Every finding on record at Camino Healthcare

Based on observation, interview, and record review, the facility failed to clarify physician's order on how to inspect the skin on one of four sampled residents (Resident 1), who has a knee immobilizer (a medical device designed to keep the knee joint in a fixed, straight position to promote healing and prevent further injury) for the management of right tibia and fibula (long bone in the lower leg) fracture (broken bone).This deficient practice resulted in Resident 1 to develop a pressure ulcer on her right leg.Findings: During an observation on 5/5/2026 at 8:35 a.m., Resident 1's skin was inspected and had a Stage 3 (deep and painful wounds in the skin) pressure ulcer noted on the calf of the right leg (back portion of the lower leg). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included encephalopathy (any disease damage or malfunction that affects the brain's structure or function resulting in an altered mental status), urinary tract infection (UTI), fracture of the right tibia and fibula. During a review of Resident1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/29/2026, the MDS indicated Resident 1 had the ability to make her needs known. Resident 1 was dependent on staff on the ability to roll from lying on back to left and right side, and return to lying on back on the bed. During a review of Resident 1's medical records from General Acute Hospital (GACH) dated 3/22/2026, it indicated that Resident 1 was treated for right leg fracture and Knee immobilizer was applied on the right knee. During a review of Resident 1's GACH Discharge Summary instructions/ documentation, dated 3/22/2026, the documentation indicated a plan for Resident 1 to wear the knee immobilizer (a medical device designed to keep the knee joint in a fixed, straight position to promote healing and prevent further injury) due to the right medial tibial fracture and non-weight bearing (cannot bear weight on the affected side) for 6 weeks. During a review of Resident 1's Order Summary Report dated 3/24/26, the order indicated right knee immobilized: monitor for any discoloration, new edema, odor that may indicate infection or skin breakdown and notify MD (physician). During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition), dated 4/22/2026, the SBAR indicated, Resident 1 was transferred to GACH for evaluation due to altered mental status. During a review of Resident 1's Discharge Summary from GACH, dated 4/26/2026, the notes indicated Resident 1 had a Stage 3 pressure ulcer at the edge of the right lower extremity splint. During a review of Resident 1's Skin Check document dated 4/27/2026, the skin check indicated Resident 1 had an unstageable pressure ulcer on the right lateral calf measuring 6 centimeters (cm- a unit of measurement) in length, 4 cm in depth with 90% eschar (dead, necrotic tissues, usually dry/ black firmly attached to the wound bed) and 10% slough (nonviable tissue in a wound, typically yellow or white). During a review of Resident 1's Surgical Consult notes dated 5/4/2026, the notes indicated Resident 1 had a wound located at the right lower calf that was revealed after the removal of orthopedic knee brace (knee immobilizer). During an interview on 5/5/2026 at 9:30 am with the License Vocational Nurse (LVN 1), LVN 1 stated after Resident 1 fell and sustained right leg fracture, Resident 1 had the knee immobilizer on. LVN 1 stated Resident 1's skin was monitored around the knee immobilizer for any signs of infection or skin breakdown. LVN 1 stated that he did not inspect the skin inside the knee immobilizer because there was no physician order to do so. On 4/22/2026, Resident 1 was transferred to GACH and returned on 4/26/2026. The knee immobilizer was removed and revealed a Stage 3 pressure ulcer on Resident 1's right leg. During a telephone interview on 5/5/2026 at 12:25 pm with Resident 1's primary physician (PCP), the PCP stated Resident 1 did not allow him to examine her leg during his visits. The PCP stated Resident 1's right leg pressure ulcer was caused by the knee immobilizer and could have been prevented, if the resident allowed him to examine her leg during his visits. During a concurrent interview and record review on 5/5/26 at 1:40 pm with the Director of Nursing (DON), Resident 1's physician order summary report dated 3/24/2026, was reviewed. The DON stated there was no physician's order to always wear the knee immobilizer for 6 weeks, nor an order to remove the knee immobilizer during skin inspection. The nursing staff monitored Resident 1's skin around the knee immobilizer. The DON stated nursing staff should have called Resident 1's PCP to clarify the order if the knee immobilizer can be removed for skin inspection. During a review of the facility's policy and procedures (P&P) titled, Skin and Wound Monitoring and Management, dated 1/2024, the P&P indicated the facility should identify risk factors which relate to the possibility of the development of pressure injury which include impaired/ decreased mobility, impaired diffuse or localized blood flow, resident refusal of some aspects of care and treatment. All risk factors identified should be documented in the resident's clinical record and when appropriate be addressed through a care plan. The P&P indicated a licensed nurse will assess/evaluate the resident's skin at least weekly. The P&P indicated for those residents admitted with a cast/ splint to an extremity that is being managed outside the facility, nursing staff should assess and evaluate the casted/ splinted area at least weekly to check the status of the skin. Any changes in the resident's skin as identified daily, weekly must be communicated to the resident's physician.

Based on interview and record review, the facility failed to ensure a comprehensive assessment (a nurse assesses a patient) was completed for one of three sampled residents (Resident 2) before Resident 2 left the facility out on pass ([OOP]- an approved temporary absence of an patient from a facility for a few hours) and after Resident 2 returned to the facility.This deficient practice had the potential to place Resident 2 at risk for the facility not being aware of any changes following her time outside of the facility.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included muscle weakness (a reduction in the strength of voluntary muscles), bone density disorder (the deterioration of bone tissue, and decreased bone strength), and lack of coordination (inability to produce smooth, accurate, and purposeful muscle movements).During a review of Patient 2's History and Physical (H&P), dated 9/19/2025, the H&P indicated Resident 2's capacity (ability) for medical decision making waxed and waned (increased and decreased) due to mental incapacitation (the inability through mental illness to carry on the everyday affairs of life).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 2's cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene, showering, and dressing.During a review of Resident 2's progress notes, dated 3/1/2026 through 3/30/2026, the progress notes indicated there was no nursing documentation on 3/18/2026 regarding Resident 2 leaving out on pass and coming back from out on pass. The progress notes indicated on 3/19/2026 at 10:17 p.m., Resident 2 was noted with swelling on her left lower extremity with skin discoloration and Resident 2's daughter stated when she took Resident 2 out of the facility the day prior, Resident 2 hit her left leg while in the vehicle.During a review of Resident 2's Situation, Background, Assessment, Recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/19/2026, the SBAR indicated Resident 2 had swelling on the left lower extremity with skin discoloration. The SBAR indicated interventions included X-ray (imaging that can detect broken bones) the left lower extremity.During a review of Resident 2's Pacific Mobile diagnostics, dated 3/20/2026, the X-ray indicated Resident 2 had a nondisplaced fracture (a broken bone where the pieces remain in their proper anatomical alignment) to the left ankle and foot.During a review of Resident 2's Release of Responsibility for Leave of Absence (OOP), dated 3/18/2026, the OOP indicated Resident 2 had left the faciity on 3/18/2026 at 9:20 a.m. and had returned to the facility on 3/18/2026 at 2pm.During a concurrent interview and record review on 4/3/2026 at 3 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 2's Weights and Vitals Summary, was reviewed. The Weights and Vitals Summary indicate vitals were not taken before Resident 2 had gone OOP and when she had returned to the facility. LVN 2 stated vital signs and assessments needed to be completed before Resident 2 leaves and when Resident 2 returns to the facility. LVN 2 stated he did not recall the vitals being taken when Resident 2 left and returned to the facility on 3/18/2026. LVN 2 stated it was important to do vitals for Resident 2 and assess her to make sure there was no significant change in condition.During a concurrent interview and record review on 4/3/2026 at 3:42 p.m., with Director of Nursing (DON), Resident 2's progress notes were reviewed. The progress notes indicated there was no assessment or documentation when Resident 2 went OOP and when she returned to the facility on 3/18/2026. The DON stated when Resident 2 left for OOP and returned to the facility, there was no assessment. The DON stated it was important to assess the resident to identify any possible medical changes in her condition.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 5/2021, the P&P indicated resident's clinical record was a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. The P&P indicated notes were to be written on all long-term residents by day, evening, and night shifts. The P&P indicated continuous nurse's notes were required on all residents.During a review of the facility's P&P titled, Resident Out on Pass, dated 11/2021, the P&P indicated nursing would document when the resident returned, and any pertinent information regarding his/her or events which took place while out on pass.

Based on observation and interview, the facility failed to: 1. Ensure one of five opened medication containers was dated with the open date. This failure had the potential to affect residents who receive medications requiring dating to ensure potency.Findings: During an observation on 3/12/2026 at 08:15 AM, Licensed Vocational Nurse (LVN) 2 administered medication from an opened bottle of Ferrous Sulfate (a medication used to restore iron levels in the blood), that was not labeled with the date it was opened. During an interview on 3/12/2026 at 1121 AM with LVN 2, LVN 2 stated, That bottle should have been labeled with the date when it was first opened to know when to remove it from the cart after 30 days. Without knowing how long ago it was opened, there is no way to know if it would possibly be effective. Residents could still have low iron levels if the medicine does not work anymore. A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated May 2022, the P&P indicated, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of three residents (Resident 72) had a care plan for the residents' dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit) not being kept in Resident 72's room. This deficient practice had the potential to delay immediate access to emergency supplies needed in case of unexpected complications such as bleeding from the dialysis shunt (access site for dialysis) or rapid evacuation from the facility.Findings:During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal dialysis, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease. During a review of Resident 72's History and Physical (H&P), dated 4/26/2025, the H&P indicated Resident 72's capacity for medical decision making was waxing and waning (increasing and decreasing). During a review of Resident 72's Minimum Data Set (MDS, a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 72 usually had the ability to make self understood and usually had the ability to understand others. The MDS indicated Resident 72 was independent with eating, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 72 received dialysis as a special treatment. During a review of Resident 72's Order Summary Report, dated 4/23/2025, the order summary report indicated Resident 72 was on dialysis treatment every Tuesday, Thursday, and Saturday. The order summary report indicated to assess the dialysis site every shift for tenderness, redness, and bleeding. During an observation on 3/11/2026 at 10:20 AM in Resident 72's room, there was no dialysis e-kit in the room. During a concurrent observation and interview on 3/11/2026 at 11:00 AM in Resident 72's room with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not know why the dialysis e-kit was not in Resident 72's room, but it should be available for emergencies. LVN 1 did not know where the e-kit was located. During an observation and interview on 3/11/2026 at 11:12 AM in Resident 72's room with the Director of Staff Development (DSD), the DSD stated Resident 72's dialysis e-kit should be kept at the bedside but due to the resident throwing out the contents because he did not want the bag there, the e-kit was kept at nursing station 2 so it would remain intact and ready in case of emergency. During a review of the facility's Policy and Procedures (P&P) titled Comprehensive Person-Centered Care Planning revised 4/2025, the P&P indicated The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk. During a review of the facility's P&P titled Resident Assessment and Associated Processes revised 12/2023, the P&P indicated The assessment process will include direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. The P&P indicated Assessment information will be used to develop, review, and revise the resident's comprehensive care plan.

