Every finding on record at Camellia Gardens Care Center

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was admitted in the facility with a pressure injury (PI- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) received the necessary care, treatment to prevent infection, promote healing, and prevent new pressure injuries from developing, by failing to:Conduct a comprehensive baseline skin assessment upon admission by measuring and staging (a standardized medical method used to classify the severity and depth of skin and tissue damage caused by prolonged pressure, friction, or shear) Resident 1's left buttock pressure injury.Develop person-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs) with measurable goals and individualized interventions for Resident 1's left buttock pressure injury. These deficient practices had the potential to result in Resident 1 receiving no wound treatments or incorrect wound treatments, delayed wound healing, developing an infection on the left buttock pressure injury, or developing a new pressure injury.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to nondisplaced comminuted fracture of shaft of left femur (a broken thighbone where the bone is shattered into multiple pieces, but the pieces remain properly aligned and have not shifted out of place), end stage renal disease (ESRD- irreversible kidney failure), type 2 diabetes (Type 2 diabetes is a chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood ), Huntington's disease (an inherited, fatal genetic disorder that causes the progressive breakdown of nerve cells in the brain) and history of falling. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 1 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. The MDS indicated Resident 1 was dependent with rolling left and right, sitting to lying, and chair/bed-to-chair transfer. The MDS also indicated Resident 1 had one unstageable pressure ulcer. During a review of Resident 1's Discharge Note, dated 5/12/2026, from the General Acute Care Hospital (GACH), the Discharge Note indicated Resident 1 had an impaired skin integrity/wound ulcer (non-intact skin) on her left ischial tuberosity (the rounded bony prominence at the bottom of the pelvis that supports the body weight when sitting) and left greater trochanter (the large, bony bump on the upper, outer side of the thighbone). During a review of Resident 1's admission Assessment, dated 5/12/2026, the admission Assessment under skin integrity indicated Resident 1 had multiple scabbed (covered with hardened crust of dried blood over a skin injury) wounds on left buttocks with redness on right, surgical wound on left and right lower extremity (LE) below knee amputation (BKA), hematomas (localized collection of blood outside of the blood vessels) on right forearm from previous IV (small tube used to deliver fluids, medications, or nutrients directly into a person's bloodstream) site, left distal femoral fracture open reduction (incision made in the left thigh and knee area to realign the broken thighbone near the knee joint into its proper position) site. During a review of Resident 1's Skin Observation Tool, dated 5/12/2026, the Skin Observation Tool indicated Resident 1 had a pressure injury on the left buttock. The Skin Observation Tool did not indicate the length (the longest linear dimension of a wound measured along the head-to-toe axis), width (the widest side-to-side measurement taken at a 90 degree angle to the length), depth (the vertical distance from the surrounding skin surface to the deepest point of a wound bed), and stage of Resident 1's pressure injury. The Skin Observation Tool indicated Resident 1 was admitted to facility and noted with pressure injury on buttocks. For Wound Care Specialist (WCS) consultation. During a review of Resident 1's Order Summary Report, dated 8/27/2026, the Order Summary Report indicated a physician order, with a start date of 5/14/2026, for treatment to buttocks pressure injury: cleanse with normal saline (NS), pat dry, apply Xeroform (a type of wound dressing) and cover with border dressing daily and as needed (PRN) for loss of skin integrity/soiling as needed for 14 days. During a concurrent interview and record review, on 8/27/2026, at 12:42 PM, with Licensed Vocational Nurse 1 (LVN 1), Resident 1's admission Assessment, dated 5/12/2026, and Skin Assessment Tool, dated 5/12/2026 were reviewed. LVN 1 stated the Licensed Nurse (LN) who admitted Resident 1 was responsible for completing the admission Assessment and the Treatment Nurse (TN) was responsible for completing the Skin Assessment Tool after admission. LVN 1 stated that the admission Assessment and the Skin Assessment Tool should have a detailed description of Resident 1's skin integrity including discoloration, wounds, or pressure injuries, identified upon admission. LVN 1 stated the admission Assessment and the Skin Assessment Tool should also indicate the location, type, length, width, depth, and stage of the skin problem. LVN 1 stated Resident 1's admission Assessment did not indicate that Resident 1 had a pressure injury. LVN 1 also stated that Resident 1's Skin Assessment Tool did not indicate the length, width, depth, and stage of the pressure injury on her left buttock. LVN 1 stated it was important to document the length, width, depth, and stage of Resident 1's pressure injury to establish a baseline and track the progress of the pressure injury's healing. During an interview, on 8/27/2026, at 1:07 PM, with Registered Nurse 1 (RN 1), RN 1 stated she was the TN when Resident 1 was admitted to the facility on [DATE]. RN 1 stated she documented Resident 1's pressure injury on her left buttock on the Skin Assessment Tool but did not measure and indicate the stage of Resident 1's pressure injury because the WCS was responsible for measuring and staging pressure injuries in the facility. RN 1 stated it was the facility's policy to have the WCS measure and stage the residents' pressure injuries. RN 1 stated Resident 1's pressure injury was not evaluated by the WCS during her stay in the facility from 5/12/2026 to 5/24/2026 because Resident 1 went to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) on the days the WCS visited to check on the residents. RN 1 stated Resident 1's pressure injury was never measured or staged before she was transferred to the hospital. During the same interview on 8/27/2026, at 1:07 PM, with RN 1, RN 1 stated she did not develop a person-centered care plan for Resident 1's pressure injury. RN 1 stated it was important for Resident 1 to have a person-centered care plan for her pressure injury, as it would communicate to staff how to properly care for her pressure injury. During an interview on 8/27/2026, at 2:23 PM, with the Director of Nursing (DON), the DON stated that admission Assessments and Skin Assessments should be comprehensive and include a description, type, measurement, and stage of the pressure injury. The DON stated RN 1 should have notified her when Resident 1 was not seen by the WCS on 5/19/2026. The DON stated that RN 1 should have notified her if RN 1 had difficulties with measuring or staging Resident 1's pressure injury. The DON stated it was important to have a comprehensive skin assessment of Resident 1's pressure injury to determine whether the wound was improving or worsening. The DON stated it was important for Resident 1 to have a person-centered care plan with specific interventions to manage Resident 1's pressure injury properly. The DON stated Resident 1 did not have a care plan addressing her pressure ulcer. During a review of the facility's P&P, titled, Prevention of Pressure Injuries, revised 4/2020, the P&P indicated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and provide interventions for risk factors to care and prevent pressure injuries. During a review of the facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial and functional needs is developed and implemented for each Resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interviews, and record reviews, the facility failed to ensure that Resident 2's low air loss mattress (LALM-designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight and the physician's order. On 8/6/2026, Resident 2, who weighed 126 pounds (lbs., unit used to measure weight), was observed with the LALM set at 350 lbs. This deficient practice had the potential to place Resident 2 at risk for the development of pressure injuries (bedsores, sores on the skin caused by too much pressure for a long time), increase pain and discomfort, and delay healing of the surgical wound.Findings: During a review of Resident 2 's admission Record, the record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of acute respiratory failure (acute respiratory failure: an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues), malignant neoplasm of the bone (cancer of the bone), and malignant neoplasm of the hypopharynx (cancer of the lower throat). During a review of Resident 2'S Minimum Data Set (MDS - a resident assessment tool), dated 7/12/2026 the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. It indicated, Resident 2 needed supervision or touching assistance (helper provides verbal cues and/ or touching assistance may be provided throughout the activity or intermittently) on eating and personal hygiene. The MDS also indicated partial moderate assistance (helper does less than half the effort) on roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During an observation and interview on 8/6/2026 at 8:24 AM in Resident 2's room, Resident 2 was observed sitting in bed and eating breakfast. Observed the LALM was set to 350 lbs. Resident 2 stated the bed was too hard and not comfortable. Resident 2 stated he would like it a little softer. During a concurrent observation and interview on 8/6/2026 at 8:26 AM with the Licensed Vocational Nurse (LVN) 1 in Resident 2's room, LVN1 stated Resident 2's LALM was set to 350 lbs., and it was firm. LVN1 also stated Resident 2 reported on 8/6/2026 bed was not comfortable and wanted the LALM to be softer. During a concurrent interview and record review on 8/6/2026 at 2:16 PM with Registered Nurse (RN) 1, Resident 2's order summary report dated 8/6/2026 was reviewed. RN 1 stated the order summary indicated that on 7/18/2026 LALM was ordered for skin management, set settings per comfort/ preference or based on the resident's weight. During a concurrent interview and record review on 8/6/2026 at 2:18 PM with RN1, Resident 2's Braden Scale (an assessment tool used for predicting the risk for developing pressure sores [pressure injury]) was reviewed. RN 1 stated that Resident 2's Braden Scale score was 10 which means, Resident 2 was at high risk for developing pressure injury. RN 1 stated that it was important for the LALM setting to be correct to prevent the development of pressure injury. During a concurrent interview and record review on 8/6/2026 at 2:20 PM with RN1, Resident 2's Skin Observation Tool dated 8/5/2026 was reviewed. RN 1 stated skin observation tool indicated that Resident 2 had thoracolumbar spine (the junction area where the upper/middle back) surgical wound. RN 1 stated that since Resident 1 has surgical wound, it was more beneficial for the resident for the LALM to be set at the correct setting to promote comfort and pressure relief. During a concurrent interview and record review on 8/6/2026 at 2:22 PM with RN1, Resident 2's care plan for mid-spine surgical incision initiated on 7/19/2026, and care plan for the resident has actual impairment of skin integrity dated 7/31/2026 were reviewed. RN1 stated Resident 2's care plan for mid- spine surgical incision indicated the intervention included the use of LALM for wound healing. RN1 also stated the care plan for the resident has actual impairment of skin integrity, indicated that the LALM bed setting was for skin management and should be set per comfort and preference or based on weight. During a concurrent interview and record review on 8/6/2026 at 2:25 PM with RN1, Resident 2's Weight and Vitals Summary, dated 8/3/2026, was reviewed. RN1 stated that Resident 2's latest weight was 126 lbs. RN 1 stated Resident 2's LALM should be set to 126 in accordance with the resident's weight last 8/3/2026. During a concurrent interview and record review on 8/6/2026 at 2:27 PM with RN1, RN1 stated that the LALM operational manual titled Brand 1 Alternating Pressure Low Air Loss Mattress Replacement System, revised on 3/22/2021, was reviewed. RN1 stated the manual indicated, determine the patient's weight and set the control knob to that weight setting on the control unit. RN1 also stated the Brand 1 manual was not followed for Resident 2's LALM setting. RN1 stated the facility is supposed to follow the physician's order and the user's manual for proper intervention to avoid causing more harm. RN 1 added, if the LALM is too firm, there will be a risk for developing skin issues such as redness or pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattresses (LALMs, designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) for two (2) of 2 sampled residents (Residents 13 and 81) reviewed for pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure) were set at the correct settings in accordance with the facility's policy and procedure (P&P) and the physician's orders:Resident 13, who weighed 90 pounds (lbs.), had a LALM setting of 50 lbs.Resident 81, who weighed 103 lbs., had a LALM setting of 120 lbs.This deficient practice had the potential for Resident 13 to develop a pressure ulcer and placed Resident 81 at risk for deterioration of the resident's current pressure ulcer.Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), arthritis (disease characterized by joint inflammation, pain, stiffness, and reduced range of motion, often causing significant damage or disability) and right femur (long bone in leg) fracture (a break in the bone). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2026, the MDS indicated Resident 1 did not have intact cognitive (ability to think and process information) ability. The MDS indicated Resident 13 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, moving from sitting on side of bed to lying flat on bed, lying to sitting on side of bed, getting in and out of shower and transferring from bed to chair. During an observation on 4/20/2026 at 10:08 AM, Resident's LALM was observed set to 50 lbs. During a concurrent observation and interview on 4/20/2026 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, Resident 13's LALM was observed to be set at 50 lbs. LVN 1 stated Resident 13's LALM is set at 50 lbs. but should be set at 87 lbs. since the resident's weight is 90 lbs. LVN 1 stated Resident 13 is bedbound, and it is important to set the LALM at the correct weight setting so that pressure could be redistributed properly to prevent pressure ulcers. During a concurrent interview and record review on 4/20/2026 at 10:18 AM with LVN 1, Resident 13's Order Summary Report dated 2/2/2026 was reviewed. The Order Summary Report indicated Resident 13 may have LALM set to resident's weight for skin management. LVN 1 stated the order indicated Resident 13's LALM is to be set at the resident's weight, but it was not set at the correct setting. During a concurrent interview and record review on 4/20/2026 at 10:20 AM with LVN 1, Resident 13's Weight Summary dated 4/3/2026 was reviewed. The Weight Summary indicated Resident 13 weighed 90 lbs. LVN 1 stated Resident 13's most recent weight is 90 lbs. and the LALM should have been set to 90 lbs. During a concurrent interview and record review on 4/23/2026 at 2:13 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Support Surface Guidelines, dated 9/2013 was reviewed. The P&P indicated: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote comfort for all bed bound residents, prevent skin breakdown, promote circulation and provide relief or reduction. The DON stated the LALM is used to prevent pressure ulcers by redistributing the pressure residents put on the bed. The DON stated that if the LALM is not set at the correct setting it may promote skin breakdown instead of preventing it. 2. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (a disturbance of brain function),end-stage renal disease (ESRD, irreversible decline in a person's own kidney function), pressure ulcer stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the coccyx (tailbone) area and diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels). During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 81 was dependent for oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer, and toilet transfer. The MDS also indicated Resident 81 was at risk for pressure ulcers, had one unhealed stage 4 pressure ulcer, and was using pressure relieving devices for bed. During a review of Resident 81's Physician's Order (PO) dated 4/13/2026, the PO indicated, low air loss mattress for skin management and set settings per resident's comfort/preference or resident's weight every shift. During a review of Resident 81's Weight and Vital signs dated 4/14/2026, it indicated Resident 81's weight is 103 pounds (lbs.- unit of measurement). During a review of Resident 81's Braden Scale Assessment (BSA, tool used to check a resident's risk for developing pressure sores), dated 4/13/2026, it indicated Resident 81 was at high risk for developing pressure ulcers. During an observation and interview on 4/20/2026 at 9:49 AM in Resident 81's room, Resident 81 was observed sleeping and lying on a LALM which was set at 120 lbs. During a concurrent observation and interview on 4/21/2026 at 2:46 PM with Registered Nurse Supervisor 3 (RNS 3) inside Resident 81's room, Resident 81 was awake and lying on a LALM which was set at 120 lbs. RNS 1 stated Resident 81's LALM was set on 120 millimeters of mercury (mmHg, unit of pressure). RNS 3 stated Resident 81's LALM had incorrect setting, LALM should be set on 103 lbs. RNS 3 stated if the LALM setting was higher than 103 lbs., the LALM would be too firm for Resident 81. During a concurrent observation and interview on 4/21/2026 at 2:48 PM with Resident 81 inside Resident 81's room, Resident 81 was awake and lying on a LALM which was set at 120 mmHg. Resident 81 stated it hurts my buttocks when the mattress was too hard. During an interview on 4/23/2026 at 2:13 PM with the Director of Nursing (DON), the DON stated LALM setting should be set based on the Resident's weight. The LALM purpose was to prevent formation of PU. If LALM was not set up correctly and the resident does not have a wound, it can form a skin breakdown. But if the Resident had a PU, the wound could get worse. During review of the facility's undated user's manual titled, Brand 1 Alternating Pressure Mattress Replacement System with Low Air Loss, the manual indicated in the product function section, adjust the dial to correspond to the patients' appropriate weight setting. During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines revised 9/2013, the P&P indicated redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.

