Every finding on record at Casa Bonita Convalescent Hospital

Based on observation, interview and record review, the facility failed to ensure,A. a safe environment was provided to prevent a fall (unintentional descent to the ground) for one of two sampled residents (Resident 106) by failing to:1. Ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance (help from two persons) when providing toileting hygiene (the ability to maintain perineal [area of the body located between the anus [opening located between the buttocks where solid waste leaves the body] and genitals [private parts of the body] hygiene, adjust clothes before and after voiding or passing stool) for Resident 106 as indicated in Resident 106's Minimum Data Set (MDS- a resident assessment tool), dated 6/3/2026.2. Ensure CNA 5 followed Resident 2's Physical Therapist's (PT, a trained professional who helps people improve, maintain, or restore movement and physical function) recommendation to provide two-person physical assistance for bed mobility (supine [lying on one's back with face upward] to side-lying and from side-lying to supine) as indicated in Resident 106's Physical Therapy Treatment Encounter Note (PTEN), dated 7/3/2026. B. Floor mats (a removable piece of soft material placed on the floor near the bedside for residents/patients who were at high risk for falls) were in place for one of two sampled residents (Resident 10), who was at risk for falls, on 7/9/2026 as indicated in Resident 10's falling star program care plan (CP), dated 5/8/2026. As a result, on 7/4/2026, Resident 106 fell from Resident 106's bed and sustained a mild displaced right femoral neck fracture (a break near the hip joint where the bone is slightly out of alignment). Resident 106 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation. Additionally, the deficient practice had the potential to result in injury to Resident 10 in the event of a fall. Cross Reference F656 A. During a review of Resident 106's admission Record (AR), dated 8/29/2024, the AR indicated Resident 106 was admitted to the facility on [DATE] and was readmitted on [DATE]. The AR indicated Resident 106 had multiple diagnoses including muscle weakness (generalized), dementia (a gradual decline in mental ability usually caused by a brain disease), and obesity (an excessive amount of body fat). During a review of Resident 106's Fall/Injury CP, initiated 10/27/2025, with a target date of 9/27/2026, the CP indicated Resident 106 was at risk for falls/injury related to impaired mobility and cognition (ability to understand and process information), weakness, and poor body balance. The CP's goal was to reduce the risk of falls and injury with interventions of providing a safe environment for Resident 106. During a review of Resident 106's MDS dated [DATE], the MDS indicated Resident 106 had impaired cognition and was dependent (helper does all the effort, the resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on staff for toileting hygiene. During a review of Resident 106's Fall Risk Evaluation (FRE), dated 6/30/2026, the FRE indicated Resident 106 was at high risk for falls due to Resident 106 having intermittent confusion (episodes of disorientation, impaired thinking, or reduced awareness that come and go over time, rather than being constant), being bedbound (unable to move without assistance and spend the majority of time in a bed or chair), and being incontinent (involuntary or accidental leakage of urine). During a review of Resident 106's History and Physical (H&P), dated 7/2/2026, the H&P indicated Resident 106 did not have the capacity to understand and make decisions. During a review of Resident 106's PTEN, dated 7/3/2026, the PTEN indicated Resident 106 was a fall risk and was confused. The PTEN indicated Resident 106 needed maximum assistance with two-person [assist] for bed mobility. During a review of Resident 106's change of condition (CoC, an alteration in a resident's physical health that differs from their previous baseline)/Interact Assessment Form Situation, Background, Assessment, Recommendation (SBAR, a structured four-step communication framework used primarily in healthcare to quickly, clearly, and concisely convey critical resident information), dated 7/4/2026, the COC/SBAR indicated Resident 106 had a witnessed fall on 7/4/2026 at 2:49 AM. The COC/SBAR indicated while CNA 5 was performing peri-care (cleaning the genital and anal areas to prevent infection, skin breakdown, and discomfort), Resident 106 slid out of bed and fell to the floor. The COC/SBAR indicated Resident 106 slid out to the right side of the bed with Resident 106's legs leading first. The COS/SBAR indicated CNA 5 tried to hold back Resident 106, but CNA 5 did not have enough time to catch Resident 106. The COC/SBAR indicated Resident 106 had discoloration (unevenness in the natural skin tone, typically bruising after a fall) under Resident 106's chin and on the right knee. The COC/SBAR indicated on [7/4/2026], at 3:07 AM the Emergency Medical Services (EMS) arrived at the facility and transferred Resident 106 to GACH 1. During a review of Resident 106's Radiology Results (RR, a written interpretation of an imaging test), dated 7/4/2026, the RR indicated Resident 106 had an X-ray (medical imaging that uses radiation to take pictures of bones and organs inside the body) of the pelvis (a basin-shaped structure of the bones located at the base of the spine, connecting the trunk to the legs) and the X-ray findings indicated a mild displaced right femoral neck fracture. During an interview on 7/6/2026 at 3 PM with the Treatment Nurse (TN), the TN stated Resident 106 could not turn independently and only answered yes or no questions. The TN stated Resident 106 was considered a two-person assist and the TN always had a CNA (any CNA in general) to help with turning while the TN performed wound care. The TN stated peri-care should be done with two-person assist to reduce Resident 106's risk of falling and staff injury due to Resident 106 being heavy set (a person with large, solid, and broad body build). During an interview on 7/8/2026 at 7:27 AM with CNA 5, CNA 5 stated on 7/4/2026 at approximately 2:30 AM, CNA 5 assisted Resident 106 with peri-care when CNA 5 witnessed Resident 106 fall to the ground. CNA 5 stated CNA 5 stood on Resident 106's left side and moved Resident 106's left arm over Resident 106's chest. CNA 5 stated Resident 106 used Resident 106's left hand to grab the right side rail. CNA 5 stated CNA 5 held Resident 106's back with CNA 5's right hand and forearm, but when CNA 5 attempted to tuck the adult brief under Resident 106 with both hands CNA 5 could no longer hold on to Resident 106's back and Resident 106 began to slide off the bed. CNA 5 stated when Resident 106 started to slide [off the bed], CNA 5 grabbed Resident 106's left forearm but Resident 106 was too heavy and fell to the floor with Resident 106 facing up. CNA 5 stated CNA 5 did not believe Resident 106 was holding the side rail when Resident 106 started to slide off the bed. During a concurrent interview and record review on 7/9/2026 at 11:53 AM with the Director of Rehabilitation (DOR), Resident 106's PTEN, dated 7/3/2026, was reviewed. The PTEN indicated Resident 106 required two-person physical assist for bed mobility. The DOR stated Resident 106 required extensive cueing and maximum assistance or was dependent on staff for bed mobility. The DOR stated the recommendation from the DOR to nursing staff was based on how Resident 106 performed during the physical therapy treatment encounter. The DOR stated the DOR recommended two-person assist [during peri-care] for Resident 106. The DOR stated Resident 106 did not always follow commands or initiate movement and Resident 106's abilities fluctuated throughout the day. The DOR stated two-person assist was safer for staff and for Resident 106. During an interview on 7/9/2026 at 2:10 PM with CNA 6, CNA 6 stated Resident 106 was less verbal since the most recent admission [DATE]). CNA 6 stated Resident 106 needed two-person assist because Resident 106 was dependent on care most of the time and Resident 106 was confused. CNA 6 stated Resident 106 did not always understand when staff (in general) were attempting to clean Resident 106 because Resident 106 tried to roll backwards onto the bed after having been turned [to the side] by staff. CNA 6 stated Resident 106 could hold onto the side rail but did not understand the instructions so Resident 106 grasped the side rail and then released it. CNA 6 stated Resident 106 could not help with turning onto the side after the most recent admission [DATE]). CNA 6 stated CNA 6 used assistance from a second person during Resident 106's peri-care to hold Resident 106 on the other side (opposite from CNA 6's side) of the bed while Resident 106 was turned onto the side, away from CNA 6. During an interview on 7/9/2026 at 2:52 PM with the Director of Staff Development (DSD), the DSD stated when Resident 106 could not turn, this indicated the resident needed two-person assistance. The DSD stated it was difficult [for staff] to turn, hold, and clean the resident all at the same time, and patient safety was a priority. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The P&P indicated individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. B. During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, and history of falling. During a review of Resident 10's H&P dated 5/7/2026, the H&P indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's COC dated 5/8/2026, the COC indicated Resident 10 had a fall on 5/8/2026 at 12:35 PM. The COC indicated a staff member had assisted Resident 10 onto a wheelchair and brought Resident 10 to the bathroom. The COC indicated the staff member waited outside the door to give Resident 10 privacy in the bathroom. The COC indicated when Resident 10 finished using the bathroom, Resident 10 attempted to stand up unassisted and without calling for help. The COC indicated Resident 10 lost Resident 10's balance, fell forward, and landed on Resident 10's right elbow. The COC indicated Resident 10 sustained a bruise on the right forearm. During a review of Resident 10's Rehab Fall Risk Assessment (FRA), dated 5/8/2026, the FRA indicated Resident 10 had limited bed mobility (when a resident has trouble moving around in bed), limited transferring mobility (when a resident struggles to get in/out of bed, wheelchair, etc.), and did not show proper balance when standing. The FRA indicated a floor mat was a useful intervention to implement after Resident 10's fall. During a review of Resident 10's Falling Star Program Care Plan (CP) initiated on 5/8/2026, the CP indicated Resident 10 was at risk for falls related to decreased strength and endurance. The CP's interventions indicated floor mats for Resident 10. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had moderately impaired cognition. The MDS indicated Resident 10 needed maximal assistance (helper does more than half the effort of the activity) for toileting hygiene, shower/bathe, and lower body dressing. During a review of Resident 10's CP History dated 7/9/2026, the CP History indicated that on 5/8/2026 a CP was created by RN 7 that included a nursing intervention to apply floor mat for Resident 10. During a concurrent interview and record review on 7/9/2026 at 10:45 AM with RN 3, Resident 10's electronic record was reviewed. RN 3 stated Resident 10's COC dated 5/8/2026 indicated Resident 10 had a witnessed fall on 5/8/2026. RN 3 stated Resident 10 was in the facility's Falling Star Program (FSP). RN 3 stated residents who were at high risk for falling were placed in the FSP. RN 3 stated that nursing interventions used in the FSP included frequent staff rounding (when nursing staff routinely check up on a resident), keeping a resident's bed in the lowest position, and placing floor mats on each side of a resident's bed. RN 3 stated Resident 10's CP History dated 7/9/2026 indicated the use of floor mats as part of the nursing interventions to be implemented for Resident 10. During a concurrent observation and interview on 7/9/2026 @ 10:51 AM with RN 3 inside Resident 10's room, RN 3 stated there were no floor mats placed on either side of Resident 10's bed. RN 3 stated there should be floor mats based on the current nursing interventions indicated in Resident 10's CP. During an interview on 7/9/2026 at 10:56 AM with RN 6, RN 6 stated the purpose of floor mats was to minimize injury if a resident falls. RN 6 stated floor mats can lessen the impact between a resident and the hard floor if a resident falls. During an interview on 7/9/2026 at 11:50 AM with the facility's DON, the DON stated residents were placed in the FSP if they were at high risk of falling. The DON stated nursing interventions related to the FSP included placing a resident in front of a nursing station for increased visibility (being able to easily see a resident), keeping the bed in low position, and using floor mats. The DON stated the purpose of floor mats was to prevent severe injury. During a review of the facility's undated P&P titled, Falling Star Program, the P&P indicated residents identified at risk for falls will participate in the falling star program. The P&P further indicated appropriate interventions will be provided, including.Care Plan.[and] low bed with floor mat.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two of two sampled residents (Resident 9 and Resident 88) when: a. The facility failed to follow Resident 9's physician's (health professional who is licensed and trained to practice medicine) order and the care plan (CP) indicating to rotate injection sites during the administration of insulin (a fast-acting vital hormone that regulates blood sugar and is used to treat diabetes [disease characterized by high blood sugar levels due to insufficient insulin production]).b. The facility failed to ensure Resident 88's medications were administered within one hour (before or after) of their prescribed time on 7/8/2026. These deficient practices had the potential to result in lipohypertrophy (a buildup of fatty, scar-like, lumpy tissue under the skin) and inconsistent medication absorption to Resident 9. The deficient practice had the potential to result in decreased effectiveness of Resident 88's medications administered and the potential for a physical decline to Resident 88. Findings: a. During a review of a Face Sheet (FS, admission record), the AR indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, long term use of insulin, and chronic (long term) respiratory failure (lungs cannot properly get oxygen into the blood). During a review of Resident 9's CP, dated 6/10/2025, the CP indicated Resident 9 was at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes. The CP's nursing interventions indicated rotating sites when injecting insulin to Resident 9. During a review of Resident 9's History and Physical (H&P), dated 5/11/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/28/2026, the MDS indicated Resident 9's cognition (the ability to think and process information) was severely impaired (never/rarely made decisions). The MDS indicated Resident 9 was dependent (helper does all the effort) on oral, toilet hygiene, and lower and upper body dressing. During a review of Resident 9's Order Summary Report (OSR), active orders as of 7/8/2026, the OSR indicated a physician order for insulin injection, dated 5/9/2026, per a sliding scale . subcutaneous (under the skin) every six hours for Diabetes Mellitus. The order indicated to rotate [injection] sites. During a review of Resident 9's Medication Administration Record (MAR), dated July 2026, the MAR indicated Resident 9 received insulin injections on the abdomen on 7/1/2026, 7/2/2026, and on 7/3/2026 at the following times: 12 AM, 6 AM, and at 12 PM. During an interview and concurrent record review on 7/8/2026 at 2:46 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 9's electronic and paper medical record was reviewed, LVN 1 stated abdomen was a general term, and the abdomen had four quadrants. LVN 1 stated Resident 9's MAR, dated July 2026, did not indicate site rotation for the administration of insulin. LVN 1 stated site rotation when administering any injection was important to prevent irritation or hardening of the skin and for better medication absorption. During an interview on 7/9/2026 at 2:45 PM with the Director of Nursing (DON), the DON stated rotation of injection sites was important for better absorption of medications and to decrease the risk of [skin] hardening of the site. During a review of the facility's policy and procedure (P&P) titled Insulin Administration, revised September 2014, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated injection sites should be rotated. During a review of the facility's P&P titled Medication and Treatment Orders, revised July 2016, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. b. During a review of Resident 88's FS, the FS indicated Resident 88 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral or fungal infection), dysphagia (difficulty swallowing), and gastrostomy (surgical procedure that creates a small opening directly into the stomach through the abdominal wall.) During a review of Resident 88's MDS dated [DATE], the MDS indicated Resident 88 had moderately impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) for bathing and toileting. During an interview on 7/8/2026 at 7:17 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated LVN 4 finished administering Resident 88's morning medication. During an interview on 7/8/2026 at 9:52 AM with LVN 4, LVN 4 stated LVN 4 began to pass morning medication at the start of the shift, at 7 AM. LVN 4 stated Resident 88's morning medications were due to be administered at 9 AM but were given at approximately 7:30 AM. LVN 4 stated Resident 88's medications due at 9 AM could be given any time between 8 AM and 10 AM. LVN 4 stated it was not part of the normal routine to administer Resident 88's medication early and medications should be given at the right time to make sure the effects of the medication are spread evenly day to day because it could affect the systems of the body. LVN 4 stated the indicated time was part of the doctor's order and it was important to follow the parameters set by the doctor. During a review of Resident 88's Medication Administration Record (MAR) for the month of July 2026, dated from 7/1/2026 to 7/31/2026, the MAR indicated the following medications were due to be administered at 9 AM: Aspirin chewable tablet (used to help prevent blood clots), 81 milligram (mg, unit of weight) ). Give one tablet via gastrostomy tube (G-tube, medical device inserted through the abdomen directly into the stomach to deliver nutrition, hydration, and medication), one time a day for peripheral vascular disease (PVD, slow and progressive disorder of narrowed blood vessels from a buildup of plaque) order date 5/4/2026. Enoxaparin Sodium (blood thinner) Injection 40 mg per 0.4 milliliters (ml – unit of volume). Inject 40 mg subcutaneously (under the skin) one time a day for deep vein thrombosis (serious condition where a blood clot forms in a deep vein, usually in the lower leg or thigh) order date 5/24/2026. Folic Acid (vitamin supplement) 1 mg tablet. Give 1 tablet via G-tube one time a day for anemia. Order date 5/4/2026. Polyethylene Glycol (over the counter laxative) 3350. Give 1 scoop via G-tube one time a day for bowel management. Hold if loose stool. Mix with 8 ounces of water. Order date 5/4/2026. Vitamin C (vitamin supplement) oral liquid. Give 10 ml via G-tube one time a day for wound healing/care for 90 days. Order date 6/8/2026. Baclofen Tablet (muscle relaxant) 10 mg. Give 1 tablet via G-tube two times a day for muscle spasms. Order date 5/4/2026 Insulin Glargine solution pen-injector 100 unit/ML. Inject 45 units subcutaneously two times a day for Diabetes Mellitus type 2. Order date 5/4/2026 Docusate Sodium 100 mg oral tablet. Give 1 tablet via G-tube two times a day for bowel management. Order date 5/4/2026 Senna 8.6 mg tablet. Give 1 tablet via G-tube two times a day for bowel management. Order date 5/4/2026 During an interview on 7/9/2026 at 3:21 PM with the Director of Nursing (DON), the DON stated the facility had policy to give medications one hour before or one hour after the scheduled time because it was part of the doctor's order. The DON state the medication administration time could change the effectiveness of the medication. The DON stated especially when the medication ordered once a day, the medication administration time need to be spaced out evenly. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P further indicated medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in one of one kitchen (Kitchen 1) when on 7/6/2026, seven waffle packages were not dated.This deficient practice had the potential to result in foodborne illness (an illness caused by eating contaminated food) to the residents being served and consuming the undated waffles.Findings:During an initial tour of Kitchen 1 and concurrent interview on 7/6/2026 at 8:48 AM with the Dietary Supervisor (DS), seven packages of round light tan colored grid- patterned texture patties were observed inside Kitchen 1's freezer and did not have an expiration date or indicate a use-by-date (the final date recommended by the maker for a consumer to use a product while it remains at peak quality, flavor, and texture).During an interview on 7/8/2026 at 12:04 PM with the DS, the DS stated labeling food with use-by-dates was important to ensure food did not lose its texture or flavor. The DS stated food could be stale (food that has lost its original freshness, flavor, or crispness due to age or exposure to air) if eaten after the use-by-date date.During an interview on 7/9/2026 at 2:42 PM with the Director of Nursing (DON), the DON stated [stored] food should have expiration or use-by-dates to ensure food [remained] fresh and safe for residents to eat.During a review of the facility's undated policy and procedure (P&P) titled Dating and Labeling, the P&P indicated to ensure food safety and prevent contamination with the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas. The P&P indicated no food item that is expired or beyond the best buy date are [kept] in stock.

