Every finding on record at Creekside Post-Acute

Based on interview and record review, the facility failed to ensure one out of five residents who are on psychotropic medications (Resident 75) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when Resident 75 received quetiapine fumarate (an antipsychotic [drugs treat psychosis] medication that helps treat several kinds of mental health conditions) without target behavior monitoring.The Failure had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being.Finding:During a review of Resident 75's facesheet indicated Resident 75 was admitted to the facility with diagnoses including schizophrenia (serious mental illness characterized by delusions, hallucinations, and disorganized thinking.), unspecified and essential (primary) hypertension (high blood pressure that develops gradually over time without a single, identifiable medical cause).During a review of Resident 75's physician's orders dated 6/5/2026. it indicated an order for Quetiapine Fumarate Oral Tablet 200 mg (milligram, unit of measure), Give 1 tablet by mouth at bedtime for Schizophrenia m/b (manifested/by) physical aggression (i.e. [like] hitting, kicking).During a review of Resident 75's electronic medication administration record (eMAR) indicated there was no monitoring for the target behavior of physical aggression (i.e. [like] hitting, kicking). The facility did not monitor the target behavior every shift from 6/6/26 to 7/23/26.During a concurrent interview and record review on 07/23/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON reviewed Resident 75's physician's order for Quetiapine target behavior. The DON confirmed Resident 75's target behavior of physical aggression (i.e. [like] hitting, kicking). was not monitored every shift. The DON stated she didn't see the physical aggression on the monitoring, she further stated they have to monitor for each target behavior in the computer true hashmarks.During a review of the facility's P&P titled Psychotropic Medication Use, dated 7/2022, indicated, 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes; a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences.

Based on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for two of four sampled residents (Residents 5 and 20) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when:1.The Skilled Nursing Facility (SNF) Licensed nurse (LN)assessment information and communication with the facility to dialysis center prior (Pre) or before transfer - Hemodialysis Communication/assessment Records (HCAR's) to dialysis treatment center were incomplete. 2.The SNF LN's did not follow up on the incomplete dialysis center's HCAR's.These failures may affect the quality of dialysis care being provided to the residents and have the potential to cause resident health complications.1a). Review of Resident 20's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including end stage renal disease (a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those kidneys that have lost normal function).Review of Resident 20's Minimum Data Set (MDS, an assessment tool), dated 7/6/26, indicated she was cognitively intact with a brief interview for mental status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14. During a concurrent observation and interview on 7/22/26 at 8:30 a.m., with Resident 20 was in her room, she stated that she was scheduled for dialysis every Monday, Wednesday and Friday. Resident 20 further stated that her dialysis access site was on her left upper chest.During a concurrent interview and record review on 7/22/26 at 9:30 a.m., with the Director of Nursing (DON), the DON reviewed Resident 20's HCAR's dated 6/5/26, and 7/6/26 indicated the access location, SNF- LN assessments information, communication with the facility to dialysis center before transfer were blank. DON stated that assessments, information and communication with the facility to dialysis center before transfer was facility LN responsibility to complete.During a concurrent interview and record review on 7/23/26 at 9:35 a.m., with the Minimum Data Set Coordinator(MDSC), she reviewed Resident 20's care plan and stated that Resident 20's dialysis site or access site location was on the Left upper chest ([NAME]) (Perma Catheter, placement of a special (Intravenous) IV line or long, flexible tube inserted into a vein most commonly in the neck and into the heart to allow dialysis to occur) in place on her left chest.During a concurrent interview and record review on 7/23/26 at 10:46 a.m., with the MDSC, she reviewed Resident 20's HCAR's and confirmed that HCAR's dated 6/12/26, 6/22/26,6/26/26, 7/3/26, 7/8/26, 7/13/26,7/15/26,7/16/26, 7/17/26 and 7/20/26 were missing the SNF- LN assessments information, communication with the facility to dialysis center before transfer to dialysis center.1b). Review of Resident 5's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis and was scheduled for dialysis every Monday, Wednesday and Friday.Review of Resident 5's order summary report dated 6/11/26 he had an arteriovenous fistula (AVF, surgically created connection between an artery and vein on a person's limb to allow dialysis to occur) on his left arm. During a concurrent interview and record review on 7/22/26 at 9:30 a.m., with the DON, she reviewed Resident 5's HCAR's dated 4/22/26, 4/29/26, 5/4/26 and 5/11/26. DON confirmed HCAR's were incomplete and blank such as the access location, the SNF- LN assessments information, communication with the facility to dialysis center before transfer. DON further stated that assessments, information and communication with the facility to dialysis center before transfer was facility LN responsibility to complete. During a concurrent interview and record review on 7/23/26 at 11:43 a.m., with the MDSC, she reviewed Resident 5's HCAR's dated 2/20/26, 3/2/26, 3/4/26,3/9/26,3/11/26, 3/16/26,3/30/26, 4/3/26, 4/8/26,4/17/26,5/20/26 and 5/22/26 were incomplete and blank such as the access location, SNF- LN assessments information, communication with the facility to dialysis center before transfer. The Access locations were blank for the following dates 3/20/26, 3/25/265,4/1/26 and 6/3/26. The MDSC stated the LNs should have completed the HCAR's for Resident 5 before Resident 5 was transferred to dialysis center. 2a). During a concurrent interview and record review on 7/22/26 at 9:30 a.m., with the DON, She reviewed Resident 20's HCAR's dated 6/5/26, and 7/6/26, DON confirmed that the skin assessment check pre- dialysis by dialysis center were blank. DON stated that the facility LN responsibility to follow up with dialysis center for missing documentation when Resident 20 is back to the facility after dialysis treatment. During a concurrent interview and record review on 7/23/26 at 11:01 a.m., with the MDSC, she reviewed Resident 20's HCAR's and confirmed that HCAR's dated 6/12/26, 6/22/26,7/8/26, 7/13/26, 7/15/26, 7/16/26,7/17/26 and 7/20/26 were missing pre- dialysis skin check assessment from dialysis center and MDSC stated that the nurses should have followed up with dialysis center and completed the DCR's for Resident 20's continuity of dialysis care and the MDSC further stated that there were no documentations in the nurse's notes indicating that the licensed nurse called the dialysis clinic to complete the DCR's.2b). During a concurrent interview and record review on 7/22/26 at 9:45 a.m., with the DON, she reviewed Resident 5's HCAR's dated 7/15/26, 7/17/26 and 7/20/26 were blank for the skin assessment check pre- dialysis by dialysis center. DON stated that facility LN should be responsible for following up with dialysis center for missing documentation when Resident 5 is back to the facility after dialysis treatment.During a concurrent interview and record review on 7/23/26 at 11:43 a.m., with the MDSC, she reviewed Resident 5's HCAR's dated 2/28/26,3/4/26,3/18/26, 3/23/26, 5/25/26 and 7/13/26 were missing pre- dialysis skin check assessment from dialysis center and the MDSC stated that the nurses should have followed up with dialysis center and completed the DCR's for Resident 5's continuity of dialysis care and MDSC further stated that there were no documentations in the nurse's notes indicating that the licensed nurse called the dialysis clinic to complete the DCR's.Review of the facility's policy titled, End -Stage Renal Disease, Care of a resident with, Revision date September 2010, indicated Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.Education and training of staff includes, specifically: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including; how the care plan will be developed and implemented; how information will be exchanged between the facilities. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when: 1.Dietary staff did not follow the proper use of kitchen hair net (a lightweight mesh cap worn by food workers to keep loose hair, dandruff, and skin particles from falling into food) while handling food in the kitchen. 2. There were unsanitary kitchen utensils and plastic ware such as: a. A clear plastic pitcher handle was burned and melted; b. A plastic spatula (a kitchen utensil with a wide, flat blade used for mixing spreading, lifting, and removing food) has chipped and brownish color on the silicon spatula. Stainless steel scoop with plastic handle has burned and melted handle; 3.Used alcohol swab in the clean area near the food steam table; 4.The facility's dietary server did not follow the proper use of gloves during meal preparation in the kitchen; 5.The ice inside the one of the two ice chests (a portable, insulated box used to keep food and drinks cold with ice or ice packs) has spots of black substances in the ice; and 6.The two ice chests has no cleaning log maintained. These failures had the potential to cause food contamination and spread food-borne illnesses to residents who received their food from the kitchen.Findings: 1.During a kitchen observation on 7/21/26 at 9:55 a.m., a Dietary [NAME] (DC) G was preparing food to serve to the residents from the food steam table. DC G was observed that her hair tied bun has a hair net and did not completely cove the loose hairs from the forehead and back of her head. During an interview with DC G on 7/21/26 at 10:19 a.m., inside the kitchen. DC G confirmed that her hair net was not completely covering her loose hair in the front and back of her head. DC G further stated hairnet should cover until half of the forehead to the back of the head because the loose hair can go to the food she was preparing. During an interview with the Licensed Dietician (LD) on 7/21/26 at 10:29 a.m., the LD stated hair nets should cover all hair and down the ears because strands of hair can come in the food. During a review of the facility's policy and procedure (P&P) titles, Food Preparation and Service, revised November 2022, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Distribution and Service: 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. 2.a During a kitchen observation and concurrent interview with DC H on 7/23/26 at 10:56 a.m., a clear plastic pitcher on the dry area has a burned and melted handle. DC H confirmed that the handle has a whitish part that was burned and melted. DC H stated this plastic pitcher can possibly cause contamination on the liquids. 2b. During a kitchen observation and concurrent interview with DC H on 7/23/26 at 11:03 a.m., inside a clean bus tray (a deep rectangular plastic container used to carry kitchen tools) with cover are several clean kitchen utensils, a spatula and stainless-steel scoop with different colored plastic handles. Four pieces of a plastic spatula has chipped and brownish color on the silicon spatula and six pieces of stainless-steel scoop with plastic handle has burned and melted handle. DC H verified above observation and further stated the plastic spatula should not be used. They are burned and it could cause food contamination. The LD verified that the kitchen utensils were burned and chipped. During a review of the facility's policy and procedure (P&P) titles, SECTION 8: SANITATION, dated 2023, the P&P indicated, 12. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas. 12. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, crack, or loss of glaze shall be discarded. 3.During the tray line preparation observation on 7/23/26 at 11:56 a.m., DC G was taking the food temperature, there was a clean foil that was spread near the food steam table with clean portion scoop (used to measure and serve exact amount of food), observe the used alcohol swab to wipe the thermometer was placed in the clean foil, after DC G throw the used alcohol swab but there was remaining used alcohol swab in the clean foil. During an interview with DC G on 7/2/3/26 at 12:11 p.m., DC G confirmed the used alcohol swab to clean the thermometer should not be in the clean area and it can cause cross contamination in the food. During a review of the facility's policy and procedure (P&P) titles, Food Preparation and Service, revised November 2022, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. General Guidelines: 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. 4. During a kitchen observation on 7/2/3/26 at 11:30 a.m., the Dietary Server (DS) was wearing gloves and pouring milk in the resident cup and covered with lid, then she opened the refrigerator and took a box of milk and opened and resumed pouring milk in the Resident's cup. The DS touched her shoulder using her gloves and did not change her gloves after touching possibly contaminated areas before continuing to prepare the food. During an interview with DC H on 7/23/26 at 12:18 p.m., DC H verified the DS should change gloves and wash their hands before every task. During a review of the facility's policy and procedure (P&P) titles, Food Preparation and Service, revised November 2022, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Distribution and Service: 7 .Gloves are when handling food directly and changed between tasks. Disposable gloves are single -use items and are discarded after each use worn. 5. During observation on 7/22/26 at 10:32 a.m., in the Nursing station (NS) AA there was a white ice chest in a movable cart that contained ice with s spots of black substance stucked to the ice. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) D on 7/22/26 at 10:36 a.m., LVN D confirmed that there are spots of black substance stucked to the ice. During a concurrent observation and interview with the Infection Preventionist (IP) on 7/22/26 at 10:38 a.m., the IP confirmed the ice spots of black substance stuck to the ice inside the ice chest. The IP further stated that is an infection control issue. During a review of the facility's policy and procedure (P&P) titles, Ice Machine and Ice Storage Chests, revised January 2012, the P&P indicated, Ice machine and ice storage /distribution containers will be used and maintained to assure a safe and sanitary supply of ice. 6. During an observation on 7/22/26 at 10:24 a.m., with the LD along the hallway near the kitchen and dining area a movable cart with ice chests and ice scoop with empty ice has some blackish substance floating inside the ice chest. The LD stated the kitchen staff should clean the ice chest after using them. During an interview with the IP on 7/22/26 at 10:42 a.m., the IP confirmed the ice chest has some blackish substance floating inside the ice chest.The IP further confirmed that there was no cleaning log for ice chests and ice scoop. The IP stated the ice chest, and ice scoop are being cleaned by the kitchen staff and stated they should have a cleaning log for the ice chests in the facility. During an interview with DC H, in the kitchen, on 7/23/26 at 10:48 a.m., DC H stated the night shift staff take the ice chests and the ice scoop from the kitchen to clean. DC H stated no log for the cleaning of ice chest and ice scoop. During a review of the facility's policy and procedure (P&P) titles, ICE CHEST CLEANING PROCEDURE, dated 2023, the P&P indicated, All ice chest will be cleaned and sanitized before and after each use, and when contaminated or visibly soiled, using the following procedure. During a review of the facility's policy and procedure (P&P) titles, Ice Machine and Ice Storage Chests, revised January 2012, the P&P indicated, Ice machine and ice storage /distribution containers will be used and maintained to assure a safe and sanitary supply of ice.1. Ice -making machines, ice storage chests/containers, and ice can all become contaminated by: a. unsanitary manipulation by employees, residents, and visitors; 2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: f. Clean and sanitize the tray and ice scoop daily; 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests.