Based on observation, interview, and record review, the kitchen staff (Cook 3) failed to follow the facility's food preparation policy by not using serving utensils and not changing gloves during the lunch tray line assembly (organized process in a healthcare or food service setting where staff assemble meal trays for residents) on 4/22/2026. This deficient practice had the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness, which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and could lead to serious medical complications or hospitalization. Findings: During an observation in the kitchen on 4/22/2026 at 12:12 PM, [NAME] 3 touched and picked up a cooked fish fillet from a baking tray with her gloved hand and placed it on a resident's serving plate. Using the same gloves, [NAME] 3 then proceeded to scoop the vegetable entree from the serving tray on the tray line assembly. During an observation in the kitchen on 4/22/2026 at 12:15 PM, [NAME] 3, with the same gloves, picked up a beef patty and half a slice of baked potato from the serving trays on the tray line assembly and placed both items on a resident's serving plate. [NAME] 3 then continued scooping food at the serving table without changing her gloves. During an observation in the kitchen on 4/22/2026 at 12:19 PM, [NAME] 3 picked up half a slice of baked potato and one beef patty with the same gloved hand, placed them on the serving plate, and continued scooping food at the serving table without changing her gloves. During a concurrent observation and interview on 4/22/2026 at 12:19 PM with the Dietary Supervisor (DTS), DTS stated that [NAME] 3 should not handle food directly with gloved hands and should use tongs to pick up items such as beef patties, as this can cause cross contamination and result in residents becoming ill. During an interview on 4/22/2026 at 12:30 PM, [NAME] 3 stated she should not have touched the beef patty with her gloved hand because it could contaminate the food. [NAME] 3 added that food contamination can cause illness for residents. During a concurrent interview and record review on 4/22/2026 at 12:40 PM with the DTS, the facility's policy and procedure (P&P) titled, Food: Preparation, revised September 2017, was reviewed. The P&P indicated that all staff must practice proper handwashing techniques and glove use and must use serving utensils appropriately to prevent cross contamination. The DTS stated that kitchen staff did not follow the policy during today's tray line assembly.

Based on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 12 and 57) reviewed for unnecessary (any drug when used without adequate monitoring, and without adequate indication for use) medications were free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure by failing to ensure: 1.a. Resident 12's behavior of being easily irritable for the use of Depakote (also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features) was monitored.b. Resident 12 was monitored for a specific manifestation of restlessness for the use of Clonazepam (Klonopin, is a prescription medicine used to calm the nervous system. It is primarily used to treat seizure disorders [epilepsy] and panic disorders/attacks by reducing abnormal brain activity and inducing relaxation). 2. Resident 57's was monitored for the specific behavior for the use of Fluoxetine (Prozac, is a medication that helps regulate the mood and treats depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (emotion characterized by feelings of tension, worried thoughts and physical changes), obsessive-compulsive disorder [OCD, is a chronic mental health condition characterized by uncontrollable, recurring thoughts {obsessions} and/or repetitive behaviors {compulsion}] that a person feels driven to perform to reduce anxiety and eating disorders). These deficient practices have the potential to increase the risk of Residents 12 and 57 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), which may lead to an overall negative impact on the residents' physical, mental, and psychosocial well-being. Findings:1. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 12's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), major depressive disorder, generalized anxiety disorder, epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 4/3/2026, the MDS indicated Resident 12 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 12 was substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, chair/ bed-to-chair transfer toilet transfer, tub/ shower transfer, and walk 10 feet. During a concurrent interview and record review on 4/22/2026 at 11:06 AM with MDS Nurse (MDS 1), Resident 12 's Physician's order (PO) dated 3/20/2026 and medical records were reviewed. The PO indicated Depakote 125 milligrams (MG, unit of volume). Give one (1) tablet by mouth three (3) times a day for mood disorder manifested by (M/B) easily irritable. MDS 1 stated there was no order to monitor Resident 12's behavior of being easily irritable for the use of Depakote. MDS 1 also stated that Resident 12's medical records did not reflect that the resident's behavior of being easily irritable was monitored. MDS 1 further stated that if there was no documentation of monitoring for Resident 12's behavior of being easily irritable, it meant the licensed staff did not monitor Resident 12's specific behavior for which Depakote was prescribed. During a concurrent interview and record review on 4/22/2026 at 11:07 AM with MDS 1, Resident 12's PO orders were reviewed. The PO indicated:> Clonazepam 0.5 MG. Give 0.25 MG by mouth at bedtime for anxiety M/B restlessness for 14 days, ordered 4/17/2026.> Monitor episodes of anxiety M/B restlessness and tally by hashmarks every shift starting on the last day of month and ending on the last day of month every month, ordered 3/30/2026. MDS 1 stated the PO did not include, but should have included, a specific manifestation for restlessness because every resident may exhibit restlessness differently. MDS 1 further stated this would ensure that staff are monitoring the same behavior in order to evaluate whether the medication is effective. During a concurrent interview and record review on 4/22/2026 at 11:09 AM with MDS 1, Resident 12's care plan, dated 4/17/2026, the care plan interventions indicated were to:Administer medication as ordered and monitor for adverse side effects.Dose reduction if appropriateTry to determine the reason for behavioral disturbancesMDS 1 stated the CP interventions for the use of clonazepam for Resident 12 were not adequate and resident specific. 2. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. The admission record indicated Resident 's diagnoses included Lewy body dementia (LBD, is a brain disorder that can lead to problems with thinking, movement, behavior, and mood, major depressive disorder, anxiety disorder, and epilepsy. During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 57 was partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for toileting hygiene, shower/ bathe self, putting on/ taking off footwear, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer. During a concurrent interview and record review on 4/22/2026 at 10:29 AM with MDS 1, Resident 12's PO order dated 2/5/2026 was reviewed. The PO indicated Fluoxetine 20 MG one time a day for depression. MDS 1 stated the PO did not include, but should have included, a specific manifestation for the use of Fluoxetine. MDS 1 stated it should have included manifestation of behavior such as Resident 12 verbalizations of missing his spouse. MDS 1 further stated this would ensure that staff are monitoring the specific behavior in order to evaluate whether Fluoxetine is effective. During a concurrent interview and record review on 4/23/2026 at 11:37 AM with the Director of Nursing (DON), Resident 12's PO order dated 2/5/2026 was reviewed. The DON stated the fluoxetine order was incomplete. The PO did not include Resident 12's manifested behavior for depression. During a review of the facility's Policy and Procedure (P&P) titled, Antipsychotic Medication Use, revised 12/2016, the P&P indicated antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The P&P also indicated: 6. Diagnosis of a specific condition for which anti-psychotic medications are necessary to treat will be based on a comprehensive assessment of the resident.16. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including anti-psychotic medications.17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. During a review of the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, The P&P Management indicated,7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.8. interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum:a. a description of the behavioral symptoms, including:( 1) frequency;(2) intensity;(3) duration;(4) outcomes;(5) location;(6) environment; and(7) precipitating factors or situations.b. targeted and individualized interventions for behavioral and/or psychosocial symptoms;c. the rationale for the interventions and approaches;d. specific and measurable goals for targeted behaviors; ande. how the staff will monitor the effectiveness of the interventions.10. 0. When medications are prescribed for behavioral symptoms, documentation will include:a. rationale for use;b. potential underlying causes of the behavior;c. other approaches and interventions tried prior to the use of anti-psychotic medications;d. potential risks and benefits of medications as discussed with the resident and/or family;e. specific target behaviors and expected outcomes;f. dosage;g. duration;h. monitoring for efficacy and adverse consequencesThe P&P Monitoring also indicated,2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported.3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment.4. If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication and implement a gradual dose reduction, or document why this cannot or should not be done (for example, recurrence of psychotic symptoms after several previous attempts to taper medications).a. The IDT will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling.b. ff such symptoms are identified, and some medication is still needed, the IDT will adjust the current regimen to try to minimize side effects while maintaining therapeutic effectiveness.

Based on observation, interview, and record review, facility staff did not develop a care plan (a dynamic, written document outlining a patient's health needs, goals, and customized interventions, formulated through assessment) to address the use of indwelling catheter (a flexible, sterile tube inserted into the bladder to continuously drain urine into a collection bag) for one (1) of 18 sampled residents (Resident 8) as indicated on the facility policy. This deficient practice had the potential for Resident 8 to have catheter-associated urinary tract infections (infection in the urinary tract due to the medical device such as indwelling catheter). Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, type 2 diabetes mellitus (high blood sugar levels in blood stream) without complications, and other seizures (a sudden, uncontrolled burst of electrical activity in the brain). During a review of Resident 8's Minimum Data Set (MDS, resident assessment tool), dated 2/6/2026, the MDS indicated Resident 8 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 8 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During a review of Resident 8's Physician's Order (PO) dated 1/30/2026, the PO indicated, to monitor indwelling catheter urinary drainage bag and document the following the color, output, odor, hematuria (blood in urine), every dayshift. During a concurrent interview and record review on 4/22/2026 at 3:55 PM with Medical Record (MR), Resident 8's Care Plan Report was reviewed dated from 1/30/2026 to 4/22/2026, MR stated she could not find any Care Plan to address the use of indwelling catheter in Resident 8's Care Plan Report. MR stated it is important for the nurses to develop the use of Foley Catheter plan of care for Resident 8, it is essential for providing individualized, safe, and consistent patient care while promoting efficient communication among healthcare teams. During a concurrent interview and record review on 4/22/2026 at 3:59 PM with the Director of Nurses (DON), the DON stated nurses are supposed to develop a resident centered care plan for Resident 8's use of indwelling catheter in order to prevent, reduce, or manage catheter-associated urinary tract infections and to providing individualized, safe, and consistent patient care while promoting efficient communication among healthcare teams. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, was reviewed. The P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan will:Include measurable objectives and time frames. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (dynamic interaction between an individual's thoughts/ emotions/ behavior with their social environment) well-being.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 72) reviewed for indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) were accurately monitored on 4/20/2026 and 4/22/2026, in accordance with the physician's (MD, medical doctor) order and facility's policy and procedure (P&P) by failing to ensure:Resident 72's indwelling catheter was monitored and documented for sedimentation (particles in liquid) in the urine (common causes include dehydration, kidney stone or urinary tract infection [UTI; an infection in the urinary system, which includes the kidneys, ureters, bladder, and urethra]) on 4/20/2026 and 4/22/2026.MD was notified of Resident 72's sedimentation in urine noted on 4/20/2026.These deficient practices have the potential for Residents 72 to develop urosepsis (a life-threatening UTI) and worsening conditions.Findings:During a review of Resident 72's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), cerebral infraction (damage to tissues in the brain due to a loss of oxygen to the area) and acute pyelonephritis (a serious UTI). During a review of Resident 72's Minimum Data Set (MDS- a resident assessment tool) dated 2/11/2026, the MDS indicated Resident 1 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 72 required maximal assistance (helper does more than half the effort) for eating. The MDS indicated Resident 72 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, getting in and out of shower and transferring from bed to chair. During an observation on 4/20/2026 at 2:22 PM, Resident 72's indwelling catheter tubing was observed with cloudy urine with sedimentation. During a concurrent observation and interview on 4/22/2026 at 12:26 PM with Registered Nurse (RN) 2, Resident 72's indwelling catheter tubing was observed to have cloudy urine and sediment. RN 2 stated that there is sedimentation in Resident 72's urine which can be harmful because it may cause the resident to get an infection. RN 2 stated that the MD should have been notified if there is sediment in urine and a change in condition (CoC) would be completed. During a concurrent interview and record review on 4/22/2026 at 12:36 PM with Licensed Vocational Nurse (LVN) 3, Resident 72's Order Summary Report dated 2/23/2026 was reviewed. The Order Summary Report indicated that Resident 72's indwelling catheter is to be monitored for sedimentation every shift and MD is to be notified of sedimentation. LVN 1 stated the order indicated Resident 72's indwelling catheter is to be monitored for sedimentation and urine consistency every shift. During a concurrent interview and record review on 4/23/2026 at 2:18 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Urinary Catheter Care, dated 9/2014 was reviewed. The P&P indicated:The purpose of this procedure is to prevent catheter associated urinary tract infections.Observe the resident for complications associated with urinary cathetersCheck the urine for unusual appearance.Observe for other signs and symptoms of UTI or urinary retention.Report findings to the physician or supervisor immediately.The DON stated staff must notify the MD and do a CoC if they see sediment in a resident's indwelling catheter urine. The DON stated that the resident may get urosepsis or a UTI if sedimentation is not addressed. During a concurrent interview and record review on 4/23/2026 at 2:32 PM with the DON, Resident 72's Treatment Administration Record (TAR) dated 4/1/2026 to 4/30/2026 was reviewed. The TAR indicated that Resident 72's indwelling catheter did not have any sedimentation from dayshift (7:00 AM to 3:00 PM) on 4/20/2026 and dayshift to afternoon shift (3 PM to 11 PM) on 4/22/2026. The DON stated that staff have been documenting that Resident 72 has not had sediment in urine from 4/20/2026 to 4/22/2026. The DON stated that there is no documented evidence that the MD was called regarding sediments noted in the resident's urine on 4/20/2026. During a concurrent interview and record review on 4/23/2026 at 2:37 PM with the DON, Resident 72's CoC dated 4/22/2026 entered at 5:39 PM was reviewed. The CoC indicated Resident 72's indwelling catheter had sediments. The DON stated that staff did a CoC for Resident 72's sediment in urine on the afternoon shift of 4/22/2026 yet they still documented normal urine appearance in the TAR for the afternoon shift. The DON stated this is inconsistent documentation and staff have been inaccurately documenting the appearance of Resident 72's urine.

