Every finding on record at English Oaks Convalescent & Rehabilitation Hospita

Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing information accurately and completely reflected the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift when the facility's daily nurse staffing posting did not reflect the actual hours worked per shift by nursing staff responsible for resident care.This deficient practice had the potential to prevent residents, staff, visitors, and the public from having access to complete, accurate, and current nurse staffing information for a facility census of 165 residents. Findings: During a concurrent interview and record review on 8/17/26 at 2:10 PM with the Staffing Coordinator (SC), the SC reviewed the facility's Nurse Staffing posting hours. The SC stated that she prepared and posted the staffing information daily. The SC reviewed the facility's posting and stated that it included the facility name, date, total resident census, projected total hours, the number of nurses and Certified Nursing Assistants (CNAs) scheduled for each shift and Nursing staffing ratio for CNAs and Licensed Nurses. The SC stated that the total hours represented the facility's projected hours. When asked whether the staffing posting reflected the actual hours worked by nursing staff for each shift, the SC stated that the posting contained only the projected hours and confirmed that actual hours worked were not included on the daily staffing posting. When asked where the actual hours worked were subsequently posted or made available, the SC stated that she did not know where the facility posted that information. During a concurrent interview and record review on 8/17/26 at 4:45 PM with the Director of Nursing (DON), the DON reviewed the facility's Nurse Staffing hours posting information. The DON confirmed that the posting reflected only the projected hours and not the actual hours worked by nursing staff per shift. The DON stated that she did not know that they were expected to post the actual hours worked per shift on the daily nurse staffing posting. The DON further stated that there was no way for the residents, family members, visitors, and staff to know the actual facility's daily nursing staffing hours status. The DON stated that accurate and complete nurse staffing information played an important role in the delivery of quality care and services to residents.

Based on observation, interviews, and record review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP - infection prevention measures requiring staff to wear gown and gloves during high-contact resident care activities [care requiring frequent hands-on contact with the resident]) for one of three sampled residents (Resident 4), when the Rehabilitation Aide (RA) 1 transferred Resident 4 from the bed to a wheelchair without wearing a gown.This deficient practice had the potential to increase the risk for transmission of multidrug-resistant organisms (MDRO - bacteria that are resistant to multiple antibiotics) and cross-contamination (the spread of germs from one person or object to another) to Resident 4, staff, and other residents.FINDINGS:Review of Resident 4's admission RECORD indicated Resident 4 was admitted to the facility with multiple diagnoses, including urinary retention (a condition in which a person cannot completely empty the bladder), generalized muscle weakness, abnormalities of gait and mobility, and aftercare following right knee replacement surgery.Review of Resident 4's Order Review Report indicated the physician ordered Enhanced Barrier Precautions (EBP) on 7/6/26 for high-contact resident care activities related to Resident 4's indwelling urinary catheter (a tube inserted into the bladder to continuously drain urine).During an observation on 7/10/26, at 11:17 a.m., RA 1 was observed transferring Resident 4 from the bed to a wheelchair without wearing a gown. Resident 4 had an indwelling urinary catheter, and an EBP sign was posted outside Resident 4's room.During an interview on 7/10/26, at 11:28 a.m., RA 1 stated gown and gloves were required only when handling the urinary catheter. RA 1 reviewed the EBP signage posted and acknowledged staff should wear the required personal protective equipment during resident transfers. RA 1 stated following the PPE requirements was important to reduce infection-control risks.During an interview and record review on 7/10/26, at 2:10 p.m., the facility's Enhanced Barrier Precautions policy and Resident 4's Order Review Report was reviewed with the Infection Preventionist (IP). The IP verified that Resident 4 was placed on EBP due to his urinary catheter. The IP verified resident transfers were high-contact resident care activities requiring gown and gloves. The IP stated staff were required to wear gown when assisted residents on EBP with transfers. During an interview on 7/10/26, at 4:11 p.m., the observation findings were reviewed with the Director of Nursing (DON). The DON stated staff were expected to follow the facility's Enhanced Barrier Precautions policy. The DON confirmed the observed transfer did not comply with the facility's policy because RA 1 did not wear the required gown during a high-contact resident care activity.Review of the facility's policy titled, Enhanced Barrier Precautions, revised 12/24, indicated, .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. 8. Examples of high-contact resident care activities requiring gown and gloves include: . e. transferring. 11. Outside the resident's room, EBPs are indicated when anticipating close physical contact, including performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym .

Based on interviews and record reviews, the facility failed to timely assess and notify the physician for one of three sampled residents (Resident 3's) change in condition of an undesirable weight change, when Resident 3 gained 10 lbs. (pounds) from 219 lbs. on 6/17/26 to 229 lbs. on 6/23/26, and staff did not complete a change in condition assessment and notified the physician until 6/29/26.This deficient practice resulted in delayed nursing assessment, identification and treatment of fluid overload, placing Resident 1 at risk for worsening edema, respiratory compromise, further clinical decline, and hospitalization.Findings: Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with multiple diagnoses, including orthopedic aftercare following surgical amputation (care provided after surgical removal of a limb or part of limb), peripheral vascular disease (poor circulation in the blood vessels outside the heart and brain), hypertension (high blood pressure), and type 2 diabetes mellitus (a condition that causes elevated blood sugar levels).Review of Resident 3's Weights and Vitals Summary indicated Resident 3 weighed 219 lbs. on 6/17/26 and 229 lbs. on 6/23/26, an increase of 10 lbs. in six days. The record further indicated Resident 3 weighed 249 lbs. on 7/1/26, an additional increase of 20 lbs. and a total increase of 30 lbs. from 6/17/26.Review of Resident 3's Progress Notes, Nursing assessments, Situation-Background-Assessment-Recommendation documentation (SBAR - a structured clinical communication tool), Change in Condition documentation, Order Review Report, and Medication Administration Record for the month of June 2026 did not show that staff assessed Resident 3's change in condition of 10 lbs. weight gain and notified the physician when identified on 6/23/26. Further review of Resident 3's Progress Notes indicated a nursing assessment addressing Resident 3's significant weight gain and notification to the physician did not occur until 6/29/26. Review of Resident 3's RD (Registered Dietitian) weight variance note dated 6/29/26, indicated, .Patient reviewed d/t [due to] significant weight gain of +10# [pounds]/4.5% in 6 days. Overall pt [patient] has wt [weight] gain of +14#/6.5% in ~30 days . Weight gain is likely r/t [related to] fluid retention [swelling caused by excessive fluid buildup in body tissues] Pt has edema to BLE [both lower extremities] .Unintended weight gain r/t fluid shifts . Review of Resident 3's Progress Notes dated 7/1/26 indicated Resident 3's weight increased to 249 pounds and the edema worsened to both lower extremities, thighs, and scrotum. During a concurrent interview and record review on 7/10/26, at 8:49 a.m., Licensed Nurse (LN 1) reviewed Resident 3's Weights and Vitals Summary, Progress Notes, and nursing assessments. LN 1 stated Resident 3's 10-pound weight gain from 6/17/26 to 6/23/26 was significant and staff should have completed a Change in Condition assessment when the weight gain was identified. LN 1 verified Resident 3's clinical record did not contain a nursing assessment related to the weight gain or documented physician notification until 6/29/26. LN 1 stated staff should have assessed Resident 3 sooner. LN 1 further stated that delayed assessment placed Resident 3 at risk for complications.During a concurrent interview and record review on 7/10/26, at 4:11 p.m., the Director of Nursing (DON) reviewed Resident 3's weight records, progress notes, nursing assessments, and change in condition documentation. The DON verified the clinical record did not contain documentation of a nursing assessment or communication with the physician or dietitian when the resident gained 10 pounds on 6/23/26. The DON stated staff should have completed a Change in Condition assessment, monitored the resident, and addressed the weight gain sooner than 6/29/26.During a concurrent interview and record review on 7/14/26, at 9:23 a.m., the Registered Dietitian (RD) 1 reviewed Resident 3's Progress Notes and Weights and Vitals Summary. RD 1 stated Resident 3's 10-pound weight gain in 6 days was significant and concerning. RD 1 added staff should have assessed and reweighed the resident. RD 1 stated resident weights were part of the nursing assessment. RD 1 verified the clinical record did not contain an assessment addressing the weight gain until 6/29/26.Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 2/21, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . significant change in the resident's physical/emotional/mental condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the facility's policy titled, Weight Assessment and Intervention, revised 3/22, indicated, .Resident weights are monitored for undesirable or unintended weight loss or gain.Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing . 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. The evaluation includes. c. the relationship between current medical condition or clinical situation and recent fluctuations in weight .

Based on interview, and record review, the facility failed to maintain complete and accurate medical records for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's medication administration record (MAR) for the intravenous (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) drug Cefepime (an antibiotic, medicine used to treat bacterial infections) was left blank for Resident 1's 11 AM scheduled dose on 6/20/26, and blank for the 7 PM scheduled dose on 6/25/26.2. Resident 1's medication side effect monitoring for IV drug Cefepime was not documented in the electronic health record (EHR) on 6/18/26, and 7/2/26; and,3. Resident 2's MAR were left blank for the scheduled IV Cefepime dose on 6/9/26 at 10 PM, 6/10/26, and 6/15/26 at 6 AM, 6/19/26 at 10 PM, 6/21/26, 6/22/26 and 6/27/26 at 6 AM, and 6/30/26 at 2PM. These failures resulted in Resident 1 and Resident 2's medical record inaccurately reflected the care provided and had the potential for breakdown in staff communication, and a delayed recognition of medication side effects.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 had diagnoses including methicillin susceptible staphylococcus aureus infection (bacterial infection that responds to standard antibiotics), bacteremia (presence of live bacteria in the bloodstream) and acute kidney failure (loss of kidney function).During a concurrent interview and record review on 7/10/26, at 3:40 PM with the Registered Nurse Supervisor (RNS) 1, Resident 1's MAR for June 2026 was reviewed. RNS 1 confirmed the administration of Resident 1's cefepime was not documented on 6/20/26 at 11 AM and 6/25/26 at 7 PM. RNS 1 stated the IV antibiotics administration should have been documented if it was given or not. RNS 1 further stated that sometimes the nurses forgot to document in the MAR.2. A review of Resident 1's Care Plan, dated 5/29/26, indicated Resident 1 was admitted with infections including enteritis (an inflammation of the small intestine), bacteremia, osteomyelitis (an infection and inflammation of the bone). Resident 1's care plan interventions included, .Administer antibiotic and treatment as prescribed by Physician. Evaluate/record/report effectiveness and any adverse side effects. Report to Physician worsening signs and symptoms of infection or lack of improvement from treatment.monitor and document PRN [as needed] adverse reactions to ANTIBIOTIC therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions.and report to Physician.During a concurrent interview and record review on 7/10/26, at 3:40 PM, with RNS 1, Resident 1's progress notes for the months of June 2026 and July 2026 were reviewed. RNS 1 stated the nurses assigned to the med carts monitored residents for antibiotic medication side effects (SE) and were responsible for the documentation. RNS 1 confirmed that there was no documentation in Resident 1's EHR for the monitoring of side effects for antibiotic use on June 18 and July 2.A review of facility provided document titled, CEFEPIME FOR INJECTION, revised 11/21, indicated that, .WARNINGS AND PRECAUTIONS. Hypersensitivity Reactions [overreaction of the body's immune system].Neurotoxicity [damage to the brain or nervous system caused by exposure to toxic substances]: May occur especially in patients with renal impairment [damaged kidneys that cannot properly filter waste and excess fluids from the blood].Clostridioides difficile-Associated Diarrhea (CDAD [harmful intestinal infection caused by the C. diff bacteria]): Evaluate if diarrhea occurs. DRUG INTERACTIONS.nephrotoxicity [kidney damage] has been reported following concomitant administration of other cephalosporins [type of antibiotic] with potent diuretics [water pills] such as furosemide. Monitor renal function.3. A review of Resident 2's admission RECORD, indicated Resident 2 had diagnoses including infection and inflammatory reaction due to internal left hip prosthesis (bacteria have entered the area around the artificial left hip joint).A review of Resident 2's Care Plan, dated 6/16/26, indicated Resident 2 was admitted on IV therapy and was at risk for IV therapy complications and adverse drug reaction. The care plan further indicated that left hip arthroplasty (joint replacement surgery) infection was the reason for IV therapy. Care Plan interventions included, .Administer IV therapy/medication as ordered by Physician. Monitor for side effects and effectiveness.Monitor and document signs and symptoms of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth and notify Physician.A review of Resident 2's Care Plan, dated 6/10/26, indicated Resident 2 was admitted with infection due to left hip arthroplasty infection, medication: Cefepime IV antibiotics. Care Plan interventions indicated, .Administer antibiotic and treatment as ordered by Physician. Evaluate/record/report effectiveness and any adverse side effects. Report to Physician worsening signs and symptoms of infection or lack of improvement from treatment.During a concurrent interview and record review on 7/10/26, at 3:50 PM, with RNS 1, Resident 2's MAR for June 2026 was reviewed. RNS 1 confirmed that there was no documentation on the MAR for cefepime being administered on June 10 at 6AM, June 15 at 6 AM, June 19 at 10 PM, June 21 and June 22 at 6 AM, June 27 at 6AM, and June 30 at 2PM. During a concurrent interview and record review on 7/10/26, at 4:31 PM, with the Director of Nursing (DON), Resident 1's Infection Nurses Notes for the month of June and July were reviewed. The DON confirmed that there were no IV antibiotic monitoring notes on June 18 and July 2 for Resident 1. The DON stated that she expected the nurses to document monitoring notes when a resident was on IV antibiotics. The DON further stated if they did not document, they would not know that the antibiotics was working or if the resident was having side effects. The DON stated that she expected the nurses to document in the MAR when they administered the medication and that the expectation was to document it as soon as it was given. The DON further stated that if the nurses got busy, then they could make a late documentation. During a phone interview on 7/16/26, at 1:33 PM, with RNS 2, RNS 2 stated she was familiar with Resident 1 and Resident 2, and she administered IV antibiotics to both residents on her shift. RNS 2 stated she would document the administration of the IV medication in the resident's MAR after she would give the IV antibiotics. RNS 2 stated that during shift change she discussed with the oncoming shift nurses about the administration of a resident's IV antibiotics and that is how they ensured the IV antibiotic dose was not missed for their residents. RNS 2 further stated she never missed a dose to hang for Resident 1 or Resident 2's IV antibiotic and that she may have forgotten to document in the MAR when the IV antibiotic was given.A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed.As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration.any complaints or symptoms for which the drug was administered.any results achieved and when those results were observed and.the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency for one of three sampled residents (Resident 1) when, Responsible Party (RP) 1 indicated to the Director of Nursing (DON) that Resident 1 might have been handled roughly by staff and RP 1 suspected physical abuse after both of Resident 1's arms were found to have bruises on them on 4/20/26.This failure resulted in a delay of the state survey agency investigating an allegation of abuse, which had the potential to put Resident 1's, and other residents in the facility, health and safety at risk.Findings:Review of Resident 1's admission RECORD indicated, Resident 1 was admitted to the facility with multiple diagnoses including but not limited to, Senile degeneration of the brain, (age-related, progressive declines in cognitive function-such as memory, reasoning, and daily living skills), dementia (decline in mental ability severe enough to interfere with daily life) and major depressive disorder (a serious mood disorder causing persistent feelings of sadness, hopelessness, and a loss of interest in activities).During an interview on 6/16/26, at 2:21 p.m., RP 1 stated that on 4/20/26, she reported to the DON that she suspected physical abuse to Resident 1 had occurred after Resident 1 was found to have bruises on both of her arms.During an interview on 6/17/26, at 12:55 p.m., Treatment Nurse (TN) 1 stated she assessed Resident 1 on 4/20/26 along with the DON and they found bruises on both arms of Resident 1.During an interview on 6/17/21, at 1:45 p.m., the DON confirmed she assessed Resident 1 on 4/20/26 with TN 1 and found bruises on both arms of Resident 1. The DON stated she reported this finding to RP 1 who then alleged that Resident 1 might have been the victim of physical abuse by a staff member. The DON stated she reported this finding to the Administrator (ADM). The DON further stated that this incident was reportable and any allegation of physical abuse was reportable to the state survey agency. The DON stated she believed that this allegation was reported to the state survey agency by the ADM.During an interview on 6/17/26, at 2:35p.m., the ADM stated, no allegation of physical abuse to Resident 1 was reported to her by the DON. The ADM stated all allegations of abuse needed to be reported to the administrator of the facility and the state survey agency. The ADM stated not reporting abuse put Resident 1 at risk of not receiving proper treatment and repeated abuse. The ADM stated it was very important to report all allegations of abuse to ensure the safety of the patient and to prevent and stop further incidents of abuse. Review of Resident 1's Skin/Wound Note, dated 4/20/26, indicated, .Upon skin evaluation by the writer and DON [Resident 1] noted with scattered discolorations to bilateral [both] upper extremities and skin tear [when the top layer of your skin separates from the underlying layer that typically resemble a large cut or scrape] to right forearm.Review of Resident 1's NSG [nursing]: Weekly Observation dated 4/21/26, under the section Nutrition/Skin, indicated, .Skin Tear(s) .right forearm.Ecchymosis [Bruising].bilateral upper extremities.Review of Resident 1's order dated 4/20/26, indicated, .TX [treatment]: Ecchymosis .Site: bilateral upper extremities. Monitor daily for increase in size, shape, skin breakdown and s/sx [signs and symptoms] of infection and notify physician if indicated until resolved, every shift.Review of a facility policy and procedure (P&P) titled Reporting Abuse to State Agencies and Other Entities/Individuals revised 12/06, the P&P indicated, .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies or individuals as may be required by the law. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility.2. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident.

