Every finding on record at Fruitvale Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), with long and cracked toenails received podiatry treatment services as ordered by the physician.This failure had the potential to place Resident 1 at risk for injuries and infection. During a review of Resident 1's Annual Minimum Data Set (MDS- a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 5/29/26, MDS indicated Resident 1's was admitted to the facility on [DATE]. Resident 1's Basic Interview of Mental status (BIMS- a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) score was 15 which indicated intact mental status. The MDS indicated Resident 1 had functional limitation in range of motion to upper and both lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 1's diagnoses included hemiplegia (paralysis on one side of the body) and diabetes mellitus (high blood sugar).During a concurrent observation and interview on 7/23/26 at 11:50 a.m., in Resident 1's room, Resident 1 was awake, responsive, and laid on back in bed. Resident 1 had long, cracked toenails with reddish discoloration around toenail bed. Resident 1 stated that she was diabetic and had requested to be seen by a podiatrist for concerns about her feet and toenails from the social worker but had not yet been seen.During a concurrent observation and interview on 7/23/26 at 12:55 p.m., with Director of Nursing (DON) in Resident 1's room, Resident 1 stated her foot hurts and had not seen a podiatrist. DON checked Resident 1's feet and stated Resident 1 toenails needed podiatry care.During a concurrent interview and record review on 7/23/26 at 1:10 p.m., with Social Services Director (SSD) and Social Services (SS), reviewed Social Services referral binders, SS notes, and Resident 1's Progress Notes (PN) dated 7/2/26. Resident 1's PN indicated a referral was sent to podiatry for evaluation and treatment. SS stated she did not know why Resident 1 was not seen by the podiatrist. SS could not provide documentation that Resident 1 received podiatry evaluation.During a review of Resident 1's physician order dated 9/24/25, indicated the physician ordered Resident 1 to receive podiatry care.During a review of the facility's policy and procedure (P&P), titled, Podiatry Services, undated, indicated, It is the policy of this facility to provide timely, appropriate, and high-quality podiatric services to all residents in need, in accordance with federal and state regulations. Podiatry services will be scheduled regularly or as clinically indicated or on as-needed basis for acute cases.

Based on interview and record review, the facility failed to ensure pain management was provided, consistent with the comprehensive resident-centered plan of care and professional standards of practice for one of two sampled residents (Resident 2) when a scheduled pain medication was not administered according to the physician's order.This failure had the potential to result in ineffective pain management.During a review of Resident 2's Resident Face Sheet (RFS), the RFS indicated Resident 2 was admitted to the facility in August 2025 with diagnoses that included systemic lupus erythematosus (a chronic autoimmune disease, causing inflammation and tissue damage, with symptoms like joint and muscle pain) and chronic pain syndrome.During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated Resident 2 received scheduled and prn (given as needed) pain medication daily, and occasionally experienced pain rated at four out of 10 (zero as no pain and 10 being the worst pain).During a review of the facility's policy and procedure (P&P), undated, titled Pain Management, the P&P indicated that a pain rating scale of four to six represented moderate pain. The P&P also indicated for the licensed nurse to administer therapeutic interventions, non-drug treatments, or pain medication as ordered by the physician.During a review of Resident 2's pain care plan dated 8/30/25, the care plan indicated approaches to manage pain that included acknowledging Resident 2's pain and administering pain medication as ordered.During a review of the Physician Order Report (POR) dated 8/30/25-9/10/25, the POR indicated a physician order dated 8/30/25 for acetaminophen (Tylenol) 500 milligrams (mg) two tablets by mouth for chronic pain, to be administered three times daily at 6 a.m., 2 p.m., and 10 p.m.During a concurrent interview and record review on 9/18/25 at 10:43 a.m. with Registered Nurse Supervisor (RNS), the Medication Administration Record (MAR) and POR for September 2025 were reviewed. RNS stated, Resident 2 requested two tramadol (opioid/narcotic pain medication) tablets during the night shift, but the physician's order was for only one tablet. RNS stated there was a misunderstanding between the licensed nurse and Resident 2 regarding the pain medication order. The POR indicated Tylenol was to be administered at 10 p.m. but the MAR indicated administration at 2 pm. RNS confirmed that Resident 2 did not receive the scheduled Tylenol dose at 10 pm, before asking for prn medication. Further review of the MAR indicated Resident 2 did not receive Tylenol 1000 mg dose scheduled for 10 p.m. from 9/1/25 to 9/7/25.During a concurrent interview and record review on 9/18/25 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she administered Tylenol 1000 mg to Resident 2 twice each day shift, at 10 a.m. and 2 p.m. During a follow-up interview on 9/18/25 at 1:25 p.m. with RNS, RNS stated a computer glitch that was overlooked by the admitting nurse. RNS stated the correct administration times were 6 a.m., 2 p.m., and 10 p.m., but this was not transcribed in the MAR. RNS stated that improper administration could result in Resident 2's pain not being properly managed.

Based on observation, interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 ' s right shin with a front wheel walker (a walker is an assistive device used to aid in walking, providing stability and reducing weight bearing on the lower extremities of an individual). This failure resulted in Resident 1 sustaining redness on his right leg, pain, and a transfer to Acute Care Hospital (ACH 1) for follow-up care. Findings: During a record review of Resident 1 ' s Face Sheet (A Face Sheet is a summary document that provides essential resident information), the record showed Resident 1 was admitted to the facility in November 2021. The record indicated Resident 1 had diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified Dementia (a condition that affects memory, thinking, and reasoning, interfering with daily life). During a record review of Resident 1 ' s Minimum Data Set (MDS is an assessment tool used to evaluate residents' health, functional status, and care) assessment dated [DATE], the assessment indicated Resident 1 had BIMS Score of 9 (nine) out of 15, indicating the moderate cognitive impairment. During a record review of Resident 2 ' s Face Sheet, the record showed Resident 2 was admitted to the facility in January 2024. The record indicated Resident 2 had multiple medical diagnosis including Alcohol dependence with withdrawal (a condition falls within substance use disorders. The characteristics of Alcohol dependence include loss of control over drinking and strong cravings or urges to drink). During a record review of Resident 2 ' s MDS dated [DATE] the assessment indicated, Resident 2 had BIMS score of 15 out of 15, indicating intact cognition. During an observation and interview on 04/17/25 at 09:58 a.m. with Resident 1, Resident 1 was sitting in his bed. Resident 1 stated on the day of the incident he was sitting in the smoking area at the back of the facility, Resident 2 was drunk, walked towards him, grabbed Resident 1 ' s walker and threw it across the table. Resident 1 stated he got hurt in his leg with the walker and that incident made him feel very sad. During an interview on 04/17/25 at 10:10 a.m. with Resident 2, Resident 2 stated, he did not want to talk about the incident on 3/25/2025 or anything. During an interview on 04/17/25 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/25/25 around lunch time, Certified Nursing Assistant (CNA) 1 came to the nursing station to inform her that there was a noisy argument between Resident 1 and Resident 2 in the smoking area. LVN 1 saw Resident 1 and Resident 2 were separated by the staff. LVN 1 saw the alcohol bottle in a plastic bag on the floor. Resident 2 became agitated when LVN 1 wanted to confiscate the alcohol bottle. The staff notified the Administrator (Admin) and Oakland Police. Resident 2 became pleasant when the police arrived. During an interview on 04/17/25 at 10:57 a.m. with CNA 1, CNA 1 stated she heard the yelling in the smoking area at the back of the facility. When she arrived at the smoking area, she saw Resident 2 was in front of Resident 1 and Resident 2 picked up the walker and smashed Resident 1 ' s legs. CNA 1 asked the other staff to separate both residents and called for help. CNA 1 said this was not the first time that she saw Resident 2 drunk and become combative and aggressive. During an interview on 04/17/25 at 11:19 a.m. with Director of Nursing (DON), DON stated Resident 1 refused assessment after the altercation between Resident 1 and Resident 2. The DON stated he observed the redness on Resident 1 ' s right shin related to the altercation. During a record review of Resident 1 ' s, Progress notes dated 3/25/25 at 1:22 pm, the Progress notes indicated, Resident 1 was noted at the smoking area in the parking lot when an altercation between Resident 1 and Resident 2 occurred. Staff witnessed that Resident 1 was arguing with Resident 2 and Resident 2 striking and kicking Resident 1 in his right shin. Skin assessment noted the redness on Resident 1 ' s right shin. Resident 1 complained of moderate pain and wanted to transfer to the hospital. During a review of Resident 1 ' s, Emergency Department After Visit Summary from Acute Care Hospital (ACH 1), dated 3/25/25, the summary indicated Resident 1 ' s reason for visit was fall with the diagnosis of right leg pain. Resident 1 was given acetaminophen and Flexeril (Flexeril is a muscle relaxant to relieve pain). During a record review of Resident 1 ' s Progress Note, dated 3/25/25, the notes indicated, Resident 1 came back from emergency room (ED) with new medication orders for cyclobenzaprine for muscle spasm up to 10 days, and lidocaine patch 5% on right lower leg to relieve pain. During a review of Resident 2 ' s Emergency Department After Visit Summary, from Acute Care Hospital, dated 3/25/25, the summary indicated, Resident 2 was evaluated for Violent behavior with the diagnosis of Agitation. During a review of facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, the P&P documented, the administration will protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors or any other individual.