Every finding on record at Hemet Valley Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the shower gurney's (a mobile, waterproof device designed to transport and bathe individuals who cannot sit upright safely) wheel brakes, used to transfer one of three sampled residents (Resident 1), were locking properly to secure positioning during resident transfer and bathing.Findings:A review of Resident 1's admission record indicated that the resident was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure.A review of Resident 1's care plan titled Potential for Falls, dated June 4, 2022, indicated the resident has potential for falls related to sensory deficit, and poor endurance related to contractures of both lower extremities.A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated April 12, 2025, indicated the resident has no discernible consciousness and is dependent (Assistance of 2 or more helpers is required for the resident to complete the activity) with transfers and showers.A review of Resident 1's Progress Note Inquiry, dated June 4, 2025, indicated the following:-At 9:09 a.m., written by a licensed vocational nurse, Was attending Pt. (patient) in another room when I (LVN) called to (name of Resident 1) room. In the room Pt. was seen on the floor with RT (Respiratory Therapist-1) holding the head and the CNA (Certified Nursing Assistant) holding the feet area. CN (Charge Nurse) was called to the room, neuro assessment done .;-At 11:44 a.m., written by RT 1, SEE NURSES NOTES FOR FULL DETAILS. At approximately 0910 hours (9:10 a.m.), I (RT 1) was called into (room of Resident 1) to assist the CNA with a patient transfer from the patient's bed to the shower gurney .As we transferred the patient, the shower gurney slipped away and the patient slipped onto the floor .The patient's head never touched the floor, the patient buttocks & (and) legs did touch the floor .; and -At 12:54 p.m., written by a Registered Nurse (RN), .Called by staff to resident's room. Found Rrsident (sic) lying on the floor. Per RT (RT 1) they were transferring resident for shower. During transfer from bed to the shower gurney, there was a shift in the resident's weight and patient slipped to the floor with the RT holding on to the head of the resident during the fall .On December 10, 2025, at 9:53 a.m., during a concurrent observation and interview, Resident 1 was observed in her room, lying in bed with head of bed elevated at 45 degrees. Resident 1's eyes were closed, with tracheostomy connected to ventilator and enteral feeding (liquid nutrition delivered via a tube directly to the stomach or small intestine) turned on. Resident 1 was non-verbal.On December 10, 2025, at 2:31 p.m., during interview, CNA 1 stated that she was assigned to Resident 1 on June 4, 2025. She and RT 1 transferred Resident 1 from the bed to the shower gurney. CNA 1 stated that the shower gurney's wheel brakes were not locking properly and the shower gurney moved during the transfer.On December 10, 2025, at 2:57 p.m., during an interview, RT 1 stated that on June 4, 2025, the shower gurney's (shower gurney used on Resident 1) wheel brakes did not lock well. RT 1 stated that they tried to lock the wheel brakes of the shower gurney, then the gurney slipped as they were transferring Resident 1 from bed to the shower gurney. He managed to support Resident 1's head, preventing it from touching the floor.On December 19, 2025, at 3:13 p.m., during a telephone interview, CNA 1 stated if the shower gurney's brakes are not locking very well, she should not have used it and should have reported the issue to the charge nurse.On December 23, 2025, at 10:17 a.m., during a telephone interview, the Director of Nursing (DON) stated that staff are expected to notify her immediately when equipment is not functioning. The DON emphasized that if staff were aware that equipment is malfunctioning and continue to use it, it is unacceptable. They were instructed to remove the equipment from service and inform her promptly.On December 23, 2025, at 2:21 p.m., during a telephone interview, the DON stated she was not aware that the brake of the shower gurney used for Resident 1 was not working properly, as it was not mentioned by the CNA (CNA 1) during investigation. The DON stated the CNA (CNA 1), and the RT (RT 1) should have informed her when the shower gurney's brakes were not locking properly and should have not brought the shower gurney into the resident's room.A review of the facility's policy and procedure titled, Reporting Medical Equipment problems, Failures and User Errors, dated April 2021 indicated, .Procedure for Reporting Equipment Failures .frequency .whenever medical equipment is known or suspected to malfunction or have defect .scope of equipment .all fixed or portable equipment used for diagnoses, treatment, monitoring and care of patients .essential steps .if any of the following conditions exists, remove equipment from service to designated area .switches, knobs or controls that are broken or loose .that do not consistently produce expected results .

Based on observation, interview, and record review, the facility failed to ensure safety and sanitation were observed in the kitchen when: 1. Nine one-gallon containers of barbeque (BBQ) sauce were undated;2. One box of rice pilaf was found to be undated;3. Multiple prepared food items in refrigerator 3 were found to be uncovered and opened to air.These failures had the potential to result in the spread of foodborne illness to the residents who consumed meals from the facility kitchen. Findings:On November 17, 2025, at 10:30 a.m., the initial kitchen inspection was conducted with the Director of Food and Nutrition (DFN). The following were found stored on the shelf in the dry storage area:- Nine one-gallon container of BBQ sauce had no expiration date; and- One box of rice pilaf had no expiration date. Multiple prepared food items were not covered and were open to air located inside refrigerator 3.On November 17, 2025, at 11:10 a.m., a concurrent interview was conducted with the DFN. The DFN stated there were no expiration dates located on the BBQ containers or the rice pilaf box. The DFN further stated the food items dispensed out on the trays the same day should be covered and not left open to air. On November 20, 2025, at 12:30 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated all food items should be labeled and covered to prevent cross contamination.A review of the policy and procedure titled, Food Storage, revised May 2024, indicated, .Manufacturer's expiration, use by or sell by dates must be adhered to.all foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers.all foods set up for service must be protected by sneezeguards or otherwise covered to prevent contamination.