Based on interview and record review, the facility failed to: 1. Revise and update person-centered care plans to reflect current physician orders, oxygen flow rate and gastrostomy tube feeding rate for two of 20 sampled residents (Resident 30 and 53). This failure had the potential to result in implementation of incorrect care interventions and placed residents at risk for respiratory compromise and nutritional imbalance. Findings:a. During a review of Resident 30's Face Sheet, the Face Sheet indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), asthma with acute exacerbation (a chronic disease making it difficult to breathe with sudden worsening of asthma symptoms), pulmonary hypertension (a condition that affects the blood vessels in the lungs), and acute pulmonary edema (a condition in which fluid builds up in the lungs, making it difficult to breathe). During a review of Resident 30's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/14/2026, the MDS assessed Resident 30 as having moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 30 required staff assistance with activities of daily living (ADLs) including toileting, showering, dressing and transferring and required maximal assistance for positioning, oral hygiene and eating, with staff performing more than half of the effort. During a review of Resident 30's Order Summary Report (physician order), dated 1/16/2026, the physician order indicated oxygen was to be administered at 2 L/min continuously via nasal canula. During a concurrent interview and record review on 3/11/2026 at 1:45 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 30's care plans were reviewed. The care plan for altered respiratory status did not reflect the physician order of continuous oxygen flow rate. LVN 2 stated the care plan showed oxygen at 4 L/min via nasal cannula while the physician ordered 2 L/min and confirmed the care plan should have been revised when the order was implemented. b. During a review of Resident 53's Face Sheet, the Face Sheet indicated Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 53's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 53's History and Physical (H&P), dated 1/30/2026, the H&P indicated, Resident 53 did not have the capacity to understand and make decisions. During a review of Resident 53's MDS, dated [DATE], the MDS assessed Resident 53 as having moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 53 required total staff assistance with ADLs including oral hygiene, toileting, showering, dressing and transferring and positioning. During a review of Resident 53's physician order, dated 2/25/2026, the physician order indicated continuous g-tube feeding at 60 mL/hour for 20 hours. During a concurrent interview and record review on 3/12/2026 at 11:58 a.m. with Minimum Data Set (MDS) Coordinator, Resident 53's care plans were reviewed, the care plan for altered nutrition/hydration did not reflect the physician order of continuous g-tube feeding at 60 mL/hour. The MDS Coordinator stated the care plan documented g-tube feeding at 70 mL/hour for 20 hours and confirmed the care plan should have been revised to reflect the current physician order. During an interview on 3/13/2026 at 11:30 a.m., with the Director of Nursing (DON), the DON stated nursing staff are responsible for ensuring care plans reflected current physician orders and confirmed staff were expected to revise care plans when changes occurred, including new physician orders. During a review of the policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 4/2025, indicated, resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including bother the comprehensive and quarterly review assessments.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of five sampled residents (Resident 7) the physician was notified when there was sediment (the solid matter that settles to the bottom of a liquid, such as urine or blood) in the indwelling catheter (a medical device inserted into the bladder to drain urine continuously) tubing. This deficient practice not notifying the physician of the sediment in the indwelling catheter tubing had the potential to cause a urinary tract infection ([UTI]- an infection in any part of the urinary system). During a review of Resident 7's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 7 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 7 diagnoses included chronic obstructive pulmonary disease([COPD]- a chronic lung disease causing difficulty in breathing), pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Patient 7's History and Physical (H&P), dated 5/6/2025, the H&P indicated, Resident 7 had fluctuated capacity to understand and make decisions. During a review of Resident 7's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 1/4/20206, the MDS indicated Resident 7's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 7 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene, showering, and dressing. During an observation on 3/10/2026 at 10:00 a.m., in Resident 7's room, Resident 7 had an indwelling catheter. The indwelling catheter had sediment in the tubing. During a review of Resident 7's care plan, High risk for resident with indwelling catheter, dated 8/20/2024, the care plan indicated to monitor, record, and report to the physician for signs and symptoms of UTI. During a concurrent observation and interview on 3/11/2026 at 8:11 a.m., with Director of Staff Development (DSD), in Resident 7's room, Resident 7 had an indwelling catheter. The indwelling catheter had sediment in the tubing. The DSD stated there was a large amount of sediment in Resident 7's indwelling catheter tubing. The DSD stated during nursing rounds the indwelling catheter should have been assessed. The DSD stated the physician should have been notified immediately so the nursing staff would know what to do. The DSD stated sediment in the indwelling catheter was an indication of possible UTI or infection. During a concurrent observation and interview on 3/11/2026 at 10:07 a.m., with Licensed Vocational Nurse (LVN) 4, in Resident 7's room, Resident 7 had an indwelling catheter. The indwelling catheter had sediment in the tubing. LVN 4 stated the sediment should have been reported to the physician. LVN 4 stated nursing was responsible for monitoring signs and symptoms of possible infection. LVN 4 stated not notifying the physician of the sediment could lead to an aggressive infection and make Resident 7 uncomfortable. During a review of facility policy and procedure (P&P) titled, Significant Change of Condition, Response, dated 12/2023, the P&P indicated the facility will ensure each resident quality of care and services to attain and maintain. The P&P indicated recognized conditions or care needs of the resident had changed the Licensed Nurse or Nurse Supervisor should be aware not limited to any signs or symptoms of infection.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 30 received oxygen at the physician ordered flow rate of 2 liters/minute (L/min).2. Ensure Resident 34's oxygen tank was secured and properly stored. These deficient practices had the potential to result in adverse outcomes, including respiratory compromise, oxygen toxicity, carbon dioxide retention, or injury related to an unsecured oxygen tank. Findings: a. During a review of Resident 30's Face Sheet, the Face Sheet indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), asthma with acute exacerbation (a chronic disease making it difficult to breathe with sudden worsening of asthma symptoms), pulmonary hypertension (a condition that affects the blood vessels in the lungs), and acute pulmonary edema (a condition in which fluid builds up in the lungs, making it difficult to breathe) During a review of Resident 30's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/14/2026, the MDS assessed Resident 30 as having moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 30 required staff assistance with activities of daily living (ADLs) including toileting, showering, dressing and transferring and required maximal assistance for positioning, oral hygiene and eating, with staff performing more than half of the effort. During an observation on 3/11/2026 at 1:45 p.m. in Resident 30's room with Licensed Vocational Nurse (LVN) 2 present, the surveyor observed Resident 30 lying in bed receiving oxygen via nasal cannula at a flow rate of 3.5 L/min. During a concurrent interview and record review on 3/11/2026 at 1:45 p.m. with LVN 2, Resident 30's physician orders were reviewed, the physician order indicated oxygen was to be administered at 2 L/min continuously. LVN 2 stated, the observed setting did not match the physician's order and confirmed staff were expected to follow physician orders when administering oxygen. LVN 2 stated incorrect oxygen settings could harm the resident, including the risk of carbon dioxide retention, and acknowledged the resident received oxygen above the ordered rate. During an interview on 3/13/2026 at 11:30 a.m., with the Director of Nursing (DON), the DON stated nursing staff were responsible for administering treatments, including oxygen, in accordance with physician orders and verifying the correct treatment prior to administration. The DON stated failure to follow physician orders could result in resident harm. During a review of the policy and procedure (P&P) titled, Medication Administration - Administration of Drugs, dated 5/2020, indicated, medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. b. During a review of Patient 34's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Patient 34 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 34's diagnoses included chronic obstructive pulmonary disease([COPD]- a chronic lung disease causing difficulty in breathing), dependence on supplemental oxygen (a person requiring an external, higher concentration of oxygen delivered via tanks), and dementia (a progressive state of decline in mental abilities). During a review of Patient 34's History and Physical (H&P), dated 8/21/2025 the H&P indicated, Resident 34 had fluctuated capacity to understand and make decisions. During a review of Resident 34's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 11/29/25, the MDS indicated Resident 34's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 34 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for personal hygiene, showering, and dressing. During an observation on 3/10/2026 at 10:30 a.m., in Resident 34's room, an oxygen tank was in an upright position without a holder to support the oxygen tank. During a concurrent observation and interview on 3/10/2026 at 3:40 p.m., with Director of Staff Development (DSD), in Resident 34's room, there was an oxygen tank in an upright position without a holder to support the oxygen tank. The DSD stated the oxygen tank needed to be secured. The DSD stated the when the oxygen tank was no longer being used; it should be placed in the oxygen storage room. The DSD stated if the oxygen tank was to fall it could burst and explode. The DSD stated if the oxygen tank was to burst it could cause harm. During a concurrent observation and interview on 3/10/2026, with Licensed Vocational Nurse (LVN) 4, in Resident 34's room, there was an oxygen tank in an upright position without a holder to support the oxygen tank. LVN 4 stated the oxygen tank was not secured. LVN 4 stated if the oxygen tank was to fall it could combust (able to catch fire and burnt easily) and could harm Resident 34. During a review of the policy and procedures (P&P) titled, Oxygen Handling and Storage, dated 2/2022, the P&P indicated it was the policy of the facility to provide use and handling of oxygen tanks in the facility. The P&P indicated storage of oxygen tanks must be accompanied in a safe manner. Oxygen tanks must be secured to a wall within a chain or heavy cable. Safety cups will be installed on all tanks not in use.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 7) had followed recommended physician orders for Resident 7's foot care. This deficient practice of not following the physician's recommendation orders caused a delay in foot care treatment for Resident 7. Findings:During a review of Resident 7's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 7 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 7 diagnoses included chronic obstructive pulmonary disease([COPD]- a chronic lung disease causing difficulty in breathing), pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Patient 7's History and Physical (H&P), dated 5/6/2025, the H&P indicated, Resident 7 had fluctuated capacity to understand and make decisions. During a review of Resident 7's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 1/4/20206, the MDS indicated Resident 7's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 7 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene, showering, and dressing. During a record review of Resident 7's Convalescent Podiatry Care Evaluation & Treatment, dated 3/6/2026, the physician had recommended Clotrimazole (treat skin infections) 1 percentage ([%]- a way of expressing a number as a fraction) cream to be applied to affect area daily and Vitamin A and Vitamin D ([A&D]- topical skin protectant ) ointment to be applied daily. During a concurrent interview and record review on 3/11/2026 at 8:11 a.m., with Director of Staff Development (DSD), Resident 7's Convalescent Podiatry Care Evaluation & Treatment, dated 3/6/2026 was reviewed. The physician had recommended Clotrimazole 1% cream to be applied to affect area daily and A&D ointment to be applied daily. The DSD stated the physician recommendations were not followed. The DSD stated when Resident 7 was seen by the physician the treatment should have been started. The DSD stated not following the recommendations had caused a delay in care and treatment for Resident 7. The DSD stated this could make Resident 7's condition worse. During a concurrent interview and record review on 3/11/2026 on 8:27 a.m., with Social Services Director (SSD), Resident 7's Convalescent Podiatry Care Evaluation & Treatment, dated 3/6/2026 was reviewed. The physician had recommended Clotrimazole 1% cream to be applied to affect area daily and A&D ointment to be applied daily. The SSD stated that after Resident 7 was seen by the physician the recommendations of treatment were not started. The SSD stated the recommendations should have been brought to the attention of the nurses to start the medical treatment. The SSD stated it was important for Resident 7 to start her treatment to prevent things from getting worse. During a review of the facility's policy and procedure (P&P) titled, Dental, Optometry, and Audiology Evaluations, dated 1/2016, the P&P indicated Social Services will maintain a system to monitor the Podiatry evaluations. The P&P indicated Social Services staff member will request that nursing obtain a physician's order for evaluations prior to scheduling of appointments. During a review of the facility's P&P titled, Resident Assessment, dated 2/2024, the P&P indicated drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe the drugs. The P&P indicated orders for drugs and treatments shall be received and must be recorded immediately in the residents' chart by the person receiving the order.

Based on observation, interview, and record review, the facility failed to: 1. Ensure licensed nursing staff informed Residents 13 and 91 of the medications being administered prior to administration. 2. Ensure Residents 13 and 91 were given an opportunity to participate during medication administration. These deficient practices violated Residents 13 and 91's rights.Findings: During a review of Resident 13's Face Sheet, the face sheet indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 13's History and Physical (H&P) dated 11/1/2025, the H&P indicated Resident 13 does not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 12/12/2025, The MDS indicated Resident 13 usually had the ability to make self understood and usually had the ability to understand others. The MDS indicated Resident 13 was dependent on staff for toileting, bathing, lower body dressing, and personal hygiene. During a review of Resident 91's Face Sheet, the face sheet indicated Resident 91 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body, and weakness), facial weakness, and type 2 diabetes mellitus. During a review of Resident 91's H&P dated 1/27/2026, the H&P indicated Resident 91 does not have the capacity to understand and make decisions. During a review of Resident 91's MDS dated [DATE], the MDS indicated Resident 91 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 91 required maximal assistance (helper does more than half the effort) for toileting, bathing, and lower body dressing. During an observation on 3/12/2026 at 9:17 AM in Resident 13's room, Licensed Vocational Nurse (LVN) 3 was observed giving Resident 13 six medicine cups without explaining what medications were in the cups. Resident 13 then swallowed the pills. During an observation on 3/12/2026 at 9:33 AM in Resident 91's room, LVN 3 was observed giving Resident 91 nine medicine cups without explaining what medications were in the cups. Resident 91 then swallowed the pills and liquid medications. During an interview on 3/12/2026 at 11:40 AM with LVN 3, LVN 3 stated she was taught to inform the residents the names of medications being administered prior to administering. During an interview on 3/12/2026 at 11:57 AM with the Director of Nursing (DON), the DON stated the nurses are trained to explain the medications to residents prior to administration. The DON stated it is important to inform residents of the medication because they have the right to refuse. During a review of the Policy and Procedure (P&P) titled Administration of Drugs, revised 5/2020, the P&P failed to identify the federally required content element that licensed nurses must explain to residents the type of medication being administered and the procedure.

