Every finding on record at Bruceville Terrace - D/P SNF of Methodist Hospital

Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of 7 sampled residents (Resident 1), who was dependent on staff for activities of daily living (ADLs, activities done every day such as personal hygiene, bathing, dressing, and toileting) and was at high risk for falls, when Resident 1's call light (the primary means of the resident to communicate need for assistance with staff) was unplugged (disconnected) from the wall outlet and not within Resident 1's reach.This failure had the potential to result in Resident 1's care needs not being met and increased Resident 1's risks for falls and injuries due to inability to reach staff for help.A review of the admission record indicated the facility admitted Resident 1 in 2018 with multiple diagnoses which included history of stroke with right side weakness and seizures (abnormal electrical activity in the brain that could make a person to shake or jerk uncontrollably, become confused, unresponsive or lose consciousness) related to traumatic brain injury.A review of Resident 1's Minimum Data Set (MDS, a federally required assessment tool) dated 6/1/26 indicated that her cognition (awareness, perception, reasoning, and judgement) was moderately impaired. The MDS assessment of Resident 1's functional abilities indicated Resident 1 was dependent on staff for personal hygiene, bathing, and toileting.A review of Resident 1's personalized care plan (a detailed approach to care customized to individual resident's concerns/needs and outlining the care and services needed to meet resident's needs) titled Self-Care Deficit initiated 11/11/25 indicated that Resident 1 had self-care deficit related to her diagnosis of stroke. One of the interventions directed staff to provide appropriate level of assistance to Resident 1.A review of Resident 1's 'Fall Risk' care plan initiated 9/15/25 with the last revision date of 6/2026, indicated Resident 1 was at high risk for falls due to impaired balance, mood disorder, and seizures. The interventions directed nursing staff to anticipate Resident 1's needs, have a call bell (call light) within reach, and answer the call light promptly.A review of Resident 1's 'Behavior' care plan initiated January 2026, with the last revision date of 8/2026 indicated Resident 1 experienced difficulty with mood. One of the interventions indicated, Remind to use call bell [call light].During an observation on 8/18/26 at 11:45 a.m., Resident 1 was overheard calling out, nurse, nurse, help from her room. Resident 1's voice was audible in the hallway. Observed Licensed Nurse (LN 1) entering Resident 1's room.During an observation on 8/18/26 at 11:55 a.m., Resident 1 was overheard calling out loudly, nurse, nurse, help. The call light above Resident 1's room in the hallway was not illuminated. As the surveyor passed by Resident 1's room, the resident waived her hand.During a concurrent observation and interview on 8/18/26 at 11:55 a.m., Resident 1 was observed in bed dressed in the hospital gown. Resident 1 was alert, pleasant, and was able to carry out a meaningful conversation. Resident 1 stated she was too weak and required lots of staff's assistance. When Resident 1 was asked whether she had activated her call light, the resident looked from side to side and attempted to locate the call light. Resident 1 stated, It should be somewhere here, but I can' find it. The call light was observed hanging on Resident 1's right side rail near the head of bed, with the call light button extending all the way to the floor. The call light was not within the resident's reach. A further observation revealed that the other end of the call light cord was disconnected from the wall outlet, rendering the call light inoperable.During a concurrent observation and interview on 8/18/26 at 12:05 p.m., with LN 1 in Resident 1's room, LN 1 validated that the call light cord was disconnected from the wall and was not operable. LN 1 stated that the call light button was out of Resident 1's reach and the resident was unable to call for assistance. LN 1 stated that Resident 1 was forgetful but was able to call for assistance and able to verbalize her needs. LN 1 stated that most of the time Resident 1 yelled for help. LN 1 stated, No idea why it's being disconnected and for how long. I was in her room not long ago and did not notice that it was disconnected. LN 1 explained that call light should always be kept within the resident's reach so the resident can summon staff for assistance when needed or in emergency situations.During an interview on 8/18/26 at 2:40 p.m., with Director of Nursing (DON), the DON explained that the purpose of call light was to enable the resident to summon staff for assistance when needed. The DON validated that every resident should have the call light within reach at all times. The DON was informed that Resident 1's call light was disconnected while the resident was observed calling out for help on two occasions within 10 minutes. The DON stated, It is her [Resident 1's] usual behavior to yell out 'nurse, nurse, help,' constant yelling and screaming.Her cognition is impaired. She is never using call light to call for assistance. The DON validated that Resident 1 was dependent on staff for assistance with most of her ADL's. The DON did not provide an answer when asked whether Resident 1's inability to have a functioning call light within reach was a safety concern.A review of the facility's policy and procedure (P&P) titled, Call Light System, with the revision date of 6/27/24 indicated, Call light system is to be operational at all times.Each resident will have their detachable call light cord readily accessible and within reach. When the resident activates the call light, the signal light about the resident's room and the signal light about that hallway will light. The red light above the red residence door indicates the resident needs assistance. Call lights are to be answered promptly and courteously.During a continued interview and record review on 8/18/26 at 2:40 p.m., the DON reviewed Resident 1's care plan titled Behavior and stated that the care plan addressed resident's constant yelling out. Upon reviewing care plan's intervention remind to use call bell the DON stated, It's a mistake, it [the intervention] should not be there. She never uses [call] light. During a review of Resident 1's fall risk care plan with DON, the DON acknowledged that the resident was at high risk for falls due to her diagnoses, impaired cognition, and mobility. When discussing fall care plan intervention for having call bell within reach and answering it promptly, the DON repeatedly stated that this intervention was mistakenly added to Resident 1's care plan. The DON added, We shouldn't be expecting her to use call light because she's not using it. The DON stated none of Resident 1's care plans indicated that the resident should not have a call light available because she was not using it. When the policy addressing call lights was reviewed with the DON, the DON did not provide an explanation for why Resident 1 should not have the call light available and within reach.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse, when Resident 2 hit Resident 1 multiple times.This failure had the potential to negatively impact Resident 1's highest practicable physical, mental, and psychosocial well-being.Findings: A review of an admission record indicated Resident 1 was admitted to the facility with diagnoses including depression (a serious mood disorder that causes persistent sadness, hopelessness, and a loss of interest in activities), failure to thrive (a complex syndrome of progressive physical, cognitive, and functional decline), and muscle weakness (lack of physical strength where your muscles cannot generate required force for normal movement). A review of an admission record indicated Resident 2 was admitted to the facility with diagnoses including sequelae of cerebral infarct (the residual neurological and functional deficits that persist after the brain's blood supply is blocked) and idiopathic neuropathy (nerve damage in the peripheral nervous system where a specific underlying cause cannot be identified). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/26, indicated Resident 1's Brief Interview of Mental Status (BIMS) score was 15 out of 15 with intact cognition. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was 15 out of 15 with intact cognition. A review of Resident 1's Change in Condition (CIC), dated 5/8/26, indicated Resident 1 reported to staff that Resident 2 hit him on his back and right jaw with his hands while he was wheeling himself out of the activity room. During an interview on 6/11/26 at 10 a.m. with Resident 1, Resident 1 stated he left the activities room and wheeled himself into the hallway when Resident 2 followed him and maneuvered his wheelchair to be beside his in the hallway. Resident 1 further stated Resident 2 hit him on the back of the head, on the shoulder, in the face, and then aggressively pulled on his left arm.During an interview on 6/11/26 at 10:45 a.m. with Resident 2, Resident 2 stated he followed Resident 1 into the hallway and punched him. Resident 2 further stated he remembered Resident 1 asking him not to do that. A review of the facility's Incident Report, dated 5/12/26, indicated Resident 1 stated he was propelling himself from the dining room after completing Bingo, when he was struck in the head and neck five times followed by a strike to the face. The report further indicated Resident 2 admitted to striking Resident 1. A review of the facility's 5 Day Follow Up, dated 5/12/26, indicated the security camera footage showed Resident 2 striking out and making contact with Resident 1's shoulder and lower neck, and when Resident 1 turned to stop any additional attempts of contact, Resident 2 grabbed Resident 1's arm and twisted it. During a concurrent observation and interview on 6/11/26 at 11:30 a.m. with Director of Safety and Security and Emergency Management (DSSEM), the facility's security camera footage was reviewed. DSSEM confirmed the video footage depicted an incident that occurred in C Hallway East on 5/8/26 at 11:11 a.m. DSSEM also confirmed the footage showed Resident 2 striking Resident 1 multiple times in the shoulder with his right hand before striking Resident 1 on the jaw and neck area, then followed by Resident 2 grabbing Resident 1's arm and forcefully pulling it. During an interview on 6/11/26 at 12:46 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was down the hallway when she heard Resident 1 and Resident 2 screaming loudly, cursing, and Resident 1 yelling that he was being hit by Resident 2. During an interview on 6/11/26 at 12:41 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was at the nurse's station when she heard loud shouting coming from the hallway. LN 1 also stated she went towards the hallway and observed Resident 1 and Resident 2 next to each other in their wheelchairs. LN 1 further stated both residents were separated and Resident 1 informed her that Resident 2 hit him. During an interview on 6/11/26 at 11:12 a.m. with Director of Nursing (DON), DON expected all residents to be free from any form of abuse. A review of the facility's policy and procedure titled, Alleged/Suspected Abuse, Resident Mistreatment and Misappropriation of Resident Property, dated 4/2025, indicated, It is the policy of this facility that mistreatment, neglect, and abuse of residents and misappropriation of resident property are prohibited . abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, mental anguish, or deprivation of an individual . physical abuse includes hitting, slapping, pinching, kicking, etc.

