Every finding on record at Delta Healthcare & Wellness Center, LP

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) when medical records were not provided to the responsible party (R/P) for one of 18 sampled residents (Resident 1) as requested. This failure resulted in Resident 1's R/P not being provided with Resident 1's medical records. Findings:During a review of Resident 1's Durable Power of Attorney (DPA) dated 8/18/12, the DPA indicated, I, (Resident 1).hereby appoint (Family Member 1) .as my attorney-in-fact ( Agent) to exercise the powers and discretions described below.My Agent's powers shall include, but not be limited to, the power to.have access to my healthcare and medical records and statements regarding billing, insurance and payments.During a review of Resident 1's Resident Request for Access to Protected Health Information (RRAPHI) dated 4/13/25, the RRAPHI indicated, (Resident 1).I would like to access and inspect my Protected Health Information (PHI) .I would like the facility to send a copy of my PHI to (FM1).I would like a summary of my requested PHI.Signature (FM 1).During an interview on 7/28/25 at 10:56 a.m. with Medical Records Supervisor (MRS), MRS stated when there was a medical records request, the request was submitted in writing to her and the request was forwarded to corporate and corporate determines whether or not the medical record can be released. MRS stated Resident 1's medical records were requested on 4/13/25 by FM 1. MRS stated the request was denied due to the facility not having the DPA on file. MRS stated the DPA was provided to the facility and the medical record was still not provided to FM 1. During a review of the facility's policy and procedure (P&P) titled, Resident Access to PHI (Protected Health Information) dated 11/1/15, the P&P indicated, All requests by a resident or a resident's personal representative for access to PHI must be directed to the HIAA Privacy Officer.Time and manner of Access a. The HIPAA Privacy Officer will allow the resident and/or their personal representative to access to inspect the resident's medical record at the facility within twenty-four (24) hours of receipt of a written request for access, excluding weekends and holidays. b. If the resident and/or their personal representative requests a copy of the resident's medical record, the HIPPA Privacy Office will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request.

Based on interview and record review, the facility failed to provide an itemized statement per the admission agreement to one of 18 sampled (Resident 1) residents when requested. This failure had the potential for Resident 1 to be unaware of services she was being billed for. Findings:During a review of Resident 1's monthly statements dated 5/31/25, 6/20/25, and 7/20/25, the monthly statements did not include an itemized billing.During an interview on 8/6/25 at 10:48 a.m. with Family Member (FM) 1, FM 1 stated he had requested an itemized bill from the facility and it had not been provided. During an interview on 8/6/25 at 1:42 p.m. with Administrator, Administrator stated FM 1 had requested an itemized bill indicating how much Resident 1 was being charged for each service. Administrator stated FM 1 was provided with a generic statement that did not indicate the individual service charge. Facility policy requested and none provided.During a review of the facility's California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities (CSAASNFICF) undated, the CSAASNFICF indicated, The resident shall receive a monthly, itemized statement of all charges incurred by the resident.

Based on interview and record review, the facility failed to collaborate care with hospice (specialized form of medical care provided to individuals with terminal illness) for one of 18 sampled residents (Resident 1) when a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was identified to Resident 1's lower back by hospice, and the facility was unaware. This failure had the potential for Resident 1's pressure ulcer to go untreated and worsen.Findings:During a review of Resident 1's Hosp SN Visit (HSV-hospice documentation) dated 5/16/25, the HSV indicated, Integumentary (skin) Status.Wounds 1 lower back pressure ulcer/injury, stage 2-partial thickness skin loss of exposed dermis, observable, most problematic pressure ulcer/injury.cleanse with DWS (dermal wound spray-used to clean wounds) and pat dry. Apply hydrogel (medication used to promote healing) to wound bed and cover with pink Allevyn sacral dressing for extra padding. Change Mondays and Thursdays or PRN soiling/dislodgement.date first identified.5/16/25.During a review of Resident 1's Order Summary Report (OSR) dated 5/1/25-5/31/25, the OSR indicated there were no physician orders for treatment of a stage 2 to the lower back.During a review of Resident 1's Treatment Administration Record (TAR) dated 5/1/25-5/31/25, the TAR indicated there were no treatments administered to a stage 2 to the lower back.During an interview on 8/21/25 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when Resident 1 was admitted to hospice on 5/16/25, she was Resident 1's nurse and hospice did not report that Resident 1 had stage 2 to her lower back. LVN 1 stated when the hospice nurse identified the stage 2 pressure ulcer they should have reported it to the facility.During a concurrent interview and record review, on 8/21/25 at 2:58 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON was unable to provide documentation of stage 2 to Resident 1's lower back being identified or treated by the facility. DON stated hospice did not report a stage 2 pressure ulcer to the nurse and the facility did not receive any treatment orders from the hospice nurse regarding a stage 2 pressure ulcer.During an interview on 8/27/25 at 3:56 p.m. with DON, DON stated hospice was expected to communicate any skin issues identified to the nurse. DON stated when a stage 2 to the lower back was identified on Resident 1 it should have been reported to the nurse. During a review of the facility's policy and procedure (P&P) titled Hospice Care of Residents dated 1/1/12, the P&P indicated, If the resident and/or surrogate decision maker decides to utilize hospice care.The hospice and facility will collaborate on a care plan for the resident.facility and hospice staff will collaborate on a regular basis concerning the resident's care.Documentation.Hospice notes will be included in the facility progress notes.nursing staff will be informed of any changes recommended by the hospice staff.