Based on interview and record review, the facility failed to complete a Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications, in accordance with the facility's policy. This deficient practice had the potential for Resident 57 to receive unnecessary medications and experience adverse drug reactions.Findings:During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. The admission record indicated Resident 's diagnoses included Lewy body dementia (LBD, is a brain disorder that can lead to problems with thinking, movement, behavior, and mood) , major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool) dated 2/10/2026, the MDS indicated Resident 57 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 was partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for toileting hygiene, shower/ bathe self, putting on/ taking off footwear, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer. During a review of Resident 57 's Physician's order (PO) dated 2/5/2026 to 2/13/2026, the PO indicated the following:Apixaban (Eliquis, a prescription medicine used to treat blood clots in the veins of the legs or lungs) 2.5 milligrams (MG, unit of volume) two times a day for DVT prophylaxis (PPX prevention).Fluoxetine (Prozac, is a medication that helps regulate mood and treats depression, anxiety, obsessive-compulsive disorder [OCD, is a chronic mental health condition characterized by uncontrollable, recurring thoughts {obsessions} and/or repetitive behaviors {compulsion}]that a person feels driven to perform to reduce anxiety and eating disorders) 20 MG one time a day for depression manifested by (M/B) withdrawal of activities.Lorazepam (Ativan, is used to treat anxiety disorders) 0.5 MG three times a day for anxiety M/B agitation and physical aggression related to preference to smokeQuetiapine (Seroquel, is an atypical antipsychotic used to treat schizophrenia, bipolar disorder [manic-depressive illness / manic depression, is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] and depression) 25 MG two times a day for psychosis (a mental health condition where a person loses touch with reality) M/B paranoia (an intense, unfounded fear or suspicion that others are trying to harm, trick, or deceive the person, despite having no real evidence) and false belief he is on emergency with repetitive saying need to use the phone to callOxcarbazepine (an anticonvulsant drug that reduces the incidence of seizures in epilepsy by inhibiting abnormal electrical activity in the brain) 300 MG three times a day for seizures. During a review of the facility's Medication /Drug Regimen Review (MRR) Binder from 2/2026 to 4/2026, the MRR Binder did not include an MRR report for Resident 57. During a concurrent interview and record review on 4/23/2026 at 11:39 AM with the Director of Nursing (DON), the MRR Binder for 2/2026 to 3/2026 was reviewed. There was no documentation that MRR was done for Resident 57 from 2/2026 to 3/2026. The DON stated MRR Binder did include an MRR report for Resident 57 for 2/2026 and 3/2026. During an interview on 4/21/2026 at 11:44 AM, the DON stated the MMR should be completed monthly for all residents. The DON stated Resident's 57 medications should be reviewed to determine any recommendation for the doctor to adjust the resident's medications because these could affect his cognitive status and could also contribute to his fall risk. During a concurrent interview and record review on 4/23/2026 at 1:37 PM with the Pharmacy Consultant (PHC), the MRR Summary, dated 2/1/2026 to 3/30/2026 was reviewed. PHC stated the MRR Summary did not reflect Resident 57's name on the list of all residents who were reviewed. Resident 57's name was not included on the list, which meant Resident 57's medications were not reviewed. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, revised 9/2013, the P&P indicated upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether:a. there is a clear indication for treating that individual with the medication;b. the dosage is appropriate;c. the frequency of administration and duration of use are appropriate andd. potential or suspected side effects are present.6. The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected.

Based on interview and record review, the facility failed to monitor the use of antiseizure medications (ASM, used to treat and prevent seizures [brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior) for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications by failing to monitor for side effects and seizure episodes in accordance with the care plan and facility policy. This deficient practice had the potential for Resident 57 to experience episodes of seizures without proper monitoring and to develop adverse drug reactions (any unwanted or harmful effect that happens when a person takes a medication at the normal dose) which may result in harm, hospitalization, and death. Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. The admission record indicated Resident 's diagnoses included Lewy body dementia (LBD, is a brain disorder that can lead to problems with thinking, movement, behavior, and mood) , major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), and epilepsy (a chronic brain disorder characterized by recurrent unprovoked seizures) During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool) dated 2/10/2026, the MDS indicated Resident 57 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 57 was partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for toileting hygiene, shower/ bathe self, putting on/ taking off footwear, roll left and right, sit to lying, lying-to-sitting on the side of the bed, and chair/ bed-to-chair transfer. During a concurrent interview and record review on 4/22/2026 at 10:33 AM with MDS Nurse (MDS 1), Resident 57 's Physician's order (PO) dated 2/15/2026 and medical records were reviewed. The PO indicated Oxcarbazepine (an anticonvulsant drug that reduces the incidence of seizures in epilepsy by inhibiting abnormal electrical activity in the brain) 300 Milligrams (MG, unit of volume) three times a day for seizures. MDS 1 stated they did not have PO for monitoring the side effects (S/E) of antiseizure medications. MDS 1 stated Resident 57's medical records did not indicate that the resident was being monitored for the S/E of oxcarbazepine and seizure episode. MDS 1 stated the licensed nurses should be monitoring Resident 57 for the S/E of ASM such as dizziness, blurred vision, nausea, fatigue, and mood changes. If they did not have a monitoring for ASM use, the staff would not be aware if Resident 57 was experiencing the S/E of ASM, which could delay a treatment evaluation of Resident 57's ASM use. During a concurrent interview and record review on 4/22/2026 at 10:37 AM with MDS 1), Resident 57 's Care Plan (CP) for seizure disorder/ epilepsy dated 2/9/2026 was reviewed. Resident 57's CP interventions indicated: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness.MDS 1 stated the CP interventions were not followed because the staff did not monitor Resident 57 for the side effects of ASM. During a review of the facility's Policy and Procedure (P&P) titled Seizures and Epilepsy -Clinical Protocol revised 11/2018, the P&P indicated the nurse shall assess and document/report the following under monitoring:a. They should document periodically and objectively the presence or absence of seizure activity.3. The staff and physician will monitor for complications related to antiepileptic medications; for example, dizziness, ataxia (neurological condition characterized by a lack of muscle coordination, resulting in unsteady or clumsy movements-such as difficulty walking, poor balance, and trouble handling object), somnolence (state of drowsiness or strong urge to sleep, where the person feels very sleepy-especially during times when the person is supposed to be awake), headache, diplopia (double vision; when a person sees two images of the same object instead of one), blurred vision, nausea, vomiting, and rash.a. The staff, consultant pharmacist, and physician will also monitor for drug interactions between antiepileptic medications and other categories of medications.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (4) of 18 sampled residents (Resident 3, 8, 10 and 44 ) in accordance with the facility's policy and procedure when: 1. Licensed Vocational Nurse 4 (LVN 4) failed to put on a gown while providing care for Resident 3, who was on contact precautions (an infection control measure used in healthcare settings to prevent the spread of infections transmitted through direct or indirect contact with a resident or their environment). 2. Registered Nurse Supervisor 1 (RNS 1) failed to put on a gown while in an enhanced barrier precaution room (EBP, infection control measures used for residents who have wounds, medical devices such as catheters, or certain germs. In an EBP room, staff must wear gloves and a gown when touching the resident or anything in their care area to help prevent the spread of infection) while flushing Resident 8's foley catheter (a thin, flexible tube that is inserted into the bladder to drain urine. It stays in place with a small balloon at the tip that is inflated once the catheter is inside the bladder). 3. RNS 1 and RNS 2 failed to wear a gown while doing a dressing change for Resident 10. RNS 1 failed to ensure trash with bodily fluids was not placed on top of Resident 10's bed while doing a dressing change. 4. Licensed Vocational Nurse 2 (LVN 2) failed to change gloves after touching the privacy curtain and before checking Resident 44's gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) placement and administering the resident's medications. These deficient practices have the potential to result in transmission of infectious organisms, leading to serious illness or harm for Residents 3, 8, 10, and 44, and other residents in the facility. Findings 1.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 3's diagnoses included chronic respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide, and a deficiency in the amount of oxygen reaching body tissues), spastic quadriplegic cerebral palsy (the most severe form involving high muscle tone and stiffness in all four limbs, the trunk, and the face), and other seizure (a sudden, uncontrolled burst of electrical activity in the brain). During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated 1/3/2026, the MDS indicated Resident 3 was severely impaired (never/rarely made decisions) with cognitive skills (mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene and roll left and right. During an observation on 4/20/2026 at 7:53 a.m. in front of Resident 3's room, Licensed Vocational Nurse 4 (LVN 4) was observed having just provided care to Resident 3 without wearing the personal protective equipment (PPE, items worn to protect staff and residents from the spread of infection such as gloves, gown, and masks) required to prevent the spread of infection. The sign on Resident 3's door indicated that the room was under contact precaution. During an interview on 4/20/2026 at 7:54 AM with LVN 4, LVN 4 stated it is very important to wear proper PPE as indicated on the contact precaution sign when providing care to the residents, as this helps prevent the spread of infections from Resident 3 to other residents. 2. During a review of Resident 8's admission Record, the admission Record indicated Resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 8's diagnoses included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, type 2 diabetes mellitus (high blood sugar levels in blood stream) without complications, and other seizures. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 8 was dependent on oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting off footwear, personal hygiene and roll left and right. During an observation on 4/22/2026 at 3:53 p.m. in Resident 8's room, Registered Nurse Supervisor 1 (RNS 1) was observed flushing Resident 8's foley catheter without a gown. The sign on Resident 8's door indicated that the resident was under EBP. During an interview on 4/22/2026 at 3:55 p.m. with RNS 1, RNS 1 stated that it is very important to wear PPE as indicated on the EBP sign when providing care to a resident, as this helps prevent the spread of infection from Resident 8 to other residents. During an interview on 4/23/2026 at 10:54 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated that it is very important for LVN 4 and RNS 1 to wear their PPE when caring for residents in rooms under contact isolation or enhanced barrier precautions. The IPN stated that this prevents the spread of pathogens and ensures that contamination is contained within the resident's immediate environment. During a record review of facility's Policy and Procedure (P&P) titled, Standard Precautions revised on 10/2018, the P&P indicated Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Gowns (clean, non-sterile) are worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. 3. During a review of Resident 10's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had intact cognitive skills for daily decision making. The MDS indicated Resident 10 was dependent for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying in bed, lying to sitting on side of bed, sitting to standing, toilet transfer, getting in and out of shower and transferring from bed to chair. The MDS indicated that Resident 10 had one stage 4 pressure ulcer present on admission. During a review of Resident 10's Order Summary Report dated 4/16/2026, the Order Summary Report indicated Resident 10 will have Stage 3 pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) cleaned and treated every day. During a review of Resident 10's Care Plan titled, Left Buttock Stage 3 Pressure injury, dated 4/14/2026, the Care Plan indicated an intervention was to keep the site clean and dry. During an observation on 4/22/2026 at 9:46 AM, RNS 1 was observed placing a trash bag on Resident 10's bed next to the resident's left leg. During an observation on 4/22/2026 at 9:51 AM, RNS 1 was observed cleaning Resident 10's sacral pressure ulcer with gauze and throwing the dirty gauze into the trash bag next to Resident 10's left leg. During an observation on 4/22/2026 at 10 AM, RNS 1 was observed rolling Resident 10 to a supine position, causing Resident 10's left leg to land on top of a trash bag full of soiled dressing materials. During a concurrent observation and interview on 4/22/2026 at 10:02 a.m. with RNS 1, Resident 10's left leg was observed resting on top of a trash bag placed on his bed, next to Resident 10's right leg. RNS 1 stated that Resident 10's left leg was on top of the trash bag. RNS 1stated that the trash bag should not be there. RNS 1 stated that Resident 10's leg should not be touching a bag containing dirty gauze from a dressing change. During a concurrent observation and interview on 4/22/2026 at 10:05 a.m. with RNS 1, RNS 2 was observed placing a trash bag next to Resident 10's right leg on his bed and throwing trash into the bag. RNS 1 stated that a trash bag should not be placed next to a resident's leg on their bed. RNS 1 explained that RNS 2 placed the trash bag there so it would not be near the resident's face. RNS 1 stated that a resident could develop an infection if their skin comes into contact with germs from dirty gauze used during a dressing change. During a concurrent observation and interview on 4/22/2026 at 10:15 a.m. with RNS 1, RNS 1 and RNS 2 were observed not wearing gowns while performing a dressing change to Resident 10's sacral pressure ulcer. RNS 1 was observed using gauze to clean the inside of Resident 10's wound and then disposing of the gauze, which was stained with bodily fluids from the wound, into a trash bag. RNS 1 stated that she did not wear a gown because Resident 10 was not on isolation precaution. During a concurrent interview and record review on 4/23/2026 at 1:50 p.m. with the Infection Prevention Nurse (IPN), the facility's policy and procedure (P&P) titled, Infection Control, dated 10/2018, was reviewed. The P&P indicated that infection control policies and practices are intended to maintain a safe, sanitary environment and to help prevent and manage the transmission of diseases and infections among personnel, residents, visitors, and the general public. The IPN stated that it was not acceptable to place a trash bag containing soiled dressing change materials on top of a resident's bed. The IPN stated that if a resident's leg touches soiled gauze from a dressing change, it creates a transmission risk for infection and could cause the resident to become infected. During an interview on 4/23/2026 at 2:29 p.m. with the Director of Nursing (DON), the DON stated that RNs should wear gowns while performing dressing changes to prevent the spread of infections. The DON stated that it is not acceptable to place a trash bag on top of a resident's bed during a dressing change because it can cause the resident to develop an infection. During a review of the facility's P&P titled, Wound Care, dated 10/2010, the P&P indicated that gowns will be necessary if there is a likelihood of soiling skin or clothing with blood or other body fluids. 4. During a review of Resident 44's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 44's diagnoses included chronic respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide), traumatic brain injury (results from a violent blow or jolt to the head), and seizure. During a review of Resident 44's MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS also indicated the resident was dependent for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and rolling left and right. During an observation on 4/22/2026 at 8:31 AM in Resident 44's room, LVN 2, while wearing gloves, touched and pulled the curtain to provide privacy and touched the resident's linens. Using the same gloves, LVN 2 then checked Resident 44's G tube residual (the amount of formula and stomach contents remaining between feedings) and administered medications via the G tube without changing gloves. During an interview on 4/22/2026 at 8:40 AM, LVN 2 stated she did not change her gloves after touching Resident 44's curtain and acknowledged she should have changed gloves prior to administering medications via the G tube due to infection control requirements. During an interview on 4/26/2026 at 12:01 PM with the Infection Prevention Nurse (IPN), the IPN stated licensed staff must change their gloves when performing different tasks during medication administration. The IPN stated licensed staff must always use clean gloves to prevent cross contamination and avoid introducing microorganisms into the resident's G tube. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated that medications are to be administered in a safe and timely manner as prescribed, and staff must follow facility infection control procedures (e.g., handwashing, aseptic technique, glove use, isolation precautions) when administering medications.