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when:Staff did not clean two ice machines located in the hospital's main kitchen and the skilled nursing facility.Staff did not maintain several pieces of cookware in usable condition.Staff left opened packaged and prepared food items in the walk in refrigerator and dry storage area without required labels and dates.The metal coating of the can opener blade was worn off.Dietary staff did not follow proper refrigerator thawing procedures that allowed identification of when food was pulled from the freezer and when it should be used.Two cooks used masks instead of proper beard restraints and did not fully cover facial hair.One Nutrition Assistant (NA) could not verbalize the correct process for manual dishwashing using the 3 compartment sink.These failures had the potential to cause food borne illness and placed 155 of 163 medically vulnerable residents at risk.Findings:1. During a concurrent observation and interview on 5/4/26 at 11:45 a.m., Stationary Engineer (SE) 1 disassembled the top section of the ice machine in the hospital's main kitchen. He found orange red slimy residue on the bottom of the evaporator unit, which felt rough and wiped off with a paper towel. SE 1 and the Chief Engineer (CE) confirmed the equipment was not clean. SE 1 reported he was not the usual person assigned to clean and sanitize the machines and that SE 2 held that responsibility. CE stated the engineering department performed monthly deep cleanings (cleaning and sanitizing the machinery parts on the top section of the ice machine and ice storage bin on the bottom section of the machine with chemical solutions designed to remove lime scale and mineral deposits and to remove algae and slime, then sanitize with chemical agent), changed water filters every six months, and the facility contracted an outside company to clean both ice machines monthly.A concurrent observation of the ice machine located in the kitchen at the skilled nursing facility and interview with SE 1 and Food-Nutrition Services Manager (FNSM) was conducted on 5/4/26 at 12:17 p.m. SE 1 disassembled the ice machine at the skilled nursing facility. He and the Food Nutrition Services Manager (FNSM) observed black slimy residue and orange buildup on the evaporator. Both substances came off with wiping and left grainy particles on the towel. FNSM confirmed the machine was not clean.During an interview with the outside company technician (OCT) on 5/5/26 at 9:10 a.m., OCT stated they got hired from the facility to do deep cleaning of the ice machines monthly. He stated he checked the ice machine at the main kitchen in hospital and found there were red/pink water marks at the evaporator unit. He verified those marks were biofilms (substances often appearing as slimy pink or black buildup, are bacterial clusters or mold that thrive in dark, moist, and cold environments within ice machines).During an interview with SE 2 on 5/5/26 at 2:15 p.m., SE 2 stated he followed manufacturer instructions to deep clean both machines and changed water filters every six months.A concurrent interview and record review on 5/5/26 at 3:46 p.m. showed work orders documenting the last deep cleans on 4/18/26 (main kitchen) and 4/12/26 (skilled nursing facility).A review of the undated facility's ice machine user manual, under Section 4: Maintenance, indicated all parts and interior surfaces of the ice machine should be clean and sanitize, includes: side walls, base (area above water trough [a tray under the evaporator unit], evaporator plastic parts and bin or dispenser.According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae).In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits.2. During an observation and a concurrent interview with FNSM on 5/4/26 at 10:55 a.m., 4 of 5 cooking pans had black buildup and deep scratches. FNSM confirmed the surfaces were not smooth and stated they should be replaced.During an interview with FNSD on 5/6/26 at 9:42 a.m., FNSD stated staff should check for wear and tear and replace equipment as needed. She agreed rough cooking surfaces were difficult to clean properly.According to 2022 FDA Food Code, on section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, it stated, (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The Food-Contact Surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits.3. A concurrent observation of walk-in refrigerator and interview with FNSM was conducted on 5/4/26 at 9:56 a.m. There was food items found opened package and prepared without labeling and dating which included: a metal container of diced carrot, a metal container of gravy, a metal container of prepared flour tortilla rolls in foil, and a block of yellow cheese in surround plastic wrap. FNSM confirmed and stated the opened package or prepared food items should have label with open or prepare date and use-by date.A concurrent observation of dry storage area and interview with FNSM was conducted on 5/4/26 at 10:19 a.m. There were three opened bags of dry pasta without open date and use-by date. FNSM confirmed and stated the staff should put the label with open and use-by dates. FNSM showed there was a label printer that the staff should use to make labels for open and use-by dates. The label showed the product name, and when the food item opened and when the food item was used by.A review of departmental policy and procedure titled, Food and Nutrition [NAME] (FNS): Food Handling, dated 8/1/24, indicated food items from refrigerator, freezer and dry storage areas should be with labels and with expiration dates visible.Foods removed from the original box must be covered, labeled and dated at all times.A review of departmental training document titled, Staff Training-Food and Nutrition Services-Part 1, dated 2025, showed the example of label for opened package, should have name of food items, open or production date and use-by date, and name or initial of staff prepared the label.4. During an observation and a concurrent interview with FNSM on 5/4/26 at 10:44 a.m., FNSM observed that one of the can opener blades was chipped and the metal coating wore off. He stated the blade needed replacement.During an interview with FNSD on 5/6/26 at 9:42 a.m., FNSD reported she and FNSM checked the can opener monthly but she was not previously aware of the worn blade. She confirmed replacement was necessary to prevent contamination.According to 2022 FDA Food Code, Section 4-202.15 Can Openers, it indicated, Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement.In addition, Section 4-501.11 Good Repair and Proper Adjustment, it indicated, .(C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.5. During a concurrent observation and interview with FNSM on 5/4/26 at 9:38 a.m. and 10:35 a.m., at the walk-in refrigerators, found there were food items were thawing but they did not have any indicator when the food items pulled out from the freezer and when they would be used by or discarded. The food items included as follows:2 pans of cooked porkA pan of plastic containers of portioned puree green bean4 boxes of cooked sliced beef5 boxes of cooked chicken breast filletsA pan of packs of Moroccan lentil soupA box of packs of vegetable soup and few packs of vegetable soup on a [NAME] box of cooked diced chickenA box of packs of butternut squash soup2 boxes of chicken breast vegan pattiesA pan of 6 bags of raw pot roast7 boxes of raw pork loin3 loaves of raw pork loin2 boxes of raw chicken breasts5 boxes of raw turkey breasts4 pans of chicken sausage3 boxes of French toastFNSM confirmed and stated the food items mentioned above were pulled out from the freezer for thawing in the refrigerator. He stated the practice for thawing food items was the staff should put a pulled-out date and a use-by date. FNSM agreed and stated if the thawing items were without any indicators, it would be hard to identify when the food items were pulled out from the freezer and when they would be used or discarded. FNSM showed their practice to monitor the thawing food with the label system Pull to Thaw which the label included date and time for thawing and date and time to be used. He agreed the dietary staff did not practice the thawing system properly. He further stated the staff needed to be re-trained.During an interview with FNSD at 5/6/26 at 9:42 a.m., FNSD acknowledged and stated the Pull to Thaw was the practice and the staff should follow. She further stated the staff needed to be re-trained regarding the thawing procedure.According to 2022 FDA Food Code, Annex 3, it indicated, .Food which is.thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for [bacteria] to multiply, before freezing and after thawing.6. During the initial kitchen and follow-up observations on 5/4/26 at 11:07 a.m., and 5/5/26 at 11:40 a.m., observed [NAME] (CK) 1 and CK 2 prepared food while wearing medical masks as beard restraints. Their facial hair remained exposed on both sides.During an interview with FNSM on 5/5/26 at 12:36 p.m., FNSM confirmed and stated the facial hair should be fully covered.During an interview with FNSD on 5/6/26 at 9:42 a.m., FNSD stated they did not have a policy and procedure for facial hair restraint, but she agreed the facial hair should not be exposed and should be fully covered.According to 2022 FDA Food Code, Section 2-402 Hair Restraints, 2-402.11 Effectiveness, it indicated, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.7. During an interview with Nutrition Assistant (NA) 1 on 5/4/26 at 1:53 p.m. regarding the process of manual dishwashing with 3-compartment sink, NA 1 explained the process. NA 1 stated she would start to scrape the food residue to the trash bin, then soaked and washed the dishes in the wash sink, then rinsed the dishes in the rinse sink, next to sanitize the dishes in the sanitize sink and the last step was to air-dry. She stated the water temperature for washing should be 160 degrees Fahrenheit (F) and the immersion time for sanitizing the dishes should be 10 seconds in the sanitizer. NA 1 reviewed the posted instruction poster titled, Scout Pot & Pan Wash Procedure, and she switched her answer of immersion time for sanitizing the dishes which should be one minute.A concurrent interview with FNSM, he stated the water temperature for washing should be 120 degrees F and the immersion time for sanitizing should be one minute. FNSM stated the new staff got hands-on training for manual dishwashing with the senior nutrition assistant, and there were competency tests for the staff to be sure their skills were updated and competent.During an interview with FNSD on 5/6/25 at 9:42 a.m., FNSD stated the dishwasher staff should have good knowledge about the procedure of manual dishwashing. She stated there was an instruction on the bottom of the 3-compartment skin temperature and PPM (part per millions - a measure unit for sanitizer concentration) log which showed the wash water temperature should be at least 110 degrees F. She further stated the staff needed to be re-trained.A review of undated departmental document titled, Pot-Sink Temp Sanitizer Log, indicated, .the 1st (wash) sink temperature must be at a minimum of 110 degrees F.A review of departmental training material titled, Staff Training - Food and Nutrition Services - Part 1, dated 2025, indicated washing sink (with detergent) with minimum water temperature of 110 degrees F and the immersion time should be one minute for quaternary ammonium sanitizer.

Based on interview and record review, the facility failed to develop a comprehensive, person centered care plan for two of 35 sampled residents (Resident 163 and 106), when:The facility placed Resident 163 on Enhanced Barrier Precautions (EBP- an infection control intervention used to reduce transmission of multidrug resistant organisms through targeted gown and glove use) and not initiate a care plan.Resident 106's care plan for EBP and for the use of Peripherally Inserted Central Catheter (PICC line- a long, flexible tube inserted into a large vein, typically in the upper arm, and threaded to a central vein above the heart, and is used for long-term intravenous treatments such as antibiotics) were not developed.These failures had the risks for Resident 163 and Resident 106 not to receive appropriate and needed care and have the potential for Resident 163 and 106 not to achieve their highest practicable well-being.Findings: During a review of Resident 163's clinical record, Resident 163 was admitted on [DATE] with the diagnosis that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), recurrent Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacterium (staph germ) that has developed resistance to many common antibiotics) bacteremia (the presence of bacteria in the bloodstream), venous ulcer (slow-healing, open wounds). During a review of Resident 163's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/13/26, Resident 163 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 163 had intact cognition. During an interview on 5/5/26 at 11:40 a.m. with Infection Preventionist (IP), the IP confirmed resident 163 was on EBP. During an interview on 5/7/26 at 8:57 a.m. with Licensed Nurse Manager (LN) 6, LN 6 confirmed that Resident 163 was not care planned for EBP. LN 6 stated that residents placed on EBP are supposed to have this intervention included in their care plan. During an interview on 5/7/26 at 9:04 a.m. with the Director of Nursing (DON), the DON stated residents on EBP should be care planned for it. During a review of the facility's policy titled, Interdisciplinary Care Plan, dated 2/28/19, the policy stipulated, . The admission Nursing Evaluation and the Initial Resident Care Plans will identify specific resident problems and specific interventions. and will also identify basic, standard nursing interventions as appropriate. Continued and prompt documentation shall be made in the Care Plan, as needs or changes of conditions are identified. The Care Plan is to be a reflection of the current and ongoing identified resident needs. 2. A review of Resident 106's clinical record indicated Resident 106 was previously admitted in June of 2020 and had diagnoses that included neutropenia (condition characterized by an abnormally low count of white blood cell, which is essential for fighting bacterial infection), and stage 4 pressure ulcer (a severe, full-thickness wound involving extensive tissue loss with exposed muscle, tendon, or bone, requiring urgent, specialized medical care.) A review of Resident 106's MDS Cognitive Patterns, dated 4/22/26, indicated Resident 106 had a BIMS score of 14 out of 15 which indicated Resident 106 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 106's Skin Conditions, dated 4/22/26, indicated Resident 106 had an unhealed stage 4 pressure ulcer. A review of Resident 106's active physician's order, dated 4/28/26, indicated, may have [company name] insert a . PICC line. A review of Resident 106's active physician's order, dated 4/29/26, indicated, cefepime [a strong antibiotic used to treat moderate to severe bacterial infection] 2,000 mg [milligrams- unit of measurement], IV, Bag, q12hr [every 12 hours] Routine, Indication: .wound culture+ [positive] pseudomonas [a specific bacteria that causes infection on skin, ears, lungs, or wounds, particularly in hospitalized or immunocompromised individuals which require targeted antibiotics due to drug resistance] .for 10 Day . During a concurrent observation and interview on 5/5/26 at 9:35 a.m. with LN 1 in Resident 106's room, LN 1 confirmed that Resident 106 has a PICC line on her right upper arm and was on EBP. A review of the facility document titled, ENHANCED BARRIER PRECAUTIONS ., provided by the Infection Preventionist on 5/6/26, indicated Resident 106 was on EBP. During an interview on 5/6/26 at 9:03 a.m. with LN 4, LN 4 stated that if a resident has a PICC line and placed on EBP, both care plan for PICC line use and EBP should be developed and initiated because the plan of care would be the guide for staff on how to care for the resident. During a concurrent interview and record review on 5/6/26 at 9:15 a.m. with LN 3, Resident 106's medical records were reviewed. LN 3 confirmed that Resident 106 was on EBP but was not included in her care plan. LN 3 also confirmed that Resident 106 uses PICC line for IV antibiotic therapy but was not included in her care plan. LN 3 stated Resident 106 should have a care plan for PICC line use and EBP so staff would be aware and would follow Resident 106's plan of care. During an interview on 5/6/26 at 2:50 p.m. with the Nurse Manger/ Infection Preventionist (NM/IP), the NM/IP stated that PICC line use and EBP should have been a part of Resident 106's plan of care because these are essential part of the care given to Resident 106. During an interview on 5/6/26 at 3:04 p.m. with the DON, the DON stated that PICC line use and EBP should be part of a resident's plan of care. A review of the facility's policy and procedures titled, Bruceville Terrace: Interdisciplinary Care Plan, dated 2/28/19, indicated, E. The Care Plan shall indicate the care to be given, the goals/objectives to be accomplished and the professional discipline responsible for each element of care .Each Care Plan shall have approaches relevant to accomplishing the goal. The approaches shall reflect all professional disciplines responsible for assisting the resident in accomplishing the goal and the frequency of approach shall be stated.

Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 163 when 11 packets of expired food thickeners (specialized powders or gels that instantly increase the viscosity of hot or cold liquids and foods primarily designed to achieve safe, consistent textures for individuals with difficulty swallowing) were found stored in D station medication cart 1.This failure created the potential for residents to receive biologicals that were expired or with unsafe or reduced potency which could have caused unwanted effects to the residents. Findings:During a concurrent observation and interview that began on 5/5/26 at 1:15 p.m. with Licensed Nurse (LN) 2, of the D station medication cart 1, 11 packets of expired food thickeners were found stored in the medication cart. LN 2 confirmed the finding and stated that expired food thickeners should not be stored in medication carts. LN 2 also stated they use food thickeners to thicken liquids for residents who would need thickened liquids for medication administration. LN 2 further stated the expired food thickeners could cause undesired effects or reactions to the residents like upset stomach, diarrhea, or vomiting.During an interview on 5/6/26 at 2:21 p.m. with the Facility Pharmacist (FP), the FP stated that expired food thickeners should not be stored in the medication carts and should be thrown out because they could have caused adverse effects if accidentally administered.During an interview on 5/6/26 at 3:04 p.m. with the Director of Nursing (DON), the DON stated the expired food thickeners should be thrown away and not stored in medication carts because they might get administered to the residents.A review of the facility's P&P titled, Medication Control & Storage Inspection, revised 4/25/24, indicated, .To insure [sic] the inspection of all medication storage areas (e.g. any areas in which medications are dispensed, administered or stored) on a monthly basis to ensure proper storage conditions, security, drug availability, expiration date and other safety factors are met .4. Outdated floor stock medications and IV's are to be returned to pharmacy.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 163 when;1.A facility staff did not wear required personal protective equipment (PPE) when accessing and using the Peripherally Inserted Central Catheter (PICC line- a type of central line which is inserted into a large vein, typically in the upper arm, and threaded to a central vein above the heart, and is used for long-term intravenous treatments such as antibiotics) of Resident 130 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2.The facility did not communicate which residents were on EBP to all staff, and there was no EBP order for Resident 163; and,3. One glucometer (blood sugar monitor device that measures glucose levels) had a red smear on it and two glucometers were soiled with blue smears out of twelve glucometers.These failures had the potential to spread germs and cause infections for a census of 163. 1. A review of Resident 106's clinical record indicated Resident 106 was previously admitted in June of 2020 and had diagnoses that included neutropenia (condition characterized by an abnormally low count of white blood cell, which is essential for fighting bacterial infection), and stage 4 pressure ulcer (a severe, full-thickness wound involving extensive tissue loss with exposed muscle, tendon, or bone, requiring urgent, specialized medical care.) A review of Resident 106's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 4/22/26, indicated Resident 106 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 which indicated Resident 106 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 106's Skin Conditions, dated 4/22/26, indicated Resident 106 had an unhealed stage 4 pressure ulcer. A review of Resident 106's active physician's order, dated 4/28/26, indicated, may have [company name] insert a .PICC line. During a medication administration observation which started on 5/5/26 at 9:22 a.m. with Licensed Nurse (LN) 1 in Resident 106's room, LN 1 was observed administering IV antibiotic to Resident 106 through her PICC line on her right upper arm. LN 1 was observed handling and using Resident 106's PICC line while only using gloves. There was an EBP signage posted outside of Resident 106's room which indicated, STOP .ENHANCE BARRIER PRECAUTIONS .PROVIDERS AND STAFF MUST .Wear gloves and a gown for the following High-Contact Resident Care Activities .Device care or use: central line . During a subsequent interview on 5/5/26 at 9:35 a.m. with LN 1, LN 1 confirmed that she only wore gloves and did not wear gown while handling and using Resident 106's PICC line. LN 1 confirmed Resident 106 was on EBP. LN 1 stated she should have worn both gloves and gown when using and caring for Resident 106's PICC line to prevent possible transfer of microorganisms to Resident 106. A review of the facility document titled, ENHANCED BARRIER PRECAUTIONS ., provided by the Infection Preventionist on 5/6/26, indicated Resident 106 was on EBP. During a concurrent interview and record review on 5/6/26 at 9:15 a.m. with Licensed Nurse (LN) 3, Resident 106's medical records were reviewed. LN 3 confirmed that Resident 106 was on EBP but was not included in her care plan. LN 3 stated Resident 106 should have a care plan for EBP so staff would be aware and would follow Resident 106's plan of care. During an interview on 5/6/26 at 10:55 a.m. with the Infection Preventionist (IP), the IP stated they do not obtain a physician's order for residents who are on EBP. During an interview on 5/6/26 at 2:50 p.m. with the Nurse Manger/ Infection Preventionist (NM/IP), the NM/IP stated staff should be using both gloves and gown when caring and using the resident's PICC line to prevent possible infection of the resident. During an interview on 5/6/26 at 3:04 p.m. with the Director of Nursing (DON), the DON stated staff should be wearing the required PPE for residents who were on EBP for infection control. A review of the facility's policy and procedures titled, Bruceville Terrace: Enhanced Barrier Precautions, dated 2/25/25, indicated, 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: .indwelling medical devices ( .central lines .) .even if the resident is not known to be infected or colonized with a MDRO .3. Implementation of Enhanced Barrier Precautions: .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .4. 4. High-contact resident care activities include: .vii. Device care or use: central lines .PICC lines . 2. During a review of Resident 163's clinical record, Resident 163 was admitted on [DATE] with the diagnosis that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), recurrent Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacterium (staph germ) that has developed resistance to many common antibiotics) bacteremia (the presence of bacteria in the bloodstream), venous ulcer (slow-healing, open wounds). A review of Resident 163's orders revealed there was no order for EBP. During an interview on 5/4/26 at 10:30 a.m. with LN 8, LN 8 stated they were unsure whether Resident 163 was on EBP. During an interview on 5/4/26 at 10:44 a.m. with the IP, the IP confirmed Resident 163 was on EBP and that EBP signs are posted outside the doors of residents on EBP. The IP confirmed resident 163's room did not have an EBP sign posted. The IP indicated that without the sign, staff may not know the resident is on EBP and may fail to gown and glove, which could lead to infection spread. During a follow up interview on 5/4/26 at 11:40 a.m. with the IP, the IP stated they do not obtain EBP orders for residents on EBP. During an interview on 5/7/26 at 9:04 a.m. with the Director of Nursing (DON), the DON stated the expectation is that EBP signs are posted on the doors of residents who are on EBP. During a review of the facility's policy titled, Enhanced Barrier Precautions, revised 2025, the policy indicated .the facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which resident require the use of EBP.An order for enhanced barrier precautions will be obtained for residents with. Multidrug-resistant organisms (MDRO- bacteria and other microorganisms, [including MRSA] that are resistant to at least three classes of antibiotics). 3. During a concurrent observation and interview with LN 7 and the Director of Staff of Development (DSD), on 5/6/26 at 9:55 a.m. at Nursing Station B, one glucometer had a red smear at the top. LN 7 disinfected the red smear, and the DSD stated it was most likely blood and not cleaned properly. During a concurrent observation and interview on 5/6/26 at 10 a.m. at Nursing Station C, two glucometers had blue smears on the top. LN 6 at Nursing Station C verified the blue smears were on the top of the glucometers and stated it was the control solution (control solution is to ensure the accuracy of the blood glucose monitoring system, confirming that the meter and strips are performing within designated ranges). During an interview on 5/6/26 at 10:20 a.m. with the IP, the IP stated staff are supposed to clean the glucometers after every use, and after the control solution is used. The IP further stated that the consequences of not cleaning can be an infection. During a review of the facility's policy and procedure (P&P) titled, Bruceville Terrace: Glucometer Disinfection, dated April 2025, the P&P indicated, The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use.

Based on observation, interview, and record review, the facility failed to ensure that staff delivered intravenous (IV) therapy (administration of fluids or medications into the vein) was consistent with standards of practice and the facility's policy and procedures (P&P) for one out of 35 sampled residents (Resident 106) when Resident 106's Peripherally Inserted Central Catheter (PICC line- a long, flexible tube inserted into a large vein, typically in the upper arm, and threaded to a vein above the heart, and is used for long-term intravenous treatments such as antibiotics) hub (the external plastic junction connecting the catheter to extension tubes) was not scrubbed with antiseptic pad before use.This failure created the potential for unsafe IV therapy delivery, possible infection, and prevented Resident 106 from achieving the highest practicable well-being.Findings:A review of Resident 106's clinical record indicated Resident 106 was previously admitted in June of 2020 and had diagnoses that included neutropenia (condition characterized by an abnormally low count of white blood cell, which is essential for fighting bacterial infection), and stage 4 pressure ulcer (a severe, full-thickness wound involving extensive tissue loss with exposed muscle, tendon, or bone, requiring urgent, specialized medical care.)A review of Resident 106's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/22/26, indicated Resident 106 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 which indicated Resident 106 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 106's Skin Conditions, dated 4/22/26, indicated Resident 106 had an unhealed stage 4 pressure ulcer.A review of Resident 106's active physician's order, dated 4/28/26, indicated, may have [company name] insert a . PICC line.A review of Resident 106's active physician's order, dated 4/29/26, indicated, cefepime [a strong antibiotic used to treat moderate to severe bacterial infection] 2,000 mg [milligrams- unit of measurement], IV, Bag, q12hr [every 12 hours] Routine, Indication: .wound culture+ [positive] pseudomonas [a specific bacteria that causes infection on skin, ears, lungs, or wounds, particularly in hospitalized or immunocompromised individuals which require targeted antibiotics due to drug resistance] .for 10 Day .During a medication administration observation which started on 5/5/26 at 9:22 a.m. with Licensed Nurse (LN) 1, LN 1 was observed administering cefepime IV antibiotic to Resident 106 through her PICC line on her right upper arm. LN 1 did not scrub Resident 106's PICC line hub with antiseptic pad before flushing the line with 10 ml [milliliters- unit of measurement] saline flush [a salt and water solution used to clear IV catheters, maintaining patency and preventing blockages or infections] and reconnecting the cefepime IV antibiotic to Resident 106's PICC line. During a subsequent interview on 5/5/26 at 9:35 a.m. with LN 1, LN 1 confirmed that she did not scrub Resident 106's PICC line hub with antiseptic pad before flushing the line with 10 ml saline flush and reconnecting the cefepime IV antibiotic to Resident 106's PICC line. LN 1 stated she should have wiped Resident 106's PICC line hub before using it to disinfect the hub and prevent introduction of microorganism to the line which could cause infection or other complications.During a concurrent interview and record review on 5/6/26 at 9:15 a.m. with LN 3, Resident 106's medical records were reviewed. LN 3 confirmed that Resident 106's use of PICC line was not care planned. LN 3 stated Resident 106 should have a care plan for the use of PICC line so staff would be aware about it and would have a plan of care to follow.During an interview on 5/6/26 at 2:50 p.m. with the Nurse Manger/ Infection Preventionist (NM/IP), the NM/IP stated that nurses should always clean the PICC line hub every time they access and use the PICC line to prevent possible infection or other complications. During an interview on 5/6/26 at 3:04 p.m. with the Director of Nursing (DON), the DON stated the PICC line hub should always be scrubbed with antiseptic before accessing and using it to prevent possible infection issues.A review of the facility's P&P titled, Bruceville Terrace: Care and Maintenance of Central Venous Catheter, undated, indicated, 9. Scrub the hub (i.e. [in example] cap) of all access ports prior to use. Scrub for at least 5 seconds using antiseptic pad (chlorhexidine-based, povidone-iodine, or alcohol pad).