Based on observation, interview, and record review, the facility failed to ensure food items were used by the discard date, dated when opened, and labeled. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) to the residents. Findings: During a concurrent observation and interview on 5/12/25 at 9:01 a.m. with Certified Dietary Manager (CDM) in the kitchen, there was a large container with brown liquid that was not labeled. CDM stated it was iced tea, and it should be labeled. During a concurrent observation and interview on 5/12/25 at 9:03 a.m. with CDM in the kitchen, there were three pitchers of juice with no labels in the refrigerator. CDM stated there should be a label with the date of when the juice was poured into the pitchers. During a concurrent observation and interview on 5/12/25 at 9:05 a.m. with CDM in the kitchen, there were opened, unlabeled containers of mayonnaise and ranch dressing in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:07 a.m. with CDM in the kitchen, there was a container of Worcestershire sauce with no label in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:10 a.m. with CDM in the kitchen, there was a half full container of 2% milk and a carton of liquid eggs with no open date labels in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:19 a.m. with CDM in the storage room, there was an opened bag of vanilla wafers on the shelf. CDM stated the bag should be sealed with an open date label. During a concurrent observation and interview on 5/12/25 at 9:20 a.m. with CDM in the storage room, there was a tray of cinnamon rolls with a use by date of 5/10/25. CDM stated the cinnamon rolls should have been thrown away. During a review of the facility's policy and procedure (P&P) titled, Food storage and Handling, dated 2022, the P&P indicated, All items will be correctly labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for two of five sampled residents (Resident 33 and Resident 6). This failure resulted in Resident 33 and Resident 6 receiving medications unsafely and had the potential for adverse outcomes. Findings: During an observation on 5/15/25 at 8:46 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 33's room. LVN 2 administered Lisinopril (used to treat high blood pressure, heart failure, and to improve survival after a heart attack) 5 milligrams (mg), Carvedilol (used to treat heart failure and high blood pressure) 3.125 mg, and Spironalactone (used to treat high blood pressure, heart failure, and fluid retention) 25 mg, by mouth to Resident 33. LVN 2 did not take Resident 33's heart rate or blood pressure before administering the medications. During an observation on 5/15/25 at 8:55 a.m. with LVN 2 in Resident 6's room, LVN 2 administered Amlodipine (used to treat high blood pressure and certain types of chest pain) 5 mg by mouth to Resident 6. LVN 2 did not take Resident 6's heart rate or blood pressure before administering the medication. During an interview on 5/15/25 at 9:26 a.m. with LVN 2, LVN 2 stated she did not take heart rates or blood pressures before administering medications to Resident 33 or Resident 6. During a review of Resident 33's Medical Record (MR), the Physician Order (PO) dated 10/9/24 at 10:59 a.m. indicated Lisinopril Oral Tablet 5 MG . Give 1 tablet by mouth one time a day for HTN [hypertension- high blood pressure] Obtain Bp [blood pressure]. If sbp [systolic blood pressure- top number when reading a blood pressure] below 100 hold [medication] and notify MD [physician]. If sbp above 180 administer [medication] and notify [MD]. Carvedilol Oral Tablet 3.125 MG . Give 1 tablet by mouth two times a day for HTN obtain Bp. If sbp is below 100 OR pulse [heart rate] below 60 Hold [medication] and notify [MD]. If sbp is above 180 administer [medication] and notify MD. Spironolactone Oral Tablet 25 MG . Give 1 tablet by mouth one time a day for HTN obtain bp & pulse. If sbp is below 100 Hold [medication] and notify MD, if sbp above 180 administer [medication] and notify MD. During a review of Resident 6's MR, the PO dated 2/27/25 at 6:15 p.m. indicated, amlodipine Besylate Oral Tablet 5 MG . Give 1 tablet by mouth one time a day for HTN[,] LVN to obtain BP, hold [medication] for SBP < [less than] 100 or pulse < 60 hold [medication] and notify MD. If SBP is greater than 180 administer [medication] and notify MD. During a review of the facility's policy and procedure (P&P) titled, Medication - Administration dated 1/1/12, the P&P indicated, Purpose to ensure the accurate administration of medications for residents in the facility . C. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. i. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring etc.

Based on observation, interview, and record review, the facility failed to implement infection control standards for two of eight residents (Resident 7 and Resident 21). This failure had the potential to spread illness to residents, staff, and visitors. Findings: During an observation and interview on 5/13/25 at 9:38 a.m. with Physical Therapist (PT) 1 in hallway, trash cans were not in the rooms and two were noted in the hallway. PT 1 exited Resident 7's isolation room with a soiled isolation gown rolled up in her hands. PT 1 crossed the hallway to dispose of the gown in the hallway trash can. PT 1 stated, There isn't a trash can in the room big enough for soiled personal protective equipment [PPE- gowns, gloves, and masks used to prevent the spread of infection]. During a concurrent observation and interview on 5/13/25 at 9:44 a.m. with Hospice Aide (HA), in Resident 21's room, which had transmission-based precautions (TBP-placed for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others) signage and a PPE cart outside of the room's entrance. HA stated she worked for a hospice agency, and came twice a week to bathe, dress, and make Resident 21's bed. HA was not wearing PPE and entered and exited Resident 21's room multiple times. During an interview on 5/13/25 at 9:49 a.m. with Infection Preventionist (IP), IP stated anyone going into rooms with TBP signage should follow the instructions. IP stated the facility should have notified the Hospice agency about the facility having a norovirus (highly contagious virus in the stomach that causes diarrhea and vomiting) outbreak on 5/12/25 that resulted in multiple rooms being placed on TBP. During an interview on 5/13/25 at 9:52 a.m. with HA, HA stated she put on PPE when she first entered the room, but she did not re-gown or re-glove when she re-entered the room multiple times. During a review of the facility's policy and procedure (P&P) titled, Resident Isolation-Categories of Transmission-Based Precaution, dated 1/1/12, the P&P indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others. Procedure: . I. Transmission-based precautions are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. examples of infections requiring Contact Precautions include, but are not limited to: a. Gastrointestinal, respiratory, skin, or wound infections . C. iii. Gloves are removed before leaving the room and hands are washed immediately with an antimicrobial agent or a waterless antiseptic agent. iv. After gloves are removed and hands are washed, the potentially contaminated environmental surfaces or items in the resident's room are not touched. D. Gown ii. The gown is removed and hand hygiene is performed before leaving the resident's environment. iii. After removing the gown, clothing is not allowed to contact potentially contaminated environmental surfaces.