Based on observation, interview, and record review, the facility failed to ensure expired medical food and dressing change supplies were not stored in the medication storage areas, and readily available for use.This failure had the potential for residents to receive ineffective medical food supplements and medical supplies.Findings:On November 20, 2025, at 1:12 p.m., a medication storage inspection was conducted with the Registered Nurse Supervisor (RNS). The following expired items were found stored and readily available for use:a. Two sterile central line (a long, thin tube [catheter] inserted into a large vein in the neck, chest, or groin, with its tip ending in or near the heart) dressing change trays containing one each of the following outdated components:- Medium Aloe Vinyl Examination gloves with expiration date of 5/28/2025 (May 28, 2025) (4/30/2025 [April 30, 2025] - date on the insert);- Stabilization PICC (peripherally inserted central catheter- a type of central line) Statlock (brand of suture free medical stabilization device) with an expiration date of 08/28/2025 (August 28, 2025); and- Aegis CHG disk (a foam disc impregnated with CHG [chlorhexidine gluconate - an antiseptic, antibacterial solution] that is used to cover and protect the insertion sites of medical devices like central lines to prevent infection), with an expiration date of 10/18/2025 (October 18, 2025).The sticker label attached to the kits indicated, .UPON OPENING THE PACK, REMOVE AND DESTROY THE EXPIRED COMPONENT-THE REMAINDER OF THE ITEMS ARE SAFE FOR USE.In a concurrent interview with the RNS, the RNS stated the above items were expired and should have been removed from storage, so as not to be used on the residents.A review of the facility's policy and procedure titled, STERILE EQUIPMENT STORAGE AND EXPIRATION DATE, revised March 2021, indicated, .Purpose.To establish standardized procedures for sterile equipment storage and shelf life.Items purchased as sterile will follow manufacturers expiration.b. 18 outdated Prostat concentrated liquid protein (brand of protein nutritional supplement), 15 grams (unit of measurement) in one fluid ounce (unit of measurement) packets with expiration dates as follows:- seven packets with expiration dates of 10/10/2025 (October 10, 2025);- six packets with expiration dates of 8/13/2025 (August 13, 2025); and- five packets with expirations dates of date 6/17/2025 (June 17, 2025).In a concurrent interview with the RNS, the RNS stated the Prostat were expired and should have been removed from storage, so as not to be given to the residents.A review of the facility's policy and procedure titled, EXPIRED/RECALLED PRODUCTS, dated May 2024, indicated .Purpose.To develop a mechanism designed to ensure the retrieval and safe disposal of expired and recalled nutrition products to reduce the potential of adverse reactions to inferior products.Outdated and recalled nutrition products will not be provided to patients.Discard outdated or recalled products immediately or return them to the manufacturer for credit.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were observed, and the facility policies and procedures related to infection control were implemented when: 1. The facility did not report to the California Department of Public Health (CDPH- state agency responsible for public health in California, enforcing some of the laws affecting healthcare facilities) of a COVID 19 (coronavirus - a contagious respiratory infection) outbreak when the facility had one COVID-19 positive staff and four COVID-19 positive residents on February 5, 2025. This failure resulted in the state agency being unaware of the presence of a COVID-19 outbreak in the facility and had the potential of delayed implementation of infection control measures to address COVID-19; and 2. The facility did not implement Enhanced Barrier Precautions (EBP - a strategy recommending the use of gown and gloves during provision of high-contact resident care activities (dressing, bathing, transferring, providing hygiene, linen change, assisting with toileting, indwelling device [a medical device that remains inside the body] care, and wound care) to the residents with wounds, indwelling devices, and colonized (the presence of microorganisms [such as bacteria, viruses, or fungi] on or in a person's body without causing any apparent symptoms or disease) MDRO [multidrug resistant organisms -germ that is resistant to many antibiotics] infection to reduce the spread of MDRO transmission), according to Centers for Disease and Prevention Control (CDC) guidelines, for 17 of 21 residents (17 residents had indwelling medical devices [Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21], five of 17 residents [Residents 5, 15, 17, 18, 21] had colonized (the presence and multiplication of microorganisms (such as bacteria, viruses, or fungi) on or in a body surface without causing any apparent signs or symptoms of infection) MDRO infection, and one of 17 residents (Resident 11) had pressure injuries [bed sores]). In addition, the facility did not have a policy and procedure with the use of EBP. On February 20, 2025, at 8 p.m., the Director of Nursing (DON) and the Quality Assurance Officer (QA) were verbally notified of the Immediate Jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure of not implementing Enhanced Barrier Precautions while providing high contact care activities to 17 residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21) with indwelling devices. The facility's failure to implement EBP during provision of high contact resident care activities had the potential to result in the spread of MDROs to the immunocompromised residents, and could cause serious harm, and aggravate the already vulnerable and compromised health conditions of the residents. On February 21, 2025, at 4:38 p.m., the QA and the DON presented an acceptable removal plan which included the following: - Members of the Governing Board and MEC (Medical Executive Committee) were notified immediately of the findings by the COO (Chief Operating Officer); - On February 20, 2025, the DON identified all residents with colonized MDROs, those at increased risk to acquire MDRO infection, and those that require high contact care activities for which EBP should be used; - On February 21, 2025, the DON validated the facility had appropriate and adequate levels of PPE (Personal Protective Equipment - protective clothing or equipment worn by healthcare workers to minimize exposure to hazards and prevent illnesses) to use for EBP. The DON contacted central supply to ensure levels were justified and supplies were available at all times; - On February 21, 2025, all residents currently on the unit were evaluated by the DON to ensure no adverse effects occurred. EBP was implemented immediately for all residents if applicable by the DON/designee; - On February 21, 2025, appropriate signage for EBP was created by the DON and placed by the room entrances of residents for whom EBP should be used to aid in identifying and reminding staff to use EBP when providing high contact care activities to the residents; - On February 21, 2025, the DON rounded on all resident's' rooms to ensure the appropriate signage for EBP is in place as per facility policy. Any missing signage was immediately placed in applicable rooms; - On February 21, 2025, the Medical Director (MD) of the subacute unit was notified of the IJ and was advised of the findings. The MD will continue to collaborate with the leadership team to create and implement the appropriate infection control measure; - On February 21, 2025, the resident and/or resident representatives of all residents impacted by the deficiency were notified of the incident via phone by the DON/designee; - On February 21, 2025, the DON/RN Charge Nurse immediately started staff education on EBP and hand hygiene using 1:1 education and group education during huddles. The staff will receive the education before the start of their next shift; - On February 21, 2025, providers for the residents impacted by this deficiency were contacted and orders obtained to include the use of EBP. The care plans of the affected residents impacted by this deficiency were updated by the DON/RN to include the use EBP; - On February 21, 2025, the DON reviewed the policy on EBP and revised it to ensure compliance with current regulations and best practices. The policy reviewed and approved by the Medical Director of the subacute unit and Medical Director of infection control; - On February 21, 2025, all staff present were educated on the revised EBP policy by the DON/designee. Staff not present will be educated on the revised policy before the start of their next shift. All staff will be educated to the policy by February 23, 2025. On February 25, 2024, at 4:26 p.m., the immediate jeopardy was removed in the presence of the DON, upon onsite verification of the implementation of the plan of actions. Findings: On February 20, 2025, at 9:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding infection control. 1.On February 20, 2025, at 12:53 p.m., during an interview with the Infection Preventionist (IP), the IP stated there was a COVID-19 outbreak in the facility which began on February 5, 2025, with one COVID-19 positive staff and four COVID-19 positive residents. On February 20, 2025, a review of the facility's COVID-19-line listing indicated Residents 2, 14, 16, and 17, and Certified Nursing Assistant (CNA) 7 were tested positive on February 5, 2025. The IP stated she reported the outbreak to the county public health officer but not to CDPH. The IP further stated the COVID-19 outbreak should have been reported to the CPDH. On February 21, 2025, Residents 2, 14, 16, and 17 records were reviewed. The record review indicated the following: a. Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure). Resident 2's Progress Note Inquiry, dated February 5, 2025, at 11:04 p.m., indicated, .Resident tested positive for Covid . b. Resident 14 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 14's Progress Note Inquiry, dated February 5, 2025, at 10:51 p.m., indicated, .Resident tested positive for Covid . c. Resident 16 was admitted to the facility on [DATE], with diagnoses which included kidney failure. Resident 16's Progress Note Inquiry, dated February 5, 2025, at 9:24 p.m., indicated, .Resident tested positive for Covid . d. Resident 17 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 17's Progress Note Inquiry, dated February 5, 2025, at 9:59 p.m., indicated, .Resident tested positive for Covid . A review of the facility's policy and procedure titled, Outbreak Investigation and Management, revised December 2022, indicated, .to control the spread of infection or disease and to identify factors that contributed to the outbreak in order to develop and implement measures to prevent similar outbreaks in the future .The Infection Prevention Committee (IPC) shall have the responsibility for investigating outbreaks .Any suspected outbreak shall be reported to the (name of county) Department of Public Health and the appropriate Public Health licensing and certification department . A review of AFL (All Facilities Letter- a CDPH communication letter to all facility types including Skilled Nursing Facilities [Nursing Homes]) 23-08, dated January 18, 2023, indicated, .This AFL reminds providers of the requirements to report outbreaks and unusual infectious disease occurrences to the local public health officer and the California Department of Public Health (CDPH) and provides definitions and updated examples of reportable incidents .Health facilities licensed by CDPH Licensing and Certification (L&C) are required to report outbreaks (occurrence of cases of a disease or condition above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific population group) and unusual infectious disease occurrences to the local public health officer and their respective District Office (DO) .Examples of Reportable Incidents .Facility outbreak of COVID-19, influenza (lung infection caused by influenza viruses), pneumonia (bacterial lung infection), other respiratory viral pathogen (e.g., respiratory syncytial virus), or gastroenteritis (e.g., norovirus- virus causing abdominal symptoms) . A review of the Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens (CORHA) and the Council of State and Territorial Epidemiologists' (CSTE) article titled Proposed Investigation/Reporting Thresholds and Outbreak Definitions for COVID-19 in Healthcare Settings, dated January 2, 2024, indicated thresholds for reporting to Public Health for Long Term Care Facilities (LTCFs- includes nursing homes) is two or more cases of probable or confirmed COVID-19 among residents identified within seven days, OR two or more cases of suspect, probable, or confirmed COVID-19 among health care providers (facility staff) and one or more case of probable or confirmed COVID-19 among residents . 2. On February 20, 2025, beginning at 9:50 a.m., an observation of the facility from Rooms 401 to 410 was conducted. The following were observed: - Residents 5 and 6 were both observed to have tracheostomies (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Respiratory Therapist 1 was observed providing respiratory care at bedside to Resident 5 while wearing a surgical mask and gloves, no gown was in use. There was no EBP sign outside Residents 5 and 6's room; - Concurrently, one female staff was observed moving around Resident 6's bed through the privacy curtain. After rendering care, the female staff drew the curtain halfway open and upon coming through the curtains, staff was observed not wearing a mask or gown, and proceeded to remove and discard her gloves in the trash can; - Residents 1, 2, 3, and 13's rooms were observed to have a sign outside the door indicating Contact Precautions (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with the patient or their contaminated environment requiring use of PPE such as mask, gown, gloves), and instructions to wear specific PPE. - There was no sign for EBP by the door of Residents 4, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21's rooms. - Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21, were observed to have indwelling devices such as tracheostomies and gastrostomy (GT - tube that is inserted into the stomach through the abdominal wall to provide nutrition, hydration, or medicine). Residents 11 and 15 had an indwelling catheter (a thin, flexible tube inserted into the urinary bladder to collect and drain urine). On February 20, 2025, at 10:03 a.m., during an interview with the IP, she stated the following residents were placed on contact precautions due to the presence of MDRO infection: - Resident 1; CRPA (carbapenem-resistant pseudomonas aeruginosa - a type of bacterial infection that is resistant to many antibiotics) in the sputum; - Resident 2; CRPA in the urine; - Resident 3; CRPA in the wound; - Resident 13; MRSA (methicillin-resistant staphylococcus aureus - a type of bacteria resistant to several antibiotics) in the wound. The IP further stated there were no residents placed on EBP. On February 20, 2025, at 11:01 a.m., Certified Nursing Assistant (CNA)1 was interviewed. CNA 1 stated she did not know what EBP was and had never heard of it before. On February 20, 2025, at 11:18 a.m., CNA 2 was interviewed. CNA 2 stated she had no awareness of what EBP was. On February 20,2025, at 12:53 p.m., a follow up interview was conducted with the IP. The IP stated there were no residents in the facility who were placed on EBP. On February 20, 2025, at 3:21 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he was not aware what EBP was and had never cared for any residents who were placed on EBP in the unit. LVN 1 further stated he never received any in-services regarding EBP, but always wore gloves and masks for any kind of patient care since all the residents were trached (had tracheostomies). LVN 1 could not articulate what type of PPEs were to be used when a resident was placed on EBP. On February 20, 2025, beginning at 4:10 p.m., the following were observed: - There were still no EBP signs by the door of the rooms not placed on contact isolation; - LVN 2 entered Residents 17 and 18's room and provided care to the residents. LVN 2 was observed wearing only gloves, did not put on a gown or mask prior to entering and while providing care to Residents 17 and 18; - CNA 3 entered Residents 17 and 18's room wearing a mask, but did not put on any gown or gloves prior to entering and was observed to change the linens of the residents; - At 4:34 p.m., CNA 2 entered Residents 17 and 18's room and observed wearing gloves, but did not put on any gown or mask while assisting CNA 3 with resident care and turning the residents. On February 20, 2025, at 4:35 p.m., CNA 3 was interviewed. CNA 3 stated the facility only used EBP during COVID-19 outbreaks. On February 20, 2025, at 4:57 p.m., LVN 2 was interviewed. LVN 2 stated she was not sure what EBP referred to and had never heard of EBP. On February 20, 2025, at 5:13 p.m., the IP was interviewed. The IP stated the staff should use gloves or gowns when providing care to residents. The IP further stated gowns were optional when doing perineal care or turning a patient when staff needed to create a barrier between staff and the resident. The IP stated they did not put EBP signs on the resident's door because all residents should be using EBP. On February 20, 2025, at 5:44 p.m., the DON was interviewed. The DON stated EBP was a new practice, and not a lot of people knew about it yet, and EBP was not being practiced at the facility. The DON stated the staff was to wear the appropriate PPEs, such as gown, gloves, when providing care to residents placed on EBP. The DON stated, the hospital doesn't understand it, and the facility staff would not know what EBP was because she had not trained them on it. The DON stated if EBP or other infection precautions were not to be followed, there would be a potential risk for spread of infections such as MDROs among the residents. The DON further stated the facility did not have a policy on EBP. On February 20, 2025, a review of residents' records indicated the following; a. A review of Resident 4's Patient Information, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included sepsis (body's extreme response to an infection, a life-threatening medical emergency). A review of Resident 4's History and Physical, dated February 6, 2025, indicated PEG placement (percutaneous endoscopic gastrostomy- a type of feeding tube), tracheostomy, and right frontal ventricular drain (a catheter inserted into the brain through the skull to monitor and drain cerebrospinal fluid) placement. Further review of Resident 4's record did not include a physician's order and care plan for Resident 4 to be placed on EBP. b. A review of Resident 5's Patient Information, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic (persisting for a long time) respiratory failure. A review of Resident 5's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube/GT. A review of Resident 5's Patient Care Summary, included physician's orders for tracheostomy therapy and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 5's record did not include a physician's order and care plan for Resident 5 to be placed on EBP. c. A review of Resident 6's Patient Information, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and anoxic (oxygen deficient) brain injury. A review of Resident 6's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 6's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment. The orders also included care and maintenance orders for the feeding tube. Further review of Resident 6's record did not include a physician's order and care plan for Resident 6 to be placed on EBP. d. A review of Resident 7's Patient Information, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure s/p (status post) trach (tracheostomy) and PEG. A review of Resident 7's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 7's Patient Care Summary, dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via J-tube (a type of GT surgically inserted into the small intestine to deliver food and medicine), as well as care and maintenance orders for the feeding tube. Further review of Resident 7's record did not include a physician's order and care plan for Resident 7 to be placed on EBP. e. A review of Resident 8's Patient Information, indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 8's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 8's Patient Care Summary, dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 8's record did not include a physician's order and care plan for Resident 8 to be placed on EBP. f. A review of Resident 9's Patient Information, indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included cardiopulmonary arrest (heart attack). A review of Resident 9's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 9's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 9's record did not include a physician's order and care plan for Resident 9 to be placed on EBP. g. A review of Resident 10's Patient Information, indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 10's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 10's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 10's record did not include a physician's order and care plan for Resident 10 to be placed on EBP. h. A review of Resident 11's Patient Information, indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included acute (begins and worsens quickly) respiratory failure and acute encephalopathy (group of conditions that cause brain dysfunction). A review of Resident 11's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 11's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care, urinary catheter care and treatment, and nutritional formula feeding via GT. Further review of Resident 11's record did not include a physician's order and care plan for Resident 11 to be placed on EBP. i. A review of Resident 12's Patient Information, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure, cardiac arrest, and anoxic brain injury. A review of Resident 12's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 12's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 12's record did not include a physician's order and care plan for Resident 12 to be placed on EBP. j. A review of Resident 14's Patient Information, indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and chronic heart failure. A review of Resident 14's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 14's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and maintenance orders for the feeding tube. Further review of Resident 14's record did not include a physician's order and care plan for Resident 14 to be placed on EBP. k. A review of Resident 15's Patient Information, indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, and anoxic quadriplegia (paralysis of all four limbs). A review of Resident 15's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 15's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, care and maintenance orders for the feeding tube, and urinary catheter change. Further review of Resident 15's record did not include a physician's order and care plan for Resident 15 to be placed on EBP. l. A review of Resident 16's Patient Information, indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included kidney failure. A review of Resident 16's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 16's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Further review of Resident 16's record did not include a physician's order and care plan for Resident 16 to be placed on EBP. m. A review of Resident 16's Patient Information, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure and acute encephalopathy. A review of Resident 17's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube/GT. A review of Resident 17's Patient Care Summary, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Further review of Resident 17's record did not include a physician's order and care plan for Resident 17 to be placed on EBP. n. A review of Resident 18's Patient Information, indicated Resident 18 was admitted to the facility on [DATE]. A review of Resident 18's History and Physical, dated May 29, 2024, indicated the physician's impression (clinical assessment) of anoxic brain injury, decubiti (pressure injury-bed sore), GT, and tracheostomy. A review of Resident 18's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 18's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via feeding tube, and care and maintenance orders for the feeding tube. Further review of Resident 18's record did not include a physician's order and care plan for Resident 18 to be placed on EBP. o. A review of Resident 19's Patient Information, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 19's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 19's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, and care and maintenance orders for the feeding tube. Further review of Resident 19's record did not include a physician's order and care plan for Resident 19 to be placed on EBP. p. A review of Resident 20's Patient Information, indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, sepsis, and pneumonia (bacterial lung infection). A review of Resident 20's History and Physical, dated November 5, 2024, indicated diagnoses of tracheostomy and PEG. A review of Resident 20's Patient Care Summary, dated January 31, 2025, included physician's orders for secretion suctioning and tracheostomy care and treatment, PICC line dressing changes (peripherally inserted central catheter- a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart), nutritional formula feeding via feeding tube, and care and maintenance orders for the feeding tube. Further review of Resident 20's record did not include a physician's order and care plan for Resident 20 to be placed on EBP. q. A review of Resident 21's Patient Information, indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure. A review of Resident 21's History and Physical, dated September 1, 2020, indicated secondary diagnoses of chronic tracheostomy and PEG status. A review of Resident 21's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and maintenance orders for the feeding tube. Further review of Resident 21's record did not include a physician's order and care plan for Resident 21 to be placed on EBP. A review of the facility's policy and procedure titled, .Category: Infection Control .Enhanced Standard Precautions (ESP) for Long-Term Care Facilities, created April 2016, indicated the absence of updated guidance regarding Enhanced Barrier Precautions. A review of the CDPH's Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), revised September 2022, indicated, .Since the publication of Enhanced Standard Precautions for Skilled Nursing Facilities, 2019, the epidemiology of multidrug-resistant organisms (MDRO) in California skilled nursing facilities (SNF) has changed considerably, in part due to healthcare challenges related to the COVID-19 pandemic .In addition, large, sustained, regional outbreaks of previously novel or rare MDRO, including Candida auris and NDM-producing Acinetobacter baumannii have occurred in SNF and high-acuity long-term care facilities such as ventilator-equipped skilled nursing facilities .Both C. auris and A. baumannii are easily transmissible among residents and particularly persistent in the healthcare environment; once identified in a healthcare facility, they can be difficult to contain. CDPH has adopted a comprehensive strategy to prevent, contain, and mitigate these MDRO in California SNF and other healthcare settings. Enhanced Standard Precautions (ESP) is a core component of this strategy, both during the prevention and mitigation phases. Increased MDRO prevalence and outbreaks in California highlight the role of ESP as a prevention strategy before transmission and outbreaks occur, as well as a need for new guidance included in this update for transitioning from Contact Precautions to ESP as part of long-term outbreak mitigation and management .To simplify and facilitate implementation of CDPH's ESP, we have consolidated the risk factors for identifying residents at high risk for MDRO colonization and transmission to include unhealed wounds and medical devices, in alignment with CDC's EBP . A review of QSO 23-08-NH (a memorandum from the Centers for Medicare and Medicaid Services' Quality, Safety and Oversight Group), dated March 20,2024, indicated, .Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities (i.e., nursing homes), contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs .In 2019, CDC introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP) as a strategy in nursing homes to decrease transmission of CDC-targeted and epidemiologically important MDROs when contact precautions do not apply. The approach recommended gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO transmission and did not involve resident room restriction .In July 2022, the CDC released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs, and therefore, CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not ap [TRUNCATED]

