Every finding on record at Bay Area Healthcare Center

Based on interview and record review, the facility failed to notify the physician of Resident 1's changes in condition when:1. Resident 1 developed warmth and tenderness on the left knee2. Resident 1 experienced episodes of respiratory distressThese failures could result in delayed medical evaluation by the physician including interventions that may be ordered by the physician on the resident.Findings:A review of resident 1's admission Record (AR), printed on 1/29/26, indicated, Resident 1 was admitted to the facility on [DATE].A review of Resident 1's Progress Note (PN), dated 6/2/25, indicated, that Resident 1 had diagnoses that included Hypertension (high blood pressure), Prediabetes, Atherosclerosis of Aorta (the main large blood vessel coming out of the heart becomes hardened and narrowed because fatty build up inside the blood vessel walls), a right distal humerus (elbow) fracture, and a frontal bone (facial bone) fracture resulting from an accidental fall.On 2/9/26 at 10:23 a.m., a record review of Resident 1's nursing admission Progress Note (APN) dated 5/30/25, the APN indicated, Resident 1 was admitted with bilateral lower leg 2+ edema (is characterized by a 3-4 millimeter deep depression in the skin that indicates fluid retention) and the skin was dry and cool.On 2/9/26 at 10:33 a.m., during a concurrent interview with the DON and review of the PN dated 6/9/25 at 9:34 a.m., the PN indicated, Change of Condition (COC). Resident [1] seen at 2300 [11 p.m.] and reported left knee swelling and weakness. The PN also indicated, Resident 1's knee was noted to be bruised, warm to touch, and mildly tender. DON stated these were new signs and symptoms noted on Resident 1 and should have been reported by the nurse to the physician.On 2/9/26 at 10:40 a.m., a review of Resident 1's PN dated 6/10/25, indicated, that at 2:30 a.m., Resident 1 experienced shortness of breath and difficulty breathing, which Resident 1 described as an asthma attack. Further, the PN indicated that at 3:26 a.m., Resident 1 was observed gasping for air with an elevated respiratory rate of 24 breaths per minute. The episode lasted less than five seconds.During an interview on 1/30/26 at 9:42 a.m., with the Licensed Vocational Nurse (LVN) who assessed Resident 1's breathing and wrote the PN on 6/10/26, stated Resident 1 assumed the symptoms were related to asthma and that the resident refused to be sent to the hospital. LVN stated that he did not recall notifying the physician because the vital signs remained normal for the rest of the shift. LVN stated he was uncertain whether Resident 1 had a diagnosis of asthma.On 2/9/26 at 10:42 a.m., during a concurrent interview with the DON and a review of Resident 1's Order Summary Report (OSR) dated 1/29/26, the OSR indicated an instruction to call MD if respiratory rated greater than 20. The DON stated Resident 1's respiratory symptoms namely, difficulty breathing, gasping for air, and a respiratory rate of 24 should have been reported to the physician.During a review of the facility's Policy and Procedure (P&P), titled, Change of Condition, undated, the P&P indicated, A Resident Change of Condition will be assessed and documented in the medical record with appropriate follow through to physician. Procedure. The Licensed Nurse will document such information in the Medical Record on the progress notes and if appropriate notify the physician and the Responsible Party of the change of condition. Change of Condition includes, but is not limited to, the following. altered Vital signs including: significantly elevated/decreased temperature, significant increase or decrease in blood pressure or heart rate, significant decrease or increase or change in characteristics of respiratory rate. Events that require MD notification ASAP include, but are not limited to, the following. Symptoms: abnormal V.S. such as elevated temperature, markedly low or high HR or B/P; development of vomiting or diarrhea, development of severe pain in a new area or at a new intensity, new significant edema, and so on.

Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure treatment and services were done to heal and prevent re-opening of a coccyx (tailbone) pressure ulcer (damage to skin and underlying tissue caused by prolonged pressure or friction, commonly occurring over bony prominences like the heels, tailbone, or hips) when physician ordered treatment was not done and the open area was not measured during assessment.This failure had the potential to result in delayed healing and re-opening of the pressure ulcer.During a review of Resident 2's admission Record (AR) printed 1/29/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (high blood sugar resulting from insulin resistance or insufficient insulin production), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and left hemiplegia (paralysis that affects only one side of the body).During a review of Resident 2's Weekly Pressure Ulcer Injury Record (WPUIR), a clinical tool used to monitor the healing progress and effectiveness of treatment for pressure ulcers, documenting the stage, size, wound bed tissue type and surrounding skin color) dated 11/3/25, the WPUIR indicated Resident 2 had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer on the coccyx that measured 1 x 0.3 cm.During a review of Resident 2's pressure ulcer care plan dated 11/3/25, the care plan indicated interventions to promote discomfort and to prevent development of infections around the area that included providing treatment as ordered.During a review of Resident 2's Order Summary Report (OSR) dated 1/29/26, the OSR indicated a physician's order to apply moisture barrier cream on the buttocks and coccyx pressure ulcer every shift and as needed.During a concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/12/25, on 1/29/26 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not do treatments during the night shift. He also stated when he assessed Resident 2's pressure ulcer on 11/12/25, there was a small open area on the coccyx, but LVN 1 did not measure as he just made a quick look at it. During another concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/19/25, on 1/29/25 at 10:41 a.m. with LVN 2, LVN 2 stated she completed the weekly assessment dated [DATE] and wrote there was a stage 2 pressure ulcer on the coccyx but did not measure it because it has already healed. LVN 2 stated she only wrote that a pressure ulcer was there as reminder that there once was a pressure ulcer on Resident 2's coccyx.During a review of the facility's policy and procedure (P&P) titled Pressure Ulcers, undated, the P&P indicated multiple factors in management of pressure ulcers that included wound assessment. The P&P indicated to monitor wound status with each dressing change documenting wound assessment parameters using quantitative instrument such as Bates-[NAME] Wound Assessment Tool (BWAT, a more detailed wound assessment tool that evaluates multiple characteristics that included wound size and depth and condition of wound edges and surrounding skin).