Based on interview and record review, the facility failed to communicate a nurse-to-nurse report when transferring a resident to the hospital for one of two sampled residents (Resident 1). This failure resulted in the hospital not having any of Resident 1's medical or surgical history. Findings: During a concurrent interview and record review on 5/14/25 at 11:12 a.m. with Social Services Director (SSD) 1, Resident 1's Medical Record (MR) was reviewed. SSD 1 stated Resident 1 was transferred to the hospital for labored breathing. The Physician Order dated 4/12/25 at 11 a.m. indicated, send to ED [emergency department] for eval[uation] and treat as needed one time only for labored breathing for 1 Day. The SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form (HTF), dated 4/11/25, indicated, the form was completed and reviewed by Licensed Vocational Nurse (LVN) 4. The HTF indicated, Report Called in By (name/title) was filled in with na [not applicable] and Report Called in to (name/title) was filled in with na. During a concurrent interview and record review on 5/14/25 at 11:46 a.m. with LVN 2, Resident 1's HTF was reviewed. LVN 2 stated the form needs to be completed when transferring a resident to the hospital. A nursing documentation policy and procedure was requested and none was provided.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning for one of four sampled residents (Resident 10). This failure resulted in Resident 10 falling and sustaining a broken femoral neck (bone that connects upper leg to hip) bone. Findings: During a concurrent interview and record review on 5/14/25 at 10:02 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's Medical Record (MR) was reviewed. SSD 1 stated Resident 10 had an unwitnessed fall on 3/17/25 in her bathroom while attempting to self-toilet. Care Plan Report (CP), dated 2/13/25, indicated, Resident 10 was at risk for falls r/t [related to] impaired mobility and unsteadiness in gait [manner of walking]. The Physician Orders (PO), dated 3/17/25, at 11:15 a.m., indicated, Transfer to acute [hospital] for further evaluation related to Fracture [sic] of the left hip. The Discharge Documentation (DD), dated 3/22/25, indicated, Resident 10 was diagnosed with a Fracture [break] of femoral neck, left [side], requiring surgery to repair. During a review of Resident 10's MR, The CP, dated 2/13/25, indicated, Goal [:] the resident will be free of falls . Intervention [:] Ensure that The [sic] resident is wearing appropriate footwear when ambulating [walking] or mobilizing [moving] in w/c [wheelchair]. The Post Fall Evaluation (PFE), dated 3/17/25, indicated, 9. Reason for fall Resident [10] wearing fuzzy socks with no grip. The Progress Notes (PN), dated 3/17/25, at 1:31 p.m., indicated, Fall Details: Date/Time of Fall: 03/17/2025 7:15 AM Fall was not witnessed. Fall occurred in the bathroom. Resident was attempting to self toilet at the time of the fall. Reason for the fall was evident. Reason for fall: Resident wearing fuzzy socks with no grip. During a review of the facilities P&P titled, Comprehensive Person-Centered Care Planning dated 9/7/23, the P&P indicated, a. The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. B. The Baseline Care Plan Summary will be developed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident's admission . 4 . b. Additional changes or updates to the resident's comprehensive care plan will be made on the assessed needs of the resident.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), was assisted to the bathroom when she asked for help. This failure resulted in Resident 196 being frustrated and had the potential for increased incontinence (inability to control urination and/or bowel) and decreased mobility. Findings: During an interview on [DATE] at 12:20 p.m. with Resident 196, Resident 196 stated when she came back from her dialysis treatment yesterday, she asked the staff to help her go to the bathroom for a bowel movement. Resident 196 stated the staff told her to wait and poop in her pants and staff will change her afterwards. Resident 196 stated she felt frustrated, and she would have gone to the bathroom if she could. Resident 196 stated she just pooped in her diaper because she could not do anything. During a review of Resident 196's Care Plan Report (CPR), undated, the CPR indicated, Resident 196 was on a B&B (bowel and bladder) management program: Staff to offer and assist with toileting Q2 -[every 2 hours] and as needed. During a review of Resident 196's Order Summary Report (OSR), dated [DATE], the OSR indicated Resident 196's Weight bearing status: WBAT [weight bearing as tolerated] LLE [left lower extremity] and pt [patient] can weight bear as tolerated through left elbow and use a platform walker. During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder Training/Toileting Program, dated [DATE], the P&P indicated, E. bowel and bladder retraining program: use of a timed schedule for voiding/bowel movement based on the Resident' identified need and routine in order to maximize control of their bowel and bladder function as much as possible. During a review of the facility's P&P titled, Resident's Rights, dated [DATE], the P&P indicated, Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights . employees are to treat all resident with kindness, respect, and dignity and honor the exercise of residents' rights. II. The Facility makes every effort to assist each resident in exercising his/her rights by providing the following services: A. The Facility's Staff encourages residents to participate in planning their daily care routines.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 196), was administered oxygen according to physician's order. This failure had the potential to result in Resident 196 to experience hypoxia (low levels of oxygen in the body) or hyperoxia (high level of oxygen in the body). Findings: During a concurrent observation and interview on 5/12/25 at 10:03 a.m. with Resident 196 in her room, Resident 196's oxygen setting on the oxygen concentrator was 5 LPM (liters per minute). Resident 196 stated it was always at 3 LPM. During an interview on 5/12/25 at 12:41 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 196's oxygen setting order was 2 LPM. During a concurrent observation and interview on 5/12/25 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1 in the Yellow Hallway, CNA 1 was wheeling Resident 196 with an oxygen tank behind the wheelchair. CNA 1 stated the oxygen was set at 2 LPM. Resident 196 told CNA 1 her oxygen was supposed to be at 3 LPM. During a review of Resident 196's Order Summary Report (OSR), dated 5/13/25, the OSR indicated, Oxygen 3 LPM Via Nasal Cannula Continuously every day and night shift for COPD (Chronic Obstructive Pulmonary Disease - lung disease where airflow is restricted). During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated November 2017, the P&P indicated, I. Administration of Oxygen A. Administer oxygen per physician orders.

