Every finding on record at Heartwood Avenue Healthcare

Based on interviews and record review, the facility failed to ensure required 1:1 supervision was provided for one of three sampled residents (Resident 2) when the assigned staff member was not closely supervising Resident 2 and did not intervene when a verbal altercation between Resident 1 and Resident 2 escalated into a physical altercation. This failure resulted in Resident 1 and Resident 2 physically kicking each other placed both residents at risk for physical harm. Findings:Resident 1 was admitted to the facility on September of 2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD) (a long term, progressive lung disease that makes it difficult to breathe) and muscle weakness.A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 3/30/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment.A review of Resident 1's Change in Condition (CIC) Evaluation, dated, 6/2/26, indicated, At 1250 today [Resident 2] was peacefully wheeling [a resident's room number] in the hallway when [Resident 1] told her [Resident 2] to stop then [Resident 2] turned around (sic) both [Resident 2] and [Resident 1] exchanged kicks simultaneously .A review of Resident 1's Interdisciplinary Team (IDT) Notes dated, 6/4/26 indicated Behavior Committee Review: Resident with recent event of inappropriate physical contact with another resident this week. Resident with history of spontaneous inappropriate verbalizations and impulsive actions toward others.A review of Resident 1's Order Summary Report (ORS) indicated, .Monitor episodes of Anxiety.agitation.aggressive behavior towards staff every shift .Start date 6/8/26A review of Resident 1's Care Plan (CP), revised date 6/18/26, indicated multiple incidents of physical aggression towards other Residents, .they each made contact to lower legs of each other. 6/3/26 resident with no recall of incident [6/2/26].no psychosocial disharmony.immediately separated from each other.On 2/7/25, resident was upset at male peer after hearing rude remarks and inappropriately made physical contact to the back of peers head.2/22/25: unpredictably, made inappropriate physical contact to female peers shoulder.Body check and pain assessment to hand. staff to immediately intervene when triggers of angry outburst in behavior are observed.Resident 2 was admitted to the facility on March of 2025 with diagnoses which included Diabetes Mellitus Type 2 (a chronic medical condition in which the body cannot use insulin properly, causing blood sugar (glucose) levels to rise above normal and Schizophrenia (a chronic, severe mental health disorder that affects how a person thinks, feels, and behaves)A review of Resident 2's ORS indicated, Monitor target behavior: physical aggression towards staff. Notify MD if observed. every shift .start date 8/7/25.A review of Resident 2's CP, dated 11/17/25 indicated Miss [Resident 2] is currently on 1:1 [a safety intervention where a dedicated staff member is assigned exclusively to observe and protect a single individual at all times] with a staff member every 30 minutes to minimize behavior .1:1 monitoring, assign staff every 30 minutes rotation .attempt to redirect resident.A review of Resident 2's MDS, dated [DATE], indicated that Resident 2 had BIMS score of 0 out of 15, indicating severe cognitive impairment.During an interview with Certified Nursing Assistant (CNA) 3 on 6/18/26 at 12:01 p.m., CNA 3 confirmed that he was assigned to be Resident 2's 1:1 when the altercation between Resident 1 and Resident 2 occurred in front Resident 2 room in the hallways. CNA 3 stated that Resident 2 was already agitated before the incident. While CNA 3 assisting another resident with meals, he observed Resident 1 verbally provoking Resident 2 by calling her crazy, you are in love, and you are acting crazy again which escalated the situation. CNA 3 stated he told Resident 1 to stop but did not intervene further. CNA 3 reported he did not know that 1:1 supervision required remaining within arm's reach to the resident and confirmed that he was assisting Resident 2's roommate in the room with meals when the altercation occurred. CNA 3 stated both residents kicked each other and acknowledged that he did not separate or redirect the residents until after the physical altercation had happened. CNA 3 stated he had never received formal 1:1 training. CNA 3 stated that when the commotion occurred and he turned around, the MRD (Medical Records Director) was already there and informed him that Resident 2 had kicked Resident 1 because Resident 1 may have thrown something at Resident 2. CNA 3 further stated that the altercation was witnessed by both the MRD and the Staffing Director (SD).During an interview on 6/18/26 at 1:04 p.m., the MRD stated, I was inside the medical records when it happened. The MRD reported hearing a commotion outside and seeing Resident 1 calling Resident 2 crazy. The MRD stated she exited the office and told CNA 3 to separate the residents, but Resident 1 continued to antagonize Resident 2, wheeled closer to Resident 2, and kicked Resident 2's leg. The MRD stated that Resident 2 became upset and told Resident 1, You kicked me, and then turned around and kicked Resident 1's right leg.During an interview on 6/18/26 at 1:18 p.m., the Director of Staff Development (DSD) stated that when a resident was on 1:1 supervision, staff must not leave the resident unless the next assigned person was present to relieve them. The DSD reported that staff were expected to follow the policy and remain focused because 1:1 supervision was intended for resident safety, including preventing elopement, falls, and potential verbal or physical altercations. The DSD also stated that staff assigned to 1:1 should not be assisting other residents with meals and must remain within arm's reach to the resident so they could react quickly. The DSD stated that Resident 2 was on 1:1 supervision by CNA 3 at that time of the incident. The DSD confirmed that CNA 3 was also assigned to assist another resident with meals. The DSD stated, [CNA 3's name] was scheduled to be 1:1, but it was also lunchtime. He asked [MRD's name] to watch Resident 2 while he fed the roommate.In addition, contrary to the DSD's statement, during the interview on 6/18/26 at 1:04 p.m., with the MRD, the MRD did not report being asked by CNA 3 to supervise Resident 2 while CNA 3 assisted another resident with meals.During an interview with the Director of Nursing (DON) on 6/18/26 at 2:10 p.m., the DON confirmed the findings regarding the incident between Resident 1 and Resident 2. The DON stated that 1:1 supervision was an important assignment from the time it began until the time it ended. The DON reported that 1:1 supervision required the staff member to remain within arm's reach to the resident and to provide constant observation. The DON stated there must always be a staff member next to a resident who required 1:1 supervision. The DON stated, That's the only thing they have to do; you are not supposed to be doing other things such as feeding. The DON acknowledged that resident safety was compromised when the assigned staff member was positioned far from the resident on 1:1 supervision and was unable to respond quickly to prevent the incident.A review of the facility Policy and Procedures (P&P) titled, 1:1 Continuous Supervision Policy and Procedures the P&P indicated, This facility provides a safe environment for all residents.High-risk behaviors includes.and aggressive incidents .Staff must remain within arm's reach of the resident at all times.to maintain maximum vigilance.Purpose.To prevent resident.behavioral incidents though uninterrupted, close-proximity tracking.Arm's Reach Standard: Staff must remain within 3 feet (arms reach).No Distractions: Staff cannot.or assist other residents while on 1:1 duty.A review of the facility P&P titled, Resident Rights, revised 12/2024, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents rights to.be treated with respect, kindness, and dignity.be free from abuse.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for three of 19 sampled residents (Resident 7, Resident 22 and Resident 60) when:1. Resident 7's blood pressure was not accurately assessed;2. Resident 22 was administered a blood pressure medication outside of the ordered parameters;3. Resident 60 was administered a lower than prescribed dose of medication; and4. Resident 60's oxygen was not accurately documented and monitored. These failures increased the risk for an inaccurate blood pressure for Resident 7, low blood pressure for Resident 20, subtherapeutic dose of medication, breathing problems, and hallucinations for Resident 60.1.Resident 7 was admitted to the facility in early 2026 with diagnoses that included high blood pressure and heart failure. During an observation and interview on 5/4/26 at 1:30 p.m. of Licensed Nurse (LN3), LN 3 was in the hallway taking Resident 7's blood pressure. Resident 7 was wearing a long sleeve down jacket. LN 3 placed the cuff end (the part of the blood pressure cuff that wraps around the bare upper arm) on Resident 7's forearm (from wrist to elbow) over the top of the jacket. LN 3 confirmed the observation and stated that it was not an accurate way to monitor a resident's blood pressure. During an interview on 5/4/26 at 1:39 p.m. with the Director of Staff Development (DSD, implements staff training), the DSD stated blood pressure should be checked on the upper arm and not over a jacket; the cuff should be on bare skin. The DSD stated it was important to obtain accurate blood pressure readings so the staff could give the appropriate medications. During an interview on 5/7/26 at 10:12 a.m. with the Director of Nursing (DON), the DON stated a blood pressure reading should not be taken on the forearm over a down jacket, as it would give an inaccurate reading. The DON stated they expected the staff to take an accurate blood pressure. During a review of the facility policy and procedures (P&P) titled, Blood Pressure, Measuring, dated 9/25, the P&P indicated, The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins and chambers of the heart.Steps in the Procedure.Expose the resident's arm by rolling the sleeve up about 5 inches above the elbow.Wrap the blood pressure cuff evenly around the upper arm, approximately one (1) inch from the elbow. 2. Resident 22 was admitted to the facility in early 2026 with diagnoses that included high blood pressure, heart failure, and a heart attack. During a review of Resident 22's Order Summary Report [OSR], order date 1/26/26, the OSR indicated, amLODIpine Besylate [medication used to lower blood pressure and treat chest pain] 10 MG [milligram, unit of measurement] Give 1 tablet by mouth one time a day for HTN [hypertension, high blood pressure] HOLD SBP [systolic blood pressure, top number of blood pressure reading] <110 HR [heart rate] <65. During a review of Resident 22's Medication Administration Record [MAR], dated 4/1-4/30/26, the MAR indicated Resident 22's SBP was 98 on 4/20/26 and 107 on 4/24/26. The MAR indicated Resident 22 was administered the amlodipine on both dates and the medication was not held as directed in the physician orders (hold for SBP less than 110). During a concurrent interview and record review on 5/6/26 at 9:58 a.m. with LN 1 regarding Resident 22's MAR, LN 1confirmed she had administered Resident 22 the amlodipine on 4/20/26 and did not follow the hold parameters when the SBP was less than 110. LN 1 stated she should not have administered the medication. During a concurrent interview and record review on 5/6/26 at 11:01 a.m. with the DON regarding Resident 22's MAR, the DON confirmed the amlodipine was given outside of the physician-ordered hold parameters. The DON stated the staff was not following physician orders, and it was important to follow physician orders, as the orders were in place to prevent complications. 3. A review of Resident 60's admission record indicated that Resident 60 was admitted to the facility in February 2026 with diagnoses that included congestive heart failure (a weak heart causing fluid buildup and difficulty breathing), obstructive sleep apnea (breathing that stopped and started during sleep), adjustment disorder with anxiety (stress causing excessive worry or nervousness), and autistic disorder (a condition affecting communication, behavior, and social interaction). A review of Resident 60's Brief Interview for Mental Status (BIMS), dated 2/28/26, indicated that Resident 60 had a BIMS score of 15 out of 15, indicating intact cognition. A review of Resident 60's OSR, dated 4/27/26, indicated an order for Mounjaro (tirzepatide, once-weekly injectable medication designed to improve blood sugar control in adults and children 10 and older with Type 2 diabetes) Subcutaneous Solution Auto injector 15 mg/0.5 mL (milliliter, unit of meausrement) to be injected subcutaneously once every Monday for obesity. A review of Resident 60's MAR for the month of May indicated that the resident received one dose of Mounjaro 15 mg/0.5 mL on 5/4/26. During an interview on 5/6/26 at 3pm with Resident 60, Resident 60 stated that the staff had been giving him Mounjaro 2.5 mg instead of 15 mg, Resident 60 further stated that he knows that he received Mounjaro 2.5 mg because it was a single dose injection labeled 2.5 mg/0.5 mL. During a concurrent observation, interview, and record review on 5/7/26 at 6:30 a.m. with LN 5 in the medication room, LN 5 stated that the Mounjaro available in the medication refrigerator was a box of prefilled pens of 2.5 mg/0.5 mL. The box was labeled Use one pen every week. 4 single dose prefilled pens. Upon opening the box, there was one of the four single dose prefilled pens remaining, labeled Mounjaro 2.5 mg/0.5 mL. During a phone interview on 5/7/26 at 7:11 a.m. with the Pharmacy Technician (PhTc), the PhTc stated that the Mounjaro 15 mg dose was not delivered. During an interview on 5/7/26 at 8:52 a.m. with the DON, the DON confirmed that the 15 mg dose of Mounjaro was not delivered due to insurance issues. Since Resident 60 received a dose and stated that he received Mounjaro on Monday (5/4/26) in a 2.5 mg dose, the DON stated that the nurse administered a lower dose than ordered. The DON stated that the expectation was for the nurse to administer medication in accordance with the physician's order, and that if the medication was not available, it should be placed on hold until available and the physician should be notified. 4. A review of Resident 60's OSR, dated 3/27/26, the OSR indicated an order for Oxygen: At 2 Liters/Min [Liters per minute, flow rate of the oxygen) via Nasal Cannula [ thin tube connecting the oxygen source to the resident's nose for administration] PRN [pro re nata, meaning as needed] as for o2 sat [oxygen saturation] less than 92% as needed. During an observation and interview on 5/4/26 at 9:04 a.m. with Resident 60, Resident 60 lay upright in bed on oxygen via nasal cannula. Resident 60 stated he needed continuous oxygen to prevent hallucinations, shortness of breath, and chest pain. The resident continued to be observed on oxygen via nasal cannula on the following dates and times: 5/4/2026 at 12:47 p.m., 2:15 p.m., and 3:20 p.m. 5/5/2026 at 11:20 a.m. 5/6/2026 at 10:15 a.m. During a concurrent interview and record review with the DON on 5/6/26 at 10:22 a.m., the DON confirmed that no nurse had documented in the May MAR or progress notes who administered the oxygen or the reason for administration. The DON stated that the oxygen order was for 2 liters per minute when oxygen saturation was less than 92%. The DON further stated that nurses should have documented when the resident was on oxygen, why it was administered, and whether the resident required continuous oxygen. The DON stated that if the resident required continuous oxygen, the physician should have been notified so the order could be changed from PRN to continuous or routine. A review of the facility's P&P titled Administering Medications, dated 4/25, indicated, Medications are administered in a safe and timely manner and as prescribed. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. A review of the facility's P&P titled Oxygen Administration, dated 10/25, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1.The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3.The rate of oxygen flow, route, and rationale. 4.The frequency and duration of the treatment. 5.The reason for p.r.n. administration. 6 All assessment data obtained before, during, and after the procedure. 7.How the resident tolerated the procedure.

