Every finding on record at Crystal Cove Care Center

Based on interview, medical record review, and facility P&P review, the facility failed to follow the physician's orders for one of five final sampled residents (Resident 12) reviewed for unnecessary medications and failed to follow safe medication storage and destruction practices for used controlled medicated patches. * Resident 12's blood pressure medications were not administered as ordered. * The DON did not wear gloves when handling used fentanyl patches medication. Additionally, the fentanyl patches medication were stored in open packages, there were missing patches, and the accompanying narcotic sheet counts were not readily available. These failures put the resident at risk a negative outcome, and potentially exposing staff to inadvertent exposure to a controlled medication.Findings: 1. Review of the facility's P&P titled Administering Medications dated 2001 showed medications are administered as ordered and vital signs are checked or verified if necessary. Medical record review for Resident 12 was initiated on 6/16/26. Resident 12 was admitted to the facility on [DATE]. a. Review of Resident 12's MAR for May 2026 showed the following orders: - dated 3/20/26 and discontinued 5/6/26, for midodrine HCl (a medication to constrict blood vessels and raise the blood pressure) 5 mg by mouth every eight hours for hypotension PRN if SBP less than 105 mmHg; and - dated 5/9/26, for midodrine HCl 5 mg by mouth every eight hours for hypotension PRN if SBP less than 105 mmHg. Further review of Resident 12's MAR showed midodrine HCl was administered on the following dates: - dated 5/12/26 at 0600 hours, for a BP of 100/70 mmHg; - dated 5/13/26 at 0427 hours, for a BP of 93/64 mmHg; - dated 5/19/26 at 0607 hours, for a BP of 91/61 mmHg; and - dated 5/20/26 at 0616 hours, for a BP of 104/69 mmHg. Review of Resident 12's Weights and Vitals Summary for May 2026 showed the resident's blood pressures were within the ordered parameters to administer midodrine HCL: - dated 5/1/26 at 1043 hours, a BP of 100/62 mmHg; - dated 5/1/26 at 1407 hours, a BP of 104/66 mmHg; - dated 5/2/26 at 1001 hours, a BP of 96/57 mmHg; - dated 5/2/26 at 1053 hours, a BP of 100/61 mmHg; - dated 5/2/26 at 1314 hours, a BP of 103/64 mmHg; - dated 5/2/26 at 1832 hours, a BP of 104/65 mmHg; - dated 5/3/26 at 1031 hours, a BP of 104/70 mmHg; - dated 5/3/26 at 1226 hours, a BP of 100/68 mmHg; - dated 5/3/26 at 1402 hours, a BP of 101/66 mmHg; - dated 5/3/26 at 1600 hours, a BP of 98/53 mmHg; - dated 5/11/26 at 1104 hours, a BP of 100/61 mmHg; - dated 5/11/26 at 1425 hours, a BP of 98/67 mmHg; - dated 5/12/26 at 1420 hours, a BP of 100/63 mmHg; - dated 5/12/26 at 1809 hours, a BP of 102/66 mmHg; - dated 5/14/26 at 1216 hours, a BP of 102/64 mmHg; - dated 5/14/26 at 1456 hours, a BP of 102/63 mmHg; - dated 5/15/26 at 1446 hours, a BP of 101/68 mmHg; - dated 5/16/26 at 1436 hours, a BP of 102/67 mmHg; - dated 5/17/26 at 0544 hours, a BP of 94/60 mmHg; - dated 5/17/26 at 1131 hours, a BP of 100/67 mmHg; - dated 5/17/26 at 1237 hours, a BP of 103/66 mmHg; - dated 5/18/26 at 1134 hours, a BP of 100/64 mmHg; - dated 5/24/26 at 0507 hours, a BP of 103/60 mmHg; - dated 5/29/26 at 0503 hours, a BP of 104/63 mmHg; and - dated 5/31/26 at 1425 hours, a BP of 103/68 mmHg. Further review of Resident 12's MAR failed to show the PRN midodrine HCL was administered for the above blood pressures. b. Review of Resident 12's MAR for June 2026 showed an order dated 5/9/26, for midodrine HCl 5 mg by mouth every eight hours for hypotension PRN if SBP less than 105 mmHg. Further review of the MAR showed midodrine HCl was administered on 6/4/26 at 0624 hours, for a BP of 101/67 mmHg. Review of Resident 12's Weights and Vitals Summary for June 2026, showed the resident's blood pressures were within the ordered parameters to administer midodrine HCL: - dated 6/2/26 at 0619 hours, a BP of 102/73 mmHg; - dated 6/2/26 at 1327 hours, a BP of 100/67 mmHg; - dated 6/3/26 at 1729 hours, a BP of 97/69 mmHg; - dated 6/6/26 at 0938 hours, a BP of 92/66 mmHg; - dated 6/9/26 at 1855 hours, a BP of 94/56 mmHg; - dated 6/10/26 at 0530 hours, a BP of 98/61 mmHg; - dated 6/10/26 at 1023 hours, a BP of 104/56 mmHg; - dated 6/11/26 at 1356 hours, a BP of 102/70 mmHg; - dated 6/12/26 at 0901 hours, a BP of 103/67 mmHg; - dated 6/15/26 at 1707 hours, a BP of 102/62 mmHg; and - dated 6/17/26 at 1136 hours, a BP of 102/66 mmHg. Further review of Resident 12's MAR failed to show PRN midodrine HCL was administered for the above blood pressures. On 6/18/26 at 1402 hours, an interview and concurrent medical record review for Resident 12 was conducted with the ADON. The ADON reviewed Resident 12's PRN documented SBPs less than 105 mmHg and the MAR for midodrine HCl for the months of May and June 2026, and verified the above SBPs were within the parameters to administer midodrine. However, the MARs failed to show they were administered as ordered. c. Review of Resident 12's MAR for June 2026 showed an order dated 5/10/26, for propranolol HCl (a medication to treat hypertension) 40 mg twice a day at 0900 and 1700 hours, for HTN. Hold for SBP less than 110 mmHg or a HR less than 60 BPM. The MAR failed to show the resident's blood pressure at the time of administration, to ensure the medication was administered per the ordered parameters. Further review of Resident 12's MAR showed the medication was not administered on the following dates: - dated 6/3/26 at 1700 hours; - dated 6/5/26 at 0900 hours; - dated 6/9/26 at 0900 and 1700 hours; - dated 6/10/26 at 0900 and 1700 hours; - dated 6/12/26 at 0900 hours; - dated 6/15/26 at 1700 hours; and - dated 6/16/26 at 1700 hours. However, the MAR also showed an order dated 6/9/26, for diltiazem HCl 30 mg every six hours for HTN, hold for a SBP less than 110 mmHg or a HR less than 60 BPM. The BPs and HRs were documented for the scheduled administration times of 0000, 0600, 1200, and 1800 hours. Review of Resident 12's Weights and Vitals Summary for June 2026 failed to show the resident's BP and HR were checked within one hour before/after the following propranolol HCl administration times: - dated 6/1/26 at 0900 hours; - dated 6/2/26 at 0900 hours; - dated 6/4/26 at 0900 hours; - dated 6/4/26 at 1700 hours; - dated 6/5/26 at 1700 hours; - dated 6/7/26 at 0900 hours; - dated 6/8/26 at 0900 hours; - dated 6/11/26 at 0900 hours; - dated 6/15/26 at 0900 hour; and - dated 6/18/26 at 0900 hours. On 6/18/26 at 1402 hours, an interview and concurrent medical record review for Resident 12 was conducted with the ADON. The ADON reviewed Resident 12's medical record and stated the MAR should have a BP and HR documented for each propranolol HCl administration. The ADON stated since the nurses could administer the medications within one hour of the scheduled dose, the propranolol HCl dose at 1700 hours, may have been administered with the diltiazem HCl at 1800 hours dose. The ADON reviewed the vital sign log and progress notes and verified there were still missing the BP and HR documentation to show the medication was administered within the ordered parameters. 2. Review of the facility's P&P titled Hazardous Drugs dated 2001 showed hazardous drugs as classified by National Institute for Occupational Safety and Health required the staff to wear personal protective equipment specific to the risk of exposure performed. According to CDC.gov, fentanyl is a potent synthetic drug that can be ingested into the body via routes including the skin and is considered an occupational hazard. Per CDC.gov, to decrease risk of exposure to Fentanyl, staff should wear personal protective equipment including gloves when handling fentanyl. On 6/18/26 at 1145 hours, an inspection of narcotics ready to be destroyed was conducted with the DON. There were a total of four opened boxes of fentanyl transdermal 25 mcg/hr patches observed inside the narcotics ready to be destroyed cabinet. Each box showed a total of five patches inside each box. The DON was observed retrieving open boxes with open packages for individual used fentanyl patches inside. The DON was observed spreading an individual package of a used fentanyl patch and was about to put his finger inside the open package. The used fentanyl patch was observed to still have medication on it. The DON verified he did not put on gloves prior to handling the used open package of fentanyl patch. The DON verified the findings. Cross reference to F836.