Based on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented when:Residents (2)'s BiPAP (bilevel positive airway pressure, a machine used to help breathe by providing two different levels of air pressure through a mask) face mask and tubing were uncovered at bedside, her foley bag ( urinary drainage bag, a medical device attached to a Foley catheter to collect urine from the bladder) was on the floor, and wound care nurse (WNC B) did not perform hand hygiene during donning of gloves when providing wound care;Resident 20's nebulizer tubing with mouthpiece (plastic mouthpiece and tubing used as a connection from compressor to deliver mist to client) were exposed outside the plastic bag and stored on top of the cloth bag with her personal belongings inside the bag, and was kept on top of the bedside table and Resident 20's used fork was stored on top of the comb and was kept on top of the bedside table;Infection control practice was not followed during wound care for Resident 111;A Licensed Vocational Nurse D(LVN D) did not place a barrier and did not sanitize the medication cart after placing a potentially contaminated items before preparing the medication for Resident 18; Facility staff did not follow contact precautions of wearing PPE (personal Protective equipment, such face shields, masks, gloves and gown) before entering room of Resident 77;Resident 92's nebulizer tubing with mouthpiece was exposed in the Residents bedside table;Appropriate hand hygiene was not followed during dining observation and The exterior part of the Ice Machine was not cleaned after the outside company cleaned the interior portion only These above failures could result in the spread of infection and cross-contamination that could affect 121 residents who currently reside in the facility. 1a). During an initial tour on 7/20/26, at 9:40 a.m., in Resident 2's room, observed her BiPAP tubing, mask and chin straps left at bedside without covering and her indwelling foley catheter bag hanging her left side of bed was on the floor. During an interview on 7/22/26, at 8:50 a.m., with the registered nurse A (RN A), RN A confirmed Resident 2's BiPAP tubing , mask and chin straps should have been in a clean bag. Also, RN A confirmed Resident 2's indwelling foley drainage bag (a collection pouch attached to a flexible tube (Foley catheter, a thin, flexible plastic tube inserted through the urethra into the bladder to drain urine into an external collection bag) inserted into the bladder to continuously drain and hold urine) should have not be kept or touching the floor. RN A stated it would cause contamination and an infection control issue. During a review of the facility's policy and procedure (P&P) titled, Emptying a Urinary Collection Bag, dated 8/2022, the P&P indicated, Keep the collection bag and tubing off the floor at all times to prevent contamination and damage. 1b). During a wound care observation and an interview on 7/23/26, at 12:30 p.m., in Resident 2's room, the wound care nurse B (WCN B) performed wound care to Resident 2's Moisture-Associated Skin Damage (MASD, an inflammation and breakdown of the skin caused by long-term contact with body fluids)and venous ulcer (a slow-healing open sore on the lower leg caused by poor blood flow, damaged vein valves, and high pressure in the veins). WCN B changed multiple times the gloves during wound care to Resident 2's buttocks for MASD, she did not perform hand hygiene in between donning gloves. WCN B confirmed she forgot bringing a hand sanitizer with her during wound care. During an interview on 7/23/26 1:10 p.m., with the infection preventionist (IP), the IP stated that during wound care in between glove changes, staff should perform hand hygiene. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated, Perform hand hygiene before applying non-sterile gloves. Hand hygiene is indicated: immediately after glove removal. 2a). Review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including pneumonia (a common lung infection caused by bacteria, a virus or fungi), bronchitis (inflammation of the bronchial tubes—the airways that carry air to and from your lungs and causes a persistent cough that often brings up mucus, wheezing, and chest discomfort), acute brocho spasm (a sudden tightening of the muscles that line the airways (bronchi) in your lungs, which narrows the air passages and makes it hard to breathe and often causes wheezing, coughing, and chest tightness) and allergy. Review of Resident 's minimum data set (MDS, an assessment tool) dated 7/6/26, indicated Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). (BIMS) score of 14 which means cognitively intact. During an observation in Resident 20's room on 7/22/26 at 8:35 a.m., Resident 20's undated nebulizer mouthpiece and tubing were exposed outside the plastic bag and stored on top of the cloth bag with personal belongings inside the bag and was kept at the bedside table. The undated nebulizer mouthpiece was exposed inside the bedside table together with pair of socks, white letter envelopes and other personal items. During an interview with Resident 20 on 7/22/26 at 8:36 a.m., she stated that she was using the nebulizer machine with nebulizer mouthpiece as needed for emergencies. During a concurrent observation and interview on 7/22/26 at 8:37 a.m., with licensed vocational nurse J (LVN J), He confirmed the above observation and stated that the nebulizer mouthpiece and tubing should have been dated or labelled. He further stated that the nebulizer mouthpiece and tubing should have been stored inside the plastic bag not outside the bag exposed and should not have been stored together with socks and other personal items inside the bedside drawer. During an observation and interview on 7/22/26 at 8:45 a.m., with infection preventionist (IP), She confirmed the above observations and stated that it should have been stored inside the plastic bag with date and the same as the Nasal Canula (NC a device used to deliver supplemental oxygen or airflow), CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) and bilevel positive airway pressure (BIPAP also referred to as BPAP) very similar in function and design to a CPAP. IP further stated that it should not have been exposed outside the plastic bag and the other nebulizer mouthpiece should not have stored inside the drawer together with personal belongings due to infection control issue. Review of the facility's policy titled, CPAP/BIPAP Support Revision date March 2015, indicated general guidelines 8. Store the mask in plastic bag with date. During a concurrent interview and record review on 7/23/26 at 9:45 a.m., with the Minimum Data Set Coordinator(MDSC), She reviewed Resident 20's Medical Doctor (MD) order dated 6/3/26 indicated DuoNeb solution (combination of two medicines—ipratropium bromide and albuterol sulfate—used to treat chronic obstructive pulmonary disease (COPD) and it is turned into mist by a machine called a nebulizer so you can breathe it into your lungs). 5-2.5 (3) milligram (ml.)/3ml. inhale orally every six hours as needed for shortness of breath (SOB)/ wheezing. 2b).During an observation in Resident 20's room on 7/22/26 at 8:35 a.m., used the fork was on top of Resident 20's comb with stray of hairs. During an interview with Resident 20 on 7/22/26 at 8:36 a.m., she stated that she was using the fork to eat her snacks and food. Resident 20 further stated it was the facility staff who stored the fork on top of my comb. During a concurrent observation and interview on 7/22/26 at 8:41 a.m., with LVN J, He confirmed the above observation and stated that the used fork should not have been stored on top of Resident 20's comb due to infection control issue. 3. During the wound vac dressing treatment observation with Licensed vocation nurse K (LVN K) on 7/24/26 at 10:23 a.m., LVN K cleaned Resident 111 wound with normal saline (saline solution -mixture of sodium chloride in water and applied to the affected area or used to clean wounds) using a sterile gauze. LVN K cleaned the wound from inner to outer stroke with no disposable cloth or chux cloth next to the resident to protect the bedlinen and other sites. During the wound vac dressing treatment observation with LVN K on 7/24/26 at 10:40 a .m., LVN K applied the wound vac with dressing using pair of gloves then wound vac machine beep, LVN K check the wound vac machine using the pair of gloves that she used during wound vac dressing, touched the machine and continued with the wound vac dressing for Resident 111 using the same pair of gloves, did not perform hand hygiene and it happened two times that the wound beeps and LVN K still using the same gloves. During an interview with LVN K on 7/24/26 at 10:56 a.m., LVN K confirmed the above observations and stated that she forgot to put disposable chux cloth next to resident 111 to protect the bedlinen and other sites. LVN K further stated that she should have perform hand hygiene and changed the used gloves to a new pair in every new procedure during wound vac dressing treatment. Review of the facility's policy titled, Wound Care Revision date April 2026, indicated Steps in the procedure 7. Place disposable cloth to the resident to protect the bed linen and other body sites. Review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated, Perform hand hygiene before applying non-sterile gloves. Hand hygiene is indicated: immediately after glove removal. 4. During a medication administration observation on 7/22/26 at 8:42 a.m., Licensed Vocational Nurse D (LVN D), LVN D took the mouth wash bottle (no lid cover) from Resident 18's roommate (Resident 63) bedside table, and placed it on the top of medication cart, then LVN D went to nurse station with the bottle of mouth wash, then LVN D stated he threw away the mouth wash bottle. LVN D proceed in preparing the medications for Resident 18 on the same spot were the mouth wash used by resident was placed without sanitizing the medication cart. During a follow up interview with LVN D shortly after the medication administration to Resident 18, LVN D stated the mouth wash was Resident 63's personal item and it was placed on her bedside table. LVN D confirmed that the medication cart was not sanitized before preparing Resident 18's medications. LVN D further stated the medication cart should have sanitized before the medication preparation. During an interview on 7/22/26 at 10:51 a.m., with the Infection Preventionist (IP), the IP stated residents' personal items should not be placed on the medication cart, and the nurse should clean or sanitize the medication cart before preparing medications. During a review of the facility's P&P titled Administering Medications, Revised date 4/2019, .25. Staff follows facility infection control procedure. During a review of facility's policy and procedure titled, Infection Prevention and Control Program Revised 9/2022, the P&P indicated, An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 5. During an observation on 7/22/2026 at 9:48 a.m., outside Resident 77's room, one staff (CNA F) went inside Resident 77's room without wearing a PPE. The staff took some towels from Resident 77's bedside table. She used a plastic bag to get the towels without gloves and gown. During an interview shortly after the observation with the staff, she stated she did not use PPE because shwas not sure what type of isolation precautions Resident 77 was on. During an interview on 7/22/2026 at 10:48 a.m., with the Infection Preventionist, she stated staff have to wear all PPE for contact precautions and when touching a resident's surface. During an observation and interview on 7/22/2026 at 11:57 a.m., outside Resident 77's entrance door, posted a sign of contact precaution indicated, put on gloves before room entry and Put on gown before room entry. The IP confirmed Resident 77 is on contact precaution and needs to wear PPE when going inside the room During a review of facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precautions Revised 9/2022, the P&P indicated, .Contact Precautions. 1.Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage).b. Gloves are removed and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8.Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 6.During an observation on 7/20/26 at 11:06 a.m., an exposed nebulizer tubing with mouthpiece was found on Resident 92's bedside table with her personal belongings. Review of Resident 92's comprehensive Minimum Data Set (MDS, an assessment tool used at skilled nursing facilities) dated 6/2/26, indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15 out of 15. A score of 13 to 15 indicates cognitively intact. During a concurrent observation and interview on 7/20/26 at 2:31 p.m., with Resident 92's inside her room. Resident 92's confirmed the nebulizer tubing with mouthpiece was exposed and further stated staff won't wait for 15 minutes. During an interview with the Infection Preventionist on 7/22/26 at 9:21 a.m., the IP stated the nebulizer tubing mouthpiece should be placed in a plastic bag and not left exposed if not in use to keep it clean from the environment. During a review of the facility's policy and procedure (P&P) titles, Small Volume Nebulizer/Respiratory Care , dated January 1, 2026, the P&P indicated, the purpose of this policy is to establish standardized clinical guidelines for the safe and effective administration of a small volume nebulizer. 6. Infection Control: 6.2. The small Volume Nebulizer cup and mouthpiece will be cleaned daily by washing pieces in warm soapy water. 7.During a dining observation on 7/20/26 at 11:56 a.m., certified nurse assistant (CNA) I was passing meal trays to residents. CNA I helped Residents to open box of milk, then proceeded to pick up the meal tray that was handed by the Director of Staff Development (DSD) then serve the meal tray to the next resident without doing hand hygiene in between tasks. During an interview with CNA I on 7/20/26 at 12:25 p.m., CNA I confirmed that he did not hand sanitize between tasks. CNA I stated it's important to do hand hygiene because of infection control. During an interview with the IP on 7/20/26 at 12:50 p.m., the IP stated that staff passing meal trays should do hand sanitize before and after feeding the residents as long as they gel in and gel out. During a review of the facility's policy and procedure (P&P) titles, Handwashing/ Hand Hygiene , revised October 2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the 8.During a concurrent observation and interview with the plant/environmental services (P/EVS) on 7/22/26 on at 9:49 a.m., inside the dining hall where the ice machine was, in the presence of the Licensed Dietician (LD), P/EVS stated the ice machine interior cleaning was being done by an outside company every six months, last visit was 7/20/26 on the service order. During a concurrent interview and record review of the log titled ICE MACHINE CLEANING LOG for the month of July, the P/EVS stated the ice machine exterior is cleaned every two weeks. The Ice Machine Cleaning Log on July 3rd week was blank. The last cleaning for the month of July 1st week was dated 7/6/26. The P/EVS confirmed the exterior of the ice machine should have been cleaned using bleach after the interior cleaning was completed by the outside company on 7/20/26. A review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Schedule and Maintenance, undated 09/18/2023, the P&P indicated It is the facility's policy to maintain the cleanliness of the ice machine.