Based on observation, interview, and record review, the facility failed to ensure accurate reconciliation and accountability of controlled medications for three of 19 sampled residents (Resident 22, Resident 56 and Resident 57) when discrepancies were found during the random controlled medication audits.These failures resulted in the facility lacking accurate accountability of controlled substances and increased the potential for diversion in a 60-certified-bed facility. Findings:The controlled medication record for three randomly selected residents (Resident 22, Resident 56 and Resident 57) who received as-needed controlled medications were requested for review during the survey.During a review of Resident 22's Medication Administration Record (MAR) dated 4/20-4/25/26, the MAR indicated an order for Morphine Sulfate [medication to treat pain] Solution 20 mg/ml (mg, milligrams: unit of measurement. ml, milliliter: measurement for a volume of liquid) Give 0.25 ml by mouth every 4 hours as needed.for pain.During a review of Resident 22's CONTROLLED DRUG RECORD [CDR], [a form that keeps count of the number of narcotics dispensed to a resident], entries from 4/20-4/25/26, the CDR indicated 0.25 ml of Morphine Sulfate was removed from the medication bottle on 4/22/26 at (time not documented) and on 4/23/26 at 6 p.m. These doses were not documented in the MAR as given to Resident 22.During a review of Resident 22's MAR dated 4/25-5/5/26, the MAR indicated an order for, Morphine Sulfate Solution 20 mg/ml Give 0.5 ml by mouth every 2 hours as needed.for pain.During a review of Resident 22's CDR, entries from 4/25-5/5/26, the CDR indicated 0.5 ml of Morphine Sulfate was removed from the medication bottle on 4/25/26 at 11:22 p.m., 4/27/26 at 5 a.m., 4/28/26 at 2:30 a.m., and 5/3/26 at 4 a.m. These medications were not documented in the MAR as given to Resident 22.During a review of Resident 56's MAR dated 4/26-5/5/26, the MAR indicated an order for, Percocet [medication to treat pain] 10-325 MG.Give 1 tablet by mouth every 4 hours as needed for.pain.During a review of Resident 56's CDR, entries from 4/26-5/5/26, the CDR indicated Percocet 10-325 was removed from the narcotic medication card (pre-packaged medications dispensed from a pharmacy) on 4/28/26 at 4 a.m. and 5/2/26 at 12:48 a.m. These doses were not documented in the MAR as given to Resident 56.During a review of Resident 57's MAR dated 4/19-4/27/26, the MAR indicated an order for, Hydrocodone-Acetaminophen [medication to treat pain] 10-325 MG.Give 1 tablet by mouth every 6 hours as needed for.pain.During a review of Resident 57's CDR, entries from 4/19-4/27/26, the CDR indicated Hydrocodone-Acetaminophen 10-325 MG was removed from the narcotic medication card on 4/23/26 at 6:05 p.m. This dose was not documented in the MAR as given to Resident 57.During an interview on 5/5/26 at 2:30 p.m. with Licensed Nurse (LN 1), LN 1 stated when narcotics were administered, the nurse was required to sign both the CDR and the MAR. LN 1 stated this was important because the CDR ensured accurate counts of controlled medication and the MAR reflected what the resident received, helping staff determine when the last dose was given.During a concurrent interview and record review on 5/6/26 at 11:01 a.m. with the Director of Nursing (DON), the DON reviewed the MAR and CDR for Resident 22, Resident 56, and Resident 57. The DON confirmed the MAR had missed entries for narcotic administration. The DON stated that she expected nurses to sign narcotics in both the MAR and CDR to ensure accurate documentation of doses and administration times.During a review of the facility policy and procedures (P&P) titled, Administering Medications, dated 4/25, the P&P indicated, .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered.Any results achieved and when those results observed.The signature and title of the person administering the drug.

Based on interview and record review, the facility failed to ensure that two of 19 sampled residents (Resident 4 and Resident 9) were free from significant medication errors when nursing staff did not administer prescribed as needed antihypertensive medications during repeated, documented episodes of elevated systolic blood pressure.This failure compromised the residents' safety and placed both Resident 4 and Resident 9 at increased risk for serious and potentially life threatening outcomes, including hypertensive crisis, stroke, and cardiac arrest.1.Resident 9 was admitted to the facility in late 2022 with diagnoses that included a stroke, an irregular heartbeat, and heart disease. During a review of Resident 9's Order Summary Report [OSR], order dated 4/2/26, the OSR indicated, cloNIDine HCl Oral Tablet 0.1 MG [milligram, unit of measurement].Give 0.1 mg by mouth every 12 hours as needed for SBP [systolic blood pressure, top number of blood pressure reading] >150. A review of Resident 9's documented blood pressure readings from 4/2/26-4/30/26, showed 15 systolic blood pressure (SBP) readings greater than 150. On 4/2/26 at 9 a.m., SBP was 167, and at 6 p.m., SBP was 163. On 4/3/26 at 9 a.m., SBP was 164. On 4/4/26 at 9 a.m., SBP was 170, and at 6 p.m., SBP was 156. On 4/5/26 at 9 a.m., SBP was 158. On 4/7/26 at 6 p.m., SBP was 172. On 4/9/26 at 6 p.m., SBP was 164. On 4/10/26 at 9 a.m., SBP was 167, and at 6 p.m., SBP was 154. On 4/11/26 at 9 a.m., SBP was 152. On 4/12/26 at 6 p.m., SBP was 154. On 4/28/26 at 6 p.m., SBP was 157. On 4/29/26 at 6 p.m., SBP was 155. On 4/30/26 at 6 p.m., SBP was 151. During a review of Resident 9's Medication Administration Record [MAR], dated 4/2/26-4/30/26, the MAR indicated clonidine was not administered for any SBP reading greater than 150. A review of Resident 9's documented blood pressure readings from 5/1/26-5/6/26 showed five SBP readings greater than 150. On 5/1/26 at 9 a.m., SBP was 154, and at 6 p.m., SBP was 166. On 5/2/26 at 6 p.m., SBP was 154. On 5/4/26 at 9 a.m., SBP was 189, and at 6 p.m., SBP was 157. During a review of Resident 9's Medication Administration Record [MAR], dated 5/1/26-5/6/26, the MAR indicated clonidine was not administered for any SBP reading greater than 150. During a concurrent interview and record review on 5/6/26 at 9:39 a.m. with Licensed Nurse (LN 1), LN 1 reviewed Resident 9's OSR and stated that if Resident 9 had an SBP greater than 150, clonidine should have been administered per the physician's orders. LN 1 reviewed the MAR and confirmed there were multiple SBP readings greater than 150 and clonidine had not been administered. LN 1 stated the staff should have followed the physician's orders. During a concurrent interview and record review on 5/6/26 at 11:01 a.m. with the Director of Nursing (DON), after reviewing Resident 9's MAR for clonidine, the DON confirmed that clonidine was not administered in April and May for SBP readings greater than 150. The DON stated Resident 9 had high blood pressure and the clonidine was needed. During an interview on 5/6/26 at 11:40 a.m. with the Medical Doctor (MD), the MD stated that if a resident had an order to give clonidine for an SBP greater than 150, they would expect the nurse to administer the medication as ordered. 2. A review of Resident 4's admission record indicated that Resident 60 was initially admitted to the facility in February 2026 with diagnoses that included congestive heart failure (a weak heart causing fluid buildup and difficulty breathing), hypertension (HTN, high blood pressure) and hypertensive urgency (blood pressure extremely high that needs medical attention). A review of Resident 4's OSR, dated 4/4/26, indicated an order for clonidine hydrochloride oral tablet 0.1 mg, Give 1 tablet by mouth every 8 hours as needed for HTN systolic blood pressure above 160, diastolic blood pressure above 90. A review of Resident 4's Weights and Vital Summary (WVS) from 4/20/26-5/6/26, the WVS indicated: 4/28/26 1:03 a.m., BP (blood pressure) = 175/87 mmHg (milliliters of mercury, unit used to measure blood pressure) 4/23/26 8:49 p.m., BP = 240/112 mmHg During a concurrent interview and record review on 5/7/26 at 8:52 a.m. with the DON, the DON stated that no PRN (pro re nata, meaning as needed) clonidine had been administered on 4/23/26 at 8:49 p.m. or on 4/28/26 at 1:03 a.m. The DON stated that the expectation was for the nurse to administer the PRN blood pressure medication as ordered and notify the physician. The DON further stated that high blood pressure could cause stroke and cardiac arrest. A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 4/25, indicated, Medications are administered in a safe and timely manner and as prescribed.As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c.The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g.The signature and title of the person administering the drug.

Based on observation, interview and documentation review, the facility failed to implement their medication storage policy when: Multiple medications were unlabeled, and Expired medications were stored and available for use.These failures had the potential for residents to receive unsafe, ineffective, or inappropriate medications for a census of 56.Findings:1. A review of the tuberculin (bacteria extract used to diagnose tuberculosis infections) manufacturer's box indicated that the tuberculin vial should be discarded 30 days after opening. During a concurrent observation and interview on 5/5/26 at 9:20 a.m., with the Director of Nurses (DON), a vial of tuberculin was observed to be open without an opened date in the medication storage fridge. The DON confirmed the finding and stated, it is not labeled.During a concurrent observation and interview on 5/5/26 at 9:47 a.m. with Licensed Nurse 1 (LN 1), two 15mg mirtazapine tablets (a prescription antidepressant drug) , one tablet of 8mg ondansetron (a medication used to treat nausea), and three 4mg tablets of ondansetron were found unlabeled without a resident name and available for use in medication cart 2. LN 2 confirmed the medications were not labeled.2. During a concurrent observation and interview on 5/5/26 at 9:20 a.m., with the DON, an emergency kit containing emergency intravenous (medications given through the veins) medications was observed to have an expiration date of April 2026. The DON verbally confirmed the observation.A review of the fluticasone propionate and salmeterol (inhaled medications to improve breathing) 500mcg/50mcg (micrograms, a unit of measurement) inhaler manufacturer's box indicated that the inhaler should be discarded one month after opening.A review of degludec (long lasting insulin variant) insulin pen (multi use insulin syringe) manufacturer's instructions indicated that the pen should be tossed eight weeks after opening.During a concurrent observation and interview on 5/5/26 at 9:47 a.m. with LN 1, the following medications were found to be expired and stored in medication cart two: one packet containing 30 10mg tablets of olanzapine (a medication used to treat mental disorders such as schizophrenia) with an expiration date of 12/2/25, one fluticasone propionate 500mcg/50mcg inhaler with an open date of 3/10/26 (four weeks past manufacturer's recommended discard date), and one degludec insulin pen with an open date of 2/11/26 (three weeks and six days past manufacturer's recommended discard date). LN 1 confirmed the observations and indicated that expired medications should have been disposed of.During an interview on 5/6/26 at 9:39 a.m. with the DON, the DON indicated that expired medications should not have been available for use and expected staff to have thrown them away. The DON further indicated that medications needed to be labeled with an opened date if required.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 11/20, the P&P indicated, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 54 residents who received food prepared from the kitchen, when: 1. Food debris and dried watermarks was observed on several kitchen utensils stored inside the plastic container. The bottom of the container, which was designated for storing clean utensils, contained visible dirt and food debris; 2. Several kitchen utensils, stock pot, plastic trays, metal pans were found stacked wet and stored at the clean and ready-to-use storage areas; 3. A plastic coffee carafe on the countertop contained a white substance adhered to the interior walls and debris collected at the bottom; 4. A staff used wiping cloth from the red bucket to wipe the countertop during cooking and food preparation without wearing gloves. The staff returned the used cloth to the red bucket and continued cooking and preparing food without washing their hands; and 5. The inside of the van which used to transport food to the facility from an off site kitchen contained food debris and both new and dried liquid marks. Three plastic food warmers inside the van also contained food debris, dried liquid, and dried food drippings on their interior surfaces. The exterior surfaces of the food warmers appeared dirty. 6. A white plate stored in the clean and dry storage container was found with dried food debris; These failures increased the risk of cross-contamination affecting a census of 54 residents. Findings:1.During a concurrent observation and interview with the Dietary Manager (DM) on 5/4/26 at 8:31 a.m. during the initial kitchen tour, several kitchen utensils stored inside a plastic tray contained visible food debris and watermarks. Some utensils were stored wet inside the plastic container, and the bottom of the container contained visible dirt and food debris. The DM confirmed the findings and stated that clean utensils must be stored completely dry and free of food particles. During an interview with the Registered Dietitian (RD) on 5/6/26 at 11:33 a.m., the RD stated that staff must make sure dishes come out of the dishwasher fully clean and completely dry before being stored. The RD also stated that the containers used for storing dishes must be cleaned and sanitized. The RD further stated that when it's stored wet, It creates an environment for bacterial growth. 2.During the initial kitchen tour and a concurrent interview with the DM on 5/4/26 at 8:46 a.m., 35 metal pans and several plastic trays and stock pots, were stacked while still wet on the clean rack. The DM confirmed the findings and stated that these items must be completely dry before being stored on the dry rack. During an interview with the RD on 5/6/26 at 11:33 a.m., the RD stated that dishes must come out of the dishwasher fully clean and completely dry before being stored. The RD also stated that when it's stored wet, It creates an environment for bacterial growth. 3.During a concurrent observation and interview with the DM and Dietary Aide (DA) 1 on 5/4/26 at 8:46 a.m., during the initial kitchen tour, a plastic coffee carafe was observed on the countertop. Upon inspection, the carafe contained a white substance adhered to the interior walls and debris collected at the bottom. The DM confirmed the findings and DA 1 verified that the coffee carafe came from the other facility. During an interview with DA 2 on 5/5/26 at 9:58 a.m., DA 2 stated that coffee carafes brought in from the other facility must be cleaned every day because, if they are not cleaned right away, they become unsafe for residents. During an interview with the RD on 5/6/26 at 11:33 a.m., the RD stated that coffee carafes should be cleaned after every meal and that staff should take them to the other facility for cleaning. 4.During a concurrent observation and interview with FC on 5/5/26 at 10:47 a.m., the FC was cooking and preparing food when the FC took a wet wiping cloth from the red bucket with bare hands and used it to wipe the countertop used for food preparation. The FC then placed the used wiping cloth back into the red bucket and continued cooking without washing hands. The FC repeated this action a second time without washing hands. When asked about the importance of handwashing after touching the red bucket, the FC stated that she needed to wash her hands after using the wiping cloth before cooking and stated, We do not want contamination during cooking. 5.During an observation on 5/4/26 at 8:49 a.m., the facility's food transport van was inspected and it was verified by the DM that the facility used the van to deliver residents' meals that were cooked and prepared at a different facility. The interior of the van contained food debris and both new and dried liquid stains. In addition, three plastic food warmers inside the van were inspected and were found to contain food debris, dried liquid marks and dried food drippings on the interior surfaces. The exterior surfaces of the food warmers also appeared dirty. During an interview with the DA 1 on 5/4/26 at 10:07 a.m., the DA 1 confirmed the findings mentioned above. When asked when the last time the van was cleaned, DA 1 stated that the food transportation van was last cleaned on Friday [5/1/26]. During an interview with the RD on 5/6/26 at 11:33 a.m., the RD stated that the food transportation van and the plastic food warmers needed to be clean and sanitized after each meal and that staff in charge should check with the DM with regards to deep cleaning. 6.During an observation of the food transportation van on 5/4/26 at 10:09 a.m., while serving wares on the cart were being unloaded from the van and brought into the facility for later use during lunch, a plate was observed with visible dried food debris on its surface. DA 1 confirmed the finding and stated that the plate was in the clean tray and should not have had any food debris on it. During an interview with the Registered Dietitian (RD) on 5/6/26 at 11:33 a.m., the RD stated that staff must make sure dishes come out of the dishwasher fully clean and completely dry before being stored. A review of the facility Policy and Procedures (P&P) titled Sanitization revised 2024, the P&P indicated, The food services area shall be maintained in clean and sanitary manner.areas shall be kept clean, free from litter and rubbish.All utensils.equipment shall be kept clean.food contact surfaces and utensils shall be washed to remove or completely loosen soils.scrape food particles.food preparation equipment and utensils that are manually washed will be allowed to air dry.Food service staff will be trained to maintain cleanliness throughout their work areas during all task, and to clean after each task. A review of the facility P&P tilled Dishwashing Machine Use Revised 03/24 indicated After running items through entire cycle, allow to air-dry A review of facility documents titled, Food & Nutrition: Competency Checklist - Cook the document indicated, Knowledge of Infection Control Practices.Correct handwashing procedure.Proper use of gloves/change between tasks.

