Every finding on record at Devonshire Care Center

Based on interview, and record review, the facility failed to implement their policy and procedure on abuse for one of three residents, Resident 1, when:1. Resident 1's allegation of physical abuse by the Certified Nursing Assistant (CNA) towards Resident 1 on July 4, 2026, was not investigated timely; and2. The alleged CNA was not suspended pending investigation of an allegation of abuse and continued to have provide care and services to the residents. These failures resulted in the delay of providing safety and protection for Resident 1 and other vulnerable residents and placed them at risk for further abuse.Findings:1. On July 16, 2026, at 8:24 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse.On July 16, 2026, at 9:23 a.m., an interview was conducted with Resident 1. Resident 1 stated an unidentified staff pushed both of her front shoulders towards the bed when she was receiving care and then the staff suddenly walked away. Resident 1 stated she told the incident to Registered Nurse (RN) 1 and she reported the incident through text message to her son. Resident 1 further stated it was not ordinary shoulders tapped, I felt it. Resident 1 stated she verbally told her family member (FM) the following day (Sunday) then the morning shift nurse talked to her about the allegation. Resident 1 stated her FM called the police and will talk to the person in charge in the facility. On July 16, 2026, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included surgical aftercare following surgery and muscle weakness.A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated July 2, 2026, indicated Resident 2 had a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact).A review of Resident 1's eInteract Change of Condition Evaluation, dated July 8, 2026, indicated, .ALLEGATION REGARDING STAFF.A review of Resident 1's Interdisciplinary Care Conference, dated July 8, 2026, indicated, .Resident made an allegation that a staff member went to her room and pushed her shoulder.On July 16, 2026, at 1:35 p.m., during an interview with RN 1, RN 1 stated on July 4, 2026, Resident 1 told her about a lady dressed in red clothes in night shift pushed Resident 1's shoulders towards the bed while receiving care. RN 1 stated she did not see anyone wearing red clothes that night, so she waited for the morning shift to relay the allegation of Resident 1. RN 1 further stated she did not report the allegation of abuse right away and should have been reported.On July 16, 2026, at 2 p.m., during an interview with RN 2, RN 2 stated the police came to the facility on July 5, 2026, to inform her a staff pushed Resident 1 to her shoulders. RN 2 stated she interviewed Resident 1 about the alleged physical abuse but did not report the incident to agencies. RN 2 further stated the allegation of physical abuse should been reported and initiated investigations on Resident 1. RN 2 stated the alleged CNA remained working on the following two (2) days after the allegation was reported. RN 2 stated the alleged abuser (CNA) should have been suspended if there is an allegation of abuse involving the staff. On July 16, 2026, at 2:10 p.m., a concurrent interview and record review was conducted with the Licensed Vocational Nurse (LVN). The LVN stated the police came to the facility on July 5, 2026, in the morning and was talking to her supervisor (RN 1) regarding allegation of abuse. The LVN stated there was no documentation for Resident 1 of the reported allegation of physical abuse on July 4, 2026. The LVN further stated the facility should have documented and reported the allegation of physical abuse to outside agencies (police department) on July 4, 2026, to keep Resident 1 safe and to prevent further abuse.On July 16, 2026, at 2:40 p.m., during concurrent interview and record review with alleged CNA. The CNA stated she remained working on the following days after the incident occurred. The CNA further stated, nobody told her that she was suspended and she continued to work on the following dates:-July 5, 2026, from 2:25 p.m., to 10:28 p.m. and;-July 6, 2026, from 2:24 p.m., to 10:31 p.m.On July 16, 2026, at 2:55 p.m., during an interview with the Director of Nursing (DON), the DON stated any alleged abuse in the facility should have been investigated and reported as soon as the incident occurred and identified. The DON stated the Certified Nursing Assistant (CNA) involved remained working after the incident occurred and should have been suspended. The DON further stated if any allegation of abuse was not reported and investigated, and the staff involved was not suspended, there was a potential for recurrence, or continuous abuse would happen to Resident 1.On July 16, 2026, at 3:02 p.m., the Administrator (ADM) was interviewed. The ADM stated any allegation of abuse in the facility should have been investigated and reported in a timely manner as soon it was identified. The ADM further stated the facility should have been reported the allegation of physical abuse immediately and prevent delay to avoid potential reoccurrence of abuse. The ADM stated the alleged abuser staff should have been suspenfed pending investigation. A review of the facility's policy and procedure titled, Abuse Prevention Program, dated December 2016, indicated, .Our Resident have the right to be free from abuse.As part of the resident abuse prevention, the administration will.protect our residents from abuse by anyone including.facility staff.Investigate and report any allegations of abuse within timeframes as required by federal requirements.Protect residents during abuse investigations.A review of the Facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .If an incident or suspected incident of resident abuse.The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.A review of the facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .All reports of resident abuse.shall be promptly reported to local, state and federal agencies.and thoroughly investigated by facility management.If an incident or suspected incident of resident abuse.The Administrator will ensure that any further potential abuse.is prevented.

Based on interview and record review, the facility failed to report an allegation of physical abuse to California Department of Public Health (CDPH) immediately or within two (2) hours after the allegation was made, for one of three residents (Resident 1).This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being.Findings:On July 16, 2026, at 8:24 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse.On July 16, 2026, at 9:23 a.m., an interview was conducted with Resident 1. Resident 1 stated an unidentified staff pushed both of her front shoulders towards the bed when she was receiving care and then the staff suddenly walked away. Resident 1 stated she told the incident to Registered Nurse (RN) 1 and she reported the incident through text message to her son. Resident 1 further stated it was not ordinary shoulders tapped, I felt it. Resident 1 stated she verbally told her family member (FM) the following day (Sunday) then the morning shift nurse talked to her about the allegation. Resident 1 stated her FM called the police and would talk to the person in charge in the facility. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included surgical aftercare following surgery and muscle weakness.A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated July 2, 2026, indicated Resident 2 had a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact).A review of Resident 1's eInteract Change of Condition Evaluation, dated July 8, 2026, indicated, .ALLEGATION REGARDING STAFF.A review of Resident 1's Interdisciplinary Care Conference, dated July 8, 2026, indicated, .Resident made an allegation that a staff member went to her room and pushed her shoulder.On July 16, 2026, at 1:35 p.m., during an interview with RN 1, RN 1 stated Resident 1 reported to her on July 4, 2026, at around 11 p.m., that a lady wearing red clothes pushed Resident1's shoulders towards the bed. RN 1 stated she did not report the alleged abuse. RN 1 further stated that she should have reported the incident immediately or within two (2) hours to CDPH.On July 16, 2026, at 2 p.m., during an interview with RN 2, RN 2 stated she was notified of the abuse allegation incident on July 5, 2026, around 10 a.m., when the police and Resident 1's family member came. RN 2 stated any allegation of abuse should be reported immediately or within two hours (2) from the time the allegation was reported. RN 2 further stated she did not report the allegation of abuse incident to CDPH or any outside agencies and she should have been reported immediately within two hours.On July 16, 2026, at 2:55 p.m., during an interview with the Director of Nursing (DON), the DON stated she was made aware of the incident on July 8, 2026, around 5 p.m. (90 hours from the time it was initially reported to RN 1 on July 4, 2026, at 11 p.m.). The DON stated any alleged or suspicion of abuse should be reported to CDPH within two hours. The DON stated the incident should have been reported immediately or within 2 hours for resident safety.A review of the facility's policy and procedure titled, Abuse Prohibition, revision dated October 25, 2024, indicated, .Upon receiving information concerning a report of suspected or alleged abuse.designee will perform the following.Report allegations involving abuse.not later than two (2) hours after allegation is made.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were being implemented, when:1.The sit to stand lift (a mechanical aid designed to help individuals with limited mobility move from a seated to a standing position, reducing physical strain on caregivers) was dirty and dusty. In addition, the sit to stand sling/pad was dirty; and2.The shower rooms were observed to have dirty linen and trash bins filled with linens with urine and stool smell.These failures had the potential for infections to be transferred among residents and staff. In addition, the strong urine and stool smell has the potential for residents and staff to experience uncomfortable and unsanitary conditions with potential for spread of infection.Findings:On March 19, 2026, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues.On March 19, 2026, at 10:50 a.m., a sit to stand lift was observed blocking shower room [ROOM NUMBER]. The sit to stand lift was observed to have a shower pad/sling used to assist the residents during transfer to have a whitish substance on it. The foot board of the sit to stand lift had crumbs, debris, dirt, and dust on it. The foot board of the sit to stand life was wiped with a glove and had hair, dust, and dirt. Concurrently, shower room [ROOM NUMBER] was observed to have linen bin full of used linen, with strong pungent urine smell coming from the bin.On March 19, 2026, at 11 a.m., a concurrent observation and interview was conducted with the Director of Nursing (DON). The DON stated the sit to stand lift and sling were dirty. The DON stated the dirty sling should be sent to laundry to be washed, and the equipment should be wiped down after use.On March 19, 2026, at 11:15 am., during a concurrent observation and interview with Certified Nursing Assistants (CNA) 1 and 2, CNA 1 stated they would take out the trash and dirty linen and place the bins in the shower areas after their morning rounds. CNA 2 stated the linen bins should be emptied after the morning rounds due to the strong smell of stool and urine. On March 19, 2026, 11:40 a.m., shower 1 was observed with the Infection Preventionist (IP). Shower 1 was observed to have linen and trash carts with urine and trash smell. In a concurrent interview, the IP stated the linen and trash should be taken out after morning rounds and the smell of trash and dirty linens in the shower area should not be there. The IP stated shared residents' equipment should be disinfected after each use, and all slings should be washed between use.A review of the facility's undated policy and procedure titled, Infection Prevention and Control Program, dated September 18, 2024, indicated, .an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure the physical environment is safe and sanitary, for 92 residents who could use the shower rooms, when:1.There were missing tiles and peeled off base boards on the shower wall of shower room [ROOM NUMBER];2.The shower walls in shower room [ROOM NUMBER] were dirty with brown/blackish substance on the grout and tiles; and3.There were used razors in the trash bin in shower room [ROOM NUMBER] and overflowing sharps container with used razors in shower room [ROOM NUMBER]. These failures had the potential for accidents and infection to residents and staff who uses the shower rooms.Findings:On March 19, 2026, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues.On March 19, 2026, at 10:50 a.m., shower room [ROOM NUMBER] was observed to have a sign out of service on the door. Upon entrance of the shower room, there were missing tiles from the floor and peeled off base boards on the shower wall, and a trash bin with used razors.Concurrently, shower 6 was observed to have a sharps container which was overflowing with razors and would not be closed, and shower tile noted with brown to black build up on the grout and tiles.On March 19, 2026, at 11 a.m., a concurrent observation and interview was conducted with the Director of Nursing (DON). The DON stated the razors should be disposed in the sharps container and not in the trash bin.On March 19, 2026, at 11:15 am., during a concurrent observation and interview with Certified Nursing Assistants (CNA) 1 and 2, CNA 1 stated the sharps container should not get too full before changing it out as it would not close for safety.On March 19, 2026, 11:40 a.m., shower room [ROOM NUMBER] was observed with the Infection Preventionist (IP). In a concurrent interview, the IP stated the sharps container should not be overfilled with used razors, and it was unsafe to have used razors sticking out of the container.On March 19, 2026, at 12 p.m., shower room [ROOM NUMBER] was observed with the Director of Maintenance (DM). The DM stated the nursing staff reported there were issues with shower room [ROOM NUMBER]. The DM stated there were missing floor tiles and the base of the shower wall broke away to see the repairs needed. The DM stated he removed some additional tiles and the facility was not able to use it at this time. The DM stated he had reported the issues to management and had ordered new tiles to repair the shower but had not place a work order in their system to monitor the repair project and no documentation provided of work done for shower room [ROOM NUMBER]. A review of the facility's undated policy and procedure titled, Maintenance Service, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment.The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Maintaining the building in good repair and free from hazards.Establishing priorities in providing repair services.the Maintenance Director is responsible for maintaining the following records.Work order requests.A review of the facility's undated policy and procedure titled, Bath, Shower/Tub, indicated, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Be sure the tub or shower is clean

Based on observation, interview, and record review, the facility failed to ensure pain medications were administered according to the physician's orders, for one of three residents reviewed (Resident A). In addition, the facility failed to ensure an accurate pain assessment was conducted on Resident A when a PRN (as needed) pain medication was administered to the resident.These failures could have resulted in unmanaged pain for Resident A and impacted their activities of daily living (ADL).Findings:On February 23, 2026, at 12 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care.On February 23, 2026, at 2:45 p.m., Resident A was interviewed. Resident A stated he was in constant pain and was supposed to receive pain medication around the clock and his pain was not being controlled.On February 23, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of the right humerus (broken upper arm bone).A review of Resident A's History and Physical, dated February 3, 2026, indicated the resident had capacity to understand and make decisions.A review of Resident A's Order Summary Report, including the following physician's order for pain:- Acetaminophen Tablet 325 MG (milligram - unit of measurement) Give 2 (two) tablet by mouth every 4 (four) hours as needed for mild pain (1-4 [pain scale])., date ordered February 1, 2026; and- oxycodone HCl (narcotic pain medication) Oral Tablet 10 MG.Give 1 (one) tablet by mouth every 4 (four) hours as needed for moderate to severe pain (5 -10), date ordered February 1, 2026.A review of Resident A's care plan, dated February 3, 2026, indicated, .Resident exhibits or is at risk for alterations in comfort related to Neuropathic pain (nerve pain), severe back pain, sciatica pain (a sharp, burning, or shooting sensation that radiates along the path of the sciatic nerve-from the lower back, through the buttocks, and down one leg).right upper arm fracture.Interventions.Evaluate pain characteristics: quality, severity, location.Medicate resident, as ordered, for pain and monitor for effectiveness and side effects.A review of Resident A's Medication Administration Record (MAR), for the month of February 2026, indicated Oxycodone was administered to the resident not according to the physician's order for pain rating of 5 - 10 on the following dates and times:-February 4, 2026, at 6:26 p.m.; pain rating of NA (not applicable);-February 20,2026, at 9:31 p.m.; pain rating of 4; and-February 22, 2026, at 55:36 p.m.; pain rating of 4.On February 23, 2026, at 5:10 p.m., during an interview with the Director of Nursing (DON), the DON explained that residents' pain should be appropriately managed and controlled through both medication and non-pharmacological interventions. According to the DON, the licensed nurses are expected to administer pain medication based on the resident's reported pain level and in accordance with physician orders. Resident A's medical record was reviewed together with the DON, who indicated that acetaminophen should have been administered to Resident A when his pain rating level was 4 out of 10. The DON also noted that recording NA as the pain level in the Medication Administration Record (MAR) when oxycodone was given to Resident A on February 4, 2026, did not accurately reflect the resident's pain assessment. A review of the facility's policy and procedure titled, Pain Management, dated August 25, 2021, indicated, .Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences is provided to Residents who require such services.Document pain presence on the Medication Administration Record (MAR).