Based on observation, interview, and record review the facility failed to: 1.Dispose of an unlabeled and undated bag of spinach in the kitchen refrigerator.2. Dispose of cardboard boxes under the kitchen hand washing sink. 3. Cover the bulk container of oatmeal. 4. Ensure two bottles of Gatorade were not stored in the meat freezer. 5. Label the bottle titled, Spice with a list of ingredients and a use by date.These failures had the potential to expose residents to infectious microorganisms (germs), pests, and allergic reactions.Findings:During a concurrent observation and interview on 3/10/2026 at 8:30 a.m., in the kitchen, a Ziplock bag of spinach, with a milky white substance, was observed in the kitchen refrigerator, next to the tomatoes. Dietary Staff 1 (DS1) stated the spinach should be labeled with a date and was not able to identify the white milky substance. DS1 stated if the spinach were served to a resident, it could cause the resident to complain or become ill. During a concurrent observation and interview on 3/10/2026 at 8:42 a.m., with DS1, in the dry goods storage room, the oatmeal bin was uncovered. The DS1 stated the oatmeal should always be covered, if not, dirty stuff from outside could get into the bin, as well as bugs and dust. During a concurrent observation and interview on 3/10/2026 at 8:43 a.m., with the Director of Staff Development (DSD), in the dry goods storage room, the DSD stated the oatmeal bin should be covered, if not, bugs can get into the oatmeal. During a concurrent observation and interview on 3/10/2026 at 8:45 a.m., with the DSD, in the kitchen, the DSD stated the Gatorade should not be in the meat freezer. Food for the residents should be stored separately from staff's food. During a concurrent observation and interview with the Dietary Manager (DM) on 3/10/2026 at 9:03 a.m., the DM stated: The Ziplock bag of spinach should have a date indicating when it was placed in the refrigerator and discarded due to not having a date and the milky substance could make the residents sick.Empty cardboard boxes could harbor pests and bugs and should be taken outside and not stored in the kitchen.The open oatmeal bin should always have the lid closed, if not, bugs and dust can contaminate the oatmeal and affect the residents.The bottles of Gatorade should not be in the freezer with the residents' food.The container labeled, Spice should have a use by date and an ingredient list, or residents could have an allergic reaction to the unknown ingredients. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods policy and procedure (P&P), dated 2023, the P&P indicated that the individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage. In addition, if the manufacturer dating shows a product is either kept longer or shorter time frame the facility will consider that date as the Use by. During a review of the facility's policy and procedure titled, Dry Goods Storage Guidelines, dated 2023, the guidelines indicated storage guidelines are based on the FoodKeeper App (U.S. Department of Health & Human Services). During a review of the State Operations Manual/Appendix PP (SOM), dated 7/23/2025, the SOM indicates that the facility should store, prepare, distribute and serve food in accordance with professional standards for food service safety. During an interview on 3/13/2026 at 11:49 p.m., with the DSD, the DSD stated the facility does not have policies for the disposal of cardboard boxes and outdoor trash bin disposal.

Based on observation, interview, and record review, the facility failed to: 1. Ensure two of three outside trash bins properly contained with covers that were completely closed. This failure had the potential to attract pests and vermin to the area which is adjacent to the laundry room.Findings: During a concurrent observation and interview on 3/10/2026 at 8:53 a.m., with the DSD, at the trash bin storage area, two large trash bins were overfilled and partially covered. The DSD stated the trash bins should be covered because rodents and other animals can get into the trash. During an interview on 3/13/2026 at 11:49 p.m., with the DSD, the DSD stated the facility does not have policies for the disposal of cardboard boxes and outdoor trash bin disposal. During a review of the State Operations Manual-Appendix PP (SOM), dated 7/23/2025, the SOM indicated the facility must properly contain refuse (trash) and dispose of it properly.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a sign for Enhanced Barrier Precautions (infection control measure to stop germ spread), was displayed, for one of six residents, Resident 104, in Resident 104's room. This failure had the potential to expose staff and visitors to an infectious organism when touching or caring for Resident 104.Findings: During a review of Resident 104's admission Record, dated 3/4/2026, the admission Record indicated Resident 104 has cellulitis (a common, potentially serious bacterial skin infection) of the right lower limb, methicillin resistant staphylococcus aureus infection (a type of staph bacteria that causes infections resistant to many common antibiotics), and hemiplegia (partial paralysis) & hemiparesis (weakness or inability to move on one side of the body) affecting the left non-dominant side. During a review of Resident 104's History & Physical (H&P), dated 3/6/2026, the H&P indicated Resident 104 has the capacity for making medical decisions and was discharged from a hospital to the facility for care of a nonhealing right lower extremity wound, initially inflicted by a burn. During a review of Resident 104's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 104 receives occupational and physical therapy and has a BIMS (brief interview for mental status) of 15, indicating Resident 104 is intact cognitively (mental processes involved in knowing, learning, and understanding). During a review of Resident 104's Care Plan Report, dated 3/5/2026, the Care Plan indicated: Resident 104 has an infection of the right lower extremity and staff are to maintain standard precautions when providing care. Resident 104 is on antibiotic therapy for a right leg wound infection with a goal to be free of any discomfort or adverse side effects of antibiotic therapy.Resident 104 is on enhanced barrier precautions for MDRO (a type of germ-usually bacteria-that has developed resistance to multiple, commonly used antibiotics) which requires visitors and staff to use gowns and gloves for personal careResident 104 requires supervision and assistance for toilet use, repositioning themself in bed, and with personal hygiene. During a review of Resident 53's admission Record, dated 1/28/2025, the admission Record indicated Resident 53 has Parkinson's and Alzheimer's Diseases. During a review of Resident 53's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 53:Does not speak, is rarely/never understood, and rarely understands others.Is moderately impaired at making decisions.Uses a wheelchair. During a review of Resident 53's History & Physical (H&P), dated 1/30/2026, the H&P indicated that Resident 53 does not have capacity to understand and make decisions. During a review of Resident 53's Care Plan Report, dated 12/1/2025, the Care Plan Report indicated Resident 53 is on enhanced barrier precautions, will remain free of infections, and staff are to follow enhanced barrier precautions, utilize gowns and gloves for all personal care. During an observation on 3/10/2026 at 9:55 a.m., in room [ROOM NUMBER]A, there was an isolation cart at the right-side entry wall, but no isolation sign on the door or inside Resident 104's room. During an interview on 3/10/2026 at 10:00 a.m., with CNA1, CNA1 stated yes, there should be a sign. If there is no sign there, we would not know what type of isolation items to wear before going into the room. During an interview on 3/12/2026 at 2:18 p.m., with Infection Preventionist (IP), IP stated the enhanced barrier signs (EBP) signs are posted over the head of the bed so families can see it when residents have wound infections. The IP stated the isolation sign was found on the floor, near the head of Resident 104's bed and was placed on the wall at the head of the bed. The IP stated if the sign is not available for visitors to see, they will not know what to do to protect themselves from organisms and they can spread it to others. During a record review of the policy & procedure titled, IPCP (Interprofessional Collaborative Practice) Standard and Transmission-Based Precautions (extra infection control measures used in healthcare settings for patients known or suspected to be infected with highly transmissible pathogens) Policy & Procedure (P&P), dated 3/2024, indicated, EBP: used in conjunction with standard precautions (all blood, body fluids, non-intact skin, and mucous membranes should be treated as potentially infectious) and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (bacteria or other microorganisms that have developed resistance to multiple classes of antimicrobial drugs, making them difficult to treat), to staff hands and clothing then indirect transferred to residents or from resident-to-resident (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRPs). PPE (Personal Protective Equipment) specialized clothing or gear worn to minimize exposure to hazards that cause injuries, illnesses, or infections : The use of gowns and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of known MDRO infection or colonization.

Based on observation, interview, and record review, the facility failed to: 1. Perform hand hygiene before touching the forehead of Resident 1.This failure had the potential to result in exposing Resident 1 to harmful organisms on the hand of CNA1.During a review of Resident 1's Face Sheet, with an admission date of 4/9/2022, the Face Sheet indicated Resident 1 is diagnosed with Dementia, Alzheimer's Disease, and Dysphagia following nontraumatic intracerebral hemorrhage. During a review of Resident1's History and Physical, dated 1/2/2025, the History and Physical indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 4/9/2022, the Order Summary Report indicated Resident 1 is ordered to have a fortified puree diet, pain assessments with pain management, and staff are to monitor right and left lower extremities for redness, discoloration, swelling, and pain, every shift for immobilizer use. During a concurrent observation and interview on 2/17/2026, at 11:19 a.m., CNA1 entered room [ROOM NUMBER] and touched the forehead of Resident 1 without performing hand hygiene. CNA 1 stated they are supposed to perform hand hygiene before touching the residents because not performing hand hygiene could cause an infection. During a review of the facility's policy and procedure titled, Hand Hygiene, dated, 12/2023, the Hand Hygiene policy indicated to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents.

Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1.This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1. Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1. This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1.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 re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included acute respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), acute pulmonary edema (a condition caused by too much fluid in the lungs) and pressure ulcer of sacral region, stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 08/26/2025, the MDS indicated Resident 1 had clear speech, difficulty communicating some words or finishing thoughts but was able if prompted or given time and usually understood others. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene and showering/bathing self.During a review of Resident 1's Physician's Order dated 10/1/2025, the Order indicated to administer Ultramist Therapy (treatment using low-frequency ultrasound to deliver saline mist, debride dead tissue, reduce bacteria and control inflammation to promote healing of wounds) every day shift every Monday, Wednesday, Friday for management of stage 4 pressure injury. During a concurrent observation and interview on 12/01/2025 at 11:45 a.m. with the Occupational Therapist (OT) at Resident 1's bedside, the OT was observed wearing gloves, pulled the privacy curtain and proceeded to administer Ultramist wound treatment for Resident 1 without changing gloves and performing hand hygiene. The OT stated failure to change gloves and wash hands before administering the wound treatment could spread germs and increase the risk of infection for the resident. During a review of the OT Encounter Treatment Note dated 12/1/2025, the Note indicated the OT permed Mist Therapy treatment to Resident 1's Sacro coccyx pressure ulcer. During a review of the facility's policy and procedure (P/P) titled Hand Hygiene), revision dated 04/2025, indicated it is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. The P/P indicated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water before performing any non-surgical invasive procedures, before and after handling an invasive device, after contact with objects (e.g., medical equipment) in the immediate vicinity of the residents, after removing and disposing of PPE.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a comprehensive care plan in place to include in and out self-catheterization (a procedure where a thin tube (catheter) is temporarily inserted into the bladder to drain urine, then immediately removed). This deficient practice placed Resident 1 at risk for insufficient care and services related to self-catheterization.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order to allow for in and out self- catheterization. During a concurrent interview and record review on 9/9/2025 at 11:50 a.m. with the Minimum Data Set Nurse (MDSN), Resident 1's Care Plan and Order Summary Report was reviewed. The MDSN reviewed Resident 1's Order Summary Report and stated Resident 1 had an order to self-catheterize himself and Resident 1 should have a care plan to reflect that. The MDSN reviewed Resident 1's care plan and stated Resident 1 did not have a care plan for in and out self-catheterization and was important to have one to identify the needs of Resident 1 and to guide their care. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 1/2021, the P&P indicated the interdisciplinary team (IDT- ) shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received their medication while being out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice resulted in Resident 1 not taking his prescribed antibiotics when it was due and could potentially lead to complications.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order for cephalexin (an antibiotic, a medicine that kills bacteria) 500 milligrams (mg- unit of measurement) to be taken four times a day by mouth for a urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1's Medication Administration Record (MAR) dated 8/2025, the MAR indicated Resident 1 did not receive cephalexin on 8/20/2025 at 5 p.m., 8/21/2025 at 1 p.m. and 5 p.m., and on 8/22/2025 at 5 p.m. and 9 p.m. because he was out of the facility. During a concurrent interview and record review on 9/10/2025 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's MAR was reviewed. LVN 2 stated if a resident was to go out on pass and there were important medications due, the nurse would have to notify the doctor to obtain an order to allow the resident to take the medication while they are away from the facility. LVN 2 stated education would be given to the resident or their representative on how to take the medication. When the resident takes the medication while away from the facility, the MAR has an option for the nurse to select that the resident took the medication while they were away on pass. LVN 2 reviewed Resident 1's MAR for the month of August and stated the cephalexin was not given at the scheduled times because Resident 1 was out of the facility. LVN 2 further stated it was important to take antibiotics when they are scheduled because you want the bacteria to be killed and the infection to be gone. During a review of the facility's policy and procedure (P&P) titled Out on Pass or Leave of Absence, dated 12/2023, the P&P indicated if applicable, resident medications will be dispensed and explained to the resident representative to include instructions on when and how the medications are to be taken.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) temperature was reassessed after acetaminophen (a fever reducing medicine) was given. This deficient practice had the potential for nursing staff to delay care for Resident 1 if a given intervention was not effective.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order for acetaminophen 650 milligrams (mg- unit of measurement) every 6 hours as needed for pain or fever. During a review of Resident 1's Medication Administration Record (MAR), dated 8/2025, the MAR indicated Resident 1 received acetaminophen on 8/16/2025 at 8:05 a.m. for a fever of 102.7 Fahrenheit (F- unit for temperature) and at 4:48 p.m. for a fever of 103.2 F. During a review of Resident 1's Progress Notes dated 8/16/2025, the Progress Notes did not show any documentation for Resident 1's temperature after acetaminophen was given. During a review of Resident 1's Temperature Vital Signs dated 8/16/2025, the Temperature Vitals Signs did now show any documentation for Resident 1's temperature after acetaminophen was given. During a concurrent interview and record review on 9/9/2025 at 2:11p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's MAR, Temperature Vital Signs, and Progress Notes were reviewed. LVN 1 reviewed Resident 1's MAR and stated acetaminophen was given twice on 8/16/2025 for fever and pain. LVN 1 stated after administering the medication, nursing staff should reassess the temperature for effectiveness and doing so was important because it would tell you if the intervention worked or not, if it did not, other interventions could be used, or staff could also call to notify the doctor for further interventions. LVN 1 reviewed Resident 1's Temperature Vitals Signs dated 8/16/2025, and Progress notes dated 8/16/2025 and stated Resident 1's temperature was not reassessed after given acetaminophen. During a review of the facility's policy and procedure (P&P) titled Administration of Drugs dated 5/2020, the P&P indicated when as needed medications are administered, the nurse must record any results achieved from administering the drug and the time such results were observed