Based on observation, interview, and medical record review, the facility failed to ensure processes for labeling and storing biologicals were maintained. * Resident's 28 Liraglutide (insulin) pen injector label showed to administer 1.8 mg while the physician's order showed to administer 1.2 mg of Liraglutide. * The enteral feeding storage area did not have a thermometer or temperature log to ensure the enteral feedings temperatures were being maintained at room temperature. These failures had the potential for the residents to not receive the correct dosage of insulin and for enteral feedings to not be stored at appropriate temperatures, potentially compromising resident safety and care.Findings: 1. On 6/17/26 at 0916 hours, a medication administration observation was conducted with LVN 4. LVN 4 was observed retrieving Resident 28's Liraglutide pen injector (use for diabetes/a glucagon-like peptide-1 (GLP-1) receptor agonist prescribed to improve blood sugar control in Type 2 diabetes). The label on the pen injector showed to administer 1.8 mg. LVN 4 stated she would administer 1.2 mg of Liraglutide medication because there had been a recent change in the order. LVN 4 verified the label on Resident 28's Liraglutide pen injector was not updated to reflect the change in dosage. Medical record review for Resident 28 was initiated on 6/17/26. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 2/21/26, showed Resident 28 was admitted to the facility with diagnoses including diabetes. Review of Resident 28's Order Summary Report showed an order dated 6/11/26, for Liraglutide inject 1.2 mg subcutaneously daily. Review of Resident 28's MAR for June 2026 showed Resident 28 was administered Liraglutide 1.8 mg. The order was discontinued 6/11/26. 2. According to Abbottnutrition.com, Jevity 1.5 1000 ml bottles were to be stored unopened at room temperature; avoiding extreme temperatures. On 6/18/26 at 0857 hours, LVN 6 was observed going to the enteral feedings storage closet to obtain enteral feeding supplies. The closet was observed to contain enteral feedings including Jevity 1.5 (enteral feeding formula) 1000 ml bottles. There was no thermometer or temperature log in the closet where the enteral feedings were stored. LVN 6 verified the closet did not have a thermometer or a temperature log in place to monitor and ensure the enteral feedings were kept at the appropriate temperature.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The facility failed to ensure food preparation equipment was air dried. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population for 77 out of 82 residents that consumed food prepared in the kitchen.Findings: According to the FDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's Diet Type Report dated 6/16/26, showed 77 out of 82 residents were receiving food prepared in the kitchen. On 6/16/26 at 0801 hours, an observation and concurrent interview was conducted with the RD. One stainless steel steam table tray was observed stacked wet. The RD verified the observation and stated the steam tray table should have been air dried before being stacked. On 6/19/26 at 0916 hours, an interview was conducted with the DON. The DON was informed of and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from outside sources for the resident consumption was properly stored. * The facility failed to ensure multiple food items were labeled, dated, and discarded before the use-by date. These failures had the potential to expose the residents who received food brought from the outside to food borne illnesses. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors dated 1/2025 showed food brought in by family visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food. Non-perishable foods are stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods are stored in resealable container with tightly fitting lids in a refrigerator. Containers are labeled with the residents' name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date. On 6/17/26 at 0850 hours, an observation of the refrigerator used to store food for residents brought in from outside and concurrent interview was conducted with the RD. The following was observed:- a paper bag containing grapes in a Ziplock bag was labeled 6/1/26. The grapes inside the bag were noted to have brownish discoloration;- an unlabeled and undated plastic red lid container with lentils;- an undated glass container containing chicken with a plastic lid;- an undated plastic container with a red lid containing a yellowish food item;- a chicken breast salad with a use by date of 5/31/26;- a Ziplock bag with plain noodles dated 6/12/26;- a plastic container with a red lid containing red sauce dated 6/12/26; and- in the freezer section, an unlabeled and undated glass container with a cream colored food item. The RD verified the above observations and stated the food items should have been labeled and discarded before the use by date. On 6/19/26 at 0916 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and the facility P&P review, the facility failed to properly dispose of multiple items when they were observed in the dumpster area. * The facility failed to ensure four mattress covers, a bed frame, a laundry cart, a small table with a machine for a special mattress and linen stored on top, and a wooden frame were properly disposed. This failure had the potential to harbor pests or rodents which carry diseases.Findings: According to FDA Food Code 2022, 5-501.115, Maintaining Refuse Areas and Enclosures, a storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items, and clean. Review of the facility's P&P titled Sanitization (undated) showed garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids ( or otherwise covered). Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests. On 6/17/26 at 0855 hours, an observation of the dumpster area and concurrent interview was conducted with the Maintenance Director. The following was observed stored around the dumpster area:- four mattresses covers (two in an open plastic bag) were observed stored on the top of a bed frame;- a laundry cart;- a small table with a machine for a special mattress and linen stored on top; and- wooden frame. The Maintenance Director verified the above observation and stated the above items were to be discarded. The Maintenance Director stated he did not know how long the above items were stored in the dumpster area. The Maintenance Director acknowledged storing the above items around the dumpster area could attract the pests or rodents. On 6/19/26 at 0916 hours, an interview was conducted with the DON . The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for three of 18 final sampled residents (Residents 1, 12, and 27) and one nonsampled resident (Resident 32). * Resident 1's post fall and fall risk assessments were inaccurate for recent falls.* Resident 12's POLST had an inaccurate date for the resident's current Advance Directive.* Resident 32's medical record failed to include the resident's decreased functional ability. * Resident 27's MAR for monitoring, pain scale, side effect monitoring, and anticoagulant monitoring was incomplete and/or inaccurate. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.Findings: 1. Medical record review for Resident 1 was initiated on 6/16/26. Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/2/26 at 1037 hours, showed the resident fell while attempting to get out of the bed without using the call light for staff's assistance. Review of Resident 1's NURSING - POST-FALL REVIEW - V 2.0 dated 5/2/26, showed the evaluation was being completed for a recent fall. However, the form showed the resident had no history of falls in the past six months. Review of Resident 1's NURSING - FALL RISK OBSERVATION/ASSESSMENT - V 2.0 dated 5/2/26, showed the resident had no falls during the past 90 days. Review of Resident 1's 02.NURSING - FALL RISK OBSERVATION/ASSESSMENT - V 2.0 dated 5/23/26, showed the resident had no falls during the past 90 days. On 6/17/26 at 1510 hours, an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON reviewed Resident 1's medical record and verified the resident's post fall and fall risk assessments dated 5/2 and 5/23/26, were inaccurate and should have shown the resident had recent falls. Review of Resident 1's H&P examination dated 5/24/26, showed the resident was airlifted on 2/22/26, after a fall sustained in a foreign country. 2. Medical record review for Resident 12 was initiated on 6/16/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Advance Directive dated 11/4/24, showed the designated Health Care Agent as Health Care Agent 1. Review of Resident 12's POLST dated 5/12/26, showed the resident's Advance Directive dated 6/27/24 was reviewed. The POLST showed the correct Health Care Agent as Health Care Agent 1, however the date of the Advance Directive was inaccurate. On 6/17/26 at 1442 hours, an interview and concurrent medical record review for Resident 12 was conducted with the SSD. The SSD stated during a previous admission, Resident 12 formulated a new Advance Directive at the facility in November 2024 to change her Health Care Agent to Health Care Agent 1. The SSD verified the POLST showed the incorrect date for the Advance Directive reviewed. 3. Medical record review for Resident 32 was initiated on 6/18/26. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's infection surveillance form dated 5/14/26, located in the facility's infection control program binder, showed the resident's symptoms, included acute functional decline, met the criteria for pneumonia. However, review of Resident 32's medical record failed to show documentation of the resident's acute functional decline. On 6/19/26 at 0938 hours, an interview and concurrent medical record review for Resident 32 was conducted with the IP. The IP reviewed Resident 32's medical records and verified the record failed to show functional decline. The IP stated she observed and interviewed the resident when she competed the surveillance tool dated 5/14/26, and confirmed the resident's acute functional decline, however, she failed to document it in the resident's medical record. 4. Review of the facility's P&P titled Charting and Documentation dated 2001 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 27 was initiated on 6/16/26. Resident 27 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 27's Order Summary Report showed the following physician's orders: - dated 11/5/25, to monitor for pain scale 0-10. 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10 = severe pain every shift; - dated 11/5/25, to monitor for anticoagulant medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/ or vital signs, shortness of breath and nosebleed every shift; - dated 12/2/25, to monitor behavior episodes for use of buspirone (antianxiety medication) manifested by inability to relax. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed, 1 = repositioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ range of motion/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise; - dated 12/2/25, to monitor behavior episodes for use of citalopram (antidepressant medication) manifested by verbalization of sadness. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ range of motion /ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise; - dated 12/2/25, to monitor behavior episodes for use of olanzapine (antipsychotic medication) manifested by verbal outburst. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed, 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/range of motion/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise every shift; - dated 3/2/26, to monitor for dry mouth, blurred vision, tachycardia (high heart rate), urinary retention, constipation, confusion, delirium, hallucinations, flushing, increased blood pressure, sedation, loss of appetite, photosensitivity, possible blood abnormalities, fainting, falls, cardiac arrhythmias, orthostatic hypotension (low blood pressure), increase in cholesterol/triglycerides, unstable/poorly controlled blood sugar, weight gain, akathisia, parkinsonism, dystonia, tardive dyskinesia, neuroleptic malignant syndrome, cerebrovascular event, every shift for olanzapine; and - dated 3/4/26, to monitor for symptoms of coronavirus disease (Covid-19)/Influenza (flu-highly contagious viral infection that attacks the nose throat and lungs)/ Respiratory Syncytial Virus (RSV; highly contagious respiratory virus that affects the lungs and breathing passages): Cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, congestion or runny nose, nausea or vomiting, diarrhea, headache. Monitor for emergency warning signs: trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face every shift. Review of Resident 27's H&P examination dated 11/8/25, showed Resident 27 had no capacity to understand and make decisions. Review of Resident 27's MAR for May 2026 showed blank and/or missing initials for the following orders on 5/8/26, during the night shift and on 5/9 and 5/11/26, during the evening shifts: - dated 11/5/25, to monitor for pain scale 0-10. 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10 = severe pain every shift; - dated 11/5/25, to monitor for anticoagulant medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/ or vital signs, shortness of breath and nosebleed every shift; - dated 12/2/25, to monitor behavior episodes for use of buspirone (antianxiety medication) manifested by inability to relax. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed, 1 = repositioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ range of motion/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise; - dated 12/2/25, to monitor behavior episodes for use of citalopram (antidepressant medication) manifested by verbalization of sadness. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/ range of motion /ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise; - dated 12/2/25, to monitor behavior episodes for use of olanzapine (antipsychotic medication) manifested by verbal outburst. Attempt nonpharmacological interventions: 0 = no nonpharmacological intervention needed, 1 = re-positioning/limb elevation, 2 = reassurance/emotional support, 3 = provide distraction/diversionary activities, 4 = exercise/range of motion/ambulation/stretching, 5 = rest period/quiet environment, 6 = deep breathing/relaxation exercise every shift; - dated 3/2/26, to monitor for dry mouth, blurred vision, tachycardia (high heart rate), urinary retention, constipation, confusion, delirium, hallucinations, flushing, increased blood pressure, sedation, loss of appetite, photosensitivity, possible blood abnormalities, fainting, falls, cardiac arrhythmias, orthostatic hypotension (low blood pressure), increase in cholesterol/triglycerides, unstable/poorly controlled blood sugar, weight gain, akathisia, parkinsonism, dystonia, tardive dyskinesia, neuroleptic malignant syndrome, cerebrovascular event, every shift for the olanzapine medication; and - dated 3/4/26, to monitor for symptoms of coronavirus disease (Covid-19)/Influenza (flu-highly contagious viral infection that attacks the nose throat and lungs)/ Respiratory Syncytial Virus (RSV; highly contagious respiratory virus that affects the lungs and breathing passages): Cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, congestion or runny nose, nausea or vomiting, diarrhea, headache. Monitor for emergency warning signs: trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face every shift. On 6/18/26 at 1406 hours, an interview and a concurrent medical record review for Resident 27 was conducted with the ADON. The ADON verified Resident 27's MAR for May 2026 was blank and was not initialed by a licensed nurse. The ADON further stated the MAR should be complete. On 6/19/2026 at 1419 hours, an interview was conducted with the DON. The DON informed and acknowledged the findings as above.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * LVN 4 failed to perform hand hygiene after touching the trash receptacle, then touching and pouring water from a water pitcher, and then pouring medications into medication cups for a resident. * A GT syringe was not rinsed after medication administration. The syringe was observed with yellow particles near the tip of syringe. * Resident 84's infection surveillance tool inaccurately showed the resident met criteria for a UTI. * The facility failed to ensure Resident 75's urinary drainage bag was not on the floor. * The facility failed to ensure staff offered Resident 95 to perform hand hygiene before receiving a meal. These failures posed the risk for transmission of disease-causing microorganisms and infections to the resident, staff, and visitors.Findings: 1. On 6/17/26 at 0916 hours, a medication administration observation was conducted with LVN 4. LVN 4 was observed throwing trash into the trash receptacle located to the right of her medication cart. LVN 4 then touched and poured water from a water pitcher into a plastic cup. LVN 4 then poured the medications into the medicine cups. LVN 4 did not perform hand hygiene after touching the trash or in between any of the above activities. The finding was discussed with LVN 4. 2. On 06/18/2026 at 857 hours, a GT medication administration observation was conducted with LVN 6. After LVN 6 was finished doing the medication administration, LVN 6 was observed putting the GT syringe used to administer medications, into a plastic bag. LVN 6 did not rinse the syringe. The syringe was observed with yellow particles near the tip of syringe. LVN 6 verified the findings and acknowledged the syringe should have been rinsed after completing the medication administration. 3. Medical record review for Resident 84 was initiated on 6/19/26. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's UTI infection surveillance tool for the symptoms started on 3/15/26, showed the data met criteria for a true infection. However, review of Resident 84's medical record failed to show the resident's symptoms met the criteria for a UTI. On 6/19/26 at 0938 hours, an interview, medical record review, and concurrent facility document review for Resident 84 was conducted with the IP. The IP stated she used the infection surveillance tool to determine if the residents' symptoms met the criteria for infection. The IP reviewed Resident 84's medical record and verified the tool was inaccurate and Resident 84's UTI did not meet the criteria for a true infection. 4. Review of the facility's P&P titled Catheter Care Urinary dated 2001 showed under the infection control section, to ensure the catheter tubing was kept off the floor. Medical record review for Resident 75 was initiated on 6/16/26. Resident 75 was admitted to the facility on [DATE]. Review of Resident 75's Order Summary Report showed a physician's order dated 6/4/26, for indwelling urinary catheter size French 16/10 ml balloon. On 6/16/26 at 0824 hours, during the initial tour of the facility, an observation was conducted of Resident 75. Resident 75 was observed in bed with an indwelling urinary drainage bag. The urinary drainage bag was on the floor. On 6/16/26 at 0828 hours, a concurrent observation of Resident 75 and interview was conducted with LVN 4. LVN 4 verified the resident's indwelling urinary drainage bag was on the floor. LVN 4 stated the indwelling urinary drainage bag should be hung on the frame of the bed. On 6/19/26 at 1425 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 5. Review of the facility's P&P titled Handwashing/Hand Hygiene (undated) showed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. On 6/16/26 at 1224 hours, a dining observation was conducted in the dining room. CNA 2 was observed wheeling Resident 95 to the dining room, in preparation for lunch. Resident 95 was observed waiting for the lunch to be served. On 6/16/26 at 1234 hours, CNA 2 was observed passing the meal trays to Resident 95 in the dining room. Resident 95 was then observed eating his lunch. CNA 2 was not observed offering Resident 95 hand hygiene prior to serving the meal tray. On 6/16/26 at 1312 hours, an interview was conducted with CNA 2. CNA 2 confirmed he did not offer hand hygiene to Resident 95 before serving the meal tray. CNA 2 stated he missed this step and acknowledged he should have offered Resident 95 hand hygiene prior to serving the meal tray. On 6/19/26 at 0916 hours, an interview was conducted with the DON. The DON was informed of and acknowledged the above findings. The DON stated the staff should offer hand hygiene to the residents before serving meals.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to report an abuse allegation for one of 18 final sampled residents (Resident 105) timely. * Resident 105 reported to the Case Manager that the night shift staff came to the resident and made the resident feel uncomfortable. Resident 105 further reported to the ADON that the night nurse was unpleasant and rude. This failure placed the resident at risk for potential ongoing abuse, delayed thorough investigation, a potential lack of protection of the resident and other residents from potential abuse, and resulted in a delay for CDPH and local law enforcement intervention.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating dated 2001 showed If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. According to the WIC S 15630 effective 1/1/24, the facility will report all abuse allegations to CDPH, local law enforcement, and the long-term care ombudsman no later than 24 hours. On 6/9/26, the CDPH received a complaint with the following allegations: the graveyard nursing staff would wake Resident 105 up by kicking the bed (Resident 105 had a heart condition and the nurse thought it was funny, she was afraid to go to sleep because of fear of retaliation), the facility nurse lied about giving Resident 105 her heart medicine, and gestured to the resident as if she was crazy, Resident 105 would hear staff talking about the residents' personal information in the hallway, and the graveyard nursing staff refused to help the resident to use the restroom and made her wear a diaper, causing her to hold toileting until day shift started. On 6/17/26 at 0802 hours, a phone interview was conducted with Resident 105. Resident 105 stated she reported her complaint to the Case Manager and ADON. Resident 105 stated the ADON told her that she would investigate her complaint. The resident further stated she insisted to be discharged from the facility because she could not go to sleep. Resident 105 stated she felt intimidated by the nurse (LVN 5) gestured his finger and circled it around his ear indicating she was crazy, when the resident inquired about her medication. Closed medical record review for Resident 105 was initiated on 6/16/26. Resident 105 was admitted to the facility on [DATE]. Review of Resident 105's H&P examination dated 4/14/26, showed the resident's cognition was normal. Review of Resident 105's MDS assessment dated [DATE], showed the resident's BIMS score was 15 which indicated the resident's cognitive capacity was intact. Review of the facility's Concern/Grievance Log (undated) showed Resident 105 reported a concern with the nurse's bedside manner. The resolution showed a grievance was offered but the resident refused. The resolved date was 4/21/26, with a comment to continue to check with the resident to confirm improvement. Review of the facility's Risk Management note dated 4/20/26, showed the ADON was summoned to the resident's room due to Resident 105's complaint regarding LVN 5 was being rude to her, had an unpleasant personality and was not given her heart medication. Review of a note presented by the DON from a notebook of the Case Manager dated 4/20/26, showed Resident 105 mentioned the night shift nurse was rude to her. Review of the DON's notes presented by the DON dated 4/20/26, showed a list of staff names with 0 mark beside the staff names. The notes failed to show times when the staff were interviewed and had no statements regarding discussion of the investigation. The DON's notes further showed a list of resident names with 0 marked beside the names. The notes failed to show times when the residents