Based on observation, interview, and record review, the facility failed to perform an interdisciplinary team (IDT, staff from different departments who coordinates the residents care) assessment and obtain a physician (MD) order for self-administration of medication and one bottle of Fluticasone propionate nasal suspension (Nasal spray known as corticosteroids (cortisone-like medicine) used to treat sneezing, itchy or runny nose, or other symptoms caused by hay fever). 50 micrograms (mcg a tiny metric unit of weight equal to one-millionth of a gram (1/1,000,000 of a gram) or one-thousandth of a milligram (1/1,000 of a mg) when a nasal spray was kept at for one of 25 sampled residents (Resident 20) 's bedside table unattended. These failures had the potential for unsafe and improper administration of medications. Review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated she had a diagnosis of pneumonia (a common lung infection caused by bacteria, a virus or fungi), bronchitis (inflammation of the bronchial tubes-the airways that carry air to and from your lungs and causes a persistent cough that often brings up mucus, wheezing, and chest discomfort), acute brocho spasm (a sudden tightening of the muscles that line the airways (bronchi) in your lungs, which narrows the air passages and makes it hard to breathe and often causes wheezing, coughing, and chest tightness) and allergy. Review of Resident 's minimum data set (MDS, an assessment tool) dated 7/6/26, indicated Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). (BIMS) score of 14 which means cognitively intact. During an observation in Resident 20's room on 7/20/26 at 11:37 a.m., and 7/21/26 at 10:15 a.m., one bottle of Fluticasone propionate 50 mcg nasal spray was kept at Resident 20's bedside table unattended. During an observation and interview on 7/22/26 at 9:08 a.m., with the infection preventionist (IP), she confirmed the above observation that one bottle of Fluticasone propionate 50 mcg nasal spray was kept at Resident 20's bedside table unattended. The IP stated that the nasal spray medication should not be kept at the bedside table of Resident 20 unattended and Resident 20 was not allowed for self-administration of medication. The IP further stated that the nasal spray medication should be kept and locked inside the medication cart by licensed nurse (LN). During an interview with Resident 20 on 7/22/26 at 9:10 a.m., she stated that she had been taking the above nasal spray as ordered by the doctor (MD). Resident 20 further stated that the staff was aware and saw the nasal spray at her bedside table. During a concurrent interview and record review on 7/23/26 at 9:30 a.m., with the minimum data sheet coordinator (MDSC), She reviewed Resident clinical records and stated that MD order dated 6/3/26 indicated Fluticasone propionate 50 mcg nasal spray one spray in each nostril two times a day for allergy relief and there was no MD order, no IDT assessment and no care plan for self-administration of medication. The MDSC further stated that Resident 20 was not allowed for self-administration of medication but should have been assessed by the IDT for safely administering the nasal spray. Review of the facility's undated policy, titled Medication Labeling and Storage, indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication are assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents.

Based on interview and record review, the facility failed to ensure to update and revise the comprehensive person-centered care plans for one of 25 sample residents (Resident 35) when the care plan was were not revised after Resident 35 was discharged from the hospice services (focuses on comfort, dignity, and quality of life for people with a serious illness who are nearing the end of life).This failure had the potential to result in not meeting Resident 35's plan of care needs.Finding:During a review of Resident 35's facesheet, it indicated Resident 35 was admitted to the facility with diagnoses including history of falling and muscle weakness (generalized).During a review of Resident 35's care plan for ADL (Activities of Daily Living are the fundamental self-care tasks people must do every day to live independently and safely, including eating, bathing, dressing, and moving around.) self-care and pain care plan, the ADL self-care care plan was revised on 6/19/26 and one of the interventions indicated, Coordinate POC (plan of care) with hospice, another care plan of Resident 35 for pain revised on 4/12/26, one of the interventions indicated, refer to hospice care plan. During a review of Resident 35's MDS assessment (a federally mandated, standardized clinical screening and evaluation tool used in long-term care facilities and skilled nursing homes) the facility initiated significant change assessment (comprehensive evaluation required in skilled nursing facilities when a resident experiences a major health decline or improvement) dated 4/8/26 after Resident 35 was discharged from hospice.During a concurrent interview and record review on 7/23/26 at 11:10 a.m., with Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 35 was discharged from hospice services on 3/27/26 and they did the MDS assessment on 4/8/26. The MDSC stated they do update the care plans including the ADL self-care and pain care plan. MDSC reviewed Resident 35's ADL self-care care plan last revision date 6/19/26 and one of the interventions indicated, Coordinate POC (plan of care) with Hospice, the MDSC reviewed another care plan of Resident 35 for pain revision date 4/12/26, one of the interventions indicated, refer to hospice care plan. The MDSC confirmed that Resident 35's ADL self-care and pain care plans were not revised after Resident 35 was discharged from hospice on 3/27/26. The MDSC further stated hospice should not be involved in the care after the 3/27/26.During a review of facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised 12/2016, 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. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for one out of six residents (Resident 22). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally).Finding:During a review of Resident 22's face sheet (summary document used mostly in healthcare ), it indicated Resident 22 was admitted to the facility with diagnosis including type 2 Diabetes Mellitus (DM- a condition which affects the body processes blood sugar) without complications.During a review of Resident 22's physician's order, dated 5/11/2026, it included Hydrocodone-Acetaminophen (a potent controlled medication for pain)5-325 mg (milligram, unit of measurement), give 1 tablet by mouth every 24 hours as needed for pain.During a record review of Resident 22's Controlled Drug Record Sheet (CDR) and electronic Medication Administration Records (eMAR) for Hydrocodone-Acetaminophen 5-325 mg in the month of May, June, and July 2026, there were two occasions on 6/2/26 and 6/5/26, the nursing staff signed out on CDR but did not document their administration on June 2026 eMAR.During an interview and record review on 7/24/26 at 1:49 p.m., with the Director of Nursing (DON), the DON reviewed Resident 22's CDR and eMAR, the DON confirmed the findings and acknowledged Hydrocodone-Acetaminophen 5-325 mg 1 tablet for Resident 22 were not signed on 6/2/26 and 6/5/26 MAR. The DON stated nurses should sign the eMAR and CDR immediately.During a review of facility's P&P titled, Administering Medications revised date 4/2019, the P&P indicated, . 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; a. The date and time the medication was administered; b. The dosage; c. The route of administration; .e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility had a medication error rate of 8.82% when three medication errors occurred for 3 out of 34 opportunities during the medication administration of three out of seven residents (Resident 20, Resident 38, and Resident 106). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), which had the potential for the residents not receiving full therapeutic effects or complications of medications.Findings:1. During the medication administration observation on 07/21/26 at 4:22 p.m., Licensed Vocational Nurse E (LVN E) observed preparing and administering six medications to Resident 20 that included medications such as Calcium Acetate (used to treat hyperphosphatemia [too much phosphate in the blood]) Oral Capsule 667 milligrams (mg, unit of measurement). During the medication administration observation, Resident 20 has no meal tray for dinner at the bedside.During a review of Resident 20's physician's order dated 6/3/26, it indicated Calcium Acetate Oral Capsule 667 mg Give 2 capsule orally with meals for supplement with meals.During a concurrent interview and record review on 7/22/26 at 3:19 p.m., with LVN E, she reviewed Resident 20's physician's order for Calcium Acetate Oral Capsule 667 mg Give 2 capsule orally with meals for supplement with meals. LVN E confirmed the medication should be given with meals, LVN E stated when she gave the medication to Resident 20 the meal trays were not there yet. LVN E further stated that meals are like dinner and the medication should be given with meals.2.During the medication administration observation on 07/21/26 at 4:43 p.m., Licensed Vocational Nurse C (LVN C) observed preparing and administering four medications to Resident 38 that included medication as sodium chloride (known as table salt) 1 gram (unit of measurement) give 1 tablet by mouth orally with meals for supplement, during administration observation, there were no meal tray at Resident 38's bedside.During an observation and interview on 7/21/26 at 5:22 p.m., with Resident 38 there were no meal tray at bedside, Resident 39 stated he did not have dinner yet.During a follow-up interview and concurrent record review of Resident 38's physician's order for sodium chloride on 7/21/26 at 5:24 p.m., with LVN C, he confirmed the order for sodium chloride 1 gram give 1 tablet by mouth orally with meals for supplement, LVN C confirmed it was given to Resident 38 without meals, LVN C further stated the medication should be given with the dinner.During an interview on 7/23/26 at 3:12 p.m., with the Director of Nursing (DON), the DON stated she expects the nurses to follow the physician's order, like medication orders given with meals.3. During the medication administration observation on 07/21/26 at 4:59 p.m., Licensed Vocational Nurse C (LVN C) observed preparing and administering four medications to Resident 106 that included medications such as: tamsulosin 0.4 MG oral capsule give 1 capsule by mouth at bedtime for BHP (benign prostatic hyperplasia, a noncancerous condition also known as an enlarged prostate.) at bedtime take 30 mins after same meal each day. On 7/21/26 at 5:06 p.m., LVN C administered the medications to Resident 106 including tamsulosin. During a concurrent interview and record review on 7/21/26 at 5:08 p.m., with the LVN C, he reviewed the tamsulosin order for Resident 106, and he confirmed the tamsulosin instruction is at bedtime, but it was given for evening time. LVN C also stated bedtime medication should be given at 9pm (9:00 P.M) and the medication should be given at bedtime and he further stated Resident 106 did not have eaten his dinner yet. During a concurrent interview and record review on 7/23/26 at 3:15 p.m., with the Director of Nursing (DON), the DON reviewed Resident 106's physician's order for tamsulosin 0.4 MG oral capsule give 1 capsule by mouth at bedtime for BHP at bedtime take 30 mins after same meal each day, start date as 3/16/26. The DON confirmed the order indicated at bedtime, but it the time on medication administration record was scheduled at 5pm. The DON also stated bedtime medication is given 9pm, and that the expectation from the nurses was to follow the physician's order.During a review of the facility's P&P titled Administering Medications, Revised date 4/2019, Medications are administered is a safe and timely manner, and as prescribed.4.Medications are administered in accordance with prescriber orders, including any required time frame. 5 Medication administration times are determined by resident need and benefit, not staff convenience.7.Medication are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for one of six residents who was on controlled drug (a chemical or medication whose manufacture, possession, and use are strictly regulated by the government due to a risk of abuse, dependence, or physical harm.) when Resident 141's PRN oxycodone (a potent controlled medication for pain) blister pack (blister pack is a molded plastic pocket container with a sealed backing used to safely hold and display small items, consumer goods, and medicines) and Controlled Drug Record (CDR) were missing the direction change sticker. The failure had the potential for medication error and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally).Findings:During a review of Resident 141's facesheet (summary document used in healthcare facilities to capture a patient's core demographic details, insurance data, and a quick medical overview), it indicated Resident 141 was admitted to the facility with diagnosis including type Diabetes Mellitus (DM- a condition which affects the body processes blood sugar) with hyperglycemia (too much sugar [glucose] in the blood).During a review of Resident 141's physician's order dated 7/16/2026, it included an order for oxycodone (a potent controlled medication for pain) oral tablet 5 mg (milligram, unit of measurement), give 1 tablet by mouth every 6 hours as needed for severe pain and another order dated 7/17/26 oxycodone oral tablet 5 mg give 1 tablet by mouth one time a day for 30 minutes prior to wound care.During a review of Resident 141's CDR and Electronic Medication Administration Record (eMAR) for July 2026 order of oxycodone oral tablet 5 mg give one tablet by mouth every 6 hours as needed (PRN) for severe pain, there were three occasions on 7/20/26, 7/21/26, and 7/22/26 when the nursing staff signed out from the CDR but did not document their administration in the July 2026 eMAR.During a concurrent interview and record review on 7/24/26 at 3:18 p.m., with the Director of Nursing (DON), the DON showed July 2026 EMAR for oxycodone oral tablet 5 mg give 1 tablet by mouth one time a day for 30 minutes prior to wound care, order dated 7/17/26. The DON stated she investigated and the missing nurse's documentation of administration on 7/20/26, 7/21/26, and 7/22/26 for as needed oxycodone 5 mg 1 tablet were documented on oxycodone 5 mg 1 tablet routine order. The DON stated the nurse used the blister pack stock for the order for oxycodone 5 mg as needed because there was no blister pack available for the routine Oxycodone order. The DON confirmed there was only one blister pack for both the PRN and routine oxycodone orders. There was no Direction change sticker found on both the CDR and the blister pack for oxycodone that indicated the added physician's order for the routine oxycodone 5mg 1 tablet daily before dressing change .During a phone interview on 7/24/26 at 3:28 p.m., with the Consultant Pharmacist (CP), the CP stated it's okay to use the oxycodone 5 mg 1 tablet as needed and routine in one blister pack, but should have two different directions on ted if no directions should have direction change sticker on the blister pack and CDR.During an observation and concurrent interview on 7/24/26 at 3:38 p.m, with Licensed Vocational Nurse C (LVN C), LVN C was asked to check Resident 141's blister pack for the Oxycodone 5 mg as needed order. LVN C confirmed there was only one blister pack of oxycodone 5 mg 1 tablet for the PRN, there were no instructions for routine oxycodone on blister pack and CDR. LVN C stated that for any changes of medication order, they would notify the pharmacy and normally they put a sticker stating adjustment on the blister pack and CDR. LVN C confirmed there were no direction change sticker on Resident 141's oxycodone 5 mg blister pack and the CDR.During a review of facility's P&P titled, Medication Labeling and Storage, revised date 2/2023, the P&P indicated, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Medication Labeling1.Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.2.The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions.

Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of three residents (1) when the wound doctor's order for Resident 1's venous ulcer (open sores that occur when the veins in the legs do not push blood back up to the heart as well as they should) on his right lower lateral leg was not carried out to the treatment administration record (TAR). This failure had the potential for Resident 1's wound did not receive the treatment, became deteriorated, and delayed wound healing.Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with chronic venous hypertension (increased pressure inside the veins) with ulcer of bilateral lower extremity diagnosis.Review of Resident 1's Skin Assessment and IDT - Skin Integrity, dated 8/5/25, indicated Resident 1 received a treatment order from the wound doctor for the licensed nurse to cleanse the venous ulcer on his right lower lateral leg with normal saline (0.9 grams [g, a metric unit of mass] of salt per 100 milliliters [ml, a metric unit of volume] of solution), apply Xeroform (a sterile, non-adhering protective dressing), and cover with dry dressing and Kerlix (soft gauze roll).However, review of Resident 1's 8/2025 TAR indicated the treatment order was not recorded.During an interview with treatment nurse A (TMN A) on 8/22/25, at 3:10 p.m., she reviewed Resident 1's Wound Docs Preliminary Wound Report, dated 8/5/25, and Resident 1's 8/2025 TAR and confirmed that the wound doctor's order for Resident 1's venous ulcer on his right lower lateral leg was not carried out to the TAR. TMN A confirmed that Resident 1 still had the venous ulcer on his right lower lateral leg and stated the wound might not receive the treatment as ordered if the order was not on the TAR for the licensed nurse to follow.Review of the facility's policy, Medication and Treatment Orders, dated 7/2016, indicated . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on observation, interview, and record review, the facility failed to implement infection control practices when certified nursing assistant B (CNA B) walked out of Resident 2's room and in the hallway without sanitizing her hands. This failure had the potential to spread infection in the facility.Findings:Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE].Review of Resident 2's physician order, dated 8/4/25, indicated she had an order for ice the knee at least 4 times per day for 20 minutes each time to help reduce pain and swelling.During an observation on 8/21/25, at 3:05 p.m., CNA B entered Resident 2's room, put on gloves, and helped Resident 2; then CNA B removed her gloves, walked out of Resident 2's room and in the hallway without sanitizing her hands.During a concurrent interview with CNA B, she stated Resident 2 asked her to fix the ice wrap on her knee because it was sliding down, so she pulled the ice wrap up and repositioned it for Resident 2. CNA B stated she should sanitize her hands when walking out of Resident 2's room.During an interview with the infection preventionist (IP) on 9/23/25, at 1:05 p.m., she stated the staff should sanitize their hands when walking out of the residents' rooms.Review of the facility's policy, Handwashing/Hand Hygiene, dated 8/2019, indicated . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . b. Before and after direct contact with residents; . m. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene .

Based on interview and record review, the facility failed to ensure they had communicated throughout the facility for one of three sampled residents (Resident 1)'s code status and documented in the medical record Resident 1's wishes and preference immediately, so that staff would know what action to take or not take when an emergency arises when: 1. The case manager (CM) did not communicate to staff immediately regarding the changes in Resident 1's code status of DNR Do Not Resuscitate (DNR, is a medical order to instruct providers not to do cardiopulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) order in her electronic medical record (EMR)when Resident 1's daughter submitted to the facility a copy of the POLST signed by Resident 1 and her attending physician while she was in the acute hospital dated [DATE]. 2. Facility staff did not remove from Resident 1's EMR the Physician Orders for Life Sustaining Treatment (POLST, is a medical order that helps give people with serious illness more control over their care during a medical emergency) signed by Resident 1 upon her admission to the facility on [DATE] that indicated she wanted to be Full code- refers to prolonging life by all medically effective means when patient is found with no pulse and/or not breathing). 3. The case manager (CM) did not document immediately into Resident 1's (EMR) regarding the confirmed change in resident's status Full code to DNR after verifying it with Resident 1 and her daughter on [DATE]. These failures created confusion as to the correct code status for Resident 1 and resulted in the provision of CPR by the 911 paramedics to the Resident 1 who had a DNR status. Findings: During a review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with the primary diagnosis of acute on chronic systolic congestive heart failure (is a situation where a person with pre-existing chronic systolic heart failure (is a long-term condition where the heart's left ventricle weakens and cannot pump blood effectively, leading to a build-up of fluid in the lungs and other parts of the body) experiences a sudden worsening of their symptoms. Review of Resident 1's admission Record indicated she was self-responsible. Her POLST dated and signed [DATE] and [DATE] indicated she was the legally recognized decision maker. Review Resident 1's Skilled Nursing Facility admission Orders from the acute hospital upon discharge date d [DATE], indicated the code status as, DNR and Patient has capacity for medical decision making. Review of Resident 1's SNF admission History and Physical, dated [DATE], indicated, Her cognitive function appears intact as she correctly identified the date and spelled lunch both forward and backwards . Patient's code status and POLST status: DNR; limited additional interventions: Use medical treatment, antibiotics, and IV (intravenous, the administration of medications and fluids by vein) fluids as indicated. Do not intubate (is a medical order that specifies a patient does not want a breathing tube (intubation) placed in their airway, even if they stop breathing or experience respiratory distress). May use non-invasive positive airway pressure (is the use of breathing support administered through a face mask, nasal mask, or a helmet by pushing air at a higher pressure into your airway). Generally, avoid intensive care (critical care is a specialized medical setting within a hospital that provides round-the-clock care and treatment for patients with life-threatening illnesses or injuries). Review of Resident 1's POLST form, dated [DATE] (from the acute hospital), indicated, she chose Do Not Attempt Resuscitation/DNR with selective treatment, and the photocopy of this POLST included only the front page which was not clear. Review of Resident 1's another POLST form, dated [DATE] signed by the resident and her attending physician, indicated she chose Attempt Resuscitation /CPR and with selective treatment. During a review of Resident 1's active orders, dated [DATE], indicated, Follow code status per POLST instructions. Review of Resident 1's case manager progress notes, dated [DATE], indicated, 4/11- palliative consult done. Initially they wanted Full Code, but they decided to do DNR / Selective Treatment, no Vents (ventilator, a device for maintaining artificial respirationor machines to keep her alive. The daughter sent a pic (picture) of the POLST done at Acute, printed it and put it in the chart. She stated if she continues to decline might consider Hospice Care. Daughter & resident understand underlying cardiac & pulmonary function, overall prognosis is poor. A further review of Resident 1's case manager progress notes, dated [DATE] at 5:20 p.m., indicated, Received a call from daughter that she is in the facility . confirmed POLST she is DNR/Selective Tx. Daughter & resident wants to disregard what was filled out here upon her admission on 4.19. 25 where it says Full Code/Selective. Resident stated the one they did at hospital on 4.11.25 should be followed where she is DNR/Selective. Review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR, is a communication tool used to structure conversations, especially in healthcare, to ensure clear and concise information transfer), dated [DATE], indicated, At 11 p.m., staff member asked nurse to assess resident because resident appears unresponsive. Licensed nurse (LN) performed bedside assessment. Resident noted with weak pulse, but unresponsive to verbal and tactile stimuli. Oxygen (O2, is a colorless and odorless gas. It is needed for animal and plant life ) saturation at 94% on O2 2 L/min via nasal cannula. Obtained physical copy of POLST from medical chart- DNR/selective treatment. At 11:05 p.m., called 911. At 11:10 emergency medical services (EMS) arrived at the scene. Determined that resident had no pulse. At 11:15 p.m., paramedics asked if there is another copy of the POLST because the current POLST is missing from the back side . updated copy of POLST was retrieved from resident's electronic file on PCC- full code/ attempt CPR. At 11:18 p.m., paramedics started CPR because of updated copy of POLST. At 11:40 p.m., resident was pronounced death by paramedics. During an interview on [DATE], at 11:10 a.m. and 3:30 p.m., the CM stated Resident 1 had a change in her code status after palliative care in the hospital, from being Full code to DNR with selective treatment on [DATE] before her admission to the facility. The CM also stated upon Resident 1's admission on [DATE] Resident 1completed another POLST that indicated she wanted full code with selective treatment. The CM clarified with Resident 1's daughter on [DATE] around 5:20 p.m. regarding Resident 1's code status. The CM stated, Resident 1's daughter told him that the code status was supposed to be DNR, so he marked VOID on the [DATE]'s POLST form, then he removed this POLST form from the hard copy of Resident 1's medical record. Further interview and record review with the CM also indicated, the [DATE]'s POLST signed by the physician on [DATE] was uploaded into Resident 1's EMR by medical record staff in the morning of [DATE]. The CM also stated that he verified Resident 1 regarding the correct code status which was DNR with selective treatment because she did not want full treatment. The CM stated that the POLST form dated [DATE] should have been removed from the EMR to avoid confusion, and he should have documented immediately in Resident 1's EMR when DNR code status was confirmed on [DATE]. During an interview on [DATE], at 3:40 p.m., with registered nurse A (RN A), RN A stated he was notified by the night shift certified nursing assistant (CNA) C at 11 p.m. regarding Resident 1's altered mental status. RN A checked Resident 1's chart for her POLST which was DNR with selective treatment, then RN A called since Resident 1 still had breathing with weak pulse. When the paramedics arrived at the facility, they did not want to take the photocopy of the [DATE]'s POLST without back side page. RN A also stated, the paramedics questioned the validity of the POLST provided because it has no back page. RN A further stated his supervisor (LVN B, licensed vocational nurse B) went to check their Resident 1's EMR to look for additional information as requested by the paramedics and she found the [DATE]'s POLST that indicated Resident 1 was full code. LVN B showed Resident 1's EMR indicating the full code status, so the paramedics started to perform CPR to Resident 1. During an interview on [DATE], at 11:50 a.m., with the director of nursing (DON), she stated, they forgot to update in their EMR to upload Resident 1's POLST dated [DATE]. During an interview on [DATE], at 5:15 p.m., with licensed vocational nurse B (LVN B), LVN B stated she was not aware the [DATE]'s POLST was voided, and no one endorsed to her. LVN also stated, when the paramedics questioned the validity of the picture of Resident 1's POLST placed at the chart, she could not provide any response and could not also validate the correct code status. During an interview on [DATE], at 12:15 p.m., the CM provided the original copy of [DATE]'s POLST that she obtained from the acute hospital on [DATE] (a day after Resident 1 passed away on [DATE]) and filed in Resident 1's chart. During an interview on [DATE], at 12:17 p.m., the administrator (ADM) stated, on [DATE] the facility (he did not mention the specific staff) should have followed up and obtained the original copy of signed POLST dated [DATE] from the hospital and filed it in Resident 1's chart. Review of the facility's performance improvement project (PIP) guide, dated [DATE], it indicated, conflicting POLST documentation caused emergency personnel to initiate interventions inconsistent with known resident wishes. Actual POLST on file not consistent with POLST uploaded on electronic medical record (EMR). Root causes identified: Dual POLST forms present without clear policy guidance on version validation. Incomplete scan of POLST form (missing back side). Lack of clear workflow for verifying POLST accuracy during emergency events. Review of the facility's undated policy and procedure (P&P) titled, Do Not Resuscitate Order, the P&P indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include Physician Orders for Life-Sustaining Treatment (POLST) Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.

Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. The licensed nurse failed to notify the physician when Resident 1 experienced a change in condition. 2. The licensed nurse failed to transfer the wound care order from the hospital discharge instructions to the Skilled Nursing Facility (SNF) orders, resulting in no wound dressing change for Resident 1 for two days. These failures resulted in Resident 1 being sent to the hospital for further evaluation and treatment. Findings: 1. A review of Resident 1's clinical record indicated she was admitted from the acute hospital to the facility on [DATE] and had the diagnosis including encounter for orthopedic aftercare following surgical amputation (the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg). A review of Resident 1's discharge instructions from the acute hospital, dated 1/24/2025, indicated notifying physician for change in conditions including acute change in mental status. A review of Resident 1 ' s nursing progress notes dated 1/26/2025 at 18:56 indicated that the resident was confused and had declined from being alert and oriented x3 on the admitted (1/24/2025) to alert and oriented x1. The nurse documented a message in the communication binder asking the physician whether the confusion could be related to narcotic medication administered in the hospital. During an current interview and record with the Director of Nursing (DON) on 4/15/2025 at 3:12 p.m., the DON reviewed the nursing progress notes and stated the nurse should have notified the physician regarding Resident 1 ' s condition change (change in mental status) instead of leaving a message on the facility's communication binder. 2. A review of Resident 1's hospital discharge orders dated 1/24/2025 indicated a wound care order for a stockinet dressing and a loosely wrapped ACE wrap (Elastic Bandage with Hook Closure delivers comfortable support) to be changed daily while in the SNF. However, a review of Resident 1 ' s SNF physician orders and the Treatment Administration Record (TAR) for January 2025 indicated that no wound care order had been transcribed and carried out. During a current interview and record review with the Wound Care Nurse (WCN) on 4/15/2025 at 2:00 p.m., the WCN reviewed Resident 1's January 2025 SNF orders and TAR. She confirmed that there was no documented wound care order. She stated that she was not aware that a wound dressing change was required and she did not change Resident 1's wound dressing on 1/25 or 1/26/2025. During a concurrent interview and record review with the DON on 4/15/2025 at 3:15 p.m., the DON reviewed Resident 1's hospital discharge orders and SNF orders. She confirmed that there was no wound care order in the SNF orders. She further stated that the admission nurse should have transcribed the hospital wound care order to the SNF orders so that the wound care nurse could carry out the treatment. A review of the facility's policy and procedure titled Change in a Resident ' s Condition or Status, revised 2/2021, indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): .significant change in the resident's physical, emotional, mental condition . A review of the facility's policy and procedure titled Timely Implementation of Treatment Orders Policy, indicated .to ensure that all treatment orders are implemented promptly and consistently, treatment orders must be initiated within 24 hours unless specified otherwise .

Based on record review, interview, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for 1 (Resident #125) of 24 sampled residents. Specifically, the facility failed to ensure Resident #125's discharge MDS accurately reflected the resident's discharge status. Findings included: The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, dated October 2024, Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0, Section A2105: Discharge Status revealed, Code 12, Home under care of organized home health service organization: if the resident was discharged home under care of an organized home health service organization. This includes only skilled services provided by a home health agency. An Admission Record indicated the facility admitted Resident #125 on 08/24/2024. According to the Admission Record, the resident had a medical history that included diagnoses of a humerus fracture of the left arm, history of falling, and muscle weakness. According to the Admission Record, Resident #125 was discharged from the facility on 09/09/2024. Resident #125's Interdisciplinary Discharge Summary, dated 09/09/2024, indicated the resident went home as planned, with family, and with a home health agency referral. A Nurses Note, dated 09/09/2024, indicated all discharge instructions were reviewed with Resident #125's family member, and the resident was discharged in stable condition. A discharge-return not anticipated MDS, with an Assessment Reference Date (ARD) of 09/09/2024, revealed the MDS was coded to reflect that Resident #125 was discharged to a short-term general hospital. During an interview on 12/05/2024 at 10:15 AM, MDS Coordinator #8 stated Resident #125's discharge MDS was incorrectly coded. MDS Coordinator #8 said Resident #125 was discharged home with a family member, not to a hospital. During an interview on 12/05/2024 at 10:20 AM, the Director of Nursing (DON) stated Resident #125 discharged home with a family member. She stated she expected correct MDS coding. During an interview on 12/05/2024 at 10:25 AM, the Administrator stated he expected accurate MDS coding.