Based on observation, interview, and record review, the facility failed to ensure one (Resident A) of three residents sampled, was receiving food and drink prepared in a form to meet the resident's needs.This failure had the potential to result in coughing and choking for Resident A. Findings:On December 5, 2024, at 4:15 p.m., an unannounced visit was conducted at the facility to investigate quality care issues. On December 8, 2025, at 12:00 p.m., a review of Resident A's, admission Record, was conducted, which indicated Resident A was admitted to the facility on [DATE], with diagnoses which included oropharyngeal dysphagia (difficulty swallowing) and Alzheimer's (progressive brain disorder) disease.A review of Resident A's Minimum Data Set (MDS-a standardized health assessment tool) indicated the following:- September 15, 2025, .Section GG- Functional Abilities.eating.supervision/touch assistance.; and - September 17, 2025, .Section K-Swallowing.Yes-cough/choke during meal.when swallowing medications.yes-pain when swallowing.mechanical altered diet.regular with change in texture of food/liquids.A review of Resident A's Order Recap Report, effective from October 1 to December 31, 2025, indicated, Regular diet Regular texture, Mildly Thick consistency, fortified food . Further review indicated the diet was ordered on November 6, 2025. A review of Resident A's Speech Therapy Treatment Encounter Notes indicated the following-December 03, 2025, .due to limitations in insight, safety awareness, new learning, oral motor strength and oral motor control.supervised the pt (patient) during PO (oral) intake. Pt (patient) presented with decreased safety awareness and coughs post swallow x (times) 5 (five) for the entire duration of the meal.; and -December 5, 2025, .precautions.confused.patient was also observed taking 4 (four) sips of nectar thick liquid via straw with congested coughing heard 7 (seven) times .mildly thick drinks MT2 (mildly thick level two) .Resident A's care plans reviewed and indicated:-Resident requires Speech Therapy (rehabilitation to help with swallowing) related to Dysphagia, initiated on September 14, 2025; and -Resident is at nutritional risk due to dementia, Bronchitis, Alzheimer's, hypertension, dysphagia, therapeutic diet and altered texture and consistency, initiated on November 6, 2025. The care plan further indicated interventions which included: Provide 1:1 assistance when needed, encourage 100% consumption of all fluids provided, and provide diet, as ordered.On December 8, 2025, at 12:30 p.m., an observation and interview were conducted with Resident A. Resident A was observed receiving his meal tray, drinking water that had been thickened. The nurse brought him (Resident A) another glass of water with thickener. However, when the resident took the drink, the thickener was observed to have settled at the bottom of the glass, leaving the water on top thinner. Resident A began coughing and choking. The resident was then assisted to sit up at a 90-degree angle and leaned forward. The nurse was called for assistance.On December 8, 2025, at 1:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing staff is permitted to add thickener to the liquids for the residents. However, the process requires a few minutes for the water to achieve the desired consistency. If only a minute had elapsed, it would not have been sufficient time for the water to thicken before Resident A attempted to drink it.On December 8, 2025, at 1:10 p.m., during an interview, the Licensed Nurse (LN) stated that she added thickener to Resident A's water, but she did not allow sufficient time for it to thicken properly before giving it to the resident, which could have prevented the resident from coughing and choking. A review of the facility's policy titled Therapeutic Diets, dated October 2017, indicated .therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals.a 'therapeutic diet' is considered a diet ordered by a physician.as part of treatment for a disease or clinical condition to modify.or to alter the texture of a diet.the resident's response to his/her therapeutic diet in the resident's medical record.A review of the facility's Diet and Nutritional Care Manual- Guidelines for Serving Thickened Liquids, dated 2021, indicated .identify and provide the appropriate fluid consistency.all liquids should be thickened to the proper consistency.the facility will determine whether nursing or food and nutrition services personnel will thicken the liquids.IDDSI (International Dysphagia Diet Standardizations Initiative) Level 2: Mildly Thick.commercial thickeners may be used to achieve mildly-thick consistency.a liquid consistency used when the tongue control is slightly reduced, provides liquids that flow at a slightly slower rate. Used when thin and slightly thin drinks flow too quickly for resident to swallow them safely.

Based on interview and record review, the facility failed to ensure Resident 1 was adequately assessed for pain during the evening and night shifts on July 12, 2025, and provide appropriate pain medication to manage pain. This failure resulted to Resident 1 calling emergency services to be transferred out of the facility on July 13, 2025, due to worsening pain.Findings:On August 12, 2025, at 1:43 p.m., an unannounced visit was made at the facility to conduct an investigation of a complaint regarding quality of care.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], around 4:31 p.m., with diagnoses which included left femur fracture (a break in the long bone of the left leg), presence of left artificial hip joint, low back pain, multiple sclerosis (body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve and spinal cord), and fibromyalgia (persisting condition characterized by widespread muscle pain and tenderness).A review of Resident 1's Minimum Data Set (MDS- a clinical assessment tool), dated July 13, 2025, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).A review of Resident 1's Order Summary Report, included physician's orders for:- Pain monitor every shift., order date July 12, 2025; and- Hydrocodone (narcotic pain medication)-Acetaminophen (used to relieve mild pain or fever) Oral (by mouth) tablet 5-325 MG (milligram- unit of measurement).Give 1 tablet by mouth every 6hours as needed for pain., order date July 12, 2025.A review of Resident 1's Medication Administration Record (MAR) for July 1 to 31, 2025, indicated the following:- Pain Monitor every shift.Start Date 7/12/2025 1500 (3 pm)., there was no pain level documented for the Evening (PM) shift and Night (NOC) shits and there were no licensed nurses' (LN) initials on the document to signify the task was performed;- The MAR did not include the order for Hydrodocone-Acetaminophen, therefore there was no indication that the medication was given to Resident 1 for pain.A review of Resident 1's care plans indicated there was no care plan initiated for pain or pain management.A review of the SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated July 13, 2025, indicated the following:- .Situation.The change in condition.is/are.Pain (uncontrolled), Shortness of Breath (SOB).- .Background.Pain Evaluation.Does the resident have pain.Yes.Worsening of chronic pain.hip pain from hip surgery.Intensity of pain rate on scale of 1-10, with 10 being the worst): 8.- .Appearance.Resident sent self out per 911 (emergency medical services). complaints of pain and SOB. No signs of SOB noted.A review of Resident 1's progress notes indicated no documentation pertaining to pain assessment for the PM or NOC shifts for July 12, 2025, to July 13, 2025, prior to Resident 1 calling 911 to be transferred out of the facility. The progress notes indicated Resident 1 left the facility at 8:09 a.m. on July 13, 2025.On August 28, 2025, at 10:57 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated she was working on July 13, 2025, when Resident 1 was sent out via 911. RN 1 recalled the endorsement from the previous shift's RN that Resident 1 was frequently asking for pain medication throughout the previous night, and no medications were delivered for Resident 1 that night. On August 28, 2025, at 2:19 p.m., RN 2 was interviewed. RN 2 stated she did not recall Resident 1, but stated if a resident asked for narcotic pain medication, and verified that the resident has an order for the narcotic pain medication, but the resident's stock was not available, then authorization has to be obtained from the pharmacy for the medication to be taken out of the emergency kit (e-kit). RN 2 stated two nurses, one RN and one LVN (Licensed vocational Nurse), have to sign for the medication's removal from the e-kit, then it would be administered to the resident. RN 2 also stated she did not recall if Resident 1 was given any regular or narcotic pain medication.On August 28, 2025, at 3:43 p.m., the Director of Nursing (DON) was interviewed. The DON confirmed Resident 1 had physician's orders for Hydrocodone-Acetaminophen and to monitor pain every shift. The DON confirmed there was no documentation on Resident 1's MAR and other Resident 1's record regarding pain monitoring for the PM and NOC shifts. The DON stated she expected LNs to document what they did, saw, or observed regarding pain monitoring in the MAR. The DON further stated pain monitoring for Resident 1 should have been documented in the MAR.A review of the facility's policy and procedure titled Pain Management, dated August 25, 2021, indicated, .To maintain the highest possible level of comfort for Residents by providing a system to identify, assess, treat, and evaluate pain.To design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with Resident directed goals.Patients will be evaluated.for the presence of pain upon admission/re-admission.with change in condition or change in pain status.At a minimum of daily, Residents will be evaluated for the presence of pain by making an inquiry of the Resident or by observing for signs of pain.Electronic Order Management (EOM): Document pain presence on the Medication Administration Record (MAR).If a Resident has a change in pain status, complete a pain evaluation (electronic).Residents receiving interventions for pain will be monitored for effectiveness and side effects.in providing pain relief. Document.non-pharmacological interventions and effectiveness.Effectiveness of PRN medications.Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician.notification.The care plan will be evaluated for effectiveness until satisfactory pain management is achieved.