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) received adequate supervision and assistance device to prevent falls when Certified Nursing Assistant (CNA) 1 transferred Resident 2, who was totally dependent on staff for activities of daily living, from wheelchair to bed without another staff present and without using a Hoyer lift (interchangeably used with mechanical lift, uniquely designed electronically operated patient lift to transfer patients between two surfaces, for example from their bed to another surface such as a wheelchair or couch). This failure resulted in Resident 2's fall and transfer to the hospital for a four-day hospitalization for closed displaced subtrochanteric fracture of the right femur (broken bone specifically in the area just below the hip joint, where the fractured pieces are significantly out of alignment, but the skin over the fracture site remains intact, making it a non-open wound). Findings: During a review of Resident 2's Resident Face Sheet, the Resident Face Sheet indicated Resident 2 was admitted to the facility in February 2023 with diagnoses that included polyneuropathy (a disease that damages the peripheral nerves, causing weakness, numbness, and burning pain), chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months and does not respond to conventional treatments), abnormalities of gait and mobility and osteoarthritis (a degenerative joint disease that occurs when the cartilage and bone in a joint break down over time). During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/10/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's mental status in regard to attention, orientation, and ability to register and recall information) score of 13 (A BIMS score of 13-15 is an indication of intact cognitive status). The MDS also indicated Resident 2's functional ability with everyday activities was impaired on both sides of the upper and lower extremities. The MDS indicated, Resident 2 was dependent (helper does all of the effort, or the assistance of two or more helpers is required for the resident to complete the activity) on staff with everyday activities that included; rolling from left and right side while in bed, sitting on the side of the bed to lying flat, lying on the back to sitting on the side of the bed, transferring to and from a bed to a chair or wheelchair. The MDS indicated, Resident 2's ability to come to a standing position from sitting in a chair was not attempted during the assessment due to medical condition or safety concern. During an interview and concurrent record review on 12/11/24 at 1:02 p.m. with Director of Nursing (DON), Resident 2's ADL (activities of daily living) care plan dated 2/22/23 was reviewed. The ADL care plan indicated for staff to provide Resident 2 with needed assistance in ADL to maintain comfort and dignity, multiple approaches that included Establish patient's physical function and capabilities and provide approaches to assist patient but did not indicate a specific approach to transfer Resident 2. DON stated Resident 2 needed a Hoyer lift for transfers. During a review of the facility's undated policy and procedure (P&P) titled Resident Transfers, the P&P indicated for staff to assess resident's functional ability and type of assist needed, and to document the type of transfer and assistance device needed on the resident's comprehensive care plan, in the electronic health record system and progress notes. During an interview on 12/11/24 at 1:08 p.m., Resident 2 stated while she was up in a wheelchair, CNA 1 picked her up and dropped her. During an interview on 12/11/24 at 1:12 p.m. CNA 2, who was Resident 2's regular CNA for almost six months, stated, Resident 2 needed a Hoyer lift and help of another CNA, to transfer Resident 2 to and from the wheelchair to bed. During an interview on 12/11/24 at 1:16 p.m. with Nurse Supervisor (NS), NS stated Resident 2 was not able to move both legs and not able to stand up even with help from staff. NS stated Resident 2 always required Hoyer lift, with two staff assisting, for transfers. During an interview and concurrent record review on 12/11/24 at 1:28 p.m. with Director of Nursing (DON) Resident 2's Care Plan Essentials (a communication tool with specific details about the resident's care needs) initiated 3/4/24 was reviewed. The Care Plan Essentials indicated Resident 2 needed Hoyer lift with assistance of two staff for transfers to and from a bed to a wheelchair. During a telephone interview on 12/11/24 at 1:59 p.m. with CNA 1, CNA 1 stated working her first shift at the facility on 11/19/24. CNA 1 stated she received report from a regular staff that Resident 2, who was in a wheelchair at the start of the shift, would not go back to bed around 8:00 p.m. to 9:00 p.m. CNA 1 stated, around 9:00 p.m., CNA 1 went to the room to transfer Resident 2 back to bed. CNA 1 stated placing Resident 2's both arms around her while CNA 1 grabbed Resident 2's waistband on the back in a hugging position. CNA 1 stated, during the transfer, Resident 2 told CNA 1 Don't drop me. CNA 1 stated reassuring Resident 2 everything was going to be okay as the bed and the wheelchair had already been locked. CNA 1 stated attempting to lift Resident 2 to a standing position towards the bed when CNA 1 noticed Resident 2 was dead weight, did not have good function on both legs, and started to slide down. CNA 1 stated she asked Resident 3 (Resident 2's roommate) to lower the bed so CNA 1 could sit Resident 2 on the side of the bed. CNA 1 stated then she thought, Resident 3 was demented (one who has impaired memory and decision-making) and could not understand CNA 1's instruction, so CNA 1 eased Resident 2 down to the floor. CNA 1 stated she needed to be told at the start of the shift that a Hoyer lift and another CNA were needed to transfer Resident 2. CNA 1 stated she left the room to call Registered Nurse Supervisor (RNS) for help while Resident 2 sat on the floor. During a review of Resident 3's MDS dated [DATE], the MDS indicated a BIMS score of 14 (A score of 13-15 indicates intact cognitive status). During an interview on 12/11/24 at 1:42 p.m., Resident 3 stated CNA 1 came to the room to get Resident 2 back to bed. Resident 3 stated she offered help to CNA 1 to transfer Resident 2 from wheelchair to bed as she thought to herself how did she think she could pick [Resident 2] up by herself? Resident 3 stated CNA 1 just picked up Resident 2 then dropped her. During a telephone interview on 12/11/24 at 1:55 p.m. with Registered Nurse Supervisor (RNS), RNS stated CNA 1 came out of the room saying she needed help with Resident 2. RNS stated, upon entering the room, Resident 2 was sitting on the floor with back against the bed. During a follow-up telephone interview on 12/13/24 at 9:47 a.m. with RNS, RNS stated Resident 2 could not bear weight at all and had always used a Hoyer lift for transfers. RNS also stated Resident 2 was not a high risk for fall as Resident 2 had no history of attempting to get out of bed unassisted. During an interview on 12/11/24 at 3:05 p.m. with DON, DON stated, for residents who are dependent on staff with transfers, a Hoyer lift should be used. During a review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation, written communication tool that helps provide essential, concise information, usually during crucial situations) dated 11/19/24, the SBAR indicated, Resident 2 had an assisted fall. The SBAR indicated, when Resident 2 slid off the bed, CNA 1 eased Resident 2 down to the floor. During a review of Resident 2's Risk Meeting Notes Initial Week One dated 11/25/24 created by DON, the Risk Meeting Notes Initial Week One indicated the following: - On 11/19/24, Resident 2 had a Guided (assisted) fall while transferring from wheelchair to bed. - On 11/22/24, Resident 2 complained of pain on the right thigh and right knee, a STAT (suggests a possible emergency condition, one where treatment must immediately be undertaken) x-ray was ordered by the Nurse Practitioner (NP). - On 11/23/24, STAT x-ray result came back. Resident 2 had a right proximal femur fracture .Resident 2 was transferred to the hospital for further evaluation and management per Nurse Practitioner's order. During a review of Resident 2's Radiology (imaging) Report dated 11/23/24, the Radiology Report indicated Resident 2 had a Proximal right femur fracture. as described. The findings are new compared to 23JUN2023. During a review of Resident 2's Physician's Order dated 11/23/24, the Physician's Order indicated an order to transfer Resident 2 to the hospital for management of fractured femur. During a review of Resident 2's hospital Internal Medicine Discharge Summary dated 11/27/24, the Internal Medicine Discharge Summary indicated Resident 2 was admitted to the hospital after a fall that resulted in right subtrochanteric femur fracture. Resident 2 was sent back to the facility after IMN (Intermedullary Nailing, a surgical procedure used to treat bone fractures by inserting a metal rod [nail] into the hollow center [medullary canal] of the bone) and an order to receive Lovenox (an injectable blood thinner that helps prevent the formation of blood clots) for 30 days. During a review of Resident 2's Progress Notes dated 11/27/24, the Progress Notes indicated Resident 2 returned to the facility from the hospital, on 11/27/24, with a 4 centimeter (cm) right upper hip incision with six staples, 5 cm right hip incision with seven staples, and 2 x 5 cm incision behind the right knee with six staples.

