Every finding on record at Escondido Post Acute

Based on interviews and record reviews, the facility failed to develop a care plan (detailed plan with information about a resident's treatment, goal, and interventions) for: 1. The care of resident's medication (Resident 1), 2. The care of a resident's medication (anticoagulant, blood thinner medications) and its side effects (Resident 84),3. The residents' refusal to nail care (Residents 22 and 36). As a result, the lack of a resident centered care plan with specific interventions had the potential to result in delayed care, miscommunication among caregivers, and a decreased physical well-being of the residents. Cross Reference: F757 and F 677. Findings: 1.Resident 1 was re-admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry, fear, or dread) according to the facility's admission Record. During an observation and interview on 6/30/26 at 8:53 A.M. Resident 1 was lying in bed, his eyes were closed and did not respond to his name. A review of physician's orders (POS) in the electronic medical record (EMR) for Resident 1 was conducted. The POS indicated, Clonazepam [anti- anxiety medication] for anxiety aeb [sic, as evidenced by] restlessness. An interview and joint record review was conducted with Licensed Nurse (LN) 1 on 7/2/26 at 8:50 A.M. LN 1 reviewed Resident 1's care plans in the EMR. LN 1 stated there was no care plan to address Resident 1's use of anti-anxiety medication. LN 1 stated there should be a care plan. LN 1 further stated the purpose of the care plan was to monitor the resident, the side effects of the medication and how to care for the resident. During an interview on 7/2/26 at 11:55 A.M. with the Director of Nursing (DON), the DON stated there should have been a care plan because the resident was on the medication and needed monitoring for side effects of the medication. The DON stated the care plan should reflect the care that was provided to the residents to evaluate if the interventions were effective. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. 2. A review of Resident 84 admission record, Resident 84 was admitted to the facility on [DATE] with a diagnosis that included peripheral vascular disease (progressive blood vessel disorder affecting vessels outside the heart.) A review of Resident 84's physician order dated 4/28/26 indicated Apixaban (blood thinner medication) oral tablet 5 mg (milligrams-a unit of measure), give one table by mouth twice a day for A-Fib (arterial fibrillation- irregular heartbeat) and Clopidogrel Bisulfate (blood thinner medication) tablet 75 mg, give 1 tablet by mouth one daily for blood clot prevention. A review of Medication Administration Record (MAR) for June 2026 indicated Resident 84 had received anticoagulant medications. A review of Resident 84's physician orders and care plan did not indicate to monitor side effects of an anticoagulant. On 7/2/26 at 9:32 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 22. LN 22 reviewed Resident 84's physicians orders and care plan. LN 22 stated there was no physicians order and no care plan to monitor the anticoagulant and its side effects for Resident 84. LN 22 stated Resident 84 was at risk for bleeding and should have been monitored for blood in the urine or stool, coffee like stools and abnormal bruising and to notify the physician. On 7/2/26 at 3:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 84 was a risk for bleeding. The DON stated Resident 84 should have had a care plan to monitor for bleeding while on anticoagulant medications. A review of the facility policy titled Anticoagulant-Clinical Protocol, revised November 2018, indicated .Monitoring.5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. 3a. Resident 22 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (severe shortness of breath, confusion and bluish skin requiring immediate medical intervention) and chronic pain syndrome according to the facility's admission Record. An observation and interview with Resident 22 was conducted on 6/29/26 at 11:10 A.M. Resident 22 was in bed, head of bed elevated and was observed with a beard and long fingernails with black debris under the fingernails of both hands. Resident 22 stated he preferred to have a beard and would ask staff to trim his fingernails. An interview with Certified Nurse Assistant (CNA) 12 was conducted on 7/1/26 at 9:09 A.M. CNA 12 stated Resident 22's fingernails were long but he was resistive to care such as shaving and nail trimming. An interview and concurrent record review with Licensed Nurse (LN) 12 was conducted on 7/1/26 at 12:42 P.M. LN 12 stated she was not aware of Resident 22 refusing care. LN 12 reviewed care plans for Resident 22. LN 12 stated Resident 22 did not have a care plan regarding refusing to be shaved or to have his fingernails trimmed. LN 12 stated Resident 22's refusals should be documented in the care plan to show proof of refusals, resident education and interventions to provide care. 3b. Resident 36 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following unspecified cerebrovascular disease affecting left non-dominant side (the less preferred side of the body). A joint observation and interview on 7/1/26 at 9:28 A.M. was conducted with Certified Nurse Assistant (CNA) 13. CNA 13 stated Resident 36 was dependent on staff for Activities of Daily Living (ADL-hygiene, dressing, getting in and out of bed or a chair, walking, toileting and eating). Resident 36 was observed laying flat in bed. Resident 36 showed her right hand to CNA 13. Resident 36 stated her fingernails needed to be trimmed. Resident 36 picked up her left hand using her right hand and showed fingernails that were also long. CNA 13 stated Resident 36's fingernails should be trimmed to prevent hurting herself and the fingernails had bacteria. CNA 13 stated Resident 36 had episodes of refusing care, hitting and scratching staff. During an interview and concurrent record review on 7/1/26 at 12:42 P.M. with Licensed Nurse (LN) 12, LN 12 stated she was not aware of Resident 36 refusing nail trimming. LN 12 checked care plans for Resident 36 and stated there was no care plan regarding refusing nail trimming. An interview with the Director of Staff Development (DSD- a licensed nurse certified for staff training) was conducted on 7/2/26 at 7:51 A.M. The DSD stated she expected CNAs to provide nail care and shaving on shower days. The DSD stated nail care and shaving were also offered on Sundays. The DSD stated resident refusals should be documented in the resident's chart. The DSD stated nail care was important due to an avenue for infection because fingernails may harbor bacteria. The DSD further stated the documentation should show attempts to offer and care plan with another solution when the resident refused. An interview on 7/2/26 at 4:13 P.M. with the Director of Nursing (DON) was conducted. The DON stated it was important to care plan resident refusals to add interventions for the resident to be compliant and to add a step in the care to be provided to the resident. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022 was conducted. The P&P indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to provide routine nail care to four of five residents (Resident 205, 22, 31, and 36), reviewed for Activities of Daily Living (ADL, activities related to personal care/ hygiene) for dependent residents. As a result, the residents' nails were long, with brown matter underneath the fingernails and were at risk for skin injury and infection. Cross Reference: F 656 Findings: 1.Resident 205 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, per the facility's admission Record. A review of Resident 205's clinical record was conducted. According to the initial MDS dated [DATE], Resident 205 had a BIMS (ability to recall) score of 12/15 which indicated Resident 205's cognition was moderately impaired. The functional status indicated Resident 205 was dependent on a staff member for personal hygiene. On 6/29/26 at 9:07 A.M., an observation and an interview were conducted of Resident 205 as he laid in bed. Resident 205's hands were exposed, and nails appeared long, and with brown substances underneath the fingernails. Resident 205 stated he just wanted his mobile phone with him. On 7/1/26 at 8:19 A.M., a joint observation of Resident 205 and an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 205's nails were long and had brown substances underneath the fingernails. CNA 1 stated Resident 205 needed assistance with ADLs. CNA 1 stated Resident 205's nails should have been kept clean and trimmed for hygiene. On 7/1/26 at 12:33 P.M., a joint review of Resident 205's clinical record and an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated she was informed that Resident 205 had long nails. LN 2 stated Resident 205's nails should be kept clean to prevent him from acquiring an infection. On 7/2/26 at 11:55 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to provide hygiene to Resident 205. The DON stated hygiene and grooming included making sure residents' nails were trimmed and cleaned to prevent infection and for the resident's well-being. A review of the facility's policy and procedure, titled, Fingernails/ Toenails, Care of, revised February 2018, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.General Guidelines, a. Nail care includes daily cleaning and regular trimming. 2.Resident 22 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (severe shortness of breath, confusion and bluish skin requiring immediate medical intervention) and chronic pain syndrome according to the facility's admission Record. An observation and interview with Resident 22 was conducted on 6/29/26 at 11:10 A.M. Resident 22 was in bed, head of bed elevated and was observed with a beard and long fingernails with black debris under the fingernails of both hands. Resident 22 stated he preferred to have a beard and would ask staff to trim his fingernails. An interview with Certified Nurse Assistant (CNA) 12 was conducted on 7/1/26 at 9:09 A.M. CNA 12 stated Resident 22's fingernails were long. 3.Resident 31 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and muscle weakness according to the facility's admission Record. Resident 31 was observed on 6/30/26 at 8:45 A.M. Resident 31 was in bed, with no verbal response. Resident 31's left hand had an orange hand roll and the right hand was closed. Resident 31's fingernails were long with black debris under the fingernails. A review of Resident 31's care plan was conducted. Resident 31's ADL care plan initiated on 3/10/26 indicated, Resident is at risk for ADL/mobility decline and requires assistance related to cognitive [thinking and decision-making ability] impairment. An interview and joint observation on 7/1/26 at 9:01 A.M. was conducted with CNA 12. CNA 12 stated Resident 31's fingernails on both hands were long with black debris. CNA 12 stated residents' fingernails were trimmed on Sundays and Resident 31's fingernails were not done. CNA 12 stated fingernails should be trimmed to prevent them from scratching themselves. An interview with the Director of Staff Development (DSD- a licensed nurse certified for staff training) was conducted on 7/2/26 at 7:51 A.M. The DSD stated she expected CNAs to provide nail care and shaving on shower days. The DSD stated nail care and shaving were also offered on Sundays. The DSD stated nail care was important due to an avenue for infection because fingernails may harbor bacteria. 4.Resident 36 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following unspecified cerebrovascular disease affecting left non-dominant side (the less preferred side of the body). During a review of Resident 36's ADL care plan initiated 12/11/23, the care plan indicated, Resident is at risk for ADL/mobility decline and requires assistance related to bed-bound status, chronic disease progression.Hygiene: Assist of one person. An interview and joint observation on 7/1/26 at 9:28 A.M. was conducted with CNA 13. CNA 13 stated Resident 36 was dependent on staff with her ADLs due to left hand weakness. Resident 36 was observed in bed and showed her fingernails on the right hand. Resident 36 stated her fingernails needed to be trimmed. Resident 36 used her right hand to pick up her left hand and showed long fingernails. Resident 36 stated she would allow staff to trim her fingernails. CNA 13 stated residents' fingernails should be trimmed to prevent hurting themselves. An interview on 7/2/26 at 4:13 P.M. with the Director of Nursing (DON) was conducted. The DON stated trimming of fingernails was part of the overall hygiene of a resident and it was reflective of how the resident was cared for. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated was conducted. The P&P indicated Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services are provided.including appropriate support and assistance with.hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when: 1. A urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for two of three residents reviewed for urinary catheter care (Residents 2 and 145).2. Blankets and linens were stored damp and cold. In addition, trash and gloves were found in the clean linen room and closets.3. Flying insects were found in the dining area during residents' mealtime. These failures had the potential for cross contamination (spread germs and bacteria) and infection. Cross Reference: F 690 Findings: 1a. Resident 2 was re-admitted to the facility on [DATE], with diagnoses which included sepsis (life-threatening reaction to an infection), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and had a urinary catheter, per the facility's admission Record. An observation was conducted of Resident 2 on 6/29/26 at 3:25 P.M., as he laid in bed. Resident 2 had a urinary catheter visible to the bed. Resident 2's catheter bag and privacy bag were on the floor. On 7/1/26 at 8:54 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 2 had a urinary catheter. CNA 2 stated the catheter bag should be off the floor because there was a tendency to rip the bag and to prevent residents from getting an infection. On 7/1/26 at 12:38 P.M., a concurrent review of Resident 2's clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 2 had a urinary catheter, and was readmitted to the facility with chronic urinary tract infection (UTI). LN 2 stated the catheter bag should be off the ground to prevent contamination and infection. 1b. Resident 145 was admitted to the facility on [DATE], with diagnoses which included neuromuscular dysfunction of bladder, per the facility's admission Record. On 7/1/26 at 9:20 A.M., a joint observation of Resident 145 in her room and an interview with Licensed Nurse (LN) 3 was conducted. Resident 145 was wheeling herself in the room with her catheter bag and privacy bag on the floor. LN 3 stated the catheter bag should be off the floor to prevent infection. On 7/1/26 at 4:17 P.M., a concurrent interview and record review with the Infection Preventionist (IP) was conducted. The IP stated urinary catheter bag should have been off the floor. The IP stated that it was important for urinary catheter bag not to touch the floor to prevent cross contamination that may be transferred to the resident and cause an infection. On 7/2/26 at 11:55 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to ensure the urinary catheter bag should always be off the floor to prevent catheter- associated infections. Per the facility's policy titled Catheter Care, Urinary, revised August 2022, indicated, .Infection Control: 2.b. Be sure the catheter tubing and drainage bag are kept off the floor . 2. During a resident council meeting on 6/30/26 at 9:05 A.M., confidential residents verbalized their concerns regarding the cold and damp linens, towels and blankets. Confidential residents stated the towels smelled like mildew. On 6/30/26 at 3:50 P.M., a joint observation of the clean linen rooms in stations 2, 3 and 4 was conducted with the IP. There were washcloths, fitted sheets, blankets and linens that were damp and cold to the touch. The IP stated the washcloths, fitted sheets, blanket and the linens feels little cold. It makes me think it was not completely dried. The IP stated, They could have used five minutes more to completely dry them (washcloths, fitted sheets, blanket and the linens). On 6/30/26 at 3:50 P.M., during the joint observation of the clean linen rooms and an interview with the IP, there was a worn pair of gloves (one on top of the other) in clean linen room in station 2A. The IP stated the gloves appeared to be worn and they should be properly thrown out and not in clean items. The clean linen room in station 2B, the floor of the linen room appeared to have brown stained, and a candy wrapper was found. The IP stated the floor looked like it was mopped with a dirty mop. The IP stated the floor had a wet floor caution and it should have been kept cleaned to ensure there was no contamination of the clean linen in the closets for infection control. On 7/2/26 at 11:55 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the moisture in the washcloths, fitted sheets, blanket and the linens could have been a factor for the bacteria to build up and could cause infection to the residents. The DON stated the staff should have ensured linens and towels were dried enough to prevent infection. A review of the facility's policy titled, Laundry and Bedding, Soiled, revised September 2022 was conducted. The policy did not address proper storage and kept the laundry dry. The policy did not address keeping the clean linen room and closets clean. 3.On 6/29/26 at 12:40 P.M. a meal observation was conducted in the small dining room. On 6/29/26 at 1:03 P.M., an observation and interview was conducted with Licensed Nurse 31. LN 31 stated there were flying insects in the small dining room during resident mealtime. LN 31 verified two gnats on the wall and one flew above residents in the dining room during meal observation. LN 31 stated the dining room should not have flying insects present because it carried diseases. On 6/29/26 at 1:12 P.M., an observation and interview was conducted with the Maintenance Director. (MaD). The MaD) stated he observe one fly on the wall in the dining room. During this interview, observe the MaD swatted the fly on the wall and killed it. The MaD stated he came in because there was a fly reported by the nurse. The MnD stated should not have flies especially in the dining area because it carries diseases. On 7/2/26 at 3:12 P.M., an interview was conducted with the Director of Nursing (DON). Thee DON stated absolutely should have no flies because they are vector for illness. The DON stated they could go on with the food and could cause illness. A review of the facility policy entitled Pest Control, revision date May 2008, indicated .Our facility shall maintain an effective pest control program.1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects.