Based on interview and record review, the facility failed to ensure accurate and complete documentation was done for one of one sampled resident (Resident 1) when going out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice had the potential for facility staff to not be aware of where a resident was when they were out of the facility.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate).During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility.During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass on 8/22/2025.During a review of Resident 1's Progress Notes, dated 8/22/2025 at 11:31 p.m., the Progress Notes indicated Resident 1 went out on pass earlier in the day, and no further documentation was seen earlier in the day when Resident 1 went out on pass.During a concurrent interview and record review on 9/9/2025 at 2:11 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes were reviewed. LVN 1 stated when a resident goes out of the facility on pass, they would require the resident to sign out on the out on pass binder which should include the date and time of when they left the facility and when they came back. The staff would also need to ask and document where the resident would be going and about how long they would be away so the next staff member would have that information if the resident did not return in the specified time and be able to notify the doctor and the resident's emergency contact. LVN 1 reviewed Resident 1's Progress Notes and out on pass binder and stated there was no documentation to show when Resident 1 left the facility, what time he was expected to be back and where he went to.During a review of the facility's policy and procedure (P&P) titled Out on Pass or Leave of Absence, dated 12/2023, the P&P indicated nursing, or designee will document when the resident leaves and returns, including any instructions given upon leaving, pertinent information regarding their return or events which took place while on leave. Information included may include date, time and with whom the resident left and returned to facility, medications provided, equipment loaned and quantities, location where resident will be over the course of the leave, general condition of the resident on return, changes or incidents experienced during leave, unused medications or supplies, and other significant information.

Based on observation, interview, and record review, the facility failed to provide a safe and accident-free environment for one of three sampled residents (Resident 1), who had impaired functional mobility (a reduction in a person's ability to move independently and perform daily activities) by failing to: -Ensure Certified Nursing Assistants (CNAs) 1 and 2 transferred Resident 1 from the wheelchair to Resident 1's bed by using appropriate assistive device (any item, piece of equipment that are designed to help individuals with disabilities increase, maintain, or improve their functional capabilities) such as the Hoyer lift (a mechanical device used to safely transfer patients who have limited mobility from one surface to another, such as from a bed to a chair or wheelchair) as indicated in Resident 1's untitled care plan dated 2/1/2025. This deficient practice resulted in Resident 1 screaming out in pain on 7/16/2025, when CNAs 1 and 2 transferred Resident 1 from the wheelchair to Resident 1's bed. Resident 1 also experiencing right foot pain and swelling to the right lower extremity, and was transferred to the General Acute Care Hospital (GACH) on 8/2/2025 where Resident 1 was diagnosed with a right trimalleolar fracture (a break in all three bony prominences of the ankle [medial {inner ankle}, lateral {outer ankle} and posterior {back part of shin}], a serious type of ankle fracture requiring surgical intervention). At the GACH Resident 1 received general anesthesia (a drug-induced state of unconsciousness, typically used for major surgical procedures) and had an open reduction and internal fixation (ORIF- a type of surgery used to stabilize and repair broken bones; some form of hardware is used to hold the bone together so it can heal) surgery of the right ankle. 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 hemiplegia (total paralysis to one side of body) and hemiparesis (slight muscle weakness or partial paralysis) affecting both right and left (dominant) side, muscle wasting and atrophy (gradual decline in effectiveness and causing a person or a part of the body to become progressively weaker). During a review of Resident 1's untitled care plan, dated 2/1/2025, the care plan indicated Resident 1 had Impaired Functional Mobility with Activities of Daily Living (ADL) self-care deficit. The care plan goal indicated to reduce the risk of complications related to impaired mobility. The care plan interventions indicated the facility would use the appropriate assistive device (non-specified) and provide a level of assistance that meets the residents' needs. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/21/2025, the MDS indicated Resident 1 was usually able to express ideas and usually able to understand others. The MDS indicated required substantial / maximal assist (helper did more than half the effort) from sitting to lying, was not able to stand or walk 10 feet, and was dependent (helper does all the effort) on staff to transfer from chair to bed. During a review of Resident 1's Occupational Therapy (OT, a branch of health care that helps people of all ages who have physical, sensory, or cognitive problems) Progress Report for certification period 5/26/2025 - 6/22/2025, the report indicated Resident 1 used a Hoyer lift for transfers.During a review of Resident 1's Physical Therapy (PT, a healthcare profession focused on improving movement and function through various techniques like exercise, manual therapy, and education) Progress Report for certification period 5/26/2025 - 6/22/2025, the report indicated Resident 1's baseline was total dependence with bed mobility. The report indicated Resident 2 was mostly bedbound and occasionally up in her wheelchair via Hoyer lift. The report indicated Resident 1 needed maximum assistance with bed mobility and was non-ambulatory for a long time. During a review of Resident 1's Transfer Level Notes, undated, the notes indicated Resident 1 required a Hoyer lift for transfer. During a review of Resident 1's July 2025 Medication Administration Record (MAR), the MAR indicated from 7/1 - 7/15/2025 Resident 1 received Tramadol (medication used to treat moderate pain in adults) 50 milligrams (mg, unit of measurement) four times out of fifteen days. The MAR indicated on 7/10/2025 Resident 1's highest pain rating score during this time was a 6 out of 10, using the zero to ten pain scale (zero indicating no pain and 10 indicating most severe pain, 6 indicated moderate pain) and there was no location of the pain documented. During a review of Resident 1's MAR dated 7/16/2025 at 2:43 p.m. (date of transfer incident), the note indicated Resident 1 was given Tramadol 50 mg for complaint of body pain rated at seven out of 10 (seven indicated strong / severe pain). During a review of Resident 1's MAR dated from 7/16 - 7/31/2025, Resident 1 received Tramadol 50 mg fourteen times out of sixteen days (almost every day). The MAR indicated Resident 1's highest pain rating score of seven on 7/16 for body pain, 7/23 for knee pain with no score, and 7/28/2025 for feet pain with no score documented. During a review of Resident 1's Nursing Note, dated 7/31/2025 (two weeks after Resident 1 screamed out in pain), the note indicated FM 1 was concerned about swelling to Resident 1's ankles. The nursing note indicated, FM 1 requested an X-ray (photographic or digital image of the internal part of the body) to be sure, and Resident 1's Physician / Medical Doctor (MD) 1 ordered a STAT (immediate) X-ray to both ankles. During a review of Resident 1's Radiology Results Report, dated 7/31/2025, the report indicated Resident 1 had an acute mildly displaced fracture of the right medial malleolus (bone on the inner side of the ankle) and an acute nondisplaced fracture of the lateral malleolus (bone on the outer side of the ankle). The Radiology Results Report indicated Resident 1's fracture appeared recent. During a review of Resident 1's Change in Condition (COC, a noticeable alteration in a person's physical or mental state, or in the circumstances surrounding a situation, often triggering a [NAME] for reassessment or intervention) Evaluation, dated 8/1/2025, the evaluation indicated FM 1 reported after Resident 1 went to a doctor's appointment on 7/16/2025, CNAs 1 and 2 tried to transfer Resident 1 back to bed. The COC evaluation indicated while FM 1 was outside of Resident 1's room, FM 1 heard Resident 1's scream. FM 1 entered the room and asked Resident 1 what happened. Resident 1 reported that her leg hurts so bad. FM 1 stated Resident 1 had complained of pain since that time (7/16/2025). The COC evaluation indicated FM 1 requested an X-ray and the X-ray result indicated a fracture of Resident 1's right ankle. The COC evaluation indicated the Nurse Practitioner ordered to transfer Resident 1 to the hospital (GACH). During a review of the GACH Emergency Department (ED) Physical Exam Note dated 8/2/2025, the ED note indicated Resident 1 had significant right lateral malleoli (outer ankle) tenderness to palpitation and right foot swelling. The ED note indicated at 2:15 p.m., Resident 1 received Morphine Sulfate (a controlled substance to treat severe pain) 2 mg intravenous (into a vein) for severe pain rated at 7-10, received Norco 5/325 one tablet (an opioid pain reliever), for moderate pain, received Tylenol 650 mg for mild pain, and Ambien (a sedative, hypnotic medication). The ED note indicated Resident 1's Radiology Results and findings indicated soft tissue swelling with fracture of medial malleolus (inner ankle), distal fibula (outer side of ankle, resulting from twisting or rolling the ankle, or from a direct impact), and posterior tibia (break in back part of shin bone). The GACH ED Physical Exam note indicated the impression of Resident 1 was a trimalleolar fracture (a break in all three bony prominences of the ankle [medial, lateral and posterior], a serious type of ankle fracture requiring surgical intervention). During a review of Resident 1's GACH Progress Notes, the notes indicated Resident 1 was admitted to the hospital on [DATE] and underwent an ORIF surgery of the right ankle on 8/3/2025. During a review of the GACH Operative Report dated 8/3/2025, the report indicated Resident 1's post-operative diagnosis as a right trimalleolar ankle fracture. During an interview on 8/5/2025 at 11:53 a.m., Family Member (FM) 1 stated Resident 1 went out to a doctor's appointment on 7/16/2025 and when she returned staff (CNA 1 and 2) transferred Resident 1 back to bed. FM 1 stated Resident 1 was bedbound (being confined to a bed due to illness or physical limitations) and was supposed to be transferred with a Hoyer lift. CNA 1 requested for another Certified Nursing Assistant (CNA 2) to come assist with the transfer. FM 1 stepped out into the hallway (to provide privacy) and the door was closed. FM 1 stated she heard Resident 1 scream, You broke my foot! FM 1 entered the room and found Resident 1 in bed crying and asking for pain medication. FM 1 asked CNA 1 what happened, and CNA 1 did not respond, shrugged his shoulders and left the room. On 7/31/2025 (15 days later) FM 1 noticed Resident 1's legs were swollen, reported it to the nurse (RN Supervisor) and requested an X-ray be done. FM 1 was notified the next day (8/1/2025) the Xray was completed and showed the right ankle was fractured. During a concurrent observation outside Resident 1's door and interview on 8/5/2025 at 12:40 p.m. - 1:30 p.m., the Director of Staff Development stated the red circle sticker outside a resident's door indicated two persons assist and the red heart sticker indicated Hoyer Lift. The observation outside Resident 1's door revealed there was a red heart which indicated the resident required a Hoyer lift with two persons assist for transfer. During an interview on 8/6/2025 at 10:50 a.m., CNA 1 stated that on 7/16/2025 he assisted transferring Resident 1 to the bed using a 2-person assist. CNA 1 stated Resident 1 had a red sticker outside her door which indicated a two-person assist. CNA 1 did not indicate if it was a red circle or a red heart. CNA 1 stated he and the assigned nurse (CNA 2) placed an arm under Resident 1's armpit and held her waistline, then transferred Resident 1 to bed. CNA 1 stated if you (staff in general) do not use the right technique to transfer a resident they can be injured. During an interview on 8/6/2025 at 1:43 p.m., the Registered Nurse Supervisor (RN) stated Resident 1 was assessed on 7/31/2025 and Resident 1 complained of soreness when the right ankle was touched. The RN stated, This was a new injury and how it happened was unknown. The RN stated FM 1 then told the RN (on 7/31/2025) that when staff (CNAs 1 and 2) were transferring Resident 1 back to Resident 1's bed on 7/16/2025, FM 1 heard Resident 1 scream My leg is hurting. The RNS stated FM 1 informed RN that Resident 1 complained of pain since that day (7/16/2025). During a concurrent observation of Resident 1's legs and interview on 8/7/2025 at 11:55 a.m. with Resident 1, Resident 1 was observed in bed with a splint to the right lower leg/ankle. Resident 1 stated on the date of incident (7/16/2025) staff called in a tall man (CNA 1) to help transfer her to bed from the wheelchair. Resident 1 stated, The guy, grabbed Resident 1's feet and the lady (CNA 2) grabbed her shoulders. Resident 1 stated when the CNA 1 grabbed her feet during the transfer she screamed. Resident 1 stated FM 1 entered the room right away and asked why she was crying. Resident 1 stated, He hurt my foot. Resident 1 stated staff (in general) have not transferred her like that, before and all that night (7/16/2025) she had right foot pain. Resident 1 stated staff (in general) used a Hoyer lift to transfer her and that when Resident 1 found out the ankle was fractured, she cried.During an interview on 8/7/2025 at 1:40 p.m., the Director of Staff Development (DSD) stated the proper technique for a 2-person transfer from wheelchair to bed was to have a staff member on both sides under the resident's arm, so the weight was evenly distributed, then stand and pivot in one or two steps to move the resident to the bed. The DSD stated staff should not have transferred Resident 1 by grabbing her feet and another person on her shoulders, because this method could not properly transfer the resident to bed. The DSD stated when staff used the wrong transfer technique the resident can be injured or dropped (fallen). The DSD stated Resident 1 could be transferred using a 2-person assist technique or using a Hoyer lift. The DSD stated Resident 1 was able to provide accurate information and was very precise on the description of CNA 1. The DSD stated Resident 1 was bedbound, did not stand, and did not walk, so it was not typical to get an ankle fracture if you did not walk. The DSD stated it was not okay for Resident 1 to be injured by staff during care. During the review of the facility investigative document, undated, received to the Department on 8/7/2025, the document indicated Resident 1 was noted as a two-person assist or Hoyer lift transfer. The document indicated CNA 2 was interviewed and stated, On the afternoon of 7/16/2025, she transferred Resident 1 back to bed with another CNA (CNA 1) for assistance. The investigative document indicated CNA 2 stated Resident 1 complained of toe pain, but CNA 2 was not aware the resident bumped her foot. CNA 2 stated she went to get the charge nurse (unidentified) who gave Resident 1 pain medication. CNA 2 stated Resident 1 complained of soreness to the right ankle on 7/30/2025. The document indicated Resident 1 was interviewed and stated, I hurt my foot when they (CNA 1 and 2) were transferring me when I came back from my doctor's appointment (on 7/16/2025). The document indicated the facility ruled out abuse and injury of unknown origin. Policies and procedures for the Use of Hoyer Lift, Resident Transfer Techniques, Two Person Transfers were requested from the facility. Medical Records personnel and the facility Administrator stated the facility did not have these policies.During a review of the facility's P&P, titled Fall Management System, dated December 2023, the P&P indicated the facility would provide an environment that remains as free of accident hazards as possible. The P&P indicated to provide each resident with appropriate assessment and interventions to prevent accidents.