Based on interview and record review, the facility failed to ensure a care plan (a detailed written document that outlines a resident's healthcare needs, goals, and treatment strategies) was developed, for four of four residents (Residents 2, 14, 16, and 17) , when the residents had COVID -19 (coronavirus - a contagious respiratory infection) infection. This failure had the potential for the staff not to be aware of the appropriate interventions needed to be implemented to address the resident's changes in health condition. Findings: On February 20, 2025, at 09:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding infection control and nursing services. On February 20, 2025, at 12:43 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the facility had a Covid outbreak on the evening shift of February 5, 2025. The IP stated Residents 2, 14, 16, and 17, were positive for COVID-19 on February 5, 2025. On February 20, 2025, at 3:30 p.m., Licensed Vocational Nurse (LVN 1) was interviewed. LVN 1 stated that care plans were being updated by the Registered Nurse (RN). LVN 1 stated he was unsure when care plans get updated. On February 21, 2025, Residents 2, 14, 16, and 17 records were reviewed. The record review indicated the following: a. Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure). Resident 2's Progress Note Inquiry, dated February 5, 2025, at 11:04 p.m., indicated, .Resident tested positive for Covid . b. Resident 14 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 14's Progress Note Inquiry, dated February 5, 2025, at 10:51 p.m., indicated, .Resident tested positive for Covid . c. Resident 16 was admitted to the facility on [DATE], with diagnoses which included kidney failure. Resident 16's Progress Note Inquiry, dated February 5, 2025, at 9:24 p.m., indicated, .Resident tested positive for Covid . d. Resident 17 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 17's Progress Note Inquiry, dated February 5, 2025, at 9:59 p.m., indicated, .Resident tested positive for Covid . Further review of Residents 2, 14, 16, and 17's record indicated no care plan was developed to address Covid infection. On February 21, 2025, at 4:24 p.m., during an interview with the IP, the IP stated the RN was the one responsible to update the care plan upon admission and when there is a resident's change of condition. The IP stated that they would update the care plans using the backside of the sheet. The IP stated she was not very familiar with care plans. On February 21, 2025, at 4: 28 p.m., during an interview with RN 1, RN 1 stated the care plan was to be updated on a regular basis. RN 1 stated care plans were to be developed when there was a new admit, any new diagnosis, and any change of condition. RN 1 stated four residents tested positive for Covid-19 on February 5, 2025. RN 1 stated she did not do the care plan for any of the four COVID positive residents. RN 1 stated she should have developed a care plan for Residents 2, 14, 16, and 17 to address COVID-19 infection. A review of the facility's policy and procedure titled Resident Care Plan, revised March 2024, indicated, .provide an individual plan of care for each Sub-Acute resident that is updated .at the time of admission, after the nursing assessment is completed . Plan of care will be initiated within 24 hours and documented on the Care Plan form. This .will be reviewed weekly by nursing staff, quarterly in care conference or as dictated by the resident's condition and nursing diagnosis. Any changes to the plan may be made by any member of the interdisciplinary team including: Physician, nursing staff, physical therapy, occupational therapy, social service, respiratory therapy, pharmacists, case management, speech therapy, and dietician .

Based on observation, interview, and record review, the facility failed to provide a homelike environment, for one of 21 residents (Resident 4), when Resident 4 was placed in the activity room when the resident was readmitted back to the facility for five days. This failure had the potential to negatively affect the resident's emotional and social well-being. Findings: On February 20, 2025, at 09:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding infection control. On February 20, 2025, Resident 4's record was reviewed. Resident 4 was readmitted to the facility on [DATE], with diagnoses which included acute - on chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hydrocephalus (abnormal accumulation of cerebrospinal fluid in the brain), psychosis (a mental disorder where there is a severe loss of contact with reality), and tracheostomy (a hole surgically created in the windpipe to relieve an obstruction to breathing). A review of Resident 4's Progress Note Inquiry, indicated Resident 4 was placed in the activity room on the following dates; - February 6, 2025, at 8:30 p.m., indicated, .Resident admitted to room [ROOM NUMBER]A but actually placed in activity room . - February 7, 2025, at 12:55 p.m., .Morning rounds completed, awake and watching TV (television) in activity room .Transferred back to Subacute .resident was placed in activity room at this time . - February 8, 2025, at 11;13 a.m., .Resident is temporarily in Activity room . - February 9, 2025, at 10;58 a.m., .resting comfortably on her bed in lowest position in the activity room . A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), recorddated February 13, 2025, indicated Resident 4 have unclear speech but could understand others. On February 20, 2025, at 12:53 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the facility had a Covid -19 (coronavirus - a contagious respiratory diseases) outbreak on February 5, 2025. The IP stated the residents were moved to different rooms to allow cohorting (grouping) of Covid positive residents. The IP stated that Resident 4 was readmitted to the facility and was placed in the activity room for about two to three days because there was no available female room. The IP stated all the furnitures in the activity room were moved to the other side of the room. On February 20, 2025, at 3:30 p.m., Licensed Vocational Nurse (LVN 1) was interviewed. LVN 1 stated Resident 4 stayed in the activity room during the Covid outbreak because another resident occupied her room. On February 20, 2025, at 5:30 p.m., a follow up interview was conducted with the IP. The IP stated Resident 4 was transferred out to the acute hospital on January 28, 2025. The IP stated another resident was moved to Resident 4's room during the outbreak while Resident 4 was on bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility). The IP stated Resident 4's bed hold ended on February 4, 2025. The IP confirmed Resident 4 was readmitted back to the facility and was placed in the activity room on February 6, 2025, and was placed back to her previous room on February 11, 2025 (five days later). On February 20, 2025, at 5:50 p.m., during an interview with the Director of Nursing (DON), the DON confirmed Resident 4's physician kept asking for Resident 4 to be admitted back to facility. The DON stated residents were admitted to the activity room for a short period of time during the pandemic. The DON stated she approved the admission of Resident 4 to the activity room because it was safe. On February 21, 2025, at 10:25 a.m., Respiratory Therapist (RT) 2 was interviewed inside the activity room. RT 2 stated he cared for Resident 4 when she was admitted to the activity room. RT 2 stated that Resident 4 was alert but nonverbal but can communicate basic needs by nodding or shaking her head to a yes or no questions. RT 2 stated that all large pieces of furniture stayed in the activity room with Resident 4 for five days. The activity room was observed to have the following inside: - Two long and heavy wooden tables with metal legs; - Five large black office chairs; - Four blue plastic chairs with metal legs; - A black metal standing fan with dust-colored particles on the stand; - Three to four black and metal multi leveled carts with television monitors placed on top; - Stacks of bins piled on top of each other at the back left corner which contained art and crafts supplies; - Pink cabinets were mounted to the wall back wall and contained many arts and crafts supplies; and - Several emergency oxygen tanks (long and heavy metal tanks containing oxygen) by the window side. RT 2 stated staff had to go to the activity room if needed to get items for activities even if Resident 4 was inside the activity room. RT 2 stated all the items observed inside the activity room were present in the activity room while Resident 4 was in there, they were just moved to the side. RT 2 stated there was no privacy curtains placed while Resident 4 was inside the activity room. RT 2 stated there was no urgent need for Resident 4 to be admitted back to the facility. On February 21, 2025, at 1:10 p.m., a follow up interview was conducted with the DON. The DON stated she was not aware all the large furnitures, chairs, and tables remained in the room while Resident 4 stayed in the activity room. The DON stated she also did not know that Resident 4 stayed in the room for five days, stated that was too long. The DON stated with all the clutter in the activity room, and staff coming in and out of the activity room, the facility failed to provide a home-like environment for Resident 4. The DON stated she could understand the frustration if she were to put herself in the patient's shoes. The DON stated although Resident 4 could not fully communicate her frustration or needs, she was alert and was aware of her surroundings. The DON stated there was no urgent need for the resident to be admitted back to the facility and they could have asked the hospital to wait until the outbreak was over or facilitate another transfer to another sub-acute unit. A review of facility's policy and procedure titled Residents Rights, revised March 2024, indicated, .The resident has the right .To a dignified existence, self-determination .inside and outside the facility .To be treated with consideration, respect and full recognition of his or her dignity and individuality .To be provided by the facility with a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .To reside and receive services in the facility with reasonable accommodation of individual needs and preferences .

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Federal (Center for Medicare & Medicaid Services- CMS) database for the second Fiscal Quarter (FQ) of the year. This failure had the potential to result in inaccuracy of numbers of Direct Care Staff needed to provide care to residents. This failure also prevented the provision of complete and accurate direct care staffing information to the public. Findings: A review of the CMS PBJ (pay roll based journal) Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) FY (fiscal year) Quarter 2 (January 1- March 31) indicated, .Failed to submit Data for the Quarter . During an interview on with the Director of Nursing Services (DON) on July 30, 2024, at 2:30 p.m., the DON stated the Infection Preventionist (IP) was also was responsible for submitting the report to CMS. However, during the said reporting period, the facility was having several issues with staffing and she and the IP were still transitioning in their roles, hence the data was not submitted timely. The DON stated the data should have been submitted timely. A review of CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, Version 2.6., dated June 2022, indicated, .Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate . Staffing and census data will be collected for each fiscal quarter (FQ 1 is from October 1-December 31; FQ 2 is from January 1-March 31; FQ 3 is from April 1-June 30; FQ4 is from July 1-September 30) . Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely .

Based on interview and record review, the facility failed to ensure two of five residents reviewed for unnecessary medication (Residents 17 and 18) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when: 1. For Resident 17, the facility did not have the prescriber-documented rationale for extended use of the as-needed (PRN) lorazepam (a psychotropic medication for anxiety) beyond 14 days; 2. For Resident 18, the facility did not monitor the effectiveness of the antipsychotic (quetiapine - medication to treat mental illness). These failures had the potential to result in unnecessary use of medications. Findings: 1. During a concurrent interview and record review on July 31, 2024 at 2:50 p.m., with staff pharmacist (RPH) 1 and Licensed Vocational Nurse (LVN) 1, Resident 17's electronic medical record was reviewed. The record indicated a physician's order, dated June 27, 2024, for lorazepam 0.5 milligrams (mg - unit of measurement), to be administered via feeding tube every six hours as needed for anxiety manifested by verbalization of feeling anxious, stop on July 4, 2024 (seven days). The record indicated an identical order for lorazepam dated July 4, 2024 to stop on July 18, 2024 (14 days). The record indicated an additional identical order for lorazepam dated July 20, 2024 to stop on July 27, 2024 (seven days). The record indicated a final identical order for lorazepam dated July 27, 2024 to stop on August 10, 2024 (14 days). RPH 1 and LVN 1 each stated they were unable to find any documentation for the extended use of the as-needed lorazepam. During an interview on July 31, 2024 at 4:29 p.m. with Director of Nursing (DON), DON stated the expectation is for the physician to evaluate the resident when extending orders for as-needed psychotropic medications. DON stated the expectation is the physician will document the need for the extension. DON stated there should be documentation of the rationale for extension for Resident 17. During a review of the facility's policy and procedure (P&P) titled, Chemical Restraints, dated, March 2024, the P&P indicated: Chemical restraints [antipsychotic/psychotropic medications] are used in the lowest possible dose and are discontinued when no longer required . 2. During a review of Resident 18's medical records on July 31, 2024, included the following: - .was admitted to the facility on [DATE], with diagnoses that included history of alcohol and cocaine abuse, multiple injuries from assault, CVA (cerebrovascular accident, stroke), craniotomy (temporary removal of part of skull to work on the brain), and chronic respiratory failure on tracheotomy tube (a tube inserted to windpipe to help with breathing) .; There was a physician order on July 13, 2024, for Seroquel (quetiapine, an antipsychotic medication to treat various mental and thought disorder including altered sense of reality) 25 mg to be given to the resident by feeding tube every 8 hours for psychosis manifested by pulling at tubes, trach(eostomy) and G-Tube (gastrostomy tube, a feeding tube); The facility's Care Plan titled, Antipsychotic Drug Use, initiated, July 13, 2024, was reviewed and it indicated: .Will have decreased episodes of pulling at tubes lines trach (tracheotomy) .Monitor episodes report increase or decrease in episodes to MD (physician) and adjust medications as needed . The electronic documentation for behavior monitoring in the resident's medical record for Seroquel indicated the documentation was not consistently done as indicated by two, or sometimes one, or sometimes no documentation of behavior monitoring each day. During an interview on July 31, 2024, at 11:30 a.m., the Clinical Nurse Educator (CNE) and the Infection Preventionist (IP) stated there were two nursing shifts per day and each day nursing staff would document behavior monitoring at the end of their shifts. They both agreed there were less than two behavior documentation in some of the days. During an interview on July 31, 2024, at 4:50 p.m., the DON stated the behavior documentation should be consistent to reflect the effective of the medication. The DON stated there had been some issues with nursing staff regarding documentation in the residents' medical records. The facility's policy and procedure titled, Interdisciplinary Care Plan, dated, March 2024, was reviewed, and it indicated, .To outline the correct use and completion of an individual multidisciplinary Care Plan that is directed toward achieving and maintaining a resident's optimal physical, psychosocial and functional status .Care Plans serve as the plan of care for the resident. They address the quality of care the resident will receive from the staff .Staff are to choose desired and measurable goals that are appropriate for the resident to attain .

Based on interview and record review, the facility failed to ensure: 1. Information regarding formulation of Advanced Directive (AD- a written document that indicates a resident's medical wishes) was provided to the Residents' Representatives (RR), for two of 14 residents reviewed for AD (Residents 18 and 7); and 2. Resident 11's AD was not readily available in the resident's medical record. These failures had the potential for the resident/resident representative's current wishes for medical care not to be honored. Findings: 1. On July 29, 2024, Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE]. Resident 18's Resident Representative (RR- makes decisions for the resident due to the resident not having mental capacity to make medical decisions) was his family member (FM). Resident 18's History and Physical, dated July 10, 2024, indicated a history of alcohol and cocaine use, post assault, stroke, status post craniotomy (opening in the skull to access the brain for surgery), chronic respiratory failure requiring tracheostomy (opening into the wind pipe from outside the neck to allow air and oxygen to reach the lungs). Resident 18 required high complexity medical decision making. Resident 18's Minimum Data Set (MDS- an assessment tool), dated July 16, 2024, indicated Resident 18 had severe cognitive impairment. Resident 18's Physician's Order for Life Sustaining Treatment (POLST), signed by the RR on July 22, 2024, did not indicate the presence of an AD. There was no documented evidence information on formulating an advance directive was provided to or received by Resident 18's RR. On July 31, 2024, at 11:43 a.m. the Infection Preventionist (IP) was interviewed. The IP stated upon a resident's admission to the facility, the POLST was to be given to the resident and/or RR and the form was to be filled up to indicate their medical wishes, then the resident and/or RR and the physician would sign the form. The IP stated if the resident had an AD, a copy would be requested and be filed in the resident's chart. She further stated if there was none, the Social Services Liaison (SSL) would work with the resident and/or RR, as well as the Ombudsman, to formulate one. On July 31, 2024, at 11:50 a.m., the SSL was interviewed. The SSL stated she would talk to the RR for residents who were not alert and oriented, provide them the pamphlet regarding AD, they could fill them out, then the Ombudsman would come to the facility to witness it. She stated if the resident was not oriented, the Ombudsman would not sign off on the AD, then she would talk to the RR about considering applying for conservatorship for the resident. On July 31, 2024, at 3:07 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON) and the SSL. The DON and SSL confirmed there was no documentation information regarding AD formulation was offered to Resident 18's RR. The SSL further stated, there was no discussion with the RR until today, regarding ADs, since she was unable to get a hold of the RR beforehand. On July 31, 2024, at 4:07 p.m., the DON was further interviewed and stated, information regarding AD formulation should have been provided to the RR when Resident 18 was admitted . 2. On July 29, 2023, at 3:42 p.m. Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE]. Resident 7's RR was her family member (FM). The History and Physical, dated January 20, 2024, indicated a chief complaint of chronic respiratory failure, as well as a history of cardiac arrest and anoxic brain injury (brain is deprived of oxygen leading to brain cell death after four minutes), currently unresponsive and unconscious. The POLST,' signed by Resident 7's RR on August 11, 2023, did not indicate the presence of an AD for Resident 7. The Progress Notes, indicated Resident 7's RR declined to complete an AD on July 19, 2019. There was no documented evidence recent attempts were made by the facility to provide information on formulating an advance directive to Resident 7's RR. On July 31, 2024 at 3:07 p.m., a concurrent interview and record review was conducted with the DON and SSL. When asked how often the facility provided follow ups with RR's regarding AD formulation, the DON and SSL were unable to state any frequency per facility protocol. The DON and SSL confirmed there were no recent attempts made to discuss or provide information to Resident 7's RR regarding AD formulation. 3. On July 30, 2024, at 10:48 a.m., Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], and was self-responsible. The POLST, signed by Resident 11 on May 31, 2022, did not indicate the presence of an AD. The History and Physical, dated June 9, 2024, indicated Resident 11 was alert and oriented. There was no documented evidence information on formulating an advance directive was provided to or received by Resident 11. There was no evidence there was an AD filed in Resident 11's record. On July 31, 2024 at 3:07 p.m., a concurrent interview and record review was conducted with the DON and SSL. The SSL stated Resident 11 was initially admitted from the acute side on May 30, 2024, and had an AD in her chart so she left it alone, nor did she write any notes regarding the AD since it was already there. The SSL attempted to locate the AD in the paper record in the unit, as well as electronic record but was unable to do so. The DON attempted to locate Resident 11's electronic records outside of the unit but within the hospital system. The DON was able to locate the POLST while Resident 11 was in the Direct Observation Unit (DOU) indicating yes to and AD, but was unable to locate an actual scanned copy of the AD. The DON stated Resident 11's AD should have been available in the current record. A review of the facility's policy and procedure titled, ADVANCE DIRECTIVE, dated March 2024, indicated, .It is the policy of (name of facility) and the Patient Access Department that every adult receiving medical care is interviewed and the appropriate responses be noted and/or the requested information be provided at the time of registration excluding routine laboratory, radiology services, concerning the patient's individual rights under state law to make decisions regarding his or her medical care. The patient's legally completed Advanced Health Care Directive (AHCD/AD) Information is to be documented in the patient's visit as well as scanned in the patient's Medical Record for future reference as needed for patient care decisions to be administered as necessary .On or before every registration, even for patients who are frequently readmitted .Patient Access staff will inquire about the status of any existing Advanced Health Care Directive .Upon completion of he questions and entry into the computer system the patient will be provided any requested Advance Directive information in order to review or discuss with the appropriate person, such as the social Workers or Nursing Staff during time of Admission and patient care .

Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and sanitary food preparation were followed in the kitchen when: 1. Multiple items in the walk-in refrigerator, freezer, and dry storage area were not labeled and/or left open to air; 2. Multiple kitchen equipment and areas in the kitchen were not clean; 3. Cooking pans were stacked wet with puddle of water at the bootom of each pot; and 4. Freezers 2 and 3 had ice buildup on the floors. This failure had the potential to place the residents at risk for foodborne illness or to receive an incorrect food or outdated food items. Findings: On [DATE], at 9:50 a.m. an initial tour of the kitchen was conducted with the weekend Dietary Aide (DA), Dietary Supervisor (DS) , and the Deputy Regional Director (DRD). The following were observed: - In walk in refrigerator 4 (four), 4 bags of red grapes and 8 heads of green leafy lettuce stored in plastic containers without a lid, open to air. Dietary Aide 1 (DA1) stated the food should never be stored open to air.'' - In walk in refrigerator 1, 1 (one) gallon of lime juice opened, not labeled with open date. The DS confirmed the juice did not have a label with open date; - In walk in refrigerator 1, 1 (one) gallon of lime juice with an expiration date of [DATE]. The DS confirmed that the lime juice was expired risking food borne illness. - In freezer 2, 1 (one) large vacuum sealed pork was not labeled or dated. The DS and DRD confirmed that the pork was not labeled or dated risking food borne illness; - In kitchen, on shelf above sink, 4 (four) large containers of spices being used, not labeled with open date. The DA, DS, and DRD all confirmed the spices should all be labeled; - In dry storage area on shelf, a 5-pound (lb - a unit of measurement) bag of Cinnamon Strudel Topping Mix not labeled, left open to air. The DS confirmed that the Strudel Topping Mix was not labeled and open to air risking food borne illness; - On shelf outside of dry storage area, 7 stainless steel pans stacked upright and wet. The DS confirmed it was not appropriate to stack wet cooking equipment that it risks cross contamination and risk of food borne illness. The DS stated this could collect particles of debris and store bacteria.; - One used black rubber glove left on a cooking prep table across from one of the warming ovens. The Prep [NAME] stated, the glove should not be laying there risking cross contamination. - On rack above table between ovens, 2 oven mitts observed hanging, tattered with batting exposed. The DS and DRD agreed the oven mitts risked material falling into food which is a risk of harm to residents; - The stainless steel shelf above one oven was observed to have peeling plastic and small loose white particles. The DRD agreed the peeling plastic and small loose particles could put residents at harm; and - Freezer 3 was observed to have thick patches of ice on the freezer floor. The DRD stated the ice build up is unacceptable and would be fixed. On [DATE], at 10:51 AM an interview was conducted with the DS who stated the kitchen staff should always label the food items showing the date received and the date opened on all the items to prevent food borne illness or harm to the residents. On [DATE], at 11:17 a.m., Freezer 3 was still observed with ice build up on the floor. The facility had contacted an engineer to resolve the problem. On [DATE], at 11:17 a.m., A review of the policy and procedure titled, Food Storage, revised [DATE], indicated, .Manufacturer's expiration,use by, or sell by dates must be adhered to .Dry food which is opened or removed from original packaging, should be stored properly covered, in food grade containers and clearly labeled .spices, extracts, and or seasonings may be labeled with opened date and are to be used within the natural shelf life .Frozen meats are to be discarded 3 months from received date . A review of the policy and procedure titled, Preventing Transmission of Disease,revised [DATE], indicated, .all food and nutrition service employees are educated as to the relationship between personal hygiene and food safety to include the association of hand hygiene/contact, personal habits and behaviors, and food employee health to foodborne illnesses . A review of the policy and procedure titled, FNS Cleaning and Sanitation Program revised ,d+[DATE], indicated . Food Service Director develops cleaning schedules for all department services wares, equipment, walls, ceilings, floors, storage racks, and vents .it is the responsibility of the Food and Nutrition Services General Manager to ensure this work is performed on a routine basis .

