Every finding on record at Bayshire San Dimas Post-Acute

Based on interview and record review, the facility failed to ensure a change in condition (COC, an alteration in a resident's physical health that differed from their previous baseline) was reported to the Medical Doctor (MD) 1 in a timely manner for one of one sampled resident (Resident 1).This deficient practice resulted in delayed treatment for Resident 1 who had a displaced femoral fracture (a break in the thigh bone where the fragments shift out of their normal alignment).During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including metabolic encephalopathy (change in how the brain works caused by an underlying medical condition rather than direct injury), rhabdomyolysis (condition where muscle breakdown releases harmful substances into the blood), osteoarthritis (degenerative joint disease in which the tissues in the joints break down over time), and a history of falling.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/9/2026, the MDS indicated Resident 1 had intact cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for personal hygiene and the ability to transfer to and from a bed to a chair.During a review of Resident 1's Physical Therapy Treatment Encounter Notes (PTTEN), dated 6/10/2026, the PTTEN indicated under complexities/ barriers impacting session: left lower extremity positioning with increased adductor tone (inner thigh muscles are tighter) when in sitting and external rotation (when the thigh and foot rotate outwards away from the body) when supine (lying flat on one's back with the face and torse facing upwards.) Increased difficulty actively moving the left lower extremity. PT discussed concerns with nursing.During a review of Resident 1's eInteract Situation, Background, Assessment, and Recommendation (SBAR Summary- standardized, communication to help professionals share clear, concise, and critical information with one another), dated 6/12/2026 at 5:59 PM, the SBAR indicated Resident 1 had a change in condition. The SBAR indicated nursing (unidentified) observed, evaluated, and recommended Resident 1 was given a x-ray based on a report given by a therapist (unidentified). The SBAR indicated Resident 1's [left hip] was not aligned. The SBAR indicated Resident 1 received an x-ray result of the left hip, indicating a fracture. The SBAR further indicated, MD 1 ordered for Resident 1 to be sent to the General Acute Care Hospital (GACH) via non-emergency transport since Resident 1 was stable.During a review of Resident 1's facility x-ray result titled, Patient Report (PR), dated 6/12/2026, the PR indicated Resident 1 had an x-ray of the left hip with results for an acute displaced intertrochanteric fracture of the left femur (type of broken hip).During a review of Resident 1's Physician Orders (PO), dated 6/12/2026, the PO indicated Resident 1 to have a left hip x-ray only time only.During a review of Resident 1's PO, dated 6/15/2026, the PO indicated Resident 1 transferred to GACH for further evaluation due to a left hip fracture.During a review of Resident 1's Progress Notes Type: IDT (PN) dated 6/15/2026 at 4:22 PM, the PN indicated on 6/12/2026, during an attempt to assist Resident 1 with standing, PT 1 observed Resident 1's lower extremities appeared uneven while seated and the hip/leg did not appear to be aligned. PT 1 noted Resident 1's left knee shortened more than the right while seated and with the left leg adducted and externally rotated. Resident 1 was also unable to bear weight. Nursing staff (unidentified) were notified of these findings at 11:00 AM and an x-ray was ordered at 11:15 AM for further evaluation that resulted at 4:45 PM. MD 1 was notified of the results at 5:17 PM and ordered to send Resident 1 to GACH for further assistance. Resident 1 was transferred at approximately 8:00 PM.During an interview on 7/1/2026 at 11:07 AM, with Physical Therapist (PT) 1, PT 1 stated Resident 1 received physical therapy five times a week but did not always with the same therapist. PT 1 stated [on 6/10/2026] Resident 1 was in the rehabilitation room sitting up in a wheelchair when PT 1 noticed the position of Resident 1's left leg was in an unexpected position. PT 1 stated PT 1 did not perform any weight bearing exercises that day and instead performed an assessment of Resident 1's legs and hips. PT 1 stated PT 1 wheeled Resident 1 in a wheelchair to the nurse's station and spoke to a nurse (unidentified) about concerns regarding Resident 1 having a possible hip dislocation (a serious emergency where the ball -shaped head of the thighbone is forced entirely out of the ball-shaped socket in the pelvis). PT 1 stated, [on the same day], while PT 1 was taking Resident 1 back to Resident 1's room, multiple nurses at the station looked at Resident 1 but did not take any further action. PT 1 stated two days later [6/12/2026], Resident 1 was in the rehabilitation room again, sitting up in a wheelchair to receive physical therapy and PT 1 observed Resident 1's left leg appeared shorter than the right leg. PT 1 stated PT 1 then involved the Director of Rehabilitation (DOR) and PT 2 for their opinion on PT 1's observations and Resident 1's therapies did not continue.During an interview on 7/1/2026 at 1:47 PM, with Family Member (FM) 1, FM 1 stated Resident 1 complained of pain in Resident 1's left leg before Resident 1 was admitted to the facility. FM 1 stated Resident 1 could not move the left leg or foot very much due to pain and FM 1 spoke with the DOR (no date recollection) regarding pain management before the fracture was discovered.During an interview on 7/2/2026 at 9:56 AM, with the DOR, the DOR stated on [6/12/2026], PT 1 asked the DOR to asses Resident 1 based on observations made by PT 1. The DOR stated Resident 1 was assessed and Resident 1 denied having pain and denied any recent falls. The DOR stated Resident 1 had a bony prominence (area of the body where the bone lies very close to the surface of the skin) on the left hip and the left knee was more forward than the other which was not a usual posture [for Resident 1]. The DOR stated the DOR spoke to the Registered Nurse Supervisor (RNS) and suggested an X-ray (a type of high-energy radiation that can pass through the body to create images of your internal bones and organs) for Resident 1. The DOR stated the DOR had not been made aware of any previous (two days prior) concerns brought up by PT 1. During an interview on 7/2/2026 at 12 PM, with the RNS, the RNS stated the RNS worked Monday through Friday from 7 AM to 3 PM. The RNS stated charge nurses (in general) often sat at the station along with the RNS. The RNS stated the RNS did not recall having a conversation with PT 1 about concerns related to Resident 1's left leg. The RNS stated there was no documentation in Resident 1's medical record indicating PT 1's concerns were communicated to Resident 1's doctor and the RNS did not know who PT 1 spoke to. The RNS stated if a concern was brought up to nursing, nursing would have completed a COC form and implemented an intervention immediately.During a telephone interview on 7/2/2026 at 12:22 PM, with Medical Doctor (MD) 1, MD 1 stated MD 1 was not notified of PT 1's concerns noted on 6/10/2026. MD 1 stated MD 1 should have been kept informed of any changes in condition and PT 1's concerns should have been reported to MD 1 because there might have been an additional intervention done or MD 1 may have decided to assess the resident themself if the initial concern was reported on 6/10/2026.During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, dated 2/2021 the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a(an): [ .]d. significant change in the resident's physical/ emotional/ mental condition;e. need to alter the resident's medical treatment significantly. [ .]2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). [ .]5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interviews and record review, the facility failed to develop and implement a comprehensive, individualized, person-centered care plan (CP), for two of two sampled residents (Resident 1 and Resident 53), that addressed:A. The use of an anticoagulant medication [Eliquis] apixaban (medication used to treat and prevent harmful blood clots from forming or getting bigger) for Resident 1.B. The use of an anticoagulant (medications used to help prevent harmful blood clots) medication [Xarelto] rivaroxaban (a medication that helps keep the blood from forming dangerous clots) for Resident 53.This deficient practice had the potential to result in unmet individualized anticoagulant therapy needs for Residents 1 and 53 and the potential to affect the resident's physical well-being.Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 2/11/2026 with diagnoses including acute (sudden) respiratory failure (a medical condition that happens when your lungs cannot get enough oxygen), pulmonary embolism (a blood clot that travels to the lungs and blocks blood flow) without acute cor pulmonale (a condition where long term high blood pressure in the lungs causes the right side of the heart to become enlarged and weak), and unspecified atrial fibrillation (an irregular, fast heartbeat). During a review of Resident 1's History and Physical (H&P), dated 2/16/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 1 required supervision or touching assistance with eating and was dependent on oral and personal hygiene, toileting, showering, and dressing. During a review of Resident 1's Order Summary Report (OSR), dated active as of 4/9/2026, the OSR indicated Resident 1 had a physician's order for Eliquis 5 milligrams (mg-a unit of measurement) to be given two times a day for atrial fibrillation, order date of 2/11/2026. During a review of Resident 1's anticoagulant CP, initiated 4/9/2026, the CP indicated drug therapy: Eliquis. During a concurrent interview and record review on 4/9/2026 at 10:13 AM with the Registered Nurse (RN), Resident 1's CPs were reviewed. The RN stated Resident 1 had a CP in place for Eliquis which was initiated [today] 4/9/2026. The RN stated Resident 1's Eliquis was ordered on 2/11/2026. The RN stated it was the policy of the facility to create an anticoagulant CP when the anticoagulant was ordered. The RN stated it was important to have an anticoagulant CP in place for Resident 1 because it ensured Resident 1's specific needs were monitored. B. During a review of Resident 53's AR, the AR indicated the facility admitted Resident 53 on 4/2/2026, with diagnoses including atrial fibrillation, abnormalities of gait (manner of walking) and mobility, and encounter for other orthopedic aftercare (care provided after bone, joint, or muscle injury or surgery). During a review of Resident 53's admission Initial Eval (AIE), dated 4/2/2026, the AIE indicated Resident 53 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and mobility was not attempted due to medical condition and/or safety concerns. During a review of Resident 53's OSR, dated active as of 4/13/2026, the OSR indicated a physician's order, order date 4/2/2026, start date 4/3/2026, for Xarelto (rivaroxaban) oral tablet 15 mg to give 1 tablet by mouth one time a day for deep vein thrombosis (DVT-a blood clot that forms in a deep vein, usually in the leg) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). During a review of Resident 53's H&P, dated 4/6/2026, the H&P indicated Resident 53 did not have the capacity to understand and make decisions. During a review of Resident 53's Medication Administration Record (MAR), dated 4/2026, the MAR indicated Resident 53 received Xarelto 15 mg from 4/3/2026 through 4/8/2026. During an interview and concurrent record review on 4/8/2026 at 3:07 PM, Resident 53's OSR, MAR, and CPs were reviewed with the RN. The RN stated there was no CP in place addressing Resident 53's use of rivaroxaban (Xarelto). The RN stated that due to the high-risk nature of the medication, a CP should have been developed. The RN stated Resident 53 was admitted on [DATE] and remained without individualized interventions addressing anticoagulant therapy. The RN stated this demonstrated a lack of timely development and implementation of a person-centered CP. The RN stated that failure to implement appropriate interventions for anticoagulant use had the potential to result in adverse outcomes, including increased risk of bleeding, delayed identification of complications, and compromised resident safety. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P's policy statement indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P's policy interpretation and implementation indicated, The comprehensive, person-centered care plan will: Include measurable objectives and timeframes; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Additionally, the P&P indicated, The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS).

Based on observation, interview, and record review, the facility failed to ensure:a. Their process for OTC product self-administration (the process where patients manage and take their own medications) of medications was followed, for two of two sampled residents (Resident 12 and Resident 9), when Resident 12 and Resident 9 had a non-legend product (drug that can be purchased over-the-counter [OTC] without a prescription) at their bedside without a physician's order or a consent (permission for something to happen or an agreement to do something) for self-administration.b. One of one sampled resident's (Resident 47) physician was notified of Resident 47's, who was newly admitted to the facility, soiled surgical dressing on 4/7/2026.This deficient practice had the potential to result in misuse and side effects (SE, an unwanted, unintended, or secondary effect that occurs in addition to the desired therapeutic effect of a drug) of the OTC products to Resident 12 and Resident 9 and the potential for OTC product sharing with other residents (in general) by Resident 12 and Resident 9. Additionally, the deficient practice had the potential to result in skin maceration (softening and whitening of skin surrounding a wound, caused by prolonged exposure to moisture, such as wound fluid, sweat, or urine) and an infection (the invasion and growth of germs in the body) to Resident 47's surgical site.Findings:a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain) affecting left dominant side, and type 2 diabetes mellitus (DM II - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications.During a review of Resident 12's History and Physical Examination (H&P), dated 3/11/2026, the H&P indicated Resident 12 had the capacity to understand and make decisions.During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 3/16/2026, the MDS indicated Resident 12's cognition (ability to think and process information) was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 12 was dependent (helper does all of the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 12's Order Summary Report (OSR), active orders as of 4/8/2026, the OSR did not indicate an order for Eucerin Advanced Repair Lotion, (an OTC dermatologist [skin doctor] -recommended, lightweight, fast absorbing body moisturizer designed to intensively repair very dry skin).During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with multiple diagnoses including need for assistance with personal care, and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 9's H&P, dated 3/25/2026, the H&P indicated Resident 9 had the capacity to understand and make decisions.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for ADL.During a review of Resident 9's OSR, active orders as of 4/8/2026, the OSR did not indicate an order for Gold Bond Medicated Original Strength Body Powder Anti-Itch Menthol 0.15% Triple Action Formula, (an OTC body powder used to treat minor skin irritations and relive itching).During a concurrent observation and interview on 4/7/2026 at 9:42 AM with Resident 12, inside Resident 12's room, Resident 12 had a 16.9 Fl. Oz. (fluid ounce - a measurement of volume) of Eucerin Advanced Repair Lotion, labeled with Resident 12's name. The lotion was located on top of Resident 12's nightstand. Resident 12 stated, Resident 12 was using the Eucerin lotion brought by Resident 12's mother (unidentified). Resident 12 stated the facility did not inform (educate) Resident 12 about OTC products.During an observation on 4/7/2026 at 10:08 AM inside Resident 9's room, an unlabeled 10 oz. of Gold Bond Medicated Original Strength Body Powder Anti-Itch Menthol 0.15% Triple Action Formula was located on top of Resident 9's nightstand.During a concurrent observation and interview on 4/8/2026 at 7:33 AM with Resident 9, inside Resident 9's room, Resident 9 had an unlabeled 10 oz. of Gold Bond Medicated Original Strength Body Powder Anti-Itch Menthol 0.15% Triple Action Formula on top of Resident 9's nightstand. Resident 9 stated, Resident 9 had been using the Gold Bond body powder for Resident 9's itching since admission to the facility. Resident 9 stated, Resident 9's son (unidentified) brought the Gold Bond body powder to the facility since the facility was out of Johnson's Baby Powder [a brand of baby powder]. Resident 9 stated Resident 9 did not have permission by the facility to use the Gold Bond body powder, but staff (unnamed) knew Resident 9 was using the Gold Bond body powder.During a concurrent interview and record review on 4/8/2026 at 7:57 AM with the Registered Nurse (RN), Resident 12 and Resident 9's medical records were reviewed. The RN stated, the Eucerin lotion and Gold Bond body powder were OTC products that the facility did not provide to Resident 12 and Resident 9. The RN stated a physician's order and a consent to self-administer OTC products were required for residents (in general) to ensure staff monitored residents for SE and to prevent sharing of OTC products with other residents. The RN stated Resident 12 and Resident 9 did not have a physician's order or consent to self-administer the OTC products. The RN stated, staff should be checking resident rooms for OTC products, when we do our rounds.During an interview on 4/9/2026 at 8:06 AM with the Director of Nursing (DON), the DON stated, obtaining a physician's order for OTC products was important to ensure the OTC products were allowed, ask the doctor if it's ok for residents to use.During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, revised December 2016, the P&P indicated, residents had the right to self-administer medications if the interdisciplinary team determined it was clinically appropriate and safe for the resident to do so. The P&P indicated, staff should identify and give to the charge nurse any medications found at the bedside that were not authorized for self-administration, for return to the family or responsible party.b. During a review of Resident 47's AR, the AR indicated, Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for other orthopedic (medical specialty dealing with conditions affecting the bones or muscles) aftercare, and displaced intertrochanteric fracture (type of a broken hip) of right femur (thigh bone), subsequent encounter for closed fracture (a broken bone that does not break the skin) with routine healing.During a review of Resident 47's Nurse Kardex (NK), dated 4/6/2026, from the General Acute Care Hospital (GACH), the NK indicated Resident 47 had surgery on 4/3/2026 for insertion nail intertrochanteric: intramedullary nailing of right intertrochanteric fracture (right) (fixing a broken hip on the right side by inserting a metal rod inside the thigh bone).During a review of Resident 47's admission Initial Eval (AIE), dated 4/6/2026, timed at 6:04 PM, the AIE indicated Resident 47 arrived at the facility on 4/6/2026 at 5:51 PM with two intact [not soiled] surgical dressings (a piece of material such as a pad applied to a wound to promote healing and protect the wound from further harm) on Resident 47's right hip. The AIE indicated multiple required admission care plans (CP) including a CP titled, Fracture Care Plan, indicating Resident 47 was at risk for further decline and incision infection. The CP's interventions indicated to change surgical incision dressing as per order and PRN (as needed).During a review of Resident 47's H&P, dated 4/8/2026, the H&P indicated Resident 47 did not have the capacity to understand and make decisions.During a concurrent observation and interview on 4/7/2026 at 10:21 AM with Resident 47 in Resident 47's room, Resident 47 was in bed, anxious, appeared uncomfortable, and fidgeted at times while pointing to Resident 47's right hip area. Resident 47 stated, Resident 47 did not feel, not too good. Resident 47's right hip area's surgical dressing was moderately (75%) saturated with red to serosanguineous [pink to light red] bloody drainage and the dressing's transparent clear cover was peeling off at the edges. Resident 47 stated, they didn't change it [surgical dressing].During a concurrent observation and interview on 4/7/2026 at 10:37 AM with Certified Nursing Assistant (CNA) 4, in Resident 47's room, Resident 47's right hip area's surgical dressing was moderately saturated, and the dressing's transparent clear cover was peeling off at the edges. CNA 4 stated, the surgical dressing needed to be changed, it's old, dirty.During a review of Resident 47's medical records on 4/8/2026 at 9:20 AM, there was no documented evidence indicating Resident 47's physician was notified of Resident 47's soiled dressing.During an interview on 4/8/2026 at 9:26 AM with the Treatment Nurse (TN), the TN stated orthopedic physicians (in general) usually did not want staff to remove the surgical dressing until the resident's (in general) follow-up appointment with the orthopedic physician. The TN stated Resident 47's surgical dressing was soiled, and staff should have notified Resident 47's physician (unidentified) to obtain an order to change the surgical dressing. The TN stated changing Resident 47's soiled surgical dressing was important to prevent infection and the risk of maceration. During an interview on 4/9/2026 at 8:06 AM with the Director of Nursing (DON), the DON stated assessing Resident 47's surgical dressing and verifying with the orthopedic physician was important because Resident 47 was newly admitted to the facility and Resident 47's surgical site [dressing] needed to be monitored.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, revised September 2012, the P&P indicated, to notify the supervisor and the Attending Physician of immediate needs the resident may have.