were interviewed, and had no statements regarding discussion of the investigation. Review of Resident 105's medical record failed to show any documentation of Resident 105's allegation and failed to show a psychosocial follow up was provided to the resident. On 6/17/26 at 0908 hours, an interview was conducted with the ADON. The ADON stated Resident 105 complained the night nurse was unpleasant, rude, not paying attention to her and had told her that the resident did not receive her medication. The ADON stated she informed the DON and would investigate the concern. Review of the facility's SOC 341 dated 6/17/26, showed on 6/17/26 at 0945 hours, Resident 105 informed CDPH about the following care concerns: staff being rude, not giving meds as ordered, staff kicked her bed to wake her up, staff gestured indicating that resident was crazy, and staff told the alleged victim to go to her diaper when she asked for toileting assistance when resident was at the facility. On 6/17/26 at 0947 hours, an interview was conducted with the DON. The DON stated he was informed of Resident 105's complaint. The DON stated when he tried to talk to the resident, the resident had told him that she had already talked to the ADON. On 6/17/26 at 0959 hours, an interview was conducted with the Case Manager. The Case Manager stated Resident 105 verbalized to her that the night shift staff came to the resident and made the resident feel uncomfortable. On 6/17/26 at 1050 hours, an interview was conducted with the Administrator. The Administrator stated he was aware of the resident's concern with regards to a complaint regarding a nurse being rude from the tonality of the nurse and the resident's medication was not properly given. The Administrator further stated he did not see the resident after the resident had complained; however the nursing staff completed the investigation. On 6/18/26 at 0945 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the above findings. The DON stated the case was not treated as abuse investigation because the resident stated she was fine and at the time, the resident stated she just wanted the administration know. On 6/18/25 at 1421 hours, a follow-up phone interview was conducted with Resident 105. Resident 105 stated she was not offered to file a grievance by the facility. Resident 105 further stated she had verbalized all the allegations she had made to the ADON. Resident 105 stated she was not asked by the facility how she was after she had complained and was not informed of the findings or outcome and the actions taken regarding the complaint she made to the ADON. 06/19/26 at 1420 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F610.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an abuse allegation for one of 18 final sampled residents (Resident 105). * Resident 105 reported a night shift staff came to the resident and made the resident feel uncomfortable, to the Case Manager. Resident 105 further reported the night nurse was unpleasant and was rude, to the ADON. This failure placed the resident at risk for potential ongoing abuse, delayed thorough investigation and potential lack of protection of the resident and other residents from potential abuse.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Investigate and report any allegations within timeframes required by federal requirements. On 6/9/26, the CDPH received a complaint with the following allegations: the graveyard nursing staff would wake Resident 105 up by kicking the bed (Resident 105 had a heart condition and the nurse thought it was funny, she was afraid to go to sleep because of fear of retaliation), the facility nurse lied about giving Resident 105 her heart medicine, and gestured to the resident as if she was crazy, Resident 105 would hear staff talking about the residents' personal information in the hallway, and the graveyard nursing staff refused to help the resident to use the restroom and made her wear a diaper, causing her to hold toileting until day shift started. On 6/17/26 at 0802 hours, a phone interview was conducted with Resident 105. Resident 105 stated she reported her complaint to the Case Manager and ADON. Resident 105 stated the ADON told her she would investigate her complaint. The resident further stated she insisted to be discharged from the facility because she could not go to sleep. Resident 105 stated she felt intimidated by the nurse (LVN 5) gestured his finger and circled it around his ear indicating she was crazy, when the resident inquired about her medication. Closed medical record review for Resident 105 was initiated on 6/16/26. Resident 105 was admitted to the facility on [DATE]. Review of Resident 105's H&P examination dated 4/14/26, showed the resident's cognition was normal. Review of Resident 105's MDS assessment dated [DATE], showed resident's BIMS score was 15 which indicated the resident's cognitive capacity was intact. Review of facility's Concern/Grievance Log (undated) showed Resident 105 reported a concern with the nurse's bedside manner. The resolution showed a grievance was offered but the resident refused. The resolved date was 4/21/26 with a comment to continue to check with the resident to confirm improvement. Review of the facility's Risk Management note dated 4/20/26, showed the ADON was summoned to the resident's room due to Resident 105's complaint regarding LVN 5 being rude to her, had an unpleasant personality and was not given her heart medication. Review of a note presented by the DON from a notebook of the Case Manager dated 4/20/26, showed Resident 105 mentioned the night shift nurse was rude to her. Review of the DON's notes presented by the DON dated 4/20/26, showed a list of staff names with 0 mark beside the staff names. The notes failed to show times the staff were interviewed, and had no statements regarding discussion of the investigation. The DON's notes further showed a list of resident names with 0 marked beside the names. The notes failed to show times the residents were interviewed, and had no statements regarding discussion of the investigation. Review of Resident 105's medical record failed to show any documentation of Resident 105's allegation, and failed to show a psychosocial follow up was provided to the resident. On 6/17/26 at 0908 hours, an interview was conducted with the ADON. The ADON stated Resident 105 complained the night nurse was unpleasant, rude, not paying attention to her and had told her the resident did not receive her medication. The ADON stated she informed the DON and would investigate the concern. Review of the facility's SOC 341 dated 6/17/26, showed on 6/17/26 at 0945, the HFEN to the DON, Resident 105 informed CDPH about the following care concerns, including a staff being rude, not giving meds as ordered; a staff kicked her bed to wake her up; a staff gestured indicating that resident is crazy; and a staff told the alleged victim to go to her diaper when she asked for toileting assistance when resident was at the facility. On 6/17/26 at 0947 hours, an interview was conducted with the DON. The DON stated he was informed of Resident 105's complaint. The DON stated when he tried to talk to the resident, the resident had told him that she had already talked to the ADON. On 6/17/26 at 0959 hours, an interview was conducted with the Case Manager. The Case Manager stated Resident 105 verbalized to her that the night shift staff came to the resident and made the resident feel uncomfortable. On 6/17/26 at 1050 hours, an interview was conducted with the Administrator. The Administrator stated he was aware of the resident's concern with regards to a complaint regarding a nurse being rude from the tonality of the nurse and the resident's medication was not properly given. On 6/18/26 at 0945 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the above findings. The DON stated the case was not treated as abuse investigation because the resident stated she was fine and at the time, the resident stated she just wanted the administration know. On 6/18/25 at 1421 hours, a follow-up phone interview was conducted with Resident 105. Resident 105 stated she was not offered to file a grievance by the facility. Resident 105 further stated she had verbalized all the allegations she had made to the ADON. Resident 105 stated she was not asked by the facility how she was after she had complained and was not informed of the findings or outcome and the actions taken regarding the complaint she made to the ADON. 06/19/26 at 1420 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F609.

Based on observation, interview, and medical record review, the facility failed to ensure the plan of care for one of 18 final sampled residents (Resident 98) was followed and revised. * Resident 98's interventions for keeping the bed in a low position was not followed. * Resident 98's plan of care was not revised to show interventions for Resident 98 raising the bed on her own, per staff. These failures posed the risk of not providing appropriate care for Resident 98.Findings: On 6/17/26 at 0802 hours, Resident 98 was observed sitting up in her bed awake with her bed approximately one and one half feet above the floor. On 6/17/26 at 0835 hours, Resident 98 was observed in bed with her bed approximately one and one-half feet above the floor. On 6/17/26 at 0900 hours, Resident 98 was observed in bed, awake with her bed approximately one and one-half feet above the floor. On 6/17/26 at 1217 hours, an observation of Resident 98 and concurrent interview was conducted with CNA 3. Resident 98 was observed in bed awake with her bed approximately one and three quarters feet above the floor. CNA 3 was summoned to Resident 98's room for an interview. CNA 3 stated she last came into Resident 98's room on 6/17/26 at around 12 pm to change Resident 98's diaper. CNA 3 verified the bed was high and stated sometimes Resident 98 moved the bed with the bed remote. CNA 3 was observed leaning over Resident 98 to retrieve the bed remote and Resident 98's bed was observed moving towards Resident 98's window with Resident 98 on the bed and CNA 3 leaning on the bed. CNA 3 verified Resident 98's bed was not locked. Medical record review for Resident 98 was initiated on 6/17/26. Resident 98 was readmitted to the facility on [DATE]. Review of Resident 98's care plan for risk for falls initiated 6/3/26 and revised 6/16/26, showed the interventions including keeping the bed in a low position with the brakes locked. Review of Resident 98's post fall risk assessment dated [DATE], showed Resident 98 had an unwitnessed fall. Further review of this document showed Resident 98 stated she rolled out of bed but did not know how she rolled out of bed. Review of Resident 98's H&P examination dated 6/9/26, showed Resident 98's diagnoses included post status right total knee arthroplasty, open left knee wound, history of stroke, altered mental status post fall at the facility. On 6/18/26 at 0754 hours, Resident 98 was observed awake in bed with her bed about one and a half feet above the floor. On 6/19/26 at 0808 hours, an observation and concurrent interview was conducted with RN 1. RN 1 stated sometimes Resident 98 was alert and sometimes confused. RN 1 verified the interventions for Resident 98's fall included keeping the bed in low position. RN 1 was informed Resident 98 was observed with multiple incidents of her bed being approximately more than one foot from the floor. Per RN 1, this height to RN 1 was low bed position. When asked what low position meant to RN 1, RN 1 said low position meant one and half ft above the floor. RN 1 verified Resident 38's bed was about one and a half feet from the floor. When asked if the height of Resident 98's bed posed a fall risk for Resident 98, RN 1 acknowledged the height of Resident 98's bed posed a fall risk for Resident 98. RN 1 acknowledged Resident 98's care plan was not being followed and the interventions did not address Resident 98's raising the bed on her own. On 6/19/26 at 0829 hours, an interview was conducted with the DON. The DON was informed of above findings. Cross reference to F689.