Based on observation, interview, and record review, the facility failed to accurately assess the skin of one of four sampled residents (Resident 31). This failure resulted in skin breakdown and pain for Resident 31. Findings: During an interview on 5/13/25 at 10:35 a.m. with Family Member (FM) 1, FM 1 stated Resident 31 was dependent on staff for positioning and repositioning in bed. FM 1 stated Resident 31 had arthritis which caused her a lot of pain. FM 1 stated Resident 31 would usually lay on her left side because it was less painful for her. FM 1 stated Resident 31 had sores and redness on her left ear, left outer ankle, left outer foot, and right inner foot. During a review of Resident 31's Admission Record (AR) dated 12/22/22, the AR indicated Resident 31's diagnoses included, OTHER ABNORMALITIES OF GAIT [manner of walking] AND MOBILITY . MUSCLE WEAKNESS . DEAF NONSPEAKING . RHEUMATOID ARTHRITIS [body's immune system attacks the lining of the joints causing pain and swelling]. During a concurrent interview and record review on 5/14/25 at 3:45 p.m. with Social Services Director (SSD) 1 and SSD 2, Resident 31's Medical Record (MR) was reviewed. SSD 1 stated she was unable to find any documentation indicating any pressure injuries (PI) or skin issues. During a concurrent observation and interview on 5/14/25 at 3:52 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 31's room, LVN 1 stated Resident 31 did not have any PIs or skin issues. LVN 1 used a white board to ask Resident 31 for permission to assess her skin and Resident 31 agreed to the assessment. LVN 1 examined Resident 31's left ear which had a permanent inward bend of the helix (curved part of outer ear). Inside the left helix was an open red and draining wound the size of a pencil eraser. LVN 1 touched the area with a tissue and Resident 31, who was non-verbal, pulled away and cried out in pain. LVN 1 then assessed Resident 31's feet. Resident 31 had a red nickel-sized area on her outer left ankle, which was partly covered in a scab, a dime-sized red area on the left outer area of the left foot near the small toe, and a red dime-sized area on the inner right foot near the big toe. Resident 31 wrote on her communication board that she had skin issues on her ear and feet for two months. LVN 1 stated certified nursing assistants (CNA) are supposed to report any resident skin issues noted during baths or showers. LVN 1 stated LVNs assess for any skin changes when weekly head-to-toe physical evaluations are completed. During an interview on 5/14/25 at 4:42 p.m. with Director of Nursing (DON), DON stated LVNs are expected to complete a weekly head-to-toe assessment of each resident and document any unusual findings on the weekly Long Term Care Evaluation. DON stated CNAs should document any unusual findings on the shower sheet (non-permanent part of the resident's MR which is used to communicate concerns from the CNA staff to the nursing staff). During an interview on 5/14/25 at 4:45 p.m. with LVN 2, LVN 2 stated nurses complete a head-to-toe assessment of each resident weekly. During a concurrent interview and record review on 5/15/25 at 10:49 a.m. with Director of Staff Development (DSD), Resident 31's Skin Monitoring: Comprehensive CNA Shower Review [SMCSR] documentation was reviewed, and the following was noted: SMCSR dated 3/4/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/7/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/11/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/14/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/18/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/21/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/25/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/28/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/1/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/15/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/18/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/22/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/25/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/2/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/9/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/13/25, Visual Assessment indicated no abnormal skin findings. DSD stated her expectation was for CNAs to document any discoloration, open areas on the skin, redness, scratches, scabs, folds, knees, under female resident's breasts, or other pressure points. During a review of Resident 31's Long Term Care Evaluation [weekly comprehensive nursing assessment] dated 3/23/25, 3/30/25, 4/6/25, 4/13/25, 4/20/25, 4/27/25, and 5/4/25 indicated Skin changes since last evaluation . No. The Skin Check dated 3/16/25, 3/23/25, 3/30/25, 4/6/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, and 5/11/25 indicated, 1. Skin Check . 8. No skin issues [was marked]. The Minimum Data Set [MDS- comprehensive assessment tool] Section M - Skin Conditions dated 4/25/25, indicated, Risk of Pressure Ulcers/Injuries 1. Yes and Unhealed Pressure Ulcers/Injuries . Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. During a review of the facility's policy and procedure (P&P) titled, Licensed Nurse Weekly Progress Notes dated 10/9/24, the P&P indicated, POLICY: Weekly nurses' progress notes will be written by licensed personnel on each resident, specific to the psychological, emotional, social, spiritual, and recreational needs and consistent with the Plan of Care. PURPOSE: To reflect observations of the resident's response to their environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the functional status of progression and/or regression. During a review of the facility's P&P titled, Pressure Injury Prevention, dated 7/31/24, the P&P indicated, 5. Staff will observe for any signs of potential or active pressure injury daily. 6. A weekly skin check will be completed and documented in the medical record. A nursing documentation P&P was requested, none was provided.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), post dialysis (mechanical removal of toxins in the blood when the kidneys no longer function adequately) access care was done timely. This failure had the potential for Resident 196's dialysis access to develop an infection or stenosis (narrowing of a vein or artery) which can cause prolonged bleeding and dialysis access failure. Findings: During a review of Resident 196's Order Summary Report (OSR), dated 5/13/25 the OSR indicated Resident 196 had an order to go to dialysis treatment every Monday, Wednesday, and Friday. During a concurrent observation and interview on 5/13/25 at 11:26 a.m. with Resident 196 in her room, Resident 196's dialysis dressing was on her left upper arm and asked Family Member (FM) 2 to take off the dressing. Resident 196 stated the staff was supposed to remove the dressing after her dialysis treatment on 5/12/25. During an interview on 5/15/25 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 196's dialysis access dressing should be removed two hours after Resident 196 returned from her dialysis treatment. During an observation on 5/15/25 at 12:17 p.m. in Resident 196's room, her dialysis access dressing remained on her left upper arm from her dialysis treatment on 5/14/25. During a review of the facility's policy and procedure (P&P) titled, Dialysis Management dated 1/25/24, the P&P indicated, 4. Vascular Access Site.viii. Dressing will be changed in accordance with Attending Physician's Order. Resident 196's post dialysis evaluations for 5/12/25 and 5/14/25 were requested and none were provided.

Based on interview and record review, the facility failed to ensure documentation of the Advance Directive (legal document outlining a person's healthcare and end of life wishes should the person become unable to verbalize those wishes) status was accurate for one of four sampled residents (Resident 10). This failure resulted in an inaccurate medical record and had the potential for Resident 10's healthcare wishes not to be honored. Findings: During a concurrent interview and record review on 5/14/25 at 10:48 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's medical record was reviewed. SSD 1 stated the Physician's Order for Life Sustaining Treatment (POLST) dated 1/20/20, indicated No Advance Directive. The Social Services Progress Notes dated 1/24/25 indicated, Advance Directive . a. Yes [has an advance directive] on file. SSD 1 stated she was unable to find a copy of Resident 10's advance directive. During a review of the facilities policy and procedure (P&P) titled, Advance Directive dated 7/31/24, the P&P indicated, Advance Directive Information . c. During the Social Service Assessment process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive. d. If the resident has an Advance Directive, the Facility shall request a copy of the document from the resident or the resident's representative . e. If a copy is provided by the resident or the resident's representative, it will be placed in the medical record. A copy of the facility's documentation policy was requested, none was provided.

Based on interview and record review, the facility failed to ensure appropriate use of an antibiotic (medication used to treat infection) for one of 20 sampled residents (Resident 99). This failure had the potential for unnecessary antibiotic usage leading to antibiotic resistant bacteria (Antimicrobial resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings: During a concurrent interview and record review, on 2/7/24 at 10:17 a.m., with Infection Prevention Nurse (IPN), the facility's Infection Surveillance Monthly Report (ISMR), dated February 2024 was reviewed. The ISMR indicated Resident 99 had an onset date of 1/25/24, Infection: UTI (urinary tract infection), signs and symptoms: Dysuria (discomfort while urinating), Fatigue/Malaise (tiredness), New or marked increase in frequency, New or marked increase in urgency, Urinary complaints. IPN stated the resident, Resident 99, received the ordered medication Macrobid (antibiotic) as prescribed and completed the medication on 2/1/24. During a review of Resident 99's Pharmacy Order Summary (PO), dated January 2024, the PO indicated Resident 99 was prescribed Macrobid Oral Capsule 100 mg (milligram) Give 1 Tablet by mouth two times a day for UTI for 7 days. Order states: completed. Order date: 1/25/24. Start date: 1/25/24. End date: 2/1/24. During a concurrent interview and record review on 2/7/24 at 10:20 a.m. with IPN, Resident 99's Urine Culture (UC- a laboratory test check for bacteria or other germs in a urine sample), dated January 24, 2024, was reviewed. The UC indicated, four or more organisms (bacteria) present. IPN stated the sensitivity (a test to see what antibiotic will work best to treat the infection) results were not obtained, we should have obtained the sensitivity results to know if the Macrobid was the appropriate antibiotic. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated May 20, 2021, the P&P indicated, The Facility will implement an Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve the outcomes for Residents.