Based on observation, interview, and record review, the facility failed to report an unusual occurrence to the state agency. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 1's History and Physical (H&P), dated 2/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 1 was not able to stand, or walk 10 feet. Resident 1 was dependent (helper does all the effort) on staff to transfer from chair to bed.During a review of Resident 1's care plan, dated 2/1/2025, the care plan indicated Resident 1 had impaired mobility. The care plan interventions indicated the facility would use the appropriate assistive device. The facility would provide the level of assistance that meets the residents' needs. The Charge Nurse will be notified if the resident complained of pain when performing or receiving assistance.During a review of Resident 1's Physical Therapy Progress Report for certification period 5/26/2025-6/22/2025, the report indicated Resident 1 was mostly bedbound and occasionally up in her wheelchair via hoyer lift. The report further indicated Resident 1needed maximum assist with bed mobility and was non-ambulatory for a long time. Resident 1's baseline was total dependence with bed mobility.During a review of Resident 1's Occupational Therapy Progress Report for certification period 5/26/2025-6/22/2025, the report indicated Resident 1 used a hoyer lift for transfers.During a review of Resident 1's Radiology Results Report, dated 7/31/2025, the report indicated Resident 1 had a mildly displaced fracture of the right medial malleolus (bone on the inner side of the ankle) and a nondisplaced fracture of the lateral malleolus (bone on the outer side of the ankle).During a review of Resident 1's General Acute Care Hospital (GACH) records, dated 8/2/2025-8/4/2025, the records indicated Resident 1 was admitted to the hospital on [DATE] and underwent an open reduction and internal fixation (ORIF- a surgical procedure used to treat a bone fracture) of the right ankle on 8/3/2025.During an interview on 8/5/2025 at 11:53 a.m. with the Family Member (FM), the FM stated Resident 1 went out to a doctor's appointment on 7/16/2025 and when she returned staff transferred Resident 1 back to bed. The FM stated Resident 1 is bedbound (being confined to a bed due to illness or physical limitations) and is supposed to be transferred with a hoyer lift (a mechanical device used to safely transfer patients who have mobility limitations). Staff requested another Certified Nursing Assistant (CNA) to come assist with the transfer. The FM stepped out into the hallway and the door was closed. The FM heard Resident 1 scream You broke my foot. The FM entered the room and found Resident 1 in bed crying and asking for pain medication. The FM asked the CNA what happened, and the CNA did not respond, just shrugged his shoulders and left the room. On 7/31/2025 the FM noticed Resident 1's legs were swollen and reported it to the nurse. The FM requested an X-ray be done. The FM was notified the next day the Xray was completed and showed the right ankle was fractured. During an interview on 8/6/2025 at 10:50 a.m. with the CNA, the CNA stated on 7/16/2025 he assisted transferring Resident 1 to the bed using a 2-person assist. The CNA stated he and the assigned nurse placed an arm under Resident 1's armpit and held her waistline, then transferred her to bed. Resident 1 did not have complaints after being placed in bed. The CNA stated he received training on how to transfer residents during his CNA course. If you don't use the right technique to transfer a resident they can be injured. The CNA received training on use of the hoyer lift at the facility. During an interview on 8/6/2025 at 1:43 p.m. with the Registered Nurse (RN), the RN stated on 8/1/2025 X-ray results were received and indicated Resident 1 had a right ankle fracture. Resident 1 was assessed and there was no swelling, redness, or bruising noted on the ankle. Resident 1 complained of soreness when the right ankle was touched. The RN notified the FM Resident 1 had an ankle fracture and we don't know how it happened. The RN stated, This was a new injury and how it happened was unknown. The RN had not previously heard anything about the Resident having a fracture. The FM then told the RN staff were placing Resident 1 back to bed on 7/16/2025 and the FM heard Resident 1 scream. Resident 1 stated my leg is hurting. The RN stated this is a red flag because Resident 1 was complaining of pain and no one knew what happened. The RN stated the FM informed her Resident 1 has complained of pain since that day. The RN stated the signs of abuse are bruising, fractures, and swelling. Resident 1 has a fracture. The fracture is unknown, so it looks like it can possibly be abuse. The RN reported the fracture and information received from the FM to the Director of Nursing (DON). The DON just said okay, and she would continue the process. It was important to notify the DON because the DON needed to notify the Administrator (ADM). The ADM needs to report the incident to police, the state department, and the ombudsman. You must report it immediately to the state department so they will know there is abuse in the facility. You must report to ensure the resident is safe. The RN did not report the incident to state agencies because the DON did not inform her to. The DON and ADM usually report incidents to agencies.During an interview on 8/7/2025 at 10:57 a.m. with the DON, the DON stated she received the X-ray results on 7/31/2025. The doctor requested a repeat X-ray to confirm the findings. The DON started an investigation and completed and incident report because the incident was classified as an unusual occurrence. The DON refused to state when the investigation was started. The DON stated the FM told her someone hit Resident 1's foot on something. The DON stated the resident was injured in the facility. The DON stated the CNA used a 2-person transfer to assist Resident 1 back to bed. DON stated she cannot say with 100% certainty the resident's foot was hit on something. The DON stated the incident is not an injury of unknown origin, It's an unusual occurrence. Resident 1 said staff bumped her foot. Staff denied bumping Resident 1's foot. The DON stated she did not report the incident because they know how it happened. The DON trusts what Resident 1 told her. Injuries of unknown origin must be reported to the California Department of Public Health (CDPH) so someone can investigate to find out what happened. You should report within 24 hours. It takes a bit of force to cause a fracture. The fracture could have happened here or while she was out. Staff would know if Resident 1's foot got caught on something. The DON stated she trusts what Resident 1 told her because the resident is alert and oriented. During an interview on 8/7/2025 at 11:55 a.m. with Resident 1, Resident 1 stated on the date of incident staff called a tall man (confirmed by staff as the CNA) to help transfer her to bed. Resident 1 was in her wheelchair. The guy grabbed Resident 1's feet and a lady grabbed her shoulders. Resident 1 stated when the CNA grabbed her feet during the transfer she screamed. When Resident 1 screamed the FM entered the room and asked why she was crying. Resident 1 stated He hurt my foot. Resident 1 stated staff have not transferred her like that before. Resident 1 doesn't know what came in contact with her foot. Resident 1 stated staff sometimes use a hoyer to transfer her. Resident 1 had pain all night after the incident. When Resident 1 found out her ankle was fractured, she cried. During an interview on 8/7/2025 at 1:40 p.m. with the Director of Staff Development (DSD), the DSD stated the proper technique for a 2-person transfer from wheelchair to bed is to have a staff member on both sides under the resident's arm so the weight is evenly distributed, then stand and pivot in one or two steps to move the resident to the bed. Staff should not transfer someone by grabbing their feet and another person at their shoulders because you can't properly transfer the resident to bed. If you use the wrong transfer technique the resident can be injured or dropped. The staff receives information on how a resident needs to be transferred from the rehab department. The DSD stated the Resident 1 can be transferred using a 2-person assist or using a hoyer. Resident 1 is able to provide accurate information and was very precise on the description of the CNA. DSD stated Resident 1 and staff are telling different stories, so she can't confirm what happened. The DSD can't say 100% but thinks something was bumped during the transfer. The DSD stated it's not common for a resident to be injured during transfer or while receiving care. It shouldn't happen. You shouldn't be bumped. Something had to have happened. Resident 1 is bedbound and doesn't stand. Resident 1 doesn't walk, so it is not typical to get an ankle fracture if you don't walk. The DSD thinks the source of the injury was something that occurred during transfer. It's not okay for a resident to be injured by staff during care. The DSD didn't report the incident when she heard about it because the resident's story made sense. You should report if the reason for the injury is unknown. The DSD stated due to this incident occurring the facility plans to have the rehab department provide training on proper transfer techniques. During an interview on 8/7/2025 with the ADM, the ADM stated staff reported to him Resident 1's leg was bumped during transfer. The ADM stated he didn't feel he needed to report the incident because the resident told them what happened. Stated he can't say with complete certainty the injury occurred in the stated manner. Further stated, if it's unknown how an injury occurred, it should be reported to CDPH, ombudsman, and police, the same as abuse, within 2 hours.During a review of the facility's policy and procedure (P&P), titled Abuse: Prevention of and Prohibition Against, dated April 2025, the P&P indicated allegations of abuse/neglect will be reported to the appropriate State or Federal agencies in the applicable timeframes.During a review of the facility's P&P, titled Unusual Occurrence, dated January 2021, the P&P indicated unusual occurrences shall be reported within 24 hours to the local health officer and the department. The P&P further defined unusual occurrences as those that threaten the welfare, safety, or health of patients.During a review of the facility's P&P, titled Resident Rights: Elder Justice Act Reporting, dated October 2011, the P&P indicated reasonable suspicion of crimes against individuals receiving care from a skilled nursing facility must be reported as required by the Elder Justice Act. The incident must be reported to local law enforcement and the State Survey Agency within two hours if the alleged victim sustained serious bodily injury, or within 24 hours if the victim did not sustain serious bodily injury.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed and the physician was notified immediately on 8/5/2023 and 8/6/2023, for a decline in condition. Resident 1 exhibited a change in level of consciousness (a person's awareness and understanding of what is happening in his or her surroundings) and had a decreased meal consumption on 8/5/2023, 8/6/2023 and 8/7/2023. As a result of this deficient practice Resident 1 received a delay in emergency medical care. Resident 1 sustained a stroke (damage to the brain from blood flow interruption) and was hospitalized on [DATE] for acute encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) secondary to a stroke, with nasogastric tube (a tube inserted through the nose into the stomach for food and medication to bypass the throat in high risk choking patients) placement for dysphasia (difficulty swallowing). Findings: During a review of Resident 1's Admission Record, dated 8/9/2023, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dependence on renal dialysis (a treatment for people whose kidneys are unable to filter out waste in the blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/8/2023, the MDS indicated Resident 1 required supervision (oversight, encouragement or cueing) for eating, and had moderate cognitive impairment. During a review of Resident 1's Order Summary Report, dated 3/25/2023, the order summary report indicated a physician's order to monitor for complications related to dialysis (a treatment to clean your blood when your kidneys are not able to) every shift, such as changes in level of consciousness. During a review of Resident 1's Meal Log - Documentation Survey Report, for the month of August 2023, the meal log indicated on 8/5/2023, there was no documented meal percentages recorded. The meal log indicated on 8/6/2023, Resident 1 had no documentation of meals eaten for breakfast or lunch, and 0 - 25 percent (%) for dinner. The meal log indicated on 8/7/2023, Resident 1 had no documentation of meals eaten for breakfast and lunch. During a review of Resident 1's Progress Note, dated 8/7/2023, at 1:13 p.m., the progress note indicated Resident 1 did not eat breakfast, and was noted to be lethargic (sluggish) with altered mental status (a change in mental function). The progress note indicated 911 was called for Resident 1's unresponsiveness. During a review of Resident 1's Physician's Telephone Order, dated 8/7/2023, untimed, (authored by LVN 2), the physician's order indicated to transfer Resident 1 to the hospital via 911 ambulance. During a review of Resident 1's general acute care hospital (GACH) History and Physical (H&P), dated 8/7/2023, at 3:33 p.m., the GACH H&P indicated Resident 1 presented to the GACH with slurred, muffled speech, was disoriented (confused) with weakness of the left upper and lower extremity (left arm and leg). The GACH H&P indicated Resident 1 was admitted for acute encephalopathy secondary to a stroke, with nasogastric tube placement for dysphasia. During a review of Resident 1's GACH Magnetic Resonance Imaging (MRI, a medical examination used to generate images of the body) report of the brain, dated 8/7/2023, at 4:36 p.m., the MRI report indicated Resident 1 had ischemic (tissue death due to lack of oxygen) changes consistent with an acute stroke. During a review of Resident 1's GACH Progress Note, dated 8/9/2023, at 12:39 p.m., the Progress Note indicated Resident 1 was not alert and oriented, pupils were sluggish (abnormally slow to respond to light), the resident did not withdraw from painful stimuli, and was unable to follow commands. During an interview on 8/8/2023, at 2:32 p.m., with Certified Nursing Assistant (CAN) 1, CNA 1 stated on 8/6/2023, during the 7 a.m. to 3 p.m. shift, Resident 1 was restless and called CNA 1 by a different name. CNA 1 stated Resident 1was normally alert and oriented. CNA 1 stated she was not sure if she reported Resident 1's change of condition to anyone. CNA 1 stated when there was a change of condition, she must report it to the charge nurse and document it. CNA 1 stated on 8/7/2023, she tried to feed Resident 1 breakfast but was unable to because the resident was not fully awake. During an interview on 8/8/2023, at 2:38 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 8/7/2023, Resident 1 did not eat breakfast that morning because she was tired, and the resident was still noted to be lethargic at lunch time. LVN 2 stated 911 was called at approximatly1 p.m. on 8/7/2023. During an interview on 8/8/2023, at 3:04 p.m., with the Director of Nursing (DON), the DON stated on 8/7/2023, at approximately 11:00 p.m., Resident 1 appeared lethargic despite normal vital signs (measurements to assess the body's physical health) and did not respond to the sternal rub (a technique to test an unconscious person's responsiveness) and pinch. The DON stated she told Registered Nurse (RN) 1 to call 911. During an interview on 8/9/2023, at 2:15 p.m., with CNA 2, CNA 2 stated on 8/5/2023 in the morning, prior to dialysis, Resident 1 was wide awake. CNA 2 stated Resident 1 came back exhausted from dialysis and would not wake up for dinner. CNA 2 stated normally Resident 1 had a good appetite. CNA 2 stated she notified LVN 1 that Resident 1 did not eat dinner because of being too tired. CNA 2 stated Resident 1 was last able to feed herself 1 week prior. During an interview on 8/9/2023 at 3:15 p.m., with Resident 1's Roommate (Resident 2), Resident 2 stated she noticed Resident 1 had not been unable to fully wake up since 8/5/2023. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had mild cognitive impairment. During an interview on 8/11/2023, at 11:40 a.m., with CNA 3, CNA 3 stated on 8/6/2023, Resident 1's responsible party (RP) 1 was visiting and was concerned about Resident 1 acting strange. CNA 3 stated RP 1 asked her what was going on with Resident 1. CNA 3 stated she informed LVN 3 of RP 1's concern. CNA 3 stated at approximately 5 p.m., on 8/6/2023, CNA 1 tried to wake up Resident 1 to eat dinner but Resident 1 was not able to wake up, so she notified LVN 3. CNA 3 stated LVN 3 told CNA 3 Resident 1 was tired due to dialysis (last dialysis treatment was on 8/5/2023). During an interview on 8/16/2023, at 9 a.m., with RP 1, RP 1 stated on 8/6/2023, at approximately 4 p.m., Resident 1 was difficult to arouse and would not wake up during his visit. RP 1 stated after 15 minutes, he was able to wake up Resident 1. RP 1 stated Resident 1 was staring off to the right towards the sky, and had trouble speaking. RP 1 stated when Resident 1 opened her eyes he tried to snap his fingers in front of her eyes to get the resident's attention, but the resident would not blink. RP 1 stated he asked CNA 3 what was wrong with Resident 1 and requested to speak to a nurse. RP 1 stated he spoke to LVN 3 who took Resident 1's vital signs and blood sugar and told RP 1 the results were normal. RP 1 informed LVN 3 that Resident 1 would not stop looking up to the right. RP 1 stated LVN 3 did not assess Resident 1's pupils. RP 1 stated that normally when Resident 1 returned from dialysis, the resident was tired but able to communicate verbally without difficulty. RP 1 stated Resident 1 did not get out of bed on 8/6/2023 for dinner, nor did the resident have anything to eat. During an interview on 8/16/2023, at 10 a.m., with LVN 3, LVN 3 stated on 8/6/2023, at approximately 5:30 p.m., Resident 1 had family members visiting that evening. LVN 3 stated RP 1 was upset and complained about the other nurses. LVN 3 stated she did not remember RP 1's complaint. LVN 3 stated she remembered Resident 1 was awake and alert on 8/6/2023, while up in a chair eating without any problems. During an interview on 8/16/2023, at 12:45 p.m., with Resident 1's Physician/Medical Doctor (MD) 1, MD 1 stated the last time he visited Resident 1 was in July 2023, and on that day, the resident was alert and oriented, able to discuss her medical condition, and answered questions. MD 1 stated he was informed of Resident 1's change of condition on 8/7/2023, via text or email. MD 1 stated he could not remember at what time, but he told the facility to transfer Resident 1 to the GACH. MD 1 stated if there was an emergency, the facility did not need his permission to call 911. During an interview on 8/16/2023, at 2:29 p.m., with LVN 1, LVN 1 stated she worked on 8/5/2023, from 3 p.m. to 11 p.m., and did not remember who was working that day, or which CNAs she was working with. LVN 1 stated CNA 2 did not informed her Resident 1 was tired and not eating. LVN 1 stated she remembered that Resident 1 was sleepy and could not feed herself but did not remember whether that was on 8/5 or 8/6/2023. LVN 1 stated Resident 1 seemed OK. During an interview on 8/24/2023, at 8:10 a.m., with CNA 2, CNA 2 stated that on 8/5/2023, Resident 1 ate 60% of her breakfast before leaving for dialysis, and 0% for dinner after coming back from dialysis because the resident was too tired. CNA 2 stated she informed the charge nurse (LVN 1). CNA 2 stated on 8/6/2023, Resident 1 ate 0% of breakfast and lunch, and she (CNA 2) was unable to awaken the resident. During an interview on 8/24/2023, at 8:37 a.m., with the DON, the DON stated on 8/7/2023, she made rounds at approximately 11 a.m. The DON stated FM 1 was present when she tried to stimulate Resident 1, but the resident was not very responsive. The DON stated Resident 1 was just grunting and she (DON) told one of the nurses to call 911. During an interview on 8/24/2023, at 2:43 p.m., with Family Member (FM) 1, FM 1 stated on 8/7/2023 at approximately 12 pm, she went to visit Resident 1. FM 1 stated Resident 1 looked dead. FM 1 stated she asked the DON when was the last time they (facility's nurses) checked on Resident 1, and the DON stated Resident 1 ate and was OK after taking her vital signs. FM 1 stated she told the DON Resident 1 was not OK and she was not going to leave Resident 1 at the facility like that. FM 1 stated LVN 2 stated he was going to text MD 1 for approval to send Resident 1 to the emergency room . FM 1 stated LVN 1 tried to wake Resident 1 up but she was not responsive. FM 1 stated she told LVN 2, Obviously she needs to go to the hospital so can you call an ambulance? During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, dated 5/20/2020, the P&P indicated all changes in residents' medical condition are to be communicated to the physician. The P&P further indicated changes in physical or mental behavior will be communicated to the physician by the licensed nurse and documented.