Based on observation, interview and record review, the facility failed to ensure the call light was within reach of Resident 1 to accommodate resident when resident needed to call for help and ask for her pain medication on 3/4/2026.This deficient practice has the potential to delay in pain relief, the necessary care, services and needs not being met for Resident 1, affect the quality of life and lead to other medical complications.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), hereditary and idiopathic neuropathy (progressive nerve damage, numbness, and muscle weakness includes pain and loss of motor function) and muscle spasms (sudden, involuntary, and often painful contraction of one or more muscles, lasting from a few seconds to several minutes) of the back.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the Resident was dependent (helper does all of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated that the resident received scheduled pain medication and received PRN (as needed) pain medication. The MDS also indicated Resident 1 had moderate pain within the last 5 days.During a review of Resident 1's Care Plan with focus acute pain on left arm/shoulder related possibly form history of status post fall, revised 11/5/2025, the Care Plan indicated to anticipate the resident's need for pain relief and respond immediately to any complaint of pain.During a review of Resident 1's Care Plan with focus potential for excessive weakness, tiredness, weight loss, pain and depression, revised 11/5/2025, the Care Plan indicated provide pain med as ordered. During a review of Resident 1's Physician Orders, dated 2/23/2026, the Physician Orders indicated Tramadol hydrochloride (HCL) (a centrally acting synthetic opioid analgesic used to treat moderate to moderately severe pain in adults) Oral Tablet 50 milligrams (mg - unit of measure) Give 1 tablet via Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, flexible feeding tube inserted through the abdomen into the stomach to provide long-term nutrition, fluids, or medication for individuals with swallowing difficulties) every 6 hours as needed for moderate to severe pain.During an observation and interview on 3/4/2026 at 10:40AM in Resident 1's room, Resident 1 stated she was in a lot of pain, and her pain level is 10/10. Resident was observed looking for her call light and she stated she does not have a call light. Resident 1's call light was observed on the side rail and behind a trash bag. Resident was then observed yelling for the nurse.During an interview on 3/4/2026 at 10:50AM, Registered Nurse Supervisor (RNS) stated it is not ok for the call light to be hidden behind the trash bag because the resident would not be able to ask for assistance when needed and have proper treatment for her pain.During an interview on 3/4/2026 at 2PM, the facility's Policy and Procedure (P&P) titled Answering the Call Light, revised 3/2021, was reviewed. RNS stated per policy the call light needs to be within resident's easy reach.During an interview on 3/4/2026 at 2:55PM, the Director of Nursing (DON) stated the call light should be within resident's easy reach and not behind a trash bag. DON also stated per policy it should be within easy reach.During a review of the facility's Policy and Procedure (P&P) titled Answering the Call Light, revised 3/2021, the P&P indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review, the facility failed to follow an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of two (2) sampled residents (Resident 1) when Resident 1 needed a brief change.This deficient practice had the potential for Resident 1 to develop skin issues and develop complications of MASD (moisture associated skin damage caused from prolonged exposure to moisture).Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), hereditary and idiopathic neuropathy (progressive nerve damage, numbness, and muscle weakness includes pain and loss of motor function) and muscle spasms (sudden, involuntary, and often painful contraction of one or more muscles, lasting from a few seconds to several minutes) of the back.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the Resident was dependent (helper does all the effort. Resident make no effort to complete the activity; Or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's Care Plan with focus on potential/actual impairment to skin integrity of the perineal area related to MASD, initiated 11/20/2025, the Care Plan indicated keep skin clean and dry.During a review of Resident 1's Care Plan with focus on resident has urinary tract infection (UTI- an infection in the bladder/urinary tract), revised on 2/14/2026, the Care Plan indicated checking at least every 2 hours for incontinence. The care plan also indicated wash, rinse and dry soiled areas.During an interview on 3/4/2026 at 11:45AM with Registered Nurse Supervisor (RNS) present, Certified Nursing Assistant 1 (CNA) 1 stated Resident 1's last change was at 8AM. CNA 1 also stated she checked Resident 1 and Resident 1's brief was wet, but CNA 1 stated she will change the resident after her lunch.During an interview on 3/4/2026 at 1PM, RNS stated Resident 1 was changed at 1PM.During an interview on 3/4/2026 at 2PM, Resident 1's Care Plans with focus on potential/actual impairment to skin integrity of the perineal area related to MASD, revised 11/20/2025, and Care Plan with focus resident has Urinary Tract Infection, revised on 2/14/2026, were reviewed. RNS stated according to Resident 1's Care Plans, the facility needs to ensure the resident is kept clean and dry and to ensure Resident 1 is checked every 2 hours for incontinence and the care plan was not being followed. RNS also stated Resident 1 can develop skin issues.During a concurrent interview and record review on 3/4/2026 at 2PM, the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, was reviewed. RNS stated the policy indicated the need to follow the residents care plan to maintain the highest practicable physical, mental and psychosocial well-being for residents.During an interview on 3/4/2026 at 2:55PM, the Director of Nursing (DON) stated the residents should be changed every 2 hours. The DON also stated it is not in the policy, but it should be in the policy. The DON also stated if the care plan indicated to keep the residents clean and dry and to check every 2 hours for incontinence then it should be implemented by staff.During a review of the facility's P&P titled Comprehensive Person-Centered Care Plans, revised 3/2022, the P&P indicated the comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, Certified Nursing Assistants (CNAs) failed to fill out the stop and watch form on 2/10/2026 and 2/11/2026 for one (1) of two (2) sampled residents (Resident 1), when Resident 1 was coughing, congested and having difficulty swallowing.This deficient practice had the potential for Resident 1 experiencing respiratory distress which can result in hospitalization and/or death.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory distress (a serious condition characterized by rapid/labored breathing, shortness of breath, gasping, wheezing, and skin/chest retractions), and dysphasia (difficulty swallowing) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/2/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making, The MDS also indicated the resident required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.During an interview on 2/26/2026 at 4:20 PM, Resident 1's Responsible Party (RP) stated Resident 1 was hot to touch on 2/10/2026.During an interview on 2/27/2026 at 10:17 AM, CNA 1 stated on 2/10/2026 at 7:15am, CNA 1 noticed Resident 1 was congested with a lot of phlegm and was having a hard time swallowing her food.During an interview on 2/27/2026 at 11:07AM, CNA 2 stated on 2/10/2026 during 3pm -11pm shift (unable to tell the time), Resident 1 was hot to touch and had diarrhea.During an interview on 2/27/2026 at 11:31AM, Licensed Vocational Nurse 1 (LVN 1) stated when a CNA notices a change of condition (COC -a deviation in a person's physical, mental, or functional health status compared to their baseline) on the resident, the CNAs must fill out a Stop and Watch Form describing what they see in the resident and report it to the licensed nurse. LVN 1 also stated when the CNA gives the form to the licensed nurse, the license nurse must sign and acknowledge it.During an interview on 2/27/2026 at 12:30PM, CNA 3 stated on 2/11/2026 at 7am-3pm shift, CNA 3 observed Resident 1 was coughing and was congested.During an interview on 2/27/2026 at 1PM with Director of Staff Development (DSD), the Stop and Watch binder, was reviewed. DSD stated when a resident experiences a change of condition, the CNAs would have to fill out a Stop and Watch form, give one copy to the license nurse and give one copy to the DSD. DSD also stated the nurses should acknowledge the Stop and Watch form that is given to them. DSD stated even if the resident is discharged , the Stop and Watch form should still be in the binder. DSD also stated there was no Stop and Watch form for Resident 1 and there should be a Stop and Watch form.During a concurrent interview and record review on 2/27/2026 at 1:30PM with Director of Nursing (DON), the facility's Policy and Procedure titled Acute Condition Changes, revised 3/1028, was reviewed. DON stated per policy, if a resident has congestion, lots of phlegm, difficulty swallowing and diarrhea, that would be an acute condition change because the resident cannot breathe properly, it can affect her eating and cause dehydration. DON also stated the CNAs need to fill out the Stop and Watch form.During a review of the facility's P&P titled Acute Condition Changes, revised 3/1028, the P&P indicated nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to California Department of Public Health (CDPH), local law enforcement, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2) hours from when the resident was noted to have dark purple discoloration on the right eye for one (1) of 2 sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting. This deficient practice had the potential to place Resident 1 at risk for further abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and resulted in a delay in the investigation. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including but not limited to dependence on respirator (ventilator, a life-support machine that mechanically assists or replaces spontaneous breathing by moving breathable air into and out of the lungs) status, nontraumatic intracerebral hemorrhage (a sudden type of stroke caused by bleeding within the brain tissue) in cerebellum (structure located at the back of the brain), and encounter for attention to tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to provide direct airway, bypassing the mouth and nose). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, personal hygiene, and rolling left and right. During a review of Resident 1's Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status), dated 1/27/2026, the COC indicated Resident 1 was noted with discoloration on right eye. The COC also indicated, upon further assessment, Resident 1 was noted with dark purple discoloration on right eye, skin is intact but discolored. During an observation on 2/4/2026 at 12:09 PM in Resident 1's room, Resident 1 was lying in bed with greenish to yellowish discoloration on the right corner of the resident's eye with a small red lined mark in the center of the discoloration. During a concurrent observation and interview on 2/4/2026 at 12:10 PM in Resident 1's room with the Director of Nursing (DON), the DON stated there is a little bit of bruising that looks grayish in color and almost like a linear red scratch on Resident 1's right eye. During an interview on 2/4/2026 at 12:18 PM with Treatment Nurse (TN), TN stated he first saw Resident 1's discoloration on the right eye on 1/27/2026 (8 days ago). TN stated on 1/27/2026 around 3 PM, RN Supervisor (RNS) asked him if he (TN) had noticed Resident 1's bruise. TN stated he went to look at Resident 1's eye after RNS informed him and saw Resident 1 had a light purple discoloration on Resident 1's right eye. TN stated staff did not know the cause of Resident 1's right eye discoloration. TN stated he did not measure the discoloration of Resident 1's right eye and only reported Resident 1's discoloration on the right eye to the physician and responsible party. During a concurrent interview and record review on 2/4/2026 at 12:31 PM with the DON, Resident 1's COC dated 1/27/2026 was reviewed. The DON stated on 1/27/2026 the COC indicated Resident 1 had right eye discoloration. The DON stated since Resident 1 had a bruise on the resident's right eye, the most important thing to determine is the cause of the bruise to rule out potential for abuse. The DON stated the facility needed to investigate to determine if there were any incidents with a particular staff and to see how staff handled Resident 1. The DON also stated she was unaware of how Resident 1 obtained the discoloration to the resident's right eye. The DON stated since the facility staff did not know how Resident 1 got the dark purple discoloration on the resident's right eye, this was an injury of unknown origin and should have been treated as a potential abuse case. The DON stated, since it is a potential for abuse case it should have been reported within the two- hour time frame from when the injury was observed or noted on 1/27/2026. During an interview on 2/4/2026 at 12:51 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 1/28/2026 she went into Resident 1's room to turn on the light and gasped when she saw Resident 1's right eyes with discoloration. CNA 1 stated Resident 1, she has a black eye. CNA 1 stated Resident 1's eye was purple in color noted underneath the resident's right eye and to the right side of the eye. During an interview on 2/4/2026 at 1:21 PM with RNS, RNS stated on 1/27/2026 Resident 1 had redness under the resident's eyes where the eye bags were located. RNS stated she was not sure what happened to cause Resident 1's eyes to become red. RNS stated TN did not inform her of TN's assessment of dark purple discoloration to the eye. RNS stated TN should have informed RNS so that they could report to the Administrator (ADM) right away since they were suspecting abuse and it should have been reported to CDPH, police and ombudsman. During a concurrent interview and record review on 2/4/2026 at 2:01 PM with the ADM, the facility's policy and procedure (P&P) titled Investigating Resident Injuries dated 04/2021 was reviewed. ADM stated according to the P&P, if the nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in the facility's established abuse reporting and investigation guidelines. During an interview on 2/4/2026 at 2:15 PM with the Licensed Vocational Nurse (LVN), LVN stated on 1/27/2026 she noticed Resident 1 had some discoloration on the right side of the eye. LVN stated she did not know what happened to Resident 1's eye and she did not report it to CDPH, ombudsman or police. During a concurrent interview and record review on 2/4/2026 at 4:08 PM with the DON, the facility's P&Ps titled Abuse Investigation and Reporting dated 12/2018 was reviewed. The P&P indicated all reports of resident abuse and/or injuries of unknown source ( abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The P&P also indicated the Administrator or designated representative will notify law enforcement immediately by telephone of an initial report of alleged abuse. The DON stated she was not informed of Resident 1's injury of unknown origin and should have been informed of Resident 1's right eye dark purple discoloration noted on 1/27/2026. The DON stated promptly in their P&P means within the two- hour time frame from the suspected abuse and Resident 1's discoloration on the right eye was not reported to CDPH, police, and Ombudsman within two hours. The DON stated the importance of reporting was to start with the investigations of abuse, to find the root cause, and to rule out abuse. During an interview on 2/4/2026 at 4:45 PM with the ADM, the ADM stated staff did not report Resident 1's injury of unknown origin noted on 1/27/2026 and should have informed the ADM of Resident 1's right eye dark purple discoloration.