Based on observation, interview, record review, and facility policy review, the facility failed to provide food at an appetizing temperature, which affected 1 (Resident #32) of 4 residents reviewed for food. Findings included: An undated facility policy titled, Meal Service, indicated, Residents will receive their food at appropriate temperatures and an appetizing appearance; therefore, trays may be set up ahead of time with non-perishable items only. A Resident Face Sheet revealed the facility admitted Resident #32 on 11/04/2014. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #32 was interviewed on 10/21/2024 at 11:42 AM. Resident #32 stated the food at the facility was not always served hot, and if they were the last one served, the food was cold. During an observation on 10/23/2024 at 8:19 AM, staff passed meal trays on Station 4. The last tray on the food cart was removed from the meal cart at 8:27 AM. The last tray was taken to the dining room. The following temperatures were observed, scrambled eggs were 102 degrees Fahrenheit (F), the sausage patty was 102 degrees F, and the oatmeal was 122 degrees F. The Registered Dietitian (RD) and the Dietary Supervisor (DS) confirmed the temperatures of the eggs, sausage, and oatmeal. The scrambled eggs and sausage patty were lukewarm, and the oatmeal was warm. Resident #32 was interviewed on 10/23/2024 at 9:12 AM. Resident #32 stated that the scrambled eggs served that morning were not hot; they were lukewarm. Resident #32 then stated the scrambled eggs were usually served lukewarm. The Director of Nursing (DON) was interviewed on 10/24/2024 at 8:28 AM. The DON stated the facility followed federal and state requirements for food temperatures. He stated that the food should be served warm to the residents and at the correct internal temperature. The Administrator was interviewed on 10/24/2024 at 9:44 AM about food temperatures. The Administrator stated the food served to residents should be served hot.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #17) of 4 residents reviewed for pressure ulcers. The facility also failed to ensure staff changed gloves and performed hand hygiene between dirty and clean tasks for 1 (Resident #14) of 1 resident observed during incontinence care. Findings included: 1. An undated facility policy titled, Enhanced Barrier Precautions (EBP) revealed, 1. EBP shall be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that may result in transfer of MRDOs [multidrug-resistant organisms] to staff hands and clothing. 2. EBP are indicated for residents with any of the following, to include b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g. [exempli gratia, for example] adhesive bandages) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure injuries, diabetes foot ulcers, unhealed surgical wounds, and venous stasis ulcers. The policy revealed, 6. For residents for whom EBP are indicated, EBP shall also be used when performing the following high-contact resident care activities, to include Providing hygiene, and Changing briefs or assisting with toileting. A Resident Face Sheet indicated the facility admitted Resident #17 on 12/09/2016. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/2024, revealed Resident #17 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). According to the MDS, the resident was dependent on staff with toileting hygiene and personal hygiene. The MDS revealed the resident was always incontinent of bowel and bladder. The MDS indicated Resident #17 had one unhealed Stage 2 pressure ulcer at the time of the assessment. Resident #17's Care Plan, included problem statements dated 10/22/2024, that indicated the resident had pressure ulcers to the right heel, right fifth toe, and right lateral foot. The Care Plan revealed a problem statement dated 10/23/2024, that indicated the resident was on EBP. Interventions directed staff to follow EBP (initiated 10/23/2024). An observation on 10/23/2024 at 3:35 PM revealed no EBP signage posted outside of Resident #17's room. There was no PPE located inside Resident #17's room. During an interview on 10/23/2024 at 3:46 PM, Certified Nurse Aide (CNA) #5 revealed she was the assigned CNA for Resident #17 and stated that the resident was not on EBP. During an observation on 10/23/2024 at 3:59 PM, CNA #5 and CNA #6 washed their hands and put gloves on before providing incontinence care to Resident #17. CNA #5 and CNA #6 did not wear a gown. The observation ended when CNA #5 and CNA #6 started to undress the resident. During an interview on 10/23/2024 at 4:54 PM, CNA #5 confirmed no additional PPE was worn during the incontinence care by either CNA. CNA #5 stated that there was no signage on the resident's door and that Resident #17 was not on EBP. During an interview on 10/23/2023 at 8:22 AM, CNA #4 revealed that if a resident was on EBP, the staff must wear a gown and gloves when proving care to the resident. CNA #4 stated that residents must have signage outside the door to indicate EBP. During an interview on 10/23/2024 at 7:41 AM, the Infection Preventionist (IP) stated Resident #17 should be on EBP. During a follow-up interview on 10/23/2024 at 4:04 PM, the IP revealed that if a resident had an open wound, then the resident should be placed on EBP. She stated that the CNAs should wear PPE when providing incontinence care to Resident #17. She stated that she had not placed any signage or PPE in Resident #17's room. During an interview on 10/24/2024 at 9:05 AM, the Wound Nurse revealed Resident #17 had four open wounds and the resident was on EBP. During an interview at 10/24/2024 at 10:19 AM, the Director of Nursing (DON) revealed that he expected any resident with open wounds to be placed on EBP and that there should be signage on the resident's door. He stated that the staff should wear a gown and gloves when providing care. During an interview on 10/24/2024 at 11:56 AM, the Administrator revealed that residents with open wounds should be placed on EBP. He stated that staff should wear gowns and gloves when providing care. 51642 2. A facility policy titled, Hand Hygiene, implemented February 2017, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, Fundamental Information included 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations, to include h. Before moving from a contaminated body site to a clean body site during resident care, j. After contact with blood or bodily fluids, and m. After removing gloves. A Resident Face Sheet indicated the facility admitted Resident #14 on 03/30/2016. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia, acquired absence of unspecified leg above knee, and an overactive bladder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was frequently incontinent of urine and required substantial/maximal assistance from staff with toileting hygiene. Resident #14's Care Plan, included a problem statement initiated on 12/24/2017, that indicated the resident was occasionally incontinent of urine due to an overactive bladder. Interventions directed staff to clean and dry the resident after each incontinence episode (initiated 02/11/2018). During an observation on 10/23/2024 at 3:58 PM, Certified Nurse Aide (CNA) #7 provided incontinence care to Resident #14. CNA #7 donned gloves and cleansed Resident #14's buttocks and anal area with disposable wipes. Without removing his gloves and without sanitizing or washing his hands, CNA #7 placed a clean incontinence brief under Resident #14, folded the resident's pillow, placed the pillow under the resident's back, and removed the resident's socks and pants. CNA #7 then removed his gloves and washed his hands. CNA #7 was interviewed on 10/23/2024 at 4:13 PM. CNA #7 stated he did not wash or sanitize his hands when going from a dirty task to a clean task while providing incontinence care to Resident #14. The Director of Nursing (DON) was interviewed on 10/24/2024 at 8:53 AM. The DON stated staff were expected to wear gloves and follow standard precautions, including washing hands. He stated that after cleansing a resident, staff were expected to remove their gloves and wash their hands. The Director of Staff Development (DSD) was interviewed on 10/24/2024 at 9:11 AM. The DSD stated that staff were expected to remove their gloves and sanitize their hands, as staff were considered dirty after cleansing a resident, then put on new gloves. The Administrator was interviewed on 10/24/2024 at 9:59 AM. The Administrator stated that staff were expected to wear gloves when providing resident care. He stated that staff were expected to change gloves when going from a dirty task to a clean task when providing care.