Based on interview and record review, the facility failed to document the options the resident (1) chose for Advanced Beneficiary Notice of Non-coverage (ABN/CMS form 131, a form which gave the choice to continue services under private pay if Medicare did not provide payment). As a result, Resident 1 was at risk of not being informed of potential liability for payment of non-covered services. Findings: Resident 1 was re-admitted to the facility on [DATE], per the facility's admission Record. On 7/1/26, a list of residents discharged in the last six months was provided by the Director of Nursing (DON). According to the list, Resident 1 remained in the facility after he was discharged from skilled services on 4/28/26. On 7/1/26, a record review was conducted. Resident 1's last day of Part A Service (the skilled nursing component of Medicare coverage-services covered by the insurance) was ending on 4/28/26. Per the document, ABN/CMS form 131 was given to the resident, but there were no options selected in the option boxes. On 7/1/26 at 3:58 P.M., a joint review of Resident 1's ABN record and an interview was conducted with the Social Services Director (SSD). The SSD stated Resident 1 did not select any options in the ABN form 131. The SSD stated she did not document what option Resident 1 chose. The SSD stated if the resident did not choose any option, the SSD was responsible for documenting information that was given and the resident and his family were aware of what to expect for the room rate, and other information about the cost of continued care at the facility. On 7/2/26 at 11:55 A.M., an interview with the DON was conducted. The DON stated the SSD should have documented the option the resident selected in his clinical record to be in compliance with the notification of payment of non-coverage. Per a facility's undated form, titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF- ABN), .Completing the SNF ABN .2. Option Boxes.If the patient is physically unable to make a selection, the SNF may enter the patient's selection at his/ her request and indicate on the notice that this was done for the patient.

Based on observation, interview and record review, the facility failed to ensure a safe and comfortable homelike environment was provided to its residents when: 1. Two of five emergency electrical outlets (red outlets) which were in the hallways were loose, and, 2. A window in a resident's (90) room was broken and was patched with cardboard. These failures had the potential for fire hazards and to negatively impact on the residents' safety, health and well-being. Findings: 1.On 7/1/26 at 10:38 A.M., a joint observation of the facility hallways in station 2 and station 3, and an interview with the Maintenance Director (MaD) and the Maintenance Staff (MS) 1 was conducted. Two of five emergency electrical outlets were loose. A computer was plugged into one of the two loose electrical outlets. MS 1 stated the electrical outlets should not be loose because the staff or the residents had the potential to get electrocuted and was a safety hazard. On 7/2/26 at 11:55 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the electrical outlets should have been secured because it was a fire hazard and for safety reasons. A review of the facility's policy, titled, Homelike Environment, revised February 2021, indicated, Residents are provided with a safe.environment. A review of the facility's policy, titled, Maintenance Service, revised December 2009, indicated, .The maintenance department is responsible for maintaining the building.and equipment in a safe.manner at all times.2b. maintaining the building.free from hazards. A review of the facility's policy, titled Fire Safety and Prevention, revised July 2024 was conducted. The policy did not address loose electrical outlets. 2. On 6/29/26 at 8:59 A.M., an observation and interview was conducted with Resident 90 while inside Resident 90's room. Observed cardboard covering one side of the window with red caution tape around it. Resident 90 stated he had been in that room for about three weeks and the window was already that way. Resident stated, it would be nice if it was fixed. On 6/30/26 at 1:45 P.M., an observation and interview was conducted with Licensed Nurse (LN 21) in Resident 90's room. LN 21 observed the window covered with cardboard with red caution tape around the window. LN 21 stated the window was broken by the previous resident. LN 21 stated the window should have been fixed immediately. On 6/30/26 at 4:05 P.M., an observation and interview was conducted with the Maintenance Director (MaD) in Resident 90's room. The MaD stated he was aware of the broken window and had reported it to the Administrator (ADM). The MaD stated it was not a homelike environment and should have been fixed. On 7/2/26 at 3:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the broken window in Resident 90's room posed a safety risk. The DON stated the window should have been fixed before assigning another resident to the room. On 7/2/26 at 3:45 P.M., an interview with the ADM was conducted. The ADM stated he was aware of the broken window in Resident 90's room. The ADM stated a work order was submitted to corporate to get approval to get the window fixed. A review of the facility policy titled Homelike Environment, revised date February 2021, indicated Residents are provided with a safe, clean, comfortable homelike environment. A review of the facility policy titled Maintenance Service, revised date December 2009, indicated .2b. Maintaining the building in good repair and free from hazards.2f. establishing priorities in providing repair services.

Based on observation, interview and record review, the facility failed to provide a written notice of bed hold rights for two (Resident 11 and Resident 48) of three residents reviewed for hospitalization. This failure had the potential for the resident and/or the resident's representative not to have information regarding bed hold rights.Findings: 1.Resident 11 was readmitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit, and dysphagia (difficulty in swallowing) following cerebral infarction (disrupted blood flow to the brain) according to Resident 11's admission Record. The admission Record further indicated Resident 11's daughter as the primary contact. During an observation and interview on 6/29/26 at 9:20 A.M. with Resident 11, Resident 11 was in bed with the head of bed elevated. Resident 11 shrugged his shoulders when asked how he was doing and if he knew what medications he was taking. Resident 11 then closed his eyes and did not respond to questions. During a review Resident 11's Minimum Data Set (MDS-a clinical assessment tool), dated 5/15/26, listed a cognitive (thinking and decision-making ability) score of 00, which indicated inability to assess Resident 11's cognitive status. A review of the Electronic Medical Record (EMR) for Resident indicated a transfer to hospital dated 4/2/26 due to vomiting/choking. An interview and joint record review was conducted with Licensed Nurse (LN) 12 on 7/1/26 at 10:45 A.M. LN 12 reviewed Resident 11's EMR and stated Resident 11 had vomiting and choking during breakfast. LN 12 reviewed the Notice of Proposed Transfer/Discharge, dated 4/2/26 and stated the form did not have notification of the resident's representative. A review of the form titled, Bed hold indicated Resident 11 was notified but no resident representative notification. Both the Notice of Proposed Transfer/Discharge and Bed hold forms did not indicate notices were sent to Resident 11's representative. LN 12 stated Resident 11's primary responsible party should be notified to because he/she had the right to know what happened with their loved one and to provide the hospital needed information 2.Resident 48 was readmitted to the facility on [DATE] with diagnoses including acute kidney failure acute kidney failure (a sudden decline in kidney function) and urinary tract infection (bladder infection) according to the facility's admission Record. The admission Record further indicated a conservator (an individual appointed by a court to manage personal affairs of someone who is unable to do so themselves) as Resident 48's emergency contact and responsible party. During an observation and interview on 6/29/26 at 9:45 A.M., Resident 48 was sitting up in bed. Resident 48 stated he had no infection and did not remember when he was last transferred to the hospital. During a review Resident 11's Minimum Data Set (MDS-a clinical assessment tool), dated 5/10/26, listed a BIMS (Brief Interview for Mental Status which evaluates cognition, the ability to remember and think clearly) score of 10, moderate cognitive impairment. An interview and joint record review on 7/1/26 at 11:15 A.M. with LN 12 was conducted. LN 12 reviewed Resident 48's EMR. LN 12 stated Resident 48 was transferred to the hospital on 5/1/26 and on 5/22/26. A review of bed hold forms for Resident 48 was conducted. Bed hold form dated 5/1/26 and 5/22/26 indicated Resident 48 was notified of bed hold. The forms did not indicate Resident 48's conservator as being notified. An interview was conducted on 7/2/26 at 11:56 A.M. with LN 16. LN 16 stated when a resident was sent out to the hospital a bed hold form should be completed. LN 16 stated if a resident had a conservator, the conservator should be notified of bed hold. During an interview with LN 17 on 7/2/26 at 12 P.M., LN 17 stated there was no form for bed hold. LN 17 reviewed a paper next to the computer and stated there was a form for bed hold and it was completed by social services. An interview with the Director of Nursing (DON) was conducted on 7/2/26 at 4:13 P.M. The DON stated during hospital transfers, the resident and/or the representative should be notified with the expectation to hold a bed for seven days. A review of the facility's policy and procedure (P&P) titled, Bed holds and Returns, dated October 20222 was conducted. The P&P indicated, All residents/representatives are provide written information regarding the facility and state bed hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave).

Based on observation, interview, and record review, the facility failed to document urine output (UO) consistently for one of three residents (2), reviewed for a urinary catheter (a tube inserted into the bladder to aid in urine flow). As a result, there was no consistent monitoring of urine output for Resident 2. Cross Reference: F 880 Findings: Resident 2 was re-admitted to the facility on [DATE], with diagnoses which included sepsis (life-threatening reaction to an infection), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and had a urinary catheter, per the facility's admission Record. A review of Resident 2's clinical record was conducted. Resident 2's History and Physical dated 6/18/26, indicated Resident 2 had fluctuating capacity to understand and make decisions. A record review was conducted of Resident 2. Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/5/26, indicated Resident 2's brief interview for mental status (BIMS, ability to recall) score was 3/15 which indicated Resident 2's cognition was severely impaired. Resident 2's MDS section for bladder and bowel indicated Resident 2 had a urinary catheter. On 7/1/26, a review of Resident 2's clinical record was conducted. Resident 2's physician's order dated 2/15/26 and care plan (detailed plan with information about a patient's treatment, goal, and interventions) dated 6/27/26 indicated to monitor and document Resident 2's UO as per facility policy. An observation and interview was conducted with Resident 2 on 6/29/26 at 3:25 P.M., as he laid in bed. Resident 2 had a catheter bag which was on the floor. Resident 2 stated he felt good, was hospitalized recently but was unable to give more information. A review of Resident 2's record of UO for May and June 2026 was conducted. The record had missed entries of UO for Resident 2 on the following dates and shifts:5/18/26 - morning shift (from 7 A.M to 3 P.M.)6/2/26, 6/21/26 - afternoon shifts (3 P.M to 11 P.M.)5/25/26, 6/6/26, 6/8/26, 6/23/26, 6/27/26, 6/30/26 - nocturnal shift (from 11 P.M. to 7 A.M.). On 7/1/26 at 8:54 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 2 had a urinary catheter. CNA 2 stated CNAs were responsible for emptying the urinary bag, measuring the UO and documenting the UO in the resident's clinical record. On 7/1/26 at 12:38 P.M., a concurrent review of Resident 2's clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 2 had a urinary catheter, was readmitted to the facility with chronic urinary tract infection (UTI). LN 2 stated there was a physician's order to monitor Resident 2's UO. LN 2 stated there were missed entries in Resident 2's UO in his clinical record. LN 2 stated the staff should have monitored Resident 2's UO every shift per the physician's order and to check if resident had issues with his urinary catheter based on his UO. On 7/2/26 at 11:55 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to monitor Resident 2's UO to ensure Resident 2's hydration was adequate and if the staff noticed the UO was less than normal, they had to inform the physician for further interventions. A review of the facility's policy titled, Catheter Care, Urinary, revised August 2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.1. Review the resident's care plan to assess for any special needs of the resident.Input/ Output, 1. Observe the resident's urine level for noticeable increases or decreases.2. Follow the facility procedure for measuring and documenting.output.

Based on observation, interview and record review, the facility failed to ensure one of nine residents (Resident 18) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 18's PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 18's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience). Findings: Resident 18 was admitted to the facility on [DATE] with diagnoses including PTSD according to the facility's admission Record. During an observation and interview on 6/29/26 at 8:44 A.M., Resident 18 was sitting at the edge of her bed. Resident 18 stated she had a traumatic experience in 2011 but preferred not to talk about it. A review of Resident 18's psychosocial care plan was conducted. The care plan dated 5/8/26 indicated, Psychosocial- Emotional/Trauma: At risk for decreased psychosocial [influence of social factors on a person's mind or behavior] well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse [harmful] effects on function, mental, physical, social, or spiritual wellbeing related to Post-Traumatic Stress Disorder (PTSD), anxiety, depression.Help resident to identify triggers that prompt symptoms. An interview on 7/1/26 at 8:49 A.M. was conducted with Certified Nurse Assistant (CNA) 11. CNA 11 stated he had worked at the facility for two years and there were no residents with a diagnosis of PTSD. CNA 11 stated residents with PTSD had trauma in the past which can cause stress if triggered. During an interview on 7/1/26 at 10:30 A.M. with CNA 14, CNA 14 stated he was not sure of the meaning of PTSD. CNA 14 further stated he was also not sure if any of his residents had PTSD. An interview on 7/2/26 at 7:51 A.M. was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training) was conducted. The DSD stated staff should know the residents with a diagnosis of PTSD, especially residents with frequent behaviors caused by certain triggers from the past. The DSD stated it was important for staff to know and to ensure care provided to the resident will not trigger the traumatic experience. During an interview on 7/2/26 at 8:36 A.M. with the Director of Social Services (SSD), the SSD stated she would contact the resident's family if PTSD triggers were not known. An interview on 7/2/26 at 4:13 P.M. with the Director of Nursing (DON) was conducted. The DON stated staff should know which residents had PTSD for staff to know how to interact with the residents and for staff to be more careful and understand why residents behaved in a certain way. A review of the facility's policy and procedure (P&P) titled, Trauma Informed Care and Culturally Competent Care, dated August 2022 was conducted. The P&P indicated, Purpose.To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.