Based on interview, medical record review, and facility P&P review the facility failed to provide the necessary care and services to ensure two of 18 final sampled residents (Residents 1 and 14) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 1's post fall neurological assessment was completed as scheduled. * The facility failed to ensure the heparin and insulin injection sites were rotated for Resident 14. These failures had the potential to result in inaccurate assessment, altered medication effectiveness, impaired insulin absorption and tissue damage which could lead to negative residents outcomes.Findings: 1. Review of the facility's P&P titled Insulin Administration dated 2001 showed insulin injection sites are routinely rotated. According to Taylor's Clinical Nursing Skills seventh edition (undated) the various sites used for subcutaneous injections are the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crest), the anterior aspect of the thigh, the upper back, and the upper ventral (front upper) or dorsogluteal area (buttocks). It is necessary to rotate sites or areas for injections to prevent buildup of fibrous tissue and permit complete absorption of the medication. Medical record review for Resident 14 was initiated on 6/16/26. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of Resident 14's H&P examination dated 4/28/26, showed resident had the capacity to understand plan of care. Review of Resident 14's Order Summary Report showed the following orders: - dated 5/17/26, to inject 1 ml, heparin sodium (fast acting blood thinner) 5000 units/ml subcutaneously every twelve hours; and - dated 5/21/26, to administer Novolog insulin (rapid-acting insulin) subcutaneously before meals and at bedtime, per sliding scale. Review of Resident 14's Location of Administration Report for June 2026 showed the heparin sodium, and Novolog insulin was administered consecutively on the same injection sites on the following dates and times: - on 6/1/26 at 102 hours, heparin sodium was administered to LUQ of the abdomen; - on 6/1/26 at 2039 hours, heparin sodium was administered to LLQ of the abdomen; - on 6/6/26 at 0847 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/6/26 at 2041 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/7/26 at 0950 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/11/26 at 1055 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/11/26 at 2054 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/14/26 at 2029 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/15/26 at 1007 hours, heparin sodium was administered to RLQ of the abdomen; - on 6/17/26 at 2135 hours, heparin sodium was administered to LLQ of the abdomen; - on 6/18/26 at 0917 hours, heparin sodium was administered to LLQ of the abdomen; - on 6/9/26 at 1225 hours, novolog insulin was administered to LLQ of the abdomen; - on 6/9/26 at 1623 hours, novolog insulin was administered to LLQ of the abdomen; - on 6/9/26 at 1225 hours, novolog insulin was administered to LLQ of the abdomen; - on 6/9/26 at 1623 hours, novolog insulin was administered to LLQ of the abdomen; - on 6/11/26 at 1655 hours, novolog insulin was administered to RLQ of the abdomen; On 6/18/26 at 1347 hours, an interview and concurrent medical record review for Resident 14 was conducted with the ADON. The ADON verified the above findings and stated the injection site should be rotated with each heparin and insulin administration. On 6/19/26 at 1422 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 1 was initiated on 6/16/26. Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/2/26 at 1037 hours, showed the resident fell while attempting to get out of bed without using the call light for staff's assistance. The form showed the clinician was notified and recommended neuro checks (neurological assessments). Review of Resident 1's Neurological Assessment Flowsheet initiated 5/2/26, showed neuro checks were to be complete every 15 minutes for four assessments, every 30 minutes for two assessments, every hour for two assessments, every two hours for two assessments, every four hours for four assessments, and then every eight hours for six assessments. The log showed the sixth, and final eight-hour assessments were blank. On 6/18/26 at 0857 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1's Neurological Assessment Flowsheet was missing sixth, and final eight-hour assessments. The DON verified it was not anywhere else in the resident's medical record.

Based on observation, interview, and medical record review, the facility failed to ensure one of three final sampled residents (Resident 98) reviewed for accident hazards remained free of accidents. * Resident 98's bed was not kept in a low position. This failure posed the risk of Resident 98 suffering serious injuries from any future falls.Findings: On 6/17/26 at 0802 hours, Resident 98 was observed sitting up in her bed awake with her bed approximately one and one half feet above the floor. On 6/17/26 at 0835 hours, Resident 98 was observed in bed with her bed approximately one and one-half feet above the floor. On 6/17/26 at 0900 hours, Resident 98 was observed in bed, awake with her bed approximately one and one-half feet above the floor. On 6/17/26 at 1217 hours, an observation of Resident 98 and concurrent interview was conducted with CNA 3. Resident 98 was observed in bed awake with her bed approximately one and three quarters feet above the floor. CNA 3 was summoned to Resident 98's room for an interview. CNA 3 stated she last came into Resident 98's room on 6/17/26 at around 12 pm to change Resident 98's diaper. CNA 3 verified the bed was high and stated sometimes Resident 98 moved the bed with the bed remote. CNA 3 was observed leaning over Resident 98 to retrieve the bed remote and Resident 98's bed was observed moving towards Resident 98's window with Resident 98 on the bed and CNA 3 leaning on the bed. CNA 3 verified Resident 98's bed was not locked. Medical record review for Resident 98 was initiated on 6/17/26. Resident 98 was readmitted to the facility on [DATE]. Review of Resident 98's initial fall risk assessment dated [DATE], showed Resident 98 had a moderate risk for falls. Review of Resident 98's care plan for risk for falls initiated 6/3/26, showed interventions including keeping the bed in a low position with the brakes locked. Review of Resident 98's fall risk assessment dated showed 6/4/26, showed Resident 98 had a high risk for falls Review of Resident 98's post fall risk assessment dated [DATE], showed Resident 98 had an unwitnessed fall. Further review of this document showed Resident 98 stated she rolled out of bed but did not know how she rolled out of bed. Review of Resident 98's H&P examination dated 6/9/26, showed Resident 98's diagnoses included post status right total knee arthroplasty, open left knee wound, history of stroke, altered mental status post fall at the facility. On 6/18/26 at 0754 hours, Resident 98 was observed awake in bed with her bed about one and a half feet above the floor. On 6/19/26 at 0808 hours, an observation and concurrent interview was conducted with RN 1. RN 1 stated sometimes Resident 98 was alert and sometimes confused. RN 1 verified the interventions for Resident 98's fall included keeping the bed in low position. RN 1 was informed Resident 98 was observed with multiple incidents of her bed being approximately more than one foot from the floor. Per RN 1, this height to RN 1 was low bed position. When asked what low position meant to RN 1, RN 1 said low position meant one and half ft above floor. RN 1 verified Resident 38's bed was about one and a half feet from the floor. When asked if the height of Resident 98's bed posed a fall risk for Resident 98, RN 1 acknowledged the height of Resident 98's bed posed a fall risk for Resident 98. On 6/19/26 at 0829 hours, an interview was conducted with the DON. The DON was informed of above findings. Cross reference to F657.