Based on observation, interview and record review, the facility failed to implement infection control practices for three of three (Resident 2, Resident 83, and Resident 88) sampled residents by:a. Failing to ensure a trash can full of trash to the brim with used PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) gowns was not kept at Resident 2's bedside. b. Failing to ensure infections control interventions were implemented when on 7/6/2026, Respiratory Therapist (RT) 1 did not use a face shield while providing tracheostomy (a surgically created hole in your windpipe to allow air to your lungs) care to Resident 83, who was a carrier of Carbapenem-Resistant Acinetobacter Baumannii (CRAB, a highly dangerous, multi-drug resistant [MDRO] superbug bacteria [microscopic, single celled living organism some can cause disease]) and on contact isolation (a set of infection control practices used to stop the spread of germs requiring healthcare workers and visitors to wear protective equipment [face shields]). c. Failing to ensure Licensed Vocational Nurse (LVN) 4 wore PPE while handling Resident 88's gastrostomy tube (G-tube, soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely) who was on Enhanced Barrier Precautions (EBP- extra measures, like wearing gowns and gloves, used during high-contact care activities for residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDRO], and antibiotics (medications used to treat infections [the invasion and growth of germs in the body]) can no longer be used to control or kill the bacteria]). These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and the spread infections) to Resident 2, Resident 83, and Resident 88. Findings: a. During a review of Resident 2's Face Sheet (FS, admission record), the FS indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including dependence on respirator (ventilator - a medical device to help support or replace breathing) status, and encounter for attention to tracheostomy. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 2's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 2 was dependent (helper does all of the effort) for activities of daily living. During a review of Resident 2's History and Physical (H&P), dated 4/27/2026, the HP indicated Resident 2 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 7/6/2026 at 10:15 AM with Registered Nurse (RN) 1, Resident 2's room had a Contact Precautions (infection control measures used to stop the spread of germs that pass easily from person to person) signage posted on the door. Next to Resident 2's left side of the bed, there was a tall gray colored trash can full of trash to the brim with disposed PPE gowns. RN 1 stated the trash can should be kept away from Resident 2's bed. RN 1 stated, keeping the trash away for Resident 2's bedside was important to avoid infections (the invasion and growth of germs in the body). During an interview on 7/8/2026 at 11:14 AM with Certified Nursing Assistant (CNA) 3, CNA 3 stated trash cans were dirty and should be kept by the door exit of the resident's (in general) room and should not be left close to the resident's bed. CNA 3 stated this was important to prevent cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect). During an interview on 7/9/2026 at 9:05 AM with the Director of Nursing (DON), the DON stated putting the trash can close to the exit of Resident 2's room was important for infection control and leaving the trash can next to Resident 2's bedside was not ok, since the trash was soiled and Resident 2's room was on Contact Precautions. During an interview on 7/9/2026 at 11:36 AM with the Infection Preventionist (IP), the IP stated a trash can should be kept away from resident's bed and belongings and should be kept by the sink or by the door of the resident's room. The IP stated this was important to prevent cross contamination among the residents and staff (in general). The IP stated, a trash can kept at the resident's bedside was not a good sight and keeping the trash can away from the resident's bedside was important for infection control, and to ensure everything is tidy. During a review of the facility's undated lesson plan titled Infection Control, dated 7/1/2026, the lesson plan indicated the purpose and objectives were to teach safe, effective infection control practices to prevent the spread of pathogens (any organism that can produce disease) in long-term care settings. The lesson plan's learning objectives indicated to follow isolation precautions (standard, contact). b. During a review of Resident 83's FS, the FS indicated Resident 83 was admitted to the facility on [DATE] with diagnosis that included carrier of CRAB, respiratory failure (lungs cannot get enough oxygen into the blood), dependance of respirator, resistance to multiple antibiotics (a powerful medication used to treat bacterial infections). During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 83 was dependent on staff with oral and toilet hygiene and upper and lower body dressing. During a review of Resident 83's Order Summary Report (OSR), dated active as of 7/8/2026, the OSR included a physician order, dated 4/26/2022, the order indicated to suction to maintain a patent airway: oral removal of saliva. The OSR included a physician order, dated 11/24/2026, the order indicated contact isolation for CRAB in the sputum (mixture of saliva and thick mucus). During an observation inside Resident 83's room on 7/6/2026 at 2:25 PM, Respiratory Therapist (RT) 1 was observed providing respiratory care to Resident 83 by suctioning the resident's tracheostomy tube. RT 1 was not wearing a face shield. During an interview on 7/6/2026 at 2:35 PM with the IP, the IP stated contact isolation precautions were necessary for staff assisting residents with CRAB. The IP stated RT 1 needed to wear a face shield because suctioning and oral care involved sputum and/or saliva, which could result in splashing risking spreading of infections to other residents. During an interview with the DON, on 7/9/2026 at 2:43 PM, the DON stated it was important for RT 1 to wear full PPEs when caring for Resident 83 to minimize the risk of spreading infection and for the safety of all [residents]. During a review of Resident 83's care plan (CP), dated 6/19/2026, the CP indicated Resident 83 was at high risk for infection secondary to: presence of tracheostomy tube and CRAB (sputum). During a review of Resident 83's CP, dated 8/26/2024, the CP indicated Resident 83 was on contact isolation for CRAB of sputum. The CP's interventions indicated donning (putting on) and doffing (take off) of necessary PPE prior to entering room and before exiting. During a review of the facility's undated Policy and Procedure (P&P) titled Persona Protective Equipment – Using Protective Eyewear, the P&P's purpose indicated to guide the use of protective eyewear. The P&P's objectives indicated to protect employees from splashes, spattering, spraying, droplets of blood, body fluids, or other potentially infectious materials. The P&P's equipment and supplies indicated: face shields. During a review of the facility's P&P titled Multidrug-Resistant Organisms, dated 2001, the P&P indicated appropriate precautions are taken when caring for individuals known or suspected to have infection with a MDRO. During a review of the facility's lesson plan titled Infection Control, dated 7/1/2026, the lesson plan indicated the purpose and objectives were to teach safe, effective infection control practices to prevent the spread of pathogens (any organism that can produce disease) in long-term care settings. The lesson plan's learning objectives indicated to follow isolation precautions (standard, contact) and to use PPE correctly by properly donning (putting on) and doffing (removing) PPEs. c. During a review of Resident 88's FS, the FS indicated Resident 88 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection), dysphagia (difficulty swallowing), and gastrostomy. During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 had moderately impaired cognition and was dependent (helper does all of the effort) for bathing and toileting. During a review of Resident 88's OSR, dated active as of 7/8/2026, the OSR indicated Resident 88 had an order for EBP, dated 5/4/2026. During a review of Resident 88's CP, revised 12/27/2024, target date 8/2/2026, the CP indicated Resident 88 was on EBP and was a moderate risk for infection. The CP indicated providing Resident 88 with EBPs [by using] gloves, gowns, and masks. During a medication pass observation on 7/8/2026 at 12 PM in Resident 88's room with LVN 4, LVN 4 was administering medications via Resident 88's G-tube without the use of a gown. During an interview on 7/9/2026 at 3:21 PM with the DON, the DON stated nurses needed to wear gowns when administering medications to Resident 88 under EBP due to the potential for splashing bodily fluids from the G-tube and the splash getting onto staff clothing and potentially spreading germs to other residents. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 6/5/2024 the P&P indicated EBPs are utilized to prevent the spread of multi-drug resistant organisms. The P&P indicated EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The P&P indicated examples of high-contact resident activities requiring the use of gown and gloves for EBPs included: device care or use (feeding tube [G-tubes]).

Based on observation, interview, and record review, the facility failed to ensure a documented clinical diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and specific indication for the use of Lexapro, for one of one sampled resident (Resident 100), prior to the administration of a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior), Lexapro (drug used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]).This deficient practice could potentially result in Resident 100 receiving an unnecessary medication resulting in severe adverse effects (undesired harmful effect resulting from a medication) and a physical decline to Resident 100.Findings:During a review of Resident 100's Face Sheet (FS, admission record), the FS indicated Resident 100 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including end stage renal disease (ESRD - irreversible kidney failure), and anxiety disorder (a mental health condition where a person experiences intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 100's History and Physical (H&P), dated 4/29/2026, the H&P indicated Resident 100 did not have the capacity to understand and make decisions.During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 100's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 100 had no symptoms of having little interest or pleasure in doing things, feeling down, depressed or hopeless. The MDS indicated Resident 100 was dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 100 had no active diagnosis of depression but was taking an antidepressant medication.During a review of Resident 100's Progress Notes (PN), dated 5/1/2026 to 6/21/2026, the PN did not indicate Resident 100 was feeling sad or verbalized sadness.During a review of Resident 100's Order Summary Report (OSR), active orders as of 7/8/2026, the OSR indicated an order on 6/21/2026 for Lexapro oral tablet five (5) mg (milligrams - metric unit of measurement), give one tablet by mouth at bedtime for depression m/b (manifested by) verbalization of sadness.During an observation and interview on 7/8/2026 at 10:40 AM inside the activity/dining room, the room had multiple residents doing activities, Resident 100 was calm and sitting up in a wheelchair looking at a tablet computer. Resident 100 stated Resident 100 was feeling bien [fine].During a concurrent interview and record review on 7/8/2026 at 3:04 PM with Registered Nurse (RN) 2, Resident 100's medical records and the Nurse Practitioner's (NP) PN, dated 7/5/2026, timed at 11:24 AM, were reviewed. RN 2 stated the NP came to the facility once a month to cover for the Psychiatrist (a medical doctor who specializes in mental health [MD]) 2. The PN indicated Resident 100 was currently on Lexapro 5 mg that helped Resident 100's anxiety and mood. RN 2 stated the PN did not indicate Resident 100 had a diagnosis of depression. RN 2 stated Lexapro was originally ordered on 4/3/2026 for anxiety as m/b restlessness and trichotillomania (hair-pulling disorder). RN 2 stated Resident 100's Lexapro ordered on 6/21/2026 for depression m/b verbalization of sadness was ordered by Resident 100's Primary Physician (MD) 1. RN 2 stated clarifying the Lexapro order with MD 2 was important to verify a proper diagnosis of depression and prevent potential side effects of Lexapro to Resident 100.During an observation and interview on 7/9/2026 at 8:46 AM with Resident 100, Resident 100 was awake and alert, resting in bed watching tv. Resident 100 stated Resident 100 was feeling [NAME] bien [very well].During an interview on 7/9/2026 at 8:51 AM with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 100 was goofy, liked to do fist bumps, liked to watch tv Telemundo, liked coffee and liked getting out of bed. CNA 4 stated CNA 4 had not observed Resident 100 being reclusive, he's very outgoing, and Resident 4 had not expressed feeling depressed since CNA 4 had taken care of Resident 100.During a concurrent interview and record review on 7/9/2026 at 9:05 AM with the Director of Nursing (DON), Resident 100's Lexapro order and MD 2's Multidisciplinary Progress Record (MPR), dated 4/3/2026, was reviewed. The DON stated the clinical indication for Lexapro was for depression or anxiety. The DON stated for Resident 100, Lexapro was specifically ordered for depression manifested by verbalization of sadness for Resident 100. The DON stated the MPR did not indicate Resident 100 had a diagnosis of depression. The DON stated verbalization of sadness alone was not an indication for depression. The DON stated clarifying the Lexapro order with Resident 100's physician, specifically with MD 2 was important to ensure Lexapro was really indicated because Lexapro could have been an unnecessary medication.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. During a review of the facility's P&P titled, Psychotherapeutic Drug Informed Consent, date revised January 2026, the P&P indicated the attending physician and/or prescriber must evaluate the resident to determine the need for psychotherapeutic drugs or physical restraints.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan (CP) for one of two sampled residents (Resident 10), when floor mats (a removable piece of soft material placed on the floor near the bedside for residents who were high risk for falls) were missing on Resident 10's bedside on 7/9/2026 as indicated in Resident 10's Falling Star Program CP, initiated 5/8/2026.This deficient practice had the potential to result in unmet individualized needs for Resident 10 and the potential to affect the resident's physical and psychosocial well-being.Cross Reference F689 Findings:During a review of Resident 10's admission Record (AR), dated 7/9/2026, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, and history of falling.During a review of Resident 10's History and Physical (H&P), dated 5/7/2026, the H&P indicated Resident 10 had the capacity to understand and make decisions.During a review of Resident 10's Change of Condition (COC, an alteration in a resident's physical health that differs from their previous baseline), dated 5/8/2026, the COC indicated Resident 10 had a witnessed fall on 5/8/2026 at 12:35 PM. During a review of Resident 10's Rehab [rehabilitation] Fall Risk Assessment (FRA), dated 5/8/2026, the FRA indicated a floor mat was a useful intervention to implement post Resident 10's fall.During a review of Resident 10's Falling Star Program CP, initiated 5/8/2026, the CP indicated Resident 10 was at risk for falls. The CP's interventions indicated floor mats for Resident 10.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 10 had mild cognitive (the ability to think and process information) impairment. The MDS indicated Resident 10 needed maximal assistance (a helper does more than half the effort of the activity) for toileting hygiene, shower/bathing, and lower body dressing.During a concurrent interview and record review on 7/9/2026 at 10:45 AM with Registered Nurse (RN) 3, Resident 10's electronic record was reviewed. RN 3 stated Resident 10's CP, dated 5/8/2026, indicated that the use of floor mats as part of nursing interventions for Resident 10. RN 3 stated the purpose of floor mats was to prevent Resident 10 from getting hurt because Resident 10 already had a history of falls.During a concurrent observation and interview on 7/9/2026 @ 10:51 AM with RN 3 inside Resident 10's room, RN 3 stated there were no floor mats placed on either side of Resident 10's bed. RN 3 stated there should be floor mats based on the current nursing interventions indicated in Resident 10's CP.During an interview on 7/9/2026 at 11:50 AM with the DON, the DON stated CPs were the nursing staff's bible because it directed the staff on what type of care needs were required for the resident (in general). The DON stated CPs must be specific to a resident, and all licensed nurses were responsible for creating, updating, [and implementing], CPs.During a review of the facility's undated policy and procedure (P&P) titled, Falling Star Program, the P&P indicated appropriate interventions will be provided, including.Care Plan.[and] low bed with floor mat.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated assessments of residents are ongoing and care plans are revised as needed. The P&P further indicated the interdisciplinary team reviews and updates the care plan.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 24), who was unable to carry out activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain personal grooming as indicated in the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting.This deficient practice had the potential to result in bacterial (microscopic, single celled living organism some can cause disease) growth possibly leading to oral infections (the invasion and growth of germs in the body) and the potential to impact Resident 24's overall health and well-being.Findings:During a review of Resident 24's Face Sheet (FS, admission record), the FS indicated Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified, and dysphagia (difficulty swallowing), unspecified.During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 24's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 24 was dependent (helper does all of the effort) with ADL.During a review of Resident 24's History and Physical (H&P), dated 6/30/2026, the H&P indicated Resident 24 did not have the capacity to understand and make decisions.During a review of Resident 24's care plan (CP), initiated 5/24/2023, revised 10/07/2024, the CP indicated Resident 24 had self-care deficits. The CP's interventions indicated assisting Resident 24 with ADLs as needed and dental/oral care BID (twice a day) and PRN (as needed).During an observation on 7/6/2026 at 10:37 AM, Resident 24's room had an EBP (Enhanced Barrier Precautions, an infection [the invasion and growth of germs in the body] control practice to prevent the spread of bacteria in nursing homes) signage posted outside of Resident 24's room. Resident 24 was lying in bed with light brownish sputum (a mixture of saliva and thick mucus) drooling from Resident 24's left side of the mouth.During an observation on 7/6/2026 at 10:55 AM, a female staff (unidentified) had a double hamper and entered Resident 24's room.During an observation on 7/6/2026 at 11:04 AM, the unidentified female staff exited Resident 24's room. Resident 24 had light brownish sputum drooling from Resident 24's left side of the mouth.During a concurrent observation and interview on 7/6/2026 at 12:18 PM with Registered Nurse (RN) 1, Resident 24 was lying in bed with light brownish sputum drooling from Resident 24's left side of the mouth. RN 1 stated providing oral care to Resident 24 was important and was part of grooming and care for Resident 24 to look presentable.During an interview on 7/8/2026 at 11:14 AM with Certified Nursing Assistant (CNA) 3, CNA 3 stated oral care was part of ADL and was important to prevent aspiration and breakdown of the gums.During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, revised date March 2018, the P&P indicated residents who were unable to carry out ADL independently would receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.