Based on interview and record review, the facility failed to ensure two residents were free from unnecessary medication when: 1. A resident (Resident 84) was receiving anticoagulant medications (AC, blood thinner that prevents and treat blood clots, side effect to include bruising or bleeding) and was not monitored for signs and symptoms of bruising/bleeding for one of two sampled residents reviewed for anticoagulant. 2. A resident (Resident 181) received insulin (medication to lower blood sugar) without following physician's orders for blood sugar levels out of range. These failures could result in medication related untoward side effects from inconsistent and poor management of medication therapy for Resident 84 and Resident 181.Findings: 1. A review of Resident 84 admission record, Resident 84 was admitted to the facility on [DATE] with a diagnosis that included peripheral vascular disease (progressive blood vessel disorder affecting vessels outside the heart.) A review of Resident 84's physician order dated 4/28/26 indicated Apixaban (blood thinner medication) oral tablet 5 mg (milligrams-a unit of measure), give one table by mouth twice a day for A-Fib (arterial fibrillation- irregular heartbeat) and Clopidogrel Bisulfate (blood thinner medication) tablet 75 mg, give 1 tablet by mouth one daily for blood clot prevention. A review of Medication Administration Record (MAR) for June 2026 indicated Resident 84 had received anticoagulant medications. A review of Resident 84's physician orders and care plan did not indicate to monitor side effects of an anticoagulant. On 7/2/26 at 9:32 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 22. LN 22 reviewed Resident 84's physicians orders and care plan. LN 22 stated there was no physicians order and no care plan to monitor the anticoagulant and its side effects for Resident 84. LN 22 stated Resident 84 was at risk for bleeding and should have been monitored for blood in the urine or stool, coffee like stools and abnormal bruising and to notify the physician. On 7/2/26 at 3:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 84 was a risk for bleeding. The DON stated Resident 84 should have had a care plan to monitor for bleeding while on anticoagulant medications. A review of the facility policy titled Anticoagulant-Clinical Protocol, revised November 2018, indicated .Monitoring.5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. 2. A review of Resident 181's admission record indicated Resident 181 was admitted to the facility on [DATE] with a diagnosis that included Type I diabetes mellitus (DM-uncontrolled blood sugar levels in the blood.) A review of Resident 181's physician order dated 4/2/26 indicated insulin glargine injection pen-injector, inject 35 unit subcutaneously in the morning for Type 1 Hold for blood sugar (BS) less than 100 milligrams/deciliters (unit of measure.) A review of Medication Administration Record (MAR) for June 2026 indicated Resident 181 had received insulin.- 6/3/26, BS 97mg/dl- 6/11/26, BS 75 mg/dl- 6/12/26, BS 75 mg/dl- 6/17/26, BS 76 mg/dl Low blood sugar plus insulin could cause symptoms like irregular heartbeat, shakiness, nausea. On 7/2/26 at 7:27 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 23. LN 23 reviewed the MAR for June 2026. LN 23 stated on June 3,11,12, and the 17th, Resident 181 blood sugar level was less than 100 mg/dl and he (LN 23) should have held the insulin. LN 23 stated Resident 181 was at risk for low blood sugar when given insulin out of range. LN 23 stated he did not follow the physicians' orders and should have. On 7/2/26 at 9:32 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 22. LN 22 reviewed Resident 181's physicians orders and MAR for June 2026. LN 22 stated Resident 181 received insulin when Resident 181 blood sugar was out of range on June 3rd,11th,12th and 17th. LN 22 stated insulin should have been held, and physician's orders should have been followed for resident safety. On 7/2/26 at 3:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated her expectation was for all nursing staff to follow the physicians' orders. A review of the policy titled Insulin Administration, revised March 2025, indicated .To provide guidelines for the safe administration of insulin .Preparation.2. The type of insulin, dosage requirements, strength, and method of administration are verified with the order on the medication sheet and the physician's order before administration.

Based on interview and record review, the facility failed to ensure accurate resident medical records when: 1. Resident 113's Advance Directive (AD - legal document outlines healthcare preferences and appoint someone to make medical decisions for a resident when unable to communicate wishes) was found in Resident 156's medical records, 2. Resident 19's physician's order for behavior monitoring did not match the care plan. This failure resulted in conflicting records and did not provide an accurate representation of residents' medical records and had the potential to cause confusion amongst care providers. Findings: 1. Resident 156 was admitted to the facility on [DATE] per the facility admission Record. A review of Resident 156's medical records was conducted. Resident 156's AD was not found, instead Resident 113's AD entitled Advance Health Care Directive, (dated 9/14/2015) was found in Resident 156's record. On 7/1/26 at 12:38 P.M., concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the AD found in Resident 156's medical record was not hers. The ADON stated Resident 113's AD should be removed from Resident 156's medical record. On 7/1/26 at 4:07 P.M., a concurrent interview and record review was conducted with the Medical Records Director (MRD). The MRD stated she removed Resident 113's advance directive in Resident 156's medical records. The MRD stated it was important to have the correct record in Resident 156's medical record. The MRD stated facility staff should place the right document for the right resident for protection of patient file that we do not share the record to others. On 7/2/26 at 3:16 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated the facility should not have a resident medical record in another resident's medical record. The DON stated this could have violate resident's health information privacy. A review of the facility policy entitled Protected Health Information (PHI), Safeguarding Electronic, revision date February 2014, indicated Security Management.3.potential violations are corrected by.to address vulnerabilities and reduce risks identified. 2.Resident 19 was readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) and bipolar disorder (a mental illness causing intense mood swings from one extreme to another) according to the facility's admission Record. During an interview and observation on 6/29/26 at 8:47 A.M., Resident 19 was sitting in a wheelchair in her room. Resident 19 stated she needed help but did not know how to call for staff. An interview and concurrent record review on 7/1/26 at 9:55 A.M. was conducted with Licensed Nurse (LN) 12. LN 12 checked the Electronic Medical Record (EMR) for Resident 19. LN 12 stated Resident 19 had an order for pimavanserin 34 mg (milligrams) to be given once a day for Parkinson's induced psychosis (loss of contact with reality). LN 12 stated the behavior monitoring for the medication was for accusing people of stealing money/belongings. LN 12 stated she was not sure if Resident 19 had this behavior. LN 12 stated Resident 12's care plan for primavanserin did not indicate behavior monitoring on the physician's order. LN 12 stated there was a care plan for episode of hitting staff and physical aggression. LN 12 stated the physician's order did not match the care plan for Resident 19. An interview on 7/1/26 at 10:30 A.M. was conducted with Certified Nurse Assistant (CNA) 14. CNA 14 stated Resident 19 refused care at times, had hit and kicked staff. CNA 14 stated Resident 19 had not complained about missing items. During an interview on 7/1/26 at 4:21 P.M. with CNA 15, CNA 15 stated Resident 19 had episodes of refusing brief change but had not claimed of staff stealing things. An interview on 7/2/26 at 4:13 P.M. with the Director of Nursing (DON) was conducted. The DON stated physician's orders for Resident 19's should match the care plan because it was the plan of care for the resident. The facility did not provide policy and procedure regarding accurate medical records for residents.

Based on observation, interview, and record review, the facility did not develop patient centered care plans for two of four residents reviewed for care plans (Resident 1 and Resident 3) when: 1. A care plan was not developed to address Resident 1's behavior at the facility's garden area, 2. A care plan was not developed to address Resident 1's discharge plan and intent to leave the facility against medical advice (AMA), 3. A care plan was not developed for Resident 3's placement preference. This failure had the potential for residents not to receive care based on their needs.FINDINGS: On 4/1/26 at 1:16 P.M., an unannounced onsite visit at the facility was conducted related to a reported resident elopement. 1.Resident 1 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) of the left ankle and foot according to the facility's admission Record. During an interview on 4/1/26 at 1:18 P.M. with the Director of Nursing (DON), the DON stated on 3/27/26, she was notified that Resident 1 eloped from the facility. The DON stated Resident 1 was on intravenous (IV- into the vein) antibiotics and had a peripherally inserted central catheter (PICC-a thin, flexible tube inserted into a vein in the upper arm used for intravenous medications). The DON stated Resident 1's wife told her that Resident 1 had a history of illicit drug (any substance prohibited from manufacture, sale or possession due to its illegal status, dangerous in nature, or high potential for misuse) use. A review of progress notes (PN) in the electronic medical record (EMR) for Resident 1 was conducted. A PN dated 3/19/26 titled, Behavior Note indicated Resident 1 mentioned being in a drug rehab program for chronic marijuana (an illegal substance which affects the brain responsible for memory, learning, attention, decision making, coordination, emotions and reaction time) use. A review of Resident 1's hospital consultation dated 3/3/26 at 3:46 P.M. indicated, Substance Abuse Use: Marijuana. Frequency: Daily. A review of Resident 1's care plans indicated no care plan regarding Resident 1's history of illicit drug use. An interview on 4/1/26 at 4:18 P.M. with the DON was conducted. The DON stated there was no care plan regarding Resident 1's illicit drug use. The DON stated there should be a care plan to maintain resident's safety with interventions to prevent use, overdose and access to the drug or substance. 2. During a review of PN completed by the Assistant Director of Nursing (ADON) for Resident 1 dated 3/26/27 at 6:45 P.M., the PN indicated a meeting was held with Resident 1 to discuss Resident 1's gardening activities. The PN indicated, Resident was educated on facility guidelines and safety protocols related to gardening. Resident verbalized dissatisfaction with the guideline and stated he preferred to engage in gardening activities without limitation. Resident expressed intent to leave the facility AMA or transfer to another facility if guidelines were not modified. mentioned facility had until tomorrow, otherwise he would go AMA. An interview on 4/1/26 at 1:44 P.M. was conducted with Licensed Nurse (LN)1. LN 1 stated Resident 1's usual routine was to go out to the facility's garden because Resident 1 had told her that he used to garden. During an interview on 4/1/26 at 2:21 P.M with LN 2, LN2 stated Resident 1 was frequently at the facility's garden replanting plants on pots. An interview on 4/2/26 at 10:10 A.M. was conducted with ADON. The ADON stated a meeting was held with Resident 1 because the activity staff complained about the resident who pulled out live plants from the garden that residents or staff planted. The ADON stated she was unsure if Resident 1 pulled the plants from pots or from the ground. The ADON stated Resident 1 was offered an individualized planting session or designated spot in the garden but Resident 1 was not in agreement and instead requested to be transferred to another facility or Resident 1 would leave the facility AMA. The ADON stated she reviewed Resident 1's care plans in the EMR and there was no care plan regarding Resident 1's behavior in the garden, discharge planning and/or Resident 1's intent to leave AMA. The ADON stated care plans should have been completed to address Resident 1's behavior and to have interventions to prevent Resident 1 from leaving AMA and to provide a safe discharge. 3. Resident 3 was admitted to the facility on [DATE] with diagnoses Traumatic Brain Injury (a sudden and violent blow to the head causing damage to the brain) according to the facility's admission Record. An interview and joint record review on 4/1/26 at 1:55 P.M. was conducted with the front desk receptionist (REC). The REC stated she was familiar with residents who were at risk for elopement. The REC stated a Wanderguard List binder was kept at the front desk with a list of residents at risk for elopement. The REC showed Resident 3's photo on the binder. An interview and joint record review on 4/1/26 at 4:15 P.M. was conducted with the DON. The DON stated Resident 3 was a long-term care resident of the facility. The DON reviewed Resident 3's care plans and stated there was a care plan dated 8/29/24 which indicated Resident 3 was at risk for elopement. The DON stated there was no care plan regarding discharge or placement preference for Resident 3. The DON stated there should be a care plan even if a resident was for long term care. During a follow up interview on 4/1/26 at 4:18 P.M. with the DON, the DON stated residents should have discharge planning care plans to reflect proper placement per resident's preferences. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/22 was conducted. The P&P indicated, A comprehensive, person-centered care plan that includes, measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.