Based on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for one of 20 sampled residents (Resident 18) when Resident 18 was not administered oxygen (O2) per physician orders. This failure resulted in Resident 18 not receiving oxygen. Findings: During a concurrent observation and interview on 2/5/24 at 10:05 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 18's room, Resident 18 was lying down in bed and her nasal cannula (tube that goes in your nose and delivers oxygen) was in her nose. Upon checking the concentrator (machine that gives oxygen) the concentrator was off. LVN 1 stated Resident 18 should have continues oxygen on, and Resident 18's concentrator was off. During review of Resident 18's Order Summary Report (OSR) dated 2/6/2024, the OSR indicated, Oxygen 2 LPM [liter per minute] via nasal cannula every shift SOB [shortness of breath] R/T [Related to] every shift for SOB while in bed. During an interview on 2/6/24 at 2:28 p.m. with Director of Nursing (DON), DON stated expectation is to have oxygen concentrator on if resident has an order for oxygen. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 2017, the P&P indicated, To ensure the safe storage and administer of oxygen in the Facility.A. Administer oxygen per physician orders.

Based on interview and record review, the facility failed to provide the minimum square footage as required by regulation in 16 of the facility's resident bedrooms. This failure had the potential to provide insufficient space in the event of an actual emergency. Findings: During a concurrent interview and record review on 2/8/24 at 8:25 a.m. with Administrator, the facility's floor plan (FP) and facility census (FC) dated 2/5/24 was reviewed. The FP and FC indicated the following rooms did not provide the minimum square footage (sq. ft.) as required by regulation (80 sq. ft. per resident for multi occupation rooms). room [ROOM NUMBER]: 152 sq. ft. - two residents room [ROOM NUMBER]: 223 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 224 sq. ft. - three residents room [ROOM NUMBER]: 153 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 151 sq. ft - two residents room [ROOM NUMBER]: 150 sq. ft - two residents room [ROOM NUMBER]: 247 sq. ft - three residents Administrator stated she had not received a waiver for less than 80 square foot per Resident.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During an interview on 2/8/24 at 8:26 a.m. with Director of Nursing (DON), DON stated we have a RN who works on the weekends but does not work the full eight hours, or consistently works on the weekends. DON stated she has to come in a lot on the weekends especially on Sundays, and sometimes there is no coverage. During a concurrent interview and record review on 2/8/24 at 8:48 a.m. with Director of Staff Development (DSD), the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 8/6/2023, 8/12/23, 8/13/23, 8/20/23, 9/3/23, 9/10/23, 9/16/23, 9/17/23, 9/30/23, 12/22/23, 12/24/23, and 12/30/23 were reviewed. DSD stated we have a weekend RN, but she does not come in on all weekends. DSD verified there was no RN on duty for the above dates.

Based on observation, interview, and record review, the facility failed to remove expired medication from the medication cart. This failure had the potential to result in medications administered not to be effective. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 2/6/24 at 8:55 a.m. in the hallway at the green medication cart, the following expired medications were found in the cart: Artificial tear solutions (eye drops-lubricate dry eyes) opened on 10/25/23. Morphine Sulfate (Pain medication) liquid un-opened expired on 9/19/23. Hyoscyamine (Decrease acid production in the stomach) 0.125 mg (milligram-unit of measurement) tablet expired on 12/12/23. LVN 1 verified the findings. During an interview on 2/6/24 at 2:18 p.m. with Director of Nursing (DON), DON stated expectation is to audit cart every day and when nurses find expired medications in their cart, they turn in to me (DON). During a review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, dated 2014, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those if the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.S. All Ophthalmic and Otic medications are to be dated upon opening and discarded 30 days after opening. Date open sticker can be attached to the container that the medication is stored in.(a) Unless otherwise specified in the individual monograph, or in the absence of stability data to the contrary, such beyond-use date shall be not later than (a) the expiration date on the manufacturer's container or (b) one year from the date the drug is dispensed, whichever is earlier.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review, on 3/24/22, at 2:43 PM, with the Director of Nursing (DON), the facility's staff schedule titled, Nursing Schedule 2022 (NS), dated 3/22, was reviewed. The NS indicated, only Licensed Vocational Nurses (LVN) were scheduled. DON stated, she was the only RN in the facility and did not always work seven days a week. DON stated, she did not have a printed schedule for herself, and her contract indicated a Monday through Friday schedule, eight hours per day. During the survey entrance conference on 3/21/22, at 9:30 AM, the Administrator stated, the facility did not have any staffing waivers.