Based on interviews and record review, the facility failed to admit one of one sample resident (Resident 1) to the facility's first available bed from 12/18/2025 to 12/24/2025. This deficient practice has the potential to result in increased Resident 1 and his family for physical and emotional distress (an unpleasant emotional, psychological, or physical reaction to a difficult experience or ongoing stress that interferes with one's ability to cope with daily life) due to unnecessary stay in the hospital. Findings:During a review of Resident 1 's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic respiratory failure unspecified whether with hypoxia or hypercapnia ( a patient has long-term trouble getting enough oxygen into their blood [hypoxia/hypoxemia] or removing carbon dioxide from their blood, but the specific type of gas exchange), paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually within 7 days, either on their own or with treatment, returning the heart to a normal rhythm), and essential hypertension ( high blood pressure that develops gradually without a single identifiable cause). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/30/2025, it indicated Resident 1 severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 is dependent, (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower, bathe self, upper and lower body dressing, putting on/ taking off footwear, change of position, and transfer. During a review of physician order (PO) dated 10/2/2025, PO indicated Resident 1 was transferred to General Acute Care Hospital (GACH) 2 for further care due to medical emergency. During a review of GACH's CM discharge plan notes dated from 11/11/2025 to 12/24/2025, it indicated the following:On 11/11/2025 - Still no available bed from the facility. On 11/14/2025- GACH's CM followed up with the facility's admission Coordinator (AC) and per AC there is no isolation bed to admit Resident 1. On 11/202/2025- GACH's CM spoke with Resident 1's Representative (RR) and RR questioned why Resident 1 has not returned to the facility. On 12/11/2025- GACH's CM followed up with AC and AC stated, the facility still does not have an available for Resident 1.On 12/24/2025- GACH's CM followed up with AC and AC stated, they (the facility) still do not currently have an available to accept Resident 1 back. During an interview on 12/24/2025 at 3:25 PM with the Director of Nursing (DON), the DON stated she did not know Resident 1 needs an isolation room for the resident was positive for Candita Auris (C. Auris- merging fungus that can cause severe, often multidrug-resistant, infections. It spreads easily among patients in healthcare facilities-, and use of contact precautions [gowns, gloves, dedicated equipment] is needed to stop its spread). The DON stated she was not aware that GACH CM has been speaking with the facility's admission Coordinator (AC) since November 2025 (not sure of exact date) that Resident 1 was ready to be discharged to the facility with contact isolation precaution. The DON stated she could have moved residents around/ made some room changes to make a bed/isolation room available for Resident 1 so they could admit the resident back to the facility. The DON also stated Resident 1 met the criteria of admission/ readmission to the facility and there was no reason for the facility not to admit Resident 1 back since the facility had an available bed for Resident 1 since 12/18/2025. During an interview on 12/24/2025 at 3:29 PM with Infection Preventionist Nurse (IPN), IPN stated she did not know that GACH's CM spoke with AC that Resident was cleared to be discharge back to the facility with contact isolation precaution. IPN stated if only she knew, she could have moved residents around and made a bed available for Resident 1 so Resident 1 can be admitted back at the facility since 12/18/2025. IPN stated Resident 1 met the facility's readmission criteria and the facility can admit Resident 1 back to the facility from 12/18/2025 to 12/24/2025. During an interview on 12/24/2025 at 3:55 PM with AC, AC stated I did not know why I did not ask the DON and IPN for any opening bed for resident with c. auris. AC stated, AC did not inquired with the DON nor IPN about room availability to admit Resident 1 to the facility when GACH CM's has been asking and/ or waiting for a bed available for Resident 1 since 12/18/2025. AC stated she told GACH CM that there was no isolation bed available, and the facility cannot admit Resident 1 back to the facility since 11/4/2025 and until 12/23/2025. AC stated she should have inquired and relayed the information to the DON and IPN regarding Resident 1 is for admission to the facility in isolation precaution. During a concurrent interview and record review on 12/24/2025 at 4:35 PM with the DON, the facility's Daily Census Report dated 12/18/2025 to 12/24/2025 were reviewed. The reports indicated starting from 12/18/2025 to 12/24/2025, there were three open beds inside Room A which is a room with four bed capacity. The DON stated she could have made some room changes and move the resident in Room A to another room to be able to admit Resident 1 in Room A from 12/18/2025. During an interview on 12/26/2025 at 10:44 AM with the DON, the DON stated she called GACH and spoke with GACH Registered Nurse (RN) to confirm if Resident 1 is still in GACH on 12/24/2025 in the late evening but she did not inform GACH RN that the facility has a bed available to admit Resident 1. The DON stated she should have let GACH RN know about the opening bed for Resident 1 to facilitate timely admission of Resident 1. During a telephone interview on 12/29/2025 at 4:36 PM with GACH CM, GACH CM stated he started his inquiry about readmission of Resident 1 to the facility on [DATE] with AC. GACH CM stated AC has been telling GACH CM that there was no bed available until 12/23/2025. During a review of the facility's Job Description titled, Admissions Coordinator, undated, indicated the Admissions Coordinator is responsible for managing the community inquiry and admission process and providing customers with community-related information via facility tours, personal visits/assessments, conversations, and follow-up. Essential Functions: Manages the admission process by maintaining updated bed availability and community services information at all time.Manages the inquiry process professionally, timely, and with the appropriate follow-up. Effectively manages occupancy levels and census/premium mix enhancement.Maintains close working relationships with the Director of Nursing Services (DNS/ DON) and the Revenue Cycle Manager (RCM) to ensure appropriate and efficient decisions about prospective admissions.Communicates special needs of newly admitted residents to staff to ensure a smooth transition During a review of the facility's policy and procedures (P&P) titled, readmission to the Facility, revised 3/2017, the P&P indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The P&P also indicated a Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident:a. requires the services provided by the facility.b. meets the admission criteria as outlined in facility policy.The P&P also indicated readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source.

Based on observation, interviews and record review, the facility failed to provide a safe environment in accordance with the facility's policy and procedures when: 1. One (1) out of two (2) sample residents (Resident 2) remained in the room with water leaking from the ceiling during the heavy rain. 2. The Hoyer Lift (a mechanical device used to lift and/or transfer a person) was left outside Room A for 6 hours and left a shower chair on the opposite side of the hallway parallel to the Hoyer lift. These deficient practices could potentially result in accidents, injuries and hazard from wet slippery floors, and obstructed hallways compromising the wellbeing of the residents, staff and the visitors.Findings:1. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypotension (low blood pressure) and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 2 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was dependent on toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with eating and oral hygiene. During a review of Resident 2's Care Plan initiated on 11/5/2025, the Care Plan indicated Resident 2 was at risk for falls related to unsteady gait and impaired balance with an approach plan of ensuring resident's risk for falls was assessed and problems identified were addressed. During an interview on 12/2/2025 at 2:38 PM, Infection Prevention Nurse (IPN) stated Resident 2 walks and goes to the bathroom. During an interview on 12/2/2025 at 2:41 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 2 goes to the bathroom by herself. CNA 1 also stated Resident 2's roommate was moved out because of the water leak but not Resident 2. CNA 2 also stated a tall bucket was placed on 11/15/2025 where the drip or leak from the ceiling was coming from. CNA 1 further stated Resident 2 should have been moved to a different room so that if water splashed on floor or the resident may accidentally trip on the bucket, Resident 2 would not slip and fall when the resident goes to the bathroom. During an interview on 12/2/2025 at 2:49 PM, the Director of Nursing (DON) stated Resident 2 was not moved to a different room when the facility noted the leak in Resident 2's room. The DON also stated there was a possibility that the rainwater might not drip into the bucket and Resident 2 could slip and fall or Resident 2 can trip herself with the tall bucket in the room. The DON also stated the facility should have provided a floor mat and a sign that indicated the floor was wet. During an interview on 12/2/2025 at 4:07 PM, Resident 2 was observed in her room lying in bed and stated she goes to the bathroom by herself. Observed a water mark on the ceiling in Resident 2's room located above Bed A and near the restroom. Resident 2 also stated the ceiling in her room by Bed B was leaking water from the rain (did not remember the exact date) and heard the drips from the ceiling. Resident 2 further stated she did not remember if there was a bucket to catch the water dripping from the ceiling but there was no safety cone saying the floor was wet or hazard signs on the floor where the dripping was. During another interview with the DON on 12/2/2025 at 4:15 PM, the DON stated it is important to do proper maintenance of the building roofing for the safety of the residents in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Services, revised 12/2009, the P&P indicated that maintenance service shall be provided to all areas of the building, grounds, and equipment. 2. During an observation on 12/2/2025 at 9:56 AM, the Hoyer Lift weighing scale was left outside Room A with leg part expanded and faced towards the hallway and a shower chair placed directly across/ parallel to the Hoyer lift. During a concurrent observation and interview on 12/2/2025 at 3:20 PM, CNA 2 stated the Hoyer lift should be parked by rehabilitation department after being used and not outside the residents' room where the Hoyer lift was currently at because it may cause resident's or staff to trip and fall. During an interview on 12/2/2025 at 3:31 PM, Licensed Vocational Nurse 1 (LVN 1) stated that the Hoyer lift should have been placed in the area or hallway where no residents and staff walks and not outside the resident's room because it can be an accident/trip hazard. LVN 1 also stated the Hoyer lift should have been placed back in the rehabilitation department where it is safe to leave it. During an interview on 12/2/2025 at 3:51 PM, the DON stated the shower chair and Hoyer lift are accidents hazards if placed along the hallway where residents and staff pass by. The DON also stated the shower chair should have been placed back inside the shower room and the Hoyer lift placed near the rehabilitation department where there is less traffic and limited number of people going to that area. During a review of the facility's P&P titled, Safety and Supervision, revised 7/2017, the P&P indicated that the facility strives to make the environment as free from accident hazards as possible. The P&P also indicated that the residents' safety and supervision and assistance to prevent accidents are facility-wide priorities.