Based on observation, interview, and record review, the facility failed to provide appropriate interventions to prevent the development or worsening of existing pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony area that results in damage of underlying tissue) for two of two sampled residents (Residents 29 and 46) when:a. Resident 29's alternating pressure pump (APP - a device that inflates and deflates parts of a mattress to reduce pressure on the body and help prevent PIs, redistributing weight and improving circulation) was not set according to Resident 29's weight or Resident 29's comfort level.b. Resident 46's, who had multiple PIs, low air loss mattress (LALM, special type of mattress used for both the prevention and treatment of PI, prioritizes moisture control and temperature regulation to prevent skin breakdown) was not set to the correct setting.These failures had the potential to result in skin breakdown to Resident 29 and the potential to affect Resident 29's psychosocial well-being. Additionally, the failures had the potential to result in delayed wound healing, worsening of Resident 46's PIs, and the development of new PIs or skin breakdown to Resident 46. Findings: a. During a review of Resident 29's admission Record (AR), the AR indicated the facility admitted Resident 29 on 1/16/2026, and readmitted the resident on 2/21/2026, with diagnoses including moderate protein-calorie malnutrition (not getting enough nutrients and calories, leading to weight and muscle loss), muscle wasting and atrophy of the right upper arm (loss of muscle mass and strength in the right arm), muscle wasting and atrophy of the left upper arm, and need for assistance with personal care (requiring help with daily activities such as bathing, dressing, and hygiene). During a review of Resident 29's Skin care plan (CP), initiated 2/23/2026, the CP indicated Resident 29 was at risk for impaired skin integrity related to decreased mobility and had a redistribution/reduction mattress on the bed for prevention of skin breakdown as an intervention/task. During a review of Resident 29's Minimum Data Set (MDS- a resident assessment tool), dated 2/28/2026, the MDS indicated Resident 29's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 29 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was dependent on mobility. During an observation on 4/7/2026 at 12:53 PM, Resident 29's APP was set at 200 pounds (lbs.-a unit of weight). During an observation on 4/8/2026 at 10:45 AM, Resident 29's APP was set at 200 lbs. During an interview on 4/8/2026 at 10:47 AM with Resident 29, Resident 29 stated Resident 29's mattress was very firm and uncomfortable to lie on. Resident 29 stated staff never asked Resident 29 how the mattress firmness felt and did not adjust it to Resident 29's comfort level. Resident 29 stated Resident 29 remained uncomfortable while in bed and was not aware of any attempts, made by staff, to reassess the mattress setting or make adjustments despite Resident 29's discomfort. During a concurrent interview and record review on 4/8/2026 at 11:45 AM, Resident 29's Weights and Vitals Summary (WVS) was reviewed with the Treatment Nurse (TN). The WVS indicated Resident 29's most recent weight dated 4/7/2026 was 84 lbs. The TN stated the APP was used for prevention of skin breakdown by redistributing pressure. The TN stated that the mattress setting should always be adjusted to the resident's comfort level. The TN stated when the setting was set too high or too low, it could result in the opposite [desired] effect, increased pressure rather than relieving it, and reduced the therapeutic effect of the mattress. The TN stated setting the mattress at 200 lbs. for Resident 29 who weighed 84 lbs. could result in ineffective pressure redistribution and placed Resident 29 at increased risk for skin breakdown due to Resident 29's frail condition. The TN stated adjusting the mattress based on the resident's comfort level and weight optimized the therapeutic effect and supported the purpose of the APP in preventing skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 1/2020, the P&P indicates that it is the policy of this facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The P&P indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. During a review of the undated Alternating Pressure Pump & Bubble Pad User Manual Proactive, the user manual indicated please use pressure adjustable knob to give maximum patient comfort. b. During a review of Resident 46's AR, the AR indicated the facility originally admitted Resident 46 on 4/1/2026 with diagnoses including PI of right upper back stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness), PI of right upper back stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), PI of left upper back unstageable (the base of the wound is covered by dead tissue), PI of the sacral region (tailbone) stage 4, pressure induced deep tissue damage of sacral (large triangular bone at the base of the spine) region (an injury at the tailbone caused by prolonged pressure), PI of left buttock stage 4, and PI of right heel stage 1. During a review of Resident 46's History and Physical (H&P), dated 4/2/2026, the H&P indicated Resident 46 did not have the capacity to understand and make decisions. During a review of Resident 46's Order Summary Report (OSR), dated active as of 4/8/2026, the OSR indicated Resident 46 had a physician's order, dated 4/1/2026, for a pressure redistribution mattress-low air loss setting per weight range for wound care. During a review of Resident 46's CP titled Pressure Ulcer Care Plan, initiated 4/3/2026, the CP indicated Resident 46 was at risk for further impairment to skin integrity and delayed or slow [wound] closure. The CP's interventions indicated, Specialty bed-low air loss mattress setting per weight range and/or comfort level check function [every] shift. During a review of Resident 46's Treatment Administration Record (TAR), dated 4/1/2026-4/30/2026, the TAR indicated Resident 46's LALM weight range setting was to be checked three times a day [day, evening, and night shifts]. During a review of Resident 46's WVS, dated 4/8/2026, the summary indicated Resident 46 weighed 100 lbs. on 4/7/2026. During an observation on 4/8/2026 at 9:11 AM, Resident 46 was observed lying on Resident 46's left side on a LALM. The LALM control unit indicated the pressure dial was set to 250 lbs. During a concurrent interview and observation on 4/8/2026 at 1:40 PM with Certified Nursing Assistant (CNA) 1, Resident 46 was observed lying on Resident 46's back on a LALM. The LALM pressure dial was observed to be set at 250 lbs. CNA 1 stated CNA 1 was unsure if this was the correct setting for Resident 46. During a concurrent interview and observation on 4/8/2026 at 1:46 PM with the TN, Resident 46's LALM pressure dial was observed to be set at 250 lbs. The TN stated Resident 46 weighed 100 lbs. and the LALM should be set to 100. The TN stated the importance of setting the LALM correctly was to ensure Resident 46's wounds did not get worse. During a review of the facility's P&P titled, Prevention of Pressure Ulcers/Injuries, revised July 2017, the P&P's purpose indicated, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The P&P's preparation indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Additionally, the P&P indicated, Select appropriate support surfaces based [on] the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. During a review of the facility's undated Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, the user manual indicated the LALM had a control unit with a pressure dial that was adjustable to the patient's weight and comfort. The user manual's operation indicated users could adjust the pressure level of the air mattress using the analog pressure dial to a desired firmness based on personal comfort or weight setting.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in one of one kitchen (Kitchen 1) when:a. An opened package of cheese in the walk-in refrigerator was unlabeled and not marked with the open date.b. One of two shelving racks in the walk-in refrigerator had amber discoloration, peeling paint, and was not smooth to touch.c. The walk-in freezer was observed with food and debris on the ground.These failures had the potential to result in pests, foodborne illnesses (an illness from eating contaminated food), and cross-contamination (transfer of harmful bacteria from one place to another) placing residents (in general) at risk and significantly impacting the resident's health.Findings:a. During a concurrent observation and interview on 4/7/2026 at 8:45 AM with the Director of Dietary Services (DDS), in Kitchen 1's walk-in refrigerator, there was an unlabeled opened package of cotija cheese, no open date was observed. The DDS stated the cotija cheese did not indicate when it was opened and the opened bag should be marked (labeled) with an open date.b. During a concurrent observation and interview on 4/7/2026 at 8:45 AM with the DDS, in Kitchen 1's walk-in refrigerator, one of two shelving racks was observed with amber discoloration, peeling blue paint, and was not smooth to touch. An unsealed box of lettuce located below the shelf was observed with peeling paint. The DDS stated the chipped paint from the shelving unit could fall onto the lettuce below.c. During a concurrent observation and interview on 4/7/2026 at 9 AM with the DDS in Kitchen 1's walk-in freezer, food and debris were observed on the ground. The DDS stated there was a breadstick on the floor, the DDS picked up the breadstick and threw it away in the trash. The DDS stated the walk-in freezer [should be clean] and was cleaned daily.During an interview on 4/9/2026 at 10:43 AM with the Registered Dietician (RD) 2, RD 2 stated it was concerning to have flaking shelves because the paint could contaminate open food. RD 2 stated it was important to keep the walk-in freezer floors clean to prevent pests and dangerous slipping hazards for employees. Additionally, RD 2 stated it was important for all open foods to be marked (labeled) with an open date to ensure the food was still useful to serve.During a review of the facility's undated Policy and Procedure (P&P) titled, Kitchen and Kitchen Equipment Policy, the P&P's general work areas indicated all shelves, drawers, and cabinets should be clean, in good repair, and not rusted. The P&P's cold storage indicated the freezer should be clean with no food on the floor. Additionally, the P&P indicated food should be covered, labeled, dated with received or use by dates and open dates.

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices when:a. Certified Nursing Assistants (CNA) 3 and CNA 5 failed to don (put on) proper PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while taking care for one of six sampled residents (Resident 5) who was on EBP (enhanced barrier precautions - an infection-control practice to prevent the spread of bacteria in nursing homes)b. One of one sampled staff (LA, Laundry Attendant) failed to store LA's personal belongings away from the clean area of the facility's laundry room.c. The Infection Preventionist (IP) failed to keep accurate Flu (influenza - a contagious infection of the nose, throat, and lungs) vaccination (immunization - a simple, safe, and effective way of protecting you against harmful diseases/infections) records for two of four sampled staff (MDS Nurse [MDSN] and CNA 6).These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to the residents residing at the facility including Resident 5.Findings:a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and pressure ulcer of sacral region, stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).During a review of Resident 5's History of Present Examination (H&P), dated 2/23/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 5's cognitive skills for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 5 was dependent (helper does all of the effort) to requiring partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility including being dependent with chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair [or wheelchair]). The MDS indicated Resident 5 had one or more unhealed pressure ulcers/injuries and diabetic foot ulcer(s).During an observation on 4/7/2026 at 9:35 AM, there was an EBP signage and a sticker indicating 6 resident care activities posted outside by Resident 5's room door and a clear colored black trimmed 3-drawer PPE cart located at the entrance of Resident 5's room. During an observation on 4/7/2026 at 10:02 AM, CNA 3 was wearing a surgical mask entered Resident 5's room without donning a gown and started cleaning up Resident 5.During a concurrent interview and record review on 4/7/2026 at 10:17 AM with CNA 3, the EBP signage posted outside of Resident 5's door was reviewed. CNA 3 stated Resident 5 was on EBP due to the wound on his bottom. CNA 3 stated wearing gown and gloves when providing [direct resident] care to Resident 5 was important for the safety of not spreading the stuff, infection, for infection control.During a concurrent observation and interview on 4/7/2026 at 4:03 PM with the IP, inside Resident 5's room, CNA 5 was not wearing PPE and was assisting Resident 5 to get Resident 5 ready to be transferred to the wheelchair and to be showered. CNA 3 entered Resident 5's room wearing PPE and assisted CNA 5 with Resident 5's transfer. CNA 5 proceeded to transport Resident 5 to the shower room. The IP stated, Resident 5 had a wound on the left and right heel and was on EBP. The IP stated, donning PPE like gown and gloves was important to prevent transmission of MDROs (Multi-Drug Resistant Organisms - superbug or a germ [bacteria] that become resistant to certain antibiotics [medicine used to treat infections caused by bacteria]), for infection control.During a review of the facility's undated policy and procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated EBP were utilized to prevent the spread and transmission of MDROs to residents in long-term care facilities. The P&P indicated gloves and gowns were applied prior to performing high contact resident activities that included: dressing a resident, transferring resident, changing linens and changing briefs or assisting with toileting. The P&P indicated EBPs were indicated for residents with unhealed wounds, pressure injuries, or diabetic ulcers.b. During a concurrent observation and interview on 4/9/2026 at 11:43 AM with the LA in the laundry room, an open shelving in the clean area of the laundry room there were packages of newly ordered bath towels, and a stack of laundered folded bath sheets open to air stored on the third (3rd) shelf. The second (2nd) shelf above the 3rd shelf had non- laundry items including multiple office supplies, a personal bag, a dark blue colored reusable tumbler, a make-up pouch, a Ziploc bag of condiments, a red colored plastic drinking cup with a lid, and an empty rectangular glass food storage container. The LA stated the nonlaundry items on the 3rd shelf belonged to the LA. The LA stated storing and separating staff personal items away from the clean laundry was important to prevent cross contamination and for infection control.During an interview on 4/9/2026 at 12:28 PM with the Assistant Infection Preventionist (AIP), the AIP stated staff personal belongings should be separated from the clean laundry to prevent cross contamination and for infection control.During a review of the facility's P&P titled, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, the P&P indicated the purpose of the P&P was to provide a process for the safe and aseptic handling, washing, and storage of linen. The P&P indicated, clean linen would remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination.c. During a concurrent interview and record review on 4/9/2026 at 1:51 PM with the IP, in the presence of the AIP, the facility's undated vaccination CNA Tracking (CTK), Licensed Tracking (LTK), CNA 6 and MDSN's Influenza Vaccine - Staff Consent and Administration (IVC), were reviewed. The CTK and LTK indicated a R for the Flu vaccine for CNA 6 and the MDSN. The IP stated, the R indicated, the staff refused the vaccine. CNA 6's IVC, dated and signed 1/9/2025 was not complete. The MDSN's IVC, dated and signed 10/2/2025 indicated the MDSN already received this season's annual influenza vaccine. The IP stated, the MDSN never received the flu vaccine for this season's annual influenza.During a phone interview on 4/9/2026 at 2:05 PM with CNA 6, CNA 6 stated CNA 6 wanted the Flu vaccine but received the vaccine early this year (did not remember date), at CVS (the U.S. largest pharmacy chain that also sells a wide assortment of general merchandise) and not at the facility.During an interview on 4/9/2026 at 2:21 PM with the MDSN, the MDSN stated the MDSN did not get the Flu vaccine for this flu season. The MDSN stated, the MDSN got confused with the flu season dates but only received the flu vaccine for the previous flu season.During an interview on 4/9/2026 at 2:26 PM with the IP, the IP stated the IP checked CAIR (California Immunization Registry - a secure, confidential, statewide computerized system that stores immunization records for California residents) and CNA 6 did not receive the flu vaccine. The IP stated ensuring the staff's Flu vaccination record was accurate and the IP following through was important to lessen the infection rate of flu and for the protection of the residents (in general). During a review of the facility's P&P titled, Infection Prevention and Control Program, revised October 2018, the P&P indicated an infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During a review of the facility's P&P titled, Influenza Vaccine, revised March 2022, the P&P indicated all residents and employees who have no medical contraindications to the vaccine would be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The P&P indicated if an employee refused the vaccine for reasons other than medical contraindication, this should be documented on the employee consent for influenza vaccine. The P&P indicated, the infection preventionist would maintain surveillance data on influenza vaccine coverage.

Based on interview and record review, the facility's licensed staff failed to obtain and/or ensure an accurate informed consent for the administration of a psychotropic medication, (a drug that affects the brain and changes how an individual feels, thinks, or behaves) alprazolam (Xanax, a medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations] and panic disorders [treatable anxiety disorder characterized by recurrent, unexpected panic attacks - sudden episodes of intense fear accompanied by physical symptoms like a racing heart, dizziness, and shortness of breath] by calming the brain and nerves), was obtained prior to the medication's administration for one of one sampled resident (Resident 15).This deficient practice violated Resident 15's and/or Resident 15's representative right to be fully informed of the purpose, risks, and benefits of the medication and violated the right to make informed decisions about Resident 15's psychiatric treatment.Findings:During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 2/16/2026, with diagnoses including, anxiety disorder, major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest), and chronic kidney disease (when the kidneys are damaged and gradually lose the ability to filter waste and extra fluid from the blood over a long period, usually months or years).During a review of Resident 15's Psychotropic Consent (PC), dated 2/16/2026, the PC indicated an informed consent was obtained on 2/16/2026, for lorazepam (Ativan, a benzodiazepine [medication used to reduce anxiety and help a person feel calm and relaxed by slowing down activity in the brain]) 0.5 mg (mg-a unit used to measure amount) three times a day.During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 15's cognition (the ability to think and process information) was intact. The MDS indicated Resident 15 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and was dependent (helper does all of the effort) with mobility.During a review of Resident 15's Order Summary Report (OSR), dated active as of 4/8/2026, the OSR indicated a physician's order, dated 2/16/2026, for alprazolam 0.5 mg PO (oral), 1 tablet by mouth three times a day for anxiety manifested by verbalization of feeling anxious related to medical conditions. The order's start date indicated 2/17/2026.During a review of Resident 15's Medication Administration Records (MAR), dated 2/2026, 3/2026, and 4/2026, the MARs indicated the following: February 2026: Resident 15 was administered alprazolam 0.5 mg from 2/17/2026 through 2/28/2026. March 2026: Resident 15 was administered alprazolam 0.5 mg from 3/1/2026 through 3/31/2026. April 2026: Resident 15 was administered alprazolam 0.5 mg from 4/1/2026 through 4/8/2026.During an interview and concurrent record review on 4/8/2026 at 2:50 PM, Resident 15's PC, OSR, and MARs were reviewed with the Registered Nurse (RN). The RN stated based on Resident 15's OSR and MAR, Resident 15 was first administered alprazolam on 2/17/2026 upon Resident 15's admission. The RN stated the order for alprazolam remained active and Resident 15 continued to receive the medication at the time of review. The RN stated Resident 15's OSR did not indicate an order for lorazepam [Ativan] and the informed consent on file was completed for lorazepam instead of alprazolam. The RN confirmed that the psychotropic medication consent was not accurately completed, and a consent should have been obtained specifically for alprazolam prior to administration of the medication. The RN stated an informed consent must include the correct medication name, dosage, frequency, and indication to ensure the resident and/or responsible party (in general) are fully informed of the treatment, including risks, benefits, and alternatives. The RN stated failure to obtain accurate informed consents may result in the resident receiving medication without proper authorization and understanding, potentially impacting the resident's rights and ability to make informed decisions regarding care.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Medication Use, dated 3/2026, the P&P indicated that Informed consent will be obtained for new admissions, new psychotherapeutic drug orders, and dosage changes, and will be renewed at least every six months while the resident remains on the medication.

Based on interview and record review, the facility failed to ensure one of two sampled residents' (Resident 27) assessment accurately reflected Resident 27's status in the Minimum Data Set (MDS - a resident assessment tool).This deficient practice could potentially result in compromised care to Resident 27 and the potential for Resident 27 not to receive the necessary care and services according to Resident 27's specific needs and due to improper care planning.Findings:During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) kidney failure and urinary tract infection (UTI - an infection [the invasion and growth of germs in the body] in the bladder/urinary tract), site not specified.During a review of Resident 27's admission Initial Eval (AIE), dated 1/5/2026, timed at 8:22 PM, the AIE indicated Resident 27 did not have an active infection and was not on antibiotic (a powerful medicine used to treat infections caused by bacteria) therapy. The AIE indicated, Resident 27 did not require a care plan (CP) for an infection or a UTI.During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27's cognitive skills (ability to think and process information) were intact (decisions consistent/reasonable). The MDS indicated Resident 27 was dependent (helper does all of the effort) requiring supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS's Section I-Active Diagnoses indicated Resident 27 had a UTI in the last thirty (30) days.During a review of Resident 27's History & Physical Examination (H&P), dated 2/1/2026, the H&P indicated, Resident 27 had the capacity to understand and make decisions.During an interview on 4/7/2026 at 9:56 AM with Resident 27, Resident 27 stated Resident 27 did not have a UTI and was not treated for UTI while at the facility.During a concurrent interview and record review on 4/8/2026 at 8:48 AM with the MDS Nurse (MDSN), Resident 27's MDS, dated [DATE] and 2/8/2026 were reviewed. The MDS indicated, Section I-Active Diagnoses included UTI in the last thirty (30) days. The MDSN stated, an MDS included the resident's (in general) data and assessments and was submitted to CMS (Centers for Medicare & Medicaid Services - U.S. federal agency that provides health coverage) [for review]. The MDSN stated the MDSN obtained a resident's data and assessment from the resident's medical records, admission paperwork, information [collected] from different disciplines (e.g. rehabilitation, dietary), and from visually assessing and interviewing the resident. The MDSN stated UTI was coded since UTI was a part of Resident 27's admitting diagnoses. The MDSN stated Resident 27's MDS dated [DATE] that was submitted to CMS on 3/2/2026 should not have been coded for UTI, that was an error, because Resident 27 no longer had an active UTI and was never treated for a UTI at the facility. The MDSN stated the facility continued to monitor Resident 27 for UTIs. The MDSN stated submitting an accurate MDS was important since the MDS, paints the picture of the patient [resident's assessment] to CMS.During an interview on 4/9/2026 at 8:06 AM with the Director of Nursing (DON), the DON stated, the MDS was an assessment for every resident that the facility was mandated to conduct and was the basis for the resident's plan of care. The DON stated, ensuring the MDS was accurate was important for CMS's way of tracking all sorts of information, about the resident.During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, date revised November 2019, the P&P indicated the Resident Assessment Coordinator was responsible for ensuring that the Interdisciplinary Team (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) conducted timely and appropriate resident assessments. The P&P indicated all persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to the accuracy of such information.