Based on interview and record review, the facility failed to ensure that an allegation of sexual abuse involving one of five sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH) within two hours after the facility had knowledge of the allegation, as required by federal regulations (Pursuant to Title 42 Code of Federal Regulations section 483.12(c)(1)). This failure delayed the CDPH's review of the alleged abuse and potentially placed Resident 1 and other residents in the facility at risk for ongoing abuse. Findings:During an interview on 1/27/26 at 3:52 PM with Resident 1 at his bedside, Resident 1 stated, .someone tried to climb on me. and it happened only once.it happened about two nights ago. It was dark but he was tall and bald. Resident 1 further stated, .He tried to have sex with me, he pulled down my pants, he took his thing out, he tried to climb on top of me.I pushed him away.I screamed for help, my neighbor heard it.then he went away. Resident 1 later identified the individual as CNA 2. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, an assessment tool) score of 9 (BIMS scores are as follows: 13 to 15: Normal thinking and memory (no or very little impairment) 8 to 12: Moderate problems with thinking and memory. 0 to 7: Severe problems with thinking and memory). During a phone interview on 1/28/26 at 10:39 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that on Sunday (1/25/26) at approximately 2:15 PM, Resident 1 showed her a notepad with the word rape written on it and stated that the male CNA on the NOC (night) shift was raping him. CNA 1 stated she reported the allegation to Licensed Nurse (LN) 3 between 2:30 PM and 3:00 PM on 1/25/26 and provided a written statement the same day.During a phone interview on 2/2/26 at 2:28 PM with Licensed Nurse (LN) 3, LN 3 stated that she was notified of the allegation involving Resident 1 at approximately 2:30 PM on 1/25/26 and immediately notified LN 2.During a review of the facility's Progress Note dated 1/25/26 at 5:15 PM, authored by LN 2, the note indicated the Administrator (ADM) and Director of Nursing (DON) were made aware of the allegation.During an interview on 1/28/26 at 11:37 AM with the ADM, the ADM stated she was notified of the allegation on 1/25/26 at approximately 3:17 PM. The ADM stated the CDPH was notified on 1/25/26; however, she was unable to provide evidence of the exact time of notification.During an interview on 1/28/26 at 1:20 PM with the Director of Nursing (DON), the DON stated that law enforcement was notified on 1/25/26 at approximately 4:15 PM. The DON stated that the CDPH was notified on 1/25/26; however, she was unable to provide evidence of the time of notification.During a review of the SOC 341 submitted to the CDPH by the facility, the SOC 341 for Resident 1 was received via email on 1/26/26 at 1:57 PM.During a telephone interview on 2/23/26 at 9:39 AM with the ADM, the ADM stated she was aware that the alleged abuse involving Resident 1 should have been reported to the CDPH within two hours. The ADM stated staff documented that the SOC 341 was sent to CDPH; however, she was unable to provide documentation confirming submission to CDPH within the required two-hour timeframe on 1/25/26.A review of the facility's policy titled Abuse Prevention Program, revised 12/2016, indicated, .residents have the right to be free from abuse.this includes.sexual abuse.Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out proper dress code when dietary relief (DR) 1 did not wear a beard net properly exposing facial hair. This failure had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. The facility census was 167.Findings: During a concurrent observation and interview on 1/14/26, at 11:15 a.m., with registered dietitian (RD) 1, tray line (assembly line for food, commonly used in hospitals and nursing homes to prepare patient meals. Workers stand at stations, adding specific items-like hot food, drinks, or cutlery-to a moving tray as it passes) was observed. RD 1 verified DR 1 beard net was not covering all of his facial hair. RD 1 stated DR 1's beard net should have been covering his mustache. RD 1 also stated wearing hair and beard nets properly prevents physical contamination from entering the food being prepared to serve. During an interview on 1/15/26, at 8:30 a.m., with RD 2, RD 2 stated not wearing a beard net properly was a sanitation issue effecting quality of food and hair could also cause residents to choke. During a review of a facility policy and procedure (P&P) titled, DRESS CODE dated 2023, the P&P indicated, .personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department.Hair net for hair.If applicable, bears and mustaches (any facial hair) must wear beard restraint.

The facility failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications based on standards of practice for a resident census of 167 when: 1. Pharmaceutical waste (discontinued or no longer needed drugs) including prescription and over the counter (drugs sold directly to consumers without needing a prescription) medications were not rendered unusable when disposed in the pharmaceutical waste bin (also known as a drug waste bucket) and were accessible with hand retrieval from the waste bin; and, 2. Medication delivery slips and manifests from the pharmacy provider were not consistently signed and dated by licensed staff upon receipt from delivery courier for accuracy and accountability of prescription medication received. These failures could result in unsafe disposal of the discontinued prescription medications and the risk of drug diversion (illegal use of drugs).Findings:1.During a concurrent observation and interview on 1/14/26, at 11:13 a.m., Licensed Nurse (LN) 8 confirmed that the pharmaceutical waste bin located in the Medication Room at the South Nurse Station was observed with the lid left open. Prescription and over-the counter medications were present in the bin and had not been rendered unusable, making them accessible to any individual with access to the medication room. LN 8 described the facility's process for disposal of non-controlled medications, stating that licensed nurses on the night shift were responsible for medication disposal. LN 8 stated process included removing resident identification stickers from the medication packaging, documenting the medication name and quantity in the non-narcotic medication destruction log maintained in the medication room, and disposing of the medications in the pharmaceutical waste bin. LN 8 added the facility policy required two licensed nurses to sign the medication destruction log. LN 8 further acknowledged that, when medications were not rendered unusable and the pharmaceutical waste bin lid was left open, there was a risk that medications could be accessed or removed by individuals with keys to the medication room, creating potential for diversion of medications. During a concurrent observation and interview on 1/14/26, at 1:40 p.m., Infection Control Nurse (IP) at the west nurses' station medication room confirmed that the pharmaceutical waste bin was observed to be open and that medications inside the bin were accessible and had not been rendered unusable. IP stated that, as safety precautions, medications should be crushed or dissolved in the approved solution prior to placement in the pharmaceutical waste bin to ensure destruction. IP further stated that nurses were required to don gloves, remove medication labels, and document the medication name and quantity in the non-narcotic medication destruction log located in the medication room, and the log must be signed by two licensed nurses in accordance with facility protocol. IP stated that leaving medications usable and accessible in the medication room posed a potential for medication diversion. IP indicated that her expectation of licensed nurses was to properly dispose of medications by following the established procedures to ensure medications were rendered non-retrievable and in compliance with regulatory requirements. The IP further stated that this expectation was not met.During an interview on 1/15/26, at 9:48 p.m., LN 10 stated that night shift nurses were responsible for destroying medications located in the medication rooms at the nurses' stations. LN 10 stated that medications that were placed into the pharmaceutical waste bin should be rendered unusable. LN 10 further stated that an approved dissolving solution was available in the medication carts for the nurses to use to dissolve medications prior to disposal of non-narcotic medications. LN 10 further added that failure to properly dispose of medications had a risk that individuals with access to the medication room could remove medications from the pharmaceutical waste bin, creating potential for diversion.During a phone interview on 1/15/25, at 2:00 p.m., the Pharmacy Consultant (PC) stated that licensed nurses were expected to dispose of non-narcotic medications with verification by two nurses, in accordance with the facility policy, and to ensure medications were placed into an approved pharmaceutical waste bin with the lid securely closed so that medications were not accessible.Review of the facility provided policy and procedure (P&P) titled Discarding and Destroying Medications, revised in June 2025 indicated, . Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. 3. Non-controlled. are disposed of in accordance with state regulations and federal guidelines. 2.Review of the facility documents titled Packing Slip, located in a delivery manifests binder in the south nurses' station, between 1/1/26 through 1/13/26, indicated, Deliver to: [facility name] . By signing below, you acknowledge that the items above have been received. Discrepancies must be reported to the pharmacy within 4 hrs of delivery. Nurse Signature Date Time. The review revealed that the documents were incomplete, as they were not consistently signed, dated, and timed by licensed nursing staff as required.During a concurrent interview and record review on 1/14/26 10:47 a.m., with LN 8 at the south nurses' station, pharmacy medication delivery manifests/slips dated from 1/01/26 through 1/13/26 were reviewed. The review revealed that medication delivery slips were not consistently signed and dated by licensed nursing staff. Delivery slips on 1/7/26, 1/10/26, and 1/11/26 were found to be missing required signatures and/or dates and times. LN 8 confirmed these findings. LN 8 stated that delivery manifest binders were located at each nurses' station and were available for nursing staff to file the delivery slips after they were properly signed and dated upon receipt of medications from the pharmacy provider. LN 8 stated that upon medication delivery, nurses were responsible for verifying that the medications received match the information documented on the delivery slips, including medication name, dosage, and quantity. LN 8 emphasized the importance of signing and dating medication delivery slips, stating that this process assisted in identifying potential medication errors related to medication name, dosage, or quantity. LN 8 further stated that without properly signed and dated delivery slips, the facility was unable to accurately track missing medications or determine which staff member received the medications and the date and time the medications were received.During an interview on 1/14/2026, at 12:30 p.m., LN 13 stated that pharmacy deliveries were primarily received during the night shift. LN 13 further stated that the nurse who received the medications was responsible for verifying the delivery for accuracy and discrepancies and ensuring that the medication delivery manifest/slip was signed and dated upon receipt.During an interview on 1/15/2026, at 9:36 a.m., LN 14 described the facility's process for receiving medications from the pharmacy provider, stating that the receiving nurse was required to sign both copies of the delivery manifest/slip. LN 14 stated one signed copy was retained in the facility's medication manifest binder. LN 14 emphasized that the receiving nurse was responsible to document signature, date, and time of receipt to ensure accurate tracking, verification of medication receipt, and compliance with insurance purposes. During a phone interview on 1/15/2026, at 2:00 p.m., PC stated that nurses were expected to sign and date medication delivery manifests/slips at the time medications were received from the pharmacy and to maintain a signed copy in the facility. PC further stated that all discrepancies should be noted upon receipt and reported to the pharmacy. PC indicated that to prevent the possibility of medication diversion, medication manifests/slips should be properly signed and dated.During an interview on 1/15/26, at 3:40 p.m., the DON stated that medications from the pharmacy provider were primarily received by the night shift nurses. The DON further stated that licensed nursing staff were expected to reconcile medications with the medication delivery manifests/slips and to sign and date the receipts at the time of delivery.Review of the facility provided P&P titled Pharmacy Services Overview, revised on April 2019 indicated, . Policy Interpretation and Implementation. 9. The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including. (1) receipt. (4) facility staff roles and responsibilities during the receipt and storage of medication.

Based on observation, interview, and record review, the facility failed to ensure that staff protected the residents' personal privacy and confidentiality for one out of 33 sampled residents (Resident 4) and one unsampled resident (Resident 19) when:1.The Respiratory Therapist (RT) performed tracheostomy care (care provided to keep a breathing tube and the opening in the neck clean and functioning to help a person breathe safely) for Resident 4 without closing the resident's room door, exposing the resident to other staff, residents, and/or visitors during a personal medical procedure; and,2.Resident 19's confidential electronic medical record (EMR, a confidential electronic medical record that details the residents' health, treatment, demographic information, and payment source) was left opened on a laptop computer in a common hallway of the facility.These failures had the potential to result in compromised resident dignity, emotional distress, and unauthorized disclosure of protected health information. Findings: Findings: 1.Review of Resident 4's admission RECORD, (a document that contains the resident's demographic information) indicated Resident 4 was admitted to the facility with multiple diagnoses, which included dysphagia (difficulty swallowing caused by problems in the mouth or throat), and aphasia (a condition that affects a resident's ability to speak, understand speech, read, or write due to damage to the brain). During a concurrent observation and interview conducted on 1/15/26 at 2:57 p.m. with the Respiratory Therapist (RT) in Resident 4's room, the RT performed tracheostomy care while Resident 4's bedroom door remained open. The RT confirmed that the door remained open throughout the medical procedure, which allowed visibility into the room by staff, residents, and/or visitors from the hallway. The RT stated that he should have ensured privacy by closing the door or pulling the privacy curtains (curtains that close around a bed to provide privacy). The RT acknowledged the bedroom door was left open and was an oversight on his part. The RT stated that he should have protected Resident 4's privacy and dignity during the provision of care. During a concurrent interview and record review on 1/15/26 at 3:34 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Dignity, dated 2/21, was reviewed. The P&P indicated, .Each resident shall be cared for in a manner that promotes.feelings of self-worth and self-esteem.11. Staff promote, maintain, and protect resident privacy, including bodily privacy, during assistance with personal care and during treatment procedures. The ADM verified that the RT had not followed the facility's policy when he had not provided privacy for Resident 4 when the RT administered tracheostomy care. The ADM stated that she expected the staff to provide privacy during all treatments and procedures. The ADM further acknowledged that when privacy was not provided during treatment, Resident 4's dignity may have been negatively impacted. 2. During an observation on 1/15/26 at 9:08 AM in the [NAME] Station Unit, (a nurses' station in the facility) an open laptop computer was left on top of a medication cart (a mobile unit on wheels used to organize, transport, and dispense medications, in healthcare facilities) which exposed Resident 19's personal and medical information to anyone who walked by the laptop computer. During an interview on 1/15/26 at 9:11 AM with the Licensed Nurse (LN) 5, LN 5 confirmed she used the medication cart with the laptop and stated she stepped away from the computer and gave a medication to a resident and had forgotten to lock the computer screen (pushing the lock button hides the computer information). LN 5 stated the facility required the staff to protect the resident's information and that she should have locked the computer screen when she stepped away from it. LN 5 stated it was important to lock the computer screen so other residents or visitors who walked by the computer could not visualize Resident 19's confidential personal information. During an interview on 1/15/26 at 9:29 AM with LN 1, LN 1 stated the expectation was when nursing staff walked away from their computers, the nursing staff were to lock the computer screens. LN 1 stated when the computer screen was left open with Resident 19's information it, it was considered a HIPPA violation (HIPPA -Health Insurance Portability and Accountability Act -a United States law that sets national standards to protect sensitive patient health information). LN 1 stated the risk to Resident 19 was exposure of their protected health information to others who did not have authority to access it. During an interview on 1/15/26 at 10:24 AM with the Administrator (ADM), the ADM stated it was important to protect residents' medical information because of HIPPA laws. The ADM further stated it was her expectation that when staff walked away from their computer, they logged off (locked the computer) so no resident's information could be seen. Review of a facility provided policy and procedure (P&P) titled, Computer Terminals/Workstations, dated 4/14, indicated, .Computer terminals and workstations will be positioned/shielded to ensure that protected health information (PHI).is protected from public view or unauthorized access.A user may not leave his/her workstation or terminal unattended unless the terminal screen is cleared and the user is logged off.