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were followed when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 163. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in one out of 9 residents (Resident 125) observed for medication administration.These failures had the potential for unsafe and ineffective medication therapy of Resident 125 and had the potential to negatively affect the residents' medical conditions.Findings:During a medication administration observation which started on 5/5/26 at 10:41 a.m. with Licensed Nurse (LN) 5, LN 5 administered a total of five pills to Resident 125 which included 1 capsule of docusate sodium (a medication utilized for managing and treating infrequent or difficult bowel movements) 100 mg (milligrams- unit of measurement), and 1 tablet of naloxegol (a medication used to treat medication-induced constipation) 12.5 mg.A review of Resident 125's active physician's order, dated 8/15/23, indicated, Docusate (docusate sodium) 100 mg, PO (by mouth), Cap (capsule), BID (twice a day) Routine, Indication: constipation .A review of Resident 125's active physician's order, dated 8/14/23, indicated, Naloxegol .12.5 mg, PO, tab [tablet], qAM [every morning], Indication: constipation .A review of Resident 125's medication administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of May 2026 indicated Resident 125's morning dose of docusate sodium and naloxegol were scheduled at 8 a.m., and were both signed as administered at 10:50 a.m.A review of Resident 125's nursing progress notes, dated 5/5/26, indicated, Patient [Resident 125] last BM [bowel movement] noted on 5/3/26 .During an interview on 5/5/26 at 1:07 p.m. with LN 5, LN 5 acknowledged that the observed medication administration of docusate sodium and naloxegol to Resident 125 were late. LN 5 stated Resident 125 was constipated. LN 5 also stated medication administration should be an hour before or after the scheduled time of administration to maintain therapeutic level (concentration of a medication in the body that is high enough to produce the desired medical effect without causing significant side effects) of medication in the resident.During a concurrent interview and record review on 5/6/26 at 2:21 p.m. with the Facility Pharmacist (FP), Resident 125's clinical records were reviewed. The FP confirmed that Resident 125's docusate sodium and naloxegol were administered late. The FP stated nurses should administer medication within the time frame of the scheduled administration in order for the medication therapy to be effective.During an interview on 5/6/26 at 3:04 p.m. with the Director of Nursing (DON), the DON stated that nurses should administer medications to residents within the time allowance of the scheduled administration time.A review of the facility's policies and procedures titled, Medication Management: Administration, dated 110/2017, indicated, 25. Non-time-critical scheduled medications .have a different timewindow for administration. a. Medications prescribed for daily, weekly or monthly administration may be within 2 hours before or afterthe scheduled dosing time, for a total window that does not exceed 4 hours. b. Medications prescribed more frequently than daily but no more frequently than every 4 hours may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours.A review of the facility's Medication Administration Schedule, dated 8/22/19, indicated, .Facility schedule for the administration of medications .Daily .0800 [8 a.m.] BID .0800 .1700 [5 p.m.] .A review of the facility's Medication Administration Schedule, dated 8/22/19, indicated, .Facility schedule for the administration of medications .Daily .0800 [8 a.m.] .BID .0800 .1700 [5 p.m.] .

Based on interview and record review the facility failed to report the results of an abuse investigation to the state survey agency (California Department of Public Health, CDPH) within 5 working days of the incident (allegation of abuse dated 2/1/26). This failure resulted in CDPH being unaware of the outcome of the abuse investigation, and had the potential for the abuse investigation to not be investigated thoroughly.A review of the facility's admission documents indicated Resident 1 and Resident 2 were admitted in February 2026.During a review of document titled Report of Suspected Dependent Adult/Elder Abuse (a California mandated reporter document used to report suspected abuse or neglect of seniors (65+) or dependent adults (18-64 with disabilities)) dated 2/1/26, indicated an allegation of abuse was reported to CDPH. Form indicated, alleged victim was Resident 1, and the alleged abuser was Resident 2. Form indicated, Reported types of abuse (Check all that apply): Physical.During an interview on 2/20/26, at 10:15 a.m., with Nursing Manager (NM), NM stated, we did not send the 5-day investigative report to CDPH for Resident 1 and Resident 2.During an interview on 2/20/26, at 10:17 a.m., with Executive Secretary (ES), ES stated, we had the 5-day report for Resident 1 and Resident 2 in the file to be sent, but it was never sent. ES stated, it is our policy to send the investigation report within 5 days of the incident.During an interview on 2/24/26, at 8:02 a.m., with Director of Nursing (DON), DON stated the facility did not send the investigative report within 5 working days.During a review of the facility's policy and procedure (P&P) titled, Alleged/Suspected Abuse, Resident Mistreatment and Misappropriation of Resident Property, dated 2025, the P&P indicated, It is the policy of this facility that mistreatment, neglect and abuse of residents, and misappropriation of resident property is prohibited. All allegations of mistreatment, neglect, abandonment, isolation and verbal or physical abuse, including injuries of unknown source, and misappropriation of resident property, will be reported immediately to the Administrative Director and to other officials in accordance with state law. All alleged violations will be promptly and thoroughly investigated.10. Results of the investigation will be documented and retained in a file, and forwarded to the appropriate reporting agencies.

Based on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) Responsible Party (RP) of Resident 1's fall in the facility.This deficient practice resulted in RP 1 being unaware of Resident 1's fall and actual condition that may impact RP 1's ability to ensure appropriate care and support following discharge. Findings:During a review of Resident 1's facesheet (a page of the chart that contains a summary of resident's basic information), the facesheet indicated Resident 1 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure).During a review of Resident 1's Nursing Progress Note (NPN), dated 11/23/25 at 2:51 a.m., the NPN indicated, Resident 1 had lost his balance while returning to bed, and a certified nursing assistant (CNA) assisted him to sit on the floor. At 1 a.m., Resident 1 was noted to complain of pain around the sacrum-coccyx area (lower back/tailbone area). During a review of Resident 1's NPN, dated 11/23/25 at 11:50 a.m., the NPN indicated, Resident 1 was discharged home with the RP. The NPN did not indicate that the RP was informed of the assisted fall that had occurred.During a concurrent interview and record review on 12/19/25 at 12:25 p.m. with Director of Nursing (DON), Resident 1's NPN on 11/23/25 at 2:51 a.m. was reviewed. The NPN indicated, .endorsed AM nurse to follow up The DON stated that calling the RP again was part of the follow-up process. Further review of the chart showed no documentation of a follow-up call to the RP. The DON confirmed that no additional follow-up call was made. The DON stated that she expected the day shift nurse to follow up and ensure the RP was made aware of the fall. The DON also stated that the nurse should have informed the RP about the fall when the RP arrived to pick up Resident 1 for discharge.During a review of the facility's policy and procedure (P&P) titled, Falling Incidents, dated 5/22/25, the P&P indicated, .notify the Physician and Responsible Party.

Based on observation, interview, and record review, the facility failed for one of four sampled residents (Resident 1) to be notified of room change, when the facility did not provide written notice for room change including reasons for the room change for Resident 1.This failure resulted in Resident 1 not receiving a written explanation of why the move was required, resulting in Resident 1 expressing sadness and frustration.Findings:Resident 1 was admitted to the facility on [DATE] with a diagnoses of End Stage Renal Disease (condition in which the kidneys no longer function normally), septic shock (life-threatening condition that occurs when sepsis, a body's extreme response to an infection, leads to dangerously low blood pressure and organ damage), and bilateral lower extremity (both legs) cellulitis (serious deep infection of the skin). Resident 1's Minimum Data Sheet (MDS - federally mandated resident assessment tool) dated 7/12/25, indicated moderate cognitive impairment.During a concurrent observation and interview on 7/30/25 at 11:11 a.m., in Resident 1's room, with Resident 1, Resident 1 stated, They put me in C (another station/unit of the facility) in a private room and then from C came here to D to this room.when I refused, they said ‘you have to do this'.They told me they don't have to give me a reason. They did not give me anything in writing.The way they did it [the room change], it's sad. It made me sad.This has taken a toll on me. The room change. Resident 1 was then observed to be sad and frustrated.During an interview on 7/30/25, at 12:07 p.m., with Registered Nurse (RN) 1, RN 1 stated, .Nothing [explanation] given in writing to the resident.During an interview on 7/30/25, at 12:27 p.m., with Social Worker (SW), SW stated, Yes, residents change rooms here.If you are speaking about [Resident 1], yes, he did refuse to move and yes that did happen to him on 7/23/25. When they have to move they do not give the resident anything in writing with the reasons they have to move.During a concurrent interview and record review on 7/30/25, at 1:31 p.m., with Systems Information IT (Information Technology) staff member (IT) 1, IT 1 reviewed Resident 1's chart in the EHR, stated no entries for 7/23/25 regarding provision of written notice of room change.During an interview on 7/30/25, on 2:27 p.m., with Director of Nursing (DON), stated, .Residents are not provided written explanation of why the move was required.During an interview on 7/30/25, at 2:45 p.m., with Admissions Officer (AO), AO stated the facility does not provide anything in writing on why they need to move residents to a new room.During a review of facility policy, titled, Bruceville Terrace: Room/Station Changes within Bruceville Terrace, dated 6/27/24, indicated, The facility will attempt to give reasonable written notice whenever a transfer within the facility is necessary.

During observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity when Resident 1's request to have family present during direct care was not acknowledged by Certified Nurse Assistant 1 (CNA 1). This failure had the potential for Resident 1 to not to receive care based on her needs and preferences. A review of Resident 1's clinical record indicated Resident 1 was admitted in Middle 2025 with diagnosis of Type 2 Diabetes Mellitus (a condition where your body either doesn't make enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/22/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 13 out of 15 indicating Resident 1 was cognitively intact. A review of Resident 1's care plan, titled .Alteration in Communication r/t [sic, related to] language barrier. dated 7/16/25, indicated, . Language(s) spoken: Spanish . The box next to .Resident will be able to communicate his/her basic needs utilizing the communication devices provided. was not checked. During a concurrent observation and interview on 7/22/25 at 1:47 p.m. in Resident 1's room with family representative present, Resident 1 was observed receiving care when surveyor and family representative were in room with Certified Nurse Assistant 1 (CNA 1). CNA 1 was asked to allow family representative and surveyor to observe care due to language barrier, CNA 1 did not respond. CNA 1 was asked again at 1:48 p.m. and 1:49 p.m. to allow surveyor and family representative to observe care, CNA 1 stated she was providing patient care and did not allow surveyor and family to enter. CNA 1 then opened the curtain and was asked how CNA 1 communicated with Resident 1 and CNA 1 pointed to a communication board. CNA 1 left the room and did not respond to surveyor questions further. Family representative and surveyor observed and interviewed Resident 1. Resident 1 was noted shaking with arms crossed, grimacing and stated she was scared of CNA 1 and wanted an interpreter to explain each step during provision of care. Family representative stated Resident 1 was now scared to receive wound care by staff due to fear of staff not explaining procedures and being too rough with her. Resident 1 stated she wanted an interpreter or family representative present during care. During a concurrent observation and interview on 7/22/25 at 1:50 p.m. with Treatment Nurse 2 (TN 2), the TN 2 acknowledged Resident rights to have family participate in care. TN 2 stated family members were allowed to participate in patient care with permission from Resident 1. TN 2 further stated the facility honors resident preferences and family members are able to help with translation for non-English speaking residents to help them feel more comfortable. During an interview on 7/22/25 at 2:00 p.m. with CNA 1, CNA 1 acknowledged she did not allow Resident 1's family representative and surveyor in the room during Resident 1's care. CNA 1 further stated she could communicate with Resident 1 using gestures and using the communication board. She further acknowledged she did not ask the resident if the family representative could come in during direct care. CNA 1 further stated she would not allow family in the room despite Resident 1's language barrier due to privacy concerns. During an interview on 7/22/25 at 4:33 p.m. with Director of Nursing (DON), the DON stated that the facility can ask family members to leave while providing care if it will interfere with Resident care. When asked about family member being present to help interpret in situation where there was communication barrier during care, the DON did not answer surveyor's questions surrounding Resident 1's preferences and stated the facility used communication boards and interpreter lines. A review of facility policy and procedure (P&P), titled .Bruceville Terrace: Resident Right., dated 5/22/25, the P&P indicated, .The resident has the right to exercise his/her rights as a resident of this facility.Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.