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being when psychiatric and mental health services were not provided to treat mental and substance use disorders. This failure had the potential to result in significant distress from unresolved psychosocial and mental health issues. Findings: During a review of Resident 1's Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included schizophrenia (serious mental health condition that affects how people think, feel and behave), auditory hallucinations (sensory perceptions of hearing in the absence of an external stimulus) and psychoactive substance abuse (strong desire or sense of compulsion to take psychoactive substance, various natural or synthetic compounds that cause changes in thoughts, emotions and behavior). During a review of Resident 1's Hospitalists SNF/Rehab Discharge Summary (Hospital DC Summary), dated 1/10/24, the Hospital DC Summary indicated Resident 1 admitted to using methamphetamine (a powerful, highly addictive stimulant that affects the central nervous system) earlier on 1/7/24. The summary also indicated urine toxicology was done and Resident 1 tested positive for methamphetamine and cocaine (also a highly addictive stimulant, a stimulant speeds up the messages traveling between the brain and the rest of the body). During a review of Resident 1's Minimum Data Set (MDS, , a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/17/24, the MDS indicated Resident 1 had the following active diagnoses: schizophrenia, other psychoactive substance abuse, and auditory hallucinations. During a review of Resident 1's Physician Order Report, dated 1/10/24 - 7/7/24, the Physician Order Report indicated the following: 1. A physician's order, dated 1/10/24, to refer Resident 1 to Mental Health. 2. A physician's order, dated 2/21/24, for psychiatric evaluation. 3. Physician's orders for Out On Pass on 6/13/24, 6/20/24 and 7/3/24. During an interview on 7/26/24 at 1:52 p.m. with Director of Nursing (DON), DON stated Resident 1's clinical record did not indicate psychiatric or mental health consults were done on Resident 1 as ordered. During a review of Resident 1's Situation, Background, Assessment, and Recommendation/Request (SBAR, a structured communication framework that can help teams share information about the condition of a patient), the SBAR indicated the following incidents: 1. On 4/28/24, the SBAR indicated a CNA saw Resident 1 dropped used drug paraphernalia on the floor. 2. On 5/12/24, a staff witnessed Resident 1 stealing another resident's belongings. 3. On 5/26/24, Resident 1 stole another resident's cell phone. During an interview and concurrent review of the clinical record on 7/26/24 at 3:10 p.m. with DON, the physician's orders and nurse progress notes were reviewed. DON stated Resident 1 went out on pass on 6/13/24, 6/20/24 and 7/3/24, but the clinical records did not indicate any documentation of Resident 1 going out of the facility and Resident 1's status upon returning to the facility. During a review of Resident 1's clinical record, the clinical record indicated the following incidents and care plans: 1. Antipsychotic (medication that treats psychosis) care plan, dated 1/10/24, to address Resident 1's schizophrenia, interventions included identifying changes in behavioral patterns and inform attending physician of any, inform family/responsible party of any changes and updates through care conference meetings, refer to psychiatric and psychological services if needed. Set limits on inappropriate /unacceptable behavior. All the interventions were dated 1/10/24. 2. Non-compliance care plan, dated 1/10/24, to address Resident 1's refusal of head to toe skin assessment and signing of admission papers. Interventions included encouraging Resident 1 to interact with others, explain importance of procedure, monitor for untoward manifestations due to non-compliance and inform attending physician for possible interventions, provide information regarding risk and complications resulting from non-compliance. All interventions were dated 1/10/24. The care plan indicated another non-compliance problem was identified when Resident 1 refused urine toxicology on 4/30/24. The care plan did not indicate any addition or revision to the interventions outlined. 3. Behavioral care plan, to address diagnosis of substance abuse, dated 1/10/24. Interventions included encouraging resident to attend activities of choice, encouraging resident to verbalize feelings and offer understanding and empathy, identify situations causing behavioral problem and assist resident in resolving identified issues, monitor behavior not easily altered and refer to attending physician, observe for pain or discomfort that might trigger negative behavior, psychiatric consult if needed, and psychosocial management as ordered. All interventions were dated 1/11/24. The care plan indicated two more problems were identified when, on 4/28/24, Resident 1 dropped a used drug paraphernalia on the floor, and on 5/12/24, when Resident 1 was caught stealing other resident's belongings. The care plan did not indicate any revisions or added interventions after the two incidents were identified. During a review of Resident 1's Monthly IDT (a group composed of individuals from different departments in the facility) Pain/Psychotropic (any drug that affects brain activities associated with mental processes and behavior; psychotropic drugs include, but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics) Review, dated 5/29/24, the Monthly IDT Pain/Psychotropic Review indicated to continue current acetaminophen order for pain and olanzapine (an antipsychotic) for management of schizophrenia. The review indicated the current care plan was not reviewed. During a review of Resident 1's Care Conference Notes, dated 4/18/24, the Care Conference Notes indicated current care plans were appropriate. The clinical record indicated there were no care conferences/meetings done to address Resident 1's behavior on 4/28/24, 5/12/24 and 5/26/24. During an interview on 7/26/24 at 12:02 p.m. with DON, DON stated he did not have knowledge of the type of drug paraphernalia found in Resident 1's possession on 4/28/24. During a review of Resident 1's Social Services (SS) Progress Notes, dated 1/12/24, the SS Progress Notes indicated an initial interview with Resident 1 about Resident 1's prior living arrangement and previous drug use. Another SS Progress Notes, dated 7/10/24, indicated efforts to reach Resident 1's family members after Resident 1 was transferred out to the hospital and passed. The clinical record did not indicate any other SS Progress Notes to address incidents on 4/28/24, 5/12/24 and 5/26/24. The clinical record did not indicate any interventions or Social Service visits with Resident 1 after 1/12/24, despite multiple behavior issues identified on 4/28/24, 5/12/24 and 5/26/24. During an interview on 7/26/24 at 1:52 p.m. with Administrator (Adm), Adm stated there were only two SS Progress Notes found in Resident 1's clinical record. Adm stated keeping a Social Services Director (SSD) and having complete documentation of Social Services Notes have been challenging. During an interview on 7/26/24 at 2:20 p.m. with Social Services Assistant (SSA), SSA stated meeting with Resident 1 to discuss financial issues and on how to get Resident 1 Social Security Income benefits. SSA stated she did not give Resident 1 counseling after the incidents on 4/28/24, 5/12/24 and 5/26/24. During a review of the facility's Facility Assessment, last revised 7/16/24, the Facility Assessment indicated the facility's current residents included those with psychiatric/mood disorder (psychosis [hallucinations, delusions], schizophrenia, and opioid dependence) which is the fifth most prevalent in the facility. During an interview on 7/26/24 at 12:38 p.m. with Adm, Adm stated the facility's policy and procedure (P&P) to address Substance Use Disorder and Opioid Overdose Response were not in place at the time Resident 1 was a resident at the facility. During a telephone interview on 8/5/24 at 8:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 7/7/24, Resident 1 was found unresponsive with no pulse and no spontaneous breathing and was foaming at the mouth. During a review of Resident 1's Resident Progress Notes, dated 7/7/24, the Resident Progress Notes indicated, on 7/7/24 at 8:00 a.m., Resident 1 was found unresponsive, was taken to the hospital by paramedics who responded to the emergency call. During a review of Resident 1's ED (Emergency Department) Provider Notes, dated 7/7/24, the ED Provider Notes indicated Resident 1 presented to the ED in cardiac arrest, Resident 1 passed at 9:04 a.m