Based on interview and record review, the facility failed to ensure furosemide oral tablets [a loop diuretic (water pill) used to treat fluid retention (edema) caused by heart failure, liver disease, or kidney conditions, and to manage high blood pressure] were refilled in a timely manner for one of one sampled residents (Resident 4).This deficient practice had the potential for Resident 4 to experience symptoms of fluid overload (occurs when the body retains too much water and sodium [salt]) such as shortness of breath and increased edema (swelling) to the lower legs.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (when the lungs cannot get enough oxygen into the bloodstream) and acute pulmonary edema (buildup of fluid in the lungs) and acute on chronic diastolic congestive heart failure (severe worsening of a long-standing inability of the heart to relax and fill properly).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, the MDS indicated Resident 4 had intact cognition (ability to understand and process information) and dependent (helper does all the effort) on staff for bathing and toilet.During a review of Resident 4's Order Summary Report (OSR) dated with active orders as of 7/9/2026, the OSR indicated an order for furosemide oral tablet 20 milligrams (mg, unit of weight), give 1 tablet by mouth one time a day for heart failure. Hold if systolic blood pressure (SBP, maximum pressure exerted against the artery walls when the heart beats and pumps blood into the body) less than 100 with a start date of 6/20/2026.During a review of Resident 4's undated Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) for risk for respiratory distress, the CP indicated Resident 4 was at risk for respiratory distress with increased respiration and visible labored breathing. The CP intervention was to administer furosemide as ordered.During a concurrent interview and record review on 7/9/2026 at 1 PM with Registered Nurse (RN) 2, Resident 4's Medication Administration Record (MAR) dated 7/1/2026 - 7/31/2026 was reviewed. The MAR indicated Resident 4 did not receive furosemide oral tablets on 7/3/2026, 7/4/2026 and 7/6/2026. RN 2 stated Resident 4 did not receive furosemide oral tablets because the facility was pending delivery of the refill from the pharmacy. RN 2 stated it was not clear why the medication had not been filled earlier because there was no documentation and refills typically took only one day to be delivered. RN 2 stated nurses (in general) should document when communicating with pharmacy staff, so everyone knows what is happening. RN 2 stated documentation also showed evidence that nursing staff completed their duty to refill residents' medication.During an interview on 7/9/2025 at 3:21 PM with the Director of Nursing (DON), the DON stated nursing (in general) is supposed to refill medications when there are four to five days of medication left to ensure the medication would be available to the residents. The DON stated Resident 4 should have had the furosemide oral tablets available because without the medication, Resident 4 could feel worse due to fluid overload (occurs when the body retains too much water and sodium [salt].)During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 1/2022, the P&P indicated medications and related products are received from the dispensing pharmacy on a timely basis. If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand.

Based on observation and interview, the facility failed to ensure a call light was within reach for one of one sampled resident (Resident 39).This deficient practice had the potential to result in unmet needs for Resident 39 due to the resident being unable to call for staff assistance.Findings:During a review of Resident 39's admission Record (AR), the AR indicated Resident 39 was admitted to the facility on [DATE] with a diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified mood [affective] disorder (a mental health conditions characterized by persistent shifts in emotional state, such as profound sadness, extreme elation, or anger), history of falling, syncope and collapse (fainting or passing out), and major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest).During a review of Resident 39's History and Physical (H&P), dated 3/4/2026, the H&P indicated Resident 39 did not have the capacity to understand and make decisions.During a review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/10/2026, the MDS indicated Resident 39's cognition (the ability to think and process information) was severely impaired. During an observation on 7/7/2026 at 9:33 AM in Resident 39's room, Resident 39 was sitting on the edge of the bed with Resident 39's feet on the floor. Resident 39 stated Resident 39 needed to go to the bathroom and didn't know where Resident 39's call light was located. The call light was not accessible to Resident 39 and located on the floor on the opposite side of Resident 39.During an interview on 7/7/2026 at 9:48AM with Registered Nurse (RN) 5, RN 5 stated the importance of the call light [being accessible to the residents] was for the residents (in general) to call for staff help.During a review of the facility's Policy and Procedure (P&P) titled, Call System, Resident, dated September 2022, the P&P indicated Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on the ground, or lower level) for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, by failing to:1. Implement a resident-centered fall prevention plan of care for Resident 1.2. Monitor Resident 1's response to fall prevention interventions. 3. Assess the causative factors of Resident 1's multiple falls per Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments).As a result, on 9/3/2025 at 9:45 AM, Resident 1 fell onto the floor mat on the right side of the bed. Resident 1 sustained a fracture (a break or crack in a bone) in the subtrochanteric left femur extending into the less trochanter (near the left hip and upper part of the thigh bone), and a nondisplaced fracture through the right intertrochanteric region (break in the upper part of the thigh bone where the fragments remain aligned and in their normal position). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 9/3/2025 at 10:28 AM.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encephalopathy (brain disorder that affects normal function leading to a range of symptoms like confusion, memory problems, and physical symptoms such as tremors or difficulty walking) and type 2 diabetes (condition in which the body cannot properly store or use sugar, the body's main source of energy).During a review of Resident 1's untitled Care Plan Report (CP), date initiated5/8/2025 and revised on 6/9/2025, the CP indicated Resident 1 had altered behavior patterns related to constant attempts to get out of bed unassisted and was at risk for falls. The CP's interventions indicated to assess what may cause and trigger Resident 1's behavior; attempt to reduce/ eliminate those triggers if possible. The CP's goal was to reduce the episodes of behavior daily and minimize the risk of decline daily through the next assessment on 11/3/2025.During a review of Resident 1's Licensed Nursing Note (LNN), dated 7/24/2025 at 11:34 AM, the LNN indicated Resident 1 was found in Resident 1's room, sitting on the floor mat and holding onto the [bed's] side rail.During a review of Resident 1's Interdisciplinary Team (IDT, a group of different healthcare professionals who meet to plan, coordinate, and implement a resident's care) - Narrative - Other Concerns (IDTN), dated 7/25/2025, the IDTN indicated the interdisciplinary (two or more professionals or departments) team conference was conducted due to Resident 1's fall incident that occurred on 7/24/2025. The IDTN indicated the facility implemented the following interventions: low bed, floor mats on each side of the bed, call light within resident's reach, bed alarm, room near the nurse's station, bilateral upper side rails, physical therapy reassessment for bed mobility training, improved body mechanics, sequencing of movements, and safety with completing transfers. The IDTN further indicated to have Resident 1 out of bed with structured activities to promote socialization and engagement.During a review of Resident 1's LNN dated 8/27/2025 at 9 PM, the LNN indicated Resident 1's bed alarm was beeping, and Resident 1 was noted attempting to get out of bed and was found leaning on the bed's side rails. The LNN indicated Resident 1 had episodes of getting out of bed and attempted to self-transfer, but the LNN did not indicate the number of episodes or if the episodes had increased or decreased.During a review of Resident 1's untitled CP, date initiated 8/27/2025 and revised 8/29/2025, the CP indicated Resident 1 had altered behavior patterns related to: Resident 1 attempting to get out of bed. The CP's interventions indicated to assess what may cause behavior and what may trigger Resident 1's behavior; attempt to reduce/ eliminate those triggers if possible. The CP's goal was to reduce the episodes of behavior daily through the next assessment and minimize the risk of decline daily through the next assessment on 11/3/2025.During a review of Resident 1's IDTN dated 8/28/2025, the IDTN indicated an interdisciplinary team conference was conducted due to Resident 1 sliding from the bed onto the floor mat on 8/27/2025. The IDTN indicated the facility implemented and exhausted multiple interventions to promote safety and the current plan of care would remain in place and be monitored for effectiveness. The IDTN did not indicate any new fall prevention interventions.During a review of Resident 1's Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions), dated 9/3/2025, the COC indicated on 9/3/2025 at 9:43 AM, the charge nurse was in the hallway and heard Resident 1's bed alarm sounding inside Resident 1's room. The COC indicated Licensed Vocational Nurse (LVN) 2 found Resident 1 lying on the floor mat. The COC indicated Resident 1 was noted with a small skin tear on the left elbow and Resident 1 complained of 10 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) bilateral (relating to both sides) hip pain. The COC indicated 911 was called and Resident 1 was transferred to GACH 1 on 9/3/2025, at 10:15 AM.During a review of Resident 1's GACH 1's History and Physical Reports (HPR) dated 9/3/2025, the HPR indicated Resident 1 was taken to GACH 1 via ambulance due to an unwitnessed fall from Resident 1's bed. The HPR indicated Resident 1 was a poor historian and not able to answer questions but complained of pain on both lower extremities (legs). The HPR indicated Resident 1 underwent an X-ray (form of electromagnetic radiation used to create images of inside the body) of the hip which showed an acute (recent) displaced comminuted fracture (severe bone injury where the bone is broken into multiple pieces and misaligned) in the left hip and a nondisplaced fracture (broken bone where the fragments remain in their normal position) through the right hip.During a review of Resident 1's IDTN dated 9/4/2025, the IDTN indicated an interdisciplinary team conference was conducted due to Resident 1's unwitnessed fall on 9/3/2025. The IDTN indicated the facility continued to implement the least restrictive measure to promote resident safety and dignity. The IDTN did not indicate any new fall prevention interventions.During an interview on 9/9/2025 at 9:49 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 did not like to stay in bed and had a history of fidgeting behaviors. RN 1 stated Resident 1 could independently move from a sitting to standing position but was unsteady. RN 1 stated Resident 1 was often kept at the nurse's station for close monitoring and only brought back to the room if Resident 1 requested. RN 1 stated the facility did not use sitters (a healthcare worker who provides continuous, non-medical supervision to residents to ensure their safety and prevent incidents like falls). RN 1 further stated RN 1 did not know if Resident 1 would say what Resident 1 wanted when attempting to get up because Resident 1 only spoke Spanish and RN 1 would need someone to translate.During an interview on 9/9/2025 at 12:10 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 did not like to stay in the room or be in bed. CNA 1 stated that as soon as Resident 1 was awake, Resident 1 was trying to get out of bed. CNA 1 stated Resident 1 was usually at the nurse's station or in activities because Resident 1 was at a high fall risk and needed close monitoring. CNA 1 stated Resident 1 would even attempt to stand while Resident 1 was in the wheelchair. CNA 1 further stated Resident 1 only stayed in bed if Resident 1 was really tired or sleeping.During an interview on 9/9/2025 at 12:41 PM with RN 2, RN 2 stated Resident 1 was known to have a history of trying to get out of bed, self-transferring (transfer from bed to chair without assistance from staff) and usually made attempts to get out of bed early in the morning. RN 2 stated Resident 1 attempted to get out of bed as soon as Resident 1's eyes opened [in the early morning] and Resident 1 loved to socialize and spend time in activities.During an interview on 9/9/2025 at 1 PM with the Physical Therapy Director (PTD), the PTD stated prior to Resident 1's fall on 9/3/2025, Resident 1 had received physical therapy for strengthening exercises and was working with Resident 1 to stand for long periods of time, balancing, and walking with a walker up to 50 feet. The PTD stated prior to Resident 's fall on 9/3/2025, Resident 1's strength had improved, and Resident 1 was able to complete sit-to-stand exercises with minimum assistance but required one person assistance due to Resident 1's impulsiveness, poor balance and trunk control.During an interview on 9/10/2025 at 10:36 AM with LVN 2, LVN 2 stated Resident 1 was sleeping just prior to the fall that occurred on 9/3/2025 and LVN 2 was frequently rounding (visually checking on Resident 1) every 15 minutes to check on Resident 1. LVN 2 stated, LVN 2 was in the hallway near Resident 1's room and heard the bed alarm sounding. LVN 2 stated Resident 1 was discovered in the room, on the floor on the right side of the bed with Resident 1's full body parallel to the bed. LVN 2 stated Resident 1 had facial grimaces and cried in pain. LVN 2 stated Resident 1's fall was unavoidable because Resident 1 was already under frequent monitoring every 15 minutes and the facility does not use sitters. LVN 2 stated the staff (in general) all knew Resident 1 was at high risk of falls and knew Resident 1 moved around a lot, so staff frequently monitored Resident 1 as much as possible. LVN 2 stated Resident 1's most effective fall prevention interventions were the bed alarm and close monitoring.During an interview on 9/10/2025 at 11:06 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 1 was very active and liked to sit up a lot. CNA 2 stated the morning of 9/3/2025, CNA 2 was checking on Resident 1 when in bed every 10 to 20 minutes. CNA 2 stated Resident 1 was impulsive and often attempted to get up without asking for [staff] assistance even if a staff member was positioned next to Resident 1. CNA 2 stated Resident 1 would have benefitted from having a sitter for closer monitoring because of Resident 1's impulsiveness but the facility did not use sitters.During an interview on 9/10/2025 at 11:16 AM with the Director of Nursing (DON), the DON stated the facility re-evaluated fall preventions as needed and at least quarterly. The DON stated Resident 1 was a high fall risk and already had fall mats, bedside rails, a low bed and bed alarms in place prior to the fall on 7/24/2025 and the only fall prevention interventions changed after the 7/24/2025 fall was related to Resident 1's physical therapy. The DON stated more emphasis was given to Resident 1's bed mobility training during physical therapy but no other interventions were implemented. The DON stated after the fall on 8/27/2025, [the facility] continued the same interventions with minor changes in physical therapy for Resident 1. The DON stated after the fall on 9/3/2025, Resident 1 was moved to another room closer to the nurse's station but Resident 1's previous rooms were also located near the nurse's station. The DON stated the facility exhausted every option to prevent falls for Resident 1 and the facility did not use sitters. The DON stated the facility had evaluated the effectiveness of Resident 1's fall prevention interventions as indicated in the IDTN dated 8/28/2025. The DON stated Resident 1's fall prevention interventions were deemed effective because Resident 1 would have fallen more frequently without the interventions in place. The DON further stated there was no documentation to indicate interventions were monitored for effectiveness.During an interview on 9/10/2025 at 12:49 PM with the PTD, the PTD stated Resident 1's physical therapy goals had not changed from 7/2025 to 9/2025 and [the facility worked with] Resident 1 on bed mobility and strengthening exercises the entire time. The PTD stated there were slight differences in emphasis depending on Resident 1's progress but the big picture remained constant.During a concurrent interview and record review on 9/10/2025 at 3:18 PM with the Administrator (ADM), Resident 1's untitled CPs, dated 5/8/2025 and dated 8/29/2025, the CP indicated Resident 1 had altered behavior patterns related to attempting to get out of bed unassisted and expected behavior related to movement to floor mat were reviewed. The ADM stated Resident 1's fall prevention interventions listed in the CPs were standard interventions and the facility had done everything possible without resorting to restraints (devices or equipment used to a person's body to restrict their freedom of movement or normal access to their body). The ADM stated a sitter was provided to preserve Resident 1's dignity. When asked if the facility had assessed causative factors of Resident 1's behavior as indicated in the CPs, the ADM stated the ADM was not aware of causative factors and if causative factors were a listed intervention, it [the CPs] should have been followed. The ADM stated the facility treated the falls but did not look into the possible causes of the falls and did not know if Resident 1 had increased impulsive behavior leading to further falls.During a concurrent interview and record review on 9/10/2025 at 3:18 PM with the ADM, the facility's P&P titled, Falls and Fall Risk, Managing, dated 3/2018, was reviewed. The P&P indicated under Resident-Centered Approaches to Managing Falls and Fall Risk, 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident with a history of falls. The ADM stated Resident 1's fall prevention care plan indicated standard fall prevention interventions used for any resident that was at high risk for falls. The P&P further indicated under Monitoring Subsequent Falls and Fall Risk: 1. the staff will observe each resident's response to interventions intended to reduce falling or the risks of falling. The ADM stated the current interventions in place were effective because Resident 1 would have otherwise fallen more often. The ADM stated the facility did not have documented evidence to indicate fall prevention interventions were evaluated for effectiveness and the facility did not do the depth of evaluation that was perhaps needed.During a review of the facility's undated P&P titled, Falling Star Program, the P&P indicated recommendations to ensure a successful program included: evaluation for appropriate useful interventions for fall reduction.

Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - pressure reducing mattress) was placed at the correct setting for two of two sampled residents (Resident 86 and Resident 32). This deficiency had the potential to place Resident 86 and 32 at increased risk of developing pressure injuries. Findings: A. During a review of Resident 86's admission Record (AR), the AR indicated Resident 86 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including functional quadriplegia (complete immobility due to severe disability or frailty) and encephalopathy (disease or disorder of the brain, characterized. During a review of Resident 86's Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 86 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for toileting and rolling from left lying position to a right lying position. The MDS further indicated Resident 86 was at risk for developing pressure ulcers and had a pressure reducing device for the bed. During a review of Resident 86's Braden Scale for Predicting Pressure Sore Risk (BS), dated 3/26/2025, the BS indicated Resident 86 had a score of 8, very high risk. During a review of Resident 86's Order Summary Report (OSR) with active orders as of 6/12/2025, the Order Summary Report indicated a physician's order for low air loss mattress for wound care and management set at 160 every shift with order start date of 12/6/2024. During an interview on 6/11/2025 at 9:44 AM with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 86 had a LAL, indicated for residents that either had pressure injuries or to prevent a resident from developing pressure injuries. During a concurrent observation and interview on 6/11/2025 at 9:58 AM with Licensed Vocational Nurse (LVN) 3 in Resident 86's room, Resident 86's LAL setting of 200 was observed. LVN 3 stated the current observed setting was incorrect and the mattress should be set at 160 based on Resident 86's weight. LVN 3 stated the mattress settings were checked every day during morning rounds and LVN 3 did not know why it was at the incorrect setting. LVN 3 stated the purpose of the LAL was to prevent pressure injuries. During an interview on 6/12/2025 at 1:11 PM with the Director of Nursing (DON), the DON stated the LAL mattress was for residents at high risk of developing pressure injuries and was used to prevent the development or worsening of pressure injuries. The DON stated if the LAL setting was incorrect, the resident could develop pressure injuries or current injuries could worsen. During a review of the facility's policy and procedure (P&P) titled, Pressure-Reducing Mattress, undated, the P&P indicated the purpose of the mattress was to prevent and/or minimize pressure on the skin, and to offer enhanced comfort when preferred by the resident. The P&P further indicated to adjust the LAL to desired firmness based on the resident's weight. B. During a review of Resident 32's AR, the AR indicated the facility admitted Resident 32 on 2/19/2021, and re-admitted the resident on 5/26/2025, with diagnoses including, chronic respiratory failure with hypoxia (when the lungs are unable to adequately transfer oxygen into the bloodstream, resulting in a chronically low level of oxygen in the blood and tissues), metabolic encephalopathy (a change in how your brain works due to an underlying condition), and pressure ulcer of sacral region Stage 4 (a severe, deep wound that has extended through the skin and into the muscle, tendon, or even bone located at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]) region). During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognition was severely impaired. The MDS indicated Resident 32 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was dependent with mobility. During a review of Resident 32's Weights and Vitals Summary, dated 6/2/2025, indicated Resident 32's weight was 107 lbs. During an observation on 6/9/2025 at 10:49 a.m., Resident 32 was noted lying on a Low Air Loss Mattress (LALM), the digital control panel on the LALM was visibly illuminated and displayed a weight setting of 400 lbs. During an interview on 6/10/2025 at 12:50 p.m., Treatment Nurse (TN) 2 stated the purpose of the LALM was to help prevent pressure ulcers by redistributing the resident's body weight and reduce pressure on high-risk areas of the body. TN 2 stated the mattress was designed to automatically adjust air pressure based on the resident's weight input to ensure proper therapeutic support. TN 2 stated that accurately setting the mattress to the resident's actual weight was essential and when set correctly, the system maintained optimal pressure to prevent excessive force on bony prominences and other vulnerable skin areas. TN 2 stated if the weight was set significantly higher or lower than the resident's true weight, the mattress did not function effectively, thereby increasing the risk of skin breakdown, and the development or worsening of pressure injuries. During a review of Resident 32's Order Summary Report, dated 6/12/2025, the Order Summary Report indicated Resident 32 had an active physician's order for a LALM for wound care and management (LALM set @ 80) every shift. The Order Summary Report indicated the start date of the LALM order was 6/10/2025. During an interview on 6/12/2025 at 12:29 p.m., the Director of Nursing (DON) stated it was important to maintain the correct settings on LALM to ensure optimal care, especially for residents at high risk of pressure ulcers or skin breakdown. The DON explained these mattresses were designed to redistribute pressure, minimize friction, and deliver continuous airflow to the skin - critical for immobile or frail residents. The DON stated that incorrect settings could compromise the mattress's effectiveness, potentially leading to discomfort or worsening of pressure-related injuries. During a review of the facility's policy and procedure (P&P) titled, Pressure-Reducing Mattresses, undated, the P&P indicated to follow the manufacturer's instruction and adjust LALM to a desired firmness based on the resident's weight and/or using the hand check method as described: slide one hand with the thumb facing up, between two LALM air tubes to feel the space between the bed frame and resident's buttocks. The space should not be too tight or too loose, with an acceptable range of approximately 1-1.5 inches. During a review of the manufacturer's operation manual titled, Proactive Medical Products, undated, the operation manual for the Protekt Aire 4000DX / 4600DX / and 5000DX the weight / pressure set up indicated users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (promotes the appropriate use of antibiotics) for two of five sampled residents (Resident 21 and Resident 87) to monitor the use of antibiotics for unnecessary or inappropriate use and ensure protocols were in place to reduce the risk of adverse events, including the development of antibiotic-resistant organisms. For Resident 87's swelling of the tooth and for Resident 21's vaginal discharge, the proper antibiotic screening forms were not used to accurately determine if the residents met the criteria of a true infection. These deficient practices had the potential for residents to develop antibiotic -resistant organisms, from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was re-admitted to the facility on [DATE] with diagnoses including vascular dementia (loss of intellectual function) and generalized weakness. During a review of Resident 10's History and Physical (H&P), dated 10/27/2024, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Change in Condition (COC), dated 6/1/2025, the COC indicated the resident had a greenish vaginal discharge (bodily fluid produced by glands in the vagina and cervix), had no pain or discomfort, and a normal body temperature of 97.8 degrees. The COC indicated Resident 21's urine was yellow, had no foul odors, and no hematuria (blood in the urine). During a review of the Physician's Orders dated 6/1/2025, the order indicated Resident 21 was to receive Diflucan (an antibiotic) 100 milligrams (mg, unit of measurement) to be taken by mouth in the evenings for five days. During a review of Resident 21's Medication Administration Record (MAR), the MAR indicted Resident 21 was administered Diflucan 100 milligrams mg on 6/1 - 6/5/2025. During a review of Resident 21's Lab Results Report, for a urine culture (a laboratory test used to detect and identify bacteria or other microorganisms in a urine sample) / urine analysis with culture and sensitivity (a lab test used to identify bacteria or other microorganisms in a urine sample and determine which antibiotics are most effective in treating an infection caused by them) collected on 6/4/2025, indicated antibiotic therapy was not recommended without signs and symptoms of localizing to the urinary tract. During an interview with the Infection Control Nurse (ICN) on 6/11/2025 at 3:23 pm, the ICN stated the facility used the McGreer's criteria (a set of standardized definitions used for surveillance of infections in long-term care facilities) for infection surveillance based on the location of the possible infection. The ICN stated for Resident 21, the Surveillance Data Collection Form for other infections, (SDCF-[NAME], a McGreer's criteria infection analysis specified for certain areas of the body) was used. The ICN stated the McGreer's UTI surveillance form should have been used to screen Resident 21 to determine if antibiotics were needed because the resident had vaginal discharge potential to having a UTI. The ICN stated it was important to have the proper antibiotic (McGreer's) screening done to determine if antibiotic use was needed and to prevent the development of [NAME] drug resistant organism (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs). The ICN stated the ICN normally monitored every resident placed on an antibiotic to determine if the McGreer's criteria was met. The ICN stated, I missed it and did not have a chance to review for the month of June. b. During a review of Resident 87's AR, the AR indicated Resident 87 was admitted to the facility on [DATE] with diagnoses including neuralgia (intense, typically intermittent pain along the course of a nerve) and generalized weakness. During a review of the Physician's Orders dated 1/13/2025, it indicated Azithromycin (an antibiotic) 250 mg was to be given by mouth daily for four days, for a tooth infection. During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2025, indicated Resident 87 had moderate cognitive impairment, clear speech, usually understands and could be understood. The MDS indicated Resident 87 needed supervision (helper sets up and cleans up) with toilet needs, lower body dressing and sit to stand (ability to stand/sit from a chair). During an interview with the ICN on 6/11/2025, the ICN stated the nurse who completed the SDCF-[NAME] used the wrong antibiotic surveillance form. The ICN stated the correct antibiotic surveillance should be specified for skin / mucosal (__) because Resident 87 had an increased swelling of the tooth. The ICN stated it was important to complete the proper antibiotic screening forms to accurately determine if Resident 87 met the criteria of a true infection and qualified for the use of antibiotic. The ICN stated the ICN did not follow up and verify if the accurate antibiotic screening was done for Resident 87. During a review of Resident 87's MAR, the MAR indicted Resident 87 was administered Azithromycin on 6/12/2025. During a review of the facility's undated policy titled, Antimicrobial Stewardship Program, undated, indicated it was the policy of the facility to implement an Antimicrobial Stewardship program that would focus on coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optical antimicrobial drug regimen including dosing, duration of therapy and route of administration. The policy indicated the goal was to curb the emergence and spread of antimicrobial resurgent infection and the leadership team was to review and monitor antibiotic usage patterns on a regular basis. The policy indicated the IP was the designated person responsible for the implementation of the facility's infection Prevention and Control Program, collection, and review of the data. During a review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 4/2023, it indicated antibiotic usage and outcome data would be collected and documented using a facility-approved antibiotic surveillance tracking form. The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility - wide antibiotic stewardship.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 68 and Resident 31), were treated with dignity while eating. Resident 68, who had limited mobility, did not have a clothing protector, while having breakfast in bed. For Resident 31, Treatment Nurse 1 remained standing and did not position themselves at the resident's eye level while assisting with the lunch meal. This deficient practice resulted in Resident 68 having food and drink spillage on Resident 68 causing potential feelings of humiliation and embarrassment. For Resident 31, there was a potential feeling of disconnection and dominance or authority from the staff during the feeding process. Findings: a. During a review of Resident 68's admission Record (AR), the AR indicated Resident 68 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side and aphasia (a disorder that makes it difficult to speak). During a review of Resident 68's Alteration in Nutritional Status care plan dated 2/23/2023, the care plan interventions indicated to set up meal tray, assist and give verbal cues if needed, and up in chair to dining room at mealtime. During a review of Resident 68's History and Physical Examinations (H&P), dated 2/20/2025, the H&P indicated Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS, a resident assessment tool), dated 3/25/2025, the MDS indicated Resident 68's cognitive skills (ability to think and process information) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 68 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). During an observation on 6/10/2025 at 7:59 AM, Resident 68 was in bed having breakfast by herself. Resident 68 was using her right hand with no movement noted from her left hand. Resident 68 was drooling milk, had messy spills of food and drinks on Resident 68's chest, neck, gown, tray, bedside table and on Resident 68's maroon colored comforter, despite having a plate guard (a device used to prevent food from being pushed off the plate while eating to keep food contained on the plate and minimize spills or messes). Resident 68's plastic cup of milk was tipped over and milk spillage was on the tray. CNA 3 was observed feeding Resident 68's roommate while Resident 68 was eating breakfast. Resident 68 was within sight from the hallway. During a concurrent interview, CNA 3 stated CNA 3 was supposed to put something, a towel over Resident 68's chest to protect Resident 68. During an interview on 6/11/2025 at 9:45 AM, Registered Nurse (RN) 1 stated Resident 68 was able to feed herself and used a plate guard. RN 1 stated staff was supposed to put a towel over Resident 68's chest to protect Resident 68 from fluid or food dropping into Resident 68's gown. RN 1 stated a towel was also used for hygiene, wiping, and for dignity. b. During a review of Resident 31's AR, the AR indicated the facility admitted Resident 31 on 2/25/2021, and re-admitted the resident on 5/15/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and severe protein-calorie malnutrition (a condition where the body lacks sufficient protein and calories, leading to a breakdown of body tissues, muscle wasting, and fluid retention). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 44's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent (helper does all of the effort) with mobility. During an observation on 6/9/2025 at 12:30 PM, Resident 31 was observed lying in bed with the head of the bed in a semi-recumbent (lying down with the upper body elevated at an angle, typically between 30 and 45 degrees) position. Treatment Nurse (TN) 1 was positioned standing at the bedside, leaning over Resident 31 while providing feeding assistance. TN 1 was observed hovering above the resident, holding the spoon at an elevated angle, and did not assume a seated position or align at eye level with Resident 31 during the feeding process. During an interview on 6/9/2025 at 1:47 PM, Resident 31 stated that she could tell when staff were standing over her during meals. Even though she could not see them, she could feel it by the way they talked and how quickly they gave her each bite. Resident 31 stated it made her feel rushed, like she had to hurry up. Resident 31 noted that this did not happen all the time, but it did occur on occasion. Resident 31 expressed that she preferred when staff sat next to her and took their time, as it made her feel more at ease and not hurried. During an interview on 6/10/2025 at 1:37 PM, Treatment Nurse 1 stated she should have sat next to Resident 31 while assisting with the lunch meal on 6/9/2025. LVN 1 acknowledged that she should have grabbed a chair and sat beside the resident while feeding her. LVN 1 stated that sitting at eye level promoted dignity and helped the resident feel more comfortable. LVN 1 expressed understanding that maintaining a calm and supportive approach during mealtime enhanced the resident's overall experience and promoted person-centered care. During an interview on 6/12/2025 at 12:29 PM, the Director of Nursing (DON) stated the facility's expectation was for staff to uphold resident dignity during all aspects of care, including meal assistance. The DON explained that sitting at eye level while assisting a resident with meals enhanced comfort and promoted dignity. The DON emphasized that residents were expected to feel respected and supported, and staff was trained to provide that level of care consistently. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. The policy indicated that when assisting with care, residents were supported in exercising their rights. For example, residents were provided with a dignified dining experience. During a review of the facility's P&P titled, Resident Rights, dated 2/2021, the P&P indicated employees shall treat all residents with kindness, respect, and dignity.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident 2), was provided care in accordance with professional standards of practice by failing to conduct an Interdisciplinary Team (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) in accordance with the facility's policy and procedure (P&P) when Resident 2 had continuous episodes of hyperglycemia (high blood sugar). This deficient practice had the potential to result in Resident 2 developing serious health complications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type 2 diabetes mellitus (DM - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, anxiety (intense, excessive, and persistent worry and fear about everyday situations, and sepsis (a life threatening blood infection), unspecified organism. During a review of Resident 2's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 2's cognitive status (memory, orientation, and judgement of the resident) was severely impaired. The MDS indicated Resident 2's primary reason for admission was due to medically complex conditions and the resident had a feeding tube (e.g., nasogastric or abdominal [PEG]). During a review of Resident 2's trend of blood glucose (sugar) levels, dated 5/4/2025 to 5/14/2025, the trend indicated Resident 2's blood glucose levels ranged anywhere from 306 mg/dL (milligrams per deciliter - a unit of measurement used to express the concentration in blood glucose testing) to 500 mg/dL. During a review of Resident 2's undated Hospital Tracking Portal (HTP), the HTP indicated Resident 2 was transferred to the GACH for abnormal blood sugar. During a review of Resident 2's Discharge Summary Report (DSR), dated, 5/14/2025, timed at 10:55 a.m., the DSR indicated Resident 2 was discharged to the GACH for uncontrolled hyperglycemia. During a review of Resident 2's Order Summary Report (OSR), active orders as of 5/31/2025, the OSR indicated an order on 5/14/2025 for puree texture, nectar/mildly thick consistency oral diet small portion for three meals per day and an order on 5/8/2025 for enteral feed (a method of providing nutrition directly into the gastrointestinal tract through a feeding tube) Glucerna 1.2 at 53 cubic centimeter (cc- a unit of volume) per hour for 20 hours. During a concurrent interview and record review on 6/12/2025 at 11:26 a.m., with Registered Nurse (RN) 3, Resident 2's medical records were reviewed. RN 3 stated the facility did not have any IDT documentation for Resident 2's hyperglycemia. RN 3 stated there was a Change of Condition (COD) on 5/14/2025 for Resident 2's hyperglycemia. During a concurrent interview and record review on 6/12/2025 at 11:59 a.m., with the Director of Nursing (DON), Resident 2's blood glucose levels for May 2025 and medical records were reviewed. The DON stated the DON could not find any documentation that an IDT was conducted to address Resident 2's hyperglycemia. The DON stated an IDT was conducted if there were any issues or trend (in general). The DON stated there should have been an IDT conducted for Resident 2's hyperglycemia, adding her blood sugar is consistently high, it's uncontrolled. The DON stated it was important to conduct an IDT to discuss the issues, problems and identify and create appropriate interventions and to see if the interventions were working and the progress of the patient. During a review of the facility's undated policy and procedure (P&P) titled, IDT Conference, the P&P indicated the care plans would be reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments, and/or if there were any significant changes. The P&P indicated the content of the IDT would include but were not limited to areas reviewed including diagnosis / health condition.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 87) was free from a significant medication error. Facility staff opened a specially formulated (how the drug is prepared and put together to make it into a usable medicine that can be taken) antibiotic capsule which disrupted the time-release (when the medicine is designed to release small amounts of the drug into your body over a long period, rather than all at once) mechanism of the medication. This deficient practice resulted in Resident 87 receiving the medication in a manner that altered its intended pharmacokinetics (what your body does to a drug after you take it), potentially impacting its therapeutic effectiveness and increasing the risk of adverse effects. Findings: During a review of Resident 87's admission Record (AR), the AR indicated the facility admitted Resident 87 on 1/15/2025, with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and encephalopathy (a serious health problem that affects brain function or structure). During a review of Resident 87's Minimum Data Set (MDS - a resident assessment tool), dated 4/22/2025, the MDS indicated Resident 87's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 87 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with mobility. During a review of Resident 87's Order Summary Report (OSR), the OSR indicated to administer the following medications to Resident 87: a. Acetaminophen Oral Tablet 500 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth one time a day for pain management due to rheumatoid arthritis. Start Date: 3/21/2025. b. Amlodipine Besylate Tablet 5 mg give 1 tablet by mouth one time a day for hypertension, hold if systolic blood pressure (SBP - the pressure in the arteries when the heart contracts and pumps blood throughout the body) less than 110. Start Date: 1/16/2025. c. Claritin Oral Tablet 10 mg (Loratadine) give 1 tablet by mouth one time a day for itchiness. Start Date: 3/18/2025. d. Colchicine Tablet 0.6 mg give 1 tablet by mouth one time a day every other day for gout. Start Date: 1/16/2025. e. Folic Acid Tablet 1 mg give 1 tablet by mouth one time a day for supplement. Start Date: 1/16/2025. f. Multiple Vitamins - Minerals Tablet give 1 tablet by mouth one time a day for supplement. Start Date: 1/16/2025. g. Ascorbic Acid Tablet 500 mg give 1 tablet by mouth two times a day for supplement. Start Date: 1/15/2025. h. Carvedilol Tablet 12.5 mg give 1 tablet by mouth two times a day for hypertension, hold if SBP less than 110 or heart rate (the number of times your heart beats in one minute) less than 60 and give with food. Start Date: 1/16/2025. i. Chlorhexidine Gluconate Solution 0.12 % give 30 ml (ml-metric unit used to measure capacity that's equal to one-thousandth of a liter) orally two times a day for good oral hygiene. Start Date: 6/11/2025. j. Cranberry Oral Tablet 450 mg (Vaccinium macrocarpon) give 1 tablet by mouth two times a day for urinary tract infection (UTI - an infection in the bladder/urinary tract) prophylaxis (measures designed to preserve health). Start Date: 6/8/2025. k. Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro) give 1 capsule by mouth two times a day for abnormal urinalysis (a simple examination of your pee to check for various health problems) for 5 days. Start Date: 6/7/2025. l. Gabapentin Capsule 300 mg give 1 capsule by mouth three times a day for neuropathic pain (nerve pain). Start Date: 3/17/2025. m. LiquaCel Oral Liquid (Amino Acids) give 30 ml by mouth three times a day for skin integrity. Start Date: 1/19/2025. During a review of Resident 87's Medication Administration Record (MAR,) the MAR indicated Resident 87 was administered Macrobid 100 mg oral capsule on 6/11/2025 at 9 AM. During an observation on 6/11/2025 at 8:30 AM, Licensed Vocational Nurse (LVN) 1 was observed opening a nitrofurantoin macrocrystals (Macrobid) 100 mg oral capsule, pouring the contents into a medication cup, and mixing with applesauce. During an interview on 6/11/2025 at 9:15 AM, LVN 1 stated that opening any capsule medication had to be verified or clarified with the pharmacist. LVN 1 stated that some capsules should not be opened, as doing so could alter how the medication worked, cause side effects, or reduce its effectiveness. LVN 1 stated that if there was any uncertainty, capsules were not to be opened from the pharmacy. Once verification had been received, the contents could be mixed with a small amount of applesauce if the resident had difficulty swallowing or preferred medications to be crushed. LVN 1 stated that opening Macrobid without proper verification could compromise the medication's safety and effectiveness. LVN 1 also stated that, particularly for antibiotics, proper delivery was important to ensure full treatment of infection and to prevent harm to the resident. During an interview on 6/12/2025 at 12:29 PM, the Director of Nursing (DON) stated it was important for nursing staff to have clarified with the pharmacist prior to opening any capsule medication, as altering the form of the medication could have affected its intended absorption, efficacy, and safety. The DON stated that this was especially important for capsule-form antibiotics, which were often time-released or specially formulated to deliver medication in a specific manner. The DON stated that failure to verify whether a capsule could be opened might have resulted in reduced effectiveness or unintended side effects. The DON further stated that if a resident preferred to take medications in crushed form, or had difficulty swallowing whole capsules, the physician should have been notified so that an alternative formulation - such as a liquid or tablet that was safe to crush - could have been ordered. The DON emphasized that ensuring the proper formulation helped maintain the integrity of the treatment plan and safeguarded the resident's health. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications dated 2001, the P&P indicated medications were administered in a safe and timely manner, and as prescribed. The P&P also indicated each nurses' station had a current Physician's Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for F755-761 (Pharmacy Services) available. Manufacturer's instructions or user's manual related to any medication administration devices were kept with the devices or at the nurses' station. During a review of the facility's Job Description (LVN - Sub-Acute) dated 3/7/2024, the Job Description indicated the LVN administered medication and treatment following regulatory guidelines.

Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for one of five sampled residents (Resident 59) by failing to wear appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when handling soiled linens under Enhanced Barrier Precautions (EBP-extra measures, like wearing gowns and gloves, used during high-contact care activities with residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms (MDROs). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 on 12/25/2021, with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and cellulitis (a skin infection that causes swelling and redness) of left lower limb. During a review of Resident 59's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 59's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 59 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance with mobility). During an observation on 6/9/2025 at 10:19 AM, there was signage indicating EBP located outside of Resident 59's room. During an observation on 6/9/2025 at 10:25 AM, Certified Nursing Assistant (CNA) 1 was observed removing soiled linen from Resident 59's bed. CNA 1 exited the resident's room while visibly carrying the soiled linen in both hands and placed it directly into the soiled linen container located in the hallway outside the resident's room. CNA 1 was not wearing a gown at any point during the linen removal process nor while exiting the resident's room with the soiled linen. During an interview on 6/9/2025 at 10:39 AM, CNA 1 explained that EBP were implemented to help prevent the spread of germs, particularly drug-resistant organisms. CNA 1 stated that when a resident was on EBP, staff were expected to wear gloves and a gown when performing tasks such as providing personal care, cleaning the resident's environment, or handling soiled laundry. CNA 1 emphasized that staff should wear a gown during direct contact tasks, such as changing soiled linens, because germs could transfer onto clothing. CNA 1 added that following these precautions helped protect both residents and staff, and that failure to wear appropriate personal protective equipment could contribute to the spread of germs to other residents or environmental surfaces. During an interview on 6/12/2025 at 11:35 AM, the Infection Preventionist (IP) stated staff were expected to always follow EBP, particularly when handling soiled linens. The IP emphasized staff were required to wear gowns and appropriate PPE during such tasks to prevent the spread of infection. The IP stated that adhering to these precautions was essential to protect both residents and staff from potential exposure to harmful pathogens. During a record review of Resident 59's Order Summary Report, dated 6/12/2025, the order summary report indicated Resident 59 had an active order for EBP, with an order date of 6/27/2024. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions dated 2001, the P&P indicated EBPs were utilized to prevent the spread of multi-drug organisms (MDROs) to residents. The P&P indicated: -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown were applied prior to performing the high contact resident care activity (as opposed to before entering the room). -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: b. Changing linens.

Based on interview and record review, the facility failed, to maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled residents (Resident 1), by placing another resident's (unidentified) dentures in Resident 1's mouth. This failure had the potential to result in the spread of infection to Resident 1. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/5/2024 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting hygiene. The MDS indicated Resident 1 required Partial/moderate (helper does less than half the effort) from staff for eating, oral and personal hygiene, and dressing. During a telephone interview on 11/21/2024 at 2:15 p.m. with Resident 1's Niece (FM 1), FM 1 stated Resident 1 had intellectual disability (person who has limitations in mental functioning and skills). FM 1 stated Resident 1's sister (FM 2) was Resident 1's conservator (a court appointed person to act or make decisions for the resident). FM 1 stated Resident 1 was recently hospitalized , at a General Acute Care Hospital (GACH) before being transferred to the facility. FM 1 stated during Resident 1's stay at the facility, Resident 1's dentures were lost. FM 1 stated on 11/23/2024, FM 2 called FM 1 and informed FM 1 that someone (unidentified) had found the dentures at the facility. FM 1 stated FM 2 informed FM 1 the Dentist (DD) put the dentures in Resident 1's mouth and discovered the dentures did not belong to Resident 1. During a telephone interview on 11/21/2024 at 3:03 p.m. with FM 2, FM 2 stated on one occasion (FM 2 cannot remember exact date), FM 2 was visiting Resident 1 at the facility when the DD put some dentures in Resident 1's mouth. FM 2 stated the dentures were inside a denture cup and had been sitting in Resident 1's drawer next to Resident 1's bed. FM 2 stated the dentures and cup were not labeled with any one's name. FM 2 stated the dentures did not belong to Resident 1. During a telephone interview on 11/26/2024 at 8:50 a.m. with the DD, the DD stated the Social Services Director (SSD) informed DD the facility found Resident 1's missing dentures. The DD stated the missing dentures were stored at Resident 1's bedside. The DD stated the dentures at Resident 1's bedside was not labeled with an identifier. The DD stated based on the DD's experience, the DD did not think the dentures belonged to Resident 1. The DD stated the DD informed the SSD the dentures did not belong to Resident 1. During an interview on 11/26/2024 at 8:55 a.m. with the SSD, the SSD stated the unidentified dentures the DD tried in Resident 1's mouth had been left at Resident 1's bedside before the DD put them in Resident 1's mouth.The SSD stated no one came forward and informed the SSD they had found Resident 1's missing dentures. The SSD stated the unidentified dentures were in a denture box. The SSD stated the unidentified dentures and box were not labeled. The SSD stated the SSD threw the unidentified dentures away. During an interview on 11/26/2024 at 10:12 a.m. with the Infection Preventionist (IP), the IP stated residents' dentures (in general) needed to be stored in a denture container when not in use. The IP stated the denture contains must be labeled to identify whose dentures they were and to ensure the dentures did not end up in the wrong residents' (in general) mouth. The IP stated there was a risk of infection for residents (in general) if the residents (in general) use the wrong dentures. During a review of the facility's policy and procedure (P&P) titled, Dentures, Cleaning and Storing, revised March 2023, the P&P indicated, The purposes of this procedure are to cleanse and freshen the resident's mouth, to clean the resident's dentures, to prevent infections of the mouth . The P&P indicated, .Be sure the denture cup is properly labeled with the resident's name and room number . During a review of the facility's P&P titled, Policies and Practices - Infection Control, revised April 2023, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. the P&P indicated, This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, nursing students, registry and the general public alike.

Based on interviews and record review, the facility failed to ensure five of nine sampled residents (Residents 41,30, 25, and 53) and/or their legal representatives (RP) were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 41, 30, 25, and 53. Findings: A. During a review of Resident 41's Admission Record (AR), the AR indicated the facility admitted Resident 41 on [DATE] with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities) and type 2 diabetes mellitus (disorder causing elevated sugar level in the blood). The AR indicated Resident 41 had Responsible Party 1 (RP 1) as the emergency contact. During a review of Resident 41's History and Physical (H&P), dated [DATE], the H&P indicated Resident 41 did not have the capacity to understand and make decisions. The H&P's portion indicating, Advanced Directive Executed, was left blank/unchecked. During a review of Resident 41's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated [DATE], the MDS indicated Resident 41 had severely impaired cognitive skills (ability to obtain and process information) for daily decision-making. During a concurrent interview and record review on [DATE] at 1:51 PM with Registered Nurse 3 (RN 3), Resident 41's medical records were reviewed. RN 3 stated RP 1 did not sign Resident 41's Advance Directive Acknowledgment [ADA, document that indicates residents and/or their legal RP were informed and/or provided written information about AD] form. RN 3 stated there was no documented evidence RP 1 was provided information regarding AD and written information on AD formulation. During an interview on [DATE] at 9:38 AM with the Social Services Director (SSD), the SSD stated the SSD offered AD information upon a resident's (in general) admission to the facility. The SSD stated if the H&P indicated a resident was unable to make decisions, the SSD offered the RP the AD information and/or written information on AD formulation and would have the resident and/or RP sign the Advance Directive Acknowledgment form. The SSD stated it was important to offer AD information upon admission to obtain the resident's wishes regarding his/her medical care if the resident's decision-making capacity was compromised. During a review of the facility's policy and procedure (P&P), titled Advance Directives, dated ,d+[DATE], the P&P indicated the following: 1. Prior to or upon admission of a resident, the SSD must inquire if the resident had any written AD. 2. The resident and/or resident's RP must be provided with written information that is easily understood by the resident or RP concerning the resident's right to refuse or accept medical or surgical treatment and to formulate an AD if he/she chooses to do so. 3. Written information must include a description of the facility's policies to implement ADs and applicable state law. 37662 B. During a review of Resident 30's AR, the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension, aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 30's H&P, dated [DATE], the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's quarterly MDS, dated [DATE], the MDS indicated Resident 30 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 30 was dependent for eating, oral hygiene, toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 30 was dependent for rolling left to right. During a review of Resident 30's physical chart (medical record), there was no ADA or AD found in Resident 30's chart. During a concurrent interview and record review on [DATE] at 12:47 PM with the SSD, the SSD stated Resident 30 had been at the facility since 2018. The SSD stated Resident 30 did not have an ADA or AD in Resident 30's chart. During a concurrent interview and record review on [DATE] at 2:32 PM, RN 2 stated the ADA should be in every resident (in general) chart so the facility staff was aware of the resident's wishes. RN 2 stated if the ADA was not in the chart, the facility staff would not be able to respect the resident's wishes. RN 2 stated Resident 30 did not have an ADA or AD in Resident's 30 chart. During a review of the facility's policy, titled, Advance Directives, revised on ,d+[DATE], indicated the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 42307 C. During a review of Resident 25's AR, the AR indicated, Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status, gastrostomy (a surgical procedure used to insert a tube, often referred to as G-Tube [GT] through the belly that brings nutrition and/or medications directly to the stomach) status and cerebral palsy (a congenital disorder that affects movement, muscle tone, or posture). During a review of Resident 25's H&P, dated [DATE], the H&P indicated, Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated, Resident 25's cognitive (ability to think and process information) skills for daily decision making was severely impaired (never/rarely made decisions). During a review of Resident 25's Care Plan [CP], titled, CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating), date initiated [DATE], the CP indicated, interventions included to respect resident's and/or family's wishes. D. During a review of Resident 53's AR, the AR indicated, Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for attention to tracheostomy, encounter for attention to gastrostomy and unspecified dementia. During a review of Resident 53's H&P, dated [DATE], 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 indicated, Resident 53's cognitive skills for daily decision making was severely impaired. During a review of Resident 53's CP, titled, Advance Directive initiated as follows, date initiated [DATE], the CP indicated, interventions included to respect resident's and/or family's wishes. During a review of Resident 53's undated (date left blank) Advance Directive Acknowledgement (ADA), the ADA indicated, the ADA form was not filled out (left blank) and had a physician's signature only. During a concurrent interview and record review on [DATE] at 1:11 PM with Registered Nurse (RN) 6, Resident 25's medical record was reviewed. RN 6 could not find an ADA form filed in Resident 25's chart. RN 6 stated, it was the responsibility of the admitting nurse and Social Service [staff] to inquire about the AD. RN 6 stated, according to the SSD (Social Services Director), there was no ADA on the chart for Resident 25. RN 6 stated, facility just started implementing the ADA earlier this year. Additionally, RN 6 stated for Resident 53, Resident 53's's husband was Resident 53's responsible party but was homeless and could not come to the facility to fill out the ADA form. RN 6 stated Resident 53 did not have an AD in Resident 53's chart and stated, it was important to have an AD so facility will know what to do with the patient, in case of emergency. During an interview on [DATE] at 1:41 PM with the SSD, the SSD stated, it was the admitting nurse who asked about [resident having an] AD upon admission and the SSD followed up. The SSD stated, the facility just implemented the ADA earlier this year. The SSD stated, Resident 25 was originally admitted 2014 and readmitted on [DATE] and the ADA form was just mailed to Resident 25's brother last week. The SSD stated, it was important to have an AD in Resident 25 and Resident 53's chart to let the facility know what the resident's last wishes and medical treatments were, if residents wanted to prolong their life, wanted CPR or to be DNR (Do Not Resuscitate). During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised ,d+[DATE], the P&P indicated, the resident had the right to formulate an AD, including the right to accept or refuse medical or surgical treatment. The P&P indicated, the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chose to do so. The P&P indicated, information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record in a section of the record that is retrievable by any staff.