Based on observation, interview, and record review, the facility failed to accurately assess one of four sampled residents (Resident 1's) skin for stageable pressure injuries (damage to the skin and underlying tissues caused by prolonged pressure on the body). This failure had the potential to result in worsening of Resident 1's skin breakdown.A review of Resident 1's clinical record indicated Resident 1 was admitted in Middle 2025 with diagnoses which included Type 2 Diabetes Mellitus (a condition where your body either doesn't make enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/22/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 13 out of 15 indicating Resident 1 was cognitively intact. During a review of Resident 1's initial skin assessment dated [DATE], the skin assessment indicated excoriation (skin damage) on sacral coccyx (bones at the base of spine) area. An image was included. During a Review of Resident 1's clinical record, the physician order dated 7/17/25 indicated, .Peri-rectal (surrounding the rectal area) area skin excoriation; Cleanse with warm water, pat dry, apply zinc oxide paste [a skin barrier paste], cover with foam dressing daily.During a concurrent observation and interview on 7/22/25 at 1:47 p.m. in Resident 1's room with Treatment Nurse 2 (TN 2), observed wound care being performed on Resident 1's coccyx (tailbone) and gluteal (buttocks) fold area. During the observation of the wounds, Resident 1 was noted to have a dark red line running up the coccyx area, gluteal folds redness, skin breakdown and peeling. The wound appeared to have partial thickness skin loss of the top layer of the skin. Upon observation, interviewed TN 2 who stated Resident 1 did not have skin break down, only redness and she did not acknowledge Resident 1's skin breakdown and potential pressure injury. TN 2 further stated only when a wound had drainage was it classified as skin breakdown and pressure injury. During a concurrent interview and record review on 7/22/25 at 2:30 p.m. with Treatment Nurse 1 (TN 1), Resident 1's admission wound photograph dated 7/17/25 was reviewed. TN 1 reviewed the photo and stated Resident 1's wound looked like a stage 2 upon admission. During an interview on 7/22/25 at 4:33 p.m. with Director of Nursing (DON), the DON refused to answer specific questions regarding wound care staging. DON stated all wound nurses are wound care certified (specialized training in wound care and certification). During a review of facility policy and procedure (P&P) titled, Bruceville Terrace: Pressure Injury Prevention and Treatment., dated 5/1995, the P&P indicated, .The facility will.accurately stage pressure injuries according to standardized guidelines.A pressure injury is localized damage to the skin and underlying soft tissue.The injury can present as intact skin.Stage 1: Non-blanch erythema (redness) of intact skin. Stage 2: Partial thickness skin loss involving epidermis (top layer of skin) , and/or dermis (base layer of the skin). The injury is superficial and presents clinically as an abrasion.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during wound care for one of four sampled residents (Resident 2) when licensed staff did not perform hand hygiene between changing gloves when performing wound care. This failure had the potential to result in cross contamination of the wound and spread of infection for Resident 2. A review of Resident 2's clinical record indicated resident 2 was admitted in July 2025 with diagnoses which included pressure injury (pressure sore, ulcer, or bedsore) of sacral (a triangular bone at the base of the spine) region. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 5/27/25 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 0 out of 15 indicating Resident 2 had severely impaired cognition. During a review of Resident 2's clinical record, the physician treatment order dated 7/11/25 indicated, . Pressure injury Stage 4 [severe, deep wound that extends through the skin, fat, and muscle, potentially reaching the bone] . Cleanse with wound cleanser, pat dry pack with calcium alginate with silver [wound care product] and apply foam dressing.During a concurrent wound care observation and interview on 7/22/25 at 2:09 p.m. with Treatment Nurse 3 (TN 3), TN 3 stated during wound observation, Resident 2 is on enhanced barrier precautions and stated the surveyor didn't need to wear a gown. TN 3 was observed removing the old dressing from the pressure wound and did not perform hand hygiene. TN 3 cleansed the wound and changed gloves but did not perform hand hygiene in between changing the gloves. TN 3 packed wound and placed scissors used for dressings on white chuck (waterproof barrier pad) on Resident 2's bed. TN 3 changed gloves but did not perform hand hygiene. TN 3 applied additional foam dressing to wound. TN 3 placed scissors back on table, changed gloves but hand hygiene was not performed. TN 3 re-positioned resident 2, grabbed gloves and threw trash bag away with discarded dressings, and did not perform hand hygiene afterwards. TN 3 then changed gloves, put off loading boots back on resident 2. TN 3 acknowledged that scissors should have been cleaned prior to placing it together with residents' clean materials. TN 3 acknowledged not performing hand hygiene between glove changes.During an interview on 7/22/25 at 4:33 p.m. with Director of Nursing (DON), the DON acknowledged the expectation was for staff to perform hand hygiene between change of gloves. During a review of facility policy and procedure (P&P) titled, .Hand Hygiene. dated, 3/2024, the P&P indicated, .hand hygiene is a critical component in preventing transmission of microorganisms (tiny living things that are too small to be seen without special lens) between personnel and patients.Health care workers shall decontaminate hands using alcohol-based hand rub.Before and after patient contact.before donning. gloves.Before moving from a contaminated body site to a clean body site on the same patient.after removing gloves.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when he was pushed by Resident 2. This failure resulted in Resident 1 falling backward and striking the back of his head and right elbow on the floor. Findings: During a review of Resident 2's admission Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/1/25, indicated Resident 2's Brief Interview for Mental Status (BIMS- a brief screening that aids in detecting cognitive impairment) score was 14 which indicated he was cognitively intact and as having no delirium or behavioral symptoms. Review of the facility's investigation report indicated Resident 2 was interviewed by the facility's Medical Social Worker (MSW) on 7/3/25. The investigation report indicated, According to the patient (Resident 2), an argument began because he believed his roommate had taken his grabber, which the roommate denies. The patient (Resident 2) acknowledged that, while his roommate was walking to the restroom, he called him a liar and a thief. The patient further reported that his roommate then bumped into him with his walker, which his roommate (Resident 1) also denies, prompting him (Resident 2) to respond by pushing the roommate (Resident 1). The patient (Resident 2) stated, I'll admit it-I shoved him. I know I shouldn't have, but I did. Then I called for help. During an interview with the Director of Nursing (DON) on 7/8/25 at 9:18 a.m., the DON confirmed Resident 2 pushed Resident 1 causing Resident 1 to fall and hit his elbow and head. During an interview on 7/8/25 at 9:49 a.m. with Resident 2 he stated he had a grabber (used to grab objects that are out of arm's length or difficulty to reach) and one day it disappeared. The other day he saw the grabber on his roommate's (Resident 1) side table and went over and took it. Resident 1 was coming out of the bathroom, and they had a verbal altercation. He called Resident 1 a liar about taking his grabber. Resident 1 tried to get by Resident 2 with his walker and bumped him with his walker. Resident 2 stated, I reacted and pushed him a little bit and he fell. During a review of Resident 1's Significant Change in Status MDS dated [DATE], indicated Resident 1's BIMS score was 15 which indicated he was cognitively intact and as having no delirium or behavioral symptoms. Review of the facility's investigation report indicated Resident 1 was interviewed by the facility's MSW on 7/3/25. The investigation report indicated, According to the patient, he was en (sic) route to the restroom when his roommate began yelling at him and accusing him of stealing his grabber. The patient (Resident 1) reported that the roommate then called him a liar'' and a thief' before physically pushing him, resulting in the patient (Resident 1) falling backward and striking the back of his head and right elbow on the floor. During an interview on 7/8/25 at 10:03 a.m. with Resident 1, he stated the other resident (Resident 2) pushed him a little bit. Resident 1 confirmed he fell and hit his right elbow and head. During a review of the facility's policy and procedure (P&P) tilted, Abuse, Resident Mistreatment and Misappropriation of Resident Property, approved 4/25/25 indicated, Abuse: The willful infliction of injury .with resulting physical harm or pain, mental anguish .It is the policy of this facility that mistreatment, neglect and abuse of residents .are prohibited.

Based on observation, interview, and record review, the facility failed to protect the privacy and confidentiality for 3 of 48 sampled residents (Resident 133, Resident 141, and Resident 314) when the Licensed Nurse (LN) left worksheets containing residents' identifiable health care information exposed to view during medication administration. This failure had the potential to result in Resident 133, Resident 141, and Resident 314's confidential information to be viewed by unauthorized staff, residents, and visitors. Findings: A review of Resident 133's Facesheet indicated Resident 133 was admitted to the facility in June 2024 with diagnoses including atrial fibrillation (irregular and very rapid heart rhythm) and cellulitis (skin infection). A review of Resident 141's Facesheet indicated Resident 141 was admitted to the facility in October 2024 with a diagnosis of alcohol induced neuropathy (chronic alcohol abuse damages the nerves leading to sensory and motor dysfunction). A review of Resident 314's Facesheet indicated Resident 314 was admitted to the facility in February 2025 with diagnosis of lower extremity (leg) cellulitis. During an observation on 2/25/25 at 7:57 a.m., observed LN 2 prepare Resident 133's medications on the medication cart in the hallway. Observed LN 2 cover computer screen, but did not cover or turn over worksheet when she left the medication cart to enter Resident 133's room to administer medications. During an observation on 2/25/25 at 8:16 a.m., observed LN 2 prepare Resident 141's medications on the medication cart in the hallway. Observed LN 2 cover computer screen, but did not cover or turn over worksheet when she left the medication cart to enter Resident 141's room to administer medications. During an observation on 2/25/25 at 8:26 a.m., observed LN 2 prepare Resident 314's medications on the medication cart in the hallway. Observed LN 2 cover computer screen, but did not cover or turn over worksheet when she left the medication cart to enter Resident 314's room to administer medications. During an interview on 2/25/25 at 8:47 a.m. with LN 2, LN 2 acknowledged she did not cover her worksheet left on the medication cart when she entered the rooms of Resident 133, Resident 141, and Resident 314, to administer medications. LN 2 stated, It was a HIPAA [Health Insurance Portability and Accountability Act- federal law that protects medical records and other personal health information] violation. Information needs to be protected. Should have turned it over. During an interview on 2/25/25 at 4:29 p.m. with the Nurse Manager (NM), the NM stated when nurses leave the medication cart to give the medications, they should cover the computer screen and should take the worksheet into the room with them. The NM then stated if left on the medication cart, the worksheet should be covered or turned over. The NM stated, If left open can be seen, HIPAA violation. During an interview on 2/27/25 at 11:01 a.m. with the Director of Nursing (DON), the DON stated that during medication administration the computer should be closed, and the worksheet should not be in view. The DON stated if the worksheet or computer screen can be viewed that is a privacy violation. A review of the facility's Policy and Procedure (P&P) titled Patient's Rights and Responsibilities, dated 12/3/18, indicated, .You have the right to: .Confidential treatment of all communications and records pertaining to your care and stay in the hospital . A review of the facility's P&P titled Privacy Program, dated 10/1/20, indicated, .It is the policy of [Name of corporation] to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable international, federal and state laws and regulations . [Name of corporation] is committed to carrying out its healthcare ministry in a manner . including adherence to established uniform organizational policies, standards, and processes that ensure privacy, information security, and confidentiality of Protected Health Information (PHI) . A review of the facility's P&P titled Disclosure of Protected Health Information to Family and Friends, dated 4/15/21, indicated, . [Name of corporation]'s policy and standard is to comply with the federal laws and regulations associated with the Health Insurance Portability and Accountability Act of 1996 .