Based on interview and record review, the facility failed to promptly notify Resident 1's doctor of Resident 1's complaint of pain and feeling that Resident 1's right hip was dislocated. This failure had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation. (Cross Reference F552, F755, F806, and F842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal, and oral hygiene, and dressing. During a review of Resident 1's History and Physical Examination (H&P), dated 9/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a telephone interview on 12/5/2025 at 12:10 PM with Resident 1, Resident 1 stated that on 9/30/2025 at 5 AM, resident woke up and realized Resident 1 did not have the abductor pillow (a foam wedge placed between the thighs to keep legs aligned, preventing painful hip dislocation after surgery) between Resident 1's legs. Resident 1 stated Resident 1 reached over to grab the abductor pillow that was next to the bed. Resident 1 stated Resident 1 heard a pop and had instant pain to the right hip. Resident 1 stated Resident 1 had dislocated Resident 1's right hip. Resident 1 stated the facility should have sent Resident 1 to the hospital at that time. Resident 1 stated Resident 1 was not sent to a GACH until 10/1/2025.During a concurrent interview and record review on12/9/2025 at 10:38 AM with LVN 2, Resident 1's elNTERACT Change in Condition Evaluation (CIC), dated 9/30/2025 and timed 6:14 AM, was reviewed. The CIC was signed by Licensed Vocational Nurse (LVN) 2 on 10/1/2025. The CIC indicated, During med pass, patient (Resident 1) verbalized pain to right hip.pt (Resident 1) verbalized possible dislocation to right hip . LVN 2 stated LVN 2 texted Resident 1's Attending Physician (DR 1) but that DR 1 did not respond during LVN's remaining shift. LVN 2 stated LVN 2 did not try to contact DR 1 again on LVN 2's shift. LVN 2 stated LVN 2 left the facility at 7:00 AM on 9/30/2025.During a concurrent observation and interview on 12/10/2025 at 9:43 AM with Registered Nurse (RN) 1, the facility's Nurses Station iPhone was observed. RN 1 pulled up a text message that was sent to DR 1 on 9/30/2025 at 5:43 AM. The text message indicated, Pt (Resident 1) is verbalizing feels like hip has popped out of place, in a lot of pain.Patient (Resident 1) wants to be transferred to ER. Can we send? RN 1 confirmed DR 1 did not respond to the text message. RN 1 stated LVN 2 should have tried to contact DR 1 again after 1/2 hour. RN 1 stated the facility should have tried to contact the medical director if DR 1 did not respond.During a telephone interview on 12/10/2025 at 10:23 AM with DR 1, DR 1 stated, after looking at Dr 1's text messages from 9/30/2025, DR 1 did not receive the text message sent from the facility's iPhone at 5:43 AM. DR 1 stated DR 1 would have given an order to send Resident 1 to a GACH if he had received the text. DR 1 stated DR 1 ordered an Xray for Resident 1 when the facility notified DR 1 that Resident 1felt like Resident 1's hip was dislocated. During a review of Resident 1's Progress Notes dated 11/8/20256, the PN indicated DR 1 was made aware on 9/30/2025 at 2:33 PM, that Resident 1's had complaint in the previous shift of feeling Resident 1's hip had popped out of place. The PN indicated DR 1 ordered a right hip Xray.During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revised July 2017, the P&P indicated, The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less).The attending physician (or a practitioner providing backup coverage) will respond.in a timely manner to notification of problems or changes in condition and status.The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when:a. Licensed Vocational Nurse (LVN) 2 failed to document Resident 1's acute condition change on 9/30/2025.b. LVN 2 documentation regarding Resident 1's acute condition change, which was recorded on 10/1/2025, contained inaccurate information. This failure resulted in Resident 1's medical record to contain inaccurate information, Registered Nurse (RN) 1 to not be aware of Resident 1's acute condition change, and had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation (a medical emergency where the thigh bone pops out of the hip socket).(Cross reference F552, F580, F755, and F806)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip, and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal, and oral hygiene, and dressing. During a review of Resident 1's History and Physical Examination (H&P), dated 9/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a telephone interview on 12/5/2025 at 12:10 PM with Resident 1, Resident 1 stated that on 9/30/2025 at 5 AM, resident woke up and realized Resident 1 did not have the abductor pillow (a foam wedge placed between the thighs to keep legs aligned, preventing painful hip dislocation after surgery) between Resident 1's legs. Resident 1 stated Resident 1 reached over to grab the abductor pillow that was next to the bed. Resident 1 stated Resident 1 heard a pop and had instant pain to the right hip. Resident 1 stated Resident 1 had dislocated Resident 1's right hip. During a concurrent interview and record review on12/9/2025 at 10:38 AM with LVN 2, Resident 1's elNTERACT Change in Condition Evaluation (CIC), dated 9/30/2025 and timed 6:14 AM, was reviewed. The CIC was signed by LVN 2 on 10/1/2025. The CIC indicated, pt (Resident 1) verbalized pain to right hip and possible dislocation. The CIC inaccurately indicated the event started on 10/1/2025. The CIC indicated, During med pass, patient (Resident 1) verbalized pain to right hip.pt (Resident 1) verbalized possible dislocation to right hip . LVN 2 stated the event happened on 9/30/25 early in the morning. LVN 2 stated LVN 2 texted Resident 1's Attending Physician (DR 1) but that DR 1 did not respond during LVN 2's remaining shift. LVN 2 stated LVN 2 did not create the CIC document until LVN 2's worked the next shift, on 10/1/2025. The CIC inaccurately indicated DR 1 was made aware of the incident on 9/30/2025 at 5:44 AM.During an interview on 12/10/2025 at 9:43 AM with Registered Nurse (RN) 1, RN 1 stated RN 1 was the RN supervisor who worked the morning shift after LVN 2 went home. RN 1 stated LVN 2 did not give report to RN 1 about Resident 1's complaint of pain and possible hip dislocation. RN 1 stated RN 1 was also not aware of the situation because LVN 2 did not complete a CIC before LVN 2 left the facility at the end of the shift.During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revised July 2017, the P&P indicated, .the nurse shall assess and document/report the following baseline information:a. Vital signs;b. Neurological status;c. Current level of pain, and any recent changes in pain level;d. Level of consciousness;e. Cognitive and emotional status;f. Resident's age and sex;g. Onset, duration, severity;h. Recent labs;i. History of psychiatric disturbances, mental illness, depression, etc.;j. All active diagnoses; andk. All current medications.During a review of the facility's P&P titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was treated with dignity and respect when Licensed Vocational Nurse (LVN) 1 made Resident 4 use a bedpan (a shallow, portable receptacle shaped like a toilet bowl, used as a toilet by people who are too ill, injured, or immobile to get out of bed to use a regular toilet for urination or defecation) instead of assisting Resident 4 to the toilet in the bathroom.This failure made Resident 4 verbalized Do they (staff) wanted me (Resident 1) to die and had the potential to result in Resident 4 feeling disrespected and had the potential for Resident 4 experience a decline in psychosocial well-being.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on [DATE] with diagnoses including abnormalities of gait (manner of walking or moving on foot) and mobility (ability to move), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased mass and strength), and need for assistance with personal care.During a review of Resident 4's History and Physical Examination (H&P), dated [DATE], the H&P indicated, Resident 4 could make needs known but could not make medical decisions.During an interview on [DATE], at 2:21 PM with Resident 4's Caregiver (CG 1), CG 1 stated that on [DATE] at 1 AM, CG 1 asked the facility staff to assist Resident 4 to use the bathroom. CG 1 stated LVN 1 instructed the unidentified Certified Nursing Assistant (CNA) to assist Resident 4 in using a bedpan. CG 1 stated CG 1 told LVN 1 Resident 1 had been getting out of bed and using the toilet in the bathroom. CG 1 stated LVN 1 claimed the night shift was low staffed so Resident 4 would have to use a bedpan instead of going to the bathroom to use the toilet. GC 1 stated the facility staff (unidentified) placed Resident 4 on a bedpan and refused to let Resident 4 use the toilet in the bathroom. CG 1 stated Resident 4 did not want to use the bedpan. CG 1 stated Resident 4 stated, What are you doing, why are you hurting me?During a concurrent interview and record review on [DATE] at 1:31 PM with the Director of Rehab (DOR), Resident 4's Care Plan Report (CPR), undated was reviewed. The CPR indicated on [DATE], a care plan was initiated to address Resident 4's mobility and safety. The care plan indicated CNAs (in general) should use 2 staff persons when transferring Resident 4. The DOR stated the physical Therapist (PT) (in general) assessed Resident 4 and indicated in the care plan how to safely transfer Resident 4 in and out of bed. The DOR stated the instructions from PT to nursing was for nursing staff (in general) to use a 2 person assist when transferring Resident 4 in and out of the bed. The DOR stated Resident 4 was safe to get out of bed if there were two people assisting Resident 4.During a telephone interview on [DATE] at 3:01 PM with LVN 1, LVN 1 stated LVN 1 instructed the CNA's (unidentified) to put Resident 4 on a bedpan during the night shift, on [DATE]. LVN 4 confirmed that CG 1 requested for Resident 4 to get out of bed and use the toilet. LVN 1 stated LVN 1 chose to make Resident 4 use a bedpan instead because Resident 4 required 2 staff persons to assist Resident 4 for transfers from the bed. During a concurrent interview and record review on [DATE] at 10:16 AM with the Director of Staff Development (DSD), Resident 4's Kardex Report (KR), undated, was reviewed. The KR indicated Resident 4 was 2 persons assist for transfers. The DSD stated LVN 1 should have allowed Resident 4 to get out of bed to use the toilet. The DSD stated the facility was not short staffed at nighttime or any shift. The DSD stated it was Resident 4's right to get out of bed to use the toilet. The DSD stated allowing the residents (in general) to use the toilet also protected the residents (in general) dignity.During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, revised February 2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, .Demeaning -practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example. promptly responding to a resident's request for toileting assistance.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was notified when Resident 1's medication was changed from tramadol (a medication used to treat pain) to norco (a medication used to treat pain) on 9/11/2025.This failure resulted in the violation of Resident 1's right to be informed of Resident 1's treatment for pain and had the potential in Resident 1 to experience unrelieved pain. (Cross Reference F580, F755, F806, and 5842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal, and oral hygiene, and dressing. During a review of Resident 1's History and Physical Examination (H&P), dated 9/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a telephone interview on 12/5/2025 at 12:10 PM with Resident 1, Resident 1 stated Resident 1 received Tramadol for pain while Resident 1 was at GACH 1. Resident 1 stated Resident 1 was transferred from GACH 1 to the facility. Resident 1 stated Resident 1 received pain medication during Resident 1's stay at the facility. Resident 1 stated Resident 1 thought Resident 1 had been receiving tramadol when Resident 1 requested pain medication. Resident 1 stated Resident 1 discovered Resident 1 had been given Norco and not tramadol when Resident 1 requested pain medication while at the facility. Resident 1 stated the nurses (unidentified) did not inform Resident 1 that the pain medication Resident 1 was given was Norco. During a concurrent interview and record review on 12/11/2025 at 9:19 AM with Registered Nurse (RN) 1, Resident 1's Discharge/Transfer Documentation (DTD), dated 9/10/2025, and Resident 1's physician orders, untitled, dated 9/10/25 and 9/11/2025 were reviewed. The DTD indicated Resident 1 had the following order while at GACH 1: Tramadol 50 milligram (mg, a unit of measurement) oral tablet every 12 hours as needed for pain. The DTD indicated Resident 1 should continue to take tramadol for pain while at the facility. A physician order dated 9/10/2025 indicated Resident 1 would continue to receive Tramadol as needed for pain while at the facility. A physician order, dated 9/11/2025, indicated the order for tramadol was changed for Norco on 9/11/2025 at 1:27 PM. RN 1 stated when a resident's (in general) pain medication is changed, the Resident (in general) should be notified, and the notification should be documented in the resident's (in general) medical record. RN 1 confirmed Resident 1's medical record failed to indicate Resident 1 was notified of the changed order for pain medication. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised December 2016, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) food allergy to bananas was:a. documented in Resident 1's assessment notes according to the facility's Policy and Procedure (P&P), titled Food Allergies and Intolerances, revised August 2017.b. Indicated on Resident 1's tray card (or tray ticket/meal ticket, a document that accompanies a resident's meal tray during preparation and delivery) according to the facility's P&P, titled Dietary Tray Card, revised 3/21/2024.These failures had the potential for Resident 1 to experience an allergic reaction to bananas.(Cross Reference F552, F580, F755, and F842)Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal and oral hygiene, and dressing. During a review of Resident 1's History and Physical Examination (H&P), dated 9/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Skilled Nursing - Nutrition Risk Review Form (NRR), dated 9/11/2025, the NRR failed to indicate Resident 1 was allergic to bananas. During a review of Resident 1's Skilled Nursing - admission Initial Eval (AIE), the AIE failed to indicate Resident 1 was allergic to bananas. During a telephone interview on 12/5/2025 at 12:10 PM with Resident 1, Resident 1 stated Resident 1 was allergic to bananas. Resident 1 stated Resident 1's mouth would swell if Resident 1 ate bananas. Resident 1 stated the meal slip on Resident 1's meal trays listed bananas as a dislike. Resident 1 stated the allergy section on the meal slip was blank. During a concurrent interview and record review on12/10/2025 at 1:00 PM with the Dietary Supervisor, Resident 1's Skilled Nursing - Dietary Pre-Screen Eval (DPS), dated 9/11/2025, and Resident 1's untitled Tray Ticket document (TTD), undated, were reviewed. Both documents (DPS and TTD), failed to indicate Resident 1 had an allergy to bananas. The DS stated the DS was responsible to fill out the DPS and to update the TTD with Resident 1's allergies. The DS stated the TTD was the program used to create tray tickets that are placed on each resident's (in general) meal trays. The DS stated Resident 1 informed the DS that Resident 1 had an allergy to bananas in 10/11/2025. The DS stated the document would not let the DS put banana in the allergy fields, so the DS listed banana as a dislike. The DS stated allergies should be listed for safety of residents (in general). The DS stated the kitchen staff (in general) look at tray tickets when preparing meal trays for the residents (in general). During a review of the facility's P&P, titled Food Allergies and Intolerances, revised August 2017, the P&P indicated, Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment.All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. During a review of the facility's P&P, titled Dietary Tray Card, revised 3/21/2024, the P&P indicated, The Food and Nutrition Services Department should maintain a tray card system in order to record dietary information necessary to use on the resident's tray card. The P&P indicated, The tray card should contain the following information on each resident.Any known allergies.

Based on interview and record review, the facility failed to provide routine drugs for one of three sampled residents (Resident 1) when Resident 1 was not provided scheduled medications on 9/10/2025 at 9:00 PM. This failure had the potential to result in Resident 1 experiencing increased pain due to neuropathy (damage or dysfunction of nerves).(Cross Reference F552, F580, F806, and F842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal, and oral hygiene, and dressing. During a review of Resident 1's History and Physical Examination (H&P), dated 9/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a concurrent interview and record review on 12/11/2025 at 9:19 AM with Registered Nurse (RN) 1, Resident 1's Discharge/Transfer Documentation (DTD), dated 9/10/2025, and Resident 1's physician orders, untitled, dated 9/10/25 and 9/11/2025 were reviewed. The DTD indicated Resident 1 had orders for the following medications while at GACH 1: 1. bupropion SR (a medication used to treat depression) 150 milligram (mg, a unit of measurement) 12-hour by mouth (oral) tablet twice a day (BID)2. gabapentin (a medication used to treat neuropathy) 300 mg 1 cap oral three times a dayThe DTD indicated the next doses to be given for both medications was due 9/10/25 at 9:00 PM. RN 1 stated Resident 1 was admitted to the facility on [DATE] at 4:15 PM. RN 1 stated Resident 1 did not get the bupropion SR or gabapentin until the next day because the pharmacy does not process the medication until the following day. During an interview on 12/11/2025 at 11:06 AM with the Director of Nursing (DON), the DON stated Resident 1's medical record did not contain any documentation regarding a discussion with Resident 1's attending physician if the bupropion SR and gabapentin could be started the next day on 9/11/2025 and not given on 9/10/2025 at 9:00 PM. During a review of the facility's policy and procedure (P&P) titled, Providing Pharmacy Products and Services, revised 1/2/2013, the P&P indicated, If a medication cannot be substituted ask Physician/Prescriber if the medication therapy can be initiated the next morning. If it is possible to initiate the medication therapy the next morning, facility staff should document the conversation with the prescriber and include the start time in the order.