Based on observation, interview and record review, the facility failed to implement infection control interventions to prevent the spread of the corona virus ([COVID-19] a very deadly virus that easily spreads from person to person) in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of infection) for 72 of 72 residents, residing in the facility, by failing to ensure: 1.Three of five staff observed, Hospitality staff (HP) 1, Certified Nurse Assistant (CNA) 1, and Licensed Vocational Nurse (LVN) 1 wore proper personal protective equipment ([PPE] clothing or equipment worn to prevent the spread of infections) while providing care to four of four resident (Residents 1, 2, 3 , and 4) and perform hand hygiene after exiting rooms in the red zone (designated area for COVID-19 positive residents) and yellow zones (designated area for residents suspected to have COVID-19). 2. One of two CNAs observed, CNA 2, who was working in the yellow zone providing care to residents did not enter the red zone and back to the yellow zone, placing yellow zone residents at an increased risk for COVID 19. 3. Five of five employees observed, HP 1, CNA 1, CNA 2, LVN 1, and LVN 2, were fit tested (a test performed to ensure a respirator (mask) forms a tight seal around the wearer's face to prevent the spread of infection) for N95 (a mask that prevents the spread of infections) mask, and wore the fit tested mask, prior to entering rooms in the red and yellow zones. The facility's census, dated 1/25/22, indicated there were there were 38 residents in the red zone, 34 in the yellow zone and no resident in the green zone. These deficient practices had the potential to lead to an increase in COVID-19 outbreak, in the facility that already had 34 positive residents in the red zone and 38 potential residents in the yellow zone. On 12/26/2022 at 9:56 a.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified due to facility's failure to ensure HP 1, CNA 1, and LVN 1 wore appropriate PPE and performed hand hygiene during residents' care and after exiting residents' rooms in the red and yellow zones. CNA 1, assigned in the red zone, CNA 2, HP 1, LVN 1 and LVN 2 were assigned to the yellow zone, were not fit tested for a N95 and the facility failed to ensure designated yellow zone staff providing care to residents did not move to the red zone and back to the yellow zone. An IJ was called in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Infection Preventionist ([IP] licensed nurse in charge of infection prevention in the facility). On 1/27/2022 at 11:37 a.m., the ADM submitted an acceptable Plan of Action ([POA], a plan of interventions that corrects the deficient practices). The IJ was lifted on 1/27/2022, at 1:50 p.m. after POA implementation was verified onsite through observations, interviews, and record review. The acceptable POA included the following immediate corrections: 1. The IP, DON, and Clinical Resources (CR) started in-servicing all staff currently working in the facility, on infection control and prevention practices including the following: Donning (wearing) and doffing (removing) PPE, hand hygiene, use of N95 mask, red/yellow/green cohorts and the Centers for Disease Control and Prevention (CDC) video Keep COVID-19 Out. Inservice training and skills competency checked for staff not currently scheduled to work will be conducted prior to their next shift by 1/31/2022. 2. Skills and competency checks were started for donning/doffing PPE and hand hygiene. i. All staff scheduled to work on 1/26/2022 will complete the skills and competency checks on 1/26/2022. ii. The skills and competency check for all staff actively on the monthly work schedule will be completed prior to their next shift by 1/31/2022. 3. N95 mask fit testing was reviewed and completed as needed for all staff working in the facility on 1/26/2022. i. All staff not scheduled to work on 01/26/2022, will have their N95 mask fit testing completed prior to starting their next scheduled shifts by 1/31/2022. ii. Upon arriving for their shift, staff will be provided with the N95 that staff had been fit tested . The receptionist will have a log of staff's fit tested N95s. Findings: During a review of the facility's census, dated January 25, 2022, the census indicated the facility had 72 in-house residents that included 39 residents were housed in the red zone and 34 residents were housed in the yellow zone. 1. A review of Residents 1's admission record, indicated the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's History and Physical (H/P) dated 7/12/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/15/2021, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required one-person assist for bed transfer, dressing and required supervision from staff for bed mobility, walking, locomotion (moving from place to place), personal hygiene, and bathing. During a review of Resident 1's Care plan titled At Risk for Severe Acute Respiratory Infection Related to COVID-19 Exposure, dated 1/6/2022, the care plan's interventions indicated transmission-based precaution, single room isolation, monitor vital signs and record any COVID-19 signs and symptoms including fever and cough. During a review of Resident 1's COVID-19 result 1dated 1/20/2022, the result indicated Resident 1 was positive for COVID-19. A review of Resident 2's admission record, indicated the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 2's H/P dated 12/7/2021, the H/P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required a two-person assist for bed mobility, transfer, dressing, toilet use, and bathing. During a review of Resident 2's Care plan titled At Risk for Severe Acute Respiratory Infection Related to COVID-19 Exposure, dated 1/6/2022, the care plan's interventions indicated transmission-based precaution, single room isolation, monitor vital signs and record any COVID-19 signs and symptoms including fever and cough. During a review of Resident 2's COVID-19 result dated 1/15/2022, the result indicated Resident 2 was positive for COVID-19. A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 could understand and be understood others. The MDS indicated Resident 3 required a one-person assist for bed mobility, transfer, walk, locomotion (moving from place to place), dressing, toilet use, personal hygiene. During a review of Resident 1's Care plan titled At Risk for Severe Acute Respiratory Infection Related to COVID-19 Exposure, dated 1/6/2022, the care plan's interventions indicated transmission-based precaution, single room isolation, monitor vital signs and record any COVID-19 signs and symptoms including fever and cough. A review of Resident 4's admission record indicated the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 could understand and be understood by others. The MDS indicated Resident 4 required a two-person assist for bed mobility, locomotion, dressing, toilet use, personal hygiene. The MDS indicated the resident required extensive assistance for transfer and set up for meals. During a review of Resident 4's Care plan titled At Risk for Severe Acute Respiratory Infection Related to COVID-19 Exposure, dated 1/6/2022, the care plan's interventions indicated transmission-based precaution, single room isolation, monitor vital signs and record any COVID-19 signs and symptoms including fever and cough. During a review of Resident 4's COVID-19 result dated 1/23/2022, the result indicated Resident 4 was positive for COVID-19. During a concurrent observation and interview with HP 1 in the yellow zone (Resident 1's room), on 1/21/2022, at 2:29 p.m., HP 1, while not wearing a gown or gloves, picked up 4 diapers from the floor. HP 1 exited the resident's room without performing hand hygiene, then proceeded to the clean PPE cart and obtained a clean gown. HP 1 stated she was supposed to wear a gown and gloves in the yellow zone, and she forgot to sanitize her hands after exiting Resident 1's room. During a concurrent observation and interview with CNA 1 in the red zone, on 1/21/2022, at 2:41 p.m., CNA 1 stood next to Resident 2 providing care, without a gown and gloves. CNA 1 exited Resident 2's room and did not perform hand hygiene. CNA 1 proceeded to a PPE cart, took a clean gown from the cart, and returned to Resident 2's room. CNA 1 stated she was supposed to wear a gown and gloves while in the resident's room in the red zone and was supposed to perform hand hygiene after exiting the room to prevent the spread of COVID-19. During a concurrent observation and interview in the yellow zone, on 1/24/2022, at 10:07 a.m., with LVN 1, LVN 1 entered Resident 3's room (in the yellow zone) providing care without a gown and upon exiting the room, LVN 1 removed his gloves opened a trash can located outside Resident 3's room with his hands and did not perform hand hygiene. LVN 1 proceeded to obtain a clean a gown from the clean PPE cart. LVN 1 stated he forgot to wear a gown prior to entering Resident 3's room. LVN 1 stated he should have performed hand hygiene to prevent the spread of COVID-19 virus. During an interview on 1/25/2022 at 11:20 a.m., with IP, IP stated all staff should wear PPEs including N95 mask, eye protection, gown and gloves when rendering patient care or entering a resident's room in the yellow zone and red zone. IP stated hand hygiene should be performed before and after resident care, after exiting residents' rooms and when hands are soiled. IP stated failure to use proper PPE in the yellow and red zones as well as not performing hand hygiene could lead to a COVID-19 outbreak in the facility and community. 2. During a concurrent observation and interview on 1/24/2022, at 1:08 p.m., CNA 2 entered Resident 4's room in the red zone, provided care to Resident 4, exited the room, and walked into the yellow zone. CNA 2 stated she was not supposed to go from the red zone to the yellow zone because there was a high risk of spreading COVID -19 since residents in the red zone were confirmed positive. During an interview with the Administrator (ADM) on 1/24/2022, at 1:15 p.m., ADM stated there was a greater risk of spreading COVID 19 coming from the red zone into the yellow zone. ADM stated crossing over from the red zone to the yellow zone increases the contamination and the spread of the virus onto more residents and staff. 3. During a concurrent observation and interview on 1/21/2022, at 2:41 p.m., with CNA 1, CNA 1 was observed to wear a blue N95 mask. CNA 1 stated the N95 she was wearing was provided by the facility. CNA 1 stated the mask was located on the front desk. CNA 1 stated she was not fit tested for N95 mask. During a concurrent observation and interview on 1/24/2022, at 11:45 a.m., with HP 1, in the yellow zone, HP 1 was observed to wear a blue N95 mask. HP 1 stated she had not been fit tested for that N95 mask. During an observation on 1/24/2022, at 12:03 p.m., LVN 1 had full facial hair and wore a blue N95 mask, which looked small for his face. The N95 was folding at the bridge of the nose, and the elastic strings were pulling over his ears. During an interview on 1/24/2022, at 2:03 p.m., with DON, DON stated HP 1 was not fit tested for a N95 respirator mask prior to 1/26/2022. DON stated it was important to fit test staff to protect staff and residents from the spread of COVID-19. During a concurrent observation and interview on 1/26/2022, at 9:19 a.m., with LVN 2, in the yellow zone, LVN2 was observed to wear a blue N95 mask which was folded and wrinkled at the bridge of her nose. The N95 was crunched up at her chin and her cheeks from the pull of string over her ears. LVN 2 stated she was told by IP to just wear a regular size N95 mask. During an interview with IP, on 1/26/2022, at 9:36 a.m., with IP, IP stated she had no proof HP 1, CNA 1, LVN 1, and CNA 2 were fit tested for the N95 masks they were wearing. IP stated it was important to fit test staff because improper fitting could cause the spread of COVID-19. During a telephone interview on 1/31/2022, at 11:49 a.m., with LVN 2, LVN 2 stated she was not fit tested by the facility. LVN 2 stated she expressed concerns to IP about the mask being too tight, but the IP did not provide LVN 2 with an appropriate N95 mask. During a review of the facility's policy and procedures (P/P) titled Infection Control and Prevention dated 3/9/2020, indicated, to minimize the spread of COVID-19, staff should perform hand hygiene before and after all residents' contact, contact with potentially infectious material, and before putting on and after removing PPE. The P/P indicated hand hygiene, after removing PPE, was important to remove any pathogens that might have been transferred to bare hands during the removal process. The P/P also indicated staff would wear eye protection (goggles or face shields that covers the front and sides of the face) upon entry to the patient room or care area, based on state and local public health guidance. The P/P indicated staff remove and discard soiled gown in a dedicated container for waste or linen before leaving a resident's room or care area. During a review of the facility's P/P titled Mitigation Plan updated 1/15/2022, indicated if there were COVID-19 cases in the facility, staff would wear recommended PPE for care of all residents, in line with the most recent Department of Public Health PPE guidance. The MP indicated the facility dedicated, consistent staffing teams who directly interact with residents' positive for COVID-19, limit other staff (when possible) to specific floors or wings, and minimize rotation of staff between floors or wings.