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for one of three sampled residents (Resident 9) when:Resident 9 did not receive diclofenac sodium gel 1% (a gel used treat joint pain and inflammation from osteoarthritis) to his leg or as needed clonidine (fast acting medication to lower blood pressure).These failures resulted in two medication errors out of 35 opportunities, yielding a medication error rate of 5.71%.Findings:During a review of Resident 9's Order Summary Report [OSR], order dated 4/30/25, the OSR indicated, Diclofenac Sodium External gel 1% .Apply to left leg topically [to the skin] four times a day for pain.During a medication pass observation on 5/4/26 at 8:42 a.m. with Licensed Nurse (LN 4), LN 4 did not apply the diclofenac gel 1% to Resident 9's left leg. LN 4 looked through the cart and stated there was no diclofenac gel 1% available. LN 4 checked Resident 9's blood pressure and recorded a reading of 189/73.During a review of Resident 9's OSR, order date 4/2/26, the OSR indicated, cloNIDine HCl Oral Tablet 0.1 MG [milligram, unit of measurement].Give 0.1 mg by mouth every 12 hours as needed for SBP >150 [Systolic Blood Pressure, top number of blood pressure reading].During a review of Resident 9's Medication Administration Record [MAR], dated 5/4/26, the MAR indicated diclofenac sodium was marked as refused, and clonidine 0.1 mg was not documented as administered when SBP was 189.During a concurrent interview and record review on 5/4/26 at 3:12 p.m. with LN 4, LN 4 confirmed she did not apply the diclofenac sodium gel because it was not available in the medication cart. LN 4 confirmed Resident 9's SBP was 189 during the morning medication pass and stated it was greater than 150. LN 4 confirmed she did not administer clonidine as ordered and stated it should have been given because it was important for preventing cardiac complications. LN 4 stated she forgot to check the as-needed medications.During an interview on 5/7/26 at 10:12 a.m. with the Director of Nursing (DON), the DON stated she expected medications to be administered correctly according to physician orders.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/25, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber order, including any required time frame .

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Facility staff failed to accurately document the use of BiPap ((Bilevel Positive Airway Pressure) machine is a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask, improving oxygen levels) for Resident 1 as ordered by her physician,2. Facility staff administered an opioid medication (controlled drug highly effective for severe, acute, or chronic pain but carries significant risks of addiction, misuse, and overdose) on two occasions without adequate indication for use to Resident 1, and3. Facility failed to order Narcan (naloxone: a life-saving, over-the-counter nasal spray that rapidly reverses opioid overdoses in 2-3 minutes) for Resident 1 while she was being given an opioid medication.These failures resulted in Resident 1's emergency transfer to an acute care hospital after an opioid overdose. 1. During a review of Resident 1's Facesheet (contains resident's demographics, diagnoses, physician etc.) dated 4/14/26, Facesheet indicated Resident 1 was diagnosed with the following conditions: Acute Respiratory Failure (life-threatening emergency where the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide; a waste product), Heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), Chronic Kidney Disease stage 3 (a middle stage chronic disease where kidneys struggle to filter waste, often causing symptoms like fatigue, fluid retention, and back pain), Obstructive sleep apnea (disorder where throat muscles relax excessively during sleep, causing the airway to collapse and breathing to stop repeatedly), and Morbid (severe) obesity with alveolar hypoventilation (is a serious breathing disorder in obese individuals characterized by chronic daytime increased carbon dioxide in the blood and inadequate ventilation-moving air into and out of the lungs; causing low blood oxygen).During a review of Resident 1's Medication Administration Record (MAR), dated January 1st through 31st, 2026, the MAR indicated, an order for BIPAP.apply at bedtime. MAR indicated, X for each day in January, indicating the order was not performed.During a review of Resident 1's Medication Administration Record (MAR), dated February 1st through 28th, 2026, the MAR indicated, an order for BIPAP.apply at bedtime. MAR indicated, X for each day in February, indicating the order was not performed.During a review of Resident 1's Medication Administration Record (MAR), dated March 1st through 31st, 2026, the MAR indicated, an order for BIPAP.apply at bedtime. MAR indicated, X for each day in March, indicating the order was not performed.During an interview and concurrent Resident 1's clinical record review on 4/14/26, at 11:30 a.m., with Director of Nursing (DON), DON stated, she is covering as the DON for this facility. DON stated, she sees in the medical record Resident 1 had an order for Bipap. DON stated, the PM [afternoon shift] nurses are supposed to place the Bipap on the resident and document when it was carried out. DON stated, there is no documentation in the MAR that nurses applied the Bipap for Resident 1 for March 2026. DON stated, the order should specify the time the Bipap machine should be put on and removal time, it does not. DON further stated, she was aware of the importance of using a Bipap is to help the patient breath and correct their C02 [Carbon Dioxide] problem. DON stated, If the patient is not using it [Bipap] there is a chance for respiratory distress.2.During a review of Resident 1's Order Summary Report dated 3/13/26, report indicated Resident 1 had a physician order for Morphine Sulfate (a Schedule II controlled opioid medication with high potential for abuse that is used to manage severe acute or chronic pain, that carries significant risks of addiction, abuse, and life-threatening respiratory depression-breathing is too slow or shallow causing high carbon dioxide levels) 15 milligrams (mg, unit of measurement). Order indicated, Give 1 tablet by mouth every 6 hours as needed for severe pain (7-10/10), pain is rated on a numerical scale from zero (no pain) to 10 (worst pain imaginable); 1-3 for mild pain, 4-6 for moderate pain and 7 -10 for severe pain.During an interview on 4/14/26, at 11:38 a.m., with DON, DON stated, it is her expectation the nurses follow all physician orders for pain medication. DON further stated, the nurses should follow the pain level verbalized by the patient [resident] and give the pain medication that corresponds to the number given by the resident and the order directions. DON stated, we should be giving the least powerful [strength] pain medication needed to resolve the pain.During a concurrent interview and record review on 4/14/26, at 11:53 a.m., with DON, Resident 1's MAR dated March 2026 was reviewed. The MAR indicated, Resident 1 was administered Morphine Sulfate 15 mg on 3/15/26 at 1638 (4:38 p.m.) with a pain level charted as 5 (moderate pain) administered by Licensed Nurse (LN 1). MAR indicated, Resident 1 was also given Morphine Sulfate on 3/16/26 at 1817 (6:17 p.m.) with a pain level charted as 6(moderate pain) administered by LN 1. DON stated, the two administrations above were not appropriate based on the pain level charted and as per the physician orders. DON further stated, there is a potential for adverse effects if a resident is given a pain medication stronger than their stated pain, one of them for Morphine is respiratory distress.During a review of Resident 1's Change in Condition dated 3/16/26, at 2145 (9:45 p.m.) indicated, Shortness of breath.-Pulse oximetry [the measure of oxygen saturation in the blood, normal value is considered around 95-100%] O2 [oxygen] 46.0%. Change in condition further indicated, Notified MD resident was sent out [to Hospital 1] for SOB [shortness of breath].During an interview on 4/16/26, at 1:44 p.m., with LN 1, LN 1 stated, she was the nurse who gave Resident 1 Morphine on 3/16/26 at approximately 6 p.m. LN 1 stated, on 3/16/26 around 9 p.m. another staff member approached her and asked her to check on Resident 1. LN 1 stated she checked on Resident 1 who was in her room in her wheelchair complaining of shortness of breath. LN 1 stated, she checked her oxygen saturation and she was desaturating (experiencing low blood oxygen (hypoxemia)). LN 1 stated, so I gave her some oxygen. When I rechecked it [oxygen level] it kept desaturating and I called 911. LN 1 stated, When the paramedics came they said she [Resident 1] was in distress and they had to increase the oxygen to 15 liters [a high flow oxygen setting used to treat severe low blood oxygen] with a mask on. LN 1 further stated, she saw paramedics take Resident 1 to the hospital, When I came back to work they said she [Resident 1] was diagnosed with an overdose.During a review of Resident 1's ED [emergency department] Provider Note dated 3/16/26, from local Acute care hospital (Hospital 1), note indicated, Differential diagnosis [a step by step process to distinguish specific disease from others that present with similar symptoms] includes, but is not limited to: -Opiate overdose: Opiate overdose is likely given the recent administration of 15 mg morphine, associated lethargy [state of sleepiness or deep unresponsiveness], hypoventilation [breathing that is too shallow or slow to meet the body's needs, causing dangerous carbon dioxide buildup (hypercapnia) and low oxygen], and response to Narcan. -Acute respiratory failure with hypoxia [low oxygen level in blood]: Acute respiratory failure with hypoxia is present, evidenced by low oxygen saturation and cyanosis [a bluish discoloration of the skin, lips, or nail beds, typically caused by low oxygen levels in the blood], likely secondary to [a direct result] opioid-induced respiratory depression. -Acute encephalopathy: [group of conditions which cause brain dysfunction] Acute encephalopathy is present, manifested by confusion and inability to answer questions, likely secondary to hypoxia and opioid toxicity [overdose, degree of damage e.g. to vital organs]. ED provider note further indicated, 2335 [11:35 p.m.] Narcan given and patient became more alert and oriented. Tue [DATE], 0003 [12:03 a.m.] Required another 2 mg of IV [intravenous, through the vein] Narcan. Will start Narcan drip [continous intravenous infusions used to manage severe opiod overdose]. 0140 [1:40 a.m.] Narcan drip was initiated and [Resident 1's] symptoms did improve. She became more alert . Disposition: Admit to hospital Condition: Critical.During a review of Resident 1's General Discharge Summary from Hospital 1, dated 3/16/26-3/24/26 indicated, Reason for admission: Patient presents with: Altered mental status [sudden change in baseline mental status ranging from confusion, delirium to coma] : BIBA [brought in by ambulance] from [facility name] c/o [complaining of] ALOC [altered level of consciousness] and low sats [oxygen level in blood]. Per EMS [emergency medical services] patient found to be 50% on RA [room air] on their arrival. EMS states patient was given 15 mg morphine @ 1800 [6 p.m.]. Was given 4 mg of Narcan by EMS and patient became more responsive.History of Present Illness.Respiratory distress and hypoxemia [low oxygen levels in the blood] -episodes of cyanosis .Precipitating [immediate triggers or events or conditions leading to] factors and interventions -Received 15 mg of morphine at [facility name] around 6pm. DC summary further indicated, to stop taking Morphine Sulfate medication.3. During a review of Resident 1's Order Summary Report dated 4/14/26, report indicated, Naloxone was ordered on 3/24/26 (11 days after Morphine Sulfate was ordered).During an interview on 4/14/26, at 12:10 p.m., with DON, DON stated, Narcan should be ordered once the opioid is ordered. DON stated, Resident 1 was ordered Morphine Sulfate on 3/13/24, and was not ordered the Narcan until 3/24/26.During an interview on 4/14/26, at 12:27 p.m., with LN 2, LN 2 stated, When we order a narcotic [opioid] we also have to order Narcan as well.During an interview on 4/16/26, at 1:18 p.m., with Medical Doctor (MD) 1, MD 1 stated, he will reference his resident's medical record prior to ordering an opioid to make sure the medication is appropriate. MD 1 stated, Morphine Sulfate may not be appropriate for residents who are on dialysis (a life-sustaining treatment for kidney failure) or have chronic kidney disease stage 4 (severe kidney function loss) because the medication can stay in their system longer. MD 1 stated, Narcan should automatically be ordered when an opioid is ordered. MD 1 further stated, he ordered the Morphine for Resident 1. MD 1 stated, he could not find in the medical record the exact reason for ordering the medication Morphine Sulfate. MD 1 stated, he expects the nurses to follow the pain scale and give pain medications based on the order's listed pain level.During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 2025, the P&P indicated, 4. Medications are administered in accordance with prescriber orders.

Based on interview and record review the facility failed to provide quality care to one of two sampled residents (Resident 1) when:The facility failed to create specific and measurable care plan interventions for Resident 1's risk for elopement.The facility staff failed to follow physician orders for monitoring elopement attempts.These failures had the potential for Resident 1 to have an increased risk for elopement, had the potential for staff caring for Resident 1 to be unaware of his elopement attempt on 2/19/26 and had the potential to contribute to Resident 1's elopement attempt on 2/19/26.1.During a review of Resident 1's Facesheet dated 2/25/26, facesheet indicated, Resident 1 was admitted to the facility 29 days ago. Resident 1 had diagnoses including Respiratory failure, Falls, and Alzheimer's Disease (disease characterized by memory loss and cognition decline).During a review of Resident 1's Elopement Risk assessment dated [DATE], Assessment indicated, Resident was scored a 7 indicating he was a moderate elopement risk.During a review of Grievance Form dated 2/19/26, form indicated, [Resident 1's family member] states [Resident 2] called her & informed her that [Resident 1] left the building.During an interview on 2/25/26, at 11:05 a.m., with Resident 2, Resident 2 stated, he saw Resident 1 open the door and walk outside the conference room area.During a review of Resident 2's Brief Interview for Mental Status (BIMS- score is a 0-15-point assessment used in long-term care to measure cognitive function in orientation, memory, and attention. Scores indicate cognitive impairment levels: 13-15 Intact) dated 1/25/26, indicated, Resident 2 scored 15 indicating Resident 2 was cognitively intact.During an interview on 2/25/26, at 12:15 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she saw Resident 1 open the door to the conference room and walk out the door.During a concurrent interview and record review on 2/25/26, at 1:01 p.m., with Director of Nursing (DON), Resident 1's Care plan was reviewed. Resident 1's Care plan indicated, At risk for: elopement and wandering out of facility. Due to: Hx [history of] Elopement/Wandering and impaired Cognitive Function and Safety Perception.Interventions: Check resident's whereabouts. Care plan indicated, no instruction for how often or when to check resident's whereabouts. DON stated, the care plan intervention for Resident 1 does not specify how often to observe the resident, it is not specific.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. During a review of Resident 1's Order Summary dated 2/25/26 indicated, an order for Wandering/Elopement: Monitor number of times per shift resident attempts exit-seeking behavior, every day shift.start dated 1/30/26.During a concurrent interview and record review on 2/25/26, at 1:01 p.m., with DON, Resident 1's Medication Administration Record (MAR) dated February 2026 was reviewed. The MAR indicated, order for Monitor number of times per shift resident attempts exit-seeking behavior, every day shift was charted as 0 on 2/19/26. DON stated, the staff should have charted a 1 for his elopement attempt on 2/19/26.During a review of the facility's P&P titled, Wandering and elopements dated 2025, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.1. If identified as at risk for wandering, elopement, or other safety concerns, the residents care plan will include strategies and interventions to maintain the resident's safety.