Based on observation, interview, and record review, the facility failed to ensure that staff treated three of 33 sampled residents with dignity and respect when,1. The infection preventionist (IP) referred to Resident 193 as a feeder (a derogatory term sometimes used by nursing staff when a resident needs total staff assistance with feeding) which labelled Resident 193 by her care needs rather than as an individual.2. Staff posted signage in Resident 22's room identifying the resident as a 1:1 feeder (one staff member assists one resident at a time with feeding) which publicly disclosed Resident 22's care needs and placed the resident at risk for diminished dignity.3. The urinary catheter bag (a urine drainage bag that collects urine via a catheter- plastic tube inserted into the bladder) of Resident 6 was left uncovered and without a privacy cover (a cover placed over the urine collection bag so that the urine in the bag cannot be seen). This failure had the potential to negatively impact the residents' dignity, self-worth, and right to be treated with respect.Findings: 1.During a concurrent observation and Interview on 1/14/25 at 9:54 AM with the Infection Preventionist (IP) at Resident 193's bedside, the IP stated Resident 193 was on aspiration precautions (intervention that prevent food, liquid, or saliva from entering the airway) and was a feeder. Review of Resident 193's care plan, (a document that contains the resident's problems, goals, and interventions) the document indicated, .At risk for altered nutritional status.poor oral intake.dysphagia [difficulty swallowing] .Aspiration Precautions: Sitting upright.1:1 feeding. Review of the facility's policy titled, Dignity, dated 2/21, indicated, .Each resident shall be cared for in a manner that promotes and enhances.feeling of self-worth and self-esteem.treated with dignity and respect at all times.Staff speak respectfully to residents at all times.and not 'labelling' or referring to the resident by.care needs. 2.Review of Resident 22's admission RECORD, (a document that contains the resident's demographic information) indicated Resident 22 was admitted to the facility with multiple diagnoses, including dysphagia (difficulty swallowing caused by problems in the mouth or throat) and protein-calorie malnutrition (a condition in which a person does not receive enough protein and calories to meet nutritional needs). During an observation on 1/13/26 at 10:05 a.m., signage was observed posted on Resident 22's communication board (a board that contains pictures, symbols, or letters—that help residents with speech, language, or cognitive challenges) indicated, Assist pt [patient] with all meals 1:1 feeder, which publicly disclosed Resident 22's care needs. The Department took a photograph of the signage for documentation and interview purposes. During an interview on 1/13/26 at 2:20 p.m. with the Certified Nursing Assistant (CNA 6), CNA 6 stated that Resident 22 should not have been labeled as a feeder. CNA 6 stated that Resident 22 was not a baby and when Resident 22 was publicly identified as a feeder it was disrespectful and could have negatively affected Resident 22's dignity. During a concurrent interview and record review on 1/13/26 at 2:25 p.m. with the Licensed Nurse (LN 12), LN 12 stated that when Resident 22 was identified as a feeder, it was inappropriate. LN 12 reviewed the photograph of the signage posted on Resident 22's communication board and confirmed that the signage was not acceptable as it could have compromised Resident 22's dignity and psychosocial well-being. During an interview on 1/13/26 at 2:42 p.m. with the Administrator (ADM) inside Resident 22's room, the Department showed the ADM the signage posted on Resident 22's communication board that indicated, Assist pt with all meals 1:1 feeder. The ADM stated that the signage was not acceptable and was not in accordance with the facility's policy. The ADM further stated that when Resident 22 was labeled in this manner, it could have negatively impacted Resident 22's psychosocial well-being and dignity. A review of the facility policy titled, Dignity, dated 2/21, indicated, .Each resident shall be cared for in a manner that promotes.feelings of self-worth and self-esteem.8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 3.A review of Resident 6's admission RECORD, (a document that contains the resident's demographic information) indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included a urinary tract infection (an infection of the bladder or kidneys). During an observation on 1/13/26 at 2:45 p.m. in Resident 6's room, Resident 6's urinary catheter bag was not covered with a privacy cover. During a concurrent observation and interview on 1/13/26 at 4:24 p.m. with the certified nursing assistant (CNA) 6, CNA 6 confirmed Resident 6 urinary catheter bag did not have a privacy cover. CNA 6 further stated a privacy cover should have been placed over Resident 6's urinary catheter bag for dignity purposes. During an interview on 1/16/26 at 9:35 a.m. with the Director of Staff Development (DSD), the DSD stated it was her expectation that urinary catheter bags would have had a privacy cover. The DSD further stated it was important for Resident 6's dignity and self-respect. During a review of the facility's policy and procedure (P&P) titled Dignity, dated 2001, the P&P indicated, .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, . helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to provide necessary care and services necessary as per professional standards of practice for one of 33 sampled residents (Resident 3) when Resident 3's physician orders for constipation were not followed in a timely manner.This failure placed Resident 3 at risk for constipation-related complications such abdominal pain, nausea, vomiting, hemorrhoids (painful swollen veins in the rectum), fecal impaction (hard stool blocking the colon requiring medical removal).Findings:Review of Resident 3's admission RECORD (a document that contains the resident's demographic information) indicated Resident 3 had aphasia (a language disorder that makes it hard to communicate), dementia (a condition that causes decline in thinking, memory, and reasoning), Alzheimer's (a disease that slowly affects memory, thinking and daily functioning), and gastrostomy (a tube that goes into the stomach through the belly to give food and fluids) among other diagnoses.During an interview on 1/14/26 at 9:26 AM, with the Infection Preventionist (IP), the IP stated that Resident 3 was non-verbal (not able to talk).During a phone interview on 1/14/26 at 11:26 AM, with Resident 3's daughter (DTR), the DTR stated that she asked the nurse when Resident 3's last bowel movement occurred and was told that it was four days ago, and that this was the only time staff acted on the situation.Review of Resident 3's bowel elimination record for the month of January 2026 indicated Resident 3 did not have a bowel movement from 1/4/26 through1/8/26.Review of Resident 3's Medication Administration Record (MAR) for the month of January 2026, indicated, . Milk of magnesia (MOM) suspension [medication for constipation] .as needed for constipation give 1 dose on evening shift IF NO BM [bowel movement] after 3 DAYS. If no results, see Dulcolax Suppository [medication used for constipation] Order Dulcolax suppository . insert 1 suppository rectally as needed for constipation. Give if no result from MOM on NOC [night] shift . If no results, see Fleet enema [medication used for constipation] order . Insert 1 unit rectally as needed for constipation . Give if no results from Dulcolax Suppository. Further review of the MAR indicated none of the constipation medications as ordered were given from 1/4/26 through 1/7/26 and suppository was administered on 1/8/25 at 9:00 PM. During a concurrent interview and record review on 1/15/26 at 5:09 PM, with the Director of Nursing (DON), Resident 3's bowel elimination record, physician orders, MAR, and care plans were reviewed. The DON confirmed Resident 3 did not have a bowel movement for 5 days from 1/4/26 through 1/8/26. The DON verified Resident 3's physician orders were not followed when he was not given constipation medications as ordered after 3 days of no bowel movement. The DON stated she expected staff to follow residents' physician orders for bowel care. During an interview with Licensed Nurse (LN) 2 on 1/16/26 at 7:42 AM, LN 2 stated that if a resident did not have a bowel movement for more than three days, it could cause increased confusion in a bedbound resident. LN 2 stated nurses should consistently monitor resident's bowel elimination record and should follow physician orders for bowel care. During a phone interview with the Facility Doctor (FAD) on 1/16/26 at 1:50 PM, the FAD stated that if a resident did not have a bowel movement for two days, the facility should start the bowel care orders. Resident 3's Care plan, dated 9/16/25, indicated, . Problem .At risk for constipation .Goal .Will report continuous satisfactory bowel movements every 2 to 3 days .Interventions . Administer mediations for constipation prevention as ordered by the Physician.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for one of 33 sampled residents (Resident 2) when:1. Resident 2 did not receive oxygen therapy as prescribed by the physician; and 2. Nursing staff did not follow the identified oxygen therapy interventions as outlined in Resident 2's care plans (a document that contains the resident's problems, goals, and interventions). These deficient practices had the potential to place Resident 2 at risk for health decline and respiratory distress.Findings: 1.Review of Resident 2's admission Record, (a document that contains the resident's demographic information) the document indicated Resident 2 was originally admitted to the facility 9/23, and then readmitted in 9/25, with diagnoses which included acute respiratory failure with hypoxia (a life threatening condition where the lungs can't get enough oxygen into the blood, causing low blood oxygen, and severe shortness of breath), chronic systolic congestive heart failure (a weak heart can't pump blood effectively over a long period of time, causing fluid backup in the body, leading to symptoms like shortness of breath, fatigue, and swelling), and pleural effusion (abnormal buildup of excess fluid in the thin gap between the lungs and chest wall causing symptoms of shortness of breath).During a concurrent observation and interview on 1/13/26 at 9:16 a.m. with Resident 2, Resident 2 was observed in bed in a sitting position and connected to an oxygen concentrator (oxygen delivery device) set at three liters (L, unit of measurement) per (/) minute (min). Resident 2 stated that he routinely received oxygen therapy while in bed via an oxygen concentrator and while seated in his wheelchair via a portable oxygen tank.Review of Resident 2's orders for oxygen, dated 9/2/25, indicated, Oxygen: At 3 Liters/Min via Nasal Cannula [a lightweight, flexible tube with two prongs that fit into the nostrils to deliver supplemental oxygen, connecting to an oxygen source like a tank or an oxygen concentrator] Every Shift for hypoxia [low oxygen in the blood]/shortness of breath. Goal is to maintain oxygen saturations [the percentage of red blood cells, carrying oxygen, indicating how well lungs oxygenate body and supply tissues] above 90%. During an observation on 1/15/26 at 2:45 p.m., Resident 2 sat in his wheelchair in the hallway near the south nurse station and was connected to a portable oxygen tank; however, the oxygen tank was turned off.During a concurrent observation and interview on 1/15/26 at 2:46 p.m. with the Respiratory Therapist (RT), the RT confirmed Resident 2 was connected to an oxygen tank that was not turned on. The RT assessed the resident's measured oxygen saturation using a pulse oximeter (a small, non-invasive device clipped onto a fingertip to measure blood oxygen saturation) which initially measured 90%, and within 30 seconds of receiving oxygen at 3 liters per minute (L/min), the oxygen saturation increased to 97%. The RT stated that Resident 2 had diagnoses of congestive heart failure and hypoxia, and that failure to receive prescribed oxygen therapy could have placed stress on the heart and led to symptoms such as syncope (fainting or passing out), and dizziness, thereby placing Resident 2's health at risk. The RT further stated that he was unable to determine how long Resident 2 had been without oxygen while seated in his wheelchair in the hallway. The RT stated that his expectation of the nursing staff was to ensure that Resident 2 remained on continuous oxygen therapy as ordered by physician. The RT further added that when Resident 2 was transferred to the wheelchair, nursing staff should have ensured the oxygen tank was turned on and delivered oxygen at the prescribed rate. The RT stated that this expectation was not met by the nursing staff.During an interview on 1/15/26 at 2:58 p.m. with the Licensed Vocational Nurse (LN) 9, LN 9 stated that Resident 2 was ordered continuous oxygen therapy 3 L/min via nasal cannula. LN 9 stated nurses were responsible for transitioning the oxygen source from the concentrator to a portable oxygen tank when Resident 2 was transferred from bed to a wheelchair. LN 9 further stated that nursing staff were expected to ensure the oxygen was turned on at the same flow rate as ordered by the physician. LN 9 further added the failure to properly receive oxygen could have placed Resident 2 at risk for respiratory distress and hypoxia. 2.A review of Resident 2's care plan for congestive heart failure, dated 9/13/25, indicated, . Interventions/Tasks. Oxygen Setting: O2 [oxygen] via (nasal cannula) @ [at] (3)L (continuously)., and a review of Resident 2's care plan for at risk for hypoxia [low oxygen in the blood], dated 9/10/25, indicated, . Interventions/Tasks. Administer oxygen as ordered and observe oxygen precautions. Review of the care plans revealed that the facility did not ensure the identified interventions were implemented as care planned.A Review of Resident 2's orders for oxygen, dated 9/2/25, indicated, Oxygen: At 3 Liters/Min via Nasal Cannula Every Shift for hypoxia/shortness of breath.During an interview on 1/15/26 at 2:58 p.m. with LN 9, LN 9 stated that Resident 2 had diagnoses of congestive heart failure and hypoxia and was ordered continuous oxygen therapy at 3 L/min via nasal cannula. LN 9 further stated that oxygen administration was addressed in Resident 2's care plan interventions and that nursing staff were responsible for reviewing and implementing the identified interventions. LN 9 also stated that failure to properly administer oxygen therapy and follow the care plans interventions for oxygen therapy placed Resident 2 at risk for respiratory distress and worsening hypoxia.During a concurrent interview and record review on 1/15/26 at 3:40 p.m. with the Director of Nursing (DON), all of Resident 2's active medication orders and active care plans were reviewed. The DON confirmed that Resident 2 had an active order for oxygen 3 L/min to be administered continuously via nasal cannula, using an oxygen concentrator while in bed and a portable oxygen tank when transferred from bed to wheelchair. During a review of the care plans the DON confirmed that Resident 2 had care plans addressing the identified interventions for oxygen administration as ordered by the physician. The DON further stated that her expectation from nursing staff was to ensure Resident 2 remained on oxygen therapy while seated in the wheelchair and that the portable oxygen tank remained on. The [NAME] stated that this expectation was not met.Review of the facility provided policy and procedure (P&P) titled, Oxygen Administration, revised 10/10, indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure. 4. Turn on the oxygen. 9. Observe the resident upon and periodically thereafter to be sure oxygen is being tolerated.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) had their initial comprehensive visit completed by a Physician for a resident under a Medicare Part A stay when, Resident 3's initial assessment (admission assessment) was conducted by a Nurse Practitioner (NP). This failure had the potential to result in unidentified medical conditions being untreated for Resident 3.Findings:A review of Resident 3's admission RECORD [a document that contains demographic information], indicated Resident 3 was admitted under Medicare Part A to the facility on [DATE].During a concurrent interview and record review on 11/26/25 at 10:34 a.m. with LN 1, Resident 3's clinical record titled, INITIAL ASSESSMENT/NEW ADMISSION/ 72 HOUR CHARTING, dated 11/14/25 was reviewed. LN 1 verified the initial assessment for Resident 3 was performed by the nurse practitioner and not the physician. LN 1 stated it was important for a physician to do the initial physical examination to establish a baseline and plan of care for the residents.During an interview on 11/26/25 at 11:45 a.m., with the Director of Nursing (DON), the DON stated it was important for the physician to do the initial assessment on Resident 3 because during the initial assessment, the physician would have reviewed and reconciled Resident 3's medication list and reviewed the pertinent diagnoses. The DON further stated the initial exam was important for establishing the plan of care.During an interview on 1/7/25 at 9:50 a.m., with the Administrator (ADM), the ADM verified the facility is dually certified under Medicare and Medicaid. The ADM stated Resident 3's initial admission assessment and admission orders were done by a nurse practitioner and not Resident 3's attending physician personally. The ADM confirmed Resident 3 was admitted under Medicare Part A. During a review of the facility's policy and procedure (P&P) titled, Physician Services, revised 2/21, the P&P indicated, .participating in the resident's assessment and care planning.conducting routine required visits.Review of a document published by the Centers for Medicaid and Medicare Services (CMS) titled, Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), dated 3/8/13, the document indicated, .Physician Required and other Medically Necessary Visits in SNFs: Under 42 C.F.R. S483.40(c)(3), all required physician visits must be made by the physician personally and cannot be delegated. A required physician visit includes the initial comprehensive visit in a SNF and every alternate required visit thereafter, as required in 42 C.F.R. S483.40(c)(4). The initial comprehensive visit in a SNF is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident. Under 42 C.F.R. S483.40(c)(1), the initial comprehensive visit must occur no later than 30 days after a resident's admission into the SNF. Further, under 42 C.F.R. S483.40(c)(4) and (e), the physician may not delegate the initial comprehensive visit in a SNF. Non-physician practitioners may perform other medically necessary visits prior to and after the physician's initial comprehensive visit. Once the physician has completed the initial comprehensive visit in the SNF, the physician may then delegate alternate visits to a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) who is licensed as such by the State and performing within the scope of practice in that State, as permitted under 42 C.F.R. S483.40(c)(4) . (www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf)