Based on interview and record review, the facility failed to accurately complete Preadmission Screening and Resident Review (PASRR- Federal requirement to screen for mental illness and intellectual disabilities to ensure individuals are placed in nursing homes with appropriate services to meet their needs) Level I Screening, for five of 28 sampled residents (Resident 39, Resident 40, Resident 3, Resident 32, and Resident 28). This failure resulted in a Level II screening not being performed and had the potential for residents to be admitted to the facility without appropriate services available to them. Findings: During a review of Resident 39's PASRR, dated 11/12/21, the PASRR indicated, Section III- Serious Mental Illness Screen 10. Does the individual have a diagnosed mental disorder such as depression, Anxiety, Panic, [CONDITION(S)]/[CONDITION(S)] Disorder [mental disorder causing reality to be interpreted abnormally], Psychotic [disconnection from reality], Delusional [inability to differentiate something real from something imagined] and/or Mood Disorder [depression and/or periods of high energy followed by periods of depression]? The facility answered no. During a review of Resident 39's Admission Record (AR), dated 11/12/21, the AR indicated, [CONDITION(S)], unspecified as one of Resident 39's admission diagnoses. During a review of Resident 40's PASRR, dated 2/25/22, the PASRR indicated, Section III - Serious Mental Illness Screen 10. Does the individual have a diagnosed mental disorder such as Depression, Anxiety, Panic, [CONDITION(S)]/[CONDITION(S)] Disorder, Psychotic, Delusional, and/or Mood Disorder? The facility answered no. During a review of Resident 40's AR, dated 11/12/21, the AR indicated Major Depressive Disorder, Single Episode, Unspecified as one of Resident 40's admission diagnoses. During a review of Resident 28's PASRR, dated 2/16/22, the PASRR indicated, Section III - Serious Mental Illness Screen 10. Does the individual have a diagnosed mental disorder such as Depression, Anxiety, Panic, [CONDITION(S)]/[CONDITION(S)] Disorder, Psychotic, Delusional, and/or Mood Disorder? The facility answered no. During a review of Resident 28's AR, dated 2/15/22, the AR indicated Anxiety Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified as two of Resident 28's admission diagnoses. During a review of Resident 3's PASRR, dated 12/31/20, the PASRR indicated, Section V- diagnosed Mental Illness 26. Does the resident have a diagnosed mental disorder such as Schizophernia/[CONDITION(S)] Disorder, Psychotic/[CONDITION(S)], Delusional, Depression, Mood Disorder, [CONDITION(S)], or Panic/Anxiety? There was neither a yes or no response by the facility. During a review of Resident 3's AR, dated 8/30/21, the AR indicated, Major Depressive Disorder, Recurrent, Unspecified and Generalized Anxiety Disorder as two of Resident 3's admission diagnoses. During a review of Resident 32's PASRR, dated 5/13/16, the PASRR indicated, Section V- diagnosed Mental Illness 26. Does the resident have a diagnosed mental disorder such as [CONDITION(S)]/[CONDITION(S)] Disorder, Psychotic/[CONDITION(S)], Delusional, Depression, Mood Disorder, [CONDITION(S)], or Panic/Anxiety? The facility response was marked no. During a review of Resident 32's AR, dated 5/13/16, the AR indicated Major Depressive Disorder, Recurrent, Unspecified as one of Resident 32's admission diagnoses. During an interview on 3/23/22, at 9:18 AM, with Director of Admissions (DA). DA stated, she completed all PASRR's, including weekends and holidays which were done remotely from her home. DA stated, she would speak with case managers to get information. DA stated, the questions on the PASRR form were answered with yes or no. DA stated, Level II screenings were triggered by a person being in a mental health facility, taking psychotropics, has [CONDITION(S)] or is manic/depressive. DA stated, a potential resident who had Major Depressive Disorder and and was taking an anti-depressant would not trigger a Level II screening, almost everyone has depression. DA stated, not all questions on Level I screening need to be answered and she had never encountered a Level II screening trigger. DA stated, PASRR's need to be completed accurately to make sure the facility can properly care for admitted residents. During an interview on 3/23/22, at 10 AM, with Administrator, Administrator stated, the facility had no process to ensure PASRR's were accurately completed. During a review of the facility's policy and procedure (P&P) titled, Pre-Admission Screening Resident Review (PASRR), dated 7/18, the P&P indicated, Purpose.To ensure that all Facility applicants are screened for mental illness and intellectual disability (ID) or a related condition (RC) prior to admission.

Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 (a mild to severe illness that is caused by a Coronavirus, is transmitted chiefly by contact with infectious material (such as respiratory droplet) and is characterized by fever, cough, and shortness of breath and may progress to pneumonia and [MEDICAL CONDITION]) infection when: 1. Five of five sampled staff (Licensed Vocational Nurse/Personal Protective Equipment Coach (LVN/PPEC) 1, Certified Nursing Assistant (CNA) 2, Licensed Vocational Nurse (LVN) 1, CNA 1 and LVN/PPEC 2) used N95 masks (a type of respiratory device which removes particle from the air that are breathed through it) several days consecutively without rotation and training on reuse of N95; 2. Used face shields ( a mask typically made of clear plastic that protects the mucous membranes of the eyes, nose, and mouth during patient-care procedures and activities that carry the risk with generating splashes of blood, body fluids, excretions or secretions) were stacked and stored on top of each other; 3. One of one sampled staff (Housekeeper (HSK)) 1 was not wearing a face mask (a protective mask covering the nose and mouth to prevent yourself from breathing bad air or from spreading germs) when in the facility; 4. Contact tracing (is an intervention where an initial case with confirmed infection is asked to provide information about contact people who were at risk of acquiring infection from the initial case within a given time period before the positive test result), monitoring, cohorting (imposed grouping, such as health care workers, potentially exposed to designated diseases) and reporting to LHD (Local Health Department) and CDPH (California Department of Public Health) were not immediately implemented when one of 17 sampled staff, (CNA) 5, was confirmed positive for COVID-19 on 7/29/20; 5. Five of 17 sampled staff (CNA 3, CNA 4, CNA 5, CNA 6 and CNA 7) positive for COVID-19 were allowed to return to work prior to recovery. These failures resulted in 27 of 29 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27) and 17 of 51 sampled staff (LVN 2, LVN 3, CNA 1, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, and Activity Director (AD)) in the facility testing positive for COVID-19. This had also the potential for the continued spread of COVID-19 infection to 29 residents, 51 staff and visitors. A condition of Immediate Jeopardy (IJ) was identified for the facility's failure to prevent the spread of infection when the facility failed to educate, monitor, and ensure staff were using and storing personal protective equipment (PPE-refers to equipments (N95 masks and face shield)) worn to minimize exposure to a variety of hazards, COVID-19 positive staff were allowed to return to work during their infectious period and contact tracing monitoring, cohorting and reporting requirements were not immediately implemented per CDC and facility policy. These failures resulted in continued spread of infection to 27 of 29 residents and 17 of 51 staff infected with COVID-19 and the potential for continued spread of infection to residents, staff and visitors. The IJ was called on 8/7/20 at 11:07 AM, with the Administrator and Chief Nursing Officer (CNO). The surveyors confirmed by observation, interview, and record review, on 8/7/20 that the facility had inserviced their staff on the proper