Based on interview and record review, the facility failed to provide care and services needed for one of three sampled residents (Resident 2), who required dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) by failing to ensure Resident 2 was provided with a means of transportation to and from dialysis treatments three times a week between 7/25/2025 and 8/13/2025. As a result of this failure, Resident 2 did not receive nine (7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/13/2025) dialysis treatments. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 8/13/2025 at 9:30 pm. Resident 1 was diagnosed with metabolic acidosis (condition where the body produces too many acids or cannot eliminate them effectively, leading to a decrease in blood pH [acidity], uremia (the build-up of urea [an organic chemical waste product that is produced in the liver and filtered from the blood by the kidneys to be excreted in urine] and other waste products in the blood due to kidney failure), and abdominal pain. Resident 2 was admitted to GACH 1 for dialysis. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/15/2025 and was readmitted on [DATE] with diagnoses that included dependence on renal (kidney) dialysis, unspecified chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as a source of energy). During a review of Resident 2's Order Summary Report (OSR), dated 8/13/2025, the OSR indicated Resident 2 had a physician's order to have dialysis Mondays, Wednesdays, Fridays at 1:15 pm. For transportation to dialysis, the OSR indicated Resident 2's husband would pick up Resident 2. The OSR indicated Resident 2's primary care provider/Medical Doctor (MD) 1 reviewed and approved the plan of care and certified that Resident 2 continued to need this level of care unless otherwise specified and to continue orders for 45 days. During a review of Resident 2's History and Physical (H&P), dated 7/16/2025 and timed at 1:36 pm, the H&P indicated Resident 2 had end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). The H&P indicated Resident 2 was receiving hemodialysis (dialysis) three times per week and to continue current schedule. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 7/22/2025, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 2 required dialysis and had renal insufficiency (improperly functioning kidneys), renal failure, or ESRD. The MDS indicated Resident 1 was dependent (helper does ALL the effort) on others for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) with chair/bed-to-chair transfers. The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to standing, car transfers and walking 10 feet. During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 7/19/2025, the SBAR indicated Resident 2 missed dialysis. The SBAR indicated Medical Doctor (MD) 1 (primary physician for Resident 2) was informed that Resident 2 missed dialysis. The SBAR indicated Registered Nurse (RN) 2, was unable to reschedule Resident 2's dialysis due to insurance. The SBAR indicated MD 1 was informed with no new orders. During a review of Resident 2's SBAR, dated 7/28/2025, the SBAR indicated Resident 2 missed dialysis due to transportation issues. The SBAR indicated MD 1 was informed that Resident 2 missed dialysis and MD 1 ordered to continue monitoring Resident 2 for fluid overload or fluid retention, for fatigue, muscle cramps, loss of appetite, and mental changes. During a review of Resident 2's PN, dated 8/7/2025 and timed at 8:21 pm, the PN indicated Resident 2 was monitored for fluid retention due to not going to dialysis. During a review of Resident 2's PN, dated 8/8/2025 and timed at 11:50 pm, the PN indicated Resident 2 was monitored for fluid retention and for elevated BUN and creatinine due to missing dialysis. During a review of Resident 2's PN, dated 8/9/2025 and timed at 7:18 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis. During a review of Resident 2's PN, dated 8/10/2025 and timed at 9:36 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis. During a review of Resident 2's SBAR, dated 8/11/2025, the SBAR indicated Registered Nurse (RN) 1 received a call from the laboratory regarding Resident 2's abnormal BUN of 79 and creatinine of 8.4. The SBAR indicated RN 1 informed MD 1 regarding Resident 2's abnormal BUN and creatinine levels and MD 1 ordered for Resident 2 to see a nephrologist (a medical doctor who specializes in diagnosing and treating kidney diseases). The SBAR also indicated the last time Resident 2 had dialysis was on 7/23/2025. During a review of Resident 2's laboratory results, dated 8/11/2025, the laboratory results indicated Resident 2's BUN level was 79 mg/dl and creatinine level was 8.4 mg/dl. During a review of Resident 2's Progress Note (PN), dated 8/13/2025 and time at 7:58 pm, the PN indicated Resident 2 was being monitored for fluid retention or any change of condition due to not going to dialysis and for elevated blood urea nitrogen (BUN - medical test that measures the amount of urea in the blood. Normal level range is 6 to 24 milligrams per deciliter [mg/dl]) of 79 mg/dl and creatinine (waste product from muscle and protein breakdown that healthy kidneys filter from the blood and remove through urine. Normal level range for women is 0.6 to 1.1 mg/dl) and creatinine of 8.4 mg/dl. During a review of Resident 2's PN, dated 8/13/2025 and timed at 9:30 pm, the PN indicated Resident 2 was transferred to GACH 1 via ambulance due to missed dialysis. During a review of Resident 2's PN, dated 8/12/2025 and timed at 3:59 am, the PN indicated Resident 2 was being monitored for fluid retention and for elevated BUN and creatinine. During a review of Resident 2's GACH 1 H&P, dated 8/14/2025, the H&P indicated Resident 2 had left-sided flank (on the side of the body between the ribs and the hip) pain with nausea for 1 week and was found to have metabolic likely due to missed hemodialysis (dialysis). During an interview on 8/29/2025 at 11:06 am with the Director of Nursing (DON), the DON stated when Resident 2 was admitted to the facility, the facility assumed responsibility for Resident 2's care and was responsible for providing Resident 2's transportation to dialysis. During an interview on 8/29/2025 at 11:11 am with MD 1, MD 1 stated a BUN level of 79 and a creatinine level of 8.4 indicated Resident 2 needed dialysis. MD 1 stated MD 1 was not sure if MD 1 recommended for Resident 2 to be dialyzed with a BUN of 79 and a creatinine of 8.4.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Residents 7, 27, and 83) and/or their Responsible Parities (RP) were offered and provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only goes into effect if the resident cannot communicate their wishes). This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making and the potential for Residents 7, 27 and 83 to receive unwanted care/treatment or unnecessary life-sustaining treatment. Findings: A. During a record review of Resident 7's Admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnosis that included kidney failure (condition where the kidneys are unable to properly filter waste products), depression, and hypertension (elevated blood pressure). During a record review of Resident 7's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 1/20/2025, the MDS indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 needed maximal assistance (helper does more than half the effort) with oral and toilet hygiene, upper and lower body dressing, and sit to stand (ability to stand from sitting on a chair). During an interview and concurrent record review of Resident 7's medical record, with the Social Services Director (SSD), on 2/7/2025 at 8:50 PM, the SSD stated Resident 7 did not have an AD. The SSD stated Resident 7 should have been asked and offered an AD to educate the resident of their health care choices and document the wishes of Resident 7 regarding life sustaining options. B. During a record review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was cognitively intact. The MDS indicated Resident 7 needed maximal assistance with oral and toilet hygiene, upper and lower body dressing, and sit to stand. During a review of Resident 27's AR indicated Resident 27 was admitted to the facility on [DATE] with diagnosis that included artificial right hip joint, dysphagia (difficulty swallowing), and anxiety (a feeling of worry, nervousness, or unease). During a review and concurrent record review of Resident 27's medical record, on 2/7/2025 at 8:32 PM, Registered Nurse 1 (RN 1) stated RN 1 was not sure if Resident 27 had an AD. RN 1 stated RN 1 was not sure if the facility offered Resident 27 information about an AD. RN 1 stated the SSD was the person responsible and discusses ADs with residents/RPs upon admission. C. During a review of Resident 83's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnosis that included dementia (a decline in mental ability severe enough to interfere with daily life) and psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them). During a record review of Resident 83's History and Physical (H&P), dated 1/31/2025, the H&P indicated Resident 83 did not have the capacity to understand and make decisions. During an interview and concurrent record review of Resident 83's medical record, with the SSD, on 2/7/2025 at 8:52 pm, the SSD stated Resident 83 did not have an AD. The SSD stated there was no documented evidence indicating an AD was offered to Resident 83's RP. The SSD stated this was important to know Resident 83's or the resident's RP wishes and for proof that the AD was offered, and that the resident was educated about AD. During a record review of the facility's policy and procedure (P&P), revised on 9/2022, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designees inquires of the resident, his/her family member and/or his or her liege representative, about the existence of any written advance directives

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen when: a. [NAME] (CK) 1 was not wearing a hair net over CK 1's beard. b. A banana cream pie was observed in one of one walk-in freezer to be undated (not provided or marked with a date). c. A tray of green beans was observed in one of one walk-in refrigerator to be uncovered and undated. These failures had the potential for improper food storage and handling, which could lead to foodborne illnesses. Findings: During an initial tour of the kitchen on 2/7/2025 at 5:06 PM with CK 1, CK 1 was prepping food next to the kitchen stove. CK 1 was not wearing a hair net over CK 1's beard. CK 1 stated CK 1 should have a hair net over CK 1's beard. During an initial tour of the kitchen on 2/7/2025 at 5:08 PM with CK 1, a frozen banana cream pie was observed in the walk-in freezer to be opened. The opened container was not dated. CK 1 stated the opened banana cream pie should be thrown in the trash. During an initial tour of the kitchen on 2/7/2025 at 5:10 PM with CK 1, a tray of green beans was observed to be uncovered and undated in the walk-in refrigerator. During an interview on 2/8/2025 at 1:09 PM with the Culinary Director (CD), the CD stated all opened food items needed to be labeled and dated with an expiration date. The CD stated the food was only good for three days after opening the container. The CD confirmed the green beans needed to be covered, labeled, and dated. The CD stated it was not healthy for residents (in general) to eat food that was too old. The CD stated hair needed to be covered when staff was working with food. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised on 12/20/2019, the P&P indicated, Food covered, labeled, and dated The P&P indicated, All food should be dated when it was placed in the storeroom, refrigerator or freezer . Food in all refrigerators must have Use-by dates. During a review of the facility's P&P titled, Personal Hygiene, revised on 5/25/2023, the P&P indicated, Wear a clean hat or other hair restraint. Hair must be completely covered. Beards, mustaches, or any body hair that may be exposed (i.e., arms) must be covered.

Based on interview and record review, the facility failed to notify the physician regarding pharmacy delays and inability to carry out the physician's order for Vagisil (a medication used to relieve vaginal itching, irritation, and burning) for one of one sampled resident (Resident 11). This deficient practice resulted in delayed provision of necessary care and services for Resident 11. Findings: During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted Resident 11 on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance (helper does less than half the effort) with mobility. During a record review of Resident 11's Order Summary Report (OSR), active orders as of 2/1/2025, indicated Resident 11 had an active order for: -Vagisil External Cream 1% (Hydrocortisone Acetate Vaginal), apply to vaginal area topically (medication application on the surface of the body such as the skin) one time a day for vaginal itching. The order date for the Vagisil was made on 2/1/2025 with a treatment start date of 2/2/2025. During an interview on 2/7/2025 at 6:31 PM, with Resident 11, Resident 11 stated she was frustrated and upset because she had very uncomfortable vaginal itching and a vaginal burning sensation for about one week. Resident 11 stated she notified the facility staff about her symptoms, however, the facility staff kept telling her that they were still waiting for the medication from the pharmacy. Resident 11 stated she hadn't received any treatment for the awful discomfort she had been experiencing from the vaginal itching and burning. During an interview and record review on 2/8/2025 at 3:07 PM, with Registered Nurse (RN) 1, Resident 11's OSR was reviewed, RN 1 stated Resident 11 had a Vagisil order that should have been started on 2/2/2025. RN 1 stated the facility had not received the medication from the pharmacy delaying Resident 11's treatment. RN 1 stated nursing staff should have contacted the physician to make them aware of the pharmacy delay for Vagisil. RN 1 stated treatment delays could worsen Resident 11's condition, cause increased discomfort, or lead to complications. During an interview on 2/9/2025 at 8:30 AM, with the Director of Nursing (DON), the DON stated licensed nurses should be notifying the physician of any pharmacy delays regarding prescribed medication orders. The DON stated a delay in treatment could result in unnecessary discomfort or distress for the resident, and timely relief should be prioritized. The DON stated by contacting the physician, nurses helped to ensure the resident's needs were met promptly, the treatment plan was followed effectively, and [made the facility aware] if an alternative treatment was necessary. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status revision dated 2/2021, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) was provided a safe and homelike environment when Resident 27's toilet leaked and caused water to puddle on the bathroom floor. This failure had the potential for Resident 27 to be injured from a fall and had the potential for Resident 27 to not be comfortable in his environment. Findings: During a review of Resident 27's Admission Record (AR), the AR indicated the facility admitted Resident 27 on 12/17/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), aftercare following joint replacement surgery, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool), dated 12/21/2024, the MDS indicated Resident 27 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 27 required substantial/maximal assistance (helper does more than half the effort) from staff for oral, toileting, and personal hygiene and dressing. During a concurrent observation and interview on 2/7/2025 at 7:01 PM with Resident 27, in Resident 27's bathroom, a puddle of water was observed on the floor, on the right side of Resident 27's bathroom toilet, between the toilet and the wall. A white towel was on the floor in front of the toilet. Resident 27 stated Resident 27 used the toilet. Resident 27 stated the toilet started leaking on 2/6/2025 after three men (unidentified) were working on the toilet plumbing. Resident 27 stated Resident 27 informed some of the nurses (unidentified) of the leaking toilet. During a concurrent observation and interview on 2/8/2025 at 9:55 AM with the Plant Operations Director (POD), a puddle of water was observed in front of, and to the right of Resident 27's bathroom toilet. The POD confirmed the puddle of water was from the leaking toilet. The POD confirmed the toilet had been leaking for three days. The POD stated the puddle of water was a safety risk to Resident 27. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment . The P&P indicated, .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean, sanitary and orderly environment .

Based on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 3) with dignity and respect when Certified Nursing Assistant (CNA) 1 referred to Resident 3 as a feeder. This failure had the potential for Resident 3 to feel disrespected. Findings: During a review of Resident 3's Admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/12/2024, and readmitted Resident 3 on 6/10/2024, with diagnoses including compression fracture of T11-T12 vertebra (a kind of broken back bone), history of falling, and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/14/2024, the MDS indicated Resident 3 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) from staff for toileting hygiene and showering/bathing. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or guard assistance) from staff for oral and personal hygiene. During a concurrent dining observation and interview on 2/8/2025 at 12:20 PM with CNA 1, Resident 3 was sitting at a table in the dining room. A staff person (unidentified) was observed setting a tray of food in front of Resident 3. CNA 1 stated to the staff person (unidentified) who was setting the tray in front of Resident 3, She is a feeder. CNA 1 sat next to Resident 3 and began to feed Resident 3. During a follow-up interview on 2/8/2025 at 12:47 PM with CNA 1, CNA 1 confirmed CNA 1 called Resident 3 a feeder. During an interview on 2/8/2025 at 1:50 PM with the Director of Staff Development (DSD), the DSD stated facility staff must not refer to residents (in general) as feeders. The DSD stated referring to residents (in general) as feeders was disrespectful to residents (in general). During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, revised July 2017, the P&P indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example . Avoiding the use of labels when referring to residents (e.g., feeders) . During a review of the facility's P&P titled, Resident Rights, revised December 2016, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to supervise (observe/watch) one of three sampled residents (Resident 1), who was at risk for elopement (leaving the facility without notice, leaving a safe area unsupervised without notice and permission) as indicated in the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, and Wandering and Elopements, by failing to: 1. Ensure Resident 1 did not leave the facility unsupervised on 10/17/24. 2. Ensure Laundry Attendant 1 (LA 1) identified and reported Resident 1 was seen standing by the storage room located in the Assisted Living (AL, housing facility for people with disabilities or for adults who cannot live independently) side of the facility's premise on 10/17/24. As a result, Resident 1 eloped from the facility, fell outside of the facility, sustained facial trauma (experiencing very stressful, frightening, or distressing events) injury with multiple mandibular (jawbone) fractures (cracks/breaks), and was transported to General Acute Care Hospital 1 (GACH 1). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Senile degeneration of brain (gradual decline in cognitive function, such as memory loss, impaired thinking, and difficulty with daily activities), essential hypertension (high blood pressure), dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), and Type 2 diabetes mellitus (high blood sugar). During a review of Resident 1's Nursing Admission (NA) dated 10/16/24, the NA indicated Resident 1's cognition/mental status was intermittently confused. The NA indicated Resident 1 was oriented to person and place. The NA indicated Resident 1'smemory/recall ability was current to season, and that Resident 1 was in a nursing home. The NA indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral hygiene. The NA indicated Resident 1's elopement risk factors included 1) mobility: propels self/requires some assistance; 2) two or more medications (psychotropics [a drug or other substance that affects how the brain works and causes changes in mood], Mood Stabilizer [a class of medications used to treat mood disturbances]), 3) conditions (dementia, depression [a serious mental illness that involves a prolonged low mood or loss of interest in activities], other type of mental health illness): 2 or more present. The NA indicated Resident 1's total score was 10. The NA indicated a total score of 10 or greater was considered an elopement risk. During a review of Resident 1's History and Physical (H&P), dated 10/17/24 (completed prior to Resident 1 eloping on 10/17/24), the H&P indicated, Resident 1 did not have the capacity to understand and make decisions due to dementia. During a review of Resident 1's care plan (CP) titled, Elopement Care Plan: Is at Risk for Wandering and/or Elopement Related To: Disoriented to Place, Dx (diagnoses) of dementia, senile degeneration of [the] brain, initiated on 10/17/24 (created prior to Resident 1's elopement on 10/17/24), the CP indicated Resident 1's safety would be maintained through the review date. The CP's interventions indicated for facility staff to distract Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The CP further indicated for the facility staff to identify patterns of wandering, intervene as appropriate, and to monitor Resident 1's location throughout the shifts (shift-based staffing, a method of scheduling employees in shifts, rather than traditional 9 to 5 schedules and to ensure around the clock coverage). During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps teams share information about the condition of a resident) Note, dated 10/17/24, the note indicated Resident 1 left the facility and fell outside of the facility (exact location was not indicated) on the pavement of the community. During a review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents))-Post Accident/Fall Evaluation dated 10/18/24 timed at 10:30 a.m., the evaluation indicated Resident 1 was at a high risk for falls with a score of 15 (total score of 10 or above represents a high risk for falls). The root cause analysis indicated Resident 1 had a diagnosis of dementia and wandering (alert and with confusion). During an observation on 11/4/24 at 10 a.m., Resident 1's room was located at the end of the hallway next to an exit door. The exit door was unlocked and led to an adjoining connector space (transition area) to the AL side of the facility. The connector space had another exit door on the left side that was unlocked and led to the outside of the building. During an interview on 11/4/24 at 10:45 a.m. with Licensed Vocational/Minimum Data Set (MDS - a federally mandated resident assessment tool) Nurse (MDS 1), MDS 1 stated Resident 1 was taken to the hospital on 10/17/24 after Resident 1 was picked up by the Fire Department and EMTs (emergency medical technicians) for sustaining a fall/fracture that occurred after Resident 1 eloped from the facility. MDS 1 stated Resident 1 was never returned or readmitted to the facility after Resident 1 eloped on 10/17/24. During an interview on 11/4/24 at 11:20 a.m. with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated, Resident 1 had a lot of movement; he walked everywhere. During an interview on 11/4/24 at 11:35 a.m. with CNA 7, CNA 7 stated, Resident 1 was ambulatory, very confused, nice man, eager to leave [and] go home to his wife. CNA 7 stated, We all knew that Resident 1 was at risk [for elopement] and we were told [by licensed nurses] to watch [Resident 1's whereabouts] this resident. During a concurrent observation and interview on 11/5/24 at 10:40 a.m. with Maintenance Supervisor 1 (MS 1), MS 1 stated, the exit door adjacent to Resident 1's room led to a transition space to the AL side. MS 1 stated within that transition space was another exit door that led to the outside of the building and led to the trash area and the open parking lot. MS 1 stated, the door could be easily pushed open from the inside, but the door is locked from the outside. MS 1 stated the door was used as a service entrance door to deliver food/drinks to the kitchen on the AL side. MS 1 stated the exit door has an alarm, but the alarm was deactivated daily from 8 a.m. to 8 p.m. due to the in and out activities from staff. MS 1 stated housekeeping and laundry staff from the AL side moved freely from the AL facility side to the skilled nursing facility (SNF) side using the transition space. MS 1 stated staff from the SNF must watch the residents and ensure residents from the SNF did not go through the exit door to the outside of the facility unsupervised. During an interview on 11/6/2024 at 8:40 a.m. with CNA 1, CNA 1 stated CNA 1 was assigned to care for Resident 1 on 10/17/24. CNA 1 stated Resident 1 had dementia and wandered around [the facility]. CNA 1 stated Resident 1's room was located next to an exit door. CNA 1 stated a huddle (a short, stand-up meeting where a team discusses patient safety and care goals) was conducted every morning. CNA 1 stated there should be a plan [in place] for residents that wandered and had dementia. CNA 1 stated CNA 1 did not know the plan for Resident 1. CNA 1 stated the only intervention for residents that wandered who had dementia was to conduct hourly checks (visual monitoring). CNA 1 stated Resident 1 walked through the door located next to Resident 1's room and went to the local gas station. CNA 1 stated Resident 1 walked across the street from the SNF and fell . During an interview on 11/6/24 at 9:36 a.m. with Director of Nursing (DON), the DON stated before the DON left to attend a meeting, on 10/17/24 (unable to recall the time), next door at the AL facility, and she told all staff to watch/supervise Resident 1. The DON stated when she left the SNF side, Resident 1 was sitting on the sofa in the dining room watching television. The DON stated the DON was gone from the facility for the meeting and by the time the DON came back to the SNF side, the Fire Department was at the facility and informed the RN Supervisor (RN 1) what happened to Resident 1 (Resident 1's fall). During a concurrent observation and interview on 11/6/2024 at 9:47 a.m. with LA 1, LA 1 stated LA 1 worked for the SNF and the AL facility. LA 1 stated LA 1 transported laundry to and from AL facility and SNF. LA 1 stated the transition space and the exit door located next to Resident 1's room was used frequently by laundry staff. LA 1 stated the exit door located next to Resident 1's room remained unlocked. LA 1 stated on 10/17/24 (LA 1 could not recall the time the encounter occurred), LA 1 saw Resident 1 standing outside of the storage room door located inside the AL side. LA 1 stated LA 1 did not know who Resident 1 was and LA 1 did not report this incident to any nursing staff because Resident 1 looked like a visitor. LA 1 stated Resident 1 told her, Have a nice day. LA 1 found out later that Resident 1 had eloped from the facility. During an interview on 11/6/2024 at 9:56 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated every staff member was responsible for the whereabouts of residents (in general) that wandered. RNA 1 stated on 10/17/24, RNA 1 was watching Resident 1 while Resident 1 was in the dining room. RNA 1 stated RNA 1 was with Resident 1 until almost 1 p.m. RNA 1 stated RNA 1 instructed Resident 1 to stay in the dining room because RNA 1 was going to help another resident (unidentified). RNA 1 stated that was the last time RNA 1 saw Resident 1. RNA 1 stated facility staff were looking for Resident 1, but the facility staff did not find Resident 1. RNA 1 stated Resident 1 was found on a street by an unknown individual and was sent to the hospital. RNA 1 stated it was the facility's practice for staff to divert (redirect) residents who wandered in the facility and remind them of their room location. During a review of the Los Angeles County Fire Department record dated 10/17/24, the record indicated the unit was notified by the dispatch staff (staff who relay work orders and information to field staff using phones or 2-way radios on 10/17/24 at 1:31 p.m. and the EMT arrived at the scene (on 10/17/24) at 1:36 p.m. where Resident 1 was found sitting on the curb, down the hill from the facility, and complained of face pain (pain rate was not indicated). The record indicated a passerby stated she witnessed Resident 1's fall while Resident 1 was walking down a hill and away from the facility. The record indicated Resident 1 was transported to General Acute Care Hospital 1 (GACH 1). During a review of General Acute Care Hospital 1's (GACH 1) Emergency Department (ED) record, admitted [DATE], the ED record indicated Resident 1 presented to the ED after a fall and on arrival Resident 1 had notable trauma to the face. The ED record indicated CT (computed tomography scan, medical imaging technique used to obtain detailed internal images of the body) imaging was obtained of Resident 1's head and face. The CT imaging revealed multiple mandibular fractures. The ED record medical decision making indicated Resident 1 had evidence of possible intracranial (within the cranium [bones that form the head]) injury due to the CT of the head showed a left-sided occipital lobe (visual processing area of the brain, located at the back of the head) petechial hemorrhage (tiny round brown, purple spots due to bleeding under the skin). The ED record indicated cardiac (heart) monitoring was initiated due to the potential for rapid decompensation (a system or structure's functional decline after it has been compensating for a defect or stressor) of Resident 1's clinical condition. The ED record indicated Resident 1 was transferred from GACH 1 to GACH 2. During a review of GACH 2's Encounter Report dated 10/17/24, the report indicated Resident 1 fell while leaving Resident 1's care facility. The report indicated Resident 1 struck Resident 1's face on the pavement/ground and Resident 1 sustained multiple mandibular fractures and a chin laceration (cut. The report indicated Resident 1 had a small contrecoup injury (a brain injury that occurs when the brain moves within the skull and hits the opposite side of the head from the initial impact). During a review of the facility's P&P, titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated systems approach to safety included, resident supervision being a core component of the systems approach to safety. The type of frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated resident risks and environmental hazards included, unsafe wandering. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised 3/2019, the P&P indicated, the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 14), to prevent the development of new pressure ulcers [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the others)] by failing to: Provide a Bariatric bed (specialized, heavy duty, wider and longer than a standard bed for tall resident) for Resident 14 who was six feet and five inches (6'5) tall. As a result, Resident 14 developed four facility acquired PIs (new PIs developed after the resident's admission to the facility) on the bilateral (both sides, left and right) great toes and heels. Findings: During a review of Resident 14's Admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right arms, abnormality of gait (walking pattern) and mobility (ability to move). During a review of Resident 14's Generations Post-Acute Admission Data Collection (GPAADC, New Admission Assessment), dated 12/12/2023, at 8:31 pm, indicated Resident 14 had no history of skin issues (conditions that affect the skin), and did not require skin interventions. During a review of Resident 14's Progress Notes (PN), dated 12/15/23, the PN indicated Resident 14 had decreased range of motion (ROM, full movement potential of a joint) on both legs. During a review of Resident14's Admission Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/18/23, the MDS indicated Resident 14 had intact cognition (ability to think and process information). The MDS indicated Resident 14 did not have any unstageable PI [full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed]. During a review of Resident 14's Generations Weekly Skin Evaluation (GWSK), dated 12/19/23 and 12/26/24 indicted Resident 14's skin was intact (not damaged or impaired in any way; complete). During a review of Resident 14's Situation, Background, Assessment, Recommendation (SBAR) Communication Form (a verbal, or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/29/23, indicated Resident 14 had a significant change in condition due to a change in skin color on bilateral heels. The form indicated staff (in general) would float heels to relieve pressure on both heels. A review of Resident 14's Care Plan titled, Pressure Injury/Skin Care, initiated on 12/31/23, indicated Resident 14 had facility acquired PIs on bilateral heels and great toes. The care plan's goal was for Resident 14's PIs to heal. The nursing interventions included to administer treatments as ordered. During a review of Resident 14's Wound Physicians Progress Note (WPPN), dated 1/2/24, indicated Resident 14 had a total of 4 wounds that included: 1. PI on the left heel measuring 4.3 centimeters (cm, unit of measurement) in length by (x) 4.6 cm in width. 2. PI on the right heel measuring 3.8 cm x 3.2 cm. 3. PI on the left great toe measuring 1.6 cm x 1.7 cm. 4. PI on the right great toe measuring 1.7 cm x 1.5 cm. During a review of Resident 14's WPP, dated 1/23/24, indicated Resident 14 had a total of 4 wounds: 1) unstageable PI om the left heel measuring 4.0 cm x 3.6 cm. 2) unstageable PI on the right heel measuring 3.5 cm x 2.4 cm. 3) PI on the left great toe measuring 1.6 cm x 1.6 cm. 4) PI on the right great toe measuring 1.3 cm x 1.2 cm. During a review of Resident 14's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation note, dated 1/28/2023, at 8:52 am, indicated Resident 14's PI on bilateral great toes and bilateral heels were developed on 12/31/2023. The COC indicated Resident 14's PIs on bilateral great toes and bilateral heels were facility acquired. During an observation inside of Resident 14's room and concurrent interview with Resident 14 on 1/26/24, at 5:19 pm, Resident 14 was sitting on a wheelchair, awake and alert. Resident 14 stated Resident 14 was 6 feet 5 inches tall. Resident 14 stated this morning (1/26/24), a staff member (unidentified) changed Resident 14's bed to a longer bed frame and mattress (unknow name or length). Resident 14 stated Resident 14's old bed (previous bed, standard size bed was 80 inches long) was too short for Resident 14. Resident 14 stated Resident 14 would often bump Resident 14's feet (heals and toes) and Resident 14's feet rubbed against the footboard of Resident 14's old bed. Resident 14 stated Resident 14 did not have a wound prior to being admitted to the facility, but now Resident 14 had a few wounds at the bottom of both feet. Resident 14 stated my feet hurt when I bumped them (feet) against the footboard. During an interview with Certified Nurse Assistant 5 (CNA 5), on 1/26/24 at 5:52 pm, CNA 5 stated Resident 14 was too tall for Resident 14's old bed. Resident 14 stated Resident 14 often elevated Resident 14's feet on pillows for Resident 14's feet not to touch the footboard of Resident 14's bed. CNA 5 stated Resident 14 had wounds on the heels and great toes of Resident 14's left and right feet. During an interview with the Director of Clinical Services (DCS), on 1/27/24 at 6:59 pm, the DCS stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were avoidable if the proper (extra-long) bed length was provided to Resident 14. During an interview and concurrent record review of Resident 17's GPAADC, dated 12/12/23, and SBAR dated 12/29/23 with Licensed Vocational Nurse 1 (LVN 1), on 1/27/24 at 7:39 pm, LVN 1 stated Resident 14 was admitted to the facility without skin issues. LVN 1 stated upon admission, Resident 14's toes, heels were clear and Resident 14's skin was intact. LVN 1 stated Resident 14's bed was too short and Resident 14's feet would rub against the footboard while Resident 14 was lying in bed. LVN 1 stated the PIs on Resident 14's left, and right heels and great toes were avoidable if Resident 14's bed was long enough to accommodate Resident 14's height. During an interview with the Director of Nursing (DON) on 1/28/24 at 2:08 pm, the DON stated special accommodations should have been done for Resident 14 due to Resident 14's height (6 feet 5 inches tall). The DON stated Resident 14's bed was too short, and the DON observed Residents 14' feet touching the footboard of the bed while Resident 14 was lying in bed. The DON stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were preventable. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, implemented on 5/23/23, the P&P indicated, the facility was committed to the prevention of avoidable PI, unless clinically unavoidable, and to provide treatment and services to heal the PU/PI, prevent infection and the development of additional PU/PI. The P&P indicated, the facility should establish and utilized a systematic approach for PU/PI prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate.

Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan to prevent a fall for one of two sampled residents (Resident 1), who had blindness on both eyes (visual impairment/unable to see) and a history of falls by failing to: Ensure the Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for the residents) met and updated Resident 1's Fall Care Plan as indicated in the facility's policy and procedure, titled Falls - Assessing Falls and Their Causes, after Resident 1 fell on [DATE], 1/6/2023, and 1/13/2023. As a result, Resident 1 sustained multiple falls (12/26/2023, 1/6/2023, 1/13/2023, and 1/15/2023,) in the facility and was hospitalized due to injuries sustained from the falls. On 1/15/2023, the facility transferred Resident 1 to General Acute Care Hospital (GACH) 1's Emergency Department (ED) due to head trauma (damage to the scalp, skull, or brain caused by injury) and cephalohematoma (an accumulation of blood under the scalp). Cross reference F689 Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted Resident 1 on 12/21/2022 with diagnoses that included unsteadiness on feet, muscle weakness, blindness on both eyes, and a history of falling at home. A review of Resident 1's Physician Progress Notes, dated 12/22/2022, at 9:01 PM, indicated Resident 1 had a fall with head injury from the previous admission (10/25/2022). The note indicated Resident 1 lost 80 percent of her eyesight. A review of Resident 1's Falls Care Plan, initiated on 12/22/2022, indicated Resident 1 was at high risk for falls related to unsteady (unable to stabilize without staff assistance) gait (walk), decreased mobility (ability to move), and activity intolerance. The goal was for Resident 1 to not sustain serious injury. The nursing interventions included to anticipate Resident 1's needs and provide prompt response to all requests for assistance, provide appropriate footwear when walking, ensure the call light was within reach and encouragement for Resident 1 to use it. A review of Resident 1's Care Conference (IDT meeting note), dated 12/23/2022, indicated Resident 1 had unsteady gait and remained a fall risk due to visual impairment. There was no indication that the IDT discussed falls and interventions to prevent falls due to unsteady gait and visual impairment. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 12/27/2022, indicated Resident 1 had severe impaired cognition (ability to think and process information). The MDS indicated Resident 1 had impaired vision. Resident 1 required extensive physical assistance during toilet use and limited physical assistance from one person when walking in the room. The MDS indicated Resident 1 was not steady when moving from seated to standing position and when walking with a walker. A review of Resident 1's Morse Fall Risk Assessments (MRS, the Morse Fall Scale is a rapid and simple method of assessing a patient's likelihood of falling), dated 12/26/2022, indicated the Resident 1 was at high risk for falls due to a history of falling, use of walker, weakness when walking, and overestimating or forgets her limits. Resident 1 scored 80 points (a score of 45 or higher means high risk for falls). A review of Resident 1's Progress Note - Change in Condition, dated 12/26/2022, timed at 4:15 PM, indicated Resident 1 experienced an unwitnessed fall and was found sitting on the floor next to the resident's walker. The note indicated Resident 1 required frequent visual monitoring due to periods of confusion and forgetfulness. Resident 1 required encouragement to use the call light, and prompt anticipation to attend to the resident's needs. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR, communication record between members of the health care team) Communication Form, dated 1/6/2023, untimed, indicated Resident 1 sustained a fall. The form indicated Resident 1 had activity intolerance but overestimated her own limits. Resident 1 did not use the walker and used furniture to hold on while walking. Resident 1 was unable to walk more steps to the bathroom and decided to sit down slowly on the floor. Resident 1 complained of lower back pain (not rated). The form indicated Resident 1 required more assistance (not indicted type of assistance) with activities of daily living (ADL, activities related to personal care such dressing, eating and personal hygiene). A review of Resident 1's Actual Fall Care Plan, initiated on 1/6/23, indicated Resident 1 had an actual fall related to an unsteady gait, poor balance, and activity intolerance. The goal was for Resident 1 to resume usual activities. Nursing interventions included to monitor Resident 1 for changes in mental status and to determine and address causative factor of the fall. A review of Resident 1's SBAR Communication Form, dated 1/13/2023, timed at 12:03 AM, indicated Resident 1 was found lying on the floor, on her right side, next to the resident's bed and walker. Resident 1 reported that she slid off her bed and lost balance when trying to get up to go to the bathroom. Resident 1 complained of body pain (unrated). Licensed Vocational Nurse 2 (LVN 2) notified Resident 1's Physician (MD 1, Doctor of Medicine), MD 1 ordered STAT (rush/immediate) X-rays (image study of the bones and soft tissue) of the right shoulder and hip to rule out fractures (breaking). The X-ray results were negative for fractures. A review of Resident 1's SBAR Communication Form, dated 1/15/2023, timed at 11:44 PM, indicated Resident 1 was found sitting on the floor with bleeding on the left ring finger, hematoma (a collection of blood outside of the vessels, a bad bruise) on the back of the head, and bruising on both buttocks. Resident 1 was sent out to the hospital via ambulance (911, phone number to call for emergency services). A review of Resident 1's GACH 1's Emergency Documentation, dated 1/16/2023, timed at 12:22 AM, indicated Resident 1 was admitted from the facility after sustaining a fall with a cephalhematoma to the left occiput (back of the head or skull). Resident 1 stated, she was walking with her walker and had a fall. The documentation indicated Resident 1 had several falls in the past, was on blood thinner medication, and had an obvious head injury. The Computed Tomography (CT, medical imaging used to obtain detailed internal images of the body) result was negative for a brain bleed. The diagnoses included head injury and cephalohematoma. A review of Resident 1's Nurse Progress Notes, dated 1/16/2023, at 10:02 AM, indicated Resident 1 returned to the facility from GACH 1 after sustaining a fall. The note indicated Resident 1 was stable with diagnosis of cephalohematoma on the left parietal (forming part of the top and side of the head) area. The note indicated Resident 1's skin was intact, had multiple bruises on the lower back, and multiple discolorations on both legs. A review of Resident 1's Admission Discharge Census List, dated 2/6/2023, indicated Resident 1 was discharged from the facility at 8:40 PM. During an interview on 2/8/2022, at 8:50 AM, the Director of Nursing (DON) stated the IDT did not meet after Resident 1's falls due to staff focused on direct resident care (hands on, face-to-face contact with residents for the purpose of diagnosis, treatment. and monitoring). The DON stated the fall care plan had to be updated after each fall and stated care plans were a guide for nurses (in general) to follow. The DON stated care plans had to be specific, detailed, and not be generalized due to every resident being unique. During a concurrent interview on 2/8/2023, at 9:06 AM, with the DON and a review of Resident 1's Fall Care Plans, dated 12/22/2022, 1/6/2023, and the IDT meeting note, dated 12/23/2022, the DON stated Resident 1 was admitted to the facility with a history of multiple falls and was legally blind (20/200 visual acuity, a person can see at 20 feet, what a person with 20/20 vision sees at 200 feet). The DON stated Resident 1's Fall Care Plan and IDT note did not include interventions to prevent recurrent falls. The DON stated the IDT did not meet after Resident 1 fell on [DATE], 1/6/2023, and 1/13/2023. The DON stated the IDT had to meet after every fall to discuss and find the root cause of the falls. The DON stated if the IDT met and addressed the falls, future falls could have been prevented for Resident 1. The DON stated Resident 1's Actual Fall Care Plan, created on 1/6/2023, did not include person-centered interventions to address the root cause of the fall. A review of the facility's policy and procedure, titled, Care Planning - Interdisciplinary Team, revised 3/2022, indicated the IDT is responsible for the development of resident care plans. Comprehensive, person-centered care plans are based on resident assessments and developed by the IDT. A review of the facility's policy and procedure, titled, Care Plan, Comprehensive Person-Centered, revised 3/2022, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy indicated assessments of residents are ongoing and care plans are revised as information about the resident's condition changes. The IDT reviews and updates the care plan when there has been a significant change in the resident's condition. A review of the facility's policy and procedure, titled, Falls - Managing Fall Risk, dated 10/1/2022, indicated fall risk factors included: cognitive impairment, lower extremity (legs) weakness, and visual deficits. A review of the facility's policy and procedure, titled, Falls - Assessing Falls and Their Causes, dated 10/01/2022, indicated the purpose of the policy was to provide guidelines for assessing a resident after a fall and to assist the staff in identifying causes of the falls.