Based on observation, interview, and medical record review, the facility failed to ensure the nutritional needs were met for one of one non-sampled resident (Resident 30) reviewed for nutrition. * The facility failed to ensure Resident 30 was offered an alternative meal item when Resident 30 consumed around 25% of her meal tray. This failure had the potential to compromise Resident 30's nutritional status.Findings: Medical record review for Resident 30 was initiated on 6/16/26. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Order Summary Report showed an order dated 6/4/26, for a regular diet. Review of Resident 30's H&P examination dated 6/9/26, showed Resident 30 had the capacity to understand and make medical decisions. Review of Resident 30's Weights and Vitals Summary for June 2026 showed the following weights:- dated 6/5/26, a weight of 203 lbs.;- dated 6/9/26, a weight of 206 lbs.; and- dated 6/16/26, a weight of 196 lbs. , a total weight loss of 10 lbs. from the weight on 6/9/26. Review of Resident 30's Documentation Survey Report dated June 2026 showed on 6/16/26 at 1300 hours, Resident 30 ate 0-25% of her meal. On 6/16/26 at 1314 hours, Resident 30 was observed lying in bed. A partially eaten meal tray was noted on the bedside table. The tray contained partially eaten fish, potatoes, green peas with red pepper, a partially eaten strawberry pear cup, and approximately 4 ounces of a beverage. The meal appeared to be about 25% consumed. On 6/16/26, at 1316 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 was observed asking Resident 30 if she had finished her meal, to which the resident responded yes. CNA 1 then removed Resident 30's meal tray. CNA 1 confirmed the resident consumed approximately 25% of the meal. CNA 1 was not observed offering an alternative meal to Resident 30. On 6/16/26 at 1319 hours, an interview was conducted with Resident 30. Resident 30 confirmed CNA 1 did not offer an alternative meal. When asked if she would like an alternative meal, Resident 30 stated she would request a chef's salad and eat it a little later. On 6/16/26 at 1450 hours, an interview was conducted with CNA 1. CNA 1 confirmed the above observations and stated she removed Resident 30's lunch tray; however, she did not offer an alternative meal to the resident. CNA 1 further stated she should have offered an alternative meal when Resident 30 consumed approximately 25% of her tray. CNA 1 stated she would go to Resident 30's room and offer an alternative meal. On 6/19/26 at 0916 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON stated when taking the meal tray out and if staff noticed the resident was eating less than 50% of the meal tray, then the staff should offer an alternative meal to the resident to maintain their nutritional status. The DON stated CNA 1 should have offered an alternative meal to Resident 30 when she ate around 25% of her tray. The DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of the GT for one of one final sampled resident reviewed for tube feeding (Resident 4). * The facility failed to ensure Resident 4's head of the bed was elevated at a 30-degree angle or above during the enteral feeding via the GT. This failure posed the risk for complications related to use of the GT for Resident 4.Findings: Review of the facility's P&P titled Enteral Nutrition (undated) showed adequate nutritional support through enteral nutrition is provided to residents as ordered. Medical record review for Resident 4 was initiated on 6/16/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed the following orders:- dated 8/21/23, an enteral feed order to elevate the head of the bed 30-45 degrees at all times during feeding, and for 30 minutes post administration of feedings; and- dated 6/10/24, an enteral feed order for Jevity 1.5 (enteral feeding formula) to administer 55 ml per hour for 20 hours for a total of 1100 ml (i.e., 1650 calories), to start feeding via pump at 1400 hours and to stop feeding at 1000 hours, or until the total volume is met. Review of Resident 4's care plan for enteral nutrition dated 8/22/23, showed Resident 4 had a GT and was at risk for enteral nutrition complications. Interventions included elevating the head of the bed to 30-45 degrees at all times during feedings and for 30 minutes post administration. Review of Resident 4's H&P examination dated 3/15/26, showed Resident 4 had the capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 was dependent on staff for her activities of daily living. On 6/18/26 at 1512 hours, Resident 4 was observed lying in bed. Resident 4's enteral feeding was observed running at 55 ml per hour. Resident 4's head of bed was not elevated at a 30-degree angle. The head of the bed angle for Resident 4 was measured using Measure application on the phone which showed 23-degree angle. On 6/18/26 at 1519 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above observation and stated Resident 4 was receiving an enteral feeding and the head of the bed was not elevated to 30-degree angle. LVN 1 stated the head of the bed for Resident 4 should have been elevated to at least 30-degree angle when the resident was receiving enteral feeding. On 6/19/26 at 0804 hours, Resident 4 was observed lying in bed. Resident 4's enteral feeding was observed running at 55 ml per hour. Resident 4's head of the bed was not observed elevated at a 30- degree angle. The head of the bed angle for Resident 4 was measured using Measure application on the phone which showed 20-degree angle. On 6/19/26 at 0805 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the above observation and stated Resident 4 was receiving enteral feeding and the head of the bed was not elevated to 30-degree angle. LVN 2 stated the head of the bed for Resident 4 should have been elevated to at least 30-degree angle when the resident was receiving enteral feeding. On 6/19/26 at 0916 hours, an interview was conducted with the DON . The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with professional standards for one of one final sampled resident (Resident 5) reviewed for respiratory care. * The facility failed to ensure Resident 5's nebulizer mask was stored in a bag when not in use. This failure had the potential for the resident to receive inadequate respiratory care and increased risk for infection.Findings: Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer dated 2001 showed in part, in the steps in the procedure to rinse and disinfect the nebulizer equipment according to facility protocol:a. wash pieces with warm, soapy water;b. rinse with hot;c. place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes;d. rinse all pieces with sterile water (NOT tap, bottled or distilled; ande. allow to air dry. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. Medical record review for Resident 89 was initiated on 6/16/26. Resident 5 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 5's Order Summary Report showed the following physician's orders:- dated 4/7/26, to administer ipratropium-albuterol (used to open and relax the airways in the lungs) solution 0.5-2.5 mg/3 ml, give 3 ml to inhale orally every four hours as needed via nebulizer; and- dated 4/15/26, to administer ipratropium-albuterol solution 0.5-2.5 mg/3 ml, give 3 ml to inhale orally every eight hours. Review of Resident 5's H&P examination dated 4/9/26, showed the resident had the capacity to make decisions. Review of Resident 5's MAR for June 2026 showed ipratropium-albuterol solution 0.5-2.5 mg/3 ml was administered to the resident at 6/15/26 at 2200 hours. On 6/16/26 at 0807 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with Resident 5. Resident 5 was observed in bed with nebulizer on the nightstand adjacent to the bed. The nebulizer mask was observed placed on the nebulizer machine and was not inside a plastic bag. Resident 5 stated she used the nebulizer last night. Resident 5 further stated the nurse left the nebulizer mask on the machine. On 6/16/26 at 0813 hours, an observation of Resident 5 and concurrent interview was conducted with LVN 3. LVN 3 verified the nebulizer was observed on the resident's nightstand with the nebulizer mask exposed to air. LVN 3 the nebulizer mask should be stored in a bag. On 6/19/26 at 1423 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observations, interviews, and a review of Title 21, the facility failed to provide documented evidence demonstrating compliance with State law. * There were used fentanyl patches (a medication used in the management and treatment of chronic pain) not stored and destroyed as per federal regulations related to the fentanyl medication use. This failure posed the risk of diversion and inappropriate storage of the used fentanyl patches.Findings: According to Federal Code of Regulations, Title 21, Chapter II, subpart 1317.80 Collection Receptacles at Long Term Facilities and subpart 1317.05 Registrant Disposal; controlled substances were to be disposed of promptly and upon removal, sealed inner liners may only be stored at the long-term care facility for up to three business days. According to CDC.gov, fentanyl is a potent synthetic drug that can be ingested into the body via routes including the skin and is considered an occupational hazard. Per CDC.gov, to decrease risk of exposure to the fentanyl, staff should wear personal protective equipment including gloves when handling Fentanyl. On 6/18/26 at 1145 hours, an inspection of the narcotics ready to be destroyed was conducted with the DON. There were a total of four boxes of fentanyl transdermal 25 mcg/hr patches observed open inside the narcotics ready to be destroyed cabinet. The DON stated the pharmacist came to destroy the narcotic medications in the facility on a monthly basis and had come last month. Each box showed a total of five patches inside each box. The boxes had fill dates on them including March, April, and May 2026. The DON was observed retrieving open boxes with open packages for individual used fentanyl patches inside. The DON was observed spreading an individual package of a used fentanyl patch and was about to put his finger inside the open package. The used fentanyl patch was observed to still have medication on it. The DON verified he did not put on gloves prior to handling the used open package of fentanyl patch. Further inspection of the narcotic sheets for one of the fentanyl medication boxes showed a total of five patches were received, however the box contained three patches; two patches were missing. A second box of the fentanyl patches did not have the accompanying narcotic sheet to show how many patches were received. Additionally, this second box contained four of five patches; one patch was missing. A third box of the fentanyl patches did not have the accompanying narcotic sheet count to show how many patches were received. This third box contained four of five patches; one patch was missing. The DON verified the findings. The DON stated the ADON had been receiving the patches. On 6/18/26 at 1200 hours, an observation and concurrent interview was conducted with the ADON. When asked about the missing patches and missing accompanying narcotic sheet counts to keep track of how many patches the ADON had received, the ADON stated she would look for the missing patches and accompanying narcotic sheet counts. Cross reference to F755.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program to show timely physician notification for one nonsampled resident (Resident 84) who received antibiotics for an infection that did not meet the facility's infection surveillance tools criteria. * The facility failed to ensure Resident 84's symptoms met the criteria for a UTI, notify the physician the infection did not meet the criteria, and reassess the need for continued antibiotic therapy. This failure had the potential for the resident being on unnecessary antibiotic therapy potentially resulting in MDRO's.Findings: Medical record review for Resident 84 was initiated on 6/19/26. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's UTI infection surveillance tool for symptoms started on 3/15/26, showed the data met criteria for a true infection. However, review of Resident 84's medical record failed to show the resident's symptoms met the criteria for a UTI. Review of Resident 84's MAR for March 2026 showed the resident received ceftriaxone sodium (an antibiotic) 1000 mg from 3/17/26 through 3/23/26. Review of Resident 84's medical record and the surveillance data records failed to show the resident's physician was notified the infection did not meet criteria, and to reassess the need for continued antibiotic therapy. On 6/19/26 at 0938 hours, an interview, medical record review for Resident 84 and concurrent facility document review was conducted with the IP. The IP stated she used the infection surveillance tool to determine if the residents' symptoms met the criteria for infection, and if the criteria was not met, the physician would be notified so they could reassess the antibiotic usage. The IP verified Resident 84's UTI did not meet criteria for a true infection, and received the full seven day antibiotic course. The IP stated since the infection surveillance tool incorrectly showed the resident's suspected infection met the criteria, the IP did not contact the physician to evaluate the antibiotic usage.