Based on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the ceiling of room [ROOM NUMBER] was observed damaged, and the television cable outlet was exposed and did not have a plate cover. This failure to maintain a functional environment had the potential to compromise resident safety.On July 9, 2025, at 1:28 p.m., an unannounced visit was conducted at the facility for several complaints including a complaint regarding a resident room.On July 9, 2025, at 4:20 p.m. room [ROOM NUMBER] was observed. room [ROOM NUMBER] was observed to have two beds occupied by two residents in bed A and bed B, respectively. The ceiling above bed B was observed to have an irregular, circular, warped protrusion, with paint peeling, and the center cracked exposing the board underneath. Towards the feet of the beds, a few inches above the counter, in the space between two closets, was one television cable outlet without a plate cover. The cable wire was exposed, and the inner wall was visible trough the opening.On July 9, 2025, at 4:30 p.m., the Maintenance Director (MD) was interviewed, the MD stated the ceiling damage looked like it was from a past water leak, maybe from the heavy rains early in the year. The MD further stated this should have been identified and fixed. On July 9, 2025,a t 4:36 p.m., in a concurrent observation in room [ROOM NUMBER] with the MD and Director of Nursing (DON), the MD confirmed the television cable outlet should have a cover.On July 9, 2025, at 4:43 p.m. The Administrator (ADM) was interviewed. The ADM stated he expected the MD and his assistants to conduct rounds in every room and check every crevice once a month. The ADM further stated the department heads should also be looking into environmental issues when they conducted their routine daily rounds, and expected all staff to report any observed issues to the MD or his assistant verbally or through the facility's electronic reporting system. A review of the facility's policy and procedure titled, Maintenance Service, revised December 2009, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Functions of the maintenance personnel include, but are not limited to.Maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure an IV (intravenous - administered into a vein) antibiotic (medication to treat infection) for septic arthritis (a serious joint infection, often caused by bacteria, that can lead to significant joint damage and even sepsis if left untreated) was administered in accordance with the physician's order and the orthopedic surgeon's (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) recommendation, for one of three residents reviewed (Resident 1), when the orthopedic physician ordered for Resident 1 to start on Rocephin (medication to treat infection) on May 23, 2025, for septic arthritis. The IV Rocephin was not administered to Resident 1 from May 23, 2025, to June 27, 2025 (35 days). In addition, the facility failed to arrange a follow up appointment with the OS in three weeks after the appointment on May 23, 2025.On June 27, 2025, at 6:07 p.m., the Administrator (ADM) was verbally notified of the Immediate Jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to administer the IV antibiotic to Resident 1 for 35 days.This failure resulted in a delay in the care and treatment of Resident 1's septic arthritis which could lead to severe and permanent joint damage, chronic pain, and even life-threatening conditions like sepsis or death.On June 30, 2025, at 12:05 p.m., the ADM presented an acceptable removal plan which included the following:-Resident 1 was assessed and examined by the primary physician on June 27, 2025, with order to discontinue IV Rocephin;-Resident 1 was scheduled for a follow up appointment with the orthopedic physician on June 30, 2025, at 9:30 a.m.;-A triple check audit (compare the physician's orders, Medication Administration Record [MAR], and the medications at hand) was conducted on June 27, 2025;-All residents medical records were reviewed on June 27, 2025, to ensure IV orders were administered as ordered;-Resident's care plans were audited by the Registered Nurse Supervisor (RNS) and ADM to ensure active IV orders were included in the care plan and were being followed;-The Medical Director (MD) was notified by the ADM of the IJ on June 27, 2025;-An in-service to the licensed nurses (LN) was conducted by the ADM on June 27, 2025, regarding administration of IV orders;-The Pharmacy Nurse Consultant will conduct skills competencies to the RN and LN on June 28, 2025, regarding following physician orders with emphasis on IV medication administration;-The Regional Nurse Consultant (RNC) will provide in-service training to LN on June 28, 2025, to review policy and procedure on proper and timely follow up, and clarify the physician's orders;-The [NAME] President for Operations and the RNC provided in-service training on June 27, 2025, to the ADM and IDT (Interdisciplinary Team - a group of healthcare professionals) on June 27, 2025, regarding the facility's process on conducting daily stand up to include review of new physician's orders, 24-hour summary, chart review of new admissions, and order listing report; and-A Quality Assurance and Performance Improvement (QAPI) has been initiated to discuss the monitoring and auditing procedures regarding ensuring IV orders were carried out as ordered.On July 1, 2025, at 1:35 p.m., the IJ was removed in the presence of the ADM and the current Director of Nursing (CDON) during the onsite survey, upon verification of the implementation of the IJ removal plan. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings:On June 19, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care. On June 19, 2025, at 1:14 p.m., Resident 1 was observed sitting on a wheelchair in the smoking area, and was able to maneuver self throughout the facility. In a concurrent interview with Resident 1, she stated she was supposed to receive IV antibiotics and the orthopedic consultation notes from a follow up appointment on May 23, 2025 was concurrently reviewed with Resident 1 which indicated the following:- Rocephin 1 (one) gram daily for 6 (six) weeks through IV midline (a type of peripheral IV catheter [PIVC] that is longer than a standard IV, inserted into a vein in the upper arm, and the tip of the catheter resides in a larger vein near the shoulder) with (name of home health agency); and-RTC (Return to clinic) in three (3) weeks.Resident 1 further stated she had not received the IV antibiotic order of Rocephin since the orthopedic appointment on May 23, 2025. Resident 1 stated she was sent to the general acute hospital (GACH) on June 11, 2025, for the IV line placement but the hospital was not able to start the IV line and did not know why it was not done. On June 19, 2025, at 1:50 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated when she received the orthopedic consult notes on May 23, 2025, after Resident 1 went to the follow up appointment on May 23, 2025, she placed the order for IV antibiotics in the system. RN 1 stated Resident 1 should have been sent to the hospital to have the IV antibiotic be administered since it was to be given through IV midline. RN 1 stated the following shift should have followed up as the order also indicated with home health agency to administer. RN 1 stated she thought Resident 1 would be getting too much antibiotic since the resident was on oral antibiotic as well. On June 19, 2025, at 2:49 p.m., during an interview with the Medical Assistant (MA) of the OS, the MA stated the IV antibiotic Rocephin should have started on May 23, 2025. The MA stated the previous Director of Nursing (PDON) had called the orthopedic clinic on June 11, 2025, and was told the Rocephin order for Resident 1 should have started on May 23, 2025. The MA stated the PDON told her she would send Resident 1 to the hospital on June 11, 2025.On June 20, 2025, at 11:20 a.m., during an interview with Resident 1, she stated she went to the GACH but nothing was done regarding her IV antibiotic. Resident 1 stated the OS told her there was something like a black spot in the x-ray (radiographic test) of her left knee. Resident 1's left knee was observed to have redness at the sides of the incision site. Resident 1 stated she gets pain medication routinely. Resident 1 stated she received physical therapy daily. Resident 1 was observed with the therapist walking slowly in the hallway with a walker. Resident 1 was observed to be unable to ambulate independently and continued to require wheelchair if not with the therapist. On June 20, 2025, at 3:50 p.m., during an interview with the ADM, the ADM stated he also has a current RN license. Resident 1's orthopedic consultation note, dated May 23, 2025, was concurrently reviewed with the ADM. The ADM stated the order should have been clarified with the orthopedic clinic as it was not clear when the IV antibiotic should be administered to Resident 1. A review of Resident 1's Orthopedic Operative Report, dated May 8, 2025, indicated, .POSTOPERATIVE (the period of time following a surgical operation) DIAGNOSES: Left knee large effusion (excess fluid accumulation within or around the knee joint), questionable septic arthritis (a painful joint infection, usually caused by bacteria, that can damage cartilage and bone) with lateral meniscus (cartilage - a strong connective tissue found in joints, ear, nose) and medial meniscus tear (a common knee injury involving damage to the cartilage that acts as a shock absorber and stabilizer in the knee joint), popliteal cyst (a fluid-filled swelling that develops behind the knee).large 30 ml (milliliter - unit of measurement) of turbid (cloudy, opaque, or thick with suspended matter) viscous (thick, sticky consistency) fluid is evacuated and is sent for Gram stain (a laboratory technique used to differentiate bacteria into two main groups: Gram-positive and Gram-negative).explained to her regarding the operation findings and the need for several weeks of IV antibiotics as consulted to infectious disease.IV midline is recommended. IV Rocephin 1 g (gram) daily for 6 (six) weeks and IV Flagyl (antibiotic to treat infection) 500 mg (milligram - unit of measurement) every 6 (six) hours recommended.A review of Resident 1's admission Record, indicated Resident 1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses which included left elbow fracture (broken bone), left knee ORIF (open reduction with internal fixation - a surgical procedure used to treat fractures, particularly those that are severely displaced or unstable), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue which could lead to inflammation and damage in various parts of the body, including the skin, joints, kidneys, heart, lungs, and blood cells).A review of Resident 1's physician's orders, date ordered May 16, 2025, indicated, .RESIDENT HAS F/U (follow up) ORTHO APPOINTMENT ON 5/23 (May 23, 2025) AT 8:30 AM (a.m.) WITH (name of orthopedic surgeon) AT (address of orthopedic clinic). A review of Resident 1's orthopedic consult notes, dated May 23, 2025, indicated, .Pt (patient) doesn't (does not) have IV access.Left knee septic arthritis.Plan.IV midline.IV Rocephin 1 gm q (every) daily x 6 weeks.A review of the facility document titled Progress Record, documented by the OS, sent with Resident 1 when she came back from appointment, dated May 23, 2025, indicated, .ordering IV midline and IV Rocephin 1 (one) gram QD (daily) x 6 wks (weeks) w/ (with) (name of home health agency).RTC (return to clinic) in 3 (three) weeks (around June 13, 2025).A review of Resident 1's physician order, date ordered May 23, 2025, .ORDER FOR IV MIDLINE AND IV ROCEPHIN 1 (one) GRAM (unit of measurement) DAILY X (times) 6 (six) WEEKS WITH (name of home health agency)., A review of Resident 1's Progress Notes, dated May 23, 2025, at 10:51 a.m., documented by RN 1, indicated the order from the orthopedic appointment for IV Rocephin, IV midline, and return to clinic in 3 weeks.Further review of Resident 1's record indicated there was no documented evidence of the orthopedic orders for IV midline and IV Rocephin was clarified with the orthopedic surgeon when to start the IV antibiotic and indication for the IV antibiotic. There was no documented evidence the physician's order for IV midline and IV Rocephin were carried out as ordered and administered to Resident 1 since May 23, 2025. A review of Resident 1's physician order, date ordered June 11, 2025, indicated, .Send to ER (Emergency Room) for IV Midline insertion.A review of Resident 1's GACH records, dated June 11, 2025, at 1:28 p.m., indicated, .Chief Complaint: midline placement.pt (patient) sent to ER (Emergency Room) from (name of skilled nursing facility) for midline placement.A review of Resident 1's Progress Notes, dated June 13, 2025, at 8:35 p.m., documented by RN 2 indicated, .Patient arrived at 2035 (8:35 p.m.) from (name of GACH).MD made aware. The progress notes did not include presence of IV access on Resident 1 or IV orders.Further review of Resident 1's records from June 13, 2025, to June 27, 2025, indicated there was no documented evidence if the physician or orthopedic surgeon was consulted regarding the IV midline not done in GACH and if the IV Rocephin was still needed to be given to Resident 1. On June 26, 2025, at 4: 20 p.m., a follow up interview was conducted with RN 1. RN 1 stated she was the RN on duty when Resident 1 came back from orthopedic appointment on May 23, 2025, and the orthopedic surgeon ordered IV midline and IV Rocephin daily for six weeks. RN 1 stated IV midline were not being done at the facility and the resident would need to be scheduled at the hospital for IV midline placement. RN 1 stated she was not able to clarify with the orthopedic surgeon when the IV Rocephin should be started as she got busy and did not endorse it to the next shift RN. RN 1 stated she did not start a peripheral line so the IV Rocephin could be started on May 23, 2025. RN 1 stated she was not aware Rocephin could also be given through intramuscular (IM - through the muscles) injection.On June 26, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated the RN should have clarified with the OS the order for IV midline and IV Rocephin when the IV antibiotic should be started, and if the IV antibiotic could be administered in a different route. The ADM stated he found out about the OS orders on June 13, 2025, when he did chart review with the Case Manager (CM), Social Services Director (SSD), and the Infection Preventionist (IP) and then discussed it with the PDON. The ADM stated he instructed the PDON to clarify the OS orders. The ADM stated the CM told him that the IV Rocephin should have started on May 23, 2025. The ADM stated Rocephin could be given through IM or IV peripheral line while waiting for an IV midline to be placed. On June 27, 2025, at 9:28 a.m., a concurrent observation and interview was conducted with Resident 1 inside the resident's room. Resident 1 was observed sitting at the edge of the bed wearing short sleeve shirt, was observed without IV access on her arms. In a concurrent interview with Resident 1, she stated she had surgery on her left knee for septic arthritis which she was treated with IV antibiotics while at the GACH and thought it would be continued in the facility. Resident 1 stated she had a follow up appointment with the OS on May 23, 2025, and was ordered for IV antibiotic but until this date, have not received any IV antibiotics. Resident 1 stated she had inquired with the licensed nurses about the IV antibiotic but did not get a clear response from anyone of them. Resident 1 stated she went to the GACH on June 11, 2025, to have an IV midline placed but did not know why it was not placed while she was at the GACH. Resident 1 stated she did not know if she had a follow up appointment with the OS.On June 27, 2025, at 10:15 a.m., an interview was conducted with the CM. The CM stated her responsibility was to oversee the care and services being provided to the residents who received skilled services, from admission to discharge planning. The CM stated she would also arrange necessary appointments and transport services, and would review consultant notes after appointments. Resident 1's record was concurrently reviewed with the CM. The CM stated the following about Resident 1:-admitted to the facility on [DATE], for rehabilitation after left knee surgery;-Had a follow up appointment with the OS on May 23, 2025, with an order for IV Rocephin daily for six (6) weeks via IV midline;-The CM was not aware of the IV orders from the OS appointment on May 23, 2025, not until the DON discussed it with her on June 11, 2025, and the OS was called by the PDON and clarified the order for IV Rocephin and was informed IV Rocephin should have started on May 23, 2025; - The CM stated there was no documentation the licensed nurses followed up with the OS to clarify the order for IV midline and IV Rocephin. The CM stated the RN should have clarified with the OS regarding the need for the IV Rocephin and when it should be administered. -RN 1 told CM that a peripheral line was attempted but unable to get one on May 23, 2025. The CM stated there was no documentation a peripheral line was attempted to be inserted on Resident 1 and was not successful; -The DON told the CM she would handle the issue on Resident 1's IV order and the resident was sent out to the GACH for IV midline placement on June 11, 2025;-Resident 1 returned to the facility on June 13, 2025, without IV access and no further recommendations for IV antibiotics;-There was no documentation the facility communicated to the OS that IV Rocephin was not administered to Resident 1 since the resident came back from GACH on June 13, 2025, and if the IV Rocephin would still be needed to be administered to the resident; -The CM stated the facility should have clarified with the OS regarding the IV Rocephin order if still needed even after coming back from the GACH on June 13, 2025; and-There was no follow up appointment scheduled with the OS after it was ordered on May 23, 2025, for a RTC in three (3) weeks (around June 13, 2025). The CM stated a follow up appointment with the OS should have been scheduled according to the physician's order. On June 27, 2025, at 11:11 a.m., an interview was conducted with the OS MA. The MA stated the PDON called the orthopedic clinic on June 11, 2025, to clarify regarding the IV Rocephin ordered by the OS on May 23, 2025, and advised the PDON the IV Rocephin should have been started on May 23, 2025. The MA stated the IV Rocephin was ordered by the OS for septic arthritis. The MA stated there was no schedule made by the facility for a follow up appointment with the OS after May 23, 2025. On June 27, 2025, at 1:32 p.m., a concurrent interview and record review was conducted with the Infection Preventionist (IP). The IP stated she was not aware Resident 1 was ordered for IV Rocephin when the resident returned from the orthopedic follow up appointment on May 23, 2025. The IP stated she should have reviewed Resident 1's record to evaluate appropriateness of the antibiotic since the resident was also ordered for Levaquin (medication to treat infection). On June 27, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated he instructed the CM to clarify with the orthopedic clinic and the primary physician to inform them the IV Rocephin was not administered to Resident 1 since May 23, 2025. The ADM stated he thought the CM would follow through with his instructions to address the issue on Resident 1. The ADM stated he was not aware the CM did call the orthopedic clinic not until today to verify for return appointment after May 23, 2025. The ADM stated Resident 1 could develop complications such as infection, pain, discomfort, and joint stiffness. On July 2, 2025, at 11 a.m., an interview was conducted with the OS. The OS stated left knee surgery was done on Resident 1 on May 8, 2025, due to fluid build up on her left knee joint with differential diagnosis (a systematic process used by healthcare professionals to identify the most likely cause of a patient's symptoms by distinguishing between various conditions that share similar characteristics) of septic arthritis. The OS stated during surgery, there was turbid viscous fluid-like pus from the knee joint indicative of septic arthritis, and he recommended for Resident 1 to receive IV Rocephin for 6 weeks while at the skilled nursing facility. The OS stated Resident 1 had a follow up appointment with him on May 23, 2025, and he ordered Resident 1 to have IV Rocephin after the appointment on May 23, 2025, for septic arthritis. The OS stated he was not aware the IV Rocephin was not administered to Resident 1 since May 23, 2025. The OS stated the IV Rocephin could be given via IV midline or peripheral line whatever was available. The OS stated the facility should have clarified with his clinic if the order was not clear and he expected the facility to have administered the IV Rocephin as ordered. The OS stated he evaluated Resident 1 on June 30, 2025, and assessed the resident to still have stiffness and pain in the affected knee. The OS stated the standard care for septic arthritis is IV antibiotic for 6 weeks and order was not followed by the facility. The OS stated Resident 1 could develop possible complications such as worsening of septic arthritis, osteomyelitis (a bone infection that occurs when bacteria or other microorganisms invade and infect the bone), destruction on the joint, chronic limp, gangrene (the death of body tissue due to a lack of blood supply or a severe bacterial infection), loss of limb, amputation (surgical removal of a limb or other body part), and death. A review of the facility's policy and procedures titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders, including any required time frame.A review of the facility's policy and procedure titled, Change in Condition: Notification of, dated August 25, 2021, indicated, .To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition.A Facility must immediately.consult with the Resident's physician.and notify.when there is.A significant change in the Resident's physical, mental, or psychosocial status.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).A review of the facility's policy and procedure titled, Physician Orders, dated March 22, 2022, indicated, .Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed on the appropriate communication system for that discipline. A review of the facility's undated policy and procedure titled, Appointments, indicated, .This policy and procedure document outlines the support a facility provides to residents in accessing specialty healthcare services to enhance their health and wellbeing.Requests for appointments are documented in the electronic medical record.The licensed nurse or designee schedules appointments based on medical necessity and other factors like cognitive status and transportation needs.License Nurse to document resident's departure and clinical condition on the day of the appointment and when resident comes back.Any orders and follow up appointment are documented in the electronic record and to follow up availability of MD (doctor of medicine) progress notes to be included in the resident's medical record.A review of the facility's policy and procedure titled, General Policies for IV Therapy, dated March 2023, indicated, .IV medications may be administered by RNs Physician's orders are required for initiating intravenous therapy .All orders must include name, dose, frequency, duration of therapy, route of administration and diagnosis .Initial antibiotic dose is be given within 4 (four) hours from the time the physician's order is obtained at at the next scheduled dose .When IV therapy is questioned, a collaborative effort amongst the physician, pharmacy, and facility will determine the safety and appropriateness of the therapy .