Based on observation, interview, and record review the facility failed to ensure food was prepared in a manner to conserve nutritive value and palatability for residents receiving a pureed diet when the pureed carrots were prepared without using a recipe. This failure had the potential of leading to poor intake and malnutrition for the residents receiving pureed meals. Findings: During a concurrent observation, interview, and recipe review on 2/25/25 at 9:45 a.m., in the food preparation area, with the Nutrition Service Worker 1-Cook (NSW 1-C), Lead [NAME] for the day, and Nutrition Service Worker 2- Trainee [NAME] (NSW 2-TC) 2), NSW 1-C was showing the puree recipes and discussed the options used for adjusting the texture of pureed dishes. NSW 1-C had stated using water is seldom used as well as thickener ingredients. NSW 2-TC was observed liberally pouring an unmeasured amount of hot water into both the carrot puree and sweet potato puree. Observed NSW 1-C attempting to remedy the very watery and runny textured purees by adding an unmeasured volume of puree thickening ingredient. During a concurrent observation and interview on 2/25/24 at 12:15 p.m., Nutrition Service Manager (NSM) brought two lunch test trays that contained one regular consistency meal and one pureed consistency meal to the conference room. The pureed meal was sampled, and while the puree carrots had a sweet flavor, the consistency was very thick and gummy indicating too much thickener was used during preparation. When asked about the carrot puree consistency, the NSM stated, The amount of thickening added [to pureed foods] should follow a recipe .consistency is too thick and gummy. During an interview on 2/27/24 at 9:30 a.m. with the Nutrition Service Director (NSD), the NSD Stated, Cooks should follow recipes and measure out ingredients. Not following the pureed recipe could alter the nutrition that residents receive . 51484

Based on observation, interview, and record review the facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1. Food items in refrigerator, freezer, and dry food storage had food items that were not securely closed, did not have expiration date labels, or no label with opened date and use by date labels; 2. Clean stainless steel table pans were found stacked and stored wet on storage shelves; and 3. Two red cutting boards for meat and 1 green cutting board for vegetables had deep grooves. Theses failures had the potential of leading to food borne illness for 159 residents who are eating facility prepared foods. Findings: 1. During the initial kitchen tour on 2/24/2025, at 9 a.m., with the Nutrition Service Manager (NSM), the following was observed: The South walk-in Veg Box #2 refrigerator contained an open bag of spinach that had cellophane loosely wrapped around the spinach bag. An opened bag of shredded cheddar cheese with cellophane loosely wrapped around it. An open plastic container with pre-sliced Monterey [NAME] Cheese which was not securely sealed. An open bag of remaining pureed carrots had cellophane loosely wrapped around it. None of these opened food items had labels with Opened Date and/ or Use by Date recorded on it. During the initial kitchen tour on 2/24/2025, at 9 a.m., the walk-in freezer #4 was observed containing an open box of frozen cheese enchiladas that was stacked in the box without any plastic bag or cellophane wrap, and not securely sealed. During the initial kitchen tour on 2/24/2025, at 9 a.m., the walk-in storage room [ROOM NUMBER] containing dry foods, canned foods, some emergency response food supplies and paper kitchen supplies (i.e., paper cups, paper plates) the following was observed: Three 102 oz cans of diced red sweet peppers without any expiration date label, Two boxes of Nutri Grain breakfast bars had an expiration date of [DATE], stamped on them, Two unopened, loosely stored bags of Low Sodium Country Gravy Mix stored on the shelf without use by dates labeled on them, Three unopened, loosely stored bags of Classic Corn Bread stuffing mix packets on shelf without use by date label/stamp, An open bag of Dry Classic Corn Bread stuffing was loosely sealed with saran wrap stored on the shelf without a use by date label on it, One loose bag of Whisk and Serve cream soup & sauce package was on the shelf without a use by date and expiration date label on it. During concurrent interview on 2/24/25 at 9 am with the NSM, the NSM stated stored open food items should be tightly sealed with a label affixed to open food item with open and use by dates written on label. NSM stated when food items are not tightly stored, there is a risk for bacterial growth as well as risk for freezer burn to froze food items. For dry stored foods, NSM stated food items stored on shelf should have expiration date labeled on the item and/or use by date label. During an interview on 2/27/25, 9:30 a.m., with the Nutrition Service Director (NSD), who oversees all Kitchen and Nutrition operations, the NSD stated that all stored foods should be tightly sealed and have labels with open dates, and use by dates written on labels, as applicable and expiration dates should also be clearly visible for all food items. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Food Handling Standard Operating Procedure, effective 8/1/24indicated, General food storage guidelines are followed for all stored foods including refrigerated, frozen and dry storage foods. Items stored neat and orderly, with labels facing out and expiration dates visible. Food stored .Follow Hazard Analysis Critical Control Point (HACCP) procedures for refrigerated food storage. Regarding labels, the P&P indicated, Most products contain an expiration date. The word sell-by or use-by precede the date. The use-by date is the last date that a food can be consumed. 2. During the initial kitchen tour on 2/24/25, 9:43 a.m., two rectangular stainless-steel table pans, and 1 square stainless-steel serving container had water droplets on them and were stored on the storage shelf with other clean, dry stainless-steel serving trays and containers. During initial tour and concurrent interview on 2/24/2025, 9:43 a.m., with NSM, NSM stated, The kitchen equipment should be clean and dry before storing as wet containers can breed bacterial growth and make residents sick. During an interview on 2/27/2025, 9:30 a.m., with the Nutrition Service Director (NSD) who oversees all Kitchen and Nutrition operations, NSD stated she expects NSWs to ensure clean kitchen supplies are completely dry before storing as it can be a source for bacterial growth. A review of the US Food and Drug Administration's (FDA) 2022 Food Code, section 4-901.11, titled, Equipment, Utensils, Air-Drying Required, indicated, After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining . and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. 3. During concurrent initial kitchen tour and interview on 2/24/2025 at 10 a.m., two red cutting boards used for cutting meat and 1 green cutting board used for cutting fresh produce, were observed with multiple deep cut marks on both sides of the cutting boards. NSM stated the cutting boards should be replaced as the deep grooves in the cutting board were a concern for bacterial growth. A review of the US FDA 2022 Food Code, section 4-501.12 titled, Cutting Surfaces, indicated, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED or discarded if they are not capable of being resurfaced.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 32) was administered pain medication before providing wound care. This failure resulted in Resident 32 having unnecessary pain during wound care. Findings: Resident 32 was admitted to the facility in mid-2024 with diagnoses which included stroke, hypertension (uncontrolled blood pressure), dementia (memory loss) and a stage IV pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). A review of Resident 32's most recent Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/29/24, indicated Resident 32's memory was severely impaired. During an observation on 2/27/25 at 8:41 a.m., in Resident 32's room, Resident 32 wound dressing change was being provided by the Wound Care Registered Nurse (WCRN). Resident 32 stated, this is painful. During an interview on 2/27/25 at 8:42 a.m., with Resident 32, Resident 32 stated, She [WCRN] never asked about pain. Yes, I have pain, this does not feel good. During an interview on 2/27/25 at 8:50 a.m., with the WCRN, the WCRN stated, I'm not sure if [Resident 32's] pain medication was given. She (Resident 32) will be ok. During a concurrent interview and record review on 2/27/25 at 8:52 a.m., with LN 2, LN 2 reviewed, the Medication Administration Record (MAR) for Resident 32 's last pain medication administered. The MAR indicated Resident 32 received tramadol (used to relieve moderate to moderately severe pain),Oral Tablet 25 MG on 2/26/25 at 7:33 a.m. LN 2 stated, She (WCRN) should have checked with [Resident 32], 30 minutes before her wound care to assess the need for pain medication. During an interview on 2/27/25 at 12:48 p.m., with the Director of Nursing (DON), the DON stated, My expectation is that the staff should assess the residents prior to any care for their comfort. The facility's policy and procedure (P&P) for Pain Management was requested, the policy was not provided.

Based on observation, interview, and record review the facility failed to ensure infection control practices were maintained for one (Resident 32) of 48 sampled Residents when: 1. Resident 32's room, with Enhanced Barrier Precautions (wearing gowns and gloves during close-contact care activities with residents with open wounds or medical devices to stop the spread of tough-to-treat infections), trash bin did not have a lid and was overflowing with used Personal Protective Equipment (PPE - items, such as gowns and gloves, worn to minimize exposure that can cause serious illnesses and healthcare workers wear to prevent contact with infectious agents or body fluids), and 2. Wound Care RN (WCRN) did not perform hand hygiene during Resident 32's wound care. These failures had the potential to spread harmful germs to patients, leading to increased risk of infections, including those resistant to antibiotics (medicines to treat bacterial infections), and potentially causing serious illness to Resident 32. Findings: 1. During a concurrent observation and interview on 2/27/25 at 10:55 a.m., with Licensed Nurse/ Infection Preventionist (LN/IP), the LN/IP confirmed the PPE trash bin was overflowing and without a lid. The LN/IP stated, They should not be that way. I don't know why the lid is missing. I will look into it .the lids prevent infection from spreading. During an interview on 2/27/25 at 12:48 p.m., with the Director of Nursing (DON). The DON stated, all rooms should have trash cans with lids. Not sure how the lid is missing. I would never expect the trash to be overflowing with PPE and the trash cans need the lids to control the spread of infection. During a review of the CDC's website, https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html, resulted on 3/3/25 at 2:33 p.m., the CDC guidance indicated, Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room. 2. Resident 32 was admitted to the facility in mid-2024 with diagnoses which included stroke, hypertension (uncontrolled blood pressure), dementia (memory loss) and a stage IV pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). A review of Resident 32's most recent Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/29/24, indicated Resident 32's memory was severely impaired. During a concurrent observation and interview on 2/27/25 at 8:41 a.m., at Resident 32's bedside the WCRN was observed using the same gloves after adjusting the bedrail, positioning the resident and taking off the old wound dressing. The WCRN then used the same gloves and picked up the clean wound dressing supplies. The WCRN confirmed that she should not have used the same pair of gloves and stated, We are supposed to hand sanitize and change our gloves. During an interview on 2/27/25 at 12:48 p.m., with the DON, the DON stated, Would expect the staff to follow hand hygiene for wound care at all times. During review of a facility policy and procedure (P&P) titled, Hand Hygiene, dated 1/2023, the P&P indicated, Health care workers shall decontaminate hands using alcohol-based hand rub or washing with soap .and water under the following circumstances. After contact with patient's intact or non-intact skin, mucous membranes, wound dressings or other objects likely to be contaminated.