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to implement written policies and procedures when an abuse allegation was not reported to the State Survey Agency and to the Law Enforcement.This failure resulted in the abuse allegation not being formally investigated by the State Survey Agency.During a review of Resident 1's admission Record (AR) printed 1/29/26, the AR indicated Resident 1 was admitted to the facility in December 2019 with diagnoses that included dependence on respirator (ventilator, a life-support machine that breathes for patients unable to do so independently) status, unspecified intellectual disabilities, muscular dystrophy (progressive weakness and degeneration of skeletal muscles, often leading to reduced mobility and, in some types, heart or breathing issues) and myoneural disorder (progressive muscle weakness, wasting, spasms or fatigue).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/13/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13 (a BIMS score of 13-15 is indication of intact cognitive status).During an interview on 1/29/26 at 2:02 p.m. with Resident 1, Resident 1 stated, in 2025, the wall-mounted vital signs machine failed while a staff member attempted to check her vitals. Resident 1 stated the blood pressure cuff did not work, and Registered Nurse (RN) 1 entered, approached Resident 1, and slapped her arm. Resident 1 stated she reported this incident to Social Services Director (SSD), who responded that it would be her word against RN 1's word.During an interview on 1/29/26 at 2:18 p.m. with SSD, SSD stated she was aware of Resident 1's allegation. SSD stated Resident 1 had changed her story, claiming RN 1 was rough with her. SSD also stated she informed Assistant Administrator (AA) about the allegation and the matter was investigated.During a review of Resident 1's Social Services (SS) notes dated 6/27/25, the SS notes indicated Resident 1 alleged an RN smacked her right arm 2 days earlier. The SS notes indicated the allegation would be investigated but no SOC 341 was provided related to this allegation on 6/27/25.During a review of SS notes dated 10/25/25, the SS notes indicated, Resident 1 informed NP about RN 1 smacking her arm, referring to the June 2025 incident. The SS notes also indicated Resident 1 telling NP that SSD was investigating the incident.During a review of SOC 341 (a mandatory document used by mandated reporters, such as facility staff, to report suspected physical, mental, or financial abuse, neglect, or isolation of individuals aged 65 or older or dependent adults) dated 10/26/25, the following details were noted:On 10/23/25, Nurse Practitioner (NP) asked Resident 1 about a previously documented abuse allegation in Resident 1's clinical record, in which Resident 1 alleged that a nurse had struck her on the arm. The SOC 341 indicated NP urged the facility to report this incident to the Ombudsman. The SOC 341 also indicated an incident from 6/27/25 when a Certified Nursing Assistant (CNA) checked Resident 1's temperature. RN 1 verified Resident 1's temperature and tapped Resident 1 on the arm to assess skin temperature due to the thermometer reading 99 degrees Fahrenheit. This incident was reported to both the physician and to the Regional Case Manager, who determined that Resident 1 had a history of fabricating stories. As a result, SOC 341 was not filed at that time. Furthermore, the SOC 341 indicated that the abuse allegation made by Resident 1 to NP on 10/23/25 was not reported to the State Agency. The section titled Written Report, which specifies the agencies to which the incident was reported, was left blank.During a telephone interview on 1/29/26 at 2:54 p.m. with Administrator (ADM), ADM stated, on 10/26/25, the facility reported the incident to the Local Ombudsman, believing that was sufficient. ADM stated she did not send a written report to the State Survey Agency.During a review of the facility's policy and procedure (P&P) titled Abuse Prevention and Mandated Reporting, undated, the P&P requires the Administrator to report suspected abuse or allegations to the California Department of Health within 24 hours.

Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure medical records were accurately documented.This failure had the potential to result in gaps in communication and uncoordinated care.During a review of Resident 2's admission Record (AR) printed 1/29/26, the AR indicated Resident 2 was admitted to the facility in on 11/3/25 with diagnoses that included type 2 diabetes mellitus (high blood sugar resulting from insulin resistance or insufficient insulin production), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and left hemiplegia (paralysis that affects only one side of the body).During a review of Resident 2's Weekly Pressure Ulcer Injury Record (WPUIR) dated 11/3/25, the WPUIR indicated Resident 2 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, pressure ulcer is damage to skin and underlying tissue caused by prolonged pressure or friction, commonly occurring over bony prominences like the heels, tailbone, or hips) on the coccyx (tailbone) that measured 1 x 0.3 cm. The WPUIR is a clinical tool for monitoring the healing progress and effectiveness of treatment for pressure ulcers, documenting stage, size, wound bed tissue type, and surrounding skin color.During a concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/12/25, on 1/29/26 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not perform treatments during the night shift. He also stated when he assessed Resident 2's pressure ulcer on 11/12/25, there was a small open area on the coccyx, but LVN 1 did not measure as he just made a quick and superficial look at it. During a review of Resident 2's Treatment Administration Record (TAR) for November 2025, the TAR indicated the following treatment orders: to coccyx pressure ulcer, wash with soap and water, pat dry, apply moisture barrier cream and keep open to air every shift and as needed. to moisture-associated skin damage on the coccyx, right and left perineum, wash with soap and water, pat dry, apply moisture barrier cream every shift and as needed.The TAR indicated LVN 1 signed off seven out of 20 scheduled NOC shift treatments for Resident 2.During another concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/19/25, on 1/29/25 at 10:41 a.m. with LVN 2, LVN 2 stated she completed the weekly assessment dated [DATE] and wrote there was a stage 2 pressure ulcer on the coccyx but did not measure it because it has already healed. LVN 2 stated she only wrote that a pressure ulcer was there as reminder that there once was a pressure ulcer on Resident 2's coccyx.During a review of the facility's policy and procedure (P&P) titled Weekly Nurses Progress Notes, undated, the P&P indicated the Weekly Nurses Progress Notes is part of the resident's medical record. It will summarize the resident's condition during the week, based upon the nurse's assessment, and reflect the nurse's assessment at the time of the documentation.