Based on observation, interview, and record review, the facility failed to ensure the right to be free from verbal abuse for one of three sampled residents (Resident 1) when a staff member used profanity while providing toileting care to Resident 1. This failure resulted in Resident 1 feeling disrespected by the facility staff. Findings: During a review of the Face Sheet (a document used to communicate basic information about a resident) for Resident 1, undated, the record indicated Resident 1 was admitted to the facility in May 2022 with generalized weakness and hemiplegia (the loss of muscle function on one side of the body) affecting the dominant side of the body. During a review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) for Resident 1, dated 2/27/24, the record indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). The record indicated that Resident 1 was always incontinent of both bowel and bladder and required substantial/maximal assistance (a term used to describe when the person assisting the resident does more than half the effort) for toileting hygiene. During a concurrent observation and interview on 4/29/24 at 9:55 a.m., Resident 1 was lying in bed with the head of bed elevated. Resident 1 stated on 4/14/24, Resident 1 was waiting in bed for toileting hygiene care to be provided. Resident 1 had an incident of diarrhea after receiving a laxative and wore adult briefs, which required Resident 1 to have the brief changed when toileting hygiene was provided. Resident 1 stated Certified Nursing Assistant 1 (CNA 1) came to provide the requested care. Resident 1 stated she heard CNA 1, cursing every other word, saying the F-word and S-word under his breath while CNA 1 changed Resident 1 ' s brief. Resident 1 spoke with the Licensed Vocational Nurse (LVN) the next morning during their daily check-in about the incident. Resident 1 stated when CNA 1 used profanity while providing care, it made me feel like they did not respect me. During a phone interview with CNA 1 on 4/29/24 at 11:38 a.m., CNA 1 stated on 4/14/24, he worked during evening shift (3:00 pm until 11:30 pm). CNA 1 stated Resident 1 received toileting hygiene care at the start of the shift. CAN 1 stated right as dinner trays came out for the evening, Resident 1 requested toileting hygiene care again. CNA 1 stated since there was no other staff available, he then stopped passing trays and entered Resident 1 ' s room to provide care. During the provision of care, CNA 1 stated I was cursing under my breath a little . I was frustrated because I had been getting her in and out of bed all day already. CNA 1 stated Resident 1 asked the CNA to stop cursing at her, and CNA 1 informed Resident 1 that it was not directed at Resident 1. CNA 1 then left the room after providing care to Resident 1. During an interview with LVN 1 on 4/29/24 at 11:01 a.m., LVN 1 stated Resident 1 reported the incident with CNA 1 the next morning on 4/15/24. Resident 1 informed LVN 1 that the CNA was cursing every other word, using the F-word. Resident 1 stated it was inappropriate for a CNA to talk to a resident like this and that Resident 1 no longer wanted to work with CNA 1 anymore. During a concurrent interview and record review with the Director of Nursing (DON) on 4/29/2024 at 12:21 p.m., Resident 1 ' s Progress Notes, dated 4/15/24 were reviewed. The record indicated Resident 1 spoke to the LVN caring for her, stating, the CNA kept using the F word while taking care of her. DON stated that it was not acceptable for a CNA to curse or use profanity while providing care because, it would be derogatory and very inappropriate and would of course be potential verbal abuse. A review of the facility policy titled, Abuse Prevention Program, dated 5/28/2019, indicated Our 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 . verbal abuse.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) yelled at Resident 1 I will knock you the 'F' out during a verbal altercation. This failure had the potential to result in psychosocial harm. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included vascular dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) with behavioral disturbance, adult failure to thrive and opioid dependence (Physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs like heroin). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/19/24, the MDS indicated Resident 1 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13 (A BIMS score of 13-15 is an indication of intact cognitive status). The MDS also indicated Resident 1 did not have any behaviors that were potential indicators of psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) and had no behavioral symptoms directed toward others. During a review of Resident 1's dementia Care Plan, with start date 1/12/24, the Care Plan indicated for staff to offer choices appropriate for resident's cognition and provide verbal cues to resident. During a review of the Investigation Summary, dated 3/8/24, the Investigation Summary indicated CNA was having a verbal altercation with Resident 1. The Investigation Summary indicated Resident 1 requested for extra cups of coffee. When CNA delivered coffee and went to remove the other coffee mug from Resident 1's table, Resident 1 started to yell and threw coffee at CNA, CNA responded in a manner that was not appropriate, which was witnessed and heard by facility staff. During an interview on 3/8/24 at 10 a.m. with Receptionist (REC), REC stated hearing a loud verbal altercation coming from Resident 1's room with Resident 1 saying No, you're not! REC stated hearing a man's voice that said, I'll knock you the f out!. REC stated Restorative Nursing Assistant (RNA) stood by Resident 1's door and said, You can't talk to a resident like that! to someone inside Resident 1's room. REC stated after a few moments, CNA walked out of Resident 1's room saying Ok, ok. and walked away. During an interview on 3/8/24 at 10:21 a.m. with RNA, RNA stated hearing an argument coming from Resident 1's room. RNA stated going to the room and stood by the door, where CNA and Resident 1 could be seen and heard yelling at each other. RNA stated CNA had just brought two cups of coffee for Resident 1 and was going to take a previously used coffee mug from Resident 1's table, but Resident 1 wanted to keep it. RNA stated Resident 1 told CNA to Get the f .out of my room!, to which CNA yelled back I'll knock you the f . out! to Resident 1. RNA stated telling CNA to not talk to Resident 1 like that and CNA said a few words before leaving the room. RNA stated CNA was in a fighting stance during the altercation like going into a street fight. RNA stated staff should never talk to any resident like CNA did, it was inappropriate and very unprofessional.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when a Certified Nursing Assistant (CNA) did not wear gloves and a gown before entering a positive COVID room and did not perform hand hygiene after exiting the room. This failure had the potential for the spread of germs and infection. Findings: During an observation on 2/15/24 at 1:12 p.m. in station 1, there was a transparent plastic shield with a zipper at the door of room [ROOM NUMBER]. The door was wide open behind the shield. There was signage on the door indicating transmission-based precautions for COVID. On the left, attached to the door, were Personal Protective Equipment (PPE - disposable protective gowns, gloves, etc.,). room [ROOM NUMBER] had two residents who were in isolation for COVID 19. CNA 1 was entering room [ROOM NUMBER]. CNA 1 unzipped the transparent plastic shield, entered the room, and did not wear gloves and a gown. CNA 1 proceeded to Bed B, delivered a food tray to Resident 1, talked to Resident 1 briefly, and proceeded to exit. CNA 1 picked up a dark cloth from the floor by Resident 1 ' s bed and placed it on the bed. CNA 1 came outside, did not perform hand hygiene, and opened the food cart stationed in the hallway opposite room [ROOM NUMBER]. During an interview on 2/15/24 at 1:15 p.m. with CNA 1, CNA1 stated she just went to drop off the tray. CNA 1 stated she thought those residents were cleared from isolation. CNA 1 later acknowledged she was supposed to follow the infection precautions instructions, wear gloves and a gown before entering the room; and perform hand hygiene after exiting the room before opening the food cart. CNA1 stated, it ' s my mistake. CNA 1 confirmed it was Resident 1 ' s bed cover that she picked up from the floor. CNA 1 stated again it ' s my mistake. During an interview on 2/15/24 at 4:20 p.m. with Director of Nursing (DON), DON stated staff is required to follow the infection precautions protocol including hand hygiene. DON stated, for a COVID positive room, staff must wear PPE including a gown, N95 mask, and gloves before they go in, even if taking in or removing the meal tray. During a review of the facility ' s policy and procedure (P&P) titled, Covid-19 Infection Control Measure, undated, the P&P indicated the company follows infection prevention and control practices . to prevent the transmission of COVID-19 within the facility .standard precautions (hand hygiene and respiratory hygiene); transmission-based precautions, where indicated .appropriate use of PPE . During a review of the P& P titled, Transmission Precautions: Contact, undated, the P&P indicated, . for residents known or suspected to be infected . with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident ' s environment .Wear clean, non-sterile gloves when entering the room .remove gloves before leaving room, discard in the garbage receptacle, and perform hand hygiene .do this to avoid transfer of microorganisms to other residents or environments .Wear a clean, non-sterile gown upon entering the resident ' s room .Remove the gown before leaving the resident ' s environment.