Based on observation, interview, and record review, the facility failed to provide pressure ulcers/injuries (PIs, injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care, and treatments for six of six sampled residents (Residents 4, 5, 6, 7, 8, and 9) by failing to: 1. Implement the facility's policies on Pressure Injury Risk Assessment, Quality of Care-Pressure Injuries, when the licensed nurses (in general) did not update the care plans, assess, measure, and follow the physician's orders to treat the following: a. Resident 4's Stage 3 PIs (full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore) on the right and left buttock, and Stage 2 PI (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) on the sacral region (at the bottom of the spine). Licensed Nurses also failed to ensure Resident 4 who was six feet and four inches (6'4) tall, had a long bed to decrease the pressures on the resident's PIs. b. Resident 5's Stage 2 PI on the coccyx (tailbone). c. Resident 6's Stage 4 PI (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules) on the Sacrococcyx (sacrum and coccyx/tailbone). d. Resident 7's Stage 2, facility acquired PI (a new pressure injury that developed after admission to the facility) on the right buttock. e. Resident 8's Stage 1 PIs (redness, painful area on the resident skin that does not turn white/blanch) on the right and left buttocks. f. Resident 9's Stage 1 PI on bilateral (both) heels and a Stage 3 PI to the coccyx. 2. Ensure Registry (a staffing agency which provide nursing personnel per shift or temporarily) Nurses (in general) received in-services (training) regarding PI treatments and assessments upon admission and weekly after. As a result, Residents 4, 5, 6, 7, 8, and 9 did not receive PI care and treatments, and placed the residents at risk for developing/worsening of the PIs, or infection which could lead to hospitalization , health complications which could result in death. On [DATE] at 1:04 PM, during a complaint investigation, The California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), in the present of the facility's Administrator (ADM), Director of Health Operations (DHO), and Director of Nursing (DON), for the facility's failure to provide PIs care and treatments to Residents 4, 5, 6, 7, 8, and 9. On [DATE], at 4:48 pm, the facility submitted an acceptable Plan of Action (POA/ IJ removal plan, a detailed plan to address the IJ finding), while onsite the surveyor verified and confirmed the implantation of the POA by observation, interview, record review, and confirmed the removal of the IJ on [DATE] at 6:17 pm with the ADM. The acceptable IJ Removal Plan included the following: 1. On [DATE], the ADM ordered a long bed for Resident 4. Resident 4 received a long bed on the same day ([DATE]). 2. On [DATE], the DON completed the skin assessments on all 32 residents who resided in the facility including Residents 4, 5, 6, 7, 8, and 9 who had PIs. 3. On [DATE], the Wound Physician (WP 1, health care professional who has specialized in the treatment of wounds [injury to the body such as the skin]) assessed Resident 4's, 5's, 6's, 7's, 8's, and 9's PIs. 4. On [DATE], the DON updated Resident 4's, 5's, 6's, 7's, 8's and 9's care plans to reflect current PIs status and care. 5. On [DATE], an outside Wound Consultant (WC 1) provided in-services on Wound Treatment Guidelines for PI management to all Licensed Nurses including facility's nurses and registry nurses. 6. On [DATE], WC 1 conducted competencies for Licensed Nurses on skin assessments, care for PIs, measuring and staging PIs. (Cross Reference F726) Findings: 1a. A review of Resident 4's Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included, type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels), and muscle weakness. A review of Resident 4's Physician's Order, dated [DATE], indicated to cleanse Resident 4's Stage 2 PI on the coccyx with wound cleanser (solution to clean the wound), pat dry, apply Medihoney (mixture of two honeys, used for wound care and contribute to wound healing), and cover the PI with foam dressing (dressing that can hold fluid/drainage) every day shift. A review of Resident 4's Generations Post-Acute Admission Data Collection (New Admission Assessment), dated [DATE], at 9:51 PM, indicated Resident 4 had two Stage 3 PIs (one on the right and one on the left buttocks), and a Stage 2 PI with redness on the sacral area. The skin integrity (the health of the skin) review section which required PI wound measurements was left blank. A review of Resident 4's Braden Scale (an assessment tool to assess the risk of PIs) for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 4 was at high risk for developing PIs. A review of Resident 4's Care Plan for actual impairment in skin integrity, dated [DATE], indicated nursing interventions included to provide pressure relieving mattress. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated the resident had an intact cognition (ability to think and process information). The MDS indicated Resident 4 was admitted to the facility with one Stage 2 PI, and two Stage 3 PIs (locations not indicated). A review of Resident 4's Generations Weekly Skin Evaluation, dated [DATE], at 3:01 PM, indicated Resident 4 had Stage 2 and Stage 3 PIs. There was no documented evidence that the weekly assessments were done for Resident 4's PIs in [DATE]. The description section for these PIs were blank. A review of Resident 4's Care Plan, dated [DATE], indicated Resident 4 was admitted with Stage 3 PIs on the right and left buttocks and a Stage 2 PI on the coccyx related to decreased mobility. The care plan indicated the goal was for Resident 4's PIs to heal and remain free from infection. The nursing interventions included to administer treatments as ordered (specific and follow the facility's policies/protocols for prevention and treatments of PIs). A review of Resident 4's Treatments Administration Record for [DATE], indicated the resident did not receive treatments for Stage 2 PI on the coccyx area, and the Stage 3 PIs on the left and right buttocks on [DATE]. The record indicated Resident 4 did not receive treatments for the Stage 3 PIs on the left and right buttocks from [DATE] to [DATE]. During an observation inside Resident 4's room and concurrent interview on [DATE], at 9:10 AM, Resident 4 was sitting on a wheelchair, awake and alert. Resident 4 stated he could not recall the last time the nurses (in general) changed the PI dressings. Resident 4 stated the nurses would peak, at the dressing. Resident 4 stated the nurses did not change the resident's PIs dressings daily. Resident 4 did not allow surveyor to observe the resident's PIs. During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) and a review of Resident 4's Physician Orders, Skin Assessments, and Care Plans, on [DATE], at 12:40 PM, LVN 1 stated Resident 4 had a Stage 2 PI on the coccyx area and two Stage 3 PIs with active orders for PIs treatments. LVN 1 stated Resident 4's PI assessments did not include measurements or description of the PIs. LVN 1 stated Resident 4's admission assessment for the PIs, dated [DATE], was incomplete. LVN 1 stated the admission assessment needed to be completed with accurate PIs' description and measurement to identify any new changes in Resident 4's PI. LVN 1 stated Resident 4's PIs needed to be monitored closely to evaluate the effectiveness of PIs treatments. LVN 1 reviewed Resident 4's care plans for PI, dated [DATE] and stated the care plan was not updated to address Resident 4's needs. LVN 1 stated the care plan did not specify the type of mattress Resident 4 (who was 6'4 tall) needed to relieve the pressure on the resident's PIs. During a concurrent observation and interview on [DATE] at 10:21 AM, Resident 4 was lying on a low air loss mattress (LAL mattress that operates using a blower-based pump that was designed to circulate a constant flow of air). Resident 4 had both feet resting on two seat pads positioned over the foot of the bed with resident's knees bent. Resident 4 stated Family Member 1 (FM 1) placed the seat pads at the foot of the bed because the resident was too tall for the bed. Resident 4 stated he was 6'4 tall and the bed was a standard twin size bed. Resident 4 stated he had to sleep with his knees bent. Resident 4 stated it was difficult for him to turn and reposition in the bed. Resident 4 stated the Licensed Nurses (in general) changed his (the resident's) dressings every other [NAME]. b. A review of Resident 5's Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included type 2 diabetes and muscle weakness. A review of Resident 5's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 5 was at high risk for developing PIs. A review of Resident 5's New Admission Assessment, dated [DATE], at 7:30 PM, indicated the resident was admitted with a PI that was not blanchable (discoloration of the skin that does not turn red when pressed), redness on both heels, and a Stage 2 PI on the coccyx area. The skin integrity review section that included sizes, measurements, and description of the PI was blank. A review of Resident 5's Physician's Order, dated [DATE], indicated to cleanse Resident 5's Stage 2 PI on the coccyx with normal saline (salt water), pat dry, apply Santyl (ointment that removes dead tissue from wounds so that they start healing), and cover the PI with foam dressing every day, for wound care, for 21 days. A review of Resident 5's Care Plan for actual skin impairment due to Stage 2 PI on the coccyx, dated [DATE], indicated the interventions included to keep the resident's skin clean and dry. A review of Resident 5's Treatments Administration Record for [DATE], indicated the resident did not receive treatments for the Stage 2 PI on [DATE]. A review of Resident 5's MDS, dated [DATE], indicated the resident had an intact cognition. The MDS indicated Resident 5 had two Stage 1 a Stage 2 PIs (location no indicated). A review of Resident 5's Generations Weekly Skin Evaluation, dated [DATE], at 5:46 PM, indicated the resident's skin was intact (no PI). A review of Resident 5's Medication Administration Audit Report, dated, [DATE], indicated to cleanse Resident 5's Stage 2 PI on the coccyx region with normal saline, pat dry, apply Santyl, and cover with foam dressing. During a concurrent interview with LVN 1 on [DATE] at 12:40 PM, and a review of Resident 5's New Admission Assessment, dated [DATE], LVN 1 stated Resident 5's admission skin assessment was incomplete. LVN 1 stated the weekly skin evaluation, dated [DATE], indicated Resident 5's skin was intact when it was not. LVN 1 reviewed Resident 5's care plan for actual skin impairment, dated [DATE], and stated the care plan was not specific to addressed Resident 5's PI treatments. During an interview on [DATE] at 11:09 AM, Resident 5 stated the nurses (in general) changed the PI dressing to her PI every three days. Resident refused to allow surveyor to observe the resident's PI. c. A review of Resident 6's Admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included Stage 4 PI on the sacral area. A review of Resident 6's untitled Care Plan, initiated on [DATE], indicated Resident 6 had a Stage 4 PI and the goal was for the PI to show signs of healing. The care plan indicated the nursing interventions including to assess, monitor PIs weekly. The care plan indicated to measure length, width, depth of the PIs. A review of Resident 6's Physician Order, dated [DATE], indicated to cleanse Resident 6's Stage 4 PI on the Sacrococcyx with wound wash solution, apply collagen (protein), lightly pack the PI with Calcium Alginate (dressing used for moderate to heavily draining PIs), and cover the PI with foam dressing or abdominal pad (pad used for large wounds that require high absorbency) every day shift. A review of Resident 6's MDS, dated [DATE], indicated the resident had severe impaired cognition. The MDS indicated Resident 6 had a Stage 4 PI (location not indicated). A review of Resident 6's Generations Weekly Skin Evaluation, dated [DATE], indicated the resident had a Sacrococcyx Stage 4 PI. There was no other information documented, and the skin integrity review section which required PI's description and measurements was blank. A review of Resident 6's Generations Weekly Skin Evaluation, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident 6's skin was intact (no PIs). During a concurrent interview, on [DATE] at 12:40 PM, and a concurrent review of Resident 6's Generations Weekly Skin Evaluations, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], LNV 1 stated the nurses (in general) did not assess Resident 6's PI and documented Resident 6'skin as intact. LVN 1 stated Resident 6's care plan for Stage 4 PI indicated the PI needed to be measured weekly. During a wound observation on [DATE] at 3:35 PM, Resident 6's PI on the Sacrococcyx region was observed with RN 1. RN 1 was asked to measure and describe the PI; RN 1 stated the wound was small round 0.25 x 0.25 x 0.25, surrounding skin dry and clear and no exudate. The wound was observed to be small around the size of a q tip head, no drainage, no malodors. The wound bed could not be visualized. Surrounding skin appeared clean and dry. The resident denied pain during the observation. A review of the facility's document titled, Generations: Missing Treatment TAR (Treatment Administration Record), wound treatments documentation, dated [DATE], indicated PI treatments administrations were not documented as done for Resident 6 on [DATE], [DATE], [DATE], and [DATE]. d. A review of Resident 7's Admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included diabetes mellitus. A review of Resident 7's New Admission Assessment, dated [DATE], at 4:30 PM, indicated Resident 7 did not have a history of skin issues. The skin integrity review section did not indicate the presence of PIs upon admission. A review of Resident 7's MDS, dated [DATE], indicated the resident had moderate impaired cognition. The MDS indicated Resident 7 had a stage 2 PI (location not indicated). A review of Resident 7's physician order's, Generations Weekly Skin Evaluations, and progress notes, dated [DATE] to [DATE], there was no documentation indicating the facility identified or obtained orders to treat a stage 2 PI for Resident 7. A review of Resident 7's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation note, dated [DATE] at 10:38 AM, indicated the resident had a new Stage 2 PI in the right buttock area. The evaluation note did not indicate a description or measurement of the PI, the section was blank. A review of Resident 7's Physician Order, dated [DATE], indicated to cleanse Stage 2 PI on the right buttock area with soap and water, pat dry, apply calmoseptine (medication used to treat and prevent minor skin irritations) cream and cover with dry dressing every shift for 21 days. A review of Resident 7's untitled Care Plan, dated [DATE], indicated the resident had a Stage 2 PI on the right buttocks area. The goal included for the PI to heal. The nursing interventions included to provide treatment, assess, monitor for PI healing, measure length, width, and depth of the PI weekly. A review of Resident 7's Generations Weekly Skin Evaluation, dated [DATE], indicated the resident did not have a PI. During a concurrent interview with LVN 1 on [DATE] at 12:40 PM, and a review of Resident 7's skin assessments, COC forms, and care plan, LVN 1 stated upon admission, Resident 7 did not have a PI. LVN 1 stated Resident 7 developed a facility acquired PI on [DATE] and LVN 1 completed the COC form. LVN 1 stated upon her assessment, she identified the PI as a Stage 2. LVN 1 stated she did not measure the PI. During an interview on [DATE] at 2:08 PM, Resident 7 stated the nurses (unidentified) did not check his skin and did not help him get out of bed. During a concurrent observation in Resident 7's room, and interview on [DATE] at 2:33 PM, Resident 7 complained of being itchy, on his buttocks. Resident 7 started scratching his buttocks and stated it felt like there was something there. Certified Nursing Assistant 2 (CNA 2) was present in Resident 7's room and asked the resident for permission to check his buttocks. Resident 7's right buttock had one inch of open skin and approximately two inches of redness around the open skin area. Resident 7 stated it felt like a pimple. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations were not documented as done for Resident 7 on [DATE], [DATE], and [DATE]. e. A review of Resident 8's Admission Record indicated the facility admitted the resident on [DATE], and was readmitted on [DATE], with diagnosis that included muscle weakness. A review of Resident 8's New Admission Assessment, dated [DATE], at 10:22 PM, indicated the resident had non-blanchable redness (skin redness that does not turn white when pressed) on the inner buttocks upon admission. The skin integrity review section indicated no PI measurements were done, and the section was blank. A review of Resident 8's Generations Care Conference note, dated [DATE] at 9:55 AM, did not indicate Resident 8 had a PI. The note indicated there were no interventions or recommendations to treat and care for the resident's PI. A review of Resident 8's Readmission Assessment, dated [DATE] at 1:43 PM, indicated the resident had a Stage 1 PI on the coccyx area and redness to both buttocks. The skin integrity review section was blank with no measurements. A review of Resident 8's Physician's Order, dated [DATE], indicated to cleanse bilateral buttocks with water, pat dry, apply Secura Protective Ointment (a petrolatum-based skin barrier that helps treat and prevent incontinence-associated dermatitis), two times a day for skin care preventative. A review of Resident 8's Generations Care Conference note, dated [DATE], at 1:12 PM, did not indicate the resident had PIs. The note did not indicate any interventions or recommendations to treat the PI. A review of Resident 8's MDS, dated [DATE], indicated the resident had an intact cognition. The MDS indicated Resident 8 had a Stage 1 PI (location not indicated). During a concurrent interview with LVN 1, on [DATE], at 1 PM and a review of Resident 8's New Admission Assessment, dated [DATE], LVN 1 stated the PI assessment was not completed and there were no measurements for the PI. LVN 1 was unable to provide a care plan for Resident 8's PI. During an observation on [DATE], at 9 AM inside Resident 8's room, the resident was out of the facility and was not available for PI observation. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations were not documented as done for Resident 8 on [DATE]. f. A review of Resident 9's Admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included sepsis (life-threatening complication of an infection). A review of Resident 9's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 9 was at high risk for developing PIs. A review of Resident 9's New Admission Assessment, dated [DATE], at 11:40 AM, indicated Resident 9 had a Stage 3 PI on the coccyx area. The skin integrity review did not indicate PI description or measurements. The section was blank. A review of Resident 9's Care Plan for Stage 3 PI on the coccyx area, dated [DATE], indicated the goal section was blank. The nursing interventions included to keep Resident 9's skin clean and dry. A review of Resident 9's Physician's Order, dated [DATE], indicated to cleanse Resident 9's Stage 3 PI on the Sacro-coccyx area, pat dry, apply Medihoney, and cover the PI with dry dressing every day shift for 21 days. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations for Resident 9's PI were not documented as done for Resident 9 on [DATE]. During an interview on [DATE] at 12:40 PM, LVN 1 stated licensed nurses (in general) needed to complete PI assessments and document the findings in the residents' (in general) medical records. LVN 1 stated the facility utilized registry nurses and they (registry nurses) did not complete the skin assessments upon admission and weekly after admission. During an interview on [DATE] at 1 PM, the DON stated two wound consultants/doctors used to go to the facility to conduct PI assessments on residents (in general). The DON stated he did not know the reason the wound consultants/doctors stopped going to the facility. The DON stated licensed nurses (in general) did not measure the PIs. The DON stated when the facility admitted a new resident, the LVNs (in general) would call the wound consultant/doctor to go to the facility to assess the PIs. The DON stated the facility did not have a full time Registered Nurse (RN) and relied on the wound consultants/doctors for the care and management of all PIs. The DON stated he could not assess the residents' PIs due to his workload. The DON stated, I can't do it. The DON stated the facility use registry nurses daily, and the registry nurses did what they wanted. The DON stated Residents 4, 5, 6, 7, 8, and 9 did not have their PIs measure upon admission and weekly thereafter. The DON stated PI treatments and interventions were based upon admission and weekly assessments. The DON stated facility license nurses (in general) did not update and implement Residents 4's, 5's, 6's, 7's, 8's, and 9's care plans. The DON stated he did not have a system to ensure Residents 4, 5, 6, 7, 8, and 9 received ordered treatments for PIs. During an interview with Resident 9's Family Member 2 (FM 2) [DATE] at 3:05 PM, FM 2 stated she did not want the surveyor to observe the PI. 2. During an interview on [DATE], at 1:25 PM, RN 1 stated he was a registry nurse, and the facility did not provide an orientation regarding PI. RN 1 stated he did not know the facility' protocol for PI assessments and treatments. During an interview on [DATE] at 1:35 PM, LVN 2 stated she was a registry nurses and the facility did not provide orientation regarding PI treatments requirements. During an interview on [DATE] at 3:04 PM, LVN 3 (registry nurse) stated she was assigned to Residents 6 and 7. LVN 3 stated Residents 6 and 7 did not have PIs. LVN 3 stated Resident 6 had a calmoseptine order, but she did not apply it. During the same interview and a concurrent review of Resident 6's physician orders, LVN 3 stated Resident 6 had a treatment order for the resident's Stage 4 PI. LVN 3 stated she documented in the PI treatments record that she completed the treatment, but she did not do it. During a concurrent interview regarding Resident 7, LVN 3 stated Resident 7 did not have a PI, just redness, on the right buttock. LVN 3 stated a CNA (unidentified) washed Resident 7's buttocks during the morning bath. LVN 3 stated she (LVN 3) was present during Resident 7's bath so she documented that Resident 7's PI treatments was done. LVN 3 stated she assumed the facility had a treatments nurse. LVN 3 stated the facility did not provide training or orientation regarding PIs. LVN 3 stated she did not know that she had to provide PI treatments. During an interview on [DATE] at 3:57 PM, LVN 4 stated it was her first time at the facility and stated she informed LVN 1 she had never done treatments on PIs. LVN 4 stated LVN 1 told her Oh well. LVN 4 stated she was not experienced with PI treatments and assessments. LVN 4 stated the facility did not provide her the help or training and left her to figure the PI treatments out on her own. During an interview on [DATE] at 12 PM, the ADM and DON both stated the facility did not have a Director of Staff Development (DSD). The AMD stated the facility's training and in service contract expired on [DATE]. The ADM stated facility's staff and registry staff did not receive regular in-services regarding PI treatment/assessment, and other care areas since the contract expired ([DATE]). During an interview on [DATE] at 1 PM, the ADM stated the facility did not have a policy for PI management. A review of the facility's policy titled, Pressure Injury Risk Assessment, dated [DATE], indicated steps in conducting a PI risk assessment including: Conduct a comprehensive skin assessment with every risk assessment, and Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. A review of the facility's policy and procedure titled Medication Administration, dated [DATE], indicated the facility would administer medications in a safe and timely (unidentified time) manner, and as prescribed. The policy indicated topical medications (medications that are applied to the skin) used in treatments were recorded on the resident's TAR. A review of the facility's policy titled, Quality of Care-Pressure Injuries, dated [DATE], indicated Skin Assessment: 1. Conduct comprehensive skin assessment upon admission (or soon after, within 8 hours), with each risk assessment, as indicated according to the resident's risk factors. The policy indicated skin assessments were to be done upon admission, weekly, and while performing ADLs.