Based on observation, interview, record review, and facility document and policy review, the facility failed to dispose of expired medications that were stored on 1 of 5 medication carts. Findings included: A facility policy titled, Storage of Medications, dated 2007, revealed, 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. An undated facility document titled, Following Meds [medications] Expired After Opening revealed latanoprost eye drops expired 42 days after opening. A concurrent interview and observation of the Station 2 medication cart with Licensed Vocational Nurse (LVN) #7 on 02/26/2025 at 11:18 AM revealed two bottles of latanoprost eye drops. One bottle was labeled for Resident #16 and had an open date of 01/01/2025, and the other bottle was labeled for Resident #1 and had an open date of 01/08/2025. LVN #7 confirmed the bottles of latanoprost for Resident #16 and Resident #1 were expired and should have been discarded 42 days after they were opened. The Director of Nursing (DON) was interviewed on 02/26/2025 at 12:11 PM. The DON stated if a medication was expired, she expected the nurses to remove the medication from the medication cart. The DON confirmed the two bottles of latanoprost for Resident #16 and Resident #1 were expired, because the medication was only good for 42 days once it was opened.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #6) of 1 resident reviewed for self-administration of medications was assessed to determine if they were clinically appropriate and safe to administer their own topical medications. Findings included: A facility policy titled, Self- Administration by Resident, dated 2007, revealed, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. The policy also indicated, 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medication by means of a skill assessment conducted as part of the care plan process. The policy specified, 3. The results of the interdisciplinary team assessment are recorded on the Medication Self Administration Assessment, which is placed in the resident's medical record. An Admission Record indicated the facility admitted Resident #6 on 05/09/2016. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident # 6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #6's Care Plan Report included a focus area, initiated on 04/21/2021 and revised on 01/15/2025, that indicated the resident self-administered supplements. The focus area included a goal that the resident would be able to perform proper procedures for medication administration. Interventions dated 01/15/2025 directed staff to assess the resident with a self-medication assessment form and to inform and update the resident's physician with the results of the assessment. The focus area did not indicate which supplements or medications staff were to assess the resident's ability to self-administer. Resident #6's Order Summary Report contained the following orders: - an order dated 07/19/2021 for hydrocortisone cream 1%, apply to itchy body areas topically every 12 hours as needed for itchiness; - an order dated 10/04/2024 for lidocaine external cream 4%, apply to toes topically every shift for pain management; - an order dated 08/01/2024 for nystatin external cream 100000 units per gram, apply to right plantar foot topically every 12 hours as needed for fungal rash; and - an order dated 08/01/2024 for nystatin powder, apply to right foot between toes every 24 hours at night as needed for fungal rash. The Order Summary Report also reflected orders for various dietary supplements with instructions that specified the resident may self administer & [and] keep at bedside; however, the above topical treatment orders contained no such instructions. A concurrent interview and observation on 02/24/2025 at 9:52 AM revealed a medication cup containing an ointment at Resident #6's bedside. Resident #6 stated the ointment was for eczema, and the nurse left it in their room. An observation on 02/25/2025 at 9:15 AM revealed three medication cups containing topical medications on Resident #6's bedside table. One of the medication cups contained an ointment and was labeled with the word toe, one contained an ointment and was labeled with the words inner thigh, and one contained a powder but was not labeled. Two additional medication cups containing ointment were observed on another table in the resident's room, one of which was labeled with the word rash. Resident #6 and a staff member were in the bathroom at the time of the observation. On 02/25/2025 at 9:22 AM, Certified Nursing Assistant (CNA) #6 emerged from the bathroom in Resident #6's room. CNA #6 stated it was the resident's assigned shower day, and the nurse left the cups of medications at the resident's bedside earlier that morning. CNA #6 further stated Resident #6 kept some of their medications with them and was able to apply the medications themselves. During an interview on 02/25/2025 at 9:27 AM, Licensed Vocational Nurse (LVN) #3 stated she was Resident #6's assigned nurse and admitted she left three prescribed ointments and a prescribed powder at the resident's bedside. LVN #3 identified the medications as triamcinolone ointment, lidocaine ointment, and nystatin powder. LVN #3 described the resident as alert and said she did not think it was a big issue; however, LVN #3 further stated the resident did not have an order to self-administer the topical medications and said perhaps the resident needed one. During an interview on 02/25/2025 at 11:01 AM, Resident #6 stated they requested the nurses leave their prescribed topical mediations with them so the resident could apply them when needed. During an interview on 02/25/2025 at 2:56 PM, LVN #1 stated that if a resident requested to self-administer a medication, staff initiated the process of assessing the resident to ensure they could safely administer the medication in question. LVN #1 reviewed Resident #6's medical record and confirmed the resident did not have a self-administration of medication assessment or an order to self-administer their topical medications. LVN #1 stated the resident had been administering their own typical medications, so an assessment should be completed and an order obtained from the physician. During an interview on 02/26/2025 at 10:37 AM, the Director of Nursing (DON) stated if a resident asked to self-administer a medication, nursing staff should know to complete an assessment or notify a supervisor or the DON. The DON stated that Resident #6 was self-administering their topical mediations, but the facility did not have a self-administration assessment or an order for the resident to do so. The DON stated she expected nurses to follow the facility's policies regarding safety and also expected them to have completed an assessment for self-administration as soon as it was known the ointments were left at the resident's bedside. During an interview on 02/26/2025 at 10:51 AM, the Administrator stated Resident #6 was managing prescribed ointments without an assessment or an order to do so. The Administrator stated she expected the nurses to follow the facility's policy regarding self-administration of medications.