The facility failed to provide care consistent with the professional standards of practice (the set of guidelines, principles, and expectations that govern the conduct and performance of nursing professionals) to prevent worsening of the pressure ulcer (PU, a localized area of skin damage caused by prolonged pressure on the skin) for one of two sampled residents (Resident 1) by failing to: 1. Assess and document detailed observations in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) of Resident 1's change with skin condition and/ or wound condition on the resident's left trochanter area (a small, conical projection located on the medial side of the upper femur, specifically at the junction of the femoral neck and shaft) on 4/10/2025, 4/17/2025 and 4/24/2025. 2. Resident 1's change of skin condition and/ or wound condition on the resident's sacral area (lower back region specifically triangular- shaped bone called the sacrum) on 4/24/2025. These failures placed Resident 1 at risk for worsening of the PUthat can lead to serious illness and/ or hospitalization . Findings: A review of Resident 1's Admission Record, the Admission Record indicated Resident is a 84- years- old- female who was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain, essential hypertension (high blood pressure that doesn't have a known underlying cause), and other pulmonary embolism without acute core pulmonale (pulmonary embolism, blood clot, that is not severe enough to immediately cause damage to the right side of the heart). During a review of Resident 1's History and Physical (H&P), dated 2/16/2025, the H&P indicated Resident 1 has no capacity to understand and make decisions. During a review of Resident 1's MDS (a resident assessment tool) dated 2/11/2025, indicated Resident 1 was independent, (helper does more than half the effort) with roll on the left and right, sit to lying, and personal hygiene. The MDS also indicated Resident 1 was assessed to be dependent (helper does all of the effort to complete the activity) on sit to stand, chair/bed-to-chair transfer and toilet hygiene. The MDS indicated Resident 1 was assessed to be at risk of developing pressure ulcer and the resident has one or more unhealed pressure ulcers/injuries (location not specified). During a review of the GACH records with an admitted [DATE] and discharge date of [DATE], the GACH records indicated Resident 1 was admitted with altered mental status ( a change in a person's mental functioning, ranging from mild confusion to severe disorientation, and can be caused by various factors like illness, injury, or substance use ) , numerous pressure ulcers, hypotensive, and concerns for septic shock ( a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage.) The GACH records indicated discharge diagnoses which included the following: a) Volume depletion (decrease in blood volume and can lead to symptoms like low blood pressure and dehydration). b) G-tube (a thin, flexible tube inserted through the abdominal wall directly into the stomach) site cellulitis (a common bacterial infection of the skin and underlying tissues. It occurs when bacteria enter the skin through a cut, scratch, or other break in the skin). c) Pressure injury of skin, During an interview on 5/12/2025 at 12:12 PM with wound treatment nurse (WTN), WTN stated she is new to the wound treatment nurse position, she was working as a wound treatment nurse for just two weeks, she did not know anything about Resident 1's wounds, but WTN stated it is WTN, charge nurse, registered nurse supervisor's (RNS) responsibility to create SBAR communication for significant wound changes to promote immediate attention and actions to the teams for preventing residents wounds getting worse, infections and hospitalization . During an interview on 5/13/2025 at 2:16 PM with Registered Nurse Supervisor (RNS) at nursing station 1, RNS stated certified nursing aid (CNAs) will report residents' skin change to charge nurse, medication passing nurse and supervisors. RNS stated it is licensed nurse's responsibility to start SBAR/COC and report to physician, obtain physician orders and WTN will start wound treatment per physician order. During a concurrent interview and record review with infection preventionist nurse (IPN) on 5/13/2025 at 1:45 PM, Resident 1's Weekly Observation Tool Pressure Injury & IDT Review (WOTPI) dated 2/19/2025 to 4/24/2025 were reviewed, indicated the following: a. On 4/2/2025, Resident 1's stage (classifies the severity of skin and tissue damage) 4 left trochanter [a bony prominence located on the posterior (back) and medial (toward the center) surface of the proximal femur (thigh bone)] wound size L:5.1 cm x W: 5.0cm D: 0.7cm b. On 4/10/2025, Resident 1's stage 4 left trochanter [a bony prominence located on the posterior (back) and medial (toward the center) surface of the proximal femur (thigh bone)] wound size changed to L:6.4 cm x W: 4.5cm x D: 0.7cm c. On 4/17/2025, Resident 1's stage 4 left trochanter wound size changed to L:4.3 cm x W: 5.4cm x D: 0.4cm d. On 4/24/2025, Resident 1's stage 4 left trochanter wound size changed to L:5.3 cm x W: 5.7cm x D: 0.5cm. e. On 4/17/2025, Resident 1's stage 4 sacrococcyx (the junction point where the sacrum and coccyx (tailbone) connect wound size was L: 4.4cm, x W:7.7cm, D, no depth measurement f. On 4/24/2025, Resident 1's stage 4 sacrococcyx wound size changed to L:8.8 cm x W: 8.0cm x D 1.4cm worsening condition. IPN stated there were no SBAR (Situation, Background, Assessment, and Recommendation. It's designed to improve communication between healthcare professionals, particularly when notifying a physician about a patient's change in condition) / change of condition form (COC) documentation had been established for the left trochanter wound size changes noted on 4/10/2025, 4/17/2025, and 4/24/2025. IPN also stated there was no SBAR/COC for sacrococcyx area on 4/24/2025 for Resident 1. IPN stated the above wound size changes of left trochanter 4/10/2025, 4/17/2025, and 4/24/2025, sacrococcyx area wound size change on 4/24/25 are significant changes that need to implement a SBAR communication form for a purpose of communications, the care team's immediate attention and action for care plan revision between physicians and all healthcare professionals to promote wound healings and to prevent further wound infection. Infection Preventionist Nurse stated wound care nurse should have created SBAR communication forms for Resident 1's left trochanter and sacrococcyx wounds to prevent wounds worsening than hospitalized due to wounds infections. During a concurrent interview and record review with director of nurses (DON) on 5/13/2025 at 3:48 PM, Resident 1's Weekly Observation Tool Pressure Injury & IDT Review (WOTPI) dated 4/10/2025, 4/17/2025, and 4/24/2025 for left trochanter wound; and WOTPI dated 4/24/2025 for Resident 1's stage 4 sacrococcyx were significantly changed per Resident 1's WOTPI listed on the above dates for left trochanter and sacrococcyx wounds. DON stated Resident 1's wound size did change from good to bad, these changes were change of conditions. DON stated she would have started the SBAR. DON stated the wound care nurses should have started the SBAR communication form to facilitate the team's immediate attention and action for Resident's wounds to prevent further wounds worsening, infections and hospitalization s. During a concurrent interview and record review on 5/13/2025 at 3:48 PM with DON, the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, undated, revised February 2021 was reviewed. The P&P indicated 1. A significant change of condition is a major decline or improvement in the resident's status that: a. wil1 not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status. c. requires interdisciplinary review and/or revision to the care plan; and ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 2. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 3. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

Based on observation, interview and record review, the facility failed to monitor the intravenous (IV, a small flexible tube placed into a small vein for intravenous therapy such as medication fluids) site and change the heplock (a type of IV device for the administration of solution or medication) dressing for two (2) of 3 sampled residents (Resident 1 and Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in Resident 1 and Resident 2 to develop IV complications which can lead to infection and possible hospitalization . Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included vancomycin-resistant enterococci (VRE, a type of bacteria that is resistant to vancomycin [a common antibiotic]) of permacath (a long-term catheter used for dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] treatment), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/16/2025, the MDS indicated Resident 1 was moderately impaired with cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand and chair/bed-to -chair transfer. During a review of Resident 1's Physician's Order Summary, with an order date of 4/9/2025, the Physician's Order Summary indicated Daptomycin (used to treat certain blood infections) Intravenous Solution 500 milligram (mg, unit of measurement) every 48 hours for VRE of the permacath until 4/13/2025. During an observation on 4/11/2025 at 9:30 AM in Resident 1's room, Resident 1 was awake and laying on his bed. Resident 1 was observed with a peripheral IV site on her right hand. The IV site had a grayish colored and blood-stained bandage dressing. There was a dried blood on the paper tape on her hand that was placed next to the IV access port. During a concurrent observation and interview on 4/11/2025 at 9:35 AM with Registered Nurse 2 (RN 2) in Resident 1's room, Resident 1's IV site was observed with blood stains. RN 2 stated, Resident 1's IV site was not clean and well secured. RN 2 stated, We should always secure the IV site to prevent dislodgment and always keep it clean to prevent infection. During an interview on 4/11/2025 at 9: 55 AM with Infection Preventionist Nurse (IPN), IPN stated, Resident (Resident 1)'s IV site was visibly soiled because there is blood on the tape that was attached on the gauze. The licensed staff should have changed the IV dressing because the area was visibly soiled. We need to always keep the IV site clean because of infection control. During a concurrent interview and record review on 4/11/2025 at 11:58 AM with IPN, Resident 1's Physician's order dated 4/9/2025 was reviewed. The physician's order indicated Daptomycin every 2 days (48 hours) via intravenous. IPN stated Resident 1 did not and should have a physician's order to monitoring the IV site to include changing the dressing every seven days or as needed when compromised. During a concurrent interview and record review on 4/11/2025 at 12PM with IPN, Resident 1's Medication Administration Record dated 4/1/2025 to 4/30/2025 was reviewed. IPN stated Resident 1 had no IV site monitoring from 4/9/2025 to 4/10/2025. IV monitoring was not initiated until today (4/11/2025). During a concurrent interview and record review on 4/11/2025 at 12:02 PM with IPN, Resident 1's Care Plan IV dated 4/11/2025 was reviewed. IPN stated the Care Plan indicated PICC line. IPN stated, Care plan had incorrect information because Resident 1 did not have a PICC line and only had peripheral IV line. IPN also stated the care plan intervention was incomplete because there was no monitoring indicated. During an interview on 4/11/2025 at 12:06 PM with IPN, IPN stated If there was no monitoring of IV site for Resident 1, the licensed nurses will not be able to assess if there were signs and symptoms of infiltration, or any complications on the IV site. During a concurrent interview and record review on 4/23/2025 at 12:08 PM, Resident 1's Nurses' Progress notes dated 4/9/2025 to 4/10/2025 were reviewed. There was no record of assessment on the IV site for Resident 1 during 7AM to 3PM shift on 4/10/2025. IPN stated there was no IV site assessment done for Resident1 in the morning shift. IPN stated the Charge nurse missed assessing and documenting Resident 1's IV site. IPN stated, if the nursing staff did not conduct an IV site assessment, there is a possibility of delayed treatment if complication such as infection and infiltration occurs. During a concurrent observation and interview on 4/11/2025 at 12:15PM with MDS Nurse (MDSN), MDSN stated Resident 1's peripheral IV site looks dirty because there was dry blood on the site. MDSN stated, The nursing staff should have changed the IV dressing right away because it was compromised. During a concurrent interview and record review on 4/11/2025 at 12:17 PM with MDSN, Resident 1's Care Plan IV dated 4/11/2025 was reviewed. MDSN stated Care Plan indicated Resident 1 had a PICC line. MDSN stated it should have indicated an IV access of a peripheral line and not a PICC line. MDSN also stated the care plan should have included interventions to monitoring signs of infection of the peripheral IV site. During a concurrent interview and record review on 4/23/2025 at 12:20PM with MDSN, Resident 2's progress notes were reviewed. MDSN stated there was no documentation that Resident 1's IV site was assessed and if IV site care was done such as flushing the site or dressing change. MDSN stated these should have been documented on the progress notes to indicate IV site assessment and care have been done for Resident 1. During a concurrent interview and record review on 4/11/2025 at 12:21 PM with IPN, Resident 1's Medication Administration Record (MAR) dated 4/1/2025 to 4/30/2025 was reviewed. IPN stated MAR did not indicated IV monitoring from 4/9/2025 to 4/10/2025. MDSN stated there was no IV monitoring in Resident 1's MAR until 4/11/2025. IPN stated the licensed staff should have documented it in the progress notes if it is not in the MAR. IPN stated the staff has to make sure they check the IV site daily. During an interview on 4/11/2025 at 12:23 PM with MDSN, MDSN stated, the licensed staff should have documented any signs and symptoms of infection of Resident 1's IV site and adverse effect of medications, if there was any. MDSN stated if licensed staff did not monitor, the IV site can get infected, possible bleeding or infiltrate. 2. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included sepsis (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 1 needs substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand chair/bed-to -chair transfer, and tub/shower transfer. During a review of Resident 2's physician's order dated 3/16/2025, the physician's order did not indicate IV site monitoring and discontinue the IV site if not in use for Resident 2. During a review of Resident 2's nurses' progress notes dated 3/16/2025 to 3/22/2025. The nurses' progress notes did not indicate any IV site monitoring for Resident 2. During an interview on 4/11/2025 at 3:08 PM with RN 2, RN 2 stated, We do not give medications via IV push. We usually call the physician and have the order changed to oral, but we also need to get an order to discontinue the IV site and remove the IV. If a resident has an IV site, we need to monitor the IV site to make sure the site has no signs of infection, bleeding or inflammation. During an interview on 4/11/2025 at 3:10PM with IPN, IPN stated, If a resident was admitted with IV medications, it will be changed to oral route, and we should also get an order to discontinue the IV line. But if the resident has IV access and staff were not using it, we need to monitor the IV site to prevent IV site complications. During an interview on 4/11/2025 at 3:14 PM with the Director of Nursing, the DON stated, The licensed staff should have a physician's order to monitor the IV site. If IV medications were changed to oral, we have to make sure to obtain an order to discontinue the Resident's IV access if resident was not using it for a specific number of days. During an interview on 4/11/2025 at 3:16 PM with RN 1, RN 1 stated Resident 2 had two peripheral IV lines on the bilateral hands upon admission. RN 1 stated, We removed the IV line on the right hand but Resident 2 was left with the peripheral IV on his left hand. The physician changed the prednisone IV medication order to oral route. We did not discontinue the IV site because we might still need to use it. I forgot to ask the physician for IV site monitoring order. We were not able to monitor Resident 2's IV site. During an interview on 4/11/2025 at 3:18 PM with RN 1, RN 1 stated, If Resident (Resident 2)'s IV site was not monitored, there is a possibility that the Resident can have an infection on the IV site. During an interview on 4/23/2025 at 3:59 PM with the DON, the DON stated, If there was no monitoring and care plan for Resident (Resident 2)'s IV site, it means the licensed staff did not properly assess the resident. The Licensed staff were not able to document and implement proper interventions and address any issues and inform the physician. During a concurrent interview and record review on 4/11/2025 at 4:03 PM with the DON, Resident 2's Nurse's progress notes dated 3/16/2025 to 3/22/2025 were reviewed. The DON stated, The licensed staff did not document any assessment regarding Resident 2's IV site in their progress notes, it means the licensed staff were not checking Resident 2's IV site for signs and symptoms of IV complications from 3/16/2025 to 3/22/2025. During an interview on 4/11/2025 at 4:06 PM with the DON, the DON stated, If a resident has an IV access and the licensed staff were not monitoring it, it can be a source of infection to the resident, because it can develop cellulitis and phlebitis. During a review of the facility's policy and procedure (P&P) titled, Peripheral and Midline IV Dressing Change, revised 3/2022, the P&P indicated Change the dressing if it becomes damp, loosened or visibly soiled and: c. immediately if the dressing or site appears compromised. 6.Assess the peripheral/midline access device at least every 4 hours (every 1-2 hours for residents with cognitive impairment. a. Visually inspect the entire infusion system (solution, administration set and dressing). b. Check expiration dates of the infusion, dressing and administration set. c. Assess the patency of the vascular access device. d. Palpate and inspect the skin, dressing and securement device for signs of complications, including: (I) dislodgement. (2) redness. (3) tenderness. (4) swelling. (5) infiltration. (6) induration. (7) elevated body temperature; or (8) drainage. Documentation 1. The following should be documented in the resident's medical record: a. Date, time, type of dressing, and reason for dressing change. b. Any complications/intervention related to insertion site or surrounding area.