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (intentional act of causing injury or trauma to another person through bodily contact) for one of four sampled residents (Resident 1) when on 9/8/25, Resident 2 who was known by the facility staff to have abusive behavior, approached Resident 1 and hit her on the hand and attempted to kick Resident 1.This failure resulted in a bruised right hand on Resident 1. In addition, this failure left Resident 1 feeling upset, uncomfortable, and unsafe.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included: need for assistance with personal care, other abnormalities of gait (walking) and mobility (ability to move around freely), and depression (a common mental health condition with continuous feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable).A review of Resident 1's minimum data set (MDS - a resident assessment and screening tool which identifies care needs) dated 8/18/25, under the section titled, .Section C: Cognitive Patterns, - (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) indicated Resident 1's Brief Interview for Mental Status (BIMS - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment] Scoring = 13-15 indicates normal intact cognitive function, 8-12 moderate cognitive impairment, 0-7 signifies severe cognitive impairment) was 14 out of 15 which indicated Resident 1 had normal intact cognitive function.A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included: dementia (a decline in cognitive functions such as memory, language, attention and problem-solving abilities that interfere with daily life) with agitation (a behavioral syndrome [a group of symptoms which consistently occur together] characterized by excessive restlessness, verbal outbursts, and/or physical aggression) and dementia with behavioral disturbance (the presence of a range of behavioral symptoms in a person with dementia such as aggression and agitation which interfere with daily life).A review of Resident 2's MDS dated [DATE], under the section titled, .Section C: Cognitive Patterns, indicated Resident 2's BIMS was 99 which indicated Resident 2 was unable to complete the interview.A review of Resident 2's MDS dated [DATE], under the section titled, .Section E: Behavior, indicated that during the review period Resident 2 had, .A. Physical behavioral symptoms directed towards others (e.g. [for example], hitting, kicking, pushing, scratching, grabbing, abusing others sexually).Behavior of this type occurred 1 to 3 days.Impact on others.A. Put others at significant risk for physical injury?.1. Yes.B. Significantly intrude on the privacy or activity of others?.1. Yes.During a concurrent interview and observation on 9/23/25, at 3:39 PM, in Resident 1's room, Resident 1 stated on 9/8/25 she was attacked by Resident 2, while sitting in a wheelchair in front of her room. Resident 1 explained her room was at the end of a long hallway and there was glass door where she could see outside. Resident 1 further explained, when she saw Resident 2 coming toward the end of the hallway, she tried to move out of the way since there was not a lot of room in the hallway. Resident 1 stated as Resident 2 approached her she said hello and then Resident 2 reached out and struck her on her hand with his hand. Resident 1 stated Resident 2 also attempted to kick her, but Resident 1 was able to use her legs to back her wheelchair into her room to avoid being kicked. Resident 1 stated no one was in the hallway when he hit and attempted to kick her, so she yelled out. Resident 1 further stated she felt upset because she was not expecting to get hit by Resident 2. Resident 1 explained she felt uncomfortable and unsafe to get into her wheelchair and roam the facility because Resident 2 frequented the hallways near her path. The end of the hallway was observed where Resident 1's room and the physical abuse incident occurred and was noted to not be visible from the nurses station.During an interview on 9/23/25, at 3:15 PM, Licensed Nurse (LN) 1 confirmed while working on 9/8/25 she was alerted by Certified Nursing Assistant (CNA) 3 of the physical abuse that occurred between Resident 1 and Resident 2. LN 1 stated CNA 3 reported to her that she heard yelling while CNA 3 was in a room and went to check on it. LN 1 further stated when Resident 1 explained what happened, LN 1 checked Resident 1 for injuries and observed Resident 1 had redness on her right hand. LN 1 explained Resident 1 was upset and told LN 1 that she did not want to see Resident 2 again. LN 1 further explained Resident 2 was known to become easily agitated, angry, moody and sometimes not approachable. LN 1 stated that Resident 2 had a history of hitting staff during care. LN 1 further stated because Resident 2 was known to have these behaviors the staff kept a close eye on Resident 2 when he was out of his room.During an interview on 9/24/25, at 11:36 AM, CNA 3 stated while she was working on 9/8/25 she was about 4 rooms down the hall in another residents room when she heard a resident start yelling, stop it. CNA 3 further stated she came out of the room toward the yelling and saw that Resident 2 had wheeled himself in his wheelchair to the end of the hallway and was in front of Resident 1's room. CNA 3 explained she went to check on Resident 1 and was told by Resident 1 that Resident 2 had hit her and attempted to kick her. CNA 3 stated that Resident 1 pointed to her hand where she was hit by Resident 2. CNA 3 further stated she separated the residents and alerted LN 1. CNA 3 stated no other staff was in the hallway when she responded to Resident 1 yelling out. CNA 3 further stated she was not assigned to Resident 1 that day but was covering for her assigned CNA while she was at lunch. CNA 3 explained the abuse occurred during lunchtime and less staff were available to monitor Resident 2.During an interview on 9/24/25, at 11:26 AM, with LN 2, LN 2 stated she was the nurse for Resident 1 on 9/8/25, but was on lunch when the abuse occurred. LN 2 explained she was informed of the incident by LN 1. LN 2 stated she asked the Treatment Nurse (TN 1- provides direct patient care for wounds) to inspect Resident 1's hand for injury. LN 2 further stated Resident 1 told her she just wanted to stay in her room after the abuse. LN 2 stated Resident 2's room was in front of the nurses station so they could keep a closer watch on him. LN 2 explained the facility staff were on alert when Resident 2 was up and out of his room so they could keep him out of reach of other residents. LN 2 added because Resident 2 got easily agitated, for the safety of the other residents, the staff monitor him closely when he was out of his room. LN 2 further explained the abuse could have been prevented if the staff had kept a closer eye on Resident 2 when he went down the far hallway.During a concurrent interview and record review on 9/24/25, at 11:04 AM, with TN 1, Resident 1's electronic health record (EHR -a digital version of a patient's medical history, containing a collection of their health information), Progress Note, (a document in a residents EHR that records their medical treatment by healthcare professionals) dated 9/8/25, was reviewed. The document indicated TN 1 was asked by LN 2 to evaluate Resident 1's injury to her hand after the abuse by Resident 2. TN 1 stated her note indicated, .scattered discoloration to the back of the patients right hand. TN 1 recalled when she evaluated Resident 1's right hand it had new blue and reddish bruising to the top of her right hand.During an interview on 9/24/25, at 11:53 AM, with the Social Services Director (SSD), the SSD stated she checked on both Resident 1 and Resident 2 for three days after the abuse was reported. The SSD explained Resident 1 did not complain of fear but added Resident 1 told her, she felt uncomfortable from time to time when Resident 1 saw Resident 2. The SSD further explained she checked on Resident 2 after the incident and Resident 2 had no recollection of the abuse. The SSD explained Resident 2 possibly had a room down the hallway near Resident 1 at some point but added that Resident 2 should have been monitored more closely. The SSD further explained Resident 2 was free to roam around but with staff supervision.During a concurrent interview and record review on 9/24/25, at 4:04 PM, with the Administrator (ADM), Resident 2's EHR was reviewed. The ADM reviewed Resident 2's, .MONITORS - Hourly Safety Check.Location of Resident While., document dated 9/8/25, indicating that the facility staff document Resident 2's hourly monitoring for day shift on 9/8/25, as follows:9/8/25 5:50 AM -Box checked that hourly monitoring was completed, Resident 2's location was documented in his room.9/8/25 11:03 AM -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room, and in the hallway.12:37 PM -Box checked that hourly monitoring was completed. Resident 2's location was documented in the hallway.13:25 [1:25 PM] -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room.17:21 [5:21 PM] -Box checked that hourly monitoring was completed. Resident 2's location was documented in his room.The ADM confirmed Resident 2 was on hourly monitoring and the hourly monitoring was initiated because Resident 2 was wandering through the facility and in the hallways. The ADM stated her expectation was that staff were aware of Resident 2's location when he was out of his room, and what he was doing. The ADM acknowledged the hourly safety check was not documented hourly per her expectation on 9/8/25. The ADM confirmed Resident 2 had known behaviors of physically striking out towards staff. The ADM stated it was important for staff to closely monitor Resident 2 so that he did not hurt anyone. The ADM stated the risk when a known physically aggressive resident was not closely monitored was that anything could happen, at any time, and to anyone.A review of Resident 1's EHR document titled, SBAR [Situation Background, Appearance, Review and Notify] Communication Form and Progress Note., dated 9/8/25, completed by LN 2, indicated, .8. Skin Evaluation .Discoloration.9. Pain Evaluation.New.Description/location of pain: pain 5/10 [on a scale of 0-10, 0-meaning no pain, 10-meaning unbearable pain], writer offered pain medication.Summarize your observations and evaluation: Writer [LN 2] notified by another LN that [Resident 1] was hit on the back of right hand by [Resident 2]. Both residents were in wheelchair at the end of hallway when [Resident 1] moved out of the way and other [Resident 2] hit pt [patient].Tx [Treatment] nurse assessed pt [patient], noted with discoloration on back of right hand.A review of Resident 2's EHR document titled, SBAR, dated 9/8/25, completed by LN 1, indicated, .[Resident 2] wheel himself down the hallway and approach [Resident 1] who is sitting outside of her room. [Resident 1] talked to [Resident 2] and he did not respond [sic] her. [Resident 2] hit [Resident 1] on her right hand with [Resident 1] hand. He attempts to kick [Resident 1] but she moved.A review of Resident 2's Care Plan Report (a personalized plan of care document that outlines a person's health conditions, needs, goals, and actions needed to [NAME] them) revised 4/10/24, indicated, .[Resident 2] Receiving [type of medication] r/t [related to].dementia w/[with] behavioral disturbance.AEB [as evidenced by] combative/threatening behaviors towards staff.A review of Resident 2's Care Plan Report, revised 5/30/24, indicated, [Resident 2] admitted with [type of medication] r/t Anxiety (feeling of fear, unease) AEB yelling at staff, striking out.A review of the facility policy and procedure (P&P) titled, Abuse Prevention Program, revised December 2026, indicated, .Our residents have the right to be free from abuse.This includes but is not limited to.verbal, mental, sexual or physical abuse.As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including.other residents.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to implement two persons assist when mechanical lift (a medical device used to safely lift and move a resident) was used to transfer (moving from one place to another) Resident 1.These deficient practices led to Resident 1 sustaining a fall that resulted in intramuscular hematoma (collection of blood within a muscle) to the right pectoralis (chest muscle) and a broken right leg.Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction, (a condition where blood flow to the brain is interrupted, also known as a stroke) and aphasia (speech or language problems as a result of a stroke).Review of Resident 1's clinical record titled, Minimum Data Set, (MDS - an assessment tool used by nursing homes to collect information about each resident's health, abilities, and care needs) dated 11/03/24, by the MDS Coordinator (MC 1), indicated under Section GG0170 - Mobility, item FF (Tub/shower transfer) that Resident 1 was coded on the assessment tool as 01 - Dependent on nursing staff for transferring. Per the MDS scoring definition, a score of 01 indicated that the helper (a nursing assistant) performed all of the effort, and the assistance of two or more nursing staff members were required for Resident 1 to complete the transfer activity.During a concurrent interview and record review on 10/30/25 at 1:21 p.m., with MC 1, Resident 1's MDS assessment records were reviewed. MC 1 verified that Resident 1's assessment indicated that Resident 1 was dependent on two or more CNAs for assistance with showering and transferring. MC 1 further stated that Resident 1 required a mechanical lift device for all transfers and stated that Resident 1 had not experienced any mobility improvements since his admission.During an interview on 10/30/25 at 2:26 p.m. with the Licensed Nurse (LN 1), LN 1 stated that he witnessed the post-fall event with Resident 1 on 10/25/25. LN 1 stated that he witnessed Resident 1 on the floor in a prone position (lying flat on the stomach, face down) with CNA 1 next to Resident 1. LN 1 stated that he interviewed CNA 1 and CNA 1 told LN 1 that she tried to transfer Resident 1 by herself, and that Resident 1 slipped from the sling (a device that attaches to a mechanical lift device that allows a resident to be lifted and transferred with minimal physical effort) and then fell to the ground. LN 1 stated that two CNAs were required to assist when Resident 1 was transferred using the mechanical lift device. LN 1 further stated that the expectation was for two CNAs to assist when the mechanical lift device was used. LN 1 stated that Resident 1's fall could have been prevented if CNA 1 had followed the facility's expectations.During a phone interview on 10/30/25 at 3:17 p.m. with CNA 1, CNA 1 admitted that she made a mistake when she transferred Resident 1 with the mechanical lift device without assistance from another CNA. CNA 1 acknowledged that she did not follow the facility's policy and procedure when she transferred Resident 1 independently with the use of a mechanical lift device. CNA 1 stated this failure contributed to Resident 1's fall and injury. CNA 1 also stated that the fall could have been prevented if she had asked for help from another CNA.Review of Resident 1's [HOSPITAL NAME] clinical record titled, TRAUMA/ACUTE CARE SURGERY PROGRESS NOTE, dated 10/31/25, indicated that Resident 1 was admitted to [HOSPITAL NAME] following a fall from four feet from a mechanical lift. Medical documentation indicated Resident 1 sustained a large intramuscular hematoma (collection of blood under the skin) to the right pectoralis (chest muscle) with areas of active bleeding (ongoing blood loss), and minimally displaced fractures of the right proximal tibia and fibula (small cracks or breaks near the top of the right lower leg bones).During a concurrent interview, record review, and policy and procedure (P&P) review on 11/07/25 at 12:53 p.m., with the Director of Nursing (DON), Resident 1's [HOSPITAL NAME] records, the facility's P&P titled, Lifting Machine, Using a Mechanical, revised 7/17, and the facility's P&P titled, Safety Precautions, Nursing Services, revised 12/09 were reviewed. The P&P titled, Lifting Machine, Using a Mechanical, indicated, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. The P&P titled, Safety Precautions, Nursing Services, indicated, .The following safety precautions have been established for all personnel to follow when providing nursing care/services .21. Follow proper lifting procedures when lifting resident or heavy objects. The DON verified that CNA 1 did not follow the facility's P&Ps when she transferred Resident 1 independently while using the mechanical lift. The DON acknowledged that this failure resulted in Resident 1's fall and injury. The DON also acknowledged that the injuries sustained by Resident 1 were acquired due to the fall incident that occurred on 10/25/25.