Based on interview and record review, the facility failed to ensure two of five sampled residents, (Resident 1 and Resident 3), were free from physical abuse when: 1. Resident 2 hit Resident 1 in the face during an altercation. 2. Resident 4 hit Resident 3's leg with a grabbing stick. This failure had the potential to result in physical harm between residents. Findings: 1. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was initially admitted to the facility in April 2023 with diagnoses that included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of ability to carry on a conversation and respond to environment), chronic atrial fibrillation (irregular heart beat), unspecified glaucoma (eye disease that cause vision loss and blindness), and unspecified hearing loss. During a review of Resident 1's Progress Notes, dated 10/18/23, the Progress Notes indicated Housekeeping Staff (HS) told Social Services Director (SSD) She's hitting her. The Progress Notes indicated SSD then saw Resident 2 walk away from Resident 1, who held her face and eye area and stated Get me out of here. Resident 2 stated being upset with Resident 1 for being in her way and called Resident 1 the B word. The Progress Notes also indicated Resident 2 stated pushing Resident 1 and Would do it again. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was initially admitted to the facility in October 2023 with diagnoses that included malignant neoplasm of the breast (breast cancer), secondary malignant neoplasm of the bone (bone cancer), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 2's Progress Notes, dated 11/1/23, the Progress Notes indicated Resident 2 had violent tendencies toward others in previous residences before being admitted to the facility. During a telephone interview on 1/19/24 at 2:03 p.m. with HS, HS stated both Resident 1 and Resident 2 were in their room, Resident 2 was standing, facing Resident 1 who was in the wheelchair. HS stated Resident 2 was very mad at Resident 1 for being in the way, and with a closed fist, hit Resident 1 in the face. HS stated there was no verbal altercation, Resident 1 quietly sat in the wheelchair and did not say anything to provoke Resident 2. 2. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility in August 2023 with diagnoses that included Type 2 diabetes mellitus (abnormal levels of blood sugar), multiple sclerosis (a disease where the immune system eats away the protective covering of the nerves, causing vision loss, pain, fatigue, and impaired coordination), left eye blindness and essential hypertension. During a review of Resident 3's Progress Notes, dated 11/8/23, the Progress Notes indicated Resident 3 was hit in the feet by Resident 4 with a grabbing stick. The Progress Notes also indicated Nurse Supervisor (NS) went to the room and intervened by taking the grabbing stick from Resident 4's hand when Resident 4 bit NS's hand too. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility in January 2019 with hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness), diabetes mellitus and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). During an interview and concurrent review of the clinical records on 1/17/24 at 1:23 p.m. with NS, Resident 4's Progress Notes, dated 11/8/23, were reviewed. Resident 4's Progress Notes indicated NS responded to Resident 3's call for help and entered the two residents' room. The Progress Notes indicated Resident 4, who was in a motorized wheelchair near Resident 3's foot of the bed, hit Resident 3's right foot with a grabbing stick while Resident 3 was in bed. NS stated he/she separated the two residents and encouraged Resident 4 to give up the grabbing stick. NS stated Resident 4 was very upset and said, She stole my money. Resident 4 refused to give the grabbing stick to NS. NS stated he/she tried to stop Resident 4 from continuously hitting Resident 3 and took the grabbing stick from Resident 4's hand when Resident 4 bit NS in the right wrist. During an interview with Resident 4 on 1/17/24 at 1:40 p.m., Resident 4 stated She took my money, that [B .], I wanted to kick her [a .] but I didn't. During an interview on 1/17/24 at 1:55 p.m., Resident 3 stated being called the B word several times by Resident 4 and continued to be harassed by Resident 4 even after a room change.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of Type 2 Diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) received comprehensive skin monitoring and assessment, when Resident 1's left foot wound with infection was not monitored, assessed and evaluated. This failure resulted in Resident 1 ' s left foot developing gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) and Resident 1 ' s left foot being amputated (the action of surgically cutting off a limb). Findings: A review of Resident 1 ' s face sheet, indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnosis including Type 2 Diabetes. Resident 1 was full code (if a person's heart stopped beating and/or they stopped breathing, all reviving procedures will be provided to keep them alive). A review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive assessment tool to guide resident care) Section G, dated 11/12/21, indicated Resident 1 needed supervision for walking. During an interview on 9/13/22 at 11:11 a.m., with Resident 1 ' s family member (FM) 1, FM 1 stated the family was not able to see Resident 1 due to COVID-19 (a respiratory infection) outbreak at the facility. FM 1 stated, FM 2 visited Resident 1 on 12/28/21 and informed FM 1 and facility nurses that Resident 1 ' s left foot had a cut and bad odor. FM 1 stated she went to the facility and requested the facility to send Resident 1 to the hospital. FM 1 stated Resident 1 ' s left foot was amputated at the hospital on 12/29/2. FM 1 further stated she was very frustrated and angry at the facility ' s care because Resident 1 would still have his foot if the facility monitored and evaluated Resident 1 ' s foot. A review of Resident 1 ' s acute care hospital (ACH) document titled, Podiatric [branch of medicine treating disorders of the foot, ankle, and lower legs] surgery consult note, dated 12/29/21, indicated . left forefoot [front part of the foot] global gangrene, wet with sloughing epithelium (a break or loose area of corneal epithelium ( the outermost layer of the cornea, whose functions include transparency, and protection from the external environment) larger than 2.0 mm [millimeter, unit of measurement] x 2.0 mm.), left 1st met head full thickness ulcer (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc) 3x3 cm (centimeter) . Patient has severe pain with probing but this tracks past the level of the ankle joint and had 10cc (cubic centimeters ) of easily expressible pus (a thick yellowish or greenish opaque liquid produced in infected tissue ) and air . A review of Resident 1 ' s ACH document titled, Triage Note, dated 12/29/21, indicated . PT (Patient) coming from Fruitvale Nursing Facility with a chief complaint of failure to thrive- according to staff PT has become non-verbal over the last several days, refusing to ambulate, eat and drink. Per EMS (Emergency Medical Services) a left wound noted-foul smelling, decaying tissue . A review of Resident 1 ' s ACH document titled, Operative note, dated 12/29/21, indicated Resident 1 ' s left foot was amputated by general surgeon. A review of Resident 1 ' s Point of Care History . ADLs (Activities of Daily living), How did the resident walk in his /her room? indicated, Resident 1 was walking with assistant and supervision until 12/25/21. The ADL record further indicated Resident 1 stopped walking from 12/25/21 through 12/29/21, when Resident 1 was transferred to ACH 1 on 12/29/21. A review of Resident 1 ' s Nursing weekly summary indicated Resident 1 was assessed by the nurses on 11/9/21, 11/30/21 and 12/14/21 and it indicated Resident 1 had no skin issue or wound. During a concurrent interview and record review on 9/13/22 at 1:20 p.m., with Regional Director of Clinical Operation (RDCO), Resident 1 ' s nurses weekly skin assessments were reviewed. RDCO confirmed weekly nurse skin assessments were completed for dates 11/9/21, 11/30/21 and 12/14/21. RDCO stated nurses should do weekly skin assessment for residents to identify early issues or wounds and report any abnormality. During a concurrent interview and record review on 9/14/22 at 10:30 a.m. with the Director of Nursing (DON), Resident 1 ' s Braden Scale (for predicting pressure sore risk) assessment, dated 11/5/21 was reviewed and the score was 18 which means at risk for pressure sore. DON stated Braden Scale needed to be checked upon admission and weekly for four weeks. DON further stated it was important to check the residents ' skin weekly to assess, monitor, and address residents' skin situation and skin issues immediately. DON confirmed the nurses did not provide skin assessment for Resident 1 on a weekly basis. DON stated Resident 1 ' s Braden Scale assessment was assessed once only. During an interview on 9/14/22 at 11:46 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she did not remember anything about Resident 1. During an interview on 9/14/22 at 11:58 a.m. with DON, DON stated the licensed nurse who was in charge at the time of discharge was not available for interview, and she was out of country. During an interview on 9/14/22 at 12:30 p.m., with Treatment Nurse (TN), TN stated no nurses reported any wound or skin issue for Resident 1. TN stated was he responsible for completing resident Braden Scale assessments for all residents upon admission and once a weekfor up to four weeks, and as needed. TN stated nurses usually complete weekly resident skin assessments. TN confirmed he completed a Braden Scale assessment for Resident 1 one time. A review of Resident 1 ' s Resident Progress Notes, dated 12/29/21, indicated, Resident noted declining in ADL ' s generalized body weakness, used to walk, not walking anymore, poor po (Per Oral) intake. Fluids encouraged. Family requesting to send out to [Acute Care Hospital 1] for evaluation . A review of Resident 1 ' s care plan for skin care, dated 11/6/21, indicated . Goal: Decrease skin dryness and fragility . Approach: Monitor skin during care for bruises, swelling, skin tears, redness, irritation and breakdown, inform MD (Medical Doctor) for interventions, weekly skin check. A review of Resident 1 ' s Braden Scale, dated 11/6/21, indicated Resident 1 ' s Braden Scale was 18 which indicated Resident 1 was at risk for pressure ulcer. A review of the facility ' s policy and procedure titled, Skin Care Management, effective date 12/1/2005 and updated 9/2009 and 5/2020, indicated . 3. The initial admission and weekly for 3 weeks screens for patient risk are completed using the Braden Scale . 5. All patients will be checked from head to toe, weekly by a licensed nurse to identify any new pressure ulcer or any other type of skin breakdown .

Based on observation, interview and record review, the facility failed to ensure sanitary conditions in the kitchen when the solution in two red buckets that contained quaternary ammonium (Quat-a disinfectant) had not been checked and changed for two days. This deficient practice had the potential to spread food borne illnesses. Findings: During the initial kitchen tour observation on 12/6/21 at 8:29 a.m., two red buckets that contained a dark, cloudy liquid were observed on the stainless steel counter top near the three way sink. During an interview and concurrent record review with the Dietary Manager (DM) on 12/6/21 at 8:33 a.m., DM stated the red buckets were sanitation buckets that contained quaternary ammonium solution. DM reviewed the Quat sanitizer log for the red sanitation buckets and stated the log indicated the Quat sanitizer were last checked and changed on 12/4/21 at 6:30 p.m. DM stated the Quat sanitizer in the red buckets should be checked and changed every four hours to prevent the spread of germs. DM stated the Quat solution in the red buckets was used to wipe down surfaces in the kitchen. Review of a facility document titled QUAT SANITIZER SPRAY BOTTLES/BUCKETS dated December 2021, indicated the time prepared and concentration check were last done on 12/4/21 between 6:00 p.m. and 6:30 p.m. Review of the facility's policy and procedure titled SANITATION AND INFECTION CONTROL dated 2018, indicated .Quat levels will be checked and recorded every two hours. 5. If water in the bucket appears turbid or cloudy or has food particles, it may be necessary to discard and refresh for appropriate concentration of Quat solution .