Based on interviews and record review, the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 hit Resident 1, a deficient practice identified for one of four sampled residents.This failure resulted in an injury to Resident 1's lip.Findings:Resident 1 was admitted to the facility in late 2025 with diagnosis which included difficulty in walking, a fall with head injury, and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/8/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 8/15 which indicated moderately impaired cognition.Resident 2 was admitted to the facility in early 2025 with diagnosis which included dementia and an anxiety disorder.During a review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 13/15 which indicated intact cognition.During a review of Resident 1's IDT Notes [Interdisciplinary Team] dated 10/23/25, the IDT notes indicated, On 10/23/25 at 0730 [7:30 a.m.] CNA [certified nursing assistant] staff reported that upon entering [Resident 1 and Resident 2's room], [Resident 2] was observed standing beside [Resident 1]. who (sic) was laying in bed, making a closed fist contact with [Resident 1's] chest.Licensed nurse did note a minor laceration to the resident's upper lip.During an interview on 10/29/25 at 11:51 a.m. with CNA 1, CNA 1 stated when he opened the door to check on the residents during his morning rounds, he observed Resident 1 lying in his bed and Resident 2 hitting Resident 1 in the chest with a closed fist. CNA 1 stated Resident 1 told him Resident 2 had busted his lip. CNA 1 stated Resident 1 had a small amount of bleeding from his lip.During an interview on 10/29/25 at 12:32 p.m. with Resident 1, Resident 1 stated while he was in bed, Resident 2 came over to his bed and smacked him in the forehead. He stated he did not remember where else he was hit.During an interview on 10/29/25 at 12:45 p.m. with Resident 2, Resident 2 stated Resident 1 had been talking all day and had said something to me and I got ticked off.During an interview on 10/29/25 at 12:49 p.m. with Licensed Nurse (LN1) stated she was notified by CNA 1 that Resident 2 had struck Resident 1 around change of shift (approximately 7:30 a.m. on 10/23/25), LN1 assessed Resident 1 and noted a small cut to his upper lip.During an interview on 10/29/25 at 2:03 p.m. with the administrator (ADM), the ADM stated residents have the right to be safe in their environment.During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention Program, dated 12/24, the P&P indicated, Our residents have the right to be free from abuse.This includes but is not limited to.physical abuse.As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to.other residents.

Based on interview, and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents (Resident 1) when an allegation of abuse was not reported to the State Agency.This failure resulted in delays in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in September 2024 with diagnoses that included anxiety disorder (repeated episodes of sudden feelings of anxiety and fear or terror), dementia (a progressive state of decline in mental abilities), and depression (persistent feeling of sadness and loss of interest). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment.During a review of Resident 2's admission records, the records indicated Resident 2 was admitted in March 2025 with diagnoses that included metabolic encephalopathy (occurs when problems with metabolism cause brain dysfunction), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression, and delusional disorders (an illness where a person cannot tell what is real from what is imaginary). Resident 2's MDS indicated Resident 2 had severe cognitive impairment.During a review of the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), dated 8/4/25, the report indicated, .[Resident 2] was walking down the hallway toward nurses station passed [Resident 1's room] where [Resident 1] was sitting in her wheelchair. [Resident 1] was reaching for gloves and [Resident 2] went to reach for the same glove box. [Resident 2] then made contact with [Resident 1's] left arm with her right hand - with an open palm. [Resident 2] and [Resident 1] were immediately separated by staff and both assessed with no injuries noted. The report further indicated that the report was faxed to the ombudsman on 8/4/25 but not to the Department.During a review of Resident 1's Interdisciplinary (IDT) Notes, dated 8/7/25, the notes indicated, IDT met to discuss a report of an incident between 2 residents. On 8/4/25 approximately 0120 PM [1:20 p.m.] CNA [Certified Nursing Assistant] staff was walking down the hallway and observed [Resident 1] sitting in her wheelchair near her room and attempted to reach for a box of gloves. [Resident 2] was also observed to be reaching for the same box of gloves. [Resident 2] with an open palm made contact with [Resident 1's] left arm.Police and Ombudsman were notified. SOC 341 was faxed to the Ombudsman.During an interview on 8/8/25 at 10:33 a.m. with the Administrator (ADM), the ADM stated, .On 8/4/25, we filed a SOC to the ombudsman.We did not report to CDPH because both residents had dementia and there were no injuries.[the incident was ] Witnessed by CNA staff, [Resident 1] stopped [Resident 2] from getting the box, [Resident 2] held the arm that [Resident 1] used to grab the box. The ADM further stated the incident was reported to ombudsman but not to CDPH per the All-Facilities Letter (AFL - informs health facilities about changes in requirements, new technologies, scope of practice, or general information affecting them) 24-09.During an interview on 8/8/25 at 3:02 p.m. with the Director of Nursing (DON), the DON stated he was aware of the incident that happened on 8/4/25 between Resident 1 and Resident 2. The DON stated, .[Resident 2] was in the wheelchair and there was a glove box nearby.[Resident 2] was reaching for the glove box, [Resident 2] touched [Resident 1's] left arm.It was witnessed.Happened in 8/4/25.It was submitted to ombudsman, not to CDPH. The DON further stated the expectation is to report immediately any allegation of abuse and stated, .If aggressor has diagnosis of dementia, it is something that you have to report to ombudsman only and the police, no need to report it to CDPH.they need to know what's going on.and to conduct investigations and follow up. The DON added, .we're here to take care of them [residents] and we try to provide a safe place for the residents.During a telephone interview on 8/8/25 at 3:22 p.m. with CNA 1, CNA 1 stated, .I was pushing another resident in the wheelchair, I was in the hallway, I saw [Resident 2] reaching the box of gloves by [Resident 1's room].[Resident 1] tried to stop [Resident 2] and [Resident 2] didn't liked that so she tapped [Resident 1] on the left arm.During a review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting, revised 7/2025, the P&P indicated, All reports of resident abuse.shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.1. All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and their privacy was protected when curtains did not reach around the resident personal space and vertical blinds were broken or missing for five residents (Resident 19, 31, 7, 14, and 16) in a census of 55. These failures resulted in Resident 19 and Resident 7 feeling a lack of privacy and had the potential for shame or embarrassment for the residents. Findings: 1. Resident 19 was admitted to the facility spring of 2023 with diagnoses of muscle weakness and need for assistance with personal care. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 1/27/25, the MDS indicated Resident 19 had a moderately impaired memory. During a concurrent observation and interview on 2/24/25 at 9:36 a.m. with Resident 19, Resident 19's privacy curtain did not reach around the bed and eight out of 33 vertical blind slats covering the sliding glass door were missing. Resident 19 stated, I change my clothes right here [at the bedside]. Sometimes people come through here. They can see me .I'm just concerned about these blinds. I just don't like the blinds missing [people walk by outside]. There's no privacy with the window blinds [missing]. During a concurrent observation and interview on 2/24/25 at 9:38 a.m. with Certified Nurses Assistant (CNA) 1, CNA 1 verified the curtains did not reach around Resident 19's bed for privacy and eight vertical blind slats covering the sliding door were missing. 2. During an observation on 2/24/25 at 2:04 p.m. of Resident 31 and Resident 7's shared bedroom, the divider curtains did not reach around their beds for privacy. During a concurrent observation and interview on 2/24/25 at 2:06 p.m. with CNA 1, CNA 1 verified the curtains didn't reach around each bed to cover Resident 31 and Resident 7 and stated, If I was being changed, I wouldn't want others to see me naked. 3. Resident 14 was admitted to the facility in the winter of 2024 with diagnoses which included bowel and urinary incontinence and need for assistance with personal care. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had a severely impaired memory. During a observation on 2/26/25 at 12:20 p.m., Resident 14 was mumbling incoherently and unable to be interviewed. Resident 14's curtains did not reach around bed for privacy. During a concurrent observation and interview on 2/26/25 at 12:23 with CNA 3, CNA 3 verified Resident 14's curtains did not reach around the bed for privacy . 4. Resident 16 was admitted to the facility in the fall of 2023 with diagnoses which included muscle weakness and need for assistance with personal care. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was alert and oriented, able to make his needs known. During an observation on 2/24/25 at 10:40 a.m. in Resident 16's room, three slats were missing from the vertical blinds covering Resident 16's sliding door. One slat was broken half way down. During a concurrent observation and interview on 2/24/25 at 10:43 a.m. with Licensed Nurse (LN) 3, LN 3 verified three vertical blind slats were missing with another one broken in half. LN 3 stated, I'm not sure if it's been put in the log. [Resident 16 is] here mostly every day . During an interview on 2/25/25 at 9:07 a.m. with the Maintenance Supervisor (MS), MS stated, [Resident 31 and Resident 7's] curtains do not close . and verified multiple vertical blind slats were broken or missing. The MS stated, Housekeeping .should be checking that the curtains reach around the bed completely. If something is broken, they should put it in the maintenance log so I can fix it I don't always indicate in which room the slats were replaced. During an interview on 2/25/25 at 9:23 a.m. with the Environmental Services Manager (ESM), the ESM was asked about the curtains that did not reach around resident personal space. The ESM stated it would be embarrassing for someone to walk in on a resident who was being changed and not having curtains around them for privacy. During an interview on 2/27/25 at 7:37 a.m. with the Director of Nurses (DON), the DON stated, The residents should be offered privacy at all times during care . During a review of the facility policy and procedure (P&P) titled Quality of Life - Dignity, revised 2/24, the P&P indicated Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .Demeaning practices and standards of care that compromise dignity are prohibited .

Based on observation, interview, and record review, the facility failed to implement their medication storage policy when medications were not labeled with an opened date and an expired medication was available for use in the medication cart. These failures placed the residents at risk for receiving contaminated medications, medications with reduced potency or unpredictable results that could lead to complications over time. Findings: During a concurrent observation and interview on 2/25/25 at 10:09 a.m., with Licensed Nurse 5 (LN 5), medication cart two was found to contain the following unlabeled opened medications: 1. an inhaler of budesonide 160 mcg / formoterol fumarate dihydrate 4.5 mcg, 2. an inhaler of fluticasone furoate 200 mcg/vilanterol 25 mcg, 3. a vial of insulin lispro 100 units/ml. A review of the facility's document titled, Abridged List of Medications with Shortened Expiration Dates [ALMSED], undated, the ALMSED indicated, budesonide 160 mcg (micrograms, a unit of measurement)/formoterol fumarate dihydrate 4.5 mcg (drugs to aide in breathing) should be discarded three months (90 days) after opening. A review of the fluticasone furoate 200 mcg/vilanterol 25 mcg (drugs to aide in breathing) inhaler manufacturer box indicated to discard the product 42 days after opening. A review of the insulin lispro (medication to lower blood sugar) 100 units/ml (milliliter, a unit of measurement) vial manufacturer box indicated to discard the product 28 days after opening. During a concurrent observation and interview on 2/25/25 at 10:09 a.m., with Licensed Nurse 5 (LN 5), medication cart two also contained a bottle of expired cromolyn sodium 4% eye drops (eye drops for allergies) with an open date of 12/21/24. A review of the facility's document titled, Abridged List of Medications with Shortened Expiration Dates [ALMSED], undated, the ALMSED indicated, cromolyn sodium 4% eye drops should be discarded 60 days after opened. During a concurrent observation and interview on 2/25/25 at 10:09 a.m., LN 5 confirmed the three undated medications and an expired eye drops in the medication cart two. LN 5 indicated it was important to label medications with the opened date due to the possibility of decreased effectiveness past the manufacturer's recommended date. LN 5 also indicated expired medications should be disposed of. During a concurrent observation and interview on 2/25/25 at 4:10 p.m., with LN 6, medication cart one contained one opened unlabeled inhaler of fluticasone furoate 200 mcg/umeclidinium 62.5 mcg/vilanterol 25 mcg. LN 6 confirmed the inhaler was not labeled and should be, because it can expire. During an interview on 2/27/25 at 7:59 a.m., with the Director of Nursing (DON), the DON indicated she expected that facility staff to dispose of expired medications and staff to date and label medications that once opened. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised 4/19, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Staff did not wear a gown when providing high contact care to one resident (Resident 206) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)], 2. Staff didn't wash hands after providing care for a resident who had C Diff [Clostridium Difficile, bacteria that cause inflammation of the colon]; and 3.Tube feeding bottle was not labeled. These failures had the potential to contribute to the spread of infections for a facility census of 55 residents. Findings: 1. Resident 206 was admitted to the facility in February 2025 following joint replacement surgery to the left hip. Resident 206 was diagnosed with methicillin susceptible staphylococcus aureus infection (MRSA-a germ that is resistant to some antibiotics) and was admitted with a peripherally inserted central catheter (PICC-a long, thin tube that's inserted into a vein in the arm and ends in a large vein near the heart used to deliver antibiotics). Resident 206 was cognitively intact and her own responsible party, according to Resident 206's face sheet. During a review of Resident 206's care plan, dated 2/10/25, the care plan indicated, Use of enhanced barrier precautions for use of: indwelling medical device .PICC .related to risk of colonization with an MDRO. The care plan further indicated, Resident will have reduced risk of obtaining or spreading colonization with an (MDRO) during high-contact resident care activities. During a review of Resident 206's physician orders, dated 2/11/25, the physician orders indicated, Enhanced Barrier Precautions due to RUA (right upper arm) PICC. During a concurrent observation and interview on 2/25/25 at 9:22 a.m. in Resident 206's room with Certified Nursing Assistant 5 (CNA 5), CNA 5 was observed having physical contact with Resident 206, getting the resident up and changing her clothes without wearing a gown. An EBP sign was posted outside of Resident 206's room indicating, Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities .dressing .changing linens .providing hygiene .changing briefs or assisting with toileting. CNA 5 stated she had changed Resident 206's clothes, briefs, and bed linen without wearing a gown. CNA 5 stated, I think I was supposed to [wear gloves, gowns] when discussed the EBP sign that was posted outside the resident's room. During an interview on 2/25/25 at 9:35 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated CNA 5 was supposed to wear the gown during resident care for Resident 206. During an interview on 2/27/25 at 8:02 a.m. with Director of Nursing (DON), the DON stated residents on EBP had a sign placed in front of the resident's room along with a personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart. The DON stated the purpose of EBP was to prevent the spread of infection. The DON further stated she would expect a CNA to wear a gown and gloves for residents on EBP while assisting with dressing, changing briefs, and changing linens, without exception. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated 6/18/24, indicated, EBP include the use of glove and gown during high-contact care activities for residents .with indwelling medical devices. The policy further indicated, High-contact resident care activities include .dressing .providing hygiene .changing linens .changing briefs. In addition, the policy indicated, Indwelling medical device include .peripherally-inserted central catheters-PICCs. The policy further indicated, Post clear signage on the door or wall outside of the resident room .signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 49814 2. Resident 24 was admitted to the facility in January of 2025 with a diagnosis of intestinal obstruction. A review of Resident 24's Order Details, dated 2/21/25, indicated, Contact precautions [precautions requiring staff to wear a gown and gloves when providing care] r/t [related to] C Diff . Resident 26 was admitted to the facility in April of 2024 with diagnoses that included fistula of intestine (an abnormal connection between two parts of the intestine or between the intestine and another organ or the skin) and history of urinary tract infection. During an observation on 2/26/25 at 12:15 p.m., Certified Nursing Assistant 4 (CNA 4) was observed leaving the room of Resident 24 after performing care and entering the room of Resident 26. CNA 4 then left Resident 26's room and entered Resident 206's room. CNA 4 did not wash her hands with soap and water during this observation. During an observation on 2/26/25 at 12:25 p.m. with CNA 4, CNA 4 confirmed it was required for staff to wash their hands for residents on contact precautions for a C Diff infection. During an interview on 2/26/25 at 12:53 p.m. with the Infection Preventionist (IP), the IP indicated staff were required to wash their hands with soap and water after leaving a room on contact precautions for C Diff. The IP indicated that was to prevent the spread of infection by the C Diff pathogen. During a review of the facility's Policy and Procedure (P&P) titled, Clostridium Difficile, undated, the P&P indicated, Steps toward prevention and early intervention include .Frequent hand washing with soap and water by staff and residents .When caring for residents with CDI [C Diff infection], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR [alcohol-based hand rub, hand sanitizer that doesn't require running water] for the mechanical removal of C. difficile spores from hands. 3. Resident 1 was admitted to the facility in March of 2005 with diagnoses that included adult failure to thrive and dysphagia (difficulty swallowing). During a concurrent observation and interview on 2/24/25 at 10:21 a.m., with LN 2, Resident 1's gastrotomy tube (a tube placed into the gut to administer nutrition) feeding bottle was unlabeled. LN 2 confirmed the finding and indicated the bottle should be labeled since the bottles were only good for a certain amount of time once opened. During an interview on 2/27/25 at 7:59 a.m., with the DON, the DON indicated her expectation for staff was to label gastrotomy tube feeding bottles with the date, time, and rate of feed. During a review of the facility's P&P titled, Enteral Feedings, undated, the P&P indicated, On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