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of four sampled residents (Resident 1) when resident 1 was found in the parking lot of the apartment complex next to the facility at approximately 10:00 p.m., on 6/17/25.This failure resulted in two skin tears to Resident 1's right knee and had the potential of serious injury and harm.A review of Resident 1's clinical record, titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with diagnoses of but not limited to malignant neoplasm of unspecified kidney (a cancerous tumor that forms in the kidney), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), failure to thrive (a condition where an adult experiences unintentional weight loss, decreased appetite, and muscle wasting that can lead to health complications).A review of Resident 1's clinical record titled, SBAR Communication Form, dated 6/17/25, written by Licensed Nurse (LN) 1, indicated on 6/17/25 at 9:30 p.m., Resident 1 was not found in her room and the building was searched and resident was found outside around 9:45 p.m.During a concurrent interview and record review on 9/11/25, at 4:01 p.m., a review of Resident 1's clinical record titled, Progress Notes, dated 6/17/25, at 11:45 p.m., written by LN 2, indicated Resident 1 was found in the parking lot of an apartment complex next to the facility. LN 2 stated Resident 1 had was assessed for injuries and two skin tears to the right knee were noted and Resident 1 was not able to recall what happened. LN 2 further stated that Resident could have potentially gotten lost and was at risk of serious injury.During an interview on 9/12/25, at 11:40 a.m., with LN 3. LN 3 stated in the event of an elopement (when a person under supervised care leaves the healthcare facility without permission or anyone noticing) staff was not able to ensure safety and monitor a residents if they were not in the building or accounted for.During an interview on 9/12/25, at 12:30 p.m., with the Administrator (ADM), the ADM stated Resident 1 eloped on 6/17/25 and was assessed and treated for skin tears to the right knee. The ADM further stated there was potential for worse injury when the resident was not monitored while outside of the facility.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was accurately assessed for the use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and use of hearing aids. These failures resulted in staff not being aware when Resident 1 ' s partial denture and hearing aids were missing and the lack of consistent use could have contributed to Resident 1 ' s confusion and weight loss. Findings: During a review of Resident 1 ' s clinical record titled, ADMISSION RECORD (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnosis included the need for assistance with personal care. A review of Resident 1 ' s clinical record titled, NSG [nursing]: Admission Data Collection and Baseline Care Plan Tool (a personalized document that identified problems, goals, and interventions), dated 1/3/25, by Licensed Nurse (LN 1), indicated Resident 1 was oriented to person, place, date, and time. The record further indicated Resident 1 ' s use of a partial denture and hearing aids were not assessed. A review of Resident 1 ' s clinical record titled, MDS [Minimum Data Set - part of a comprehensive assessment] - Section B - Hearing, Speech, and Vision, dated 1/10/25, by the MDS nurse (MDS 1), indicted Resident 1 did not use hearing aids. During a review of Resident 1 ' s clinical record titled, Nutritional Comprehensive Assessment, dated 1/14/25, by the Registered Dietitian (RD), indicated Resident 1 had dentures. A review of Resident 1 ' s clinical record titled, Theft/Loss Monitoring Report, by the Housekeeping Director (HD), indicated Resident 1 ' s partial denture was found in the laundry area of the facility on 1/8/25, and on 1/24/25, FRIEND 1 reported the missing partial denture, and the partial denture was returned to Resident 1. A review of Resident 1 ' s clinical record titled, Patient ' s Clothes and Possessions, dated 1/29/25, indicated Resident 1 had two hearing aids. A review of Resident 1 ' s clinical record titled, Weights and Vitals, dated 1/3/25 through 1/26/25, indicated Resident 1 lost 15 pounds (lbs.) while at the facility with the following weights recorded: 1/3/25 = 197 lbs. 1/5/25 - 194 lbs. 1/20/25 = 185 lbs. 1/26/25 - 182 lbs. During an interview on 2/6/25, at 1:55 p.m., with LN 2, LN 2 stated she was not aware that Resident 1 utilized a partial denture or hearing aids. LN 2 stated upon admission, the LN was supposed to assess Resident 1 ' s use of partial dentures or hearing aids. LN 2 stated Resident 1 had intermittent confusion while at the facility. During an interview on 2/6/25, at 2:05 p.m., Certified Nursing Assistant (CNA 1) stated she was not aware Resident 1 utilized a partial denture or hearing aids. CNA 1 stated Resident 1 had bouts of confusion. During a phone interview on 1/12/25, at 10 a.m., with Resident 1 ' s Family Member (FM 1), FM 1 stated Resident 1 ' s partial denture had been lost while at the facility. FM 1 stated when the denture was found, it was cracked and not able to be used. FM 1 stated after discharge from the facility, the partial denture was taken to a dentist for repair, however Resident 1 was not able to eat with the partial denture for over three weeks. FM 1 stated Resident 1 ' s hearing aids were lost for a few days but had been found. FM 1 stated the facility should have taken an accurate inventory assessment for Resident 1 ' s partial denture. During a phone interview on 1/12/25, at 12:34 p.m., Resident 1 ' s Friend (FRIEND 1) stated the facility had lost Resident 1 ' s partial denture soon after arriving at the facility. FRIEND 1 stated when the facility returned the partial denture to Resident, it was cracked. FRIEND 1 stated Resident 1 ' s hearing aids were also missing for a couple days at the facility. During a phone interview on 12/14/25, at 12:30 p.m., with Resident 1 ' s FM 2, FM 2 stated a family member had placed a sign above Resident 1 ' s bed that reminded staff to take out Resident 1 ' s partial dentures every night and soak them in cleaning solution and to charge Resident 1 ' s hearing aids each night. FM 2 stated the facility should have ensured the partial denture and hearing aids were accessible and properly cared for each day and that an inventory list and sensory assessment was accurately completed. FM 2 stated Resident 1 was confused while at the facility, which was not Resident 1 ' s baseline. During a phone interview on 2/17/25, at 5:14 p.m., with Resident 1, Resident 1 stated his partial dentures (upper) was lost at the facility. Resident 1 stated he looked all over for the partial and reported the loss to the staff, but staff stated the facility did not have a lost and found department. Resident 1 stated after approximately three weeks, the partial denture was returned to him, and it was cracked. Resident 1 stated his hearing aids were lost for a couple of days while he was at the facility. Resident 1 stated he was confused during his stay at the facility. During a phone interview on 2/20/25, at 11 a.m., with MDS 2, MDS 2 stated if the LN was unable to assess Resident 1 ' s hearing and dental status upon admission, the LN should have reassessed at a later date. MDS 2 stated the admission assessment problems and concerns generated Resident 1 ' s care plan and because hearing and dental was not assessed, there was not a careplan for hearing aids or partial dentures. MDS 2 stated Resident 1 ' s inventory list should have been updated with the partial denture when the dentures were found and returned to Resident 1. MDS 2 stated it was important to have identified if dentures were used because food modifications may have needed to be made. During phone interview on 2/20/25, at 11:05 a.m., with the RD, the RD stated Resident 1 reported to her that Resident 1 had dentures. The RD stated she had not asked Resident 1 to open his mouth and show RD his dentures. The RD stated she would have noticed if Resident 1 had seven missing front teeth. During a joint phone interview on 1/20/25, at 11:10 a.m., with the Administrator (ADM) and Director of Nursing (DON), the ADM and DON acknowelged that the LN should have reassessed Resident 1 ' s dental and hearing status which would have generated a hearing and dental care plan. During a concurrent phone interview, review of Resident 1 ' s clinical record, and review of the facility ' s policy and procedure (P&P), on 2/20/25, at 12:20 p.m., with the DON, the P&P titled, Resident Assessment/Care Plan Coordinator (MDS), dated 2003, was reviewed. The P&P indicated, .Ensures that all assessments are completed . Works with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident . Evaluate each resident ' s condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment . The DON acknowelged the LN did not reassess Resident 1 ' s use of hearing aids or partial denture. The DON acknowelged the P&P was not followed.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a care plan (a document that identified Resident 1 ' s problems, goals, and interventions) in place that addressed Resident 1 ' s use of a partial denture (fully removable dental inserts that replaced seven missing top teeth) and hearing aids. These failures resulted in a lack of knowledge by nursing staff of Resident 1 ' s use of a partial denture and hearing aids, lack of care of the partial denture and hearing aids, and could have contributed to Resident 1 ' s confusion and 15-pound weight loss while at the facility. Findings: During a review of Resident 1 ' s clinical record titled, ADMISSION RECORD, (a document that contained Resident 1 ' s demographic information), indicated Resident 1 ' s diagnosis included the need for assistance with personal care. A review of Resident 1 ' s clinical record titled, NSG [nursing]: Admission Data Collection and Baseline Care Plan Tool (an individualized plan of care that identified Resident 1 ' s problems, goals, and interventions), dated 1/3/25, by Licensed Nurse (LN 1), indicated Resident 1 was oriented to person, place, date, and time. The record further indicated Resident 1 ' s use of a partial denture and hearing aids were not assessed. During a review of Resident 1 ' s clinical record titled, Nutritional Comprehensive Assessment, dated 1/14/25, by the Registered Dietitian (RD) indicated Resident 1 had dentures. A review of Resident 1 ' s clinical record titled, Theft/Loss Monitoring Report, indicated Resident 1 ' s partial denture was found in the laundry area of the facility on 1/8/25 and on 1/24/25, FRIEND 1 reported the missing partial denture, and the partial denture was returned to Resident 1. A review of Resident 1 ' s clinical record titled, Weights and Vitals, dated 1/3/25 through 1/26/25, indicated Resident 1 lost 15 pounds while at the facility with the following weights recorded: 1/3/25 = 197 lbs. 1/5/25 - 194 lbs. 1/20/25 = 185 lbs. 1/26/25 - 182 lbs. A review of Resident 1 ' s clinical record titled, Patient ' s Clothes and Possessions, dated 1/29/25, indicted Resident 1 had two hearing aids. During an interview on 2/6/25, at 1:55 p.m., with LN 2, LN 2 stated she was not aware that Resident 1 utilized a partial denture or hearing aids. LN 2 stated upon admission, the LN was supposed to assess Resident 1 ' s use of partial dentures or hearing aids. LN 2 stated Resident 1 had intermittent confusion while at the facility. During a phone interview on 1/12/25, at 10 a.m., with Resident 1 ' s Family Member (FM 1), FM 1 stated Resident 1 ' s partial denture (7 false teeth on the top of the mouth) had been lost while at the facility. FM 1 stated when the denture were found, it was cracked and not able to be used. FM 1 stated after discharge from the facility, the partial denture was taken to a dentist for repair, however Resident 1 was not able to eat with the partial denture for over three weeks. FM 1 stated Resident 1 ' s hearing aids were missing for a few days but had been found. During a phone interview on 1/12/25, at 12:34 p.m., Resident 1 ' s Friend (FRIEND 1), FRIEND 1 stated the facility had lost Resident 1 ' s partial denture soon after arriving at the facility. FRIEND 1 stated when the facility returned the partial denture to Resident 1. FRIEND 1 stated Resident 1 ' s hearing aids were lost for a couple of days at the facility. During a phone interview on 12/14/25, at 12:30 p.m., with Resident 1 ' s FM 2, FM 2 stated a family member had placed a sign above Resident 1 ' s bed that reminded staff to take out Resident 1 ' s partial denture every night and soak them in cleaning solution and to charge Resident 1 ' s hearing aids each night. FM 2 stated the facility should have ensured the partial denture and hearing aids were accessible and properly cared for each day and that an inventory list and sensory assessment was accurately completed. FM 2 stated Resident 1 was confused while at the facility, which was not Resident 1 ' s baseline. During a phone interview on 2/17/25, at 5:14 p.m., with Resident 1, Resident 1 stated his partial denture (upper) was lost at the facility. Resident 1 stated he looked all over for the partial and reported the loss to the staff, but the staff stated the facility did not have a lost and found department. Resident 1 stated after approximately three weeks, the partial denture was returned to him, and it was cracked. Resident 1 stated his hearing aids were lost for a couple of days while at the facility. During a phone interview on 2/20/25, at 11 a.m., with MDS 2, MDS 2 stated if the LN was unable to assess Resident 1 ' s hearing and dental status upon admission, the LN should have reassessed at a later date. MDS 2 stated the admission assessment problems and concerns generated Resident 1 ' s care plan and because hearing and dental was not assessed, there was not a care plan created for Resident 1 to include hearing aids or partial dentures. MDS 2 stated it was important to have identified if dentures were used because food modifications may have needed to be made. During phone interview on 2/20/25, at 11:05 a.m., with the RD, the RD stated Resident 1 reported to her that Resident 1 had dentures. During a joint phone interview on 1/20/25, at 11:10 a.m., with the Administrator (ADM) and Director of Nursing (DON), the ADM and DON acknowelged that the LN should have reassessed Resident 1 ' s dental and hearing status which would have generated a hearing and dental care plan. During a concurrent phone interview and review of facility policies on 2/20/25, at 12:20 p.m., with the DON, the facility ' s policy and procedures (P&Ps) titled, Care planning - Interdisciplinary Team, dated 3/22, and Care Plans, Comprehensive Person-Centered, dated 3/22, were reviewed. The P&P titled Care planning - Interdisciplinary Team, indicated, . Comprehensive, Person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) . The P&P titled, Care Plans, Comprehensive Person-Centered, indicated, .The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment .The compressive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident ' s highest physical, mental, and psychosocial well-being . The DON acknowelged when Resident 1 ' s initial hearing and dental needs were not reassessed by the LN, the hearing and dental care plans were not generated. The DON acknowelged the P&Ps were not followed.