Based on observation, interview, and record review, the facility failed to submit a five-day (5-day) summary of investigation to the California Department of Public Health (CDPH- state agency that protect the public's health and enforces state and federal laws) related to an abuse allegation for one of two residents reviewed for abuse. (Resident 6) This failure had the potential to result in a delay in determining the occurrence of abuse and had the potential to affect Resident 6's safety and well-being.Findings: On 12/30/24 at 8:53 A.M., an unannounced onsite visit at the facility was conducted related to a reported abuse allegation. Resident 6 was re-admitted to the facility on [DATE] with diagnoses including other sequelae (consequence of a previous disease or injury) of other cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility's admission Record. An observation and interview was conducted with Resident 6 on 10/30/25 at 10:29 A.M. Resident 6 was in bed with a dark purple discoloration, size of a small tangerine on the left forearm. Resident 6's left forehand had a band aid on top of steri-strips (thin, adhesive skin closure strips used to hold the edges of minor cuts and lacerations). Resident 6 raised both arms and stated he was attacked by a staff member which caused bruises on his left and right arms. An interview with the Director of Nursing (DON) was conducted on 12/30/25 at 11:04 A.M. The DON stated Resident 6's son reported that Resident 6 had bruises on the right forearm and skin tears on both hands and would like to know what happened. During an interview on 12/30/25 at 11:38 A.M. with Licensed Nurse (LN) 2, LN 2 stated he was not sure how Resident 6 sustained bruises and skin tears. During an interview on 1/7/25 at 12:04 P.M. with the DON, the DON stated she initiated and completed abuse investigations for any alleged abuse incidents. The DON stated Resident 6 was at the hospital when the abuse allegation was made and the resident returned to the facility on [DATE]. The DON stated she completed an investigation but did not submit a 5-day summary of the investigation to CDPH. The DON stated she should have submitted one because it would show as a follow up on the investigation and the root cause of the incident. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2021 was conducted. The P&P indicated, All reports of resident abuse [including injuries of unknown origin] .are reported to local, state and federal agencies.Reporting Results of Investigations 1. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview, and record review, the facility failed to provide privacy and dignity by covering a urinary catheter bag (a flexible tube that drains urine into a collection bag) for one of three resident's (Resident 1), when reviewed for Resident Rights. This failure had the potential for Resident 1 to be embarrassed and exposed with a urinary catheter collection bag. Findings: Resident 1 was admitted to the facility 2/14/25, with diagnosis which included displaced fracture of left hip and diabetes mellitus (abnormal blood sugar levels in the blood), per the facility's admission Record. The physician's order was reviewed on 6/11/25 at 11:13 A.M., dated 6/11/25, .External condom catheter (a device that collects urine from the bladder and directs it into a collection bag) due to a diagnosis urinary retention (the inability to completely empty the bladder of urine) . An observation and interview was conducted with certified nursing assistant 1 (CNA 1) of Resident 1 on 6/11/25 at 12:08 P.M., as he laid in bed. On the lower right side of the bed frame was a urinary collection bag, which contained approximate 200 cubic centimeter (cc-a unit of volume) of yellow urine . The collection bag was uncovered and visible to all who entered the room. CNA 1 stated the urinary collection bag was not covered and it should be. CNA 1 stated a dignity bag over the collection bag provided the resident with privacy and promoted dignity. An interview was conducted with the Director of Staff Development (DSD) on 6/11/25 at 12:14 P.M. The DSD stated all residents with urinary catheters should have a dignity bag placed over the collection bag. The DSD stated it provided dignity to the resident, and it would not matter if the resident was alert or not. An interview was conducted with the Director of Nursing (DON) on 6/11/25 at 12:53 P.M. The DON stated dignity bags should always be covering a urinary collection bag, in order to provide privacy for the resident. According to the facility's policy, titled Dignity, dated 2001, .11. Staff promote, maintain, and protect privacy .

Based on interview and record review, the facility failed to notify the physician when parameters for blood sugar levels were out of range, for one of three residents (Resident 1), when reviewed for Quality of Care. This failure resulted in the physician being uninformed when additional insulin (a hormone which regulates blood sugar levels in the blood) could have been ordered to reduce the risk of hyperglycemia (high blood sugar levels which can lead to health problems that affect the eyes, kidneys, nerves and heart). Findings: Resident 1 was initially admitted to the facility 2/14/25, with diagnosis which included displaced fracture of left hip and diabetes mellitus (abnormal blood sugar levels in the blood), per the facility's admission Record. Resident 1's record was reviewed on 6/11/25. Resident 1's nurses note, dated 6/6/25 at 8:48 P.M., Resident 1 was noted with confusion, doctor notified and new order to send to emergency room for evaluation. According to Resident 1's nurses note dated 6/9/25 at 11:15 P.M., resident returned from hospital with diagnoses of hyperglycemia (high blood sugar). According to Resident 1's physician's order, dated 6/10/25, Accu-Chek (a machine that analysis blood sugar levels with a drop of blood) call medical doctor if blood sugar is below 70 and/or above 250. According to Resident 1's Medication Administration Record (MAR), Resident 1's blood sugar level was 343 at 7 A.M. There was no documented evidence in Resident 1's nursing progress notes, that the medical doctor was notified of Resident 1's blood sugar level which was documented at 343 on 6/11/25, or that any new orders for insulin were obtained. According to Resident 1's care plan, titled Diabetes, revised on 4/14/25, interventions included, Blood sugar checks as ordered. Report to physician if blood glucose is outside of set parameters. According to Resident 1's care plan, titled Refusing Insulin, dated 5/23/25, no interventions were listed for addressing the resident's refusal of insulin. An interview was conducted with Licensed Nurse 2 (LN 2) on 6/11/25 at 1:05 P.M. LN 2 stated if blood sugar levels were outside the parameters set by the physician, then LNs were responsible for notifying the physician and documenting the physician's response, along with any new orders. LN 2 stated untreated high blood sugar levels could lead to diabetes ketoacidosis (DKA-a serious, life-threatening complication of diabetes), coma, and even death. An interview was conducted with LN 3 on 6/11/25 at 1:07 P.M. LN 3 stated the physician needed to be informed immediately if the blood sugar levels were outside the parameters set. LN 3 stated LNs were expected to document when the physician was and if additional insulin was ordered. LN 3 stated if there was no documentation of the physician being notified, then it was not done. An interview and record review was conducted with the Director of Nursing (DON), on 6/11/25 at 1:20 P.M. The DON reviewed Resident 1's physician's order to blood sugar parameters and then reviewed the MAR. The DON stated Resident 1's blood sugar level was 343 on the morning of 6/11/25, which was outside the parameter set for 250. The DON could not find any documented evidence from nursing staff that the physician was notified of the abnormal blood sugar level. The DON stated hyperglycemia could cause harm to the resident, and the physician should have been notified so an intervention could have been implemented. According to the facility's policy, titled Medication and Treatment Orders, dated July 2016, 'Orders for medications and treatment will be consistent with principals of safe and effective order writing . The facility was unable to provide a policy related to hyperglycemia.

Based on observation, interview and record review, the facility failed to ensure medications were not left unattended for one resident (Res 1). This failure had the potential to affect Resident 1 ' s safety and staff drug diversion. Findings. A record review of the facility ' s undated admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation (irregular rapid heart rate) and Urinary Tract Infection (bladder infection). An observation during a facility reported investigation on 5/12/24 at 10:00 A.M., in Resident 1 ' s room was conducted. Resident 1 had multiple number of medications, inside a small clear cup sitting on Resident 1's bedside table. Resident 1 stated, I think the nurse left the medications there for me to take, but I was still asleep. Resident 1 stated she did not know what the medications were and what they were for. A review of Resident 1 ' s minimum data set( MDS- federally mandated assessment tool) dated 2/3/25 indicated Resident 1 ' s brief interview for mental status (BIMS) score was 12 which meant Resident 1 ' s cognition (thought process) was intact. A joint interview and record review on 5/12/25 at 11 A.M., with Licensed Nurse (LN) 1 was conducted. LN 1 discussed the following medications listed on Resident 1 ' s Medication Administration Record( MAR). LN1 stated she had left the medications in a cup and placed on Resident 1 ' s bedside table. An observation of Medications at Resident 1's bedside were reconciled with Resident 1's MAR during an interview with LN 1. Amiodarone 200 mg ,give 1 tablet twice a day -Arrythmias. Check apical pulse .Hold if below 60. Cholecalciferol 50 mg by mouth one time a day for Supplement Co-enzyme Q10, 100 mg by mouth two times a day for Supplement Doxycycline 100 mg , give 1 tablet twice a day for Pneumonia x 10 days Duloxetine 30 mg , give 1 capsule by mouth one time a day for Depression Eliquis 5 mg , give I tablet by mouth two times a day for Atrial Fibrillation Ferrous sulfate 325 mg , 1 tablet by mouth one time a day for Supplement Florastor 250 mg , I capsule by mouth two times a day for Supplement Lasix 40 mg , give 1 tablet one time a day for Fluid retention Metoprolol 25 mg , 1 tablet by mouth two times a day for Hypertension Midodrine 25 mg, 1 tablet by mouth two times a day for Hypotension Mirabegron 24-hour 50 mg , give 1 tablet by mouth one time a day for Overactive bladder. Do not crush or chew. Mucinex 12 hours , give 600 mg by mouth two times a day for chest congestion x 7 days Multivitamin , give 1 tablet by mouth one time a day for Supplement Oxybutynin 15 mg , give 1 tablet one time a day for Bladder management Potassium Chloride 10 meq , give 1 tablet by mouth twice a day for Supplement. Give medication with food or snacks and/or with 4-8 oz of water or juice to prevent Gastrointestinal upset. Pregabalin 75 mg , give 1 capsule by mouth twice a day for pain Sertraline 50 mg , give 1.5 tablet by mouth one time a day for Depression. Ticagrelor 90 mg , give 1 tablet by mouth twice a day for Clot prevention LN 1 stated she was distracted when another resident was yelling, and she went to check on the other resident and left the medications for Resident 1 at bedside. LN 1 stated there were 19 medications that she had left unattended. LN 1 stated it was important not to leave medications unattended in a resident room for resident safety. LN 1 stated some of the medications required certain instructions before administration like apical pulse (pulse that is measured by listening to the heart directly with a stethescope) check, and instruction that include, do not crush or chew and to take medication with snack or water. An interview on 5/12/24 at 11:30 A.M., with the Director of Nursing (DON) was conducted. The DON stated medications are not to be left unattended anywhere in the facility including resident ' s rooms for their safety and to prevent drug diversion. A review of the facility ' s policy titled, Medication Labeling and Storage dated 2/2023 indicated, Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation in a clean, safe and sanitary manner.

Based on interview, record review, and facility policy review, the facility failed to assess a resident's ability to self-administer their medication for 1 (Resident #153) of 33 sampled residents. Findings included: A facility policy titled, Self-Administration of Medications, with a copyright date of 2001, indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. An Admission Record revealed the facility admitted Resident #153 on 02/12/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of rhabdomyolysis (a breakdown of muscle tissue). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed Resident #153 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #153's comprehensive Care Plan Report with an admitted [DATE], revealed no care plan to indicate the resident could self-administer their medications and/or keep medications at their bedside. Resident #153's Order Summary Report, with active orders as of 05/05/2025, did not include an order for Tums (an over-the-counter antacid medication). Resident #153's medical record revealed no evidence to indicate the resident could self-administer their medications and/or keep medications at their bedside. During a concurrent observation and interview on 05/05/2025 at 10:28 AM, the surveyor noted a bottle of Tums on Resident #153's bedside table. Resident #153 stated staff were aware the medication was in their room and added a family member brought the medication to them. During an observation on 05/06/2025 at 1:30 PM, Resident #153 was not in their room, but the surveyor noted a bottle of Tums on the resident's nightstand. During an observation on 05/07/2025 at 9:58 AM, Resident #153 was noted lying in bed with their eyes closed but answered when spoken to. There was a bottle of Tums noted on the resident's nightstand. Certified Nursing Assistant (CNA) #3 was interview on 05/07/2025 at 10:17 AM and stated if she saw medication at a resident's bedside she called the nurse because she was not allowed to remove medication by herself. CNA #3 stated she had not seen any medication by Resident #153's bedside. CNA #3 stated she had been assigned to care for Resident #153 on 05/05/2025 and 05/06/2025.CNA entered Resident #153's room, saw the medication on the nightstand, and stated she had not noticed the medication on 05/05/2025 or 05/06/2025. Resident #153 was interviewed on 05/07/2025 at 10:23 AM and stated they took Tums every night for their stomach. Resident #153 stated they wanted to be able to keep the medication at their bedside and take the medication as needed. Licensed Vocational Nurse (LVN) #4 was interviewed on 05/07/2025 at 10:23 AM and stated there were no residents on the unit that self-administered medications. LVN #4 stated if she saw medication at a resident's bedside she would remove the medication since residents were unable to self-administer medications without a physician's order and again stated no resident on her assignment had an order for self-administration. LVN #4 stated the hall had also been assigned to her on 05/05/2025. LVN #4 stated she was unaware Resident #153 had medication at their bedside. LVN #4 stated if Resident #153 wanted to self-administer medication, she was responsible for the self-administration assessment. LVN #4 went into Resident #153's room and removed the bottle of Tums. LVN #4 added she would call the resident's physician and request an order for Resident #153 to self-administer the medication. The Director of Nursing (DON) was interviewed on 05/07/2025 at 10:31 AM. The DON stated that prior to any resident self-administering medication the resident had to be assessed to see if it was safe for the resident to self-administer. The DON stated the physician would be made aware of the resident's desire to self-administer and an order would be obtained for self-administration and to keep the medication at the bedside. The DON stated the facility would plan for storage of the medication to keep the medication out of the reach of other residents. The DON stated she was unaware of any resident that had orders to self-administer medications, including any over-the-counter medications. The DON stated if medication was seen at a resident's bedside she expected staff to remove the medication. The Administrator was interviewed on 05/08/2025 at 10:06 AM. The Administrator stated he would not expect medication to be left at Resident #153's bedside. The Administrator stated he expected staff to be more observant and to remove medication from the resident's room.

Based on interview, record review, and facility policy review, the facility failed to ensure beneficiary notifications were completed accurately for 2 (Resident #128 and Resident #143) of 3 sampled residents reviewed for beneficiary notices. Findings included: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised 09/2024, indicated, 4. Written notices are provided in person to the beneficiary when possible. A copy of the notice is provided to the beneficiary (or authorized representative) immediately after the notice is signed. 1. An Admission Record revealed the facility admitted Resident #128 on 12/03/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of metabolic encephalopathy. A skilled nursing facility (SNF) Part A Prospective Payment System (PPS) [NAME] Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2025, revealed Resident #128 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. An undated Advance Beneficiary Notice of Non-coverage (ABN) for Resident #128 revealed the section titled E. Reason Medicare May Not Pay was left blank. The notice revealed the options listed in the section titled G. Options: Check only one box. We cannot choose a box for you was blank. Further review revealed the notice was not signed or dated. During an interview on 05/08/2025 at 9:20 AM, Business Office Manager (BOM) #1 stated he had missed it. BOM #1 stated the ABN for Resident #128 was not signed or dated. He stated the ABN for Resident #128 was not filled out completely due to no options being selected in Section G. He stated Section E should not have been left blank. He stated the ABN should have been filled out completely and signed and dated. He stated he should have reached out to Resident #128's representative to have them sign the ABN and should have issued a Notice of Medicare Non-coverage (NOMNC). BOM #1 stated he did not issue a NOMNC to Resident #128. During an interview on 05/08/2025 at 9:38 AM, the Director of Nursing (DON) stated she was not involved in the beneficiary notification process. The DON stated she expected notifications to be filled out completely and correctly. She stated she also expected them to be issued within 48 hours of the effective date. During an interview on 05/08/2025 at 9:46 AM, the Administrator stated he was not involved in the beneficiary notification process. The Administrator stated he expected notifications to be filled out accurately and completely. The Administrator stated he expected NOMNCs to be issued in the time allowed. 2. An Admission Record revealed the facility admitted Resident #143 on 11/07/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of an unspecified fracture of the left tibia shaft. A skilled nursing facility (SNF) Part A Prospective Payment System (PPS) [NAME] Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2025, that revealed Resident #143 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #143's Advance Beneficiary Notice of Non-coverage (ABN), dated 02/11/2025, revealed the section titled E. Reason Medicare May Not Pay was left blank. The notice revealed the options listed in the section titled G. Options: Check only one box. We cannot choose a box for you was blank. During an interview on 05/08/2025 at 9:20 AM, Business Office Manager (BOM) #1 stated the ABN for Resident #143 did not have an option selected under Section G. The BOM stated an option should have been chosen and since there was not an option chosen then the form was not filled out correctly. The BOM stated Section E should not have been left blank. He stated he did not issue Resident #143 a Notice of Medicare Non-coverage (NOMNC) due to a lack of communication and dropped the ball on issuing it. He stated the ABN should have been filled out completely and signed and dated. During an interview on 05/08/2025 at 9:38 AM, the Director of Nursing (DON) stated she was not involved in the beneficiary notification process. The DON stated she expected notifications to be filled out completely and correctly. The DON stated she also expected them to be issued within 48 hours of the effective date. During an interview on 05/08/2025 at 9:46 AM, the Administrator stated he was not involved in the beneficiary notification process. The Administrator stated he expected notifications to be filled out accurately and completely. The Administrator stated he expected NOMNCs to be issued in the time allowed.