Based on observation, interview and record review the facility failed to accommodate resident needs when one of 15 sampled residents (Resident 27) call light was not within reach. This failure increased the risk that Resident 27's needs would go unmet. Findings: Resident 27 was admitted to the facility in fall of 2017 with diagnoses which included lung disease, muscle weakness, need for assistance, long term pain, the most advanced stage of eye disease that severe damage to the optic nerve, depression and anxiety. During a review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 2/6/25, the MDS indicated Resident 27 had moderate memory impairment and no impairment of her arms and legs. During a review of Resident 27's physician progress note (PPN), dated 2/6/25, the PPN indicated Resident 27 was on inhalers . [had] chronic pain .at high risk for .falls . During a review of Resident 27's care plan (CP) titled, [Resident 27] .is observed to have ability to use call light, gross and fine hand motor function intact, was dated 11/1/24. During a review of Resident 27's CP titled, [Resident 27 is at risk for falls ., dated 11/24, the CP indicated, Be sure The (sic) resident's call light is in reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . During a concurrent observation and interview on 2/24/25 at 1:42 p.m. with Resident 27, Resident 27's call light was on the chest of drawers behind the resident but she indicated she was unable to reach it to call staff. During a concurrent observation and interview on 2/24/25 at 1:44 p.m. with Certified Nurses Assistant (CNA) 1, CNA 1 verified the observation and said, No it's [call light] not in reach for her. It should be in reach. During an interview on 2/27/25 at 7:37 a.m. with the Director of Nurses (DON) , the DON was asked her expectations regarding the resident call lights and said, The call lights should be accessible at all times. During a review of the facility policy and procedure (P&P), titled Answering the Call Light, dated 9/24, the P&P indicated When the resident is in bed .be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to meet professional standards for two of 15 sampled residents (Resident 206 and Resident 19), when: 1. Resident 206's peripherally inserted central catheter's dressing (PICC, a long, thin tube that's inserted into a vein in the arm and ends in a large vein near the heart used to deliver antibiotics) was not changed per physician orders, 2. Resident 19 recieved metformin (a diabetes medication for blood sugar control) without food as ordered by the provider. These failures had the potential to result in a serious bloodstream infection for Resident 206 and upset stomach for Resident 19. Findings: 1. Resident 206 was admitted to the facility in February 2025 following joint replacement surgery to the left hip. Resident 206 was cognitively intact and her own responsible party, according to Resident 206's face sheet. During a review of Resident 206's physician orders, dated 2/10/25, the physician orders indicated, PICC .dressing change .every seven days. During a concurrent observation and interview on 2/24/25 at 12:26 p.m. with Resident 206 in Resident 206's room, the PICC dressing on Resident 206's right arm was dated 2/17/25. Resident 206 stated staff told her, It would be changed today. During a concurrent observation and interview on 2/25/25 at 8:48 a.m. with Resident 206 in Resident 206's room, the PICC dressing on Resident 206's right arm was dated 2/17/25. Resident 206 reported her dressing had not been changed. It was also observed that Resident 206 was receiving an antibiotic infusion of ceftriaxone through her PICC. During a concurrent observation and interview on 2/25/25 at 9:13 a.m. with Licensed Nurse 2 (LN 2) in Resident 206's room, LN 2 verified the date on the PICC dressing was 2/17/25. LN 2 stated, The order states to change .every seven days or if it's dirty. LN 2 stated physician orders were not followed and the dressing should have been changed Monday, 2/24/25. During a concurrent interview and record review on 2/26/25 at 12:33 p.m. with the Director of Nursing (DON), Resident 206's physician orders, dated 2/10/25, were reviewed. The physician orders indicated, PICC .dressing change .every seven days. The DON stated the (dressing change for Resident 206) was due on 2/24. The DON further stated changing the dressing past seven days is, .very dangerous .these are central lines .they go to the heart .the risk of infection is very high. The DON stated the nurse should have followed the physician orders. During a review of the facility's policy and procedure (P&P) titled, Midline Dressing Changes, dated April 2016, indicated, To prevent catheter-related infections .change midline catheter dressing .every 5-7 days. 49814 2. Resident 19 was admitted to the facility in March of 2023 with diagnoses that included Diabetes (disease where the body has poor blood sugar control) and hyperglycemic-hyperosmolar coma (coma induced by severely elevated blood sugar levels). A review of Resident 19's Order Details, dated 3/25/23, indicated, metFORMIN Oral Tablet 500 MG (Metformin HCL). Give 1 tablet by mouth two times a day for DM2 Twice a day with breakfast and dinner During an observation on 2/24/25 at 3:42 p.m. with LN 4, LN 4 administered metformin to Resident 19 without a meal or any observable snacks in the resident's room. During an interview on 2/25/25 at 3 p.m. with Resident 19, Resident 19 indicated she didn't have any snacks at her bedside and did not receive any food prior to her receiving her diabetes medications on 2/24/25 at 3:42 p.m. During an interview on 2/27/25 at 7:59 a.m., with the DON, the DON indicated diabetes medications should be given with food and her expectation from facility staff is to ensure food is available to resident to prevent hypoglycemia (low blood sugar levels). During a review of the facility's P&P titled, Administering Medications, revised April 2024, the P&P indicated, Medications are administered in accordance with the prescriber orders, including any required time frame .Medication administration times are determined by resident need and benefit, not staff convenience .

Based on observation, interviews and record reviews, the facility failed to ensure proper infection control was practiced when: 1. Dietary Staff (DS) was observed to touch the part of a fork that goes into the mouth with bare hands, and 2. DS did not perform hand hygiene (HH, hand washing) prior to putting on new gloves. These failures had the potential to increase the transmission of illness and infection among the 56 vulnerable residents of the facility. Findings: 1. During a concurrent observation and interview on 2/10/25 at 12:10 p.m., while arranging silverware for a resident ' s lunch tray, the DS acknowledged he touched the part of the fork that goes into the resident ' s mouth with his bare hands and he should not have. The Dietary Manager (DM), who was also present, verified seeing DS touching the part of the fork that goes into the mouth of the resident with his bare hands and stated it was not acceptable for infection control purposes. 2. During a concurrent observation and interview on 2/10/25 at 12:13 p.m., DS was observed to put a glove on his right hand without performing HH prior. DS verified he did not perform HH prior to putting on the new glove. The DM who was also present, verified DS did not performed HH prior to putting on a new glove. During an interview on 2/10/25 at 12:49 p.m., the DM stated staff should always perform HH prior to putting on new gloves for infection control purposes. The DM stated the facility cared for residents who are immunocompromised (weakened immune system, making residents more susceptible to infection) and could easily get an infection. The DM added, not practicing infection control, such as HH, could result in transfer of bacteria from hands to food which could result to gastrointestinal (GI, related to stomach and intestines) illness and put the residents' safety at risk. During an interview on 2/10/25 at 12:58 p.m., the Director of Nursing (DON) stated staff should not touch the part of the utensil that goes into the residents ' mouths with their bare hands and should perform HH prior to putting on new gloves for infection control. The DON stated not performing HH could transfer bacteria from hands to the resident or their food, which could make them sick from GI illness. A review of the facility ' s policy and procedure titled, Handwashing/Hand Hygiene, revised in 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use . soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after handling an invasive device . Before and after eating or handling food . Perform hand hygiene before applying non-sterile gloves .

Based on observations, interviews and record reviews, the facility failed to ensure residents were provided a clean and safe environment when: 1. A.the floor were sticky in rooms [ROOM NUMBERS]. B.the tissue was touching the floor in room [ROOM NUMBER]'s bathroom. C.there was a brownish colored material on the floor in room [ROOM NUMBER]'s bathroom. D.there were multiple clothes hanging in the towel rack in room [ROOM NUMBER]'s bathroom and a purple colored sweat pants was seen on the floor in room [ROOM NUMBER]. E.there was a stack of basin on top of the paper towel dispenser in room [ROOM NUMBER]. F. there was a brownish material smeared on the toilet bowl seat which staff identified as feces. 2. there was a hole in room [ROOM NUMBER]'s bathroom door. These failures resulted in an unclean, unsanitary and unsafe environment for the residents in rooms [ROOM NUMBERS]. These failures were also an infection control issue which could result in cross contamination and could result in residents getting sick with GI (gasto-intestinal; stomach) illness and skin infections. The hole on room [ROOM NUMBER]'s bathroom door was a safety risk and could lead to residents acquiring cuts, abrasions, and splinters. Findings: A review of Resident 1's face sheet (demographics) indicated she was admitted on [DATE] with a diagnoses of Essential Hypertension (HTN, high blood pressure), Sciatica (pain that starts in your lower back or buttock and radiates down your leg) and Anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). Her Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) dated 4/3/24 score was 15 indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). 1. During a concurrent observation and interview on 6/4/24 at 2:45 p.m., Unlicensed Staff A verified the following: Rm 20's floor were sticky, there were 2 brownish stain/material on the bathroom floor which Unlicensed Staff A identified as probably poop , there were 3 clothes hanging on the towel rack in the bathroom and the tissue paper was touching the bathroom floor. Unlicensed Staff A stated this was a big infection control issue. Unlicensed Staff A stated the floor was sticky because it was probably not cleaned well enough. Unlicensed Staff A stated the floor should not be sticky, there should be no clothes hanging on the towel rack, no tissues touching the bathroom floor and the bathroom should be clean for infection control purposes. Unlicensed Staff A stated the clothes should not be hanging on the towel rack because they don't know if that was clean or dirty and resident might put the clothes back on. Unlicensed Staff A stated the tissue should not be touching the floor because the floor was dirty and contaminated and if a resident used the tissue, they might have cross contamination with the bacteria from the floor. Unlicensed Staff A stated it was a resident's right to ensure their environment was homelike, clean and safe. During a concurrent observation in room [ROOM NUMBER]'s bathroom and interview on 6/4/24 at 2:54 p.m., Unlicensed Staff A verified there was a brownish material smeared on the toilet bowl seat which Licensed Staff A identified as definitely a poop , there was a stack of basin on top of the paper towel dispenser and there was a purplish colored pants on the floor. Unlicensed Staff A also verified room [ROOM NUMBER]'s bathroom reeked of urine smell and the bathroom floor was sticky. Unlicensed Staff A stated these were unacceptable. Unlicensed Staff A stated the bathroom floor should not be sticky, there should not be clothes on the bathroom floor and the toilet bowl seat should not have a smeared poop. Unlicensed Staff A stated this was a big infection control issue. During an interview on 6/4/24 at 2:55 p.m., Licensed Staff B stated the bathroom floor should not be sticky. Licensed Staff B stated if the bathroom floor was sticky, it could be an indication the floor was not cleaned thoroughly. Licensed Staff B also stated there should be no brownish stain/material on the bathroom floor which could be poop or poop smeared in the toilet bowl seat. Licensed Staff B stated this was disgusting and was a big infection control issue. Licensed Staff B stated there should be no stack of basin on top of the paper towel dispenser. Licensed Staff B stated those basin should not be used and should be discarded because it was now considered dirty. Licensed Staff B stated it was not acceptable to place clothes on the towel rack or on the floor because you would not know whether resident would put this on again which could result to possible cross contamination. Licensed Staff B stated it was important to ensure residents were in a clean environment and residents were protected from infection due to environmental factors such as dirty bathrooms and floors. Licensed Staff B stated it was also a resident's right to have a clean and safe environment. During an interview on 6/4/24 at 3:05 p.m., Resident 1 stated the facility over all cleanliness could be improved. During an interview on 6/4/24 at 3:10 p.m., Licensed Staff C stated sticky floor meant the floor was not cleaned thoroughly. Licensed Staff C stated the bathroom floor should not have any brownish stains or materials, no clothes on the floor or the towel rack, no stack of basin in the paper towel dispenser and the tissue paper was not supposed to touch the floor. Licensed Staff C also stated the toilet bowl seat should not have any smeared bowel movement. Licensed Staff C stated this was disgusting and should have been cleaned right away. Licensed Staff C stated these were big infection control issues and could lead to residents getting sick. Licensed Staff C stated it was a resident right to have a clean bathroom and to live in a clean and safe environment. During an interview on 6/4/24 at 3:15 p.m., Housekeeping D stated the floors should not be sticky. Housekeeping D stated a sticky floor could be an indication the floor was not thoroughly cleaned. Housekeeping D stated it was not acceptable to have a smeared poop on the toilet bowl seat. Housekeeping D stated the tissue should not touch the floor and there should be no clothes on the bathroom floor or on the towel rack. Licensed Staff D stated all of these were an infection control issue and residents could get sick and infected through contaminated and dirty items. During an interview on 6/4/24 at 3:25 p.m., the Director of Nursing (DON) stated it was not acceptable to have a sticky floor, to have the tissue touching the floor, to have a stack of basin on top of the paper towel dispenser, to have brownish stain/material on the bathroom floor or have a bowel movement smeared on the toilet bowl seat, to have clothes on the bathroom floor or have clothes hanging on the towel rack in the bathroom. The DON stated these were an infection control issue. When asked if it was a resident right to live in a clean and safe environment, the DON stated yes. When sked if a sticky floor, having a tissue touching the floor, having a stack of basin on top of the paper towel dispenser, having a brownish stain or material on the bathroom floor, having bowel movement smeared on the toilet bowl seat, having clothes on the bathroom floor and clothes hanging on the towel track meant the resident was living in a clean environment, the DON stated I get it. During an interview on 6/4/24 at 3:33 p.m., Unlicensed Staff E stated sticky floor meant it was not cleaned thoroughly. Unlicensed Staff E stated it was not acceptable to have tissue touching the floor, to have a stack of basin kept in the paper towel dispenser, to have a poop smeared in the toilet bowl seat or to have clothes hanging on the towel rack or left on the floor. Unlicensed Staff E stated these were all an infection control issue and residents could get sick if they use these contaminated items. During an interview on 6/4/24 at 3:35 p.m., Licensed Staff F stated it was not acceptable to have a sticky floor, to have tissue touching the floor, to have a stack of basin on top of the paper towel dispenser in the bathroom, to have clothes on the bathroom floor or hanging on the towel rack. Licensed Staff F stated it was not acceptable and it was disgusting to have a brown colored discoloration or material on the bathroom floor or a bowel movement smeared on the toilet bowl seat. Licensed Staff F stated it was a resident's right to live in a safe and clean environment. Licensed Staff F stated these were all an infection control issue and could result to cross contamination which could lead to residents getting sick. A review of the facility's policy and procedure (P&P) titled Cleaning and Disinfection of Environmental Surfaces revised 8/2019, the P&P indicated housekeeping surface will be cleaned in regular basis, when spills occurs and when these surfaces were soiled .spills of blood and other potentially infectious materials be promptly cleaned . 2. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 2:45 p.m., Unlicensed Staff A stated the hole on room [ROOM NUMBER]'s bathroom door had been there for a while. When asked if this hole had been reported to the maintenance, Unlicensed Staff A stated she did not know. When asked if it was important to get this fixed, Unlicensed Staff A stated yes for safety purposes. Unlicensed Staff A stated residents might touch the hole in room [ROOM NUMBER]'s bathroom and have splinters on their hand. Unlicensed Staff A stated it was a resident right to live in a safe, clean and home like environment. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 3:30 p.m., the DON stated the hole in room [ROOM NUMBER]'s bathroom door appeared like it had been there for a while. The DON stated this should be repaired right away for residents' safety. The DON stated it was a safety risk for cuts and abrasion. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 3:32 p.m., the Maintenance Director (MD) stated the hole on room [ROOM NUMBER]'s bathroom door hole did not look like it was recent. The MD stated the hole appeared like it had been there for a while. The MD stated it appeared like staff were trying to cover it with something based on the presence of tape around the hole. The MD stated staff did not report this to him, so it was not fixed. The MD stated for safety purposes, this hole should be fixed. The MD stated resident might put their hand on the hole which could result in cut and splinters. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 3:33 p.m., Unlicensed Staff E stated the hole in room [ROOM NUMBER]'s bathroom door was not new and had been there for a while. Unlicensed Staff E stated this should be fixed for residents' safety. Unlicensed Staff E stated this hole put residents at risk for cuts and abrasions. During an interview on 6/4/24 at 3:35 p.m., Licensed Staff F stated the hole on room [ROOM NUMBER]'s bathroom door had been there for a while. Licensed Staff F stated she was not sure if anyone reported this to the maintenance yet. Licensed Staff F stated she was not sure why it had not been fixed yet. Licensed Staff F stated the hole should be fixed by maintenance because this hole put residents at risk for getting splinters or cuts. A review of the facility's policy and procedure (P&P) titled Maintenance Services , undated, the P&P indicated the maintenance department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times .functions of the maintenance personnel include maintaining the building in good repair