Based on interview, and record review, the facility failed to provide restorative (RNA- nursing intervention to increase or maintain resident's mobility and prevent further decline in mobility) treatment and services for one of three sampled residents (Resident 2) when Resident 2 did not receive her ordered RNA therapy for the week of 9/23/24. This failure had the potential to result in a decline in physical functioning for Resident 2, resulting in a negative impact on Resident 2's health and well-being. Findings: A review of Resident 2's Admission Record, indicated Resident 2 was admitted to the facility in 2024 with diagnoses that included difficulty in walking, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as stroke) affecting the left side. A review of Resident 2's Order Summary Report, (list of physician orders) dated 10/11/24, indicated RNA therapy was ordered two times a week for both upper extremity active range of motion (AROM) and transfer training on 9/24/24. Further review of the record indicated RNA therapy was ordered three times a week for both upper extremity AROM on 9/28/24 and RNA therapy three times a week for transfer training to the bedside commode on 10/4/24. A review of Resident 2's Case Manager Note, dated 10/4/24, indicated, .Met with .res [resident] and spouse to review ending of skilled services and end of therapy .Discussed that res is now receiving RNA program . A review of Resident 2's Restorative Nursing Referral and Care Plan, dated, 9/24/24, indicated, .Type of Restorative Program .Therapeutic Exercise/ROM [range of motion] .Problem: Resident at risk for decline in ROM .Goals: Maintain/increase range of motion Maintain/increase muscle strength .Decrease c/o [complaint of] pain and discomfort Maintain/improve functional use of extremity Prevent/reduce risk of deformity [a distortion or disfigurement that changes the shape or size of a body part from what's normal] and/or contracture [where muscles, tendons, joints or other tissues tighten or shorten] Task: RNA 2x/week [2 times a week] for both upper extremity AROM .Type of Restorative Program: Transfer/Sit to Stand .Problem: Resident at risk for decline in transfers .Goals: Resident will maintain transfer status .Task: RNA: 2x/week for transfer training . During a concurrent interview and record review on 10/11/24, at 11:33 a.m., with Restorative Nurse Assistant RNA (1) and RNA (2), Resident 2's electronic health record (EHR) was reviewed. RNA 1 stated RNA services were provided to residents on Sunday, Tuesday, and Friday of each week. RNA 1 confirmed there was no record of RNA services for the week of 9/23/24 in Resident 2's EHR. RNA 1 and RNA 2 stated they were not sure if Resident 2 received RNA services during the week of September 23rd. RNA 2 further stated that Resident 2's orders for RNA services were changed by the physician from two times a week to three times a week. RNA 2 stated that if Resident 2 received RNA services during the week of September 23rd, the documentation for RNA services would be in the medical record. During an interview on 10/11/24, at 12:17 p.m., with the Director of Rehabilitation (DOR), the DOR stated the original physician order for Resident 2's RNA services was received on 9/24/24 for RNA therapy two times a week. The DOR further stated that when RNA services were provided, they were documented in the EHR. The DOR stated the RNAs had a specific place in the EHR to document RNA services. The DOR stated that if the order for RNA services changed the documented services would still be part of the resident's EHR. During a concurrent interview and record review on 10/11/24, at 1:15 p.m., with the Asst ADM, Resident 2's EHR was reviewed. The Asst ADM confirmed there was no documentation for Resident 2 receiving RNA therapy from 9/23/24 through 9/28/24. The Asst ADM further confirmed there was no paper documentation of RNA services provided to Resident 2 from 9/23/24 through 9/28/24 in the medical record. The Asst ADM stated the risk for the resident not receiving RNA services was a decline in function and delayed recovery. During an interview on 10/11/24, at 1:45 p.m., with Resident 2 and Family Member (FM) 1, in Resident 2' s room, Resident 2 and FM 1 both stated RNA services started the week of 9/29/24. During a review of an undated facility policy titled, Restorative Nursing Services, indicated .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .It is the policy to assist each and every resident to achieve the highest level of self-care possible . During a review of an undated facility policy titled, Charting and Documentation, indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record .1. Documentation in the medical record may be electronic, manual, or a combination .2. The following is to be documented in the resident medical record .c. Treatments or services performed .7. Documentation of procedures and treatments will include care-specific details, including a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1) Three serving scoops were dirty with green and brown crusted substances, and were stored with clean serving utensils in a cook's undercounter drawer; 2) Eleven cases of thawed, soft mighty healthshakes were stored in the walk-in refrigerator and two cases of them were received on [DATE]; 3) A pipe from the dish machine did not have an air gap; and, 4) Two ice machines were not cleaned and maintained according to manufacturer's instructions. These deficient practices exposed 145 of 155 facility residents who consume food from the kitchen to potentially harmful substances which could have led to widespread foodborne illness. Findings: 1. During the initial kitchen tour on [DATE] at 10:19 AM, an observation and interview was conducted with the Dietary Services Manager (DSM). There were six (6) serving scoops of different sizes found with dirt and brown food debris crusted on them, stored in a drawer with clean serving scoops. The DSM acknowledged the dirty scoops stored in the drawer and stated they should have been clean, and the drawer should have been checked by the Cooks. According to the 2022 Federal FDA Food Code, Section ,d+[DATE].11 titled Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, Cleaned equipment and utensils .shall be stored clean .in a clean, dry location. 2. On [DATE] at 12:17 PM, a kitchen observation and interview with the DSM was conducted inside the walk-in refrigerator. There were 11 cases of mighty heathshakes stored in the walk-in refrigerator and were thawed and soft to touch. Two (2) cases had a received date of [DATE], one half full and the other with about seven healthshakes inside. The other nine cases were full and unopened with 50 mighty healthshakes per case and had a [DATE] received date. The DSM acknowledged the mighty health shakes were thawed and some were expired past their use by date. The DSM stated the healthshakes were used heavily in the facility. Review of the health mightyshakes manufacturers label indicated the Store Frozen and to Thaw and serve within 4 days. https://www.hormelhealthlabs.com/wp-content/uploads/ProductFactSheet_26337_[DATE].pdf 3. During the initial kitchen tour on [DATE] at 10:30 AM with the DSM in the dish machine area, a pipe was extended directly into a floor sink drain without an air gap space. The DSM stated she was unaware the pipe extended into the floor drain and did not have an air gap. On [DATE] at 9:12 AM, an observation and interview were conducted in the kitchen dish machine area with the Plant Operations Director (POD). The POD acknowledged the pipe underneath the dish machine did not have an air gap space, and stated the pipe needed to be raised higher. According to the 2022 Federal FDA Food Code section ,d+[DATE].13 titled Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonfood EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 4. A) During an observation and interview with the DSM and POD on [DATE] at 4:06 PM of the facility's ice machine in the dining room, the DSM stated the Maintenance/Plant Operations Department cleaned the ice machine, including deep internal cleaning and bin cleaning. The POD stated the facility's ice machines were cleaned every 3 months. During an observation and interview on [DATE] at 8:55 AM of the main ice machine with the POD, DSM, and Assistant Administrator (AADM), the ice machine was checked for cleanliness. The POD opened the ice machine cover and described how he followed the manufacturers guidelines for cleaning the ice machine. The ice machine curtain covering the grid had small brownish pink spots on it. The rubber baffle piece inside the ice bin had black, dark grayish spots resembling mold on the right side between one of the folds. The POD acknowledged the dirty black grayish spots on the baffle which touches the ice, and stated they must have missed the area during cleaning. The DSM and AADM acknowledged the black-grayish mold looking debris on the baffle inside the ice bin and stated it should be clean without the dirty colored spots. Review of the ice machine cleaning log schedule indicated the ice machine was last cleaned on [DATE]. Review of the main ice machine manufacturer's cleaning instructions, Ice Machine Cleaning Procedure step 3: Remove ice from bin .step 4: Turn toggle switch to the clean position .step 6: .Remove all parts for cleaning and sanitizing . B) On [DATE] at 4:25 PM, an observation of the [NAME] Hall wing section ice/water machine was conducted. The walls inside the ice spout dispenser were dirty, filled with white and gray hard residue and debris. During an observation and interview on [DATE] at 9:41 AM with the DSM, POD, and AADM, the [NAME] Hall wing section ice/water machine was checked for cleanliness. Inside the ice spout walls were white grayish colored thick debris, and build up inside the ice shoot where the ice came out. The POD stated the ice/water machine was cleaned according to manufacturer's guidelines using the recommended manufacturers chemicals. The POD acknowledged the debris and residue inside the ice spout and stated the area could have been scrubbed and wiped more to remove the crusty buildup. The AADM and DSM acknowledged the discolored thick hard debris on the inside wall of the ice dispenser spout and stated it should have been clean. During an interview with the Registered Dietitian (RD) on [DATE] at 1:20 PM, the RD stated she expected the ice machines to be clean following the manufacturers guidelines and without black grayish residue or debris. According to the 2022 Federal FDA Food Code, section ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils, Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Review of the facility's policies and procedures (P&P) dated 2023, titled Sanitation indicated .All equipment shall be maintained as necessary and kept in working order .14. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner . 17. All Food & Nutrition Services staff shall know the proper hand washing technique . 21 . Thermometers will be used to check temperatures of refrigerators, freezers, and food storeroom. Thermometers will also be used to check the food at mealtimes . 24. Airgaps/Backflow prevention is necessary . Review of the facility's policies and procedures (P&P) dated 2023, titled General Cleaning of Food & Nutrition Services Department indicated .Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition . Review of the facility's policies and procedures (P&P) dated 2023, titled Refrigerator and Freezer indicated Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods.1. Refrigerator and freezer should be on a weekly cleaning schedule.3. Clean the evaporator and condensing coils at least twice a year . Review of the facility's policies and procedures (P&P) dated 2023, titled Shelves, Counters, and Other surfaces including Sinks indicated, .Remove any large debris and wash surface with a warm detergent solution following manufacturer's instructions. Use a brush where necessary .2. Rinse with clear water using a clean sponge or cloth. Wipe dry with clean cloth. 3. Spray with a sanitizer .Do not rinse. Review of the facility's policies and procedures (P&P) dated 2023, titled Walls, Ceilings, and Light Fixtures indicated, .2. Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently, as necessary.5. Ceramic tile, stainless steel sections, and other surfaces must be cleaned according to product manufacturer's instructions . Review of the facility's policies and procedures (P&P) dated 2023, titled Ice Machine Cleaning Procedures indicated, .The internal components cleaned monthly or per manufacturer's recommendations .5. Be sure special attention is paid to cleaning the door molding and lid . Review of the facility's policies and procedures (P&P) dated 2023, titled Ice Procedures indicated, .Ice is to be handled properly to prevent infection.2. A covered plastic or stainless steel container will be used to hold the scoop.3. The scoop is not to left in the ice at any time.

Based on observation, interview and record review, the facility failed to ensure residents were free from verbal and physical abuse for one of nine sampled residents (Resident 103) when: Certified Nursing Assistant (CNA) 8 cursed at Resident 103, and used physical force to provide care by climbing on top of Resident 103's bed and forcibly straddled Resident 103 to hold her legs down; the Care Partner (CP) (an assistant to the facility residents who answers call lights) and CNA 9 failed to protect Resident 103 when they witnessed the use of physical force during care by CNA 8. This failure resulted in the excessive use of force and verbal abuse of Resident 103 who had a known history of cognitive impairment and placed Resident 103 at risk for physical and psychosocial harm. Findings: During an observation on 6/20/19, at 5:45 p.m. in the dining room, Resident 103 was eating dinner with staff supervision. Resident 103 sat in a geriatric chair (large padded chair with wheeled bases designed for residents with limited mobility). Resident 103 did not respond when asked how she was doing. Resident 103 rambled from subject to subject and proceeded to tell a story about her children. During a review of the clinical record for Resident 103's face sheet (document containing resident profile information) dated 8/13/19, indicated Resident 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 103's Minimum Data Set (MDS) assessment (assessment of healthcare and functional needs) dated 4/5/19, indicated Resident 103's Brief Interview for Mental Status (BIMS) (assessment of cognitive status) score of 3 of 15 points indicated Resident 103 had severe cognitive impairment. During an interview with Licensed Vocational Nurse (LVN) 15, on 6/20/19, at 6:15 p.m., LVN 15 stated she was the assigned nurse for Resident 103 on 6/4/19. LVN 15 stated the CP reported to her on 6/4/19 at about 5 p.m., CNA 8 was feeling stressed out because of a difficult work shift. LVN 15 stated the CP's report about CNA 8 was vague and did not give details about being stressed. LVN 15 stated she spoke to CNA 8, who told her she was having a difficult work day. LVN 15 stated she instructed and advised CNA 8 to ask for help if she felt overwhelmed. LVN 15 stated CNA 8 worked the rest of the evening shift from 2:30 p.m. to 11:30 p.m. LVN 15 stated she was not aware of the physical and verbal abuse that occurred between CNA 8 and Resident 103 on 6/4/19. LVN 15 stated the Director of Nursing (DON) informed her the next day on 6/5/19 at 2:30 p.m., about the verbal and physical abuse that occurred between CNA 8 and Resident 103. LVN 15 stated the DON told her CNA 8 yelled, cursed, held down and pulled Resident 103's pants down. LVN 15 stated if she had known about CNA 8's abuse of Resident 103, she would have reported it immediately to the Administrator (ADM), DON, Police, and the family. LVN 15 stated she did not do a head to toe assessment nor a care plan for Resident 103 because she was not aware of the incident of abuse. During an interview with the CP, on 6/20/19, at 7:15 p.m., she stated her job responsibilities included the assistance of residents by answering call lights and giving them water. The CP stated she was physically present in the room on 6/4/19 when the incident between Resident 103 and CNA 8 occurred at approximately 7 to 8 p.m. The CP stated Resident 103 was combative, yelling, hitting and refused care from CNA 8. The CP stated CNA 8 cursed, yelled and aggressively told Resident 103 to shut up. The CP stated she saw when CNA 8 grabbed and held Resident 103's legs in an effort to pull her pants down, which resulted in Resident 103 kicking CNA 8. The CP stated she knew something wasn't right about the interaction. The CP stated Resident 103 had the right to refuse care and was not provided with dignity and respect by CNA 8. The CP stated she immediately reported the incident to LVN 15 between 7 and 8 p.m. the same day. The CP stated she told LVN 15 that CNA 8 yelled and cursed at Resident 103. The CP stated, I did not report to anybody except to (LVN 15) who was the charge nurse at that time. The CP stated she should have reported the incident to the ADM, DON, or the local police and did not do so. During a telephone interview with CNA 8, on 6/26/19, at 1:39 p.m., she stated the incident happened on 6/4/19 at around 6:30 p.m., inside Resident 103's room. CNA 8 stated she was in the room with the CP, CNA 9 and Resident 103. CNA 8 stated Resident 103 was combative during care. CNA 8 stated Resident 103 hit and kicked with her arms and legs as she attempted to provide care. CNA 8 stated she asked CNA 9 to help her by holding on to Resident 103's arms. CNA 8 stated she got on top of the bed and straddled Resident 103. CNA 8 stated she held her legs down as she straddled her in order to pull her pants down to apply a clean brief. CNA 8 stated she verbally cursed at Resident 103. CNA 8 stated she told (Resident 103), Stop the (expletive). CNA 8 stated she reported to the charge nurse (LVN 15) about the physical and verbal abuse that happened while she was providing care to Resident 103. CNA 8 stated LVN 15 advised her, if she was having a hard time with Resident 103 to come back later when she cooled off and ask another CNA for help. CNA 8 stated she continued to work, finished her shift, and returned to work the following day on 6/5/19 from 2:30-6 p.m. CNA 8 stated she took care of the same assigned residents including Resident 103 as the day before. CNA 8 stated she requested a change of assignment to another area with less combative residents, but her request was denied by the Director of Staff Development (DSD). CNA 8 stated the DSD told her she needed to handle and