Based on record review, interview, and facility policy review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRRs) were submitted when required and failed to complete them accurately for 2 (Resident #41 and Resident #70) of 3 residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #41's Level I PASRR screening reflected the presence of a serious diagnosed mental disorder and failed to submit a Level I PASRR screening after Resident #70 remained in the facility longer than 30 days. Findings included: A facility policy titled, Admission Criteria, revised in 03/2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) [another acronym for PASRR] process. The policy revealed, z. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. Resident #41's Admission Record indicated the facility admitted Resident #41 on 07/22/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of paranoid schizophrenia (onset 07/22/2024). Resident #41's Medicine Discharge Summary from the hospital that transferred the resident to the facility, dated 07/22/2024, revealed a Discharge Diagnosis of paranoid schizophrenia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS indicated that the resident had an active diagnosis of schizophrenia. Per the MDS, the resident received antipsychotic medication during the assessment timeframe. Resident #41's care plan revealed a focus area, initiated 08/01/2024, that indicated the resident received psychotropic medications related to their diagnosis of paranoid schizophrenia. Resident #41's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 07/19/2024, completed by a hospital, indicated the resident did not have a diagnosis of a serious mental disorder. The screening also indicated the resident did not have a suspected mental illness and was not prescribed psychotropic medication. The screening indicated that a Level II evaluation was not required. A letter to Resident #41 from the California Department of Health Care Services, dated 07/19/2024, indicated, Your Level I Screening indicates that a Level II Mental Health Evaluation is not required. During an interview on 12/05/2024 at 9:36 AM, MDS Coordinator #8 stated she was responsible for ensuring the accuracy of PASRR submissions. She stated that Resident #41's Level I screening did not list a serious mental illness diagnosis. She confirmed that the resident's admission MDS revealed that the resident had schizophrenia. She stated Resident #41's diagnosis of paranoid schizophrenia should have been listed on the Level I screening. MDS Coordinator #8 stated the Level I screening for Resident #41 was completed by the hospital staff before admission. She stated she should have reviewed the Level I screening to ensure it was completed accurately by the hospital staff. She stated if she had identified the error, she would have resubmitted a new Level I screening to the state. During an interview on 12/05/2024 at 9:48 AM, the Director of Nursing (DON) stated that when a resident was admitted , she ensured the hospital submitted a Level I screening. She stated she looked at the Level I Screening to make sure it was submitted accurately by the hospital. She stated that Resident #41's Level I Screening did not list a serious mental illness diagnosis. She stated Resident #41 had a diagnosis of paranoid schizophrenia and it should have been listed on the Level I screening. She stated she did not notice that schizophrenia was not included on Resident #41's Level I screening. The DON stated that she expected each section of the Level I screening to be reviewed for accuracy. 29358 2. An Admission Record indicated the facility admitted Resident #70 on 12/03/2022. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder (onset 12/03/2022) and major depressive disorder (onset 12/03/2022). Resident #70's care plan included a focus area, initiated 12/09/2022, that indicated the resident was at risk for altered mood and behavior due to diagnoses of depression and schizoaffective disorder. Resident #70's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 12/04/2022, indicated that the resident had a serious diagnosed mental disorder. The screening indicated that the resident had diagnoses of schizoaffective disorder and major depressive disorder. Per the Level I screening, the resident had been prescribed psychotropic medications for a serious mental illness. The screening indicated that the screening result was Negative, with a Reason Code that revealed 30-Day Exempted Hospital Discharge. During an interview on 12/03/2024 at 9:17 AM, MDS Coordinator #8 stated that Resident #70 was discharged from a hospital and was not expected to stay longer than 30 days and was considered exempt from the PASRR process. She stated the facility did not submit a Level I screening after the resident remained in the facility longer than 30 days but should have. MDS Coordinator #8 stated that they were educated the previous year on the PASRR process and learned that if a resident was discharged from the hospital and stayed longer than 30 days, they had to submit a Level I screening to the state. She stated that after their training, they did not review the previous Level I screenings of residents who may have stayed longer than 30 days. During an interview on 12/05/2024 at 9:47 AM, the Director of Nursing (DON) stated that Resident #70's Level I screening should have been resubmitted after the resident remained in the facility longer than 30 days. During an interview on 12/05/2024 at 9:59 AM, the Administrator stated that he was not involved in the PASRR process. He stated that his expectation was for the PASRRs to be completed and submitted within the guidelines.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a fall for 1 (Resident #68) of 2 residents reviewed for falls and failed to ensure the environment remained free of accident hazards for 1 (Resident #45) of 1 resident reviewed for accident hazards. Findings included: 1. An Admission Record, indicated the facility admitted Resident #68 on 10/04/2021. According to the Admission Record, the resident had a medical history that included diagnoses of muscle weakness, difficulty in walking, spinal stenosis, and muscle spasms. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/10/2024, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident required partial/moderate assistance with bathing and supervision or touching assistance with tub/shower transfers. A Morse Fall Assessment, dated 09/10/2024, indicated Resident #68 was at moderate risk for falling. Resident #68's care plan, initiated 10/01/2024, indicated the resident was at risk for injuries related to sudden body movements. An intervention initiated on 10/01/2024 directed staff to provide a safe environment. A document titled, SBAR [Situation, Background, Assessment, and Recommendation]-Falls, dated 11/22/2024, indicated Resident #68 had an unwitnessed fall without injury in the shower room. The document indicated that at 10:00 AM on 11/22/2024, a nurse heard yelling from the shower room, and upon entry, the nurse found the resident sitting on the floor of the shower room, alone. Per the document, a certified nursing assistant (CNA) left the resident alone in the shower room to obtain linens. On 12/04/2024 at 8:15 AM, Resident #68 stated they were in a shower chair and slid out of the shower chair onto the floor. The resident stated they fell out of the chair during the shower and the water was running over them. The resident stated they told staff not to leave them there and they left anyway. On 12/04/2024 at 10:56 AM, CNA #2 stated Resident #68 was in a shower chair, and the CNA had turned on the water. She stated she dropped the towels on the floor, and they got wet. CNA #2 stated she left the room to get a new towel. She stated she was aware the resident needed to be supervised and should not be left alone. However, she stated because of the inconvenience of the resident's shower towels getting wet, she left the room and left the resident unattended for less than two minutes. On 12/04/2024 at 11:08 AM, Licensed Vocational Nurse (LVN) #3 stated partial/moderate assistance meant there should always be someone with the resident, supervising and assisting the resident when needed. She stated none of the residents should be left alone in the shower for safety reasons. On the day of the incident, LVN #3 stated a CNA called her to the shower room because Resident #68 had fallen to the floor. She stated the CNA had stepped out to get a dry towel, because she dropped the towel on the floor and the towel got wet. On 12/05/2024 at 8:40 AM, the Director of Nursing (DON) stated if a resident required partial/moderate assistance during a shower, the resident should not be left alone. She stated Resident #68 had jerking movements, which created a concern with the resident being left alone in the shower. On 12/05/2024 at 8:55 AM, the Administrator stated if a resident required partial to moderate assistance, they needed to be assisted with their needs. He stated he would expect staff to be in the shower room assisting the resident unless the resident requested them to be out of the room. 2. A facility policy titled, Proper Use of Bed Rails, revised 12/2016, revealed The purposes of these guidelines are to ensure the safe use of bed rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's symptoms. The policy revealed, 11. The resident will be checked periodically for safety relative to bed rail use. An Admission Record, indicated the facility admitted Resident #45 on 01/17/2020. According to the Admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, acquired absence of the right leg below the knee, muscle weakness, abnormal posture, Alzheimer's disease, and a history of falling. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/17/2024, revealed the resident had moderately impaired cognitive skills for daily decision-making and short-term and long-term memory problems, per a Staff Assessment for Mental Status (SAMS). The MDS revealed the resident was totally dependent on staff for rolling left and right in bed, moving from a sitting to lying or lying to sitting on the side of bed, and for chair/bed to chair transfers. Per the MDS, bed rails were not being utilized as a physical restraint. Resident #45's care plan revealed a focus area, initiated 08/23/2024, that indicated the resident was at risk for falls/injuries related to cognitive impairment, physical limitations, a history of falls, status post partial below the knee amputation, incontinence, and side effects of medication. An intervention initiated on 08/23/2024 directed staff to place bed rails in the upright position for mobility, repositioning, and transfers. On 12/02/2024 at 10:25 AM, an observation was made of Resident #45's bed rails. The resident had a bed rail on each side of the bed that began approximately six inches from the head of the bed and extended to the center of the bed. The right bed rail was not tight and was able to be moved. On 12/03/2024 at 11:13 AM, an observation revealed there was a two-to-three-inch gap between the bed and the bed rail. On 12/03/2024 at 11:59 AM, Certified Nursing Assistant (CNA) #6 stated she was not sure how long the bed rail had been loose and said the loose rail could cause the resident to fall. On 12/04/2024 at 8:51 AM, CNA #4 stated she worked with Resident #45 on 12/02/2024. She stated she had not noticed anything wrong with the bed rails. CNA #4 stated when the resident began hospice services, they got a new bed. The CNA observed the rails during the interview and stated she had not noticed being able to move the bed rails in and out and up and down. She stated if she had noticed, she would have attempted to fix the bed rail. She stated if she could not fix it, she would have called the supervisor. On 12/04/2024 at 11:26 AM, Licensed Vocational Nurse (LVN) #5 stated she was also assigned to care for Resident #45 on 12/02/2024. She stated she had not noticed the bed rails being loose. LVN #5 observed Resident #45's bed rails during the interview and stated the bed rails should be secure, and they should not move. She stated if she had noticed the rails were not secure, she would have called maintenance right away. She stated the bed rail should be secure for the resident's safety. On 12/03/2024 at 12:17 PM, LVN #3 stated everyone should be checking the bed rails for safety. LVN #3 observed Resident #45's bed rail and stated the bed rail was loose and it could come off. She stated she was not aware that the bed rail was loose. On 12/03/2024 at 12:33 PM, Environmental Services (EVS) Staff #9 stated the facility installed Resident #45's bed rails approximately two weeks prior. He stated they checked bed rails every month, but did not document the installation or the monthly checks. He stated they made sure the bed rails were bolted to the bed frame. EVS Staff #9 observed Resident #45's bed rail and stated the bed rail should not be loose or rotate. According to EVS Staff #9, the resident could fall if the bed rail came loose. He stated he was not aware of any issues with Resident #45's bed rail. He stated the CNA staff should have reported the loose bed rail to him. On 12/05/2024 at 8:34 AM, the Director of Nursing (DON) stated staff should identify hazards and ensure any issues were taken care of. Per the DON, staff should have identified the loose bed rail. On 12/05/2024 at 9:01 AM, the Administrator stated staff should identify and report any bed rail concern. He stated anything that would jeopardize the safety of the resident should be reported. He stated he was not sure how long Resident #45's bed rail had been loose, and the loose bed rail was not brought to their attention. He stated a bed rail should not be loose or moving.

Based on interview and record review, the facility failed to timely complete and submit a Discharge Minimum Data Set (MDS, a clinical assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for three of three residents (1, 2, and 3). This failure resulted in non-compliance with CMS regulatory requirements. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] and discharged from the facility on 9/14/24. Review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/13/24. Review of Resident 3's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/17/24. On 11/6/24, review of Resident 1's, Resident 2's, and Resident 3's clinical records indicated their Discharge MDS were overdue, still in progress, not completed, and not submitted to the CMS. During an interview with MDS coordinator A (MDSCO A) on 11/6/24, at 3:45 p.m., she reviewed Resident 1's, Resident 2's, and Resident 3's clinical records and confirmed that their discharge MDS were overdue and showing still in progress. MDSCO A stated the residents' Discharge MDS should be completed within 14 days and submitted to the CMS within 28 days after the residents were discharged . MDSCO A stated the discharge MDS of Resident 1, Resident 2, and Resident 3 should have already been completed and submitted to the CMS. Review of the facility's policy, MDS Completion and Submission Timeframes, dated 7/2017, indicated The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Review of the CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/2024, indicated discharge MDS Completion Date was no later than discharge date plus 14 calendar days and the MDS Transmission Date was no later than MDS Completion Date plus 14 calendar days.

Based on interview and record review, the facility failed to ensure one of three residents (1) received the necessary care and services when Resident 1's wounds did not have the weekly wound assessments completed consistently as required. This failure resulted in undetermined wound status and could negatively affect the progress of wound healing for Resident 1. Findings: Review of Resident 1's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection), atelectasis (a collapsed lung), and diabetes (a disease that occurs when the blood sugar is too high). Review of Resident 1's clinical record indicated he had wounds on his left toes, right toes, left knee, mid spine, and perianal area. Review of Resident 1's Skin Assessments indicated that his left and right toes wounds were not assessed from 4/30/24 to 6/9/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his left knee wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his mid spine wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24. Review of Resident 1's physician order indicated that he had an order for the licensed nurse to cleanse the wound on his perianal area with soap and water, gently wash skin, pat dry, and apply thin layer of Triad (a wound care product that combines the benefits of a protective ointment and a moisture barrier cream) every day and as needed, started on 9/12/23. However, review of Resident 1's Skin Assessments indicated that the wound on his perianal area was not assessed until 8/20/24. During an interview with the director of nursing (DON) on 11/8/24, at 3 p.m., she reviewed Resident 1's clinical record and confirmed that his left and right toes wounds were not assessed from 4/30/24 to 6/9/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his left knee wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his mid spine wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; and the wound on his perianal area was not assessed until 8/20/24. The DON stated the residents' wounds should be assessed every week. The Skin Assessment (for Non-Pressure Injury) Form indicates that the Skin Assessment for each wound should be completed by the LIcensed Nurse weekly. Review of the facility's policy, Pressure Injury Risk Assessment, dated 3/2020, indicated . Step in the Procedure: . 4. Conduct a comprehensive skin assessment with every risk assessment: . b. Once inspection of skin is completed, document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin.

Based on observation, interview, and policy review, the facility failed to provide a safe, functional, and comfortable environment for the residents and staff when the facility's floor had multiple holes. This failure placed the residents, staff and visitors at risk for accident and/or injury. Findings: During an observation with maintenance staff B (MTNS B) on 11/7/24, at 2:20 p.m., the floor in the hallway in front of nursing station 3 had a hole below the handrail which was measured 6 x 3 x 0.5 inches, and the floor in the rehabilitation area had 8 holes which each hole was measured 53/4 x 3/4 x 0.5 inches. During a concurrent interview with MTNS B, he stated the floor with these holes was not good and not safe. MTNS B stated he would fix them. Review of the facility's policy, Floors, dated 12/2009, indicated Floors shall be maintained in a clean, safe, and sanitary manner.