49613 Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One out of four licensed nurses used her finger to check the water temperature before use for diluting medications and flushing the feeding tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach or small intestine) for Resident 2; 2. Two out of four nurses did not perform hand hygiene before administering eye drops to Residents 2 and 5; and 3. One suction canister was found not labeled or dated. These failures had the potential to spread infections between residents and staff. Findings: 1. During a medication pass observation on July 30, 2024 at 9:34 a.m., Licensed Vocational Nurse (LVN) 1 was observed putting on a pair of gloves and preparing nine medications, including feeding tube medications and eye drops, for Resident 2 outside the resident's room. Wearing the same gloves, LVN 1 entered the room and filled up the water pitcher at the sink. LVN 1 then put her gloved finger in the water inside the water pitcher and stated she wanted to make sure the water was warm enough for the resident. LVN 1 stated the water is used to dilute the medications and was observed pouring the water from the pitcher to dilute Resident 2's medications for administration. The same water was used to flush out Resident 2's feeding tube between each medication given. During an interview on July 30, 2024 at 11:26 a.m., with LVN 1, LVN 1 verified she used her finger to check the temperature of the pitcher water. LVN 1 stated she did this to make sure the water was not too hot for the resident or too cold for diluting the medications. During an interview on July 31, 2024 at 11:08 a.m. with the Infection Preventionist (IP), the IP stated it was not acceptable for a nurse to put their finger in the water pitcher. The IP stated this was an infection control issue and the nurse contaminated the water. During an interview on July 31, 2024 at 4:36 p.m., the Director of Nursing (DON), the DON stated the nurse should not have put her finger in the water pitcher. The DON stated this practice was an infection control issue. 2a. During the same medication pass observation on July 30, 2024 at 9:34 a.m. for Resident 2, LVN 1 was observed putting on a pair of gloves and preparing nine medications, including feeding tube medications and eye drops, for Resident 2 outside the resident's room. Wearing the same gloves, LVN 1 entered the room and filled up the water pitcher at the sink. LVN 1 proceeded to administer feeding tube medications to Resident 2. LVN 1 then administered the eye drops as one drop into each of Resident 2's eyes, all without changing gloves or performing hand hygiene. During an interview on July 30, 2024 at 10:11 a.m. with LVN 1, LVN 1 stated she put on one pair of gloves before entering Resident 2's room and discarded the same pair of gloves after medication pass was complete. LVN 1 stated there were no gloves in Resident 2's room so she couldn't change her gloves and stated she was supposed to change gloves between residents. During an interview on July 30, 2024 at 11:31 a.m. with LVN 1, LVN 1 stated she was supposed to change her gloves after giving feeding tube medications and before giving eye drops to Resident 2. 2b. During a medication pass observation on July 31, 2024 at 8:24 a.m., registered nurse (RN) 1 was observed preparing and administering ten medications to Resident 5, including feeding tube medications and eye drops. RN 1 administered the last feeding tube medication wearing gloves. RN 1 then removed her gloves and immediately put on a new pair of gloves without performing hand hygiene. RN 1 then administered the eye drops as one drop into each of Resident 5's eyes. During an interview on July 31, 2024 at 10:20 a.m. with RN 1, RN 1 stated nurses are supposed to wash or sanitize hands before taking care of a patient and when hands are soiled. RN 1 stated she did not perform hand hygiene during Resident 5's medication pass because her hands were not soiled. RN 1 verified she did not need to wash her hands after changing gloves unless her hands were soiled. During an interview on July 31, 2024 at 11:08 a.m. with the IP, the IP stated the expectation is nurses perform hand hygiene by either washing or sanitizing their hands before administering eye drops. The IP stated after giving feeding tube medications, the nurse was supposed to remove gloves, wash or sanitize hands, put on new gloves, and then give eye drops. During an interview on July 31, 2024 at 4:36 p.m., with the DON, the DON stated the expectation was after giving feeding tube medications, the nurses removed their gloves, used hand sanitizer, put on new gloves, and then administer the eye drops. The DON stated there was a risk of transferring infections to eyes. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene Five Moments, dated, April 2024, the P&P indicated:, .5 Moments for HAND HYGIENE for Healthcare Providers Before clean/aseptic procedure .After body fluid exposure risk .Gloves should not be worn in the place of hand hygiene . 3.On July 28, 2024 at 11:12 a.m., Resident 15 was observed lying in bed, with trach (to allow air to fill the lungs patent and intact attached to oygen. There was a suction canister at the wall of the back of the bed which was not labeled or dated. On July 28, 2024, Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE] with a diagnosis of respiratory failure (a condition where you don't get enough oxygen). On July 28, 2024, at 12:40 p.m., an interview was conducted with the Respiratory Therapist (RT). The RT confirmed the suction cannister of Resident 15 did not have a label and was not dated. The RT stated the suction cannisters should have a label and date to know when to change them. The suction cannisters are to be changed every two weeks and as needed. A review of the policy and procedure titled, Resident Equipment Change revised on March 3, 2024, indicated, .supplies will be labeled .suction canisters are changed every other week or when 2/3 (two third) full or PRN (as needed) .

Based on interview and record review, for one of 18 residents, the facility failed to ensure interventions were placed to address Resident 4's frequent shower refusals . This failure had a potential to result in a delay in the care and treatment of Resident 4's skin conditions and to develop new skin conditions. Findings: On July 29, 2024, at 2:33 p.m., Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure (not enough oxygen in the blood) and diabetes mellitus (abnormal blood sugars). The Minimum Data Set (MDS - an assessment tool), dated May 5, 2024, indicated Resident 4 had a BIMS score of zero, indicating severely cognitive function. The Medication Administration Record (MAR), included physician's orders for Nystatin (an antifungal- medication to prevent fungal growth) powder to the following areas: - Inflamed skin under left axillary (armpit) area; - Inflamed skin under left breast; - Inflamed skin under right breast; - Inflamed skin on left axilla; and - Inflamed skin on right axilla. The MAR, included physician's orders for Nystatin-Triamcinolone cream (combination antifungal and antibacterial medication) to the following areas: - Redness on left groin; and - Redness on right groin. On July 31, 2024 at 9:30 a.m., a concurrent interview and review of Resident 4's record was conducted with the Infection Preventionist (IP). The IP stated she also performed Treatment Nurse responsibilities during the week from Monday to Friday in the facility. The IP was asked regarding any current skin issues Resident 4 had which required treatments. The IP stated Resident 4 frequently refused showers, so she usually presented with redness to her underarms, under her breasts or groin, for which she had orders for Nsytatin to be applied to the affected areas. The IP stated bed bath would be offered to the resident if the resident would refuse showers. Resident 4's Progress Notes, were reviewed with the IP and the IP stated there was one bed bath offered and completed on May 6, 2024 and on June 17, 2024, Resident 4 had a shower. Resident 4's care plans were reviewed with the IP and indicated medication treatments for multiple areas in the resident's body were included. The care plans did not include any interventions to address Resident 4's frequent refusals for showers or bed bath. On July 31, 2024, at 5:01 p.m. the Director of Nursing (DON) was interviewed. The DON stated there should have been a plan of care or interventions developed to address Resident 4's skin issues in relation to her shower refusals. The DON stated, At one point in time, it should have been identified why the issues keep happening so it can be addressed accordingly. A review of the facility's policy and procedure titled, INTERDISCIPLINARY CARE PLANS, dated March 2024, indicated, .an individualized plan of care for the resident .should be initiated when a resident is admitted and may be adjusted in response to identified problems throughout the hospital stay .Each implemented Care Plan must be addressed by Nursing at least once every 7 days in weekly summary until the problem has been resolved .Documentation in the resident's medical record by licensed Health Care Team members will identify each Care Plan by number and will include an evaluation of the progress or lack of progress towards the goal .

Based on interview and record review, the facility failed to develop policies and procedures for the monthly drug regimen review. This failure had the potential for delayed identification of harmful drug interactions, side effects, and inadequate monitoring that could negatively impact residents' physical, mental, and psychosocial well-being. Findings: On July 31, 2024 at 11:30 a.m., during a concurrent interview and record review with the Director of Pharmacy (DOP), the facility's policies and procedures (P&P) were reviewed. There was no documented evidence the facility had developed and implemented written policies and procedures for monthly drug regimen reviews by a pharmacist. On July 31, 2024 at 1:26 p.m., during an interview with the DOP, the DOP stated there was no current policy addressing monthly drug regimen review.

Based on observation, interview, and record review, the facility had a medication error rate of 9.68% when three medication errors occurred out of 31 opportunities during medication administration, for two out of four residents (Residents 2 and 5). This failure resulted in medications not given according to the prescriber's orders and/or manufacturer's specifications and had the potential for residents to not receive the full therapeutic effects of medications. Findings: 1a. During a medication pass observation on July 30, 2024 at 9:34 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering nine medications to Resident 2. The medications included tobramycin (to treat eye infections) 0.3% eye drops. During an observation on July 30, 2024 at 10:03 a.m. in Resident 2's room, LVN 1 administered one drop of tobramycin into Resident 2's left eye and then one drop into the right eye. During a review of Resident 2's electronic medical record, the record indicated a physician's order dated June 3, 2024 for tobramycin sulfate 0.3% eye drops, to be administered as one drop every 12 hours for red right eye. During a concurrent interview and record review on July 30, 2024 at 11:19 a.m. with LVN 1, Resident 2's physician's orders were reviewed. LVN 1 stated she gave Resident 2 one drop of tobramycin in each eye. When asked to read the physician's orders dated June 3, 2024 for tobramycin eye drops, LVN 1 stated she accidently gave Resident 2 a drop into the left eye. During an interview on July 31, 2024 at 4:19 p.m. with Director of Nursing (DON) regarding Resident 2's tobramycin eye drops given to both eyes, DON stated her expectation is that Resident 2 only gets tobramycin in the right eye as the physician ordered. 1b. During the same medication pass observation on July 30, 2024 at 9:34 a.m., LVN 1 was observed preparing and administering nine medications to Resident 2. LVN 1 had an additional medication, fludrocortisone (to treat low blood pressure) set aside. LVN 1 stated the fludrocortisone would be held because Resident 2's blood pressure (BP) was 107/68 (BP result consists of two numbers: the top number or systolic blood pressure [SBP] and the bottom number or diastolic blood pressure [DBP]). During a review of Resident 2's electronic medical record, the record indicated a physician's order dated June 3, 2024 for fludrocortisone 0.1 milligrams (mg), to be administered via feeding tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach or small intestine) twice a day, hold for SBP greater than 110. During a concurrent interview and record review on July 30, 2024 at 11:19 a.m. with LVN 1, Resident 2's physician's orders were reviewed. LVN 1 stated to hold the fludrocortisone for SBP less than 110. When asked to re-read the physician's orders dated June 3, 2024 for fludrocortisone, LVN 1 acknowledged that the orders indicated to hold for SBP greater than 110 and stated she would clarify the orders. During an interview on July 30, 2024 at 11:31 a.m. with LVN 1, LVN 1 stated she was supposed to give fludrocortisone to Resident 2 this morning because the blood pressure was lower than the hold parameters. During an interview on July 31, 2024 at 4:19 p.m. with the Director of Nursing (DON) regarding Resident 2's fludrocortisone, the DON stated her expectation is nursing staff give medications if the parameters are met as ordered by the physician. The DON stated Resident 2's fludrocortisone should have been given with SBP reading of 107. 2. During a medication pass observation on July 31, 2024 at 8:24 a.m., registered nurse (RN) 1 was observed preparing and administering ten medications to Resident 5. The medications included two packets of Phos-NaK (supplement with sodium, potassium, and phosphorous) powder. RN 1 poured the two packets into a cup and diluted with water. RN 1 stated she added about 30 milliliters (ml) of water to the powder before giving to Resident 5 via feeding tube. During a review of Resident 5's electronic medical record, the record indicated there was a physician's order dated November 13, 2023 for Phos-NaK, two packets to be administered via feeding tube every 12 hours. During a review of Resident 5's Phos-NaK package labeling, undated, each packet indicated, .Directions: Mix contents of 1 packet with 2.5 ounces (75 ml) of water or juice. Stir well . During a review of Lexicomp Online (a nationally recognized drug information resource), updated May 9, 2024, the Phos-NaK monograph (a document that describes a medication's uses, dosing, and administration) indicated, .Each packet must be diluted in 75 mL of water or juice prior to administration; stir well . During an interview on July 31, 2024 at 10:20 a.m. with RN 1, RN 1 stated she gave 40 ml of water with Resident 5's Phos-NaK. When shown the Phos-NaK labeling indicating to add 75 ml of water to each packet, RN 1 stated she would need to check the directions with someone. RN 1 stated she did not receive any training on how to dilute Phos-NaK for feeding tube administration. During an interview on July 31, 2024 at 4:19 p.m. with DON, regarding Resident 5's Phos-NaK, DON stated the expectation is for the nurse to follow the dilution directions or check with the pharmacy if directions are not specified in the orders. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated, March 2024, the P&P indicated, Medication is considered to be given in error if any of the following conditions are present .Wrong dose .Omission of a dose .

Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment was provided, when two (2) air vents above Resident 17 and 107's beds were found to be stained with dark colored dust particles. This failure had the potential to cause and/or worsen medical conditions of the residents who have respiratory conditions which could lead to respiratory distress. Findings: On July 30, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with the Director of Nursing DON) and the Deputy Regional Director (DRD) confirmed that there was staining and dark colored dust particles coming for the air vents above bed of 409A and 410A and that these particles could cause harm to the residents. On July 30, 2024 Resident 17 record was reviewed. Resident 17 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure (not enough oxygen in the blood). On July 30, 2024 Resident 170 record was reviewed. Resident 170 was admitted to the facility on [DATE], with a diagnosis of respiratory failure. On July 30, 2024, at 10:55 a.m., an interview was conducted with the Director of Facility (DOF). The DOF stated, We are planning to place new covers on the vents.'' A review of the policy and procedure titled, Environment of Care, revised March 2021, indicated, .Hazards that are identified are expected to be resolved within a reasonable timeframe .Hazards that pose an imminent danger to life or property must be corrected immediately .

Based on interview and record review, the facility failed to ensure, for one of three sampled residents (Resident A): 1. Proper positioning of a female resident with lower extremity (legs and feet) contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) was implemented during urine sample collection with the use of a straight catheter (a flexible tube inserted into the urethra [where urine passes out of the body]). Resident A's hip and leg/thigh were lifted up six inches from the mattress for urine collection. In addition, the licensed nurse continued to collect a urine sample from Resident A despite hearing an abnormal sound from Resident A's hip area. This failure resulted in Resident A to sustain a left hip fracture (broken bone) and was subsequently transferred to the acute hospital for surgical procedure; and 2. Resident A's bluish discoloration to the left eyelid was assessed, monitored, evaluated, and referred to the physician for appropriate treatment. This failure resulted in delayed provision of treatment to address Resident A ' s bluish discoloration to the left eyelid and could potentially compromise the resident ' s overall health condition. Findings: On March 28, 2024, at 3:10 p.m., an announced visit to the facility was conducted to investigate a facility reported incident and complaints regarding quality of care. 1. On March 28, 2024, at 3:43 p.m., an interview was conducted with Registered Nurse (RN) 1, RN 1 stated she worked as a charge nurse on the morning shift on March 13, 2024. RN 1 stated Resident A's had change of condition, and the physician ordered for urinalysis. She stated she instructed Licensed Vocational Nurse (LVN) 1 to collect urine from Resident A, and LVN 1 reported hearing a pop while trying to collect urine from Resident A. She stated the physician ordered x-ray (a photographic or digital image of the internal composition of something, especially a part of the body). She stated Resident A's x-ray indicated a fracture on the femur (hip) and Resident A was subsequently transferred to the acute care hospital. On March 28, 2024, at 4:02 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she assisted LVN 1 in collecting urine from Resident A on March 13, 2024. CNA 2 stated she was at the left side of Resident A and CNA 1 was at the right side of Resident A. CNA 2 stated they (CNA 1, CNA 2, AND LVN 1) heard a pop when she lifted the resident's left leg. CNA 2 was asked to demonstrate how she lifted Resident A's leg, and CNA 2 was observed placing both hands under the resident's left leg and lifted it about six inches up from the mattress and CNA 2 stated that was the moment they heard the popping sound from Resident A's left thigh/hip area. She further stated LVN 1 reported to RN 1 that a popping sound was heard from Resident A's left hip and LVN 1 was instructed by RN 1 to still try to get the urine sample. On March 28, 2024, at 4:36 p.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated LVN 1 had asked her and CNA 2 for assistance in getting a urine sample from Resident A on March 13, 2024, at around 11:30 a.m. CNA 1 stated Resident A was very contracted on her upper and lower extremities with her hip towards the left side and the upper body was towards the right side. CNA 1 stated she and CNA 2 lifted (few inches above the mattress) Resident A ' s hip slightly to spread her legs so that LVN 1 could insert the catheter in her perineal area (area of the body between the anus and the vagina) to collect the urine sample, then they heard a pop. CNA 1 stated the popping sound came from Resident A's left hip. She stated LVN 1 left the room to report the incident to RN 1 and upon return to the room told CNAs 1 and 2 that the charge nurse instructed her (LVN 1) to collect the urine sample. She stated, during the second attempt to collect the urine sample, they lifted Resident A the same way and spread the resident's legs open while another LVN inserted the catheter on Resident A and finally got the urine sample. CNA 1 stated during the second attempt, RN 1 was present. Resident A's admission record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (lung failure), status post tracheostomy (a surgical procedure to cut an opening on the neck to aid in breathing), and persistent vegetable state (a person who has loss of awareness of their surroundings). A review of Resident A's History and Physical, dated January 27, 2024, indicated, .NEUROMUSCULAR .Restrictive ROM (range of motion [the extent or limit to which a part of the body can be moved around a joint or a fixed point]) . A review of Resident A's Care Plan, dated January 27, 2024, indicated, .Immobility .Contractured Extremities .Position for comfort . A review of Resident A's Progress Notes, indicated the following: - March 13, 3024, at 11:15 a.m.; .MD (physician) ordered a UA (urinalysis - urine test) d/t (due to) residents (sic) change in mental status while straight cath (catheter), x (times) 2 (two) CNAs assist writer and the x (times) 2 (two) CNAs heard a pop noise that came from residents (sic) lip (sic) hip .writer and cnas stopped and and assessed residents left leg and left hip for any changes . - March 13, 2024, at 11:35 a.m.; .Notified by LVN performing the urine collection that she heard a POP from the left hip while trying to collect the urine .MD ordered a (sic) X RAY left .Urine was collected and sent to lab . - March 13, 2024, at 6:10 p.m.; .After sending left hip X-ray result to MD an order was received to transfer resident to DOU (Direct Observation Unit) under (name of doctor), due to left femur (thigh bone) fracture . On April 18, 2024, at 3:42 p.m., an interview with RN 1 was conducted. She stated on March 13, 2024, between 10 a.m. to 11 a.m., LVN 1 reported that when the CNAs lifted Resident A ' s legs while she was attempting to collect the urine sample, she heard a pop that came from Resident A's left hip. She stated LVN 1 reported that she did not feel comfortable in continuing to collect the urine sample. RN 1 stated she then asked another LVN to help. RN 1 stated she observed CNAs 1 and 2 lift the resident by the hip on each side with one hand on the hip and the other hand on her upper leg in which Resident A ' s lower part of the body was completely suspended several inches from the bed. RN 1 stated she realized that she should not have continued getting the urine sample after hearing the report from LVN 1 about the popping sound heard during the first attempt of urine collection. She also stated she should have stopped the CNAs when they lifted the resident from the hip and legs as she realized that this was probably not the safest positioning of the resident when the urine sample was collected. She further stated that they should have attempted to place the resident at side-lying position to prevent the fracture. On April 18, 2024, at 4:02 p.m., an interview with LVN 1 was conducted. LVN 1 stated Resident A ' s legs were very contracted. She described Resident A ' s legs on both sides to be internally rotated (knee and foot twist toward the midline of the body) with both knees almost touching each other. She further stated Resident A ' s legs on both sides could not be spread apart since there was resistance due to her contractures. LVN 1 stated on March 13, 2024, while CNAs 1 and 2 were helping her collect the urine sample for Resident A, using straight catheter, she heard a popping noise when the two CNAs lifted the resident from the hip on both sides. She stated she immediately told the CNAs to stop and bring Resident A back down in bed. She stated she reported to RN 1 the popping noise while positioning the resident during urine sample collection but was told that urine sample was still needed. She further stated she told RN 1 she did not feel comfortable collecting the sample. She stated, RN 1 brought another LVN to Resident A ' s room who eventually was able to collect the urine sample using straight catheter. LVN 1 stated she observed the CNAs lifting Resident A ' s hip on both sides when the other LVN collected the urine sample, which was the same procedure they did on the first attempt. LVN 1 stated after further discussion of the incident, she realized the positioning of Resident A when the urine sample was collected was probably not the safest to prevent injuries. On April 18, 2024, at 4:19 p.m., an interview with CNA 2 was conducted. She stated Resident A ' s legs on both sides could not be spread apart due to her contractures. She stated on March 13, 2024, CNA 2, and CNA 1 assisted LVN 1 in collecting the urine sample from Resident A. CNA 2 stated Resident A was lying in bed on her back with both of her knees slightly bent at the knees. CNA 2 stated she was on the left side of the bed while CNA 2 was on the opposite side. CNA 2 stated they (CNA 1 and CNA 2) lifted Resident A from her hip on each side with one hand on the hip and other hand right below the upper leg. She stated Resident A ' s lower part of the body was completely suspended in the air about several inches above the bed while LVN 1 attempted to collect the urine sample. She stated while LVN 1 was attempting to collect the urine sample, they heard a pop that came from resident ' s left hip and immediately placed resident ' s lower body back in bed. She stated LVN 1 left the room to report the popping sound from Resident A's left hip to RN 1. She stated LVN 1 came back with RN 1 and another LVN to continue with collecting the urine sample. CNA 2 stated they used the same positioning by lifting Resident A ' s hip and leg as they did on the first attempt. On April 18, 2024, at 4:56 p.m., an interview was conducted with the Medical Doctor (MD). The MD stated she was aware of the incident that occurred on March 13, 2024, for Resident A. The MD stated the staff reported that the resident sustained a fracture on her left hip after the staff attempted to collect the urine sample. She stated she was not aware the CNAs who assisted with collecting the urine sample had lifted the resident by the hip and legs. She stated due to the resident's lower legs contracture, other position like side-lying would have been the safest way to collect the urine sample from Resident A. She stated Resident A ' s left hip fracture was likely caused by improper positioning of the resident when the urine sample was collected by the staff. She further stated if the staff reported that they heard a pop on the first attempt to collect urine, she would not have them continue collecting urine sample from Resident A. She stated due to improper positioning by the staff, the resident had to go to the hospital for a surgical procedure. On April 18, 2024, at 5:27 p.m., an interview with the DON was conducted. She stated she was not aware the CNAs who assisted with collecting the urine sample from Resident A had lifted resident from the hip and legs while suspended in the air. She stated this was not the proper positioning to collect the urine sample since she was aware of Resident A ' s contractures. She was surprised how the resident was positioned considering the weight of the resident and the LVN who collected the urine sample was able to insert the catheter without spreading her legs apart. She stated the staff who was involved during the time of the incident should have attempted to place resident in side-lying position instead of being lifted by the hip and legs to prevent injuries to the resident. She also stated RN 1 should not have instructed the LVN to continue with urine sample collection after hearing the report from LVN 1 about the popping noise that was heard after the first attempt. The DON further stated the cause of the fracture was likely due to improper positioning of the resident by her staff, considering the location of the fracture. The DON stated the facility did not have a policy and procedure related to the urine collection through straight catheter. A review of a web article titled Urinary Catheters- Clinical Procedures for Safer Patient Care, published on 2015, by Glunda [NAME] and [NAME] McCutheon, indicated, .Positioning of patient depends on gender .Patients should be comfortable, with perineum (an area between the anus and vagina) or penis exposed, for ease and safety in completing the procedure .Female patient: On back with knees flexed and thighs relaxed so that hips rotate to expose perineal area. Alternatively, if patient cannot abduct leg at the hip, patient can be side lying with upper leg flexed at knee and hip, supported by pillows . A review of the facility ' s policy and procedure titled General Restorative & Supportive Nursing Care, dated April 4, 2021, indicated, .It is the policy of this facility that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities .Restorative and supportive care shall include .Maintaining good body alignment and proper positioning of bedfast and dependent residents . A review of Resident A's (name of hospital) Discharge Summary, dated March 21, 2024, indicated, .ADMISSION DIAGNOSES: Left hip fracture .HOSPITAL COURSE: The patient .was getting a urinalysis when the nurse heard a popping sound on the left hip. X-ray was done showing a left hip fracture .The patient with left hip fracture, status post repair with ORIF (Open reduction and internal fixation [a type of surgery used to stabilize and heal a broken bone]) by (name of doctor) . 2. On March 28, 2024, at 3:18 p.m., an interview was conducted with the Director of Nursing (DON). She stated Resident A ' s family member notified the staff on December 25, 2023, that they had noticed bruising on her left eye which she thought occurred when the resident was showered by the staff. The DON stated when she assessed Resident A on December 25, 2023, she observed Resident A with slight brown and yellowish discoloration on her left eyelid. The DON stated it looked like it was an old bruise that was healing. The DON stated she conducted interviews of the CNAs who showered resident on December 8, 2023, and denied ever noticing any discoloration to Resident A ' s left eyelid and that there was no incident that occurred during the shower on December 8, 2023. The DON stated after further review of Resident A ' s medical records, she noted a short-term care plan was initiated to monitor the resident's discoloration to her left eyelid on December 14, 2023. The DON further stated there was no further assessment, evaluation, and monitoring done to address resident ' s discoloration on her left eyelid after it was identified on December 14, 2023. Resident A ' s record was reviewed. Resident A was admitted on [DATE], with diagnoses which included chronic respiratory failure, status post tracheostomy, and persistent vegetable state (a person who has loss of awareness of their surroundings). A review of Resident A's Care plan, dated July 9, 2020, indicated, .Resident has an increased potential for bleeding secondary to use of anticoagulant (a type of medication to thin the blood to prevent blot clot) .Resident will be free from signs and symptoms of bleeding daily .Monitor for S/S (sign and symptoms) of excessive anticoagulant .bruises .notify MD (doctor) . A review of the Short Term Care Plan for the following dates indicated: - December 14, 2023 - .Bruise on left eyelid .monitor bruise on eyelid q (every) shift x (times) 3 (three) days then reassess on 12/19/2023 (December 19, 2023) . - December 19, 2023- .Bruise on left eyelid .monitor bruise on L (left) eyelid q shift x 7 days then reassess on 12/26/2023 (December 26, 2023) . In further review of Resident A ' s Progress Notes, there was no documented evidence Resident A ' s discoloration to the left eyelid was assessed, monitored, evaluated, and referred to the physician after it was identified on December 14, 2023. A review of Resident A's Progress Notes, indicated a Head to toe assessment was conducted for the following dates: December 14, 15, 17, 19, 25, and 26, of 2023. There was no documented evidence the discoloration on left eyelid was noted for Resident A. A review of the Progress Notes dated December 25, 2023, at 4:40 p.m., indicated, .Patients (sic) (family member) was in to visit patient and realized that patient has a bruise on her left eye . (Family member) and patient stated that she received the bruise from when she was given a shower . On April 17, 2024, at 1:15 p.m., an interview with the DON was conducted. The DON stated when Resident A was hospitalized on [DATE], the family member had reported to the hospital staff that Resident A received a bruise during shower that occurred back in December of 2023. She stated that this was the same incident that was investigated on December 25, 2023, and did not find any issues with her staff providing rough care for Resident A. However, the DON stated the RN who had documented the bruise on Resident A ' s left eye lid on December 14, 2023, did not document in detail about the bruise on the left eyelid that was noted. In addition, the DON stated there was no documentation of any reassessment and/or reevaluation of the bruise, as well as notifying the physician after it was initially identified on December 14, 2023. The DON stated the family member should have been notified of the bruise on December 14, 2023. The facility ' s policy and procedure titled Change of Resident Condition dated April 2021, was reviewed. The policy indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician .All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are minor change in physical .that are not life threatening .The nurse in change is responsible for notification of the physician prior to end of assigned shift when a routine change in a resident ' s condition noted .Document resident change of condition and response in Nursing Progress Notes . The facility ' s policy and procedure titled BODY ASSESSMENT FOR SKIN dated April 2024, was reviewed. The policy indicated, .To provide an ongoing system for monitoring resident skin condition and to implement interventions, when needed, to prevent complications .It is the policy of this facility to monitor the resident ' s skin condition and provide documented licensed nurse assessments on an as needed and weekly basis .Nursing assistants will check resident ' s skin check according to weekly summary schedule .Licensed nurse will notify physician for orders and follow-up of treatment. Notify resident or family of changes in the resident ' s skin status .Licensed nurse will document findings in the weekly summary .