Based on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items were not labeled and dated with use-by date in refrigerator: -Three gallons of milk opened not dated; - Bottle of pickle relish opened not dated; - One container of garlic spread opened not dated; - Bowl of cooked minestrone dated 4/23/23; - One container of low fat cottage cheese opened dated 4/21/23; - One bottle of horse Radish opened not dated ; - Bowl of crushed garlic not labeled or dated; - One container of low fat cottage cheese opened not dated; - One Med Pass 2.0 nutritional shake vanilla opened dated 2/3/23; - One bottle of yellow mustard opened dated 4/6/23; - One bottle of mayonnaise opened an dated 4/6/23; - One tray of dispensed cups with juice and milk beverage dated 4/25/23; - Two trays of dispensed cups of beverage not label or dated; - One bottle of caramel sauce opened and dated 12/2/22; - One can of peanut butter opened and dated 3/24/23; - Bowl of cooked yam dated 4/25/23; These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 5/1/23 at 9:17 a.m., accompanied by Cook and Dietary Supervisor/Dietician (RD) the followings were observed in the refrigerator; three gallons of milk opened not dated, gallon of pickle relish opened not dated, one container of garlic spread opened not dated, bowl of cooked minestrone dated 4/23/23, one container of low fat cottage cheese opened dated 4/21/23, one bottle of horse Radish opened not dated, bowl of crushed garlic not labeled or dated, two carton of low fat cottage cheese opened not dated, one Med Pass 2.0 nutritional shake vanilla opened dated 2/3/23, one bottle of yellow mustard opened dated 4/6/23, one bottle of mayonnaise opened an dated 4/6/23, one tray of dispensed cups with juice and milk beverage dated 4/25/23, two trays of dispensed cups of milk and juice beverage not label or dated and bowl of cooked yam dated 4/25/23; and in kitchen cabinet observed one bottle of caramel sauce opened and dated 12/2/22 and one can of peanut butter opened and dated 3/24/23. During an interview on 5/1/23 at 9:33 a.m., Cook stated, all food items must be labeled and dated when opened and placed in refrigerator with expiration date. During an interview on 5/1/23 at 9:54 a.m., RD stated, the expectation was that all food items are covered, labeled and dated including milk products must be labeled and dated in refrigerator. During an observation on 5/1/23 at 12:14 p.m., Certified Nursing Assistant (CNA1) picked up a paper napkin from the floor and proceeded to distribute meal tray without performing hand hygiene. During an interview on 5/1/23 at 12:17 p.m., CNA1 stated, she was trained to perform hand hygiene before passing meal trays. CNA1 said she felt she was only picking up clean paper from the floor. During an interview on 5/3/23 at 10:08 a.m., Infection Preventionist/Registered Nurse (IP) stated, CNAs are trained to wash hands or perform hand hygiene before distributing meal trays. IP said the floor is dirty. The facility's policy, titled Procedure for refrigerated storage, dated 2018, indicated ; Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. Leftovers will be covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication for Resident 356 was in the medication cart, which put residents 356 at risk of receiving expired medication, 1b. One expired can of test strip was in the medication cart, which put all residents at risk of receiving testing with expired test strips. 2a. One opened bottle of medication in the medication cart was not labeled, which put all residents at risk of receiving expired or outdated medication, 2b. Two expired medications were for Resident 28 and 44 were in the medication cart, which put residents 28 and 44 at risk for receiving expired medications. 2c. One expired medication was in the treatment cart, which put all residents at risk for receiving expired medications. 3a. One expired medication was in the medication cart, which put all residents at risk for receiving expired medications. 3b. One expired medication for Resident 6 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3c. One expired medication for Resident 20 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3d. One expired medication for use for Resident 19 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3e. One opened bottle of medication in the medication cart was not labeled and dated, which put all residents at risk of receiving expired or outdated medication, 3f. One opened bottle of medication in the medication cart was not labeled, which put all residents at risk of receiving expired or outdated medication, 3g. Loose pills were found in the medication carts, which could result in diversion of the loose medication, 4. One expired can of test strip was in the medication cart, which put all residents at risk of receiving testing with expired test strips. These deficient practices had the potential for residents to receive medications with reduced potency, had the potential to result in medication errors, or drug diversion. Findings: 1. During an inspection of the Medication Cart number 1 on 5/1/23, at 11:03 a.m., with Registered Nurse (RN) 3, two expired and unlabeled with open date medications were identified in the locked compartment of the medication cart, as follows: a. An opened multi-dose bottle containing heparin (medication is used to prevent and treat blood clots)50,000 units ([NAME] unit, a unit of measurement) /10 ml (milliliter, a unit of measurement)for Resident 356 without an open date. b. An opened multiuse bottle containing glucose test strips without an open date. During an interview on 5/1/23, at 11:10 a.m., with RN 3, s/he stated s/he could not verify when the heparin bottle was opened, and it has a life span for 28 days after opening. RN3 stated, s/he considered the Heparin expired. RN3 stated, the manufacturer's label on glucose test strip bottle indicated, good for 6 months after first opening. RN3 stated, s/he was unable to confirm the open date as it does not have an open date and that s/he would consider it to be expired. 2. During an inspection of the Medication Cart number 2 and the sub-acute treatment cart on 5/1/23, at 11:31 a.m., with Registered Nurse (RN) 4 two expired, one expired and unlabeled with resident information were identified in the locked compartment of the medication cart, and one expired medications were identified in the locked compartment of the treatment cart, as follows: a. An opened unlabeled multi-dose bottle containing insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood by helping glucose enter the body's cells)100 units/ml (the number of units of insulin in one milliliter (mL)) with an open date of 3/25/23. b. 1. A Systane eye drop for Resident 44 with an opened date of 2/17/23. 2. A Systane eye drop for Resident 28 with an open date of 2/21/23. c. An unlabeled hemorrhoidal ointment with an expiration date of 11/2022 During an interview on 3/01/23, at 11:50 a.m., with RN 4, s/he verified the findings above and stated, s/he could not verify which Resident the Insulin belonged to. RN4 stated, Insulin expires 28 days after opening and this insulin is expired. RN 4 stated, both eye drops are expired, we are to discard them 42 days after opening, they both have been open for more than 42 days. RN4 stated the hemorrhoid ointment expired on 11/2022, and s/he did not know who was responsible for the rotating and removing of the expired medication from the carts. 3. During an inspection of the Medication Cart number in Station 2 with RN2 on 5/02/23, at 11:06 a.m., four expired, one unlabeled and undated, one unlabeled, and three loose pills were identified in the locked compartment of the medication cart, as follows: a. An opened multi-dose bottle of Melatonin with a printed expiration date of 04/30/23. b. An unopened bottle of Naloxone (a medicine that rapidly reverses a narcotic overdose) for Resident 6 with a printed expiration date of 03/2023. c. An Lumigan eye drop bottle for Resident 20 with an open date of 03/29/23 d. A multi-dose inhaler Combivent Respimat for Resident 19 with an open date of 1 10/19/22. e. An unlabeled opened Artificial Tears eye drops without an open date. f. An unlabeled opened Artificial Tears eye drops with an open date of 3/30/23. g. Three loose pills at the bottom of the cart drawer During an interview on 5/02/23 at 11:15 a.m., with RN2, s/he verified the findings above and stated, Both the Melatonin and the Naloxone are expired, The Lumigan eye drops expires 28 days after opening. RN2 stated the Combivent inhaler expired 90 days after opening as printed on the medication box. RN2 could not verify which Resident/s the Artificial eye drop bottles belonged to. RN2 stated eye drops should have been labeled and dated, and expire 30 days after opening, and that both eye drop bottles were now expired. RN2 stated s/he was not able to correctly identify the three loose pills and it could cause an issue with medication count. RN2 stated she did not know who was responsible for removing of the expired medication from the carts. 4. During an inspection of the Medication Cart number 4 with Licensed Vocational Nurse (LVN) 2 on 5/02/23, at 11:18 a.m., one opened glucose test strip without an open date, was identified in the locked compartment of the medication cart. During an interview on 5/02/23 at 11:20 a.m. with LVN2, she stated, she could not verify the open date and that per the manufacturer's instructions Use within 6 months after first opening, I would consider these expired. During an interview with the DON on 5/2/23 at 12:52 p.m., she verified all the above findings, and stated the staff nurse was supposed to give expired and discontinued medications to the Charge Nurse right away. The DON verified the above expired medications should have been removed from the medication carts to prevent medication errors. The DON stated the Charge Nurse, and the Pharmacist are responsible for removing expired and discontinued drugs from the medication carts. A review of the facility's policy and procedure(P&P) titled Disposal of Medications, dated 2007, the P&P indicated, .8. Outdated medications, contaminated, or deteriorated medications and the contents of containers with no label shall be destroyed . A review of the facility's policy and procedure titled Storage of Medication, dated 2007, the P&P indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stocks, disposed of according to procedures for medication disposal . A review of the facility's policy and procedure titled medication Administration, dated 2007, the P&P indicated, 8. No expired medication will be administered to a resident .b. The nurse shall place a 'date opened' sticker on the medication .and enter the date opened.