Based on interview and record review, the facility failed to ensure comprehensive assessments of the disease diagnoses, health conditions, and/or medications, were complete and accurate, for two of two sampled residents (Residents 27 & 20). This failure had the potential to result in a decline in the residents' physical and psychosocial well-being due to inaccurate or inconsistent plan of care. Findings: A. During a review of Resident 27's Admission Record (AR), the AR indicated the facility admitted Resident 27 on 5/7/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), and major depressive disorder (depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]). During a review of Resident 27's History and Physical (H&P), dated 7/6/2023, the H&P indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's physician order (PO), dated 7/14/2023, the PO indicated healthcare provider 1 (HCP 1) initially ordered Ativan (generic name lorazepam, medication to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]) 0.5 milligrams (mg, unit of measurement) 1 tab by mouth twice a day for generalized anxiety disorder (a mental health disorder characterized by feelings of fear, anxiety, or fear that are strong enough to interfere with daily activities) manifested by verbal outbursts screaming for help. During a review of Resident 27's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 4/8/2024, the MDS indicated Resident 27 had moderate impairment in cognition (ability to obtain and process information). The MDS indicated Resident 27 required substantial/maximal assistance with most self-care activities and partial/moderate assistance with mobility. During a review of Resident 27's Order Summary Report (OSR) for 5/2024, the OSR indicated the following physician's order: 1. Order Date: 10/30/2023 - lorazepam tablet 1 mg by mouth two times a day for generalized anxiety disorder manifested by verbal outburst, screaming for help and tally by hashmarks. During a review of Resident 27's Medication Administration Record (MAR) for 5/2024, MAR indicated the following: 1. Lorazepam 1 mg 1 tablet was administered at 9 AM and at 5 PM from 5/1/2024 through 5/28/2024. 2. Resident 27 had 6 episodes of verbal outbursts/screaming for help on 5/1/2024 and 8 episodes on 5/4/2024. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with Registered Nurse 4 (RN 4), Resident 27's AR, physician notes, physician orders, MDS, and MARs were reviewed. RN 4 stated Resident 27's AR, MDS, dated [DATE], and MDS, dated [DATE] did not indicate Resident 27 had generalized anxiety disorder. RN 4 stated it was important to ensure accurate comprehensive MDS assessment was done for [Resident 27] to ensure appropriate care was provided. B. During a review of Resident 20's Admission Record (AR), the AR indicated the facility admitted Resident 20 on 2/6/2023 with multiple diagnoses including dementia. During a review of Resident 20's History and Physical (H&P), dated 2/9/2024, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS (MDS), dated [DATE], the MDS indicated Resident 20 had severe impairment in cognition. MDS 2 indicated Resident 20 required substantial/maximal assistance with most self-care activities and partial/moderate assistance with mobility. During a review of Resident 20's MARs from 3/2024 through 5/2024, the MARs indicated a physician's order, dated 2/27/2024, indicated to administer Ativan 0.5 mg by mouth every 8 hours as needed (PRN) for anxiety manifested by constant worrying about her health condition for 90 days. The MARs indicated the following: 1. On 3/3/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. 2. On 3/4/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. 3. On 3/5/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with RN 4, Resident 20's AR, MDS, physician orders, physician notes, MAR, and nursing notes were reviewed. RN 4 stated Resident 20's MDS, dated [DATE], and MDS, dated [DATE] did not indicate Resident 20 had anxiety. RN 4 stated Ativan 0.25 mg was initially ordered for Resident 20 on 9/2023 for anxiety. RN 4 stated Resident 20's MDS, dated [DATE], did not indicate Resident 20 was on any anti-anxiety medication. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated the MDS nurse must physically assess the residents (in general), interview the staff assigned to the residents, interview the family member/s of the residents, and review all the resident's medical records to complete an accurate MDS assessment and determine the correct plan of treatment for the resident. During a review of the facility's policy and procedure (P&P), titled Resident Assessment, dated 4/2014, the P&P indicated the following: 1. Sources of information to complete the MDS assessment include: review of the resident's record, observation of and communication with the resident, communication with the health provider, physician, and resident's family. 2. Once the MDS is completed, the Interdisciplinary Team (IDT) must develop the plan of care. 3. Care plans must be updated as the resident's condition or needs change by coordinating with the physician's orders as they are received, and/or with calls to the physician.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services were provided for three of three sampled Residents (Resident 36, 25 and 252) by failing to ensure: A.Resident 36's head of bed (HOB) was elevated to at least 30 - 45 degrees while receiving g-tube (GT, gastrostomy tube; a type of tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feedings as indicated in the facility's policy and procedure (P&P), titled, Enteral Feeding- Safety Precautions. B - C.Residents 25 and 252, who were receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services by failing to respond timely to the GT pump that was continuously beeping (alarming). These failures had the potential to result in GT complications and harm to Residents 36, 25 and 252, additionally, there was a potential for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) pneumonia (infection that inflames the air sacs of the lungs) to Resident 36. Findings: A.During a review of Resident 36's Admission Record (AR), the AR indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy placement (a surgical procedure used to insert a tube, often referred to as GT through the belly that brings nutrition and/or medications directly to the stomach) dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and gastro-esophageal reflux disease (GERD; digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]). During a review of Resident 36's History and Physical (H&P), dated 1/4/2024, the H&P indicated, Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/27/2024, the MDS indicated Resident 36 had severe impairment in cognitive (ability to understand and process information) skills for daily decision making. The MDS indicated Resident 36 had impairment on bilateral (both sides) upper extremities (shoulders, elbows, wrists, or hands) and bilateral lower extremities (hip, knee, ankle, foot). During a review of Resident 36's Order Summary Report (OSR), dated active as of 5/28/2024, the OSR included a physician's order (PO), dated 12/30/2024, that indicated to elevate the HOB 30 to 45 degrees at all times during GT feeding for aspiration precautions. Additionally, the ORS included a physician's order, dated 12/31/2023, that indicated to administer Glucerna 1.2 (calorically dense formula of low glycemic [presence of sugar in the blood] and slowly digestible carbohydrates designed to help minimize blood sugar) at 65 millimeters (ml, volume measurement) per hour for 20 hours to provide 1300 ml/1560 calories per day. During a review of Resident 36's GT feeding at risk for aspiration Care Plan (CP), dated 5/20/2024, the CP indicated to keep the HOB elevated. During an observation of Resident 36 in the Resident 36's room on 5/28/2024 at 10:19 AM, Resident 36 was receiving GT feeding at 55 cc and hour (cc/hr) and Resident 36's HOB was elevated at 20 -25 degrees. During an observation of Resident 36 and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 5/28/2024 at 10:23 AM, LVN 1 suctioned (the act of sucking, removal of solids or fluid with air) Resident 36's mouth and stated Resident 36's HOB looked about 20 to 25 degrees. LVN 1 stated the resident's HOB should be at 30 degrees or higher to avoid aspiration. During an interview with the Assistant Director of Nursing (ADON), on 5/29/2024 at 10:43 AM, the ADON stated residents receiving GT feedings could not swallow and should have the HOBs [raised] greater than 30 to 40 degrees to prevent aspiration. During an observation and concurrent interview with Licensed Vocational Nurse 4 (LVN 4) on 5/29/2024 at 4:05 PM, LVN 4 stated residents who received GT feedings were placed on aspiration precautions because [those residents] usually did not have the capacity to swallow, and the HOB [for those residents] should be at least 30 degrees [raised] when the g-tube feeding was turned on. During an interview with the Director of Nursing (DON), on 5/30/2024 at 8:24 AM, the DON stated the HOB for residents who received GT feedings must be kept at least 30 degrees or higher to prevent aspiration from the feeding or from secretions (saliva). The DON stated the HOB should be greater than 30 degrees, so the residents do not aspirate. During a review of the facility's P&P, titled, Enteral Feeding- Safety Precautions, revised on 11/2018, indicated to elevate the head of bed (HOB) at least 30 degrees during tube feeding and at least 1 hour after feeding to prevent aspiration. 42307 B. During a review of Resident 25's AR, the AR indicated, Resident 25 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole [stoma] in the windpipe [trachea] that provides an alternative airway for breathing) status, gastrostomy status, cerebral palsy (a congenital disorder that affects movement, muscle tone, or posture) and unspecified severe protein-calorie malnutrition (lack of sufficient nutrients in the body). During a review of Resident 25's CP titled, Resident is on GT feeding, date initiated 6/2/2023, the CP indicated, interventions included to monitor GT patency every shift. During a review of Resident 25's H&P, dated 2/3/2024, the H&P indicated, Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated, Resident 25's cognitive (ability to think and process information) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 25 had a feeding tube for nutritional approach. During a review of Resident 25's OSR, dated active as of 5/29/2024, the OSR indicated, an order dated 2/2/2024 for enteral feeding: Fibersourse (nutritionally complete tube feeding formula with fiber) HN 1.2 at 55cc (millimeters) per hour for 20 hours or until dose completed via pump to provide 1100 cc/1320 kcal (kilocalories, unit of heat energy) per day. The OSR indicated, an order dated 2/3/2024 to monitor GT patency every shift. During a review of Resident 25's Medication Administration Record (MAR), dated 5/2024, the MAR indicated, Resident 25 was receiving enteral feeding during the day, evening, and night shifts. C.During a review of Resident 252's AR, the AR indicated, Resident 252 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), encounter for attention to gastrostomy and unspecified protein-calorie malnutrition. During a review of Resident 252's CP, titled, Resident is on GT feeding, date initiated 10/3/2023, the CP indicated, interventions included to check and maintain placement and patency of GT. During a review of Resident 252's MDS, dated [DATE], the MDS indicated Resident 252's cognition was severely impaired. The MDS indicated, Resident 252 had a feeding tube for nutritional approach. During a review of Resident 252's H&P, dated 5/24/2024, the H&P indicated Resident 252 did not have the capacity to understand and make decisions. During a review of Resident 252's OSR, dated active as of 5/29/2024, the OSR indicated, a physician's order dated 5/23/2024 for enteral feeding: Jevity (calorically dense fiber-fortified therapeutic nutrition that provides complete balanced nutrition) 1.5 at 55 cc per hour for 20 hours via pump to provide 1100 CC/1320 kcal per day. The OSR indicated, an order dated 5/23/2024 to monitor GT patency every shift. During a review of Resident 252's MAR, dated 5/2024, the MAR indicated Resident 252 was receiving the enteral feeding during the day, evening, and night shifts. During an observation on 5/28/24 at 9:42 AM., Resident 25 was nonverbal and was sitting up on a wheelchair doing a coloring activity. Resident 25 was receiving Fibersource HN tube feeding via GT and the GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. During a concurrent observation and interview on 5/28/2024 at 10:15 AM., with LVN 6, Resident 25's GT pump continued to beep indicating Flow Error Clog in Line Downstream of Pump. LVN 6 stated, it was important to respond to the GT pump when the pump was beeping because if the GT was pump beeped, Resident 25 was not getting his feeding and that could result in weight loss, could result in clogging up the GT and cause more complications [to Resident 25]. During an observation and interview on 5/28/2024 at 10:22 AM., with Certified Nursing Assistant (CNA) 7, Resident 252 was awake in bed and receiving Jevity tube feeding via GT. The GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. Resident 252 stated, the GT pump had been beeping a long time. The HFEN (Health Facilities Evaluator Nurse) had to asked CNA 7 to get a licensed staff to check the GT pump. During a concurrent observation and interview on 5/28/2024 at 10:30 AM., with LVN 2, Resident 252's GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. LVN 2 stated, it was important to respond to the GT pump alarm to ensure Resident 252 was getting his feeding. LVN 2 stated [not responding to a GT alarm] could [result in] the GT getting clogged, complications, and could result in the replacement of the GT. During an observation on 5/28/2024 at 10:41 AM., Resident 252's GT pump was beeping. During an observation on 5/28/2024 at 11:10 AM., Resident 252's GT pump continued to beep, HFEN had to get an unidentified staff to check the GT pump. During a review of the facility's P&P titled, Enteral Tube Feeding via Continuous Pump, date revised November 2018, the P&P indicated, to ensure the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility.

Based on observation,interview and record review the facility failed to provide treatment and services to prevent pressure sore (localized injury to the skin and or underlying tissue as a result of pressure or pressure in combination with shear and or/friction) development for three of six residents observed for pressure sores (Residents 1, 5, and 10 ) in a total of 21 sampled residents by failing to: 1 a. Ensure the Resident 1 was not lying on her back directly on the pressure sore. b. Revise Resident 1's plan of care to address the frequency in which the resident should be turned as well as the positioning of the resident. c. Implement Resident 1's Care Plan to turn and reposition the resident every two hours while in bed. d. Assess accurately Resident 1's skin condition of the sacral coccyx pressure sore ((sacral) - a triangular shaped bone at the bottom of the spine (coccyx) -tailbone). e. Relieve the pressure from Resident 1's heels when in bed. These failures resulted in Resident 1 developing an avoidable Stage III pressure sore (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to the sacral coccyx with suspected deep tissue injury (DTI-purple or maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to the periwound (tissue surrounding the wound itself). The Resident 1 also developed suspected deep tissue injury to the left heel. 2. For Residents 5 and 10, the facility failed to ensure the resident was not directly lying on pressure sore . This had the potential for delayed healing and worsening of the sacral coccyx pressure sore. Findings: 1. A review of the Admission Record (face sheet) indicated Resident 1 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Admission assessment dated [DATE], indicated Resident 1 was readmitted to the facility without a pressure sore. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 7/10/16, indicated Resident 1 was assessed with [REDACTED]. A review of the Wound Risk Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure sore) indicated a total score of 8 and above represented at high risk for developing pressure sore. Resident 1 scored 24 on 7/4/16, and 25 on 7/25/16 which indicated as high risk of developing pressure sore. During multiple observations on 9/20/16 at 7:52 a.m., 9:32 a.m.,10:00 a.m., 11:05 a.m., 12:00 p.m., 1:50 p.m., 2:55 p.m., 3:10 p.m., 4:00 p.m.; 9/21/16 at 7:14 a.m., 8:07 a.m., 9:14 a.m., 10:30 a.m., 11:20 a.m., 2:00 p.m., Resident 1 was observed lying on her back in bed. Her left heel had a dressing and was observed resting on the mattress on 9/20/16 at 3:10 p.m.; 9/21/16 at 9:14 a.m., 10:30 a.m. and 11:20 a.m. Resident 1 was non-communicative. During an interview on 9/21/16 at 7:32 a.m., Treatment Nurse 1 (TN 1) stated she did the treatment to Resident 1's sacral coccyx and left heel pressure ulcers earlier at 6:30 a.m. because the dressing to sacral coccyx was soiled. TN 1 stated that on 9/21/16 at 6:30 a.m., the sacral coccyx pressure sore was UTD ((unstageable)-full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and /or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or IV). TN 1 also stated the left heel pressure sore was Stage I pressure sore (intact skin with non-blanchable redness of a localized area usually over a bony prominence). On 9/21/16 at 2:00 p.m., Resident 1 was observed lying on her back and was non-communicative. During the body check of Resident 1 conducted with TN 1, Certified Nursing Assistant (CNA 1) and Registered Nurse (RN 1), Resident 1 was observed with Stage III pressure sore to the sacral coccyx with deep tissue injury to the periwound that was purple and maroon in color. Resident 1's left heel was observed purple in color with fluid filled blister. TN 1 measured the pressure sores. The sacral coccyx pressure sore measured 8.5 centimeter (cm) in length (L) x 7 cm in width (W). The left heel pressure sore measured 1.5 cm (L) x 2 cm (W). TN 1 and CNA 1 both stated Resident 1's sacral coccyx pressure sore looked the same when treatment was done on 9/21/16 at 6:30 a.m. TN 1 and CNA 1 both stated Resident 1's left heel was red in color on 9/21/16 at 6:30 a.m. TN1 did not measure the sacral coccyx pressure sore for depth, undermining (destruction of tissue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface), and tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) until requested. The depth was 2.5 cm. with undermining of 3.1 cm at 12:00 o'clock, 0.9 cm at 3:00 o'clock, 0.4 cm at 6:00 o'clock, and 1.5 cm at 9:00 o'clock. TN 1 cleansed the sacral coccyx pressure sore with normal saline (salt with water), applied [MEDICATION NAME] gel (antibacterial wound gel), packed Alginate wound dressing (absorbent wound dressing) in the wound bed, applied Inzo cream (antifungal cream) around the periwound area and covered the pressure sore with dry dressing. The resident was quiet and did not show any signs and symptoms of pain while on the right side lying position for 30 minutes during body check and treatment of [REDACTED]. During an interview on 9/21/16 at 2:50 p.m., CNA 1 stated she was the regular caregiver assigned to Resident 1. CNA 1 was aware Resident 1 had pressure sores to her sacral coccyx and left heel. She stated several days (unable to remember specific dates) before her last day of work on 9/18/16 , she observed during treatment Resident 1's sacral coccyx pressure sore appeared bigger and deeper. She stated Resident 1 was turned and repositioned to her right side, left side and back every two hours when in bed. She stated the facility had repositioning schedule posted at the nurses' station. The Repositioning Schedule indicated to reposition the residents every two hours as follows: 8:00-window 10:00-door 12:00-back 2:00-window 4:00-door 6:00- back CNA 1 was asked why she repositioned Resident 1 on her back when she knew the resident had pressure sore to her sacral coccyx. CNA 1 stated she was not informed by any staff member that Resident 1 should not be turned and repositioned on her back while in bed and was just following the facility's repositioning schedule. CNA 1 stated Resident 1's left heel kept on going down to the mattress because the pillow under the left foot was thin. CNA 1 also stated the resident's pressure sore to the coccyx was getting bigger from lying on her back. On 9/21/16 at 3:50 p.m., the medical record of Resident 1 was reviewed with TN 1. The Skin Progress Report indicated Resident 1 was assessed as follows: On 7/14/16, with Stage 1 pressure sore (reddened intact skin) to her sacral coccyx measured 3 cm (L) x 3cm (W). On 8/15/16 (one month later), the pressure sore was assessed as deep tissue injury (DTI) measured 2.6 cm (L) x 2.6 (W) described as intact skin and maroon in color. TN 1 stated DTI is a pressure sore caused by pressure to the skin tissue. On 8/19/16 (four days later), Resident 1's had a skin breakdown to her sacro-coccyx assessed as UTD (unstageable) measured 4 cm (L) x 4 cm (W) described as having thick yellow slough (dead tissue) covering the wound. The resident's sacral coccyx remained unstageable pressure sore as follows: On 8/26/16 = 4 cm x 4 cm, yellow slough 100% On 9/2/16 = 4 cm x 4 cm, yellow slough 100% On 9/9/16 = 4.5 cm x 4.5 cm, slough 50% gray and 50% yellow On 9/16/16 = 4.8 cm x 4.8 cm, slough 50% gray and 50% yellow The Skin Progress Report did not indicate Resident 1's unstageable pressure sore to her sacral coccyx was assessed for depth, undermining and tunneling by TN 1 since 8/19/16. A review of the facility's undated policy and procedure for measuring pressure sore indicated, All pressure sores shall be measured upon admission and on a weekly basis. The length, width, and depth of pressure sores are to be measured in centimeters (cm), undermining and tunneling shall also be gauged in cm. TN 1 stated she cannot measure the resident's pressure sore for depth, undermining and tunneling due to presence of yellow and gray slough to sacral coccyx pressure sore. TN 1 was asked why she was able to measure Resident 1's sacral coccyx pressure sore for depth and undermining when requested on 9/21/16 at 2:00 p.m., when the wound bed of the pressure sore was observed with yellow and gray slough. TN 1 stated, I don't know. She stated the sacral coccyx pressure sore will not heal when Resident 1 was directly lying on the pressure sore. TN 1 stated CNA 1 was not made aware Resident 1 should not be repositioned on her back in bed. During an interview and record review of Resident 1's medical record with Director of Nursing (DON) on 9/23/16 at 2:51 p.m., she stated Resident 1 was admitted under hospice (an approach to caring for the terminally ill individual that provides palliative (keeping the resident comfortable as possible while maintaining dignity and quality of life) care rather that that traditional medical care and curative treatment) care on 7/3/16, due to [DIAGNOSES REDACTED]. MDS is considered a type [MEDICAL CONDITION]). The initial care plan for pressure sore dated 4/11/15, indicated Resident 1 was at risk for developing pressure sore related to impaired bed mobility and incontinence. The care plan goal was to minimize the risk of skin breakdown, bruising and pressure sore by the next review on 10/9/16; the care plan interventions included turning and repositioning the resident whenever necessary when in bed. Resident 1 developed pressure sore to her sacral coccyx assessed as Stage 1 on 7/14/16, deep tissue injury on 8/15/16 and unstageable on 8/19/16. Resident 1's care plan for sacral coccyx pressure sore dated 7/14/16, 8/15/16 and 8/19/16, indicated the resident was to be turned and repositioned every two hour or as often as necessary when in bed. The care plan interventions did not indicate which specific side the resident's body should be turned and repositioned every two hours in bed to prevent pressure sore development and to prevent worsening of the existing pressure sore. Resident 1's care plan was not revised since 7/14/16, to prevent the resident from developing Stage III pressure sore to her sacral coccyx. The care plan for Stage 1 pressure sore to the left heel dated 9/20/16 did not indicate specific measures how the resident's left heel should be relieved from pressure when lying in bed to prevent skin breakdown. Resident 1's Stage 1 pressure sore to her left heel had progressed to deep tissue injury on 9/21/16. The DON stated staff did not have a written or visual monitoring system to ensure a resident with a pressure sore was not turned and repositioned directly on a pressure sore while in bed. According to Medical Surgical Nursing Ninth Edition pages 186-187, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/13/16, indicated the resident had short-term memory problem and impaired decision-making skills (decisions poor, cues/supervision required). The MDS also indicated the resident was totally dependent on staff to perform daily activities, such as transfers, eating, and personal hygiene. A care plan dated 7/26/16 indicated the resident developed redness (Stage I pressure ulcer) measuring 1.5 x 1.5 centimeters (cm) on the sacrococcyx area (sacrum - triangular bone in the lower back, coccyx - the very bottom portion of the spine, also referred to as the tailbone). In a Stage I pressure ulcer, the skin is not broken. The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin. The care plan indicated approaches that included to keep the skin clean and moisturized and to provide protective skin care. The goal was for the resident's skin to remain intact and free of breakdown for 30 days. A care plan dated 8/8/16 indicated the resident's Stage 1 pressure ulcer at the sacrococcyx area progressed to a Stage II . In a Stage II pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost. The wound may be shallow and pinkish or red. The wound may look like a fluid-filled blister or a ruptured blister (http://www.mayoclinic.org/diseases-conditions/bedsores/basics/symptoms/CON- 848). A treatment order was received to apply [MEDICATION NAME] cream and to leave open to air daily for 30 days. The goal was for the pressure ulcer to resolve/heal without complications daily x 30 days. Approaches included to provide treatment as ordered, provide protective skin care, assess causative factors and evaluate potential for recurrence, and provide pressure relief that is appropriate for degree of alteration in skin integrity as ordered or indicated. The pressure ulcer measured 2 x 2 cm on 8/9/16. On 9/6/16, a new physician's orders [REDACTED]. The wound measured 0.7 x 0.7 cm. During the initial tour of the facility on 9/20/16, at 7:48 a.m., the resident was observed in bed lying on her back (direct contact of the sacrococcyx area against the mattress). On 9/21/16, at 7:20 a.m., the resident was observed in bed lying on her back. At 8:05, she was observed still in bed lying on her back. At 8:20 a.m., the medication nurse took the resident's blood pressure while the resident was in bed lying on her back, then administered the morning medications through the gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach). The medication administration procedure ended at approximately 8:45 a.m. at which the resident was lying on her back with the pressure sore at the sacrococcyx area directly over the mattress. On 9/21/16, at 9:50 a.m., treatment of [REDACTED]. The resident was lying on her back and was repositioned to her left side to provide access to the pressure ulcer site. On 9/26/16, at 7:17 a.m., the resident was observed in bed lying on her back. At 8 a.m., the resident was still lying on her back. At 8:05 a registered nurse (RN 1) was asked to see the resident's position. RN 1 concurred the resident was lying on her back and stated the resident should not be positioned on her back and should be turned/repositioned side to side to facilitate healing of the pressure ulcer. She stated she will tell the staff to off-load the resident's sacrococcyx area and to have the resident turned side to side. On 9/27/16, at 7:10 a.m., an interview was conducted with the facility's Administrator about the issue with the resident's pressure ulcer, how the resident was observed lying on her back multiple times. The Administrator and this writer went to see the resident in hopes that the resident will be positioned on either side and not on her back. However, the resident was observed lying on her back with the sacrococcyx area directly against the mattress. The Administrator acknowledged the staff's failure of positioning the resident directly on the pressure ulcer. The facility's undated policy and procedures, Pressure Sores - Risk Factors & Common Causes, indicated the following are common causes: 1. Pressure against a skin area for prolonged periods; 2. Friction against a skin area. According to Medical Surgical Nursing, 9th Edition, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. 3. A review of Resident 10's Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's quarterly Minimum Data Set ((MDS) assessment and care screening tool), dated 8/25/16, indicated Resident 10 was severely impaired for cognitive skills for daily decision making. It also indicated Resident 10 was totally dependent to all activities of daily living. A care plan dated 9/15/16 indicated the resident developed a Stage III pressure ulcer measuring 3.0 x 3.0 x 0.1 centimeters (cm) on the sacrococcyx area (sacrum - triangular bone in the lower back, coccyx - the very bottom portion of the spine, also referred to as the tailbone). In a Stage III pressure ulcer, there is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. The care plan indicated approaches that included to keep the skin clean and moisturized and to provide protective skin care. The goal was for the resident's skin will remain intact and resolve/prevent any further development of skin breakdown daily x 90 days. During a review of the physician order [REDACTED]. A treatment order by physician for sacrococcyx Stage III pressure ulcer to irrigate with normal saline, pat dry, and cover with [MEDICATION NAME] wound dressing every 72 hours for 30 days. A new treatment order on 9/13/16 indicated to discharge previous treatment on sacrococcyx Stage III and to cleanse with normal saline, pat dry, apply [MEDICATION NAME] cream, cover with Duoderm daily, and apply as needed for dislodgement. During the initial tour of the facility on 9/20/16 at 8:15 am, the resident was observed in bed lying on his back (direct contact of the sacrococcyx area against the mattress). On 9/21/16 at 8:10 am, treatment of [REDACTED]. The resident was observed lying supine on her back prior to treatment and positioned on her right side during treatment to access the pressure ulcer site. After the treatment, resident was then placed on his left side with a pillow between his legs and a pillow underneath right shoulder. On 9/21/16 at 1:00 pm, Resident 10 was observed in bed lying on his left side with a pillow between his legs and a pillow underneath right shoulder. On 9/26/16 at 7:00 am, Resident 10 was observed in bed lying on his back (direct contact of the sacrococcyx area against the mattress). On 9/27/17 at 7:30 am, Resident 10 was observed in bed lying on his back (direct contact of the sacrococcyx area against the mattress). During an interview with Registered Nurse (RN) 1 on 9/27/16 at 7:45 am, she was asked to observe the position of Resident 10 (who was still lying supine on his back). RN1 acknowledged that resident was lying on his back and that Resident 10 should be fully repositioned from side to side to facilitate healing of the pressure ulcer. At that time she stated she will have the staff reposition Resident 10 from side to side to off load pressure from the sacrococcyx area. The facility's undated policy and procedures, Pressure Sores - Risk Factors & Common Causes, indicated the following are common causes: 1. Pressure against a skin area for prolonged periods; 2. Friction against a skin area. According to Medical Surgical Nursing, 9th Edition, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore.