Based on interview, record review, and facility policy review, the facility failed to report timely, an allegation of verbal abuse to the state survey agency for 1 (Resident #23) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a copyright date of 2001, indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy specified, 9. Investigate and report any allegations within timeframes required by federal requirements. An Admission Record specified the facility admitted Resident #23 on 06/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of muscle weakness, need for assistance with personal care, and hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/2025, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 05/05/2025 at 2:28 PM, Resident #23 stated their former roommate, Resident #371, had threatened and was very mean to them. Per Resident #23, they woke up one day and found Resident #371 going through their dresser and pulling out their things. Resident #23 stated they told Resident #371 to stop and that was when Resident #371 cursed, yelled and accused them of stealing their things. Resident #23 stated Resident #371 did not physically touch them but yelled all the time at them. According to Resident #23, Resident #371 was moved to another room on another unit. Resident 23 stated they were told that Resident #371 would be kept on another unit in the facility. Resident #23 acknowledged they were scared of Resident #371. During an interview on 05/05/2025 at 4:15 PM, the Administrator was made aware of the allegations of abuse reported by Resident #23. The Administrator stated he was not aware, would initiate an investigation, and report any findings to the surveyor on 05/06/2025. During an interview on 05/06/2025 at 8:52 AM, the Administrator stated he attempted to speak with Resident #23 on 05/05/2025, but the resident reported they were tired and did not want to talk. According to the Administrator, an investigation was being conducted and he would decide if the resident's allegation needed to be reported to the state survey agency. During an interview on 05/06/2025 at 10:06 AM, the Director of Nursing (DON) and Administrator acknowledged the allegation of abuse reported by Resident #23 was reported to the state survey agency on 05/06/2025 at 9:30 AM. During an interview on 05/07/2025 at 2:53 PM, the DON stated she was informed by the Administrator on 05/05/2025 at 4:45 PM, that Resident #23 alleged their former roommate was verbally abusive to them. During an interview on 05/07/2025 at 3:45 PM, the Administrator stated he was made aware by the surveyor of Resident #23's allegation of abuse on 05/05/2025 at 4:15 PM. Per the Administrator, Resident #23 reported their former roommate was verbally abusive to them. The Administrator confirmed the allegation of verbal abuse was reported to the state survey agency on 05/06/2025 at 9:30 AM. According to the Administrator, allegations of abuse should be reported within two hours and it was his fault that Resident #23's allegation of verbal abuse was not timely reported. The Administrator stated that allegations of abuse should be timely reported.

Based on interview, record review, and facility policy review, the facility failed to ensure staff submitted a new Preadmission Screening and Resident Review (PASRR) to the state agency for review after a significant change in status occurred for 1 (Resident # 53) of 5 residents reviewed for PASRR. Findings included: A facility policy titled, PASRR (Pre-Admission Screening & [and] Resident Review), dated 06/2018, indicated, 3. A negative Level I screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later. An Admission Record revealed the facility admitted Resident #53 on 04/03/2016. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified cerebral infarction (stroke), unspecified schizophrenia (with an onset date of 05/08/2018), and other specified depressive episodes (with an onset date of 05/08/2018). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #53 had no hallucinations, delusions, or behaviors. The MDS indicated Resident #53 had active diagnoses that included depression and schizophrenia. Resident #53's Care Plan Report, included a focus area initiated 07/15/2024, that indicated the resident used antidepressants for major depressive disorders and insomnia. Interventions directed staff to administer the antidepressant medication as ordered by the physician, observe the resident's mood and response to the medication, consider non-pharmacological approaches, and consult psychology as needed. The Care Plan Report indicated a focus area initiated 02/17/2023, that indicated the resident had a diagnosis of schizophrenia. Interventions directed staff to assist the resident, family, and caregivers to identify strengths and positive coping skills; behavioral health consults as needed; and monitor, document, and report any risks for harm. A State of California-Health and Human Services Agency Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated 04/03/2016, indicated Resident #53 had a negative Level I PASRR due to having no mental illness such as schizophrenia or depression. Resident #53's Diagnosis Report revealed unspecified schizophrenia and other specified depressive episodes were added as active diagnoses for Resident #53 on 05/08/2018. The report revealed the section titled Comments indicated that a PASRR Level II was not required. Resident #53's Order Summary Report, with orders active as of 05/05/2025, included an order dated 02/23/2024, for Paxil (an antidepressant) 30 milligrams (mg), with instructions to give 0.5 tablet by mouth one time a day for depression as evidenced by expressions of sadness. The Order Summary Report included an order dated 01/20/2025, for trazadone (an antidepressant that is also used for insomnia) 50 mg, with instructions to give one tablet by mouth at bedtime for depression as evidence by inability to sleep. On 05/06/2025 at 2:19 PM, the Administrator stated he was unsure who was responsible for submitting a new PASRR to the state agency when a resident had a change in condition. During a follow-up interview on 05/06/2025 at 2:59 PM, the Administrator stated the PASRR process was multifaceted and multileveled. The Administrator stated the Admissions Director was the first line of defense when she looked at PASRRs for admission to the facility. He stated that after admission, the MDS department was the follow-up for any process questions related to a resident's PASRR. The Administrator stated the Director of Nursing (DON) would then follow up and review the PASRR for completion and accuracy. The Admissions Director was interviewed on 05/07/2025 at 8:48 AM. The Admissions Director stated the PASRR was sent to the facility from the hospital on an electronic file exchange and she had no access to the file exchange. She stated the nurses had access to the electronic file exchange portal, but she was unsure who was responsible for sending information to the state agency when a change in a resident's condition occurred or the resident received a new psychiatric diagnosis. The Director of Social Services (DSS) was interviewed on 05/07/2025 at 9:02 AM. The DSS stated she had no responsibility for reviewing a resident's PASRR or making sure the PASRR was accurate. The DSS stated the MDS Coordinator #17 was responsible for submitting a new PASRR for review to the state agency when a psychiatric diagnosis was added for a resident. MDS Coordinator #17 was interviewed on 05/07/2025 at 9:12 AM. MDS Coordinator #17 stated the previous admission nurse had been responsible for reviewing residents' PASRRs on admission for accuracy. MDS Coordinator #17 stated she was unaware of any current residents who had a new psychiatric diagnosis added, but if there had been a resident with a new psychiatric diagnosis added it was the responsibility of the MDS department to submit the information to the state agency for review. MDS Coordinator #17 stated she had worked in the facility for three years, and prior to her arrival submitting new information to the state agency for review was the responsibility of the MDS department and the DON. MDS Coordinator #17 reviewed the diagnoses list for Resident #53 and confirmed that depression and schizophrenia had been added in 2018. She stated this information should have been sent to the state agency for review, since the addition of new diagnoses indicated a significant change in status for Resident #53. MDS Coordinator #17 stated the facility had not designated anyone to review PASRRs for accuracy. The DON was interviewed on 05/07/2025 at 10:41 AM. The DON stated if psychiatric diagnoses were added to a resident's profile after admission the MDS department was notified and a new Level I PASRR was submitted to the state agency due to the resident's significant change in condition. The DON stated that during the quarterly reviews, the PASRRs were reviewed along with any new diagnoses. The DON stated the MDS nurses or the nurses on the floor should have caught the addition of Resident #53's new diagnoses and stated the PASRR was not accurate. The DON stated that although the diagnoses were added in 2018, the expectation was for residents' PASRRs and their diagnoses to be reviewed quarterly. The DON stated the 2016 PASRR was the only one on file in the facility for Resident #53. The Administrator was interviewed on 05/08/2025 at 10:03 AM. The Administrator stated he expected someone to catch the error on the resident's PASRR, the new diagnoses, and to submit a new PASRR to the state agency.

Based on observation, interview, facility document review, and facility policy review, the facility failed to provide necessary treatments and services consistent with professional standards of practice during wound care for 1 (Resident #150) of 2 residents reviewed for pressure ulcers. Findings included: A facility policy titled, Wound Care, revised 10/2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy revealed the section titled, Preparation, included, 1. Verify that there is a physician's order for this procedure and 3. Assemble the equipment and supplies as needed. A facility policy titled, Physician Orders, revised 06/2013, revealed, Physician orders must be given, managed and carried out in accordance with applicable laws and regulations. Resident #150's Admission Record indicated the facility admitted the resident on 01/17/2025. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, cellulitis of the right lower limb, fracture of the right great toe, pressure induced deep tissue damage of the left heel, and pressure induced deep tissue damage of the right heel. A Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2025, revealed Resident #150 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive to total assistance for all activities of daily living (ADLs). Resident #150's Care Plan Report, included a focus area initiated 02/11/2024 and revised 04/24/2025, that indicated the resident had a left deep tissue injury (DTI) and was at risk for further breakdown and/or slow, delayed healing related to cardiovascular disease, incontinence of bladder, and incontinence of bowel. The focus area also indicated Resident #150 had a right heel DTI that had resolved. Interventions (initiated 2/11/2025) directed staff that the resident had a pressure-reduction cushion for their chair, a turning and repositioning wedge, and used lift pads to minimize friction and shear. Interventions directed staff to provide vitamins and nutritional supplements as ordered (initiated 2/11/2025). Resident #150's Physician Orders Details dated 05/06/2025, from the wound care provider, revealed Resident #150 had received treatment orders for Wound #1 Left Heel, Wound #2 Right Heel, Wound #3 Right, Medial Second Toe, and Wound #4 Right Third Toe Tip. Resident #150's Order Recap [Recapitulation] Report, for the timeframe from 01/01/2024 through 05/31/2025, revealed the following treatment orders: - An order dated 05/06/2025, for TX [treatment] orders for abrasion @ [at] R [right] 3rd toe. Apply topical Lidocaine 2% [percent] to wound bed. Cleanse with NS [normal saline], pat dry. Notify MD [medical doctor] if changes occur. Reassess in 14 days. - An order dated 05/06/2025, for TX orders for abrasion @ R medial 2nd toe. Apply topical Lidocaine 2% to wound bed. Cleanse with NS, pat dry, apply skin prep to surrounding skin, insert HFB [Hydrofera Blue] and cover with foam dressing. Notify MD if changes occur. Reassess in 14 days. - An order dated 05/06/2025, for TX orders for s/p [status post] DTI @ L [left] heel. Apply topical Lidocaine 2% to wound bed. Cleanse with NS, pat dry, apply skin prep to periwound, let dry, apply foam dressing. Notify MD if changes occur. Reassess in 14 days. Every day shift every Wed [Wednesday], Sat [Saturday] for L heel. - An order dated 05/06/2025, for TX orders for s/p DTI @ R heel. Apply topical Lidocaine 2% to wound bed. Cleanse with NS, pat dry, apply Skin Prep to periwound, let dry, apply foam dressing. Notify MD if changes occur. Reassess in 14 days. every day shift every Wed, Sat for R heel. During an observation of wound care on 05/07/2025 at 10:04 AM, Licensed Vocational Nurse (LVN) #2 gathered wound care supplies from the treatment cart, knocked on Resident #150's room door, and entered the resident's room. LVN #2 removed the blankets from the resident's lower legs and feet, placed a barrier pad underneath the resident's feet, and removed Resident #150's socks. LVN #2 removed a dressing from the resident's left heel. There was no dressing present on the resident's right heel to remove. LVN #2 then peeled back the soiled dressing from Resident #150's right second toe and using a syringe, put Lidocaine on the wound bed and laid the soiled dressing back over the wound; per LVN #2, she did it to let it soak a little. LVN #2 then cleaned the right heel wound and left heel wound with normal saline and gauze and applied skin prep around the wound bed of both heels. LVN #2 then took a pair of bandage scissors from her pocket and cut two dressings to fit over both heel wounds and placed the bandages on both heels. LVN #2 then removed the dressing from Resident #150's right second toe wound and cleaned the wound with normal saline and gauze. LVN #2 then cut a small piece of Hydrofera Blue foam and placed it over the wound bed of the right second toe. Once the Hydrofera Blue foam was in place, LVN #2 took a 5-inch by 5-inch adhesive bordered foam dressing and placed it over the end of Resident #150's right foot, enclosing all their toes on the right foot in the dressing. LVN #2 did not address the wound on Resident #150's right third toe during the wound treatment. She then placed the resident's socks back on both feet and pulled the blankets back from their lower legs. LVN #2 threw away the soiled supplies and placed the Lidocaine syringe into the sharps container on the treatment cart and documented the treatments as completed. During an interview on 05/07/2025 at 12:19 PM, LVN #2 stated she had worked at the facility for two years and had been doing Resident #150's wound treatments since February 2025. LVN #2 stated the resident's wound treatments had been changed by the wound clinic the day prior. LVN #2 stated that the Lidocaine was for the second toe mainly, because it was painful to the resident during the dressing change, the other wounds on both heels quit hurting the resident about two weeks ago when the wounds started to close up, so she did not put it on any other wound but the second toe. LVN #2 stated there was no dressing change order for the wound on the residents right third toe. LVN #2 stated she put a dressing over the entire end of the resident's foot to help protect all the toes and did not think about the possibility that the resident's toes would be pressed together and could create more pressure between the toes. LVN #2 stated she had not followed the physician's orders for wound treatments. During an interview on 05/08/2025 at 10:58 AM, the Director of Nursing (DON) stated that not following the physician's orders to use Lidocaine on all of Resident #150's wounds and not dressing their third toe at all, were all issues. The DON stated her expectation was for the nurse to verify the physician's order for the resident prior to gathering their supplies, and they must follow the physician's order and prepare the supplies according to the order. During an interview on 05/08/2025 at 11:19 AM, the Administrator stated his expectation was that the nurses follow the physician's orders exactly as written.