Based on observation, interview, and facility P&P review, the facility failed to ensure the confidential personal and health information of the residents in the facility were protected. * The facility failed to ensure a non-employee was not permitted inside the medical records office. This failure had the potential for the residents' personal and health information to be accessed by an unauthorized person.Findings: Review of the facility's P&P titled Resident Rights dated 2001 showed the unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy information issues. All inquiries concerning the release of resident information should be directed to the HIPPA compliance officer. Review of the facility's P&P titled Protected Health Information (PHI), Management and Protection of dated 2001, showed PHI shall not be used or disclosed except as permitted by current federal and state laws. On 3/3/26 at 1103 hours, an observation and interview was conducted with MRA 1. When asked who were working in the medical records department, MRA 1 stated the Medical Records Director and MRAs 1 and 2. On 3/3/26 at 1419 hours, a interview was conducted with MRA 1. When asked what training she was provided, MRA 1 stated HIPPA. When asked what the HIPPA training covered, MRA 1 stated the resident's privacy which included the topics of not releasing or sharing the resident information to those that were not the resident themselves, or the resident's durable power of attorney. On 3/3/26 at 1517 hours, an interview was conducted with Medical Records Director. When asked if anybody could help sort the medical records for filing, the Medical Records Director stated no, it is only herself, her two assistants and there were no volunteers in the medical records department. On 3/3/26 at 1613 hours, an interview was conducted with the DON. The DON stated the authorized persons who could access the medical records would include the medical records staff, licensed nurses, therapists, physicians, admissions, administrator, activities staff, DSD, dietary supervisor, and registered dietician. On 3/3/26 at 1639 hours, a follow-up interview was conducted with MRA 1. When asked if MRA 1 worked on 2/22/26, MRA 1 stated yes. When asked who was present in the medical records office with her, MRA 1 stated Family Member 1, as Family Member 1 was her means of transportation. MRA 1 stated on 2/22/26, she had to put away the 2025 discharged resident's medical records in a box. MRA 1 further stated Family Member 1 was sitting with her inside the medical records office for approximately one to two hours, and Family Member 1 was using her cellphone. When asked if Family Member 1 was allowed inside the medical records office, MRA 1 stated we were not supposed to bring anyone in the office. When asked why Family Member 1 was in the medical records office, MRA 1 stated I know, I just asked her to stay in there because it was hot outside. On 3/3/26 at 1644 hours, a follow up observation and concurrent interview was conducted with MRA 1. The Medical Records Office was observed with two large open bookshelves which had three rows of medical records to the right of the office entrance. The multiple medical record folders contained a visible resident's name and some folders had visible admission dates, discharged dates, and medical record number. A long folding table and a pink chair was also observed in the middle of the office. MRA 1 stated on 2/22/26, Family Member 1 was sitting on the pink chair where the long folding table was. MRA 1 verified the medical record folders on the bookshelf with the resident's names were visible from where Family Member 1 was sitting. On 3/3/26 at 1702 hours, an interview was conducted with the DON. The DON stated unauthorized persons were not allowed in the medical records office as there were a lot of easily accessible medical records that would need to be protected. On 3/4/26 at 1158 hours, a follow-up interview was conducted with the DON. The DON verified Family Member 1 was not an employee of the facility. The DON was made aware and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * RN 1 and LVN 2 failed to wear a gown during the wound care treatment for Resident 3, who had a Stage 3 pressure injury (a full-thickness skin loss where fat tissue is visible, but the bone, tendon, or muscle are not exposed). In addition, there was no EBP signage near the resident's room doorway or bedside to alert the facility staff and/or visitors of the precautions. These failures posed the risk of potential for cross-contamination and spread of infectious organisms in the facility.Findings: Review of the facility's P&P titled Enhanced Barrier Precautions dated 2001 showed the Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents. The Policy Interpretation and Implementation showed the following:- EBPs refer to infection prevention and control interventions designed to reduce the transmission of multi-drug resistant organisms during high contact resident care activities;- EBPs apply when a resident is not known to be infected or colonized with any multi-drug resistant, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained;- Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status;- EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied to performing the high contact resident care activity;- Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged high contact with items in the resident's room, with resident's equipment or with resident's clothing or skin, device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), and wound care (any skin opening requiring a dressing); and- Signs are posted on the door or wall outside the resident's rooms which communicate the type of precautions and PPE required. Medical record review for Resident 3 was initiated on 12/18/25. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had moderate cognitive impairment. Review of Resident 3's Wound Care Consult Note dated 12/17/25, showed under the Wound Progress/Details section, Resident 3 was on hospice (specialized care for residents with terminal illnesses) and the skin breakdown was expected and unavoidable at end of life. The wound was reclassified to a Stage 3 pressure injury after debridement (removal of damaged tissue or foreign objects from a wound). Review of Resident 3's plan of care revised on 12/19/25, showed a care plan problem addressing Resident 3's requirement of enhanced barrier precautions (EBP) during high-contact resident care activities due to the presence of sacrococcyx [fused sacrum and coccyx (tailbone)] wound. The interventions included to ensure items for following EBP were in placed (gloves, gown, alcohol-based hand rub, face-shield, signage, trash receptacle, etc.), hand hygiene utilizing alcohol-based hand rub, place EBP notification/signage near resident room doorway to alert staff/visitors of precautions, and to utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g., dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care). On 12/19/25 at 0935 hours, a wound care treatment observation for Resident 3 and concurrent interview was conducted with RN 1 and LVN 2. No EBP signage was observed in the resident's room door or at the bedside of Resident 3. RN 1 stated LVN 2 would be assisting in turning Resident 3 during the wound care treatment. RN 1 stated Resident 3 had a Stage 3 pressure injury in the sacrococcyx area, which was reclassified by the wound consultant after the debridement on 12/17/25. RN 1 was observed removing Resident 3's old dressing from the sacrococcyx area while LVN 2 was holding Resident 3. RN 1 and LVN 2 were observed only wearing gloves but no isolation gown. RN 1 was stopped when she was about to clean Resident 3's wound. RN 1 and LVN 2 were asked if they needed to observe any precautions during the wound care treatment. RN 1 and LVN 2 verified the EBP was to be observed for Resident 3, since they were providing high contact resident care. RN 1 and LVN 2 verified they needed to wear the isolation gown and an EBP signage needed to be posted by the resident's room door to alert the facility staff or visitors of the precautions needed to observe or followed to prevent the spread of infection. On 12/19/25 at 1450 hours, an interview was conducted with the IP. The IP stated the EBP was needed to be observed during high-contact resident care activities like wound care treatment. The IP stated the facility staff needed to wear gloves and gowns during the wound care treatment when the resident was on an EBP. The IP further stated there could be possible transmission of infection when the proper PPE was not utilized by the facility staff. The IP was informed and acknowledged the above findings. On 12/23/25 at 1640 hours, an interview was conducted with the DON and Quality Assurance Nurse. The DON and Quality Assurance Nurse were informed and acknowledged the above findings for Resident 3.

Based on interview and medical record review, the facility failed to ensure the discharge medication list was appropriate for one of two sampled residents (Resident 3) reviewed for discharge. * Resident 3's discharge medication list did not include the Verapamil (blood pressure medication), Ambien (medication used to treat insomnia) and oxycodone-acetaminophen (pain reliever medication). This failure had the potential for the resident not receiving appropriate care and proper medication management after the discharge. Findings: On 9/18/25, the CDPH, L&C Department received a complaint alleging upon discharge, Resident 3 was not provided with the Verapamil or Ambien medications upon leaving the facility on 6/12/25. On 10/2/25 at 1256 hours, a telephone interview was conducted with Resident 3. Resident 3 stated she left the faciity on 6/12/25, because the facility did not administer her Verapamil or Ambien medications. Closed medical record review for Resident 3 was conducted on 10/2/25. Resident 3 was admitted to the facility on [DATE], and discharged on 6/12/25. Review of Resident 3's Order Summary Report showed the following orders:- dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep- dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep for 14 days.- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give one tablet by mouth every four hours as needed for moderate pain 4-6 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst), hold if RR (respiratory rate) less than 12- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give two tablets by mouth every four hours as needed for severe pain 7-10, hold if RR less than 12- dated 6/12/25, Verapamil Extended Release oral tablet 120 mg, give one tablet by mouth two times a day for high blood pressure. Hold if SBP greater than 110 mmHg.- dated 6/12/25, Verapamil oral tablet 120 mg, give 120 mg by mouth in the afternoon for hypertension. Review of Resident 3's H&P examination dated 6/12/25, showed Resident 3's diagnoses included PTSD, anxiety, and high blood pressure. Review of Resident 3's Transfer/Discharge Report dated 6/12/25, showed the following medications were listed on the discharge medication list but not marked as given to the resident upon discharge: - Verapamil 120 mg in the afternoon- Verapamil 120 mg Extended Release 120 mg twice daily- oxycodone-acetaminophen oral tablet 10-325 mg On 10/14/25 at 1709 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified Resident 3's Verapamil, Ambien, and oxycodone-acetaminophen medications were not provided to the resident upon the resident's discharge. Cross reference F755.