Based on observation, interview, and record review, the facility failed to follow its policy to ensure residents were free of abuse and neglect for one of one sampled residents (Resident A). A Certified Nursing Assistant 1 (CNA 1) left Resident A wet for over four hours and when changing the resident's diaper, the CNA was rough and rude during care. These deficient practices resulted in Resident A being neglected, and had the potential for physical abuse. Findings: A review of Resident A's Admission Records (Face Sheet) indicated the resident was readmitted to the facility on (MONTH) 13, (YEAR), and last readmitted on (MONTH) 6, (YEAR). Resident A's [DIAGNOSES REDACTED]. A review of Resident A's Minimum Data Set (MDS), a standardized assessment and care plan screening tool, dated (MONTH) 20, (YEAR), indicated Resident A was able to answer 15 out of 15 questions on the brief interview for mental status (BIMS), but was totally dependent on staff for toilet use. According the MDS, Resident A was incontinent of both bowel and bladder functions (involuntary voiding of urine and stool) and had functional limitation in range of motion ((ROM) the distance and direction a joint can move to its full potential) to one side (left) of his upper and lower extremity. On (MONTH) 12, (YEAR), at 4 p.m., during an interview, the Administrator stated it was reported to her that CNA 1 was instructed to change Resident A's diaper a couple of times and after finally complying, CNA 1 snatched the resident's diaper off. The Administrator stated Resident A asked CNA 1 not to be so rough, and CNA 1 responded, Do you want me to change you or not? The Administrator stated this was witnessed by Licensed Vocational Nurse 1 (LVN 1). The Administrator stated CNA 1 was suspended during the investigation and they determined, because CNA 1 had previous issues with insubordination and patient care issues, they terminated her. On (MONTH) 12, (YEAR), at 4:10 p.m., during an interview, LVN 1 stated at approximately 4:30 p.m. on (MONTH) 29, (YEAR), she heard Resident A yelling out her name, and she went to his room where she found his call light on. LVN 1 stated Resident A told her he had been trying to get his nurse (CNA 1) to change him since 12 noon that day (over four hours). LVN 1 stated she found CNA 1, who was Resident A's assigned CNA, walking around in the hallway. LVN 1 stated she asked CNA 1 to change the resident's diaper and watched as she went into Resident A's room and immediately came out. LVN 1 stated shortly after CNA 1 left Resident A's room, she heard him calling her name again. LVN 1 stated she went to see what Resident A wanted and found his diaper had not been changed. LVN 1 stated she again asked CNA 1 to change Resident A's diaper, but instead of going to Resident A's room as she was instructed to do. CNA 1 went into another resident's room. After being asked several times, CNA 1 finally went to Resident A's room. LVN 1 stated she stood near the resident's door and overheard Resident A say, Baby, don't be so rough, don't push my leg like that, I just had surgery on that leg. LVN 1 then overheard CNA 1 tell Resident A in an irritated tone, Do you want me to change you or not? LVN 1 stated she went to Resident A's room and asked CNA 1 to leave. LVN 1 stated this was not the first time she had a problem with CNA 1 performing patient care, LVN 1 further stated CNA 1 often had an attitude with staff when asked to do something. On (MONTH) 17, (YEAR), at 8:20 a.m., during an observation and concurrent interview, Resident A was observed lying in bed, in his room, alert and oriented times four (name, place, date, and time). Resident A was interviewed regarding the incident, and Resident A stated he was wet and needed his diaper changed and asked CNA 1 to change him but she disappeared. Resident A stated when CNA 1 finally came back she had an attitude and yanked his diaper from between his legs, and he asked CNA 1 to be careful. Resident A stated CNA 1 then told him, with an attitude, to turn over and pushed his leg. Resident A stated he told her not to push his leg like that because he had just had surgery on that leg, and CNA 1 asked him with an attitude, do you want me to change you or not? Resident A stated that was when LVN 1 came in and asked CNA 1 to leave. Resident A stated he did not feel like it was personal, but just the way CNA 1 behaved with everyone, with an attitude. Resident A stated it was difficult to get care when CNA 1 was assigned to care for him. At 9:05 a.m., on (MONTH) 17, (YEAR), during an interview, the Director of Staff Development (DSD) stated she had received reports from the charge nurses that CNA 1 had a bad attitude. The DSD stated CNA 1 had to be closely monitored to make sure her assigned duties were completed. A review of CNA 1's Notice of Employee Separation record indicated CNA 1 was hired on (MONTH) 10, (YEAR), and terminated on (MONTH) 31, (YEAR) for violation of company policies. A review of CNA 1's Employee Corrective Action Notice indicated on (MONTH) 29, (YEAR), CNA 1 received a final notice for verbal abuse/aggression/physical.