Based on observations, interviews and records review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free from accidents, when: 1. The facility did not provide two-person assistance to Resident 1 during care, when Resident 1 was dependent (resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) from staff to maintain perineal hygiene (washing the genital and rectal areas of the body) and to turn in bed. This failure resulted in Resident 1 rolling over while receiving perineal care and falling on the other side of the bed sustaining a left tibia (the inner and usually larger of the two bones of the leg between the knee and ankle) fracture (a break on the bone). 2. The facility staff took more than an hour to answer Resident 2's call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 2 turned on her call light for assistance to use the toilet. This failure resulted in Resident 2 falling on the floor while attempting to get out of bed without staff assistance, causing Resident 2 to experience neck pain and headache. Resident 2 subsequently was sent to the hospital for complaint of dizziness. Findings: Resident 1 A review of the Admission Record indicated Resident 1 was admitted on [DATE], with diagnoses including but not limited to Cerebral Infarction (also known as stroke) and Muscle Weakness. A review of the Activities of Daily Living (ADL - the tasks of everyday life like eating, dressing, getting into or out of a bed or chair, turning in bed, taking a bath or shower, and using the toilet), Care Plan, revised on 9/23/21, indicated Resident 1 was totally dependent on staff for all ADLs. A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 3/15/24, indicated Resident 1 had a BIMS score of 02 out of 15 points (Brief Interview for Mental Status, a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 00 to 07 is severe impairment). The MDS indicated Resident 1 had functional limitations in range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) to both upper and lower extremities. The MDS indicated Resident 1 was dependent on staff to maintain perineal hygiene and to turn in bed. A review of the Progress Note, dated 3/22/24 at 7:11 a.m., indicated around 6 a.m. on 3/22/24, Resident 1 fell out of bed. The Progress Note indicated Resident 1 had contusion (also known as bruise) and swelling close to her right eye. Resident 1 also had left shin swelling and bruising. The Progress Note indicated the NP (Nurse Practitioner - nurse who has advanced clinical education and training) ordered an X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) and to send Resident 1 out to the hospital if her condition changed. A review of the X-ray report, dated 3/22/24 at 11:29 a.m., indicated Resident 1 had left tibia fracture. A review of the Progress Note, dated 3/23/24 at 1 a.m., indicated Resident 1 returned to the facility around 11 p.m., with a cast (holds a broken bone in place and prevents the area around it from moving as it heals) above her left knee. The Progress Note indicated Resident 1 had a fracture to her left tibia. During an interview with Unlicensed Staff A on 5/03/24 at 10:54 a.m., when Unlicensed Staff A was asked how much assistance was needed to turn Resident 1 in bed, Unlicensed Staff A stated Resident 1 was dependent from staff with turning and repositioning. When Unlicensed Staff A was asked how many staff were required to assist dependent resident with turning in bed, Unlicensed Staff A stated at least two staff. She stated Resident 1 had contractures (a fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement of the associated body part) and could not help with turning. She stated she would always ask another staff to help her when providing care, for safety. During an interview with Licensed Staff B on 5/03/24 at 11:02 a.m., when Licensed Staff B was asked how much assistance was needed to turn Resident 1 in bed, Licensed Staff B stated Resident 1 was dependent on staff with turning and repositioning. During an observation in Resident 1's room on 5/03/24 at 11:08 a.m. with Licensed Staff B, Resident 1 was sitting on a geriatric chair (a large, padded chair that is designed to help seniors with limited mobility) with her right leg flexed and left leg extended. Resident 1 appeared uncomfortable, grimacing, face reddened and moaning. Resident 1 was nonverbal. During an interview with the Director of Nursing (DON) on 5/03/24 at 11:11 a.m., when the DON was asked about the fall incident on 3/22/24, involving Resident 1, the DON stated, when Unlicensed Staff C was providing care to Resident 1, Resident 1 inadvertently moved and accidentally fell on the other side of the bed. The DON stated Unlicensed Staff C could not move fast enough on the other side of the bed to catch Resident 1. When the DON was asked how many staff was required to assist a dependent resident with turning in bed, the DON stated usually one to two staff. During a telephone interview with Unlicensed Staff C on 5/03/24 at 12:16 p.m., when Unlicensed Staff C was asked about the fall incident involving Resident 1, Unlicensed Staff C stated he was providing care to Resident 1 when the incident happened. He stated Resident 1 was turned on her side when Resident 1 suddenly moved, rolled over and fell out of bed. When Unlicensed Staff C was asked how much assistance was needed to turn Resident 1 in bed, Unlicensed Staff C stated Resident 1 was dependent on staff with two-person assist. However, he stated he had been providing care to Resident 1 with no help from other staff for a long time and was familiar with Resident 1. Resident 2 A review of the Admission Record indicated Resident 2 was admitted on [DATE], with diagnoses including but not limited to left side Hemiplegia (the loss of the ability to move [and sometimes to feel anything] one side of the body) and Hypertension (high blood pressure). A review of the MDS, dated [DATE], indicated Resident 2 had a BIMS score of 14 out of 15 (a score of 13 to 15 is cognitively intact). The MDS indicated Resident 2 required Substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting, hygiene; toilet transfer; and chair/bed-to-chair transfer. Resident 2 was always incontinent (unable to voluntarily control retention of urine or feces in the body) with bowel and bladder function. A review of the ADL Functioning with Self-Care Deficit Care Plan, initiated on 3/25/24, indicated Resident 2 required substantial assistance with ADL. A review of the Progress Note, dated 4/23/24 at 8:01 p.m., indicated Resident 2 was found lying on her right arm on the left side of the bed and complained of neck pain and headache on 4/23/24. The Progress Note indicated Resident 2 was subsequently sent to the hospital on 4/23/24, for complaint of dizziness. During an interview with Unlicensed Staff D on 5/03/24 at 10:57 a.m., when Unlicensed Staff D was asked how much assistance was needed to transfer Resident 2 from her bed/wheelchair-to-bed, Unlicensed Staff D stated Resident 2 was dependent with transfer requiring two staff assistance. During an interview with Licensed Staff B on 5/03/24 at 11:05 a.m., when Licensed Staff B was asked how much assistance was needed to transfer Resident 2 from her bed/wheelchair-to-bed, Licensed Staff B stated Resident 2 was dependent with transfer requiring two staff assistance. During an interview with DON on 5/03/24 at 11:11 a.m., when the DON was asked about the fall incident on 4/23/24, involving Resident 2, the DON stated Resident 2 was taking Lactulose (used in the treatment of constipation (a problem with passing stool [poop]) and hepatic encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease) causing Resident 2 to have loose bowel movement. She stated the CNA (Certified Nursing Assistant) had just gone to Resident 2's room to provide bowel incontinence care. The DON stated, when Resident 2 turned her call light again for assistance, the CNA was busy assisting other residents, and when the nurse went to answer Resident 2's call light, Resident 2 was already on the floor. During an observation and concurrent interview with Resident 2 in her room on 5/03/24 at 11:27 a.m., Resident 2 was sitting in her wheelchair waiting for staff to assist her back to bed. She stated she had asked the staff thirty minutes ago to assist her back to bed because her back was hurting but nobody had come to help her. When Resident 2 was asked about her fall incident on 4/23/24, Resident 2 stated she turned her call light for assistance because she was, all covered with poop. She stated an unidentified staff came and told her she would be right back. Resident 2 stated one hour, and twenty minutes past but nobody came to help her, so she decided to get up to use the toilet and fell on the floor. Resident 2 stated she had neck pain, headache and felt dizzy after the fall and ended up going to the hospital. When Resident 2 was asked how much help she needed to transfer from her bed to her wheelchair, Resident 2 stated her left side was paralyzed (unable to move or feel all or part of the body), and she always needed two persons to help her. A review of the Facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised on March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting).

Based on observation, interview and record review, the facility failed to provide adequate infection control guidelines for Resident 1 ' s Permacath central line catheter (intravenous tube that is inserted into a main blood vessel in the chest). This failure resulted in Resident 1 ' s central line catheter tip becoming infected and needed to be replaced in the hospital. During a review of Resident 1 ' s medical record, History and Physical dated 1/25/24, authored by MD G, indicated Resident 1, was a [AGE] year-old man hospitalized for acute decompensated heart failure, end stage kidney failure, Diabetes, history of TIA (injury from lack of oxygen to the brain), deconditioning, (muscle weakness and wasting) and history of methamphetamine use. Fair rehab potential. During an interview with the DON on 3/4/23 at 1:45 p.m., in the conference room, DON stated Resident 1 was admitted for rehab and the Resident 1 would also be receiving dialysis (artificial kidney machine treatments that cleanse the toxins out of the body). DON stated, she was aware that Resident 1 was sent to the hospital with signs and symptoms of an infection. DON queried as to what the facility ' s central line policy and procedure is when a central line dressing becomes soiled or dislodged. DON stated she has instructed the staff not to change the dressing and to only reinforce the dressing. DON queried if the central line policy indicates the resident may shower with a central line. DON stated, she believes the central line policy indicates the resident should not shower with the central line due to an increased risk of getting the insertion site wet and therefore risk of infection. DON queried if Resident 1 came back from the hospital. DON stated she knows he did not return to the facility after his hospitalization . During a review of Resident 1 ' s medical record, MD (medical doctor) order summary dated 2/2/24, authored by MD G, indicated, Dialysis Days: Tuesday, Thursday, and Saturday at Dialysis Facility H. During a review of Resident 1 ' s medical Records from Dialysis Facility H, dated 1/23/24, lab results for Blood Cultures times two (test that looks for bacteria and fungi in the blood) were negative. During a review of Resident 1 ' s medical record, MD order summary dated, 2/2/24, authored by MD G, indicated, Permacath site, right upper chest, ensure dressing remains intact every shift. Check Permacath site right upper chest for color, warmth, and edema. Notify MD with changes, every shift. Dialysis Days: Tuesday, Thursday and Saturday at Facility H. During a review of Resident 1 ' s medical record, nurses note, dated, 1/25/24, authored by LVN C, indicated, Permacath minimal bleeding noted around catheter, dressing done. During a review of Resident 1 ' s medical record, nurses note, dated, 1/27/24, authored by LVN C, indicated, Resident 1 showered. During an interview with LVN C, on 3/5/24 at 4:00 p.m., LVN C was queried about the central line catheter policy and procedure regarding who can change a central line dressing. LVN C responded, she believes RNs administer all IV ' s and change central line dressings in the facility. LVN C queried about her nurses note written on 1/27/24 where it indicated, Permacath minimal bleeding noted around catheter, dressing done. LVN C queried if she changed the dressing. LVN C responded that she reinforced the dressing. LVN C queried if she notified MD G about the blood around the Permacath site. LVN C stated she doesn ' t believe she notified MD G. LVN C queried as to what dressing was over the tip of the Permacath catheter and could see the insertion site of the Permacath. LVN C responded, a gauze was around the Permacath catheter tip. LVN C queried as to how the facility can assess the insertion site if there is a bloody gauze over the tip of the catheter. LVN C, stated, she looks on the dialysis communication transfer form to see if the dressing has been changed, if the dressing is not noted as being changed on the dialysis communication form, then I do not know if the site has been assessed. LVN C queried if Resident 1 was showering with his Permacath. LVN C responded, yes, she knew Resident 1 was taking showers. During an interview with the LVN A on 3/5/24 at 2 p.m., LVN A queried if she ever changed the dressing on Resident 1 ' s Permacath. LVN A stated, she had not changed the dressing but did look at the dressing to see if it needed to be reinforced. LVN A queried if Resident 1 had taken showers with the Permacath. LVN A stated, yes, Resident 1 had been taking showers. During an interview with the Infection Preventionist LVN F, on 3/7/24 at 1:30 p.m., LVN F queried if the Permacath Central Line Policy indicated that Residents could shower with a Permacath. LVN F responded, she thinks she remembers the policy indicates the resident cannot shower with the Permacath. LVN F queried as to who can change a central line dressing. LVN F states, she knows that RNs are the only ones who can change a central line dressing. LVN F queried how she would know that Facility H is changing the dressing after a dialysis treatment. LVN F stated, she believes Facility H writes it on their Transfer Form. LVN F queried if she has completed staff in services on Infection Prevention, End Stage Renal Disease and Dialysis. LVN F stated, she has not. During a review of Resident 1 ' s medical record, Dialysis Transfer Form, dated 2/3/24, Dialysis Transfer Form observed to have no information about the Permacath site or that the dressing had been changed from Facility H post dialysis treatment. During a review of Resident 1 ' s Care Plan, dated 1/23/24, indicated, On admission, Resident 1 is at risk for unavoidable bleeding and infection from right upper chest Permacath due to End Stage Renal Disease with Hemodialysis; Risk of any occurrence of unavoidable bleeding and infection from dialysis central line site will be reduced through appropriate interventions. Document monitoring of dialysis site every shift and as needed for any evidence of nursing changes in condition to include (but not limited to): bleeding, vital signs, access site patency, breathing patterns/breath sounds, level of consciousness, low blood pressure, diaphoresis, paleness, Notify physician of any changes. During a review of Resident 1 ' s medical record, Change of Condition Form, dated 2/5/24, authored by RN B, indicated, Resident 1 had thrown up 2 times this early morning, feels dizzy around 9:00 a.m., not eating food or drinking, lethargic and less verbal, blood pressure 90/60, temperature 101 degrees, pulse 109 per minute, oxygen 87 % (percent oxygen in the blood), and respirations 26 per minute. Called 911 and sent Resident 1 to hospital. During a review of Resident 1 ' s medical records, Nurses noted, dated 2/8/24, authored by RN I, indicated, Follow up made from hospital, Resident 1 still on medical treatment from central line infection. Informed that he has a new central line in place. During a review of the contract between the facility and Dialysis Facility H, signed 2/14/23, indicated, Center Obligations, (c) If requested by Facility, Center may in its sole discretion, agree to provide instructional materials and an annual in-service training for Facility staff relating to the care of dialysis patients at no charge to Facility. Center makes no representations or warranties respecting the training described above, and center shall not be responsible for the acts of Facility ' s staff in connection with their care of Facility ' s patients including without limitation, the designated resident. During a review of Facility H ' s Permacath Central Venous Catheter Policy, revised October 2022, indicated, Education of patients with catheters that require a dressing should include the following: Sponge bath only, keep dressing site clean and dry, observe for signs and symptoms of infection and report any signs and symptoms of infection. During a review of the facility ' s policy and procedure titled, Facility Assessment 2024, dated 2024, indicated, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operation and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility ' s resident population, including, but not limited to, both the number of residents and the facility ' s resident capacity. Included in the list of facilities current diagnosis but not limited to is, End Stage Renal Disease and Sepsis. All residents are assessed prior to admission to assure that the facility can provide adequate care for the acuity of the Resident based on their diagnosis, health needs and the acuity of the other resident in the facility. The Facility must also provide staff competencies that are necessary to provide the level and types of care needed for the resident population. All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. During a review of the facility ' s policy and procedure titled, End stage Renal Disease Care of Resident, revised September 2010, indicated, Residents with End-Stage Renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: The nature and clinical management of ESRD (including infection prevention and nutritional needs); the type of assessment data that is to be gathered about the resident ' s condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD. During a review of the facility ' s policy and procedure titled, Hemodialysis Access Care revised, September 2010, indicated, Central Line Catheter, Care Immediately Following Dialysis Treatment, If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. Care of Central Dialysis Catheters: The central catheter site must be kept clean and dry at tall times. Bathing and showering are not permitted with this device. During a review of CDC National Standards, Guidelines for the Prevention of Intravascular Catheter-Related Infections dated 2011, # 6 Catheter Site Dressing Regimens 3) Replace catheter site dressing if the dressing