learn how to deal with all types of care and conditions of residents in the facility. During an interview with the DON, on 6/27/19, at 8:55 a.m., the DON stated the CP reported the incident she witnessed between CNA 8 and Resident 103 to her on 6/5/19 at around 5 p.m. The DON stated two CNAs and a CP were inside the room when the incident happened. The DON stated the CP heard CNA 8 yell and curse at Resident 103 while providing care. The DON stated the CP reported to LVN 15 that CNA 8 was feeling stressed out with caring for Resident 103 but did not mention the actual incident that happened on 6/4/19. The DON stated LVN 15 told her she called CNA 8 to the side to let her know that Resident 103 was difficult and combative. The DON stated if CNA 8 was having a hard time with Resident 103, she could have asked for help from another staff person. The DON stated, LVN 15 was not aware of the incident at that time. The DON stated Resident 103's head to toe assessment and care plan were not done on 6/4/19 because LVN 15 was not aware of the incident of abuse. The DON stated the care plan was initiated on 6/6/19 and the assessment was done by LVN 15 on 6/5/19. The DON stated Resident 103's physical and verbal abuse could have been avoided if CNA 9 and the CP intervened immediately. The DON stated CNA 9 and the CP could have stopped CNA 8 from climbing onto the bed of Resident 103. The DON stated CNA 9 and the CP could have called LVN 15 to step in and could have avoided the physical and verbal abuse. During an interview with DSD 1, on 6/27/19, at 11:10 a.m., DSD 1 stated all facility staff were trained to report any suspected abuse. If they witnessed any incident they were to report it immediately to the proper authorities and the abuse coordinator. The DSD stated the incident of physical and verbal abuse with Resident 103 was avoidable if CNA 9 and the CP would have intervened and stopped CNA 8. The DSD stated CNA 9 and the CP should have reported the incident immediately to the Charge Nurse. The DSD stated if Resident 103 was refusing care, CNA 8 should have stopped performing care. The DSD stated Resident 103's rights and dignity were violated at the time of the incident. During an interview with Minimum Data Set-Registered Nurse (MDS-RN), on 6/27/19, at 11:45 a.m., the MDS-RN stated CNA 8 and the CP could have intervened immediately by stopping to report the abuse to the charge nurse. The MDS-RN stated Resident 103 refused care at the time of the incident. The MDS-RN stated CNA 8 should have stopped and attempted to provide care at a later time with the help of other staff members or the charge nurse. During a telephone interview with a Family Member (FM), on 6/27/19, at 5:30 p.m., FM stated, LVN 15 notified her on 6/5/19 at 5:30 p.m., about CNA 8's use of physical force and verbal abuse toward Resident 103. The FM stated she requested the facility staff keep her informed as soon as possible anytime of the day of any incidents that occurred with Resident 103. The FM stated she was disappointed and sad that this incident took place between Resident 103 and CNA 8. The FM stated the facility staff should have used a different approach in caring for Resident 103 if the initial approach did not work. The FM stated Resident 103 had a right to her own preferences and the staff violated Resident 103's rights and dignity. During a telephone interview with CNA 9, on 7/3/19 at 9:01 a.m., CNA 9 stated she was working the evening shift on 6/4/19 when CNA 8 asked for assistance to provide care to Resident 103. CNA 9 stated she was with CNA 8, and the CP inside Resident 103's room. CNA 9 stated, (Resident 103) was yelling and cursing when we entered the room. CNA 9 stated Resident's 103's brief was soaked with urine and needed to be changed. CNA 9 stated she held the right hand of Resident 103 gently to keep Resident 103 from hitting and scratching CNA 8. CNA 9 stated Resident 103 continued to hit CNA 8 with her left hand. CNA 9 stated the facility did not have a system to call for help for an extremely combative resident. CNA 9 stated the facility should have developed a better system and trained all staff to deal with extremely combative residents to avoid physical and verbal abuse. CNA 9 stated in the past she had seen other CNA and licensed staff care for Resident 103 the same way as CNA 8 and adopted the same method of care for Resident 103. CNA 9 stated there was no protocol or better technique in place to care for combative residents in the facility. CNA 9 stated she was not taught to call the charge nurses when she had a problem with the residents. CNA 9 stated, I did not even know who was the charge nurse at that time. I know now that it was physical and verbal abuse that happened that day. (CNA 8) forcefully provided care and used foul language. CNA 9 stated she should have stopped CNA 8 and reported the incident to the charge nurse and did not do so. During a telephone interview with CNA 8, on 7/3/19, at 1:31 p.m., CNA 8 stated Resident 103 was confused and yelled and cursed during her shift on 6/4/19. CNA 8 stated Resident 103 was physically resistant to care. CNA 8 stated she asked CNA 9 to help her change Resident 103's shirt, pants and brief which were soaked with urine. CNA 9 stated LVN 15 told her not to yell or apply force when providing care to Resident 103. CNA 8 stated, (LVN 15) told me just to walk away and call other staff for help. CNA 8 stated, I realize I made a mistake by forcing her care. I wish I had not used foul language towards (Resident 103). During a review of the facility policy and procedure titled, Rights-Protection From Abuse/Elder Abuse Reporting undated, indicated, 1.0 Policy 1.1 It shall be the policy of this facility to fully protect the rights of the individuals for whom we provide care and treatment; any form of abuse and neglect will not be tolerated.1.2 The basic responsibility of every employee is to ensure safety and well beings 1.3 The resident has the right to be free from verbal, sexual, physical, mental, financial . 1.5 Abuse must be reported if it is observed by a mandated reporter (California law requires all employees of a long term care facility to report abuse or suspected abuse to the proper authorities) or if the elderly person tells a mandated reporter that he/she suffered abuse, or if the mandated reporter had knowledge of an incident that reasonably appeared to be abuse .3.3 Failure to report suspected or known abuse may be punishable by incarceration and/or fine if death or great bodily injury resulted from abuse . Procedure 4.1 Any person having information either by direct observation or by report, of any act or suspected act that he/she considers may be abuse .b. Immediately reporting any observed or suspected case of resident physical abuse to the Ombudsman . 4.3 Failure to report Abuse information is cause for disciplinary Action up to termination . 1.12 The facility will make every attempt to prevent further potential abuse while the investigation is in progress .REPORTING RESPONSIBILITIES 3.1 Any care custodian, medical practitioner, non-medical practitioner, or employee of an elder protective agency who has actual knowledge that an elder has been a victim of any type of abuse shall report the suspected abuse. The report shall be telephoned to the local Ombudsman, Department of Licensing and Certification and to the law enforcement agency, immediately or as soon as practical, but within 2 hours of notification that abuse may have occurred . 3.3 Failure to report suspected or known abuse may be punishable by incarceration and/ or a fine . The facility policy and procedure titled, Rights- Protection from Abuse Prevention Adult/Elder Abuse undated indicated, 1.0 POLICY 1.1 It shall the policy of this facility to fully protect the rights of the individuals for whom we provide care and treatment: any form of abuse and neglect will not be tolerated.1.2 The facility will make every attempt to prevent any form of abuse by initiating an Adult/Elder Abuse Prevention Program .3.0 TRAINING 3.1 The facility will conduct employee training on issues related to abuse prohibition practices through new employee orientation and continuing in service training: a. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents: b. staff should report their knowledge related to allegations without fear of reprisal: c. How to recognize signs of burnout, frustration and stress that may lead to abuse .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for 3 of 25 sampled residents (Residents 1, 2, and 12) to prevent the transmission of disease and infection when: 1. Transmission-based precautions were not implemented by the facility for Residents, 1, 2, and 12 who were diagnosed with [REDACTED]. difficile) (a bacterium that can cause diarrhea in individuals, usually during or after the use of antibiotics or a Medication Resistant Organism (MRO) and MRSA (Methicillin Resistant Staphylococcus Aureus- a microorganism characterized by resistance to certain antibiotics). 2. Cleaning products being utilized to disinfect surfaces and equipment in the resident environment were not indicated as being effective in killing Clostridium Difficile (C. difficile) (a bacterium that can cause diarrhea in individuals, usually during or after the use of antibiotics). These failures resulted in the potential for cross contamination and transmission of [DIAGNOSES REDACTED]icile and MRSA to residents, staff, and visitors. The survey team identified an Immediate Jeopardy situation on 3/9/15 at 7:35 p.m. due to the facility's failure to minimize cross contamination of infectious organisms to residents, staff, and visitors. The following staff were present at the time the facility was verbally notified of the Immediate Jeopardy: Administrator (Admin), Infection Control Preventionist (ICP), Director of Nursing (DON) and two Directors of Staff Development (DSD). Findings: 1. (a) On 3/9/15 at 10:15 a.m., during an initial tour observation and concurrent interview outside Resident 1's room, the ICP stated Resident 1's [DIAGNOSES REDACTED]. The entrance to Resident 1's room contained no precautionary alert signage for staff or visitors. No Personal Protective Equipment (PPE - garments such as gowns, gloves and masks worn to minimize the spread of infections) for staff and visitors was present at the entrance to Resident 1's room. Upon inquiry regarding the type of precaution used to minimize the transmission of Resident 1's [DIAGNOSES REDACTED]icile infection, the ICP stated, "Well, it's just standard precautions." Review of the facility document titled, "Standard Precautions" dated 2003, indicated, under Purpose, "It is the intent of this facility that: 1) all resident blood and body fluids will be considered potentially infectious 2) Standard Precautions are indicated for all residents." Under Barriers Indicated in Standard Precautions III., "Gowns/Aprons should be worn when there is a potential for soiling clothing with blood/body fluids." Under Personal Protective Equipment (PPE) II it indicated, "The type of personal protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated. Review of "JOINT INFECTION PREVENTION AND CONTROL GUIDELINES ENHANCED STANDARD PRECAUTIONS (ESP) CALIFORNIA LONG-TERM CARE FACILITIES, 2010, indicated under Introduction, " In addition to hand hygiene, Standard Precautions require gowns, gloves, masks, and face shields when healthcare personnel (HCP) anticipate that their hands, clothes or the mucous membranes of the eyes, nose, mouth, or skin on the face will be exposed to blood or other body fluids....Contact Precautions are an extension of Standard Precautions in that gowns and gloves are required for all patient/resident contacts...as well as contact with environmental surfaces in the patient's/resident's room." On 3/9/15 at 10:30 a.m., during an interview, Licensed Nurse (LN) 5 stated she worked 3/8/15 on the morning shift and was notified by the night nurse in the early morning on 3/8/15 of Resident 1's laboratory results were positive for [DIAGNOSES REDACTED]icile. LN 5 stated at that she transferred Resident 1 to a private room and, "I notified housekeeping and the Certified Nursing Assistants (CNAs)." LN 5 stated she had not placed Resident 1 under any type of infection control precautions. On inquiry regarding the location of PPE when staff needs to obtain it for the care of Resident 1, LN 5 stated, "They go down the hallway to get it." On 3/9/15 at 10:35 a.m., during an interview with the ICP regarding how visitors would know of Resident 1's recommended infection control precautions when there was no signage posted near Resident 1's door, LN 5 stated, "He is right here (indicating Resident 1's room was close to the nurses station), the nurses watch." On 3/9/15 at 11 a.m., during an observation and concurrent interview, LN 1 (The wound care treatment nurse) was observed entering Resident 1's room. LN 1 entered Resident 1's room, put on a set of gloves, partially pulled the curtain around Resident 1 's bed, walked around to the right side of the bed, retrieved Resident 1's urinal from his bedside table, emptied it into the toilet, returned it, removed her gloves in the resident bathroom, washed her hands, and exited the room. No other protective gown was worn by LN 1. On inquiry regarding LN 1's knowledge of Resident 1 she stated, "I don't really know much about him, he just needed his urinal emptied." Review of the facility document titled, "Treatment Nurses and treatment provided" indicated LN 1 provided direct care treatment to 14 other residents during her work shift on 3/9/15. On 3/9/15 at 11:05 a.m., during an observation, no staff person was present at Resident 1's nurses' station to alert visitors of any precautions to be taken. On 3/9/15 at 11:10 a.m., during an observation, CNA 1 and CNA 2 entered Resident 1's room. There was no evidence of a signage to alert staff or residents of the [DIAGNOSES REDACTED]icile infection in Resident 1's room. CNA 2 stated to the resident she was going to "help clean you up." CNA 1 and CNA 2 were observed donning (putting on) gloves and partially pulled the curtain closed. When finished with Resident 1's care, the CNA's pulled back the curtain placed the brief in a double bag, and removed their gloves, disposing of them in an unmarked trash receptacle located under the resident's sink. No gowns were used by CNA 1 and CNA 2. On 3/9/15 at 11:15 a.m., during an observation and concurrent interview, the ICP was observed taping a white paper sign to the left of Resident 1's door frame, which read, "Check with nurse before entering resident room." On 3/9/15 at 11:16 a.m., during an interview, the ICP stated the facility was notified of Resident 1's positive laboratory test for [DIAGNOSES REDACTED]icile infection on 3/7/15. The ICP stated she was advised by LN 7 housekeeping staff and CNAs were informed of Resident 1's diagnosis. On 3/9/15 at 11:23 a.m., during an interview with CNA 1 regarding her knowledge of Resident 1, she stated, "I don't know. He isn't my patient." On further inquiry regarding the type of PPE appropriate for changing a resident diagnosed with [REDACTED]." On inquiry as to proper disposal of PPE after use, she stated, "You double bag the linens but you put your gloves in the trash." Review of the facility document titled, "Nursing Staffing Assignment and Sign in Sheet," dated 3/9/15 (the CNA to resident assignment schedule) indicated CNA 1 was assigned direct care for 8 additional residents and CNA 2 was responsible for care of 6 additional residents. On 3/9/15 at 11:35 a.m., during an interview with CNA 3, regarding facility procedures for disposal of PPE for residents with infectious illness, CNA 3 stated, "Usually there is a trash can within the bathroom to discard PPE... there would be a can in the hall... we don't use red bags anymore, it's a dignity issue." Regarding the type of PPE CNA 3 would use in caring for a resident with diarrhea caused by an infectious illness, CNA 3 stated, "I would use gloves." Review of Resident 1's facility infection surveillance sheet titled, "GASTROINTESTINAL (GI) TRACT INFECTIONS, Clostridium Difficile Infection," dated 3/5/15, completed by the ICP, indicated under Treatment, "Isolation/Precaution." Precaution was indicated by a circle. Under Type, it indicated, "Standard/contact" (indicating Standard and contact precautions were indicated). "Healthcare Associated Infection (HAI)" was indicated by an "x," (indicating the infection was acquired while at the facility). Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Resident 1's Physician Progress Record notes dated 3/5/15 indicated, "c/o (complaining of) diarrhea.....will check stool for [DIAGNOSES REDACTED]." Resident 1's laboratory results indicated a stool test was collected on 3/7/15 at 9:30 a.m., and received by the laboratory on 3/7/15 at 11:27 a.m. Results indicated, "C. diff Toxin EIA (enzyme immunoassay) (test), (a test to detect the presence of [DIAGNOSES REDACTED] in the stool).)Rsl (Result) Pos (positive)...Phoned result to (LN) at 2125 (9:25 p.m.)