Based on interview and record review, the facility failed to obtain a physician's progress note in a timely manner, and perform skin assessments of a surgical site for 1 of 3 sampled residents (Resident 1). As a result of these failures, 31 staples were retained in Resident 1's left hip surgical incision site for 72 days (usually removed 7 to 14 days after surgery, per the surgeon) after the surgeon ordered the removal of the staples. In addition, [AGE] year old Resident 1's incision dehisced (split open), and he underwent a 2nd surgical operation for irrigation, debridement (flush and remove dead tissue from a wound), in the left hip incision site under general anesthesia (use of medications to make a person unconscious and unable to feel pain during a surgical procedure). The resident remained in the hospital for 4 days and was treated with a 6 week course of antibiotics for an infection at the incision site. Findings: Resident 1 was admitted to the facility on [DATE], according to the Record of Admission. Resident 1's clinical record was reviewed on 11/21/13. Resident 1 sustained a fall with a fracture while residing in the facility. The resident was transferred to the hospital, and underwent a left hip hemiarthroplasty (surgical repair of [MEDICAL CONDITION]) on 8/22/13, per the hospital physician's Operative Report, dated 9/3/13. Resident 1 returned to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/3/13, Resident 1 was seen in his surgeon's office and returned to the facility with orders for, "Suture/staples removal (L) (left) hip." On 9/3/13 at 3:30 P.M., Licensed Nurse (LN) 1 documented in the Nurses Notes, "Back from...appt (appointment)...sutures/staples were removed..." LN 1 stated in an interview on 11/26/13 at 4:45 P.M., she interpreted the surgeon's orders as the sutures/staples were removed. LN 1 said when a resident had surgical staples removed she was supposed to re-assess the skin to ensure wound healing, and to monitor for signs and symptoms of infection. LN 1 said when a resident went out of the facility for a physician's appointment she was supposed to obtain a progress note from the physician. LN 1 said if a resident returned from an appointment without a progress note, she was supposed to follow up with the physician to obtain one or place the information on a calendar for another nurse to follow up. LN 1 also said she did not assess Resident 1's incision site when he returned from his surgeon's appointment, and did not obtain the physician's progress note or place it on the calendar for another LN to follow-up and obtain it. There was no documentation in the resident's clinical record of a progress note for the surgeon's office visit on 9/3/13. According to the American Health Information Management Association's Long-Term Care Health Information Practice and Documentation Guidelines, updated 10/2010, "If a resident requires a consultation with a specialist,...the medical record must contain documentation of the visit, progress notes and recommendations." Also, "For consultations that occur out of the facility, a separate referral/consultation record can be sent to the physician obtain documentation for the resident's long-term care record." According the status [REDACTED]. Between 9/5/13 and 9/15/13, the facility LNs documented on 4 separate occasions that Resident 1 did not have signs and symptoms of infection and/or complications at his left hip surgical site. In an interview on 11/21/13 at 2:35 P.M., LN 2 stated she documented 3 of 4 nursing notes which reflected Resident 1 did not have signs and symptoms of infection and/or complications at his left hip surgical incision site. LN 2 said she never looked at the hip wound and documented her assessment based on Resident 1's lack of fever or complaints of pain. LN 2 said, "You can't say there were no signs of symptoms of infection if you don't look at it (the wound)." According to the facility policy, entitled, Surgery-Related (Pre- and Postoperative) Management Clinical Protocol, revised, April 2009, "The staff...will monitor for, and address, postoperative risks and complications such as infections...failure of surgical wounds to heal...." According to the facility policy, entitled, Pressure Ulcer Risk Assessment, revised March 2005, "Skin will be assessed...on a weekly basis or more frequently if indicated." There were nine Weekly Progress Note forms (a summary completed once per week which would reflect all aspects of a resident's care), dated between 9/8/13 and 11/10/13, in Resident 1's clinical record. Each form had a section to document a skin assessment, which included a sub-section for the documentation of a surgical wound assessment. On 10/13/13, LN 6 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 6 stated on 12/5/13 at 2:24 P.M., she did not conduct a skin assessment because Resident 1 refused. LN 6 said she was supposed to check a surgical incision site, but could not recall why she did not check Resident 1's incision. LN 6 said she should have documented Resident 1 refused a skin assessment. On 10/27/13, LN 4 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 4 stated on 11/21/13 at 3:25 P.M., a head to toe, full body inspection of the skin was supposed to be evaluated as part of the weekly summary documentation. LN 4 said she completed the weekly summary, but did not inspect Resident 1's skin because he was sleeping. On 11/3/13, LN 3 documented in the Skin Assessment section of the Weekly Progress Note that Resident 1's skin was, "Intact (healthy skin in which there are no breaks, scrapes, cuts, or abnormal openings)." LN 3 stated during an interview on 11/21/13 at 1:45 P.M., Resident 1 refused to have his skin checked on 11/3/13. LN 3 said that on 11/3/13, she reviewed Resident 1's treatment sheets (forms used to document treatments provided, such as treatments to the skin), the Certified Nursing Assistants (CNA) documentation forms, which included shower sheets (forms utilized by the CNAs to document care and skin evaluations during showers). LN 3 said she documented on the Weekly Progress Note that Resident 1's skin was, "Intact," because Resident 1 denied any skin problems, there was no documentation of any skin treatments, and no documentation by the CNAs that Resident 1 had any skin issues. LN 3 said she should have documented Resident 1 refused a skin check. On 11/10/13, LN 5 documented in the Skin Assessment section of the Weekly Progress Note. The surgical wound assessment section was blank. LN 5 stated during an interview on 11/21/13 at 3:50 P.M., she was supposed to look at Resident 1's skin from head to toe. LN 5 said she did not do a full body skin assessment and only looked at the parts of his body that were uncovered, such as his arms and face, etc. On 11/14/13, Resident 1 sustained a fall during an outing from the facility, per a Change in Condition - Post Fall/Trauma report. Per the report, Resident 1 had a moderate amount of bleeding on the left hip surgical site. LN 7 stated on 11/26/13 at 3:59 P.M., she did a full body assessment on Resident 1 after his fall on 11/14/13. LN 7 said when she viewed Resident 1's left hip surgical incision site after the fall and saw the staples, she reviewed his clinical record, saw the order for staple removal and removed a total of 31 staples. LN 7 said she observed roughly 1 - 1.5 inches of a dehisced area of the incision at that time. The facility sent Resident 1 to his surgeon's office (MD 1) on 11/15/13. The physician transferred Resident 1 to the hospital directly from his office because upon assessment of Resident 1's incision, the physician observed the incision site was dehisced 3 inches, and he suspected it was infected. According to a hospital Operative Report, dated 11/15/13, Resident 1 underwent a left hip open irrigation and debridement, under general anesthesia. According to the report, the dead tissue in Resident 1's hip wound extended into a serous (clear fluid) collection in a bursa (fluid-filled sacs or cavities positioned in joints throughout the body), and an antibiotic was started. On 11/20/13, 5 days after Resident 1 was transferred to the hospital, the facility obtained Resident 1's surgeon's progress note, dated 9/3/13, per the fax notation at the top of the page. Had the facility obtained the progress note in a timely manner, they could have identified the surgeon did not remove the staples, because the physician documented in the note Resident 1's pants were never removed during the office visit. On 11/26/13 at 5:25 P.M., the facility Administrator and Vice President of Quality (VPQ) were interviewed. The VPQ stated, when a resident was sent out of the facility for a physician's appointment, it was expected that a progress note, as well as physician orders, should be obtained from the outside physician. The VPQ also stated, if orders and a progress note were not received when the resident returned to the facility, the LNs should follow up with the physician and obtain them. Both said, "It's a standard of practice (level of performance or an expectation for professional intervention, formulated by professional organizations based upon current scientific knowledge and clinical expertise)." MD 1 stated in an interview on 12/17/13 at 11:17 A.M., the facility did not remove the staples as he ordered on [DATE]. MD 1 said the facility staff should have assessed and monitored Resident 1's incision site and should have identified the staples remained in his hip. MD 1 said, as a result of the staples remaining in place for an extended period of time, the resident developed a seroma (a pocket of clear serous fluid) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus-a type of bacteria that is resistant to the antibiotics commonly used to treat ordinary infections) infection. The facility's failure to obtain the 9/3/13 surgeon's progress note, which reflected the surgeon never removed Resident 1's pants, resulted in the misinterpretation by the LN of the surgeon's order for removal of the staples. The facility failed to ensure the LNs monitored Resident 1's wound/incision site as required per facility policy, and the failure to follow the plan of care resulted in the failure to identify staples remained in Resident 1's left hip incision site for 72 days after the surgeon ordered the removal of the staples.

Based on interview and record review, the facility failed to demonstrate compliance with their plan of correction. As a result, the facility failed to: 1. Obtain physician progress notes [REDACTED]. 2. Consistently document accurate skin assessment by the nursing staff, per the plan of correction for 6 of 30 sampled residents (3, 4, 5, 6, 7, 8); and 3. Clearly validate current nursing staff were inserviced, per the plan of correction. Findings: 1b. Resident 2 was admitted to the facility 2/18/14, with [DIAGNOSES REDACTED]. On 2/25/14 a review was conducted of Resident 2's clinical record and the facility Outside Appointment Log (a form developed by the facility to track residents who went to medical appointments outside of the facility). There was a section on the log to document whether or not a physician's progress note was obtained when the resident returned from the appointment. According to the log, on 2/21/14, Resident 2 went to a physician's appointment at a wound clinic. The section on the log to document a progress note was obtained from the visit was blank. There was no physician's progress note for the outside physician visit located in Resident 2's clinical record. Additionally, there was no documentation to show the licensed nurses (LNs) followed up with Resident 2's wound clinic physician to obtain the progress note. On 2/25/14 at 3 P.M., LN 12 stated she was the nurse who checked Resident 2 back in to the facility after his outside physician's appointment on 2/21/14. LN 12 said she did not follow up to obtain a progress note from the physician because she thought a physician's orders [REDACTED]. On 2/25/14 at 3:10 P.M., the facility treatment nurse (LN 14), who was responsible for the daily monitoring of the appointment logs per the plan of correction, stated she did not review the logs on 2/24/14. On 2/25/14 at 3:11 P.M., LN 13, the Unit Manager responsible for tracking the appointment logs to ensure progress notes were obtained per the plan of correction, stated she reviewed the appointment log on 2/24/14. LN 13 acknowledged she did not follow up to obtain the physician's progress note. 2a. Resident 3 (identified as Resident A in the plan of correction) was admitted to the facility on [DATE], per the Admission Record. Resident 3's clinical record was reviewed on 2/25/14. According to a Non Pressure Skin Condition Report, dated 2/17/14, Resident 3 had an incision with stitches to her right upper arm. On 2/22/14, five days later, a Certified Nursing Assistant (CNA) documented a skin assessment for Resident 3 on a Shower Sheet. There was no documentation on the Shower Sheet which reflected Resident 3's stitches on her right upper arm. The Shower Sheet was co-signed by Licensed Nurse (LN) 15. On 2/23/14, one day after Resident 3's shower, a facility LN documented in the Skin Assessment Section of the Weekly Progress Note, Resident 3 had 9 stitches in her right upper arm. Resident 3's skin assessment documentation by the facility LNs and CNA did not match. LN 15 was interviewed on 2/25/14 at 4:50 P.M. LN 15 said she reviewed Resident 3's Shower Sheet on 2/22/14 and overlooked the CNA's lack of documentation of the stitches on the Shower Sheet when she co-signed it. 2b. Resident 4 was admitted to the facility on [DATE], according to the facility's Record of Admission. A joint clinical record review was conducted with Licensed Nurse (LN) 20 on 2/25/14. According to the resident's Non-Pressure Skin Condition Report on 2/23/14, Resident 4 had an open wound on her right chest. Resident 4's Shower Sheet dated 2/24/14 did not reflect her right chest wound. LN 20 confirmed Resident 4's Shower Sheet did not reflect her right chest wound. According to Resident 4's Non-Pressure Skin Condition Report, dated 2/23/14, the wound was red and moist. LN 20 confirmed the skin assessment by the LN and CNA for Resident 4 did not match. 2c. Resident 5 was re-admitted to the facility on [DATE], according to the facility's Record of Admission. A joint clinical record review was conducted with Licensed Nurse (LN) 20 on 2/25/14. According to the resident's Treatment Record, Resident 5 was being treated for [REDACTED]. Resident 5's Shower Sheet dated 2/24/14, did not reflect her neck excoriation. LN 20 stated the nurse should complete a Non-Pressure Skin Condition Report on skin issues. LN 20 confirmed a Non-Pressure Skin Condition Report was not found in the Resident 5's clinical record. 2d. Resident 6 was re-admitted to the facility on [DATE], according to the facility's Record of Admission. A joint clinical record review was conducted with Licensed Nurse (LN) 20 on 2/25/14. According to the resident's Treatment Record, dated 10/24/13, Resident 6 was receiving treatment for [REDACTED]. On 2/25/14 at 4:07 P.M., the Director of Staff Development (DSD) stated, any old and new skin issue should be documented on the Shower Sheet. The DSD stated a [MEDICAL CONDITION] should be documented in the Shower Sheet. LN 20 confirmed Resident 6's [MEDICAL CONDITION] was not documented on the Shower Sheet. 2e. Resident 7 was re-admitted to the facility on [DATE], according to the facility's Record of Admission. A joint clinical record review was conducted with Licensed Nurse (LN) 20 on 2/25/14. According to Resident 7's Treatment Record, Resident 7 was being treated for [REDACTED]. LN 20 stated the nurse should complete a Non-Pressure Skin Condition Report on skin issues. LN 20 confirmed there was no documentation of Resident 7's left arm discoloration on the Shower Sheet dated 2/19/14. LN 20 also confirmed the Non-Pressure Skin Condition Report related to his left arm was not in the clinical record. 2f. Resident 8 was re-admitted to the facility on [DATE], according to the facility's Record of Admission. A joint clinical record review was conducted with Licensed Nurse (LN) 20 on 2/25/14. According to Resident 8's Treatment Record, Resident 8 was receiving treatment for [REDACTED]. LN 20 confirmed the resident's shower sheet dated 2/22/14 did not reflect Resident 8's suprapubic catheter. On 2/25/14 at 4:07 P.M., the Director of Staff Development (DSD) stated, any old and new skin issue should be documented on the Shower Sheet. The DSD stated a suprapubic catheter should be documented in the Shower Sheet. 3. On 2/25/14 at 5 P.M., a joint review of the inservices provided to the nursing staff, per the plan of correction, and the current nursing staff roster, was conducted with the Director of Staff Development (DSD). The nursing staff employee roster had 132 names of nursing staff listed as current employees. There was no documentation on the inservice sign in sheets that could be located for 42 (32%) of the nursing staff to show the facility provided inservice education, as per their plan of correction. The DSD stated on 2/25/14 at 5:30 P.M., the nursing staff employee roster was not up to date/current. When asked why the roster was not current, the DSD stated she hadn't had the time to process the paperwork. 1a. Resident 1 was admitted to the facility 9/8/12, according to the Record of Admission. On 2/21/14 Resident 1 went to an outside physician visit, according to the facility's Outside Appointment Log. The section of the Outside Appointment Log for documenting if a progress note was obtained from the appointment had a check mark. On 2/25/14 at 3:05 P.M., during a joint review of the clinical record with Licensed Nurses (LN) 1 & 2, no progress notes for the outside visit could be found. There was no documentation in Resident 1's clinical record to show the LNs followed up with the physician to obtain the progress note. On 2/25/14 at 3:10 P.M., the facility treatment nurse (LN 14) who was responsible for the daily monitoring of the appointment logs per the plan of correction, stated she did not review the logs on 2/24/14.