Based on observation, interview, and record review, the facility failed to provide supervision and additional assistance to one of 4 sampled Residents (Resident 1), when Resident 1 fell from the mechanical lift to the floor while being transferred by a Certified Nurse Assistant (CNA 4) from the bed to the wheelchair. This failure resulted in Resident 1 sustaining a scalp contusion (bruise) and pain. This failure also had the potential to cause serious injury or death. Findings: During record review of the Facesheet, Resident 1 was admitted in 2019 with diagnosis including deconditioning, impaired mobility, generalized weakness, chronic low back pain and [CONDITION(S)] (nerve damage). Record review of the Minimum Data Set (MDS- nursing home screening tool), dated 4/9/21, Resident 1's Functional status - Activities of Daily Living (ADL) indicated transfers required total dependence upon 2 person physical assistance. Review of the medical record document titled, Care Plan, dated 4/15/21, indicated, Resident 1 had a History of falls, impaired balance, and impaired judgment. Under the section, Interventions, the Care Plan directed, OOB (out of bed) to wc (wheelchair) .mechanical lift for transferring . During a phone interview on 6/24/21 at 3:55 p.m., CNA 4 stated, she was assigned to care for Resident 1 on 4/18/21. CNA 4 stated she could not find any CNA or LN (Licensed Nurse) to help with the transfer and, I did the mechanical lift by myself. The sling came out of the bar hook and the resident fell . Review of Resident 1's medical record titled Change of Condition form dated 4/18/21, at 11:20 a.m., indicated .pt (patient) found lying on the flour (sic- floor) head is resting on the base of the hoyer (name of mechanical lift) left (sic) machine. Per CNA when pt (patient) was up the sling came off on the left side of the shoulder . left shoulder first on the ground then the head. Pt (patient) was crying and verbalizing I have pain in my head .Pt (patient) transfer to ED (Emergency Department) for evaluation . Review of Resident 1's Hospital record titled ED MD Notes dated 4/18/21, 13:16 (1:16 p.m.) indicated .Patient fell while transferred on hoyer at facility .Final diagnosis: fall, scalp contusion . Review of Resident 1's record titled Physician note dated 4/19/21 at 5:50 a.m., indicated patient recently fell and came back from ED after evaluation . Pt (patient) had 3 bruises to left side of the body . Shearing (skin injury) to left upper back near shoulder . left occipital (head) hematoma (bruising/bump) . During an interview on 6/3/21 at 10:45 a.m., Licensed Nurse (LN) 2, who was the charge nurse on the day of the incident, 4/18/21, stated that normally you need 2 people to transfer with the mechanical lift and that was what was usually instructed. During a concurrent observation and interview on 6/3/21 at 11:54 a.m. in Resident 1's room, CNA 3 stated, 2 people are always used with the lift. CNA 3 stated and confirmed that each Resident had an ADL (Activities of Daily Living) checklist and it was located inside the Resident's closet door. Resident 1's closet door ADL Checklist indicated a 2-person assist was required. During an interview on 6/3/21 at 11:28 a.m., the Director of Staff Development (DSD) stated, the expectation is for the staff to use a 2-person assistance (for mechanical lift). During an interview on 6/3/21 at 12:06 p.m., the Interim Director of Nursing (IDON) stated, I expect the staff to follow the policy and what is appropriate for the patient. Review of the facility policy titled Fall Prevention Program, dated 4/1996 and approved 3/28/2019, indicated .all residents will receive adequate supervision and assistive devices to prevent accidents. Review of the facility Policy: Safe Patient Handling and Mobility, dated December 13, 2017, indicated .The level of assist and type of equipment will be posted in such a way to communicate to the patient care team what is required to safely handle the patient.

Based on observation, interview, and record review, the facility failed to ensure the safety of one of three sampled residents (Resident 1) during a Hoyer lift (an electrical assistive equipment to transfer residents who no longer bear weight) transfer when Resident 1's leg thumped against the wall. This failure resulted in Resident 1's leg fracture, excruciating pain, an unintended emergency room visit and hospital stay and compromising the resident's ability to enjoy normal life activities due to the injury. Findings: Resident 1 was a long term resident and recently readmitted to the facility on [DATE], after a hospitalization due to a left leg fracture. The resident's diagnoses included diabetes and an above the right knee amputation. Review of the MDS (Minimum Data Sets, an assessment tool), dated 8/2/21, indicated Resident 1 was cognitively intact with a score of 14/15 in the BIMS (the Brief Interview for Mental Status) assessment. In a concurrent observation and interview on 10/12/21 at 11:30 a.m., Resident 1 was lying on her bed in her room. Resident 1 stated she fractured her leg one morning, a few weeks ago, when a Certified Nurse Assistant (CNA) transferred her from her bed to her wheelchair using the Hoyer lift. The resident recounted that the CNA first transferred her from the bed onto the wheelchair using the lift and then she suddenly put the back down of the wheelchair behind the resident which made her recline backward abruptly. The resident stated she shrieked for fear of falling backward and on her shrieking, the CNA quickly lifted the back of the wheelchair straight up and at that time the resident hit her left leg hard against the wall. The resident voiced it hurt so much she screamed. Resident 1 stated only one CNA operated the lift during the transfer and no other staff was in the room. Resident 1 grimaced in pain and the interview was discontinued. Review of Resident 1's clinical record, Change of Condition, LTC (Long Term Care), dated 9/24/21, Licensed Nurse (LN) 1 documented, Resident c/o [complained of] severe pain on her left upper leg .noted upper leg with tenderness to touch, pt [patient, Resident 1] been jumpy when slightly touch the area. Even when touch the foot pt stated its (sic, it's) radiating the pain to her upper leg. Also stated even little shaking on he (sic, the) bed causes pain to her upper leg. Per pt the [pain] gradually started from morning when she was sitting down from the w/c [wheelchair] .ordered to transfer pt to ED for further evaluation. Review of the hospital Emergency Department (ED) Physician Notes, dated 9/24/21, indicated, The patient [Resident 1] presents with Left-sided lower extremity pain .presenting with a chief complaint of left hip, leg, and foot pain since this morning. Patient states that she has been in pain since she was transferred earlier today in her room. The ED physician documented, Patient has a markedly angulated [the ends of the broken bone have shifted out of alignment] left proximal shaft femur fracture [where the upper bone of the left leg head joins to the hip bone], .She is bedbound and paralyzed. She is however in marked pain. The resident was admitted to the hospital on the same day. Review of Resident 1's clinical record, 9/28/21 History and Physical (H&P), indicated the resident readmitted to the facility after the hospitalization for the leg fracture on 9/24/21. The H&P indicated Resident 1's fracture was to be treated with anticoagulant (blood thinner) therapy, rehabilitation, and pain management as documented, Start on [MEDICATION(S)] [to decrease blood clot] drip transition to [MEDICATION(S)] [to prevent deep veins and arteries blood clot blockage] recommended to rehab [rehabilitation] and skilled care continue pain control. In an interview on 10/12/21 at 11:45 a.m., CNA 2 indicated Resident 1 used to get up and out of bed everyday for either attending activities at 10 a.m. or for lunch at the dining hall at 11:40 a.m. daily. CNA 2 stated, She loves to get up .able to self wheel herself and look outside near the nursing station. CNA 2 indicated the resident no longer got out of bed since her return from the hospital because she had so much pain .for now .has been in bed. CNA 2 stated Hoyer lift transfers were a two-person assist that always required 2 staff to conduct the lift. In an interview on 10/12/21 at 12:26 p.m., the Clinical Manager (CM) verified Resident 1 did not have diagnoses or underlying diseases including [CONDITION(S)] (less bone mass or strength) or osteopenia (a condition that begins to lose bone mass therefore bones get weaker). The CM confirmed the ED physician notes on 9/24/21 did not indicate the resident's fracture was related to a pathologic disease (i.e a pathologic fracture; a break in a bone that is caused by an underlying disease). The CM verified it was CNA 1 who transferred the resident in the morning on 9/24/21 and stated CNA 1 no longer worked for the facility. The CM stated Resident 1 had no history of false accusation. In an interview on 10/12/21 at 12:55 p.m., the Director of Nursing (DON) stated the facility's care goals for all residents were to be active and indicated Resident 1 used to be active getting up daily, participating in activities and having meals in the dining hall. The DON stated it was the facility's policy for 2 persons to assist in the transfer of residents using a Hoyer lift. In an interview on 10/12/21 at 1:15 p.m., the Activity Director (AD) stated Resident 1 used to be very active, sociable and participate in group activities like Bingo, word games, cookie [NAME], Catholic mass, and parties. The AD stated she had not seen Resident 1 in group activities since her readmission from the hospital. The AD recounted that Resident 1 recently told her that she was, Looking forward to going back to group activities. In a concurrent interview and review of Resident 1's Medication Administration Record (MAR) on 10/12/21 at 2:15 p.m., LN 2 verified the resident took narcotics which were a combination of two pain medications, [MEDICATION(S)]/acetaminophen (a strong prescription pain reliever 5/325 milligram, a unit of measurement) from one to four tablets daily since her readmission. The MAR from 9/28/21 through 10/12/21 indicated Resident 1 took the narcotics to control the fractured leg pain as follows: >1 tablet: 9/28/21, 9/29/21, 10/4/21, 10/6/21, 10/9/21, 10/10/21, and 10/12/21 >2 tablets: 9/30/21, 10/1/21, 10/3/21, 10/5/21 and 10/7/21 >4 tablets: 10/2/21, 10/8/21 In an interview on 10/12/21 at 2:35 p.m., LN 2, in the presence of the CM, acknowledged Resident 1 was in pain due to the fracture and stated the resident did not take pain medications prior to the leg injury. LN 2 and the CM acknowledged the fracture injury negatively affected the resident's daily routine and resulted in the resident's inability to participate in activities that she used to enjoy. LN 2 stated the facility's policy and procedure, safe handling, required two staff, always a pair when using the Hoyer lift to transfer residents. LN 2 stated, The CNA should have gotten another CNA's assistance .to ensure safety of the resident. In a telephone interview on 10/14/21 at 10:32 a.m., LN 1 stated on 9/24/21 she worked double shifts both AM and PM on the day of Resident 1's emergency room transfer. LN 1 stated she had taken care of the resident for more than a year, therefore, she was familiar with the resident's care and her health status. LN 1 stated she thought it was unusual when Resident 1 asked for pain medication on 9/24/21 at about 8 p.m. stating, [Resident 1] never asked for pain meds[medications] .maybe 1 or 2 times during the year. LN 1 assessed the resident and recited what she documented on Change of Condition notes on 9/24/21. LN 1 stated Resident 1 used to get up in her wheelchair everyday, attend activities, have meals in the dining hall, sit in her wheelchair in the room and enjoyed getting out of bed. LN 1 stated Resident 1 had changed since she returned from the hospital and refused to get up. LN 1 stated Resident 1 had been taking [MEDICATION(S)]/acetaminophen two tablets as needed. CNA 1 did not return the two calls requesting interviews when voice messages were left on the facility provided phone number for CNA 1 on 10/14/21 at 10:07 a.m. and on 10/21/21 at 4:08 p.m. On 10/19/21, the CM confirmed via email that CNA 1 transferred Resident 1 by herself in the morning of 9/24/21. The CM's email wrote, I called the CNA [CNA 1's Name] who confirmed she was by herself the morning she assisted [Resident 1's Name] into the wheelchair with a hoyer lift.