Based on interviews, observation, and record review the facility failed to prevent an accident for 1 of 4 residents reviewed for accidents/incidents (Resident 1) when CNA 1 transferred Resident 1 from a shower chair using one person assist, instead of two person assist, in accordance with the resident assessment. The deficient practice resulted in Resident 1 falling out of a Vander-Lift (an assistive device that allows residents with limited mobility to be transferred between a bed and a chair or other similar resting places, using hydraulic power); and sustaining a laceration (cut) to the right parietal scalp (area near the side and top of the head), requiring five staples (used in surgery in place of sutures to close skin wounds). Findings: Record review indicated Resident 1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) a comprehensive assessment tool) dated 5/29/15, indicated Resident 1 was moderately impaired in daily decision making, and was totally dependent with two plus-person physical assist during transfers. The MDS Section G0300 Balance During Transitions and Walking indicated Resident 1 was not steady and was only able to stabilize with staff assistance during transfer between bed and chair or wheelchair. The most recent Rehabilitation Screening assessment dated [DATE], indicated Resident 1 required two-person assist with transfers. A review of Resident 1's care plan revised on 6/1/15, titled The resident has self- care deficit indicated one of the interventions was to provide a safe environment, but it did not include the use of two persons assist during transfers, in accordance with the assessment. A review of the facility's Interdisciplinary Team (IDT) Conference Record dated 8/2/15, indicated Resident 1 was a [AGE] year old female with [DIAGNOSES REDACTED] (paralysis of one side of the body) and required total assistance with activities of daily living (ADL's). The IDT notes indicated Resident 1 fell on [DATE], when the certified nurse assistant (CNA1) transferred Resident 1 from a shower chair to bed using a Hoyer lift and sling. The notes indicated that during the transfer, Resident 1 shifted to one side and started to slip out of the sling. CNA 1 held on to Resident 1 and assisted her to the floor. Resident 1 sustained a laceration on the right lateral part (side) of the head. Resident 1 was transferred to the acute emergency hospital for evaluation and treatment. A review of the acute hospital notes dated 7/30/15, indicated Resident 1 sustained a laceration to the right parietal scalp. The notes indicated that the caretaker dropped the resident while transferring from shower chair to her bed. Resident 1 hit her head sustaining a laceration. The laceration was about 1 inch long, had a moderate amount of bleeding. The report also indicated Resident 1 was treated with wound repair with five staples to the head, and returned to the nursing home facility after treatment. During an interview on 8/13/15, at 7:30 a.m., Staff A stated that CNA 1 transferred Resident 1 from the shower chair to the bed without any assistance on 7/30/15. Staff A stated that CNA 1 had transferred Resident 1 without any assistance from the bed to the shower chair in the morning without any incident, and thought she could transfer the resident again from the shower chair to the bed without any assistance. Staff A stated CNA 1 used a Vander lift. A review of the manufacturer's Operating Manual for Vander-Lifts contained the following warnings: Before using the Vander Lift, residents must be assessed by the facility's professional nursing or professional rehabilitation staff to determine the number of staff members necessary to transfer each resident. Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. The above information must be recorded in the patient ' s record and must be communicated to the staff. On 8/13/15, at 8:30 a.m., during a concurrent observation and interview, CNA 2 and CNA 3 both stated We always transfer Resident 1 with two persons. Both CNAs then demonstrated the use of the Vander Lift II (as would be performed in the transfer of a totally dependent resident). They stated this was the lift they always used for Resident 1. On 8/19/15, at 3:40 p.m., during a telephone interview, CNA 1 stated she used the lift to transfer Resident 1 from the shower chair to bed on 7/30/15. CNA 1 further stated that as she cranked the lift she noticed Resident 1 started to shift towards the right side. CNA 1 attempted to prevent the fall, but the resident's head hit the wheel of the lift that caused a cut and bleeding to the right side of Resident 1's head. CNA 1 stated she should have called for assistance to transfer the resident

The facility's staff failed to thoroughly assess and monitor residents with rashes, failed to determine if visitors of symptomatic residents had signs and symptoms of scabies, and failed to establish a baseline of the number of symptomatic residents in the facility. The failure to protect from the nosocomial (hospital acquired infection) infection was an immediate threat to the facility's residents, staff, and visitors. On March 19, 2014 at 5:20 p.m., an Immediate Jeopardy (IJ) was declared and the facility's administrator and director of nursing (DON) were notified. The facility submitted the first plan of correction on March 20, 2014 at 8:15 a.m., it was not accepted due to the facility's failure to determine if visitors of symptomatic residents had been informed if they were experiencing signs and symptoms of scabies, and to establish a baseline of the number of symptomatic residents in the facility. The second plan was submitted on the afternoon of March 20, 2014, and was accepted. The accepted plan of correction was as follows: Corrective Actions: 1. DHS notification was faxed on March 19, 2014. 2. Updated treatment plans for all residents with skin rashes. 3. Updated line listings (a spreadsheet used for investigations of outbreaks or unexplained respiratory illness. The data on cases with reportable diseases is recorded on the spread sheet, each case is listed on a separate row). for all residents with skin rashes. 4. The Medical Director was notified. Identifying Other Residents Potentially Affected: 1. Licensed nurses including DON, Director of Staff Development (DSD), Treatment nurses and Registered nurses (RN) conducted full body checks of all residents in house on March 19, 2014, to identify if other residents had the potential to be affected. 2. The dermatologist was contacted and will conduct follow-up examinations on March 20, 2014. Process to Prevent Re-Occurrence: 1. Completed in service to nursing staff on all shifts regarding skin assessment and reporting skin changes. 2. Monthly in-services will be on-going for an additional three months and quarterly thereafter regarding body checks and reporting skin changes. 3. Continued in-services on a quarterly basis and as needed will be given to employees regarding the reporting of any noted skin discolorations or suspected rashes. 4. Signs have been posted at facility entrance and throughout facility to inform family and visitors to report to the nurse's station regarding the outbreak prior to entering resident rooms. 5. Scabies information packets are being provided to family and visitors. 6. Family members/responsible parties informed by DON and DSD on preventative measures. Monitoring Process: 1. The treatment nurses will perform weekly body checks on all residents and the RN supervisor and DSD will also conduct body checks for 30 randomly selected residents on a weekly basis. 2. The DON will present findings during the monthly utilization review (UR) meeting for review and take action as necessary. On March 20, 2014 at 4:17 p.m., the administrator was notified the IJ was lifted. Based on observations, interviews, and record reviews, the facility failed to thoroughly assess and monitor ten residents with skin rashes (Resident's 6, 29, 30, 31, 32, 33, 34, 35, 36, 37) in order to prevent the spread of scabies (a condition of very itchy skin caused by tiny mites that burrow into the skin. Easily spread from person to person by close contact, touching one's skin, sharing towels, linens, clothing and other personal item) infection. The symptomatic (showing the symptoms) two residents (Residents 4 and 15) were not provided the required care, and further medical evaluation and treatment. In total 17 residents, 10 with rashes (Residents 6, 29, 30, 31, 32, 33, 34, 35, 36, and 37) and 7 roommates (Residents 38, 39, 7, 8, 40, 41, 42) with no rash were also treated with [MEDICATION NAME] on March 14, 2013. In addition, the facility failed to reassess for the effectiveness of the pain management medication for Resident 6 and for Resident 16, the [MEDICATION NAME] acid (for [MEDICAL CONDITION]) laboratory levels were obtained without a physician's orders [REDACTED]. Findings: a. On March 18, 2014 at 4:30 p.m. the director of nursing (DON) informed the evaluator there had been a Scabies (a condition of very itchy skin caused by tiny mites that burrow into the skin. Easily spread from person to person by close contact, touching one's skin, sharing towels, linens, clothing and other personal item) infection). outbreak in the facility on March 13, 2014. A review of dermatology consults, dated March 13, 2014, indicated 17 residents were examined by the dermatologist. (Residents 6, 7, 8, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42) and all were treated with [MEDICATION NAME] on March 14, 2014. Further review of the dermatology consult indicated seven (Residents 29, 6, 30, 31, 32, 34, 36, ) residents were diagnosed as: Scabies vs Pruritus (itching) vs Contact [MEDICAL CONDITION] (rash that is itchy, red, with no distinct margins, three residents (Residents 33, 35, and 37) were diagnosed with [REDACTED]. All 17 residents were treated with [MEDICATION NAME], a topical medication used to treat Scabies. During an interview on March 19, 2014 at 8:12 a.m., the DON stated "Various" residents had been having rashes. The physician was notified and stated it was not scabies. The DON stated she notified the dermatologist because, "I did not want to take any chances." The DON also stated, the dermatologist stated the resident's rashes were contact [MEDICAL CONDITION] and ordered these residents and their roommates (total=17 residents) be treated with [MEDICATION NAME] (a cream used for treating scabies). The DON further stated, all the resident's rooms, except for two, were from the subacute unit (two rooms were from the long term unit). When asked if all remaining residents in the facility (including subacute and long term) were assessed for rashes (body checks) the DON stated the residents in the subacute were assessed but not documented. During an interview with licensed vocational nurse (LVN 1 for the subacute) on March 19, 2014 at 3:05 p.m., she reviewed the weekly body check form for the month of March. For the week of March 4, 2014 to March 10, 2014, she documented six residents as having rashes (Residents 6, 29, 32, 34, 40, and 31). She stated the rashes were not reported, she added it was her first week performing the body checks by herself. For the week of March 11, 2014 to March 17, 2014, she stated she began the body checks on March 11, 2014 and noticed new residents with rashes. When ask if she could identify the residents with the date the body check were performed, she was unable to identify how many since she did not document body assessments for the period of March 11-17. The body check form only has the range for the week and not the actual date the body check was performed. The LVN 1 stated by March 13, 2014, she had completed her body checks and reported the residents with rashes (Residents 29, 6, 30, 31, 32, 33, 34, and 35, 36, 37), and the roommates (38, 39, 7, 8, 40, 41, 42) to the dermatologist and the DON. During an investigation to identify the facility's process of establishing a baseline of the number of symptomatic residents in the facility, the licensed vocational nurse (LVN 2- long term care unit nurse) was interviewed on March 19, 2014 at 3:15 p.m. When asked to review the body checks for the week of March 11, 2014 to March 17, 2014, she stated she had not done her body checks. The weekly body check form provided to the surveyor for the week of the 11th to the 17th was blank. During a general observation in the presence of the Registered Nurse (RN) Supervisor on March 19, 2014 at approximately 4:30 p.m. , two residents (Residents 4 and 15) were observed with skin rashes on their upper front and back, arms and neck areas that were raised, reddened and itchy. According to the RN Supervisor, Resident 4 (from the subacute unit) had a "self-inflicted scratches," that started on March 8, 2014 and Resident 15 ( from the long term unit-LTC) had a chronic [MEDICAL CONDITION] since admission on December 4, 2012. However, these residents were not included when the dermatologist examined and assessed the resident with rashes on March 13, 2014. Residents 4 and 15 were also not included in the line listing dated March 13, 2014. The facility staff was notified on March 19, 2014, of the residents rashes. Following the notification of the residents rashes, the facility completed skin assessments on residents in the facility including both the subacute unit and the long term unit on March 20, 2014. Four more residents (Residents 4, 15, 16 and 17) from the both the sub-acute and LTC (long term care) units were assessed as having pink or orange scaly plagues (thickened areas of the skin) and crusts (scab, dried blood formed over a scratched and irritated [MEDICAL CONDITION]) distributed all over upper body according to the documentation by the Dermatologist. The facility staff's failure to identify the extent of the outbreak that started on March 13, 2014, and the delay in services and treatment to symptomatic residents (10 residents identified as having rashes, Resident's 29, 6, 30, 31, 32, 33, 34, 35, 36, 37) resulted in an immediate threat to residents, staff, and visitors. During a phone interview on March 20, 2014 at 8:50 a.m., the public health nurse (PHN) stated she began working with the facility staff, over the phone concerning the scabies outbreak, on March 14, 2014, although she did not physically visit the facility until March 18, 2014. The PHN was notified by the DON that the dermatologist saw the residents with rashes and diagnosed the residents with contact [MEDICAL CONDITION]. The dermatologist had ordered the residents be treated with [MEDICATION NAME]. The PHN stated in order for a resident to be treated with [MEDICATION NAME] he/she must have an appropriate [DIAGNOSES REDACTED]. The PHN stated that [MEDICATION NAME] is very toxic and has side effects (side effects include rashes, itching, redness, and swelling). The PHN stated she informed the facility, on March 14, 2014, they were closed for new admissions related to the scabies outbreak. On March 19, 2014, the PHN stated she informed the facility they were open for admissions. When asked about surveillance and tracking, the PHN stated she had requested the facility staff to provide a line listing (a spreadsheet used for investigations of outbreaks or unexplained respiratory illness. The data on cases with reportable diseases is recorded on the spread sheet, each case is listed on a separate row). The PHN stated the line listing should include all residents assessed as having rashes, the resident's roommates, and staff that had any interaction with any of the affected residents. Every time a new rash is assessed the line listing needs to be updated to reflect the finding. The PHN stated every resident in the facility should have been thoroughly assessed for rashes following the scabies outbreak. The PHN stated, "This is a Scabies outbreak, the facility staff needs to start treating it like what it is." The July 2009 Los Angeles County Department of Public Health Acute Communicable Disease Control Program Scabies Prevention and Control Guidelines Acute and Sub-Acute Care Facilities indicated, "Prevention and Control: Scabies usually is passed by direct, prolonged skin to skin contact with an infested person. Scabies treatment usually is recommended for members of the same household, particularly for those who have had prolonged skin to skin contact. All household members and other potentially exposed persons should be treated at the same time as the infested person to prevent possible re-exposure and reinfestation. Institutional outbreaks can be difficult to control and require a rapid, aggressive, and sustained response." http://publichealth.lacounty.gov/acd/docs/ScabiesGuidelinesFinal8.20.09_1.pdf b. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care planning tool) dated February 2, 2014, indicated the resident was able to understand and be understood. The MDS indicated that the resident was totally dependent with all of her activities of daily living (ADLs)included toilet use, transferring, dressing, personal hygiene, bathing, bed mobility. The MDS Section M, Skin Conditions revealed the resident was receiving "Applications of ointments/medications other than feet." During an interview with Resident 4, she stated she had been scratching her arms and hands for "several weeks", the staff had been putting creams and made her feel better afterward but would be itching again especially during the night. Upon closer observation Resident 4 had several black pinpoint scabs to the back of both hands, reddened rash to her arms and several raised reddened spots to her front upper body parts. A review of Resident 4's clinical records indicated a physician's orders [REDACTED]." During an interview with the RN Supervisor on March 19, 2014, at 4 p.m., she stated that the resident was being treated for [REDACTED]. The RN supervisor also stated that the physician was aware of the resident's skin issues and that the resident was not included in the listing of residents with new skin rashes. Review of the resident's medical record, the RN Supervisor at 4:20 p.m., revealed the lack of weekly skin assessments, or a Dermatology consult as indicated in the resident's care plan. c. Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care planning tool) dated December 15, 2013, indicated the resident was able to understand and be understood. The MDS also indicated that the resident required extensive assistance with all of his activities of daily living (ADLs) that included toilet use, transferring, dressing, personal hygiene, bathing, bed mobility. The MDS Section M, Skin Conditions revealed the resident was receiving applications of ointments/medications other than feet. The facility's assessment form or change of condition (COC/INTERACT ASSESSMENT FORM or Situation Background Assessment Recommendation (SBAR- a standardized way of communicating requiring a clinician's immediate attention and action. It enables you to clarify what information should be communicated between members of the team)dated January 8, 2014, indicated the resident's symptoms identified as facial flakiness, and the resident's physician was called and ordered treatment with [MEDICATION NAME] 1 %. The care plan developed on April 9, 2013, revealed a problem: skin integrity impairment manifested by [DIAGNOSES REDACTED].) The approaches included were: 1. Monitor skin for response to treatment; 2. Body check every week; 3. Dermatology (a branch of medicine dealing with the skin, its structure, functions, and diseases) consult/follow-up as indicated. On March 19, 2014, at 11 a.m., Resident 15 was observed sitting on his wheelchair in the Activity/Dining Area. Upon closer observation, resident was observed with generalized pink to reddened skin rashes around the neck, both arms and face. During a concurrent interview with the resident, he stated that he also has some itching especially at night. Further examination of the resident's skin, in the presence of the director of staff development (DSD) revealed the resident's upper trunk was covered with raised reddened areas. During a concurrent interview with the director of staff development (DSD), she stated the resident had the chronic skin condition since admission. She also stated that Resident 15 was not included in the listings of resident with skin rashes because the resident's condition was diagnosed as Seborrheic [MEDICAL CONDITION] (an [MEDICAL CONDITION] skin condition that causes flaky, white to yellowish scales to form on oily areas such as the scalp or inside the ear.) On March 19, 2014, at approximately 4:30 p.m., the DON was informed of both Resident 4's and 15's skin conditions. The DON, stated there was no skin outbreak in the facility but she would arrange for an immediate Dermatology consult for the residents affected. She also stated there was no isolation precautions implemented at this time. On March 20, 2014, at 8:20 a.m., during an interview with the DON, she stated the Dermatologist examined all the residents in the facility including those that were identified by the survey team and did not find any residents with Scabies. She also stated the Dermatologist refused to obtain skin scraping for confirmation because they will need to perform the test in his office. The DON also stated the Dermatologist insisted none of the residents have scabies and there was no need to perform a definitive testing for scabies. During an interview was conducted with the DON on March 20, 2014, at 9 a.m., she stated Resident 15's skin condition was chronic and he was not placed among the listings of resident's with rashes and did not believe Resident 15 had scabies. The survey team was not able to get an interview with the dermatologist due to non-availability. A review of the facility's policy and procedure undated policy, "Infection Control Program," objectives of the infection control plan include, implementing systematic, effective policies and procedures for detecting and reporting all infections and maintaining accurate records of nosocomial infections, infection control measures and surveillance. In addition, the facility will establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. Residents will be provided with the following including: infection monitoring, and screening for infectious diseases. Surveillance of residents and their family members will include maintenance of an infectious disease log by facility staff, reporting individual incidents of infection, and monthly recording incidents by infection sites. d. A review of the Face Sheet for Resident 16 indicated the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated January 2, 2014, indicated the resident was rarely to never understood by others and rarely to never was able to understand others and required total assistance with the activities of daily living. A review of Resident 16's physician's orders [REDACTED]. In addition, the resident had a physician order [REDACTED]. During an interview with the subacute unit charge nurse, on March 27, 2014 at 9:28 a.m., she reviewed the resident's clinical record and was not able to find a physician's orders [REDACTED]. e. A review of the clinical record for Resident 6, the physician order [REDACTED]. The resident had an order for [REDACTED]. A review of the Face Sheet for Resident 6 indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 26, 2014, indicated the resident was rarely to never understood by others and rarely to never was able to understand others and required total assistance with the activities of daily living. In addition, the MDS indicated the resident received a scheduled pain medication regimen in the last five days. During an interview with the direct of nursing (DON), on March 24, 2014 at 10:01 a.m., she reviewed the clinical record for Resident 6 and was unable to find appropriate documentation of the effectiveness of the pain management medication on: January 8, 2014 for the use of Ibuprofren 600 mg, January 15, 2014 for the use of [MEDICATION NAME] 5/500 tablet, February 4, 2014 for the use of [MEDICATION NAME] 5/500 tablet and February 12, 2014 for the use of Ibuprofren 600 mg. The undated facility policy and procedure, indicated any reassessment of pain should use the appropriate pain assessment tools for their documentation. Furthermore, the physician should be notified if the pharmacological interventions are ineffective.