Based on interview and record review, the facility failed to ensure appropriate nursing services were provided to carry out the physician and orthopedic surgeon (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) orders to administer IV antibiotic, for one of four residents reviewed (Resident 1), when:1.Registered Nurse (RN) 1 did not clarify with the physician or the OS regarding the IV orders after Resident 1's follow up appointment on May 23, 2025. In addition RN 1 did not endorse to the following RN the need to clarify the IV order, and there was no documentation other licensed nurses (RNs and Licensed Vocational Nurses), followed up or clarified the IV order with the OS from May 23, 2025, to June 11, 2025; 2. RN 1 was not knowledgeable regarding other routes of administration of Rocephin (a medication to treat infection);These failures resulted to Resident 1 to not receive the IV antibiotic as ordered by the physician and the OS and had the potential to experience pain or discomfort, infection, joint stiffness, and affect overall health condition.Cross Reference F684Findings:On June 19, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care.On June 19, 2025, at 1:14 p.m., Resident 1 was observed sitting on a wheelchair in the smoking area, and was able to maneuver self throughout the facility. In a concurrent interview with Resident 1, she stated she was supposed to receive IV antibiotics and the orthopedic consultation notes from a follow up appointment on May 23, 2025 was concurrently reviewed with Resident 1 which indicated the following:- Rocephin 1 (one) gram daily for 6 (six) weeks through IV midline (a type of peripheral IV catheter [PIVC] that is longer than a standard IV, inserted into a vein in the upper arm, and the tip of the catheter resides in a larger vein near the shoulder) with (name of home health agency); and-RTC (Return to clinic) in three (3) weeks.Resident 1 further stated she had not received the IV antibiotic order of Rocephin since the orthopedic appointment on May 23, 2025. Resident 1 stated she was sent to the general acute hospital (GACH) on June 11, 2025, for the IV line placement but the hospital was not able to start the IV line and did not know why it was not done. On June 19, 2025, at 1:50 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated when she received the orthopedic consult notes on May 23, 2025, after Resident 1 went to the follow up appointment on May 23, 2025, she placed the order for IV antibiotics in the system. RN 1 stated Resident 1 should have been sent to the hospital to have the IV antibiotic be administered since it was to be given through IV midline. RN 1 stated the following shift should have followed up as the order also indicated with home health agency to administer. RN 1 stated she thought Resident 1 would be getting too much antibiotic since the resident was on oral antibiotic as well. A review of Resident 1's admission Record, indicated Resident 1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses which included left elbow fracture (broken bone), left knee ORIF (open reduction with internal fixation - a surgical procedure used to treat fractures, particularly those that are severely displaced or unstable), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue which could lead to inflammation and damage in various parts of the body, including the skin, joints, kidneys, heart, lungs, and blood cells).A review of Resident 1's physician's orders, date ordered May 16, 2025, indicated, .RESIDENT HAS F/U (follow up) ORTHO APPOINTMENT ON 5/23 (May 23, 2025) AT 8:30 AM (a.m.) WITH (name of orthopedic surgeon) AT (address of orthopedic clinic). A review of Resident 1's orthopedic consult notes, dated May 23, 2025, indicated, .Pt (patient) doesn't (does not) have IV access.Left knee septic arthritis.Plan.IV midline.IV Rocephin 1 gm q (every) daily x 6 weeks.A review of the facility document titled Progress Record, documented by the OS, sent with Resident 1 when she came back from appointment, dated May 23, 2025, indicated, .ordering IV midline and IV Rocephin 1 (one) gram QD (daily) x 6 wks (weeks) w/ (with) (name of home health agency).RTC (return to clinic) in 3 (three) weeks (around June 13, 2025).A review of Resident 1's physician order, date ordered May 23, 2025, .ORDER FOR IV MIDLINE AND IV ROCEPHIN 1 (one) GRAM (unit of measurement) DAILY X (times) 6 (six) WEEKS WITH (name of home health agency)., A review of Resident 1's Progress Notes, dated May 23, 2025, at 10:51 a.m., documented by RN 1, indicated the order from the orthopedic appointment for IV Rocephin, IV midline, and return to clinic in 3 weeks.Further review of Resident 1's record indicated there was no documented evidence of the OS orders for IV midline and IV Rocephin was clarified with the OS when to start the IV antibiotic and indication for the IV antibiotic. There was no documented evidence the physician's order for IV midline and IV Rocephin were carried out as ordered and administered to Resident 1 since May 23, 2025. On June 26, 2025, at 4: 20 p.m., a follow up interview was conducted with RN 1. RN 1 stated she was the RN on duty when Resident 1 came back from orthopedic appointment on May 23, 2025, and the orthopedic surgeon ordered IV midline and IV Rocephin daily for six weeks. RN 1 stated IV midline were not being done at the facility and the resident would need to be scheduled at the hospital for IV midline placement. RN 1 stated she was not able to clarify with the orthopedic surgeon when the IV Rocephin should be started as she got busy and did not endorse it to the next shift RN. RN 1 stated she did not start a peripheral line so the IV Rocephin could be started on May 23, 2025. RN 1 stated she was not aware Rocephin could also be given through intramuscular (IM - through the muscles) injection.On June 26, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated the RN should have clarified with the OS the order for IV midline and IV Rocephin when the IV antibiotic should be started, and if the IV antibiotic could be administered in a different route. The ADM stated he found out about the OS orders on June 13, 2025, when he did chart review with the Case Manager (CM), Social Services Director (SSD), and the Infection Preventionist (IP) and then discussed it with the previous DON (PDON). The ADM stated he instructed the PDON to clarify the OS orders. The ADM stated the CM told him that the IV Rocephin should have started on May 23, 2025. The ADM stated Rocephin could be given through IM or IV peripheral line while waiting for an IV midline to be placed. On June 27, 2025, at 10:15 a.m., an interview was conducted with the Case Manager (CM). The CM stated her responsibility was to oversee the care and services being provided to the residents who received skilled services, from admission to discharge planning. The CM stated she would also arrange necessary appointments and transport services, and would review consultant notes after appointments. The CM the PDON called the OS clinic on June 11, 2025, and clarified the IV order from May 23, 2025, and was told the IV ordered by the OS should have been started on May 23, 2025. The CM stated the PDON sent out Resident 1 to the hospital for IV midline placement on June 11, 2025, and thought the PDON handled Resident 1's IV issue even after the resident came back to the facility on June 13, 2025. The CM stated she was not aware Resident 1 did not get an IV access from the hospital and if Resident 1 still needed the IV antibiotic. On June 27, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated he instructed the CM to clarify with the orthopedic clinic and the primary physician to inform them the IV Rocephin was not administered to Resident 1 since May 23, 2025. The ADM stated he thought the CM would follow through with his instructions to address the issue on Resident 1. The ADM stated he was not aware the CM did call the orthopedic clinic not until today to verify for return appointment after May 23, 2025. The ADM stated Resident 1 could develop complications such as infection, pain, discomfort, and joint stiffness. On July 2, 2025, at 11:30 a.m., a concurrent interview and review of training records of RN 1 with the Director of Staff Development (DSD), the DSD stated RN 1 did not have training regarding notification of the Medical Director, and documentation. The DSD stated RN1 missed the skills lab scheduled as she was working at that time, and was not able to make up for it. The DSD stated RN 1 should have completed the training as scheduled. A review of the facility's job description for RNs, indicated, .The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state .Consult and coordinate with the interdisciplinary team (IDT - a group of healthcare professionals) and healthcare professionals to assess, plan, implement and evaluate individualized resident care plans .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care .Maintain documentation of all nursing care and services provided to the residents; use nurses' notes, flow sheets and electronic medical records according to facility protocol .Administer medications according to practitioner orders .Attend continuing education and in-service training programs as required to provide person-centered and competent care .A review of the facility's policy and procedure titled, Competency of Nursing Staff, dated May 2019, indicated, .All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law .Competency in skills and techniques necessary to care for residents' needs includes .Basic nursing skills .Training and competency evaluations include elements of critical thinking and processes necessary to identify and report resident changes of condition .RNs are trained for and evaluated on managing and reporting pertinent findings to the provider .

Based on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improved (QAPI - a systematic, interdisciplinary, comprehensive, and data - driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address issue on carrying out physician's order for IV antibiotics, when the facility identified the resident did not receive the IV antibiotic the orthopedic surgeon (OS - a medical director specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) ordered.This failure resulted to the resident not to receive the appropriate care and treatment after a surgical procedure and had the potential for the resident to develop complications such as pain or discomfort, infection, joint stiffness, and affect overall health condition. Findings:On June 27, 2025, at 6:07 p.m., the Administrator (ADM) was verbally notified of the Immediate Jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to administer the IV antibiotic to Resident 1 for 35 days. A substandard quality of care (SQC) was identified related to the facility's failure to administer IV antibiotic to Resident 1. See findings under F684. On July 1, 2025, at 2:33 p.m., an interview was conducted with the ADM to discuss regarding the facility's QAPI program. The ADM stated the facility did not proceed to conduct a QAPI program to address the issue on the IV medications order not carried out as ordered by the physician and the OS on May 23, 2025, after it was identified as a missed administration on June 11, 2025 (19 days after the IV medication was initially ordered). A review of the facility's QAPI program meeting information, indicated QAPI meetings were held on February 6, 2025, April 24, 2025, and June 19, 2025, which was attended by the Medical Director, ADM, Director of Nursing (DON), Director of Staff Development (DSD), Infection Preventionist, Activity Director, Dietary Director, Social Services Director, Medical Records Designee, Maintenance Supervisor, Pharmacy Consultant, and [NAME] President of Operations. On July 2, 2025, at 10:45 a.m., a follow up interview and concurrent review of QAPI meetings was conducted with the ADM. The ADM stated the facility had a QAPI meeting on June 19, 2025, but did not discuss the IV medication order not carried out since May 23, 2025. The ADM stated the facility should have included the issue on IV medication during their QAPI meeting on June 19, 2025. The ADM stated he thought the previous DON had taken cared of the issue. The ADM stated he was not aware the facility had an issue on IV medication order not carried out until it was brought to their attention on June 19, 2025, during the investigation of the complaint.A review of the facility's policy and procedure titled, Quality Assurance and Performance and Improvement (QAPI) Program - Governance and Leadership), dated March 2020, indicated, .The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee, which reports its findings, actions and results to the Administrator and governing body .The Administrator .is ultimately responsible for the QAPI program, and for interpreting the results and findings to the governing body .The governing body is responsible for ensuring that the QAPI program .Focused on problems and opportunities that reflect processess, functions and services provided to the residents .

Based on interview and record review, the facility failed to ensure an effective antibiotic surveillance program (program to help monitor the effectiveness of antibiotics, identify emerging resistance patterns, and inform strategies for infection prevention and control) was conducted, for four of four residents (Residents 1, 2, 3, and 4) according to the facility's policy and procedure, when:1.For Resident 1, there was no appropriate indication for the use of Levaquin (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Levaquin;2.For Resident 2, the physician was not notified the use of Cipro (medication to treat infection) did not meet the criteria of the symptoms of urinary tract infection;3.For Resident3, there was no appropriate indication for the use of Macrobid (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Macrobid; and4.For Resident 4, there was no appropriate indication for the use of Cirpo (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Cipro and Doxycycline (medication to treat infection).These failures resulted to the residents' use of antibiotic not to be evaluated for the appropriateness of its use, which could lead to development of complications related to use of the antibiotics. Findings:On June 25, 2025, at 1:11 p.m., during an interview with the Infection Preventionist (IP), the IP stated the facility conducts antibiotic surveillance of the residents who were prescribed antibiotics on admission and during their stay in the facility to ensure the antibiotic is necessary for the resident to be administered. The IP stated she would run a report indicating a list of residents on antibiotic. The IP stated the facility form titled, Antibiotic Surveillance Data Collection, was to be completed by the licensed nurse who initiated the antibiotic order either during admission or during the resident stay in the facility. The IP stated the document utilizes McGeer's criteria (a standardized definitions of infection used primarily for surveillance in long-term care facilities) or Loeb's criteria (a set of minimum clinical guidelines used in long-term care facilities to help determine when antibiotic treatment is appropriate for residents) to determine if the antibiotic is appropriate for the resident. The IP stated if the antibiotic surveillance indicated the criteria was not met, they will proceed with a time out to call the physician if still needed for the antibiotic to be administered to the resident. The IP stated it was her responsibility to ensure the antibiotic surveillance form was completed accurately and implement the antibiotic surveillance program according to the guidelines.On June 25, 2025, at 1:32 p.m., a concurrent interview and review of Residents 1, 2, 3, and 4's records were conducted with the IP. The following indicated:1.Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare following joint replacement and fracture of right elbow.A review of Resident 1's physician order, dated May 23, 2025, indicated the following:- .Levaquin (antibiotic) Tablet 500 MG (milligram - unit of measurement).Give 1 (one) tablet by mouth one time day for R/O (rule out) FRACTURE for 20 days.; and- .Order for IV Midline and IV Rocephin 1 (one) gram (unit of measurement) daily x (times) 6 (six) weeks with (name of home health).A review of Resident 1's Progress Notes, indicated, .RESIDENT CAME BACK FROM APPOINTMENT WITH A STAFF MEMBER AND TRANSPORT COMPANY. SUTURE WAS REMOVED, STERISTRIPS APPLIED.ORDER FOR IV MIDLIN (sic) AND IV ROCEPHIN 1 GRAM DAILY X 6 WEEKS WITH (name of home health).LEVAQUIN 500MG PO DAILY X 20.In a concurrent interview with the IP, the IP she stated there was no antibiotic surveillance form completed for the use of Levaquin for Resident 1. The IP stated she thought the indication for the antibiotic was for prophylaxis (prevent disease) related to the fracture. The IP stated she did not review the orthopedic consult notes to check why the physician ordered Levaquin for Resident 1. The IP stated the indication for Levaquin use was not appropriate and should have been clarified and reviewed. The IP stated she was not aware Resident 1 was ordered for IV Rocephin.2.Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease) and diabetes mellitus (abnormal blood sugar).A review of Resident 2's Progress Notes, dated June 15, 2025, at 5:49 a.m., indicated, .Pt (patient) had episode of delirious (an acutely disturbed state of mind resulting from illness or intoxication and characterized by restlessness, illusions, and incoherence of thought and speech). Pt was sitting on edge of bed stating she was going to jump off to start walking.A review of Resident 2's lab Results Report, dated June 16, 2025, indicated cloudy urine, and many bacteria.A review of Resident 2's Progress Notes, dated June 18, 2025, at 12:32 a.m., indicated, .(name of physician) reviewed urine test result and he ordered Cipro 500 mg tab (tablet) bid (twice a day) x 10 days.A review of Resident 2's physician order, dated June 18, 2025, indicated, .Cipro Oral Tablet 500 MG.Give 1 (one) tablet by mouth two times a day for UTI (urinary tract infection) for 10 days. A review of Resident 2's Antibiotic Surveillance Data Collection, dated June 18, 2025, indicated, .Type of Infection.Urinary Tract Infection.Without an Indwelling Catheter.Criteria 1 and 2 must be present (none clicked).Not a True Infection.In a concurrent interview with the IP, the IP stated Resident 2's symptoms did not meet the criteria of a urinary tract infection. The IP stated a time out should have been conducted and the physician should have been notified that Resident 2's symptoms did not meet the criteria of urinary tract infection.3.Resident 3 was admitted to the facility on [DATE], with diagnoses which indicated fracture (broken) of the right femur (thigh bone) and urinary retention.A review of Resident 3's physician order, dated June 18, 2025, indicated, .Macrobid Oral Capsule 100 MG.Give 1 (one) capsule by mouth two times a day for infection for 5 (five) days).In a concurrent interview with the IP, she stated the Nurse Practitioner (NP) would usually order urinalysis (urine test) upon admission regardless of if the resident had symptoms or not. The IP stated the NP ordered urinalysis for Resident 3 on June 15, 2025. The IP stated the urinalysis results came back on June 17, 2025, with the presence of mucus and bacteria. The IP stated Resident 3 did not manifest any signs and symptoms of urinary tract infection. The IP stated the NP ordered for Macrobid (medication to treat infection) twice a day for five days. The IP stated the order for Macrobid for Resident 3 should have been clarified with the NP of what infection was being treated for it. The IP stated there was no antibiotic surveillance assessment initiated for the use of the Macrobid for Resident 3. The IP stated the antibiotic surveillance assessment should have been completed to determine if criteria for a true infection was met or not and if the antibiotic medication was necessary for the resident.4.Resident 4 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness) and diabetes mellitus (abnormal blood sugar).A review of Resident 4's physician order, dated June 7, 2025, indicated, .Doxycycline Hyclate (medication to treat infection) Oral Tablet 100 MG .Give 1 (one) tablet by mouth two times a day for wound infection for 10 days.A review of Resident 4's physician order, dated June 23, 2025, indicated, .Cipro (medication to treat infection) Oral Tablet 500 MG.Give 1 (one) tablet by mouth two times a day for Infection for 10 days.In a concurrent interview with the IP, she stated there was no antibiotic surveillance assessment form completed for the use of the doxycycline. The IP stated there should be an antibiotic surveillance assessment each time a resident was ordered for antibiotic. The IP stated the order for Cipro should have been clarified with the physician to have a specific diagnosis. The IP stated there was no antibiotic surveillance assessment completed for the use of Cipro, and stated there should have been completed to determine if it met the criteria for a true infection.A review of the facility's policy and procedure titled, Antibiotic Stewardship, dated September 18, 2023, indicated, .Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.If an antibiotic is indicated, prescribers will provide complete antibiotic orders including.Indications for use.When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information.signs and symptoms.