Based on observation, interview, and record review, the facility failed to ensure 1 resident in a census of 58 (Resident 156) was free from significant medication error when: For Resident 156, Oxycodone (a potent pain medication) was not administered as prescribed by the physician. This failure resulted in Resident 156 suffering from moderate to severe pain. Findings: During a review of Resident 156's Admission Record dated 5/4/23, the Admission Record indicated, Resident 156 was admitted to the facility in April of 2023 with multiple diagnosis including right femur (thigh bone) fracture, and chronic gout (painful swelling of the big toe joint). During an observation and interview on 5/02/23, at 9:04 a.m., with Licensed Vocational Nurse (LVN) 2 and Resident 156, Resident 156 stated, she wanted to do Rehab therapy (a care that can help you get back, keep, or improve abilities that you need for daily life) for pain management) time and that she was in severe pain every time she moved in bed. LVN 2 stated that she was unable to find her prescription pain medication in the medication cart and informed the resident We are going to order the pill. During a review of Resident 156's clinical record, the clinical record indicated, a physician order dated 5/1/23, Premedicate with Oxycodone, 5 mg (give 0.5 tablet = 2.5 mg [milligram, a unit of measurement] tablet, need to be given every morning 30-60 minutes prior to Rehab. During a subsequent interview on 5/02/23, at 12:03 p.m., with LVN 2, LVN 2 stated, she had informed the Director of Nursing (DON) who is calling the pharmacy now. LVN 2 stated that Resident 156 has not had Rehab Therapy today. During an interview on 5/02/23, at 12:04 p.m., with Resident 156, stated, she had not yet received the medication to relieve the pain in her right knee and that her leg hurt every time she moved. Resident 156 stated, she lay still and do not move to help with the pain and her pain was 10 out of 10. (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). During an interview on 5/02/23 at 12:54 p.m., with the DON, she stated, the medication was not delivered by the pharmacy, and the nurses were not able to pull out a one-time dose from the emergency kit (e-kit, a small quantity of medications that can be dispensed when pharmacy services are not available) as the Physician was not notified. DON stated, the physician should have been called to get a one-time dose to eliminate severe pain and to ensure [Resident 156] had morning rehab therapy . [Resident 156] is here for rehab therapy, they should have to not lay in pain for 5 hours .it took me 20-30 minutes on the phone with pharmacy, and the pain medication will be available soon. During an interview on 5/02/23 at 1:46 p.m., with LVN2, she stated, she was finally able to access the e-kit and get the pain pill. LVN2 sated, I am going to administer it now. A review of facility policy titled, Medication Administration, dated 2007, indicated Medications must be administered in accordance with written orders of the prescriber .medications are administered withing 60 minutes of scheduled time.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 sampled residents (Resident 29 and Resident156) when: 1. Resident 29 was not administered Chlorhexidine solution (a prescription oral rinse that prevents the growth of bacteria in your mouth and reduces inflammation in gums) 15 ml (milliliter, unit of measurement) per manufacturer's guidelines. 2. Resident 156 was not administered oxycodone (a pain medication) 5 mg (milligram, unit of measurement) as prescribed by the physician. This failure resulted in 2 medication errors being identified out of 28 opportunities during an observation of medication administration which then resulted in the facility having a medication error rate of 7.14%. Findings: 1.During a review of Resident 29's Admission Record, dated 5/2/23), the admission record indicated, Resident 36 was admitted to the facility in March of 2023 with multiple diagnoses including broken internal left hip prosthesis (an artificial body part) and left hip pain. During a medication pass observation on 5/2/23 at 8:47 a.m., with Licensed Vocational Nurse (LVN) 2, LVN2 administered Resident 29's Chlorhexidine solution. Resident 29 swished the medication for two seconds and spit out the medication in a cup. Based on a review of medication label on 5/2/23 at 8:50 a.m., with LVN2, s/he verified the manufacturer's guidelines printed on the Chlorhexidine solution bottle indicated Swish the medication in your mouth for 30 seconds. During a review of Resident 29's Physician's Order, dated 4/15/23, indicated, Chlorhexidine 15cc (cubic centimeter, unit of measurement), to be given every 12 hours, and to swish and spit. During an interview with LVN2 on 5/2/23 at 8:54 a.m., LVN2 stated, s/he was not aware of the manufacturer's guidelines on having the resident swish the medication for 30 seconds. LVN2 stated, swishing for 30 seconds is important to mouth to be clean, the resident did it for only 2 seconds. 2.During a review of Resident 156's Admission Record dated 5/4/23, the review indicated, Resident 156 was admitted to the facility in April of 2023 with multiple diagnosis including right femur (thigh bone) fracture, and chronic gout (painful swelling of the big toe joint). During a medication pass observation on 5/2/23 at 9:10 a.m., with LVN2, LVN2 did not administer Resident 156'sr oxycodone as ordered by the physician. LVN2 stated to Resident 156 You have therapy this morning. Resident 156 pointed at her right thigh stated, I have so much pain, will that hurt? During a review of Resident 156's Physician Orders, dated 5/1/23, indicated Premedicate with Oxycodone, 5 mg (give 0.5 tablet = 2.5 mg (milligram, a unit of measurement) tablet, need to be given every morning 30-60 minutes prior to Rehab (care that can help Resident 156 get back, keep, or improve abilities needed for daily life) for pain management. During an interview on 5/2/23, at 9:21 a.m., with LVN 2, LVN 2 stated,the pain medication was not available in the medication cart, and no other pain medication was available. LVN 2 stated, she would inform the charge nurse to get the pain medication. During an interview on 5/2/23, at 12:00 p.m., with LVN 2, LVN 2 stated, the pain medication had not been administered to Resident 156 and the Director of Nursing (DON) was calling the pharmacy. LVN 2 stated, Resident 156's rehab therapy was not conducted as the resident did not get the pain medication. During an interview on 5/2/23, at 12:04 p.m., with Resident 156, Resident 156 rated her pain level at 10 out 10 (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). Resident 156 stated I scream when I have to move, my right leg hurts a lot. During an interview on 5/02/23, at 1:44 p.m., with DON, DON stated We did not make sure the pain medication was delivered today .the physician should have been called to get a one-time dose to eliminate severe pain and to ensure the resident had morning rehab therapy This resident is here for rehab therapy, they should have to not lay in pain for 5 hours. During a review of the facility's policy titled, Medication Administration, dated 2007, indicated, Medications are administered as prescribed in accordance with manufacturer's specifications .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .

Based on observation, interview, and record review, the facility failed to ensure controlled medications (medications with high potential for abuse or addiction) were available and given according to the Physician's Order and fully accounted for, when: A random controlled medication use audit for three out of three residents (Residents 20, Resident 1 and Resident 19) indicated that Morphine (a potent medication for pain) was not administered as prescribed for Resident 20, and medications were documented as given to the Resident 1 and Resident 19 on the Medication Administration Records (MAR), but were not signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). These failures resulted in Resident 20 enduring unnecessary pain, and had the potential to result in loss, misuse, and/or diversion of controlled prescription medications. Findings: During a random controlled drug audit, the CDRs of three residents (20, 1 and 19) were reviewed during the survey. 1. During a concurrent interview and record review on 5/02/23 at 11:10 a.m., with Registered Nurse (RN) 2, a review of Resident 20's CDR sheet for Morphine reflected the following Morphine Sulfate ER (extended release) 15 mg (milligram, a unit of measurement) 1 tablet by mouth every 12 hours for chronic post-traumatic headache. The CDR documentation indicated that the medication was only being administered QD (once a day) at 9:00 a.m. RN2 stated the current Morphine Sulfate order in the MAR dated 6/30/2020, indicated Morphine Sulfate Contin ER 15 mg 1 tablet by mouth every morning around the clock for pain management. RN2 stated s/he goes by the MAR while administering controlled medication and do not pay close attention to the label on the CDR sheet. RN 2 stated, s/he was not aware of the discrepancy in the order until today .It looks like Resident 20 has not been receiving her pain medications as ordered. RN2 stated QD is every day and Q12 is every 12 hours. RN2 stated, Resident 20 is able tell the staff when she is in pain, by pointing to the pain area of her body. During a Record Review of the Clinical Progress Notes dated 5/05/2023, printed on 5/2/2022, indicated, Morphine (MS Contin/Oramorph SR) 15 mg Oral tablet, take 1 tablet by mouth every 12 hours prescribed by a physician with a start date of 4/15/2022. During a phone interview on 5/02/23 at 12:41 p.m., with Pharmacy Tech (PT). PT sated, the electronic script (a digital alternative to a paper prescription) submitted on 04/15/22, indicated Morphine Sulfate Contin Sustained release 15 mg oral tablet, take 1 tablet by mouth every 12 hours, a change in frequency from 1 tablet a day. 2. During a concurrent interview and record review on 5/01/23 at 11:13 a.m., with the RN2, a review of the Resident 1's MAR indicated, oxycodone HCL (a potent controlled medication for moderate to severe pain) was administered for 5/02/23 at 8:00 a.m., but not signed out as removed on the CDR. RN2 stated s/he administered the medication at 8:00 a.m. but forgot to sign out the CDR after administering the medication. 3. During a concurrent interview and record review on 5/02/23 at 11:29 a.m., with the RN 2, a review of Resident 19's MAR for pregabalin (a potent controlled medication used to treat nerve pain) indicated the following medication's 3 capsules were administered on 5/02/23 at 9 a.m., but not documented removed on the CDR. The medication bubble-pack contained 30 capsules. RN2 verified the findings and acknowledged the medication bubble pack contained 30 capsules, and the CDR reflected the number of capsules remaining was 33. RN2 stated, s/he forgot to document on CDR after administering the morning dose at 9:00 a.m. During an interview on 5/02/23 at 1:40 p.m., with the Director of Nursing (DON). DON stated, when the nurse is pulling a controlled medication from the medication cart, the nurse is to confirm the order, sign out on the CDR, and then prep the medication in the MAR. As soon as the controlled medication is administered, the nurse is to sign the MAR 'as given. S/he stated, All medications must be documented both in the MAR and CDR, if it is not documented, it is not given. DON stated, it was her expectation for nurses to check the CDR label, narcotic bubble pack label and the MAR order prior to a medication administration, If it's not matching, they have to inform the charge nurse and notify the physician. DON stated, s/he was not sure why the morphine order was missed for more than one year, it's very concerning. DON stated, the risk of under medicating a resident means they are in constant unmanaged and uncontrollable pain. During a review of the Resident 20's Face Sheet dated 5/02/23, the record indicated, Resident 20 was admitted to the facility on [DATE] with multiple diagnoses which included Motor Vehicle Accident, and Right Femur (thigh bone) fracture. During an interview with Resident 20 on 5/02/23at 2:29 p.m., Resident 20 pointed to her right thigh and stated she was in a lot of pain and rated her pain level at 10 out of 10. (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). During a review of the facility's policy titled, Medication Administration, dated 2007, indicated, Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the prescriber's orders are checked for the correct dosage schedule .9. Read medication label three (3) times before preparing/pouring medication. a. when pulling medication package from med cart, b. When dose is prepared, c. before dose is administered . Medications are administered in accordance with written orders of the prescriber .