Based on interview and record review the facility failed to activities of daily living care assistance were provided for one of two sampled residents (Resident 1) by failing to ensure: a. Resident 1 was assessed for incontinence (involuntary loss of urine or stool) care in accordance with the plan of care. b. Resident 1 received tongue scraping (the practice of using a tool such as metal tongue scraper to gently remove bacteria, food particles, and other debris from the surface of the tongue, promoting better oral hygiene and potentially reducing bad breath) in accordance with the physician order. These deficient practices had the potential to lead to skin breakdown, poor hygiene, and diminished quality of life. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area) affecting left non-dominant side, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), and encounter for attention to tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing). During a record review of Resident 1's care plan, revised 1/27/2025, the care plan indicated Resident 1 had an ADL self-care performance deficit related to late effects cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply) and hemiplegia. The care plan interventions were to provide personal hygiene/oral care since Resident 1 was totally dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for personal hygiene and oral care. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 1/29/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 1 had impairment to both sides of the upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles, feet). The MDS indicated Resident 1 was dependent for oral hygiene, toileting hygiene, shower/bathing self, personal hygiene, rolling left and right, lying to sitting on side of bed, and tub/shower transferring. During a record review of Resident 1's Nursing Note, dated 3/9/2025 at 8:15 PM, the record indicated found Resident 1 soaking wet. The record indicated per Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was last checked around 4 PM to 4:30 PM. During a record review of Resident 1's Physician Order Summary Report, dated 3/12/2025, the order indicated metal tongue scraper once a day best to do after dinner, scrape the tongue gently with metal tongue scraper. During a record review of Resident 1's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of March 2025, the record did not indicate the order for tongue scraping was transcribed in the MAR and it was done for Resident 1. During a record review of Resident 1's care plan, revised 3/25/2025, the care plan indicated Resident 1 had bowel and bladder incontinence related to impaired mobility and cognitive deficit. The care plan interventions for staff were to check every two (2) hours and as required for incontinence; wash, rinse, and dry perineum; and change clothing as needed after incontinence episodes. a. During an interview on 3/25/2025 at 8:59 AM with Responsible Party 1 (RP 1), RP 1 stated on 3/9/2025 RP 1 arrived in Resident 1's room and found Resident 1's gown was completely soaked in urine. RP 1 stated Resident 1's brief (protective underwear to prevent leakage) was huge, and the mattress sheets and the side pillows were also soaked in urine. During an interview on 3/26/2025 at 1:54 PM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated RP 1 called RNS 1 into Resident 1's room on 3/9/2025 around 8 PM. RNS 1 stated Resident 1 was really soaked with urine. RNS 1 stated Resident 1's brief was filled with urine and there was urine on the bedsheet and gown. RNS 1 stated CNA 1 told RNS 1 on 3/9/2025 that CNA 1 last checked on Resident 1 around 4 PM to 4:30 PM. RNS 1 stated CNA 1 was supposed to check Resident 1 every 2 hours. RNS 1 stated Resident 1 was prone to an infection since the resident was taking antibiotics (a medication used to kill bacteria and to treat infections) for a urinary tract infection (UTI, an infection of the bladder and urinary system). During an interview on 3/26/2025 at 3:25 PM with the Director of Nursing (DON), the DON stated staff should be reassessing residents every 2 hours. During a concurrent record review of Resident 1's Nursing Notes dated 3/9/2025 at 8:15 PM, the record indicated found Resident 1 soaking wet and CNA 1 last checked the resident between 4 PM to 4:30 PM. The DON stated Resident 1 had not been assessed for three (3) hours and 45 minutes. During a concurrent record review of Resident 1's Care Plan revised 3/25/2025, the care plan indicated for the staff to check Resident 1 every two hours or as needed for incontinence. The DON stated, staff did not and were supposed to check Resident 1 every 2 hours and as required for incontinence care. b. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 3/25/2025 at 2:54 PM, Resident 1's MAR for the month of March 2025 was reviewed. The MAR did not indicated tongue scraping was provided for Resident 1. LVN 1 stated there was an order for Resident 1's tongue scraping to be done in the evening. LVN 1 stated the license nurses needed to document in the MAR to indicate the tongue scraping was done. LVN 1 stated the tongue scrapping should have been logged if it was done and it was not in the MAR. During a concurrent interview and record review with RNS 2 on 3/25/2025 at 3:17 PM, Resident 1's MAR for the month of March 2025 was reviewed. The MAR did not indicate the order for tongue scraping was transcribed in the MAR and it was done for Resident 1. RNS 2 stated Resident 1 required total care with ADLs. RNS 2 stated the physician placed an order for Resident 1's tongue scraping on 3/12/2025 and it was not transcribed/ reflected in Resident 1's MAR. RNS 2 stated the licensed nurses needed to document in the MAR once the procedure was done. RNS 2 stated the documentation in the MAR was to confirm that the order was done. RNS 2 stated if the tongue scraping was not documented, then the licensed nurse did not complete the order and did not provide the tongue scraping to Resident 1. A concurrent record review of Resident 1's Nursing Notes with RNS 2, RNS 2 stated the Nursing Notes did not indicate the tongue scraping was done. During an interview on 3/26/2025 at 3:32 PM with the DON, the DON stated the physician's order needed to be acknowledged, transcribed in the MAR, and signed in the MAR once treatment is done. The DON stated the licensed nurses did not and should have documented in Resident 1's medical records the tongue scraping once the procedure was done. The DON stated documentation was needed for the justification that the license nurses performed the tongue scraping per physician's order. During a record review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised 3/2018, the policy indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) and elimination (toileting).

Based on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for two (2) of 17 sampled residents (Resident 36 and 37) when facility failed to: 1. Ensure Resident 36 and Resident 37's room did not have used gloves left on the floor. 2. Ensure Resident 36 and Resident 37's trashcan in the room was not overflowing with used disposable gowns. These deficient practices resulted in unsanitary conditions placing Resident 36 and 37 at risk for infection and uncomfortable living. Findings 1. a) During a review of Resident 36's Admission Record, the Admission Record indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE], chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), traumatic brain injury (results from a violent blow or jolt to the head) and pneumonia (a lung infection). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool) dated 1/31/2025, the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 36 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, and tub/shower transfer. 1. b) During a review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE], chronic respiratory failure, quadriplegia (is the condition in which both the arms and legs are paralyzed and lose normal motor function) and Stage 4 pressure ulcer of the sacral region sacral region (it is a triangular-shaped bone at the base of the spine just superior to the coccyx[tailbone]) During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 37 was dependent for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, and tub/shower transfer. During an observation on 3/5/2025 at 2:25 PM inside Resident 36 and 37's room, the small trashcan in the room was overflowing with a used gown, and used glove on the floor. During a concurrent observation and interview on 3/5/2025 at 2:31 PM with Housekeeping Manager (HKM) inside Resident 36 and 37's room, HKM stated it was not appropriate to have resident's trashcan overflowing. HKM stated that staff should dispose used items, such as gown and gloves, properly for infection control. During an interview on 3/7/2025 at 11:18 AM with Infection Prevention Nurse (IPN), IPN stated the staff should not use the small trashcan in the residents' room, and should use the bigger trash can with a lid for proper disposal of used Personal Protective Equipment (PPE, is specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles). IPN stated if the staff were not disposing the PPE properly, they can spread germs or bacteria that was attached onto the PPE, and could potentially transfer germs/bacteria to the residents in the room. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised 8/2019, the P&P indicated, Housekeeping Surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. During a review of the facility's P&P titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. The characteristics include a) clean, sanitary, and orderly environment.

