interview was attempted with Resident 1 on 1/28/15 at 12:15 p.m., but she did not respond to questions.During an interview on 1/28/15 at 1:45 p.m., charge nurse 5 stated, "The CNA (4) was cleaning the Resident (1) and felt resistance and called me. I looked at the Resident (1) and told the CNA (4) to take the swab out. I did a digital exam. The swab was one half way into her rectum. I faxed the report to the doctor." During a telephone interview with CNA 4, on 2/4/15 at 12:30 p.m., she stated, "I usually work with that Resident (1). I was going to do another Resident, but she (Resident 1) was screaming. It's normal for her to scream. But she was screaming, "Ouch." So I decided to do her first. When I cleaned her front she was fine. But when I turned her to clean her buttocks, I noticed a little bowel movement. While I was wiping the bowel movement with a wet wipe, I felt something on my finger tip. I got another wipe and wiped again. I saw a plastic stick coming out of her anus. I was cleaning her by myself. I usually get help to get her up in the chair, but not for bed bath and turning her in bed. I stopped and called my charge nurse. The charge nurse watched me while I cleaned the plastic stick. The charge nurse told me to remove it. When I removed it, the cotton was still on (attached to) the tip of the lemon swab. She (Resident 1) would not have been able to put the swab up (inside her anus) herself; she can't reach that far in back of her."During a telephone interview with the Director of Nurses on 2/19/15 at 10:11 a.m., she re-reviewed the facility's Abuse Policy and Procedure for date and content and stated the policy was current.

Based on interview and record review, the facility failed to re-admit one (Resident 1) of three sampled residents after he was sent to the hospital for evaluation of coffe ground (indication of bleeding) emesis. Resident 1, who was on a ventilator, was sent to the hospital on [DATE], after having episodes of emesis (vomiting), and was ready to return to the facility on [DATE]. The facility did not do any discharge planning for the resident and refused to readmit him due to an unpaid bill. This resulted in Resident 1 having a prolonged stay in an acute care hospital and not returning to an appropriate level of care. Findings: On 7/22/14, review of the medical record, showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. extremities). The complete resident assessment, dated 6/27/14, showed Resident 1 was totally dependent in all activities of daily living and required the extensive assistance of two or more staff for all care. Resident 1 was on a ventilator to assist with breathing. Review of the medical record showed nursing notes, dated 7/18/14, "Patient noted to have ...emesis twice." The physician was notified and an ambulance transported Resident 1 to the hospital emergency room . Review of the hospital emergency department admission by the physician on 7/18/14, showed "[AGE] year old male with [MEDICAL CONDITION] (oxygen deprived) [MEDICAL CONDITIONS] following [MEDICAL CONDITION], chronically trached and vented,...and gastrostomy tube. Emergency department course: stable. An emergency department physician's note, dated 7/19/14, showed, "[AGE] year old male with history of [MEDICAL CONDITIONS], trached, pegged (gastrostomy tube), vented, bedbound and nonverbal. Sent here by skilled nursing facility for reported coffee ground emesis. No other complaints." During an interview on 7/22/14 at 9:05 a.m., the Admissions Director (AD) stated, "He (Resident 1) went to the hospital on Friday 7/18/14. He was ready to return on Sat., 7/19/14, but we lacked staff to admit over the weekend. On Monday, 7/21/14, the Administrator (ADM) told me to refuse to readmit." During a phone interview on 7/22/14 at 9:45 a.m., the Administer (ADM) stated, "He's (Resident 1) a private pay patient and they owe us money. We're not taking him back." During an interview on 7/22/14 at 9:50 a.m., the Assistant Director of Nurses (ADON) stated, "He (Resident 1) was admitted here 2/14. This was not a planned discharge." During an interview on 7/22/14 at 10:15 a.m., the Social Service Designee (SSD) stated, "There was no plan for him to leave. He was long term. I don't know about a notice to discharge. In May, I spoke to Resident 1's wife and informed her of the last covered day. He would be moved to another building or pay privately. She said she had a lawyer helping her." During a phone interview on 7/24/14 at 9:25 a.m., the hospital case manager (HCM) stated, "He's (Resident 1) still at the hospital." During an interview on 7/24 at 3:40 p.m., the insurance case manager stated, "A letter was sent to inform the (Resident 1's) wife that the insurance ended and directions for appealing the decision. Prior to the exhaustion of benefits, we discussed payer source and she said Medicaid was pending. I spoke to her lawyer who told me the application was pending. The wife believes that Medicaid will pay the bill." __________________________________________________________ Class "B" Citation 02-2352- 64-F The facility violated the aforementioned regulation, by failing to re-admit one (Resident 1) of three sampled residents after he was sent to the hospital for evaluation of coffee ground (indication of bleeding) vomiting. Resident 1, who was on a ventilator (a breathing device), was sent to the hospital on [DATE], after having episodes of vomiting, and was ready to return to the facility on [DATE]. The facility did not do any discharge planning for the resident and refused to readmit him due to an unpaid bill. This failure resulted in Resident 1 having a prolonged stay in a hospital instead of returning to an appropriate level of care. On 7/22/14, review of the medical record, showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].). The complete resident assessment, dated 6/27/14, showed Resident 1 was totally dependent in all activities of daily living and required the extensive assistance of two or more staff for all care. Resident 1 was on a ventilator to assist with breathing. Review of the medical record showed nursing notes, dated 7/18/14, "Patient noted to have ...emesis twice." The physician was notified and an ambulance transported Resident 1 to the hospital emergency room .During an interview on 7/22/14 at 9:05 a.m., the facility Admissions Director (AD) stated, "He (Resident 1) went to the hospital on Friday 7/18/14. He was ready to return on Sat., 7/19/14, but we lacked staff to admit over the weekend. On Monday, 7/21/14, the Administrator (ADM) told me to refuse to readmit."During a phone interview on 7/22/14 at 9:45 a.m., the Administer (ADM) stated, "He's (Resident 1) a private pay patient and they owe us money. We're not taking him back." During an interview on 7/22/14 at 9:50 a.m., the Assistant Director of Nurses (ADON) stated, "He (Resident 1) was admitted here 2/14. This was not a planned discharge."During an interview on 7/22/14 at 10:15 a.m., the Social Service Designee (SSD) stated, "There was no plan for him to leave. He was long term. I don't know about a notice to discharge. In May, I spoke to Resident 1's wife and informed her of the last covered day. He would be moved to another building or pay privately. She said she had a lawyer helping her."During a phone interview on 7/24/14 at 9:25 a.m., the hospital case manager (HCM) stated, "He's (Resident 1) still at the hospital."During an interview on 7/24 at 3:40 p.m., the case manager stated, "A letter was sent to inform the (Resident 1's) wife that the insurance ended and directions for appealing the decision. Prior to the exhaustion of benefits, we discussed payer source and she said Medicaid was pending. I spoke to her lawyer who told me the application was pending. The wife believes that Medicaid will pay the bill."Therefore the facility refused to readmit Resident 1 when he was stabilized and ready to be readmitted .