Based on observation, interview and record review, the facility did not provide care and treatment to reduce the risk of infection for 2 of 29 sampled residents (17, 34) with indwelling urinary catheters (a flexible plastic tube used to drain urine from the bladder) as evidenced by: 1. Resident 34's supra-pubic catheter (urine drainage catheter inserted through the abdominal wall just above the pubic bone and into the bladder) was not changed per physician order; the facility did not follow a recommendation made by Resident 34's urologist (a physician who specializes in diseases of the urinary organs) to reduce the risk of infection; and the facility failed to assess and develop a comprehensive plan of care to address Resident 34's 9 urinary tract infections [MEDICAL CONDITION] and 1 urine yeast infection. As a result, Resident 34 required treatment for 4 symptomatic UTIs, 4 asymptomatic (without symptoms) UTIs, and 1 urinary yeast infection. Two of the urinary infections required Resident 34 be placed on isolation precautions (special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases). In addition, Resident 34 was transferred to the hospital on 2 separate occasions for treatment of [REDACTED]. 2. The failure to remove Resident 17's indwelling urinary catheter when it was no longer medically necessary: failed to follow the physician recommendation for [MEDICATION NAME] (prevention of or protective treatment for [REDACTED]. As a result, Resident 17, who was admitted with a urinary catheter, had the catheter remain for 4 months after it was no longer medically necessary. In addition, Resident 17 was treated for [REDACTED]. Findings: 1. On 4/29/13 at 10 A.M., Resident 34 was sitting in his wheelchair. Resident 34 repeatedly and rapidly pointed at his lower abdomen. Resident 34 stated, "I have been having lots of pain." Resident 34 stated his catheter was inserted in June 2012. According to the resident, the catheter should be changed every month. Resident 34 said he told staff the catheter should be changed every month but "They don't listen." During a subsequent interview on the same day at 2:45 P.M., Resident 34 stated the tube had not been changed since it was inserted. In addition, Resident 34 said he complained of pain to the nurse and, "All they do is flush (irrigate) it." Resident 34's clinical record was reviewed on 4/29/13. Resident 34 was admitted to the facility on [DATE], per the Record of Admission. On 6/13/12, Resident 34 was transferred from the facility to the hospital. On admission to the hospital, the resident was diagnosed with [REDACTED]. Also, per the summary, a supra-pubic catheter was inserted for a [DIAGNOSES REDACTED]. On 7/31/12, Resident 34 was discharged from the hospital and readmitted to the facility. On 7/31/12, his physician ordered, "Change supra-pubic catheter...every last day of the month and PRN (as needed)." Two days later, on 8/2/12, the nursing staff developed a Bladder Elimination care plan for Resident 34. The nursing staff identified Resident 34 had a supra-pubic catheter and experienced a UTI within the last 30 days. One of the approaches was to provide, "Supra-pubic catheter care per protocol." There was no documentation the care plan included the physician's orders [REDACTED]. There was no documentation Resident 34's supra-pubic catheter was changed in August, September, October or November of 2012, as ordered by the physician. In December 2012, Resident 34's catheter spontaneously fell out. After the catheter fell out, the nursing staff inserted a new catheter. According to the Minimum Data Set Assessment, dated 2/25/13, Resident 34 was cognitively intact. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed on 5/2/13 at 8:30 A.M. The DON and ADON stated the licensed nurses (LN) did not change the catheter because they were unfamiliar with Resident 34's type of catheter. The DON and ADON stated the LNs should have contacted the urologist for directions on changing the catheter. During an interview on 5/2/13 at 12:35 P.M., Resident 34's physician (MD 1) stated he ordered the monthly supra-pubic catheter changed because it was considered a urology standard of practice to prevent infections. During a 4 month period of time, between 8/31/12 and 12/31/12, the licensed nurses (LN) documented multiple issues and complaints from Resident 34 such as, bladder pain, pressure and spasms, abdominal discomfort and distention, cloudy orange colored urine, thick yellow/whitish urine, feeling weak, no appetite, an increased temperature, and clogged catheter. During this same four month period, Resident 34 was transferred to an emergency department on 2 separate occasions (9/2/12 and 10/3/12) for evaluation and treatment of [REDACTED]. On 5/7/13, the facility provided an undated policy entitled, Criteria for Defining Infections By Signs and Symptoms. According to the facility's criteria, during a 4 month period of time, between 8/31/12 and 12/31/12, Resident 34 was treated on 2 separate occasions with oral antibiotics for "symptomatic" UTIs and on 2 additional occasions with intramuscular (in the muscle) injections of antibiotics for "symptomatic" UTIs. In addition, during this time period, the resident received oral antibiotics for treatment of [REDACTED]. During this 4 month time period, two of the infections identified were found resistant to several antibiotics which required Resident 34 to be on isolation precautions, per the facility infection control logs. According to the Center for Disease Control's (CDC) Get Smart: Antibiotic Resistance Questions and Answers, dated 6/30/09, the repeated use of antibiotics was one of the primary causes of the increase in drug-resistant bacteria. On 5/7/13 at 8:45 A.M., the facility's Infection Control Nurse (ICN) stated she was unaware Resident 34's supra-pubic catheter was not changed as ordered by the physician and stated, "Of course it contributed to his infections." Further clinical record review indicated on 6/17/12, a urologist (MD 2) provided a consultation for Resident 34. MD 2 documented in his consultation report, "It would not hurt to have cranberry added to his medication and supplement regimen to reduce a chance for future bladder infections." The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed on 5/2/13 at 8:30 A.M. The DON and ADON stated Resident 34 did not receive a cranberry supplement to help reduce the risk of infection, as recommended by his urologist. During an interview on 5/2/13 at 12:35 P.M., Resident 34's physician (MD 1) stated the facility staff should have contacted the urologist and obtained an order from him for the cranberry supplement. On 8/2/12, the nursing staff developed a Bladder Elimination care plan for Resident 34. There was no documentation the LNs updated or revised the interventions section of the resident's Bladder Elimination care plan to reflect multiple treatments with antibiotics and multiple episodes of the clogged catheter, 2 of which required treatment in an emergency room . According to the facility policy, revised 8/2009, entitled, Goals and Objectives, Care Plans, "Care plan goals and objectives are defined as the desired outcome for a specific resident problem... When goals and objectives are not achieved, the plan of care will be revised." Resident 34's clinical record contained three Assessments of Residents with Indwelling Catheters, completed on 9/3/12, 11/30/12 and 2/25/13. Each of these assessments had a section to document, "Risk Factors: Any history of or indication of: Bacteremia (bacteria in the blood)," and, "Catheter blockage." The sections on all three forms were left blank, or had a straight line drawn through the section. There was no documentation the LNs addressed Resident 34's multiple risk factors/history of UTIs and the catheter blockages which required treatment in an emergency roiagnom on 2 separate occasions. Resident 34's clinical record contained 3 Care Plan Conference Note forms (used to document current status and ongoing issues covering all aspects of care), dated 9/10/12, 11/27/12, and 2/25/13. Four staff members signed the forms, to indicate they attended the conference; however, there was no documentation on any of these forms to reflect Resident 34's ongoing and recurrent UTIs were discussed. Resident 34's current clinical record contained an Interdisciplinary Team (IDT) form (a form used to document resident care issues identified by the team). The form was blank. There was no documentation the IDT addressed any of Resident 34's care issues. On 5/6/13 at 2:40 P.M., the DON and ADON were interviewed. The DON and ADON stated the facility should have discussed Resident 34's frequent and recurring infections with MD 1. They further acknowledged the IDT should have addressed the management of the resident's 9 urinary infections. According to the facility policy entitled Infection Control in Long-Term Care, revised December 2012, the duties of the ICN (Infection Control Nurse) included, "Reviewing potential and actual infection problems with the Medical Director and Director of Nursing Services." Included in the duties was, "Monitoring specific problem cases." On 5/7/13 at 8:45 A.M., the facility's Infection Control Nurse (ICN) stated she was not aware of Resident 34's frequent treatments for UTI, nor did she participate in any meetings to discuss the issue. The ICN was unable to provide documentation that she reviewed Resident 34's frequent treatment for [REDACTED]. In addition, the ICN was unable to provide documentation that she closely monitored the ongoing potential causes for Resident 34's recurring infections. The facility failed to change a supra-pubic catheter as ordered by the physician; follow recommendations made by Resident 34's urologist to reduce the risk of infection; update the care plan after repeated treatments for UTI; and conduct an IDT meeting to address the recurring infections. In addition the facility failed to ensure the ICN assessed and monitored the potential causes for Resident 34's frequent treatment for [REDACTED]. 2. Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 17's clinical record was reviewed on 4/29/13. According to the Clinical Health Status admission assessment, dated 9/24/12, Resident 17 had pressure ulcers on her left buttock, right hip bone, and multiple pressure ulcers on her ankles, heels and feet. Additionally, per the assessment, Resident 17 was admitted with an indwelling urinary catheter (a flexible plastic tube used to drain urine from the bladder). On admission Resident 17's physician ordered, "Foley catheter...to straight drainage for wound care." According to the wound documentation, Resident 17's left buttock pressure ulcer healed on 9/26/12 and her hip ulcer healed on 10/10/12. On 12/23/12, a facility LN documented on the Assessment of Residents with Indwelling Catheters, Resident 17's catheter could not be removed because of, "Skin management." Contrary to the LN assessment, Resident 17's catheter was no longer medically necessary for skin management since the pressure ulcers on her hip and buttock were healed. On 3/26/13, a LN documented on a subsequent Assessment of Residents with Indwelling Catheters, Resident 17's catheter could be removed and would, "Recommend to DC (remove) catheter." There was no documentation to show Resident 17's indwelling urinary catheter was removed following the 3/26/13 recommendation. On 5/6/13 at 4:15 P.M., the DON stated the LN who completed the 12/23/12 bladder assessment was not aware the wounds on the buttock and hip bone were healed. According to the DON the LN should have recommended removal of the catheter at that time. The DON said when the same LN documented the recommendation for the catheter to be removed on 3/26/13, she forgot to communicate the information to the staff and failed to obtain a physician's orders [REDACTED]. On 5/7/13, the facility provided an undated policy entitled, Criteria for Defining Infections By Signs and Symptoms. According to the facility's criteria, between 10/5/12 and 4/20/13, Resident 17 was treated with oral antibiotics, twice for symptomatic UTIs and 5 times for asymptomatic (without symptoms) UTIs. On 2/7/13, Resident 17's physician documented in the Progress Notes, "Consider putting her on [MEDICATION NAME] ABX (antibiotics) for rec (recurring) UTI. There was no documentation in Resident 17's clinical record that the recommendation was addressed by the LNs. Resident 17's Bladder Elimination care plan, which was developed on 9/25/12, did not contain any updated interventions when UTIs were recurring. Resident 17's clinical record contained a care plan conference note, dated 3/25/13, which was used to document current status and ongoing issues covering all aspects of care. There were 4 staff members and 1 responsible party member who signed the document to indicate they attended the conference. There was no documentation the facility staff members discussed Resident 17's recurring treatments with antibiotics for UTIs. On 4/30/13 Resident 17's indwelling urinary catheter was removed, which was 4 months after it was no longer medically necessary. The facility failed to remove an indwelling urinary catheter when it was no longer medically necessary; did not follow the physician's recommendations for [MEDICATION NAME] antibiotics; and update the care plan after repeated treatments for UTI.