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure an allegation of abuse was reported to the State Survey Agency and report the result of their investigation within five working days as required. This failure had the potential to result in unidentified resident abuse. Findings: During review of Resident 1's Face Sheet indicated Resident 1 was initially admitted to the facility with major depressive disorder (persistently depressed mood or loss of interest in activities) and [CONDITION(S)] (paralysis of the legs and lower body). During a telephone interview with Resident Representative (RR) 1 on 3/7/22 at 2:36 p.m., RR 1 stated Resident 1 told RR 1 that on 12/24/21, a facility staff bruised Resident 1's hand. During a telephone interview and concurrent review of the Social Services Departmental Notes dated 2/17/22, with Social Services Director (SSD) on 3/8/22 at 12:12 p.m., SSD stated on 2/17/22, a telephone conference was held with Resident 1 and RR 1. The Social Services Departmental Notes indicated RR 1 Reported [Resident 1] had a bruise on her right wrist a few weeks ago from a CNA [Certified Nursing Assistant] .administration will investigate, to follow up within 24 hours. SSD stated the Associate Administrator (AA) told RR 1 that the allegation would be investigated. During a concurrent interview with AA and the Infection Preventionist (IP) on 3/8/22 at 11:17 a.m., AA stated after the meeting with RR 1 on 2/17/22, AA checked on Resident 1 and did not find any sign of bruising (55 days after the alleged incident). AA stated Resident 1's records were reviewed for documentation by staff of any reported or observed bruising on 12/24/21 but did not find any. AA also stated Resident 1 was asked but could not say any details about the abuse allegation. Review of Resident 1's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 1/31/22 indicated a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 13 out of 15 (meaning cognitively intact). During an interview with Resident 1 on 3/8/22 at 4:05 p.m., Resident 1 stated on 12/24/21, there was bruising on the left wrist where the bone was split, pointing at the webspace/contour between the left thumb and left index finger, when staff hit Resident 1's hand with the bed controls. During a follow-up interview with AA on 3/8/22 at 1:53 p.m., AA stated, the allegation was investigated and it was determined on 2/22/22 that resident abuse did not happen. During a concurrent interview with the Administrator (Adm) and AA on 3/8/22 at 1:08 p.m., Adm stated this allegation was not reported to the State Survey Agency because when it was brought up, the facility had many things going on and lost focus. Adm also stated, the normal process of reporting an abuse allegation was to follow the facility's abuse policy and procedure. Adm stated, in Resident 1's case, the normal process of reporting was not followed because the allegation was only a part of the many issues RR 1 had brought up and that Resident 1's family was difficult. Adm stated, RR 1's report of a bruised hand was not considered an abuse allegation because Resident 1 and the family had many opportunities to report the allegation if they really wanted to. Review of the facility's undated policy and procedure titled, Abuse Prevention indicated the, Administrator shall report all incidents of alleged abuse or suspected abuse to DHS (Department of Health Services/State Survey Agency) within 24 hours . and the results of the investigation to DHS with within 5 working days of the incident .

Based on observation, interview and record review, the facility failed to ensure proper infection control measures were followed related to hand washing for one of three residents (Resident 38) when hand hygiene was not performed in between glove change during wound care. This deficient practice placed residents at risk for developing infection. Findings: Review of the Face Sheet indicated Resident 38 was admitted to the facility with multiple unstageable pressure ulcers (injury to the skin due to prolonged pressure). During an observation on 8/29/19 at 10:28 a.m., Registered Nurse 1 (RN 1) performed dressing change of Resident 38's pressure ulcer on the right hip. During the procedure, RN 1 changed her gloves five times without washing or sanitizing hands before putting on new gloves. During an interview with RN 1 on 8/29/19 at 10:40 a.m., RN 1 stated she should sanitize her hand during glove change. Review of an undated and untitled facility policy indicated proper handwashing and hygiene techniques will help prevent transmission of infections. The policy further indicated alcohol-based hand rub may be used after contact with resident's intact skin, after handling used dressings, contaminated equipment and after removing gloves.

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was administered as ordered by the physician for one of three sampled residents (Resident 29), when Resident 29 was not given her oxygen as ordered by the doctor. This deficient practice may result in ineffective oxygen therapy. Findings: A review of the document titled, Face Sheet, dated 8/29/19 indicated Resident 29 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 8/26/19 at 9:06 a.m., Resident 29's oxygen was given at 4.5 Liters Per Minute (LPM, unit of measurement). During a concurrent observation and interview on 8/26/19 at 9:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 29 was receiving oxygen at 4.5 LPM and was not reporting any anxiety or shortness of breath. LVN 1 stated Resident 29's order for oxygen was for 2 LPM. Review of the Physician order [REDACTED]. A review of the facility undated policy and procedure: Chronic respiratory Illness, it indicated The resident that is dependent on oxygen support will be monitored to assure oxygen supply and delivery is in accordance with MD (Medical Doctor) order.

Based on interview and record review, the facility failed to offered and provide a written seven day bed hold information to one (Resident 1) of three sampled residents upon transfer to the acute hospital; when the facility did not provide Resident 1 or Resident 1's representative of bed hold notice upon transfer to the hospital permitting Resident 1 to return to the facility. This failure displaced Resident 1 and had the potential to cause emotional distress. Findings: During an interview on 4/8/19 at 10:00 a.m., Resident 1's conservator stated Resident 1 had resided at the facility for four years, was transferred to the hospital for evaluation and not offered a seven day bed hold or allowed to return back to the facility. During an interview on 4/8/19 at 11:24 a.m., the Administrator (Admin), stated facility did not offer or provide seven days bed hold to Resident 1 and her conservator because upon transfer to the hospital, the facility decided not to readmit Resident 1 because of Resident 1's behavioral episodes of agitation, refused care and altercation with roommate. Record review of the Annual Minimum Data Set (MDS - Resident Assessment tool used to guide care), dated 3/12/19, indicated the facility admitted Resident 1 on 4/15/15 with [DIAGNOSES REDACTED]. Record review of the nurse progress notes, dated 3/22/19, indicated Resident 1 had a resident to resident physical altercation with her roommate, was combative with staff members, attempted to bite, hit, screaming, kicking and was transferred to the hospital 5150. (5150 refers to the California law code for temporary, involuntary commitment of individuals who present a danger to themselves or others due to signs of mental illness). Record review of the interdisciplinary team notes, dated 3/26/19, indicated the facility advised the hospital that Resident 1 was not on bed hold and will not be allowed to return back to the facility. Record review of the hospital discharge summaries, dated 4/3/19, indicated Resident 1 was relatively pleasant if she was allowed to eat, watch television and not have anything done to her she doesn't want. Comfort focused care is more in line with her goal. Condition of discharge was stable. Resident 1 discharge disposition was to skilled nursing care. Record review of the facility's document, titled, Bed Hold, undated, indicated; Upon transfer to the acute hospital, the discharging nurse will advise the resident/resident representative of bed hold. a. If the resident/ patient has Medical in place, Medical will cover bed hold days up to 7 during the resident's hospital b. If the resident does not have MediCal in place to cover the cost, the resident/ representative will be contacted by social services or business office to explain the per diem charges for bed hold.