Based on interview and record review, the facility failed to follow its policy and procedure, physician's orders, and a resident's plan of care to ensure one of three sampled residents (Resident 1) finger-stick blood sugar ((FSBS) a device used to test blood sugar levels with a drop of blood obtained from the fingertips) levels were checked routinely as prescribed by the physician. This deficient practice resulted in Resident 1 having a change in condition and an elevated serum blood sugar level of 623 milligrams per deciliter ((mg/dL) the normal reference range (NRR) is 70 and 130 mg/dL) and marked as critically high. Resident 1 was transferred to a general acute care hospital (GACH) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H /P), dated 3/3/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/4/17, indicated the resident's cognition (thought process) was no assessed, was totally dependent on the staff for physical assistance with activities of daily living ((ADLs) routine daily activities, such as eating, bathing, dressing, toileting, transferring and walking). The MDS further indicated Resident 1 had a gastrostomy tube (a tube surgically placed into the stomach to provide nutrition, medication, and water) and had a Stage IV pressure ulcer (deep tissue injury with exposure of the muscles and/or bones). A review of Resident 1's revised plan of care, dated 3/4/17, and titled, At Risk for Hypo/[MEDICAL CONDITION] Diabetes Mellitus due to Underlying Condition with other Skin Ulcer indicated for the staff to monitor, document, and report to the physician as needed for signs and symptoms of [MEDICAL CONDITION], such as fatigue, stupor and/or coma. A review of Resident 1's recapitulated Physician Orders, dated 10/1/17 to 11/01/17, indicated to perform blood sugar checks twice daily at 6:30 a.m. and 4:30 p.m. and to administer Insulin [MEDICATION NAME] (a medication used to treat high blood sugar levels) Solution Injection 100 units/milliliter (mL) as per sliding scale (the progressive increase in pre-meal or nighttime insulin doses) before meals (AC) and at bedtime (HS). According to Resident 1's physician's orders for the insulin sliding scale indicated the following for blood sugar levels: 0-150 mg/dL= None 151-200 mg/dL= 1 Unit 201-250 mg/dL = 2 Unit 251-300 mg/dL = 3 Unit 301-350 mg/dL = 4 Unit 351- 400 mg/dL = 5 Unit 401-450 mg/dL = 6 Unit A review of Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of the nursing progress note, dated 11/1/17, and timed at 5:42 p.m., indicated Resident 1 was transferred out to the GACH via an emergency (911(paramedics)), via a gurney, due to being less responsive and not responding to tactile stimuli (the ability to sense touch) and had a blood pressure of 98/68 (NRR is 120/80 millimeters of mercury (mmHg)) and a heart rate of 103 beats per minute ((bpm) NRR is less than 100 bpm). A review of Resident 1's clinical and electronic medical records, there were no further documentation of the resident's condition and assessment regarding to the resident's condition on 11/1/17, from the hours of 8:01 a.m. to 5:42 p.m. A review of Resident 1's GACH emergency department (ED) records, dated 11/1/17, indicated the resident was brought in by the paramedics and arrived in the at 5:51 p.m., with a temperature of 102.6 degrees Fahrenheit ((F) NRR 97-99 F) and the ED nurse was unable to obtain a blood sugar reading. A review of the GACH's Emergency Physician's H/P, dated 11/1/17, indicated Resident 1 had an altered level of consciousness and was hypotensive, with the blood pressure at 94/61 (low blood pressure) and was intubated (tube insertion in the windpipe as a life saving measure for breathing; placed on a mechanical ventilator (breathing machine)) at 6:08 p.m., had a blood glucose level of 623 mg/dL and marked as critically high. Resident 1 was admitted to the ICU and placed on an insulin drip via intravenous. According to the H/P, Resident 1's final [DIAGNOSES REDACTED]. During a telephone interview on 11/21/17 at 10:21 a.m., Resident 1's Family Member 1 (FM 1) stated Resident 1 did not receive her insulin and was sent to the hospital with a blood sugar level of 658 mg/dL and was dehydrated. On 1/12/18 at 10:08 a.m., during a telephone interview, the Assistant Director of Nursing (ADON) stated Resident 1 experienced a change in condition, but there was no change of condition (C[NAME]) documentation located in the resident's clinical records. The ADON stated the nurses' progress note, dated 11/1/17, and timed at 5:57 p.m., indicated the resident was transported to the hospital via 911. The ADON stated the MAR, dated 11/1/17, and timed at 4:30 p.m., had a code that indicated Resident 1 was hospitalized and another code indicating to see the nurses' notes. During a telephone interview on 1/12/18 at 1:51 p.m., the Director of Nursing (DON) stated the nurses were required to complete a change of condition form, which included a resident assessment. During a telephone interview on 1/17/18 at 5:41 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that she would regularly check Resident 1's blood sugar, but was not able to recall details regarding the care of Resident 1 on 11/1/17 at 4:30 p.m. During a telephone interview on 1/26/18 at 10:43 a.m., the DON stated she had updated and provided LVN 1 with a copy of Resident 1's MAR, dated 11/1/17. The DON stated LVN 1 verbalized to her that she could not recall if a blood sugar check was performed on Resident 1 and could not recall the resident's blood sugar reading. A review of the facility's policy titled, Blood Glucose Monitoring and Quality Control and dated on 7/2008, indicated for the staff to obtain accurate blood glucose levels per the physician's order, if the blood glucose result is abnormal or beyond the established ranges ordered by the physician, the staff should notify the physician for further orders, repeat the test if there was an insufficient blood sample. A review of the facility's revised policy, dated 12/2013, and titled Insulin Injections indicated if the order is for sliding scale insulin dosage, perform a finger stick blood glucose level using the monitor utilized by the facility and adjust the dose of insulin based on the result as prescribed by the physician.

Based on observation, interview, and record review, the facility failed to accurately and consistently assess, update the plan of care, and implement existing plan of care to prevent a decrease in range of motion (the normal amount a joint can be moved in certain directions) for one of twenty sampled residents (3). This deficient practice resulted in Resident 3 developing decreased range of motion in her left hand. Findings: A review of Resident 3's Admission Information Sheet indicated she was an eighty one year old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a comprehensive, systematic assessment tool, dated March 12, 2011, indicated the resident was rarely able to express ideas and wants, responded adequately only to simple, direct communication, and required extensive assistance with activities of daily living (ADLs; routine activities that people tend do everyday involving personal care and functional mobility). In addition, the MDS indicated Resident 3 had functional limitation in range of motion only on one side of the body. The resident used a walker and a wheelchair for mobility. A review of Resident 3's prior MDS, dated [DATE], indicated the resident's range of motion was impaired only on one side at the time the assessment was done. A review of the physician's orders [REDACTED]. upper extremities seven times a week as tolerated, to apply hand roll to the right hand seven times a week as tolerated after morning care, and to assist with ambulation, seven times a week as tolerated. Also, there was an order for [REDACTED]. During a passive range of motion exercises observation on May 18, 2011 at 9:05 a.m., RNA 1 placed a hand roll (a rolled washcloth or commercially prepared hand roll used to position the hand/fingers to help prevent contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints)of the fingers) on the right hand of Resident 3. The last three fingers of Resident 3's left hand were observed to be closed at a 45 degree angle. When the surveyor asked what was being done for the resident's left hand, the RNA stated, "No one has talked to me about a hand roll for her left hand". When the RNA was asked to extend the fingers of Resident 3's left hand to the full range of motion, the resident pulled her hand back and moaned. When asked if this was a new behavior for the resident, the RNA stated she did not usually perform Resident 3's PROM. On May 18, 2011 at 9:25 a.m., Resident 3's certified nursing assistant (CNA) from hospice care (care services that focuses on improving the quality of life for the residents and their families faced with a life-limiting illness) stated she bathed and assisted Resident 3 with ADLs daily. In addition, the CNA stated she had reported the decreased range of motion in Resident 3's left hand to the secretary at the hospice, but did not remember when. The CNA further stated she should have notified the hospice nurse, not the secretary. On May 18, 2011 at 9:45 a.m., when the surveyor asked Licensed Vocational Nurse 1 (LVN 1) if she was aware of the decreased range of motion in Resident 3's left hand, the charge nurse stated, "That left hand has slowly started contracting, she used to open it." When asked if anyone had reported the change in the resident's left hand, the charge nurse turned to the hospice CNA and asked her if the resident's left hand had been reported to the hospice nurse. On May 18, 2011 at 10:36 a.m., the director of nursing (DON), while reviewing the chart, stated she could not find any documentation in Resident 3's clinical record indicating there had been a change in the resident's range of motion in her left hand. The DON further stated the hospice CNA had just reported the resident's hand to the hospice nurse and an order was being placed for the resident to have a hand roll placed in her left hand as well as her right hand. A review of Resident 3's "Rehabilitation: Interdisciplinary Rehabilitation Review" quarterly assessment form indicated: March 4, 2010, through December 2, 2010, Resident 3 had some functional joint motion limitation (site not indicated), the resident remained on the RNA program, and there has not been any changes in the resident's condition since the previous assessment. The December 2, 2010, rehabilitation assessment was the most recent assessment in the resident's clinical record. This was verified with the MDS nurse on May 18, 2011 at 10:10 a.m. (see F 278) On May 19, 2011 at 1:30 p.m., when the physical therapy director was asked why the last physical therapy assessment was not in the resident's clinical record, she stated, "I must have missed the March assessment. We re-assessed her based on what you found and she will be getting a hand roll for her left hand also now." On May 19, 2011 at 2:05 p.m., a review of the new physical therapy assessment, dated May 18, 2011, indicated Resident 3 had limited range of motion in both hands. A review of Resident 3's plan of care, dated March 16, 2010, and updated through March 2011, indicated Resident 3 was at risk for new and/or further development of joint limitation/contracture due to her [DIAGNOSES REDACTED]. The plan of care further indicated the physician (MD) would be notified of any significant changes in the resident's joint mobility status. This was not followed for Resident 3. Review of the facility's policy titled "Contracture Management", July 2008, indicated when new joint mobility limitations are identified during the resident's stay, the rehab department would be consulted for further evaluation, treatment, or recommendations. This was not done.