storage and use of PPE and a system was put in place to monitor the staff. The COVID-19 positive staff were sent home and the LHD was contacted for guidance. The facility's plan of correction was accepted. The IJ was removed on 8/7/20, at 2:43 PM with the Administrator. Findings: 1. During an interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, LVN/PPEC 1 stated, the individual N95 masks has to be worn for 48 hours and stored in sandwich containers that were labeled day 1, day 2 and day 3. LVN/PPEC 1 was unaware how many days an N95 mask has to be worn before it is replaced. During a concurrent observation and interview on 8/6/20, at 3:55 PM, with CNA 2, in the yellow zone (designated area for residents that have been exposed to COVID-19), CNA 2 was observed wearing an N95 mask. CNA 2 stated she had been using the same mask four days in a row. CNA 2 stated No one has given me anymore. This is my fourth day to work, yes, I've used this mask four times in a row. During an interview on 8/6/20, at 3:57 PM, with LVN 1, LVN 1 stated the N95 mask should be used two to three days or until soiled. LVN 1 stated, he was unaware how many times his N95 mask had been used. During a concurrent observation and interview on 8/6/20, at 4:02 PM, with CNA 1, CNA 1 was wearing an N95 mask. CNA 1 stated she had worn the N95 mask for two consecutive days. She also stated she was not trained on how to rotate the N95 mask or how many times to wear the N95 mask before disposing it. During a concurrent observation and interview on 8/6/20, at 4:47 PM, with LVN/PPEC 2, in the red zone (COVID-19 positive designated unit), LVN/PPEC 2 was observed wearing an N95 mask. LVN/PPEC 2 stated she was provided one N95 mask and three styrofoam containers to store her mask. LVN/PPEC 2 stated the containers are dated and labeled day one, day two, day three and she rotates her one N95 mask between the three containers. LVN/PPEC 2 also stated the N95 mask she was currently wearing had also been worn on 8/4/20 and 8/5/20. She stated after three days of wearing the N 95 mask consecutively, the N95 mask and containers will be thrown away and a new N95 mask and three containers should be provided. During a concurrent interview and review of the facility training record on 8/7/20, at 9:52 AM, with the Infection Preventionist (IP- are the person who specializes in preventing infection), the IP stated, the facility had implemented extended use of N95 and each employee was given three N95 masks and three containers. The containers are labeled day 1, day 2 and day 3. Day 1 mask is worn on day 1 and stored in the day 1 container, on day 2, day 2 mask is worn and then stored in day 2 container and on day 3, day 3 mask is worn and stored in day 3 container. After using each N95 three times the masks are discarded and the employees are provided a new set of N95 mask and containers. The IP was unable to provide evidence that staff were trained on the extended use of the N95 masks. IP stated there was no lesson plan for extended use of the N95 mask and competencies had not been completed by the staff. During a review of the facility's policy and procedure (P&P) titled, COVID-19 Facility Exposure Management, undated, the P&P indicated, Employees may utilize extended use techniques with masks and eye protection when caring for residents .Staff competencies and observations of daily handwashing and PPE procedures must be completed by the facility management staff. During a review of the Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators updated on 4/2019, it indicated, Training on indications for use of N95 respirators-It is important that HCP (Health Care Personnel) be trained on indications for use of N95 respirators. The OSHA Respiratory Protection standard requires employers to provide respirator training to an employee prior to use in the workplace. Limited re-use of N95 respirators-One effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to COVID-19 patients a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for [DIAGNOSES REDACTED]-CoV2 (virus that caused COVID-19). HCP should still treat the respirator as though it is still contaminated. 2. During a concurrent observation and interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, in the yellow zone, there were multiple face shields stacked on top of each other on two tables near the entrance/exit of the yellow zone. LVN/PPEC 1 confirmed the findings and stated, the face shields are shared among the staff in the yellow zone. During a concurrent observation and interview on 8/6/20, at 3:55 PM, with CNA 2, multiple face shields were stacked on a bed side table in the hallway in between yellow zone entrance/exit and resident room. Stacked face shields were open to air and accessible to staff and residents. CNA 2 stated all face shield were shared by all staff working in the yellow zone. CNA 2 stated face shields were sprayed with a disinfectant after each use and stacked after it was dry. During a concurrent observation and interview on 8/6/20, at 4:25 PM, with LVN/PPEC 2, in the red zone, there was a sign inside the entry/exit door of the unit on the right and left side of the hall that indicated, donning (clean area for employees to put on PPE) and a doffing (area for removal of PPE) sign on the right side of the hallway. There were several face shields stacked on top of one another on a table on the left side of the hall that contained staff names. LVN/PPEC 2 confirmed the findings and stated, the staff are to put the face shields in the doffing area and nurses are responsible to sanitize the face shields after use and place in the donning area. LVN/PPEC 2 stated, with two donning signs it was confusing to determine the clean side from the dirty side. During a concurrent observation and interview on 8/7/20, at 10 AM, with LVN/PPEC 2, two stacks of approximately 10 face shields were placed on a bed side table in the red zone hallway. Stacked face shields were open to air and accesible to staff and residents. LVN/PPEC 2 stated the face shields were shared between all positive and negative staff working in the red zone. LVN/PPEC 2 stated, Each staff is responsible to spray a disinfectant on their own face shield after each use and after it's dry (sic). I stack them on the clean side. During a review of the Centers for Disease Control and Prevention (CDC) Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings updated 5/5/20, it indicated, Reuse: A. Reprocessing and reusing disposable face shields for one HCW (Healthcare Worker) to use on multiple patients with COVID-19 for a limited time-period (multiple shifts). This strategy is not consistent with best practices and therefore not recommended, but if adopted: A face shield should be dedicated to one HCW. They should be immediately reprocessed when they are visibly soiled, whenever they are removed such as when leaving the isolation area, and at least daily (after every shift) prior to putting them back on (See reprocessing guidance below). After reprocessing, a face shield should be stored in a transparent plastic container and labeled with the HCW name to prevent accidental sharing between HCW. 3. During a concurrent observation and interview on 8/6/20, at 3:28 PM, with HSK 1, outside the laundry room, HSK 1 went to the dining room with N95 mask on. It was noted she was no longer wearing an N95 mask or facial mask when she went back to the laundry room to gather her personal belongings. She spoke with two other laundry staff who were less than six feet from her. HSK 1 confirmed the findings and stated a facial mask has to be worn when inside the facility. During an interview on 8/6/20, at 3:40 PM, with LVN/PPEC 1, LVN/PPEC 1 stated, The staff should have a facial mask on after removing their N95 mask . During an interview on 8/6/20, at 5:05 PM, with the CNO, the CNO stated when staff are in the facility they are expected to wear a facial mask. During a review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 7/15/20, it indicated HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. 