Based on observation, interview, and record review, the facility failed to identify hazards in the environment (the hand sanitizers, an alcohol based liquid used to minimize the spread of infection) and eliminate them to provide a safe environment and provide adequate supervision (an intervention to mitigate the risk of an accident) for one of 8 sampled residents with a behavior of grabbing items (Resident 159) in accordance with the facility's policies and procedures by failing to: 1. Provide visual monitoring as recommended and documented on the Situation-Background-Assessment-Recommendation (SBAR, a communication tool), dated 6/21/2021, due to Resident 159's behavior of grabbing staff and other people's belongings. 2. Implement interventions for Resident 159's behavior of grabbing items and specify how the staff will monitor the resident in the hallways or the resident's whereabouts. 3. Place or store the liquid Alcohol-Based Hand Sanitizer (ABHS, used to minimize the spread of infection) in a safe area and away from Resident 159's reach to prevent Resident 159, who had a behavior of grabbing items and impulse control disorder (having trouble controlling emotions or behaviors), from grabbing the hand sanitizer. Resident 159 ingested (eat or drink) some (unknown amount) of the hand sanitizer. These deficient practices had the potential for Resident 159 and other residents to sustain gastrointestinal (stomach), respiratory (lungs) and cardiac (heart) distress and altered level of consciousness from ingesting (swallowing) the liquid hand sanitizer that was not meant for consumption (eating or drinking). On 6/23/2021 at 1:10 p.m. an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) in the facility. The Administrator (ADM), Director of Nursing (DON), and Environmental Services Supervisor (EVSS), were notified of the findings regarding leaving a resident, who obtained a bottle of hand sanitizer and consumed an uncertain amount, unattended. On 6/23/2021 at 5 p.m., the ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. The reachable locations for residents to grab (the hand sanitizer) were identified like countertop, bathroom sinks, carts. Concerned resident's (grabbing) behavior will be monitored every shift and cared plan accordingly. At least one staff will always be at nurses' stations . Staff is alternately assigned to supervise Resident 159 every 1 to 2 hours for which a schedule will be put in place and log the resident's activity and behavior. Outcome will be evaluated every week by charge nurses or DON. The Director of Staff Development (DSD) will ensure that staff schedule is followed. Resident 159's behavior monitoring will be done and documented every shift. Resident 159's Care Plan was updated to include interdisciplinary team (IDT, consist of members from different disciplines working collaboratively) recommendations and physician (MD) and responsible party notification of plan of care. 2. There were 8 residents out of 61 residents in house who were identified with some confusion and able to move about using the wheelchair. All 8 residents were assessed by the Assistant Director of Nursing (ADON) and DON on 6/23/2021 for any signs and symptoms of hand sanitizer ingestion or potential to grab items. No residents showed any signs and symptoms of hand sanitizer ingestion or behaviors of grabbing items to put in their mouth. All hand sanitizer bottles were removed from residents' reach on 6/23/2021. The IDT review was done for all residents identified and care plans were updated. MD and responsible party of each resident were made aware of care plan updates. 3. All standing hand sanitizer bottles were removed from all residents reach on 6/23/2021 by the Infection Prevention (IP) nurse. This includes hand sanitizers on top of isolation bins in the hallways and on top of nurses' station counters. These hand sanitizers were removed and kept inside the isolation bin drawers and drawers in the nurses' stations respectively. Staff will be provided their personal sanitizers to carry with them. Staff were given in-services to do hand hygiene using the resident's sink inside the resident's room when needed and to bring with them the provided personal or individual hand sanitizers. The Policy and Procedure on Hazardous Areas, Devices and Equipment was reviewed and revised on 6/23/2021 to indicate the removal of hand sanitizers within the residents' reach and refrain from a possible access to confused residents. Housekeeping storage doors will be changed to have automatic locks and hydraulic doors to ensure doors are always locked on 6/24/2021. In-services for all staff was initiated on 6/23/2021 up to 6/30/2021 regarding (1) F689 Free of Accident Hazards/ Supervision/Devices; (2) Policy and Procedure on Hazardous Areas, Devices and Equipment, and removal of hand sanitizers within residents' reach; (3) Hand sanitizers should be kept inside the drawers of isolation bin and nurses' stations. (4) Staff will be carrying an individual sized hand sanitizer provided for their personal use. (5) All housekeeping storage doors should be locked at all times. The facility is actively hiring for full time Maintenance Supervisor. Meanwhile, a contracted Maintenance Supervisor is hired temporarily effective 6/24/2021. 4. The Infection Preventionist or designee will monitor compliance to the Plan of Correction daily for 2 weeks then weekly for 4 weeks, then monthly for 2 months until 100% compliance is achieved. The Infection Preventionist or designee will provide the report to the DON for trending and analysis. This topic will additionally be discussed in the monthly Quality Assurance Performance Improvement (QAPI, a systemic, comprehensive, data-driven, proactive approach for performance management and improvement) meeting and findings and data will be reviewed and addressed for a period of 3 months until substantial compliance is achieved. Negative trends will require revision of the QAPI action plan. Findings will also be shared and discussed in the Quality Assurance (QA, an on-going and both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards) Committee as scheduled. On 6/25/2021 at 12:30 p.m., after verifying and confirming on-site the implementation of the facility's immediate corrective actions within the POA, the Immediate Jeopardy was lifted in the presence of the ADM and the DON. Findings: During an observation, on 6/23/2021 at 11:30 a.m., Resident 159 was at the East and West Nursing Station sitting in her wheelchair. Resident 159 placed an open bottle of hand sanitizer on top of the counter while grimacing. Resident 159 wheeled herself back to her room. There was no staff present in the nursing station. During a review of the facility's video footage, on 6/23/2021 at 11:37 a.m., with the DON and Dietary Supervisor, the video showed that Resident 159 ingested some (unknown amount) of the hand sanitizer. The video showed there was no staff at the nursing station. Resident 159 place the bottle of hand sanitizer on top of the counter at the East and West Nursing Station. A review of the manufacturer's alcohol-based hand sanitizer label on 6/23/2021 at 12:15 p.m., indicated our gel formula consists of 70% (percent) alcohol. The manufacturer's label indicated, For external use only and If swallowed, get medical help or contact a Poison Control Center right away. During an interview, on 6/23/2021 at 12:41p.m., Licensed Vocational Nurse 1 (LVN 1) stated she heard a resident (Resident 159) swallowed hand sanitizer. LVN 1 stated the bottle of hand sanitizer was usually placed on the desk (at the nursing station) and not at the counter so that the residents would not have access. LVN 1 stated the facility did not give an in-service on where to place or store hand sanitizers. LVN 1 stated that if hand sanitizer was swallowed, the resident could have nausea, throw up, be lethargic, and have a change of condition. LVN 1 stated hand sanitizer is a chemical only meant for external use. During an interview, on 6/23/2021 at 12:46 p.m., Registered Nurse 1 (RN 1) stated a person should not drink a hand sanitizer because it is poisonous. During an interview, on 6/23/2021 at 12:47 p.m., the DON stated when a person consumes a hand sanitizer, the person would have tachycardia (fast heartbeat), shortness of breath, gastrointestinal (stomach) distress, and severe reaction. During an interview with the assistance of LVN 1, on 6/23/2021 at 12:50 p.m., who helped to translate for Resident 159, Resident 159 stated she drank the hand sanitizer that was on top of the counter at the East and West Nursing Station because she thought it was water . During an interview, on 6/23/2021 at 3:30 p.m., the DON stated it is the facility's protocol to place the hand sanitizer bottle on top of each isolation cart (a cart used to keep isolation precaution supplies, such as gowns and gloves). The DON stated that when the hand sanitizer is placed in the nursing station, the hand sanitizer should be placed below the counter, away and out of reach of the residents. A review of the admission record indicated Resident 159 was originally admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses of unspecified dementia (memory loss and impaired judgement) without behavioral disturbance, unspecified [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood affective disorder (illness that affects the way you think and feel), anxiety disorder unspecified (feelings of worry or fear that are strong enough to interfere with one's daily activities), unspecified [CONDITION(S)] (a mental disorder in which thought an emotions are impaired that contact is lost with external reality) not due to a substance or known physiological (normal function of a living organism or bodily parts) condition. A review of a care plan dated 1/9/2015 last revised on 4/9/2015 indicated Resident 159 had severely impaired decision making. The approach plan (intervention) indicated staff to keep environment free of hazards. A review of a care plan dated 1/9/2015 last revised on 4/9/15 indicated Resident 159's alteration in communication due to impaired cognition. The approach plan indicated frequent visual checks to assess for needs and to ensure safety. A review of the History and Physical report completed on 6/4/2021, indicated Resident 159 had fluctuating capacity to understand and make decisions. A review of the Social Service Assessment, dated 6/4/2021, indicated Resident 159 had no capacity to understand and make decisions. The Social Service Assessment indicated Resident 159 was readmitted yesterday, on 6/3/2021, awake, alert with confusion and disorientation. A review of the Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/10/2021, indicated Resident 159 has severe cognitive impairment based on the Brief Interview for Mental Status (BIMS, an assessment tool used to assist with identifying a resident's current cognition and help determine if any interventions need to occur). A review of the Situation-Background-Assessment-Recommendation (SBAR, a communication tool), dated 6/21/2021, indicated Resident 159 was seen with increased behavior of impulse control manifested by (m/b) grabbing at staff and grabbing other people's or her roommates' belongings leading to the resident (Resident 159) being upset and agitated. The recommendations include monitoring Resident 159's impulse control behavior manifested by grabbing at staff, grabbing at her roommate's belongings, sliding down from her bed and crawling on the floor opening roommates drawer; providing therapeutic communication as needed; intervening as necessary to protect the rights and safety of others; approaching and speaking with the resident in a calm manner; diverting the resident's attention; removing the resident from the situation; safety measures in place; and providing frequent visual monitoring. A review of a care plan on Point Click Care online on 6/24/2021 last revised on 6/3/2021 indicated Resident 159 has a behavior problem manifested by grabbing at staff related to impulse control (having trouble controlling emotions or behaviors). Resident 159's care plan indicated the resident has a behavior problem manifested by grabbing roommate's belongings, sliding down from bed, crawling on the floor, opening her roommate's drawer or closet. The interventions are to administer medication as ordered, monitor and document for side effects and effectiveness of the medications, administer [MEDICATION(S)] (a medication used to treat mental or mood conditions) 250 milligrams per milliliter orally every eight hours for impulse control disorder (having trouble controlling emotions or behaviors) manifested by striking at staff, and approach the resident in a calm and unhurriedly, friendly manner. During an interview, on 6/25/21 at 8:15 a.m., the DON stated to ensure safety of Resident 159 and other facility residents, the facility has removed all the hand sanitizer bottles from the counters of all stations. The hand sanitizers in the hallways were stored in the drawers to keep them away for facility residents. A review of the facility's Hazardous Areas, Devices and Equipment policy, revised on 7/2017, the policy indicated, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Under section Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: g. Access to toxic chemicals. Assessment and Analysis of Hazards 1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. 3. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments (e.g., medications). 4. Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident.

Based on observation, record review, and interview, the facility did not establish and maintain an infection control program that included a system of surveillance designed to identify, investigate, control, and prevent the development and transmission of communicable diseases and infections for all residents and staff. The failure resulted in an outbreak so that residents and staff were exposed and tested positive for Covid-19, a serious illness that can lead to death. Findings include: 1. Review of the facility's infection control log on 12/01/20 revealed that the facility did not always document surveillance activities conducted for residents who tested positive for Covid-19. For example: The facility's Daily Reporting, a registry of residents confirmed positive for Covid-19 revealed that Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident, according to the registry, was the first to have tested positive in the facility on 5/05/20 and had Symptoms. Another resident (Resident 2) was identified as having [MEDICAL CONDITION] on 7/18/20 and was transferred to an acute care hospital thereafter. A test conducted at the hospital on [DATE] revealed that the resident was positive for Covid-19. Review of the infection control log (which was maintained in a binder) revealed a quarterly infection control summary from July 2020 through September 2020. The summary which was supposed to track incidence of infections and whether they were nosocomial or community-acquired, included urinary tract, skin/wound, and respiratory infections. While it also monitored infection rates, the summary made no mention about emerging Covid-19 infections. While the facility's policy and procedures for surveillance of infections required analyzing data to identify trends, No other quarterly infection control summaries were noted in the facility's infection control log for 2020. In addition, while the facility also maintained the Daily Reporting registry which listed the names of residents and staff who have tested positive for the coronavirus, the registry, however, was used as a tool to report infections to the city, county, and other agencies where reporting was required, according to Staff 4, another infection control staff. Further review of the infection control log revealed the lack of documentation of the coronavirus infections included [REDACTED]. During an interview at 10:50 a.m. on 12/01/20, an infection control staff member (Staff 3), when asked where the rest of the infection control documents evidencing monthly monitoring and surveillance activities could be found responded, they have not been written up, and added that she was still working on it. Review of another report created by Staff 3 on 10/22/20 as a follow-up to the quarterly infection control summary (for July through September 2020 noted above) revealed several steps undertaken by the facility as a response to the coronavirus. While these included monitoring staff handwashing practices, social distancing, assigning designated nursing staff to specific zones within the facility, temperature screening on all staff and care givers before coming in and going out of the facility, and continuing to restrict residents in their rooms, there was no indication of attempts made to determine how the infection was being transmitted. Review of the facility's surveillance policy and procedure noted that if preventive measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to help determine the effectiveness of such measures. No such data collection or analysis was available for review. In September 2020, the Daily Reporting registry noted that two more residents (Residents 3 and 4) tested positive for the coronavirus on 9/10/20. While the facility had about 4 residents with the infection by 9/10/20, it also had, by this time, about 15 employees who were identified as positive for Covid-19 which included licensed and unlicensed staff, and employees working in the kitchen, housekeeping, and business office. Resident 5, for example, was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident who was also essentially bedbound had a [MEDICAL CONDITION] and received enteral tube feedings. Review of the medical record revealed that Resident 5 was cognitively impaired, dependent on staff for all activities of daily living, and had a relative who visited regularly as a caregiver. Further review of the medical record revealed that care and supervision rendered to Resident 5 was provided by several facility staff on different shifts including licensed and unlicensed staff, rehab personnel, and respiratory therapists. Further record review revealed that while Resident 5 and her caregiver were being tested regularly for the coronavirus with negative results, there was no indication that a review of the facility's protections (against the coronavirus) was conducted after Resident 5 had a positive result on 11/18/20. There was no documentation, for example, about how the resident was exposed and acquired the infection particularly in light of the number of facility staff providing care and supervision who may have been exposed and had direct contact with the resident. Record review also noted that Resident 5 who had a [MEDICAL CONDITION] that required suctioning occupied the middle bed of a room she shared with two other residents, potentially increasing the risk of transmission. Resident 5's roommates were subsequently transferred to different rooms, according to an interview with Staff 3. 2. On 12/01/20, another log maintained by Staff 3 was made available for review. The two-page log, according to Staff 3, was how the facility was tracking and monitoring staff infections included [REDACTED]. Review of the log revealed that while comments were being noted relative to symptoms manifested by the affected employee such as fever, cough, sore throat, and runny nose, and body aches, it did not provide any other information except for the quarantine start date for each name on the list, and the quarantine end date for 3 names at the top of the list. 3. Review of employee and visitor screening forms revealed the lack of oversight of the screening process. During an interview on 12/01/20, Staff 10, one of the designated screeners observed outside the door at the employee entrance, explained that the facility had two main locations where the screening of visitors and employees took place: the main front entrance for vendors; and the employee entrance located at the back of the facility. Staff 10 stated that while she was the designated screener at the employee entrance, a receptionist was posted at the front entrance. Staff 10 stated that her work hours were regularly from 8:00 a.m. to 4:30 p.m. In another interview on 12/01/20, an administrative nursing staff member (Staff 2) verified that Staff 10 and Staff 11 were the designated screeners for the back and front entrances of the facility, respectively. Staff 3 added that since both also have their own regular work hours, any of the licensed staff or CNAs (certified nurse aides) would conduct the screening before Staff 10 and 11 arrived at the facility in the morning and in the afternoon after their shift. Staff 2 added that the front and back entrances were locked and that anyone entering the building had to be buzzed in. When asked to see evidence of training for other facility staff members who were not designated screeners but conducted screening, none was made available for review by Staff 2 on 12/01/20. In separate interviews on 12/01/20, Staff 10 and 11 stated that they received training as designated screeners. Review of completed screening forms revealed that employee names were sometimes illegible; the screening time (or Time In) were left blank or did not indicate morning or evening; and the names of other facility staff members who were conducting screening (but not designated screeners) were not identified. In a confidential interview, a facility staff member stated that he conducted his own screening if he arrived at the facility before the designated screener and filled in the data fields on the form by himself. Review of the facility's Daily Reporting log revealed that the staff member had tested positive for Covid-19. During the entrance conference at 11:15 a.m. on 11/30/20, and administrative staff member (Staff 1 stated that the facility had about 24 residents who tested positive for Covid-19 and another 3 who were currently admitted at the hospital. The daily reporting log also noted that 26 facility employees had tested positive for the coronavirus since September 2020. Staff 1 added that the current outbreak began on 11/13/20. When asked during the same interview on 11/30/20 how residents were getting the infection when they were isolating in their rooms, not attending social dining or group activities, and not receiving any visitors, an administrative nursing staff (Staff 2) stated that facility employees were likely the source of the infection. Based on the findings noted above which was determined to constitute a serious and immediate threat to the life and safety of residents (and staff), the survey team declared Immediate Jeopardy at about 4:15 p.m. on 12/01/20. The declaration was conveyed to both Staff 1 and Staff 2. Immediate Jeopardy was removed at 12:10 p.m. on 12/02/20 after a plan of correction was submitted by the facility which included redesigning the facility's surveillance process and initiating a case review of each patient who tested positive for the coronavirus; and revising the facility's screening process which included the hiring and training of other designated screeners.