Based on observation, interview, and record review, the facility failed to ensure, for one of three sampled residents (Resident A), an injury of unknown origin was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours, when Resident A was found to have a bluish discoloration on the side of the eye. This failure had the potential to result in a delay of the implementation of appropriate action and the provision of protection for Resident A and placed other residents at risk for further abuse. Findings: On March 28, 2024, at 3:10 p.m., an announced visit to the facility was conducted to investigate a facility reported incident regarding injury of unknown origin. On March 28, 2024, at 3:18 p.m., an interview was conducted with the Director of Nursing (DON). She stated Resident A's family notified the staff that they had noticed bruising on Resident A's left eyelid which the family member thought occurred when she was showered by the staff on December 25, 2023. The DON stated when she assessed the resident on December 25, 2023, she observed Resident A with slight brown and yellowish discoloration on the left eyelid. The DON stated it looked like it was an old bruise that was healing. The DON stated she investigated but the resident nor the staff were not able to identify how and when the discoloration occurred. The DON stated on December 14, 2023, it was documented by the licensed nurse that Resident A had a bruise on the left eyelid. Resident A's record was reviewed, and indicated the resident was admitted on [DATE], with diagnoses which included chronic respiratory failure, status post tracheostomy, and persistent vegetable state (a person who has loss of awareness of their surroundings). A review of the care plan dated July 9, 2020, indicated, .Resident has an increased potential for bleeding secondary to use of anticoagulant (a type of medication to thin the blood to prevent blot clot) .Resident will be free from signs and symptoms of bleeding daily .Monitor for S/S (sign and symptoms) of excessive anticoagulant .bruises .notify MD (doctor) . A review of the Short Term Care Plan, for the following dates indicated: - December 14, 2023- .Bruise on left eyelid .monitor bruise on eyelid q (every) shift x (times) 3 (three) days then reassess on 12/19/2023 . - December 19, 2023- .Bruise on left eyelid .monitor bruise on L (left) eyelid q shift x 7 days then reassess on 12/26/2023 . A review of the Progress Notes dated December 25, 2023, at 4:40 p.m., indicated, .Patients (sic) daughter was in to visit patient and realized that patient has a bruise on her left eye .Sister and patient stated that she received the bruise from when she was given a shower . Further review of Resident A's record indicated no documented evidence Resident A's discoloration to the left eyelid was reported to CDPH after it was initially identified on December 14, 2023. On April 17, 2024, at 1:15 p.m., an interview with the DON was conducted. The DON stated when Resident A was hospitalized on [DATE], the family member had reported Resident A sustained a bruise on the left eyelid during shower which occurred back in December of 2023. She stated this was the same incident that was investigated back on December 25, 2023 (11 days from the time it was initially identified on December 14, 2023) but was not reported to CDPH. The DON stated this was considered an injury of unknown origin since Resident A and/or the staff was not able to identify the cause of the discoloration on the left eyelid. Therefore, she stated it should have been reported to CDPH within 2 hours after the injury was initially identified on December 14, 2023. She stated Resident A's bruise on the left eyelid was reported to CDPH on March 15, 2024 (81 days from the first time it was initially identified). The facility's policy and procedure titled PREVENTION OF ABUSE, dated April 4, 2021, was reviewed. The policy indicated, .IDENTIFYING SUSPECTED OR KNOWN DEPENDENT ADULT OR ELDERLY ABUSE .Complaints, observations of indicators, described below or others, of abuse (of suspicious or unknown origin), suspicious, or reporting of incident .bruises .will be investigated to rule out abuse .Indicators of Physical Abuse .bruises .REPORTING PROCEDURES/RESPONSES TO ALLEGATIONS OF ABUSE .Cases of suspected or known abuse will be given priority, investigated thoroughly, and reported immediately to the appropriate agency .designee shall make a telephone report to the local law enforcement immediately or as soon as possible and shall make a written report to the Department of Public Health, local law enforcement and the long-term care Ombudsman within 2 hours .

Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: 1. Multiple food items stored in the walk-in refrigerator and walk-in freezer were not labeled with the name of the food item, the date open, prepared date or use-by date; 2. Open food items stored in the dry storage area were not labeled with the name of the food item, the opened date, or use-by date; 3. The kitchen can opener had an accumulation of a thick brown substance on and around the blade; and 4. One dented can in the dry storage area was readily available for use. These failures had the potential to place the residents of the facility at risk for foodborne illness, or to receive an incorrect food, or outdated food items. Findings: On [DATE], beginning at 9:25 a.m., during the kitchen tour with the Director of Food and Nutrition Service (DFNS) in the skilled nursing facility, the following items were observed stored in the walk-in refrigerator: - 22 Styrofoam cups of fresh salad, were not labeled with the name of the food item, prepared date, or use-by date; - Eight Styrofoam boxes containing food, were not labeled with the name of the food item, prepared date, or use-by date; - One dark brown frozen meat for thawing, was not labeled with the name of the food item, and the start and end date of thawing; - One box of frozen sausage link for thawing, was not labeled with the start and end date of thawing; and - One box of frozen smoked bacon for thawing, was not labeled with the start and end date of thawing. The following opened food items were observed stored in the dry food storage area not labeled with the name of the food item, the opened date, or use-by date; - One container of uncooked pasta; and - One bag of quinoa. In a concurrent interview with the DFNS, she confirmed the food items in the walk-in refrigerator were not labeled with the name of the food item, prepared date or use-by date. The DFNS stated the food items for thawing should have been labeled with the start and end date of thawing. The DFNS stated all food items in the walk-in refrigerator and dry food storage area should have been labeled and dated. On [DATE], at 9:40 a.m., during a kitchen observation in the skilled nursing facility, the can opener attached to the table in the food preparation area was observed with a thick brown substance on and around the blade. In a concurrent interview with the Director of Food and Nutrition Service (DFNS), she confirmed there was a thick brown substance on and around the blade of the can opener. The DFNS took the can opener to the sink and stated to the kitchen staff, It needs to be washed. The DFNS stated the can opener should have been cleaned after each use. An undated facility document titled, PRACTICE FOR SHARPS - CAN OPENER, KNIVES, was reviewed. The document indicated, .Can opener and knives are washed after each use . On [DATE], beginning at 9:55 a.m., during the kitchen tour with the Executive Chef in the sub-acute unit, the following items were observed stored in the walk-in refrigerator: - One plate of tuna salad was not labeled with the name of the food item, prepared date, or use-by date; - One package of shredded jack cheese was opened and not labeled with the date opened, or use-by date; - One container of Glucerna Carb Steady (milk - meal replacement suppliment drink for diabetics [person with abnormal blood sugar]) with a use-by date of [DATE]; - One box of potato salad with a use-by date of [DATE]; - One tub of plain yogurt with a use-by date of [DATE]; - One package of grated parmesan cheese with a use-by date of [DATE]. One dented can of Campbell's soup was observed in the dry food storage area readily available for use. In a concurrent interview with the Executive Chef, she stated the above food items in the walk-in refrigerator were not labeled with the name of the food item, prepared date or use-by date. She stated the above opened food items in the walk-in refrigerator should have been labeled with an open and use-by date. The Executive Chef stated the food items that were outdated should have been removed and discarded. She stated the dented can should have been removed. The facility's policy and procedure titled, Food and Nutrition-Expired/Recalled Products, dated [DATE], was reviewed. The policy indicated, .Outdated and recalled products will not be provided to patients .Food and Nutrition employees will .Check expiration dates on a daily basis .Discard outdated or recalled products immediately . The facility's policy and procedure titled, Food and Nutrition - Food Storage, dated [DATE], was reviewed. The policy indicated, .Date all products to ensure first in-first out procedure .Products must be checked to detect unacceptable items, i.e., dented, swollen or rusted cans .Manufacture's expiration, use by .dates must be adhered .Dry food, which is opened or removed from original packaging, should be .clearly labeled .All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers .All foods set up for service must be protected by sneezeguards or otherwise covered to prevent contamination .Frozen meats are pulled 3 days prior to preparation and cooked on the 3rd day as a standard practice .All items will be labeled, covered and dated when placed in refrigerators or freezers using an established labeling rule .Prepared foods are discarded after 3 days if not used . 2.

Based on observation, interview, and facility document review, the facility failed to ensure a clean environment for the residents and visitors was provided when one dumpster was observed without a lid and the lids of two dumpsters were not securely closed. This failure had the potential to attract pests, insects, and vermin which could create an unsanitary environment for vulnerable residents residing in the facility. Findings: On June 23, 2022, at 10:35 a.m., three dumpsters were observed outside the facility. One dumpster was observed without a lid and contained garbage trash. The lides of two dumpsters (one with garbage trash and one with cardboard boxes) were observed to be wide open (not securely closed). On June 23, 2022, at 10:38 a.m., an interview was conducted with the Dietary Manager (DM). The DM stated one dumpster was missing a cover lid and the two dumpsters lids were wide open. He stated the dumpster lids should have been completely closed. The facility's policy and procedure titled, Medical Waste Management Plan, dated June 23, 2022, was reviewed. The policy indicated, .Regular waste will be stored in a secured area inside the lidded containers and ensure the lid remains closed at all times .To prevent rodents and vectors from entering the facility . According to Federal Food Code 2017, published by the United States Food & Drug Administration, .Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas .Outside receptacles must be constructed with tight-fitting lids or covers to prevent scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents .

Based on interview and record review, the facility failed to ensure; 1. The residents and/or resident's representative (RR) was provided a written information regarding formulating an Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions), for four of 13 residents reviewed for AD (Resident 1, 29, 238 and 240); and 2. A follow up with the resident was conducted regarding obtaining a copy of the resident's AD, for one of 13 residents reviewed (Resident 10). These failures had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves. Findings: On June 20, 2022, Residents 1, 10, 29, 238, and 240's record review were reviewed. 1a. Resident 1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool), dated May 29, 2022, indicated Resident 1 had a BIMS (Brief Interview for Mental Status - cognitive assessment) score of 14 (cognitively intact). 1b. Resident 29 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], indicated Resident 29 had a BIMS score of 15 (cognitively intact); 1c. Resident 238 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], indicated Resident 238 had a BIMS score of 15 (cognitively intact); and 1d. Resident 240 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], indicated Resident 240 had a BIMS score of 12 (moderately impaired). There was no documented evidence the facility provided information on formulating an AD to Residents 1, 29, 238, and 240. 2. Resident 10 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], indicated Resident 10 had a BIMS score of 14 (cognitively intact). On June 21, 2022, at 4:08 p.m., a concurrent interview and record review was conducted with the Social Service Designee (SSD). She stated the facility's process was to offer information regarding formulating an AD to the resident upon admission. She stated a copy of an AD should be placed in the resident's record if the resident had formulated an AD. She stated discussion about AD should be documented in the resident's record. The SSD stated there was no documentation information regarding formulating an AD was provided to Residents 1, 29, 238, and 240. She stated information regarding formulating an AD should have been provided to the residents. The SSD stated the progress notes, dated April 7, 2022, indicated Resident 10 had an AD. The SSD was not able to provide a copy of Resident 10's AD. She stated she was not sure if the facility made attempts to obtain a copy of the resident's AD since April 7, 2022. She stated the facility should have followed up with the resident to obtain a copy of his AD and be included in the resident's record. The facility's policy and procedure titled, Advance Health Care Directives, dated March 2021, was reviewed. The policy indicated, .To maintain a patient's right to make health care decisions on their own behalf and to honor those wishes according to regulations/statues through Advance Health Care Directives .facilities shall provide each adult individual, at the time of admission .written information describing .an individual's rights under the California Statues and Court decisions to accept or refuse medical or surgical treatment and to formulate Advance Health Care Directives .The facility's policy regarding these rights to make health care decisions and to formulate Advance Health Care Directives, and the way such decisions and Directives will be implemented .Facility shall document in the individual's medical record whether or not the individual has executed an Advance Health Care Directives .The patient shall be encouraged to provide a copy of their Advance Health Care Directive to be placed in the chart by the caregiver at the time of admisssion .

Based on interview and record review, the facility failed to ensure a safe environment, by failing to prevent a burn, for one of 10 sampled residents (Resident 2). Facility staff warmed a blanket in the microwave and placed the blanket on Resident 2 (who was paralyzed from the neck and could not feel anything from the neck down), which resulted in second degree burns to the patient's right chest area. Findings: The record for Resident 2 was reviewed on March 22, 2011. Resident 2, a [AGE] year old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. Following this, smoke was noted, and the blanket was immediately removed. The resident sustained [REDACTED]. A Dermatology consult dated November 11, 2010, indicated the resident sustained [REDACTED]. The physician noted an [DIAGNOSES REDACTED]tous, non-blanchable patch on the right breast (red area that does not fade when pressure is applied), with a single bullae (blister) in the middle. According to the notes, the patch covered, "roughly 50% of the R breast, not involving the nipple". A Dermatology consult dated November 15, 2010, indicated the wound may take several weeks to heal. A review of the Licensed Nurses Notes indicated the following: 1. On November 11, 2010: a. At 6 a.m., the resident was assessed following an, "incident." The nurse noted skin discoloration, "pinkish in appearance," on the right breast; b. At 7:10 a.m., the nurse received an order to apply silvadene cream (an antibiotic cream used to prevent and/or treat infection) to the right breast every shift; c. At 7:20 a.m., the redness on the right breast measured 11.0 cm long, and 11.5 cm wide (approximately four inches by four and one half inches) with a small blister; d. At 8 a.m., the nurse received an order to monitor the right breast for infection; e. At 9:15 a.m., the nurse received an order to obtain a dermatology consult for the right breast burn area; and, f. At 1 p.m., the dermatologist arrived for a consult. The nurse received an order to change the treatment to apply silvadene cream to the right breast burn area and cover it with vaseline (soaked) guaze every shift. The resident agreed to change rooms due to, "some smell," and to have the room cleaned. 2. On November 14, 2010, at 12:30 p.m. (3 days later), Resident 2 was moved back into her room. A review of the Wound Progress Notes indicated the following: a. On November 11, 2010, the wound measured 11.0 cm long and 11.5 cm wide; b. On November 16, 2010, there was no change in size, and there was blistering over the entire wound with a moderate amount of drainage; and, c. On November 18, 2010,there was no change in size, and necrotic (dead) tissue was present. 3. A review of The Resident Care Plan indicated problem #3 (Skin Integrity) included the following: a. On November 11, 2010, the problem of right breast redness was added, with a goal to be clear in 14 days, and a future review date of November 25, 2010; b. On November 15, 2010, the problem was changed to right breast redness with an intact blister related to a second degree burn, with a goal to be clear in 14 days, and a future review date of November 29, 2010; c. On November 29, 2010, the problem was changed to right breast open areas, with a goal to be healed in 14 days, and a future review date of December 13, 2010; d. On December 13, 2010, there was no change in the problem, the goal remained to heal in 14 days, with a future review date of December 31, 2010; e. On January 1, 2011, the problem was changed to right breast open areas - non pressure, with a new goal to heal in 30 days, and a future review date of February 1, 2011; f. On February 1, 2011, there was no change in the problem, the goal remained to heal in 30 days, with a future review date of March 1, 2011; and, g. On March 1, 2011, there was no change in the problem, the goal remained to heal in 30 days, with a future review date of March 27, 2011. The wound was still present at the time of survey. During an interview with the DON and RN 1 on March 24, 2011, at 10:45 a.m., they stated on November 11, 2010, at approximately 4 a.m., Resident 2 was complaining she was cold. They stated the RN CN instructed the LVN caring for Resident 2 to warm a blanket in the microwave and put it on the resident. They stated the LVN warmed the blanket in the microwave, then folded it over many times, and wrapped it around Resident 2's head with the ends draped over her shoulders and chest area. They stated the staff then smelled burning, went to check on Resident 2, and the blanket was smoldering. They stated the blanket was removed and the resident was assessed, and she had a burn to the right breast area. During an interview with Resident 2 on March 24, 2011, at 3:40 p.m., the resident stated the following: 1. On the night of November 11, 2010, she was very cold and could not sleep; 2. The staff put a blanket in the microwave to warm it, then put it on her; 3. She fell asleep, and woke to the staff shaking her and asking if she was OK; 4. The staff pulled her blankets off, and the room filled with smoke; 5. The staff told her she was burned, but she had no feeling below her neck, so she did not know what was happening; 6. The staff had to move her and her room mate out of their room and get rid of the smoke smell; and, 7. It was, "scary." During an interview with CNA 1 on March 29, 2011, at 6:30 a.m., the CNA stated on November 11, 2010, at approximately 4 a.m., the RN CN asked her to check on Resident 2 because she smelled a burning smell and knew a microwaved blanket had just been given to the resident. She stated she went to the room and saw a blanket wrapped around Resident 2's head and draped over her shoulders and chest, and the blanket had a burnt hole with black edges on the right side. The CNA stated she pulled the blanket off and smoke started coming out of it, so she doused it with water. She stated the room filled with smoke, and she opened the window to get the smoke out of the room. The job description for the RN CN was reviewed on March 29, 2011. The job description indicated the RN CN was responsible for maintaining a safe, comfortable, and therapeutic environment for the residents. The job description for the LVN was reviewed on March 29, 2011. The job description indicated the LVN must demonstrate the knowledge and skill necessary to provide safe care. According to the ECRI, using a microwave oven to warm a blanket may result in severe hot spots in the blanket and ignition due, in part, to uneven heating patterns within the oven. Unlike items heated within a conventional oven or warming cabinet, items heated in microwave ovens do not equilibrate to a set chamber temperature. Rather, they continue to heat as long as they are exposed to the microwave energy. Hot spots from microwave heating can cause smoldering and burning of the blanket while it is in the oven. Once removed from the oven, a blanket that is smoldering within its folds may burst into flames if exposed to oxygen or if permitted to smolder long enough. The organization recommends the following: 1. Do not use microwave ovens for warming any blankets. Such use can result in fire, which could cause injury or death; and, 2. Use commercially available hospital blanket warming cabinets. Such cabinets are warmed by either electric heaters or steam and do not present a blanket ignition hazard, even if the warmed blanket is subsequently exposed to an open oxygen source.