." Review of Resident 1's facility infection surveillance sheet titled, "Gastrointestinal Tract (GI) Infections, Clostridium Difficile Infection," dated 3/5/15, completed by the ICP, indicated under Treatment, "Isolation/Precaution." Precaution was indicated by a circle. Under type, the document indicated, "Standard contact" (indicated standard and contact precautions were indicated). "Healthcare Associated Infection (HAI)" was indicated by an "x," (indicating the infection was acquired while in the facility). On 3/9/15 at 3:15 p.m., during an interview the Physical Therapist (PT) 1 regarding PPE to use with a resident who has a [DIAGNOSES REDACTED]icile infection, he stated, "Gloves and a mask." The PT further stated, "We take our direction from the nurses in relation to PPE." On 3/9/15 at 3:40 p.m., during an interview, PT 2 stated she was responsible for a weekly update on physical therapy goals for Resident 1 which would include any change of condition. On inquiry PT 2 stated she was not aware of a change of condition with Resident 1. On 3/9/15 at 4:15 p.m., during an interview with LN 2 regarding precautions for residents with CDI, she stated appropriate PPE included gloves, a gown if changing the resident and washing hands. She stated she was unsure whether the resident's side rails, bedside stand, linen, clothes, or curtains could be infectious. On 3/9/15 at 5:15 p.m., during an interview with the ICP regarding Resident 1's initial tour observation and interview, the ICP stated she was concerned regarding the absence of alert signage at the resident door. On inquiry regarding a concern for a lack of PPE at the resident's door, the ICP stated, "He doesn't need a PPE cart. The staff can go down the hall to get what they need." Regarding how the facility determines the need for precautions, the ICP stated the Director of Staff Development (DSD), the Director of Nursing (DON), and the ICP jointly determine infection precautions indicated. They phone the physician to request an order for [REDACTED]. Review of Nurses Notes dated 3/9/15 at 10:30 p.m., indicated, "...Pt. (patient) on contact precautions for[DIAGNOSES REDACTED]....," the first entry indicated the use of contact precautions. On 3/10/15 at 12:15 p.m., during an observation and concurrent interview with Resident 1, an alerting sign was observed posted at the left side of Resident 1's doorway. Disposable PPE was stored in a plastic cart at Resident 1's door. A plastic dispenser of ... Sani-Cloth Disposable Wipes was observed at the resident's sink in the room. Review of the back label of the Sani-Cloth wipes indicated no information on its effectiveness for [DIAGNOSES REDACTED]icile. Resident 1 stated he was not feeling well, and was experiencing shortness of breath in attempting to answer questions. He stated, "If I could just get rid of this diarrhea." On 3/10/15 at 1:05 p.m., during an observation, the same brand of disposable germicidal wipes was observed sitting on the counter at the nurse station outside Resident 1's room. Review of the back label indicated no information on its effectiveness for [DIAGNOSES REDACTED]icile. On 3/10/15 at 3:30 p.m., during an interview with CNA 4 regarding Resident 1's care, she stated Resident 1 was continent of urine and used his urinal at the bedside, but was incontinent of bowel. She stated he used a brief to try to contain his diarrhea, and required CNA assistance in clean-up of incontinent episodes. CNA 4 stated Resident 1 was not physically able to use the bathroom. Review of Resident 1's "Documentation Charting Record" for the period of 2/23/15 to 3/9/15, indicated Resident 1 had experienced episodes of fecal incontinence since 2/27/15, with increasing frequency from 3/5/15 to 3/9/15. Resident 1's "Nursing Admission Assessment" indicated under GU (Gastro/Urinal) History "continent" by use of a hash mark, (indicating complete control on admission). The assessment was signed by LN 6, and was not dated. Resident 1's Physician Orders, dated 3/8/15, indicated the following medication order, "[MEDICATION NAME] (an antibiotic) 500 mg. (milligrams) 1 po (by mouth) QID (four times daily)." Under Indication-Dx (diagnosis) it indicated, "Dx[DIAGNOSES REDACTED]." Resident 1's Physician Orders dated, 3/9/15, indicated the following order, "Contact precautions." An updated physician medication order dated 3/10/15 expanded the [MEDICATION NAME] medication order to give the medication for 14 days. Resident 1's Physical Therapy schedule for 3/4/15 and 3/5/15 indicated Resident 1 received physical therapy and occupational therapy services on both days, when experiencing incontinent diarrhea. On 3/11/15 at 7:45 a.m., during an interview, Physical Therapy Assistant (PTA) 1 stated he was providing physical therapy daily to Resident 1. Services provided included use of pulley weights and sit to stand assistance in his wheelchair and assistance with ambulation. PTA 1 stated Resident 1 had received services in the physical therapy unit until 3/9/15, when he learned of Resident 1's change in health status. On 3/11/15 at 8:10 a.m., during a concurrent observation and interview, Janitor (Jan) 1 was observed cleaning the counter tops of the nurses station outside Resident 1's room. On inquiry he stated he uses the facility Disinfectant Germicidal solution to clean counter tops at the nurses station, door frames, door knobs, resident bed frames, and bedside tables and counters (per review of product back label, the solution is not effective against [DIAGNOSES REDACTED]icile). He further stated bleach solution is used only in the toilet bowls and rim of the resident bathrooms. On 3/11/15 at 11:40 a.m., during an interview, the ICP stated all cleaning products used by the facility are brought to the Infection Control committee for review and approval. Once approved, they are forwarded to the Quality Assurance committee for approval and used in the facility. Regarding the purpose of Sani Cloth Disposable Wipes placed in Resident 1's room, the ICP stated, "We use that for disinfecting the glucometer and the BP cuffs (Resident 1's room contained a disposable BP cuff)... I don ' t know why" (the wipes were placed in resident room)." On review of the labeling on the back of product container, the ICP acknowledged there was no information regarding the effectiveness of the product against [DIAGNOSES REDACTED]icile. The ICP stated, "I don't use this, they are at the nurses station so staff can use them." On 3/12/15 at 8:30 a.m., during an interview, the Director of Rehab (DOR) stated the physical therapy unit learns of resident precautions at the daily facility stand up meeting. He stated he verbally discusses updates with the physical and occupational staff involved, and follow precautions advised by the nursing staff. He stated therapy aides and the physical therapists were responsible for the day to day cleaning of the unit. He stated the physical therapy unit had not implemented or changed any cleaning practices since learning of the Immediate Jeopardy called on 3/9/15. He stated the unit uses two types of products, the ...Sani Cloth Disposable Wipes (previously found in Resident 1's room and at the nurse's station) and the ...Disinfectant Germicidal solution used for daily cleaning in the facility. Regarding residents who may be symptomatic with or have confirmed [DIAGNOSES REDACTED]icile infection, he stated therapy would be done in the resident room if the staff were aware. The DOR reviewed the back label of the ...Sani-Cloth Disposable Wipes and acknowledged there was no information on its effectiveness for [DIAGNOSES REDACTED]icile. The DOR stated he was not sure whether the ...Disinfectant Germicidal solution provided to the unit was effective for [DIAGNOSES REDACTED]icile. Review of the facility policy and procedure titled, "Departmental (Physical Therapy)-Prevention of Infection" revised October 2010, indicated under Purpose, "The purpose of this procedure is to prevent the spread of infections in the physical therapy department." No information was found on appropriate cleaning and disinfecting products for the physical therapy unit. Review of Resident 1's physician progress notes [REDACTED]. On [MEDICATION NAME] (an antibiotic) for [DIAGNOSES REDACTED]..." Review of <http://www.cdph.ca.gov/programs/hai/Pages/ClostridiumDifficile(CDiff).aspx> a California Department of Public Health (CDPH) internet resource, indicated, "Clostridium difficile (also known as [DIAGNOSES REDACTED]) is a...bacterium that can cause diarrhea....The most common symptoms of Clostridium Difficile Infection (CDI) are: watery diarrhea, abdominal (belly) pain/tenderness, fever, nausea, loss of appetite ...[DIAGNOSES REDACTED]icile bacterium can form spores which can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. The bacterium and its spores can spread from person to person on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors...Use Contact Precautions to prevent [DIAGNOSES REDACTED] from spreading to other patients. Contact Precautions mean whenever possible, patients with CDI will have a single room or share a room only with someone else who also has CDI. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with CDI. Visitors may also be asked to wear a gown and gloves. When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands..." The facility policy and procedure titled "Transmission-Based Precautions" revised 2010, indicated under Contact Precautions, "In addition to Standard Precautions, implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to:... 2. Diarrhea associated with Clostridium difficile." Under d. Gown, "(1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. (2) After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces." Review of the facility document titled, "(Facility) Infection Control QA (Quality Assurance) for February 2015," a document used to track infections in the facility, indicated the facility had 7 residents with Clostridium difficile, 4 residents with Community Acquired Infections (acquired outside the facility) and 3 with Healthcare Acquired Infections (acquired at the facility)." Review of the facility document titled, "Standard Isolation Precautions" dated 2001, indicated, "Standard Isolation Precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]." Under 4. Gowns the document indicated, "Wear a gown (clean non sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids,...excretions or cause soiling of clothing." Under 6. Environmental Control, "a. Ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned." Review of the facility document titled, "Isolation-Initiating Transmission-Based Precautions" dated October 2010, indicated, "When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need: b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information...c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room; d. Place necessary equipment and supplies in the room that will be needed during the period of Transmission Based Precautions;..." Review of the facility document titled, "Personal Protective Equipment-Using Gowns" dated October 2010, indicated under Objectives 2. "To prevent soiling of clothing with infectious material; 3. To prevent splashing or spilling blood or body fluids onto clothing or exposed skin..." Under Miscellaneous 6. it indicated, "When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident." Review of the facility document titled, "Clostridium Difficile" dated April 2010, indicated under Contact Precautions 3. "Residents with diarrhea associated with Clostridium difficile...will be placed on Contact Precautions for the duration of illness."` 1. (b) On 3/9/15 at 9:30 a.m., during an observation and concurrent interview, LN 3 stated Resident 2 had a [DIAGNOSES REDACTED].e., coughing, sneezing) in her sputum. No signage was observed to be posted near Resident 2's door to alert staff and visitors that precautions were necessary for Resident 2. Resident 2's roommate, Resident 3, was diagnosed with [REDACTED]. No cart with Personal Protective Equipment (PPE) was observed near Resident 2's doorway. Review of Resident 2's clinical record, "Admission Physicians Orders" dated 2/25/15 indicated, "Admission Diagnosis 1. MRSA pneumonia... Special Instructions: MRSA Precaution..." Resident 2's Physician Orders dated 3/9/15, indicated, "droplet precautions." Resident 2's care plan dated 3/9/15, indicated, "At risk for cross contamination secondary to presence of Pneumonia with MRSA in the sputum." Resident 3's admission orders [REDACTED] Review of www.cdc.gov/ ...healthcare/clinicians/precautions.html indicated: Contact Precautions CDC recommends contact precautions when the facility (based on national or local regulations) deems MRSA to be of special clinical and epidemiologic significance. The components of contact precautions may be adapted for use in non-hospital healthcare facilities, especially if the patient has draining wounds or difficulty controlling body fluids...Patient placement In Patient placement in hospitals and LTCFs, Long Term Care Facilities) when single-patient rooms are available, assign priority for these rooms to patients with known or suspected MRSA colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. When single-patient rooms are not available, cohort patients with the same MRSA in the same room or patient-care area. When cohorting patients with the same MRSA is not possible, place MRSA patients in rooms with patients who are at low risk for acquisition of MRSA and associated adverse outcomes from infection and are likely to have short lengths of stay. On 3/9/15 at 2:30 p.m., during an interview, CNA 5 stated, "For a resident with MRSA they will post a sign on the door that reads "Speak to Charge Nurse before entering." The facility policy and procedure titled, "Isolation - Categories of Transmission-Based Precautions revised October 2010, indicated, "Droplet Precautions... f. Signs - The facility will implement a system to alert staff to the type of precaution resident requires." On 3/9/15 at 2:45 p.m., during an interview, CNA 6 stated she was caring for the residents in specific rooms, which included Resident 2's room, and stated she did not have any residents with MRSA. She stated if she had a resident with MRSA, they would have a cart outside of the room (with PPE equipment and supplies). CNA 6 stated she would ask the nurse what PPE to put on. CNA 6 heard Resident 2 coughing and stated she would use gloves to avoid getting Resident 2's sputum on her. On 3/9/15 at 3:30 p.m., during an interview, the Infection Control Preventionist (ICP) stated standard precautions are used for MRSA. The ICP stated if a resident has MRSA in their sputum and the resident is coughing, the CNA may use a gown if they think they need it. ICP stated to her knowledge Resident 2 was no longer coughing. On 3/9/15 at 3:35 p.m., during an observation and concurrent interview, Resident 2 was observed coughing repeatedly. Resident 2 stated she was still congested and she spits into the tissue and throws it in the bag. The bag with tissue was observed on the bedside table. Resident 2 stated she went to the Physical Therapy unit on 3/8/15 for therapy. On 3/10/15 at 3:05 p.m., with CDPH Infectious Disease Nurse Consultant stated the Centers for Disease Control does recommend contact precautions with known MRSA residents, and residents with MRSA should be separated from non-MRSA infected residents. Resident 2's Physician's order dated 2/26/15, indicated, "PT (Physical Therapy) 5x/wk x4 wks (meaning five times per week for four weeks)." Review of Physical Therapy schedules indicated Resident 2 attended physical therapy on 3/2/15, 3/3/15, 3/4/15, 3/7/15 and was scheduled for 3/9/15 at 4 p.m. The facility policy and procedure titled, "Departmental (Physical Therapy) - Prevention of Infection" revised October 2010, indicated, "1. Therapy workers should follow Standard Precautions for all individuals and Contact Precautions if indicated by a resident's condition, physician's orders, or appropriate notification from the nursing staff." Review of the California Department of Public Health-"Enhanced Standard Precautions for Long Term Care Facilities," dated 2010, indicated, "In addition to hand hygiene, Standard Precautions require gowns, gloves, masks, and face shields... Standard Precautions are always used in addition to Transmission-Based Precautions... Transmission Based Precautions includes Droplet, Airborne and Contact Precautions". The facility policy and procedure titled, "Isolation Precautions, Categories of" revised October, 2010, indicated under Policy, "Transmission-based isolation precautions will be used for residents who are documented or suspected to have infections or communicable diseases that can be transmitted by airborne or droplet transmission...Transmission based isolation precautions are to be used in addition to Standard Precautions." Under 4. it indicated, "In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include...1....infections or colonization with multidrug-resistant bacteria (e.g., MRSA)..." The facility policy and procedure titled, "Isolation - Initiating Transmission-Based Precautions" revised October 2010, indicated, "5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door ... so that all personnel will be aware of precautions..." 1. (c). On 3/9/15 at 10:45 a.m., during an observation and concurrent interview on initial tour, the DSD stated Resident 12 had a [DIAGNOSES REDACTED]. The DSD stated there was no sign on Resident 12's room door to indicate Resident 12 was on isolation. The DSD stated there should have been a sign on the outside of the door which would indicate transmission precautions for Resident 12 were needed. On 3/9/15 at 10:55 a.m., during an interview, the ICP stated there should have been a sign on Resident 12's door to alert the staff and visitors about necessary precautions. On 3/11/15 at 7:30 a.m., during an interview the ICP stated Resident 12 was admitted to the facility on [DATE]. Resident 12 was admitted for a urinary tract infection (UTI) with MRSA. Review of Resident 12's acute care discharge instructions dated 03/07/15, indicated, "CONTACT PRECAUTIONS, Frequency: Continuous." Review of Resident 12's PASARR (Preadmission Screening and Resident Review report) dated 03/07/15, indicated a primary admission [DIAGNOSES REDACTED]. Review of Resident 12's care plan dated 3/9/15 indicated, "UTI with MRSA, standard precautions." Review of Resident 12's Physician's order dated 3/9/15 at 10:30 p.m., indicated, "D/C (discontinue) standard precautions. Contact precautions." 2. On 3/10/15 at 3:05 p.m., during an interview, the Infection Control Consultant Registered nurse for the California of Department of Public Health (ICC RN) stated rooms of residents that have [DIAGNOSES REDACTED]icile need to be cleaned daily including the floor. Products need to be specific to killing [DIAGNOSES REDACTED]icile and manufacturer's instructions need to be followed. On 3/13/15 at 2:35 p.m., during an interview, HK 1 stated she used a disinfectant germicidal solution to mop the floors of rooms for residents with [DIAGNOSES REDACTED]icile. Review of disinfectant germicide solution information indicated no information on its' efficacies (how effective the solution was to provide disinfection against the bacteria) for [DIAGNOSES REDACTED]icile. On 3/13/15 at 2:45 p.m., during an interview, HK 2 stated she used the same disinfectant germicidal solution to mop the floors of residents infected with [DIAGNOSES REDACTED]icile. On 3/13/15 at 3:15 p.m., during an interview, the HKD stated disinfectant germicidal solution was used to mop all resident's room floors. On 3/13/15 at 3:30 p.m., during an interview the ICP and DON stated housekeepers need to use a product that kills[DIAGNOSES REDACTED] when the floors are mopped in affected resident rooms. The ICP and DON stated housekeeping should be using germicidal bleach. Review of http://www.cdph.ca.gov/programs/hai/Pages/ClostridiumDifficile(CDiff).aspx a CDPH internet resource, indicated, "To prevent CDI, doctors, nurses, and other healthcare providers: Clean their hands with soap and water before and after caring for every patient. This can prevent spores from being passed from one patient to another on their hands. Carefull