Based on interview and record review, the facility failed to ensure sufficient number of nursing staff was provided to attend to the resident's needs and assure resident safety, when the nursing staff had an extended lunch break with no staff coverage. This failure had the potential to result in several residents to not have their needs met safely nor in a way to promote their rights. Findings: On April 29, 2025, at 10 a.m. an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and insufficient staffing. On April 29, 2025, at 4:45 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated all staff who were hourly employees must clock in and out for lunch breaks, payroll keeps track of their breaks, and it should be reflected in the payroll sheets. The DSD stated she received a phone call on April 27, 2025, from a staff member regarding a few Certified Nursing Assistants (CNAs) taking extended lunches, during the weekend, and the CNAs thought no one would notice. The DSD stated she would assign the lunch breaks for the CNAs with only one CNA to go on lunch break in their assigned area, leaving two CNAs on the floor to cover one another. The DSD stated CNAs do go to lunch together, but two CNAs need to be in each assigned area to care for residents, if one of the CNAs goes late, it could put the remaining lunches behind, and the CNAs need to wait until they come back and then can go on their break. On May 1, 2025, at 11:05 a.m., an email was received from the DSD. The document was reviewed and indicated, Following a comprehensive investigation into the reported incident of April 27, 2025, concerning Certified Nursing Assistants exceeding their allotted 30-minute lunch break. The findings indicated CNA 2 and CNA 3 took extended lunch breaks during the PM shift (2:30 p.m.-11 p.m.) on April 27, 2025. On May 1, 2025, a review of the documents, pertaining to CNA schedules and timecards, dated April 15, 2025, April 16, 2025, and April 27, 2025, were conducted. The documents indicated, on April 15, 2025, the facility census was 93, there were 10 CNAs, and one Restorative Nursing Assistant (RNA) scheduled to work the day shift from 6:30 a.m. until 2:30 p.m., nine or ten residents were assigned to each CNA. Four CNAs covering rooms 15C to 18C, and 53A to 74A, clocked out for lunch between 10:31 a.m. and 10:38 a.m. and clocked back in from lunch between 11:02 a.m. and 11:09 a.m., with no CNA coverage to the front hallway of the facility for approximately 20 minutes. Five CNAs covering rooms 10A to 15B, and 74B to 24C clocked out for lunch between 11 a.m. and 11:10 a.m. and clocked back in from lunch between 11:30 a.m. and 11:40 a.m., leaving the back hallway of the facility without CNA coverage for approximately 20 minutes. The PM shift (2:30 p.m. until 11:00 p.m.) had 8 CNAs scheduled to work, with a census of 92. Three of the CNAs clocked out for lunch between 7:05 p.m. and 7:17 p.m. and clocked back in from lunch between 7:43 p.m. and 7:49 p.m., with no CNA coverage to the station two hallway of the facility for approximately 20 minutes. The documents indicated, on April 16, 2025, the facility census was 94, there were 11 CNAs and one RNA, scheduled to work the day shift. Five CNAs covering rooms 15A to 24C and 84A to 99B, clocked out for lunch between 11:00 a.m. and 11:14 a.m. and clocked back in from lunch between 11:30 a.m. and 11:46 a.m., with no CNA coverage to the back hallway of the facility for approximately 16 minutes. The document indicated, on April 27, 2025, the facility census was 96, there were eight CNAs, and one RNA assigned to work the day shift from 6:30 a.m. until 2:30 p.m., 12 residents were assigned to each CNA. Six CNAs clocked out for lunch between 10:58 a.m. and 11:02 a.m. and clocked back in from lunch between 11:28 a.m. and 11:32 a.m., this left two CNAs and one RNA to care for 96 residents for approximately 30 minutes. On May 2, 2025, at 1:05 p.m., an interview and concurrent record review were conducted with the DSD. The DSD reviewed schedules, CNA break times, and timecards, dated April 15, 16, and 27, 2025. The DSD stated CNA 3 was written up for taking a long lunch and then going to payroll after to adjust his time, for his time out and time in for lunch, he was given a final warning. The DSD stated she does not know how long CNA 3 took his break; the timecard was adjusted by payroll from 7:08 p.m. until 7:43 p.m., and she stated it was longer than 30 minutes. The DSD stated two to three employees cannot care for 96 residents in a safe manner, this many CNAs should not have been at lunch at the same time, this is not safe for the residents. The DSD stated the CNAs should have varied their lunches, to ensure there was adequate coverage for all the residents in the facility. A review of the facility ' s job description titled Certified Nursing Assistant, dated June 27, 2017, indicated, .provides patient care in a manner conducive to safety and comfort .answer call light or bell promptly .promotes a culture of safety to ensure a healthy practice and living environment .contributes to an environment that is respectful, team-oriented, and responsive to the concerns of staff, patients and families .

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards, when two nursing staff members were observed using their personal cell phones in the patient care areas. This failure had the potential to affect the quality of care the residents would receive in the facility. Findings: On April 29, 2025, at 10 a.m. an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On April 29, 2025, at 10:20 a.m., an observation and concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed looking at her personal cell phone, with an earbud in her right ear, sitting at nurse ' s station two. LVN 1 stated she should not have been on her cell phone, or have an ear bud in, the facility has rules about personal cell phone use. On April 29, 2025, at 12 p.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was observed at nurse ' s station one, leaning onto countertop, texting on her cell phone. CNA 1 stated she was not supposed to use her cell phone when she is on the floor working. CNA 1 further stated they were supposed to go into the break room if they need to use their cellphones. On April 29, 2025, at 4:45 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated personal cell phone use is discouraged on the floor as the staff would be distracted, and not pay attention to their residents. The DSD further stated personal cell phone use is allowed before and after their shift, or while on break. A review of the facility ' s employee handbook titled Personal Electronic Devices, dated November 1, 2023, indicated, .workplace use of these devices can raise a number of issues involving safety, security, privacy, and productivity .rules regarding the use of personal communication devices in the workplace during working hours .employees should conduct personal business during meal breaks and other rest periods .phones and other devices with cameras or recording capabilities are strictly prohibited in all work areas that contain proprietary information . A review of an article, published by Hospital Topics, titled Use of Personal Cell Phones by Nurses is Barrier to Effective Nursing Care in Hospitals: A Qualitative Research, published August 14, 2024, indicated, .using cell phones by nurses can affect the quality of care .using a cell phone during work could jeopardize patients ' safety and ruins the nursing profession image .

Based on interview and record review, the facility failed to ensure follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital, for one of six residents (Resident A). This failure resulted in a delay in care and treatment for Resident A and had a potential to affect the resident's overall health condition. Findings: On April 29, 2025, at 10:00 a.m. an unannounced visit was conducted to the facility for the investigation of a complaint regarding quality of care. On April 29, 2025, at 12:20 p.m., an interview was conducted with Resident A. Resident A stated he was admitted to the facility for rehabilitation services after he had surgical repair of a hernia (a bulging of an organ or tissue through an abnormal opening). On April 29, 2025, at 2:25 p.m., a follow up interview was conducted with Resident A. Resident A stated he had not had a follow up appointment with the surgeon since his surgery. Resident A stated he has heart and breathing problems, and none of the staff have told anything about following up with a cardiologist or pulmonologist. Resident A stated he had blood draw done about three weeks ago, but that was the last time, and he was not aware what the blood test was for. On April 29, 2025, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), inguinal hernia repair (a surgical procedure to repair, where part of the intestine or fatty tissue pushes through a weak spot in the abdominal wall near the groin), and atherosclerotic heart disease (damage or disease in the heart ' s major blood vessels). A review of Resident A's History and Physical Examination, dated March 29, 2025, indicated Resident A had the capacity to understand and make decisions. A review of Resident A ' s SNF (Skilled Nursing Facility) Transfer Orders & (and) Report, dated March 25, 2025, indicated CBC (complete blood count - blood draw to check blood cell levels) every week. A review of Resident A ' s Order Summary Report, included a physician's order for CBC to be completed on March 28, 2025. A review of Resident A ' s CBC results indicated the following: - RBC (red blood cell) count was 2.24 million cells per microliter (a type of measurement) of blood, a normal range is between 4.2 to 5.5. - HGB (hemoglobin - an iron rich protein found in red blood cells that is responsible for transporting oxygen throughout the body) was 7.9 grams per deciliter (a unit of measurement), a normal range is 12.0 to 18.0; and - HCT (hematocrit - a percentage of red blood cells in the blood) was 25.1%, a normal range is 38-52%. A review of Resident A ' s hospital summary, dated March 26, 2025, indicated Resident A needed to have follow up appointment with the surgeon in two weeks and as well with the cardiologist (a physician who focuses on treating the heart and blood vessels) and pulmonologist (a physician who focuses on the respiratory system, including the lungs and airway). Further review of Resident A's record indicated there was no documented evidence follow up physician appointments were ordered and scheduled for the resident. On April 29, 2025, at 2:40 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated when a resident was admitted to the facility, the admitting nurse should review the admission orders, put in any needed services, consults, or appointments. The SSD stated the nursing department will contact social services once the appointments were made and would arrange the transportation to the appointment. The SSD stated social services were not responsible in scheduling the appointments for the residents, it was the responsibility of the nursing staff. The SSD stated there was no documentation follow up physician appointments were made for Resident A and there have been no requests for transportation. On April 29, 2025, at 3:00 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when residents are admitted , the Registered Nurse (RN) supervisor normally reviews all orders, and the discharge plan of care from the acute care facility. LVN 2 stated all hospital orders, medications, laboratory orders were to be verified with the physician who will be caring for the resident while in the facility, after verification, orders were to be placed in the computer, any additional tasks may be completed by nursing if requested. On April 29, 2025, at 3:15 p.m., an interview and concurrent record review were conducted with the RN supervisor (RNS). The RNS stated the admission packet was given to the front desk, station one, when the resident was admitted . The RNS or if there was a desk nurse, will begin to review the resident ' s diet and medications first, to ensure continuity of care, and verify all the orders with the primary physician. The RN stated then consults, appointments, treatments and labs were to be reviewed and placed into the system. The RNS stated Resident A ' s admission orders from the hospital indicated there was recommendation for the resident to consult with the surgeon in two (2) weeks, and follow ups with the cardiologist and pulmonologist ordered, as well as a CBC every week. The RNS stated Resident A had a CBC done on March 28, 2025, he had a medication ordered for his low hemoglobin and hematocrit, but no additional orders for labs to continue every week. The RNS stated there was no documentation appointments were scheduled for Resident A to see the surgeon, cardiologist, and pulmonologist. The RNS reviewed who entered the orders, she stated our interim MDS (Minimum Data Set - a standardized assessment tool used in nursing homes to collect basic, essential information about the resident) nurse entered the orders and could give more information. On April 29, 2025, at 3:25 p.m., an interview and concurrent record review were conducted with the MDS nurse. The MDS nurse stated the admission nurse was to follow up with a resident ' s orders, their discharge summary, and plan of care from the hospital, and place the information in the electronic health record of the resident, such as follow up appointments, ordered labs. The MDS nurse stated once the admission nurse had scheduled the follow up appointments, a copy of the order with the appointment time, place, and date was to be given to the social services department to arrange transportation. The MDS nurse reviewed Resident A ' s admission orders and his discharge summary from the hospital and stated she did not see the order for the CBC weekly nor the follow up appointments with the surgeon, cardiologist, and pulmonologist, they should have been put in and were missed. A review of the undated facility ' s policy and procedure titled Appointments, indicated, .the support a facility provides to residents in accessing specialty healthcare services to enhance their health and wellbeing. The facility will help residents contact specialty providers as needed, based on healthcare recommendations .assist in scheduling appointments and arranging necessary transportation for residents .Requests for appointments are documented in the electronic medical record .Licensed nurse informs the social service department or designee about the appointment order .The licensed nurse or designee schedule appointments based on medical necessity .This structured approach ensures that resident receive the necessary support and resources for their healthcare appointments, thereby promoting better health outcomes .

Based on observation, interview, and record review, the facility failed to ensure the California Department of Health (CDPH - a state agency) was notified timely or within two hours after an abuse allegation against a Certified Nursing Assistant (CNA) was reported to the facility staff according to the facility's policy and procedure, for one of three residents reviewed (Resident A). This failure had the potential for a delay in the investigation and implementation of the abuse protocol and exposed the vulnerable residents to further abuse. Findings: On March 9, 2025, at 1:30 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On March 9, 2025, at 3:22 p.m., during an interview with Resident A and Resident A's family member, Resident A stated CNA 1 kept on putting her cellphone in his pocket on April 27, 2025. Resident A stated she told her family members about it when they visited her on April 28, 2025. On March 9, 2025, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included end stage renal disease and diabetes mellitus (abnormal blood sugar). Resident A's Minimum Data Set (MDS - a resident assessment tool), dated May 1, 2025, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 15 (indicating cognitively intact). Review of Resident A's progress notes did not indicate the abuse allegation reported to the facility on [DATE]. Resident A's Interdisciplinary Care Conference, dated April 30, 2025, at 8:45 a.m., indicated, .SSD (Social Service Director) DSD (Director of Staff Development) interview the patient .Per the resident, she is stating that on Sunday (April 27, 2025), the male CNA she describe as medium height lighter skin tone than the DSD with his hair in braids, entered her oom provided no patient care at the time and picked up her cell phone and proceeded to walk out of the room per the resident. She stated she got his attention by saying hey, hey, hey myc cell phone and he said oh I'm sorry and placed it back on the table .There was nothing on it besides her water pitcher, and her cell phone she stated that the CNA placed her cell phone in his pocket twice the third time he placed it in his pocket on his shirt each time she asked him to give her cell phone back and he would state. Oh, I'm sorry. Per the patient, she stated that her (family member) came into the facility on Monday (April 28, 2025) to bring her tablet (an electronic device) so she would be able to watch her shows on her tablet and she told the family to take it home because a male CNA had tried to steal her cell phone. According to CN (Charge Nurse) that was endorsed to the RN (Registered Nurse) Supervisor (RNS) on the PM (evening) shift on Monday. IDT (Interdisciplinary Team - a group of healthcare professionals) was made aware of the incident today around 9:45 a.m . On May 21, 2025, at 11:07 a.m., during an interview conducted with the SSD, the SSD stated Licensed Vocational Nurse (LVN) 1 called LVN 2 on April 29, 2025, at around 9 a.m., about the abuse allegation reported by Resident A's family member on April 28, 2025. The SSD stated LVN 2 reported to her the abuse allegation reported by Resident A on April 29, 2025, at around 10 a.m. The SSD stated LVN 1 informed the RNS about Resident A family member's allegation of abuse toward CNA 1 on April 28, 2025. The SSD stated the RNS did not report to CDPH the abuse allegation immediately or within two hours after the abuse allegation was reported on the PM shift of April 28, 2025. The SSD stated the RNS should have reported Resident A's abuse allegation to CDPH immediately or within two hours after the report was made, according to the facility's policy and procedure. On May 21, 2025, at 11:27 a.m., during an interview conducted with the Administrator (ADM), the ADM stated the abuse allegation reported by Resident A's family member should have been reported to CDPH immediately or within two hours from the facility's knowledge of the abuse allegation. A review of the facility's policy and procedure titled, Abuse Prohibition, dated February 23, 2021, indicated, .Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents .After receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect .designee will .Report allegations involving abuse .not later than two (2) hours after the allegation is made .