Based on observation, interview and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection as follows: 1. A certified nursing assistant (CNA 1), who provided care for Resident 5 (infected with Clostridium difficile), failed to wash his hands after providing care to the resident and subsequently handling the resident ' s soiled linens with his bare hands. After putting the soiled linen in the soiled linen cart located outside the resident ' s room, the CNA retrieved linen from the clean linen cart without washing his hands and, then, proceeded to provide care to another resident. 2. A physical therapy assistant (PTA 1) failed to wear a protective gown while providing treatment to the same resident (Resident 5) and being in direct contact with the resident. 3. A licensed treatment nurse (LVN 1) also failed to disinfect (to remove bacteria, viruses, etc., sterilize) a bottle of wound ([MEDICATION NAME]), which was used for Resident 5's care before replacing the [MEDICATION NAME] spray (non-prescription topical wound spray that stimulates the healing of pressure sores) in the treatment cart, which had the potential of contaminating other treatment materials in the cart. 4. A housekeeping staff (HS 1) failed to wash her hands after removing the trash bag under the sink in Resident 5's room where soiled gloves and gowns were discarded. The staff then proceeded to place a new roll of paper towel in the paper towel dispenser near the above mentioned sink without washing her hands. The above practices put residents, visitors, and staff at risk of possibly becoming infected with[DIAGNOSES REDACTED] bacteria. [DIAGNOSES REDACTED] is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon (http://www.mayoclinic.com/health/c-difficile/DS ). The pattern of the facility's failure to prevent the transmission of disease and infection by not adhering to established (policies already in place by the facility) isolation precautions and hand washing resulted in an immediate threat to the residents, staff and visitors in the facility. Because of the facility's failure, on August 23, 2011, at 6:10 p.m., an Immediate Jeopardy (IJ) was called in the presence of the Administrator, the Director of Nursing, the Infection Control nurse, and a Registered Nurse Supervisor. Findings: A review of Resident 5's admission record revealed she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was fed through a gastrostomy tube ([DEVICE] - a tube inserted through a small incision in the abdomen into the stomach and is used for formula feeding and medication administration). The Minimum Data Set (a standardized assessment tool) dated 8/6/11, indicated that the resident had a short- and long-term memory problem and her cognitive skills for daily decision-making were severely impaired (never/rarely made decisions). The resident was totally dependent on staff to perform daily activities such as transfers and personal hygiene. On August 23, 2011, at 7 a. m., an isolation sign (a warning sign indicating the resident was on infection precautions) was observed outside of the resident's room with the following instructions: 1. Hands must be washed after touching the resident or potentially contaminated articles (items that may have been in contact with[DIAGNOSES REDACTED] bacteria) and before taking care of another resident. 2. Gloves are indicated for touching infected material (items that may have had contact or contain the[DIAGNOSES REDACTED] bacteria). 3. Gowns are indicated if soiling is likely. There was also an isolation cart outside the room where the gowns were placed. According to "Clostridium Difficile Fact Sheet," dated 2008, that was provided by the facility to the survey team on 8/23/11, "These bacteria are able to form spores which can colonize the environment and survive for long periods of time. The bacteria is found in stool. Infection can occur when someone touches items or surfaces that have been contaminated with feces and then touches their mouth or mucous membranes. It can be transmitted by the healthcare worker through hand contact if handwashing is not performed after contact with an infected person. Good housekeeping and disinfecting the environment at least once daily is an important part of controlling the spread of this condition. Attention should be paid to siderails, door knobs and light switches. Alcohol based disinfectants are not effective in killing spores. A 1:10 bleach dilution of disinfectant should be used...When the patient is diagnosed as having a "C. Diff. Infection," he is placed on Contact Isolation while he is on antibiotics and is still experiencing symptoms. What this means, is that anyone who handles the infected patient or comes within 3 feet of his bed, must wear gloves and a gown and should wash their hands after removing his equipment before leaving the patient's room. Hand washing is imperative to prevention of the spread of this infection." Additionally, No agent used in antiseptic handwash or antiseptic hand-rub preparations is reliably sporicidal against [DIAGNOSES REDACTED] ([MEDICATION NAME], alcohols, PCMX, triclosan). Spores may be physically removed from contaminated hand surfaces by washing hands vigorously with either non-antimicrobial or antimicrobial soap and water. (Retireved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/jun2(2)/Pages/01b.aspx#bm9) A care plan dated 8/18/11 had approaches that included to: 1) Observe Clostridium difficile isolation contact precautions guidelines per facility, and 2) Observe universal precautions - emphasis on hand washing techniques. 1. On 8/23/11 at 9:45 a.m., Surveyor A and Surveyor B were standing in the hallway in front of Resident 5's bedroom when Surveyor A observed CNA 1 discard soiled linen with ungloved hands into the soiled linen cart outside of the resident's room. Without washing his hands, CNA 1 proceeded to obtain linen from the clean linen cart that was located in the hallway and then went inside Resident 5's room to drop off the clean linen. Then without washing his hands, CNA 1 proceeded to attend to another resident in another room. Surveyor B observed CNA 1 as he entered the other resident's room and attended to the resident without washing his hands. During an interview on 8/23/11, at 9:49 a.m., CNA 1 stated that he cleaned Resident 5 who had a lot of watery stool. He stated that he forgot to wash his hands before leaving the resident's room to get clean linen from the clean linen cart. CNA 1 further stated that when he saw the call light from the other resident's room, he just placed the linen that he got from the clean linen cart on Resident 5's bed and went directly to assist the other resident who had the call light on without washing his hands. He acknowledged his failure of not washing his hands after attending to Resident 5 who had a bowel movement with a lot of watery stool. 2. On 8/23/11, at 1:25 p.m., Surveyor B observed a staff that was providing care to Resident 5. The staff was not wearing a protective gown, but was wearing blue jeans and a blue shirt. She was wearing a pair of gloves. At 1:30 p.m., the staff came out of the room after washing her hands. The staff was a physical therapy assistant (PTA 1) who stated she performed stretching and passive range of motion (exercises provided to the resident as the resident was unable to do them on her own) on Resident 5's lower extremities, and applied bilateral knee splints that will be removed after 3 hours. When asked why she did not wear a protective gown while providing care to the resident, PTA 1 stated that she was not aware that the resident had active[DIAGNOSES REDACTED] infection and that the resident was on contact isolation precautions. She acknowledged her failure for not wearing a protective gown and not knowing or noticing the isolation precautions sign outside Resident 5's door. 3. On 8/23/11 at 1:45 p.m., a treatment nurse (LVN 1) was observed as she provided wound treatment to Resident 5 ' s deep tissue injury (a pressure-related injury to tissues under intact skin) on the sole of the left foot, below the small toe, for which a wound spray ([MEDICATION NAME]) was used. During the procedure, LVN 1 was observed as she handled the [MEDICATION NAME] spray bottle with her gloved hands that had been in contact with the resident's foot, linen, and bedding. After the procedure, LVN 1 placed the spray bottle on the sink as she washed her hands. LVN 1, then, placed the [MEDICATION NAME] spray bottle inside one of the treatment cart drawers. During an interview on 8/23/11, at 2:40 p.m., LVN 1 stated that she did not disinfect (clean to remove infection/germs) the wound spray bottle before placing it in the treatment cart. She acknowledged her failure of putting the spray bottle of [MEDICATION NAME] with other treatment items in the treatment cart and acknowledged that other resident treatment care products (items used for wound treatments) that came in contact with the un-disinfected [MEDICATION NAME] spray bottle ([MEDICATION NAME] spray, Hydrogel, moisture barrier antifungal cream) may have been contaminated with[DIAGNOSES REDACTED] bacteria. LVN 1, then, cleansed all of the resident treatment care products with "Sani-Cloth Plus " wipes. However, the product information did not indicate that it was effective against[DIAGNOSES REDACTED] bacteria. When asked if LVN 1 knew what cleaning solution was effective against[DIAGNOSES REDACTED] bacteria, LVN 1 stated she did not know. 4. On 8/23/11, at 2:35 p.m., a housekeeping staff (HS 1) entered Resident 5's room wearing gloves and a gown to change the trash bag under the sink where soiled gloves and gowns had been discarded. She, then, discarded the trash bag, her gown and gloves into a trash receptacle that was placed outside the resident ' s room. Without washing her hands, HS 1, then, wheeled the main trash barrel that was placed outside Resident 5 ' s room through the hallway. On 8/23/11, at 2:38 p.m., HS 1 returned to Resident 5's room to replace paper towels in the dispenser next to the handwashing sink. After the procedure, she removed her protective gloves and gown and placed them in the trash receptacle outside the resident's room and left without washing her hands. During an interview on 8/23/11, at 2:57 p.m., the Infection Control Nurse/Director of Staff Development stated that she had in-serviced all the nursing staff (registered nurses, licensed vocational nurses, certified nursing assistants) regarding isolation precautions and the importance of hand-washing. She also indicated that the housekeeping staff and therapists had been in-serviced by their supervisors. She acknowledged that the facility staff failed to maintain an effective Infection Control Program to prevent the transmission of disease and infection. During an interview with Resident 5's primary physician (MD 1) on 8/23/11, at 4:50 p.m., he stated that the possibility of other residents getting contaminated with[DIAGNOSES REDACTED] bacteria was very high, and that infection control measures such as handwashing was very important to prevent the transmission of disease to other residents. The pattern of the facility's failure to prevent the transmission of disease and infection by not adhering to established isolation precautions and hand washing resulted in an immediate jeopardy to all the residents, staff and visitors in the facility. On August 23, 2011 at 6:10 p.m., an Immediate Jeopardy (IJ) was called in the presence of the administrator, the director of nursing, the infection control nurse, and a registered nurse supervisor. On August 23, 2011, at 7:10 p.m., the administrator submitted a plan of action, which included the removal of all clean linen from the clean linen cart and replacing them with emergency linen, disinfection of the treatment cart, and initiation of in-services to all staff on hand-washing and isolation precautions. The surveyors confirmed that the facility had implemented the following plan of action: 1. Completion of in-services to all staff on isolation precautions and hand washing. 2. Removal of all linen that were possibly contaminated. 3. Disinfection of treatment carts for both North and South stations. 4. Removal/discarding of treatment items that were possibly contaminated, including [MEDICATION NAME] spray. 5. Monitoring all residents for signs and symptoms of[DIAGNOSES REDACTED] infection. On August 24, 2011 at 4:30 p. m., the facility was back in compliance with the facility's infection control policies and procedure and the Immediate Jeopardy was lifted. f. Resident 3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. LVN 3 touched and lifted the resident's feet with bare hands to check if there was redness or skin breakdown. LVN 3 left Resident 10's room without washing his hands. The same LVN removed the nasal cannula from the nostrils of a resident in room [ROOM NUMBER] bed A with gloved hands but did not wash his hands after removing his gloves. During an interview on 8/30/11, at 1:45 p.m., LVN 3 stated he was aware that he left the room without washing his hands after he touched the feet of Resident 10 and after removal of the nasal cannula of the resident in room [ROOM NUMBER] bed A. LVN 3 stated that he forgot to wash his hands although he have received an inservice to wash hands after direct care contact with a resident. This is a repeat deficiency from last year's Recertification survey.

Based on observation, interview and record review, the facility's staff failed to wash their hands after each direct resident contact for which hand-washing was indicated. Findings: On 10/6/11, at 12:10 p.m., a staff (OT 1) was observed as she attended to residents in the dining room during lunch. OT 1 was observed as she positioned and handled with her bare hands Resident 9's slippers. Without washing her hands, OT 1 proceeded to assist a randomly-selected resident (RS 31) by aligning the resident's body/legs/feet. During the process, OT 1 also handled the resident's wheelchair parts, including the footrests and wheel locks/brakes. Without washing her hands, OT 1, then, proceeded to assist another randomly-selected resident (RS 32) by repositioning the resident's upper body on the wheelchair. Afterwards, without washing hands, OT 1 proceeded to Resident 29 to assist with the resident's meal. OT 1 was observed as she handled multiple times, with her unwashed hands, the resident's plasticware including a juice glass and an ice cream cup. During an interview on 10/6/11 at 12:25 p.m., OT 1 acknowledged her failure to wash her hands after providing care to each individual resident mentioned above. The facility's undated policy and procedures, titled "Hand Hygiene," indicated, "All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infections."