Based on observation, interview, and record review the facility failed to provide housekeeping services and linen services to maintain a clean home-like environment for two of 36 sampled residents (Resident 110 and Resident 128). The wall and ceiling in Resident 128's room was dirty with a reddish-brown splatter stain, and the sheets on Resident 110's bed were thin and full of holes. This deficient practice resulted in Resident 110 and Resident 128 not living in a homelike environment. Findings: 1. During a review of the Minimum Data Set (MDS - a resident assessment tool used to guide care), for Resident 110, dated 11/15/21, the MDS indicated Resident 110 was admitted to the facility on [DATE]. During a review of Section C 0500 of the MDS, the MDS indicated Resident 110 had a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 12 (moderate cognitive impairment). During an interview with concurrent observation with Resident 110 on 12/6/21 at 10:16 a.m., Resident 110 stated they rarely change her sheets and the sheets have holes in them. Resident 110 got out of bed and sheets were very thin with multiple holes. During an interview with Social Worker (SW) on 12/7/21 at 11:00 a.m., stated no one's sheets should have holes in them. 2. During a review of the MDS, for Resident 128, dated 11/22/21, the MDS indicated Resident 128 was admitted to the facility on [DATE]. During a review of Section C 0500 of the MDS, the MDS indicated Resident 128 had a BIMS of 15 (cognitively intact). During an observation with concurrent interview on 12/6/21 at 9:00 a.m., reddish-brown dried splatter noticed on wall and ceiling across from Resident 128's bed. During an interview with Resident 128 stated she did not know what the substance was and stated it had been there for a while.

Based on observation, interview, and record review the facility failed to provide services to prevent contractures from worsening for one (Resident 111) of 16 sampled residents. This failure had the potential for Resident 111 to develop limitations in range of motion and decrease theability to participate in activities of daily living. Findings: During a review of the Minimum Data Set (MDS - a resident assessment tool used to guide care) for Resident 111, dated 8/16/21, the MDS indicated Resident 111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Section C 0500 of the MDS, the MDS indicated Resident 111 had a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 03 (severe cognitive impairment). Section O 0500 of the MDS indicated Resident 11 did not receive passive or active range of motion during the assessment period. Resident 111 also did not use a brace or splint. During an observation on 12/6/21 at 9:30 a.m., Resident 111 was observed in the hall with his left arm bent at the elbow and held against his chest. He was unable to straighten his arm when asked. During an interview with the Licensed Vocational Nurse 1 (LVN 1) on 12/8/21 at 12:50 p.m., LVN 1 stated the Certified Nursing Assistant (CNA) does range of motion exercises when providing his care. During an interview with CNA 1 on 12/8/21 at 12:55 p.m., CNA 1 stated he does not provide range of motion exercises with Resident 111 because Resident 111 was in the RNA program. During an interview with Restorative Nursing Aid (RNA) on 12/8/21 at 12:45 p.m., RNA stated Resident 111 was not in the RNA program because he does not have an order.

Based on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 231), was given foley catheter care every eight hours according to Medical Doctor (MD) orders. This deficient practice had the potential to result in urinary tract infections for Resident 231. Findings During a review of Resident 231's undated facesheet (a document that gives a resident's information at a quick glance), the facesheet indicated Resident 231 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 231's Physician orders, dated 11/24/2021, the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 12/10/2021, at 9:43 a.m., with the Director of Nursing (DON), Resident 231's Treatments Administration Record (TAR), dated 12/01/2021-12/10/2021, was reviewed. DON stated, there was no documentation on the TAR, dated 12/01/2021-12/10/2021, that indicated Resident 231 had received indwelling Foley catheter care or that urine output had been monitored for signs and symptoms of infection on 12/1/2021 AM shift, PM shift and Night shift, 12/2/2021 Night shift, 12/4/2021 Night shift, 12/5/2021 AM shift, PM shift and Night shift, 12/6/2021 PM shift and Night shift, 12/7/2021 PM shift, 12/8/2021 PM shift, and 12/9/2021 AM shift. DON stated it is important that indwelling Foley catheter care was given as ordered by the physician, and urine output is monitored for signs and symptoms of infection every shift because they were measures taken to prevent, or identify as early as possible, [CONDITION(S)]'s, and clogging of the Foley catheter. DON stated it was especially important for Resident 231 because Resident 231 has a history of urinary tract infection. During a review of Resident 231's Indwelling Catheter care plan, dated 11/24/2021, the care plan indicated, Long term goals .to decrease risk of complications due to indwelling catheter use such as urinary tract infection ([CONDITION(S)]), irritated urethra and discomfort or pain; Maintain adequate urine output. Approaches .indwelling Foley catheter care every shift with soap and water .empty drainage bag at least every shift .observe for adequate urine output. Observe for signs/symptoms of infection .refer to MD accordingly. During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Care, dated 3/2000, the P&P indicated, Routine catheter care helps prevent infections and other complications .

Based on observation, interview and record review, the facility to assist two (Resident 55 and 117) out of 36 sampled residents in obtaining prescription glasses. This failure had the potential to result in Resident 55 and Resident 117's limitation in performing their activities of daily living due to their inability to see their surroundings clearly. Findings: During an interview on 12/6/21, at 9:14 a.m. with Resident 117, Resident 117 stated that she had been waiting for her eyeglasses. Resident 117 was told it would take 6-8 weeks, but she has been waiting for three and a half months. During an interview on 12/13/21, at 7:55 a.m., with Resident 117, Resident 117 stated that she can see but she can't read without her eyeglasses and that they have not updated her about the status of her eyeglasses. During an interview on 12/6/21, at 11:42 a.m. with Resident 55, Resident 55 stated that he had seen an eye doctor while he was in the facility, he was prescribed an eyeglass to which they said would arrive in 2-3 weeks and it has been four months already and it still has not been received. Resident 55 stated that he was not updated of the status of the eyeglasses. During a review of Resident 117's Care Plan, dated 8/24/21, Care Plan indicated that Resident 117 has visual deficit due to decreased visual acuity. During a review of Resident 55's Care Plan, dated 3/16/21, Care Plan indicated that Resident 55 has visual deficit due to decreased visual acuity. During a review of Resident 117 and 55's medical record indicated Residents 117 and 55 were seen on 9/20/21 and were prescribed eyeglasses. During a concurrent interview and record review, on 12/7/21, at 12:01 p.m., with Social Service Director (SSD), SSD stated that an outside company comes in the facility and they would prescribe eyeglasses for the residents, order it and have it delivered to the facility. SSD stated that turn around time for eyeglasses was six to eight weeks or longer and that she follows up with them if they have not received it yet. SSD stated that she did not have the chance to follow-up on the eyeglasses for Resident 117 and Resident 55.

Based on interview and record review, the facility failed to monitor the signs and symptoms of bleeding for one of one sampled residents (Resident 43) that received [MEDICATION(S)] (anticoagulant-a medicine used to decrease the clotting ability of the blood). This deficient practice had the potential to result in Resident 43's care needs not being addressed and delay initiation of appropriate treatment in a timely manner. Findings: Review of Resident 43's undated Facesheet (a document that provides resident specific information at a quick glance), indicated Resident 43 was admitted to the facility on ,d+[DATE]//21 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment is sometimes given via a arteriovenous [AV-a connection between an artery and vein] shunt). Review of Resident 43's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review with the Director of Nursing on 12/09/21 at 11:54 a.m., DON stated Resident 43 was not monitored for signs and symptoms of bleeding and bruising while on [MEDICATION(S)] from 9/16/21-11/18/21. DON stated due to Resident 43's [MEDICATION(S)] use , Resident 43 should have have been monitored for signs and symptoms of bleeding and bruising because adverse reaction of bleeding could be prevented and detected early, especially since Resident 43 had an AV shunt. DON stated he could not find documentation in Resident 43's medical record that Resident 43 was monitored for signs and symptoms of bleeding. Review of the facility's policy and procedure titled Anticoagulant Therapy release date 7/31/03, indicated .9. Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding . If signs and symptoms of bleeding are noted., Hold anticoagulant medication and notify physician immediately .