Based on interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care were maintained for 12 of 18 residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) (Residents 14, 21, 32, 40, 41, 50, 55, 59, 61, 71, 78, and 138), when: 1. For Resident 14, the signing doctor was different from the physician's name on the Physician Orders for Life-Sustaining Treatment (POLST - documents a patient's preferences for end-of-life care in the face of serious illness or irreversible conditions); 2. For Resident 32, the POLST did not have the physician's information or license number on the form; 3. For Resident 41, the POLST was not signed by the physician since January 28, 2025; 4. For Resident 50, there was no physician information and physician signature on the POLST form; 5. For Residents 21, 55, 59 and 61, there was no documented evidence the POLST was reviewed periodically; and 6. For Residents 14, 21, 32, 40, 41, 50, 55, 59, 61, 71, 78, and 138, there was no documented evidence formulation of an Advance directive was offered to the residents and/or resident representatives. In addition, there was no documented evidence IDT reviews regarding advance directives for these residents were conducted quarterly and annually per facility policy. These failures had the potential for the resident's decisions regarding their healthcare and treatment to not be honored. Findings: 1. A review of Resident 14's record indicated Resident 14 was readmitted to the facility on [DATE], with an original admitted [DATE], with diagnosis of respiratory failure (not enough oxygen in the body) and metabolic encephalopathy (brain dysfunction). A review of Resident 14's POLST, dated September 4, 2024, indicated the signing doctor was different from the physician's name on the POLST. On April 11, 2025, at 2:04 p.m., an interview was conducted with the Social Services Director. The SSD stated the POLST was uploaded at time of admission, and they review the POLST every 3 months (quarterly) to see if any changes. On April 14, 2025, at 10:02 a.m., an interview was conducted with the Director of Nursing, DON. The DON stated there should be documentation indicating an annual review of the POLST. A review of the policy and procedure titled, Do Not Resuscitate Order, dated March 2021, indicated, .Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record .a do not resuscitate (DNR) order from must be completed and signed by the attending physician . 2. A review of Resident 32's record indicated Resident 32 was admitted to the facility on [DATE] with a diagnoses of multiple sclerosis (autoimmune disease). A review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated March 7, 2025, indicated Resident 32's had a Brief Interview for Mental Status (BIMS) score of 15 (cognition intact). A review of Resident 32's POLST, dated ____, indicated Resident 32's POLST did not have the physician information or license number on the form. On April 11, 2025, at 2:06 p.m., an interview was conducted with the SSD. The SSD stated the POLST should consist of the physician name, license number, signature, and date. The SSD stated the POLST were uploaded at the time of admission and reviewed every three months. On April 14, 2025, at 10:04 p.m., an interview was conducted with the DON. The DON stated there should be documentation indicating an annual review of the POLST. The POLST should be reviewed at the quarterly care conference, any changes should be made at that time. A review of the policy an procedure titled, Do Not Resuscitate Order dated, March 2021, indicated, .a do not resuscitate (DR) order from must be completed and signed by the attending physician . 3. A review of Resident 41's record, indicated Resident 41 was admitted to the facility on [DATE], with diagnoses of heart failure (heart doesn't pump as well as it should). A review of Resident 41's POLST, dated January 28, 2025, indicated the POLST was not signed by the physician. A review of Resident 41's MDS, dated [DATE], indicated Resident 41 had a BIMS score of 7 (cognition impaired). On April 11, 2025, at 2:07 p.m., an interview was conducted with the Social Services Director. The SSD stated the physician should have signed the POLST. On April 14, 2025, at 10:06 a.m., an interview was conducted with the Director of Nursing, DON. The DON stated the physician should have signed the POLST within 30 days of the POLST being filled out. A review of the policy and procedure titled, Physician Visits, dated April 2013, indicated, .attending physican must visit his/her patients at least once every 30 days for the first ninety days following the residents admission, and then at least every sixty days thereafter . A review of the policy and procedure titled, Do Not Resuscitate Order, dated March 2021, indicated, .a do not resuscitate order form must be completed and signed by the attending physician . 4. A review of Resident 50's record indicated, Resident 50 was admitted to the facility on [DATE] with a diagnoses of intraspinal abscess and granuloma (a collection of pus within the spinal canal). A review of Resident 50's POLST, dated January 5, 2025, indicated Resident 50's POLST had no physician information or physician signature on the POLST form. A review of Resident 50's MDS, dated [DATE], indicated Resident 50 has a BIMS score of 15 (cognition intact). On April 11, 2025, at 2:09 p.m., an interview was conducted with the Social Services Director. The SSD stated Resident 50's POLST should have the physician's information including the physician's signature. On April 14, 2025, at 10:06 a.m., an interview was conducted with the Director of Nursing, DON. The DON stated the physician should have filled out his section of the POLST at the time of his visit after admission. A review of the policy and procedure titled, Do Not Resuscitate Order, dated March 2021, indicated, .do not resuscitate orders must be signed by the residents attending physician on the physician's order sheet maintained in the resident's medical record . 5a. A review of Resident 21's record indicated Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of heart failure and chronic kidney disease (lose of ability to filter waste and fluid out of blood). A review of Resident 21's MDS, dated [DATE], indicated a BIMs score of 13 (cognition intact). A review of Resident 21's interdisciplinary case conference, dated February 10, 2025 indicated there was no documented evidence Resident 21's POLST was reviewed periodically. 5b. A review of Resident 55's record indicated, Resident 55 was admitted to the facility on [DATE], with a diagnoses of delusional disorders (serious mental illness) and dementia (decline in cognition). A review of Resident 55's MDS, indicated a BIMS score of 15 (cognition intact). A review of Resident 55's record indicated there was no documented evidence Resident 55's POLST was reviewed periodically. 5c. A review of Resident 59's record indicated Resident 59 was admitted to the facility on [DATE] with a readmitted [DATE], with a diagnoses of abscess of epididymis or testis (infection of the testicle) and chronic obstructive pulmonary disease (COPD - ongoing lung condition). A review of Resident 59's MDS, dated [DATE], indicated a BIMs score of 14 (cognition intact). A review of Resident 59's record indicated there was no documented evidence Resident 59's POLST was reviewed periodically. 5d. A review of Resident 61's record indicated Resident 61 was admitted to the facility on [DATE] with a readmit of June 17, 2025 with a diagnoses of hepatic encephalopathy (brain function that occurs as a result of liver dysfunction) A review of Resident 61's MDS, dated [DATE], indicated a BIMs score of 13 (cognition intact). A review of Resident 61's record indicated there was no documented evidence Resident 61's POLST was documented regularly. On April 11, 2025, at 2:12 p.m., an interview was conducted with the SSD. The SSD stated the POLST was uploaded at time of the resident's admission and reviewed quarterly (every 3 months) to see if any changes. The SSD stated Resident 21, 55, 59 and 61's POLST were not reviewed quarterly. On April 14, 2025, at 10:11 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the POLST's should be reviewed quarterly and as needed. The DON stated it did not appear the POLST for Residents 21, 55, 59 , and 61 have been reviewed quarterly. A review of the policy and procedure, titled, Do Not Resuscitate Order, dated March 2021, indicated, . do not resuscitate orders must be signed by the resident attending physician on the physician's order sheet maintained in the resident's medical record .the interdisciplinary care planning team will review with the resident during quarterly care planning sessions to determine if the resident wishes to make changes . 6a. A review of Resident 14's record indicated Resident 14 was readmitted to the facility on [DATE], with an original admitted [DATE], with diagnosis of respiratory failure (not enough oxygen in the body) and metabolic encephalopathy (brain dysfunction). A review of Resident 14's brief interview for mental status, dated January 2, 2025, indicated a score of 15 (cognition intact). 6b. A review of Resident 21's record indicated Resident 21 was admitted to the facility on [DATE], with a readmit of November 11, 2024 with diagnoses of heart failure and chronic kidney disease (lose of ability to filter waste and fluid out of blood). A review of Resident 21's MDS, dated [DATE], indicated a BIMs score of 13 (cognition intact). 6c. A review of Resident 32's record indicated Resident 32 was admitted to the facility on [DATE] with a diagnoses of Multiple Sclerosis (autoimmune disease). A review of Resident 32's MDS, dated [DATE], indicated a BIMs score of 15 (cognition intact). 6d. A review of Resident 40's record indicated Resident 40 was admitted to the facility on [DATE] with a readmit on January 17, 2025 with diagnoses calculus of kidney (kidney stones) and uropathy (urine flow is obstructed). A review of Resident 40's MDS, dated [DATE], indicated a BIMs score of 15 (cognition intact). 6e. A review of Resident 41's record, indicated Resident 41 was admitted to the facility on [DATE], with diagnoses of heart failure (heart doesn't pump as well as it should). A review of Resident 41's MDS, dated [DATE], indicated a BIMs score of 7 (cognition impaired). 6f. A review of Resident 50's record indicated Resident 50 was admitted to the facility on [DATE], with a diagnoses of intraspinal abscess and granuloma (a collection of pus within the spinal canal). A review of Resident 50's MDS, dated [DATE], indicated a BIMs score of 15 (cognition intact). 6g. A review of Resident 55's record indicated Resident 55 was admitted to the facility on [DATE], with a diagnoses of delusional disorders (serious mental illness) and dementia (decline in cognition). A review of Resident 55's MDS, indicated a BIMs of 15 (cognition intact). 6h. A review of Resident 59's record indicated Resident 59 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnoses of abscess of epididymis or testis (infection of the testicle) and chronic obstructive pulmonary disease (COPD - ongoing lung condition). A review of Resident 59's MDS, dated [DATE], indicated a BIMs score of 14 (cognition intact). 6i. A review of Resident 61's record indicated Resident 61 was admitted to the facility on [DATE] with a readmit of June 17, 2025, with a diagnoses of hepatic encephalopathy (brain function that occurs as a result of liver dysfunction). A review of Resident 61's MDS, dated [DATE], brief interview for mental status indicated a BIMs score of 13 (cognition intact). 6j. On April 7, 2025, Resident 71 record was reviewed. Resident 71 was admitted to the facility on [DATE], with diagnoses which included acute on chronic systolic congestive heart failure (the heart can't pump enough blood to meet the body's needs) and respiratory failure (not enough oxygen). A review of Resident 71's MDS, dated [DATE], indicated Resident 71 had a BIMs score of 14 (cognitive intact). 6k. On April 7, 2025, Resident 78's record was reviewed. Resident 78 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis of the left ankle and foot (bone infection) and diabetes mellitus, type 2 (body has trouble controlling blood sugar). A review of Resident 78's MDS, dated [DATE], indicated a BIMs score of 15 (cognitive intact). 6l. On April 7, 2025, Resident 138's record was reviewed. Resident 138 was admitted to the facility on [DATE], with diagnoses which indicated aftercare for joint replacement surgery and diabetes mellitus. A review of Resident 138's MDS, dated [DATE], indicated Resident 138 had a BIMs score of 15 (cognitive intact). There was no documented evidence information regarding formulation of an Advance Directive was offered to the residents and/or resident representatives, for Residents 14, 21, 32, 40, 41, 50, 55, 59, 61, 71, 78, and 138. In addition, there was no documented evidence of an IDT review regarding advance directives for these residents was conducted quarterly and annually per facility policy. On April 11, 2025, at 2:18 p.m., an interview was conducted with the SSD. The SSD stated the POLST was uploaded at time of admission and reviewed quarterly (every 3 months) to see if any changes, there was no documentation a written information regarding formulating an AD was provided to the resident or resident's representative. On April 14, 2025, at 10:20 a.m., an interview was conducted with the Director of Nursing, DON. The DON stated the written information regarding formulation of advance directive was being provided due to no documentation during quarterly IDT meetings. A review of the job description for Social Worker, indicated, .Administrative functions .Provide residents with information concerning resident rights, living will, etc . A review of the facility's policy and procedure titled Advance Directives, dated December 2016, indicated, .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .If a resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .The interdisciplinary team will conduct ongoing review of the resident's decision-making and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record .the interdisciplinary team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument .

Based on interview and record review, the facility failed to ensure resident care plans were initiated and/or updated when: 1. No discharge care plans were developed and/or updated for Residents 33, 71, 78 and 139. This failure had the potential for the residents' pre and post-discharge needs to not be anticipated and addressed by the facility staff; 2. No care plan was developed for the use of a indwelling catheter (a flexible tube inserted into the bladder to drain urine) for Resident 13. This failure had the potential to result in Resident 13's indwelling catheter care issues to not be addressed and monitored by the facility staff; and 3. No care plan was developed regarding the change in condition on April 3, 2025, regarding a urinary tract infection (UTI) for Resident 138. This failure had the potential for Resident 138's UTI to not be addressed and monitored by the facility staff. Findings: 1a. On April 8, 2025, at 1:30 p.m., the (name on county) Ombudsman (OMB) was present in the facility to assist residents with discharge issues, including Resident 33. On April 10, 2025, at 2:43 p.m., Resident 33's FM was interviewed. The FM stated Resident 33 was admitted to the facility around July 2024, and a previous Social Services Director (SSD) had initially assisted with the Assisted Living Waiver program (ALW- allows eligible seniors and individuals with disabilities who need a nursing facility level of care to receive care in a residential care facility for the elderly (RCFE) or other participating assisted living setting instead of a nursing home) application process, but has since left the facility. The FM stated they had been reaching out to the facility since September 2024 to get Resident 33 to a permanent care home. On April 10, 2025, Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses which included mood disorder and dementia. A review of Resident 33's History and Physical Examination, dated August 11, 2024, indicated Resident 33 had fluctuating capacity to understand and make decisions due to dementia. A review of Resident 33's care plan, dated August 12, 2024, indicated, .Resident/patient has potential for discharge, or is expected to be discharged related to .Resident's desire to discharge to community . A review of Resident 33's Minimum Data Set (MDS- a clinical assessment tool), dated January 31, 2025, indicated Resident 33 had a Brief Interview of Mental Status (BIMS- a brief screening tool that aids in detecting cognitive status) score of 9 (moderate impairment). A review of Resident 33's Progress Notes, dated March 4, 2025, at 4:14 p.m., indicated the facility had arranged with the Assisted Living facility but was declined several times due to the resident's aggressive behavior and was referred to another placement that would better addressed Resident 33's behavior. Further review of Resident 33's care plan indicated there was no documented evidence the interventions of the care plan for discharge were updated to reflect changes or developments in Resident 33's discharge planning process. 1b. A review of Resident 71's record indicated Resident 71 was admitted to the facility on [DATE], with diagnoses which included acute on chronic systolic congestive heart failure (the heart can't pump enough blood to meet the body's needs) and respiratory failure (not enough oxygen in the blood). A review of Resident 71's MDS dated [DATE], indicated Resident 71 had a BIMS score of 14 (cognitively intact). A review of Resident 71's interdisciplinary (IDT) progress note, dated March 11, 2025, indicated Resident 71 was interviewed by the SSD. The progress note indicated the Social Services Director (SSD) went over a welcome letter stating to Resident 71 he was at the facility under HMO (health maintenance organization- network or organization that provides health insurance coverage for a monthly or annual fee) insurance. The SSD stated to Resident 71, his estimated time frame of stay could be one to three weeks. The SSD stated Resident 71 had a CM (Case Manager) and a physician, and the three would collaborate and determine the course of action for his care while in the facility. A review of Resident 71's CM progress notes, dated April 4, 2025, indicated a CM from IEHP had provided the facility's CM a list of recuperative care programs for Resident 71 to choose from, as well as programs with resources such as how to apply for EBT (Electronic Benefit Transfer- system used in the United States to deliver government benefits to eligible recipients, such as SNAP (food stamps) and cash assistance, via a debit-like card), and even food banks in the area. A review of Resident 71's CM progress notes, dated April 7, 2025, indicated the CM from IEHP requested the facility to request the required DME (durable medical equipment- medical devices, equipment, or supplies that can be used repeatedly and are primarily used for medical purposes, especially at home) that would be needed prior to Resident 71 going to a recuperative care program. Further review of Resident 71's record indicated there was no documented evidence a care plan was initiated regarding discharge plans. On April 10, 2025, at 3:10 p.m. an interview was conducted with the facility CM. The CM stated Resident 71 was told on the day of admission he would be at the facility for 1 to 3 weeks, and IEHP had been covering his current stay. The CM stated a care plan should be started the day of admission and updated as discharge process continued. The CM further stated Resident 71 was shown how to take his blood sugars and the facility had requested the DME required for him to be placed in a recuperative care program. The CM further stated Resident 71 had an appeal, but that would only delay the discharge for a few days, and the facility was just waiting for the authorization from IEHP for the care program. 1c. A review of Resident 78's record indicated Resident 78 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis of the left ankle and foot (bone infection) and diabetes mellitus, type 2 (body has trouble controlling blood sugar). A review of Resident 78's MDS, dated [DATE], indicated Resident 78 had a BIMS score of 15 (cognitively intact). A review of Resident 78's IDT care conference notes, dated April 2, 2025, indicated the SSD provided Resident 78 with needed resources for discharge back to the community. Resident 78 had no income and was trying to get Supplemental Security Income (SSI- a program run by the Social Security Administration (SSA) that provides monthly benefits to individuals with limited income and resources who are blind, age 65 or older, or have a qualifying disability). A review of Resident 78's Social Services (SS) progress note, dated April 3, 2025, indicated the SSD spoke with Resident 78 and provided her with the website to go to and start her application process for disability. The SSD stated that once Resident 78 was discharged from the facility, she could go see her primary doctor, and her doctor could assist with the rest of the information needed for the disability paperwork. A review of Resident 78's care plans indicated there was no documented evidence a discharge care plan was initiated. On April 7, 2025, at 2:40 p.m., an interview was conducted with Resident 78. Resident 78 stated she was homeless and got an infection on her foot. Resident 78 stated she was supposed to get discharged on ce the antibiotics (medicine that fights bacterial infections by either killing the bacteria or preventing them from growing and multiplying) were done. Resident 78 stated the SSD gave her websites and printouts to try and get Social Security benefits. On April 9, 2025, at 10:22 a.m., an interview was conducted with the SSD. The SSD stated she provided information for the residents and their CM would follow up. On April 11, 2025, at 2:43 p.m., an interview was conducted with CM. The CM stated, We create a plan of care as we go. Long term care plan is started with updates when I have an actual discharge date . 1d. On April 10, 2025, Resident 139's record was reviewed. Resident 139 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain dysfunction), kidney failure, and diabetes (abnormal blood sugars). Resident 139 was discharged from the facility on February 3, 2025. A review of Resident 139's History and Physical Examination, dated December 23,2024, indicated Resident 139 had fluctuating capacity to understand make decisions. A review of Resident 139's MDS, dated [DATE], indicated Resident 139 had a BIMS score of 15 (cognitively intact). A review of the Social Service Progress Note, dated January 30, 2025, indicated Resident 139's family member had found placement for the resident at board and care, the Social Service Director (SSD) stated resident could still benefit from more rehabilitative therapy but due to high share of cost and resident not wanting to apply for MediCal, the discharge would move forward, and the IDT create a plan of care. A review of Resident 139's care plans indicated no discharge care plan was initiated since Resident 139's admission to the facility on [DATE]. On April 11, 2025, at 2:54 p.m., a concurrent interview was conducted with the SSD. The SSD further stated Resident 139's discharge care plan should have been updated. On April 14, 2025, at 10:02 a.m., the DON stated residents' discharge care plans should be initiated on day one of care and the initial care plan should be updated as needed. The DON stated if the resident was going to discharge to the community, the care plan should be updated. The DON further stated the Ombudsman should be included in discharge planning, and a care conference conducted within 72 hours from the time the SSD or case manager communicated the planned discharge. A review of the job description for Case Manager, indicated, .Administrative Functions .Implement and monitor the care plan to ensure effectiveness of appropriate services as part of the interdisciplinary team (IDT) and discharge planning process .Ensure that discharge needs of each resident are identified and result in the development of a discharge plan for each resident .Include regular re-evaluation of residents to identify changes that require modifications of the discharge plan; update the discharge plan as needed to reflect these changes .Ensure residents care plans accurately reflect appropriate goals, problems, and approaches and revisions based on resident needs . A review of the job description for Social Worker, indicated, .Care Plan and Assessment Functions .Participate in the development of a resident-centered care plan for each resident .Involve the resident/family in planning individualized goals for the resident .Communicate the social, psychological and emotional needs of the resident/family to other members of the IDT . A review of the policy and procedure titled, Care Planning-Interdisciplinary Team, dated August 25, 2021, indicated, .a comprehensive care plan for each resident is developed within seven (7) days of completion of the comprehensive assessment (MDS) . 49113 2. On April 7, 2025, at 9:59 a.m., Resident 13's foley catheter was observed to be cloudy with excessive sediments in the tubing. Resident 13's record was reviewed. Resident 13 was admitted on [DATE], with diagnoses which included benign prostatic hyperplasia (enlarged prostate), obstructive and reflex uropathy (blockage in the urinary tract with back flow from the bladder) and retention of urine (difficulty emptying the bladder). Resident 13's History and Physical, dated June 26, 2024, indicated Resident 13 had fluctuating capacity to understand and make decisions. Resident 13's Minimum Data Set (MDS - an assessment tool), dated January 25, 2025, indicated Resident 13 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated moderate cognition, The MDS also indicated Resident 13 was dependent for toileting hygiene, substantial to maximal assistance with lower body dressing and putting on and taking off footwear. Resident 13's Order Listing Report, included a physician's order, dated November 9, 2024, to Perform Foley (indwelling) Catheter Care every day shift and perform Foley Catheter Care as needed. A further order dated March 13, 2025, indicated, Indwelling Catheter: Foley catheter; change for blockage, leaking, pulled out, excessive sedimentation. Further review of Resident 13's record indicated there was no plan of care developed to address the use of an indwelling catheter. On April 9, 2025, at 2:08 p.m., a concurrent observation of Resident 13 and interview with Licensed Vocational Nurse (LVN) 1 was conducted. LVN 1 observed Resident 13 and stated Resident 13's foley catheter was cloudy with sediments. LVN 1 stated there was no care plan initiated regarding Resident 13's indwelling catheter. LVN 1 stated there should be a care plan developed to address the use of the indwelling catheter. On April 10, 2025, at 3:25 p.m., a concurrent record review and interview with the Director of Nursing (DON) was conducted. The DON stated there was no current care plan for foley catheter care or current daily treatment documentation. The DON stated the expectation was there should be a care plan to address Resident 13's use of the indwelling catheter. 3. On April 7, 2025, Resident 138's record was reviewed. Resident 138 was admitted to the facility on [DATE], with diagnoses which included diabetes (abnormal blood sugars) and chronic (persisting for a long time) kidney disease stage 3b (moderate kidney damage). A review of Resident 138's eINTERACT Change in Condition, dated April 3, 2025, indicated Resident 138 complained of burning during urination. Subsequently the physician was notified and the physician recommended a urinalysis. A review of Resident 138's urinalysis report indicated the urine specimen was collected on April 4, 2025, at 6 a.m., and the result was reported to the facility on [DATE], at 6:06 p.m. The result indicated Resident 138 had a signs of urinary tract infection (UTI) and the culture of the urine specimen was pending. A review of Resident 138's urine culture report, reported to the facility on [DATE], at 2:39 p.m., indicated Resident 138 had a urinary tract infection (UTI) caused by the bacteria Escherichia coli and was sensitive to several antibiotics (medication to treat infection). A review of Resident 138's care plan indicated there was no documented evidence a care plan for the change in condition identified on April 3, 2025 regarding the UTI, was initiated. On April 8, 2025, at 2:57 p.m., Resident 138 was interviewed. Resident 138 stated a few days ago she thought she had a UTI because she had a burning sensation when urinating. Resident 138 further stated she gave a sample for urine culture, but They haven't told me about the results, so I don't know if I had it or not, and they haven't started any antibiotics (medicine that stops or destroys microorganisms that cause infection). On April 10, 2025, at 3:11 p.m., a concurrent interview and review of Resident 138's record was conducted with the Director of Nursing (DON). The DON stated there was no care plan developed when Resident 138 had a change of condition on April 3, 2025, to address signs of UTI. The DON further stated a care plan should have been developed when Resident 138 had a change in condition due to the UTI. A review of the facility's policy and procedure titled, Care Planning-Interdisciplinary Team, dated August 25, 2021, indicated, .Our facility's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .care plan is based on the resident's comprehensive assessment and is developed by an Interdisciplinary Team which includes .a Registered Nurse, with responsibility for the resident, Social Services Worker responsible for the resident, the Charge Nurse Nursing Assistants with responsibility for the resident .

Based on observation, interview, and record review, for four of four residents, (Residents 14, 18, 49, and 8), the facility failed to ensure the residents were not left soiled, wet, and unchanged by staff. These failures resulted in Resident 8, 14, 18, and 49, being left soiled in their urine, feces, and wet linen for hours and feeling ignored and not cared for. In addition, the failure has the potential for the residents to develop skin conditions and infection which could affect the resident's overall health condition. Findings: 1.On April 9, 2025, at 12:50 p.m., an interview with Certified Nursing Assistant, (CNA) 1 was conducted. CNA 1 stated Resident 8 complained to her she was soiled and CNA 2 answered the light, came into the room, did not acknowledge her need, walked out and never came back to change her. CNA 1 stated she observed Resident 8 entire bed linen was soiled. On April 9, 2025, Resident 8's record was reviewed. Resident 8 was admitted on [DATE], with diagnoses which included, type 2 diabetes mellitus (body doesn't produce enough blood sugar), dementia (decline in mental abilities), and malignant neoplasm of right breast (cancer in the breast). Resident 8's care plan, revised on September 19, 2023, indicated at risk for decreased ability to perform Activity of Daily Living (ADL(s)-self care tasks) in bathing, grooming, personal hygiene, dressing and eating. Resident 8's Nursing Documentation Evaluation, dated November 12, 2024, indicated Resident 8 was incontinent for bowel and bladder. Resident 8's History and Physical, dated November 30, 2024, indicated Resident 8 had the capacity to understand and make decisions. Resident 8's Minimum Data Set (MDS-an assessment tool), dated February 5, 2025, indicated Resident 8 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact) and Resident 8 required substantial to maximal assistance with oral and personal hygiene, and was dependent for toileting hygiene, shower/bathe self, lower body dressing, putting on and taking off footwear and tub/shower transfer. On April 9, 2025, at 1:04 p.m., an interview with Resident 8 was conducted. Resident 8 stated she called for CNA 2 to clean her, CNA 2 came in the room, left and never came back to change her. Resident 8 also stated she laid in her own urine and feces for about 35-40 minutes until another CNA came and cleaned her. Resident 8 further stated she and her linen was left soiled, and she felt like she was at their mercy and not being cared for. On April 9, 2025, at 1:09 p.m., an interview CNA 2 was conducted. CNA 2 stated he was assigned to Resident 8 on April 8, 2025. CNA 2 stated Resident 8 asked for help to be cleaned, and he did not clean her as Resident 8 was due for a shower. CNA 2 stated he should have cleaned the resident and changed her linen. CNA 2 also stated, Resident 8 should not have had to wait to be cleaned, and it probably did not make her feel good. CNA 2 further stated it was not respectful to leave Resident 8 soiled in her urine and stool. On April 9, 2025, at 1:11 p.m., an interview with Resident 8's roommate (Resident 50) was conducted. Resident 50 stated CNA 2 came into the room and did not respond to Resident's 8 need. Resident 50 stated CNA 2 came in the room, left out and did not come back to clean Resident 8. Resident 50 stated it happened all the time. On April 9, 2025, Resident 50 record was reviewed. Resident 50 was admitted to the facility on [DATE], with diagnoses which included local infection of the skin, depression (mental health disorder characterized by persistent sadness) and asthma (lung disease). Resident 50's History and Physical, dated January 5, 2025, indicated Resident 50 had the capacity to understand and make decisions. Resident 50's 'Minimum Data Set (MDS), dated [DATE], indicated Resident 50 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact0. On April 9, 2025, at 4:47 p.m., an interview with , CNA 3 was conducted. CNA 3 stated she cared for Resident 8 on April 8, 2025 (3 p.m. to 11 p.m. shift), and Resident 8 informed her that she was left soiled and was not changed since before lunch. CNA 3 further stated Resident 8 stated she was not happy about the situation. CNA 3 stated she immediately cleaned Resident 8 as Resident 8's linens were soiled all over. 2. On April 7, 2025, at 1:11 p.m., an interview with Resident 14 was conducted. Resident 14 stated her call light was night answered in a timely manner. Resident 14 stated on April 6, 2025, the CNA on the day shift never changed her from morning until 2:30 p.m. Resident 14 stated she was incontinent, and her bed was wet from the top of her back to the bottom end of the bed. Resident 14 stated she felt terrible, and she felt like a dog. On April 9, 2025, Resident 14's record was reviewed. Resident 14 had an initial admitted [DATE], and was readmitted on [DATE], with diagnoses which included, acute respiratory failure (difficulty breathing), morbid obesity (too much body fat), signs involving the genitourinary system (conditions affecting the urinary systems) and lower back pain. Resident 14's History and Physical, dated September 14, 2024, indicated Resident 14 had the capacity to understand and make decisions. Resident 14's Minimum Data Set, dated dated [DATE], indicated Resident 14 had a BIMS score of 15 (cognitively intact) and Resident 14 was dependent for Activities of Daily Living (ADL) toileting hygiene, shower/bathe self, lower body dressing and putting on and taking off footwear. required substantial /maximal assistance with oral and personal hygiene, and was dependent for toileting hygiene, shower/bathe self, lower body dressing. Resident 14's care plan, revised on September 4, 2024, indicated Resident 14 required extensive assistance for ADL care in bathing, grooming, personal hygiene, dressing bed mobility, toileting related to functional decline. The care plan indicated intervention such as to provide dependent assist for toileting for Resident 14. 3. On April 7, 2025, at 4:05 p.m., an interview with Resident 18 was conducted. Resident 18 stated on April 6, 2025, he and his roommate was left wet and soiled in their urine the entire day shift from morning until 2 p.m. Resident 18 stated two weeks ago he was left soiled in his own stool and he felt like an ass. Resident 18 stated he felt neglected and ignored. Resident 18 further stated he used the call light, and no one answered. Resident 18 further stated he told staff and administration but know one came back to update him. On April 9, 2025, Resident 18's record was reviewed. Resident 18 initial admitted was June 5, 2020, with a readmitted on March 31, 2024, with diagnoses which included heart failure, morbid obesity (too much body fat), diabetes mellitus and foot ulcer (sore on the foot). Resident 18's History and Physical, dated November 30, 2024, indicated Resident 18 had the capacity to understand and make decisions. Resident 18's Minimum Data Set (MDS), dated [DATE], indicated Resident 18 had a BIMS score of 15 (cognitively intact) and Resident 18 was dependent for Activities of Daily Living (ADL) toileting hygiene, shower/bathe self, lower body dressing and putting on and taking off footwear, and required substantial/maximal assistance with shower/bathe self. Resident 18's care plan, initiated June 7, 2020, indicated a focus that Resident 18 required/is dependent for ADL care in bathing, grooming, personal hygiene, dressing eating, bed mobility, transfer, locomotion, toileting related diabetic foot infection, sepsis, general weakness, physical debility, decreased circulation, and use of diuretic. On April 14, 2025, at 10:26 a.m., an interview with Registed Nurse (RN) 1 was conducted. RN 1 stated staff reported to her that Resident 18 was left soiled. RN 1 stated she went to the room and saw the soiled stains on Resident 18 sheets. RN 1 stated she paged the CNA at 2:30 p.m. but she did not respond. RN 1 stated her expectations was that the CNA's should check all their residents to see if they are dry and clean before their shift ends. 4. On April 7, 2025, at 9:19 a.m., an anonymous online complaint was submitted. The complaint indicated Resident 49 was not touched all day as witnessed by his roommate. The complaint further indicated Resident 49 was nonverbal and could speak for himself. On April 9, 2025, Resident 49's record was reviewed. Resident 49 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (one sided paralysis) and hemiparesis (partial weakness), hear failure, and encephalopathy (disease of the brain). Resident 49's History and Physical, dated August 14, 2024, indicated Resident 49 had fluctuating capacity to understand and make decisions. Resident 49's Minimum Data Set (MDS), dated [DATE], indicated Resident 49 was dependent for Activities of Daily Living (ADL) toileting hygiene, and required substantial/maximal assist with oral hygiene, shower/bathe self, upper and lower body dressing and putting on and taking off footwear, and personal hygiene. Resident 49's care plan, initiated August 12, 2023, indicated a focus that Resident 49 required/is dependent for ADL care in bathing, grooming, personal hygiene, dressing eating, bed mobility, transfer, locomotion, toileting related recent illness, fall, hospitalization resulting in fatigue, activity intolerance and confusion. On April 10, 2024, at 8:41 a.m., an interview with CNA 4 was conducted. CNA 4 stated she worked the day shift from 6:30 a.m. to 2:30 p.m. CNA 4 stated her duties was to get residents up, dressed, groom and help with hygiene. Stated she also helps with bathing and keeping the room clean. CNA 4 stated everyone was responsible for answering the call lights. CNA 4 stated she worked the day shift on April 6, 2025, and no resident complained to her about not receiving care. CNA 4 stated she cared for all the residents assigned to her on April 6, 2025. CNA 4 also stated no staff or licensed nurse informed her of any residents complaint of not receiving care. CNA 4 stated she did not observe call lights not being answered. CNA 4 denied leaving the residents assigned to her soiled and in wet linen. On April 10, 2025, at 4:01 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was all staff can answer call lights. The DON stated no residents should have to wait pass 10 minutes to be changed and should not be left in their own stool. The DON also stated residents call light should be answered and acknowledge and the expectation was that staff would clean and change residents when made aware. On April 14, 2025, at 10:29 a.m. an interview with RN 1 was conducted. RN 1 stated the CNAs should answer the call light right away and acknowledge the resident's request. RN 1 stated the expectation was for CNAs to be attentive to the needs of the patients. RN 1 stated the CNA should have answered and acknowledged Resident's 8 call light. RN 1 also stated Resident 8 should not have had to wait to be cleaned. A review of the facility's job description titled, Certified Nursing Assistant, dated October 2020, indicated .Duties and Responsibilities .Keep the nurses' call system within easy reach of the resident . A review of the facility's policy and procedure titled, Answering the Call Light, dated October 24, 2024, indicated .The purpose of this procedure is to ensure timely response to the resident's requests and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .level of satisfaction with life .and feelings of self-worth and self-esteem .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident's request for toileting assistance . A review of the facility's policy and procedure titled, Resident Rights: dated February 2021, indicated .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to: a dignified existence .be treated with respect, kindness, and dignity .