Based on interview and clinical record review, the facility failed to implement interventions recommended to help heal Resident 1's Stage 1 (intact skin with redness, which is not resolved within 30 minutes of pressure relief) sacral pressure ulcer and prevent Resident 1 from developing additional pressure ulcers. Resident 1 developed three Stage III (full thickness tissue loss extending through the skin to the tissue underneath) pressure ulcers on her sacral (area right above the tip of the tailbone) and buttocks, while at the facility, between admission on 11/26/11 and 12/15/11. Interventions recommended on 12/2/11, were not carried out until 12/16/11 to 12/19/11, after the Stage III pressure ulcers already developed. Findings: According to the facility's P&P titled Prevention of Pressure Ulcers dated 3/2005, showed pressure ulcers are a serious skin condition. The resident should receive adequate hydration and nutrition to meet their needs. The resident should receive vitamins and protein supplements in accordance with the RD's recommendations and a physician's orders [REDACTED]. According to Dietetics-Nutrition and Wound Healing, online website, there is an increase in demand for protein in the presence of wounds and protein depletion can affect the rate and quality of wound healing. The article also showed even short periods of low protein intake can result in significantly delayed wound healing. According to the National Pressure Ulcer Advisory Panel, nutrition is an important part of pressure ulcer prevention and treatment for [REDACTED]. Pressure ulcer occurrence may be higher for residents who experience significant weight loss, 30 to 35 calories per kg should be provided for residents who have a pressure ulcer. Residents who are underweight or who have had a significant unintentional weight loss may need additional calories. On 4/11/12, clinical record review for Resident 1 was initiated and showed Resident 1 was admitted on [DATE]. The MDS dated [DATE], showed Resident 1 required assistance from staff for ADLs. The Nurse's Admission Record dated 11/26/11, showed Resident 1 was admitted on [DATE]. The resident was alert, oriented and verbally responsive. The nurse noted Resident 1 had redness to her sacral area. The Weekly Pressure Sore (ulcer) Report dated 11/26/11, showed the reddened sacral area measured 4.0 cm by 3.0 cm. A care plan titled Risk for Skin Breakdown dated 11/27/11, showed Resident 1 was at risk for developing pressure ulcers due to decreased mobility and fragile skin. The goal showed Resident 1's skin integrity would be maintained. Interventions showed the licensed nurse would conduct weekly skin assessments, provide a pressure relieving mattress and provide adequate hydration and nutrition. The coccyx Weekly Pressure Sore (ulcer) Report dated 11/26/11 through 11/29/11, showed Resident 1 was admitted with a Stage 1 pressure ulcer to her sacral area, measuring 4.0 cm by 3.0 cm with no necrotic (dead tissue) tissue present. On 11/29/11 the pressure ulcer remained the same. The progress notes dated 12/2/11, showed Resident 1 was transported to the acute care hospital at 2006 hours, for an evaluation due to confusion. Resident 1 returned from the hospital on [DATE] at 0123 hours. Review of the acute care hospital's Discharge Instruction Summary dated 12/2/11, showed Resident 1 was treated for [REDACTED]. The hospital's laboratory results dated [DATE], showed Resident 1's blood sugar level was 259 mg/dL (normal range shown is 65 mg/dL to 99 mg/dL) and she received insulin (a medication used to lower high blood sugar). The hospital's Emergency Department's Focused Assessment Flowsheet Information notes dated 12/2/11 at 2100 hours, showed Resident 1 was noted with two Stage II pressure ulcers on her sacral area. The pressure ulcers measured 1.0 cm by 1.5 cm, one on each side of her coccyx (tailbone area) with redness and a small amount of drainage. The notes showed the acute care hospital called the facility to update them to the resident's plan of care and discharged back to the facility. The note showed the facility was aware of the resident's Stage II pressure ulcers. However, review of the resident's clinical record from the facility showed no assessment of Resident 1's skin upon readmission on 12/3/11, until 12/7/11, eight days after the previous assessment. a. The Weekly Pressure Sore (ulcer) Report, for the resident's sacral area dated 12/7/11, showed the Stage 1 pressure ulcer deteriorated to a Stage II pressure ulcer, measuring 2 cm by 2.8 cm with no necrotic tissue present. On 12/15/11, eight days later, the sacral pressure ulcer deteriorated to a Stage III pressure ulcer, measuring 2 cm by 1.4 cm with an undetermined depth, and 75 % necrotic tissue present. On 12/20/11, the pressure ulcer remained the same and the nurse documented Resident 1 "prefers" to lay on her back. b. Review of the The Weekly Pressure Sore (ulcer) Report, for the resident's left buttocks, dated 12/8/11 through 12/20/11, showed Resident 1 was identified with a Stage II pressure ulcer on her left buttocks, measuring 1.2 cm by 0.8 cm with a depth of 0.1 cm. On 12/15/11, the pressure ulcer deteriorated to a Stage III ulcer, measuring 1.0 cm by 0.8 cm with an undetermined depth, with 75 % necrotic tissue present. On 12/20/11, the pressure ulcer remained the same. c. The Weekly Pressure Sore (ulcer) Report dated 12/8/11 through 12/20/11, showed Resident 1 was identified with a Stage II pressure ulcer on her right buttocks, measuring 1.0 cm by 0.5 cm with a depth of 0.1 cm. On 12/15/11, the pressure ulcer deteriorated to a Stage III ulcer, measuring 1.2 cm by 1.0 cm with an undetermined depth with 75 % necrotic tissue present. On 12/15/11, the report showed Resident 1 was non-compliant with turning and repositioning. On 12/20/11, the report showed the pressure ulcer remained the same, and Resident 1 had a tendency to stay in one position, and refused to be repositioned at times. Review of the RD's assessment dated [DATE], showed Resident 1's meal percentages intake ranged from 25 % to 75 %, and the resident was at risk for decreased oral intake and dehydration due to receiving a mechanically altered diet and fluid restriction. The RD noted the resident's elevated HgbA1c (a test which measures the percentage of blood sugar present in the blood over the last two to three months) indicated inadequate glycemic (sugar level in the blood) control and recommended the resident's diet be changed to an ADA (a diet which helps control blood sugar) diet due to her elevated HgbA1c. The RD made a recommendation for the physician to consider ordering Accuchecks (a test which measures blood sugar) to monitor the resident's blood sugar. The RD recommended the physician adjust the resident's fluid restriction due to indications of inadequate hydration. In addition, the RD noted Resident 1 had increased nutritional needs to help heal her sacral redness Stage 1 pressure ulcer. The RD recommended the resident receive a multivitamin tablet daily for supplementation. The Resident Progress Notes dated 12/8/11, showed Resident 1's Stage I pressure ulcer on her sacral area progressed to a Stag II pressure ulcer and the resident was developing pressure ulcers on her buttocks. The notes showed Resident 1 was non-compliant with turning and repositioning and preferred to lay on her back. The RD's progress note dated 12/10/11, showed Resident 1 had a two pound weight loss and her meal percentage intake ranged from 25 % to 75 %. The note showed the resident was not receiving an ADA diet and her fluid restriction of 1000 ml daily was still in effect. The RD documented Resident 1 had developed two Stage II pressure ulcers on her buttocks. The RD recommended diabetic snacks three times daily in between meals be ordered. The resident's elevated HgbA1c level "indicating inadequate glycemic control." The RD again recommended the physician consider ordering Accuchecks to monitor the resident's blood sugar. The RD noted the resident had an elevated blood sugar on 12/8/11 and increased nutritional needs to help heal her two Stage II pressure ulcers on her buttocks. The RD again recommended the resident receive a daily multivitamin, vitamin C 500 mg tablet twice daily and a [MEDICATION NAME] (a test used to check for protein levels indicating [MEDICAL CONDITION]) level to monitor the resident's current nutritional status, and possible need for a protein supplement. The RD's progress note dated 12/22/11, showed Resident was noted with a six pound weight loss since admission and three Stage III pressure ulcers, one on each buttocks, and one on her sacral area. The resident's HgbA1c level was elevated and her [MEDICATION NAME] level was low. The RD documented Resident 1 stated she had "a decreased appetite due to increased pain." The RD documented the resident continued with increased nutritional needs for skin care and she had a low [MEDICATION NAME] level indicating inadequate protein stores. The RD also noted elevated HgbA1c level "indicating inadequate glycemic control." Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The daily multivitamin tablet, recommended on 12/2/11, was not ordered until 12/18/11 (16 days later). The adjustment of the fluid, recommended on 12/2/11, was not discontinued until 12/16/11 (14 days later). The diet change recommended on 12/2/11, was not changed until 12/17/11 (15 days later). The vitamin C 500 mg twice daily recommendation on 12/10/11, was not ordered until 12/18/11 (eight days later) and the diabetic snacks recommended on 12/10/11, were not started until 12/17/11 (seven days later). The [MEDICATION NAME] level recommended 12/10/11, was not ordered until 12/19/11 (nine days later) and a protein supplement not ordered until 12/17/11. The MAR indicated [REDACTED]. [MEDICATION NAME] (a medication which lowers blood sugar) was ordered 12/19/11 to treat Resident 1's high blood sugars. Review of the laboratory results dated [DATE], showed Resident 1's [MEDICATION NAME] level was 6.0 mg/dL (normal is 17.0 mg/dL to 34.0 mg/dL). On 4/12/12 at 0830 hours, during an interview and clinical record review with RN 1, RN 1 stated she did not know why some of the RD's recommendations took two weeks or longer to be carried out. On 4/12/12 at 1040 hours, during an interview with the RD, the RD stated when she makes a recommendation she enters the recommendation in a communication log for the nursing staff to then notify the physician. The RD stated the recommendations should be followed up on within 72 hours. On 4/16/12 at 1630 hours, during an interview with the DON, the DON stated when a resident returns from the acute care hospital a skin assessment will be done and documented. When asked if there was a skin assessment documented for Resident 1 when she returned from the acute care hospital on [DATE], the DON was unable to answer. The DON stated she would look for the assessment. On 4/17/12 at 1020 hours, during a follow up interview with the DON, the DON stated the facility didn't do a body check when the resident returned from the acute care hospital. On 4/23/12, a review of additional information received by the facility on 4/19/12 was conducted. Documentation provided showed Resident 1 received the low air loss mattress when her pressure ulcers deteriorated. Review of the Weekly Pressure Sore (ulcer) Report dated 12/7/11, showed Resident 1's sacral area pressure ulcer deteriorated from a Stage I pressure ulcer to a Stage II pressure ulcer, which was identified on 12/7/11. However, review of the MAR for December 2011, showed the low air loss mattress was not ordered until 12/15/11 (eight days later, when the pressure ulcer was a Stage III).