Based on observation, interview and record review, the facility failed to ensure a resident receive care consistent with professional standards of practice when one out of two sampled residents (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed 4 pressure ulcers: one stage 4 pressure ulcer (PU, the most serious type of pressure ulcer, it extend below the muscle, tendons, and in severe cases, the bone) on his sacrum (the bottom of the spine) and three stage 2 pressure ulcers (PU that extend through deeper tissue and fat but do not reach muscle or bone) on his right inner foot, left inner proximal (near the center) foot and left inner distal (away from the center) foot. These failures led to treatments with antibiotic (medicines that fight infections caused by bacteria) and debridement (the removal of dead or infected skin tissue to help a wound heal). These failures also led to Resident 1 not being able to reach his highest physical level of well-being. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Stage 4 Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone), Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). His MDS section M skin assessment indicated he was at risk for developing pressure ulcers and he had 1 stage 4 pressure ulcer and 2 stage 2 pressure ulcers. In comparison, Resident 1 ' s MDS assessment section M (skin assessment) dated 1/27/23 indicated he was at risk for developing pressure ulcers and he had no pressure ulcers at that time. The MDS assessment dated [DATE] indicated Resident 1 was not on a turning and repositioning program (turning people to change their body position to relieve or redistribute pressure). During an interview on 1/28/23 at 2:11 p.m., Unlicensed Staff A stated residents could have pressure ulcer due to staff not turning and repositioning residents every 2 hours and not providing incontinence care every 2 hours. Unlicensed Staff A stated staff try their best, but it was difficult for staff to turn, reposition and provide incontinence care to the residents every 2 hours when they were frequently short staffed. Unlicensed Staff A stated not turning and repositioning resident and not providing incontinence care every 2 hours could lead to the development of pressure ulcer and wound infection. Unlicensed Staff A stated residents could get sick and hospitalized . During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated to prevent pressure ulcer to develop, the facility policy was to ensure residents were provided incontinence care every 2 hours and as needed and turned and repositioned every 2 hours. Unlicensed Staff B stated these tasks were hard to follow as the facility was frequently short staffed. Unlicensed Staff B stated not turning and repositioning residents every 2 hours and leaving residents wet or soiled for prolonged time could lead to the development of pressure ulcer, pain and infection. During an observation on 11/28/23 at 2:51 p.m., Resident 1 was asleep while lying on his back. During a concurrent interview and electronic treatment administration record (eTAR, a system used by nurses in long term care facilities to ensure that treatment was rendered accurately and reliably) on 11/28/23 at 3:17 p.m., the MDS coordinator (a nurse that assess and evaluate the quality of care being given to long-term care residents)verified Resident 1 continued to be treated with an antibiotic per physician ' s order due to active wound infection and prophylaxis (all the things people do to prevent disease). During a concurrent interview and Braden skin assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcer)record review on 11/28/23 at 3:21 p.m., the MDS stated the initial Braden skin assessment done for Resident 1 on 7/17/2019 score was 17, indicating Resident 1 was at risk for pressure ulcer development. The MDS coordinator stated Resident 1 should have been placed on skin intervention such as turning and repositioning every 2 hours and incontinence care every 2 hours per facility policy. The MDS coordinator verified there was no wound Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) note created for the Resident 1 when he started acquiring pressure sores. The MDS coordinator stated there was no care plan that specifically addressed Resident 1 ' s risk factors for developing pressure ulcer when he was initially admitted . The MDS coordinator stated there were no care plans created when Resident 1 initially had an unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic (death of body tissue) tissue or by an eschar (dead tissue that sheds or falls off from the skin) pressure sore on his sacrum. The MDS coordinator stated Resident 1 ' s pressure ulcer care plan was not updated to reflect the status of the pressure ulcer on his right and left inner foot. The MDS coordinator stated the pressure ulcer care plan for sacrum and the right and left inner foot does not really reflect the current treatment being provided for the resident. The MDS coordinator stated care plans were supposed reflect current status, treatment and interventions being provided for the residents. The MDS coordinator stated that in this case, Resident 1 ' s care plan was not updated and was not reflective of Resident 1 ' s current pressure ulcer status. The MDS coordinator stated it was important a care plan was created and updated because this would help staff to determine what type of care the resident need. The MDS coordinator stated Resident 1 currently had 4 pressure ulcers, the biggest and the worst was the one on sacrum at stage 4. The MDS coordinator stated Resident 1 was admitted at the facility with no pressure ulcer. The MDS coordinator verified Resident 1 developed the pressure ulcers on his sacrum, right inner foot, left inner proximal foot and left inner distal foot at the facility. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated staff would need to closely monitor and assess residents for skin issues, turn and reposition residents at least every 2 hours and incontinence care should be provided every 2 hours to prevent pressure ulcer to develop. Licensed Staff C stated Resident 1 was dependent on staff for provision of care. Licensed Staff C stated Resident 1 ' s pressure ulcers could have been prevented if staff were monitoring and assessing Resident 1 ' s skin regularly and closely and Resident 1 was being turned and reposition every 2 hours regularly. Licensed Staff C stated it was difficult for staff to turn and reposition residents every 2 hours and provide incontinence care every 2 hours when the facility was frequently short staffed. When asked what could happen if residents were left in the same position for an extended period of time or if residents were left soiled or wet for extended period of time, Licensed Staff C stated residents could develop pressure ulcer, pressure ulcer will increase in size, pressure ulcer could worsen and wound infection could develop. During a visual observation on 11/28/23 at 4:48 p.m., Resident 1 was still in lying on his back. Resident 1 was observed in the same position as seen earlier today at 2:51 p.m. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated nurses were expected to document skin issues and treatment provided for the residents. The Administrator stated if the treatment order on the eTAR was left blank, it could mean that specific treatment was not done. The Administrator stated if it was not documented then it did not happen. When asked what the risk for missing treatment could be, he stated, if it was ordered by the physician then a treatment should be done. During a telephone interview on 11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to document skin status of the residents weekly, and every time there were skin issues. The DON stated to prevent the development of pressure ulcer, staff were expected to turn and reposition the residents every 1 to 2 hours and to offer incontinence care and toileting every 1 to 2 hours as needed. The DON stated residents not being turned and repositioned every 1to 2 hours and residents being left soiled and wet for extended period could develop pressure ulcer and wound infection. When asked what the risk for resident could be if they have a pressure sore and was left wet or soiled for extended period, the DON stated, the wound could worsen and there was a possibility of wound infection. During a telephone interview on 12/1/23 at 2:24 p.m., when asked if she was aware there were no weekly skin checks being completed for Resident 1, the DON stated no. When asked if she was aware the pressure ulcer care plan for Resident 1 was not updated and does not reflect the current status of Resident 1 ' s pressure ulcer and treatment, the DON stated they were trying to do better. The DON stated they knew it was an issue. The DON verified the nurses were signing off on the eTAR indicating they were assessing the resident skin weekly, however the facility was not able to provide documentations nurses were assessing Resident 1 ' s skin weekly. When asked what the risk for the residents could be if staff were not assessing the resident skin weekly, the DON stated staff could miss a skin issue that was starting to develop, and this skin issue could worsen. The DON stated treatment should be done per physician ' s order. The DON stated if an eTAR was left blank, then it meant the treatment was not done. The DON stated it meant the physician order was not followed. When asked what the risk could be if a treatment for pressure ulcer was missed, the DON stated the wound could worsen and could be infected. During a telephone interview on 12/1/23 at 3:19 p.m., the MDS coordinator verified Resident 1 did not have documentations his skin was being assessed by the nurses weekly. The MDS coordinator stated since there were no documentations nurses were completing the weekly skin assessment, it meant the skin assessment was not done by the nurses. The MDS coordinator stated skin assessments were important to ensure prompt identification of skin issues and implementation of prompt treatment. When asked what the risk for the resident could be if staff were not assessing the residents ' skin weekly, the MDS coordinator stated staff could miss a skin impairment and may miss acquiring an appropriate treatment. The MDS coordinator stated this could result to worsening of the skin impairment, infection, and hospitalization . When asked what the risk could be if staff missed rendering a pressure ulcer treatment for a resident, the MDS coordinator stated wound could worsen and could get infected. A review of Resident 1 ' s eTAR indicated staff were signing the eTAR indicating they had completed a skin assessment audit once a week, the facility was not able to provide weekly skin assessments documentation for these dates: on 2/2023: 2/7/23, 2/14/23, 2/21/23 and 2/28/23, for 3/2023: 3/7/23, 3/14/23, 3/21/23 and 3/28/23, for 4/2023: 4/4/23, 4/11/23, 4/18/23 and 4/25/23, for 5/2023: 5/2/23, 5/9/23, 5/16/23, 5/23/23 and 5/30/23, for 6/2023: 6/6/23, 6/13/23, 6/20/23 and 6/27/23, for 7/2023: 7/4/23, 7/11/23, 7/18/23 and 7/25/23, for 8/2023: 8/1/23, 8/8/23, 8/15/23, 8/22/23 and 8/29/23, for 9/2023: 9/5/23, 9/12/23, 9/19/23 and 9/26/23, for 10/2023: 10/3/23, 10/10/23, 10/17/23, 10/24/23 and 10/31/23, for 11/2023: 11/7/23, 11/14/23, 11/21/23 and 11/28/23. A further review of Resident 1 ' s eTAR indicated the nurses missed the pressure ulcer treatments for Resident 1 on these dates in 2/2023: 2/18/23, 2/19/23 and 2/21/23, in 3/2023: 3/16/23 and in 4/2023: 4/4/23, 4/5/23, 4/6/23 and 4/13/23. A review of Resident 1 ' s medical record indicated there were no wound IDT notes created for Resident 1 when he started developing pressure ulcers. There were no IDT notes created for the stage 4 pressure ulcers on his sacrum, right inner foot and left proximal inner foot and left distal inner foot. A review of Resident 1 ' s pressure sore ulcer plan indicated he was started on antibiotic on 3/29/23 for wound infection. The pressure ulcer care plan did not indicate how to prevent Resident 1 from acquiring pressure ulcers, worsening of pressure ulcer and preventing his pressure ulcers from getting infected. The pressure ulcer care plan was not accurate and did not reflect the status of Resident 1 ' s pressure ulcer. The pressure ulcer care plan did not accurately reflect the current treatments for Resident 1 ' s pressure ulcers. There was no care plan created for the stage 2 pressure ulcer on Resident 1 ' s left proximal inner foot and left distal inner foot. A review of Resident 1 ' s MDS assessment dated [DATE] indicated Resident 1 was always incontinent of bowel and bladder and he was at risk for developing pressure ulcer but he had no pressure ulcer at that time. It also indicated he was not on turning and repositioning program. A review of Resident 1 ' s MDS assessment dated [DATE] indicated he was at risk for developing pressure ulcers and he had 2 stage 2 pressure ulcers and 1 stage 4 pressure ulcer. It also indicated Resident 1 was still not on turning and repositioning program. A review of Resident 1 ' s Admission/Readmission Skin assessment dated [DATE] indicated he had no pressure ulcer. The Admit/Readmission Assessment V2 dated 2/14/23 indicated there were no pressure sore noted however the wound communication log with the physician dated 2/8/23 indicated Resident 1 already had an unstageable pressure ulcer on his sacrum. The Admit/Readmission assessment dated [DATE] indicated Resident 1 had a stage 4 pressure ulcer on his Coccyx with foul odor and copious (abundant) exudate. The wound communication log with the provider dated 3/29/23 indicated Resident 1 was started on oral antibiotic twice a day for 7 days for wound infection. A review of the nurse progress note dated 11/7/23 11:42 indicated Resident 1 was on antibiotic for wound infection on left foot and sacrum. A review of the facility ' s policy and procedure (P&P) titled Pressure Injury Risk Assessment, revised 3/2020, the P&P indicated the purpose of the pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot .risk factors that increases risk susceptibility to develop or to not heal pressure injury include malnutrition, impaired/decreased functional mobility, exposure of skin to urinary and fecal incontinence, altered skin status over pressure points .the risk assessment should be conducted as soon as possible after admission not later than 8 hours after admission was completed .once the assessment is conducted and risk factors identified and characterized, a resident centered care plan can be created to address the risk factors .repeat the risk assessment weekly for the first 4 weeks, if there is a significant change in condition or as often as required based on resident ' s condition.conduct a comprehensive skin assessment with every risk assessment .if a new skin alteration is noted, initiate a (pressure or non pressure sore) form related to the type of alteration in skin .develop an resident centered care plan and interventions based on the risk factors identified . effects of the interventions must be evaluated .care plan must be modified as the resident ' s condition changes or if current interventions are deemed inappropriate.