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents, 1. For four of 88 residents (Residents 14,18, 46, and 51) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total Direct Care Service Hours (Actual DCSH) of 3.5 and the actual CNA DCSH of 2.4 hours for the month of March 2025. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents. Findings: 1. On April 7, 2025, at 1:11 p.m., during an interview with Resident 14, Resident 14 stated the call light was not answered in a timely manner. Resident 14 stated 30 percent of the time the call light is not answered at all. Resident 14 stated the CNA's go to lunch and no one covered them. Resident 14 further stated there was no teamwork, and she used the call light because she needed assistance with ice water or toileting. Resident 14 stated the CNA never changes her for the morning shift of April 6, 2025, [NAME] bed was wet from top of her back all the way down to the bottom of her bed. On April 9, 2025, Resident 14's record was reviewed. Resident 14 had an initial admitted [DATE], and was readmitted on [DATE], with diagnoses which included, acute respiratory failure (difficulty breathing), morbid obesity (too much body fat), signs involving the genitourinary system (conditions affecting the urinary systems) and lower back pain. Resident 14's History and Physical, dated September 14, 2024, indicated Resident 14 had the capacity to understand and make decisions. Resident 14's Minimum Data Set (MDS - an assessment tool), dated March 27, 2025, indicated Resident 14 had a BIMS (Brief Interview for Mental Status) score of 15 cognitively intact and Resident 14 was dependent for Activities of Daily Living (ADL) toileting hygiene, shower/bathe self, lower body dressing and putting on and taking off footwear. required substantial /maximal assistance. 2. On April 7, 2025, at 4:05 p.m. during an interview with Resident 18, Resident 18 stated he and his roommate (Resident 49) was left wet and soiled in their urine the entire day shift, from the morning until 2 p.m. on April 6, 2025. Resident 18 stated Resident 49 needed assistance and he would speak up for him because Resident 49 was non - verbal. Resident 18 also stated he was left soiled in his own bowel, two weeks ago. Resident 18 stated he used the call light, and no one would answer, and by 2:30 p.m. staff was gone. Resident 18 also stated he complained to staff, and no one responded to him. On April 9, 2025, Resident 18's record was reviewed. Resident 18 initial admitted was June 5, 2020, with a readmitted on March 31, 2024, with diagnoses which included heart failure, morbid obesity (too much body fat), diabetes mellitus (too much sugar in the blood) and foot ulcer (sore on the foot). Resident 18's History and Physical, dated November 30, 2024, indicated Resident 18 had the capacity to understand and make decisions. Resident 18's Minimum Data Set (MDS-an assessment tool), dated January 15, 2025, indicated Resident 18 had a BIMS (Brief Interview for Mental Status) score of 15 cognitively intact and Resident 18 was dependent for Activities of Daily Living (ADL) toileting hygiene, shoer/bathe self, lower body dressing and putting on and taking off footwear, and required substantial/maximal assistance with shower/bathe self. Resident 18's care plan, initiated June 7, 2020, indicated Resident 18 required/is dependent for ADL care in bathing, grooming, personal hygiene, dressing eating, bed mobility, transfer, locomotion, toileting related diabetic foot infection, sepsis, general weakness, physical debility, decreased circulation, and use of diuretic. 3. On April 8, 2025, at 8:25 a.m., during an interview with Resident 46, Resident 46 stated she had been left soiled in her own urine and stool more than three times. Resident 46 stated it t been happening so long until you feel like this was the way it was in the facility. Resident 46 stated she had told administration before that she was left in her urine and stool, and she felt like they did not care for the people in the facility. Resident 46 also stated the weekends were the worst. Resident 46's record was reviewed. Resident 46's was admitted to the facility on [DATE], with diagnoses which included lymphedema (swelling caused by blockage), muscle weakness, morbid obesity (too much body fat), right leg above knee amputation, and ulcer (sore) to left lower leg. Resident 46's History and Physical, dated June 26, 2024, indicated Resident 46 had the capacity to understand and make decisions. A review of Resident 46's MDS, dated [DATE], indicated Resident 46 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), and Resident 46 was dependent for toileting hygiene, shower/bathing, and lower and upper body dressing. A review of Resident 46's care plan, initiated January 6, 2023, indicated a focus that Resident 46 was at risk for decreased ability to perform ADLs (activity of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, toileting related to history of right above knee amputation, multiple wounds to left lower extremity, and infection with lymphedema. 4. On April 9, 2025, at 8:37 a.m., during an interview with Resident 51, Resident 51 stated the facility was short of CNAs and she had been left in her urine and stool for hours. Resident 51 stated it got so bad she told a supervisor. Resident 51 stated she had asked CNA's for things, but the staff never came back. Resident 51 stated when 2 o'clock comes you can be sure the CNA's were gone. Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included peripheral autonomic neuropathy (damaged nerves), hypertension (high blood pressure), and disorders of the diaphragm (health issues with the muscle that helps you breath). Resident 51's History and Physical, dated February 24, 2023, indicated Resident 51 had intermittent capacity to make decisions. A review of Resident's 51's MDS, dated [DATE], indicated Resident 51 had a BIMS score of 13 (cognitively intact), and Resident 51 was dependent for toileting hygiene, and lower body dressing. A review of Resident 51's care plan, initiated February 21, 2025, indicated Resident 51 had an ADLs (activity of daily living) self-care performance deficit related to activity intolerance. On April 9, 2025, at 12:50 p.m. during an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated call lights should be answered as soon as possible. On April 11, 2025, at 5:53 p.m. a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day, (DHPPD - measures the number of hours of direct care given to patients in skilled nursing facilities) was conducted with the Director of Staff Development (DSD). The DSD acknowledged and confirmed records for multiple days in March 2025, indicated the Actual Total Direct Care Service Hours (Actual DCSH) were below the required minimum of 3.5 for seven (7) of 30 days reviewed and the actual CNA DCSH were below the stated required minimum of 2.4 hours for seventeen (17) of the 30 days reviewed. The Actual Total DCSH hours were below 3.5, and the CNA DHPPD was below 2.4 on the following dates: - March 1, 2025 (Saturday): 3.22 hrs (DCSH); 2.06 (CNA DCSH) - March 5, 2025 (Wednesday): 3.28 hrs (DCSH); 2.21 (CNA DCSH); - March 7, 2025 (Wednesday): 3.48 hrs (DCSH); 2.29 (CNA DCSH); - March 8, 2025 (Saturday): 3.37 hrs (DCSH); 2.38 (CNA DCSH); - March 9, 2025, (Monday): 2.34 hrs (CNA DCSH); - March 10, 2025 (Sunday): 2.29 hrs (CNA DCSH); - March 11, 2025 (Sunday): 2.26 hrs (CNA DCSH); - March 12, 2025 (Sunday): 2.32 hrs (CNA DCSH); - March 13, 2025 (Sunday): 2.34 hrs (CNA DCSH); - March 16, 2025 (Sunday): 3.41 hrs (DCSH); 2.28 (CNA DCSH); - March 18, 2025 (Tuesday): 3.25 hrs (DCSH); 2.10 (CNA DCSH); - March 19, 2025 (Sunday): 2.14 hrs (CNA DCSH); - March 20, 2025 (Sunday): 2.38 hrs (CNA DCSH); - March 22, 2025 (Sunday): 2.39 hrs (CNA DCSH); - March 24, 2025 (Sunday): 2.38 hrs (CNA DCSH); - March 25, 2025 (Sunday): 2.33 hrs (CNA DCSH); and - March 30, 2025 (Sunday): 3.09 hrs. (DCSH); 2.27 (CNA DCSH). On April 11, 2025, at 8:29 p.m., during an intervie with the DSD, she stated CNAs should not get more than 8 residents on the a.m. shift (7 a.m. to 3 p.m.), 10 residents on the p.m. shift (3 p.m. to 11 p.m.) and 12 CNAs on the noc shift (11 p.m. to 7 a.m.). A concurrent record review and interview with the DSD of the Nursing Staff Assignment and Sign-In Sheet, for the mentioned dates indicated one CNA provided more than the projected number of residents per shift on the following dates: -March 1, 2025 (Saturday): AM shift - 10 residents each; PM shift - 13 residents each; - March 5, 2025 (Wednesday): AM shift - 9 residents each; PM shift - 11 residents each; NOC shift -15 residents each; - March 8, 2025 (Saturday): AM shift - 9 residents each; PM shift -11 residents each; NOC shift -10 residents each; - March 16, 2025 (Sunday): AM shift - 9 residents each; PM shift -11 residents each; NOC shift - 11 residents each; - March 18, 2025 (Tuesday): AM shift - 9 residents each; PM shift -11 residents each; NOC shift - 16 residents each; - March 30, 2025 (Sunday): AM shift -10 residents each; PM shift - 10 residents each; NOC shift -15 residents each. The DSD also stated some concerns was staff burn out, and residents can experience possible neglect. The DSD stated the DHPPD for Actual Total Direct Care Service Hours and Actual Total CNA Direct Are Service Hours were not met on documented dates reviewed. The DSD further stated the expectation was that the facility meets the DHPPD. The DSD stated possible causes of not meeting was challenges in the pay offered, and no hiring bonuses. On April 11, 2025, at 8:21 a.m. during an interview with the DSD, the DSD stated she determined staffing by using a facility software for (staffing labor projections) and the census to determine staffing needs. The DSD also stated if patient acuity is high, she balanced out the assignment between the CNAs and asks staff to stay over as a float to assist. The DSD stated the facility was impacted as the census increased. The DSD stated the facility required at least a two-hour notice for call offs. The DSD stated she did not use registry and offered facility staff double shifts. She stated some staff had brought some workload concerns to her attention and it was a process of weeding out the staff that did not meet the facility needs.The DSD also stated she determined resident's needs by listening to the residents, referred them to quality assurance and assessments, in-services, and exit interviews to determine the competency needs. The DSD stated she make sure staff are appropriately assigned by knowing the individual staff competencies and personally observing their skills. On April 11, 2025, at 9:22 p.m., during a concurrent record review and interview with the Director of Nursing (DON), the DON acknowledged and confirmed the facility did not meet the DHPPD for documented dates reviewed. The DON further stated not meeting the hours for patient care affect the quality of resident care. On April 14, 2025, at 11:20 a.m., an interview with Certified Nursing Assistant (CNA) 6 was conducted. CNA 6 stated she worked the day shifts 6:30 a.m. to 2:30 p.m. CNA 6 stated she was normally assigned 10 residents when the census was high. CNA 6 stated today she had 13. CNA 6 stated when the acuity was high, her workload was harder. CNA 6 stated she did her best to work safely, but she felt rushed to get her work done and felt pulled in many directions. CNA 6 stated when the census was 90 there was 9 to 10 CNAs assigned, but lately it was about 7 CNAs assigned. CNA 6 stated they had been short staffed during the weekdays and the weekend. CNA 6 stated the facility did not have enough staff and administration was made aware. A review of the facility's job description titled, Certified Nursing Assistant, dated October 2020, indicated .Duties and Responsibilities .Keep the nurses' call system within easy reach of the resident . A review of the facility's policy and procedure titled, Answering the Call Light, dated October 24, 2024, indicated, .The purpose of this procedure is to ensure timely response to the resident's requests and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . A review of the facility's policy and procedure titled, Staffing, revised October 2017, indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services .staffing numbers and the skill requirement of direct care staff are determined by the deeds of residents .