Based on interview and record review, the facility failed to ensure the safety for one of two residents (Resident 1) when: 1. The Certified Nursing Assistant A (CNA A) did not position Resident 1 properly in wheelchair before doing another task, 2. CNA A did not notify the Licensed Nurse (LN) immediately to assess Resident 1 for possible injury after the fall prior to transferring back Resident 1 to wheelchair and 3. The facility failed to document the correct information on how the fall incident happened for Resident 1 on 8/5/24. These failures put Resident 1's safety at risk. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, an illness at its final stage where kidneys are permanently damage and can no longer function properly) and dependence on renal dialysis (a process that involve a machine that removes excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Review of Resident 1's admission nursing assessment dated [DATE] indicated she had short term memory problem and was totally dependent with staff for transfers. During an interview with CNA A on 8/23/24 at 10:52 a.m., he stated on 8/5/24 at around 1:20 a.m., he assisted Resident 1 in transferring to the wheelchair after toileting using a gait belt. CNA A stated he helped Resident 1 sat in the wheelchair but Resident 1's buttock was halfway in the wheelchair, then CNA A stated he turned around from Resident 1 to fix the garbage and change his gloves, then when he turned back around he saw Resident 1 was already sitting on the bathroom floor with her legs in a straight position. CNA A stated Resident 1 told him she was okay when he asked her how she was doing. CNA A told Resident 1 to hold on to his both shoulders, and he lifted up and assisted Resident 1 back to her wheelchair then assisted her back to bed. CNA A admitted he did not notify the LN staff after the fall prior to him transferring back Resident 1 to the wheelchair. CNA A stated he reported the fall incident to Registered Nurse F (RN F) after he already put Resident 1 in bed after he lifted Resident 1 from the floor, transferred to wheelchair then to bed on 8/5/24. During an interview with the Licensed Vocational Nurse B (LVN B) on 8/27/24 at 1:25 p.m., she stated when transferring resident who needed assistance, the staff should make sure the buttocks is all way in the wheelchair to prevent resident sliding down on the floor. During an interview with CNA C on 8/27/24 at 1:47 p.m., she stated the resident's buttocks should be put all the way in when transferring resident to prevent sliding from wheelchair. During an interview with the Director of Staff Development (DSD) on 8/28/24 at 4:11 p.m., she stated CNA A should have made sure Resident 1's buttocks was positioned all the way in the wheelchair to prevent sliding down from wheelchair. During an interview with LVN D on 8/30/24 at 1:58 p.m., she stated facility staff should notify the Charge Nurse/Licensed Nurse (CN/LN) immediately after any resident's witnessed and unwitnessed fall to assess for possible injuries prior to transferring back the resident to wheelchair or bed. During an interview with CNA E on 8/30/24 at 3:40 p.m., she stated CNAs should have reported to the CN immediately and ask for help for any resident's witnessed and unwitnessed fall for assesment first for injury and follow the instruction from the CN if it is okay to assist resident to transfer back to wheelchair or bed or not. During an interview with the DSD on 9/4/24 at 10:28 a.m., she stated CNA A should have reported first to the Charge Nurse to assess the resident after any fall for possible injuries before transferring back Resident 1 to wheelchair and /or bed. During an interview with the Assistant Director of Nursing (ADON) on 10:35 a.m., she stated CNA A should have positioned Resident 1 all the way in the wheelchair, not halfway in to prevent sliding down and fall from wheelchair. The ADON further stated CNA A should have notified first the CN for assessment of possible injuries prior to transferring Resident 1 from floor to wheelchair and bed when Resident 1 fell on the floor on 8/5/24. During an interview with the DSD on 9/4/14 at 3:21 p.m., the DSD stated she was with the DON when the DON interviewed CNA A regarding the Resident 1's incident of fall on 8/5/24. The DSD stated CNA A narrated to the DON that he put Resident 1 in wheelchair after using the bathroom. CNA A stated he turned around to clean up the garbage and change his gloves, then when CNA A turned back around he saw Resident 1 already on the floor. During an interview with the ADON on 9/5/24 at 11:19 a.m., she confirmed she did not find any documentation in Resident 1's medical records regarding the correct information about Resident 1's fall incident on 8/5/24 even after the DON and DSD have verified from CNA A on how the fall incident happened. During an interview with Administrator (ADM) with the presence of Health Facilities Evaluator Supervisor (HFES) on 9/6/24 at 12:03 p.m., the ADM confirmed there was no documentation in Resident 1's medical record indicating the correct statement provided by the CNA A (staff who has the first-hand information on the incident of fall happened on 8/5/24) from an interview conducted by the Surveyor and from the results of DON's and DSD's interview from CNA A about the fall incident happened on 8/5/24 for Resident 1. Review of the Facility's revised policy and procedure dated 03/2018 titled, Assessing Falls and Their Causes- Steps in the procedure: After a Fall indicated 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 11. Obtain and record vital signs as soon as it is safe to do so. 12. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 13. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Review of the Facility's undated policy and procedure titled Job Description: Certified Nursing Assistance indicated, Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical. Report all accidents and incident observed as they occur . Monitor and always supervise resident to ensure resident safety. Review of the facility's revised policy and procedures dated 3/2018 titled Assessing Falls and Their Causes: Identifying Causes of a Fall or Fall Risk indicated Continue to collect and evaluate information until the cause of falling is identified . Review of the facility's revised policy and procedures dated 3/2018 titled Falls - Clinical Protocol: Assessment and Recognition indicated, In addition, the nurse shall assess and document/report the following: . h. Precipitating factors, details on how fall occurred. For Cause Identification it indicated: The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified .

Based on interview and record review, the facility failed to ensure the safety of one of three residents (Resident 1) when the facility did not investigate thoroughly the root causes of the incidents of skin tears during transfers from bed to wheelchair and transfer to wheelchair after using the bathroom. This failure led to four recurrent incidents that resulted to lower legs skin tears for Resident 1. Resident 1 had skin tear incidents on 2/24/24, 4/2/24, 5/17/24, and 6/10/24. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] with diagnoses that included peripheral vascular disease (PVD, narrowing of blood vessels that cause poor blood flow to the legs and feet), osteoarthritis (a disorder due to aging that caused wear and tear on a joint) of bilateral knee, muscle weakness and abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, a comprehensive resident assessment tool) dated 1/6/24, 4/4/24 and 7/2/24 indicated her Brief Interview for Mental Status (BIMS, a mental status test that measures orientation, learning and memory) was 12, a score of 8-12 indicates her cognition (mental process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. Further review of Resident 1's MDS dated [DATE], 4/4/24 and 7/2/24 indicated she had no impairment on both sides of her upper and lower extremities. She required partial/moderate assistance (helper does less than half of the effort) during chair/bed to chair transfer and toilet transfer. During an interview with Resident 1 on 7/19/24 at 8:22 am, she stated sometime in February 2024 her right leg was caught in the wheelchair when CNA transferred her from bed to wheelchair. During an interview with Certified Nursing Assistant A (CNA A) on 7/19/24 at 9:02 a.m., she stated Resident 1 was alert and oriented to time, person, and place and was able to verbalize her needs. During an interview with Licensed Vocational Nurse B (LVN B) on 7/19/24 at 10:58 a.m., she stated Resident 1 was alert and oriented to time, person, and place. Review of Resident 1's Nursing Care Plan (NCP, a plan that provides direction on the type of nursing care the patient may need) for at risk of skin breakdown dated 1/1/24 indicated, to assess for any skin breakdown during activities of daily living (ADLs). Notify nurse immediately for any new areas of skin breakdown. Review of Resident 1's NCP for Fall/Injury Risk dated 1/1/24 indicated, Provide with equipment/wheelchairs brakes that are intact. Review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps healthcare teams share information about patients) dated 2/24/24 indicated, sometime after 5:30 p.m. after dinner, Resident 1 was observed with active bleeding to the right lateral side of the leg measuring 4.5 centimeter (cm, unit of measurement) by 0.5 cm. Pressure was applied to the affected site and first aid rendered. Resident 1's physician and Resident 1's friend was notified of the incident. During an interview with LVN C on 7/19/24 at 11:13 a.m., she stated Resident 1 informed her that her right lateral side of her leg was hit at something. LVN C stated she did not know the exact cause of Resident 1's right leg skin tear on 2/24/24. Review of Resident 1's NCP dated 2/24/24 indicated, skin tear on lateral side of right leg will resolve without complications. Monitor for signs and symptoms of infection and notify the physician if symptoms present. Treatment as ordered. During a concurrent interview and record review with the Director of Nursing (DON) on 8/9/24 at 11 a.m., she confirmed there was no documentation in Resident 1's medical record regarding a follow-up investigation on how and what was the exact cause of Resident 1's right leg lateral skin tear on 2/24/24 incident. The DON acknowledged it should have been investigated and followed-up on what was the reason and exact cause of Resident 1's skin tear on her right leg. Review of Resident 1's SBAR dated 4/2/24 indicated, Resident 1 was noted with skin tear on the right lower leg. Resident 1 verbalized it got caught on the wheelchair from transferring from bed to wheelchair. Pressure and steristrip (a thin and sticky bandages that are used to closed small wounds and cuts) applied then covered with xeroform (non-adherent dressing that maintain a moist wound environment) and dry dressing. Resident 1's physician and friend were notified. During an interview with CNA D on 7/29/24 at 2:43 p.m., she stated she was the assigned CNA for Resident 1 on 4/2/24 morning shift. CNA D stated she could not remember how Resident 1 sustained the skin tear on her right leg. During an interview with Treatment Nurse E (TN E) on 7/29/24 at 3 p.m., she stated the CNA called her and reported that CNA was helping Resident 1 to transfer from bed to wheelchair then the right leg was caught in the wheelchair. TN E stated she did not know how and what was the exact reason Resident 1's leg was caught in the wheelchair on 4/2/24. Review of Resident 1's NCP on skin tear on right lower leg dated 4/2/24 indicated, Check wheelchair for any sharp edges. Identified potential causative factors and eliminate/resolve them when possible. Treatment as ordered. Review of the SBAR dated 5/17/24 at 4 p.m. indicated, noted left lower leg skin tear 2.5 by 6 cm. Cleansed with normal saline, pat dry and applied steristrip. Resident 1 claimed she sustained the skin tear when her left leg caught the wheelchair brake handle. During an interview with CNA F on 8/7/24 at 3:12 p.m., she stated on 5/17/24 she assisted Resident 1 in the bathroom and assisted her to sit on the wheelchair. The wheelchair was positioned behind Resident 1 and her left leg was caught in the wheelchair during the transfer. During an interview with the DON on 8/14/24 at 10:56 a.m., she stated on 5/17/24 Resident 1 hit her left leg on the wheelchair handle break. The DON confirmed there was no documentation in the Resident 1's medical record regarding how the incident happened. Review of Resident 1's NCP for skin tear on left lateral lower leg dated 5/17/24 indicated, wheelchair brake handle was padded with plumber tube and other areas of wheelchair to minimize recurrence. Review of the SBAR dated 6/10/24 at 10:30 a.m. indicated, the CNA was transferring Resident 1 from bed to wheelchair and Resident 1 right leg got caught on wheelchair and sustained skin tear on right lateral leg measuring 3 cm by 1.5 cm with minimal bleeding. Treatment was provided. During an interview with TN E on 7/29/24 at 3 p.m., she stated the CNA [no longer work at the facility] reported to her that CNA was assisting Resident 1 transferring from bed to wheelchair and Resident 1's right leg was caught in the wheelchair. TN E stated she did not know the exact cause and how Resident 1 sustained the skin tear on 6/10/24. Review of Resident 1's NCP for skin tear on the right lateral leg dated 6/10/24 indicated, to ensure Resident 1 was wearing pants and to handle Resident 1 gently. Treatment as ordered. During an interview with the DON on 8/14/24 at 10:56 a.m., she confirmed there was no documentation in the SBARs and Resident 1's medical record regarding a follow-up investigation on how and what was the exact cause of Resident 1's right leg lateral skin tear on 2/24/24, 4/2/24 and 6/10/24. She also acknowledged the initial investigation on how Resident 1 sustained left lower leg skin tear on 5/17/24 should have been documented in Resident 1's medical record. The DON further stated Resident 1's incident of sustaining skin tears on 2/24/24, 4/2/24 and 6/10/24 should have been investigated and followed-up. Resident 1 sustained skin tear on 2/24/24, 4/2/24, 5/17/24 and 6/10/24, however there was no documentation the facility discussed the incidents on how or what was the cause of the skin tear/incidents. During a concurrent interview and record review with the DON on 8/9/24 at 11 a.m., she reviewed the facility's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who work together to provide person-centered care to patients) record signed and dated 4/11/24, 5/15/24 and 6/11/24. The DON confirmed there was no detailed discussions of Resident 1's four repeated incidents where she sustained skin tear during transfers from bed to wheelchair and after using the toilet. Review of the facility's revised policy and procedures dated 09/2013 titled Skin Tears-Abrasions and Minor Breaks, Care of: Documentation indicated, Record the following information in the resident's medical record: 1. Complete in-house investigation of causation. Review of the facility's undated policy and procedures titled Investigating Resident Injuries indicated, All resident injuries are investigated. The Director of Nursing services or a Designee assesses all resident injuries and document findings in the medical records. Review of the facility's undated policy and procedures titled Registered Nurse (RN) Job Description indicated, Initiate investigations of accidents and unusual occurrences and makes the necessary written report to the Director of Nursing Services (DNS). Review of the facility's revised policy and procedures dated 3/2022 titled Care Plans, Comprehensive Person-Centered indicated, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying sources (s) of the problem area(s) and not just the symptoms or triggers .12. The IDT team reviews and updates the care plan . when the desired outcome is not met.

Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure for one of three sampled residents (Resident 1) by failing to: 1) Prevent Resident 1 from being sexually abused by Certified Nursing Assistant A (CNA A). 2) Protect Resident 1 from sexual abuse and mental abuse. As a result, Resident 1 has experienced uncontrollable sadness and crying spells, has expressed an increasing desire to return home, and has indicated she was not sure if she felt safe at the facility. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/3/22, indicated she had a brief interview for mental status (BIMS) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment). The MDS indicated Resident 1 was able to understand others and able to make herself understood. Review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form & Progress Note, dated 4/23/22, indicated around 3:00 a.m., Inside [Resident 1's room], this writer noted [CNA A] on top of resident with his pants down. This writer confronted him, and noted he had a look of shock on his face. He put his pants back on, got off the resident and kept repeating 'I'm sorry, I ' m sorry,' to this writer. CNA was immediately separated from the resident. Resident mentioned this was the second time it happened to her. Resident verbally used the word 'rape' when discussing the situation. The SBAR Communication Form & Progress Note further indicated the police were contacted and Resident 1 was sent to the acute hospital. Review of Resident 1's Nurses Notes, dated 4/25/22, indicated Resident 1 remembered being kissed by a guy and stated, he wanted to have sex with me but I told him no. Review of Resident 1's Social Service Note, dated 4/25/22, indicated Resident 1 mentioned, There was a guy who got on [top] of her the other day. Resident said that she told the guy that she will scream if he will not get out off of her, when the LN [licensed nurse] came in to the room and the guy pulled up his pants, took off and flew. Resident verbalized, 'I am innocent.' Review of another Social Service Note, dated 4/25/22, indicated social services reached out to Resident 1's responsible party (RP, person designated to make decisions on behalf of the resident) and notified the RP that Resident 1 would like to be moved to a different facility because she was afraid that the guy will come back since he knew where the resident lives. The Social Service Note indicated Resident 1's RP declined to refer Resident 1 to a different facility. During an interview with Resident 1 on 4/25/22 at 3:40 p.m., Resident 1 stated someone woke her up and started feeling her breast. Resident 1 stated she said, What are you doing?, then told him to leave her alone before she screams. Resident 1 stated it made her angry that he would do that to people who can't walk. Resident 1 stated she was not sure if she felt safe in the facility. Resident 1 further stated that in the past, the same guy rubbed her breast and tried to get in bed with her, but she did not tell anyone. Resident 1 stated, Why do I always get picked on? Review of Resident 1's IDT (interdisciplinary team, staff from different disciplines who work together to plan and provide resident care) Notes, dated 4/28/22 indicated, Resident appears to remember bits and pieces of the incident and there was an episode when she stated that she wants to move out because the perpetrator might come back to the facility. Provided emotional support and reassurance and informed her that SJPD [San [NAME] Police Department] has arrested that person. During an interview with licensed vocational nurse B (LVN B) on 5/24/22 at 7:05 a.m., LVN B confirmed he was the one who witnessed the incident between CNA A and Resident 1 on 4/23/22. LVN B stated he was doing rounds (checking on residents) at 3:00 a.m. and saw CNA A with his pants down on top of Resident 1 in the resident's bed. LVN B stated, I think he was kissing her, but don't know for sure. LVN B further stated, I think I saw [CNA A's] buttocks exposed, but he was not sure because it was dark. LVN B stated he knocked on the door to get CNA A's attention, then with a look of shock on his face, CNA A pulled his pants up and started to say, I'm sorry. I don't know what came over me. LVN B stated CNA A begged him not to say anything about the incident and, At one point he got on his knees and begged me not to say anything. LVN B stated when he talked to Resident 1 about what happened, she stated, That [expletive]. He was kissing me. LVN B stated he called the police and from what he understood, CNA A was in police custody. LVN B stated what CNA A did to Resident 1 was sexual abuse. Review of Resident 1's psychiatry notes, dated 6/17/22 indicated, Pt [patient] with concerns for wanting to go home. Unable to tell me where ' home ' is. She clarifies that she ' just wants to leave this place. ' Stating she has a black cloud hanging over her and wants to run from it. Reporting that she has feelings of uncontrollable sadness and crying spells .Per facility reports, Pt was involved in possible sexual assault by a caretaker - caretaker was found on top of patient with pants off. Facility staff reports that the client has been having the same feelings of wanting to go home even before this event occurred, but to a less frequent extent .Per [director of nursing (DON)], Pt's complaints of wanting to go home seem to have increased since this event. Review of the police department ' s report of the incident between CNA A and Resident 1, released 7/1/22 indicated, On 4/23/2022 at approximately 0300 hours [3:00 a.m.], an alleged sexual assault, sexual battery and elder abuse occurred .The arrestee entered the victim ' s room, got into the bed with the victim, and began to kiss her in the mouth. The victim woke up and told the arrestee to get out of the room or else she was going to yell out ' rape. ' The arrestee had his pants down to his knees and got on top of the victim as if he was straddling her. The arrestee also touched the victim[ ' s] breasts. The arrestee did not stop until he saw the witness. The arrestee was identified, taken into custody, and later booked into the .County Jail for the above charges. The facility's undated investigation summary of the incident between CNA A and Resident 1 was reviewed. The investigation summary indicated, On 4/23/22, at around 3AM, the Station 3 Charge Nurse [LVN B] found [CNA A] on top of [Resident 1] with his pants down .Licensed nurse instructed [CNA A] to go home, but [CNA A] was refusing to leave the building and kept on begging the charge nurse not to report. The investigation summary indicated that during an interview conducted by the DON on 4/23/22 at 3:30 p.m., Resident 1 stated the hospital did multiple tests because the guy kissed her. The investigation summary indicated that during an interview conducted by the DON on 4/25/22 at 8:15 a.m., Resident 1 indicated she remembered being kissed by a guy and that he wanted to have sex with me, but I told him no. The investigation summary indicated CNA A was arrested and currently in jail. The investigation summary indicated, IDT concluded that incident occurred as witnessed. Review of the facility's Policy and Procedure on Abuse Prevention and Reporting, revised 4/23/20 indicated, It is the policy of [facility name] that each resident shall be free from any form of abuse. The policy further indicated, Sexual abuse is non-consensual sexual contact of any type with a resident .It includes, but is not limited to: Unwanted intimate touching of any kind, especially of breasts or perineal area [genital area]; All types of sexual assault or battery, such as rape, sodomy, and coerced nudity .

Based on interview and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 1) when Resident 1 was placed on her left side near the edge of her bed and fell from the bed head first as certified nursing assistant A (CNA A) was pulling on Resident 1's clothing. This failure resulted in Resident 1 sustaining a cervical (neck) fracture, a right facial fracture and a laceration of her right eyebrow. Findings: Review of Resident 1's record was initiated on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 12 (scores of 13 to 15 indicate the person has intact cognition, scores of 9 to 12 indicate the person has moderate impairment of cognition), was wheelchair bound and required extensive assistance from staff for activities of daily living and dressing. Review of Resident 1's Morse Fall Assessment Scale, dated [DATE], indicated she had a score of 45 (a score of 45 and higher indicates a high risk for falls). Review of Resident 1's Physician order [REDACTED]. Review of Resident 1's Interdisciplinary Team Post Fall Review, dated [DATE], indicated Resident 1 slid off of her bed as CNA A was in the process of turning her in the bed and pulling up her pants. An interview with Registered Nurse B (RN B) indicated he found the resident lying face down on the floor in a pool of blood coming from Resident 1's right eyebrow. Resident 1 was alert and verbally responsive prior to leaving for the hospital via 911 (emergency services). Review of Resident 1's hospital History and Physical report dated [DATE] indicated her computed tomography scan (CT scan, uses X-rays to make detailed pictures of part of the body) of the head and cervical spine showed multiple fractures of her cervical spine and a right facial fracture. The history and physical further indicated a laceration of her right eyebrow. During an interview with CNA A on [DATE] at 1:10 p.m., he stated he was dressing Resident 1 at the time she fell off the bed on [DATE]. CNA A stated Resident 1 was lying on the edge of the bed on her left side facing him, the bed was in the high position at his waist level with the side rail down. CNA A stated he was standing in front of the resident's hips and upper legs. CNA A stated Resident 1 slipped out of the upper part of the bed head first as he pulled up her pants after the resident's incontinent care. CNA A stated Resident 1 was lying on an air mattress, which was more slippery than a regular mattress, when he moved her in the bed. CNA A stated he had not had any training about caring for someone who is lying on a LAL mattress, or about moving the patient to the center of the bed and away from the edge of the bed. During a phone interview with CNA C on [DATE] at 3 p.m., he stated he was Resident 1's evening shift CNA. CNA C stated he always raised the side rail when he cared for Resident A to prevent a fall, and kept her in the center of the bed when turning her. CNA C stated he took extra precaution to prevent a fall because the LAL mattress was slippery and it would become flat under Resident 1's weight, which would make it easy to roll off if she was too close to the edge of the bed. During an interview with the Director of Staff Development (DSD) on [DATE] at 2 p.m., she stated she teaches the CNAs to put the residents in the middle of the bed prior to turning them onto their side. The DSD stated CNA A should have had the side rail up to prevent Resident 1 from falling. The DSD stated she teaches the CNAs to place a pillow next to the side rail to prevent the resident from hitting their head when they are turned. Review of the DSD's lesson plan for an inservice, dated [DATE], titled Turning and Repositioning, indicated the CNAs were taught to place the resident in the middle of the bed and to place pillows inside the side rails prior to repositioning. During an interview with the DSD on [DATE] at 4 p.m., she stated CNA A received an inservice similar to the one provided on [DATE] during his orientation in January of 2017. The facility provided a copy of the manufacturer's instructions for Resident 1's LAL mattress. The safety information section indicated there was an increased risk of gradual movement and/or inadvertent bed exit with the use of the LAL mattress. It further indicated it would be helpful to activate the Autofirm mode (air deflates from the mattress to achieve a firm mattress for repositioning purposes). Review of the Bedard Pharmacy and Medical Supplies Website (www.BedardMedical.com) indicated there was an increased risk of resident falls with the use of the low air loss (LAL) mattress: failure to use bed rails in raised position could lead to accidental resident falls as air mattresses have soft edges that may collapse when residents roll to the edge of the bed. Resident 1 was transferred to a second acute care facility on [DATE] with discharge [DIAGNOSES REDACTED]. Resident 1 expired on [DATE], one day after transfer to the second acute care facility.