Based on staff and resident interviews, resident clinical and hospital record, and policy and procedure review, the facility failed to provide adequate supervision for 1 of 6 sampled residents (Resident 1). Resident 1 was on the smoking patio unsupervised and attempted to light a cigarette when a fire started. The failure to provide supervision resulted in Resident 1 sustaining a third degree burn, defined as injury that extends to all layers of the skin, to her right anterior trunk and right upper arm, which required transfer to a hospital and emergency treatment, which included: -hospitalization in an Intensive Care Burn Unit; -Surgical removal of the injured/burned skin; -Skin grafting (defined as a surgical procedure that involves removing the skin from one area of the body and moving it, or transplanting it, to a different area of the body); -Sepsis, (defined as a complication caused by the body's overwhelming and life-threatening response to infection, which can lead to tissue damage, organ failure, and death); -Respiratory failure with pulmonary edema (defined as an inability to breathe due to excess fluid in the lungs); -Intubation (a tube inserted into the airway (windpipe) to keep it open); and, -Mechanical ventilation (tube inserted into the airway is connected to a ventilator which breaths for the patient). Findings: On 11/30/16 and 12/8/16, the Department received two notifications regarding an incident that occurred on 11/29/16. Resident 1 suffered third degree burns to her right lateral side, right arm pit and chest when she was smoking outside unsupervised on the facility's patio. An interview with the Director of Nursing (DON) was conducted on 12/8/16 at 4:05 p.m. She stated that she witnessed the incident when Resident 1 caught on fire while smoking outside at the smoking patio on 11/29/16 and she estimated the time of incident at around 5:45 p.m. She said, That it was cold and dark outside already and the resident was by herself in the smoking patio. At the time of the incident, the DON stated that she was standing and talking to one of the staff physician's in a hallway. She was standing facing a resident's room whose window cover was opened providing a view of the smoking patio. The DON stated .I saw a flash, which is what caught her attention to the beginning of the fire incident. She stated that she grabbed the fire extinguisher, and she and physician ran immediately to where Resident 1 was located. When they reached the resident the fire became bigger. The fire was mostly on the right side of Resident 1's body. The DON stated that she was removing the resident's clothing, which consisted of a pink sweater and a hospital gown, while the physician was hosing the resident down with the fire extinguisher. The DON stated that the resident did not lose consciousness. She said the resident was telling her, Help me, help me, I am on fire. The DON stated that while the physician was hosing the resident with the fire extinguisher, the physician was yelling to Put it down, put it down. The DON asked him, To put what down? The DON explained, the physician was instructing the resident to put down the lighter that the resident was clasping tightly in her right hand. The DON denied and odor of gas burning while extinguishing the fire. She said, No, but more of smell of burned fabric and rubber. The DON stated that she and the physician were not sure if the resident was holding valve to the lighter open (allowing the butane gas to continue to flow out). The DON confirmed the resident was not receiving oxygen when the incident happened. She stated that the resident was wearing a smoking apron, but the apron only covered the front portion of the resident's clothing and was not big enough to cover the sides of the resident. The physician wheeled Resident 1 back inside the building while waiting for the Emergency Medical Technicians (EMTs) to arrive to take the resident to an acute care hospital. The DON stated that the whole event, Must have taken about 10 minutes only. She stated that she and the physician moved extremely fast to put the fire out by removing the resident's clothing and extinguished the fire, and for the EMTs to arrive and took her to the hospital. The DON acknowledged there should have been staff out on the patio directly supervising the resident when the fire started. A video camera captured the fire incident on the evening of 11/29/16. The video was reviewed with the DON on 12/8/16. The video showed Resident 1 wheeled herself out to the smoking patio. The surrounding area was dark, but a light was on at the section of the smoking patio where the resident was sitting. A few minutes later, the video captured a second person entering the smoking patio. We don't know. Do we have to have this? The DON was asked who the person was and she stated, It was me. The DON was shown going around the resident and stopped to speak to her. A few minutes later, the DON left and entered the facility and left the resident by herself in the smoking patio. A few minutes after, a bright light lit to the right side of the resident, followed by a bigger bright light. The DON was asked what the bright lights were, and she said, Fire. The video showed two people, the DON and the physician, helping the resident, and few minutes later the physician wheeled the resident back inside the facility. On 12/12/16, at 11:55 a.m., the resident's clothing, wheelchair, and other items that the resident had with her during incident were inspected with the DON. A brown colored smoking apron was inspected and there was no burned marks noted on it. The wheelchair the resident was sitting on, had burned patches on the right side of the wheelchair's rubber tire and on the metal frame of the wheel. The DON stated that the resident was wearing a hospital gown with the pink sweater over it. The hospital gown the resident was wearing was burned at the bottom of the right sleeve and to the right side of the opening of the gown. The pink sweater had burned patches to the pocket of the right of the sweater and to the lower portion near the right pocket. The sweater's pockets were inspected by the DON. The contents of the sweater's pocket included following items: -A blue color lighter and a washcloth was in the right side pocket. -A half full bag of snacks was in the left pocket, when the DON took the bag of snacks out of the pocket, -a white colored lighter fell out of the pocket. The DON stated that she was not aware that the resident had the white lighter as well. In total, Resident 1 had three lighters with her when the incident occurred. The third lighter had a design with multiple colors including tan color. The DON stated that it was this lighter that the resident had in her right hand and was clasping it tightly when the fire started. The three lighters were inspected, the blue lighter and white lighter still contained butane The third lighter was empty. A review of Resident 1's clinical record revealed that the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord). A review of the Social Work Note, dated 11/10/16, revealed a brief description of Resident 1's psychosocial activities. The note indicated (Resident 1) is up daily, wheels self out on the patio to smoke . A review of Resident 1's Smoking Assessments revealed the following: 1. Assessment done on 7/6/16 indicated: Resident Alert: Yes Able to hold smoking materials: No Able to extinguish fallen cigarette: No Able to call for help if materials fall: No Able to move (without) assist to smoking area: No Past (history of) poor safety judgement: No Medical contraindications to smoking: No . Resident Smoking Status: Supervised smoker. 2. Assessment done on 10/11/16 indicated: Resident Alert: Yes Able to hold smoking materials: Yes Able to extinguish fallen cigarette: Yes Able to call for help if materials fall: Yes Able to move (without) assist to smoking area: Yes Past (history of) poor safety judgement: Yes Medical contraindications to smoking: No . Resident Smoking Status: Supervised smoker. During a concurrent interview with the MDS (Minimum Data Set, a Resident and Assessment and Care Screening tool) Coordinator (MDSC) on 12/17/16 at 10:15 a.m., the two smoking assessments (above) and smoking care plan of Resident 1 were reviewed. She stated the smoking assessment was done quarterly and it would correlate during the quarterly MDS Assessment. The MDSC stated that smoking care plan was also updated after smoking assessment was done. The MDSC explained when the 7/6/16 smoking assessment was completed, the resident was not doing well and was hospitalized . She said at that time, the resident was forgetful and confused with lapses of memory, and she required supervision (when smoking). Resident 1's 10/11/16 smoking assessment was reviewed with the MDSC. She stated that she mistakenly answered yes to the first question, Resident Alert, and that at that time the resident did have impaired cognition and was forgetful. The resident's smoking care plan was reviewed with MDSC, and it indicated the following: Updated on 10/11/16: NEEDS AND PROBLEMS: Resident requests to smoke. GOALS: (a.) Resident will display safe smoking ability as indicated by smoking assessment. (b.) Resident will be assisted by staff/family to smoke at all times. INTERVENTIONS APPROACH: (a.)Resident will be monitored by staff for safe independent smoking ability. (b.)Resident will comply with smoking in designated areas using safe practices. (c.) Resident will be assisted by staff to smoke as resident requests. (d.) smoking bib will be utilized/offered as needed . The MDSC confirmed the current smoking care plan was appropriate for Resident 1, however, she acknowledged that staff did not ensure interventions in Resident1's care plan, e.i., monitoring for safe independent smoking ability, and provide assistance as needed, were implemented. Multiple residents, who were smokers and were usually with Resident 1 in the smoking patio, were interviewed: Resident 2 was interviewed on 12/16/16 at 9 a.m., and the resident stated that Resident 1 should have been supervised. When asked to clarify, Resident 2 stated, She was not all there. She was .more forgetful. Resident 4 was interviewed on 12/16/16 at 9:15 a.m., and the resident said, She (Resident 1) was not supposed to go out by herself. Resident 4 stated that Resident 1 would drop things, and she could not bend down to pick up the objects she dropped, we would pick the items up for her. We kind of watched her (during smoking) . Resident 4 stated that she and Resident 1 would usually go to the smoking patio together, and they got along well. Unfortunately, the evening of 11/29/16, Resident 4 stated that she was not with Resident 1 and she (Resident 1) went out to the smoking patio alone. A review of documentation by a licensed nurse, dated 11/29/16 at 10:10 p.m., revealed the following: Change of Condition: Condition Change Impact: Other: burns Describe Change of Condition: At (6 p.m., Certified Nursing Assistant) notified (nurse) that the resident got burns while she was smoking outside. At same time (name of a physician) brought resident to nurse's station, sitting on wheelchair, assessed resident by (Medical Doctor and nurse), noted burns on right lateral side and right arm pit and chest. Resident alert, verbally responsive .No (shortness of breath) noted. No cardiopulmonary distress noted .Resident transfer(red) to (name of acute care hospital) at (6:15 p.m.), by fire department ambulance with 5 paramedics, on gurney . A review of Resident 1's clinical record, from the acute care hospital revealed the following: 1.) BURN SURGERY: History & Physical: Date: 11/29/16 at (7:38 p.m.) . History of Present Illness: (Resident 1) .presented to the (Emergency Department brought in by ambulance) from her (skilled nursing facility) after sustaining a 15% TBSA (total body surface area)/ full thickness burns to her anterior trunk and right upper arm. She claimed she was smoking a cigarette when her gown lit on fire . Physical Examination: SKIN: 15% TBSA/full thickness flame burns to her right anterior trunk (front side of the upper body) and right upper arm; . GENERAL: The patient is alert, oriented to self . ABDOMEN: .Partial thickness burns on lateral aspect of abdomen. EXTREMITIES: Right upper extremity with 2% TBSA burns thought medial (middle) aspect of upper arm. Right hand with small area of partial thickness burns on finger tips . Plan: .Burn/Wound: Admit to BURN (intensive care unit) for cleaning/debridement. Likely need surgery of full thickness burns . 2.) INPATIENT OPERATION RECORD OPERATION DATE: 12/1/16 PREOPERATIVE Diagnosis: [REDACTED]. POSTOPERATIVE Diagnosis: [REDACTED]. PROCEDURE PERFORMED: Tangential excision, (defined as a removal of the outer layer of devitalized tissue by shaving it off at an angle), with split-thickness skin grafting, (defined as less than the entire thickness of the dermis, (another layer of skin) is included), to the chest, abdomen, and right upper arm. Total area excised and grafted was 15% TBSA . 3.) Burn Surgery Daily Progress Note at 12/15/16: . Assessment and Plan: .Patient became septic (defined as infected with bacteria) . In addition, the note indicated that the resident went into acute respiratory failure due to pulmonary edema requiring intubation. The note further indicated the resident was placed on multiple intravenous drip medications to sustain her vital signs (blood pressure and heart beat). A review of the facility's policy and procedure titled Smoking, Residents, ORIGINATION: 10/(2009), indicated the following: PURPOSE: To provide safe smoking for residents who smoke. POLICY: Smoking is prohibited in the facility. Smoking by residents is discouraged to promote healing. However, residents who desire to smoke shall be assessed for safety prior to being allowed to smoke independently. ,The ability to smoke will be determined by an evaluation to do so safely . PROCEDURE: A. Residents that smoke will be evaluated for their ability to smoke safely upon admission, quarterly, and with a significant change of condition . C. The facility may restrict and/or revoke the resident's ability to smoke based on a change in condition, cognition, and/or safety awareness that poses a safety concern for the resident or others . F. Residents who are evaluated as not safe smokers must be accompanied by a staff person while smoking. G. The facility shall designate smoking times in the resident's Care Plan for residents who require supervised smoking .