Based on interview and record review, the facility failed to monitor the side effects of [MEDICATION NAME] (a mood-stabilizing medication) for one of four sampled residents (Resident 1). Resident 1 had a history of [REDACTED]. As a result, the licensed nurses did not promptly identify signs and symptoms of [MEDICATION NAME] toxicity. Resident 1 progressively became lethargic (feeling sleepy, fatigued or sluggish), nauseated (feeling sick with inclination to vomit), and confused. On 4/8/19, the facility transferred Resident 1 to General Acute Care Hospital 2 (GACH 2), and the [DIAGNOSES REDACTED]. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 from GACH 1 on 3/15/19. Resident 1's [DIAGNOSES REDACTED]. A review of the documents GACH 1 sent to the facility upon Resident 1's admission, included a Consultation Note dated 3/12/19. The note indicated Resident 1 had [MEDICATION NAME] poisoning and to avoid thiazides (diuretic medications (water pills) that increase urine flow by acting directly on the kidneys. Thiazides have a significant potential to cause [MEDICATION NAME] toxicity). A review of Resident 1's Physician's Orders on admission, 3/15/19, included the following medications continued from GACH 1: - [MEDICATION NAME] ([MEDICATION NAME] - a diuretic or water pill to remove excessive fluids in the body) tablet 40 milligrams (mg - unit of measurement), by mouth, twice a day for legs swelling, - [MEDICATION NAME] 300 mg capsule, by mouth, once a day for [MEDICAL CONDITION] disorder and, - [MEDICATION NAME] (a thiazide diuretic that helps prevent the body from absorbing too much salt, which can cause fluid retention) tablet 2.5 mg taken by mouth one time a day for bilateral leg swelling. The physician's orders did not include for the licensed nurses to monitor Resident 1 for side effect from [MEDICATION NAME] use (common side effects include hand tremors (shaking), diarrhea, vomiting, and drowsiness), and for signs and symptoms of [MEDICATION NAME] toxicity (shakiness, confusion, slurred speech, blurred vision, severe muscle spasms, [MEDICAL CONDITION] (convulsions), and coma (inability to respond to people and activities). A review of Resident 1's Nursing Process Focus/Clients Receiving [MEDICATION NAME] form indicated to monitor Resident 1's apical pulse (measure of the heart rate by placing a stethoscope (an instrument used to transmit low-volume sounds such as a heartrate to the ear of the listener) over the chest) as [MEDICATION NAME] toxicity may cause muscular irritability which could result in cardiac [MEDICAL CONDITION] (abnormal heartbeat) or [MEDICAL CONDITION] (chest pain). [MEDICATION NAME] is to be used with caution in residents with a history of [MEDICAL CONDITION]. Monitor the gastrointestinal tract (GI tract- related to the stomach and the intestines (bowels) status because [MEDICATION NAME] may cause diarrhea (frequent loose, watery stools). A review of Resident 1's Pharmacy Consultation Report dated 3/16/19, indicated Pharmacist 1 reviewed Resident 1's medication regimen and did not identify medication irregularities. Pharmacist 1 did not address the concurrent use of [MEDICATION NAME] and thiazide. Pharmacist 1 did not alert the physician and nursing staff to monitor Resident 1 for [MEDICATION NAME] toxicity closely. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 3/22/19, indicated Resident 1 did not have memory problems, was able to make decisions, had a clear speech, and could communicate her needs. The Care Area Assessment (CAA) Summary did not include Resident 1 was receiving [MEDICAL CONDITION] medication. A review of Resident 1's Vital Signs Summary form from 3/15 to 4/8/19, indicated no documentation of apical pulses. A review of Resident 1's Medication Administration Record [REDACTED]. A review of the Bowel Continence Summary Report form from 3/16 to 4/8/19, indicated Resident 1 had loose stool/diarrhea on 3/23, 3/24, 3/29, 4/6, and 4/7/19. A review of Resident 1's Physical Therapy (PT) notes indicated on 3/28, 3/29, and 4/1 to 4/5/19, Resident 1 had increased confusion. On 4/5/19, Resident 1 easily fatigued, complained of nausea, and was confused. A review of Resident 1's Nursing Notes dated 3/28/19, timed at 9:33 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) gave Resident 1 [MEDICATION NAME] ([MEDICATION NAME] - medication for nausea/vomiting). A review of Resident 1's Nursing Notes dated 4/6/19, timed at 10:27 p.m., indicated LVN 4 documented Resident 1 was lethargic, aroused by touch and sound, ate 25% of dinner, and slept a lot during the shift (3 p.m. to 11 p.m.) LVN 4 contacted Physician 1, who ordered intravenous fluids (IVF) and STAT (immediate) blood tests which did not include [MEDICATION NAME] blood level). At 10:30 p.m., LVN 4 documented Resident 1 was noticeably showing head shaking and facial twitching when awake and was lethargic. A review of Resident 1's Communication Form and Progress Note dated 4/7/19, timed at 5 p.m., indicated Resident 1 was showing involuntary head shaking and facial twitching while awake. Resident 1 was lethargic, did not show the abnormal body movements when asleep, and was nauseous. A review of Resident 1's Nursing Notes dated 4/7/19, timed at 5:46 p.m., indicated LVN 5 documented giving Resident 1 oxygen because the blood saturation (a measurement of oxygen in the blood) was 90% (normal levels between 95 to 100%). Resident 1's respiratory rate was 20 breaths per minute, uneven due to tremors. At 6:17 p.m., LVN 5 documented Resident 1 was having an exacerbation of twitching and tremors and notified Physician 1 Resident 1 had episodes of lethargy and complained of nausea. LVN 5 administered medication for nausea. Physician 1 gave a new order for a chest x-ray to be done on 4/8/19 and to continue to monitor Resident 1 and transfer to the emergency department (ED) for evaluation if the status of Resident 1 deteriorated. LVN 4 indicated Resident 1 was noticeably showing head shaking and facial twitching when awake and was lethargic. Upon notification, Physician 1 ordered blood tests, including [MEDICATION NAME] level for 4/8/19. A review of Resident 1's Nursing Notes dated 4/8/19, timed at 10 a.m., LVN 2 documented Resident 1's temperature was 100.4 degrees Fahrenheit (normal range from 97 to 99). At 11:33 a.m., Registered Nurse 1 (RN 1) documented Physician 1 ordered to transfer Resident 1 to GACH 2 for worsening of the condition. A review of Resident 1's GACH 2 Nephrology Consultation, dated 4/10/19 indicated Resident 1 had acute (sudden) on chronic (persisting for a long time) kidney failure. Resident 1 had [MEDICAL CONDITION] was stage 4 (severely damaged kidney function). GACH 2 admitted Resident 1 for significant worsening of renal function. A review of Resident 1's GACH 2 History and Physical dated 4/14/19, indicated the blood [MEDICATION NAME] level was 1.890 millimoles per liter (mmol/L, reference range from 0.6 to 1.2 mmol/L) on 4/8/19. A review of Resident 1's GACH 2 Discharge Summary dated 4/17/19, indicated Resident 1 had acute [MEDICATION NAME] toxicity resolved during the hospital stay. On 8/28/19 at 3:10 p.m., during an interview and concurrent record review of Resident 1's MAR, the Director of Staff Development (DSD) verified Resident 1's MAR indicated [REDACTED]. DSD was unable to find evidence in Resident 1's clinical record the nursing staff monitored side effects from [MEDICATION NAME] use. On 9/5/19 at 4 p.m., during an interview and concurrent Resident 1's record review, DSD stated there was not a physician's order to check Resident 1's apical pulse. DSD verified the licensed nurses did not check Resident 1's apical pulse. On 9/9/19 at 11:10 a.m., during a telephone interview, Physician 1 stated becoming Resident 1's attending physician upon admission to the facility on [DATE] and was aware Resident 1 had a history of [REDACTED]. Physician 1 stated that the likelihood of [MEDICATION NAME] intoxication for Resident 1 was high. On 9/10/19 at 12:50 p.m., during a telephone interview, Pharmacist 1 stated she was the facility's pharmacist consultant and reviewed residents' medication regimen within 72 hours from admission and monthly after that. Pharmacist 1 explained that upon reviewing Resident 1's medication regimen, she determined there were no irregularities. Pharmacist 1 stated that making recommendations was not a part of the admission review. On 9/20/19 at 11:24 a.m., during a telephone interview, Resident 1 stated on the last five days at the facility, she was not conscious (alert and aware of surroundings). Resident 1 remember very little such as being nauseous when going to physical therapy. A review of the facility's policy on [MEDICAL CONDITION] Drug Management, revised on 7/2019, indicated the facility would monitor residents using [MEDICAL CONDITION] for efficacy and adverse reaction. The consulting pharmacist shall advise healthcare providers regarding medication or dose adjustments.

Based on interview and record review, the facility's staff failed to prevent accident for one of two sampled residents (Resident 1), who was assessed as a high risk for falls, including: 1. Failure to for housekeeping staff to place the floor mats back at the resident's bedside after cleaning the floor and before leaving the resident's room. 2. Failure to implement the facility's policy on Falls Preventions by not promoting resident safety and following safety precautions for Resident 1. As a result, on 3/22/19, Resident 1 fell and experienced pain on the left arm and leg. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident was admitted and had surgery for [REDACTED]. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Nursing Admission Data Collection dated 3/21/19, timed at 10:30 p.m., indicated Resident 1 was oriented to self, sometimes able to communicate and had short and long term memory problem. Resident 1's mobility status was confined to chair with unsteady balance and only able to stabilize with physical assistance. The admission assessment indicated Resident 1 was at risk for falls. A review of the Licensed Nurse Progress Notes dated 3/21/19, timed at 10:30 p.m., indicated Resident 1 required extensive assistant (Resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer and total assistance (full staff performance) with activities of daily living (ADL) including incontinence care. A review of the Interim Care Plan dated 3/21/19, indicated Resident 1 was at risk for falls. The goal was for Resident 1 to not sustain serious injury through the review date. The interventions included making Resident 1 a falling star program participant (a resident identified at a higher risk for falls with safety precaution approaches outlined on the care plan), providing Resident 1 with a high-lo bed (a bed with an extra motor that allows the entire bed deck to raise and lower and can drop as low as 7 off the floor to help prevent injury from falling out of bed), placing mats on the floor at Resident 1's bedside, and providing Resident 1 with appropriate assistive devices as ordered. A review of the Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note dated 3/22/19, timed at 11:41 a.m., indicated Resident 1 was found on the floor at bedside and was noted with a skin tear to the left elbow. The note indicated Resident 1 had no pain. The licensed nurse (unidentified) notified Physician 1, who ordered stat (immediately) x-ray of Resident 1's left elbow and hip. A review of the Fall Investigation Worksheet dated 3/22/19, untimed, indicated Resident 1 had an unwitnessed fall in his room. The investigation Worksheet indicated the Housekeeping staff was cleaning up the room right before Resident 1 was found on the floor. Resident 1 sustained a 2.5 centimeters (cm) by 2.5 cm skin tear on the left elbow. A review of the Nursing Home to Hospital Transfer Form dated 3/22/19, timed at 3:10 p.m., indicated Resident 1 was sent to GACH 1 due to a fall. Resident 1 complained of 7 out of 10 pain (0 being no pain and 10 being the worst pain), and the pain location was not specified. Resident 1 had confusion and attempted to ambulate on his own and was assessed as at risk for fall. The form indicated Resident 1's family member called 911. A review of the Licensed Nurse Progress Notes dated 3/22/19, timed at 5:05 p.m., indicated Resident 1's Family Member (FM 1) called 911 around 1:30 p.m. to take Resident 1 to another facility. The note indicated per FM 1, Resident 1 had sun downers (a person with dementia who becomes increasingly irritable or difficult as the day progresses) and dementia and needed to go to a different facility. FM 1 disregarded Physician 1 and the case manager who was in the facility. The note indicated x-rays were pending. A review of GACH 1's Emergency Department (ED) History & Physical exam dated 3/22/19, timed at 3:28 p.m., indicated Resident 1 was brought in by ambulance for evaluation of left-sided pain status [REDACTED]. Resident 1 had an unwitnessed fall on his left side, causing sudden onset of pain in his left shoulder, elbow and knee. Resident 1 had x-ray of the left femur which showed comminuted fracture (a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) of the left femoral neck with slight varus (bent or twisted inward) deformity. A review of GACH 1's Operative Report dated 3/28/19, timed at 3:17 p.m., indicated Resident 1 with displaced left femoral neck fracture s/p left hip hemiarthroplasty (a surgical procedure that replaces the head of a damaged femur with an implant designed to stabilize the femur and restore hip function) on 3/27/19. A review of GACH 1's Discharge Summary dated 4/1/19, indicated Resident 1 was admitted with a left femoral fracture and was discharged under stable condition on 3/31/19. During an interview on 5/2/19 at 10:40 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she received a report Licensed Vocational Nurse 2 (LVN 2, charged nurse from the 11 p.m. to 7 a.m. shift) that Resident 1 was a fall risk and had episodes of trying to get out of bed during the night. LVN 1 stated LVN 2 informed her that Resident 1's bed was put at the lowest position and floor mats were placed at Resident 1's bedside. LVN 1 stated she made her initial rounds around 7:30 a.m. and saw Resident 1 trying to get out of bed without calling for help. LVN 1 stated she reoriented Resident 1 and redirected the resident and made sure that Resident 1's bed was low and the floor mats were in place. During further interview on 5/2/19 at 10:40 a.m., LVN 1 stated between 9 a.m. to 10 a.m., while passing medications two rooms away from Resident 1's room and she saw Resident 1 on the floor next to his bed. LVN 1 stated she went to Resident 1's room right away and did not see the floor mats at the bedside. LVN 1 stated Housekeeper 1 just finished cleaning Resident 1's room and forgot to put the floor mats back in place. LVN 1 stated Resident 1 had a bleeding abrasion on his left elbow and complained of left elbow pain. During an interview on 5/2/19 at 12:01 p.m., the Director of Nursing (DON) stated Resident 1 was newly admitted and was in the facility for less than 24 hours. The DON stated Physician 1 was notified of the fall and ordered x-rays of Resident 1's left elbow, knee, and bilateral hips. The DON stated on 3/22/19, FM 1 was upset and called 911. During an interview on 5/8/19 at 9:40 a.m., Housekeeper 1 (HK 1) stated she cleaned Resident 1's room around 10 a.m., she removed the floor mats to clean the floor, but did not put the floor mats back in place because she was waiting for the floor to dry. HK 1 stated Resident 1 was in bed, calm and relaxed at that time. Housekeeper 1 stated she left Resident 1's room and went to the next room to clean. Housekeeper 1 stated I'm sorry. During an interview on 5/8/19 at 10:05 a.m., the Housekeeping Director stated when housekeeping staff cleaning a resident's room with floor mats, they should move the mats to clean the floor, but put them back right after cleaning. The Housekeeping Director stated housekeeping staff should never leave the resident's room without replacing the floor mats for safety reasons. A review of the facility's policy and procedures titled Falls Prevention, revised on 10/2018, indicated residents will be evaluated for the risk of falling so that interventions may be considered in order to: promote resident safety, promote appropriate clinical and multi-disciplinary assessment of falls and fall risk factors and coordinate management of acute and recurrent falls. The policy indicated if the resident scores above a 10 in Fall Risk Data Collection, he/she shall be placed on the Falling Star Program. Resident's Care Plan shall reflect that he/she is at a higher risk for falls and identifies approaches that are to be taken. A distinction will be made to alert care providers to observe safety precautions by placing a star on resident's name plate outside his/her door. The safety precautions for high risk residents may include, but are not limited to the following: keep room free from clutter, additional lighting or night light, call light and/or personal items within reach, review for adaptive equipment at the bedside (walker, bedside commode, non-slip footwear, fall mat, transfer pole, non-skid strips), and maintain safe environment (dry floors, properly maintained resident equipment).

Based on interview, and record review, the facility failed to provide treatment and services for one of two residents (Resident 1), with pressure sores in a total facility census of 27 residents to prevent the development of pressure sores to Resident 1 by failing to: 1. Notify the physician immediately and promptly obtain treatment orders when Resident 1 developed an open sore on the coccyx. 2. Accurately and thoroughly assess Resident 1 ' s pressure sore as a basis for the initiation of interventions to promote healing. 3. Revise Resident 1 ' s plan of care to include additional interventions to prevent worsening of the pressure sore. These failures resulted in Resident 1 and developing an avoidable Stage 3 to 4 pressure sore on the coccyx with foul smelling discharge and resulted in a delay in care and services necessary for treatment of [REDACTED]. Findings: On December 4, 2014, at 12:30 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and resident neglect involving Resident 1. A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the admission assessment dated [DATE], Resident 1 had no pressure sores upon admission. Resident 1 ' s assessment for Predicting Pressure Sore Risk dated September 4, 2014, indicated Resident 1 was a high risk for developing pressure sores. Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care planning tool, dated September 11, 2014, indicated Resident 1 was able to complete the brief mental status interview, understands others and was able to make herself understood, required extensive assistance with most activities of daily living and had no pressure sores. Resident 1 ' s care plan dated September 12, 2014, indicated the resident had the potential to develop pressure sores related to weakness and bed mobility. The care plan goal indicated the resident would have intact skin, be free of redness, blisters or discoloration. The listed nursing interventions included to follow facility policies and protocols for prevention and treatment of [REDACTED]. A review of Resident 1 ' s nurse's note dated September 19, 2014, at 2 p.m., indicated the resident was assessed with [REDACTED]. The same day the physician ordered to apply [MEDICATION NAME] ointment (acts as a barrier to protect skin from moisture and irritating substances) to the coccyx topically (apply to a body surface) every shift for 14 days for mild redness. Mild redness is indicative of a stage 1 pressure sore. (October 3, 2014 would end the 14 days) According to Resident 1 ' s Licensed Nurse Weekly Summary dated September 22, 2014, at 10:05 p.m., the resident was assessed with [REDACTED]. The documentation did not include a detailed description of the skin tear as indicated in the facility ' s policy and procedure. There was no documented evidence that the resident's physician was notified of the change in the resident's skin condition, so as to promptly obtain treatment orders to promote healing of the skin tear. The treatment record of September 2014, indicated [MEDICATION NAME] ointment treatment continued to be applied to the coccyx topically every shift even after the resident ' s skin condition worsened from September 19, 2014, when the resident was assessed with [REDACTED]. There was no plan of care developed to address the resident's skin tear. A review of Resident 1 ' s nurse's note dated September 23, 2014, at 4:25 a.m., indicated the resident was being monitored for an open sore to the coccyx, which is indicative of a is a Stage II pressure sore, partial - thickness of dermis (skin) (Medical-Surgical Nursing, Lewis,Dirksen,Heitkemper,Bucher, Ninth Edition, page 185). There was no documented evidence on September 23, 2014, to indicate that the physician was notified of the resident ' s Stage II pressure sore on the coccyx, so as to promptly obtain treatment orders and initiate interventions based on the characteristics of the sore to promote healing of the pressure sore. The treatment record of September 2014, indicated the treatment nurses continued to apply [MEDICATION NAME] ointment to the coccyx every shift from September 23, 2015, through September 30, 2014, even after the resident developed the Stage II pressure sore. The plan of care was not revised to include additional measures to prevent worsening of the open sore such as systematically assessing the skin at least once a day. ( Nursing Care Ready Reference: Resident Assessment Protocols, Ross, November 1997, Page 63.) Once a pressure sore has developed, interventions should be initiated based on the characteristics of the sore e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain and the resident ' s general status, Medical-Surgical Nursing, Lewis,Dirksen,Heitkemper,Bucher, Ninth Edition, page 186. A review of the Medicare/PPS (prospective payment system) of Daily Charting dated September 25, 2014, at 9:26 p.m., indicated the resident had excoriation (a raw and open break in the skin surface usually caused by scratches, burns, or abrasion) on the coccyx. The charting did not include a thorough assessment of the resident's coccyx and it did not contain documented evidence that the resident's physician was notified of a change in the resident's skin condition. According to the treatment record for September 2014, the resident continued to receive [MEDICATION NAME] ointment on her coccyx every shift for mild redness from September 19, 2014 to September 30, 2014. Resident 1 ' s plan of care dated September 25, 2014, indicated the resident had an actual impairment to skin integrity, unstageable pressure sore (unable to determine (UTD) stage due to coverage of wound bed by slough (dead tissue in the process of separating from viable portions of the body) and/or eschar (thick, leathery, dead, devitalized tissue), related to fragile skin. The care plan nursing interventions indicated to evaluate the resident ' s skin condition on a daily and weekly basis. A review of the resident ' s clinical record did not contain an accurate and detailed evaluation of the resident's skin condition for three days, from September 26, 2014 through September 28, 2014, as indicated on the resident ' s care plan dated September 25, 2014. As such, the status of the unstageable pressure sore was not determinable from the documentation. A review of Resident 1 ' s treatment record for September 2014, indicated the treatment was changed on September 26, 2014. The treatment indicated to cleanse coccyx with normal saline (salt solution), pat dry, and to apply [MEDICATION NAME] ointment on the coccyx topically and cover with a dry dressing every shift. A review of the treatment record for September 2014, indicated the [MEDICATION NAME] ointment treatment continued to be applied to the resident ' s coccyx for mild redness from September 25, 2014 through September 30, 2014, even though the resident ' s pressure sore had worsened on September 25, 2014, to an unstageable pressure sore. There was no documented evidence the physician was notified immediately to obtain treatment orders for the resident's worsening unstageable pressure sore on the coccyx from the time it was identified by the facility on September 25, 2014, until September 29, 2014. The nurse's note dated September 29, 2014, at 2:55 p.m., indicated the resident's physician was notified about the resident's progressing excoriation and an order for [REDACTED]. On September 30, 2014, the physician ordered to cleanse the unstageable pressure sore (UTD) with normal saline, pat dry, apply santyl (topical medication that helps to break up and remove dead skin and tissue) and cover with dry dressing every day and as needed until the follow-up with the wound surgeon. The physician's order [REDACTED]. Santyl is an FDA approved prescription medicine that removes dead tissue from wounds so they can start to heal. HealthCare professionals have prescribed Santyl ointment for more than [AGE] years to help clean many types of wounds including chronic dermal ulcers. A review of a plan of care dated September 30, 2014, indicated the resident was at risk for complications/injury to unstageable pressure sore related to the resident scratching at her pressure sore, pulling off the dressing, and noncompliance with not touching the wound. The care plan goal indicated the resident will not have further complications from the unstageable pressure sore. The listed nursing interventions included to encourage good hygiene and replace dressing to sacrum as necessary. According to Resident 1 ' s nurse's note dated October 1, 2014, at 3:23 p.m., the resident was found with altered level of consciousness and chest pain and was transferred to the general acute care hospital due to a change in condition. The acute hospital Emergency Department (ED) Stat Admit (immediate admission) record, dated October 1, 2014, indicated the resident was assessed with [REDACTED]. to muscle, bone, or supporting structures; may include undermining (tissue destruction underlying intact skin along wound margins) and tunneling (pathway that can extend in any direction from the wound, resulting in dead space)) sacral pressure sore, measuring two to three centimeters (cm) with foul smelling discharge and had a temperature of 100.5 degrees. The acute hospital emergency room physician notes further indicated the resident had [DIAGNOSES REDACTED]. According to Mayo Clinic internet signs of an infected pressure sore include; fever, drainage or a foul odor from a sore, and increased heat and redness in the surrounding skin, <http://www.mayoclinic.org/diseases-conditions/bedsores/basics/symptoms/con- 848> A review of the GACH's (general acute care hospital) Assessment Report by the ED registered nurse (RN) dated October 1, 2014, at 3:28 p.m., indicated the resident had a foul smelling open wound on the coccyx, stage 3 to 4, with eschar covering and around the edges. During an interview on December 4, 2014, at 2:45 p.m., Licensed Vocational Nurse (LVN) 1 stated that the resident was receiving [MEDICATION NAME] ointment for the excoriation on her coccyx. LVN 1 further stated that the resident's excoriation got worse so fast due to the resident scratching the area and taking off the dressing. On March 26, 2015, at 2:40 a.m., during an interview, the director of nursing (DON) reviewed the clinical record and was unable to find accurate and detailed assessments of the resident's skin condition and wound progression from September 22, 2014 through September 30, 2014. The DON further stated that there were some inconsistencies in the licensed nurses' documentation. On April 22, 2015, at 12:45 p.m., during a telephone interview, LVN 1 stated that the resident's unstageable pressure sore worsened and had gotten bigger when she saw it on September 30, 2014. LVN 1 stated that she never measured the resident's wound and the attending physician had not seen the resident's wound. A review of the facility's policy and procedure titled Pressure Ulcer/Skin Breakdown - Clinical Protocol dated October 2010, indicated the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or non-healing wounds. According to the US Department of Health and Human Services publication: Clinical Practice Guideline for Pressure Ulcer Treatment dated December 1994, pressure ulcers should be uniformly described to facilitate communication among staff and to ensure adequate monitoring of the progress toward healing. To monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width, and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudate, and the presence or absence of granulation tissue and epithelization (the regrowth of skin over a wound). To determine the adequacy of the treatment plan, it is essential to monitor pressure ulcers at consistent intervals. Assessment and documentation should be carried out at least weekly, unless there is evidence of deterioration, in which case both the pressure ulcer and the patient's overall management must be reassessed immediately.