Based on observation, interview and record review the facility failed to: 1. Operate 2 of 4 resident lift devices (devices to move patients in and out of beds and chairs), within the manufacturer's safety requirements for 6 sampled residents (26, 57, 124, 134, 146, and 161), and 8 unsampled residents (63, 85, 95, 104, 115, 119, 133 and 144). In addition, the facility failed to maintain the resident lift devices and failed to train the staff regarding the safety requirements of the resident lift. 2a. Ensure 42 electrical wall outlets in 29 of 93 resident rooms were approved by OSHPD (Office of Statewide Health Planning and Development); 2b. Provide maintenance to a wall outlet (Room 112 B) which had a loosened metal cover plate and signs of black burn marks on the outlet and; and failed to provide maintenance on 2 damaged electrical wall outlets in 2 resident rooms (305 B and 310 A). 2c. Ensure medical equipment in 5 of 93 resident rooms were plugged into approved electrical outlets. Findings: 1. On 6/25/12 at 8 A.M., during the initial tour of the facility, two resident lifts were observed without 4 of 6 safety latches on each of the cross bars (The cross bar is where the resident sling is attached, via hooks, to the lift device. The hooks have safety latches to prevent the resident sling from becoming detached from the cross bar and failing during the transfer). On 6/25/12 at 11:30 A.M., the Director of Nursing (DON) provided a list of fourteen residents who used the lifts to get in and out of bed, often multiple times, daily. On 6/25/12 at 2:05 P.M., during a joint interview and record review with the Certified Nursing Assistant (CNA) 1 and the DON, CNA 1 stated, "I use the lifts all the time. Many of my patients require them to get in and out of bed daily and for showers. We don't use any safety latches, they aren't on the hooks we use. I don't even know why they'd be there." On 6/25/12 at 2:05 P.M., the DON stated, "We have had those lifts since I've been here and I've never seen the safety latches." The DON provided a copy of the facility policy Lifting Machine, Using a Portable (revised April 2007). The DON acknowledged that the policy did not require staff to inspect the machine for safe operation prior to its use, as instructed by the manufacturer's user manual. On 6/25/12 at 3 P.M., the Maintenance Director (MD) provided a copy of the preventative maintenance log that indicated a monthly "Check Mark" next to the box labeled "Lift Sling." The MD could not define what the check mark indicated. The MD also provided a printed copy of the manufacturer's user manual indicating routine maintenance by a qualified technician must be performed for continue safe operation of the device. The MD acknowledged that the lifts had not been serviced as directed by the manufacturer's user manual and did not know the date when the lifts were last serviced. On 6/25/12 at 5 P.M., the Director of Staff Development (DSD) was unable to provide any documentation to show staff had been trained on the resident lift devices. The DSD stated, "I can't find any records." On 6/25/12 at 5:10 P.M. and 5:20 P.M., CNAs 1, 2, and 3 were interviewed and could not recall any recent resident lift training. CNA 1 stated, "I use it all the time but I don't remember any training." CNA 2 stated, "I use it all the time. I don't know when the last lift training was held. I don't know anything about the safety latches." CNA 3 acknowledged she used the lifts to get residents up and down all the time and didn't remember any training dates or topics. Due to the facility's failure to: 1. Ensure two resident lifts had six safety latches each, as required per the manufacturer; 2. Ensure staff using the lifts were trained, related to the requirements for the safety latches on the lifts and; 3. The resident lifts were routinely maintained per the manufacturer's requirements, the survey team called an Immediate Jeopardy (IJ). On 6/25/12 at 5:45 P.M., the survey team called the IJ and informed the NHA and the DON. The team requested the Nursing Home Administrator (NHA) and DON provide the survey team with immediate measures that would be taken to ensure the safety of the residents using the resident lifts. On 6/25/12 at 7:46 P.M., the survey team received and reviewed the Plan of Correction (POC) presented by the facility. According to the POC: 1. The facility removed the lifts and labeled the lifts, "Out of service" until the arrival of safety clips from the manufacturer. Per the NHA, once the installment of the safety clips was completed, the lifts would be placed back in service; 2. Daily monitoring of the prescence of all safety clips on the lifts would be done by the maintenance staff; 3. An inservice for the use of the mechanical lift with orientation and return demonstration would be done by the Director of Staff Development; 4. All monitoring findings would be forwarded to the monthly and quarterly Quality Assurance meetings. The team accepted the POC and informed the NHA at 7:46 P.M. that the IJ was abated. On 6/26/12 at 7:30 A.M., during a telephone interview with the lift manufacturer Customer Service Presentative (CSR), the CSR stated, "Yes, that model of lift does have safety latches on each hook. They are for operational safety and the lift should not be operated without them for risk of dropping the patient. The lift owner must service, repair, and maintain the lift through an authorized vendor, per the User Manual instructions, for safe operation." 2a. On 6/25/12, during the initial tour, 20 of 93 resident rooms were noted to have electrical wall outlets with four plug positions installed, next to standard dual plug outlets. Nine of 93 resident rooms had additional two plug outlets installed, adjacent to standard dual plug outlets. On 6/27/12 at 9:20 A.M., during a joint tour with a Department Health Facility Evaluator (HFE - Life Safety Code Specialist), the Maintenance Director, and Maintenance Worker (MW) 1, the Maintenance Director stated, "My staff installed the quad plugs in the walls. MW 1 is an electrician." MW 1 stated, "I installed the quad plugs in the walls next to the dual plugs of the rooms. I just connected the wires to the existing dual plugs." Both the Maintenance Director and MW 1 acknowledged that they had not conducted a load calculation (a calculation of the amount of electricity needed versus what was available in the circuit) test nor received any permits for the quad plug installations. MW 1 stated, "I did my training in the Philippines. I do not have any training certifications or license in the United States (U.S.)." On 6/27/12 at 9:50 A.M., during a joint interview with the Maintenance Director and HFE, the HFE referenced the California Code of Regulations that required facilities to seek approval and notify the Department of any alterations to existing buildings. The Maintenance Director stated, "I don't have any permits for the electrical work. I didn't go through the city or OSHPD (Office of Statewide Planning & Development) and I didn't notify anyone." On 6/27/12 at 10 A.M., the Maintenance Director provided a list of resident rooms where he acknowledged the facility had installed quad plugs in the walls without OSHPD approval. According to the list provided by the facility, the list indicated 42 plugs had been installed in 29 out of 93 resident rooms without the proper permits. 2b. On 6/25/12 at 8 A.M., during the initial tour of the facility, a wall socket in Resident 11's, room (112 B), with two televisions plugged into it, was observed with the metal cover plate hanging from the lower plug with black burn marks and signs of scorching (a superficial burn). On 6/26/12 at 1:45 P.M., during a joint observation and interview with Certified Nursing Assistant (CNA) 4, Licensed Nurse (LN) 1, the Assistant Director of Nursing (ADON), the Maintenance Director, and the Nursing Home Administrator (NHA), the same wall socket with two televisions plugged into it was observed with the metal socket cover plate hanging from the lower plug with signs of scorching (a superficial burn). CNA 4 stated, "I don't know what happened." On 6/26/12 at 1:45 P.M., CNA 4 provided the maintenance log for room 112 through June 2012, with no indications of problems or repairs noted. There were no entries in the log to reflect that the problem wall socket was reported to maintenance. LN 1 stated, "I don't know what happened. It looks like something burned." The ADON observed the socket and stated, "I don't know what happened." The Maintenance Director observed the socket and stated, "I don't know, it shorted." The Maintenance Director then removed the metal plate from the plug it was hanging from and began to rub off the black scorch marks. The NHA observed the socket and stated, "I don't know what happened." On 6/27/12 at 8:35 A.M., during an interview, Resident 11 (Room 112 B) stated, "Of course, I know what happened. A couple of days ago in the evening it sparked with a big flash of fire. I was lying in bed and the TV went off. I didn't tell anybody because they don't listen to me." On 6/27/12 at approximately 8:40 A.M., CNA 5 reviewed the maintenance request log book for nursing station 1 (re: Room 112 B) and stated, "I can't find any indication that a repair request was made for room 112 B. This is how we request maintenance for our rooms." On 6/27/12 at 8:45 A.M., during a tour of the facility with the Maintenance Director, a four plug electrical wall outlet was observed in a Resident room (305 B). Adjacent to the resident's bed was a four plug electrical wall outlet which had black burn marks and a 2 inch by 2 inch hole in the plaster. An oxygen concentrator was plugged into the socket. The Maintenance Director stated, "It happened a long time ago." The Maintenance Director stated, he was not aware of the burn marks and 2 inch by 2 inch hole in the plaster. On 6/27/12 at 8:56 A.M., the Nursing Home Administrator (NHA) stated he was not aware of any of the electrical problems in the facility. On 6/27/12 at 10 A.M., a four plug electrical wall outlet was observed in a resident room (310 A). adjacent to the resident's bed, with black burn marks and what appeared to be a broken part of an electrical plug wedged inside one of the sockets. The remaining three outlets were cracked. 2c. On 6/25/12, at 8 A.M., during the initial tour, there were 10 multi-plug devices (power strips) and 6-outlet electrical plug adapters in resident rooms. There was one desk fan mounted in the dining room wall with its power cord spliced (power cord had been cut in two and each wire was twisted together with a different cord to create a longer cord to reach the wall outlet). On 6/25/12 at 1:45 P.M., during a tour of the facility, 45 multi-plug power strips, 7 multi-plug adapters, and one extension cord were observed plugged into wall sockets. Four beds (Rooms: 118 B, 124 B, 214 B and 418 B) and 1 oxygen concentrator (Room 217) were observed plugged into multi-plug devices. On 6/27/12 at 8:35 A.M., during an interview, the Maintenance Director stated, "I removed the fan with the spliced together wires, it's a big building and I just overlooked it." On 6/27/12 at 10 A.M., Resident 20 stated, "The plug (multi-plug) adapter on the wall is so they can plug both TVs into it." Due to the facility's: 1. Installment of unapproved additional electrical wall receptacles in resident rooms; 2. Failure to repair electrical wall receptacles with metal outlet plates in 3 resident rooms that had evidence of scorching, and: 3. Use of unapproved electrical outlets (power strips) for medical equipment, the survey team call a second Immediate Jeopardy (IJ). On 6/25/12 at 10:45 A.M. the NHA and DON were informed the survey team called the IJ. The team requested the NHA and DON provide the survey team with immediate measures to ensure a safe environment for the residents. On 6/27/12 at 3:45 P.M., during a joint interview and observation with a facility contracted electrician (Electrician 1), the NHA and the Maintenance Director, Electrician 1 stated the outlets in resident rooms were scorched because, "It was the metal cover that arced (an electrical flash which can cause damage, fire or injury and caused the spark). I would recommend replacing the plug (Room 112 B)." On 6/27/12 at 3:45 P.M., a joint observation with the facility contracted electrician (Electrician 1) for the scorched outlet of room 310 A was conducted. The Maintenance Director stated his staff had initiated the removal of all metal outlet plates and replaced the metal plates with plastic outlet plates. Upon inspection of room 310 A's electrical receptacle, Electrician 1 removed the plastic outlet plate and discovered the metal outlet plate was not removed. The Maintenance Director stated he did not know why the metal outlet plate was not removed. On 6/27/12 at 5:10 P.M., during a re-tour of the facility, three resident beds (Rooms: 118 B, 124 B, 214 B and 418 B) and one resident oxygen concentrator (Room 217) remained plugged into multi-plug power strips. On 6/27/12 at 8 P.M., during an interview, the NHA was asked if the facility's circuit breaker tripped off at any time. He stated, "The only time a circuit breaker goes off is when we use the floor buffer machine, then we have to unplug things." On 6/28/12 at 9 A.M., Resident 29 stated, "My T.V. goes off all of a sudden. It happened 3 to 4 times a week for the last month." Resident 29 stated he informed the staff when his television spontaneously turned off and further stated, "But it still keeps happening." On 6/29/12 at 2 P.M., the Nursing Home Administrator (NHA) provided copies of two e-mails he received from two electrical contractors. Electrician 1's, e-mail dated 6/29/12, indicated he examined the facility's electrical plugs on 6/27/12 and, "The additional outlets bring up the concern for overloading the circuit. **Recommend a site wide load calculation, or simply remove additional outlets. A couple of receptacles had signs of arcing (an electrical flash which can cause damage, fire or injury)." Electrician 2's, e-mail dated 6/29/12, indicated he had examined the facility and, "Inspection of the quad receptacles that were installed in patient rooms revealed that they were installed with NM (non metallic) cable which is not rated for patient care areas. Also, the cut boxes or remodel boxes are residential grade and are not rated for patient care facility. Both of these items lack the required grounding and were tied into an existing circuit that would require being brought up to current NEC (National Electrical Code) and OSHPD standards to be acceptable along with a course of proper engineering and OSHPD inspection. It is our recommendation that all work be undone and returned back to original condition." On 6/28/12 at 5:30 P.M., the facility's President/Chief Operating Officer was aware that in addition to the replacement of all metal plate covers; the removal of medical equipment from power strips and; the mainteance of the scorched electrical outlets, the removal of all unapproved additional electrical wall receptables were required in order to abate the IJ. On 6/29/12 at 2 P.M., the survey team re-toured the facility. On 6/29/12 at 3:54 P.M., the survey team received and reviewed the Plan of Correction (POC) presented by the facility. According to the POC, the facility: 1. Replaced all metal plate covers with unbreakable plastic covers; 2. Removed medical equipment from multi plug adapters (surge protector and multi prong adapters); 3. Ensured all medical equipment would be plugged directly into an original wall outlet; 4. Obtained an electrical contractor (Electrician) and per the recommendation by the electrician and OSHPD, the facility removed the added outlet receptacles; 5. Began the permit process with OSHPD to have the receptacles installed by a licensed electrical contractor. Stated the facility would provide written interim progress reports as needed to the California Department of Public Health District Office. 6. Had a licensed electrician inspect resident rooms 112, 305 and 310 and replace the electrical outlets. 7. Will ensure the Maintenance Director will conduct daily rounds for 30 days and then weekly to check the conditions of electrical outlets, cover plates and ensure that no surge protectors or adapter in resident rooms. 8. Staff will be in-serviced to utilize the maintenance log book to write all maintenance problems and to report immediately to the maintenance staff or Administrator any emergency maintenance issues that needs to be fixed immediately. The team accepted the POC and abated the IJ. The survey team informed the facility's President/Chief Operating Officer at 3:54 P.M.