Based on interview and record review the facility failed to follow infection control practices for one of three sampled residents when Resident 1's intravenous tubing (used to administer medication through veins) was dropped on the floor before being used to administer medication to the resident. The deficient practice had the potential to result in the resident having a preventable infection. Findings: According to a face sheet dated 12/06/18, Resident 1 had multiple [DIAGNOSES REDACTED]. During an interview on 1/22/19 at 3:03 p.m., Registered Nurse (RN) 1 stated he dropped part of the intravenous tubing on the floor on 11/3/18 before using it to administer intravenous medication to Resident 1. During an interview on 2/21/19 at 11:16 a.m., Director of Nursing (DON) stated, IV (intravenous) tubing should be changed if it is dropped on the floor. Review of the facility's General Clinical Policies of Infusion Therapy Infection Control Standards dated 04/08 section 3.2 page 3 indicated, Primary continuous tubing is changed every 72 hours and immediately upon suspected contamination or when the integrity of the tubing has been compromised.

Based on interview and record review, the facility failed to treat resident with respect and dignity for one of two sampled residents (Resident 1) when Certified Nursing Assistant 1 (CNA 1) argued with Resident 1. This failure resulted in Resident 1 feeling disrespected and angry. Findings: During a review of the Face Sheet indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 4/23/18 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident 1 was cognitively intact. During a review of a voice recording dated 4/22/18 at 6:42 p.m., Resident 1 was heard telling CNA 1 to turn off the roommates television since all the residents were either out of the room or asleep. Resident 1 stated he did not want the TV on and he did not want to watch a game in the channel CNA 1 put. CNA 1 answered back and forth with Resident 1 stating she will not turn off the TV using a high pitched voice. During an interview with Resident 1 on 6/1/18 at 4:01 p.m., Resident 1 stated CNA 1 always argued with him and it made him really angry and disrespected. During an interview with CNA 1 on 6/1/18 at 3:56 p.m., CNA 1 stated she got frustrated with Resident 1 and answered back. CNA 1 stated staff should not answer back to the resident. During an interview with the Administrator (ADM) on 6/1/18 at 2:45 a.m., and review of the voice recording, ADM stated the staff should not argue with the resident and the way CNA 1 answered Resident 1 was not the proper way of talking to a resident. Review of the facility's Resident Bill of Rights dated 02/09 indicated the facility shall ensure residents rights are not violated. The residents rights included to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs .

Based on observation, interview and record review, the skilled nursing facility did not provide care in a manner that prevented the potential spread of bacteria for four of 18 sampled residents (Residents 26, 31 and 39). Staff did not perform hand hygiene between changing gloves and touching a non-clean area during Resident 26's dressing change and Registered Nurse 2 (RN 2) failed to clean a stethoscope before and between providing care to Residents 31 and 39. These failures resulted in the potential for cross contamination and spread of bacteria and infections. Findings: 1. During a medication pass observation on 9/10/18 at 7:40 a.m., Registered Nurse 2 (RN 2) went into Resident 31's room to listen to Resident 31's abdomen using a stethoscope (medical instrument for detecting sounds). Resident 31 had a Gastrostomy Tube (GT, a tube placed surgically directly into to the stomach to deliver liquid food). RN 2 did not clean her stethoscope before using it on Resident 31. RN 2 then moved onto Resident 39 who also had a GT. RN 2 was observed listening to Resident 39's abdomen using the same stethoscope. RN 2 did not clean and sanitize the stethoscope before using it for Resident 39. RN 2 Stated she did not clean the stethoscope before using and in between Residents 31 and 39. In an interview on 9/11/18 at 1:37 p.m., the facility's Infection Control Nurse (ICN) stated stethoscopes must be sanitized between residents and especially when, Making direct contact with the resident. 2. Review of Resident 26's Face Sheet indicated, Resident 26 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation of the wound treatment on 9/11/18 at 10:21 a.m., RN 1 performed the wound care and dressing change on Resident 26's right buttock's wound. During the whole procedure, RN 1 changed her gloves four times and but did not perform hands hygiene in between glove changes. During an interview with RN 1 on 9/11/18 at 10:25 a.m., she stated that she should sanitized her hand between change of gloves. During an interview with ICN on 09/11/18 at 1:30 p.m., ICN stated all the nurses should sanitize their hands between glove change. Review of an undated facility policy and procedure titled Dressing Change Guidelines indicated during dressing change, the nurse should remove soiled gloves, wash their hands and done new gloves.

Based on observation, interview and record review, the facility failed to provide appropriate care and treatment to a Gastrostomy Tube (GT, a tube placed surgically directly into to the stomach to deliver liquid food) for one of 18 residents (Resident 39) when Registered Nurse 2 (RN 2) did not verify GT placement prior to administering medication and restarting the liquid food. This failure could result in Resident 39 developing complications related to improper GT placement. Findings: In a concurrent observation and interview on 8/10/18 at 7:40 a.m., RN 2 used a stethoscope to hear Resident 39's bowel sound using a stethoscope (medical instrument for detecting sounds), RN 2 administered Resident 39's medications through the GT and restarted the liquid food. RN 2 stated she did not need to check for placement since she listened to the stomach bowel sounds and there was no residual (volume of fluid remaining in the stomach at a point in time during enteral nutrition). In an interview on 9/11/18 at 1:44 p.m., the facility's Interim Director of Nursing (IDON) stated, prior to administering medication or food through a GT, staff were to check placement. Review of the Physician Orders, dated 9/5/18 showed staff were to, Confirm GT placement prior to feedings, flushes and medication administration. Review of the facility's policy titled Medication Administration Enteral Tubes, dated 10/07 showed the steps to verify the tube placement during administering medication through a GT. The procedure included a. Unclamp tube and use the following procedures. Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. Aspirate stomach contents with syringe. Check residue. Allow stomach contents to go back into stomach .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) was accurate for one of 16 sampled residents ( Resident 5) when Resident 5's limitation in Range of Motion was not reflected in the MDS. This deficiency had the potential for residents to not receive appropriate treatment and care. Findings: Review of the document titled, Face Sheet, showed the facility admitted Resident 5 on 6/27/16 with [DIAGNOSES REDACTED]. During an observation on 8/7/17 at 10:15 a.m., Resident 5's right and left hand were contracted (stiffness or [MEDICATION NAME] of the connective tissue or muscle). Review of the annual MDS dated [DATE], Section G0400- Functional Limitation in Range of Motion, indicated Resident 5's assessment was coded 0 (resident has full functional range of motion) indicating Resident 5 had no impairment on the upper extremities. In an interview on 8/7/17 at 10:45 a.m., the MDS Coordinator (MDS) stated Resident 5 had contractures on her right and left hands. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual dated October 2016, indicated the intent of the assessment was to determine whether functional limitation in range of motion (ROM) interferes with the resident ' s activities of daily living or places him or her at risk of injury.