Based on observation, interview, and record review the facility failed to provide treatment and services to prevent pressure sores development and to prevent worsening of existing pressure sores for five out of 10 sampled residents (Residents 8, 4, 5, 1, and 7). 1. For Resident 8, the facility failed to:(a) Develop a plan of care to address the frequency in which the resident should be turned, as well as the positioning of the resident (b) Implement the plan of care to turn and reposition the resident in bed( c) Avoid positioning the resident in a back lying position (d) Accurately assess the location of the pressure sore. These failures resulted in Resident 8 developing an avoidable Stage III pressure sore to the coccyx. 2. For Resident 4, the facility failed to (a) initially assess Resident 4's Stage IV pressure sore (b) Ensure Resident 4 was not lying on his back directly on the pressure sore and (c) Failed to follow the physicians treatment orders. This had the potential to result in the worsening of the pressure sore. 3. The facility failed to follow the physician's orders [REDACTED]. Resident 5, who was admitted to the facility with pressure sores on both heels, was observed in bed with both heels touching the mattress. Failure to follow the physician's orders [REDACTED]. 4. For Resident 1, who had a stage IV pressure sore to the coccyx, the facility failed to follow Resident 1's plan of care interventions to turn and reposition the resident off the pressure sore area. This had the potential to delay wound healing and placed the resident at risk for the development of new avoidable pressure sores. 5. For Resident 7, the facility failed to reposition Resident 7 who has a Stage II pressure sore to the left buttock extending to his sacrum, every two hours and to elevate both feet with pillows as ordered by the physician. This had the potential to delay wound healing and placed the resident at risk for the development of new avoidable pressure sores. Findings: a. The admission face sheet indicated Resident 8 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Nursing Admission Data Collection form, dated February 26, 2015, indicated the resident did not have a history of skin issues. There was no indication the resident had any pressure sores. According to the Braden Scale, a nursing tool which uses a special scoring system to evaluate a patient's risk of developing a pressure sore, dated February 26, 2015, Resident 8 scored a 13, which indicated the resident was at moderate risk of developing pressure sores. An untitled care plan dated February 27, 2015, indicated the resident had a potential for impairment to skin integrity related to fragile (that easily tears or breaks) skin, and incontinence (lack of bladder/bowel control). The nursing goal indicated the resident was to remain free from skin breakdown. The care plan interventions included to assist with turning and repositioning, as needed, and to evaluate the resident's skin condition on a daily and weekly basis. Although, the care plan indicated to turn and reposition the resident, it did not contain the frequency in which the resident should be turned. According to Medical Surgical Nursing Ninth Edition pages 186, 187 indicated: Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure ulcer. A Progress Note, dated March 10, 2015 at 5:46 p.m., indicated skin breakdown was observed on Resident 8's coccyx (tailbone). The progress note indicated a ½ inch lateral break down at coccyx (tailbone) site, slight pink/red, no odor, no swelling, no drainage. A barrier cream (Calmoseptin) was applied as ordered. On March 11, 2015 at 4:45 p.m., a Progress Note, indicated to Cleanse Coccyx Excoriation(scraped or abraded) , with Hibicens (skin cleanser/antiseptic) and apply [MEDICATION NAME] (multipurpose moisture barrier, ointment). On March 20, 2015 at 11:01 a.m., the progress notes indicated certified nursing assistant (CNA) had reported to the charge nurse regarding some open skin to the buttocks . A wound care consult dated March 23, 2015, indicated Resident 8 was assessed as having a Stage III (full thickness loss of subcutaneous fat lying directly under the skin) pressure sore to the left buttock. Treatment orders included: aggressive offloading, and turning every two hours. A Progress Note note dated March 25, 2015 at 12:01 p.m., indicated the wound had progressed to a Stage III pressure ulcer with 70% slough (yellow, tan dead tissue). A new order was obtained, Cleanse left buttock Stage III with wound cleaner, pat dry. Documentation on the, Progress Notes, was unclear as to whether the pressure sore was to the coccyx, the buttock, or both or whether there were more than one pressure sores. An untitled care plan dated March 25, 2015, indicated Resident 8 had a Stage III pressure sore to the left buttock related to immobility. Nursing interventions included to evaluate skin condition on a daily and weekly basis and frequent turning and repositioning as tolerated. A Minimum Data Set (MDS) a comprehensive standardized assessment and care screening tool, dated May 28, 2015, indicated Resident 8 scored a 5 out of a total of 15 on the, Brief Interview for Mental Status. The resident required extensive two person assist with bed mobility (repositioning in bed), transfers, and activities of daily living (ADLs) and had impairments to both upper and lower extremities on one side (left side). The MDS indicated the resident had a Stage III pressure sore (full thickness loss of subcutaneous fat lying directly under the skin) may be visible. Slough (yellow, tan dead tissue) may be present and there may be undermining-lies beneath the wound opening, and tunneling-like a cave). Treatments for the pressure sore included: Turning and repositioning. A wound care consult dated May 31, 2015, indicated Resident 8 had a Stage III pressure sore to the sacral/coccygeal (tailbone). The pressure sore was described as having a wound base covered with a scab (hard coating on the skin formed during wound healing) and was unable to assess. Treatment included: Reinforcing positioning to family and staff. During the survey, Resident 8 was observed in bed lying on her back on the following dates and times: a. On June 2, 2015 at 9:50 a.m., Resident 8 was lying on her back. b. On June 3, 2015 at 9:57 a.m., treatment nurse 1 (TN 1), who was also present in Residents 8's room did not try to reposition the resident off her back nor requested that the resident be repositioned. c. On June 5, 2015 at 7 a.m., 11:50 a.m., Resident was lying on her back. During an interview on June 5, 2015 at 12:25 p.m., the director of nursing (DON) stated residents should be turned every two hours. The DON stated the resident should not be positioned on her back because the pressure sore was located on the coccyx. The DON also stated the licensed nurses are supposed to ensure residents are being turned and properly positioned every two hours. In another interview on June 5, 2015 at 1:10 p.m., certified nursing assistant (CNA 1) stated Resident 8 was confused but cooperative. According to CNA 1 the resident should not be placed on her back except for meals because she had a pressure sore on her buttock. CNA 1 stated residents were supposed to be turned every two hours. According to CNA 1 the facility did not have a specific turning schedule indicating the frequency and position to which residents should be turned. d. On June 5, at 1:45 p.m., Resident 8 was observed lying on her back with a stage III pressure sore measuring 1.5 centimeters (cm) X 0.1 cm. The wound bed had approximately 75% green tinted/yellow slough. The surrounding tissue was red with mild drainage and a round outer margin. e. On June 5, 2015 at 1:50 p.m., Resident 8 was lying on her back. During an interview on June 5, 2015 at 1:50 p.m., Resident 8's family member stated the resident developed the pressure sore two weeks after being admitted to the facility following a stroke. The family member stated she visited Resident 8 daily, usually from 10:30 a.m. to 4 p.m., including weekends. According to the family the resident was always in bed lying on her back. The family stated I have to come here every day to tell the staff to get my mom out of bed otherwise she'll stay in bed, in the same position, all day long. Even when I'm here my mom doesn't get moved unless I tell the staff. When asked if the resident is able to position herself while in bed, the family member stated, No. According to the family member the resident had left sided weakness due to a stroke and also was overweight which made it difficult for her to position herself in bed. On June 8, 2015 at 9:20 a.m., in an interview with the treatment nurse (TN 2) stated Resident 8 required heavy care with two person assist. According to TN 2 the resident was confused but cooperative with care. TN 2 stated Resident 8 had a pressure sore to the coccyx. When asked about the documentation on the, Progress Notes, TN 2 stated the nurses had been confused about the location of the pressure sore. TN2 stated the resident should never be placed on back lying position because it could worsen the pressure sore. According to TN 2 the CNAs are responsible for turning and repositioning the residents. TN 2 stated the licensed nurses are supposed to check every two hours to make sure residents are being turned. Treatment records for the month of June 2015 indicated the charge nurse is to ensure resident gets repositioned from side to side every two hours for wound management. Review of the treatment records on June 5, 2015 at p.m., indicated charge nurses had not documented ensuring Resident 8 was being turned on June 2, 2015, at 4 p.m., p.m.,, 8 p.m. and 10 p.m., on June 3, 2015, at 8 a.m., 10 a.m.,, 12 p.m., and p.m., and on June 5, 2015 at 6 a.m., 8 a.m., 10 a.m., and 2 p.m. TN 2 stated if it was not documented then it was not done. Review of the policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised October 2010, indicated nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility .in addition the nurse shall assess and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. The physician will authorize pertinent orders related to wound treatments. 2. An admission face sheet indicated Resident 4 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of, Nursing Admission Data Collection, dated May 28, 2015, indicated the resident had pressure ulcers to the sacrum and left buttock. There was no description as to the length, width, depth, or stage of the pressure ulcers. Review of a wound consult dated June 1, 2015, indicated Resident 4 had a Stage IV pressure sore to the sacrogluteal (the groove between the buttocks that runs from just below the sacrum (triangular shaped bone at the bottom of the spine) to the perineum (the area between the anus and the scrotum in the male and between the anus and vulva in the female)). Treatment orders included aggressive offloading, and turning every two hours. Resident 4 was observed lying on his back on the following dates and times: June 2, 2015 at 7:55 a.m., 1:11 p.m., on June 3, 2015 at 7:35 a.m., on June 5, 2015 at 12:25 p.m. During an interview on June 5, 2015 at 12:25 p.m., the director of nursing (DON) stated residents should be turned every two hours. The DON stated resident who have pressure sores on the coccyx or buttocks should not be positioned on their backs. The DON also stated the licensed nurses are supposed to ensure residents are being turned and properly positioned every two hours. 3. An admission face sheet indicated Resident 5 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident 5 was observed in bed with both heels not floated (elevated with pillows) on June 2, 2015 at 7:45 a.m., and 10:29 a.m., and on June 3, 2015, at 8:04 a.m., and on June 5, 2015 at 7:50 a.m. During an interview on June 5, 2015 at 1:10 p.m., certified nursing assistant (CNA 1) stated Resident 5 was supposed to have heels floated n while in bed. CNA 1 stated, Sometimes we don't do it because he is alert and he knows they should be floated. 4. A review of the admission face sheet for Resident 1 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/12/15, indicated the resident had short and long term memory recall problems, required extensive assistance in transfer and was incontinent of bowel. During multiple observations on 6/2/15 at 7:49 a.m., 9:10 a.m., 10:05 a.m., Resident 1 was observed lying on her back while in bed. During further observations on the same day at 11:10 a.m., 12:00 p.m., 1:15 p.m., 2:10 p.m., 3:15 p.m., and at 4:17 p.m., the Resident 1 was lying on her left side in bed. During the treatment observation on 6/5/15 at 11:28 a.m., Resident 1 was observed with a Stage IV pressure sore (full thickness tissue loss with exposed bone, tendon or muscle) of the sacrum (triangular bone at the base of the spine) that measured 4.3 cm x 5 cm with a depth of 1 cm. The wound bed had moderate amount of yellow green colored slough tissue (dead tissue). Treatment Nurse 1 cleansed the sacral area with Normal Saline, applied [MEDICATION NAME] (antibacterial) ointment and was covered with dressing. The resident was alert with periods of confusion. A review of resident's body check (nursing admission data collection) indicated initial body check for Resident 1 was not done until 2/14/15. Resident 1 was assessed on 2/14/15, with a pressure sore to the coccyx (tailbone) described as Sacral wound unstageable. There was no documented evidence the size of the pressure sore was measured on 2/14/15. A review of the facility's weekly wound data collection flow sheet dated 2/18/15 indicated Resident 1 was assessed with [REDACTED]. A review of Resident 1's plan of care dated 2/14/15, for sacrum pressure sore indicated the care plan interventions included turning and repositioning the resident regularly as needed and as tolerated while in bed. The care plan interventions did not indicate specific frequency of turning and repositioning schedule for Resident 1. Also, the care plan interventions did not indicate which specific side the resident's body should be turned and repositioned while in bed to promote healing of the pressure sore. Clinical Practice Guideline, number 15, for Pressure ulcer treatment dated December 1994, indicated Avoid positioning patients on a pressure ulcer. Because pressure that is of sufficient intensity and duration to cause soft tissue ischemia and necrosis contributes to the development of pressure ulcers, it is reasonable to assume that pressure on an ulcer can delay healing. During an interview on 6/5/15 at 12:04 p.m., CNA 1 stated she was aware Residents 1 and 7 had pressure sore to the sacrum. She was asked which specific side the resident's body should be turned and repositioned while in bed. She responded, I turned and repositioned them to right side, back, and left side at least every two hours. She was asked why Residents 1 and 7 remained on the same position on 6/2/15, 6/4/15, if the resident was to be turned and repositioned at least every two hours. She responded, I was busy taking care of other residents. CNA 1 stated she was not informed by any staff member Residents 1 and 7 should not be repositioned on their back. During an interview on 6/5/15 at 12:15 p.m., the Director of Nursing and Registered Nurse(RN 1) both stated staff did not have written or visual monitoring system to ensure resident with a pressure sore was not turned and repositioned on a pressure sore site while in bed. 5. During the initial tour of the facility on 6/2/15 at 7:49 a.m., Resident 7 was observed lying on his back while in bed. His right and left heels were resting on the mattress. The resident was non-communicative. On 6/4/15 at 8:02 a.m., 9:00 a.m., 10:00 a.m., and at 11:25 a.m., Resident 7 was observed lying on his back and his heels were resting on the mattress. During the treatment observation on 6/4/15 at 11:25 a.m., Resident 7 was observed with Stage II pressure sore (topmost layer of the skin was broken, creating a shallow open sore) to left buttock extending to his sacrum that measured 5.5 cm x 2.2 cm. Treatment Nurse 2 cleansed the pressure sore with wound cleanser, applied [MEDICATION NAME] ointment and was covered with dry dressing. A review of the admission face sheet for Resident 7 indicated the resident was admitted to the facility on [DATE],with [DIAGNOSES REDACTED]. Resident 7's initial body check dated 5/2/15, indicated he was admitted to the facility with Stage II pressure sore with suspected DTI (DTI-deep tissue injury is purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (pressure exerted against the surface)) to his right and left medial (middle) buttocks and coccyx (tailbone). Also, his right heel and left foot (first metatarsal heel (sole bones)) was assessed with [REDACTED]. The resident's initial body check dated 5/2/15, did not indicate measurement of the pressure sore until 5/6/15. The weekly wound data collection flow sheet dated 5/6/15, indicated there was 2.2 cm x 1.5 cm with 0.1 cm depth Stage II pressure sore to the sacrum instead of coccyx. A review of the Minimum (MDS) data set [DATE], indicated Resident 7 had short and long term memory recall problems, was incontinent of bowel and bladder and required total dependence in bed mobility. A review of Resident 7's plan of care dated 5/6/15, for pressure sore of the sacrum indicated he should be turned and repositioned regularly as needed while in bed to heal his pressure sore. The care plan interventions neither indicated specific frequency of the turning and repositioning schedule nor were specific to which side the resident's body should be turned and repositioned. A review of the physician order [REDACTED]. During an interview on 6/5/15 at 12:04 p.m., CNA 1 stated she was aware of the physician's orders [REDACTED]. CNA 1 stated she floated the resident's heels on pillows but unable to monitor if the resident's heels remained floated because she was busy taking care of other residents. During an interview on 6/5/15 at 12:15 p.m., DON stated residents with pressure sore to the sacrum should not be turned and repositioned on their back because it would not relieve the pressure and delayed the healing of the pressure sore. The DON was asked what is Regular turning and repositioning means in the resident's plan of care. She stated residents with pressure sores should be turned and repositioned at least every two hours.