4. During a concurrent observation and interview on 8/7/20, at 10:05 AM, with CNA 5, in the red zone, CNA 5 stated she had gone to her own clinic to get tested for COVID-19 on 7/28/20, and had received her positive test result on 7/29/20. CNA 5 stated she developed COVID-19 symptoms including a runny nose on the day she tested (7/28/20), a sore throat three days after being tested (7/31/20), and a headache two days ago (8/5/20). CNA 5 stated she notified the Assistant Administrator (AA) of her positive test result on 7/29/20 and was notified by AA on 8/6/20 to return to work on 8/7/20. During an interview on 8/7/20, at 10:05 AM, with IP, IP stated she was aware CNA 5 had tested positive for COVID-19 on 7/29/20. IP stated she did not notify LHD of CNA 5's positive test result. During an interview, on 8/7/20, at 10:41 AM, with AA, AA stated CNA 5's husband had been exposed to COVID-19 and CNA 5 had decided to get tested on her own. AA stated CNA 5 was confirmed positive for COVID-19 on 7/29/20. AA stated CNA 5 was a part time employee of the facility and was not required to notify LHD or CDPH of CNA 5's confirmed positive test result. AA stated, Why should I she's (CNA 5) not an employee. She's not full time, she's only part time. AA reviewed the facility Daily Assignment Sign-In Sheet and confirm CNA 5 had worked on 7/28/20. AA stated she did not implement contact tracing, cohorting and/or monitoring to any exposed residents and staff after CNA 5 was confirmed positive of COVID-19. During an interview on 8/7/20, at 11:07 AM, with the CNO, the CNO stated, when CNA 5 tested positive for COVID-19 on 7/29/20, response-driven testing (contact tracing and testing in response to an outbreak) should have been implemented. During an interview, on 8/7/20, at 2:31 PM, with the Local Health Department Physician (LHDP), LHDP stated she was not informed of CNA 5 being positive on 7/29/20. LHDP stated it is the responsibility of the facility to notify LHD of any new COVID-19 positive residents and staff and all exposed residents and staff. LHDP stated contact tracing should have been implemented immediately. During an interview on 8/7/20, at 11:08 AM, with the Administrator, the Administrator was unaware CNA 5 had tested positive for COVID-19. During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) Prevention and Control, undated, the P&P indicated, The Infection Preventionist is responsible for establishing and overseeing the active surveillance and monitoring efforts including: Immediately reporting new cases of suspected or confirmed COVID-19 to the local health department. During a review of the Centers for Disease Control and Prevention guideline titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 6/19/20, it indicated, Healthcare facilities should have a process for notifying the health department about suspected or confirmed cases of [DIAGNOSES REDACTED]-CoV-2 Infection, and should establish a plan, in consultant with local public health authorities, for how exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. During a review of the Centers for Disease Control and Prevention (CDC) Testing Guidelines for Nursing Homes Testing Individuals updated on 7/21/2019, it indicated, Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility .A single new case of [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection in any HCP or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC (Infection Prevention and Control) (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. During a review of the facility's policy and procedure (P&P) titled, COVID-19 Facility Exposure Management, undated, the P&P indicated, Facilities .Should communicate with physician, local health department, regulatory agency, families, staff and residents .The management staff must maintain a line listing of all staff who work in other health care settings. It must be communicated to each staff member to self-report any exposure they may have had offsite. 5. During an interview on 8/6/20, at 8:49 AM, with the AA, the AA stated, between 8/3/20 and 8/5/20, there were five nursing staff (CNA 3, CNA 4, CNA 5, CNA 6 and CNA 7) who tested positive for COVID-19, and continued to work in the red zone between 8/3/20 to 8/7/20. During an interview on 8/6/20, at 10:22 AM, with the AA, the AA stated, the facility would not be able to meet staffing needs if the COVID-19 positive staff were not working. AA stated, the facility had not used staffing registries nor had they changed the staff to 12 hour shifts to decrease the amount of employees needed to meet staffing needs. AA confirmed facility had not implemented it's own policy to address staffing shortage including contingency strategies. During a concurrent observation and interview on 8/6/20, at 2:03 PM, with CNA 3, in the red zone, CNA 3 stated she was tested for COVID-19 on 8/3/20, was notified by Director of Nursing (DON) of her positive test result on the evening of 8/4/20 and had returned to work on 8/6/20. CNA 3 stated, I was told to come to work if I was asymptomatic. During a concurrent observation and interview on 8/6/20, at 4:52 PM, with CNA 4, in the red zone, CNA 4 stated she was tested for COVID-19 on 8/3/20 and was reassigned to work from the yellow zone to the red zone after she was notified of her positive result on 8/4/20 . CNA 4 stated, I was actually working in the yellow zone, (AA) told me to get out of the yellow zone and go to red zone. During a concurrent observation and interview on 8/7/20, at 10:05 AM, with CNA 5, in the red zone, CNA 5 stated she had gone to her own clinic to get tested for COVID-19 on 7/28/20, and had received her positive test result on 7/29/20. CNA 5 stated she developed COVID-19 symptoms including a runny nose on the day she tested (7/28/20), a sore throat three days after being tested (7/31/20), and a headache two days ago (8/5/20). CNA 5 stated she was notified by AA to return to work on 8/7/20. CNA 5 stated she was never cleared by LHD to return to work on 8/7/20. CNA 5 stated, AA just told me to come back to work if I didn't have a fever. CNA 5 confirmed she never developed a fever but developed other COVID-19 symptoms including the sore throat and headache. During an interview on 8/7/20, at 10:05 AM, with IP, IP stated she was aware CNA 5 was tested positive for COVID-19 on 7/29/20. IP stated based on symptoms, CNA 5 was cleared by the AA to return back to work 8/7/20. IP confirmed CNA 5 had worked in the red zone on 8/7/20. During an interview, on 8/7/20, at 10:41 AM, with AA, AA stated CNA 5 last worked on the floor on 7/28/20. AA stated CNA 5's husband was exposed to COVID-19 and decided to get tested on her own. AA stated CNA 5 was positive of COVID-19 on 7/29/20. AA stated she determined CNA 5 can return back to work 8/7/20 when CNA 5 reported having a fever and/or taking any fever reducing agent within the last 24 hours. AA stated she did not notify LHD for guidance on CNA 5 returning back to work 8/7/20. AA stated, I told her she can come back to work. During an interview on 8/7/20, at 2:31 PM, with the LHDP, the LHDP stated, CNA 5 should not return to work until after at least 10 days have passed from the onset of COVID-19 symptoms. LHDP stated, if the facility was in a staffing crisis and had tried all other avenues and solutions to meet staffing needs, CNA 5 could return to work prior to the 10 days. LHDP stated, guidance was not given to the facility for CNA 5 to return to work prior to the 10 day period. During a review of the facility's approved COVID 19 Mitigation Plan (MP), undated, the MP indicated, Facility will ensure IP reviews guidance and recommendations provided by CDC, CDPH, and/or LHD to maintain consistent situational awareness with highly evolving nature of COVID. During a review of the facility's policy and procedure (P&P) titled, Planning for Additional Staffing Needs undated, the P&P indicated, When staffing shortage are anticipated, the facility, should use contingency capacity strategies to plan and prepare for mitigating this problem. The facility will adjust staff schedules, hire additional HCP, and rotate HCP to positions that support patient care activities as appropriate.