Based on observations, interviews and record reviews, the facility failed to ensure residents were provided an environment that is free from accident hazards over which the facility has control when staff failed to identify, evaluate, analyze hazards and risks and implement interventions to reduce hazards and risks for using a low air loss mattress (LAL, an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to prevent avoidable accidents for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 fall incident on 11/4/23 and Resident 1 being sent to the hospital for further evaluation and treatment. This fall incident also resulted in Resident 1 sustaining a laceration (a cut, referring to a skin wound which tends to be caused by blunt trauma- an injury of the body by forceful impact such as falls) on his anterior scalp (located just in front of the head). The fall also resulted in swelling, contusion (a bruise, an injury in which the skin is not broken), hematoma (a collection of blood outside of blood vessels) and small areas of subarachnoid hemorrhage (bleeding in the space that surrounds the brain) in the left frontal (front most part of the brain, important for voluntary movement, expressive language and for managing higher level executive functions) and temporal lobes (part of the brain that sits behind the ear, functions include hearing, memory and learning) of his brain. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone) stage 4, Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). During an interview on 11/28/23 at 2:11 p.m., Unlicensed Staff A stated to prevent falls, staff should monitor residents every 30 minutes. Unlicensed Staff A stated residents who were unable to move in bed should still be monitored and ensured they were in the right position in bed, so they do not roll off the bed. Unlicensed Staff A stated bed should be in lowest position to prevent injury when a resident falls. Unlicensed Staff A stated sometimes staff could not monitor resident frequently or every 30 minutes because they have a lot of residents to care for so resident sometimes end up on the floor with injury. When asked if staff regularly monitors his LAL mattress to ensure it was working properly and not deflated, she stated no. During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated Resident 1 was dependent on staff for provision of care. Unlicensed Staff B stated Resident 1 hardly moves in bed. Unlicensed Staff B stated falls usually happens when there ' s short staffing. Unlicensed Staff B stated Resident 1 ' s bed was about at hip level when he fell . Unlicensed Staff B stated for some reason, Resident 1 ' s bed could not really be placed in lowest position. Unlicensed Staff B stated Resident 1 was a fall risk so his bed should be in the lowest position to prevent injury in case he falls. Unlicensed Staff B stated the facility ' s fall policy was to monitor residents every 2 hours or more if needed. Unlicensed Staff B stated sometimes it was difficult to monitor residents every 2 hours especially if they were short staffed. During an interview on 11/28/23 at 3:25 p.m., Licensed Staff C stated Resident 1 was a high fall risk. To prevent falls, Licensed Staff C stated staff should be monitoring residents every 2 hours. Licensed Staff C stated Resident 1 was totally dependent on staff for provision of care. Licensed Staff C stated Resident 1 was mostly in bed. During an interview on 11/28/23 at 3:27 p.m., the Minimum Data Set coordinator (MDS coordinator, assess and evaluate the quality of care being given to long-term care residents)stated Resident 1 fell because he had a LAL mattress. The MDS coordinator stated one of the LAL mattress tubes was undone or unlatched so the LAL mattress deflated a bit and then Resident 1 slid off the mattress. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated Resident 1 ' s fall could have been prevented if staff were monitoring Resident 1 regularly and ensuring his LAL mattress was functioning well. Licensed Staff C stated to lessen the risk of fall, staff should monitor residents for safety every 2 hours or more often. Licensed Staff C stated every 2 hours monitoring could be difficult especially if the facility was short staffed. During an interview on 11/28/23 at 3:51 p.m., Licensed Staff D stated to decrease risk of falls staff should monitor residents every 2 hours. Licensed Staff D stated this every 2 hour rounding would be too hard to do at times if the facility was short staffed. During a concurrent interview, care plan (a summary of a person's health conditions, specific care needs, and current treatments, it should outline what needs to be done to manage the residents care needs), nursing note, fall risk assessment (an assessment that checks to see how likely it is that you will fall) and computed tomography scan (CT, a diagnostic imaging procedure that uses a combination of X-rays (a type of radiation called electromagnetic waves, X-ray imaging creates pictures of the inside of your body) and computer technology to produce images of the inside of the body) result record review on 11/28/23 at 4:20 p.m., the MDS coordinator stated for fall prevention, staff should check and monitor residents every 2 hours or more frequently if needed. The MDS coordinator stated fall risk assessments were completed on admission/readmission, when there was a fall incident, and quarterly. The MDS coordinator stated Resident 1 fell in the early morning of 11/4/23 and Resident 1 was sent to hospital on 11/4/23 at 1:04 a.m. The MDS coordinator stated, the fall progress note dated 11/4/23 04:13 a.m. was not what the facility expected. The MDS coordinator stated when she looks at the progress note she wanted to find out what happened, but this progress note does not have any of that. The MDS coordinator stated Resident 1 ' s fall could have been prevented and stated they could have done a better job with keeping him safe. The MDS coordinator stated fall risk assessment should be completed quarterly and any time there was a fall incident. The MDS coordinator stated, Resident 1 ' s fall risk assessment should have been done on 5/2023, 8/2023 and 11/2023. The MDS coordinator stated fall risk assessment for 5/2023 and 8/2023 were missed, which meant the facility policy was not followed. The MDS coordinator stated the fall risk assessment was done to ensure risk and changes were noted so an appropriate intervention could be implemented as needed based on Resident 1 ' s fall risk assessment. The MDS coordinator stated if a fall risk assessment was not done, new risks and needs would not be identified, and no new interventions would be in place to decrease risks of falls. A review of the result of the CT scan of the brain without contrast done at the hospital on 11/4/23 indicated Resident 1 had swelling, contusion, and small areas of subarachnoid hemorrhage in the left frontal and temporal lobes of the brain. The MDS coordinator stated these findings were new and was a direct cause of the fall on 11/4/23. A review of the fall care plan dated 2/23/23 only had 2 interventions which was to anticipate his needs and provide devices as needed. The MDS coordinator stated the care plan does not have an intervention that would prevent Resident 1 from falling. The MDS coordinator stated there was no fall care plan created after Resident 1 fell on [DATE]. The MDS coordinator stated fall care plan were important to identify needs and mitigate risks factors. The MDS coordinator stated if a fall care plan was not created, it could lead to safety risk because resident needs would not be identified, and intervention could not be implemented. The MDS coordinator stated having a care plan could help identify what the residents ' needs were. When asked if staff should be monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS coordinator stated yes. When asked if the there was a documentation the nurses or CNAs were monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS stated she was not aware there were any documentations regarding staff monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated. When asked if the facility staff now had a tracking log or a monitoring log to ensure the LAL mattress was functioning well and the tubes were well connected and not dislodged and the mattress was not dedflated, she stated no. The MDS coordinator stated there were no documentation to prove staff were monitoring the LAL mattress was functioning well, the tubes were well connected and not dislodged and the LAL mattress was not deflated even before Resident 1 fell . The MDS coordinator stated monitoring LAL mattress if it was functioning well, the tubes were well connected and not dislodged, and the mattress was not deflated could have possibly prevented Resident 1 from falling off his bed due to a deflated LAL mattress. The MDS coordinator stated it was important to monitor the LAL mattress was working well and the tubes are intact, connected, not dislodged and mattress not deflated for safety reasons and to prevent another fall incident due to deflated LAL mattress. During a concurrent interview and care plan record review on 11/28/23 at 5:09 p.m., the MDS coordinator stated there was no care plan for Resident 1 ' s fall incident on 11/4/23 and there was no IDT fall meeting done as well. The MDS coordinator stated it was a safety risk if a fall care plan and IDT meeting was not done with regards to fall incidents. The MDS coordinator stated it was important to create a fall care plan and complete an IDT to identify problem and implement intervention to decrease likelihood of falls and injuries. During a telephone interview on 11/29/23 at 4:29 p.m., Licensed Staff E stated there were no documentation to prove staff were monitoring Resident 1 ' s LAL mattress for functionality, ensuring tubes were connected and the mattress was not deflated. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated falls were a change in condition and as such the IDT should meet to discuss fall during the clinical meeting. The Administrator stated the IDT meeting was to talk about root cause analysis and possible interventions to prevent the fall incident to occur again. When asked if staff were expected to monitor the LAL mattress to ensure it was functioning well and the tubes were connected properly, the Administrator stated that Resident 1 ' s cause of fall was sliding off the LAL mattress due to deflated mattress caused by tube not connected properly so staff were expected to monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The Administrator was not able to provide documentations that would verify staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. When asked if the staff were expected to create a care plan after a fall incident, the Administrator stated yes. During a telephone interview on11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to create a care plan for every fall incident. The DON stated she was aware there was no care plan created for Resident 1 ' s fall incident on 11/4/23. The DON stated it was expected that staff monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The DON stated they do not have a documentation to prove staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. The DON stated it was important staff were monitoring the LAL mattress was functioning well and the tubes were connected properly to prevent another fall incident caused by a LAL mattress deflating. The DON stated there should be an IDT completed for Resident 1 ' s fall incident on 11/4/23, however there was none completed for this incident. The DON was also aware there was no care plan created for Resident 1 ' s fall on 11/4/23. The DON stated creating a care plan and completing an IDT meeting for the fall incident was important for resident ' s safety, so the team could discuss resident ' s status, the cause of the fall, interventions to prevent further occurrence of fall incidents and to prevent injury. During a telephone interview on 12/1/23 at 2:24 p.m., the DON verified there was a fall care plan on 9/2020 about a perimeter mattress. When asked what a perimeter mattress was, the DON stated it was a type of bed that was slightly raised at the sides to keep the resident positioned at the center. The DON verified Resident 1 was not using a perimeter mattress when he fell . The DON verified the fall care plan was not updated to reflect the perimeter mattress was not appropriate for use based on Resident 1 ' s current condition. The DON stated it was expected that care plans were current and updated. The DON stated it was important care plans were followed. When asked if Resident 1 ' s fall incident on 11/4/23 could have been prevented, the DON stated yes. The DON stated the fall care plan should have been updated to ensure current interventions were appropriate. The DON stated it was important care plans address the issue and the fall risk. A review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risk, Managing revised 3/2018, the P&P indicated the staff with the input of the attending physician will implement a resident centered fall prevention care plan to reduce the specific risk factors of falls for each residents at risk or with a history of falls . in conjunction with the consultant pharmacist and nursing staff , the attending physician will identify and adjust medications that may be associated with increased risk of falling, or indicate why those medications could not be tapered or stopped . in conjunction with the attending physician , staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, staff interview, document and record review the facility failed to protect 1 resident (Resident 1) out of 51 residents from abuse when a staff member (Staff B)slapped the resident. This had the potential of the resident having both physical and emotional harm. Findings: During an interview on 3/29/12 at 7:50 a.m., Administrative Staff A stated that Staff B had been accused of slapping Resident 1 on 3/23/12. Administrative Staff A stated that during an investigation on 3/27/12, Student C reported that while assisting Staff B, to give Resident 1 a shower, Resident 1 had a bowel movement (B.M.). Administrative Staff A stated that Student C had reported that Staff B had stepped into the B.M. Administrative Staff A stated that Student C reported that she was told by Staff B to take Resident 1 back to her room and dry her off. Administrative Staff A stated that Student C reported that, after cleaning up in the shower, that Staff B joined Resident 1 and Student C in the room of Resident 1. Administrative Staff A stated that Student C reported that after drying off and placing a new gown on Resident 1, Staff B attempted to transfer Resident 1 to her bed without help. Administrative Staff A stated that Student C reported that while transferring Resident 1 to her bed, Resident 1 had another B.M. and was placing her fingers into the B.M. and onto her clean gown and herself. Administrative Staff A stated that Student C reported that Staff B pushed the right arm of Resident 1 away from her and then slapped at the right forearm. Administrative Staff A stated that Student C reported that she noticed blood from the right forearm Resident 1. Administrative Staff A stated that a report was made to Licensed Staff E on 3/23/12. During an interview on 3/29/12 at 9 a.m., Administrative Staff D stated that she received a voice mail on the evening of 3/26/12 by the Licensed Instructor F but no message was left. Administrative Staff D was not made aware of the potential abuse until the morning of 3/27/12 when she was able to speak to Licensed Instructor F. During an interview on 3/29/12 at 10:10 a.m., Licensed Instructor F stated that she had received a voice mail from Student C on the evening of 3/23/12 but no message was left. Licensed Instructor F stated that Student C did not report the potential abuse to me until the afternoon of 3/26/12. Licensed Instructor F stated that she had placed a phone call to the facility on [DATE] but did not leave a message. Licensed Instructor F stated that she did not speak with anyone at the facility concerning the potential abuse until the morning of 3/27/12. Licensed Instructor F stated that students are all trained in abuse reporting at the school. During an interview on 3/29/12 at 10:45 a.m., Licensed Instructor G stated that she was not aware of any issues between Staff B and Student C. Licensed Instructor G stated that Student C had requested to work with Staff B. Licensed Instructor G stated that after the student's shift, on 3/23/12 at 8 p.m., the students were gathered for a debriefing. Licensed Instructor G stated that nothing was reported by Student C, not even the skin tear. During an interview on 3/29/12 at 11 a.m., Licensed Staff E stated that he was requested to come to the room of Resident 1 by Student C. Licensed Staff E stated that he observed a new skin tear on the right forearm of Resident 1. Licensed Staff E stated that he cleaned and placed a dressing on the skin tear. Licensed Staff E stated that he placed a call to Resident 1's M.D. Licensed Staff E stated that he was told by Staff B that Resident 1 had scratched herself causing a skin tear and Student C said nothing to counter that statement. Licensed Staff E stated that he completed an incident report concerning the skin tear on Resident 1. During an observation on 3/29/12 at 12:30 p.m., the right forearm of Resident 1 had multiple bruises in various stages of healing. Also was noted was a skin tear, 1" x 1 1/2", to the right forearm of Resident 1 with a see through dressing in place. During an interview on 3/29/12 at 12:30 p.m., Resident 1 stated that she did not know how she received the skin tear on her arm or the bruising. During an interview on 3/29/12 at 4:48 p.m., Student C stated that while working with Staff B on 3/23/12, Staff B was observed to slap Resident 1 on the right forearm. Student C stated that the slap was hard enough to be audible and causing a skin tear. Student C stated that she attempted to call her instructor but was unable to make any connection as we were going into a weekend. Student C stated that she did not think Staff B was angry with Resident 1 but "I did not think it (slap) was not right". Student C stated that she was unaware that a slap was considered abuse. Student C also stated that she wrote a declaration concerning the incident on 3/27/12. During a record review on 3/29/12, a document noted to be a "Declaration", dated 3/23/12, by Student C indicated that she witnessed Staff B slap Resident 1 on the right forearm causing a skin tear. A medical record titled "Nursing Notes" of Resident 1, indicated that there was no entry made concerning the skin tear or contacting of the M.D. until 3/24/12 at 7:15 a.m. The next nursing note concerning the skin tear of Resident 1 was not made until after 3/25/12 at 5 p.m. and was recorded as a "Late Entry", dated 3/23/12 at 7 p.m. A telephone order, to the M.D. was noted to be dated 3/23/12 but not timed, "Clean skin tear to R (right) forearm NSS (normal saline solution) pat dry triple ATB (antibiotic) ointment BID (two times per day) cover with dry dressing until healed. During a document review on 3/29/12, a facility document titled "California State Mandatory Reporting", dated 2/2007, indicated that "Facility employees, including contracted employees, are mandated reporters in California, per California State Law and will be required to report all abuse, abandonment, financial exploitation, sexual and physical assault in two ways: to the local ombudsman or local law enforcement agency and by written report using Social Services Form (SOC 341)".