This requirement was NOT MET as evidenced by: Based on observation, interview, and record review the facility failed to provide daily wound treatments for one (Resident 1) of three sampled residents as ordered by the physician. This failure had the potential to result in delayed wound healing and an increased risk of infection. Findings: During a review of Resident 1's Admission Record (AR), dated 7/28/21, AR indicated Resident 1 was admitted to the facility on [DATE] with left heel pressure ulcer(ulcer that is caused by putting pressure on the heel) During a concurrent observation and interview on 8/24/21, at 11:45 a.m., with. Certified Nursing Assistant (CNA)1, Resident 1 had both legs bent at the knees with heels and lower legs semi covered with woven gauze dressings. The woven gauze dressings had multiple areas the size of a quarter with yellow drainage. CNA 1 stated Resident 1 had pulled and scratched at the woven gauze dressings on his legs CNA1 also stated the dressings were changed every other day but was not sure of the schedule because it was done by a nurse During a review of Resident 1's Treatment Administration Record (TAR) , dated 8/1/21 to 8/31/21, the TAR indicated the physician ordered daily wound care of the left heel, to be cleansed with normal saline solution (salt water-based solution) (NSS), pat dry, apply [NAME] oil sparingly and cover with foam and wrap with soft gauze dressing starting on 7/28/21. Review of the TAR indicated wound treatments were not done on 8/1, 8/2, 8/6, 8/9, 8/10, 8/13, 8/14, 8/15, 8/16, 8/17, 8/21, 8/23 and 8/24/21. During a concurrent interview on 8/24/21, at 2:00 p.m., with Registered Nurse (RN)1, RN 1 stated dressing changes to Resident 1's wounds were ordered to be changed daily. RN 1 stated if the nurse assigned to perform wound care was not available to change the dressing, the nurse assigned to administer medications for the resident was responsible to complete the task. RN 1 also stated the absence of dressing change documentation indicated either the dressing was not changed, or it was changed but not documented.

Based on interview and record review, the facility failed to protect one (Resident 1) of three sampled resident's rights to personal privacy and confidentiality when a video of Resident 1 was posted on social media on 5/11/21 by Certified Nursing Assistant (CNA) 1 . This failure exposed Resident 1 to public viewing without her consent or her Resonsible Party's (RP) consent. Findings: During an interview on 9/3/21, at 11:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 knew her name but was unable to give consent of any kind. LVN1 stated Resident 1 is no longer oreinted. During a record review of Resident 1's Medical Record (MR) , on 9/3/21, at 11:50 a.m., Resident 1's BIMS was 9 (brief interview for mental status score, a required screening tool used in nursing homes to assess cognition [the mental action of process of acquiring knowledge and understanding through thought]). A score of 9 indicated Resident 1 had mild impaired cognition . During an interview on 9/3/21, at 11:45 a.m.,with Director of Staff Development (DSD), DSD stated she could not recall or provide documention if staff education was provided regarding resident rights after the video of Resident 1 was posted on social media. During a review of Personnel Attendence Record with the title of, Resident Rights , at 3:00 p.m., dated 5/13/21, indicated a training session was given to staff on confidentilaity and their rights not to release any information about residents information, but did not include posting on social media. During a record review of Resident 1's facility admission packet, under Resident Rights section, dated 03/2017, indicated The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. During a concurrent interview and record review on 9/3/21, at 1:55 p.m.,with the Director of Nursing (DON) and the Administrator(ADMIN) Resident 1's care plan, dated 5/13/21 was reviewed. The ADMIN stated it appeared the care plan for Resident 1 was appropriate, but the problem was not with Resident 1 but with the facility's education and follow-up. During an interview on 9/15/21, at 2:15 p.m., with CNA 1, CNA1 stated she took a video of Resident 1 dancing at a facility activity and posted it on her personal social media site. CNA 1 stated she removed the video ten minutes after she posted it. CNA 1 stated a co-worker saw the video of Resident 1 on social media. CNA 1 stated she had received education regarding resident rights but did not receive education on how that related to social media.

Based on observation, interview, and record review, the facility failed to ensure residents were provided the supervision to prevent them from wandering outside of the facility for one of 17 residents (Resident 1) and three of three randomly sampled residents (Resident 2, 3 and 4). The facility did not monitor the elopement alarm device functionality of Roam Alert (a system that tracks the person using a wrist or ankle bracelet which automatically alarms if the person moves outside a defined area) monitoring system for one of five door monitor (main door). Resident 1 left the facility undetected. Resident was found three miles away from the facility and was returned to the facility by the police after more than 24 hours later. This failure resulted in delay in identification of the system malfunction and potentially placed 17 of 17 residents in the facility with Roam Alert monitoring device (sensing tags) in serious harm. It was determined to constitute an Immediate Jeopardy (IJ) situation. The Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the IJ on 1/29/18 at 12:31 p.m. The facility failed to ensure a fully functioning Roam Alert system was maintained. Through observations and interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of action through in-services of employees regarding Roam Alert monitoring. The facility repaired the nonfunctioning Roam Alert door monitor at the front door. The IJ was lifted on 1/29/18 at 3:10 p.m. Findings: Review of Resident 1's undated Face Sheet indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Progress Notes dated 11/17/17 indicated Resident 1 was last seen by the Certified Nursing Assistant 1 (CNA 1) around 8:10 a.m. and was identified to be missing at 8:30 a.m. Review of Resident 1's Progress Note dated 11/18/7 11 a.m., indicated Resident returned to the facility accompanied by Police .found him in the (street of Oakland) near a store .Resident then claimed while while in the room that he fell while he was in the street and c/o (complained of) both knee pain .also c/o pain on his left fingers .Resident stated I slept in the street it was too cold . Review of the Minimum (MDS) data set [DATE], indicated Resident 1 had a Brief Mental Interview Score (BIMS, an assessment intended to determine the resident's attention, orientation and ability to register and recall new information) of nine (moderately impaired). Further review indicated Resident 1 required oversight supervision when ambulating in and out of the unit. Review of Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 was at risk for elopement. Review of Resident 1's care plan At risk for Elopement & (and) wandering out of facility dated 10/30/17, indicated an approach that included wearing a Wanderguard bracelet and to check the alarm for functioning. Review of Resident 1's physician's orders [REDACTED]. During an interview with CNA 1 on 1/29/18 at 10:03 a.m., CNA 1 stated she was the CNA for Resident 1 on 11/17/18. CNA 1 further stated she did not hear any door alarm on 1/17/18, when Resident 1 eloped from the facility. During an observation on 1/29/18 at 10:20 a.m. Resident 2 was in a wheelchair wearing a Roam Alert sensing bracelet on the right wrist. The DON pushed Resident 2's wheelchair through the front door and the alarm sensor did not sound. During a second observation on 1/29/18 at 10:25 a.m. Resident 3 was ambulatory and was wearing a Roam Alert sensing bracelet on the left wrist. The DON and Resident 3 walked out of the front door and the alarm sensor did not sound. During a third observation on 1/29/18 at 10:50 a.m. Resident 4 was in a wheelchair wearing a Roam Alert sensing bracelet on the left wrist. The DON pushed Resident 4's wheelchair through the front door and the alarm sensor did not sound. During an interview on 1/29/18 at 10:50 a.m., the DON and ADM stated the Roam Alert sensing bracelet should have activated the sensor of the Roam Alert system on the front door and all protected exit doors with the Roam Alert door monitors. During an interview with the Maintenance Director (MD) on 1/29/18 at 11:15 a.m. regarding door monitoring testing, MD stated his responsibility was to check the Roam Alert system once a week, usually every Friday. MD stated that he failed to perform the monitor check on 1/26/18. MD stated he does not have any documentation to indicate that monitoring was being conducted and further stated that he was not in compliance with the facility's policy to test and inspect each door monitor daily. In a follow up interview on 1/29/18 at 11:50 a.m., the ADM stated that the vendor did not regularly come to service unless the facility called them to come. He further stated that MD was responsible for monitoring the door alarm system and ensured it was in good working condition. Review of the facility's policy and procedure Wander/Elopement Alarm System Testing dated 4/2001 indicated, Regular testing of door monitors and signaling devices in the alarm system verifies the integrity of the system .Regular testing is essential .This is a function of the preventive maintenance program and regular testing is essential to resident safety .Door Monitor Test 1. Inspect and test each door monitor daily .